Self-expandable stents for benign esophageal leakages and perforations: long-term single-center experience

British Society of Gastroenterology (BSG) and British Society of Paediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN) joint consensus guidelines on the diagnosis and management of eosinophilic oesophagitis in children and adults

BACKGROUND

Eosinophilic oesophagitis (EoE) is an increasingly common cause of dysphagia in both children and adults, as well as one of the most prevalent oesophageal diseases with a significant impact on physical health and quality of life. We have provided a single comprehensive guideline for both paediatric and adult gastroenterologists on current best practice for the evaluation and management of EoE.

METHODS

The Oesophageal Section of the British Society of Gastroenterology was commissioned by the Clinical Standards Service Committee to develop these guidelines. The Guideline Development Group included adult and paediatric gastroenterologists, surgeons, dietitians, allergists, pathologists and patient representatives. The Population, Intervention, Comparator and Outcomes process was used to generate questions for a systematic review of the evidence. Published evidence was reviewed and updated to June 2021. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system was used to assess the evidence and make recommendations. Two rounds of voting were held to assess the level of agreement and the strength of recommendations, with 80% consensus required for acceptance.

RESULTS

Fifty-seven statements on EoE presentation, diagnosis, investigation, management and complications were produced with further statements created on areas for future research.

CONCLUSIONS

These comprehensive adult and paediatric guidelines of the British Society of Gastroenterology and British Society of Paediatric Gastroenterology, Hepatology and Nutrition are based on evidence and expert consensus from a multidisciplinary group of healthcare professionals, including patient advocates and patient support groups, to help clinicians with the management patients with EoE and its complications.

Endoscopic vacuum therapy for the management of upper GI leaks and perforations: a multicenter retrospective study of factors associated with treatment failure (with video)

BACKGROUND AND AIMS

The optimal management of upper GI (UGI) leaks and perforations remains controversial. Endoscopic vacuum therapy (EVT) is a new alternative endoscopic treatment that has recently shown a high rate of successful closure of UGI leaks and perforations. However, only few reports have been made on the factors that affect clinical success rates.

METHODS

Four referral hospitals participated in this retrospective multicenter study. Between September 2015 and February 2020, 119 patients who underwent EVT for a UGI perforation or leak were included. We retrospectively evaluated the clinical outcomes of EVT and the factors associated with EVT failure. Neoadjuvant treatments included chemotherapy, radiotherapy, or chemoradiotherapy before surgery, and the intraluminal method meant that the sponge was placed directly onto the defect within the lumen of UGI tract.

RESULTS

Among 119 patients, 84 showed clinical success (70.6%). Eighty-nine patients (74.8%) underwent EVT as primary therapy and 30 patients as rescue therapy. On multivariate analysis, neoadjuvant treatment and the intraluminal method were significant independent risk factors for EVT failure. During the follow-up period (median, 8.46 months), stenosis occurred in 22 patients (18.5%). The overall survival rate of the EVT success group was significantly higher than that of the EVT failure group. Twenty-two patients died because of non-EVT-related causes, and 7 patients died because of leakage-related adverse events. No death was caused by the EVT itself.

CONCLUSIONS

EVT is a promising treatment method for UGI leaks and perforations. Further studies are needed to establish the indications for successful EVT.

Current status in endoscopic management of upper gastrointestinal perforations, leaks and fistulas

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.

Individualized endoscopic management strategy for impacting jujube pits in the upper gastrointestinal tract: a 3-year single-center experience in northern China

Background

Impaction of jujube pits in the upper gastrointestinal (GI) tract is a special clinical condition in the northern Chinese population. Endoscopic removal is the preferred therapy, but there is no consensus on the management strategies. We reported our individualized endoscopic strategies on the jujube pits impacted in the upper GI tract.

Methods

In this retrospective study, we included 191 patients (male: 57; female: 134) who presented to our hospital with ingestion of jujube pits between January 2015 and December 2017. Demographic information, times of hospital visiting, locations of jujube pits, endoscopic procedures, post-extraction endoscopic characteristics were analyzed. Management strategies including sufficient suction, repeated irrigation, jejunal nutrition and gastrointestinal decompression were given based on post-extraction endoscopic characteristics and impacted locations.

Results

Peak incidence was in the second quarter of each year (85/191 cases, 44.5%). Among the 191 cases, 169 (88.5%) showed pits impaction in the esophagus, 20 (10.5%) in the prepyloric region and 2 (1.0%) in the duodenal bulb. A total of 185 patients (96.9%) had pits removed with alligator jaw forceps, and 6 (3.1%) underwent suction removal with transparent caps placed over the end of the endoscope to prevent injury on removal of these pits with two sharp painted edges. Post-extraction endoscopic manifestations included mucosal erosion (26.7%), mucosa laceration (24.6%), ulceration with a white coating (18.9%) and penetrating trauma with pus cavity formation (29.8%). All patients received individualized endoscopic and subsequent management strategies and showed good outcomes.

Conclusions

Individualized endoscopic management for impacted jujube pits in the upper GI tract based on post-extraction endoscopic characteristics and impacted locations was safe, effective, and minimally invasive.

Gastrointestinal fistula endoscopic closure techniques

With the improvement in flexible endoscopic technology and the availability of new endoscopic devices, current endoscopic therapies spare many patients who would otherwise undergo surgical repair of gastrointestinal fistulas. These endoscopic techniques include gastrointestinal stents, endoscopic suturing, cardiac septal occluders, endo-sponge, vacuum therapy and others. This review elaborates on the indications, evidence, procedural details, efficacy, and complications of various endoscopic techniques for the management of gastrointestinal fistulas.

Diagnosis and management of iatrogenic endoscopic perforations: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement - Update 2020

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.

Early diagnosis is associated with improved clinical outcomes in benign esophageal perforation: an individual patient data meta-analysis

Background

Time of diagnosis (TOD) of benign esophageal perforation is regarded as an important risk factor for clinical outcome, although convincing evidence is lacking. The aim of this study is to assess whether time between onset of perforation and diagnosis is associated with clinical outcome in patients with iatrogenic esophageal perforation (IEP) and Boerhaave’s syndrome (BS).

Methods

We searched MEDLINE, Embase and Cochrane library through June 2018 to identify studies. Authors were invited to share individual patient data and a meta-analysis was performed (PROSPERO: CRD42018093473). Patients were subdivided in early (≤ 24 h) and late (> 24 h) TOD and compared with mixed effects multivariable analysis while adjusting age, gender, location of perforation, initial treatment and center. Primary outcome was overall mortality. Secondary outcomes were length of hospital stay, re-interventions and ICU admission.

Results

Our meta-analysis included IPD of 25 studies including 576 patients with IEP and 384 with BS. In IEP, early TOD was not associated with overall mortality (8% vs. 13%, OR 2.1, 95% CI 0.8–5.1), but was associated with a 23% decrease in ICU admissions (46% vs. 69%, OR 3.0, 95% CI 1.2–7.2), a 22% decrease in re-interventions (23% vs. 45%, OR 2.8, 95% CI 1.2–6.7) and a 36% decrease in length of hospital stay (14 vs. 22 days, p < 0.001), compared with late TOD. In BS, no associations between TOD and outcomes were found. When combining IEP and BS, early TOD was associated with a 6% decrease in overall mortality (10% vs. 16%, OR 2.1, 95% CI 1.1–3.9), a 19% decrease in re-interventions (26% vs. 45%, OR 1.9, 95% CI 1.1–3.2) and a 35% decrease in mean length of hospital stay (16 vs. 22 days, p = 0.001), compared with late TOD.

Conclusions

This individual patient data meta-analysis confirms the general opinion that an early (≤ 24 h) compared to a late diagnosis (> 24 h) in benign esophageal perforations, particularly in IEP, is associated with improved clinical outcome.

Electronic supplementary material

The online version of this article (10.1007/s00464-020-07806-y) contains supplementary material, which is available to authorized users.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Outcome after iatrogenic esophageal perforation

OBJECTIVES

Iatrogenic perforations are the most common cause of esophageal perforation. We present our experience mainly based on a non-operative treatment approach as well as long-term outcome in these patients.

MATERIALS AND METHODS

Twenty-one patients were treated for iatrogenic esophageal perforation at Oslo University Hospital, Ullevål from February 2007 to March 2014. The etiology of perforation was dilation of benign stricture in eight patients, either dilation, stenting or stent removal in four with malignant stenosis, during diagnostic endoscopy in four, removal of foreign body in two and by other causes in three patients, respectively. After median 82 months, 10 patients alive (47.6%) were sent questionnaires about dysphagia, HRQoL and fatigue.

RESULTS

Median age at time of treatment was 66 years. Median in-hospital stay and mortality were 10.5 days and 4.8%, respectively. Initial treatment in 15 patients (71.4%) was non-surgical of whom one needed delayed debridement for pleural empyema. Initial treatment in six patients (28.6%) was surgical of whom three needed delayed stenting. Altogether 14 patients (66.7%) were stented. Eight (57.1%) had restenting. Median number of stents used was 1 (1-4). The stents were removed after median 36 days. The perforations healed after 2.5 months. After median 82 months, the patients reported reduced HRQoL. There was no significant difference regarding level of dysphagia and fatigue.

CONCLUSIONS

We report satisfactorily short-term and long-term results of iatrogenic esophageal perforations. Mortality was low and HRQoL was deteriorated. Dysphagia and fatigue were comparable to a reference population.

Endoluminal Therapies for Esophageal Perforations and Leaks

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.

Influence of Different Lengths of Rubber Tube on Patients After Esophageal Stent Implantation Using a Silk Thread

Our objective was to compare the efficacy of different lengths of rubber tube (6 French) on patients with esophageal stent implantation performed using a silk thread. We measured the effects in terms of pain and foreign body sensation felt in the pharynx and esophageal mucosa of the patients. A retrospective analysis was conducted using records of 65 patients who were divided into 3 groups. Group A had 20 cases with the distal end of the tube toward the nasal cavity, Group B had 21 cases with the distal end of the tube reaching the nasopharynx without exceeding the soft palate, and Group C had 24 cases with the distal end of the tube toward the upper end of the stent. Follow-up was performed on 1 day, 2 days, 1 week, 2 weeks, 4 weeks, 6 weeks, and 8 weeks postoperatively. During each period, the pain scores for Groups B and C were lower than those for Group A (p < .05), whereas no difference was observed when Groups B and C were compared. Although no variations were seen between the 3 groups in terms of the proportion of patients with foreign body sensation on the first day (p > .05), Groups A and B had a lower proportion than Group C (p < .05) at those periods. No difference was observed when Groups A and B were compared. In conclusion, the Group B method was successful in alleviating the side effects caused by the silk thread.

Clinical Outcomes, Efficacy, and Adverse Events in Patients Undergoing Esophageal Stent Placement for Benign Indications: A Large Multicenter Study

INTRODUCTION

Esophageal stents are commonly used to treat benign esophageal conditions including refractory benign esophageal strictures, anastomotic strictures, fistulae, perforations and anastomotic leaks. Data on outcomes in these settings remain limited.

METHODS

We performed a retrospective multicenter study of patients who underwent fully or partially covered self-expandable stent placement for benign esophageal diseases. Esophageal stent placements were performed for the following indications: (1) benign refractory esophageal strictures, (2) surgical anastomotic strictures, (3) esophageal perforations, (4) esophageal fistulae, and (5) surgical anastomotic leaks.

RESULTS

A total of 70 patients underwent esophageal stent placement for benign esophageal conditions. A total of 114 separate procedures were performed. The most common indication for esophageal stent placement was refractory benign esophageal stricture (48.2%). Global treatment success rate was 55.7%. Treatment success rate was 33.3% in refractory benign strictures, 23.1% in anastomotic strictures, 100% in perforations, 71.4% in fistulae, and 80% in anastomotic leaks. Stent migration was noted in 28 of 70 patients (40%), most commonly seen in refractory benign strictures.

CONCLUSIONS

This is one of the largest studies to date of esophageal stents to treat benign esophageal diseases. Success rates are lowest in benign esophageal strictures. These patients have few other options beyond chronic dilations, feeding tubes, and surgery, and fully covered self-expandable metallic stent give patients a chance to have their problem fixed endoscopically and still eat by mouth. Perforations, fistulas, and leaks respond very well to esophageal stenting, and stenting should be considered as a first-line therapy in these settings.

Endoscopic modalities for upper gastrointestinal leaks, fistulae and perforations

Background

Endotherapy techniques are a recent addition to the suite of non‐surgical and minimally invasive strategies to manage patients with perforations, leaks and fistulae. The emergency nature of these conditions and the heterogeneity of pathologies encountered create difficulties when trying to select appropriate tools in these complex situations. The purpose of this article is to review experience at a tertiary academic centre, describe the various endoscopic tools available and the situations where they can be considered for use.

Methods

Single‐centre series and review of the published literature.

Results

Of 64 patients, 57 were successfully treated using endoscopic therapy, with surgery used only to provide drainage and suture fully covered metal stents in place to prevent migration.

Discussion

Selection of an appropriate endotherapy or stent for a patient with an oesophago‐gastric perforation or fistula requires an understanding of the anatomy and physiology underlying the patient's presentation and an understanding of the strengths and weaknesses of the available methods. Standard surgical principles of drainage, avoidance of distal obstruction and nutrition remain central to successful outcomes. A combination of surgical and endoscopic treatments may reduce the number of required treatments and can provide the ability to anchor fully covered stents to prevent them from migrating.

Clinical outcomes of self-expandable stent placement for benign esophageal diseases: A pooled analysis of the literature

AIM

To analyze the outcomes of self-expandable stent placement for benign esophageal strictures and benign esophageal leaks in the literature.

METHODS

The PubMed, Embase and Cochrane databases were searched for relevant articles published between January 2000 and July 2014. Eight prospective studies were identified that analyzed the outcomes of stent placement for refractory benign esophageal strictures. The outcomes of stent placement for benign esophageal leaks, perforations and fistulae were extracted from 20 retrospective studies that were published after the inclusion period of a recent systematic review. Data were pooled and analyzed using descriptive statistics.

RESULTS

Fully covered self-expandable metal stents (FC SEMS) (n = 85), biodegradable (BD) stents (n = 77) and self-expandable plastic stents (SEPS) (n = 70) were inserted in 232 patients with refractory benign esophageal strictures. The overall clinical success rate was 24.2% and according to stent type 14.1% for FC SEMS, 32.9% for BD stents and 27.1% for SEPS. Stent migration occurred in 24.6% of cases. The overall complication rate was 31.0%, including major (17.7%) and minor (13.4%) complications. A total of 643 patients were treated with self-expandable stents mainly for postsurgical leaks (64.5%), iatrogenic perforations (19.6%), Boerhaave's syndrome (7.8%) and fistulae (3.7%). FC SEMS and partially covered SEMS were used in the majority of patients. Successful closure of the defect was achieved in 76.8% of patients and according to etiology in 81.4% for postsurgical leaks, 86.0% for perforations and 64.7% for fistulae. The pooled stent migration rate was 16.5%. Stent-related complications occurred in 13.4% of patients, including major (7.8%) and minor (5.5%) complications.

CONCLUSION

The outcomes of stent placement for refractory benign esophageal strictures were poor. However, randomized trials are needed to put this into perspective. The evidence on successful stent placement for benign esophageal leaks, perforations and fistulae is promising.

Temporary insertion of a covered self-expandable metal stent to treat esophageal perforation due to endoscopic submucosal dissection

There are no previous reports of esophageal perforation due to endoscopic submucosal dissection developing into pyothorax. We herein describe a case of esophageal healing following perforation in a 60-year-old woman undergoing esophageal endoscopic submucosal dissection. Post-procedural computed tomography revealed pyothorax in the right thoracic cavity, compressing the right lung. The pyothorax did not improve despite treatment with thoracic drainage because the esophageal lumen was connected to the right thoracic cavity. In order to close the site of esophageal perforation, we inserted a covered self-expandable metal stent. The affected site subsequently healed without complications, allowing the drainage tube and stent to be removed.

Timing of esophageal stent placement and outcomes in patients with esophageal perforation: a single-center experience

BACKGROUND

Endoscopic treatment for esophageal perforation with stenting is an alternative to surgery. There is no data on the impact of timing of esophageal stent placement and outcomes in patients with esophageal perforation.

OBJECTIVE

To determine the significance of timing of esophageal stent placement on short-term (30-day complications) and long-term clinical outcomes of patients with esophageal perforation.

METHODS

Patients with esophageal perforations who underwent endoscopic treatment with stenting from 2007 to 2012 at the Cleveland Clinic were included for the study. Main outcomes measurements were impact of time to esophageal stent placement on 30-day complications and long-term outcomes.

RESULTS

A total of 20 patients (males 40 % and females 60 %) were included. Mean age was 72.5 ± 10 years. The most common etiology for perforation was iatrogenic after endoscopy procedure in 10 (50 %) patients. The stent was in place for a median of 24.6 days in our cohort. Eight patients (40 %) had stent placement within 24 h, while the remaining 12 patients (60 %) had stent placement after 24 h. The mortality rate due to perforation related causes was 10 % (2/20) in our study. The 30-day complication rate was 10 %; 1 with stent migration and the other with chest pain. The 30-day readmission rates excluding patients who died during the initial hospitalization were 10 %. On long-term follow-up, 30 % complication rates were encountered; 3 (15 %) stent migrations, 2 (10 %) patients presented with hematemesis, and 1 (5 %) with chest pain. The timing of stent placement (within 24 h or later) did not impact the risk of complications (Odds Ratio [OR] 1.13, 95 % confidence interval 0.1-8.9, P = 0.91).

CONCLUSIONS

Endoscopic stent placement is safe and effective for treating esophageal perforations. However, the timing of stent placement on outcomes remains unclear.