Feasibility and safety of self-expandable metal stent in nonmalignant disease of the lower gastrointestinal tract

In recent years, self-expandable metal stents (SEMSs) have been employed to treat benign gastrointestinal strictures secondary to several conditions: Acute diverticulitis, radiation colitis, inflammatory bowel disease (IBD), and postanastomotic leakages and stenosis. Other applications include endometriosis and fistulas of the lower gastrointestinal tract. Although it may be technically feasible to proceed to stenting in the aforementioned benign diseases of the lower gastrointestinal tract, the outcome has been reported to be poor. In fact, in some settings (such as complicated diverticulitis and postsurgical anastomotic strictures), stenting seems to have a limited evidence-based benefit as a bridge to surgery, while in other settings (such as endometriosis, IBD, radiation colitis, etc.), even society guidelines are not able to guide the endoscopist through decisional algorithms for SEMS placement. The aim of this narrative paper is to review the scientific evidence regarding the use of SEMSs in nonmalignant diseases of the lower gastrointestinal tract, both in adult and pediatric settings.     

Endoscopic treatment of benign esophageal strictures: a literature review

Introduction: Benign esophageal strictures arise from various etiologies and are frequently encountered. Although endoscopic dilation is still the first-line therapy, recurrent strictures do occur in approximately 10% of the cases and remains a challenge to gastroenterologists.

Areas covered: A literature search was performed using PubMed and Google Scholar databases for original and review articles on endoscopic treatment of benign esophageal strictures. This review outlines the main available treatment options and its controversies in the management of refractory benign esophageal strictures.

Expert commentary: Adding local steroid injections to dilation can be effective for peptic stenosis and strictures after endoscopic submucosal dissection, but remains uncertain for anastomotic strictures. Intralesional injections of mitomycin-C could be useful in corrosive strictures. Incisional therapy can be a reliable alternative in Schatzki rings and in anastomotic strictures, in experienced hands. By contrast, long-term outcome with endoprosthetic treatment is disappointing, and stent placement should be carefully considered and individualized.     

Resolution of an esophageal leak and posterior gastric wall necrosis with esophageal self-expandable metal stents

The use of weight reduction surgeries has increased over the years with a higher proportion of these surgeries being sleeve gastrectomies,this has been associated with some complications including staple line leaks.We report a 32-year-old male who had undergone a laparoscopic gastric band surgery and subsequently a laparoscopic sleeve gastrectomy,this was complicated by both an staple line leak at the gastroesophageal junction as well as a large(> 4 cm) posterior gastric wall defect due to gastric wall necrosis. We used two co-axially inserted self-expandable stents(SEMS) in the management of this patient,5 stents were used over repeated endoscopy sessions and 20 wk. Both defects had resolved without the need for surgical intervention.This is the first reported case were SEMS are used for both a staple line leak as well as a gastric wall defect.We also review the literature on the use of SEMS in the management of leaks post weight reduction surgeries.     

Regulating migration of esophageal stents-management using a Sengstaken-Blakemore tube:A case report and review of literature

Stent migration, which causes issues in stent therapy for esophageal perforations, can counteract the therapeutic effects and lead to complications. Therefore, techniques to regulate stent migration are important and lead to effective stent therapy. Here, in these cases, we placed a removable fully covered self-expandable metallic stent(FSEMS) in a 52-year-old man with suture failure after surgery to treat Boerhaave syndrome, and in a 53-yearold man with a perforation in the lower esophagus due to acute esophageal necrosis. At the same time, we nasally inserted a Sengstaken-Blakemore tube(SBT), passing it through the stent lumen. By inflating a gastric balloon, the lower end of the stent was supported. When the stent migration was confirmed, the gastric balloon was lifted slightly toward the oral side to correct the stent migration. In this manner, the therapy was completed for these two patients. Using a FSEMS and SBT is a therapeutic method for correcting stent migration and regulating the complete migration of the stent into the stomach without the patient undergoing endoscopic rearrangement of the stent. It was effective for positioning a stent crossing the esophagogastric junction.     

全覆膜金属支架治疗良性胆道狭窄的初步研究

目的探讨全覆膜胆道金属支架治疗良性胆道狭窄的安全性及其疗效。方法36例良性胆道狭窄患者行全覆膜胆道金属支架置入术治疗,术后每1～2个月接受1次门诊随访,观察并发症发生及胆道狭窄改变情况。结果36例均一次性成功置入全覆膜胆道金属支架,未出现与操作相关的严重并发症,支架放置3～6个月后全部成功拔除,其中28例（77．8％）良性胆道狭窄消失。结论置入全覆膜胆道金属支架治疗良性胆道狭窄是安全的,近期疗效显著。     

高位食管狭窄覆膜食管支架个体化治疗的疗效评估

目的 探讨覆膜食管支架治疗高位食管狭窄的疗效及安全性.方法 对43例高位食管癌性狭窄患者行覆膜食管支架个体化治疗,统计疗效及不良反应发生情况等.结果 43例均成功置入支架,共行45例次支架置入术,其中43例次(95.6％,43/45)一次性置入成功.吞咽困难评分由术前的(3.3±0.6)分改善至术后的(1.8±0.9)分(P＜0.001),其中显效18例次、好转25例次,吞咽困难缓解率为95.6％ (43/45).9例合并食管瘘患者中7例(77.8％,7/9)成功封堵瘘口.发生早期不良反应16例次,包括术后疼痛5例次、气肿1例次、中等度发热9例次和支架上口变形1例次;发生晚期不良反应9例次,包括支架移位3例次和支架上口再狭窄6例次.结论 可回收覆膜食管支架个体化治疗高位食管狭窄是安全和有效的,对于封堵食管瘘口亦有较好的临床效果.     

Endoscopic incisional therapy for benign esophageal strictures: Technique and results

Benign esophageal strictures refractory to the conventional balloon or bougie dilatation may be subjected to various adjunctive modes of therapy, one of them being endoscopic incisional therapy (EIT). A proper delineation of the stricture anatomy is a prerequisite. A host of electrocautery and mechanical devices may be used, the most common being the use of needle knife, either standard or insulated tip. The technique entails radial incision and cutting off of the stenotic rim. Adjunctive therapies, to prevent re-stenosis, such as balloon dilatation, oral or intralesional steroids or argon plasma coagulation can be used. The common strictures where EIT has been successfully used are Schatzki’s rings (SR) and anastomotic strictures (AS). Short segment strictures (< 1 cm) have been found to have the best outcome. When compared with routine balloon dilatation, EIT has equivalent results in treatment naïve cases but better long term outcome in refractory cases. Anecdotal reports of its use in other types of strictures have been noted. Post procedure complications of EIT are mild and comparable to dilatation therapy. As of the current evidence, incisional therapy can be used for management of refractory AS and SR with relatively short stenosis (< 1 cm) with good safety profile and acceptable long term patency.     

Clinical outcome of self-expandable metal stent placement in the management of malignant proximal colon obstruction

Background/Aims

There are limited data regarding the clinical outcomes of self-expandable metal stents in the treatment of proximal colon obstruction. We compared the clinical outcomes of stent placement in patients with malignant proximal to distal colon obstructions.

Methods

We reviewed medical records from 37 consecutive patients from three institutions (19 men; mean age, 72 years) who underwent endoscopic stent placement at a malignant obstruction of the proximal colon. We also examined the records from 99 patients (50 men; mean age, 65 years) who underwent endoscopic stent placement for a distal colon obstruction. Technical success, clinical improvements, complications and stent patency were compared between treatments.

Results

The technical success rate tended to be lower in stents inserted to treat proximal colon obstructions than in those used to treat distal colon obstructions (86% vs 97%, p=0.06). Clinical improvement was achieved in 78% of patients (29/37) with proximal colonic stenting and in 91% of patients (90/99) with distal colonic stenting (p=0.08). Complications (24% vs 27%), stent migration (8% vs 8%) and stent reocclusion rates (11% vs 17%) did not differ significantly between groups. Two cases of bowel perforation related to stenting (5%) occurred in patients with proximal colonic stenting.

Conclusions

The technical success and clinical improvement associated with self-expandable metal stents used to treat proximal colon obstruction tend to be lower than cases of distal colon obstruction. Technical failure is an important cause of poor clinical improvement in patients with proximal colon stenting. Complication rates and stent patency appear to be similar in both groups.     

内镜下覆膜食管支架治疗食管癌性狭窄及食管气管瘘的临床应用价值

目的探讨内镜下覆膜食管支架治疗食管癌性狭窄及食管气管瘘的临床价值及食管支架置入术并发症的防治。方法回顾性分析163例晚期食管癌患者内镜下覆膜食管支架治疗食管癌性狭窄及食管气管瘘的临床资料,其中7例患者为食管癌性狭窄并食管-支气管瘘伴双下肺感染,19例患者为食管癌术后复发吻合口狭窄置入镍钛记忆合金覆膜支架。102例患者由于食管过于狭窄先行食管扩张,再进行内镜下放置食管支架,35例患者直接内镜下置入食管支架。结果 163例患者先后放置174个支架,均一次性置入成功,成功率为100%。163例患者均有不同程度胸痛不适,有32例支架再狭窄,其中19例单纯行支架内球囊扩张,11例于原支架上端内部分重叠再放置一支架,有26例行氩气刀再通治疗。7例患者出现支架移位,有2例支架进入食管瘘管内于次日在内镜下取出支架重新放置。所有病例均未出现食管破裂、食管血肿或出血等严重并发症,术后患者进食能力提高,食管气管瘘闭合。结论内镜下覆膜食管支架置入术是中晚期食管癌性狭窄简单、安全、有效的姑息治疗方法,能提高患者的生活质量,延长患者的生存期。     

Quality of life in patients with esophageal stenting for the palliation of malignant dysphagia

Incidence of esophageal cancer(EC) is rising more rapidly in the Western world than that of any other cancer. Despite advances in therapy,more than 50% of patients have incurable disease at the time of presentation.This precludes curative treatment and makes palliative treatment a more realistic option for most of these patients. Dysphagia is the predominant symptom in more than 70% of patients with EC and although several management options have been developed in recent years to palliate this symptom,the o...     

A 17 years retrospective study on multiple metal stents for complex malignant hilar biliary strictures: Survival,stents patency and outcomes of re-interventions for occluded metal stents

BackgroundEndoscopic placement of SEMSs for malignant hilar biliary strictures (MHBS) is well-established palliative treatment for inoperable patients. Objectives of this study were evaluation of survival and stents patency after placement of multiple SEMS for palliation of complex MHBS.MethodsRetrospective review of patients with MHBS that underwent ERCP with insertion of multiple SEMSs for palliation. Survival-associated factors and stents patency were analyzed by Cox multivariate analysis.ResultsBetween January 1998 and January 2015, 740 patients with nonoperable MHBS that underwent ERCP were identified and only 18.2% of these received multiple SEMSs. Complications were observed in 7.5% of the patients with no procedure-related mortality. Palliative therapies (chemotherapy, external beam radiotherapy and high dose rate brachytherapy) were done in some patients, and outcomes were evaluated. Overall mean survival of the 134 patients was 323 days. Of these, 59% did not had stents malfunction while 41% patients had episodes of SEMSs malfunction and mean survival after re-interventions was 502.9 days. Survival was not influenced by type of tumor, sex or age.ConclusionsEndoscopic multiple SEMSs placement is safe and effective in patients with complex MHBS. Survival is independent from the type and complexity of MHBS while is prolonged in patients undergoing HDR brachytherapy. Prompt recognition of SEMSs malfunction is fundamental for survival.     

predictors for failure of stent treatment for benign esophageal perforations- a single center 10-year experience

AIM:To investigate possible predictors for failed selfexpandable metallic stent(SEMS)therapy in consecutive patients with benign esophageal perforationrupture(EPR).METHODS:All patients between 2003-2013 treated for EPR at the Karolinska University Hospital,a tertiary referral center,were studied with regard to initial management with SEMS.Patients with malignancy as an underlying cause and those with anastomotic leakages were excluded.Sealing of the perforation with a covered SEMS was the primary strategy whenever feasible.Stent therapy failure was defined as a radical change of treatment strategy due to uncontrolled mediastinitis,which in this setting consisted of emergency esophagectomy with end-esophagostomy or death as a consequence of the perforation and subsequent uncontrolled sepsis.Patient and lesion characteristics were analyzed and are presented as median and interquartile range.Possible predictors for failed stent therapy were analyzed with uni-variate logistic regression,while variables with P<0.2 were further analyzed with multi-variate logistic regression.RESULTS:Of the total number of 48 patients presenting with EPR,40 patients(83.3%)were treated with SEMS at the time of admission,with an intention to heal the perforation.Twenty-three patients had Boerhaave’s syndrome(58%),16 had an iatrogenic perforation(40%)and 1 had external trauma to the esophagus(3%).The total in-hospital mortality,including the cases that had other initial treatments(n=8),was10.4%and 7.5%among those who were subjected to the SEMS-based strategy.In 33 of the 40 patients(82.5%)who were treated with stent,the EPR healed without further change in treatment strategy.Patients classified as treatment success received a SEMS at a median time of 1(1-1)d after the actual EPR,compared to 3(1-10)d among those where the initial treatment failed,P=0.039 in uni-variate analysis and P=0.052 in multi-variate analysis.No other significant factors emerged,indicating an increased risk for failure.Six of 7 patients,where stent treatment of the defect failed,underwent an emergency esophagectomy with end esophagostomy and one patient died.CONCLUSION:SEMS as an upfront therapeutic strategy seems to be a successful concept,when applied to an unselected group of patients with EPR.     

Current treatment and outcome of esophageal perforation: A single-center experience and a pooled analysis

Background:Esophageal perforation has been one of the serious clinical emergencies, because of the high mortality and complication rates. However, the current prognosis of esophageal perforation and the outcomes of available treatment methods are not well defined. This study attempted to pool the immediate outcomes of esophageal perforation in the past 2 decades.Methods:The clinical data of 22 consecutive adult patients with esophageal perforation in our center were analyzed. A pooled analysis was also conducted to summarize results from the literatures published between 1999 and 2020. Studies that met the inclusion criteria were assessed, and their methodological quality was examined.Results:The mortality and complication rates in our center were 4.55% and 31.82%, separately. The pooled analysis included 45 studies published between 1999 and 2019, which highlighted an overall immediate mortality rate of 9.86%. Surgical treatments were associated with a pooled immediate mortality of 10.01%, and for conservative treatments of 6.49%. Besides, in the past decade, the mortality and complication rates decreased by 27.12% and 46.75%, respectively.Conclusions:In the past 2 decades, the overall immediate mortality rate of esophageal perforation was about 10% in the worldwide, and the outcomes of esophageal perforation treatment are getting better in the last 10 years.Ethics Registration Information:LW2020011.     

Economical effect of lumen apposing metal stents for treating benign foregut strictures

AIM To evaluate the clinical and economical efficacy of lumen apposing metal stent(LAMS) in the treatment of benign foregut strictures.METHODS A single center retrospective database of patients who underwent endoscopic treatment of benign foregut strictures between January 2014 and May 2017 was analyzed. A control group of non-stented patients who underwent three endoscopic dilations was compared to patients who underwent LAMS placement. Statistical tests performed included independent t-tests and fiveparameter regression analysis RESULTS Nine hundred and ninety-eight foregut endoscopic dilations were performed between January 2014 and May 2017. 15 patients underwent endoscopic LAMS placement for treatment of benign foregut stricture. Thirty-six patients with recurrent benign foregut strictures underwent three or more endoscopic dilations without stent placement. The cost ratio of endoscopic dilation to LAMS(stent, placement and retrieval) is 5.77. Cost effective analysis demonstrated LAMS to be economical after three endoscopic dilation overall.LAMS was cost effective after two dilations in the Postsurgical stricture subgroup. CONCLUSION Endoscopists should consider LAMS for the treatment of benign foregut strictures if symptoms persist past three endoscopic dilations. Post-surgical strictures may benefit from LAMS if symptoms persist after two dilations in a post-surgical. Early intervention with LAMS appears to be a clinically and economically viable option for durable symptomatic relief in patients with these strictures.     

Fully covered self-expanding metallic stent placement or three-tube method for esophagomediastinal fistula: A STROBE-compliant article

To determine the safety, feasibility and clinical outcomes of interventional methods for the management of esophagomediastinal fistula, and to investigate the effect of stent placement on fistula healing and the swallowing. Sixty consecutive patients with esophagomediastinal fistula were treated using interventional method and were retrospectively assessed. Patients received 3-tube but without covered stent placement were placed in group A, the remaining patients received covered stent placement with/without 3-tube method were placed in group B. Tubes and stents would be removed once fistula heals. Interventional procedures were technically successful all patients (100%). Esophageal stents and abscess drainage tubes were successfully removed from 14 patients. Three patients underwent stent removal during the perioperative period, resulting in a clinical success rate of 88.5% of 26 patients in group B. A total of 13 complications were found in all patients, including 5 major complications. Patients in group B showed a higher healing rate of abscess cavity and better dysphagia score than group A. During follow up, 17 patients in group A and 11 patients in group B were still alive. Interventional treatment is safe, feasible and efficacious for esophagomediastinal fistula; covered stent placement can promote fistula healing and improve swallowing.     

经不同途径置入覆膜支架封堵气管瘘的临床分析

目的探讨经气管或食管置入覆膜支架封堵气管瘘的疗效。方法13例气管瘘患者,男9例,女4例,年龄55～83岁,平均60．3岁,其中食管癌性狭窄伴气管瘘8例,食管癌术后胃吻合口伴气管瘘3例,食管癌术后胸腔胃气管隆突瘘1例,肺癌术后左主支气管残端胸膜瘘1例。根据原发病变的性质、狭窄范围、瘘口部位的不同,在数字减影血管造影（DSA）监视下经食管或气管途径置入个体化设计覆膜支架封堵瘘口。结果10例经食管置入覆膜支架10枚,其中管状覆膜支架8枚,下端大喇叭口覆膜支架2枚;3例经气管置入覆膜支架4枚,其中管状覆膜支架2枚,倒“Y”型覆膜支架1枚,“子弹头”残端瘘支架1枚。所有患者呛咳、呼吸困难和憋喘等症状迅速缓解,碘水造影显示瘘口封堵完全,CT检查显示支架贴壁良好。结论经气管或食管置入个体化覆膜支架治疗气管瘘,能迅速封堵瘘口和解除临床症状,简单、安全,值得推广。