Rajan P S, Bansal S, Balaji N S, Rajapandian S, Parthasarathi R, Senthilnathan P, Praveenraj P, Palanivelu C
Department of Upper GI Surgery and Therapeutic Endoscopy, GEM Hospital, 45/A Pankaja Mill Road, Ramanathapuram, Coimbatore, 641045, India,
Surg Endosc. 2014 Aug;28(8):2368-73. doi: 10.1007/s00464-014-3471-4. Epub 2014 Mar 8.
Leaks following oesophageal surgery are considered to be amongst the most dreaded complications and contributory to postoperative mortality. Controversies still exist regarding the best option for the management of oesophageal leaks due to lack of standardized treatment protocols. This study was designed to analyse the feasibility outcome and complications associated with placement of removable, fully covered, self-expanding metallic stents for oesophageal leaks with concomitant minimally invasive drainage when appropriate.
The study group included 32 patients from a prospectively maintained database of oesophageal leaks, with the majority being anastomotic leaks after minimally invasive oesophagectomy (n = 28), followed by laparoscopic cardiomyotomy (n = 3) and extended total gastrectomy (n = 1). The procedures took place between March 2007 and April 2013.
Most patients had an intrathoracic leak (n = 22), with a mean time to detection of the leak following surgery of 7.50 days (SD = 2.23). Subsequent to endoscopic stenting, enteral feeding via a nasojejunal tube was started on the second day and oral feeding was delayed until the 14th day (n = 31). Six patients underwent thoracoscopic (n = 5) or laparoscopic drainage (n = 1) along with stenting for significant mediastinal and intra-abdominal contamination. The stent migration rate of our study was 8.54%. The overall success in terms of preventing mortality was 96%.
Endoscopic stenting should be considered a primary option for managing oesophageal leaks. Delayed oral intake may reduce the incidence of stent migration. Larger stents (bariatric or colorectal stents) serve as a useful option in case of migrated stents. Combined minimally invasive procedures can be safely adapted in appropriate clinical circumstances and may contribute to better outcomes.
食管手术后的渗漏被认为是最可怕的并发症之一，也是术后死亡率的一个因素。由于缺乏标准化的治疗方案，食管渗漏的最佳管理选择仍存在争议。本研究旨在分析在适当情况下放置可移除、完全覆盖、自膨式金属支架治疗食管渗漏并伴有微创引流的可行性结果及并发症。
研究组包括32例来自前瞻性维护的食管渗漏数据库的患者，大多数为微创食管切除术后的吻合口漏（n = 28），其次是腹腔镜贲门肌切开术（n = 3）和扩大全胃切除术（n = 1）。手术于2007年3月至2013年4月进行。
大多数患者存在胸内渗漏（n = 22），术后渗漏检测的平均时间为7.50天（标准差 = 2.23）。内镜下置入支架后，第二天开始经鼻空肠管进行肠内喂养，口服喂养推迟至第14天（n = 31）。6例患者因严重的纵隔和腹腔内污染，在置入支架的同时接受了胸腔镜（n = 5）或腹腔镜引流（n = 1）。本研究的支架移位率为8.54%。预防死亡方面的总体成功率为96%。
内镜下置入支架应被视为治疗食管渗漏的主要选择。延迟口服摄入可能会降低支架移位的发生率。在支架移位的情况下，较大的支架（减重或结直肠支架）是一种有用的选择。在适当的临床情况下，可以安全地采用联合微创手术，这可能有助于获得更好的结果。
