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

Background

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

Methods

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

Results

No complication with clip placement was observed, and the retrieval of the stent was not unsettled by the persistence of at least one clip (12 cases). Stent migration was noted in 15 patients (34%) but in only in 3 of the 23 patients with clips (13%). The number of patients treated to prevent one stent migration was 2.23. The predictive positive value of nonmigration after placement of the clip was 87%. In the multivariate analysis, the fixation with clips was the unique independent factor for the prevention of stent migration (odds ratio, 2.3; 95% confidence interval, 0.10?C0.01; p?=?0.03).

Conclusions

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

Esophageal Stenting and Radiotherapy: A Multimodal Approach for the Palliation of Symptomatic Malignant Dysphagia

Background

Esophageal stents provide immediate palliation of malignant dysphagia; however, radiotherapy (RT) is a superior long-term option. We review the outcomes of combined esophageal stenting and RT for patients with malignant dysphagia.

Methods

We retrospectively reviewed patients with esophageal stents placed for palliation of malignant dysphagia from esophageal stricture, esophageal extrinsic compression, or malignant tracheoesophageal fistula (TEF). We excluded patients with radiation-induced TEF in the absence of tumor. We analyzed and compared outcomes between patients with no RT, RT before stent placement, and RT after stent placement.

Results

We placed stents in 45 patients for esophageal stricture from esophageal cancer (n?=?30; 66.7?%), malignant TEF (n?=?8; 17.7?%), and esophageal compression from airway, mediastinal, or metastatic malignancies (n?=?7; 15.6?%). Twenty patients (44.4?%) had no RT; 25 patients had RT before stent placement (n?=?16; 35.6?%), RT after stent placement (n?=?8; 17.8?%), or both (n?=?1; 2.2?%). Median follow-up was 30?days. Complications requiring stent revision were similar with or without RT. Subjective symptom relief was achieved in 68.9?% of all patients, with no differences noted between groups (p?=?0.99). The 30-day mortality was 15.6?%. Patients with RT after stent placement had a longer median survival compared to those without RT (98 vs. 38?days).

Conclusions

Esophageal stent placement with RT is a safe approach for malignant dysphagia.     

Endoscopic therapy for esophageal perforation or anastomotic leak with a self-expandable metallic stent

Background

Leaks of the esophagus are associated with a high mortality rate and need to be treated as soon as possible. Therapeutic options are surgical repair or resection or conservative management with cessation of oral intake and antibiotic therapy. We evaluated an alternative approach that uses self-expandable metallic stents (SEMS).

Methods

Between 2002 and 2007, 31 consecutive patients with iatrogenic esophageal perforation (n = 9), intrathoracic anastomotic leak after esophagectomy (n = 16), spontaneous tumor perforation (n = 5), and esophageal ischemia (n = 1) were treated at our institution. All were treated with endoscopic placement of a covered SEMS. Stent removal was performed 4 to 6 weeks after implantation. To exclude continuous esophageal leak after SEMS placement, radiologic examination was performed after stent implantation and removal.

Results

SEMS placement was successful in all patients and a postinterventional esophagogram demonstrated full coverage of the leak in 29 patients (92%). In two patients, complete sealing could not be achieved and they were referred to surgical repair. Stent migration was seen in only one patient (3%). After removal, a second stent with larger diameter was placed and no further complication occurred. Two patients died: one due to myocardial infarction and one due to progressive ischemia of the esophagus and small bowl as a consequence of vascular occlusion. Stent removal was performed within 6 weeks, and all patients had radiologic and endoscopic evidence of esophageal healing.

Conclusions

Implantation of covered SEMS in patients with esophageal leak or perforation is a safe and feasible alternative to operative treatment and can lower the interventional morbidity rate.     

Efficacy and safety of covered self-expandable metal stents for management of distal malignant biliary obstruction due to lymph node metastases

Background

Distal malignant biliary obstruction (MBO) due to lymph node metastases (LNM) is a common problem in advanced malignant disease. However, the role of covered self-expandable metal stents (SEMS) in treating MBO has not been studied. The aim of this study was to evaluate the efficacy and safety of covered SEMS for the treatment of distal MBO due to LNM.

Methods

Between November 1994 and December 2009, a total of 65 patients with distal MBO due to LNM underwent covered (n?=?44) and uncovered (n?=?21) SEMS placement.

Results

Successful drainage was achieved in all patients. There was no significant difference in patient survival. The cumulative stent patency of covered SEMS was significantly higher than that of uncovered SEMS (P?=?0.0020). Stent occlusion occurred in 5 patients (11%) with covered SEMS and in 8 (38%) with uncovered SEMS. There was no tumor ingrowth in covered SEMS, but seven in the uncovered SEMS group showed some ingrowth. Cholecystitis was not observed, but mild pancreatitis was observed in 6 (14%) of those with covered SEMS. No stent-insertion-related deaths occurred.

Conclusions

Covered SEMS are safe and effective for treatment of distal malignant biliary obstruction due to LNM.     

Partially versus fully covered self-expanding metal stents for benign and malignant esophageal conditions: a single center experience

Background

Fully covered self-expanding metal stents (FCSEMS), unlike partially covered SEMS (PCSEMS), have been used to treat benign as well as malignant conditions. We aimed to evaluate the outcome of PCSEMS and FCSEMS in patients with both benign and malignant esophageal diseases.

Methods

Data were reviewed of all patients who underwent SEMS placement for malignant or benign conditions between January 1995 and January 2012. Patients with cancer were followed for at least 3 months, until death or surgery. Patients with benign conditions had stents removed between 4 and 12 weeks. Patient demographics, location and type of lesion, stent placement and removal, clinical success, and adverse events were analyzed.

Results

A total of 252 patients (mean ± standard deviation age 68.5 ± 14 years; 171 male) received 321 SEMS (209 PCSEMS, 112 FCSEMS) for malignant (78 %) and benign (22 %) conditions. Stent placement and removal was successful in 97.6 and 95.6 % procedures. Successful relief of malignant dysphagia was noted in 140 of 167 patients (83.8 %) and control of benign fistulas, leaks, and perforations was noted in 21 of 25 patients (84 %), but only 8 of 15 patients (53 %) with recalcitrant benign strictures had effective treatment. Fifty-six patients (22.2 %) experienced at least one stent-related adverse events. Migration was frequent, occurring in 61 of 321 stent placements (19 %), and more frequently with FCSEMS than PCSEMS (37.5 vs. 9.1 %, p < 0.001). FCSEMS, benign conditions, and distal location were the variables independently associated with migration (p < 0.001, p = 0.022, and p = 0.008). Patients with PCSEMS were more likely to have tissue in- or overgrowth than FCSEMS (53.4 vs. 29.1 %, p = 0.004).

Conclusions

Both PCSEMS and FCSEMS can be used in benign and malignant conditions; they are both effective for relieving malignant dysphagia and for closing leaks and perforations, but they seem less effective for relieving benign recalcitrant strictures. Stent migration is more common with FCSEMS, which may limit its use for the palliation of malignant dysphagia.     

Outcome of palliative self-expanding metal stent placement in malignant colorectal obstruction according to stent type and manufacturer

Background

Self-expandable metallic stents (SEMS) of varying designs and materials have been developed to reduce complications, but few comparative data are available with regard to the type of stent and the stent manufacturer. We analyzed the success rates and complication rates, according to stent type (uncovered vs. covered stent) and individual stent manufacturer, in malignant colorectal obstruction.

Methods

From November 2001 to August 2008, 103 patients were retrospectively included in this study: four types of uncovered stents in 73 patients and two types of covered stents in 30 patients. The SEMS was inserted into the obstructive site by using the through-the-scope method.

Results

Technical and clinical success rates were not different between stent type or among stent manufacturers: 100 and 100% (p?=?ns) and 100 and 96.6% (p?>?0.05), respectively, in uncovered and covered stents. Stent occlusion and migration rates were 12.3 and 3.3% (p?=?0.274) and 13.7 and 16.7% (p?=?0.761), respectively, in uncovered and covered stents, and 11.1, 5, and 9% (p?=?0.761) and 25.9, 15, and 0% (p?=?0.037) in Wallstent, Niti-S, and Bonastent uncovered stents, respectively.

Conclusions

The placement of SEMS is an effective and safe treatment for patients with malignant colorectal obstruction. Although minor differences in outcome were detected according to the type and the manufacturer of the stents, no statistically significant difference was observed, except in stent migration among the stent manufacturer.     

Risk factors for pancreatitis following transpapillary self-expandable metal stent placement

Background

Pancreatitis is one of complications after self-expandable metal stent (SEMS) placement. The purpose of this study was to evaluate risk factors for pancreatitis after endoscopic SEMS placement for malignant biliary obstruction (MBO).

Methods

We retrospectively reviewed 370 consecutive patients who underwent initial transpapillary SEMS placement for biliary decompression. The characteristics of inserted SEMSs were classified according to axial and radial force.

Results

Pancreatitis following SEMS insertion was observed in 22 patients (6%). All of them were mild according to consensus criteria. Univariate analysis indicated that injections of contrast into the pancreatic duct (frequency of pancreatitis, 10.3%), the placement of an SEMS with high axial force (8.3%), and nonpancreatic cancer (16.1%) significantly contributed to the development of pancreatitis, whereas female gender, a younger age, a covered SEMS, and a SEMS with high radial force or without a biliary sphincterotomy did not. In a multivariate risk model, SEMSs with high axial force (odds ratio [OR], 3.69; p?=?0.022) and nonpancreatic cancer (OR, 5.52; p?Conclusions SEMSs with high axial force and an etiology of MBO other than pancreatic cancer were strongly associated with a high incidence of pancreatitis following transpapillary SEMS placement in patients with distal MBO.     

Peroral Endoscopic Myotomy (POEM) Is Safe and Effective in the Setting of Prior Endoscopic Intervention

Objective

We aimed to determine the safety and feasibility of peroral endoscopic myotomy (POEM) in the setting of prior endoscopic interventions.

Patients

This study involves 40 consecutive patients undergoing POEM.

Intervention

POEM was performed for esophageal motility disorders, including achalasia, nutcracker with nonrelaxing lower esophageal sphincter (LES), hypertensive lower esophageal sphincter, and diffuse esophageal spasm.

Main Outcome Measures

Outcome measures include length of procedure (LOP), intraoperative complications, and dysphagia relief.

Results

Forty patients, with a mean age of 54?±?19 years, underwent POEM. The pre-POEM intervention group consisted of 12 patients (nine achalasia, two nutcracker with nonrelaxing LES, and one diffuse esophageal spasm) who also had previous endoscopic treatment, while the pre-POEM non-intervention group consisted of 28 patients (22 achalasia, 3 hypertensive LES, 2 nutcracker with nonrelaxing LES, and 1 diffuse esophageal spasm). Ten patients had botox injections and two patients had large caliber balloon dilations prior to POEM. The median preoperative Eckardt score was 5 in the pre-POEM intervention group vs 6 in the pre-POEM non-intervention group (p value?=?0.4). There was no statistical difference in the mean LOP (134?±?43 vs 131?±?41, p?=?0.8) or the incidence of intraoperative complications (17 vs 3 %, p?=?0.2) between the two groups. There was also no difference in the 6-month postoperative median Eckardt scores between the two groups (1 vs 1, p?=?0.4).

Conclusion

POEM is safe and effective even following preoperative endoscopic large caliber balloon dilations or botox injection. These interventions do not seem to contribute to increased adverse intraoperative or postoperative clinical outcomes.     

Weight Loss and Weight Regain—5-Year Follow-Up for Circular- vs. Linear-Stapled Gastrojejunostomy in Laparoscopic Roux-en-Y Gastric Bypass

Background

Weight regain (WR) occurs in some patients after laparoscopic Roux-en-Y gastric bypass (LRYGBP). Loss of restriction due to dilation of the gastrojejunostomy (GJS) or the gastric pouch might be the main cause for WR. With different techniques available for the establishment of the GJS, the surgical technique might influence long-term success.

Methods

We present a 5-year follow-up for weight loss and WR of a matched-pair study comparing circular stapled (CSA) to linear stapled (LSA) GJS in a series of 150 patients who underwent primary antecolic antegastric LRYGBP. Complete 5-year follow-up was obtained for 79 % of the patients.

Results

Excess BMI loss (EBL) at 3 months was better with the CSA (p?=?0.02) and comparable thereafter. The 5-year %EBL was 67.3?±?23.2 vs. 73.3?±?24.3 % (CSA vs. LSA, p?=?0.19) WR of?>?10 kg from nadir was found in 24 patients (16 %) with higher incidence in CSA than in LSA patients (20 % vs. 12 %). The %WR was comparable for both groups, 16?±?13 vs. 15?±?19 % (CSA vs. LSA, p?=?0.345). Eleven patients underwent surgical re-intervention for WR by placement of a non-adjustable band (n?=?2), adjustable band (n?=?7) and conversion to distal gastric bypass (n?=?2).

Conclusions

CSA and LSA lead to comparable weight loss in this 5-year follow-up. More patients in the CSA group had WR. Weight regain of more than 10 kg was found in one out of seven patients within 5 years postoperatively.     

Mechanisms of Bolus Clearance in Patients with Laparoscopic Adjustable Gastric Bands

Background

The components of esophageal function important to success with laparoscopic adjustable gastric banding (LAGB) are not well understood. A pattern of delayed, however, successful bolus transit across the LAGB is observed.

Methods

Successful LAGB patients underwent a high-resolution video manometry study in which bolus clearance, flow, and intraluminal pressures were recorded. Liquid and semi-solid swallows and stress barium (a combination of semi-solid swallows and liquid barium) were performed. A new measurement, the lower esophageal contractile segment (LECS), was defined and evaluated.

Results

Twenty patients participated (mean age 48.3?±?12.0 years, four men, %excess weight loss 65.6?±?18.0). During semi-solid swallows, two patterns of esophageal clearance were observed: firstly, a native pattern (n?=?10) similar to that which is expected in non-LAGB patients; secondly, a lower esophageal sphincter-dependent pattern (n?=?7), where flow only occurred when the intrabolus pressure increased during the lower esophageal sphincter (LES) aftercontraction. In both patterns, if there was incomplete bolus clearance, reflux was observed and was usually followed by another swallow. A mean of 4.5?±?2.9 contractions were required to clear the semi-solid bolus. Contractions with an intact LECS demonstrated longer flow duration: 7.1?±?3.8 vs.1.6?±?3.2 s, p?<?0.005. During the stress barium, an intrabolus pressure of 44.5?±?16.0 mm Hg leads to cessation of intake.

Conclusions

In LAGB patients, normal esophageal peristaltic contractions transition to a LES aftercontraction, producing trans-LAGB flow. Repeated contractions are required to clear a semi-solid bolus. Incorporating measurements of the LECS into assessments of esophageal motility in LAGB patients may improve the usefulness of this investigation.     

Influence of Eating Profile on the Outcome of Laparoscopic Sleeve Gastrectomy

Background

The aim of this study was to assess the eating profile of patients after laparoscopic sleeve gastrectomy (LSG) and its impact on weight loss.

Methods

One hundred ten patients who underwent LSG were interviewed using Suter questionnaire and revised Questionnaire on Eating and Weight Patterns in follow-up visits. Eating patterns were assessed preoperatively and postoperatively. Patients were divided into six groups according to the timing point of assessment. Group 1 (n?=?10) included patients <3 months, group 2 (n?=?11) 3–6 months, group 3 (n?=?11) 6–12 months, group 4 (n?=?39) 1–2 years, group 5 (n?=?23) 2–3 years, and group 6 (n?=?16) >3 years. The excess weight loss (EWL) was correlated with the results.

Results

The total score of the Suter questionnaire was 15.0?±?5.87, 20.3?±?7.07, 26.2?±?1.54, 23.8?±?4.25, 24.65?±?2.8, and 23.43?±?4.14 for the groups 1–6, respectively (p?<?0.0001). No significant differences were denoted when long-term follow-up groups 3 to 6 were compared. No association was found between the preoperative eating pattern and EWL. Postoperatively, 91 patients modified their eating pattern. Postoperative eating pattern was significantly correlated with EWL (p?=?0.015). Patients with normal and snacking eating pattern achieve the best EWL (63.57?±?21.32 and 60.73?±?20.62, respectively). Binge eating disorder and emotional patterns had the worst EWL (42.84?±?29.42 and 34.55?±?19.34, respectively).

Conclusions

Better food tolerance is detected after the first postoperative year after LSG. The postoperative eating patterns seem to affect excessive weight loss.     

Factors associated with 30-day readmission and long-term efficacy of enteral stent placement for malignancy

Background

Readmissions to the hospital within 30 days of discharge (30-day readmission rate) may impact stent use in palliative treatment of cancer.

Objective

Our objective was to investigate the incidence of readmission and factors predicting readmissions and long-term outcomes in patients with self-expanding metal stents (SEMS) placed for malignant obstruction.

Methods

Retrospective analysis of all patients who underwent placement of SEMS from 2007 to 2012 for malignant esophageal, gastroduodenal, and colonic obstruction. Incidence and variables associated with 30-day readmission and long-term outcomes were determined.

Results

A total of 191 patients underwent stent placement. The 30-day readmission rate was 17.3 % (N = 33). Readmissions were for stent-related complications in 7.3 % (N = 14) and non-stent-related complications in 9.9 % (N = 19). Stent placement was technically successful in 185 of 191 (96.9 %) and clinically successful in 170 of 191 (89.0 %) patients. On long-term follow-up, 32 (16.8 %) patients needed re-intervention. The mean stent patency was 142 days. Readmission within 30 days was independently associated with development of early complications (<7 days) following stent placement (odds ratio [OR] 5.90; 95 % confidence interval [CI] 2.04–17.1), while the stent location did not impact readmission risk. On Cox regression analysis, American Society of Anesthesiologists physical classification (OR 1.36; 95 % CI 1.02–1.87) and stent location in the esophagus (OR 1.82; 95 % CI 1.10–3.02) were independently associated with long-term mortality.

Conclusions

Early complications following stent placement increase the risk of 30-day readmission. SEMS is efficacious long-term for palliation of malignant gastrointestinal obstruction.     

Long-Term Outcomes of Laparoscopic Surgery for Advanced Transverse Colon Cancer

Background

The role of laparoscopic surgery for advanced transverse colon cancer (TCC) remains controversial, especially in terms of long-term oncologic outcomes.

Methods

This retrospective cohort study enrolled 157 consecutive patients who underwent curable resections for advanced TCC between January 2002 and June 2011 (laparoscopic-assisted colectomy (LAC), n?=?74; open colectomy (OC), n?=?83). Short-term outcomes and oncologic long-term outcomes were compared between the two groups.

Results

Compared to the OC group, patients in the LAC group had less blood loss (LAC vs. OC, 79.6?±?70.3 vs. 158.4?±?89.3 ml, p?<?0.001), faster return of bowel function (2.6?±?0.7 vs. 3.8?±?0.8 days, p?<?0.001), and shorter postoperative hospital stay (10.3?±?3.7 vs. 12.6?±?6.0 days, p?=?0.007). Conversions were required in four (5.4 %) patients. Rates of short-term complication, mortality, and long-term complication were comparable between the two groups. The median follow-up time was 54 (26–106) months in the LAC group and 58 (29–113) months in the OC group (p?=?0.407). There were no statistical differences in the rates of 5-year overall survival (73.6 vs. 71.1 %, p?=?0.397) and 5-year disease-free survival (70.5 vs. 66.7 %, p?=?0.501) between the two groups.

Conclusions

Laparoscopic surgery for advanced TCC yield short-term benefits while achieving equivalent long-term oncologic outcomes.     

Reoperations for esophageal achalasia

Purpose

To define the factors predisposing to recurrence and evaluate the results of reoperations for achalasia.

Methods

We reviewed the medical records of ten patients (4 men and 6 women; mean age, 51.5?±?11.0?years), who underwent reoperations for achalasia between August 1994 and August 2010.

Results

The primary surgical procedures were Heller–Dor (HD) cardioplasty in nine patients and Heller myotomy in one patient. The factors contributing to failure of the primary operation included inadequate myotomy (n?=?2), recurrent adhesion after myotomy (n?=?2), reflux esophagitis (n?=?2), difficulty in passage caused by tortuosity of the esophagus (n?=?2), difficulty in passage through the thoracic esophagus (n?=?1), and severe chest pain (n?=?1). The reoperations included repeated HD procedures (n?=?4), repair of an esophageal hiatal hernia (n?=?2), thoracic esophageal myotomy (n?=?2), straightening of the lower esophagus with gastropexy (n?=?1), and subtotal esophagectomy (n?=?1). The success rate of the reoperations for resolving symptoms was 90?% (9 patients).

Conclusion

Selecting surgical procedures based on the causes and conditions of recurrence led to symptomatic improvement and acceptable outcomes.     

Comparison of treatment outcomes of endoscopic stenting for colonic and extracolonic malignant obstruction

Background

Self-expandable metal stents (SEMS) have been used as a bridging or palliative treatment for malignant colorectal obstruction. Colonic obstruction also may arise from advanced extracolonic malignancy, but the clinical outcomes of stent placement for extracolonic malignancy are unclear. This study compared the clinical outcomes of SEMS between patients with colorectal cancer and those with extracolonic malignancy.

Methods

Patients who underwent endoscopic SEMS placement for a malignant colorectal obstruction were enrolled at Seoul National University Hospital from April 2005 and August 2011. Their medical records were retrospectively reviewed in terms of success rate, complications, and duration of stent patency.

Results

Endoscopic SEMS placements were performed for colorectal cancer in 149 patients and for extracolonic malignancy in 60 patients. The causes of obstruction in extracolonic malignancy were advanced gastric cancer in 39 patients (65 %), pancreatic cancer in nine patients (15 %), ovarian cancer in three patients (5 %) and other causes in nine patients (15 %). The clinical success rates were similar between the two groups (92.6 vs 86.7 %; p = 0.688), and multivariate analysis showed no significant risk factor for unsuccessful endoscopic SEMS placement. Reobstruction in palliative endoscopic SEMS placement occurred for 16 patients with colorectal cancer (21.9 %) and 18 patients with extracolonic malignancy (30 %) during a median follow-up period of 90 days (p = 0.288). The rates did not differ significantly between the two groups (4.1 vs 8.3 %; p = 0.467). The median duration of stent patency was 193 ± 42 days for the patients with colorectal cancer and 186 ± 31 days for the patients with extracolonic malignancy (p = 0.253). The duration of stent patency was not affected by underlying malignancy, previous surgery, or palliative chemotherapy.

Conclusions

Endoscopic SEMS placement is highly effective and comparable for palliation of obstruction in extracolonic malignancy and colorectal cancer in terms of clinical success, complications, and duration of patency.     

Laparoscopic Bariatric Surgery Can Be Performed Through a Single Incision: A Comparative Study

Background

The application of single-incision laparoscopic surgery (SILS) in bariatric patients has been limited to less complex procedures. We evaluated the short-term outcomes of SILS sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB), compared to a group of well-established minimally invasive techniques.

Methods

Twenty-eight morbidly obese patients who underwent SILS SG (n?=?14) and RYGB (n?=?14) were compared to a matched control group composed of 28 cases of conventional laparoscopic surgery (CLS). A single vertical 2.5–3-cm intra-umbilical incision, three-ports placed trans-fascially, and a liver suspension technique were used to perform SILS.

Results

Both groups were comparable in terms of age (p?=?0.96), gender (p?=?1.0), type of procedure (p?=?1.0), and number of comorbidities (p?=?0.63). Two (7 %) SILS patients required placement of one additional port, and no conversions to CLS or open surgery were needed. The estimated blood loss (p?=?0.48), operative time (p?=?0.33), length of hospital stay (p?=?0.79), overall 90-day perioperative complication rate (p?=?1.0), and short-term weight loss (p?=?0.53) were comparable between the two groups. In terms of pain control, the frequency of patient-controlled analgesia use in both groups was similar. However, the pain score (assessed by visual analog scale) was significantly less for SILS patients on postoperative days 1 (5.0?±?2.1 vs. 6.5?±?1.8; p?=?0.007) and 2 (4.0?±?2.0 vs. 5.1?±?2.4; p?=?0.49). Cosmetic satisfaction with the scar was high in the SILS group. No patients required reoperation or readmission during the 90 days after surgery.

Conclusion

SILS is feasible in carefully selected bariatric patients and results in short-term outcomes comparable to those observed after CLS. Improved pain and cosmesis are potential benefits of SILS.     

Outcomes of Laparoscopic Sleeve Gastrectomy in Patients Older than 60 Years

Background

Morbidity and mortality following laparoscopic sleeve gastrectomy (LSG) occur at acceptable rates, but its safety and efficacy in the elderly are unknown.

Methods

A retrospective review was performed of all patients aged >60 years who underwent LSG from 2008 to 2012. These patients were 1:2 matched, by gender and body mass index (BMI) to young patients, 18?<?age?<?50. Data analyzed included demographics, preoperative and postoperative BMI, postoperative complications, and improvement or resolution of obesity-related comorbidities.

Results

Fifty-two morbid obese patients older than 60 years underwent LSG (mean age, 62.9?±?0.3 years). These were matched to 104 young patients, age 18–50 years (mean age, 35.7?±?0.8 years). Groups did not differ in male gender (44 vs. 43 %, p?=?0.9), preoperative BMI (42.6?±?0.7 vs. 42.6?±?0.6, p?=?0.97), and length of follow-up (17?±?2 vs. 22?±?1.4 months, p?=?0.06). Obesity-related comorbidities were significantly higher in the older group (96 vs. 65 %, p?<?0.001). Excess weight loss (EWL) was higher in the younger group (75?±?2.4 vs. 62?±?3 %, p?=?0.001). Older patients had a significantly higher rate of a concurrent hiatal hernia repair (23 vs. 1.9 %, p?<?0.001). Overall postoperative minor complication rate was higher in the older group (25 vs. 4.8 %, p?<?0.001). This included atrial fibrillation (9.5 %), urinary tract infection (7 %), trocar site hernia (4 %), dysphagia, surgical site infection, bleeding, bowel obstruction, colitis, and nutritional deficiency (2 %, each). No perioperative mortality occurred. Comorbidity resolution or improvement was comparable between groups (88 vs. 80 %, p?=?0.13).

Conclusions

LSG is safe and very efficient in patients aged >60, despite higher rates of perioperative comorbidities.     

Clinical outcomes following secondary self-expandable metal stent (SEMS) insertion due to previous stent migration in malignant colorectal obstruction

Background

There has been no research on the clinical outcomes of secondary self-expandable metal stent (SEMS) placement after initial stent migration. Therefore, this study aimed to assess the clinical outcomes of secondary SEMS placement after initial stent migration compared to the outcomes of secondary SEMS placement done for reasons other than migration and identify factors predictive of long-term outcomes.

Methods

Between January 2005 and February 2011, a total of 422 patients underwent SEMS insertion for malignant colorectal obstruction at Severance Hospital. Of these, there were 98 cases of secondary SEMS placement, 38 of which were due to previous stent migration. We compared the clinical outcomes of secondary SEMS between stent migration and nonmigration groups. We also sought to identify risk factors for long-term outcomes of secondary SEMS after initial stent migration.

Results

The baseline clinical characteristics were similar between the two groups. The technical and clinical success rates of secondary SEMS insertion in the migration and nonmigration groups were 94.7 % and 83.3 % (p = 0.09) and 73.7 % and 53.3 % (p = 0.122), respectively. In the migration group, sustained clinical success after secondary SEMS was associated with the absence of complications after insertion of the first stent (p < 0.001) and a longer time interval (more than 100 days) between the first and second stent insertion (p = 0.011).

Conclusions

Our data showed that secondary colorectal SEMS after stent migration is safe and effective. Moreover, the sustained clinical success of the secondary stent following migration was dependent on the outcomes of the first stent.     

Endoscopic stenting for benign upper gastrointestinal strictures and leaks

Background

Self-expandable metal stents (SEMS) and self-expandable plastic stents (SEPS) maybe used for the treatment of benign upper gastrointestinal (GI) leaks and strictures. This study reviewed our experience with stent insertions in patients with benign upper GI conditions.

Methods

Patients who underwent stent placement for benign upper GI strictures and leaks between March 2007 and April 2011 at a tertiary referral academic center were studied using an endoscopic database and electronic patient records. The technical success, complications, and clinical improvement after stent removal were compared according to type of stent. The outcomes measured were clinical response, adverse events, and predictors of stent migration.

Results

Thirty-eight patients (50 % male, mean age = 54 years, range = 12–82) underwent 121 endoscopic procedures. Twenty patients had stents placed for strictures, and 18 had stents placed for leaks. Stent placement was technically successful in all patients. The average duration of stent placement was 54 days (range = 18–118). Clinical improvement immediately after stent placement was seen in 29 of the 38 patients (76.3 %). Immediate post-procedure adverse events occurred in 8 patients. Late adverse events were seen in 18 patients. Evidence of stent migration occurred in 16 patients and was seen in 42 of the 118 successfully placed stents (35.5 %). Migration was more frequent with fully covered SEMS (p = 0.002). After stent removal, 27 patients were evaluable for long-term success (median follow-up time of 283 days, IQR 38–762). Resolution of strictures or leaks was seen in 11 patients (40.7 %). Predictors for long-term success included increasing age and if the stent did not cross the GE junction.

Conclusions

Placement of SEPS and SEMS for benign refractory strictures and fistulas has modest long-term clinical efficacy and is limited by a significant migration rate. Stent migration is common and frequent with fully covered SEMS compared to other types of stents, regardless of indication or location.     

The value of multiple rapid swallows during preoperative esophageal manometry before laparoscopic antireflux surgery

Background

When multiple swallows are rapidly administered, esophageal peristalsis is inhibited, and pronounced lower esophageal sphincter relaxation ensues. After the last swallow of the series, a robust contraction sequence results. The authors hypothesize that multiple rapid swallows (MRS) may have value in predicting esophageal transit symptoms in patients undergoing laparoscopic antireflux surgery (LARS).

Methods

Records of patients undergoing esophageal high-resolution manometry (HRM) before LARS were evaluated. The evaluation of MRS included adequate inhibitory response during swallows and the contraction pattern after MRS. Dysphagia was scored based on a product of symptom frequency and severity using 5-point Likert scales. A composite dysphagia score comprised the sum of scores for solid and liquid dysphagia, and a score of 4 or higher was considered clinically significant. The normal and abnormal MRS responses of patients with preoperative, early, and late postoperative dysphagia were compared with those of patients with no dysphagia.

Results

In this study, 63 patients (mean age, 60.3?±?1.7?years, 48 women) undergoing HRM before LARS successfully performed MRS (median, 5 swallows; longest interval between swallows, 3.2?±?0.1?s). After MRS, 14 patients (22.2?%) had an intact peristaltic sequence. Complete failure of peristalsis was seen in 21 (33.3?%), and incomplete esophageal inhibition in 25 (39.7?%) of the remaining patients. When stratified by presence or absence of dysphagia, 58.3?% of the subjects without dysphagia had a normal MRS response, whereas 83.3?% had formation of peristaltic segments after MRS. In contrast, only 14?% of the subjects with dysphagia had a normal MRS response (p????0.003 vs. the subjects with no dysphagia). Abnormal MRS responses were more prevalent in the patients with any preoperative and late postoperative dysphagia (p?=?0.04 across groups) and in those with clinically significant dysphagia (p?=?0.08 across groups).

Conclusions

High-resolution manometry with MRS helps to predict dysphagia in subjects undergoing preoperative esophageal function testing before LARS.