Closure of benign leaks, perforations, and fistulas with temporary placement of fully covered metal stents: a retrospective analysis

Treatment of Boerhaave syndrome: experience from a tertiary center

BACKGROUND

Boerhaave syndrome is a rare, life-threatening condition, characterized by spontaneous esophageal rupture. This study aims to share our 13-year experience in managing Boerhaave syndrome.

METHODS

A retrospective, observational study was conducted of consecutive patients with Boerhaave syndrome who presented at our tertiary referral center, between 2011 and 2023. Patients were categorized by time to diagnosis, to assess the impact of diagnostic delay.

RESULTS

Among 21 patients, 13 (62%) were diagnosed early (< 24 h) and 8 (38%) late (> 24 h). In the early-diagnosed group (n = 13), 6 patients (46%) received primary intervention with stent placement in combination with surgical drainage (5 with mediastinal and pleural drainage and 1 with only pleural drainage), while 5 patients (38%) were initially treated with only a stent. One patient (8%) underwent surgical pleural drainage alone and one (8%) underwent an esophagectomy. Among the 8 late-diagnosed patients, 4 (50%) were primarily treated with both stent placement and surgical drainage (2 with mediastinal drainage, 1 with pleural drainage and 1 with both), 3 (38%) with only stent placement, and one (13%) was managed conservatively. Additional interventions were required in 14 patients (67%). Additional surgical drainage was performed in 5 of 8 patients who had initially been treated with stent only (63%) and in 2 of 10 patients who had initially received both stent and surgical drainage (20%). Stent complications occurred in 7 patients (37%), including leakage (16%), migration (16%), and bleeding (5%). The median hospital stay was 32 days (IQR 15-37) and the overall 90-day mortality was 14%. Mortality was significantly higher in late-diagnosed patients (n = 3, 38%) compared to those early diagnosed (n = 0, 0%) (p = 0.042), with all 3 deceased patients either refusing or being unfit for treatment.

CONCLUSION

Based on this study, we recommend prioritizing closure of the defect combined with drainage, while considering individual patient factors, including advanced age.

Efficacy and risk factors of stent placement in the treatment of malignant tracheoesophageal fistula

BACKGROUND

Due to the low incidence of malignant tracheoesophageal fistula and the paucity of relevant clinical studies, the benefits of stent implantation have not been well documented. It remains unclear which factors may affect fistula closure.

METHODS

Between January 2015 and January 2021, 344 patients who were diagnosed with malignant tracheoesophageal fistula at Zhongda Hospital, Southeast University, were retrospectively enrolled. Demographic and clinical data were collected. Risk factors for fistula closure identified by univariate analysis were further analyzed using multivariable logistic regression.

RESULTS

A total of 288 patients were analyzed in this study, of which 94 were treated conservatively, 170 were treated with an esophageal stent, and 24 were treated with a tracheal stent. Among them, the delta Karnofsky's performance status score values (after 2 weeks/before treatment [p = 0.0028], after 1 month/before treatment [p = 0.0103]) were significantly different between conservative and stent treatment. There was a significant reduction of pneumonia incidence in the stenting group (33.53%) compared to the conservative treatment group (77.05%) after one month (p <0.0001). In addition, the closure of fistulas was influenced by four independent risk factors: 1) treatment methods (p < 0.0001), 2) fistula size (p = 0.0003), 3) preoperative white blood cell count (p = 0.0042), and 4) preoperative Karnofsky's performance status score (p = 0.0001).

CONCLUSIONS

Stent implantation has become an effective method for treating malignant tracheoesophageal fistula compared to conservative treatment. Additionally, stent implantation, smaller fistula size, lower preoperative white blood cell count, and higher preoperative Karnofsky's performance status score suggest a better outcome.

Technical Review on Endoscopic Treatment Devices for Management of Upper Gastrointestinal Postsurgical Leaks

Upper gastrointestinal postsurgical leaks are challenging to manage and often require radiological, endoscopic, or surgical intervention. Nowadays, endoscopy is considered the first-line approach for their management, however, there is no definite consensus on the most appropriate therapeutic approach. There is a wide diversity of endoscopic options, from close-cover-divert approaches to active or passive internal drainage approaches. Theoretically, all these options can be used alone or with a multimodality approach, as each of them has different mechanisms of action. The approach to postsurgical leaks should always be tailored to each patient, taking into account the several variables that may influence the final outcome. In this review, we discuss the important developments in endoscopic devices for the treatment of postsurgical leaks. Our discussion specifically focuses on principles and mechanism of action, advantages and disadvantages of each technique, indications, clinical success, and adverse events. An algorithm for endoscopic approach is proposed.

Endoscopic Stent Placement Can Successfully Treat Gastric Leak Following Laparoscopic Sleeve Gastrectomy If and Only If an Esophagoduodenal Megastent Is Used

PURPOSE

Gastric staple line leakage (GL) is a serious complication of laparoscopic sleeve gastrectomy (LSG), with a specific mortality ranging from 0.2 to 3.7%. The current treatment of choice is stent insertion. However, it is unclear whether the type of stent which is inserted affects treatment outcome. Therefore, we aimed not only to determine the effectiveness of stent treatment for GL but also to specifically clarify whether treatment outcome was dependent on the type of stent (small- (SS) or megastent (MS)) which was used.

PATIENTS AND METHODS

A single-centre retrospective study of 23 consecutive patients was conducted to compare the outcomes of SS (n = 12) and MS (n = 11) for the treatment of GL following LSG. The primary outcome measure was the success rate of stenting, defined as complete healing of the GL without changing the treatment strategy. Treatment change or death were both coded as failure.

RESULTS

The success rate of MS was 91% (10/11) compared to only 50% (6/12) for SS (p = 0.006). An average of 2.3 ± 0.5 and 6.8 ± 3.7 endoscopies were required to achieve healing in the MS and SS groups respectively (p < 0.001). The average time to resumption of oral nutrition was shorter in the MS group (1.4 ± 1.1 days vs. 23.1 ± 33.1 days, p = 0.003).

CONCLUSIONS

Stent therapy is only effective and safe for the treatment of GL after LSG if a MS is used. Treatment with a MS may not only increase treatment success rates but may also facilitate earlier resumption of oral nutrition and shorten the duration of hospitalization.

A Comprehensive Review of Endoscopic Management of Sleeve Gastrectomy Leaks

BACKGROUND

Bariatric surgery leaks result in significant morbidity and mortality. Experts report variable therapeutic approaches, without uniform guidelines or consensus.

OBJECTIVE

To review the pathogenesis, risk factors, prevention, and treatment of gastric sleeve leaks, with a focus on endoscopic approaches. In addition, the efficacy and success rates of different treatment modalities are assessed.

DESIGN

A comprehensive review was conducted using a thorough literature search of 5 online electronic databases (PubMed, PubMed Central, Cochrane, EMBASE, and Web of Science) from the time of their inception through March 2020. Studies evaluating gastric sleeve leaks were included. MeSH terms related to "endoscopic," "leak," "sleeve," "gastrectomy," "anastomotic," and "bariatric" were applied to a highly sensitive search strategy. The main outcomes were epidemiology, pathophysiology, diagnosis, treatment, and outcomes.

RESULTS

Literature search yielded 2418 studies of which 438 were incorporated into the review. Shock and peritonitis necessitate early surgical intervention for leaks. Endoscopic therapies in acute and early leaks involve modalities with a focus on one of: (i) defect closure, (ii) wall diversion, or (iii) wall exclusion. Surgical revision is required if endoscopic therapies fail to control leaks after 6 months. Chronic leaks require one or more endoscopic, radiologic, or surgical approaches for fluid collection drainage to facilitate adequate healing. Success rates depend on provider and center expertise.

CONCLUSION

Endoscopic management of leaks post sleeve gastrectomy is a minimally invasive and effective alternative to surgery. Their effect may vary based on clinical presentation, timing or leak morphology, and should be tailored to the appropriate endoscopic modality of treatment.

First UK experience of endoscopic vacuum therapy for the management of oesophageal perforations and postoperative leaks

Oesophageal perforations and anastomotic leaks are associated with high morbidity and mortality. Endoscopic vacuum therapy (EVT) is a promising novel treatment that promotes healing and avoids sepsis. There are no data reporting its use in the UK. We report the first British experience of EVT in two elderly frail patients. Two patients were treated in our institution with EVT using Eso-SPONGE®. One patient had spontaneous oesophageal perforation and the other had anastomotic leakage post-Merendino oesophageal reconstruction (oesophagogastric continuity with jejunal interposition anastomosis). Both patients were over 65 years of age. One patient had 13 endoscopic Eso-SPONGE® exchanges over 8 weeks, while the other one had 6 exchanges over 4 weeks. Complete resolution of oesophageal leakage was achieved in both cases. EVT should be considered in the management of patients with oesophageal perforations and postoperative leaks. This novel therapeutic intervention has the potential to significantly reduce morbidity and mortality in these patients.

Gastroseal: A Novel Stent Design for the Management of Post-Bariatric Surgery Leaks

Bariatric surgery leaks remain a dreaded complication with ominous consequences. Fully covered stents have shown efficacy in the treatment of leaks; however, stent migration remains a major drawback. Ultra-large stents have shown reduced rates of migration and coapt better against the walls, but deep ulcers occur in almost all patients, as well as frequent severe intolerance, bleeding, and perforation. We have developed a large expandable stent with physical characteristics and a particularly flexible mesh design that make it much less traumatic than conventional large stents while maintaining the advantage of being less prone to migration. In this patient with a post-sleeve gastrectomy leak, we provide a proof of concept that the Gastroseal stent is effective and nontraumatic despite its very large size.

Endoluminal Therapies for Esophageal Perforations and Leaks

Esophageal perforation has historically been a devastating condition resulting in high morbidity and mortality. The use of endoluminal therapies to treat esophageal leaks and perforations has grown exponentially over the last decade and offers many advantages over traditional surgical intervention in the appropriate circumstances. New interventional endoscopic techniques, including endoscopic clips, covered metal stents, and endoluminal vacuum therapy, have been developed over the last several years to manage esophageal perforation in an attempt to decrease the related morbidity and mortality.

Self-Expanding Biodegradable Stents for Postoperative Upper Gastrointestinal Issues

BACKGROUND AND OBJECTIVES

Endoscopic stenting is a minimally invasive treatment modality for patients with various gastrointestinal conditions. We evaluated the safety and efficacy of uncovered biodegradable stents for postoperative leaks and strictures in the upper gastrointestinal tract.

METHODS

This was a retrospective study of patients treated endoscopically with biodegradable stents from January 2010 through November 2017.

RESULTS

Thirteen patients were enrolled, 7 of whom were men. Their mean age was 46 (range, 21-82) years. The indications for stent placement were postoperative leakage and stricture in 9 and 4 patients, respectively. The primary diagnoses were obesity in 7 patients, gastric cancer in 5, and peptic ulcer in 1. The average time to stent placement after surgery was 35 (range, 17-125) and 166 (range, 153-185) days for patients with postoperative leakage and stricture, respectively. Stent insertion was successful at the first attempt in all patients. Complete resolution of the leak and stricture was achieved after stent application in 11 patients, for a clinical success rate of 85%. The mean follow-up duration was 50 (range, 24-76) months. There were no major complications.

CONCLUSIONS

Compared to self-expanding metal and plastic stents, the main advantages of uncovered biodegradable stents are that they do not have to be removed and have a low migration rate. Our results suggest that these stents have promise for management of postoperative gastrointestinal complications. Further randomized trials with larger sample sizes are necessary to determine the role of biodegradable stents in the treatment algorithm.

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

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

Endoluminal solutions to bariatric surgery complications: A review with a focus on technical aspects and results

Obesity is a growing problem in developed countries, and surgery is the most effective treatment in terms of weight loss and improving medical comorbidity in a high proportion of obese patients. Despite the advances in surgical techniques, some patients still develop acute and late postoperative complications, and an endoscopic evaluation is often required for diagnosis. Moreover, the high morbidity related to surgical reintervention, the important enhancement of endoscopic procedures and technological innovations introduced in endoscopic equipment have made the endoscopic approach a minimally-invasive alternative to surgery, and, in many cases, a suitable first-line treatment of bariatric surgery complications. There is now evidence in the literature supporting endoscopic management for some of these complications, such as gastrointestinal bleeding, stomal and marginal ulcers, stomal stenosis, leaks and fistulas or pancreatobiliary disorders. However, endoscopic treatment in this setting is not standardized, and there is no consensus on its optimal timing. In this article, we aim to analyze the secondary complications of the most expanded techniques of bariatric surgery with special emphasis on those where more solid evidence exists in favor of the endoscopic treatment. Based on a thorough review of the literature, we evaluated the performance and safety of different endoscopic options for every type of complication, highlighting the most recent innovations and including comparative data with surgical alternatives whenever feasible.

Self-expanding metal stents in postoperative esophageal leaks

BACKGROUND

Postoperative esophageal leaks have a high morbidity and mortality. Self-expanding metal stents (SEMS) have been used as an alternative to re-operation.

AIM

Evaluating predictors of success of SEMS in postoperative esophageal leaks.

METHODS

Retrospective study of patients with postoperative esophageal leaks referred for SEMS placement in a reference center during a period of 3 years. Technical success was defined as closure of the leak in barium swallow at 15 days. Clinical success was considered as endoscopic and/or radiographic confirmation of closure after stent removal.

RESULTS

Thirteen patients placed SEMS. Median follow-up was 58 days. Leaks had a median size of 20 mm. Time between surgery and SEMS placement was 20 days. One patient died 2 days after SEMS placement and one had worsening of the fistula after SEMS expansion. Time till stent migration was 9 days. Technical success was achieved in 9 of 11 patients, with clinical success without recurrence in 5 patients. All leaks with less than 20 mm were solved endoscopically. Technical and clinical success was higher when time between surgery and SEMS placement was lower, even though without statistical significance (respectively, p = 0.228 and 0.374). In the 8 patients who died during follow-up, median survival was 59 days.

CONCLUSIONS

Technical success of SEMS was higher than 80%; however, due to high morbidity and mortality, only 45% of patients had their stent removed. Lower time from diagnosis to SEMS placement and leak size less than 20 mm may be associated with better results.

Safety and efficacy of a fully covered large-diameter self-expanding metal stent for the treatment of upper gastrointestinal perforations, anastomotic leaks, and fistula

Upper gastrointestinal perforations, fistula, and anastomotic leaks are severe conditions with high mortality. Temporary endoscopic placement of fully covered self-expanding metal stent (fSEMS) has emerged as treatment option. Stent migration is a major drawback of currently used stents. Migration is often attributed to a relatively too small stent diameter as esophageal stents were initially intended for the treatment of strictures. This study aimed to investigate the safety and efficacy of a large-diameter fSEMS for treatment of these conditions. Data were retrospectively collected from patients who received this stent in the Netherlands between March 2011 and August 2013. Clinical success was defined as sufficient leak closure after stent removal as confirmed by endoscopy or X-ray with oral contrast without surgical intervention or placement of another type of stent. Adverse events were graded according a standardized grading system. Stent placement was performed in 34 patients for the following indications: perforation (n = 6), anastomotic leak (n = 26), and fistula (n = 2). Technical success rate was 97% (33/34). Clinical success rate was 44% (15/34) after one stent and 50% (17/34) after an additional stent. There were no severe adverse events and stent-related mortality. The overall adverse event rate was 50% (all graded 'moderate'). There were 14 (41%) stent migrations (complete n = 8, partial n = 6). Other adverse events were bleeding (n = 2) and aspiration pneumonia (n = 1). Reinterventions for failure of the large-diameter fSEMS were placement of another type of fSEMS (n = 4), surgical repair (n = 3), or esophagectomy (n = 1). Eleven patients (32%) died in-hospital because of persisting intrathoracic sepsis (n = 10) or preexistent bowel ischemia (n = 1). This study suggests that temporary placement of a large-diameter fSEMS for the treatment of upper gastrointestinal perforations, fistula, and anastomotic leaks is safe in terms of severe adverse events and stent-related mortality. The larger diameter does not seem to prevent stent migration.

Major complications of bariatric surgery: endoscopy as first-line treatment

Leaks are the most frequent early postoperative complication in the two most popular bariatric procedures, Roux-en-Y gastric bypass (RYGB) and laparoscopic sleeve gastrectomy. Multimodal therapy based on self-expandable stent insertion 'to cover' the defect is the most widely documented technique to date with a reported success rate >80%. Additional experimental techniques 'to close' the defect or 'to drain' the paradigestive cavity have been reported with encouraging results. The role of endoscopy in early postoperative bleeding is limited to management of bleeds arising from fresh sutures and the diagnosis of chronic sources of bleeding such as marginal ulcer after RYGB. Post-RYGB stricture is a more delayed complication than leaks and the role of endoscopic dilation as a first-line treatment in this indication is well documented. Ring and band placement are outdated procedures for obesity treatment, but might still be an indication for endoscopic removal, a technique which does not compromise further surgery, if needed.

Endoscopic vacuum therapy for esophageal perforations and leakages

BACKGROUND AND STUDY AIMS

Injuries to the esophageal wall, such as perforations and anastomotic leaks, are serious complications of surgical and endoscopic interventions. Since 2006, a new treatment has been introduced, in the form of endoscopically placed vacuum sponge therapy.

PATIENTS AND METHODS

Between April 2012 and October 2014, 10 patients (5 men and 5 women) aged 57 to 94 years were treated at our institution using endoscopic vacuum therapy (EVT) in the upper gastrointestinal tract.

RESULTS

The defect in the esophageal wall was successfully closed in seven of the 10 patients (70 %). No severe complications occurred.

CONCLUSIONS

EVT is a valuable tool for management of defects in the esophageal wall and should be considered as a treatment option for patients with this condition.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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