Endoscopic stents in the management of anastomotic complications after foregut surgery: new applications and techniques

Treatment mode and prognosis of esophageal perforation after radiotherapy in patients with esophageal carcinoma

Objective

Retrospectively analyzed the esophageal carcinoma (EC) patients with esophageal perforation (EP) after radiotherapy to discuss the treatment and prognosis.

Methods

Data of patients with EC who had EP after radiotherapy in Hebei Cancer Hospital were collected from 2001 to 2020 and retrospectively analyzed. All analyses were performed using SPSS Statistics for Windows, version 18. 0 (SPSS Inc., Chicago, Ill., USA). P values less than 0.05 were considered statistically significant.

Results

A total of 94 patients with EC were enrolled, among which 72 were males and 22 were females, with a median age of 62 (38-82) years. The tumor was located in the upper thoracic in 45 patients, middle thoracic in 45 patients, and lower thoracic in 4 patients. There were 30 cases of tracheoesophageal fistula (TEF) and 64 cases of esophagomediastinal fistula (EMF). All patients died within 11 months (median: two months) after EP. After EP, 48 patients were treated by tube feeding (include nasal feeding and gastrostomy), 26 patients by esophageal stenting, and 20 patients by fluid infusion therapy, and their one, three, and six months survival rates after EP were 81.3%, 31.3%, and 12.5% (P = 0.000). In the TEF group, the one, three, and six month survival rates after EP of tube feeding, esophageal stenting and fluid infusion groups were 88.2%, 17.6%, 11.8%; 45.5%, 27.3%, 0%; and 50.0%, 50.0%, 0% (P = 0.345). In the EMF group, the one, three, and six months survival rates after EP of this three groups were 77.4%, 38.7%, 12.9%; 26.7%, 20.0%, 6.7%; and 22.2%, 11.1%, 0% (P=0.002), respectively.

Conclusion

Most patients with EP after radiotherapy died within six months, with low survival and poor prognosis. Tube feeding therapy can achieve relatively good survival, especially for patients with EMF. The survival of patients treated by tube feeding therapy is significantly better than the survival of those treated by other methods.

Superselective arterial microcoil embolization for delayed bleeding after peroral endoscopic myotomy

Peroral endoscopic myotomy (POEM) has been shown to be an effective treatment for achalasia and with few adverse events. Only a few cases of delayed bleeding have been described. This current case report describes a patient with delayed bleeding in the submucosal tunnel on the eighth day after POEM. The patient was a 21-year-old woman with a 4-month history of dysphagia, vomiting and excessive weight loss. Achalasia was diagnosed according to her symptoms, barium oesophagogram, oesophageal manometry and endoscopy examination. POEM was performed by an experienced operator. On the eighth day after POEM, the patient suddenly developed continuous haematemesis presented with vomiting of fresh blood and melena. An emergency exploratory esophagogastroduodenoscopy was performed. A large number of blood clots were found at the wound and a long haematoma was found along the lining of the submucosal tunnel. Re-entry into the submucosal tunnel and exposure of the haemorrhagic site was attempted but failed because of severe submucosal tissue adhesion. An emergency angiography was undertaken and haemostasis was achieved with superselective arterial microcoil embolization.

Personalized Health Care Technology in Managing Postoperative Gastrointestinal Surgery Complications: Proof of Concept Study

Background: Advances in three-dimensional (3D) printing technology have allowed the development of customized medical devices. Endoscopic internal drainage (EID) is a novel method to facilitate drainage of an abscess cavity into the lumen of the gastrointestinal tract by placing a double pigtail biliary stent through the fistula opening, originally designed for biliary drainage. They are available in manufacture-determined sizes and shapes. The aim of this study is to explore the feasibility of 3D printing personalized internal drainage stents for the treatment of leaks following gastrointestinal surgery over a sequential period. Methods: We retrospectively identified patients who underwent gastrointestinal anastomotic surgery complicated by postoperative leaks and underwent serial EID for treatment. Computerized Tomography scans were reviewed over a period of time, abscess cavity dimensions and characterizations were evaluated, and 3D reconstructions were obtained. The stents were designed, their shape and size were customized to the unique dimensions of the abscess and lumen of the patient. Stereolithography (SLA) 3D printing technique was used to produce the stents. Results: A total of 8 stents were produced, representing 3 patients. These stents corresponded to 2 or 3 stents per patients. Each patient underwent several endoscopic treatments, before resolution of leak. Conclusions: Customized stents may improve drainage of intra-abdominal abscesses after gastrointestinal surgery, if based on unique anatomy. This proof-of-concept study is a real-world application of personalized health care, which introduces the novel description of customizable 3D printed stents to manage complications following gastrointestinal surgery and may advance therapy for this complex clinical condition. Research Ethics Committees (REC) number is A-2021-012.

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.

Fallback technique with circular stapler prevents anastomotic obstruction after esophagectomy: A case report of surgical approach

RATIONALE

While performing esophago-ileal anastomosis after esophagectomy with circular staplers, the mucosal folds of the ileum can complicate stapling and lead to obstruction, especially when the diameter of the circular stapler is equal or greater than that of the small bowel lumen.

PATIENT CONCERNS

A 53-year-old man, presented with complaints of difficulty in swallowing for 2 weeks. Fifteen years previously, he had undergone partial gastrectomy for gastric ulcers.

DIAGNOSIS

The endoscopy showed that there was a large ulcer in the middle-third of the esophagus, about 28 to 32 cm from the incisors. Biopsy of the ulcer confirmed esophageal squamous cell carcinoma.

INTERVENTIONS

We performed an esophageal replacement using the right colon with circular staplers, but anastomotic site occurred due to stacking of the mucosa ahead of the stapler. To revise the anastomosis, we inserted the stapler 2 to 3 cm farther into the lumen than the intended site of anastomosis, and then pulled it back and rotated the stapler to complete the anastomosis. Consequently, the obstruction was corrected.

OUTCOMES

With nearly 16 months' follow-up duration until now, the patient has no difficulty swallowing and has twice received chemotherapy, and returned to his normal life relatively.

LESSONS

In the event of potential anastomotic obstruction due to accumulated mucosa, the stapler fallback technique can be successfully used achieve patent anastomosis.

Self-expandable metal stents in patients with postoperative delayed gastric emptying after distal gastrectomy

AIM

To investigate the efficacy and safety of endoscopic stent insertion in patients with delayed gastric emptying after gastrectomy.

METHODS

In this study, we prospectively collected data from patients who underwent stent placement for delayed gastric emptying (DGE) after distal gastrectomy between June 2010 and April 2017, at a tertiary referral academic center. Clinical improvement, complications, and consequences after stent insertion were analyzed.

RESULTS

Technical success was achieved in all patients (100%). Early symptom improvement was observed in 15 of 20 patients (75%) and clinical success was achieved in all patients. Mean follow-up period was 1178.3 ± 844.1 d and median stent maintenance period was 51 d (range 6-2114 d). During the follow-up period, inserted stents were passed spontaneously per rectum without any complications in 14 of 20 patients (70%). Symptom improvement was maintained after stent placement without the requirement of any additional intervention in 19 of 20 patients (95%).

CONCLUSION

Endoscopic stent placement provides prompt relief of obstructive symptoms. Thus, it can be considered an effective and safe salvage technique for post-operative DGE.

Indications and benefits of intraoperative esophagogastroduodenoscopy

Introduction

Intraoperative esophagogastroduodenoscopy (IOG) is a diagnostic and therapeutic method for a variety of special conditions in upper gastrointestinal (UGI) pathology. The indication remains individual due to insufficient evidence and limited training of surgeons in digestive endoscopy.

Aim

To evaluate the indications, benefits and risks of IOG.

Material and methods

A single-center retrospective study of 110 consecutive IOGs in 104 patients was performed. The preoperative plan, the timing of IOG, preoperative evaluation, intraoperative finding, localization of the pathology, type of the procedure, change of expected therapy and complications were assessed.

Results

The cohort comprised 29 esophageal tumors, 5 tumors of the cardia, 36 gastric tumors, gastrointestinal bleeding (8), esophageal diverticula (3), perforations (3), GERD (5), mediastinal pathology (3), fistula (4), assessment of nutrition (10), duodenal adenoma (2), ulcer disease, esophageal stenosis and gastric volvulus. The indication for IOG was established preoperatively in 79% and intraoperatively in 21%. The lesion was localized in 96.4%. The therapy was altered to a wider resection (11), smaller resection (5), localization and surgical therapy of bleeding (8) or allowed minimally invasive surgery (25). A total of 3 postoperative complications included gastric perforation and positivity of resection line (following EMR/ESD) and recurrent bleeding. The 30-day mortality reached 3.6% without a specific cause in IOG.

Conclusions

The IOG is a complementary method in the diagnosis and treatment of UGI pathology. It enables minimally invasive finalization of the procedures and individualization of the therapy.

Covered Esophageal Stenting Is Effective for Symptomatic Gastric Lumen Narrowing and Related Complications Following Laparoscopic Sleeve Gastrectomy

BACKGROUND AND STUDY AIMS

Laparoscopic sleeve gastrectomy (LSG) is gaining popularity in treating morbid obesity. Prior studies showed a 3.5% risk of gastric sleeve stenosis (GSS). There is no consensus on how to treat these patients, and the role of endoscopic therapy has been addressed in only a few studies. We aim to assess the efficacy and safety of endoscopic stenting in the management of GSS following LSG.

PATIENTS AND METHODS

Retrospective data were reviewed from July 2009 to November 2013. Patients were referred for endoscopic therapy for symptoms or imaging findings suggestive of gastric leak or narrowing following LSG. Endoscopic therapy included the use of fully covered self-expanding esophageal metal stents (FCSEMS) in addition to over-the-scope clip system (OTSC) when necessary.

RESULTS

All 27 patients were females with mean age of 40 years; six patients were excluded from the study. Major symptom was nausea and vomiting in 57% of the patients. Five of 21 patients had concomitant leaks. All 21 patients underwent FCSEMS placement, and four out of five patients (80%) with concomitant leak had OTSC. The success rate in both groups for resolution of stricture and leak was 100%, and no surgical intervention was required. There were no immediate or delayed complications of endoscopic therapy. Median follow-up of 6 months was available for 20/21 patients. Among patients with gastric leak, 80% had resolution of their symptoms compared with 93% of patients with GSS.

CONCLUSIONS

Endoscopic therapy for LSG-related GSS or leaks with FCSEMS is highly effective and safe.

Endoscopic management of post-bariatric surgery complications

Understanding the technical constructs of bariatric surgery is important to the treating endoscopist to maximize effective endoluminal therapy. Post-operative complication rates vary widely based on the complication of interest, and have been reported to be as high as 68% following adjustable gastric banding. Similarly, there is a wide range of presenting symptoms for post-operative bariatric complications, including abdominal pain, nausea and vomiting, dysphagia, gastrointestinal hemorrhage, and weight regain, all of which may provoke an endoscopic assessment. Bleeding and anastomotic leak are considered to be early (< 30 d) complications, whereas strictures, marginal ulcers, band erosions, and weight loss failure or weight recidivism are typically considered late (> 30 d) complications. Treatment of complications in the immediate post-operative period may require unique considerations. Endoluminal therapies serve as adjuncts to surgical and radiographic procedures. This review aims to summarize the spectrum and efficacy of endoscopic management of post-operative bariatric complications.