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J Thorac Cardiovasc Surg 2007;133:337-338
© 2007 The American Association for Thoracic Surgery

General Thoracic Surgery

Discussion

Dr Henning A. Gaissert (Boston, Mass). I have no disclosures.

To summarize, Dr Freeman and associates report 21 patients in whom acute postoperative esophageal leaks of fistulae were treated with a self-expanding Polyflex stent after failure of at least 1 operative repair. A seal was achieved in 20 of these 21 patients, and stenting lasted for a mean of 51 days. There were 3 complications. One patient died from disruption of an aortic repair, 1 patient had disruption of an esophageal repair, and 1 patient had a stricture.

I have 2 comments and several questions. The first point is that successful sealing of the leak is gratifying and important, but it is not the complete management of an esophageal leak. Other important components are the drainage of extraluminal fluid collections, decortication for pleural sepsis, and separation of the esophagus from adjacent structures, such as the aorta or airway, with vascularized tissue.

The second point is that self-expanding stents have important disadvantages related to the radial force necessary to maintain their position. If this radial force is too high, the stent erodes the mucosa and causes ulceration and stricture, and if it is too low, the stent slips and migrates, which occurred in 24% of patients. Placed across the esophagogastric junction, the stent might cause debilitating reflux and a stricture above. This treatment is therefore not without complications.

Now to my questions. There were 29 patients in the 2 years with postoperative esophageal leaks and fistulae. I realize many of these were referred to you, but is there anything that you have learned in this period from the primary repair that would lead you to improve that management to decrease the need for stent intervention?

Second, do you trust the scar that results from stenting alone? I note that one . . . [Full Text of this Article]

Related Article

Postoperative esophageal leak management with the Polyflex esophageal stent

Richard K. Freeman, Anthony J. Ascioti, and Thomas C. Wozniak
J. Thorac. Cardiovasc. Surg. 2007 133: 333-338. [Abstract] [Full Text] [PDF]