Covered Biodegradable Stent: New Therapeutic Option for the Management of Esophageal Perforation or Anastomotic Leak

Management of fistulas in the upper gastrointestinal tract

Fistulas in the upper gastrointestinal (GI) tract are complex conditions associated with elevated morbidity and mortality. They may arise as a result of inflammatory or malignant processes or following medical procedures, including endoscopic and surgical interventions. The management of upper GI is often challenging and requires a multidisciplinary approach. Accurate diagnosis, including endoscopic and radiological evaluations, is crucial to build a proper and personalized therapeutic plan, that should take into account patient's clinical conditions, time of onset, size, and anatomical characteristics of the defect. In recent years, several endoscopic techniques have been introduced for the minimally invasive management of upper GI fistulas, including through-the-scope and over-the-scope clips, stents, endoscopic suturing, endoluminal vacuum therapy (EVT), tissue adhesives, endoscopic internal drainage. This review aims to discuss and detail the current available endoscopic techniques for the treatment of upper GI fistulas.

Endoscopic Management of Postoperative Esophageal and Upper GI Defects-A Narrative Review

Anastomotic defects are deleterious complications after either oncologic or bariatric surgery, leading to high morbidity and mortality. Besides surgical revision in early stages or instable patients, endoscopic treatment has become the mainstay. To date, many options for endoscopic treatment in this setting exist, including fully covered metal stent placement, endoscopic vacuum therapy (EVT), endoscopic internal drainage with pigtail placement (EID), leak closure with through the scope or over the scope clips, endoluminal suturing, fibrin glue sealing and a combination of all these techniques. Current evidence is mostly based on retrospective single and multicenter studies. No guidelines exist in this important field. Treatment options have to be chosen upon each case individually, taking into account clinical and anatomic criteria, such as timing, size, infectious wound complications and hemodynamic stability. Local expertise and availability of treatment devices need to be taken into account whenever choosing a treatment strategy. This review aimed to present current treatment options in terms of effectiveness, advantages and disadvantages in order to guide the clinician for his decision making. Additionally, we aimed to provide a treatment algorithm.

Use of double-layered covered esophageal stents in post-surgical esophageal leaks and esophageal perforation: Our experience

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.

A Complex In Vitro Degradation Study on Polydioxanone Biliary Stents during a Clinically Relevant Period with the Focus on Raman Spectroscopy Validation

Biodegradable biliary stents are promising treatments for biliary benign stenoses. One of the materials considered for their production is polydioxanone (PPDX), which could exhibit a suitable degradation time for use in biodegradable stents. Proper material degradation characteristics, such as sufficient stiffness and disintegration resistance maintained for a clinically relevant period, are necessary to ensure stent safety and efficacy. The hydrolytic degradation of commercially available polydioxanone biliary stents (ELLA-CS, Hradec Králové, Czech Republic) in phosphate-buffered saline (PBS) was studied. During 9 weeks of degradation, structural, physical, and surface changes were monitored using Raman spectroscopy, differential scanning calorimetry, scanning electron microscopy, and tensile and torsion tests. It was found that the changes in mechanical properties are related to the increase in the ratio of amorphous to crystalline phase, the so-called amorphicity. Monitoring the amorphicity using Raman spectroscopy has proven to be an appropriate method to assess polydioxanone biliary stent degradation. At the 1732 cm⁻¹ Raman peak, the normalized shoulder area is less than 9 cm⁻¹ which indicates stent disintegration. The stent disintegration started after 9 weeks of degradation in PBS, which agrees with previous in vitro studies on polydioxanone materials as well as with in vivo studies on polydioxanone biliary stents.

Endoscopic Management for Post-Surgical Complications after Resection of Esophageal Cancer

Simple Summary

Flexible endoscopy has an important part in the diagnosis and treatment of postoperative complications after oncologically intended esophagectomy. Endoscopy offers the possibility of effective therapy with minimal invasiveness at the same time, and the use of endoscopic therapy procedures can avoid re-operations. In this review we present the advantages of endoscopic treatment opportunities during the last 20 years regarding patients’ treatment after esophageal cancer resection. According to prevalence and clinical relevance, four relevant postoperative complications were identified and their endoscopic treatment procedures discussed. All endoscopic therapy procedures for anastomotic bleeding, anastomotic insufficiencies, anastomotic stenosis and postoperative delayed gastric emptying are presented, including innovative developments.

Abstract

Background: Esophageal cancer (EC) is the sixth-leading cause of cancer-related deaths in the world. Esophagectomy is the most effective treatment for patients without invasion of adjacent organs or distant metastasis. Complications and relevant problems may occur in the early post-operative course or in a delayed fashion. Here, innovative endoscopic techniques for the treatment of postsurgical problems were developed during the past 20 years. Methods: Endoscopic treatment strategies for the following postoperative complications are presented: anastomotic bleeding, anastomotic insufficiency, delayed gastric passage and anastomotic stenosis. Based on a literature review covering the last two decades, therapeutic procedures are presented and analyzed. Results: Addressing the four complications mentioned, clipping, stenting, injection therapy, dilatation, and negative pressure therapy are successfully utilized as endoscopic treatment techniques today. Conclusion: Endoscopic treatment plays a major role in both early-postoperative and long-term aftercare. During the past 20 years, essential therapeutic measures have been established. A continuous development of these techniques in the field of endoscopy can be expected.

Esophageal stenting for benign and malignant disease: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2021

MALIGNANT DISEASE

1: ESGE recommends placement of partially or fully covered self-expandable metal stents (SEMSs) for palliation of malignant dysphagia over laser therapy, photodynamic therapy, and esophageal bypass.Strong recommendation, high quality evidence. 2 : ESGE recommends brachytherapy as a valid alternative, alone or in addition to stenting, in esophageal cancer patients with malignant dysphagia and expected longer life expectancy.Strong recommendation, high quality evidence. 3: ESGE recommends esophageal SEMS placement for sealing malignant tracheoesophageal or bronchoesophageal fistulas. Strong recommendation, low quality evidence. 4 : ESGE does not recommend SEMS placement as a bridge to surgery or before preoperative chemoradiotherapy because it is associated with a high incidence of adverse events. Other options such as feeding tube placement are preferable. Strong recommendation, low quality evidence.

BENIGN DISEASE

5: ESGE recommends against the use of SEMSs as first-line therapy for the management of benign esophageal strictures because of the potential for adverse events, the availability of alternative therapies, and their cost. Strong recommendation, low quality evidence. 6: ESGE suggests consideration of temporary placement of self-expandable stents for refractory benign esophageal strictures. Weak recommendation, moderate quality evidence. 7: ESGE suggests that fully covered SEMSs be preferred over partially covered SEMSs for the treatment of refractory benign esophageal strictures because of their very low risk of embedment and ease of removability. Weak recommendation, low quality evidence. 8: ESGE recommends the stent-in-stent technique to remove partially covered SEMSs that are embedded in the esophageal wall. Strong recommendation, low quality evidence. 9: ESGE recommends that temporary stent placement can be considered for the treatment of leaks, fistulas, and perforations. No specific type of stent can be recommended, and the duration of stenting should be individualized. Strong recommendation, low quality of evidence. 10 : ESGE recommends considering placement of a fully covered large-diameter SEMS for the treatment of esophageal variceal bleeding refractory to medical, endoscopic, and/or radiological therapy, or as initial therapy for patients with massive bleeding. Strong recommendation, moderate quality evidence.

Critical Appraisal of the Impact of Oesophageal Stents in the Management of Oesophageal Anastomotic Leaks and Benign Oesophageal Perforations: An Updated Systematic Review

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.

Management of anastomotic leaks after esophagectomy and gastric pull-up

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.

[Minimally invasive treatment of post-burn esophageal perforation]

Perforation of the esophagus is a serious and dangerous condition due to progressive development of mediastinitis and sepsis. This disease is often fatal. In the last decade, endoscopic stenting of the esophagus became more common in these patients as an alternative to traditional surgery. We report successful minimally invasive endoscopic treatment of esophageal perforation with post-burn necrosis of its wall.

Mechanical properties of a biodegradable self-expandable polydioxanone monofilament stent: In vitro force relaxation and its clinical relevance

Biodegradable stents are promising treatments for many diseases, e.g., coronary artery disease, urethral diseases, tracheal diseases, and esophageal strictures. The mechanical properties of biodegradable stent materials play a key role in the safety and efficacy of treatment. In particular, insufficient creep resistance of the stent material could result in premature stent collapse or narrowing. Commercially available biodegradable self-expandable SX-ELLA stents made of polydioxanone monofilament were tested. A new, simple, and affordable method to measure the shear modulus of tiny viscoelastic wires is presented. The important mechanical parameters of the polydioxanone filament were obtained: the median Young's modulus was [Formula: see text] = 958 (922, 974) MPa and the shear modulus was [Formula: see text] = 357 (185, 387) MPa, resulting in a Poisson's ratio of ν = 0.34. The SX-ELLA stents exhibited significant force relaxation due to the stress relaxation of the polydioxanone monofilament, approximately 19% and 36% 10 min and 48 h after stent application, respectively. However, these results were expected, and the manufacturer and implanting clinician should be aware of the known behavior of these biodegradable materials. If possible, a biodegradable stent should be designed considering therapeutic force rather than initial force. Additionally, new and more advanced biodegradable shape-memory polymers should be considered for future study and use.

Biodegradable oesophageal stents: A potentially useful adjunct in the treatment of dysphagia in patients undergoing radiotherapy for oesophageal carcinoma

Aim:

Dysphagia is common in patients presenting with oesophageal malignancy. This study aimed to determine the clinical effectiveness of biodegradable stents to help with malignant dysphagia due to radiotherapy for oesophageal cancer and furthermore to establish the complication and re-intervention rates associated with their use.

Methods:

This was a retrospective, observational study of 22 patients between 2008 and 2013. Complications within 2 weeks and episodes of re-intervention required within 4 months of stent insertion prior to radiotherapy were recorded.

Results:

Pre-stent insertion, the mean O’Rourke dysphagia score was 3·5 (median 3, range 2–5). This improved to a mean score of 2·8 (median 3, range 1–4) 1–3 weeks following stent insertion. Complications occurred in seven patients (32%) in an immediate 2-week period, including: pain (2), dysphagia requiring dilatation (1), food obstruction not requiring intervention (1), food obstruction requiring intervention (2) and upper gastrointestinal bleed not requiring intervention (1). Re-intervention was required in 18% within a 4-month period.

Findings:

We propose that biodegradable oesophageal stents are safe and may have benefit over self-expanding metal stents. We recommend they are placed alongside a radiologically inserted gastrostomy in a combined procedure prior to radiotherapy planning.

Lumen-apposing Metal Stents, Fully Covered Self-expanding Metal Stents, and Biodegradable Stents in the Management of Benign of GI Strictures: A Systematic Review and Meta-Analysis

BACKGROUND

Refractory benign gastrointestinal (GI) strictures are difficult to treat and placement of a stent is a commonly sought resort. Stents used for this purpose are fully covered self-expanding metal stent (FCSEMS), a biodegradable stent (BDS) and recently, a lumen-apposing metal stent (LAMS). There is no data comparing these stents to this end.

METHODS

We conducted a comprehensive search of multiple electronic databases and conference proceedings (from inception through October 2018) to identify studies that reported on the performance of FCSEMS, BDS, and LAMS in the treatment of refractory benign GI strictures. Our goals were to evaluate the pooled rate of technical success, clinical success, and adverse events with these stents and compare the outcomes between them.

RESULTS

A total of 31 studies were analyzed. In total, 14 (342 patients), 11 (226 patients), and 8 studies (192 patients) reported the use of FCSEMS, BDS, and LAMS, respectively. The pooled rate of technical success was 96.5% [95% confidence interval (CI): 93.5-98.1], 91.9% (95% CI: 85.6-95.6), and 97.6% (95% CI: 94.0-99.0) with FCSEMS, BDS, and LAMS respectively. No statistical significance to the difference was noted. The pooled rate of clinical success was 48.4% (95% CI: 37.1-59.8), 34.9% (95% CI: 23.6-48.1), and 78.8% (95% CI: 65.8-87.8) with FCSEMS, BDS, and LAMS, respectively. Statistical significance was noted in LAMS versus FCSEMS (P=0.001) and LAMS versus BDS (P=0.001). LAMS demonstrated statistically better outcomes in regards to stent migration and postprocedure pain when compared with FCSEMS and BDS.

CONCLUSION

Our study demonstrates that LAMS gives better clinical outcomes in the treatment of refractory benign GI strictures when compared with FCSEMS and BDS. Variability in the site, as well as the length of stricture, indirect comparison, and heterogeneity, were the limitations of our study.

Recent advancements in the minimally invasive management of esophageal perforation, leaks, and fistulae

INTRODUCTION

Historically, the gold standard management of esophageal perforations, leaks, and fistulae has been traditional open surgery, but it is associated with significant morbidity and mortality. Minimally invasive approaches offer alternatives to surgery in treating hemodynamically stable patients with such defects. In this review article, we will discuss the recent advancements in the minimally invasive management of esophageal perforations, leaks, and fistulas.

AREAS COVERED

This review includes information from case reports, case series, and clinical trials on minimally invasive management of esophageal perforations, leaks, and fistulas. The focus is on the devices, outcomes, and application of the technology.

EXPERT COMMENTARY

Minimally invasive treatment represents significant progress in the management of esophageal perforations, leaks, and fistulas. Based on current evidence, it seems safe and effective but it is evolving and more studies are needed to help draw definitive conclusions.

Endoscopic management of recurrent tracheoesophageal fistula induced by chronic use of nonsteroidal anti-inflammatory drugs: A case report and review of the literature

Tracheoesophageal fistula (TEF) is frequently congenital and requires surgical correction. TEF can also occur secondary to malignant esophageal tumors or benign diseases and these cases are managed by endoscopic means, such as closing the defect with metallic stents. Although esophageal injury can occur secondary to nonsteroidal anti-inflammatory drugs (NSAIDs), TEF secondary to chronic NSAIDs use has not been described in the literature. We report the case of a male patient with refractory migraine and chronic use of NSAIDs, with a history of esophageal stenosis presenting with acute-onset total dysphagia. Upper gastrointestinal endoscopy and CT-scan revealed TEF located at 25 cm from the incisors. An esophageal stent was placed endoscopically, and 6 weeks a second stent was placed in a stent-in-stent manner to allow removal of both stents. Endoscopic control after the removal of the stents showed the persistence of the fistula, so a third stent was placed as a rescue therapy. Against medical advice, the patient continued to use OTC painkillers and NSAIDs in large doses. Three months later, he was readmitted with total dysphagia and recent-onset dysphonia. CT scan revealed a new fistula above the already placed stent. A second metallic stent was endoscopically placed through the old stent to close the newly developed fistula. The patient was discharged on the third day with no complications and he remains well at 6 months follow-up. Due to small cases studies, recurrent TEF remains a therapeutic challenge. Endoscopic therapy is usually an effective solution, but complex cases might require multiple treatment sessions.

Endoscopic Management of Benign Esophageal Ruptures and Leaks

OPINION STATEMENT

Esophageal leaks (EL) and ruptures (ER) are rare conditions associated with a high risk of mortality and morbidity. Historically, EL and ER have been surgically treated, but current treatment options also include conservative management and endoscopy. Over the last decades, interventional endoscopy has evolved as an effective and less invasive alternative to primary surgery in these cases. A variety of techniques are currently available to re-establish the continuity of the digestive tract, prevent or treat infection related to the leak/rupture, prevent further contamination, drain potential collections, and provide nutritional support. Endoscopic options include clips, both through the scope (TTS) and over the scope (OTS), stent placement, vacuum therapy, tissue adhesive, and endoscopic suturing techniques. Theoretically, all of these can be used alone or with a multimodality approach. Endoscopic therapy should be combined with medical therapy but also with percutaneous drainage of collections, where present. There is robust evidence suggesting that this change of therapeutic paradigm in the form of endoscopic therapy is associated with improved outcome, better quality of life, and shortened length of hospital stay. Moreover, recent European guidelines on endoscopic management of iatrogenic perforation have strengthened and to some degree regulated and redefined the role of endoscopy in the management of conditions where there is a breach in the continuity of the GI wall. Certainly, due to the complexity of these conditions and the variety of available treatment options, a multidisciplinary approach is strongly recommended, with close clinical monitoring (by endoscopists, surgeons, and intensive care physicians) and special attention to signs of sepsis, which can lead to the need for urgent surgical management. This review article will critically discuss the literature regarding endoscopic modalities for esophageal leak and perforation management and attempt to place them in perspective for the physician.

Endoscopic stent suture fixation for prevention of esophageal stent migration during prolonged dilatation for achalasia treatment

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.

Biodegradable Stents: An Evolution in Management of Benign Intestinal Strictures

Benign intestine strictures secondary to postoperative narrowing or inflammatory bowel disease can be managed surgically or conservatively. Some patients may not be suitable surgical candidates and some patients may choose not to have repeat surgery. Biodegradable (BD) stents offer a prolonged dilatory effect before gradual degradation and obviates the need of a second procedure for stent removal. BD stents have high technical success rates (mean, 94.4%; median, 100%; range, 86% to 100%) but widely variable clinical success rates (range, 45% to 100%). Stent migration is the most commonly reported complication (mean, 22.2%; range, 0% to 36%). In the future, with better understanding of the factors contributing to stent migration, improvement in present stent design and better anchoring techniques, the stent migration rate is expected to decrease and improve clinical outcome. The role of prophylactic BD stent placement to prevent stricture development postintestine surgery is an intriguing idea and needs to be explored. As of now, the use of BD stents is a reasonable option for patients with dilatation resistant intestinal strictures who are unfit for surgery or refuse to have surgical treatment.

Computationally Designed 3D Printed Self-Expandable Polymer Stents with Biodegradation Capacity for Minimally Invasive Heart Valve Implantation: A Proof-of-Concept Study

The evolution of minimally invasive implantation procedures and the in vivo remodeling potential of decellularized tissue-engineered heart valves require stents with growth capacity to make these techniques available for pediatric patients. By means of computational tools and 3D printing technology, this proof-of-concept study demonstrates the design and manufacture of a polymer stent with a mechanical performance comparable to that of conventional nitinol stents used for heart valve implantation in animal trials. A commercially available 3D printing polymer was selected, and crush and crimping tests were conducted to validate the results predicted by the computational model. Finally, the degradability of the polymer was assessed via accelerated hydrolysis.

Endoscopic Closure for Full-Thickness Gastrointestinal Defects: Available Applications and Emerging Innovations

Full-thickness gastrointestinal defects such as perforation, anastomotic leak, and fistula are severe conditions caused by various types of pathologies. They are more likely to require intensive care and a long hospital stay and have high rates of morbidity and mortality. After intentional full-thickness opening of hollow organs for natural orifice transluminal endoscopic surgery, safe and secure closure is urgently required. The currently available advanced endoscopic closing techniques have a major role in the treatment of full-thickness gastrointestinal defects. Appropriate usage of these techniques requires taking into account their advantages and limitations during practical application. We reviewed the available endoscopic modalities, including endoscopic clips, stents, vacuum-assisted closure, gap filling, and suturing devices, discussed their advantages and limitations when treating full-thickness gastrointestinal defects, and explored emerging innovations, including a novel endoluminal surgical platform for versatile suturing and a cell-laden scaffold for effective gap filling. Although these emerging technologies still require further pre-clinical and clinical trials to assess their feasibility and efficacy, the available modalities may be replaced and refined by these new techniques in the near future.

Fabrication of a Delaying Biodegradable Magnesium Alloy-Based Esophageal Stent via Coating Elastic Polymer

Esophageal stent implantation can relieve esophageal stenosis and obstructions in benign esophageal strictures, and magnesium alloy stents are a good candidate because of biodegradation and biological safety. However, biodegradable esophageal stents show a poor corrosion resistance and a quick loss of mechanical support in vivo. In this study, we chose the elastic and biodegradable mixed polymer of Poly(ε-caprolactone) (PCL) and poly(trimethylene carbonate) (PTMC) as the coated membrane on magnesium alloy stents for fabricating a fully biodegradable esophageal stent, which showed an ability to delay the degradation time and maintain mechanical performance in the long term. After 48 repeated compressions, the mechanical testing demonstrated that the PCL-PTMC-coated magnesium stents possess good flexibility and elasticity, and could provide enough support against lesion compression when used in vivo. According to the in vitro degradation evaluation, the PCL-PTMC membrane coated on magnesium was a good material combination for biodegradable stents. During the in vivo evaluation, the proliferation of the smooth muscle cells showed no signs of cell toxicity. Histological examination revealed the inflammation scores at four weeks in the magnesium-(PCL-PTMC) stent group were similar to those in the control group (p > 0.05). The α-smooth muscle actin layer in the media was thinner in the magnesium-(PCL-PTMC) stent group than in the control group (p < 0.05). Both the epithelial and smooth muscle cell layers were significantly thinner in the magnesium-(PCL-PTMC) stent group than in the control group. The stent insertion was feasible and provided reliable support for at least four weeks, without causing severe injury or collagen deposition. Thus, this stent provides a new stent for the treatment of benign esophageal stricture and a novel research path in the development of temporary stents in other cases of benign stricture.

Polymeric Biodegradable Stent Insertion in the Esophagus

Esophageal stent insertion has been used as a well-accepted and effective alternative to manage and improve the quality of life for patients diagnosed with esophageal diseases and disorders. Current stents are either permanent or temporary and are fabricated from either metal or plastic. The partially covered self-expanding metal stent (SEMS) has a firm anchoring effect and prevent stent migration, however, the hyperplastic tissue reaction cause stent restenosis and make it difficult to remove. A fully covered SEMS and self-expanding plastic stent (SEPS) reduced reactive hyperplasia but has a high migration rate. The main advantage that polymeric biodegradable stents (BDSs) have over metal or plastic stents is that removal is not require and reduce the need for repeated stent insertion. But the slightly lower radial force of BDS may be its main shortcoming and a post-implant problem. Thus, strengthening support of BDS is a content of the research in the future. BDSs are often temporarily effective in esophageal stricture to relieve dysphagia. In the future, it can be expect that biodegradable drug-eluting stents (DES) will be available to treat benign esophageal stricture, perforations or leaks with additional use as palliative modalities for treating malignant esophageal stricture, as the bridge to surgery or to maintain luminal patency during neoadjuvant chemoradiation.

Endoscopic "rescue" treatment for gastrointestinal perforations, anastomotic dehiscence and fistula

Luminal perforations and anastomotic leaks of the gastrointestinal tract are life-threatening events with high morbidity and mortality. Early recognition and prompt therapy is essential for a favourable outcome. Surgery has long been considered the "gold standard" approach for these conditions; however it is associated with high re-intervention morbidity and mortality. The recent development of endoscopic techniques and devices to manage perforations, leaks and fistulae has made non-surgical treatment an attractive and reasonable alternative approach. Although endoscopic therapy is widely accepted, comparative data of the different techniques are still lacking. In this review we describe, benefits and limitations of the current options in the management of patients with perforations and leaks, in order to improve outcomes.

Endoscopic Treatment of Gastrointestinal Perforations, Leaks, and Fistulae

Gastrointestinal leaks and fistulae are common postoperative complications, whereas intestinal perforation more commonly complicates advanced endoscopic procedures. Although these complications have classically been managed surgically, there exists an ever-expanding role for endoscopic therapy and the involvement of advanced endoscopists as part of a multidisciplinary team including surgeons and interventional radiologists. This review will serve to highlight the innovative endoscopic interventions that provide an expanding range of viable endoscopic approaches to the management and therapy of gastrointestinal perforation, leaks, and fistulae.

Endoscopic management of bariatric surgical complications

PURPOSE OF REVIEW

Bariatric surgery is recognized as the most effective treatment against obesity as it results in significant weight reduction and a high rate of remission of obesity-related comorbidities. However, bariatric surgery is not uncommonly associated with complications and an endoscopic approach to management is preferred over surgical reintervention. This review illustrates the latest developments in the endoscopic management of bariatric surgical complications.

RECENT FINDINGS

For successful management of complications, precipitating and perpetuating factors must be addressed in addition to directing therapy at the target pathology. Endoscopy is well tolerated even in the acute postoperative setting when performed carefully with CO2 insufflation. Chronic proximal staple-line leaks/fistulas frequently do not respond to primary closure with diversion therapy, and a new technique of stricturotomy has been reported to improve outcomes. Innovations in the field of transoral endoscopic instruments have led to the development of a single-session entirely internal endoscopic retrograde cholangiopancreatography by creating a gastrogastric anastomosis.

SUMMARY

Endoscopy allows for early diagnosis and prompt institution of therapy and should, therefore, be the first-line intervention in the management of complications of bariatric surgery in patients who do not need urgent surgical intervention. Computed tomography-guided drainage may be necessary in patients with drainable fluid collections.

VIDEO ABSTRACT

http://links.lww.com/COG/A11.

Literature Analysis of the Treatment of Benign Esophageal Disease with Stent

To analyze the efficacy and safety of benign esophageal disease used biodegradable (BD) stent or metal stent. The English literatures of benign esophageal disease that were treated by biodegradable or metal stents implantation were retrieved and summarized. In all 323 benign esophageal disease, the most common etiologies were benign refractory stricture, surgical anastomotic stricture and esophageal fistula/leak/perforation, but the main characteristics between the two groups were not significantly different. One hundred fifty-four cases were completely healed by using BD stents or self-expandable metal stents (SEMS) (47.7 %). Clinical success was achieved in 47.7 % of all patients and there was no significant difference between BD stents (51 %) and SEMS (46.2 %) (P = 0.472), while stent migration occurred more frequently with SEMS (33.9 %) than with BD stent (19.6 %) (P ≤ 0.05), and tissue in- or overgrowth occurred more frequently with SEMS (22.2 %) than with BD stents (8.8 %) (P ≤ 0.05). Furthermore, the time about degradation of BD stents in esophageal was longer than removal of SEMS from the esophagus (P ≤ 0.05). Placement of BD stents or SEMS provides effective and safe relief for benign esophageal disease. Clinical success and mortality were not significantly different. BD stents offers an advantage of fewer complications. Although stent placement is a viable strategy in patients with benign esophageal disease, the ideal treatment strategy and further randomized trials with large number of patients are needed.

Endotherapy of leaks and fistula

Perforations, leaks and fistula involving gastrointestinal (GI) tract are increasing encountered in clinical practice. There is a changing paradigm for their management with surgical approach being replaced by conservative approach including endoscopic therapy. Clips (through the scope and over the scope) and covered stent are front runners for endotherapy for GI leaks and fistula. Over the scope clips introduced recently, can treat larger defects compared to through the scope clips. Covered stents are suited for larger defects and those associated with luminal narrowing. However cervical esophagus, gastro-esophageal junction, stomach and right colonic lesions may be better for clip therapy rather than stenting. Recent developments in this field include use of endovac therapy which consists of a sponge with suction device, biodegradable stent, use of fibrin glue and some endo-suturing device. Conservative therapy with no surgical or endoscopic intervention, may be suitable for a small subset of patients. An algorithm based on location, size of defect, associated stricture, infection and available expertise needs to be developed to reduce the mortality and morbidity of this difficult clinical problem.

Refractory esophageal strictures: what to do when dilation fails

Benign esophageal strictures arise from a diversity of causes, for example esophagogastric reflux, esophageal resection, radiation therapy, ablative therapy, or the ingestion of a corrosive substance. Most strictures can be treated successfully with endoscopic dilation using bougies or balloons, with only a few complications. Nonetheless, approximately one third of patients develop recurrent symptoms after dilation within the first year. The majority of these patients are managed with repeat dilations, depending on their complexity. Dilation combined with intra lesional steroid injections can be considered for peptic strictures, while incisional therapy has been demonstrated to be effective for Schatzki rings and anastomotic strictures. When these therapeutic options do not resolve the stenosis, stent placement should be considered. Self bougienage can be proposed to a selected group of patients with a proximal stenosis. As a final step surgery is an option, but even then the risk of stricture formation at the anastomotic site remains. This chapter reviews refractory benign esophageal strictures and the treatment options that are currently available.

The novel use of a biodegradable stent placed by percutaneous transhepatic cholangiography for the treatment of a hepaticojejunostomy biliary leak following an extended left hepatectomy and pancreaticoduodenectomy

A 61-year-old man presented with jaundice, and subsequently underwent an extended left hepatectomy and pancreaticoduodenectomy for a cholangiocarcinoma invading the head of the pancreas. The patient developed sepsis due to a biliary leak at the hepaticojejunostomy. We describe the original use of a biodegradable stent, deployed via percutaneous transhepatic cholangiography into the Roux limb, resulting in good drainage and resolution of sepsis. The chief benefit of this procedure is the lack of need for subsequent removal as well as purported reduced biofilm accumulation. We believe this to be the first reported case of this type and the literature surrounding the subject is also discussed.

Plastic and biodegradable stents for complex and refractory benign esophageal strictures

Endoscopic stent placement is a well-accepted and effective alternative treatment modality for complex and refractory esophageal strictures. Among the currently available types of stents, the partially covered self-expanding metal stent (SEMS) has a firm anchoring effect, preventing stent migration and ensuring effective covering of a narrowed segment. However, hyperplastic tissue reaction driven by the uncovered mesh may prevent easy and safe stent removal. As an alternative, a fully covered SEMS decreases the recurrence of dysphagia caused by hyperplastic tissue ingrowth; however, it has a high migration rate. Likewise, although a self-expanding plastic stent (SEPS) reduces reactive hyperplasia, the long-term outcome is disappointing because of the high rate of stent migration. A biodegradable stent has the main benefit of not requiring stent removal in comparison with SEMS and SEPS. However, it still has a somewhat high rate of hyperplastic reaction, and the long-term outcome does not satisfy expectations. Up to now, the question of which type of stent should be recommended for the effective treatment of complex and refractory benign strictures has no clear answer. Therefore, the selection of stent type for endoscopic treatment should be individualized, taking into consideration the endoscopist's experience as well as patient and stricture characteristics.

The role of esophageal stents in the management of esophageal anastomotic leaks and benign esophageal perforations

OBJECTIVE

The aim of this review was to assess the safety and effectiveness of esophageal stents in the management of benign esophageal perforation and in the management of esophageal anastomotic leaks.

BACKGROUND

Benign esophageal perforation and postoperative esophageal anastomotic leak are often encountered. Endoscopic placement of esophageal stent across the site of leakage might help control the sepsis and reduce the mortality and morbidity.

METHODS

All the published case series reporting the use of metallic and plastic stents in the management of postoperative anastomotic leaks, spontaneous esophageal perforations, and iatrogenic esophageal perforations were identified from MEDLINE, EMBASE, and PubMed (1990-2012). Primary outcomes assessed were technical success rates and complete healing rates. Secondary outcomes assessed were stent migration rates, stent perforation rates, duration of hospital stay, time to stent removal, and mortality rates. A pooled analysis was performed and subgroup analysis was performed for plastic versus metallic stents and anastomotic leaks versus perforations separately.

RESULTS

A total of 27 case series with 340 patients were included. Technical and clinical success rates of stenting were 91% and 81%, respectively. Stent migration rates were significantly higher with plastic stents than with metallic stents (40/148 vs 13/117 patients, respectively; P = 0.001). Patients with metallic stents had significantly higher incidence of postprocedure strictures (P = 0.006). However, patients with plastic stents needed significantly higher number of reinterventions (P = 0.005). Mean postprocedure hospital stay varied from 8 days to 51 days. There was no significant difference in the primary or secondary outcomes when stenting was performed for anastomotic leaks or perforations.

CONCLUSIONS

Endoscopic management of esophageal anastomotic leaks and perforations with the use of esophageal stents is technically feasible. It seems to be safe and effective when performed along with mediastinal or pleural drainage. Esophageal stent can, therefore, be considered as a treatment option in the management of patients who present early after esophageal perforation or anastomotic leak with limited mediastinal or pleural contamination.

Biodegradable stents in gastrointestinal endoscopy

Biodegradable stents (BDSs) are an attractive option to avoid ongoing dilation or surgery in patients with benign stenoses of the small and large intestines. The experience with the currently the only BDS for endoscopic placement, made of Poly-dioxanone, have shown promising results. However some aspects should be improved as are the fact that BDSs lose their radial force over time due to the degradable material, and that can cause stent-induced mucosal or parenchymal injury. This complication rate and modest clinical efficacy has to be carefully considered in individual patients prior to placement of BDSs. Otherwise, the price of these stents therefore it is nowadays an important limitation.

Stents for benign and malignant esophageal strictures

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

Endoscopic therapy for postoperative leaks and fistulae

Endoscopic techniques for the treatment of postoperative fistulae and leaks are rapidly developing. Conventional surgical therapy for postsurgical leaks and fistulae is associated with significant morbidity and mortality. Novel endoscopic therapies have demonstrated safety, despite the inherent challenges of intervention in this patient population, and are steadily building evidence for efficacy relative to surgical management. The article examines endoscopic therapy for leaks and fistulae after esophageal, gastric, bariatric, colonic, and pancreaticobiliary surgery.

The use of biodegradable (SX-ELLA) oesophageal stents to treat dysphagia due to benign and malignant oesophageal disease

BACKGROUND

Biodegradable (BD) oesophageal stents have been available commercially only since 2008 and previous published research is limited. Our aim was to review the use of BD stents to treat dysphagia in benign or malignant oesophageal strictures.

METHODS

Patients were identified from a prospective interventional radiological database. BD stents were inserted radiologically under fluoroscopic control.

RESULTS

Between July 2008 and February 2011, 25 attempts at placing SX-ELLA biodegradable oesophageal stents were made in 17 males and five females, with a median age of 69 (range = 54-80) years. Two patients required more than one BD stent. Indications were benign strictures (n = 7) and oesophageal cancer (n = 17). One attempt was unsuccessful for a technical success rate of 96% with no immediate complications. Clinical success rate was 76%. Median dysphagia score before stent insertion was 3 (range = 2-4) compared to 2 (range = 0-3) after stent insertion (p = 0.0001).

CONCLUSION

BD stents provide good dysphagia relief for the life time of the stent. They may help avoid the use of feeding tubes in patients having radical chemoradiotherapy or awaiting oesophagectomy. They do not require removal or interfere with radiotherapy planning via imaging. However, the reintervention rate is high after the stent dissolves.

Esophageal stenting in the setting of malignancy

Esophageal cancer is often diagnosed at an advanced stage, with many patients found to have locoregional or metastatic disease at time of diagnosis. Because of this, cure may be unlikely, leading treatment efforts to focus more on symptom palliation and improving patient quality of life. The majority of patients with advanced disease suffer from some degree of dysphagia. Palliative efforts are therefore directed at relieving dysphagia, allowing patients to manage their oropharyngeal secretions, reduce aspiration risk, and maintain caloric intake orally. A variety of endoscopic treatment modalities have been utilized with these objectives in mind, with options determined by the location and size of the tumor, as well as the patient's expected prognosis. In this article, we review the use of endoscopically-placed stents for palliation in patients with advanced esophageal cancer. We discuss the history of stent use in such cases, as well as more recent developments in stent technology. We give an overview of some of the more commonly used stents in practice, discuss the technique of insertion, and survey the short- and long-term outcomes of stent placement.