Self-expanding plastic stent for esophageal leaks and fistulae

Endoscopic management of gastrointestinal leaks and fistulae: What option do we have?

Gastrointestinal leaks and fistulae are serious, potentially life threatening conditions that may occur with a wide variety of clinical presentations. Leaks are mostly related to post-operative anastomotic defects and are responsible for an important share of surgical morbidity and mortality. Chronic leaks and long standing post-operative collections may evolve in a fistula between two epithelialized structures. Endoscopy has earned a pivotal role in the management of gastrointestinal defects both as first line and as rescue treatment. Endotherapy is a minimally invasive, effective approach with lower morbidity and mortality compared to revisional surgery. Clips and luminal stents are the pioneer of gastrointestinal (GI) defect endotherapy, whereas innovative endoscopic closure devices and techniques, such as endoscopic internal drainage, suturing system and vacuum therapy, has broadened the indications of endoscopy for the management of GI wall defect. Although several endoscopic options are currently used, a standardized evidence-based algorithm for management of GI defect is not available. Successful management of gastrointestinal leaks and fistulae requires a tailored and multidisciplinary approach based on clinical presentation, defect features (size, location and onset time), local expertise and the availability of devices. In this review, we analyze different endoscopic approaches, which we selected on the basis of the available literature and our own experience. Then, we evaluate the overall efficacy and procedural-specific strengths and weaknesses of each approach.

Changing epidemiology of esophageal stent placement for dysphagia: a decade of trends and the impact of benign indications

BACKGROUND AND AIMS

In addition to managing malignant obstruction, esophageal stents (ESs) have evolved to address various benign etiologies of dysphagia. We sought to evaluate national trends and changes in practice of ES placement for both benign and malignant etiologies in hospitalized patients with dysphagia.

METHODS

The National Inpatient Sample (2003-2013) was used to include all adult inpatients (≥18 years of age) with endoscopy-guided ES placement for a symptom of dysphagia. Multivariable analyses for indications that impact temporal trends (3 time periods: 2003-2005, 2006-2009, and 2010-2013) and for hospital outcomes were performed.

RESULTS

A total of 7198 ESs were deployed endoscopically in hospitalized patients with dysphagia. Compared with malignant etiologies, there was a significant increase in ES placement for benign conditions (2013 vs 2003: 32.7% vs 14.5%, respectively; P < .001). Multivariable analysis using 2003 to 2005 as a reference showed that patients with benign etiologies for dysphagia predominantly contributed to the increase of ES placement during the most recent time period (2010-2013: odds ratio, 2.09; 95% confidence interval, 1.40-3.13). Multivariable analysis of hospital outcomes revealed no differences in inpatient mortality, duration of hospital stay, and hospital costs between malignant and benign indications.

CONCLUSIONS

In the preceding decade, ES placement for hospitalized patients with dysphagia has increased, driven largely by an over 8-fold rise in stent placement for benign indications. These findings warrant continued efforts to improve stent technology to decrease the risk of migration and review practice guidelines involving ES placement for benign etiologies.