Treatment of esophageal perforations and anastomotic leaks: the endoscopist is stepping into the arena

Digestive neo-epithelialization after endoscopic stenting for upper digestive tract complete disunion

BACKGROUND

Complete digestive disunion due to anastomotic necrosis is considered a contraindication to endoscopic repair. However, recent publications have suggested that endoscopic treatment by insertion of a self-expandable metal stent (SEMS) is possible. The report of this patient series aims to demonstrate the use of endoscopic management in selected cases with complete digestive disunion.

METHODS

Seven consecutive patients with complete and circumferential upper gastrointestinal anastomotic disunion were treated at two European tertiary care centers between 2009 and 2021 by endoscopic insertion of an SEMS. Treatment was performed with a therapeutic gastroscope under general anesthesia, carbon dioxide insufflation, and fluoroscopic guidance, after surgical or percutaneous drainage.

RESULTS

All patients were successfully treated by endoscopic insertion of fully or partially covered SEMS left in place for a median of 8 weeks, with a median of 3 endoscopic sessions. Digestive neo-epithelialization was associated with a restored circumferential gut lumen in all cases. The rate of stent migration was 23% and three patients (43%) experienced symptomatic strictures, which were successfully treated by endoscopic dilation.

CONCLUSION

Complete digestive rupture could be successfully treated by endoscopy in selected cases, adding proof-of-concept data regarding guided tissue regeneration alongside SEMS placement.

Stem-cell therapy via gastroscopy improves the outcome of esophageal anastomotic leakage

Background

Esophageal anastomotic leakage (EAL) is a severe complication usually occurring after esophagectomy. Although there are various therapeutic methods for EAL treatment, they have not achieved satisfactory results. A previous study showed that the combination of mesenchymal stem cells (MSCs) and fibrin scaffold (FS) can treat EAL. This study aimed to evaluate the efficacy of the injection of MSCs and FS through a new engraftment gastroscope for EAL treatment.

Methods

Twelve adult pigs were randomly divided into the MSCs group (n = 6) and control group (n = 6). A stomach tube was then inserted through the leakage to construct the EAL model, which was removed after one week. The combination of MSCs and FS was autografted at the EAL site for pigs in the MSCs group using the tailor-made gastroscope while only FS was autografted for the pigs in the control group. Local status of EAL was evaluated using gastroscopy. Histological analyses and western blot (WB) were used to assess the gross specimens of esophagi around EALs.

Results

Gastroscopy showed a higher closure rate and a lower infection rate in the MSCs group than in the control group. However, the mortality was not significantly different between the two groups. HE staining showed a severe inflammatory response with dispersive infiltration of inflammatory cells and unhealed leakage in the control group. However, the infiltration of inflammatory cells was not altered in the MSCs group, and the leakage was completely healed. WB analyses showed that Myogenin and α-SMA expressions were significantly higher in the MSCs group than in the control group.

Conclusion

A porcine model of EAL was successfully developed by accessing the transplantation site through the esophagus. Further data revealed that the implantation of MSCs in FS via the novel engraftment gastroscope can promote the repair and occlusion of EAL. Therefore, the proposed method is a promising strategy for EAL treatment.

Fully covered self-expanding metallic stent placement or three-tube method for esophagomediastinal fistula: A STROBE-compliant article

To determine the safety, feasibility and clinical outcomes of interventional methods for the management of esophagomediastinal fistula, and to investigate the effect of stent placement on fistula healing and the swallowing. Sixty consecutive patients with esophagomediastinal fistula were treated using interventional method and were retrospectively assessed. Patients received 3-tube but without covered stent placement were placed in group A, the remaining patients received covered stent placement with/without 3-tube method were placed in group B. Tubes and stents would be removed once fistula heals. Interventional procedures were technically successful all patients (100%). Esophageal stents and abscess drainage tubes were successfully removed from 14 patients. Three patients underwent stent removal during the perioperative period, resulting in a clinical success rate of 88.5% of 26 patients in group B. A total of 13 complications were found in all patients, including 5 major complications. Patients in group B showed a higher healing rate of abscess cavity and better dysphagia score than group A. During follow up, 17 patients in group A and 11 patients in group B were still alive. Interventional treatment is safe, feasible and efficacious for esophagomediastinal fistula; covered stent placement can promote fistula healing and improve swallowing.

Three-tube method and covered metallic stent for the treatment of anastomotic leakage after esophagectomy

BACKGROUND

Anastomotic leakage is common and life-threatening complication after esophagectomy. The management of esophageal anastomotic leakage remains challenging. We aimed to determine the safety, feasibility and efficacy of three-tube method and covered metallic stent placement for the management of anastomotic leakage.

METHODS

Twenty-six consecutive patients with anastomotic leakage were treated using three-tube method and covered metallic stent and the medical records were retrospectively assessed. All patients received placement of abscess drainage tube, jejunal feeding tube and gastrointestinal decompression tube as well as esophageal covered stent, followed by continue abscess drainage, nutritional support and anti-inflammatory treatment. Tubes and esophageal stents will be removed once anastomotic leakage heals.

RESULTS

The procedure was technically successful in 23 patients (95.8%). A total of 31 covered stents were used. Esophageal stents and abscess drainage tubes were successfully removed from 14 patients. The median retention duration was 2.3 months and 2.6 months for stent and abscess drainage tubes, respectively. No perioperative death, esophageal rupture, massive hemorrhage, or other severe complications were observed during procedures. The abscess cavity had markedly decreased in 8 patients or disappeared in 16 cases. During follow-up, 8 patients died of cancer recurrence and 2 patients died of severe pulmonary infection. The 1-, 3-, 5-year survival rates were 60.1, 51.5 and 51.5%, respectively.

CONCLUSION

Three-tube method and covered metallic stent placement is safe, feasible and efficacious for treatment of anastomotic leakage after esophagectomy.

Covered metallic stent for the treatment of malignant esophageal fistula combined with stricture

Background

Esophageal fistula and stricture is rare but life-threatening complication for esophageal cancer. The management of esophageal fistula and stricture remains challenging. We aimed to determine the safety, feasibility and efficacy of covered metallic stent and three tubes placement for the management of esophageal fistula and stricture.

Methods

Between May 2012 and March 2018, all patients with esophageal fistula and stricture were treated using three tubes or covered metallic stent placement. Patients in group A received covered stents and three tubes placement. Patients in group B only received three tubes placement. Continue abscess drainage and nutritional support was performed after procedure. Three tubes or esophageal stents were removed once esophageal fistula heals. The related medical records were retrospectively assessed.

Results

Thirty-seven consecutive patients with esophageal fistula and stricture were enrolled, including 26 patients in group A and 11 patients in group B. Stent placement procedure was technically successful in 25 patients (96.2%). A total of 42 covered stents were inserted. Seventeen esophageal stents were successfully removed from 10 patients. The median retention duration was 3.3 months and 3.4 months for stent and abscess drainage tubes, respectively. One perioperative death due to massive hemorrhage was observed 21 days after stent placement. The abscess cavity was decreased or disappeared in 17 cases and 4 cases in group A and group B, respectively. During follow up, patients in group A still showed a significant better condition of normal diet than that in group B (p < 0.05). Fourteen patients died of cancer recurrence, 3 patients died of massive digestive bleeding and 2 patients died of severe pulmonary infection. The median survivals were 14.8 months and 13.2 months for group A and group B, respectively.

Conclusions

Covered metallic stent placement is safe, feasible and efficacious for treatment of esophageal fistula and stricture, with a better condition of normal diet than patients only received three tubes placement.

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.

Interventional radiology protocol for treatment of esophagogastric anastomotic leakage

PURPOSE

We aimed to determine the safety, feasibility and efficacy of interventional radiology method for the management of esophagogastric anastomotic leakage.

METHODS

We retrospectively assessed the medical records of 23 consecutive patients with esophagogastric anastomotic leakage treated using intervention protocol. Patients received three-tube method (abscess drainage tube, gastrointestinal decompression tube and jejunal feeding tube) with or without temporary covered esophageal stent placement. Abscess drainage, anti-inflammatory treatment and nutritional support were performed thereafter. The esophageal stents and three tubes were removed after leakage healing.

RESULTS

All patient received three-tube method and eight patients received covered stent placement. All operations were technically successful. After a median of 2.4 months, the stents were successfully removed from five patients. No death, esophageal rupture or massive hemorrhage occurred during procedures. The abscess cavity had markedly decreased in seven patients or disappeared in 16 cases. During follow-up, four patients died of cancer recurrence, one died of heart dysfunction and one died of pulmonary infection. The 1-, 3-, 5-year survival rates were 86.4%, 52.3% and 52.3%, respectively.

CONCLUSION

Interventional radiology protocol is safe, feasible and efficacious for treatment for esophagogastric anastomotic leakage.

Diagnosis, assessment, and management of surgical complications following esophagectomy

Despite improvements in operative strategies for esophageal resection, anastomotic leaks, fistula, postoperative pulmonary complications, and chylothorax can occur. Our review seeks to identify potential risk factors, modalities for early diagnosis, and novel interventions that may ameliorate the potential adverse effects of these surgical complications following esophagectomy.

Treatment of Postoperative Leaks of the Upper Gastrointestinal Tract with Colonic Self-Expandable Metal Stents

Introduction

The use of self-expandable metal stents (SEMS) for the treatment of postoperative leaks of the upper gastrointestinal tract is already established. However, there are discrepancies between the relatively small caliber of the esophageal stents available and the postsurgical luminal size, which may determine an inadequate juxtaposition. As colonic stents have a bigger diameter, they might be more adequate. Additionally, stents with a larger diameter might have a lower risk of migration.

Materials and Methods

The aim of this study was to evaluate the efficacy and complications associated with the use of colonic fully covered SEMS (FSEMS) in the treatment of postoperative leaks in critical patients. All patients with postoperative leaks of the upper gastrointestinal tract treated with colonic stents (Hanarostent® CCI) between 2010 and 2013 were retrospectively included.

Results

Four patients with postoperative leaks were treated with colonic SEMS. The underlying surgeries were a gastric bypass, an esophagogastrectomy for Boerhaave syndrome, a primary repair of esophagopleural fistula due to Boerhaave syndrome, and an esophagectomy due to esophageal cancer. The leaks were detected on average 17 days after the initial surgery. All patients needed admission to a critical care unit after index surgery. Stent placement was technically feasible in all patients. The median residence time of the stents was 7 weeks, and no complications were verified when they were removed. There were no cases of stent migration. The treatment was successful in all patients, with complete healing of the leaks.

Discussion and Conclusions

The placement of colonic FSEMS seems to be successful and safe in the treatment of postoperative leaks of the upper gastrointestinal tract.

Stage-directed individualized therapy in esophageal cancer

Esophageal cancer is the eighth most common cancer worldwide, and the incidence of esophageal carcinoma is rapidly increasing. With the advent of new staging and treatment techniques, esophageal cancer can now be managed through various strategies. A good understanding of the advances and limitations of new staging techniques and how these can guide in individualizing treatment is important to improve outcomes for esophageal cancer patients. This paper outlines the recent progress in staging and treatment of esophageal cancer, with particularly attention to endoscopic techniques for early-stage esophageal cancer, multimodality treatment for locally advanced esophageal cancer, assessment of response to neoadjuvant treatment, and the role of cervical lymph node dissection. Furthermore, advances in robot-assisted surgical techniques and postoperative recovery protocols that may further improve outcomes after esophagectomy are discussed.

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

BACKGROUND

Anastomotic complications after foregut surgery include leaks, fistulas, and late strictures. The management of these complications can be challenging, and it may be desirable to avoid complex reoperation.

OBJECTIVES

We aim to describe the indications and outcomes of the use of esophageal self-expanding metal stents in the management of postoperative anastomotic complications after foregut surgery.

SETTING

Tertiary-referral academic medical center.

METHODS

We performed a retrospective review of a prospectively managed database. Data was collected on patient demographic characteristics, work-up, intraprocedure findings, and outcomes.

RESULTS

From October of 2009 to November of 2014, 47 patients (mean age 51.1, 36 women and 11 men) underwent endoscopic stent placement for anastomotic complications following upper gastrointestinal (UGI) surgery. The median time from index operation to endoscopic stent placement was 52 days (range 1-5280 days). Indications were sleeve leak or stenosis, gastrojejunal leak or stenosis after Roux-en-Y gastric bypass (RYGB), pouch staple-line leak after RYGB, enterocutaneous fistula, perforation after endoscopic dilation, upper gastrointestinal bleeding after peroral endoscopic myotomy (POEM), and peptic stricture after POEM. Symptomatic improvement occurred in 76.6% of patients, and early oral intake was initiated in 66% of patients. 14 patients (29.8%) went on to require definitive surgical intervention for persistent symptomatology. The average follow-up was 354.1 days (range 25-1912 days).

CONCLUSION

This paper describes the use of endoscopic stent therapy for a variety of pathologies after upper gastrointestinal surgery. We demonstrate that, in the appropriate setting, it is an effective and less-invasive therapeutic approach.

Treatment of anastomotic leaks with metallic stent after esophagectomies

The diagnosis and the treatment of anastomotic leak after esophagectomy are the keys to reduce the morbidity and mortality after this surgery. The stent plays an important role in the treatment of the leakage and in the prevention of reoperation. We have analyzed the database of the section of the esophagogastric surgery of Donostia University Hospital from June 2003 to May 2012. It is a retrospective study of 113 patients with esophagectomy resulting from tumor, and 24 (21.13%) of these patients developed anastomotic leak. Of these 24 patients, 13 (54.16%) have been treated with a metallic stent and 11 (45.84%) without a stent. The average age of the patients was 55.69 and 62.45 years, respectively. All patients treated with and without a stent have been males. Eight (61.5%) stents were placed in the neck and five (38.5%) in the chest. However, among the 11 fistulas treated without a stent, 9 patients had cervical anastomosis (81.81%) and 2 patients (18.18%) had anastomosis in the chest. Twelve patients (92.30%) with a stent preserve digestive continuity, and 10 patients (90.90%) were treated without a stent. One patient died in the stent group and one in the nonstent group. The treatment with metallic stent of the anastomotic leak after esophagectomy is an option that can prevent reoperation in these patients, but it does not decrease the average of the hospital stay. The stent may be more useful in thoracic anastomotic leaks.

Self-expandable metal stent placement for closure of a leak after total gastrectomy for gastric cancer: report on three cases and review of the literature

In the setting of the curative oncological surgery, the gastric surgery is exposed to complicated upper gastrointestinal leaks, and consequently the management of this problem has become more critically focused than was previously possible. We report here three cases of placement of a partially silicone-coated SEMS (Evolution Controlled Release Esophageal Stent System, Cook Medical, Winston-Salem, NC, USA) in patients who underwent total gastrectomy with Roux-en-Y end-to-side esophagojejunostomy for a gastric adenocarcinoma. The promising results of our report, despite the small number of patients, suggest that early stenting (through a partially silicone-coated SEMS) is a feasible alternative to surgical treatment in this subset of patients. In fact, in the treatment of leakage after total gastrectomy, plastic stents and totally covered metallic stents may not adhere sufficiently to the esophagojejunal walls and, as a result, migrate beyond the anastomosis. However, prospective studies with a larger number of patients might assess the real effectiveness and safety of this procedure.

Endoscopic treatment of iatrogenic gastrointestinal perforations: an overview

In the past, the treatment of iatrogenic gastrointestinal perforations was limited to surgical management or to medical observation. Natural Orifice Transluminal Endoscopic Surgery (NOTES) has paved the way towards the development of reliable endoscopic closure techniques, which can be applicable in accidental perforations of the gastrointestinal tract. When endoscopic treatment is feasible, hemoclips are preferred in smaller perforations, while over-the-scope-clips or a combination of hemoclips, endoloops, and glue are used in larger ones. Endoscopic stitching is rarely utilized, and endoscopic stapling has been practically abandoned. The use of self-expandable covered stents can be considered in the esophagus and duodenum. Broad spectrum antibiotics are recommended in most cases. Clinical follow-up in a medico-surgical unit is mandatory and surgical intervention should not be delayed more than 24h if clinical or biological worsening occurs. Imaging with oral contrast medium is advisable before resumption of oral feeding in the case of large perforations.

Stents for benign and malignant esophageal strictures

This paper presents commentaries on endotherapy for esophageal perforation/leaks; treatment of esophageal perforation; whether esophageal stents should be used for treating benign esophageal strictures; what determines the optimal stenting period in benign esophageal strictures/leaks; how to choose an esophageal stent; how a new fistula secondary to an esophageal stent should be treated; which strategy should be adopted when a fistula of a cervical anastomosis occurs; intralesional steroids for refractory esophageal strictures; balloon and bougie dilators for esophageal strictures and predictors of response to dilation; whether refractory strictures from different etiologies respond differently to endotherapy; surgical therapy of benign esophageal strictures; and whether stenoses following severe esophageal burns should be treated by esophageal resection or esophageal bypass.

Endoscopic management of complications in digestive surgery

Endoscopy has an ever-increasing role in the treatment of complications in digestive surgery. Endoscopic treatment is essentially used for (i) fistula or intra-abdominal collection secondary to anastomotic dehiscence and (ii) anastomotic stricture, especially esophagogastric, but also sometimes after colorectal surgery. First intention treatment of fistula following esophagogastric surgery is the insertion of an extractable self-expandable metallic stent (partially or entirely covered); this is supported by a low level of scientific evidence, but clinical experience has been satisfactory. Other techniques for treatment of anastomotic leak have also been reported anecdotally (clip placement, sealing with glue). There are few data available in the literature on endoscopic management (stents essentially) of postoperative colonic fistula. Whatever the approach chosen to treat a postoperative digestive tract fistula, management is medico-surgical and cannot be limited to simple closure of the digestive tube wall defect. Drainage of any collections by endoscopic, radiologic or surgical approach, systemic treatment of infection and nutritional support are essential adjuvant treatment modalities. Treatment of postoperative esophageal or colonic strictures is essentially endoscopic and is based on initial dilatation (endoscopic with hydrostatic balloon or bougie), and placement of extractable metallic stents (partially or entirely covered) in case of refractory outcome.

Endoscopic placement of fully covered self expanding metal stents for management of post-operative foregut leaks

BACKGROUND:

Fully covered self-expanding metal stent (SEMS) placement has been successfully described for the treatment of malignant and benign conditions. The aim of this study is to evaluate our experience of fully covered SEMS placement for post-operative foregut leaks.

MATERIALS AND METHODS:

Retrospective analysis was done for indications, outcomes and complications of SEMS placed in homogeneous population of 15 patients with post-operative foregut leaks in our tertiary-care centre from December 2008 to December 2010. Stent placement and removal, clinical and radiological evidence of leak healing, migration and other complications were the main outcomes analyzed.

RESULTS:

Twenty-three HANAROSTENT^® SEMS were successfully placed in 14/15 patients (93%) with post-operative foregut leaks for an average duration of 28.73 days (range=1-42 days) per patient and 18.73 days per SEMS. Three (20%) patients needed to be re-stented for persistent leaks ultimately resulting in leak closure. Total 5/15 (33.33%) patients and 7/23 (30.43%) stents showed migration; 5/7 (71.42%) migrated stents could be retrieved endoscopically. There were mucosal ulceration in 2/15 (13.33%) and pain in 1/15 (6.66%) patients.

CONCLUSIONS:

Stenting with SEMS seems to be a feasible option as a primary care modality for patients with post-operative foregut leaks.

Fully covered self-expandable metal stents (SEMS), partially covered SEMS and self-expandable plastic stents for the treatment of benign esophageal ruptures and anastomotic leaks

Background

Benign esophageal ruptures and anastomotic leaks are life-threatening conditions that are often treated surgically. Recently, placement of partially and fully covered metal or plastic stents has emerged as a minimally invasive treatment option. We aimed to determine the clinical effectiveness of covered stent placement for the treatment of esophageal ruptures and anastomotic leaks with special emphasis on different stent designs.

Methods

Consecutive patients who underwent placement of a fully covered self-expandable metal stent (FSEMS), a partially covered SEMS (PSEMS) or a self-expanding plastic stent (SEPS) for a benign esophageal rupture or anastomotic leak after upper gastrointestinal surgery in the period 2007-2010 were included. Data on patient demographics, type of lesion, stent placement and removal, clinical success and complications were collected

Results

A total of 52 patients received 83 esophageal stents (61 PSEMS, 15 FSEMS, 7 SEPS) for an anastomotic leak (n = 32), iatrogenic rupture (n = 13), Boerhaave's syndrome (n = 4) or other cause (n = 3). Endoscopic stent removal was successful in all but eight patients treated with a PSEMS due to tissue ingrowth. Clinical success was achieved in 34 (76%, intention-to-treat: 65%) patients (PSEMS: 73%, FSEMS: 83%, SEPS: 83%) after a median of 1 (range 1-5) stent and a median stenting time of 39 (range 7-120) days. In total, 33 complications in 24 (46%) patients occurred (tissue in- or overgrowth (n = 8), stent migration (n = 10), ruptured stent cover (all Ultraflex; n = 6), food obstruction (n = 3), severe pain (n = 2), esophageal rupture (n = 2), hemorrhage (n = 2)). One (2%) patient died of a stent-related cause.

Conclusions

Covered stents placed for a period of 5-6 weeks may well be an alternative to surgery for treating benign esophageal ruptures or anastomotic leaks. As efficacy between PSEMS, FSEMS and SEPS is not different, stent choice should depend on expected risks of stent migration (SEPS and FSEMS) and tissue in- or overgrowth (PSEMS).

Fully covered self-expandable metal stents (SEMS), partially covered SEMS and self-expandable plastic stents for the treatment of benign esophageal ruptures and anastomotic leaks

BACKGROUND

Benign esophageal ruptures and anastomotic leaks are life-threatening conditions that are often treated surgically. Recently, placement of partially and fully covered metal or plastic stents has emerged as a minimally invasive treatment option. We aimed to determine the clinical effectiveness of covered stent placement for the treatment of esophageal ruptures and anastomotic leaks with special emphasis on different stent designs.

METHODS

Consecutive patients who underwent placement of a fully covered self-expandable metal stent (FSEMS), a partially covered SEMS (PSEMS) or a self-expanding plastic stent (SEPS) for a benign esophageal rupture or anastomotic leak after upper gastrointestinal surgery in the period 2007-2010 were included. Data on patient demographics, type of lesion, stent placement and removal, clinical success and complications were collected

RESULTS

A total of 52 patients received 83 esophageal stents (61 PSEMS, 15 FSEMS, 7 SEPS) for an anastomotic leak (n=32), iatrogenic rupture (n=13), Boerhaave's syndrome (n=4) or other cause (n=3). Endoscopic stent removal was successful in all but eight patients treated with a PSEMS due to tissue ingrowth. Clinical success was achieved in 34 (76%, intention-to-treat: 65%) patients (PSEMS: 73%, FSEMS: 83%, SEPS: 83%) after a median of 1 (range 1-5) stent and a median stenting time of 39 (range 7-120) days. In total, 33 complications in 24 (46%) patients occurred (tissue in- or overgrowth (n=8), stent migration (n=10), ruptured stent cover (all Ultraflex; n=6), food obstruction (n=3), severe pain (n=2), esophageal rupture (n=2), hemorrhage (n=2)). One (2%) patient died of a stent-related cause.

CONCLUSIONS

Covered stents placed for a period of 5-6 weeks may well be an alternative to surgery for treating benign esophageal ruptures or anastomotic leaks. As efficacy between PSEMS, FSEMS and SEPS is not different, stent choice should depend on expected risks of stent migration (SEPS and FSEMS) and tissue in- or overgrowth (PSEMS).

Endoscopic removal of self-expandable metal stents from the esophagus (with video)

BACKGROUND

Self-expandable metals stents (SEMSs) have increasingly been used as a temporary device to bridge chemoradiotherapy in patients with malignant esophageal disease or in patients with benign esophageal defects or stenosis.

OBJECTIVE

To evaluate the outcome of removal of SEMSs in a large cohort of patients with benign and malignant esophageal disease.

DESIGN

Observational study with standardized treatment and follow-up.

SETTING

Single university center.

PATIENTS

Between 2001 and 2010, 95 consecutive patients referred for endoscopic SEMS extraction were included.

INTERVENTIONS

Endoscopic stent removal.

MAIN OUTCOME MEASUREMENTS

Technical and functional outcome and complications.

RESULTS

A total of 124 stent extractions were undertaken in 95 patients; both partially covered (68%) and fully covered (32%) SEMSs were removed. Three patients had 2 overlapping SEMSs in place. Successful primary removal was achieved in 89%; the secondary removal rate was 96%. Uncomplicated primary removal rate was significantly higher for fully covered versus partially covered stents (P = .035) and for single versus overlapping stents (P = .033). Patients with a complicated stent removal had the stent in place significantly longer compared with patients with an uncomplicated primary stent removal (126 days vs 28 days; P = .01). Surgical removal was required in 3 patients (2.4%). Six moderate and severe complications (5%) related to the endoscopic extraction occurred.

LIMITATIONS

Retrospective, nonrandomized study design.

CONCLUSIONS

Primary endoscopic removal of an SEMS is feasible in the majority of patients with benign and malignant esophageal disease. A longer time that a stent is in place and the use of partially covered SEMSs both impede removal. Moreover, overlapping SEMSs should be avoided for temporary use because stent disintegration and subsequent complications may occur.

Systematic review: temporary stent placement for benign rupture or anastomotic leak of the oesophagus

BACKGROUND

Placement of self-expanding metal stents (SEMS) or plastic stents (SEPS) has emerged as a minimally invasive treatment option for benign oesophageal ruptures and leaks; however, it is not clear which stent type should be preferred.

AIM

To assess clinical effectiveness and safety of treating benign oesophageal ruptures and anastomotic leaks with temporary placement of a stent with special emphasis on different stent designs.

METHODS

A pooled analysis was performed after searching PubMed and EMBASE databases for studies regarding placement of fully covered and partially covered SEMS (FSEMS and PSEMS) and SEPS for this indication. Data were pooled and evaluated for clinical outcome, complications and survival.

RESULTS

Twenty-five studies, including 267 patients with complete follow-up on outcome, were identified. Clinical success was achieved in 85% of patients and was not different between stent types (SEPS 84%, FSEMS 85% and PSEMS 86%, P = 0.97). Time of stent placement was longest for SEPS (8 weeks) followed by FSEMS and PSEMS (both 6 weeks). In total, 65 (34%) patients had a stent-related complication. Stent migration occurred more often with SEPS [n = 47 (31%)] and FSEMS [n = 7 (26%)] than with PSEMS [n = 2 (12%), P ≤ 0.001], whereas there was no significant difference in tissue in- and overgrowth between PSEMS [12% vs. 7% (FSEMS) and 3% (SEPS), P = 0.68].

CONCLUSIONS

Although there is a lack of randomised controlled trials, it seems that covered stent placement for a period of 6-8 weeks is safe and effective for benign oesophageal ruptures and anastomotic leaks to heal. As efficacy between different stent types is not significantly different, stent choice should depend on expected risk of stent migration (self-expanding plastic stents and fully covered self-expanding metal stents) and, to a minor degree, on expected risk of tissue in- or overgrowth (partially covered self-expanding metal stents).

Impact of endoscopic assessment and treatment on operative and non-operative management of acute oesophageal perforation

BACKGROUND

Surgeons have not typically utilized an endoscopic approach for diagnosis and management of acute oesophageal perforation, mainly due to fears of increased mediastinal contamination. This study assessed the evolution of endoscopic approaches and their effect on outcomes over time in acute oesophageal perforation.

METHODS

All patients with documented acute oesophageal perforation between 1990 and 2009 were enrolled prospectively in an Institutional Review Board-approved database.

RESULTS

Of 81 patients who presented during the study period, 52 had upper gastrointestinal endoscopy for diagnosis alone (12 patients; 23 per cent) or as a component of acute management (40 patients; 77 per cent). Use of endoscopy increased from four of 13 patients in the first 5 years of the study to 20 of 24 patients in the final 5 years. Endoscopy was used in conjunction with surgery in 28 patients, of whom 21 underwent primary repair, three had resection, and one a diversion; 12 patients in this group had hybrid operations (combination of surgical and endoscopic management). Primary endoscopic treatment was used in 15 patients (29 per cent), most commonly involving stent placement (7). Of those having endoscopy, complication rates improved (from 3 of 4 to 8 of 20 patients), as did mean length of stay (from 21·8 to 13·4 days) between the initial and final 5 years of the study. There were two deaths (4 per cent). Of 21 patients who had both endoscopic assessment and management in the operating room, endoscopy identified additional pathology in ten, leading to a change in management plan in five patients.

CONCLUSION

Endoscopy is a safe and important component of the management of acute oesophageal perforation. It provides additional information that modifies treatment, and its wider use should result in improved outcomes.

Management of esophageal anastomotic leaks, perforations, and fistulae with self-expanding plastic stents

OBJECTIVE

Esophageal anastomotic leaks, perforations, and fistulae are associated with considerable morbidity and mortality. The aim of the present study was to assess the efficacy of self-expanding plastic stents in the treatment of esophageal leaks.

METHODS

From 2001 to 2009, 41 patients with postoperative anastomotic leaks (n = 30), esophageal perforations (n = 6), or fistulae (n = 5) were treated by endoscopic insertion of self-expanding plastic stents. The clinical outcome of the patients was analyzed, including leak healing, morbidity, and mortality.

RESULTS

Self-expanding plastic stents were successfully inserted in all 41 patients without procedure-related complications. Non-ventilated patients received oral feeding an average of 3.9 days after stent placement. Complete leak healing was obtained in 27 of 30 patients (90%) with anastomotic leaks and 5 patients (83%) with perforation. Sealing of fistulae by the stents was achieved in all 5 patients, and closure of the fistula was observed in 2 patients (40%). The mean healing time was 30 days for anastomotic leaks, 15 days for esophageal perforations, and 16 days for fistulae. Stent migration occurred in 14 cases, but endoscopic reintervention and new stent placement were successful in all cases. In-hospital mortality after treatment of esophageal leaks with stents was 10%.

CONCLUSIONS

In combination with effective interventional or surgical drainage, stenting is a viable option for the treatment of esophageal anastomotic leaks and perforations, but the success in tracheoesophageal fistula is limited.

Stent placement provides safe esophageal closure in thoracic NOTES(TM) procedures

BACKGROUND

Safe esophageal closure remains a challenge in transesophageal Natural Orifice Transluminal Endoscopic Surgery (NOTES). Previously described methods, such as suturing devices, clips, or submucosal tunneling, all have weaknesses. In this survival animal series, we demonstrate safe esophageal closure with a prototype retrievable, antimigration stent.

METHODS

Nine Yorkshire swine underwent thoracic NOTES procedures. A double-channel gastroscope equipped with a mucosectomy device was used to create an esophageal mucosal defect. A 5-cm submucosal tunnel was created and the muscular esophageal wall was incised with a needle-knife. Mediastinoscopy and thoracoscopy were performed in all swine; lymphadenectomy was performed in seven swine. A prototype small intestinal submucosal (SurgiSIS(®)) covered stent was deployed over the mucosectomy site and tunnel. Three versions of the prototype stent were developed. Prenecropsy endoscopy confirmed stent location and permitted stent retrieval. Explanted esophagi were sent to pathology.

RESULTS

Esophageal stenting was successful in all animals. Stent placement took 15.8 ± 4.8 minuted and no stent migration occurred. Prenecropsy endoscopy revealed proximal ingrowth of esophageal mucosa and erosion with Stent A. Mucosal inflammation and erosion was observed proximally with Stent B. No esophageal erosion or pressure damage from proximal radial forces was seen with Stent C. On necropsy, swine 5 had a 0.5-cm periesophageal abscess. Histology revealed a localized inflammatory lesion at the esophageal exit site in swine 1, 3, and 9. The mucosectomy site was partially healed in three swine and poorly healed in six. All swine thrived clinically, except for a brief period of mild lethargy in swine 9 who improved with short-term antibiotic therapy. The submucosal tunnels were completely healed and no esophageal bleeding or stricture formation was observed. All swine survived 13.8 ± 0.4 days and gained weight in the postoperative period.

CONCLUSIONS

Esophageal stenting provides safe closure for NOTES thoracic procedures but may impede healing of the mucosectomy site.

Treatment of upper gastrointestinal leaks with a removable, covered, self-expanding metallic stent

BACKGROUND

Anastomotic and staple line leaks are serious complications after upper gastrointestinal and bariatric procedures. In patients who are actively septic "diversion and drainage" with aspiration of esophageal and gastric secretions, operative placement of perianastomotic drains, bowel rest, and parenteral nutrition form the conventional management strategy of leaks. Treatment of leaks by direct suture repair, revision, patching, and application of fibrin glue to leaks have failed to gain widespread acceptance owing to a high failure rate in the septic patient. This report describes a case series where anastomotic leaks in patients with established sepsis after upper gastrointestinal resections and bariatric procedures as well as Boerhaave syndrome were managed with a combination of surgical drainage and stent placement. A new technique where the stent is sutured into place transluminally to prevent migration is described.

METHOD

Seven patients with staple line and anastomotic dehiscences and a single case of Boerhaave syndrome were treated at St George Hospital, Sydney, over the period January 2003 to December 2006 by using a removable, polyester covered self-expanding metal stent (ELLA Boubella, Ella-CS, Hradec, Czech Republic). All patients had active severe sepsis and significant contamination in the abdomen or thorax at the time of stenting. In 4 cases, the stent was sutured in place with dissolvable synthetic sutures with suture bites incorporating the full thickness of the gut wall and the stent itself to prevent stent migration.

RESULTS

All patients showed resolution of their intra-abdominal sepsis and were able to resume an oral diet after stenting. All stents were retrieved endoscopically after clinical resolution of the leak. Stent migration after leak resolution was observed in 3 patients. In patients with large defects or minimal anatomic barriers to stent migration, suture fixation stabilized the stent. There were no episodes of persistent leak or development of stricture in this series.

CONCLUSIONS

In this small series, the use of a removable covered stent in the setting of anastomotic leak or spontaneous perforation, alone or as an adjunct to conventional surgical management, is feasible in sealing the leak, resolving sepsis, and expediting return to enteral nutrition. Stenting is feasible in cases with substantial tissue loss or contamination. Suturing the stent transluminally stabilizes the stent where risk of migration is high.

Treatment of oesophageal anastomotic leaks by temporary stenting with self-expanding plastic stents

BACKGROUND

Oesophageal anastomotic leakage is associated with considerable morbidity and mortality. The aim of the present study was to assess the feasibility of using temporary self-expanding plastic stents to treat postoperative oesophageal leaks.

METHODS

Patients with anastomotic leakage after abdominothoracic oesophagectomy treated by endoscopic insertion of self-expanding plastic stents between 2001 and 2007 were studied. Clinical outcomes were analysed, including healing of the leak, morbidity and mortality.

RESULTS

Stents were inserted successfully in all 22 patients without procedure-related complications. Ten patients also required computed tomography-guided drainage because surgical drains had been removed. Non-ventilated patients received oral nutrition a mean of 4 days after stent placement. Combined treatment with stenting and drainage resulted in resolution of the leak in 21 of 22 patients. The mean healing time (time to stent removal) was 23 days. Stent migration occurred in five of 22 patients, but endoscopic reintervention with placement of a new stent was successful in all patients. Repeat thoracotomy with intraoperative stent placement was necessary in one patient with an oesophagocolonic anastomosis. One patient died in hospital.

CONCLUSION

In combination with effective drainage, self-expanding plastic stents are an option for the treatment of oesophageal anastomotic leaks, and may reduce leak-related morbidity and mortality.

From iatrogenic digestive perforation to complete anastomotic disunion: endoscopic stenting as a new concept of "stent-guided regeneration and re-epithelialization"

BACKGROUND

Iatrogenic intestinal tract perforation and anastomotic disunion traditionally required surgical treatment. Complete anastomotic break was considered until now as an absolute contraindication for endoscopic management.

OBJECTIVE

The aim of this series was to show that endoscopic management is able to treat a spectrum of bowel wall breaks, from focal perforation to complete anastomotic disunion.

SETTING

A single-center prospective cohort study.

PATIENTS

Nine consecutive patients with nonmalignant gastrointestinal perforations were treated with endoscopic stenting between 2005 and 2008. Perforations were related to endoscopic perforations (4 cases: 2 esophageal and 2 colorectal), postoperative fistula or leakage (2 cases: 1 colorectal anastomosis and 1 esophageal), and complete anastomotic disunion (3 cases: 2 ileoanal anastomosis and 1 esophagogastric anastomosis).

INTERVENTIONS

All 9 patients underwent endoscopic installation of fully covered stents under endoscopic and radiologic guidance, sometimes associated with simultaneous endoscopic collection drainage. Oral feeding was resumed when radiologic contrast studies showed no residual leak.

RESULTS

The outcome in all 9 patients was favorable. Two migrated stents were replaced, and 2 stents were spontaneously expelled without consequence. All stents were withdrawn within an average of 5 weeks.

LIMITATIONS

Uncontrolled pilot study, small sample size.

CONCLUSION

The successful endoscopic management of bowel wall breaks ranging from perforation to complete postoperative disunion with fully covered stent could support a new concept of "stent-guided regeneration and re-epithelialization." Controlled trials are needed before this new endoscopic treatment can be proposed as a substitute for traditional treatments.

Use of self-expandable metal stents for the treatment of esophageal perforations and anastomotic leaks

BACKGROUND

Esophageal perforations and extensive anastomotic leaks after esophageal resection or gastrectomy are surgical emergencies with high mortality rates. In recent years, the use of self-expanding metallic stents (SEMS) has emerged as a promising treatment alternative for bridging and sealing the damage. This study aimed to evaluate the role of covered SEMS for the management of esophageal perforations and anastomotic leaks.

METHODS

All esophageal stent placement procedures (174 procedures for 157 patients) at the authors' unit between January 1999 and April 2008 were assessed by a retrospective chart review. Of the 157 patients, 10 (6.4%) were treated with SEMS for sealing of an iatrogenic esophageal perforation (n = 4), a spontaneous esophageal rupture in Boerhaave's syndrome (n = 4), or an anastomotic leakage (n = 2).

RESULTS

The median time from perforation or anastomotic leak to stent insertion was 13 days (range, 2 h to 48 days). The esophageal leak was totally sealed for 8 (80%) of 10 patients. The overall mortality rate was 50% (n = 5), and three (30%) of the five deaths were related to the perforation (n = 2) or leakage (n = 1). In both of the perforation cases, the diagnosis and treatment were substantially delayed. One patient with an anastomotic leak after gastrectomy died of the complication despite successful operative and SEMS treatment. Two of the deaths were unrelated to the perforation. In both cases, the cause of death was a disseminated malignant disease.

CONCLUSIONS

Traumatic perforations and anastomotic leaks can be treated effectively with covered SEMS together with adequate drainage of the thoracic cavity even in cases of severely ill patients with inveterate esophageal perforations and leaks.

Endoscopic therapy for esophageal perforation or anastomotic leak with a self-expandable metallic stent

BACKGROUND

Leaks of the esophagus are associated with a high mortality rate and need to be treated as soon as possible. Therapeutic options are surgical repair or resection or conservative management with cessation of oral intake and antibiotic therapy. We evaluated an alternative approach that uses self-expandable metallic stents (SEMS).

METHODS

Between 2002 and 2007, 31 consecutive patients with iatrogenic esophageal perforation (n = 9), intrathoracic anastomotic leak after esophagectomy (n = 16), spontaneous tumor perforation (n = 5), and esophageal ischemia (n = 1) were treated at our institution. All were treated with endoscopic placement of a covered SEMS. Stent removal was performed 4 to 6 weeks after implantation. To exclude continuous esophageal leak after SEMS placement, radiologic examination was performed after stent implantation and removal.

RESULTS

SEMS placement was successful in all patients and a postinterventional esophagogram demonstrated full coverage of the leak in 29 patients (92%). In two patients, complete sealing could not be achieved and they were referred to surgical repair. Stent migration was seen in only one patient (3%). After removal, a second stent with larger diameter was placed and no further complication occurred. Two patients died: one due to myocardial infarction and one due to progressive ischemia of the esophagus and small bowl as a consequence of vascular occlusion. Stent removal was performed within 6 weeks, and all patients had radiologic and endoscopic evidence of esophageal healing.

CONCLUSIONS

Implantation of covered SEMS in patients with esophageal leak or perforation is a safe and feasible alternative to operative treatment and can lower the interventional morbidity rate.

Esophageal perforation as a complication of esophagogastroduodenoscopy

Fifty years ago, esophageal perforation was common after rigid upper endoscopy. The arrival of flexible endoscopic instruments and refinement in technique have decreased its incidence; however, esophageal perforation remains an important cause of morbidity and mortality. This complication merits a high index of clinical suspicion to prevent sequelae of mediastinitis and fulminant sepsis. Although the risk of perforation with esophagogastroduodenoscopy alone is only 0.03%, this risk can increase to 17% with therapeutic interventions in the setting of underlying esophageal and systemic diseases. A wide spectrum of management options exist, ranging from conservative treatment to surgical intervention. Prompt recognition and management, within 24 hours of perforation, is critical for favorable outcomes.

Retrievable esophageal stents for benign indications

Until recently, esophageal stents have not been a realistic option for the management of benign disease owing to difficulty removing the stents and associated high complication rates. However, progress in esophageal stent design has led to the development of retrievable esophageal stents. Clinical experience has shown promise for the management of benign esophageal diseases with retrievable stents, including refractory strictures, esophageal leaks, fistula and perforations. They have been shown to be safe and effective, though stent migration remains a concern. This article reviews the current designs, indications, efficacy and complications of retrievable esophageal stents.

Post-operative esophageal leak treated with removable silicone-covered polyester stent

Self-expanding removable covered stents are increasingly being used for the treatment of benign esophageal diseases such as leaks or perforations and stenosis. They are easy to place and remove and good outcomes have been reported. We report a case of a postoperative esophageal leak successfully managed with a removable silicone-covered polyester stent.

Esophageal stent improves ventilation in a child with a broncho-esophageal fistula caused by Mycobacterium tuberculosis

The deployment of an esophageal stent to aid in the ventilation of a child who had developed an acquired broncho-esophageal fistula caused by Mycobacterium tuberculosis (MTB) is described. The 12-month-old boy presented with respiratory failure requiring ventilation. The air leak via the fistula led to inadequate mechanical ventilation. The deployment of the stent resulted in successful ventilation, closure of the fistula, and eventual successful treatment.

Therapeutic esophageal interventions for dysphagia and bleeding

PURPOSE OF THIS REVIEW

This article reviews the most notable results of esophageal interventions for dysphagia and bleeding published in 2005.

RECENT FINDINGS

Long-term rubber tube placement was shown to be an interesting treatment option for difficult esophageal strictures. Two studies demonstrated that only 50% of patients who had undergone pneumatic dilation for achalasia were dysphagia-free after long-term follow-up. It was shown that patients with dysphagia from esophageal cancer should be treated by intraluminal radiotherapy (brachytherapy), whereas stent placement was preferable in those with a poor prognosis. Temporary stent placement is an option in patients undergoing radiotherapy for inoperable esophageal cancer to increase the dysphagia-free period. Two studies were published on the successful use of silicone-covered plastic stents for sealing of leaks after surgery of the esophagus. The optimal treatment for bleeding varices was confirmed to be endoscopic band ligation. A meta-analysis demonstrated that adding sclerotherapy to band ligation for secondary prophylaxis of bleeding varices had no effect on clinical outcome.

SUMMARY

In 2005, new techniques for the treatment of complicated strictures were presented. In addition, expanding indications for stents were reported. Finally, endoscopic band ligation was confirmed to be the most optimal technique for the treatment of varices.