V. Vudatha1, Z. Rollins1, E. Bashian1, R. Cholyway1, H. L. Warren1, C. Puig Gilbert1, W. Julliard1, R. Shah1 1Virginia Commonwealth University, Division Of Cardiothoracic Surgery, RIchmond, VA, USA
Introduction:
Esophageal perforation has traditionally been managed with surgical repair for large tears or unstable patients, while medical management can be attempted for stable patients with small contained perforations. Surgical options include primary repair with or without muscle flaps, esophageal resection, esophageal diversion and drainage, or esophageal T-tube placement. Endoscopically placed esophageal stents are becoming an increasingly popular way of managing perforations. However, their use has been limited in larger perforations >6cm and in unstable patients. Our study aimed to evaluate the efficacy of fully covered nitinol esophageal stents in esophageal perforations based on one institutions experience.
Methods:
Patients who underwent esophageal stent placement for uncontained esophageal perforation between 2009-2021 at a tertiary care center were retrospectively evaluated. Fully covered esophageal nitinol stents were placed under fluoroscopic guidance. Leak occlusion and stent position were confirmed with an esophagram post-operatively. Outcomes included concurrent procedures, timing of stent removal, additional surgical interventions, and survival.
Results:
Esophageal stents were placed in 54 patients for perforation. Mean age was 63, with a 63% (34/54) male preponderance. During stent placement, 31.5% (17/54) of patients met criteria for sepsis. Esophageal perforations ranged from 1 to 10 cm in length with 7% (4/54) greater than 6cm. The majority had concurrent VATS or open drainage (36/54, 67%). Post-stenting 89% (48/54) had adequate seal on esophagram, 7% (4/54) had stent migration, 9% (5/54) required IR drainage, 9% (5/54 ) had decortications, and 78% (43/54) received a gastrostomy tube. 21% (11/52) had ongoing leak requiring additional stent (4/11, 36%) or percutaneous drainage (2/11, 18%). Only 2% (1/46) of patients treated primarily with stenting required surgical repair with esophagectomy. 83% (45/54) of patients had their stents removed with an average removal time of 39 days. 93% (50/54) survived the hospitalization. 1-year and 2-year survival were 82% (31/38) and 73% (22/30) respectively. Of the 4 patients with >6 cm perforation 1 had stent migration requiring additional stent placement and 1 had an additional stent placed for ongoing leak. None of the >6cm perforations required further invasive surgical intervention.
Conclusion:
Fully covered stent placement for the management of esophageal perforation is safe and effective, even in the setting of large perforations >6 cm and sepsis. The majority of complications can be managed endoscopically or with drainage alone.