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Medas R, Ferreira-Silva J, Girotra M, Barakat M, Tabibian JH, Rodrigues-Pinto E. Best Practices in Esophageal, Gastroduodenal, and Colonic Stenting. GE PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2023; 30:19-34. [PMID: 37818397 PMCID: PMC10561327 DOI: 10.1159/000527202] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 08/22/2022] [Indexed: 10/12/2023]
Abstract
Endoscopic stenting is an area of endoscopy that has witnessed noteworthy advancements over the last decade, resulting in evolving clinical practices among gastroenterologists around the world. Indications for endoscopic stenting have progressively expanded, becoming a frequent part of the management algorithm for various benign and malignant conditions of the gastrointestinal tract, from esophagus to rectum. In addition to expanded indications, continuous technological enhancements and development of novel endoscopic stents have resulted in an increased success of these approaches and, in some cases, allowed new applications. This review aimed to summarize best practices in esophageal, gastroduodenal, and colonic stenting.
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Affiliation(s)
- Renato Medas
- Gastroenterology Department, Centro Hospitalar São João, Porto, Portugal
- Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Joel Ferreira-Silva
- Gastroenterology Department, Centro Hospitalar São João, Porto, Portugal
- Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Mohit Girotra
- Digestive Health Institute, Swedish Medical Center, Seattle, Washington, USA
| | - Monique Barakat
- Division of Gastroenterology, Stanford University, Stanford, California, USA
| | - James H. Tabibian
- Division of Gastroenterology, Department of Medicine, Olive View-UCLA Medical Center, Sylmar, California, USA
- UCLA Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Eduardo Rodrigues-Pinto
- Gastroenterology Department, Centro Hospitalar São João, Porto, Portugal
- Faculty of Medicine of the University of Porto, Porto, Portugal
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Mandarino FV, Barchi A, Leone L, Fanti L, Azzolini F, Viale E, Esposito D, Salmeri N, Puccetti F, Barbieri L, Cossu A, Treppiedi E, Elmore U, Rosati R, Danese S. 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. Surg Endosc 2023; 37:7039-7050. [PMID: 37353654 DOI: 10.1007/s00464-023-10213-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 06/12/2023] [Indexed: 06/25/2023]
Abstract
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.
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Affiliation(s)
- Francesco Vito Mandarino
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute University, Milan, Italy.
| | - Alberto Barchi
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute University, Milan, Italy
| | - Lorenzo Leone
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute University, Milan, Italy
| | - Lorella Fanti
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute University, Milan, Italy
| | - Francesco Azzolini
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute University, Milan, Italy
| | - Edi Viale
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute University, Milan, Italy
| | - Dario Esposito
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute University, Milan, Italy
| | - Noemi Salmeri
- Department of Gynecology/Obstetrics Unit, IRCCS San Raffaele Hospital, Vita-Salute University, Milan, Italy
| | - Francesco Puccetti
- Department of Gastrointestinal Surgery, IRCCS San Raffaele Hospital, Vita-Salute University, Milan, Italy
| | - Lavinia Barbieri
- Department of Gastrointestinal Surgery, IRCCS San Raffaele Hospital, Vita-Salute University, Milan, Italy
| | - Andrea Cossu
- Department of Gastrointestinal Surgery, IRCCS San Raffaele Hospital, Vita-Salute University, Milan, Italy
| | - Elio Treppiedi
- Department of Gastrointestinal Surgery, IRCCS San Raffaele Hospital, Vita-Salute University, Milan, Italy
| | - Ugo Elmore
- Department of Gastrointestinal Surgery, IRCCS San Raffaele Hospital, Vita-Salute University, Milan, Italy
| | - Riccardo Rosati
- Department of Gastrointestinal Surgery, IRCCS San Raffaele Hospital, Vita-Salute University, Milan, Italy
| | - Silvio Danese
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute University, Milan, Italy
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Hua F, Sun D, Zhao X, Song X, Yang W. Update on therapeutic strategy for esophageal anastomotic leak: A systematic literature review. Thorac Cancer 2022; 14:339-347. [PMID: 36524684 PMCID: PMC9891862 DOI: 10.1111/1759-7714.14734] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Revised: 10/31/2022] [Accepted: 11/02/2022] [Indexed: 12/23/2022] Open
Abstract
Anastomotic leak is still a severe complication in esophageal surgery due to high mortality. This article reviews the updates on the treatment of anastomotic leak after esophagectomy in order to provide reference for clinical treatment and research. The relevant studies published in the Chinese Zhiwang, Wanfang, and MEDLINE databases to December 21, 2021 were retrieved, and esophageal carcinoma, esophagectomy, anastomotic leakage, and fistula selected as the keywords. A total of 78 studies were finally included. The treatments include traditional surgical drainage, new reverse drainage trans-fistula, stent plugging, endoscopic clamping, biological protein glue injection plugging, endoluminal vacuum therapy (EVT), and reoperation, etc. Early diagnosis, accurate classification and optimal treatment can promote the rapid healing of anastomotic leaks. EVT may be the most valuable approach, simultaneously with good commercial prospects. Reoperation should be considered in patients with complex fistula in which conservative treatment is insufficient or has failed.
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Affiliation(s)
- Feng Hua
- Department of Thoracic SurgeryShandong Cancer Hospital and Institute Shandong First Medical University and Shandong Academy of Medical SciencesJinanChina
| | - Dongfeng Sun
- Department of Thoracic SurgeryShandong Cancer Hospital and Institute Shandong First Medical University and Shandong Academy of Medical SciencesJinanChina
| | - Xiaoming Zhao
- Department of Thoracic SurgeryShandong Cancer Hospital and Institute Shandong First Medical University and Shandong Academy of Medical SciencesJinanChina
| | - Xuemin Song
- Department of Thoracic SurgeryShandong Cancer Hospital and Institute Shandong First Medical University and Shandong Academy of Medical SciencesJinanChina
| | - Wenfeng Yang
- Department of Thoracic SurgeryShandong Cancer Hospital and Institute Shandong First Medical University and Shandong Academy of Medical SciencesJinanChina
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Sanz Segura P, Gotor Delso J, García Cámara P, Sierra Moros E, Val Pérez J, Soria Santeodoro MT, Uribarrena Amezaga R. Use of double-layered covered esophageal stents in post-surgical esophageal leaks and esophageal perforation: Our experience. GASTROENTEROLOGIA Y HEPATOLOGIA 2022; 45:198-203. [PMID: 34052404 DOI: 10.1016/j.gastrohep.2021.04.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 04/02/2021] [Accepted: 04/14/2021] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Patricia Sanz Segura
- Servicio de Aparato Digestivo, Hospital Universitario Miguel Servet, Zaragoza, España.
| | - Jesús Gotor Delso
- Servicio de Aparato Digestivo, Hospital Universitario Miguel Servet, Zaragoza, España
| | - Paula García Cámara
- Servicio de Aparato Digestivo, Hospital Universitario Miguel Servet, Zaragoza, España
| | - Eva Sierra Moros
- Servicio de Aparato Digestivo, Hospital Universitario Miguel Servet, Zaragoza, España
| | - José Val Pérez
- Servicio de Aparato Digestivo, Hospital Universitario Miguel Servet, Zaragoza, España
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Martínez Hernández A, Beltrán Herrera H, Martínez García V, Ibáñez Belenguer M, Queralt Martín R, Maiocchi Segredo AK, Aliaga Hilario E, Laguna Sastre JM. Stent Management of Leaks After Bariatric Surgery: a Systematic Review and Meta-analysis. Obes Surg 2022; 32:1034-1048. [PMID: 35132569 DOI: 10.1007/s11695-022-05890-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 12/31/2021] [Accepted: 01/10/2022] [Indexed: 12/17/2022]
Abstract
BACKGROUND Despite the low rates of complications of bariatric surgery, gastrointestinal leaks are major adverse events that increase post-operative morbidity and mortality. Endoscopic treatment using self-expanding stents has been used in the therapeutic management of these complications with preliminary good results. METHODS We performed a systematic review and meta-analysis of self-expanding stents placement for the management of gastrointestinal leaks after obesity surgery. Overall proportion of successful leak closure, stent migration, and reoperation were analysed as primary outcomes. Secondary outcomes were patients' clinical characteristics, duration and type of stent, other stent complications, and mortality. RESULTS A meta-analysis of studies reporting stents was performed, including 488 patients. The overall proportion of successful leak closure was 85.89% (95% CI, 82.52-89.25%), median interval between stent placement and its removal of 44 days. Stent migration was noted in 18.65% (95% CI, 14.32-22.98%) and the overall proportion of re-operation was in 13.54% (95% CI, 9.94-17.14%). The agreement between reviewers for the collected data gave a Cohen's κ value of 1.0. No deaths were caused directly by complications with the stent placement. CONCLUSIONS Endoscopic placement of self-expanding stents can be used, in selected patients, for the management of leaks after bariatric surgery with a high rate of effectiveness and low mortality rates. Nevertheless, reducing stent migration and re-operation rates represents an important challenge for future studies.
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Affiliation(s)
| | | | | | | | | | | | | | - José Manuel Laguna Sastre
- Department of General Surgery, University General Hospital, Castellon, Spain.,Jaume I Univeristy, Castellon, Spain
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Chan SM, Auyeung KKY, Lam SF, Chiu PWY, Teoh AYB. Current status in endoscopic management of upper gastrointestinal perforations, leaks and fistulas. Dig Endosc 2022; 34:43-62. [PMID: 34115407 DOI: 10.1111/den.14061] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 06/10/2021] [Indexed: 02/06/2023]
Abstract
Recent advancement in endoscopic closure techniques have revolutionized the treatment of gastrointestinal perforations, leaks and fistulas. Traditionally, these have been managed surgically. The treatment strategy depends on the size and location of the defect, degree of contamination, presence of healthy surrounding tissues, patients' condition and the availability of expertise. One of the basic principles of management includes providing a barricade to the flow of luminal contents across the defect. This can be achieved with a wide range of endoscopic techniques. These include endoclips, stenting, suturing, tissue adhesives and glue, and endoscopic vacuum therapy. Each method has their distinct indications and shortcomings. Often, a combination of these techniques is required. Apart from endoscopic closure, drainage procedures by the interventional radiologist and surgical management also play an important role. In this review article, the outcomes of each of these endoscopic closure techniques in the literature is provided in tables, and practical management algorithms are being proposed.
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Affiliation(s)
- Shannon Melissa Chan
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Kitty Kit Ying Auyeung
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Siu Fung Lam
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Philip Wai Yan Chiu
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Anthony Yuen Bun Teoh
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
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Mandarino FV, Esposito D, Spelta GNE, Cavestro GM, Rosati R, Parise P, Gemma MF, Fanti L. Double layer stent for the treatment of leaks and fistula after upper gastrointestinal oncologic surgery: a retrospective study. Updates Surg 2021; 74:1055-1062. [PMID: 34510378 DOI: 10.1007/s13304-021-01155-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 08/23/2021] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Francesco Vito Mandarino
- Division of Gastroenterology and Gastrointestinal Endoscopy, Department of Experimental Oncology, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Via Olgettina 60, 20132, Milan, Italy.
| | - Dario Esposito
- Division of Gastroenterology and Gastrointestinal Endoscopy, Department of Experimental Oncology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Greta Natalia Edmea Spelta
- Division of Gastroenterology and Gastrointestinal Endoscopy, Department of Experimental Oncology, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Via Olgettina 60, 20132, Milan, Italy
| | - Giulia Martina Cavestro
- Division of Gastroenterology and Gastrointestinal Endoscopy, Department of Experimental Oncology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Riccardo Rosati
- Division of Gastrointestinal Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Paolo Parise
- Division of Gastrointestinal Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Marco Fabio Gemma
- Department of Anaesthesia and Intensive Care, Fatebenefratelli Hospital, Milan, Italy
| | - Lorella Fanti
- Division of Gastroenterology and Gastrointestinal Endoscopy, Department of Experimental Oncology, IRCCS San Raffaele Scientific Institute, Milan, Italy
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Kamarajah SK, Bundred J, Spence G, Kennedy A, Dasari BVM, Griffiths EA. Critical Appraisal of the Impact of Oesophageal Stents in the Management of Oesophageal Anastomotic Leaks and Benign Oesophageal Perforations: An Updated Systematic Review. World J Surg 2020; 44:1173-1189. [PMID: 31686158 DOI: 10.1007/s00268-019-05259-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Endoscopic placement of oesophageal stents may be used in benign oesophageal perforation and oesophageal anastomotic leakage to control sepsis and reduce mortality and morbidity by avoiding thoracotomy. This updated systematic review aimed to assess the safety and effectiveness of oesophageal stents in these two scenarios. METHODS A systematic literature search of all published studies reporting use of metallic and plastic stents in the management of post-operative anastomotic leaks, spontaneous and iatrogenic oesophageal perforations were identified. Primary outcomes were technical (deploying ≥ 1 stent to occlude site of leakage with no evidence of leakage of contrast within 24-48 h) and clinical success (complete healing of perforation or leakage by placement of single or multiple stents irrespective of whether the stent was left in situ or was removed). Secondary outcomes were stent migration, perforation and erosion, and mortality rates. Subgroup analysis was performed for plastic versus metallic stents and anastomotic leaks versus perforations separately. RESULTS A total of 66 studies (n = 1752 patients) were included. Technical and clinical success rates were 96% and 87%, respectively. Plastic stents had significantly higher migration rates (24% vs 16%, p = 0.001) and repositioning (11% vs 3%, p < 0.001) and lower technical success (91% vs 95%, p = 0.032) than metallic stents. In patients with anastomotic leaks, plastic stents were associated with higher stent migration (26% vs 15%, p = 0.034), perforation (2% vs 0%, p = 0.013), repositioning (10% vs 0%, p < 0.001), and lower technical success (95% vs 100%, p = p = 0.002). In patients with perforations only, plastic stents were associated with significantly lower technical success (85% vs 99%, p < 0.001). CONCLUSIONS Covered metallic oesophageal stents appear to be more effective than plastic stents in the management of oesophageal perforation and anastomotic leakage. However, quality of evidence of generally poor and high-quality randomised trial is needed to further evaluate best management option for oesophageal perforation and anastomotic leakage.
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Affiliation(s)
- Sivesh K Kamarajah
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Freeman Hospital, Newcastle University NHS Foundation Trust Hospitals, Newcastle upon Tyne, UK
- Institute of Cellular Medicine, University of Newcastle, Newcastle upon Tyne, UK
| | - James Bundred
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Gary Spence
- Division of Gastroenterology and Surgery, Ulster Hospital, Belfast, Northern Ireland, UK
| | - Andrew Kennedy
- Department of Upper Gastro-Intestinal Surgery, Belfast City Hospital, Belfast Health and Social Care Trust, Belfast, UK
| | - Bobby V M Dasari
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Ewen A Griffiths
- Department of Upper Gastrointestinal Surgery, University Hospitals Birmingham NHS Foundation Trust, Area 6, 7th Floor, Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Edgbaston, Birmingham, B15 2WBUK, UK.
- Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.
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Abstract
Gastrointestinal surgery is increasingly being performed. Despite improving technology and outcomes, complications are not completely avoidable. Frequently, surgical complications require invasive procedures for management. However, with increasing availability of flexible endoscopy and a wider array of tools, more often these complications can be managed with an endolumenal approach. This article is an in-depth review of endoscopic management of surgical complications.
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Paspatis GA, Arvanitakis M, Dumonceau JM, Barthet M, Saunders B, Turino SY, Dhillon A, Fragaki M, Gonzalez JM, Repici A, van Wanrooij RLJ, van Hooft JE. Diagnosis and management of iatrogenic endoscopic perforations: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement - Update 2020. Endoscopy 2020; 52:792-810. [PMID: 32781470 DOI: 10.1055/a-1222-3191] [Citation(s) in RCA: 68] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
1: ESGE recommends that each center implements a written policy regarding the management of iatrogenic perforations, including the definition of procedures that carry a higher risk of this complication. This policy should be shared with the radiologists and surgeons at each center. 2 : ESGE recommends that in the case of an endoscopically identified perforation, the endoscopist reports its size and location, with an image, and statement of the endoscopic treatment that has been applied. 3: ESGE recommends that symptoms or signs suggestive of iatrogenic perforation after an endoscopic procedure should be rapidly and carefully evaluated and documented with a computed tomography (CT) scan. 4 : ESGE recommends that endoscopic closure should be considered depending on the type of the iatrogenic perforation, its size, and the endoscopist expertise available at the center. Switch to carbon dioxide (CO2) endoscopic insufflation, diversion of digestive luminal content, and decompression of tension pneumoperitoneum or pneumothorax should also be performed. 5 : ESGE recommends that after endoscopic closure of an iatrogenic perforation, further management should be based on the estimated success of the endoscopic closure and on the general clinical condition of the patient. In the case of no or failed endoscopic closure of an iatrogenic perforation, and in patients whose clinical condition is deteriorating, hospitalization and surgical consultation are recommended.
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Affiliation(s)
- Gregorios A Paspatis
- Gastroenterology Department, Venizelion General Hospital, Heraklion, Crete-Greece
| | - Marianna Arvanitakis
- Gastroenterology, Hepatopancreatology, and Digestive Oncology, Erasme Hospital, Universite Libre de Bruxelles, Brussels, Belgium
| | - Jean-Marc Dumonceau
- Gastroenterology Service, Centre Hospitalier Universitaire de Charleroi, Charleroi, Belgium
| | | | - Brian Saunders
- St Mark's Hospital, Wolfson Unit for Endoscopy, North West London Hospitals University Trust, Harrow, London, UK
| | | | - Angad Dhillon
- St Mark's Hospital, Wolfson Unit for Endoscopy, North West London Hospitals University Trust, Harrow, London, UK
| | - Maria Fragaki
- Gastroenterology Department, Venizelion General Hospital, Heraklion, Crete-Greece
| | | | - Alessandro Repici
- Department of Gastroenterology, Digestive Endoscopy Unit, IRCCS Istituto Clinico Humanitas, Milan, Italy
| | - Roy L J van Wanrooij
- Department of Gastroenterology and Hepatology, AG&M Research Institute, Vrije Universiteit Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, The Netherlands
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11
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Famiglietti A, Lazar JF, Henderson H, Hamm M, Malouf S, Margolis M, Watson TJ, Khaitan PG. Management of anastomotic leaks after esophagectomy and gastric pull-up. J Thorac Dis 2020; 12:1022-1030. [PMID: 32274171 PMCID: PMC7139088 DOI: 10.21037/jtd.2020.01.15] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Anastomotic leak is one of the most feared complications of esophagectomy, leading to prolonged hospital stay, increased postoperative mortality, and additional cost both to the patient and the hospital. Historically, anastomotic leaks have been treated with several techniques including conservative measures, percutaneous or operative drainage, primary surgical repair with buttressing, T-tube drainage, or excision of the esophageal replacement conduit with end esophagostomy. With advances in treatment modalities, including endoscopic stenting, clips and suturing, endoluminal vacuum-assisted closure (EVAC), such leaks increasingly are being managed without operative re-intervention and with salvage of the esophageal replacement conduit. For the purposes of this review, we identified studies analyzing the management of postoperative leak after esophagectomy. We then compared the efficacy of the various newer modalities for closure of anastomotic leaks and gastric conduit defects. We found both esophageal stent and EVAC sponges are effective treatments for closure of anastomotic leak. The chosen treatment modality for salvage of the esophageal replacement conduit is entirely dependent on the patient’s clinical status and the surgeon’s preference and experience. Emerging endoscopic and endoluminal therapies have increased the armamentarium of tools the esophageal surgeon has to facilitate successful resolution of anastomotic leaks following esophagectomy with reconstruction. While some literature suggests that EVACs have a slightly superior result in conduit success, we question this endorsement as EVACs mostly are utilized for contained leaks, many of which may have healed with conservative measures. This poses a challenge as there is clearly a bias given patient selection.
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Affiliation(s)
- Amber Famiglietti
- Department of Surgery, Georgetown University School of Medicine, MedStar Washington Hospital Center, Washington, DC, USA
| | - John F. Lazar
- Department of Surgery, Georgetown University School of Medicine, MedStar Washington Hospital Center, Washington, DC, USA
- Division of Thoracic and Esophageal Surgery, Georgetown University School of Medicine, MedStar Washington Hospital Center, Washington, DC, USA
| | - Hayley Henderson
- Department of Surgery, Georgetown University School of Medicine, MedStar Washington Hospital Center, Washington, DC, USA
- Division of Thoracic and Esophageal Surgery, Georgetown University School of Medicine, MedStar Washington Hospital Center, Washington, DC, USA
| | - Margaret Hamm
- Department of Surgery, Georgetown University School of Medicine, MedStar Washington Hospital Center, Washington, DC, USA
- Division of Thoracic and Esophageal Surgery, Georgetown University School of Medicine, MedStar Washington Hospital Center, Washington, DC, USA
| | - Stefanie Malouf
- Department of Surgery, Georgetown University School of Medicine, MedStar Washington Hospital Center, Washington, DC, USA
- Division of Thoracic and Esophageal Surgery, Georgetown University School of Medicine, MedStar Washington Hospital Center, Washington, DC, USA
| | - Marc Margolis
- Department of Surgery, Georgetown University School of Medicine, MedStar Washington Hospital Center, Washington, DC, USA
- Division of Thoracic and Esophageal Surgery, Georgetown University School of Medicine, MedStar Washington Hospital Center, Washington, DC, USA
| | - Thomas J. Watson
- Department of Surgery, Georgetown University School of Medicine, MedStar Washington Hospital Center, Washington, DC, USA
- Division of Thoracic and Esophageal Surgery, Georgetown University School of Medicine, MedStar Washington Hospital Center, Washington, DC, USA
| | - Puja Gaur Khaitan
- Department of Surgery, Georgetown University School of Medicine, MedStar Washington Hospital Center, Washington, DC, USA
- Division of Thoracic and Esophageal Surgery, Georgetown University School of Medicine, MedStar Washington Hospital Center, Washington, DC, USA
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12
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Rogalski P, Swidnicka-Siergiejko A, Wasielica-Berger J, Zienkiewicz D, Wieckowska B, Wroblewski E, Baniukiewicz A, Rogalska-Plonska M, Siergiejko G, Dabrowski A, Daniluk J. Endoscopic management of leaks and fistulas after bariatric surgery: a systematic review and meta-analysis. Surg Endosc 2020; 35:1067-1087. [PMID: 32107632 PMCID: PMC7886733 DOI: 10.1007/s00464-020-07471-1] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Accepted: 02/19/2020] [Indexed: 02/06/2023]
Abstract
Background Endoscopic techniques have become the first-line therapy in bariatric surgery-related complications such as leaks and fistulas. We performed a systematic review and meta-analysis on the effectiveness of self-expandable stents, clipping, and tissue sealants in closing of post-bariatric surgery leak/fistula. Methods A systematic literature search of the Medline/Scopus databases was performed to identify full-text articles published up to February 2019 on the use of self-expandable stents, clipping, or tissue sealants as primary endoscopic strategies used for leak/fistula closure. Meta-analysis of studies reporting stents was performed with the PRISMA guidelines. Results Data concerning the efficacy of self-expanding stents in the treatment of leaks/fistulas after bariatric surgery were extracted from 40 studies (493 patients). The overall proportion of successful leak/fistula closure was 92% (95% CI, 90–95%). The overall proportion of stent migration was 23% (95% CI, 19–28%). Seventeen papers (98 patients) reported the use of clipping: the over-the-scope clips (OTSC) system was used in 85 patients with a successful closure rate of 67.1% and a few complications (migration, stenosis, tear). The successful fistula/leak closure using other than OTSC types was achieved in 69.2% of patients. In 10 case series (63 patients), fibrin glue alone was used with a 92.8–100% success rate of fistula closure that usually required repeated sessions at scheduled intervals. The complications of fibrin glue applications were reported in only one study and included pain and fever in 12.5% of patients. Conclusions Endoscopic techniques are effective for management of post-bariatric leaks and fistulas in properly selected patients. Electronic supplementary material The online version of this article (10.1007/s00464-020-07471-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Pawel Rogalski
- Department of Gastroenterology and Internal Medicine, Medical University of Bialystok, M. Sklodowskiej-Curie 24a, 15-276, Białystok, Poland
| | - Agnieszka Swidnicka-Siergiejko
- Department of Gastroenterology and Internal Medicine, Medical University of Bialystok, M. Sklodowskiej-Curie 24a, 15-276, Białystok, Poland.
| | - Justyna Wasielica-Berger
- Department of Gastroenterology and Internal Medicine, Medical University of Bialystok, M. Sklodowskiej-Curie 24a, 15-276, Białystok, Poland
| | - Damian Zienkiewicz
- Department of Gastroenterology and Internal Medicine, Medical University of Bialystok, M. Sklodowskiej-Curie 24a, 15-276, Białystok, Poland
| | - Barbara Wieckowska
- Department of Computer Science and Statistics, Poznan University of Medical Sciences, Rokietnicka 7 St. (1st floor), 60-806, Poznan, Poland
| | - Eugeniusz Wroblewski
- Department of Gastroenterology and Internal Medicine, Medical University of Bialystok, M. Sklodowskiej-Curie 24a, 15-276, Białystok, Poland
| | - Andrzej Baniukiewicz
- Department of Gastroenterology and Internal Medicine, Medical University of Bialystok, M. Sklodowskiej-Curie 24a, 15-276, Białystok, Poland
| | - Magdalena Rogalska-Plonska
- Department of Infectious Diseases and Hepatology, Medical University of Bialystok, ul. Żurawia 14, 15-540, Białystok, Poland
| | - Grzegorz Siergiejko
- Department of Pediatrics, Gastroenterology, Hepatology, Nutrition and Allergology, Medical University of Bialystok, M. Sklodowskiej-Curie 24a, 15-276, Białystok, Poland
| | - Andrzej Dabrowski
- Department of Gastroenterology and Internal Medicine, Medical University of Bialystok, M. Sklodowskiej-Curie 24a, 15-276, Białystok, Poland
| | - Jaroslaw Daniluk
- Department of Gastroenterology and Internal Medicine, Medical University of Bialystok, M. Sklodowskiej-Curie 24a, 15-276, Białystok, Poland
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13
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Vedantam S, Roberts J. Endoscopic Stents in the Management of Bariatric Complications: Our Algorithm and Outcomes. Obes Surg 2019; 30:1150-1158. [DOI: 10.1007/s11695-019-04284-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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14
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Gastroseal: A Novel Stent Design for the Management of Post-Bariatric Surgery Leaks. ACG Case Rep J 2019; 5:e85. [PMID: 30775388 PMCID: PMC6358575 DOI: 10.14309/crj.2018.85] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Accepted: 08/21/2018] [Indexed: 11/23/2022] Open
Abstract
Bariatric surgery leaks remain a dreaded complication with ominous consequences. Fully covered stents have shown efficacy in the treatment of leaks; however, stent migration remains a major drawback. Ultra-large stents have shown reduced rates of migration and coapt better against the walls, but deep ulcers occur in almost all patients, as well as frequent severe intolerance, bleeding, and perforation. We have developed a large expandable stent with physical characteristics and a particularly flexible mesh design that make it much less traumatic than conventional large stents while maintaining the advantage of being less prone to migration. In this patient with a post-sleeve gastrectomy leak, we provide a proof of concept that the Gastroseal stent is effective and nontraumatic despite its very large size.
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15
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Abstract
Background The aim of this study was to analyze the safety and effectiveness of stenting using partially covered self-expandable stents in palliation of dysphagia in patients with unresectable esophageal cancer. Methods Retrospective analysis of hospital records of all patients who underwent esophageal stenting in the period 2008–2015 was performed. The study included patients with unresectable esophageal and esophagogastric cancer. Results There were 442 patients included. Mean age was 56 years (range 28–89), and 379 were males. In 40 (9.0%) patients, stenting was performed in the cervical, in 150 (39.3%)—in the middle thoracic, in 141 (31.9%)—in lower thoracic esophagus and in 111 (25.1%)—in the esophagogastric junction. Stenting resulted in significant alleviation of dysphagia grade (3.0 vs. 1.0, p = 0.00001). During the follow-up, 55 (12.4%) patients experienced recurrent dysphagia due to tumor or granulation tissue overgrowth, and in 18 (4.1%) patients, migration of the stent occurred, for which an independent risk factor was adjuvant chemo- and/or radiation therapy (p = 0.001). Minor complications included chest pain (54.5%), delayed complete stent expansion (12.0%), feeling of a foreign body (25.3%), hiccup (1.6%), gastroesophageal reflux (45.6%) and post-discharge pneumonia (2.5%). A feeling of a foreign body in the esophagus was significantly more common after stenting of the cervical esophagus (p = 0.0001), and hiccup was more common after stenting of the esophagogastric junction (p = 0.02). Major complications included bleeding (1.3%), respiratory insufficiency (0.7%), esophageal perforation (0.9%) and irregular heartburn (2.3%). Overall procedure-related mortality was 0.4%. The median survival time was 117.8 days (range 2–732). Conclusions Stenting is an effective procedure in relieving dysphagia in patients with unresectable malignant esophageal stenosis and is associated with low rate of postoperative and long-term complications.
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Affiliation(s)
- Janusz R Włodarczyk
- Department of Thoracic and Surgical Oncology, Jagiellonian University Collegium Medicum, John Paul II Hospital, Kraków, Poland. .,Department of Thoracic Surgery, John Paul II Hospital, ul. Prądnicka 80, 31-202, Kraków, Poland.
| | - Jarosław Kużdżał
- Department of Thoracic and Surgical Oncology, Jagiellonian University Collegium Medicum, John Paul II Hospital, Kraków, Poland.,Department of Thoracic Surgery, John Paul II Hospital, ul. Prądnicka 80, 31-202, Kraków, Poland
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Abstract
Esophageal perforation has historically been a devastating condition resulting in high morbidity and mortality. The use of endoluminal therapies to treat esophageal leaks and perforations has grown exponentially over the last decade and offers many advantages over traditional surgical intervention in the appropriate circumstances. New interventional endoscopic techniques, including endoscopic clips, covered metal stents, and endoluminal vacuum therapy, have been developed over the last several years to manage esophageal perforation in an attempt to decrease the related morbidity and mortality.
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Affiliation(s)
- Jeffrey R Watkins
- Division of Thoracic Surgery, Swedish Cancer Institute, 1101 Madison Street Suite 900, Seattle, WA 98104, USA
| | - Alexander S Farivar
- Division of Thoracic Surgery, Swedish Cancer Institute, 1101 Madison Street Suite 900, Seattle, WA 98104, USA.
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17
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van der Bogt RD, Vermeulen BD, Reijm AN, Siersema PD, Spaander MCW. Palliation of dysphagia. Best Pract Res Clin Gastroenterol 2018; 36-37:97-103. [PMID: 30551864 DOI: 10.1016/j.bpg.2018.11.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Accepted: 11/19/2018] [Indexed: 01/31/2023]
Abstract
Palliation of dysphagia is the cornerstone of palliative treatment in patients with incurable oesophageal cancer. Available palliative options for dysphagia are oesophageal stent placement and radiotherapy. In general, oesophageal stent placement is the preferred therapeutic option in patients with a relatively poor prognosis because of its rapid relief of dysphagia. Regardless of ongoing technical developments, recurrence of dysphagia and stent-related complications are still occurring. For patients with a relatively good prognosis, intra-luminal brachytherapy is advised because of its sustained palliation of dysphagia. Due to limited availability of intra-luminal brachytherapy in clinical practice, fractionated external beam radiation therapy is commonly applied as an alternative. Selection of the optimal palliative approach for patients remains however challenging as conclusive high-quality evidence is limited. Moreover, with the introduction of new palliative treatment options (e.g. palliative chemotherapeutic and radiotherapeutic options) and the concurrent change of patient characteristics, supporting evidence from large randomised studies is warranted.
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Affiliation(s)
- R D van der Bogt
- Department of Gastroenterology & Hepatology, Erasmus MC University Medical Centre, Rotterdam, the Netherlands.
| | - B D Vermeulen
- Department of Gastroenterology & Hepatology, Radboud University Medical Centre, Nijmegen, the Netherlands.
| | - A N Reijm
- Department of Gastroenterology & Hepatology, Erasmus MC University Medical Centre, Rotterdam, the Netherlands.
| | - P D Siersema
- Department of Gastroenterology & Hepatology, Radboud University Medical Centre, Nijmegen, the Netherlands.
| | - M C W Spaander
- Department of Gastroenterology & Hepatology, Erasmus MC University Medical Centre, Rotterdam, the Netherlands.
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18
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Endoscopic Management of Post-bariatric Surgery Fistula: a Tertiary Care Center Experience. Obes Surg 2018; 28:3910-3915. [DOI: 10.1007/s11695-018-3432-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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19
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Cheng Y, Gao Y, Chang R, Juma AN, Chen W, Zhang C. Analysis of risk factors and classification of aortic fistula after esophagectomy. J Surg Res 2018; 229:316-323. [PMID: 29937008 DOI: 10.1016/j.jss.2018.04.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 04/02/2018] [Accepted: 04/12/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND Aortic fistula after esophagectomy is a rare and serious complication. The aims of this study were to describe the causes of and classify the fistulas. MATERIALS AND METHODS Between January 2008 and December 2017, a total of 1018 patients underwent esophageal resection, mainly for esophageal cancer; aortic fistula after esophagectomy was diagnosed in four patients. We perform a literature review through a database search for similar cases. Aortic fistulas may be classified into two types based on the site at which they occur in relation to the alimentary tract and area of anastomosis. Type 1 fistula occurs within the area of anastomosis, whereas type 2 fistula occurs above or below the anastomosis. The risk factors and clinical features associated with aortic fistulas are described, and comparison between the two types is made. RESULTS Through a literature search, 39 cases were identified, of which 26 cases were classified as type 1, and 13 cases were classified as type 2. Of 13 patients (33.3%) who underwent emergent intervention, seven patients survived. Approximately 76.9% of aortic fistula were related to anastomotic fistula, which was more prevalent in type 1 aortic fistula than in type 2 (92% versus 50%, P = 0.005). There was no statistically significant difference in age, gender, side of thoracotomy, type of anastomosis, the postoperative day the hemorrhage occurred, warning hemorrhage, chest pain, or the outcome between the two types of fistula. CONCLUSIONS Anastomotic fistula is the primary cause of type 1 aortic fistula after esophagectomy, and early diagnosis and intervention of aortic fistula can improve prognosis. This classification may be a useful guide in determining the approach for second-stage alimentary tract reconstruction.
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Affiliation(s)
- Yuanda Cheng
- Department of Thoracic Surgery of Xiangya Hospital Central South University, Changsha, China
| | - Yang Gao
- Department of Thoracic Surgery of Xiangya Hospital Central South University, Changsha, China
| | - Ruimin Chang
- Department of Thoracic Surgery of Xiangya Hospital Central South University, Changsha, China
| | - Abdillah N Juma
- Department of Surgery, Kilosa Clinical Offficer Training College, Morogoro, Tanzania
| | - Wei Chen
- Department of Thoracic Surgery, The First Affiliated Hospital, Anhui Medical University, Changsha, China
| | - Chunfang Zhang
- Department of Thoracic Surgery of Xiangya Hospital Central South University, Changsha, China.
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20
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Abstract
OPINION STATEMENT PURPOSE OF REVIEW: Esophageal stents are used in clinical practice for endoscopic treatment of a wide variety of esophageal diseases and conditions. This review provides key principles and a literature update on the utility and limitations of esophageal stenting in clinical practice. RECENT FINDINGS Indications for esophageal stenting can be subdivided into two groups. The first group consists of patients with malignant or benign dysphagia, in which an esophageal stent restores luminal patency. In the past years, temporary stent placement has increasingly been used in the therapeutic management of refractory benign esophageal strictures. When endoscopic repeated bougie dilation and other endoscopic treatment modalities have failed, an esophageal stent could be considered. Based on the literature, a fully covered self-expandable metal stent may be the preferred choice for the treatment of both malignant and benign dysphagia. The second group consists of patients with leakage from the esophageal lumen into the surrounding tissue. Esophageal leakage can be subdivided into three forms, benign esophageal perforations (iatrogenic and spontaneous), anastomotic leakage after reconstructive esophageal surgery, and fistula. In a carefully selected group of patients, a covered esophageal stent may be used for sealing off the leakage, thereby preventing further contamination of the tissue surrounding the defect. The past few years, several validated prediction tools have been developed that may assist clinicians in the selection of patients eligible for esophageal stent placement. Based on retrospective studies and expert opinion, a partially or fully covered self-expandable metal stent may have a role in treatment of esophageal leakage. Research do date supports the utilization of esophageal stents for the treatment of malignant or benign dysphagia and esophageal leakage.
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Affiliation(s)
- Bram D Vermeulen
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Geert Grooteplein-Zuid 8 (route 455), 6500, HB, Nijmegen, the Netherlands.
| | - Peter D Siersema
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Geert Grooteplein-Zuid 8 (route 455), 6500, HB, Nijmegen, the Netherlands
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21
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Herbold T, Chon SH, Grimminger P, Maus MKH, Schmidt H, Fuchs H, Brinkmann S, Bludau M, Gutschow C, Schröder W, Hölscher AH, Leers JM. Endoscopic Treatment of Transesophageal Echocardiography-Induced Esophageal Perforation. J Laparoendosc Adv Surg Tech A 2018; 28:422-428. [PMID: 29327976 DOI: 10.1089/lap.2017.0559] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Perforation of the esophagus is the most severe complication of transesophageal echocardiography (TEE) and can lead to mediastinitis, pleural empyema, or peritonitis. Currently, the majority of patients receive operative treatment with only 6% treated endoscopically. We report our experience with endoscopic and conservative approaches. METHODS We retrospectively reviewed all patients treated for esophageal perforation and included all patients with perforation caused by TEE. All patients with perforation of the esophagus by TEE probe underwent conservative or endoscopic treatment, drainage of pleural and mediastinal retentions, and adjusted to antibiotic therapy. RESULTS From January 2004 to December 2014 a total of 109 patients were treated for esophageal perforation in our department. In 6 patients (5.5%) the perforation was caused by TEE. Location was cervical and midthoracic in 2 and 4 cases, respectively. All patients underwent successful endoscopic treatment and no further surgical procedure, such as esophageal suture or resection was necessary. The mean time between TEE and therapy of the perforation was 7.3 days. In all patients closure of the leakage could be achieved within 30 days. Mortality rate was 0%. CONCLUSIONS Esophageal perforations caused by TEE are typically small, in the cervical and mid esophagus, and minimally contaminated. These are good prognostic factors for successful endoscopic treatment with preservation of the esophagus. Operative treatment should only be considered in cases of failed endoscopic treatment.
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Affiliation(s)
- Till Herbold
- 1 Department of General-, Visceral- and Tumor-Surgery, University of Aachen , Aachen, Germany .,2 Department of General, Visceral Surgery, and Surgical Oncology, University of Cologne , Cologne, Germany
| | - Seung-Hun Chon
- 2 Department of General, Visceral Surgery, and Surgical Oncology, University of Cologne , Cologne, Germany
| | - Peter Grimminger
- 3 Department of General, Visceral, and Transplant Surgery, University of Mainz , Mainz, Germany
| | - Martin K H Maus
- 2 Department of General, Visceral Surgery, and Surgical Oncology, University of Cologne , Cologne, Germany
| | - Henner Schmidt
- 4 Department of Visceral and Transplant Surgery, University Hospital of Zürich , Zürich, Switzerland
| | - Hans Fuchs
- 2 Department of General, Visceral Surgery, and Surgical Oncology, University of Cologne , Cologne, Germany
| | - Sebastian Brinkmann
- 2 Department of General, Visceral Surgery, and Surgical Oncology, University of Cologne , Cologne, Germany
| | - Marc Bludau
- 2 Department of General, Visceral Surgery, and Surgical Oncology, University of Cologne , Cologne, Germany
| | - Christian Gutschow
- 4 Department of Visceral and Transplant Surgery, University Hospital of Zürich , Zürich, Switzerland
| | - Wolfgang Schröder
- 2 Department of General, Visceral Surgery, and Surgical Oncology, University of Cologne , Cologne, Germany
| | - Arnulf H Hölscher
- 2 Department of General, Visceral Surgery, and Surgical Oncology, University of Cologne , Cologne, Germany
| | - Jessica M Leers
- 2 Department of General, Visceral Surgery, and Surgical Oncology, University of Cologne , Cologne, Germany
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23
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Gastroseal: A Novel Stent Design for the Management of Post-Bariatric Surgery Leaks. ACG Case Rep J 2018. [DOI: 10.14309/02075970-201805120-00001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Sdralis EIK, Petousis S, Rashid F, Lorenzi B, Charalabopoulos A. Epidemiology, diagnosis, and management of esophageal perforations: systematic review. Dis Esophagus 2017; 30:1-6. [PMID: 28575240 DOI: 10.1093/dote/dox013] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Indexed: 12/11/2022]
Abstract
We performed a systematic review of epidemiological, diagnostic, and therapeutic outcomes of esophageal perforations. A systematic review was performed in PubMed database using the key-phrase 'esophageal perforation'. All studies regarding acute esophageal perforations were reviewed and parameters of epidemiology, diagnosis, and management published in the literature from 2005 up to 2015 were included in the study. Studies of postoperative esophageal leaks were excluded. Two researchers performed individually the research, while quality assessment was performed according to GRADE classification. Main outcomes and exposure were overall mortality, perforation-to-admission interval, anatomical position, cause, prevalent symptom at admission, diagnostic tests used, type of initial management (conservative or surgery), healing rate, and fistula complication. There were 1319 articles retrieved, of which 52 studies including 2,830 cases finally met inclusion criteria. Mean duration of study period was 15.2 years. Mean patient age was 58.4 years. Out of 52 studies included, there were 43 studies of very low or low quality included. The overall mortality rate according to extracted data was 13.3% (n = 214, 1,644 patients, 39 studies). Admission before 24 hours was reported in 58.1% of patients (n = 514). Position was thoracic in 72.6% of patients (n = 813, 1,120 patients, 20 studies). Mean cause of perforation was iatrogenic in 46.5% of patients (n = 899, 1,933 patients, 40 studies). Initial management was conservative in 51.3% of cases (n = 904, 1,762 patients, 41 studies) CT confirmed diagnosis in 38.7% of overall cases in which it was used as imaging diagnostic procedure (n = 266), X-ray in 36.6% (n = 231), and endoscopy in 37.4% (n = 343). Sepsis on admission was observed in 23.3% of cases (209 out of 898 patients, 16 studies). The present systematic review highlighted the significant proportion of cases diagnosed with delay over 24 hours, mortality rates ranging over 10% and no consensus regarding optimal therapeutic approach and optimal diagnostic management. As esophageal perforation represents a high-risk clinical condition without consensus regarding optimal management, there should be large multicenter prospective studies or Randomized Controlled Trial (RCT)s performed in order to advance diagnostic and therapeutic approach of such challenging pathology.
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Affiliation(s)
- E Ilias K Sdralis
- Department of Upper Gastrointestinal Surgery, Broomfield Hospital, Mid Essex Hospital Services NHS Trust, England, UK.,Department of Surgery, 424 General Military Hospital, Eukarpia, Thessaloniki, Greece
| | - S Petousis
- Department of Surgery, 424 General Military Hospital, Eukarpia, Thessaloniki, Greece
| | - F Rashid
- Department of Upper Gastrointestinal Surgery, Broomfield Hospital, Mid Essex Hospital Services NHS Trust, England, UK
| | - B Lorenzi
- Department of Upper Gastrointestinal Surgery, Broomfield Hospital, Mid Essex Hospital Services NHS Trust, England, UK
| | - A Charalabopoulos
- Department of Upper Gastrointestinal Surgery, Broomfield Hospital, Mid Essex Hospital Services NHS Trust, England, UK
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Rieder E, Asari R, Paireder M, Lenglinger J, Schoppmann SF. Endoscopic stent suture fixation for prevention of esophageal stent migration during prolonged dilatation for achalasia treatment. Dis Esophagus 2017; 30:1-6. [PMID: 28375470 DOI: 10.1093/dote/dow002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Indexed: 02/07/2023]
Abstract
The aim of this study is to compare endoscopic stent suture fixation with endoscopic clip attachment or the use of partially covered stents (PCS) regarding their capability to prevent stent migration during prolonged dilatation in achalasia. Large-diameter self-expanding metal stents (30 mm × 80 mm) were placed across the gastroesophageal junction in 11 patients with achalasia. Stent removal was scheduled after 4 to 7 days. To prevent stent dislocation, endoscopic clip attachment, endoscopic stent suture fixation, or PCS were used. The Eckardt score was evaluated before and 6 months after prolonged dilatation. After endoscopic stent suture fixation, no (0/4) sutured stent migrated. When endoscopic clips were used, 80% (4/5) clipped stents migrated (p = 0.02). Of two PCS (n = 2), one migrated and one became embedded leading to difficult stent removal. Technical adverse events were not seen in endoscopic stent suture fixation but were significantly correlated with the use of clips or PCS (r = 0.828, p = 0.02). Overall, 72% of patients were in remission regarding their achalasia symptoms 6 months after prolonged dilatation. Endoscopic suture fixation of esophageal stents but not clip attachment appears to be the best method of preventing early migration of esophageal stents placed at difficult locations such as at the naive gastroesophageal junction.
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Sousa P, Castanheira A, Martins D, Pinho J, Araújo R, Cancela E, Ministro P, Silva A. Treatment of Postoperative Leaks of the Upper Gastrointestinal Tract with Colonic Self-Expandable Metal Stents. GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2016; 24:169-175. [PMID: 29255746 DOI: 10.1159/000453115] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Revised: 10/30/2016] [Indexed: 01/28/2023]
Abstract
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.
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Affiliation(s)
- Paula Sousa
- Gastroenterology Department, Centro Hospitalar Tondela/Viseu, Viseu, Portugal
| | - António Castanheira
- Gastroenterology Department, Centro Hospitalar Tondela/Viseu, Viseu, Portugal
| | - Diana Martins
- Gastroenterology Department, Centro Hospitalar Tondela/Viseu, Viseu, Portugal
| | - Juliana Pinho
- Gastroenterology Department, Centro Hospitalar Tondela/Viseu, Viseu, Portugal
| | - Ricardo Araújo
- Gastroenterology Department, Centro Hospitalar Tondela/Viseu, Viseu, Portugal
| | - Eugénia Cancela
- Gastroenterology Department, Centro Hospitalar Tondela/Viseu, Viseu, Portugal
| | - Paula Ministro
- Gastroenterology Department, Centro Hospitalar Tondela/Viseu, Viseu, Portugal
| | - Américo Silva
- Gastroenterology Department, Centro Hospitalar Tondela/Viseu, Viseu, Portugal
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Emerging Trends in the Etiology, Prevention, and Treatment of Gastrointestinal Anastomotic Leakage. J Gastrointest Surg 2016; 20:2035-2051. [PMID: 27638764 DOI: 10.1007/s11605-016-3255-3] [Citation(s) in RCA: 120] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Accepted: 08/12/2016] [Indexed: 02/08/2023]
Abstract
Anastomotic leaks represent one of the most alarming complications following any gastrointestinal anastomosis due to the substantial effects on post-operative morbidity and mortality of the patient with long-lasting effects on the functional and oncologic outcomes. There is a lack of consensus related to the definition of an anastomotic leak, with a variety of options for prevention and management. A number of patient-related and technical risk factors have been found to be associated with the development of an anastomotic leak and have inspired the development of various preventative measures and technologies. The International Multispecialty Anastomotic Leak Global Improvement Exchange group was convened to establish a consensus on the definition of an anastomotic leak as well as to discuss the various diagnostic, preventative, and management measures currently available.
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Li Y, Wu JH, Meng Y, Zhang Q, Gong W, Liu SD. New devices and techniques for endoscopic closure of gastrointestinal perforations. World J Gastroenterol 2016; 22:7453-7462. [PMID: 27672268 PMCID: PMC5011661 DOI: 10.3748/wjg.v22.i33.7453] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2016] [Revised: 05/30/2016] [Accepted: 06/15/2016] [Indexed: 02/06/2023] Open
Abstract
Gastrointestinal perforations, which need to be managed quickly, are associated with high morbidity and mortality. Treatments used to close these perforations range from surgery to endoscopic therapy. Nowadays, with the development of new devices and techniques, endoscopic therapy is becoming more popular. However, there are different indications and clinical efficacies between different methods, because of the diverse properties of endoscopic devices and techniques. Successful management also depends on other factors, such as the precise location of the perforation, its size and the length of time between the occurrence and diagnosis. In this study, we performed a comprehensive review of various devices and introduced the different techniques that are considered effective to treat gastrointestinal perforations. In addition, we focused on the different methods used to achieve successful closure, based on the literature and our clinical experiences.
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Efficacy of endoscopic management of leak after foregut surgery with endoscopic covered self-expanding metal stents (SEMS). Surg Endosc 2016; 31:612-617. [PMID: 27317034 DOI: 10.1007/s00464-016-5005-8] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Accepted: 05/23/2016] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Anastomotic or staple-line leak after foregut surgery presents a formidable management challenge. In recent years, with advancement of endoscopy, self-expanding covered stents have been gaining popularity. In this study, we aimed to determine the safety and effectiveness of self-expanding covered stents in management of leak after foregut surgery. METHODS Consecutive patients who received a fully covered self-expandable metal stent (SEMS) due to an anastomotic leak after upper gastrointestinal surgery between 2009 and 2014 were retrospectively reviewed. Demographic data, stent placement and removal, clinical success, time to resolution, and complications were collected. Predictive factors for clinical success rate were assessed. RESULTS A total of 20 consecutive patients underwent placement of fully covered SEMS for anastomotic leak, following esophagectomy (n = 5), esophageal diverticulectomy (n = 1), gastric sleeve (n = 4), gastric bypass (n = 3), partial gastrectomy (n = 4), and total gastrectomy (n = 3). All the stents were removed successfully, and clinical resolution was achieved in 18 patients (90 %) after a median of two (range 1-3) procedures and a mean of 6.2 weeks (range 0.4-14). Complications presented in 12 patients (60 %), including stent migration (n = 8), mucosal friability (n = 4), tissue integration (n = 2), and bleeding (n = 2). Two (10 %) patients' treatment was complicated by aorto-esophageal fistula formation resulting in one death. Demographic factors, comorbidities, and type of surgery were not predictive of clinical success rate or time to resolution. CONCLUSION SEMS are effective tools for the management of leaks after foregut surgery. The biggest challenge with this approach is stent migration. Caution is warranted due to the risk of fatal complications such as aorto-esophageal fistula formation. No type of surgery or particular patient factor, including age, sex, BMI, albumin, history of radiation, malignancy, and comorbid diabetes or coronary artery disease, appeared to be correlated with success rate. Larger studies are needed to determine factors predictive of clinical success.
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