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

Lumen-apposing metal stents provide early and late clinical benefits for the management of benign gastrointestinal strictures: Is there a role for definitive therapy?

Objectives

This study aimed to characterize the clinical outcomes, safety, and efficacy of lumen-apposing metal stents (LAMS) in treating benign gastrointestinal strictures.

Methods

A single-center retrospective review of all patients who underwent LAMS placement for benign strictures from June 2017 to July 2023. Primary outcomes were technical success, early clinical success, late clinical success (LCS), and sustained post-LAMS clinical success (SPLCS). Secondary outcomes included stent dwell time, stenosis changes, adverse events, reintervention rates, and symptomatology evaluation.

Results

Thirty-five patients underwent placement of 42 LAMS (74% female, mean age: 54.2 ± 11.7 years). Anastomotic strictures accounted for 64% of cases (N = 27, 45% at the gastrojejunal anastomosis). The median STD was 91.0 days (interquartile range [IQR]: 55.0-132.0). Technical success was obtained in all cases. Early clinical successand LCS were achieved in 80% of cases overall. SPLCS was achieved in 45% (n = 15) of cases. The overall reintervention rate was 63%, with a median time to reintervention being 50.5 days (IQR: 24-105). adverse events occurred in 28% (n = 12) overall, with a 24% migration rate (n = 10). Follow-up was completed in 83% of cases with a median duration of 629 days (range: 192.0-1297.0). Overall symptom improvement occurred in 79% (n = 27) during indwelling LAMS versus 58% and 56% at 30- and 60-days post-removal, respectively.

Conclusions

LAMS for benign gastrointestinal strictures are associated with high technical and early clinical success/LCS rates, positive quality-of-life metrics, and a tolerable adverse event rate. Overall, recurrence of symptoms and high reintervention rates post-LAMS removal reinforce the difficulty in managing benign gastrointestinal strictures but also argue for LAMS as a definitive therapy in select cases.

Efficacy of endoscopic vacuum therapy in esophageal luminal defects: a systematic review and meta-analysis

BACKGROUND/AIMS

Endoscopic vacuum-assisted closure (EVAC) is a novel technique used to repair esophageal perforation and leaks. Varying data have been reported on the overall success rate of EVAC. We aimed to conduct a meta-analysis of the available data on the clinical success rate of EVAC.

METHODS

Electronic databases were searched for publications addressing the efficacy of EVAC in esophageal luminal defects. Pooling was conducted using both fixed and random-effects models. The overall clinical success of EVAC therapy was considered the primary outcome, whereas, overall complication rates, need for adjunct therapy, and mortality were considered secondary outcomes.

RESULTS

In total, 366 patients were included in the study. On pooled analysis, the mean age was 66 years with 68.32% of patients being men. Overall pooled clinical success rate of EVAC therapy was 87.95%. Upon subgroup analysis, the pooled clinical success rate of postsurgical anastomotic leak and transmural esophageal perforation were found to be 86.57% and 88.89%, respectively. The all-cause hospital mortality was 14% and 4.2% in patients with esophageal perforation and EVAC, respectively.

CONCLUSIONS

This study demonstrates that EVAC therapy has a high overall clinical success rate, with low mortality. EVAC therapy seems to be a promising procedure with excellent outcomes in patients with luminal esophageal defects.

Closure of a secondary tracheoesophageal fistula in severe pneumonia using an Amplatzer Duct Occluder II during invasive mechanical ventilation: A case report

Key Clinical Message

Early and timely closure of secondary tracheoesophageal fistula (TEF) is crucial for critically ill patients. For those requiring invasive mechanical ventilation, the Amplatzer Duct Occluder II (ADO II) can be used as an emergency therapeutic option to rapidly close secondary TEF, providing opportunities for subsequent treatments.

Abstract

Secondary tracheoesophageal fistula (TEF) is a life-threatening condition characterized by high mortality, high recurrence rates, and multiple complications. Reports on the management of secondary TEF in critically ill patients are limited due to the challenges in treatment and the lack of suitable therapeutic options. We report a case of secondary TEF in a 69-year-old male diagnosed with severe pneumonia, whose condition deteriorated rapidly following the onset of TEF. Despite invasive mechanical ventilation, maintaining blood oxygen saturation above 80% was unachievable due to the TEF. Bedside bronchoscopy revealed expansion TEF expansion caused by gastrointestinal fluid reflux and respiratory machine pressure. The TEF was urgently closed using an ADO II device during invasive mechanical ventilation to prevent further deterioration. After the patient's condition stabilized, the ADO II was replaced with a Y-shaped tracheal membrane-covered stent for further TEF management. The patient's condition improved, meeting the criteria for liberation from invasive mechanical ventilation, and bedside chest X-rays revealed a gradual resolution of pulmonary inflammation. Selecting appropriate treatment modalities for early and timely closure of secondary TEF is crucial for critically ill patients. ADO II can serve as a rescue therapy to achieve rapid closure of secondary TEF in critically ill patients requiring invasive mechanical ventilation support, providing opportunities and time for subsequent treatment.

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.

How I Do It: Esophageal Stenting for Benign and Malignant Conditions

Esophageal stent placement is an effective technique used in the management of different benign and malignant conditions. Over time, various types of stents and techniques have been developed and optimized to treat distinct pathologies. With the extensive array of strategies available for utilizing esophageal stenting, a thorough understanding of the characteristics of each stent type and usage is paramount in choosing the ideal stent in a particular case. This article presents a brief review of esophageal stenting as well as tips and tricks for clinical practice.

Nonoperative Management Strategies for Anastomotic Leaks After One Anastomosis Gastric Bypass (OAGB): A Literature Review

One Anastomosis Gastric Bypass (OAGB) has gained widespread acceptance as an effective bariatric surgery due to its relative simplicity and favorable outcomes in weight loss and metabolic improvement. However, anastomotic leaks, though uncommon, present a significant complication with the potential for severe morbidity and mortality if not managed appropriately. This review examines the range of nonoperative strategies currently employed to manage anastomotic leaks and fistulae following OAGB. The focus is on endoscopic techniques, including the use of clips, stents, suturing systems, internal drainage, vacuum therapy, and tissue sealants, which have been successfully used in various gastrointestinal surgeries. Although a proportion of patients will require surgical treatments, these strategies offer less invasive alternatives to surgical intervention and can be tailored to the specific characteristics of the leak and patient condition. However, the application of these techniques specifically for OAGB-related leaks is not as well-documented. This review lists the available evidence on these nonoperative approaches, highlighting some of their potential benefits and limitations. While these methods show promise, there is a clear need for further research to establish standardized protocols and optimize their use in the context of OAGB-related leaks and fistulae.

Innovative Design of a 3D Printed Esophageal Stent Inspired by Nature: Mitigating Migration Challenges in Palliative Esophageal Cancer Therapy

Esophageal cancer is a complex and challenging tumor to treat, with esophageal stenting being used as a palliative measure to improve the quality of life of patients. Self-expandable metal stents (SEMS), self-expandable plastic stents (SEPS), and biodegradable stents are the most commonly used types of stents. However, complications can arise, such as migration, bleeding, and perforation. To address issues of migration, this study developed a novel 3D printed bioinspired esophageal stent utilizing a highly flexible and ductile TPU material. The stent was designed to be self-expanding and tubular with flared ends to provide secure anchorage at both the proximal and distal ends of the structure. Suction cups were strategically placed around the shaft of the stent to prevent migration. The stent was evaluated through compression-recovery, self-expansion, and anti-migration tests to evaluate its recovery properties, self-expansion ability, and anchoring ability, respectively. The results indicated that the novel stent was able to recover its shape, expand, keep the esophagus open, and resist migration, demonstrating its potential for further research and clinical applications. Finite element analysis (FEA) was leveraged to analyze the stent's mechanical behavior, providing insights into its structural integrity, self-expansion capability, and resistance against migration. These results, supported by FEA, highlight the potential of this innovative stent for further research and its eventual application in preclinical settings.

Management of fistulas in the upper gastrointestinal tract

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

A novel self-inflatable balloon for treating refractory benign esophageal strictures: a prospective, single-arm, multicenter study

BACKGROUND AND AIM

Current treatments for refractory benign esophageal strictures (BESs) often take several years and have poor effects. The authors propose a novel method of self-help inflatable balloon (SHIB) and evaluate its efficacy and safety.

METHODS

A prospective, multicenter study was conducted from January 2019 to March 2022. All enrolled patients were diagnosed with refractory BESs and received SHIB. The primary endpoint was the clinical success rate at 12 months after removing SHIB. The secondary endpoints were the number of days of placing SHIB, and changes from baseline in BMI and health-related quality of life at 1, 3, 6, and 12 months.

RESULTS

The clinical success rate was 51.2% (21/41) with the median days of placing SHIB being 104.0 days (range: 62.0-134.5 days), which was higher in the endoscopic group compared to the caustic and surgery groups (63.3 vs. 28.6% vs. 0, P=0.025). All patients (100%) showed significant improvement in dysphagia scores during placing SHIB. Although 20 patients (48.8%) experienced recurrent stricture, the median stricture length was decreased (P<0.001) and the median intervention-free interval was prolonged (P<0.001). In all patients, the mean BMI at and health-related quality of life at 1, 3, 6, and 12 months were significantly increased compared with baseline (P<0.05). On multivariate analysis, stricture etiology and wearing time were independent predictors of recurrent stricture.

CONCLUSIONS

The SHIB has high efficacy and safety in treating refractory BESs of different origins, especially for endoscopic resection. Stricture etiology and wearing time were independent predictors of recurrent stricture.

Endoscopic treatment of upper gastrointestinal postsurgical leaks: a narrative review

Upper gastrointestinal postsurgical leaks are life-threatening conditions with high mortality rates and are one of the most feared complications of surgery. Leaks are challenging to manage and often require radiological, endoscopic, or surgical intervention. Steady advancements in interventional endoscopy in recent decades have allowed the development of new endoscopic devices and techniques that provide a more effective and minimally invasive therapeutic option compared to surgery. Since there is no consensus regarding the most appropriate therapeutic approach for managing postsurgical leaks, this review aimed to summarize the best available current data. Our discussion specifically focuses on leak diagnosis, treatment aims, comparative endoscopic technique outcomes, and combined multimodality approach efficacy.

Effectiveness of the Interventional Technique for the Removal of Self-Expanding Metallic Esophageal Stents Under Fluoroscopy

RATIONALE AND OBJECTIVES

Timely removal of esophageal stents can help avoid or reduce the occurrence of complications. This study was aimed at elucidating the interventional technique for the removal of self-expanding metallic esophageal stents (SEMESs) under fluoroscopy and analyzing its safety and efficacy.

MATERIALS AND METHODS

The medical records of patients who underwent removal of SEMESs by interventional techniques under fluoroscopy were retrospectively analyzed. Furthermore, the success and adverse event rates for different interventional techniques of stent removal were analyzed and compared.

RESULTS

Overall, 411 patients were included, and 507 metallic esophageal stents were removed. There were 455 and 52 fully and partially covered SEMESs, respectively. According to the stent indwelling time, benign esophageal diseases were divided into two groups: ≤68 days and >68 days. There was a significant difference in the incidence of complications between the two groups (13.1% and 30.5%, respectively, p < .001). The stents in cases of malignant esophageal lesions were divided into the following two groups: ≤52 days and >52 days. Intergroup differences in complication incidence were not significant (p = .81) Further, there was a significant difference in removal time between the recovery line pull and proximal adduction techniques (4 and 6 minutes, respectively, p < .001). In addition, the recovery line pull technique was associated with a lower rate of complications (9.8% vs 19.1 %, p = .04). There was no statistical difference in the technical success rate and incidence of adverse events between the inversion and stent-in-stent techniques.

CONCLUSION

Interventional technique to remove SEMESs under fluoroscopy is safe, effective, and worthy of clinical application.

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.

Esophageal Stenting: How I Do It

Endoscopic esophageal stent placement is an effective palliative treatment for malignant strictures and has also been successfully used for benign indications, including esophageal refractory strictures and iatrogenic leaks and perforations. Despite several decades of evolution and the wide variety of esophageal stents available to choose from, an ideal stent that is both effective and without adverse events such as stent migration, tissue ingrowth, or pressure necrosis has yet to be developed. This paper is an overview of how this evolution happened, and it also addresses the characteristics of some of the currently available stents, like their material and construction, delivery device, radial and axial force pattern, covering and size which may help to understand and avoid the occurrence of adverse events. The insertion delivery systems and techniques of placement of an esophageal self-expandable metal stent are reviewed, as well as some tips and tricks regarding placement and management of adverse events.

Chinese expert consensus on interventional diagnosis and management of acquired digestive-respiratory tract fistulas (second edition)

Acquired digestive-respiratory tract fistulas occur with abnormal communication between the respiratory tract and digestive tract caused by a variety of benign or malignant diseases, leading to the alimentary canal contents in the respiratory tract. Although various departments have been actively exploring advanced fistula closure techniques, including surgical methods and multimodal therapy, some of which have gotten good clinical effects, there are few large-scale evidence-based medical data to guide clinical diagnosis and treatment. The guidelines update the etiology, classification, pathogenesis, diagnosis, and management of acquired digestive-respiratory tract fistulas. It has been proved that the implantation of the respiratory and digestive stent is the most important and best treatment for acquired digestive-respiratory tract fistulas. The guidelines conduct an in-depth review of the current evidence and introduce in detail the selection of stents, implantation methods, postoperative management and efficacy evaluation.

SX-ELLA biodegradable stent for benign oesophageal strictures: a systematic review and proportion meta-analysis

BACKGROUND

This systematic review aimed to analyse the use of the SX-ELLA biodegradable stent (BDS) for benign oesophageal strictures through the assessment of clinical and technical success, differences in pre- and post-BDS insertion dysphagia scores, rates of stent migration, and safety.

METHODS

A systematic review was reported according to PRISMA guidelines, with a prospectively registered protocol. The databases PubMed, Embase, SCOPUS, and ClinicalTrials.gov were searched up to March 2022. Studies assessing the use of the SX-ELLA BDS in adults with benign oesophageal strictures were included. A pooled data analysis was conducted to analyse the clinical and technical success associated with BDS use, rate of stent migration, and safety.

RESULTS

Of the 1509 articles identified, 16 studies treating 246 patients were eligible for inclusion. BDS was clinically successful in 41.9% of cases (95% CI = 35.7 - 48.1%), defined as those who experienced complete symptom resolution following BDS insertion. Technical success was achieved in 97.2% of patients (95% CI = 95.1 - 99.3%). A pooled analysis concluded a decrease in mean dysphagia score of 1.8 points (95% CI = 1.68 - 1.91) following BDS insertion. Re-intervention was required in 89 patients (36.2%, 95% CI = 30.2 - 42.2%), whilst stent migration occurred in 6.5% of patients (95% CI = 3.4 - 9.6%). A total of 37 major clinical complications related to BDS insertion were reported (15.0%, 95% CI = 10.5 - 19.5%).

CONCLUSION

The pooled data analysis demonstrates the high technical and moderate clinical success of the SX-ELLA biodegradable stent, supporting its use for benign oesophageal strictures in adults. However, greater evidence is required for more robust conclusions to be made in terms of success when compared to alternative methods of intervention, such as endoscopic dilation.

Laparoscopic antireflux surgery or PPIs in the management of reflux-related esophageal stricture

BACKGROUND

Gastroesophageal reflux disease (GERD) is often associated with esophageal stricture, particularly benign esophageal stricture. We aimed to evaluate the effects of balloon catheter dilation (BD) combined with laparoscopic fundoplication (LF) surgery and proton pump inhibitors (PPIs) in patients with reflux-induced esophageal strictures.

METHODS

We retrospectively analyzed 116 patients with reflux-induced benign esophageal strictures who underwent balloon dilatation therapy combined with PPIs (BD-PPIs group, n = 58) and balloon dilatation combined with LF (BD-LF group, n = 58). Patients were followed up for 24 months. The outcomes of the patients were monitored, including clinical success, symptom improvement, adverse events, and the frequency of esophagitis.

RESULTS

At the latest follow-up, the rate of clinical success was higher in BD-LF group than in BD-PPIs group (80.4% vs. 57.7%, P = 0.011). The patients in the BD-PPIs group required more dilation sessions to achieve successful dilation, as compared to those in the BD-LF group (2.1 ± 1.2 vs. 0.7 ± 0.8, P < 0.001). The DeMeester score, number of reflux episodes for which pH was < 4, and lower esophageal sphincter pressure were significantly better in the BD-LF group than in the BD-PPIs group (all P < 0.001). The incidence of reflux esophagitis was higher in the BD-PPIs group than in the BD-LF group, at 24 months (58.8% vs. 18.2%, P = 0.003).

CONCLUSIONS

Balloon dilatation with concomitant LF is effective and safe for esophageal stricture secondary to GERD. Moreover, antireflux surgery techniques, such as Nissen or Toupet procedure, should be added for reflux-induced benign esophageal stricture.

A novel stent fixation method for anastomotic leaks after gastrectomy: anchoring of the distal flare to the jejunum by using through-the-scope endoclips

Introduction

An anastomotic leak is a life-threatening complication after gastrectomy. A fully covered, self-expandable, metal stent (FC-SEMS) can be used as an alternative to traditional surgical re-intervention. However, stent migration can be worrisome.

Aim

To evaluate the feasibility and effectiveness of anchoring of the distal flare of the FC-SEMS to the jejunum by using through-the-scope (TTS) endoclips to prevent stent migration.

Material and methods

Patients, who received a FC-SEMS capable of being fixed to the jejunum by using TTS endoclips due to an anastomotic leak after gastrectomy, were reviewed retrospectively. Demographic and clinical characteristics, the properties of the deployed stents, and outcomes were evaluated.

Results

A total of 7 patients underwent FC-SEMS placement. The mean age was 59 ±13.8 years, and the mean body mass index was 29.8 ±8.4 kg/m2. All patients' American Society of Anesthesiologists scores were between II and IV. The mean time between gastrectomy and stent insertion was 6.7 ±6.1 days. Technical success was achieved in all patients. Stent migration was not observed in any of the patients. All but one were removed between 4 and 6 weeks after placement. The mean stent removal time was 37 ±4.6 days. Complete resolution of the leak was achieved in 6 patients.

Conclusions

Anchoring of the distal flare of the FC-SEMS to the jejunum with TTS endoclips is feasible and may reduce the risk of migration. This inexpensive and safe technique may be proposed to patients with factors predictive of FC-SEMS migration.

Endoscopic Treatment Options for Gastrointestinal Leaks

Background

Spontaneous or postoperative gastrointestinal defects are still life-threatening complications with elevated morbidity and mortality. Recently, endoscopic treatment options - up and foremost endoscopic vacuum therapy (EVT) - have become increasingly popular and have shown promising results in these patients.

Methods

We performed an electronic systematic search of the MEDLINE databases (PubMed, EMBASE, and Cochrane) and searched for studies evaluating endoscopic options for the treatment of esophageal and colorectal leakages and/or perforations until March 2022.

Results

The closure rate of both esophageal and colorectal defects by EVT is high and even exceeds the results of surgical revision in parts. Out of all endoscopic treatment options, EVT shows most evidence and appears to have the highest therapeutic success rates. Furthermore, EVT for both indications had a low rate of serious complications without relevant in-hospital mortality. In selected patients, EVT can be applied without fecal diversion and transferred to an outpatient setting.

Conclusion

Despite multiple endoscopic treatment options, EVT is increasingly becoming the new gold standard in endoscopic treatment of extraperitoneal defects of the upper and lower GI tract with localized peritonitis or mediastinitis and without close proximity to major blood vessels. However, further prospective, comparative studies are needed to strengthen the current evidence.

Development of Bio-artificial Esophageal Tissue Engineering Utilization for Circumferential Lesion Transplantation: A Narrative Review

The esophagus is the gastrointestinal tract's primary organ that transfers bolus into the stomach with peristaltic motion. Therefore, its lesions cause a significant disturbance in the nutrition and digestive system. Esophageal disease treatment sometimes requires surgical procedures that involve removal and circumferential full-thickness replacement. Unlike other organs, the esophagus has a limited regeneration ability and cannot be transplanted from donors. There are various methods of restoring the esophageal continuity; however, they are associated with certain flaws that lead to a non-functional recovery. As an exponentially growing science, tissue engineering has become a leading technique for the development of tissue replacement to repair damaged esophageal segments. Scaffold plays a significant role in the process of tissue engineering, as it acts as a template for the regeneration of growing tissue. A variety of scaffolds have been studied to replace the esophagus. Due to the many tissue quality challenges, the results are still inadequate and need to be improved. The success of esophageal tissue regeneration will finally depend on the scaffold's capability to mimic natural tissue properties and provide a qualified environment for regeneration. Thereby, scaffold fabrication techniques are fundamental. This article reviews the recent developments in esophageal tissue engineering for the treatment of circumferential lesions based on scaffold biomaterial engineering approaches.

Inversion technique under fluoroscopy for removal of self-expanding nitinol esophageal stent after long-term placement: review of 107 consecutive cases

BACKGROUND

Removal of self-expanding esophageal metal stents that have been implanted for a long time can be difficult and risky.

PURPOSE

In this paper, we describe the use of the "inversion technique" under fluoroscopy for removal of self-expandable nitinol esophageal stents that have been placed for long periods and evaluate the effectiveness and safety of the method.

METHODS

Retrospective analysis of patients who underwent removal of self-expanding nitinol esophageal stents by the inversion technique under fluoroscopy at our center. Demographic characteristics, type of esophageal stents, stent retention time, reasons for stent removal, and related complications were collected from the case records and analyzed.

RESULTS

A total of 112 metal esophageal stents (62 fully covered esophageal stents and 50 partially covered esophageal stents) were extracted from the 107 patients included in the study. Indications for stent implantation were malignant esophageal stenosis (27 patients), benign esophageal stenosis (42 patients), and esophageal fistula (38 patients). Median duration of stent retention was 77 days (29-727 days). All stents were removed successfully without major complications such as esophageal rupture, massive hemorrhage, asphyxia, or cardiorespiratory arrest.

CONCLUSION

Inversion technique under fluoroscopy appears to be a safe, effective, and quick procedure for removal of self-expanding nitinol esophageal stent after long-term placement.

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.

Futuristic Developments and Applications in Endoluminal Stenting

Endoscopic stenting is a well-established option for the treatment of malignant obstruction, temporary management of benign strictures, and sealing transmural defects, as well as drainage of pancreatic fluid collections and biliary obstruction. In recent years, in addition to expansion in indications for endoscopic stenting, considerable strides have been made in stent technology, and several types of devices with advanced designs and materials are continuously being developed. In this review, we discuss the important developments in stent designs and novel indications for endoluminal and transluminal stenting. Our discussion specifically focuses on (i) biodegradable as well as (ii) irradiating and drug-eluting stents for esophageal, gastroduodenal, biliary, and colonic indications, (iii) endoscopic stenting in inflammatory bowel disease, and (iv) lumen-apposing metal stent.

Current status in endoscopic management of upper gastrointestinal perforations, leaks and fistulas

Recent advancement in endoscopic closure techniques have revolutionized the treatment of gastrointestinal perforations, leaks and fistulas. Traditionally, these have been managed surgically. The treatment strategy depends on the size and location of the defect, degree of contamination, presence of healthy surrounding tissues, patients' condition and the availability of expertise. One of the basic principles of management includes providing a barricade to the flow of luminal contents across the defect. This can be achieved with a wide range of endoscopic techniques. These include endoclips, stenting, suturing, tissue adhesives and glue, and endoscopic vacuum therapy. Each method has their distinct indications and shortcomings. Often, a combination of these techniques is required. Apart from endoscopic closure, drainage procedures by the interventional radiologist and surgical management also play an important role. In this review article, the outcomes of each of these endoscopic closure techniques in the literature is provided in tables, and practical management algorithms are being proposed.

Safety and effectiveness of endoluminal vacuum-assisted closure for esophageal defects: Systematic review and meta-analysis

Background and study aims  Esophageal defects (leaks, fistulas, and perforations) are associated with significant morbidity and mortality. Endoluminal vacuum-assisted closure (EVAC) is a novel intervention that entails the use of sponges in the defect along with negative pressure to achieve granulation tissue formation and healing and has been gaining popularity. We performed a systematic review and pooled analysis of available literature to assess the safety and effectiveness of EVAC for esophageal defects. Patients and methods  We queried PubMed/Medline, Embase, Cochrane, and Web of Science through September 25, 2020 to include all pertinent articles highlighting the safety and effectiveness profile of EVAC for esophageal defects. Pooled rates, 95 % confidence intervals (CIs), and heterogeneity ( I ² ) were assessed for each outcome. Results  A total of 18 studies with 423 patients were included (mean age 64.3 years and males 74.4 %). The technical success for EVAC was 97.1 % (CI: 95.4 %-98.7 %, I ²  = 0 %). The clinical success was 89.4 % (CI: 85.6 %-93.1 %, I ²  = 36.8 %). The overall all-cause mortality and adverse events (AEs) noted were 7.1 % (CI: 4.7 %-9.5 %, I ²  = 0 %) and 13.6 % (CI: 8.0 %-19.1 %, I ²  = 68.9 %), respectively. The pooled need for adjuvant therapy was 15.7 % (CI: 9.8 %-21.6 %, I ²  = 71.1 %). Conclusions  This systematic review and meta-analysis showed high rates of technical success, clinical success, and low all-cause mortality and AEs using EVAC. Although the technique is a promising alternative, the lack of comparative studies poses a challenge in making definite conclusions regarding use of EVAC compared to other endoscopic modalities, such as clips and stents.

Self-expanding Metal Stents for Anastomotic Leaks After Upper Gastrointestinal Cancer Surgery

BACKGROUND

Anastomotic leakage (AL) is a common and severe complication after upper gastrointestinal (UGI) surgery. Although evidence is scarce, endoscopic deployed self-expanding metal stents (SEMS) are well-established for the management of AL in UGI surgery. The present study aimed to evaluate the feasibility, effectiveness, and safety of SEMS in terms of success, mortality, and morbidity in patients with AL after UGI cancer surgery.

MATERIALS AND METHODS

Patients with AL after primary UGI cancer surgery were retrospectively analyzed with regard to demographics, disease, surgical and endoscopic procedures, and complications. Stent treatment success was divided into technical, primary (within 72 hours of stent deployment), sustained (after 72 hours of stent deployment), and sealing success.

RESULTS

In a total of 63 patients, 74 stents were used and 11 were deployed in endoscopic reinterventions. Stent deployment was successful in all patients. Primary and sustained success rates were 68.3% (n = 43) and 65.1% (n = 41), respectively. Of the primarily successfully treated patients, 87.8% remained successfully treated. If primary treatment was unsuccessful, it remained unsuccessful in 66.6% of the patients (P = 0.002). Final sealing of the leakage was observed in 65.1% of patients (n = 41). Longer stent shafts and wider stent end widths were correlated with successful stent treatment (P < 0.05).

CONCLUSION

SEMS are a safe and sufficient tool in the treatment of AL after UGI cancer surgery. Treatment success is improved with longer stent shafts and wider stent end widths. Switching to alternative treatments is strongly suggested if signs of persistent leakage are present beyond 72 hours after stent placement, as this is highly indicative of sustained stent failure.

Outcome of dogs and cats with benign oesophageal strictures after balloon dilatation or stenting: 27 cases (2002-2019)

OBJECTIVES

Acquired oesophageal strictures remain challenging to manage in canine and feline patients. The aims of this study were to describe the treatment, complications, short-term outcome and long-term follow-up of benign oesophageal strictures treated by balloon dilatation or stenting in dogs and cats and to describe adjunctive techniques to minimise the complication rate of stent placement.

MATERIALS AND METHODS

Retrospective analysis of medical records of dogs and cats with benign oesophageal stricture diagnosed under endoscopy between 2002 and 2019.

RESULTS

Eighteen dogs and nine cats were included, representing 39 strictures. Balloon dilatation was used as first-line therapy, with a good outcome in 59% of cases. Stents were placed in eight cases due to stricture recurrence; 88% had a long-term satisfactory outcome. Short-term complications occurred in six of eight cases; migration and aberrant mucosal reaction were uncommon. In three cases, progressive mesh cutting during follow-up reduced discomfort and trichobezoars formation and improved long-term stent tolerance. Overall median survival time was 730 days.

CLINICAL SIGNIFICANCE

Long-term prognosis of balloon dilatation as a first-line therapy for esophageal strictures and of stenting as a rescue therapy was considered satisfactory. Although discomfort associated with stenting was frequent, tolerability might be improved by per-endoscopic adjunctive techniques.

An Approach to Accelerate Healing and Shorten the Hospital Stay of Patients With Anastomotic Leakage After Esophagectomy: An Explorative Study of Systematic Endoscopic Intervention

Objective

To explore the comprehensive role of systemic endoscopic intervention in healing esophageal anastomotic leak.

Methods

In total, 3919 consecutive patients with esophageal cancer who underwent esophagectomy and immediate esophageal reconstruction were screened. In total, 203 patients (5.10%) diagnosed with anastomotic leakage were included. The participants were divided into three groups according to differences in diagnosis and treatment procedures. Ninety-four patients received conventional management, 87 patients received endoscopic diagnosis only, and the remaining 22 patients received systematic endoscopic intervention. The primary endpoint was overall healing of the leak after oncologic esophageal surgery. The secondary endpoints were the time from surgery to recovery and the occurrence of adverse events.

Results

173 (85.2%; 95% CI, 80.3-90.1%) of the 203 patients were successfully healed, with a mean healing time of 66.04 ± 3.59 days (median: 51 days; range: 13-368 days), and the overall healing rates differed significantly among the three groups according to the stratified log-rank test (P<0.001). The median healing time of leakage was 37 days (95% CI: 33.32-40.68 days) in the endoscopic intervention group, 51 days (95% CI: 44.86-57.14 days) in the endoscopic diagnostic group, and 67 days (95% CI: 56.27-77.73 days) in the conventional group. The overall survival rate was 78.7% (95% CI: 70.3 to 87.2%) in the conventional management group, 89.7% (95% CI: 83.1 to 96.2%) in the endoscopic diagnostic group and 95.5% (95% CI: 86.0 to 100%) in the systematic endoscopic intervention group. Landmark analysis indicated that the speed of wound healing in the endoscopic intervention group was 2-4 times faster at any period than that in the conservative group. There were 20 (21.28%) deaths among the 94 patients in the conventional group, 9 (10.34%) deaths among the 87 patients in the endoscopic diagnostic group and 1 (4.55%) death among the 22 patients in the endoscopic intervention group; this difference was statistically significant (Fisher exact test, P < 0.05).

Conclusion

Tailored endoscopic treatment for postoperative esophageal anastomotic leakage based on endoscopic diagnosis is feasible and effective. Systematic endoscopic intervention shortened the treatment period and reduced mortality and should therefore be considered in the management of this disease.

Self-dilatation of benign oesophageal strictures: a literature review

BACKGROUND

Benign oesophageal strictures can have several aetiologies and often require serial endoscopic dilatation. The aim of this study was to review the existing literature regarding the efficacy of self-dilatation for benign oesophageal strictures.

METHODS

This study presents the results of a systematic review that was performed on the available literature using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Full-text articles from Medline, PubMed and Embase were used, as well as associated reference lists. This study systematically reviews the literature to present the efficacy and different outcome measurements associated with self-dilatation of benign oesophageal strictures.

RESULTS

This study identified 13 articles with 274 participants.

CONCLUSION

Self-dilatation for refractory benign oesophageal strictures is effective regardless of aetiology. It is well tolerated, safe and leads to lasting symptom resolution in the majority of patients.

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.

Endoscopic Management of Post-Laparoscopic Sleeve Gastrectomy Leakage and Stenosis Using Fully Covered Stent

Background

Laparoscopic sleeve gastrectomy (LSG) is the most commonly performed surgery to treat morbid obesity. Post-LSG leak and stenosis are serious complications that can be associated with significant morbidity and mortality.

Objective

The objective was to report the efficacy and safety profile of using specifically designed fully covered self-expandable metallic stent for the treatment of post-LSG complications.

Methods

This retrospective study included adult patients who underwent placement of a fully covered esophagogastric, self-expandable metallic stent for post-LSG leak or stenosis. The procedure was carried out at King Abdulaziz University Hospital, Jeddah, Saudi Arabia, between September 2017 and May 2019. Data regarding demographics, indication for stenting, size of the stent, procedural success and poststenting adverse events were collected.

Results

A total of 14 patients met the inclusion criteria, with indication for endoscopic stenting being post-LSG leak in 11 patients and stenosis in 3 patients. The technical success rate of self-expandable metallic stent placement was 100%, and the clinical success was 85.7% (12 of 14 patients). Nausea (71.4%) and vomiting (85.7%) were the most frequent mild adverse events reported. Stent-induced esophageal stricture was the only major adverse event reported in two patients.

Conclusion

Placement of specifically designed self-expandable metallic stent for the treatment of post-LSG leak and stenosis is an effective and safe approach. Further studies with larger cohorts are needed to assess the optimal duration needed to treat such complications.

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.

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.

Biodegradable esophageal stents for the treatment of refractory benign esophageal strictures

This review attempts to present the available evidence regarding the use of biodegradable stents in refractory benign esophageal strictures, especially highlighting their impact on clinical success and complications. A comprehensive literature search was conducted in PubMed, using the terms "biodegradable" and "benign"; evidence from cohort and comparative studies, as well as data from one pooled analysis and one meta-analysis are presented. In summary, the results from these studies indicate that the effectiveness of biodegradable stents ranges from more than one third to a quarter of cases, fairly similar to other types of stents used for the same indication. However, their implementation may reduce the need for re-intervention during follow up. Biodegradable stents also seem to reduce the need for additional types of endoscopic therapeutic modalities, mostly balloon or bougie dilations. Results from pooled data are consistent, showing moderate efficacy along with a higher complication rate. Nonetheless, the validity of these results is questionable, given the heterogeneity of the studies included. Finally, adverse events may occur at a higher rate but are most often minor. The lack of high-quality studies with sufficient patient numbers mandates further studies, preferably randomized, to elucidate the exact role of biodegradable stents in the treatment of refractory benign esophageal strictures.

Esophageal stent migration to the transverse colon, entrapped within a hiatal hernia status post esophagectomy

Self-expandable metal stents are used in both benign and malignant esophageal conditions for the treatment of strictures, leaks and perforations. With this intervention, the most common complication is stent migration. Those in whom migration occurs are subject to additional procedures with significant risk. We present a unique case of stent migration in a 61-year-old male who underwent transhiatal esophagectomy secondary to esophageal adenocarcinoma. Postoperatively, two covered stents were applied to relieve anastomotic stricture and proximal esophageal occluding web. Several months thereafter, the initial stent was found to have migrated to the transverse colon subsequently entrapped in a hiatal hernia defect. Fortunately, the migrated stent was amenable to colonoscopic retrieval. As endoscopic stent use grows, it is important to recognize that covered stents may migrate through anatomic narrowing’s such as pylorus and ileocecal valve, but can also become entrapped in nonanatomic narrowing’s such as a hernia leading to further complications.

Changing epidemiology of esophageal stent placement for dysphagia: a decade of trends and the impact of benign indications

BACKGROUND AND AIMS

In addition to managing malignant obstruction, esophageal stents (ESs) have evolved to address various benign etiologies of dysphagia. We sought to evaluate national trends and changes in practice of ES placement for both benign and malignant etiologies in hospitalized patients with dysphagia.

METHODS

The National Inpatient Sample (2003-2013) was used to include all adult inpatients (≥18 years of age) with endoscopy-guided ES placement for a symptom of dysphagia. Multivariable analyses for indications that impact temporal trends (3 time periods: 2003-2005, 2006-2009, and 2010-2013) and for hospital outcomes were performed.

RESULTS

A total of 7198 ESs were deployed endoscopically in hospitalized patients with dysphagia. Compared with malignant etiologies, there was a significant increase in ES placement for benign conditions (2013 vs 2003: 32.7% vs 14.5%, respectively; P < .001). Multivariable analysis using 2003 to 2005 as a reference showed that patients with benign etiologies for dysphagia predominantly contributed to the increase of ES placement during the most recent time period (2010-2013: odds ratio, 2.09; 95% confidence interval, 1.40-3.13). Multivariable analysis of hospital outcomes revealed no differences in inpatient mortality, duration of hospital stay, and hospital costs between malignant and benign indications.

CONCLUSIONS

In the preceding decade, ES placement for hospitalized patients with dysphagia has increased, driven largely by an over 8-fold rise in stent placement for benign indications. These findings warrant continued efforts to improve stent technology to decrease the risk of migration and review practice guidelines involving ES placement for benign etiologies.

Clinical score predicting a successful endoscopic approach of esophageal anastomotic leaks: external validation

BACKGROUND

Recently, a clinical prediction rule has been proposed to predict the chance of successful endoscopic stenting in benign esophageal anastomotic leakage, perforation and fistula. We aimed to validate this score in a cohort of patients with anastomotic leaks managed with self-expanding metal esophageal stents, by assessing technical and clinical success rates and comparing the agreement between the predicted and the actual clinical success.

METHODS

A multicenter retrospective cohort study including patients submitted to endoscopic stenting due to anastomotic leak was conducted. Variables of the score (leak size, location and C-reactive protein) were collected and the chance of success (≤50, 50-70 and ≥70%) and its accuracy was assessed.

RESULTS

Fifty-three patients, submitted to esophageal stenting after cancer (n = 47) and bariatric surgery were included. Clinical success was achieved in 62% of patients. The area under the ROC curve to differentiate between successful and failed therapies showed a good discriminative power of the score (AUC 0.705; P < 0.01). For a predicted chance of success >50%, the positive predictive value was 72.5%; for a chance of success ≤50%, the negative predictive value was 69.2%.

CONCLUSIONS

The application of this predictive model in patients with anastomotic leaks proved to be valid in a different cohort from that in which it was derived. Its usefulness in clinical practice may be anticipated, favoring stenting in patients with a chance of success >50%. However, we must be cautious in patients with a lower probability of success and a case-by-case decision should be made.

A Novel Method of Esophageal Remodeling: Thinking Outside the Box

Caustic esophageal strictures are complex strictures with high rates of recurrence and complications. Management of these strictures requires a multipronged approach including endoscopic dilation and complex surgeries. Even with these modalities, treatment of each patient has to be individualized because it requires high clinical discretion. We present a 38-year-old female woman who had required esophagostomy and total gastrectomy in the acute phase after caustic ingestion. The definitive surgical procedure was deferred because of cicatrization of the proximal esophageal remnant. We remodeled scarred esophagus using a novel technique, which facilitated definitive surgery.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Permanent Implantable Medical Devices in Exotic Pet Medicine

Medical devices are defined as implantable if they are intended to remain in the body after the procedure. In veterinary medicine, use of such devices is marginal but may find some indications. Use in exotic pet medicine is even more challenging due to size restriction and the limited data available. This review focuses on the esophageal and tracheal stent in the case of stricture, ureteral stent and subcutaneous ureteral bypass in the case of ureteral obstruction, permanent urinary diversion in the case of bladder atony, and pacemaker in the case of severe arrythmias. Comparative aspects are developed.

Tracheomalacia as Complication of Stenting for Esophageal Injury After Transsternal Approach to High Thoracic Vertebral Metastasis

BACKGROUND

Esophageal injury is a severe surgical complication of a transsternal approach to high thoracic vertebral metastasis, which can result in mediastinitis and life-threatening consequences. A covered stent can be placed in the esophagus to prevent mediastinal leakage. However, tracheomalacia is a rare complication following esophageal stenting.

CASE DESCRIPTION

A 56-year-old man had a pathologic fracture of the T3 vertebral body with spinal cord compression, myelopathy, and neurogenic bladder. An esophageal injury was noticed during the transsternal approach. Immediate suture repair, drainage tube placement, and subsequent esophageal stenting were carried out. One month after discharge, the endoscopic examination revealed nonhealing of the esophagus, and a new covered stent was replaced. Episodes of severe stridor and dyspnea led to the patient being sent to the emergency department. Computed tomography scan of the chest revealed a focal collapse of the trachea at the thoracic inlet, and tracheomalacia was suspected. The covered stent was removed, despite nonhealing of the esophagus. His stridor, dyspnea, and constant coughing subsided afterwards. The endoscopic examination at 3 months after stent removal showed complete healing of the esophagus.

CONCLUSIONS

Esophageal stenting can be used to prevent mediastinal leakage due to esophageal injury in the transsternal approach for high thoracic vertebral metastasis, but the stent might be a cause of tracheomalacia. Stent removal should be considered if upper airway obstruction occurs. Awareness of the radial force of the stent, esophageal composition (e.g., status post suture repair), and esophageal diameter must be considered for optimal stent tolerance to avoid complications.

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.

Comparison of endoscopic vacuum therapy versus endoscopic stenting for esophageal leaks: systematic review and meta-analysis

Esophageal leaks remain a life-threatening postoperative complication of esophagectomy. Currently, self-expanding metal stents (SEMS) represent the endoscopic mainstay of treatment. Recently, endoscopic vacuum therapy (EVT) has emerged and shown promising results in these patients. We conducted an electronic systematic search using MEDLINE databases (PubMed, EMBASE, and Web of Science) looking for studies comparing EVT and SEMS for the treatment of esophageal leak and/or perforation. Four studies including 163 patients matched the inclusion criteria. Esophageal leak closure rate is significantly higher with EVT than SEMS [pooled odds ratio 5.51 (95% CI 2.11-14.88; P < 0.001)]. Additionally, EVT has a shorter treatment duration [pooled mean difference -9.0 days (95% CI 16.6-1.4; P = 0.021)], lower major complication (P = 0.011), and in-hospital mortality (P = 0.002) rate compared to SEMS. EVT for esophageal leak is feasible and safe. It has the potential to become the new gold standard in the endoscopic treatment of esophageal leaks and perforations. However, further comparative studies with SEMS are needed to strengthen the current evidence.

Endoscopic management of perforations, leaks and fistulas

The endoscopic management armamentarium of gastrointestinal disruptions including perforations, leaks, and fistulas has slowly but steadily broadened in recent years. Previously limited to surgical or conservative medical management, innovations in advanced endoscopic techniques like natural orifice transluminal endoscopic surgery (NOTES) have paved the path towards development of endoscopic closure techniques. Early recognition of a gastrointestinal defect is the most important independent variable in determining successful endoscopic closure and patient outcome. Some devices including through the scope clips and stents have been well studied for other indications and have produced encouraging results in closure of gastrointestinal perforations, leaks and fistulas. Over the scope clips, endoscopic sutures, vacuum therapy, glue, and cardiac device occluders are other alternative techniques that can be employed for successful endoscopic closure.

Chinese expert consensus on diagnosis and management of acquired respiratory-digestive tract fistulas

Acquired respiratory‐digestive tract fistulas occur with abnormal communication between the airways and digestive tract, causing the interflow of gas and liquid. Despite advances in surgical methods and the development of multimodal therapy in recent years, patients with acquired respiratory‐digestive tract fistulas continue to exhibit unfavorable clinical outcomes. Therefore, in order to guide clinical practice in China, the Respiratory and Cancer Intervention Alliance of the Beijing Health Promotion Association organized a group of experienced experts in the field to develop this consensus document. Based on a study of clinical application and expert experience in the diagnosis and management of acquired respiratory‐digestive tract fistulas at home and abroad, an Expert Consensus was developed. The panelists recruited comprised experts in pulmonology, oncology, thoracic surgery, interventional radiology, and gastroenterology. PubMed, Chinese Biology Abstract, Chinese Academic Journal, and Wanfang databases were used to identify relevant articles. The guidelines address etiology, classification, pathogenesis, diagnosis and management of acquired respiratory‐digestive tract fistulas. The statements on treatment focus on the indications for different procedures, technical aspects, and preprocedural, post‐procedural and complication management. The proposed guidelines for the diagnosis and management of acquired respiratory‐digestive tract fistulas are the first to be published by Chinese experts. These guidelines provide an in‐depth review of the current evidence and standard of diagnosis and management.