Treatment of upper gastrointestinal leaks with a removable, covered, self-expanding metallic stent

Anastomotic and staple line leaks are serious complications after upper gastrointestinal and bariatric procedures. In patients who are actively septic "diversion and drainage" with aspiration of esophageal and gastric secretions, operative placement of perianastomotic drains, bowel rest, and parenteral nutrition form the conventional management strategy of leaks. Treatment of leaks by direct suture repair, revision, patching, and application of fibrin glue to leaks have failed to gain widespread acceptance owing to a high failure rate in the septic patient. This report describes a case series where anastomotic leaks in patients with established sepsis after upper gastrointestinal resections and bariatric procedures as well as Boerhaave syndrome were managed with a combination of surgical drainage and stent placement. A new technique where the stent is sutured into place transluminally to prevent migration is described.

Seven patients with staple line and anastomotic dehiscences and a single case of Boerhaave syndrome were treated at St George Hospital, Sydney, over the period January 2003 to December 2006 by using a removable, polyester covered self-expanding metal stent (ELLA Boubella, Ella-CS, Hradec, Czech Republic). All patients had active severe sepsis and significant contamination in the abdomen or thorax at the time of stenting. In 4 cases, the stent was sutured in place with dissolvable synthetic sutures with suture bites incorporating the full thickness of the gut wall and the stent itself to prevent stent migration.

All patients showed resolution of their intra-abdominal sepsis and were able to resume an oral diet after stenting. All stents were retrieved endoscopically after clinical resolution of the leak. Stent migration after leak resolution was observed in 3 patients. In patients with large defects or minimal anatomic barriers to stent migration, suture fixation stabilized the stent. There were no episodes of persistent leak or development of stricture in this series.

In this small series, the use of a removable covered stent in the setting of anastomotic leak or spontaneous perforation, alone or as an adjunct to conventional surgical management, is feasible in sealing the leak, resolving sepsis, and expediting return to enteral nutrition. Stenting is feasible in cases with substantial tissue loss or contamination. Suturing the stent transluminally stabilizes the stent where risk of migration is high.