The role of esophageal stents in the management of esophageal anastomotic leaks and benign esophageal perforations.

OBJECTIVE: The aim of this review was to assess the safety and effectiveness of esophageal stents in the management of benign esophageal perforation and in the management of esophageal anastomotic leaks. BACKGROUND: Benign esophageal perforation and postoperative esophageal anastomotic leak are often encountered. Endoscopic placement of esophageal stent across the site of leakage might help control the sepsis and reduce the mortality and morbidity. METHODS: All the published case series reporting the use of metallic and plastic stents in the management of postoperative anastomotic leaks, spontaneous esophageal perforations, and iatrogenic esophageal perforations were identified from MEDLINE, EMBASE, and PubMed (1990-2012). Primary outcomes assessed were technical success rates and complete healing rates. Secondary outcomes assessed were stent migration rates, stent perforation rates, duration of hospital stay, time to stent removal, and mortality rates. A pooled analysis was performed and subgroup analysis was performed for plastic versus metallic stents and anastomotic leaks versus perforations separately. RESULTS: A total of 27 case series with 340 patients were included. Technical and clinical success rates of stenting were 91% and 81%, respectively. Stent migration rates were significantly higher with plastic stents than with metallic stents (40/148 vs 13/117 patients, respectively; P = 0.001). Patients with metallic stents had significantly higher incidence of postprocedure strictures (P = 0.006). However, patients with plastic stents needed significantly higher number of reinterventions (P = 0.005). Mean postprocedure hospital stay varied from 8 days to 51 days. There was no significant difference in the primary or secondary outcomes when stenting was performed for anastomotic leaks or perforations. CONCLUSIONS: Endoscopic management of esophageal anastomotic leaks and perforations with the use of esophageal stents is technically feasible. It seems to be safe and effective when performed along with mediastinal or pleural drainage. Esophageal stent can, therefore, be considered as a treatment option in the management of patients who present early after esophageal perforation or anastomotic leak with limited mediastinal or pleural contamination.

Splenic injury after colonoscopy requiring splenectomy.

We present a case of a middle-aged woman, who presented with abdominal pain less than 24 h following an uneventful colonoscopy for rectal bleeding. Initial diagnosis was thought to be colonic perforation. An urgent CT scan performed owing to dropping haemoglobin and blood pressure revealed a large perisplenic haematoma. An urgent laparotomy was performed in which the patient had a total blood loss of 2500 ml and required splenectomy. The patient recovered well postoperatively.Colonoscopy is a commonly performed procedure in which complications of perforation and bleeding are well recognised. This case represents one of the rare but serious complications that endoscopists and patients should be aware of to aid prevention and early diagnosis.