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

BackgroundCovered 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.ObjectiveTo 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.DesignProspective outcome study.SettingA tertiary-care referral university hospital.PatientsThis study involved all patients at our center who experienced postoperative esophageal leakage after esophagectomy, primary closure, or total gastrectomy.InterventionPR-SEMS insertion with the direct vision technique and use of transnasal endoscopy without fluoroscopy.Main Outcome MeasurementsSuccess rate of stent insertion, healing rate of postoperative esophageal leaks, and stent migration rate.ResultsAll 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.LimitationsA small number of patients. Further prospective, randomized, controlled trials are needed.ConclusionPR-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.