title: Utility of removable esophageal covered self-expanding metal stents for leak and fistula management.
abstract: BACKGROUND
  Esophageal or gastric leakage from anastomotic wound dehiscence, perforation, staple line dehiscence, or trauma can be a devastating event. Traditional therapy has often consisted of either surgical repair for rapidly diagnosed leaks or diversion for more complicated cases, commonly associated with a delayed diagnosis. This study summarizes our experience treating leaks or fistulas with novel, covered self-expanding metal stents (cSEMS). The primary objective of this study was to determine the efficacy and safety of covered self-expanding metal stents when used to treat complicated leaks and fistulas.
  
  
  METHODS
  Over 15 months, 25 patients with esophageal or gastric leaks were evaluated for stenting as primary treatment. A prospective database was used to collect data. Stents were placed endoscopically, with contrast evaluation used for leak evaluation. Patients who did not improve clinically after stenting or whose leak could not be sealed underwent operative management.
  
  
  RESULTS
  During a mean follow-up of 15 months, 23 of the 25 patients with esophageal or gastric leaks during a 15-month period were managed with endoscopic stenting as primary treatment. Healing occurred in patients who were stented for anastomotic leakage after gastric bypass or sleeve gastrectomy (n = 10). One patient with three esophageal iatrogenic perforations healed with stenting. Eight patients successfully avoided esophageal diversion and healed with stenting and adjunctive therapy. Two of the 4 patients with tracheoesophageal fistulas sealed with the assistance of a new pexy technique to prevent stent migration; 1 additional patient had this same technique used to successfully heal an upper esophageal perforation.
  
  
  CONCLUSIONS
  Esophageal leaks and fistulas can be effectively managed with cSEMS as a primary modality. The potential benefits of esophageal stenting are healing without diversion or reconstruction and early return to an oral diet.
authors.affiliation: Department of Surgery, The Methodist Hospital, Houston, Texas 77030, USA. shblackmon@tmhs.org
authors.forename: Shanda H
authors.initials: SH
authors.lastname: Blackmon
authors.forename: Rachel
authors.initials: R
authors.lastname: Santora
authors.forename: Peter
authors.initials: P
authors.lastname: Schwarz
authors.forename: Alberto
authors.initials: A
authors.lastname: Barroso
authors.forename: Brian J
authors.initials: BJ
authors.lastname: Dunkin
mesh_terms: D000714:Anastomosis, Surgical / Q000009:adverse effects; D020099:Coated Materials, Biocompatible; D020878:Device Removal; D004939:Esophageal Perforation / Q000628:therapy*; D004947:Esophagus; D005260:Female; D006801:Humans; D008297:Male; D008670:Metals; D008875:Middle Aged; D015607:Stents / Q000009:adverse effects; D014138:Tracheoesophageal Fistula / Q000628:therapy*
chemical_list: D020099:Coated Materials, Biocompatible; D008670:Metals