Should we consider endoscopic clipping for prevention of esophageal stent migration?

Stent-in-stent, a safe and effective technique to remove fully embedded esophageal metal stents: case series and literature review

BACKGROUND

Endoscopic stenting is a widely used method for managing esophageal anastomotic leaks and perforations. Self-expanding metal stents (SEMSs) have proved effective in sealing these defects, with a lower rate of displacement than that of self-expanding plastic stents (SEPSs) as a result of tissue proliferation and granulation tissue ingrowth at the uncovered portion of the stent, which anchor the prosthesis to the esophageal wall. Removal of a fully embedded stent is challenging because of the risk of bleeding and tears.

MATERIALS AND METHODS

Temporary placement of a new stent within the first stent (stent-in-stent technique) may facilitate the mobilization and safe removal of both stents by inducing pressure ischemia of the granulation tissue. We report our own experience with the stent-in-stent technique in five consecutive patients in whom a partially covered Ultraflex stent had previously been implanted and compare our results with those in the current literature.

RESULTS

The first SEMSs remained in place for a median of 40 days (range 18 - 68) without displacement. Placement of the new stent was technically successful in all patients. All stents were left in place for a median of 9 days. The overall stent-in-stent success rate was 100 % for the removal of embedded stents. No serious adverse events related to the procedure occurred.

CONCLUSION

The procedure was safe, well tolerated, and effective. The use of a partially covered Ultraflex stent of the same size as the old stent for a limited time (≤ 6 days) was consistently successful.

Prevention of covered enteral stent migration in patients with malignant gastric outlet obstruction: a pilot study of anchoring with endoscopic clips

OBJECTIVE

Placement of a self-expandable metal stent is a palliative treatment of choice for patients with malignant gastric outlet obstruction (GOO). Although covering an enteral stent with a membrane almost solves the problem of tumor ingrowth, stent migration continues to be a major unresolved problem. Our aim was to evaluate the clinical efficacy of endoscopic clipping for prevention of covered stent migration in the treatment of malignant GOO.

MATERIAL AND METHODS

A total of 25 consecutive patients with malignant GOO were evaluated prospectively. After deployment of a double-layered combination stent (comprising an outer uncovered stent and an inner covered stent), three endoscopic clips were applied for fixation of the proximal end of the enteral stent to the gastric or duodenal mucosa.

RESULTS

Technical and clinical success rates were 100% (25/25) and 88% (22/25), respectively. No stent migration was observed in any of the patients. Five patients (20%) experienced complications such as tumor overgrowth and stent compression.

CONCLUSION

Endoscopic clipping for enteral stent placement seems to be effective for prevention of covered stent migration in patients with malignant GOO.

Comparative study of endoscopic clips: duration of attachment at the site of clip application

BACKGROUND

Several designs of endoscopic clips are now commercially available, and the indications for endoclip application are rapidly expanding. However, very limited data have been published to aid in choosing between the different types of endoclips.

OBJECTIVE

To compare the duration of clip attachment between all commercially available endoclips.

SETTING

Long-term experiments on 50-kg pigs under general anesthesia.

DESIGN AND INTERVENTIONS

Upper endoscope was inserted into the stomach. One clip of each type (Resolution clip, TriClip, and HX-5L clip) was placed along the same gastric fold at a distance of 0.5 to 1 cm from each other. The animals were recovered. In pig nos. 1 and 2, repeat endoscopy was performed after 2 and 4 weeks. In pig nos. 3 to 5, endoscopy was repeated after 1, 2, and 5 weeks.

MAIN OUTCOME MEASUREMENTS

Duration of clip retention at the site of application.

RESULTS

In all animals, only the Resolution endoclip remained attached to the site of application for the entire duration of the study (4-5 weeks). No TriClips or HX-5L clips were attached at the 4- to 5-week follow-up endoscopies. Most of the TriClips (67%) detached within the first week after application. Most of the HX-5L clips (80%) dislodged within the first 2 weeks of follow-up.

LIMITATIONS

The study was performed in a porcine model with a small number of animals.

CONCLUSIONS

The Resolution clip has the longest duration of retention at the site of application (more than 4-5 weeks) and should be preferred when long-term attachment of endoclips is necessary.