Proximal-releasing stent insertion under transnasal endoscopic guidance in patients with postoperative esophageal leakage

Background: Covered metallic or plastic stent placement has become an important treatment for postoperative esophageal leakage; however, fluoroscopic guidance is also required. Here we present a novel stent insertion technique with a newly designed proximal-releasing, self-expanding metallic stent (PR-SEMS) and transnasal endoscope that can enable stent insertion without fluoroscopy as a new method to prevent stent migration.

Objective: To describe our experience with 7 patients who underwent PR-SEMS insertion with the direct-vision technique and our use of the transnasal endoscope without fluoroscopy.

Design: Prospective outcome study.

Setting: A tertiary-care referral university hospital.

Patients: This study involved all patients at our center who experienced postoperative esophageal leakage after esophagectomy, primary closure, or total gastrectomy.

Intervention: PR-SEMS insertion with the direct vision technique and use of transnasal endoscopy without fluoroscopy.

Main outcome measurements: Success rate of stent insertion, healing rate of postoperative esophageal leaks, and stent migration rate.

Results: All stents were placed at the expected location without complications. One patient had massive hematemesis and underwent surgery. The bleeding focus was the splenic artery, which was damaged during gastrectomy. A significant marginal ulcer occurred in one patient, and the stent was immediately retrieved with an endoscope. After stent removal, 4 postoperative leakages were completely healed, and 2 lesions were not occluded. The 2 remaining minimal lesions became completely occluded with conservative management after stent removal. Stent migration did not occur.

Limitations: A small number of patients. Further prospective, randomized, controlled trials are needed.

Conclusion: PR-SEMS insertion under transnasal endoscopic guidance is a feasible, safe, and effective treatment for postoperative esophageal leakage, and it can be performed as a bedside procedure. Our anchoring method is effective for the prevention of migration from nonobstructed lesions.