Interventional Protocol for Treatment of Complications after Esophagojejunostomy for Esophagogastric Carcinoma

Background Anastomotic stenosis and leakage are rare complications after esophagojejunostomy. The management of complications after esophagojejunostomy remains a challenge. We evaluated the outcomes and clinical effectiveness of an alternative interventional protocol. Objectives To determine the safety and efficacy of interventional treatment for the management of complications after esophagojejunostomy. Methods This study included 24 consecutive patients with complications after esophagojejunostomy treated using interventional protocol. Patients received balloon dilation or stenting for anastomotic stenosis. Patients with anastomotic leakage received three-tube placement or retrievable covered esophageal stent placement, followed by abscess drainage, nutritional support, and anti-inflammatory treatment. The three tubes and esophageal stents were removed after leakage healing and stenosis ceased. Results Thirteen patients received three-tube method, and 16 patients received covered stent placement. All procedures were technically successful, except for a failure of Y-type esophageal stent placement in one patient. The median retention time of stent and abscess drainage tube was 67.5 days and 87 days, respectively. No perioperative death, esophageal rupture, or massive hemorrhage was found during procedures. During follow-up, 14 patients died of cancer recurrence, and one died of severe pulmonary infection. The 1-, 3-, 5-year survival rates were 39.5%, 23.7%, and 23.7%, respectively. Conclusion Interventional protocol is safe, feasible, and efficacious for treatment of complications after esophagojejunostomy.

To date, only limited data are available on interventional treatment of anastomotic leakage or stenosis under fluoroscopic guidance. We used an interventional protocol consisting of balloon dilation for benign anastomotic stenosis, stent for malignant, and three-tube method with or without covered esophageal stent placement for anastomotic leakage. In this study, we aimed to determine the safety and efficacy of this protocol for treatment of complications after esophagojejunostomy.

Patient Selection.
This study was approved by the Ethics Committee Board of the First Affiliated Hospital of Zhengzhou University. All informed consents were obtained from the patients. This study enrolled all patients with anastomotic stenosis and/or anastomotic leakage who received interventional treatments in our department between May 2012 and February 2018. The diagnosis of complications after esophagojejunostomy was made based on finding of esophagography and the chest-computed tomography (Figures 1(a) and 1(b)). Patients with esophagotracheal fistula or spontaneous esophageal perforation were excluded. All patients were treated on an inpatient basis.
2.2. Three-Tube Method. All interventional procedures were performed under fluoroscopic guidance and conscious sedation. After the esophagus was anesthetized by oral lidocaine gel, esophagography was performed to show the site of anastomotic leakage and stenosis (Figure 2(a)). A 5 F catheter was introduced through the outlet of anastomotic leakage into the distal end of the abscess cavity (Figure 2(b)). The catheter was then exchanged with a 5 F straight or pigtail catheter (Cook Medical, Inc., Bloomington, IN). Continuous negative pressure suction was used to achieve effective drainage of abscess cavity. A gastrointestinal decompression tube and jejunal feeding tube were inserted in the intestinal cavity of the anastomosis and the proximal jejunum, respectively.

Balloon Dilation and Esophageal Stent Placement.
Balloon dilation was performed in patient with benign anastomotic stenosis (Figures 3(a) and 3(b)). The diameter of the stents ranges from 10 to 26 mm. The length of the stents ranges from 40 to 60 mm. The retrievable covered esophageal stent was used for the treatment of anastomotic leakage or malignant stenosis, and 2 Y type of intestinal stent were used (Nanjing Micro-Tech Medical Company, Nanjing, China). The stent diameter ranges from 18 to 22 mm. The stent length ranges from 80 to 140 mm. Adequate stent coverage is allowed on both sides of the stenosis or leakage to ensure complete coverage. A 5 F catheter was introduced into the gastral cavity, and a stiff guidewire was exchanged. A stent delivery system was introduced along the stiff guidewire and then adjusted and released slowly (Figure 2(c)). Esophagography was performed again to show change of anastomotic leak and stenosis (Figure 2(d)).

Postoperative
Care. Enteral nutrition (Milupa Gmbh & Co. KG, Friedrichsdorf, Germany) was provided through the jejunal feeding tube. Patients were not permitted to oral feed until leakage sealing and stenosis relief was confirmed by esophagography. Broad-spectrum antibiotic treatment was used for patients with anastomotic leakage before and after procedure. The abscess cavity was irrigated twice a day by physiological saline via the drainage tube.

General Information.
This study involved a total of 24 patients with complications after esophagojejunostomy, including 18 men and 6 women ( Table 1). The ages of the patients ranged from 38 years to 74 years, with a median age of 64 years. The median disease course before referral to our department was 5.5 months (range: 0.3 to 72 months). The median interval between esophageal surgery and complications was 6.8 months (range: 0.2 to 52 months). There were 11 cases of anastomotic leakage, 11 cases of anastomotic stenosis, and 2 patients showed anastomotic leakage combined with stenosis.

Intervention
Outcomes. Three-tube method was used for 13 patients with anastomotic leakage, of which, 7 patients received covered stent placement. For patients with anastomotic stenosis, 4 patients received balloon dilation, and 9 patients received stent placement. A total of 21 covered esophageal stents were placed for 16 patients, with a median diameter of 20 mm and median length of

Discussion
Anastomotic stenosis and anastomotic leakage are rare complications after esophagojejunostomy [3]. The overall incidence of anastomotic leakage and stenosis after esophagojejunostomy was 2.1%-3.0% and 2.7%-2.9%, respectively [4]. Management of complications after esophagojejunostomy is still challenging with no optimal treatment protocol [2,6,11]. Surgical repair was the traditional protocol [12], and various conservative treatment protocols have been reported, including endoscopic transluminal drainage/clipping, stent placement, biodegradable leakage plugs, or fibrin glue [5][6][7][8]. Esophageal stent was initially used as a palliative treatment for malignant dysphagia. Recently, esophageal stents have expanded to treat benign disease [13,14], including plastic stents [15][16][17] and metal stents [13,18,19]. Esophageal metallic stent placement may serve as an alternative protocol for complications after esophagojejunostomy. Metallic stent has been used for treatment of malignant stenosis or perforation [18,19], which is also used for the treatment of benign diseases in recent years, such as anastomotic leakage or stenosis [13]. In this study, a total of 21 covered esophageal stents were placed in 7 patients with anastomotic leakage, with a median retention time of 67.5 days. Successful management of anastomotic leakage after esophagojejunostomy requires adequate therapy of the associated infection and effective elimination of contamination by prompt placement of the covered stent. We present 24 consecutive patients treated with interventional protocol for complications after esophagojejunostomy. We found that interventional protocol can be easily and effectively performed under fluoroscopic guidance with a high technical success rate and no severe complications. No perioperative death was observed in this study, which was lower than previous reports [15,16,20,21]. The gastral cavity is still allowed to drain by a drainage tube after placement of a covered stent. The median retention time of abscess drainage tube was 87 days.
There were certain complications of the interventional protocol. Stent migration is a common complication, especially in patients without luminal stenosis [22,23]. Covered stents were used in this study; stent migration was found in 2 patients and was adjusted effectively. Stent restenosis was found in 3 patients, and an additional stent was inserted for        these patients. The drainage tube was exchanged or adjusted for 0 to 6 times. There are some limitations in this study. This is a retrospective study with a relatively small number of patients. The healing time required for anastomotic leakage is long; however, the esophageal stents are usually removed within 3 months to avoid long-term complications.

Conclusions
Our study shows that interventional treatment of complications after esophagojejunostomy can be considered a safe and effective alternative protocol. Combination of interventional treatment and additional supportive therapy is essential for anastomotic leakage.

Data Availability
The data used to support the findings of this study are available from the corresponding author upon request.

Conflicts of Interest
Authors have nothing to disclose with regard to commercial support.

Authors' Contributions
Yonghua Bi and Jindong Li contributed equally to this work and are co-first authors.