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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Applications of endoscopic vacuum therapy in the upper gastrointestinal tract

Endoscopic vacuum therapy (EVT) is an increasingly popular treatment option for wall defects in the upper gastrointestinal tract. After its initial description for the treatment of anastomotic leaks after esophageal and gastric surgery, it was also implemented for a wide range of defects, including acute perforations, duodenal lesions, and postbariatric complications. Apart from the initially proposed handmade sponge inserted using the “piggyback” technique, further devices were used, such as the commercially available EsoSponge and VAC-Stent as well as open-pore film drainage. The reported pressure settings and intervals between the subsequent endoscopic procedures vary greatly, but all available evidence highlights the efficacy of EVT, with high success rates and low morbidity and mortality, so that in many centers it is considered to be a first-line treatment, especially for anastomotic leaks.

Endoscopic luminal stenting: Current applications and future perspectives

Endoscopic luminal stenting (ELS) represents a minimally invasive option for the management of malignant obstruction along the gastrointestinal tract. Previous studies have shown that ELS can provide rapid relief of symptoms related to esophageal, gastric, small intestinal, colorectal, biliary, and pancreatic neoplastic strictures without compromising cancer patients’ overall safety. As a result, in both palliative and neoadjuvant settings, ELS has largely surpassed radiotherapy and surgery as a first-line treatment modality. Following the abovementioned success, the indications for ELS have gradually expanded. To date, ELS is widely used in clinical practice by well-trained endoscopists in managing a wide variety of diseases and complications, such as relieving non-neoplastic obstructions, sealing iatrogenic and non-iatrogenic perforations, closing fistulae and treating post-sphincterotomy bleeding. The abovementioned development would not have been achieved without corresponding advances and innovations in stent technology. However, the technological landscape changes rapidly, making clinicians’ adaptation to new technologies a real challenge. In our mini-review article, by systematically reviewing the relevant literature, we discuss current developments in ELS with regard to stent design, accessories, techniques, and applications, expanding the research basis that was set by previous studies and highlighting areas that need to be further investigated.

Multimodal treatment of colorectal postsurgical leaks: long-term results of the over-thescope clip (OTSC) application

BACKGROUND

Post-surgical anastomotic colorectal leaks often require a surgical second look with a definite morbidity and the risk of delaying adjuvant treatment. The aim of this study is to analyse the long-term results of the endoscopic closure of colorectal leak following low anterior resection (LAR) using the over-the-scope (Ovesco™) clip.

METHODS

Patients who were submitted to endoscopic closure of a colorectal leak of maximum 2 cm with an Ovesco™ clip following LAR from 2016 to 2018 were enrolled in this retrospective single-center study (Humanitas Mater Domini Clinical Institute, Italy). The follow-up was obtained through radiologic and clinic assessments.

RESULTS

In the study period 48 patients were submitted to LAR. Six patients were enrolled in the study. The median diameter of the leak was 7 mm. 14/6t or 12/6t OTSC® clip was applied. Three patients were managed exclusively endoscopically, 2 of them had a protective ileostomy; 3 patients underwent urgent laparotomy with ostomy and then underwent endoscopic procedure. Complete healing was reached in all patients in a median of 23 days. Adjuvant chemotherapy was indicated and performed in 4 patients after a median of 64 days from the surgery. Among the 5 carriers of an ostomy, 4 patients underwent recanalization. The median follow-up was 21.5 months. During the follow-up no leak reoccurrence or complications were reported.

CONCLUSIONS

In the multimodal management of anastomotic leaks following LAR , Ovesco™ clipping system appears a safe and effective technique in the closure of small leaks (<2 cm), allowing an early recanalization of the bowel and not delaying adjuvant chemotherapy when indicated.

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.

Feasibility and safety of self-expandable metal stent in nonmalignant disease of the lower gastrointestinal tract

In recent years, self-expandable metal stents (SEMSs) have been employed to treat benign gastrointestinal strictures secondary to several conditions: Acute diverticulitis, radiation colitis, inflammatory bowel disease (IBD), and postanastomotic leakages and stenosis. Other applications include endometriosis and fistulas of the lower gastrointestinal tract. Although it may be technically feasible to proceed to stenting in the aforementioned benign diseases of the lower gastrointestinal tract, the outcome has been reported to be poor. In fact, in some settings (such as complicated diverticulitis and postsurgical anastomotic strictures), stenting seems to have a limited evidence-based benefit as a bridge to surgery, while in other settings (such as endometriosis, IBD, radiation colitis, etc.), even society guidelines are not able to guide the endoscopist through decisional algorithms for SEMS placement. The aim of this narrative paper is to review the scientific evidence regarding the use of SEMSs in nonmalignant diseases of the lower gastrointestinal tract, both in adult and pediatric settings.

Use of the Over the Scope Clip to Close Perforations and Fistulas

In gastrointestinal perforation or fistula, endoscopic closure techniques could be used as alternatives to surgery. Early endoscopic recognition and treatment of gastrointestinal perforation is the most important factor determining procedural success and clinical outcomes. The over-the-scope clip with full-thickness grasping capability provides greater technical and clinical success rates compared with the through-the-scope clips. Although the technical success rate of chronic fistula closure is comparable to perforation closure, it has a significantly lower clinical success owing to its less healthy tissue edge of the fistula. The over-the-scope clip system should be considered before surgery for the closure of perforation and fistula.

Early anastomotic complications in colorectal surgery: a systematic review of techniques for endoscopic salvage

Background

Anastomotic complications following colorectal surgery are associated with significant morbidity and mortality. For patients in whom systemic sepsis is absent or well controlled, minimal access techniques, such as endoscopic therapies, are being increasingly employed to reduce the morbidity of surgical re-intervention. In this review, we aim to assess the utility of endoscopic management in the acute setting of colorectal anastomotic complications, focusing on anastomotic leak.

Method

A literature search was performed for published full text articles using the PubMed, Cochrane and Scopus databases using the search criteria string “colorectal anastomotic (“leak” OR “bleed”), “endoscopy”, endoscopic management”. Additional papers were detected by scanning the references of relevant papers. Data were extracted from each study by two authors onto a dedicated pro-forma. Given the nature of the data extracted, no meta-analysis was performed.

Results

A total of 89 papers were identified, 16 of which were included in this review; an additional 14 papers were obtained from reference searches. In patients who are not physiologically compromised, there are promising data regarding the salvage rate of stents, over-the-scope endoscopic clips, vacuum therapy and fibrin glue in the early management of colorectal anastomotic leak. There is no consensus regarding the optimal approach, and data to assist the physician in patient selection are lacking. Whilst data on salvage (i.e. healing and avoidance of surgery) are well understood, no data on functional outcomes are reported.

Conclusion

Endoscopic therapy in the management of stable patients with colorectal anastomotic leaks appears safe and in selected patients is associated with high rates of technical success. Challenges remain in selecting the most appropriate strategy, patient selection, and understanding the functional and long-term sequelae of this approach. Further evidence from large prospective cohort studies are needed to further evaluate the role of these novel strategies.

Endoscopic Treatment of the Coloanal Anastomotic Dehiscence and Stricture: Stenting Via Rendezvous Technique

An anastomotic leak is a serious complication of colorectal surgery. Leak management is often grueling, and a definitive stoma is often mandatory for rescue therapy. Herein, we present a patient who experienced coloanal anastomotic dehiscence and complete stricture at the proximal part of the anastomosis. This case was successfully treated with a fully covered self-expandable metallic stent placement via the combined endoscopic (per ileostomy) and manual (per anal channel) rendezvous technique.

The role of stents in the management of colorectal complications: a systematic review

BACKGROUND

Complications in colorectal surgery include a wide range of clinical conditions, which increase mortality, morbidity, hospital stay and costs. In some cases, the placement of a self-expanding metal stent may represent a possible therapeutic strategy, avoiding further surgery.

METHODS

In order to verify the feasibility and safety of the technique, we reviewed the medical literature, between January 1997 and 2015, selecting 32 studies. Inclusion criteria were based on Preferred Reporting Items for Systematic reviews and Meta-Analyses recommendations.

RESULTS

The estimated rate of early success was 73.3% (95% CI 66.3-79.3), raising from 25 to 68% in the time frame 1997-2007. The rate of early complications was 31.4% (95% CI 25.3-38.3%), progressively decreasing from 75 to 43% up to 2009. The rate of surgery for acute complication was 9.3% (95% CI 6.0-14.2%), reduced on time course from 25 to 9%. The rate of closure of dehiscence was 74.5% (95% CI 62.8-83.5%), while the rate of long-lasting success was 57.3% (95% CI 50.3-64.0%).

CONCLUSIONS

Endoscopic stenting in the early postoperative management of anastomotic complications after colorectal surgery should be considered in patients with minimal risk for sepsis, as a safe and often effective alternative to surgery. However, in order to establish the safety and efficacy of this technique, prospective studies involving a larger cohort of patients are required.

Fully covered metal stents for the treatment of leaks after gastric and esophageal surgery

OBJECTIVE

The use of fully covered metal stents (FCMS) for the treatment of benign conditions is increasing. The aim of our study was to assess the efficacy of FCMS in the management of post-operative leaks after gastric or esophageal surgery.

MATERIAL AND METHODS

During a three year period (2011-2013), patients who underwent a surgery related with esophageal or gastric cancer and developed a postoperative anastomotic leak treated with FCMS were prospectively included.

RESULTS

Fourteen patients were included (11 men, 3 women), with median age of 65 years. Placement of at least one stent was achieved in 13 patients (93% of cases), with initial closure of the leak in 12 of these 13 cases (92.3%). A final success (after removal of the stent) could be demonstrated in 9 cases (69.2%, intention to treat analysis); stent failed only in one case (7.7%) and there were 3 patients (23.1%) not evaluated because death before stent retrieval (not related with the endoscopic procedure). One stent were used in 9 cases (69.2%), and two in 4 (30.8%). Migration was observed in two cases (15.3%). There were no major complications related with the use of stents. There were no complications related with retrieval.

CONCLUSIONS

The placement of FCMS to achieve the leak closure after esophageal or gastric surgery is an effective and probably safe alternative feasible with minor risks.

Endoscopic Management of Gastrointestinal Leaks and Bleeding with the Over-the-Scope Clip: A Prospective Study

Background/Aims

The over-the-scope clip (OTSC) is a device used for endoscopic closure of perforations, leaks and fistulas, and for endoscopic hemostasis. To evaluate the clinical effectiveness and safety of OTSC.

Methods

Between October 2013 and November 2015, 12 patients underwent OTSC placement by an experienced endoscopist. OTSC was used for the closure of gastrointestinal (GI) leaks and fistula in six patients, three of which were iatrogenic (esophageal, gastric, and duodenal) and three of which were inflammatory. In six patients, OTSC was used for hemostasis of non-variceal upper GI bleeding. Endoscopic tattooing using India ink was used to assist the accurate placement of the clip.

Results

All subjects except one with a colonic defect experienced immediate technical success as well as long-term clinical success, during a mean follow-up of 6 weeks. Only one clip was required to close each of the GI defects and to achieve hemostasis in all patients. There were no misfirings or complications of clips. The procedure was well tolerated, and patients were hospitalized for an average of 8 days (range, 3 to 10). Antiplatelet therapy was continued in patients with GI bleeding.

Conclusions

In our experience, OTSC was safe and effective for the closure of GI defect and to achieve hemostasis of non-variceal GI bleeding.

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.

Gastrointestinal stenting: Current status and imaging features

The use of stents in the gastrointestinal tract has been subjected to major changes. Initially, the use of stents was restricted to malignant strictures in patients with metastatic disease. But thanks to reduction of the morbidity and mortality rates, they are now used with curative intention and in patients with benign diseases after careful selection. However, for patients presenting with colon obstruction due to an advanced colon carcinoma, the mortality and morbidity are still high. The purpose of this review is to provide an overview of indications, techniques and further developments of the stents in the gastrointestinal tract and to highlight the predominant role of multidetector row computed tomography (MDCT) in the detection of potential complications.

Usefulness of over-the-scope clipping system for closing digestive fistulas

BACKGROUND AND AIM

Therapeutic endoscopy has recently evolved into the treatment of complex gastrointestinal (GI) postoperative leakage, especially with over-the-scope clips (OTSC). We describe our 2-year experience of 30 patients treated for digestive fistulas using the OTSC device.

METHODS

This was a retrospective study conducted on patients referred for GI fistulas in two French hospitals. Technical aspects, clinical outcomes and closure rates were recorded.

RESULTS

Thirty patients were treated for GI leaks: 19 (63%) had a gastric fistula after laparoscopic sleeve gastrectomy (LSG); the others had rectovaginal, urethrorectal, rectovesical, gastrogastric, gastrocutaneous, esophagojejunal fistulas and colorectal anastomotic leak. Average follow up was 10.4 months. Eighteen (60%) had undergone previous endoscopic or surgical treatment. Orifice size was 3-20 mm (average 7.2 mm). Successful OTSC placement was achieved in 30 out of 34 attempts. There were four intraoperative undesired events (13.3%) but these were successfully managed. Overall success rate was 71.4% and 16 patients (53%) recovered with primary efficacy. Six patients (20%) required a subsequent endoscopic treatment. Eight patients (26.7%) required surgery for failure. In nine cases, we used one or more additional endoscopic procedures concomitantly with the OTSC combining self-expandable metal stents, standard clips and glue injection. Healing rate after LSG fistula was 88.9%, which was significantly higher than the overall rate (P = 0.01).

CONCLUSION

OTSC placement seems to be safe and effective for the treatment of GI fistulas. Better results were seen in leaks after LSG.

Outcomes of the use of fully covered esophageal self-expandable stent in the management of colorectal anastomotic strictures and leaks

Introduction. Colorectal anastomotic leak or stricture is a dreaded complication leading to significant morbidity and mortality. The novel use of self-expandable metal stents (SEMS) in the management of postoperative colorectal anastomotic leaks or strictures can avoid surgical reintervention. Methods. Retrospective study with particular attention to the indications, operative or postoperative complications, and clinical outcomes of SEMS placement for patients with either a colorectal anastomotic stricture or leak. Results. Eight patients had SEMS (WallFlex stent) for the management of postoperative colorectal anastomotic leak or stricture. Five had a colorectal anastomotic stricture and 3 had a colorectal anastomotic leak. Complete resolution of the anastomotic stricture or leak was achieved in all patients. Three had recurrence of the anastomotic stricture on 3-month flexible sigmoidoscopy follow-up after the initial stent was removed. Two of these patients had a stricture that was technically too difficult to place another stent. Stent migration was noted in 2 patients, one at day 3 and the other at day 14 after stent placement that required a larger 23 mm stent to be placed. Conclusions. The use of SEMS in the management of colorectal anastomotic leaks or strictures is feasible and is associated with high technical and clinical success rate.

Double-type metallic stents efficacy for the management of post-operative fistulas, leakages, and perforations of the upper gastrointestinal tract

INTRODUCTION

The management of post-operative anastomotic leakage and fistulas of the upper GI tract remains challenging. Fully covered stents are used despite a high risk of migration because of a better removability. The goal of our study was to evaluate the effectiveness of this new type of endoscopic stent in this indication. The secondary objective was to determine the ability of withdrawing this stent.

METHODS

Thirty-six patients treated for upper GI fistula using a double-type metallic stent (DTMS) (Taewoong, Korea) for a benign indication were included in this retrospective study. This stent associates an outer uncovered metallic stent, decreasing the risk of migration, to an inner fully covered stent that ensured its tightness. The DTMS was removed after 4 weeks of treatment.

RESULTS

Twenty-four patients had a post-operative fistula (15 sleeve gastrectomies), eight had an anastomotic leakage, and four had an esophageal perforation. Seventeen patients underwent a previous failed stenting, and fourteen had an associated treatment with OTSC clips. A final complete healing was achieved in twenty-six patients (72%). For patients with fistulas, the overall success rate was 66.6% (16/24) mostly in case of post sleeve fistula (80%), and it was 75% (6/8) for patients with anastomotic leakages (3/4). We reached a primary success (one session) in twenty-one cases (58.3%), and a second session was required in five cases. All the stents were removed without complications after a median stenting time of 32 [20-71] days. The spontaneous migration rate was 16.6%.

CONCLUSION

This new double-type stent is a new and efficient way to treat post-operative fistulas and leakages in the upper GI tract. The stents were always removable despite the external uncovered part with a low migration rate.

Reliable management of post-esophagectomy anastomotic fistula with endoscopic trans-fistula negative pressure drainage

Background

A gastroesophageal anastomotic fistula remains a potentially life-threatening post-esophagectomy complication. To promote fistula closure, we developed a modified endoscopic method of trans-fistula drainage with persistent negative pressure. In this study, we aimed to evaluate the efficacy of this endoscopic therapy.

Methods

Between June and November 2013, five male patients with post-surgical esophageal leakages who had undergone trans-fistula drainage therapy were treated with the modified endoscopic trans-fistula negative pressure drainage (E-TNPD) method. We placed a nasogastric silicone tube into the paraesophageal cavity through the fistula and accomplished drainage of the infected effusion with continuous negative pressure, resulting in shrinkage of the para-anastomotic cavity and eventual fistula closure. We withdrew the trans-fistula drainage when there were no signs of leakage, as confirmed by esophagography. Final closure was confirmed by esophagography before the patient was allowed to begin oral intake.

Results

E-TNPD was successful in all five patients. The median duration of drainage until tube removal was 34 days (range: 18 to 81 days). The duration for Cases 1 to 4 was 18 to 28 days. Case 5 suffered from multiple separate leaks at the anastomotic site and the gastric conduit. Complete restoration was achieved in 81 days for this patient. We found that in general, the earlier that trans-fistula drainage was established, the shorter the duration of hospitalization until complete defect closure.

Conclusions

E-TNPD provided reliable and convenient management of post-surgical gastroesophageal anastomotic fistula and esophageal perforation. This method promoted fistula closure and prevented unnecessary repeated endoscopic examinations, extra equipment and expense.

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.

Endoscopic therapy in inflammatory bowel diseases (with videos)

Endoscopic therapies are important modalities in the treatment of IBD, adjunct to medical and surgical approaches. These therapeutic techniques are particularly useful in the management of IBD-associated or IBD surgery–associated strictures, fistulas, and sinuses and colitis-associated neoplasia. Although the main focus of endoscopic therapies in IBD has been on balloon stricture dilation and ablation of adenoma-like lesions, new endoscopic approaches are emerging, including needle-knife stricturotomy, needle-knife sinusotomy, endoscopic stent placement, and fistula tract injection. Risk management of endoscopy-associated adverse events is also evolving. The application of endoscopic techniques in novel ways in the treatment of IBD is just beginning and will likely expand rapidly in the near future.

Self-expanding metal stents or nonstent endoscopic therapy: which is better for anastomotic leaks after total gastrectomy?

BACKGROUND

Anastomotic leaks are a life-threatening complication of gastrectomies with high mortality after surgical reintervention. Endoscopic therapy using fibrin glue injection, endoclip, and other devices is an alternative to surgical intervention for anastomotic leaks. Recently, self-expanding metal stents (SEMS) were introduced to treat anastomotic leaks. The purpose of this study was to assess the clinical characteristics and therapeutic outcomes of SEMS and nonstent endoscopic therapy (NSET) for treatment of anastomotic leaks after total gastrectomy with the aim of assisting endoscopists in choosing a treatment method.

METHODS

Between July 2002 and March 2013, 13 patients treated with SEMS and 14 patients treated with NSET for anastomotic leaks after total gastrectomy were enrolled onto the study. Enrolled patients received 16 SEMS placement sessions and 21 NSET sessions.

RESULTS

No significant differences in baseline characteristics or clinical characteristics related to leakage were detected in patients with SEMS compared to NSET. The successful sealing rate at the first attempt by SEMS was significantly better than that of NSET (80.0 vs. 28.6 %, P = 0.036), whereas the successful sealing rate after multiple endoscopic treatments was not statistically different (80.0 vs. 64.3 %, P = 0.653). The main reason for reintervention with SEMS was complications and with NSET was nonseal (P = 0.004). Clinical outcomes including length of hospital stay, endoscopic treatment-related mortality, and all-cause mortality were not significantly different between the 2 groups.

CONCLUSIONS

In terms of efficacy by single effort, SEMS was superior to other methods for treating anastomotic leaks after total gastrectomy. However, complications with SEMS should be considered when choosing an endoscopic treatment method.

Complex anastomotic leaks following esophageal resections: the new stent over sponge (SOS) approach

A new approach for the treatment of complicated anastomotic leaks following esophageal resections by combining vacuum-assisted therapy with covered self-expanding stents is reported. This is not an approach for a simple leak but a rescue maneuver for complex uncontained leaks. It is known that anastomotic leakages particularly situated in the chest can be successfully treated with endoscopically placed self-expanding stents with/without additional drainage. If this approach fails, reoperation with substantial morbidity is frequently necessary. Two complicated anastomotic leakages refractory to stenting alone were successfully treated with the combination of an endo-sponge-assisted device covered by a self-expanding metallic stent. If stent therapy fails or the perianastomotic abscess cavity is large and complex to drain from outside, the endoscopic two-modality approach can be considered.

Endoscopic management of complications in digestive surgery

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

Omentum patch substitute for facilitating endoscopic repair of GI perforations: an early laparoscopic pilot study with a foam matrix plug (with video)

BACKGROUND

Endoscopic perforations are surgically repaired by using an omentum patch. Omentum substitutes may have broader applications particularly in certain sites (eg, esophagus).

OBJECTIVE

Evaluate a self-expandable foam matrix plug as a synthetic omentum substitute for repairing iatrogenic gastric perforations in a 4-week survival pig model.

DESIGN

Experimental pilot study.

SETTING

Laboratory.

INTERVENTION

A laparoscopic plug repair of a 1-cm, full-thickness, gastric perforation was carried out by using either a polyurethane foam matrix plug (FMP, 8 animals) or an omentum plug (OP, 6 animals, control group).

MAIN OUTCOME MEASUREMENTS

Follow-up endoscopy was carried out at 1 and 4 weeks. At necropsy, the perforation site was evaluated for adhesions and histology by using hematoxylin and eosin analysis. A portion of the implant was sent for bacterial and fungal culture.

RESULTS

All procedures were technically simple and successful. Thirteen animals thrived well for 4 weeks. One animal from the FMP group died 3 days postoperatively from diffuse peritonitis because of a misplaced plug. All remaining FMPs were intact at 4 weeks and colonized with mixed bacteria, except one animal presenting with FMP migration after 1 week. Histologically, the FMP group had more prominent inflammation and suppuration as compared with the OP group, all limited to its adjacent tissue.

LIMITATIONS

Animal study.

CONCLUSION

The FMP offered a technically simple and feasible option for repairing iatrogenic gastric perforations. With effective sealing, the clinical outcome is similar to that of an omentum patch repair. Migration and inadequate sealing is a concern, which can lead to peritonitis and sepsis. Further development is needed to improve FMP performance.

Sutureless primary repair of colonic perforation with a degradable stent in a porcine model of fecal peritonitis

PURPOSE

Colonic perforation with fecal peritonitis is a life-threatening clinical condition. For these patients, a two-stage operation of fecal diversion and a postponed colostomy closure is generally recommended. Accordingly, a simple and feasible primary repair technique was explored.

METHODS

A sutureless banding method using a biodegradable stent and a porcine model of artificial colonic perforation were introduced. The colonic perforation model was created successfully with an open procedure in 34 pigs. The primary repair with a stent or the conventional hand-sewn control was performed 72 h later. Morbidity and mortality were recorded. Pigs in each group were also sacrificed to evaluate the healing on postoperative days (PODs) 3, 7, 14, and 90. The peripheral white blood cell counts, albumin, anastomotic bursting pressure, hydroxyproline contents, and histology data were evaluated.

RESULTS

There were 17 pigs in either group. Four pigs (23.5 %) of the control group died, but no mortality occurred in the stent group. There were no significant differences in white blood cell counts and albumin. Though anastomotic hydroxyproline contents between the two groups were comparable, the collagen per protein ratio on POD 14 in the stent group was higher, as well as the bursting pressure on PODs 3 and 7. Microscopically, the local inflammation of the cut edges in the control group was more severe, and the collagen synthesis started later.

CONCLUSIONS

A sutureless primary repair of a colonic perforation with a degradable stent is a feasible method in a porcine model of fecal peritonitis.

Mid-gut stents

PURPOSE OF REVIEW

Gastrointestinal stents offer a feasible, safe, cost effective, and minimally invasive method for reestablishing luminal patency. Previous clinical reports and systematic reviews have demonstrated the role of enteral stents in both the upper and lower gastrointestinal tract. Over the last two decades, the rapid development of deep enteroscopy in concert with the evolution of various stent devices/deployment mechanisms has enabled placement of enteral stents in the mid-gut; hence this has been increasingly reported. The present article focuses on stenting in the mid-gut, a relatively novel term, referring to the small bowel between the ampulla and the ileocecal valve.

RECENT FINDINGS

Mid-gut stenting is technically more difficult than stenting in the upper and lower gastrointestinal tract, and therefore requires particular expertise, restricting its widespread utility. In total, 86 reported cases involving mid-gut stent deployment, by either endoscopic approaches (80.2%) or percutaneous approaches (19.8%), have been published. Although limited, these results have demonstrated that mid-gut stenting is reliable, effective, and a minimally invasive method for palliating malignant obstruction, as well as sealing leaks and fistulae.

SUMMARY

This article reviews the current status of mid-gut stenting, including endoscopic technique. The article also speculates about the potential for future advances within this field.

Performance of the OTSC System in the endoscopic closure of gastrointestinal fistulae--a meta-analysis

BACKGROUND

Conventional endoscopic treatment options for closure of gastrointestinal fistulae are impaired by several limitations and therefore yield high rates of recurrence. Aim of the study is the evaluation of the primary-technical and secondary-clinical success rates in closure of gastrointestinal fistulae by means of the OTSC System.

DESIGN/METHODS

The database Medline was systematically searched for primary research on the evaluation of the OTSC System in closure of gastrointestinal fistulae. Appraisal of studies for inclusion and data extraction were performed independently by two reviewers using an a priori determined data extraction grid.

RESULTS

A total of 19 primary research articles were identified. The examined studies comprised case reports as well as case series and clinical single-arm studies (n = 7) with a limited number of participants. Reviewed studies revealed a high rate of procedural success (mean 84.6%; 95% confidence interval 66.6 to 93.8%) and durable clinical success (mean 69.0%; 95% confidence interval 51.8 to 82.2%). Failed attempts and incomplete closures were mainly ascribed to the challenging effort of treating highly fibrotic chronic fistulae.

CONCLUSION

Endoscopic closure of gastrointestinal fistulae by means of the OTSC System is a safe and effective method.

Endoscopic muscularis dissection for upper gastrointestinal subepithelial tumors originating from the muscularis propria

BACKGROUND AND AIMS

Based on our experience with endoscopic submucosal dissection (ESD) and new endoscopic techniques for endoscopic closure of iatrogenic upper gastrointestinal (upper-GI) perforations, we developed methods to remove upper-GI subepithelial tumors (SETs) originating from the muscularis propria by endoscopic muscularis dissection (EMD). The aim of this study is to evaluate the clinical feasibility and safety of EMD.

METHODS

31 patients with upper-GI SETs originating from the muscularis propria were treated by EMD. The EMD differed from ESD in (1) precutting the overlying mucosa above the lesion by using snare or longitudinal incision instead of circumferential incision, (2) dissecting the complete tumors away from submucosal and muscularis propria tissue by electrical dissection combined with blunt dissection, and (3) closing the wound with clips. Perforations occurring during dissection were closed by endoscopic methods.

RESULTS

30 of 31 tumors were resected completely (96.8 %). One esophageal lesion was resected partially because of severe adhesions with surrounding tissue. Mean resected tumor size was 22.1 mm × 15.5 mm, and mean operation time was 76.8 min (range 15-330 min). Histological diagnosis was gastrointestinal stromal tumor (GIST) in 16 lesions [6 esophageal, 3 cardial, 7 gastric; 6 very low risk and 10 low risk according to the National Institutes of Health (NIH) risk classification] and leiomyoma in 15 lesions (8 esophageal, 4 cardial, 3 gastric). No patient developed delayed hemorrhage. Perforation occurred in four patients (12.9 %), all of which were managed successfully by endoscopic techniques. The mean follow-up time was 17.7 months (range 7-35 months). Follow-up found no tumor recurrence in any patient.

CONCLUSIONS

In this early experience, EMD appears to be a feasible and minimally invasive treatment for some patients with upper-GI SETs originating from the muscularis propria. Although there is a higher risk of perforation than with ESD, this will improve with extended practice, and perforations have become manageable endoscopically.

A new approach to gastrointestinal fistula closure: endoloop and clips technique using double endoscope

Several endoscopic techniques have been described for closure of gastrointestinal fistulas. Herein, we describe a case of iatrogenic gastric fistula successfully treated with a new approach by simultaneous insertion of two endoscopes and using the endoloop and endoclips technique.

The role of clips in preventing migration of fully covered metallic esophageal stents: a pilot comparative study

BACKGROUND

Migration is the most common complication of the fully covered metallic self-expanding esophageal stent (SEMS). This study aimed to determine the potential preventive effect of proximal fixation on the mucosa by clips for patients treated with fully covered SEMS.

METHODS

In this study, 44 patients (25 males, 57%) were treated with fully covered SEMS including 22 patients with esophageal stricture (4 malignant obstructions, 6 anastomotic strictures, and 12 peptic strictures) and 22 patients with fistulas or perforations (10 anastomotic leaks, 4 perforations, and 8 postbariatric surgery fistulas). The Hanarostent (n = 25), Bonastent (n = 5), Niti-S (n = 12), and HV-stent (n = 2) with diameters of 18 to 22 mm and lengths of 80 to 170 mm were used. Two to four clips (mean, 2.35 ± 0.75 clips) were used consecutively in 23 patients to fix the upper flared end of the stent with the esophageal mucosal layer. Stent migration and its consequences were collected in the follow-up assessment with statistical analysis to compare the patients with and without clip placement.

RESULTS

No complication with clip placement was observed, and the retrieval of the stent was not unsettled by the persistence of at least one clip (12 cases). Stent migration was noted in 15 patients (34%) but in only in 3 of the 23 patients with clips (13%). The number of patients treated to prevent one stent migration was 2.23. The predictive positive value of nonmigration after placement of the clip was 87%. In the multivariate analysis, the fixation with clips was the unique independent factor for the prevention of stent migration (odds ratio, 2.3; 95% confidence interval, 0.10-0.01; p = 0.03).

CONCLUSIONS

Anchoring of the upper flare of the fully covered SEMS with the endoscopic clip is feasible and significantly reduces stent migration.

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

BACKGROUND

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A prospective, randomized trial of esophageal submucosal tunnel closure with a stent versus no closure to secure a transesophageal natural orifice transluminal endoscopic surgery access site

BACKGROUND

Secure esophagotomy closure methods are a critical element in the advancement of transesophageal natural orifice transluminal endoscopic surgery (NOTES) procedures.

OBJECTIVE

To compare the clinical outcomes in swine receiving an esophageal stent or no stent after a submucosal tunnel NOTES access procedure.

DESIGN

Prospective, randomized, controlled trial in 10 Yorkshire swine.

SETTING

Academic center.

INTERVENTION

An endoscopic mucosectomy device was used to create an esophageal mucosal defect. An endoscope was advanced through a submucosal tunnel into the mediastinum and thorax, and diagnostic mediastinoscopy and thoracoscopy were performed. Ten animals were randomized to no stenting (n = 5) or stenting (n = 5) with a prototype small-intestine submucosa-covered stent.

MAIN OUTCOME MEASUREMENTS

Gross and histologic appearance of the mucosectomy and esophagotomy sites as well as clinical outcomes.

RESULTS

There was a significant difference in the overall procedure time between the animals that received a stent (35.0 min, range 27-46.0 min) and those with no closure (19.0 min, range 17-32 min) (P value = .018). The unstented group achieved endoscopic and histologic evidence of complete re-epithelialization and healing (100%) at the mucosectomy site compared with the stented group (20%, P = .048). Stent migration into the stomach occurred in two swine. Both groups had complete closure of the submucosal tunnel and well-healed esophagotomy sites.

LIMITATIONS

Animal study, small number of subjects.

CONCLUSION

The placement of a covered esophageal stent significantly interferes with mucosectomy site healing.

An endoscopic strategy for management of anastomotic complications from bariatric surgery: a prospective study

BACKGROUND

Treatment of anastomotic fistulas after bariatric surgery is difficult, and they are often associated with additional surgery, sepsis, and prolonged non-oral feeding.

OBJECTIVE

To assess a new, totally endoscopic strategy to manage anastomotic fistulas.

DESIGN

Prospective study.

SETTING

Tertiary-care university hospital.

PATIENTS

This study involved 27 consecutive patients from July 2007 to December 2009.

INTERVENTION

This strategy involved successive procedures for endoscopic drainage of the residual cavity, diversion of the fistula with a stent, and then closure of the residual orifice with surgical clips or sealant.

MAIN OUTCOME MEASUREMENTS

Technical success, mortality and morbidity, migration of the stent.

RESULTS

Multiple or complex fistulas were present in 16 cases (59%). Endoscopic drainage (nasal-fistula drain or necrosectomy) was used in 19 cases (70%). Diversion by a covered colorectal stent was used in 22 patients (81%). To close the residual or initial opening, wound clips and glue (cyanoacrylate) were used in 15 cases (55%). Neither mortality nor severe morbidity occurred. Migration of the stent occurred in 13 cases (59%) and was treated by replacement with either a longer stent or with 2 nested stents. The mean time until resolution of fistula was 86 days from the start of endoscopic management, with a mean of 4.4 endoscopies per patient.

LIMITATIONS

Moderate sample size, nonrandomized study.

CONCLUSION

An entirely endoscopic approach to the management of anastomosing fistulas that develop after bariatric surgery--using sequential drainage, sutures, and diversion by stents--achieved resolution of the fistulas with minimal morbidity.

Update on the indications and use of colonic stents

Self-expandable metal stent (SEMS) placement is a minimally invasive option for achieving acute colonic decompression in obstructed colorectal cancer. Colorectal stenting offers nonoperative, immediate, and effective colon decompression and allows bowel preparation for an elective oncologic resection. Patients who benefit the most are high-risk surgical patients and candidates for laparoscopic resection with complete obstruction, because emergency surgery can be avoided in more than 90% of patients. Colonic stent placement also offers effective palliation of malignant colonic obstruction, although it carries risks of delayed complications. When performed by experienced endoscopists, the technical success rate is high with a low procedural complication rate. Despite concerns of tumor seeding following endoscopic colorectal stent placement, no difference exists in oncologic long-term survival between patients who undergo stent placement followed by elective resection and those undergoing emergency bowel resection. Colorectal stents have also been used in selected patients with benign colonic strictures. Uncovered metal stents should be avoided in these patients, and fully covered stents are associated with high risk of migration. Patients with benign colonic stricture with acute colonic obstruction who are at high risk for emergency surgery can gain temporary relief of obstruction after SEMS placement; the stent can be removed en bloc with the colon specimen at surgery. This article reviews the techniques and indications of SEMS placement for benign and malignant colorectal obstructions.

Over-the-scope clip closure of two chronic fistulas after gastric band penetration

Gastrointestinal perforations are conservatively managed at endoscopy by through-the-scope endoclips and covered self expandable stents, according to the size and tissue features of the perforation. This is believed to be the first report of successful closure of two gastro-cutaneous fistulas with over-the-scope clips (OTSCs). After laparoscopic gastric banding, a 45-year old woman presented with band erosion and penetration. Despite surgical band removal and gastric wall suturing, external drainage of enteric material persisted for 2 wk, and esophagogastroduodenoscopy demonstrated two adjacent 10-mm and 15-mm fistulous orifices at the esophagogastric junction. After cauterization of the margins, the 10-mm fistulous tract was grasped by the OTSC anchor, invaginated into the applicator cap, and closed by a traumatic OTSC. The other 15-mm fistula was too large to be firmly grasped, and a fully-covered metal stent was temporarily placed. No leak occurred during the following 6 wk. At stent removal: the OTSC was completely embedded in hyperplastic overgrowth; the 15-mm fistula significantly reduced in diameter, and it was closed by another traumatic OTSC. After the procedure, no external fistula recurred and both OTSCs were lost spontaneously after 4 wk. The use of the anchor and the OTSC seem highly effective for successful closure of small chronic perforations.

Recent advances in the use of stents for esophageal disease

The use of self-expanding metal esophageal stents has evolved dramatically over the last 20 years. Stents themselves have morphed from simple open-mesh wire devices to a variety of partially and fully covered metal and plastic protheses designed to resist in-growth and migration. Indications include grown considerably from simply palliating malignant dysphagia to the treatment of benign conditions such as refractory strictures, perforations, and fistulas, bridging tumors through neoadjuvant therapy and even serving as support for mucosal healing after ablative therapies. This article describes the current experience with esophageal stenting for malignant and benign conditions and examines new innovations in stent design and applications.