J Gastric Cancer.  2018 Mar;18(1):37-47. 10.5230/jgc.2018.18.e2.

Novel Endoscopic Stent for Anastomotic Leaks after Total Gastrectomy Using an Anchoring Thread and Fully Covering Thick Membrane: Prevention of Embedding and Migration

• Jung GM
• Lee SH
• Myung DS
• Lee WS
• Joo YE
• Jung MR
• Ryu SY
• Park YK
• Cho SB

• KMID: 2414545
• DOI: http://doi.org/10.5230/jgc.2018.18.e2

Abstract

PURPOSE
The endoscopic management of a fully covered self-expandable metal stent (SEMS) has been suggested for the primary treatment of patients with anastomotic leaks after total gastrectomy. Embedded stents due to tissue ingrowth and migration are the main obstacles in endoscopic stent management.
MATERIALS AND METHODS
The effectiveness and safety of endoscopic management were evaluated for anastomotic leaks when using a benign fully covered SEMS with an anchoring thread and thick silicone covering the membrane to prevent stent embedding and migration. We retrospectively reviewed the data of 14 consecutive patients with gastric cancer and anastomotic leaks after total gastrectomy treated from January 2009 to December 2016.
RESULTS
The technical success rate of endoscopic stent replacement was 100%, and the rate of complete leaks closure was 85.7% (n=12). The mean size of leaks was 13.1 mm (range, 3-30 mm). The time interval from operation to stent replacement was 10.7 days (range, 3-35 days) and the interval from stent replacement to extraction was 32.3 days (range, 18-49 days). The complication rate was 14.1%, and included a single jejunal ulcer and delayed stricture at the site of leakage. No embedded stent or migration occurred. Two patients died due to progression of pneumonia and septic shock 2 weeks after stent replacement.
CONCLUSIONS
A benign fully covered SEMS with an anchoring thread and thick membrane is an effective and safe stent in patients with anastomotic leaks after total gastrectomy. The novelty of this stent is that it provides complete prevention of stent migration and embedding, compared with conventional fully covered SEMS.

Keyword

Anastomotic leak; Gastrectomy; Stomach neoplasms; Self expandable metallic stents

MeSH Terms

Anastomotic Leak*
Constriction, Pathologic
Gastrectomy*
Humans
Membranes*
Pneumonia
Retrospective Studies
Self Expandable Metallic Stents
Shock, Septic
Silicon
Silicones
Stents*
Stomach Neoplasms
Ulcer
Silicon
Silicones

Figure

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  Fig. 1 The flow chart of patients with anastomotic leaks after total gastrectomy for gastric cancer.

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  Fig. 2 Embedded stent was a major complication after the use of a conventional fully SEMS in a patient with leaks. (A) Large dehiscence at esophagojejunal anastomosis site after total gastrectomy. (B) Endoscopic placement of conventional fully SEMS. (C) Severe circumferential embedded stent after 4 weeks. (D) The stent was removed with difficulty under endoscopic and fluoroscopic guide. (E) Removed stent with attaching hyperplastic mucosa at compressed area. (F) Delayed severe stricture developed at mid esophagus with refractoriness to repeated endoscopic balloon dilatation. The patient finally underwent a second operation after 1 year.SEMS, self-expandable metal stent.

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  Fig. 3 Placement of a benign fully covered SEMS with thick membrane and Shim's technique. (A) Large dehiscence at esophagojejunal anastomosis site (B) fully SEMS with thick and long membrane (white arrow) and silk thread (yellow arrow). (C) No leakage after infusion of gastrografin under fluoroscopy. (D) No embedded stent without any tissue hyperplasia after 4 weeks. (E) Near complete sealing of dehiscence in prechecking endoscopy before removal after 4 weeks. (F) The removal of the stent was delayed to 1 week, and the leaks were completely sealed after 5 weeks.SEMS, self-expandable metal stent.

• 

  Fig. 4 An additional feeding tube was inserted into the deep jejunum below the stent under endoscopic and fluoroscopic guide (A). This is helpful to improve nutritional status and to decrease food leakage through the space of esophageal wall and stent (B).

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