Fate of migrated esophageal and gastroduodenal stents: experience in 70 patients

Small bowel obstruction due to migrated oesophageal metal stent

INTRODUCTION AND IMPORTANCE

Endoscopic oesophageal stents have numerous applications, including palliative management for unresectable oesophageal cancer, treatment of benign strictures and blocking early oesophageal perforations. However a significant limitation of fully covered self-expandable metallic stents (FC-SEMs) is their risk of migration. While oesophageal stenting is generally safe, it carries risks of mainly minor complications and a few major complications like tracheoesophageal fistulae, intestinal perforation, and, very rarely, intestinal obstruction due to stent migration. We hereby describe an instance of the last complication.

CASE PRESENTATION

A 48-year-old male with chronic kidney disease and hypertension presented with Boerhaave's syndrome which was successfully managed with FC-SEMs placement. He was lost to follow-up, but returned 8 months later presented with features of intestinal obstruction. Imaging revealed migrated FC-SEMs in the mid-jejunum with features of small bowel obstruction. After conservative management failed, he underwent exploratory laparotomy and stent retrieval. He had an uneventful post-operative recovery.

CLINICAL DISCUSSION

Boerhaave syndrome, a rare spontaneous oesophageal perforation, has seen evolving management strategies, from surgical repair to minimally invasive endoscopic interventions like self-expandable metallic stents (SEMs). While SEMs effectively manage perforations, migration remains a major complication, influenced by stent type and placement location. In this case, a migrated stent caused small bowel obstruction, necessitating surgical retrieval. This highlights the need for careful stent selection, close follow-up, and individualized management to prevent severe complications.

CONCLUSION

Migrating, covered SEMs, placed for oesophageal perforation, may cause intestinal obstruction necessitating surgical retrieval.

Endoscopic suturing to prevent migration of esophageal fully covered self-expanding metal stents: a randomized controlled trial (with video)

BACKGROUND AND AIMS

High migration rates for fully covered self-expanding metal stents (FC-SEMSs) have been reported in the literature. Endoscopic suture fixation has been explored as a mitigation strategy. This study sought to compare rates of migration and other adverse events after esophageal FC-SEMS placement with and without endoscopic suturing.

METHODS

We performed a randomized controlled trial involving adult patients who underwent FC-SEMS placement at our institution for management of esophageal strictures. Patients were randomly allocated (1:1 stratified randomization based on benign or malignant etiology) to undergo FC-SEMS placement with endoscopic suture fixation or FC-SEMS placement alone. All investigators were blinded to the randomization sequence. Patients and statistical analysts were blinded to intervention assignment. Primary outcome was stent migration, and secondary outcomes were other stent-related adverse events, technical success, procedure duration, time to migration, and premature stent removal due to adverse events. A cost-effectiveness analysis was also performed comparing endoscopic suturing with FC-SEMS placement alone.

RESULTS

Between July 2021 and December 2022, a total of 46 patients were enrolled: 24 in the fixation group and 22 in the non-fixation group. In the intention-to-treat analysis, the stent migration rate was significantly lower in the fixation group compared with the non-fixation group (risk ratio, .28; 95% CI, .11-.74; P = .008). All secondary outcomes were similar in both groups, except procedure duration, which was longer in the fixation group (P = .001). Endoscopic suturing was cost-effective for preventing stent migration compared with stent placement alone. The trial was terminated early after an interim analysis clearly showed inferior primary outcomes in the non-fixation group.

CONCLUSIONS

These findings support the efficacy, safety, and cost-effectiveness of endoscopic suture fixation for preventing esophageal FC-SEMS migration. Further studies comparing endoscopic suturing and other stent fixation strategies are warranted. (Clinical trial registration number: NCT05082948.).

Endoscopic Management of Bariatric Surgery Complications: Fistulas, Leaks, and Ulcers

Bariatric surgery is a safe and effective treatment option for patients with obesity and obesity-related comorbidities, with Roux-en-Y gastric bypass and sleeve gastrectomy being the two most common procedures. Despite the success of these interventions, adverse events are not uncommon. Endoscopic management has become first-line therapy when complications occur, and the armamentarium of devices and techniques continues to grow. This article focuses on the management of fistulas, leaks, and ulcers and also focuses on the etiology and endoscopic management strategy of each complication.

Percutaneous Removal of Migrated Gastrointestinal Stents Using Gastrostomy Access

This report describes the experience of removing migrated gastrointestinal (GI) stents using a gastrostomy (G) access. Four male patients aged 23-62 years (mean, 42 years) had 6 migrated stents removed using an existing (n = 3) or new (n = 1) G access. Removed stents included 5 covered esophageal stents that migrated into the stomach and 1 distal noncovered duodenal stent that migrated into the proximal duodenum. One patient had 2 stents removed during the same session. All stents were removed successfully without adverse events. Techniques used included the folding technique using a wire in 3 stents and forceps in 2 stents. Eversion technique was used in the duodenal stent. The G or gastrojejunostomy tubes were replaced after stent removal and used for enteral feedings. In conclusion, removing migrated GI stents using an existing or new G access was technically successful and safe.

Risk factors of stent migration in esophageal cancer patients who underwent fully-covered self-expanding metal stents for malignant dysphagia or tracheoesophageal fistula

BACKGROUND

More than 50% of esophageal cancer patients are diagnosed with advanced diseases and commonly experience dysphagia, some of whom even have tracheoesophageal fistula. Self-expandable metal stent (SEMS) is one of the recommended palliative methods, although complications such as chest pain and stent migration are not uncommon. The goal of this study was to examine the predictors of stent migration.

METHODS

We conducted a retrospective cohort study to include patients with esophageal cancer and dysphagia/tracheoesophageal fistula. Clinicopathological information, stent characteristics and patient outcomes were collected for analysis, while side-effects of SEMS were recorded, potential predictors were examined, and patients' nutritional outcomes were compared in the migration and non-migration groups.

RESULTS

A total of 54 patients with esophageal cancer who received fully covered SEMS between 2013 and 2022 were included. We found tumor across the esophagogastric junction (adjusted odds ratio (OR) = 32.64, P = 0.01) and the female sex (adjusted OR = 12.5, P = 0.02) were significant predictors for stent migration. There was a decreasing tendency in body mass index/body weight in migration and non-migration groups, but the former had a steeper downslope.

CONCLUSION

Fully covered SEMS is a safe and effective strategy to palliate dysphagia or fistula. Tumor across esophagogastric junction and the female sex were higher risk predictors of stent migration. A careful patient selection would optimize the effects of SEMS placement, especially in those with short-expected lifespan.

Incidence and factors associated with stent dysfunction and pancreatitis after gastroduodenal stenting for malignant gastric outlet obstruction

Background and study aims Endoscopic gastroduodenal stent (GDS) deployment is currently a standard treatment for malignant gastric outlet obstruction (mGOO) in patients with limited life expectancy; however, stent dysfunction (SD) and complicated pancreatitis often occur after GDS deployment. We investigated incidence and contributing factors of SD and complicated pancreatitis. Patients and methods We retrospectively reviewed 203 patients who underwent initial GDS deployment for palliation of mGOO symptoms between October 2017 and July 2022, including 109 who underwent GDS deployment across the duodenal papilla (sub-cohort). Results SDs, including tumor ingrowth (n = 26), kinking (n = 14), and migration (n = 13), occurred in 68 patients (33.5%). Cumulative SD incidence was 41.1% (95% confidence interval, 32.6-49.4%). SD incidence increased to 0.4%, 0.16%, and 0.06% per day at < 8, 8-16, and>16 weeks, respectively. On multivariate analysis, Niti-S pyloric/duodenal stent deployment (sub-distribution hazard ratio [sHR] 0.26, P = 0.01) and survival length ≥ 90 days (sHR 2.5, P = 0.01) were respectively identified as favorable and risk factors significantly associated with SD. Pancreatitis developed in 14 patients (12.8%) in the sub-cohort, which had significantly higher parenchymal diameter ( P < 0.01) and lower main pancreatic duct (MPD) caliber ( P < 0.01) than the non-pancreatitis cohort. On multivariate analysis, MPD caliber < 3 mm independently predicted pancreatitis (odds ratio 6.8, P = 0.03). Conclusions Deployment of the Niti-S pyloric/duodenal stent, with conformability even for angulated strictures, significantly reduced the incidence of SD. Stent selection, life expectancy, and MPD caliber should be taken into consideration during decision-making for GDS deployment for mGOO.

Outcomes of Endoscopic Intervention Using Over-the-Scope Clips for Anastomotic Leakage Involving Secondary Fistula after Gastrointestinal Surgery: A Japanese Multicenter Case Series

BACKGROUND

The over-the-scope clip (OTSC) is a highly effective clipping device for refractory gastrointestinal disease. However, Japanese data from multicenter studies for anastomotic leakage (AL) involving a secondary fistula after gastrointestinal surgery are lacking. Therefore, this study evaluated the efficacy and safety of OTSC placement in Japanese patients with such conditions.

METHODS

We retrospectively collected data from 28 consecutive patients from five institutions who underwent OTSC-mediated closure for AL between July 2017 and July 2020.

RESULTS

The AL and fistula were located in the esophagus (3.6%, n = 1), stomach (10.7%, n = 3), small intestine (7.1%, n = 2), colon (25.0%, n = 7), and rectum (53.6%, n = 15). The technical success, clinical success, and complication rates were 92.9% (26/28), 71.4% (20/28), and 0% (0/28), respectively. An age of <65 years (85.7%), small intestinal AL (100%) and colonic AL (100%), defect size of <10 mm (82.4%), time to OTSC placement > 7 days (84.2%), and the use of simple suction (78.9%) and anchor forceps (80.0%) were associated with higher clinical success rates.

CONCLUSION

OTSC placement is a useful therapeutic option for AL after gastrointestinal surgery.

Small Bowel Obstruction Secondary to Migration of a Fractured Esophageal Stent

Esophageal stent placement is commonly indicated for the management of inoperable esophageal malignancies, benign strictures, and esophageal perforations including Boerhaave's syndrome. We present a case of a 74-year-old female, who presented with small bowel obstruction secondary to a migrated esophageal stent, which was placed 20 weeks previously for Boerhaave's syndrome. She was surgically managed with laparotomy and retrieval of the fractured stent with local resection of the small bowel, followed by primary anastomosis.

Personalized Health Care Technology in Managing Postoperative Gastrointestinal Surgery Complications: Proof of Concept Study

Background: Advances in three-dimensional (3D) printing technology have allowed the development of customized medical devices. Endoscopic internal drainage (EID) is a novel method to facilitate drainage of an abscess cavity into the lumen of the gastrointestinal tract by placing a double pigtail biliary stent through the fistula opening, originally designed for biliary drainage. They are available in manufacture-determined sizes and shapes. The aim of this study is to explore the feasibility of 3D printing personalized internal drainage stents for the treatment of leaks following gastrointestinal surgery over a sequential period. Methods: We retrospectively identified patients who underwent gastrointestinal anastomotic surgery complicated by postoperative leaks and underwent serial EID for treatment. Computerized Tomography scans were reviewed over a period of time, abscess cavity dimensions and characterizations were evaluated, and 3D reconstructions were obtained. The stents were designed, their shape and size were customized to the unique dimensions of the abscess and lumen of the patient. Stereolithography (SLA) 3D printing technique was used to produce the stents. Results: A total of 8 stents were produced, representing 3 patients. These stents corresponded to 2 or 3 stents per patients. Each patient underwent several endoscopic treatments, before resolution of leak. Conclusions: Customized stents may improve drainage of intra-abdominal abscesses after gastrointestinal surgery, if based on unique anatomy. This proof-of-concept study is a real-world application of personalized health care, which introduces the novel description of customizable 3D printed stents to manage complications following gastrointestinal surgery and may advance therapy for this complex clinical condition. Research Ethics Committees (REC) number is A-2021-012.

Endoscopic management of gastrointestinal leaks and fistulae: What option do we have?

Gastrointestinal leaks and fistulae are serious, potentially life threatening conditions that may occur with a wide variety of clinical presentations. Leaks are mostly related to post-operative anastomotic defects and are responsible for an important share of surgical morbidity and mortality. Chronic leaks and long standing post-operative collections may evolve in a fistula between two epithelialized structures. Endoscopy has earned a pivotal role in the management of gastrointestinal defects both as first line and as rescue treatment. Endotherapy is a minimally invasive, effective approach with lower morbidity and mortality compared to revisional surgery. Clips and luminal stents are the pioneer of gastrointestinal (GI) defect endotherapy, whereas innovative endoscopic closure devices and techniques, such as endoscopic internal drainage, suturing system and vacuum therapy, has broadened the indications of endoscopy for the management of GI wall defect. Although several endoscopic options are currently used, a standardized evidence-based algorithm for management of GI defect is not available. Successful management of gastrointestinal leaks and fistulae requires a tailored and multidisciplinary approach based on clinical presentation, defect features (size, location and onset time), local expertise and the availability of devices. In this review, we analyze different endoscopic approaches, which we selected on the basis of the available literature and our own experience. Then, we evaluate the overall efficacy and procedural-specific strengths and weaknesses of each approach.

Small Bowel Perforation Secondary to Esophageal Stent Migration: A Comparative Review of Six Cases

Esophageal stent placement is used to treat benign strictures, esophageal perforations, fistulas and for palliative therapy of esophageal cancer. Although it is a safe and effective method, complications are increasing the morbidity and mortality rate. Small bowel perforation as a result of esophageal stent migration is a remarkably rare occurrence. We report one case from our clinical experience and undertake a review of the previously reported cases retrieved from the PubMed. A total of six cases were found accessible. Abdominal pain was the common clinical presentation. The mean time from stent placement to perforation was 3.4 months (range, two weeks to 12 months). The jejunum was the frequently perforated portion of the small bowel. Surgical intervention was the mainstay of treatment. This comparative review illustrates that clinicians should remain vigilant for small bowel perforation in patients with esophageal stent placement. Further studies are required to delineate the magnitude and scope of this association.

Fully-covered metal stents with endoscopic suturing vs. partially-covered metal stents for benign upper gastrointestinal diseases: a comparative study

BACKGROUND AND STUDY AIMS

Self-expandable metallic stents (SEMS) have been increasingly used in benign conditions (e. g. strictures, fistulas, leaks, and perforations). Fully covered SEMS (FSEMS) were introduced to avoid undesirable consequences of partially covered SEMS (PSEMS), but come with higher risk of stent migration. Endoscopic suturing (ES) for stent fixation has been shown to reduce migration of FSEMS. Our aim was to compare the outcomes of FSEMS with ES (FS/ES) versus PSEMS in patients with benign upper gastrointestinal conditions.

PATIENTS AND METHODS

We retrospectively identified all patients who underwent stent placement for benign gastrointestinal conditions at seven US tertiary-care centers. Patients were divided into two groups: FSEMS with ES (FS/ES group) and PSEMS (PSEMS group). Clinical outcomes between the two groups were compared.

RESULTS

A total of 74 (FS/ES 46, PSEMS 28) patients were included. On multivariable analysis, there was no significant difference in rate of stent migration between FS/ES (43 %) and PSEMS (15 %) (adjusted odds ratio 0.56; 95 % CI 0.15 - 2.00). Clinical success was similar [68 % vs. 64 %; P  = 0.81]. Rate of adverse events (AEs) was higher in PSEMS group [13 (46 %) vs. 10 (21 %); P  = 0.03). Difficult stent removal was higher in the PSEMS group (n = 5;17 %) vs. 0 % in the FS/ES group; P  = 0.005.

CONCLUSIONS

The proportion of stent migration of FS/ES and PSEMS are similar. Rates of other stent-related AEs were higher in the PSEMS group. PSEMS was associated with tissue ingrowth or overgrowth leading to difficult stent removal, and secondary stricture formation. Thus, FSEMS with ES for stent fixation may be the preferred modality over PSEMS for the treatment of benign upper gastrointestinal conditions.

Endoscopic suturing of esophageal fully covered self-expanding metal stents reduces rates of stent migration

BACKGROUND AND AIMS

Endoscopic suturing of fully covered self-expanding metal stents (FC-SEMSs) may prevent migration. The aim of this study was to compare rates of migration between sutured FC-SEMSs (S-FCSEMSs), unsecured FC-SEMSs, and partially covered SEMSs (PC-SEMSs) placed for benign esophageal leaks and strictures.

METHODS

In a retrospective, single-center, cohort study, rates of migration for S-FCSEMSs, FC-SEMSs, and PC-SEMSs were assessed in patients with at least 1 month of follow-up or experiencing clinically significant stent migration (CSSM) any time after placement. CSSM was defined as proximal or distal displacement of the stent by ≥2 cm or passage into the stomach plus the recurrence of pre-SEMS symptoms or signs. A multivariable analysis was done to identify additional risk factors for stent migration.

RESULTS

A total of 184 SEMSs were placed in 101 patients, including 32 S-FCSEMSs in 25 patients, 114 FC-SEMSs in 59 patients, and 38 PC-SEMSs in 30 patients. CSSM occurred with 56 of 184 stents (30.4%) in 36 of 101 patients (35.6%), including 3 of 32 (9.4%) S-FCSEMSs, 45 of 114 (39.5%) FC-SEMSs, and 8 of 38 (21.1%) PC-SEMSs (P = .005). Migration was less likely for S-FCSEMSs than for FC-SEMSs (9.4% vs 39.5%; P = .01) but not between S-FCSEMSs and PC-SEMSs (9.4% vs 21.1%; P = .07) or between FC-SEMSs and PC-SEMSs (39.5% vs 21.1%; P = .38). Previous stent migration (odds ratio [OR], 3.93; 95% confidence interval [CI], 1.88-8.19; P = .01) and previous esophageal surgery (OR, 0.33; 95% CI, 0.16-0.67; P = .002) were associated with increased and decreased risk of CSSM, respectively.

CONCLUSIONS

Endoscopic suturing of FC-SEMSs for benign esophageal disease reduces CSSM compared with unsecured FC-SEMSs but not PC-SEMSs. Patients with previous stent migration may benefit from prophylactic suturing of FC-SEMSs.

Migrated esophageal stent posing a challenge for ventilation

Self-expandable esophageal stents are being commonly used for palliative treatment in advanced esophageal cancer patients to relieve dysphagia, prevent tracheoesophageal fistula, and facilitate symptomatic betterment. The modern covered stents reduce the ingrowth of the tumor but have seen an increase in the incidence of stent migrations. We report a rather complicated presentation of an esophageal stent for esophageal dilatation and a challenging management of a difficult tracheostomy.

Efficacy of Retrievable Metallic Stent with Fixation String for Benign Stricture after Upper Gastrointestinal Surgery

Objective

To determine the efficacy of retrievable metallic stent with fixation string for benign anastomotic stricture after upper gastrointestinal (UGI) surgery.

Materials and Methods

From June 2009 to May 2015, a total of 56 retrievable metallic stents with fixation string were placed under fluoroscopy guidance in 42 patients who were diagnosed with benign anastomotic stricture after UGI surgery. Clinical success was defined as achieving normal regular diet (NRD).

Results

The clinical success rate after the first stent placement was 57.1% (24/42). After repeated stent placement and/or balloon dilation, the clinical success rate was increased to 83.3% (35/42). Six (14.3%) patients required surgical revision to achieve NRD. One (2.4%) patient failed to achieve NRD. Stent migration occurred in 60.7% (34/56) of patients. Successful rate of removing the stent using fixation string and angiocatheter was 94.6% (53/56). Distal migration occurred in 12 stents. Of the 12 stents, 10 (83.3%) were successfully removed whereas 2 could not be removed. No complication occurred regarding distal migration.

Conclusion

Using retrievable metallic stent with a fixation string is a feasible option for managing early benign anastomotic stricture after UGI surgery. It can reduce complications caused by distal migration of the stent.

Efficacy of Gastric Balloon Dilatation and/or Retrievable Stent Insertion for Pyloric Spasms after Pylorus-Preserving Gastrectomy: Retrospective Analysis

Purpose

We retrospectively investigated the feasibility and clinical efficacy of balloon dilatation and subsequent retrievable stent insertion, when necessitated, for pyloric spasms after pylorus-preserving gastrectomy (PPG).

Materials and Methods

Forty-five patients experiencing pyloric spasms after PPG underwent fluoroscopic balloon dilations to alleviate obstructive symptoms due to delayed gastric emptying. Patients showing poor response to balloon dilation underwent subsequent retrievable stent insertion. Safety of the procedures was analyzed, and subjective symptoms and objective signs of pyloric spasms were analyzed and compared before and after treatment.

Results

Thirty-three patients (73.3%, 33/45) showed good response to balloon dilatation requiring no further treatment (balloon group). Conversely, 12 patients (26.7%, 12/45) showed poor or no response after balloon dilation requiring subsequent stent insertion (stent group). Balloon dilations and/or stent insertions were safely performed in all patients except one patient who suffered a transmural tear after balloon dilatation. In both groups, mean subjective symptom score was significantly improved and mean pyloric canal-to-height of the adjacent vertebral body ratio was significantly increased after the procedures (P <.05).

Conclusion

Balloon dilation is a safe and effective treatment for patients with pyloric spasms after PPG. In patients refractory to balloon dilations, retrievable stent placement can be a safe alternative tool.

Esophageal Stenting With Sutures: Time to Redefine Our Standards?

BACKGROUND AND STUDY AIMS

Migration is the most common complication of the fully covered metallic self-expanding esophageal stent (FCSEMS). Recent studies have demonstrated migration rates between 30% and 60%. The aim of this study was to determine the effect of fixation of the FCSEMS by endoscopic suturing on migration rate.

PATIENT AND METHODS

Patients who underwent stent placement for esophageal strictures and leaks over the last year were captured and reviewed retrospectively. Group A, cases, were patients who underwent suture placement and group B, controls, were patients who had stents without sutures. Basic demographics, indications, and adverse events (AEs) were collected. Kaplan-Meier analysis and Cox regression modeling were conducted to determine estimates and predictors of stent migration in patients with and without suture placement.

RESULTS

Thirty-seven patients (18 males, 48.65%), mean age 57.2 years (±16.3 y), were treated with esophageal FCSEMS. A total of 17 patients received sutures (group A) and 20 patients received stents without sutures (group B). Stent migration was noted in a total of 13 of the 37 patients (35%) [2 (11%) in group A and 11 (55%) in group B]. Using Kaplan-Meier analysis and log-rank analysis, fixation of the stent with suturing reduced the risk of migration (P=0.04). There were no AEs directly related to suture placement.

CONCLUSIONS

Anchoring of the upper flare of the FCSEMS with endoscopic sutures is technically feasible and significantly reduces stent migration rate when compared with no suturing, and is a safe procedure with very low AEs rates.

Migration of retrievable expandable metallic stents inserted for malignant esophageal strictures: incidence, management, and prognostic factors in 332 patients

OBJECTIVE

The purpose of this study was to evaluate the incidence, prognostic factors, and secondary management of stent migration in patients with malignant esophageal strictures.

MATERIALS AND METHODS

A retrospective study was performed in a single tertiary referral university hospital to identify the incidence, management, and prognostic factors for stent migration in 332 consecutive patients with placement of a retrievable expandable metallic stent. Stent migration was classified into four patterns as locations of a migrated stent: pattern I, partially migrated in the proximal direction; pattern II, partially migrated in the distal direction; pattern III, completely migrated into the stomach; and pattern IV, completely migrated into the bowel.

RESULTS

Stent migration occurred in 42 (12.6%) of 332 patients. Migration was partial (n = 21) or complete (n = 21), and nine (21%), 12 (29%), 11 (26%), and 10 (24%) patients had patterns I, II, III, and IV, respectively. Multivariate analysis identified the following prognostic factors: esophagogastric junction strictures caused by cancer of the gastric cardia (odds ratio 1.330; p = 0.004), patients who underwent anticancer treatment after stent placement (17.514; p < 0.001), and patients with a longer survival time (1.994; p < 0.001). Secondary management was needed for 33 of 42 patients. The strictures in the remaining nine patients improved throughout follow-up.

CONCLUSION

Stent migration occurs most commonly in patients with cancer of the gastric cardia, patients with longer survival time, and those who underwent anticancer treatment after stent placement. Stent migration is successfully managed by further intervention. Accurate knowledge of the pattern of stent migration is important for successful management.

Endoscopic suture fixation of self-expanding metallic stents with and without submucosal injection

BACKGROUND

Self-expanding metallic stents (SEMS) are useful for treating leaks after bariatric procedures but stent migration (12 to 40 %) remains a problem. Suture fixation has been used to minimize migration but has attendant risks of transmural penetration. We hypothesized that submucosal injection would decrease the risk of full thickness suture penetration while still providing greater pullout forces than endoscopic clipping.

METHODS

Porcine explant models and 155 mm SEMS were used with a force meter to measure the pullout forces required to dislodge the stent. Stents were first deployed without fixation and this pullout force acted as a control. The explants were then randomized to receive fixation with clips, endoscopic suturing with submucosal elevation, or endoscopic suturing without submucosal elevation. The pullout force was again measured and the ratio of the experimental to control pullout forces was used as a measure of the efficacy of the fixation.

RESULTS

Endoscopic suture fixation after submucosal injection resulted in statistically significant increased pullout force compared to clip fixation (n = 5; mean force ratio 462 %; 95 % confidence interval [CI] 281-643 %; p < 0.01). Endoscopic suturing fixation without submucosal injection also resulted in statistically significant increased pullout force (n = 5; mean force ratio 765 %; 95 % CI 258-632 %; p < 0.01). Fixation with clips did not result in significantly increased pullout force compared to no fixation (n = 5; mean force ratio 108 %; 95 % CI 56-159 %; p < 0.01). Submucosal injection also eliminated full thickness suture penetration (0/10 submucosal injection; 7/10 no injection).

CONCLUSIONS

Endoscopic suture fixation of SEMS resulted in a statistically significant increase in pullout force necessary to displace the stents. Submucosal injection prior to suture fixation preserves the increased pullout force while minimizing the risk of transmural penetration with the potential for less risk of injury to mediastinal structures.

The cooperation between endoscopists and surgeons in treating complications of bariatric surgery

The results of lifestyle interventions and pharmacotherapy are disappointing in severe obesity which is characterised by premature death and many obesity-associated co-morbidities. Only surgery may achieve significant and durable weight losses associated with increased life expectancy and improvement of co-morbidities. Bariatric surgery involves the gastrointestinal tract and may therefore increase gastrointestinal complaints. Bariatric surgery may also result in complications which in many cases can be solved by endoscopic interventions. This requires a close cooperation between surgeons and endoscopists. This chapter will concentrate on the most commonly performed operations such as the Roux-en-Y gastric bypass, the adjustable gastric banding and the sleeve gastrectomy, in the majority of cases performed by laparoscopy. Operations such as the vertical banded gastroplasty and the biliopancreatic diversion with or without duodenal switch will not be discussed at length as patients with these operations will not be encountered frequently and their management can be found under the headings of the other operations.

Endoscopic therapies for leaks and fistulas after bariatric surgery

Bariatric surgery is the most effective treatment for the medical comorbidities associated with morbid obesity. Though uncommon, staple line or anastomotic leaks after bariatric surgery are highly morbid events and challenging to treat. In selected patients without severe sepsis or distant pollution, endoscopic transluminal peritoneal drainage may provide source control. For leaks within 3 days of surgery, endoscopic stenting does not appear to speed closure but does permit oral nutrition. In uncomplicated situations, the risk of migration and resulting complications of enteric stents appear to overshadow the benefits. Initial treatment failures and leaks presenting more than 48 hours after surgery respond to enteric diversion by endoscopic stenting. Occlusion of the leak by injection of fibrin glue also shows promise; however, these case series are limited to a small number of patients. Endoclips may work best to occlude leaks and close fistulas if the epithelium is debrided. As suturing technology improves, direct internal closure of fistulas may prove feasible. Therapeutic endoscopy offers several technologies that can assist in the closure of early leaks and that are essential to the treatment of late leaks and fistulas after bariatric surgery.

How to design the optimal self-expandable oesophageal metallic stents: 22 years of experience in 645 patients with malignant strictures

OBJECTIVES

To evaluate the clinical efficacy and safety of self-expandable metallic stent (SEMS) placement for malignant oesophageal strictures and their relationship with stent designs.

METHODS

Seven generations of SEMS were used to treat 645 consecutive patients with oesophageal strictures. Logistic regression models were constructed to identify predictive factors associated with complications.

RESULTS

Stent placement was technically successful in 641 of 645 patients (99.4%). The clinical success rate was 95.5%. There were 260 (40.3%) complications after stent placement. Due to complications, 68 stents were removed; 66 of 68 stents (97.1%) were removed successfully. Stainless steel (SS) stents (odds ratio [OR] 4.18; 95% confidence interval [CI] 2.10, 8.32) and radiation therapy (RT) before stent placement (OR 4.23; CI 2.02, 8.83) were significantly associated with severe pain. Flared ends (OR 9.63; CI 3.38, 27.43), stricture length <6 cm (OR 2.01; CI 1.13, 3.60), and a stent diameter <18 mm (OR 3.00; CI 1.32, 6.84) were predictive factors of stent migration. Polyurethane membranes were associated with more frequent tumour ingrowth than polytetrafluoroethylene (PTFE) membranes (P = 0.002).

CONCLUSIONS

Despite the relatively high complication rate, retrievable self-expandable PTFE-covered nitinol stents equipped with a head and a tail appeared to be an effective treatment for malignant oesophageal strictures.

Oesophageal stent migration following Billroth I gastrectomy: an unusual cause of small bowel obstruction

We report the case of an elderly female patient with a history of a previous Billroth I gastrectomy who presented with small bowel obstruction secondary to a migrated oesophageal stent. This patient had an iatrogenic oesophageal perforation following therapeutic endoscopy for a benign stricture 4 months prior to presentation. This was treated endoscopically with a covered stent that was not removed as planned. The stent migrated distally lodging in the terminal ileum, causing small bowel obstruction. Oesophageal stent migration is a rare but well-recognized complication of stent placement. Endoscopic stenting is an effective treatment for oesophageal perforation with lower morbidity and mortality than operative repair. Clinicians should be aware that although patients with a history of previous gastric surgery are at no greater risk of stent migration than others, the altered anatomy can affect the final resting place of the migrated stent and hence the clinical effects and sequalae.

Placement of a covered expandable metallic stent to treat nonanastomotic malignant jejunal obstructions after total gastrectomy with esophagojejunostomy

OBJECTIVE

The objective of our study was to assess the technical feasibility and clinical effectiveness of expandable metallic stent placement in patients with nonanastomotic malignant jejunal obstruction after total gastrectomy with esophagojejunostomy.

MATERIALS AND METHODS

We retrospectively analyzed data from 21 patients with malignant jejunal obstruction after total gastrectomy with esophagojejunostomy who received one of two types of expandable metallic stent. Clinical effectiveness was assessed using the following variables: technical and clinical outcomes, complications, dysphagia scores before and after stent placement, patient survival, and stent patency. Complications with related interventions were evaluated and compared between the two stent types.

RESULTS

Stent placement was technically successful in 20 of the 21 patients (95%) with 19 of 20 patients (95%) showing symptomatic improvement. Type A stents were used in 10 patients and type B stents in the remaining 10 patients. Complications occurred with seven of 20 stents (35%) and involved stent migration (n = 3), tumor overgrowth (n = 3), or pain (n = 1). The dysphagia score before stent placement (mean ± SD, 3.2 ± 0.5) had improved by 3 days after stent placement (1.3 ± 0.9, p < 0.001) and was maintained compared with the initial score up to 1 month (1.7 ± 1.1, p < 0.001) and 3 months (2.1 ± 1.5, p = 0.021) after stent placement. The median patient survival and stent patency were 114 and 46 days, respectively. The type of stent was not significantly related to complications (p = 0.350).

CONCLUSION

Placement of expandable metallic stents to treat nonanastomotic malignant jejunal obstruction in patients who have undergone total gastrectomy with esophagojejunostomy is feasible and clinically effective.

Stent placement for esophageal strictures: an update

The use of stents for esophageal strictures has evolved rapidly over the past 10 years, from rigid plastic tubes to flexible self-expanding metal (SEMS), plastic (SEPS) and biodegradable stents. For the palliative treatment of malignant dysphagia both SEMS and SEPS effectively provide a rapid relief of dysphagia. SEMS are preferred over SEPS, as randomized controlled trials have shown more technical difficulties and late migration with plastic stents. Despite specific characteristics of recently developed stents, recurrent dysphagia due to food impaction, tumoral and nontumoral tissue overgrowth, or stent migration, remain a major challenge. The efficacy of stents with an antireflux valve for patients with distal esophageal cancer varies between different stent designs. Concurrent treatment with chemotherapy and/or radiotherapy seems to be safe and effective. In the future, it can be expected that removable stents will be used as a bridge to surgery to maintain luminal patency during neoadjuvant treatment. For benign strictures, new stent designs, such as fully covered SEMS and biodegradable stents, may potentially reduce complications during stent removal.

Clinical outcomes, quality of life, advantages and disadvantages of metal stent placement in the upper gastrointestinal tract

PURPOSE OF REVIEW

This review will discuss the immediate- and long-term success, complications and overall benefits of self-expandable metal stents (SEMSs) in malignant or benign obstruction of the oesophagus, stomach and duodenum. Over recent years, indications such as benign disease have expanded, as has SEMS diversity with self-expandable plastic stents (SEPSs) or fully covered and biodegradable stents, for example.

RECENT FINDINGS

SEMSs have been increasingly used in malignant upper gastrointestinal obstruction with many reports confirming efficacy, despite a significant complication rate. Fully covered stents are increasingly used for a variety of benign oesophageal disease, but their place in gastric outlet obstruction is still unclear. Covered and uncovered stents have different functional characteristics and stent type must be selected on an individual basis. Biodegradable stents show promise and the outcome of experience in larger patient cohorts is eagerly awaited.

SUMMARY

This area is an evolving field, in which the clinician requires up-to-date knowledge of therapeutic options to make individualized treatment choices in difficult clinical circumstances. Technical and clinical success for oesophageal or gastroduodenal SEMSs are then above 90%. Minor complications are common, but serious complications seldom occur. Biodegradable stents may be useful, especially when stenting is needed for a short period of time.

Outcomes following oesophageal stent insertion for palliation of malignant strictures: A large single centre series

BACKGROUND

Self-expanding metal stents (SEMS) are an accepted intervention for malignant dysphagia. Stents vary in ease of insertion, removability, migration and occlusion rates. This series reports the complications, morbidity and mortality associated with several SEMS.

METHOD

A prospective database of patients undergoing fluoroscopic guided oesophageal stent insertion for malignancy between June 2001 and June 2009 was analysed. Patient demographics, intervention outcomes and tumour variables were correlated with stent failure and patient survival. Multivariate analysis was performed to evaluate predictors for stent failure.

RESULTS

Two hundred and seventy-three stents were deployed using nine different types of SEMS. The median Mellow-Pinkas dysphagia score significantly improved from 3 to 1 post-stent insertion (P < 0.001), with a technical success rate of 98%. Stent complications occurred in 95 (36%) patients [recurrent dysphagia n = 49 (19%), migration n = 24 and occlusion n = 25]. Multivariate analysis demonstrates that the covered Niti S stent fails significantly more than the double-layered Niti S stent (OR = 4, P < 0.005).

CONCLUSION

Oesophageal stent insertion provides good palliation for malignant dysphagia, however recurrent dysphagia remains a problem. This major complication occurs more frequently with covered Niti S stents than double-layered Niti S stents. This finding may aid the stent choice used in advanced oesophageal malignancy.

Evaluation of the incidence of esophageal complications associated with balloon dilation and their management in patients with malignant esophageal strictures

OBJECTIVE

The objective of this study was to investigate the incidence of esophageal complications associated with balloon dilation and their management in patients with malignant esophageal strictures.

MATERIALS AND METHODS

Fluoroscopically guided esophageal balloon dilation was performed in 89 patients with malignant esophageal strictures during a period of 15 years. Inclusion criteria were patients with unresected esophageal or gastric carcinoma showing short-segment stricture (≤4 cm) at the esophagogastric junction; patients who had previously received chemotherapy, radiation therapy, or both to manage malignant strictures; or patients who were scheduled for chemotherapy or radiation therapy to manage malignant strictures. Of these patients, 72 had esophageal cancer and 17 had stomach cancer. Esophageal rupture was categorized as intramural, transmural, or transmural with mediastinal leakage.

RESULTS

A total of 120 procedures were performed, with each patient undergoing one to four procedures. Esophageal rupture occurred in 13 patients (15%): eight with intramural rupture, four with transmural rupture, and one with transmural rupture with mediastinal leakage. Improvements in dysphagia score were observed in 76 of 89 patients (85%) after balloon dilation. All esophageal ruptures were detected immediately after the procedure. Intramural and transmural ruptures were treated conservatively, whereas transmural rupture with mediastinal leakage was treated by temporary stent placement.

CONCLUSION

The overall prevalence of esophageal rupture was 15%. All intramural and transmural ruptures were successfully managed conservatively, whereas transmural rupture with mediastinal leakage was treated by temporary stent placement. We found no relationship between rupture incidence and balloon diameter.

Fluoroscopically guided balloon dilation of benign esophageal strictures: incidence of esophageal rupture and its management in 589 patients

OBJECTIVE

The purpose of this article is to investigate the incidence and management of esophageal rupture caused by balloon dilation in patients with benign esophageal strictures.

MATERIALS AND METHODS

Fluoroscopically guided esophageal balloon dilation was performed on 589 patients with benign esophageal strictures during an 18-year period. The strictures had a range of causes: postoperative anastomotic stricture, corrosive stricture, postradiation stricture, esophageal achalasia, esophageal reflux, congenital stricture, esophageal web, esophageal ulcer, medication fibrosis, chronic inflammation, and posttraumatic stricture (in descending order of frequency). Esophageal rupture was assigned to one of three categories: type 1 was intramural, type 2 was transmural with a contained leak, and type 3 was transmural with an uncontained mediastinal leakage.

RESULTS

A total of 1421 procedures were performed in 589 patients, with each patient undergoing 1-29 procedures. The technical success rate was 99.8%, and the clinical success rate was 91.7%. Patients with corrosive stricture underwent the highest number of procedures (mean, 4.38 procedures). The incidence of esophageal rupture was 14.7%. All esophageal ruptures were detected immediately after the procedure. Most ruptures (98.6%) were types 1 and 2 and were successfully managed conservatively. Only 1.4% of the ruptures were type 3 and required active management. One of the type 3 ruptures was successfully treated with a retrievable covered stent. Two patients with type 3 ruptures (0.96% of ruptures) underwent surgery and were successfully treated. The rupture rate was not statistically related to the diameter of balloon used.

CONCLUSION

The incidence of esophageal rupture after fluoroscopically guided esophageal balloon dilation was 14.7%. Almost all ruptures were type 1 or 2 and were successfully managed conservatively. Only 1.4% of the ruptures were type 3 and required active management. There was no procedure-related mortality in any patient. Therefore, in spite of the high incidence of ruptures, fluoroscopically guided balloon dilation is a safe procedure, particularly if a rupture is identified early and managed appropriately.

Role of esophageal stents in the nutrition support of patients with esophageal malignancy

Endoluminal stents are commonly used for palliative treatment of dysphagia in patients with advanced esophageal malignancies. The most frequently used esophageal stents are self-expanding metal stents. Removable self-expanding plastic stents have recently been used in the management of esophageal cancer patients treated with curative intent. Esophageal stents effectively alleviate dysphagia in most patients, and stent placement is associated with a low rate of complications. This article reviews the use of self-expanding esophageal stents in patients with esophageal cancer. Nutrition considerations following stent placement are addressed.

Endoscopic resection of ampullary adenoma after a new insulated plastic pancreatic stent placement: a pilot study

BACKGROUND AND AIM

Although pancreatic stent insertion is recommended for the prevention of post-procedure pancreatitis during endoscopic papillectomy, insertion of the stent after the procedure can be technically difficult. The aim of the present study was to determine the feasibility and safety of inserting a newly developed insulated pancreatic stent before endoscopic papillectomy.

METHODS

We conducted a prospective pilot study involving 11 consecutive patients with adenomas of the major duodenal papilla. After a 5F polytetrafluoroethylene-insulated pancreatic stent was inserted through the tumor, the stent and tumor were simultaneously grasped with a snare. After resection of the tumor with the stent in place, the tumor was incised perpendicularly along the edge of the stent for retrieval of the specimen.

RESULTS

In all patients, the insulated pancreatic stents were successfully inserted before endoscopic papillectomy and were resistant to electrical current; retrieval of the specimen was technically feasible and successful without stent migration. There were no stent-related complications, but five papillectomy-related complications (including mild bleeding [n = 4] and late papillary stenosis [n = 1]) occurred without any episodes of acute pancreatitis or perforation.

CONCLUSIONS

Pre-resection stenting with a polytetrafluoroethylene-insulated stent in patients with adenomas of the major duodenal papilla is a feasible and useful technique to prevent pancreatitis.

Stenting of the upper gastrointestinal tract: current status

Minimally invasive image-guided insertion of self-expanding metal stents in the upper gastrointestinal tract is the current treatment of choice for palliation of malignant esophageal or gastroduodenal outlet obstructions. A concise review is presented of contemporary stenting practice of the upper gastrointestinal tract, and the procedures in terms of appropriate patient evaluation, indications, and contraindications for treatment are analyzed, along with available stent designs, procedural steps, clinical outcomes, inadvertent complications, and future technology. Latest developments include biodegradable polymeric stents for benign disease and radioactive or drug-eluting stents for malignant obstructions.

Palliative treatment of unresectable esophagogastric junction tumors: balloon dilation combined with chemotherapy and/or radiation therapy and metallic stent placement

PURPOSE

To prospectively evaluate an algorithm for palliative treatment of unresectable esophagogastric junction tumors based on stricture length.

MATERIALS AND METHODS

Eighty-six patients with malignant esophagogastric obstructions were referred to the interventional radiology department for balloon dilation or stent placement due to dysphagia. Balloon dilation was performed in patients (n = 39) with a short segmental (< or =4 cm) stricture, whereas stent placement was performed in patients (n = 47) with a long segmental (>4 cm) stricture. In the balloon group, 16 patients with esophageal carcinoma underwent both chemotherapy and radiation therapy, whereas 23 patients with gastric carcinoma underwent only chemotherapy.

RESULTS

Technical success was achieved in all procedures in all patients (100%). The overall clinical success rate of balloon dilation and stent placement for a malignant esophagogastric junction was 87% (75 of 86 patients). Clinical success was achieved in 29 of the 39 patients in the balloon group (74%) and 98% (46 of the 47 patients in the stent group (98%). The overall complication rate was 21% (18 of 86 patients). Seventeen complications, which consisted of reflux (n = 8), migration (n = 6), tumor overgrowth (n = 2), and tissue hyperplasia (n = 1), occurred after stent placement, whereas one complication (intramural rupture) occurred after balloon dilation. The median symptom-free and survival periods were 120 (95% confidence interval: 114, 263) and 147 (95% confidence interval: 98, 196) days, respectively.

CONCLUSIONS

The treatment strategies seem to be reasonable for palliative therapy in patients with malignant esophagogastric junction obstructions. However, further investigations are needed to minimize the drawbacks of the methods and to determine optimal treatments in patients with unresectable malignant esophagogastric junction obstructions.

Early symptomatic strictures after gastric surgery: palliation with balloon dilation and stent placement

PURPOSE

To evaluate the clinical efficacy and safety of balloon dilation and stent placement in the treatment of early benign anastomotic strictures after gastric surgery.

MATERIALS AND METHODS

From 1997 to 2006, 63 patients with early (< or =3 months) benign anastomotic strictures after gastric surgery underwent fluoroscopic balloon dilation or stent placement due to obstructive symptoms. In all patients, balloon dilation was initially performed. Stent placement was indicated in patients who showed poor response to repeat balloon dilation.

RESULTS

Balloon dilations were successfully performed in all 63 patients, with only three intramural tears. Thirty-one of the 63 patients (49%) showed good response to initial balloon dilation and required no further treatment until the end of follow-up or death. Conversely, 32 patients (51%) had poor or no response or recurrence after initial balloon dilation and required multiple balloon dilations (n = 20), stent placement (n = 7), percutaneous gastrojejunostomy (n = 2), and/or surgical revision (n = 3). At multivariate analysis, the anastomotic site was the only independent factor predictive of the response to balloon therapy (P < .001). During a mean follow-up of 12 months, overall clinical success was achieved in 56 of the 63 patients (89%) after a single balloon dilation (n = 31), multiple balloon dilations (n = 20), and stent placement (n = 5).

CONCLUSIONS

Balloon dilation is safe and effective for the treatment of patients with early benign anastomotic strictures after gastric surgery. Stent placement can be effective in selected patients with early benign anastomotic strictures refractory to balloon dilation.

Covered stent placement in patients with recurrent cancer after a Billroth I reconstruction

PURPOSE

To assess the technical feasibility and clinical effectiveness of covered stent placement in patients with recurrent malignant obstructions after Billroth I reconstruction.

MATERIALS AND METHODS

From June 1997 to November 2005, 16 patients underwent covered stent placement for recurrent gastric cancer after Billroth I reconstruction. A total of 19 covered stents were used, including 14 dual stents and five fully covered stents, as available.

RESULTS

Stent placement was technically successful in all patients, with 13 of 16 patients (81%) showing improvement of symptoms. Stent migration occurred in one patient, tumor ingrowth in one, and stent collapse and/or bowel perforation in one. Nine patients (56%) had concomitant (n=7) or subsequent (n=2) biliary obstruction. One patient was lost to follow-up. The remaining 15 patients died 5-628 days (median, 52 days; mean, 120 days) after stent placement due to progression of disease or pneumonia.

CONCLUSIONS

Placement of covered metallic stents is feasible and effective in patients with recurrent malignant obstruction after Billroth I reconstruction.