Efficacy of endoscopic management of leak after foregut surgery with endoscopic covered self-expanding metal stents (SEMS). Surg Endosc. 2017;31:612-617. [PMID: 27317034 DOI: 10.1007/s00464-016-5005-8]

Endoluminal Vacuum Therapy as Effective Treatment for Patients with Postoperative Leakage After Metabolic Bariatric Surgery-A Single-Center Experience

BACKGROUND

Metabolic bariatric surgery (MBS) is standardized and safe. Nevertheless, complications such as anastomotic leakage (AL) or staple-line leakage (SLL) can occur. In upper GI or colorectal surgery, endoluminal vacuum therapy (EVT) offers a therapeutic alternative to revisional surgery. Data on EVT in patients with leakage after MBS remain scarce. The aim of this study is to evaluate the efficacy of EVT and its potential as endoscopic alternative to revisional surgery.

MATERIAL AND METHODS

All patients treated for AL or SLL with EVT after MBS between 01/2016 and 08/2023 at the Department for General Surgery, Medical University Vienna, were included in this retrospective, single-center study. Therapeutic value of EVT as management option for acute postoperative leakage after MBS in daily practice was evaluated. Statistical analyses were performed descriptively.

RESULTS

Twenty-one patients were treated with EVT within the observational period of 7 years. In 11 cases (52.4%), the index surgery was a primary bariatric intervention; in 10 cases (47.6%), a secondary surgery after initial MBS was performed. Favored approach was a combination of revisional surgery and EVT (n = 18; 85.7%), intermediate self-expanding metal stent (SEMS) in 16 (76.2%) cases. EVT was changed six times (0-33) every 3-4 days. Mean EVT time was 25.1 days (3-97). No severe associated complications were detected and EVT showed an efficacy of 95.2%.

CONCLUSION

This small case series supports the trend to establish EVT in daily clinical practice when revisional surgery after MBS is needed, thus preventing further reoperation and reducing associated morbidity and mortality in critically ill patients.

VAC-Stent in the Treatment of Post-Esophagectomy Anastomotic Leaks: A New "Kid on the Block" Who Marries the Best of Old Techniques-A Review

Esophagectomy, while a pivotal treatment for esophageal cancer, is not without adverse events. Among these, anastomotic leak (AL) is the most feared complication, threatening patient lives and incurring significant healthcare costs. The management of AL is complex and lacks standardization. Given the high morbidity and mortality rates associated with redo-surgery, which poses risks for already fragile patients, various endoscopic treatments have been developed over time. Self-expandable metallic stents (SEMSs) were the most widely used treatment until the early 2000s. The mechanism of action of SEMSs includes covering the wall defect, protecting it from secretions, and promoting healing. In 2010, endoscopic vacuum therapy (EVT) emerged as a viable alternative for treating ALs, quickly gaining acceptance in clinical practice. EVT involves placing a dedicated sponge under negative pressure inside or adjacent to the wall defect, aiming to clear the leak and promote granulation tissue formation. More recently, the VAC-Stent entered the scenario of endoscopic treatment of post-esophagectomy ALs. This device combines a fully covered SEMS with an integrated EVT sponge, blending the ability of SEMSs to exclude defects and maintain the patency of the esophageal lumen with the capacity of EVT to aspirate secretions and promote the formation of granulation tissue. Although the literature on this new device is not extensive, early results from the application of VAC-Stent have shown promising outcomes. This review aims to synthesize the preliminary efficacy and safety data on the device, thoroughly analyze its advantages over traditional techniques and disadvantages, explore areas for improvement, and propose future directions.

The Triple-S Advantage of Endoscopic Management in Gastrointestinal Surgery Complications: Safe, Successful, and Savings-Driven

Despite advances in gastrointestinal (GI) surgery, post-operative complications are not entirely avoidable [...].

Endoscopic vacuum therapy versus self-expandable metal stent for treatment of anastomotic leaks < 30 mm following oncologic Ivor-Lewis esophagectomy: a matched case-control study

BACKGROUND

Management of anastomotic leaks after Ivor-Lewis esophagectomy remains a challenge. Although intracavitary endoscopic vacuum therapy (EVT) has shown great efficacy for large dehiscences, the optimal management of smaller leaks has not been standardized. This study aims to compare EVT versus self-expandable metal stent (SEMS) in the treatment of leaks < 30 mm in size, due to the lack of current data on this topic.

METHODS

Patients undergoing EVT (cases) or SEMS (controls) between May 2017 and July 2022 for anastomotic leaks < 3 cm following oncologic Ivor-Lewis esophagectomy were enrolled. Controls were matched in a 1:1 ratio based on age (± 3 years), BMI (± 3 kg/m2) and leak size (± 4 mm).

RESULTS

Cases (n = 22) and controls (n = 22) showed no difference in baseline characteristics and leak size, as per matching at enrollment. No differences were detected between the two groups in terms of time from surgery to endoscopic treatment (p = 0.11) or total number of procedures per patient (p = 0.05). Remarkably, the two groups showed comparable results in terms of leaks resolution (90.9% vs. 72.7%, p = 0.11). The number of procedures per patient was not significant between the two cohorts (p = 0.05). The most frequent complication in the SEMS group was migration (15.3% of procedures).

CONCLUSION

EVT and SEMS seem to have similar efficacy outcomes in the treatment of anastomotic defects < 30 mm after Ivor-Lewis esophagectomy. However, larger studies are needed to corroborate these findings.

Applications of endoscopic vacuum therapy in the upper gastrointestinal tract

Endoscopic vacuum therapy (EVT) is an increasingly popular treatment option for wall defects in the upper gastrointestinal tract. After its initial description for the treatment of anastomotic leaks after esophageal and gastric surgery, it was also implemented for a wide range of defects, including acute perforations, duodenal lesions, and postbariatric complications. Apart from the initially proposed handmade sponge inserted using the “piggyback” technique, further devices were used, such as the commercially available EsoSponge and VAC-Stent as well as open-pore film drainage. The reported pressure settings and intervals between the subsequent endoscopic procedures vary greatly, but all available evidence highlights the efficacy of EVT, with high success rates and low morbidity and mortality, so that in many centers it is considered to be a first-line treatment, especially for anastomotic leaks.

The Use of Esophageal Stents in the Management of Postoperative Fistulas-Current Status, Clinical Outcomes and Perspectives-Review

Esophageal fistula remains one of the main postoperative complications, with the treatment often requiring the use of stents. This article reviews the updates on the use of endoscopic stents for the treatment of postoperative esophageal leakage in terms of indications, types of stents used, efficiency, specific complications and perspectives.

MATERIALS AND METHODS

We searched the PubMed and MEDLINE databases for the keywords postoperative esophageal anastomotic leak and postoperative esophageal anastomotic leak stent, and retrieved relevant papers published until December 2022.

RESULTS

The endoscopic discovery of the fistula is usually followed by the insertion of a fully covered esophageal stent. It has an efficiency of more than 60% in closing the fistula, and the failure is related to the delayed application of the method, a situation more suitable for endo vac therapy. The most common complication is migration, but life-threatening complications have also been described. The combination of the advantages of endoscopic stents and vacuum therapy is probably found in the emerging VACstent procedure.

CONCLUSIONS

Although the competing approaches give promising results, this method has a well-defined place in the treatment of esophageal fistulas, and it is probably necessary to refine the indications for each individual procedure.

Propensity score matching analysis comparing outcomes between primary and revision Roux-en-Y gastric bypass after adjustable gastric banding: a retrospective record-based cohort study

BACKGROUND

One-stage revision Roux-en-Y gastric bypass (RRYGB) after Laparoscopic adjustable gastric banding (LAGB) is widely adopted, but its safety is still debated.

OBJECTIVE

This study aimed to compare outcomes between primary Roux-en-Y gastric bypass (PRYGB and RRYGB after LAGB.

METHOD

A retrospective record-based cohort study of patients who underwent PRYGB and RRYGB for failed LAGB and completed at least 2 years of follow-up from 2008 to 2019. Propensity score matching (PSM) analysis was conducted to obtain a balanced sample of patients with RRYGB and PRYGB interventions by adjusting for baseline covariates including age and sex.

RESULTS

Patients with PRYGB (n = 558) and RRYGB (n = 156) were included. PSM identified 98 patients for RRYGB and 98 patients for PRYGB. Both cohorts exhibited significant reductions in BMI compared to baseline values (p < 0.001), but reductions were significantly higher in PRYGB compared to those in RRGYB at 6 months (- 10.55 ± 8.54 vs. - 8.38 ± 5.07; p = 0.032), 1-year (- 21.50 ± 8.19 vs. 16.14 ± 6.93; p < 0.001), and 2 years (- 24.02 ± 7.85 vs. - 18.93 ± 6.80; p < 0.001), respectively. A significant improvement in food tolerance from the 1st to the 2nd year was seen after RYGB (p < 0.001). The rates of early and late complications were similar in both cohorts (p = 0.537, p = 1.00). Overall re-intervention rates were 5.1 and 3.1% for RRYGB and PRYGB p = 0.721). Both cohorts exhibited significant improvement in comorbidities after 2 years (p < 0.001).

CONCLUSIONS

One-stage RRYGB for failed LAGB is safe and effective with comparable rates of complications, re-interventions, and resolution of associated comorbid conditions compared to PRYGB.

Predictability of Endoscopic Success for Foregut and Bariatric Leak in an Experienced Quaternary Center

BACKGROUND

Leaks of the esophagus and stomach are difficult to manage and associated with significant morbidity and mortality. Endoscopic therapy can manage these leaks without surgical intervention. Our goal is to create a scoring tool to aid in predicting the success of endoscopic therapy in these patients.

STUDY DESIGN

An IRB-approved prospectively maintained database was retrospectively reviewed for all patients treated for gastrointestinal leaks from July 2013 to January 2021, including patients treated for esophageal and stomach leaks. Endpoints include success of leak closure for patients treated solely by endoscopic therapy (ET) compared with surgical therapy as failed endoscopic therapy (FET). A multivariable logistic regression model was fitted to identify independent risk factors for predicting success of endoscopic therapy, and a scoring calculator was developed.

RESULTS

There were 80 patients (60 females) with a mean age of 50 years. The ET group included 59 patients (74%), whereas the FET group included 21 patients (26%). Patient demographics, comorbidities, surgical history, and timing of leak diagnosis were used. Multivariable analysis resulted in 4 variables associated with higher probability of successful endoscopic leak management without need for additional surgery. These included increased age, lower BMI, lack of previous bariatric surgery, and quicker identification of the leak. Consequently, a scoring nomogram was developed with values from 0 to 22.

CONCLUSION

Our data show the development of a scoring calculator capable of quantifying the likelihood of success treating foregut and bariatric leaks with endoscopic therapies. This can be used clinically to guide treatment decisions.

Use of double-layered covered esophageal stents in post-surgical esophageal leaks and esophageal perforation: Our experience

INTRODUCTION

The use of esophageal stents for the endoscopic management of esophageal leaks and perforations has become a usual procedure. One of its limitations is its high migration rate. To solve this incovenience, the double-layered covered esophageal stents have become an option.

OBJECTIVES

To analyse our daily practice according to the usage of double-layered covered esophageal metal stents (DLCEMS) (Niti S™ DOUBLE™ Esophageal Metal Stent Model) among patients diagnosed of esophageal leak or perforation.

METHODS

Retrospective, descriptive and unicentric study, with inclusion of patients diagnosed of esophageal leak or perforation, from November 2010 until October 2018. The main aim is to evaluate the efficacy of DLCEMS, in terms of primary success and technical success. The secondary aim is to evaluate their (the DLCEMS) safety profile.

RESULTS

Thirty-one patients were firstly included. Among those, 8 were excluded due to mortality not related to the procedure. Following stent placement, technical success was reached in 100% of the cases, and primary success, in 75% (n=17). Among the complications, stent migration was present in 21.7% of the patients (n=5), in whom the incident was solved by endoscopic means.

CONCLUSIONS

According to our findings, DLCEMS represent an alternative for esophageal leak and perforation management, with a high success rate in leak and perforation resolutions and low complication rate, in contrast to the published data. The whole number of migrations were corrected by endoscopic replacement, without the need of a new stent or surgery.

The impact of severe postoperative complications on outcomes of bariatric surgery-multicenter case-matched study

BACKGROUND

Bariatric surgery has relatively low complication rates, especially severe postoperative complications (defined by Clavien-Dindo classification as types 3 and 4), but these rates cannot be ignored. In other than bariatric surgical disciplines, complications affect not only short-term but also long-term results. In the field of bariatric surgery, this topic has not been extensively studied.

OBJECTIVES

The aim of the study was to assess the outcomes of bariatric treatment in patients with obesity and severe postoperative complications in comparison to patients with a noneventful perioperative course.

SETTING

Six surgical units at Polish public hospitals.

METHODS

We performed a multicenter propensity score matched analysis of 206 patients from 6 Polish surgical units and assessed the outcomes of bariatric procedures. A total of 103 patients with severe postoperative complications (70 laparoscopic sleeve gastrectomy [SG] and 33 with laparoscopic Roux en Y gastric bypass [RYGB]) were compared to 103 patients with no severe complications in terms of peri- and postoperative outcomes.

RESULTS

The outcomes of bariatric treatment did not differ between compared groups. Median percentage of total weight loss 12 months after the surgery was 28.8% in the group with complications and 27.9% in patients with no severe complications (P = 0.993). Remission rates of both type 2 diabetes mellitus and arterial hypertension showed no significant difference between SG and RYGB (36% versus 42%, P = 0.927, and 41% versus 46%, P = 0.575. respectively).

CONCLUSIONS

The study suggests that severe postoperative complications had no significant influence either on weight loss effects or obesity-related diseases remission.

Double layer stent for the treatment of leaks and fistula after upper gastrointestinal oncologic surgery: a retrospective study

Anastomotic dehiscence is one of the most morbidity related and deadly complication after foregut oncologic surgery. The aim of the study is to evaluate the effectiveness of double layer stents (Niti-S™ Beta™ Esophageal Stent) in the management of dehiscences after upper gastrointestinal oncologic surgery. We retrospectively studied consecutive patients who underwent Niti-S™ Beta™ esophageal stent placement from June 2014 to September 2019 for the treatment of anastomotic leaks/fistula following esophagectomy or gastrectomy for cancer. Univariate two-sided logistic regression analysis was used to evaluate possible predictors of successful anastomotic leak/fistula closure. A total of 37 patients were studied and 75 stents were positioned in these patients during the endoscopic procedures. Effective leak/fistula closure was obtained in 23/37 (62.2%). No technical endoscopic failure or complications ensued during the placing of the devices. Regarding delayed complications, migration was observed in 17/75 (22.7%) procedures and stent leaking in 29/75 (38.6%). Three variables significantly favoured stent treatment failure, namely previous neoadjuvant therapy (OR 9.3, P = 0.01), fistula (instead of leak) (OR 6.5, P = 0.01), and stent leak (OR 17.0, P = 0.01). Placement of Beta Niti-S esophageal stent is a safe and effective method that could be considered for the management of leaks and fistula after upper gastrointestinal cancer. Crucial points in the management of post-surgical leaks with this technique are the prompt recognition of leaks and fistula, the prompt endoscopic/radiologic drain of collection and the choice of adequate size of the stent.

A Comprehensive Review of Endoscopic Management of Sleeve Gastrectomy Leaks

BACKGROUND

Bariatric surgery leaks result in significant morbidity and mortality. Experts report variable therapeutic approaches, without uniform guidelines or consensus.

OBJECTIVE

To review the pathogenesis, risk factors, prevention, and treatment of gastric sleeve leaks, with a focus on endoscopic approaches. In addition, the efficacy and success rates of different treatment modalities are assessed.

DESIGN

A comprehensive review was conducted using a thorough literature search of 5 online electronic databases (PubMed, PubMed Central, Cochrane, EMBASE, and Web of Science) from the time of their inception through March 2020. Studies evaluating gastric sleeve leaks were included. MeSH terms related to "endoscopic," "leak," "sleeve," "gastrectomy," "anastomotic," and "bariatric" were applied to a highly sensitive search strategy. The main outcomes were epidemiology, pathophysiology, diagnosis, treatment, and outcomes.

RESULTS

Literature search yielded 2418 studies of which 438 were incorporated into the review. Shock and peritonitis necessitate early surgical intervention for leaks. Endoscopic therapies in acute and early leaks involve modalities with a focus on one of: (i) defect closure, (ii) wall diversion, or (iii) wall exclusion. Surgical revision is required if endoscopic therapies fail to control leaks after 6 months. Chronic leaks require one or more endoscopic, radiologic, or surgical approaches for fluid collection drainage to facilitate adequate healing. Success rates depend on provider and center expertise.

CONCLUSION

Endoscopic management of leaks post sleeve gastrectomy is a minimally invasive and effective alternative to surgery. Their effect may vary based on clinical presentation, timing or leak morphology, and should be tailored to the appropriate endoscopic modality of treatment.

Self-expanding Metal Stents for Anastomotic Leaks After Upper Gastrointestinal Cancer Surgery

BACKGROUND

Anastomotic leakage (AL) is a common and severe complication after upper gastrointestinal (UGI) surgery. Although evidence is scarce, endoscopic deployed self-expanding metal stents (SEMS) are well-established for the management of AL in UGI surgery. The present study aimed to evaluate the feasibility, effectiveness, and safety of SEMS in terms of success, mortality, and morbidity in patients with AL after UGI cancer surgery.

MATERIALS AND METHODS

Patients with AL after primary UGI cancer surgery were retrospectively analyzed with regard to demographics, disease, surgical and endoscopic procedures, and complications. Stent treatment success was divided into technical, primary (within 72 hours of stent deployment), sustained (after 72 hours of stent deployment), and sealing success.

RESULTS

In a total of 63 patients, 74 stents were used and 11 were deployed in endoscopic reinterventions. Stent deployment was successful in all patients. Primary and sustained success rates were 68.3% (n = 43) and 65.1% (n = 41), respectively. Of the primarily successfully treated patients, 87.8% remained successfully treated. If primary treatment was unsuccessful, it remained unsuccessful in 66.6% of the patients (P = 0.002). Final sealing of the leakage was observed in 65.1% of patients (n = 41). Longer stent shafts and wider stent end widths were correlated with successful stent treatment (P < 0.05).

CONCLUSION

SEMS are a safe and sufficient tool in the treatment of AL after UGI cancer surgery. Treatment success is improved with longer stent shafts and wider stent end widths. Switching to alternative treatments is strongly suggested if signs of persistent leakage are present beyond 72 hours after stent placement, as this is highly indicative of sustained stent failure.

Application of endoscopic technique in completely occluded anastomosis with anastomotic separation after radical resection of colon cancer: a case report and literature review

BACKGROUND

Anastomosis-related complications are common after the radical resection of colon cancer. Among such complications, severe stenosis or completely occluded anastomosis (COA) are uncommon in clinical practice, and the separation of the anastomosis is even rarer. For such difficult problems as COA or anastomotic separation, clinicians tend to adopt surgical interventions, and few clinicians try to solve them through endoscopic operations.

CASE PRESENTATION

In this article, we present a case of endoscopic treatment of anastomotic closure and separation after radical resection for sigmoid carcinoma. After imaging examination and endoscopic evaluation, we found that the patient had a COA accompanied by a 3-4 cm anastomotic separation. With the aid of fluoroscopy, we attempted to use the titanium clip marker as a guide to perform an endoscopic incision and successfully achieved recanalization. We used a self-expanding covered metal stent to bridge the intestinal canal to resolve the anastomotic separation. Finally, the patient underwent ileostomy takedown, and the postoperative recovery was smooth. The follow-up evaluation results showed that the anastomotic stoma was unobstructed.

CONCLUSIONS

We reported the successful application of endoscopic technique in a rare case of COA and separation after colon cancer surgery, which is worth exploring and verifying through more clinical studies in the future.

Outcome and Adverse Events of Endoscopic Bariatric Stents for Management of Leakage after Bariatric Surgery

INTRODUCTION

Bariatric leakage (BL) is a serious complication with a variety in available treatment options. Endoscopic stenting is preferred because of its minimally invasive nature in morbidly obese patients. Various modifications have been applied to stents since its use in palliation of malignant strictures. Few studies have exclusively evaluated the efficacy of bariatric stents in management BL.

METHODS

A retrospective cohort study of patients with BL managed by bariatric stents in the period between July 2014 and January 2019. The primary outcome was the clinical success in healing of leakage and secondary outcomes included adverse events (AEs), hospital stay and procedure-related mortality.

RESULTS

Forty-five patients were included in this study. Clinical success occurred in 33 patients (73.3%). There was no stent-related mortality. The most frequent stent-related complications were reflux (62.2%), intolerance (55.6%), and migration (17.8%). Severe AEs occurred in 9 patients (20%). The overall complications rate was higher in diabetic patients (P = 0.048). Intolerance was significantly associated with shorter interval to management (P = 0.02). Stent migration was higher in male patients (P = 0.019) and higher BMI (P = 0.024).

CONCLUSION

Endoscopic stenting is a double-edged weapon that must be handled cautiously. It is a highly effective therapy, and early intervention is the main determinant of its efficacy. But it is not a treatment without complications (80%). The variant and high prevalence of complications mandates a strict follow-up throughout the stenting duration.

Feasibility, effectiveness, and safety of endoscopic vacuum therapy for intrathoracic anastomotic leakage following transthoracic esophageal resection

Background

Anastomotic leakage (AL) in the upper gastrointestinal (GI) tract is associated with high morbidity and mortality rates. Especially intrathoracic anastomotic leakage leads to life-threatening complications. Endoscopic vacuum therapy (EVT) for anastomotic leakage after transthoracic esophageal resection represents a novel concept. However, sound clinical data are still scarce. This retrospective, single-center study aimed to evaluate the feasibility, effectiveness, and safety of EVT for intrathoracic anastomotic leakage following abdomino-thoracic esophageal resection.

Methods

From March 2014 to September 2019 259 consecutive patients underwent elective transthoracic esophageal resection. 72 patients (27.8%) suffered from AL. The overall collective in-hospital mortality rate was 3.9% (n = 10). Data from those who underwent treatment with EVT were included.

Results

Fifty-five patients were treated with EVT. Successful closure was achieved in 89.1% (n = 49) by EVT only. The EVT-associated complication rate was 5.4% (n = 3): bleeding occurred in one patient, while minor sedation-related complications were observed in two patients. The median number of EVT procedures per patient was 3. The procedures were performed at intervals of 3–5 days, with a 14-day median duration of therapy. The mortality rate of patients with AL was 7.2% (n = 4). Despite successfully terminated EVT, three patients died because of multiple organ failure, acute respiratory distress syndrome, and urosepsis (5.4%). One patient (1.8%) died during EVT due to cardiac arrest.

Conclusions

EVT is a safe and effective approach for intrathoracic anastomotic leakages following abdomino-thoracic esophageal resections. It offers a high leakage-closure rate and the potential to lower leakage-related mortalities.

Trial registration: This trial was registered and approved by the Institutional Ethics Committee of the University of Heidelberg on 16.04.2014 (Registration Number: S-635/2013).

Aortic Injuries Following Stent Deployments in Bariatric Surgery-Review of Literature

Introduction: Consecutive to an increase in the number of bariatric surgeries worldwide, the number of articles reporting complications have also increased. The most dreadful bariatric complication is represented by the leak, and the endoscopic stent is still the standard treatment for some bariatric teams despite the poor quality of life and associated complications. The purpose of this review was to identify the very rare cases of aortic injuries associated with stent use in bariatric surgery. Methods: Aortic injuries related to stent use was the main criteria to summarize the literature by a careful assessment of PubMed/MEDLINE databases. Leak characteristics, primary endoscopic treatment, and the outcome of endoscopic complication were retrieved and categorized from each eligible article. Results: Thirty-five articles were selected for analysis. After abstract analysis, 22 studies were excluded, and 13 articles were reviewed in full-text version. Four articles were confirmed with aortic injury following stent use for complications after different bariatric procedures. These contained one retrospective case series and three retrospective case reports. There were 4 patients involved with complications following bariatric surgery: Roux-en-Y Gastric Bypass-3 cases and laparoscopic sleeve gastrectomy-1 case. The reported mortality of the aorto-esophageal fistula was 50%. Conclusions: Using stents in the treatment of leaks following bariatric surgery could be an efficient treatment, despite the poor quality of life and the stent migration. Even though it is rare, the aortic injury is a dreaded complication related to stent use and associated with high mortality rates.

Endoscopic treatment of postoperative esophagogastric leaks with fully covered self-expanding metal stents

BACKGROUND

the management of postoperative esophageal leaks is a huge therapeutic challenge. Thanks to the advances in endoscopy, treatment with esophageal stents has been proposed as a valid option.

AIMS

the main objective of the study was to evaluate the effectiveness and safety of the use of fully covered esophageal metal stents in the treatment of postoperative esophageal leaks.

METHODS

a retrospective observational study was performed in patients with postoperative esophageal leaks, treated with fully covered self-expandable metal stents between June 2011 and May 2018.

RESULTS

twenty-five patients were evaluated and 34 stents were placed. The closure of the leak was observed in 21 patients after removal of the stent, with an overall technical success rate of 84 %. The mean time with a stent placed for closure of the fistula was 55.7 ± 27.11 days/patient (mean of 39 ± 24.30 days/stent). The most frequent complication was a partial distal stent migration (7/34 stents), followed by five cases of complete migration into the stomach.

CONCLUSIONS

endoscopic treatment with fully covered self-expandable metal stents seems to be an effective and safe first-line treatment for postoperative esophageal leaks, according to the experience in our center.

Gastric Stenosis After Sleeve Gastrectomy: an Algorithm for Management

BACKGROUND

Gastric stenosis (GS) is a well-recognized complication after sleeve gastrectomy (SG) with a negative impact on patients' nutritional status and quality of life. There is no consensus on a validated, comprehensive management algorithm for GS. This study evaluates treatment modalities and proposes a management algorithm for obstructive gastric symptoms (OGSs) after SG.

METHODS

This is a retrospective cohort study of patients with GS after SG between January 2013 and January 2019. Patients with concomitant GS and staple-line leak were excluded. The primary outcome was the clinical response to treatment.

RESULTS

Forty-nine patients presented with OGSs. One patient underwent urgent surgical treatment for acute migration of cardia. Of 42 patients who had evident GS, pneumatic balloon dilatation (PBD) achieved clinical success in 28 (66.7%) patients. Six patients were diagnosed with indolent GS, and four of them improved after empirical PBD. The mean interval from index surgery to PBD was 5.3 (± 4.2) months. Longer duration of PBD session was associated with better clinical outcomes (5.8 ± 3.7 vs. 3.2 ± 1.7 min) (P = 0.017). After failed PBD, endoscopic stenting (n = 2) and revisional surgery (n = 7) were performed with clinical success in all patients.

CONCLUSION

PBD using achalasia balloon is the mainstay of treatment with good clinical outcomes. The utility of endoscopic stenting for GS should be different from its use for leakage in aspects of dwelling time and required endoscopic expertise. RYGB is the gold standard revisional procedure due to the high success rate and technical familiarity. Controversial aspects of management require future prospective comparative studies.

Endoscopic closure of refractory esophageal fistula after esophagectomy using polyglycolic acid sheets: a pilot study

Background and study aims  Esophageal fistulas after esophagectomy are associated with high mortality and poor quality of life. They are sometimes intractable to conservative management and surgery that increases mortality. Few studies have assessed use of polyglycolic acid (PGA) sheets with fibrin glue for esophageal fistulas. We investigated the safety of using PGA sheets with fibrin glue for esophageal fistulas after esophagectomy. Patients and methods  This was a single-center prospective pilot study. Patients who had refractory esophageal fistulas after esophagectomy were included. PGA sheets were filled in the fistula using biopsy forceps. Fibrin glue was applied to the PGA sheets. We repeated the procedure 1 week later. The outcome measures were the incidence of adverse events (AEs) and closure of the fistula. Results  Five patients were assessed. No adverse events were observed. The esophageal fistula was closed with the application of PGA sheets four times in 40 % (2/5) of the cases. Conclusions  PGA sheets with fibrin glue were safe for esophageal fistula closure after esophagectomy and do not involve the risk of AEs.

Clinical score predicting a successful endoscopic approach of esophageal anastomotic leaks: external validation

BACKGROUND

Recently, a clinical prediction rule has been proposed to predict the chance of successful endoscopic stenting in benign esophageal anastomotic leakage, perforation and fistula. We aimed to validate this score in a cohort of patients with anastomotic leaks managed with self-expanding metal esophageal stents, by assessing technical and clinical success rates and comparing the agreement between the predicted and the actual clinical success.

METHODS

A multicenter retrospective cohort study including patients submitted to endoscopic stenting due to anastomotic leak was conducted. Variables of the score (leak size, location and C-reactive protein) were collected and the chance of success (≤50, 50-70 and ≥70%) and its accuracy was assessed.

RESULTS

Fifty-three patients, submitted to esophageal stenting after cancer (n = 47) and bariatric surgery were included. Clinical success was achieved in 62% of patients. The area under the ROC curve to differentiate between successful and failed therapies showed a good discriminative power of the score (AUC 0.705; P < 0.01). For a predicted chance of success >50%, the positive predictive value was 72.5%; for a chance of success ≤50%, the negative predictive value was 69.2%.

CONCLUSIONS

The application of this predictive model in patients with anastomotic leaks proved to be valid in a different cohort from that in which it was derived. Its usefulness in clinical practice may be anticipated, favoring stenting in patients with a chance of success >50%. However, we must be cautious in patients with a lower probability of success and a case-by-case decision should be made.

Endoscopic vacuum assisted closure of esophagogastric anastomosis dehiscence: A case report

BACKGROUND

Esophagogastric leakage is one of the most severe postoperative complications. Partial disruption of the anastomosis, can be successfully treated with an endoscopic vacuum assisted closure (E-VAC). The advantage of that method of treatment is the ability to adjust a vacuum dressing individually to the size of the dehiscence and thus to reduce the risk of a secondary fistula or abscess. The authors present two patients with postoperative gastroesophageal leakage treated successfully with E-VAC.

CASE SUMMARY

Two male patients developed a potentially life threatening esophagogastric leakage. Patient A underwent resection of the distal half of the esophagus and upper part of the stomach due to Siewert type II adenocarcinoma of the gastroesophageal junction. Proximal resection of the stomach was performed in the patient B after massive bleeding from Mallory-Weiss tears. Both patients were treated successfully with an individually adapted E-VAC with concomitant correction of fluid and electrolyte disturbances, and treatment of sepsis with appropriate antibiotics.

CONCLUSION

Endoscopic vacuum closure is an effective alternative to endoscopic stenting or relaparotomy. Through individual approach it allows a more accurate assessment of healing.

Massive hemorrhage from an aortoesophageal fistula caused by esophageal stent implantation: A case report and literature review

RATIONALE

Aortoesophageal fistula (AEF) is the direct communication between the aorta and esophagus, which can cause fatal hemorrhage, and its incidence increased with the use of an esophageal stent (ES).

PATIENT CONCERNS

A 79-year-old man was admitted due to hemodynamic shock with massive hematemesis caused by AEF 1 month after the implantation of an ES.

DIAGNOSES

Computed tomography angiography visualized an AEF with an ulcer-like projection on the aortic arch where the ES was placed. Angiography of the aorta revealed extravasation of contrast media from the aortic arch into the stented esophagus, which confirmed the diagnosis.

INTERVENTIONS

Thoracic endovascular aortic repair (TEVAR) was performed for massive hematemesis caused by ES-related, AEF but did not solve the underlying problem, leading to the second fatal hemorrhage.

LESSONS

TEVAR for the unique treatment of ES-related AEF is feasible in certain cases but may lead to collapse after a specific period.

Outcome of Self-Expanding Metal Stents in the Treatment of Anastomotic Leaks After Ivor Lewis Esophagectomy

BACKGROUND

Esophageal anastomotic leakages after Ivor Lewis esophagectomy are severe and life-threatening complications. We analyzed the outcome of using self-expanding metal stents (SEMS) in the treatment of postoperative leakage after esophagogastrostomy.

METHODS

Seventy patients with esophageal anastomotic leakage after Ivor Lewis esophagectomy for esophageal cancer who had received SEMS treatment between January 2006 and December 2015 at our clinic were identified in this retrospective study. The patients were analyzed according to demographic characteristics, risk factors, leakage characteristics, stent characteristics, stent-related complications, sealing success rate and mortality.

RESULTS

Over a 10-year period, 70 patients received SEMS as treatment for postoperative anastomotic leakage after esophagectomy. Technical success of esophageal stenting in anastomotic leakage was achieved in 50 out of 70 cases (71.4%). Sealing success rate was 70% (n = 49) with a median treatment of 28 days (range 7-87). In 20 patients (28.6%), stent-related complications, such as stenosis, dislocation, leakage persistence, perforation or esophagotracheal fistula occurred after the SEMS treatment. Sixty-one patients (87.1%) survived SEMS treatment of esophagogastric anastomotic leakage. Mean follow-up for all patients was 38 months (IQR 10-76), and no significant difference was found in a comparison of the long-term survival rate between patients with successful and unsuccessful SEMS treatment.

CONCLUSIONS

The management of esophageal anastomotic leaks after Ivor Lewis esophagectomy with SEMS is effective, safe and technically feasible. Aggressive non-surgical management should be considered when developing a treatment plan for stenting.

Self-Expanding Metal Stents Versus Endoscopic Vacuum Therapy in Anastomotic Leak Treatment After Oncologic Gastroesophageal Surgery

BACKGROUND

Anastomotic leak after gastroesophageal surgery is a life-threatening complication. Self-expanding metal stent (SEMS) implantation or endoscopic vacuum therapy (EVT) have been established as alternatives to reoperation. This study compares the outcome of both interventions for anastomotic leak clinical management.

METHODS

In this retrospective study, we identified all patients who received SEMS or EVT for anastomotic leaks after oncological gastroesophageal surgery between January 2007 and December 2016. Only patients with type II leaks according to the Esophagectomy Complications Consensus Group were included. Sealing rates, intervention-related complications, demographic characteristics, clinical history, leak characteristics, therapy duration, and in-hospital mortality were analyzed.

RESULTS

One hundred eleven patients who received SEMS (n = 76) or EVT (n = 35) were identified and categorized by primary and final treatment. The overall closure rate in the final treatment analysis was 85.7% for EVT and 72.4% for SEMS (p = 0.152). ICU stay ranged from 0 to 60 days (median 6 days) for EVT and from 0 to 295 days (median 9 days) for SEMS (p = 0.704). EVT patients were hospitalized for 19-119 days (median 39 days) and SEMS patients for 13-296 days (median 37 days; p = 0.812). Demographic factors, comorbidities, and surgical parameters did not correlate with treatment or treatment success.

CONCLUSIONS

SEMS and EVT show comparable results for anastomotic leak management after oncologic gastroesophageal surgery. No superior outcome could be found for either one of the two treatments options.

Laparoscopic extraction of gastric self-expandable metallic stent after migration in ileum: A case report

Revisional surgery in bariatric patients can sometimes lead to life-threatening complications that need a fast diagnosis and treatment as well as a multidisciplinary approach. If left undiagnosed or untreated, this may lead to sepsis, multiple organ failure, and death. In this case report, we describe the management of a gastric perforation which occurred after conversion of a gastric banding to a sleeve gastrectomy.

Esophagojejunal anastomotic leakage following gastrectomy for gastric cancer

Esophagojejunal anastomotic leakage (EJAL) is a serious complication of total or proximal gastrectomy for gastric cancer, with a reported incidence of 2.1-14.6% and mortality of up to 50%. EJAL is an independent prognostic factor for the poor survival of gastric cancer patients. Meticulous surgical techniques, experience with anastomotic devices, and a thorough understanding of various risk factors and preventive measures are essential and early diagnosis is critical for preventing EJAL-related death. Patients with suspected EJAL must be evaluated promptly, but contrast swallow is not recommended. There is no standard treatment strategy for EJAL, although conservative treatment with drainage and nutritional support is the most common approach. Effective endoscopic treatments have been reported but need further validation. Surgical treatment is associated with high mortality but should be considered to prevent death from suboptimal EJAL management, for patients with severe sepsis or when conservative treatment has failed.

Regulating migration of esophageal stents - management using a Sengstaken-Blakemore tube: A case report and review of literature

Stent migration, which causes issues in stent therapy for esophageal perforations, can counteract the therapeutic effects and lead to complications. Therefore, techniques to regulate stent migration are important and lead to effective stent therapy. Here, in these cases, we placed a removable fully covered self-expandable metallic stent (FSEMS) in a 52-year-old man with suture failure after surgery to treat Boerhaave syndrome, and in a 53-year-old man with a perforation in the lower esophagus due to acute esophageal necrosis. At the same time, we nasally inserted a Sengstaken-Blakemore tube (SBT), passing it through the stent lumen. By inflating a gastric balloon, the lower end of the stent was supported. When the stent migration was confirmed, the gastric balloon was lifted slightly toward the oral side to correct the stent migration. In this manner, the therapy was completed for these two patients. Using a FSEMS and SBT is a therapeutic method for correcting stent migration and regulating the complete migration of the stent into the stomach without the patient undergoing endoscopic rearrangement of the stent. It was effective for positioning a stent crossing the esophagogastric junction.

Double Pigtail Stent Insertion for Healing of Leaks Following Roux-en-Y Gastric Bypass. Our Experience (with Videos)

BACKGROUND

Roux-en-Y gastric bypass (RYGB) is complicated by a leak in 0-4.3% of cases. Treatment by fully covered stents has been reported to be associated with some life-threatening complications. We report our experience of insertion of double pigtail stents.

METHODS

Thirty-three patients (20M, 43 years-20/65), presenting with a leak at an average of 10 days after RYGB (4-35), were treated by double pigtail stent insertion and a nasojejunal feeding tube. Sixty percent of these patients had undergone surgical drainage prior to stenting for control of sepsis. Thirty leaks were located at the top of staple line and three at the gastro-jejunal anastomosis. At a 4-weekly follow-up, ablation or re-stenting was performed depending on status of fistula closure and patients were placed on normal diet.

RESULTS

At the first follow-up, 10/33 fistulae healed, one patient presented with clinical failure (3%) and needed surgery, and 22/33were re-stented. Twenty-one out of these 22 developed a secondary sub-clinical gastro-gastric fistula and one, instead, developed complex (gastro-gastric, gastro-colic) fistula. All (22) primary fistulae healed following four more weeks of treatment. Average treatment duration was of 61 days (28-99). Thirty-two patients (97%) at a follow-up of 1-33 months are asymptomatic.

CONCLUSIONS

Leaks following RYGB can be successfully and safely managed by double pigtail stents. Upper gastric staple line leaks are responsible for the formation of a secondary sub-clinic gastro-gastric fistula which needs no additional treatment.

Full covered self-expandable metal stents for the treatment of anastomotic leak using a silk thread

To evaluate the safety and effectiveness of fixation of the fully covered self-expandable metal stent (SEMS) placement using a silk thread for complete closure of an anastomotic leak. An anastomotic leak is a life-threatening complication after gastrectomy. Although the traditional treatment of choice was surgical re-intervention, an endoscopic SEMS can be used alternatively.During the study period, we retrospectively reviewed consecutive patients who received a modified covered SEMS capable of being fixed using a silk thread (Shim technique) due to an anastomotic leak after gastrectomy to prevent stent migration. Demographic data, stent placement and removal, clinical success, time to resolution, and complications were evaluated.A total of 7 patients underwent fully covered SEMS with a silk thread placement for an anastomotic leak after gastrectomy to treat gastric cancer. The patients' mean age was 71.3 ± 8.0 years. Man sex was predominant (85.7%). All patients' American Society of Anesthesiologists (ASA) scores were between I and III. Total gastrectomy was performed in 5 patients (71.4%) and proximal gastrectomy was performed in 2 patients (28.6%). The time between gastrectomy and stent insertion was 22.3 ± 11.1 days. The size of the leaks was 27.1 ± 11.1 mm. Technical success and complete leak closure were achieved in all patients. Stent migration was absent. All stents were removed between 4 and 6 weeks. Delayed esophageal stricture was found in 1 patient (14.2) and successfully resolved after endoscopic balloon dilation.For an anastomotic leak after gastrectomy, fully covered SEMS placement with a silk thread is an effective and safe treatment option without stent migration. The stent extraction time between 4 and 6 weeks was optimal without severe complications.

Evolution of endoscopic treatment of sleeve gastrectomy leaks: from partially covered to long, fully covered stents

BACKGROUND

Laparoscopic sleeve gastrectomy (SG) has become a widely accepted option in the treatment of morbid obesity. Gastric leaks after SG occur in .9%-2.2% of the patients, mostly at the gastroesophageal junction. The current treatment algorithm includes drainage, antibiotics, nutritional support, and endoluminal control.

OBJECTIVES

Our hypothesis is that long, fully covered stents represent a safe, effective solution for SG leaks.

SETTING

University hospital.

METHODS

A retrospective analysis of our prospectively collected bariatric database was performed between June 2014 and May 2016. We included all patients treated for leaks after SG. Endoscopic treatment included partially covered metallic stent (Wallstent, Boston Scientific, Galway, Ireland), fully covered stent (Mega stent, Taewoong Medical Industries, Gyeonggi-do, South Korea), over-the-scope clip (Ovesco Endoscopy, Tubingen, Germany), and internal pigtail drainage.

RESULTS

A total of 872 SGs were performed. Overall, 10 of 872 patients (1.1%) developed a gastric leak. One patient was an outside referral. The 11 patients underwent endoscopic treatment accompanied by either percutaneous or laparoscopic abscess drainage. Endoscopic fistula closure at the gastroesophageal junction was achieved in 10 of 11 cases and the average time for closure was 9.9 (range: 4-24) weeks. One patient developed a second leak in the antrum, treated by subtotal gastrectomy. Overall, treatment with Wallstent failed in 3 of 5 patients, and these patients were eventually successfully treated with a Mega stent. The initial use of long, fully covered stents was successful in 5 of 6 cases.

CONCLUSION

Long, fully covered stents appear to be a good alternative to traditional stents either as primary treatment or after failure of other endoscopic treatments.