Esophageal stent migration: when endoscopy is not enough

Clinical Case

Esophageal anastomotic leak (EAL) is a severe complication associated with significant increase in postoperative mortality. Some authors have even described a negative association between the occurrence of a leak and recurrence and long-term survival for esophago-gastric cancers. 0 to 35% are reported after esophagectomy and 2.7% to 12.3% after gastrectomy. Most clinical signs are septic, related to mediastinitis or peritonitis, but any atypical symptom in the postoperative setting may be the sign of leak. Even though digestive swallowing test may be useful, its sensitivity is only o40.4% and thus a computed tomography (CT) scan with oral contrast is the favored examination. Endoscopy may be useful as a diagnostic tool as it helps assess the gastric pull-up or jejunal loop viability and may guide potential therapeutic endoscopic procedures . The key points of EAL treatment are the need for early and aggressive management. Transfer to an intensive care unit is often necessary and nutritional support is mandatory , preferably enterally (feeding jejunostomy or nasojejunal feeding tube). Any collection at the level of the anastomosis should be drained via radiology, endoscopy or surgery. Gastric conduit or jejunal loop necrosis requires immediate re-intervention. Endoscopic treatment of EAL is poorly reported in the literature and various types of stents have been used (metallic, plastic, double, covered, etc.). The usual recommendation is to use long stents (12 and 15 cm) with enlarged ends and to place the proximal ⅔ of the stent in the esophagus and the distal third as a bridge at the anastomosis level. The success rate ranges from 69% to 90% . The main complication of stent insertion is stent migration . Migration rates range from 17% to 59% depending on stent diameter, covering, location of insertion and material. Stent migration is significantly greater when fully covered stents are used relative to uncovered and partially covered one. Stent covering is used to create a barrier to prevent fluid leakage through the stent walls as well as prevent integration of the stent into the walls of the GI tract. Treatment of stent migration is usually endoscopic retrieval of the stent. In those cases in which the stent cannot be reached by endoscopy waiting until expulsion with the feces is an option. Some groups have described small bowel perforation by stent decubitus that should prompt surgical intervention . In the case of intestinal obstruction caused by the stent ( see video ) an enterotomy was the classic treatment . In this case, a laparoscopic approach with mobilization of the stent towards the anastomosis and endoscopic retrieval could be an option if performed by an expert endoscopist, which may prevent anastomotic disruption . Other stent complications include tissue ingrowth, mucosal erosion and endoscopic complications associated with placement and removal such as perforation. Various promising techniques have been recently reported, but only through small series or case reports: hemostatic clips associated with fibrin biological glue, Over-the-Scope Clips or endoscopic application of negative pressure therapy. All these technical innovations for endoscopic treatment of EAL may help physicians offer a tailored treatment to patients with EAL . The development of new stents with anti-migration devices might in the future reduce stent-associated morbidity. Communication and multidisciplinary team work are key points for treatment success. In the case of stent placement, intensive surveillance should follow to detect complications as soon as possible.