Use of endoscopic stents to treat anastomotic complications after bariatric surgery

BACKGROUND: Complications after bariatric surgery often require longterm parenteral nutrition to achieve healing. Recently, endoscopic treatments have become available that provide healing while allowing for oral nutrition. The purpose of this study was to present outcomes of the largest series to date treating staple line complications after bariatric surgery with endoscopic covered stents. STUDY DESIGN: A retrospective evaluation was performed of all patients treated for staple line complications after bariatric surgery at a single tertiary care bariatric center. Acute postoperative leaks, chronic gastrocutaneous fistulas, and anastomotic strictures refractory to endoscopic dilation after both gastric bypass and sleeve gastrectomy were included. RESULTS: From January 2006 to June 2007, 19 patients (11 with acute leaks, 2 with chronic fistulas, and 6 with strictures) were treated with a total of 34 endoscopic silicone covered stents (23 polyester, 11 metal). Mean followup was 3.6 months. Immediate symptomatic improvement occurred in 90% (91% of acute leaks, 100% of fistulas, and 84% of strictures). Oral feeding was started in 79% of patients immediately after stenting. Resolution of leak or stricture after stent treatment occurred in 16 of 19 patients (84%). Healing of leak, fistula, and stricture occurred at means of 33 days, 46 days, and 7 days, respectively. Three patients (1 with leak, 1 with fistula, and 1 with stricture) had unsuccessful stent treatment. Migration of the stent occurred in 58% of 34 stents placed. Most migration was minimal, but three stents were removed surgically after distal small bowel migration. There was no mortality. CONCLUSIONS: Treatment of anastomotic complications after bariatric surgery with endoscopic covered stents allows rapid healing while simultaneously allowing for oral nutrition. The primary morbidity is stent migration.     

Stent implantation as a treatment option in patients with thoracic anastomotic leaks after esophagectomy

Background In patients with esophagectomy and gastric pull up for esophageal carcinoma anastomotic leaks are a well-known complication and a major cause of morbidity and mortality. Objective We evaluated stent implantation as a treatment option in patients with thoracic anastomotic leaks after esophagectomy. Methods 269 patients with esophageal cancer (adenocarcinoma n = 212, squamous cell carcinoma n = 57) had undergone esophagectomy and gastric pull up with an intrathoracic anastomosis between January 1998 and December 2005. A thoracic anastomotic leak was clinically and endoscopically proven in 12 patients (4.5%). Endoscopic insertion of a self-expanding covered metal stent at the site of the anastomotic leak was performed in 10 patients; two patients were treated with fibrin glue. Results Stents were successfully placed in all patients without complications. In all but one patient (n = 9) radiological examination showed complete closure of the leakage. In one patient the stent was endoscopically corrected and complete closure could be achieved thereafter. The stent could be removed after six weeks in five patients. Stent migration occurred in four patients. In all but one patient (n = 7) definitive leak occlusion was achieved. Two patients died during their hospital stayfor reasons not related to the stent placement. Conclusion Stent implantation in patients with thoracic anastomotic leaks after esophagectomy is an easily available and effective treatment option with low morbidity, but stent migration does occur.     

Polyflex self-expanding,removable plastic stents: assessment of treatment efficacy and safety in a variety of benign and malignant conditions of the esophagus

Background Historically, esophageal fistulas, perforations, and benign and malignant strictures have been managed surgically or with the placement of permanent endoprostheses or metallic stents. Recently, a removable, self-expanding, plastic stent has become available. The authors investigated the use of this new stent at their institution. Methods The study reviewed all the patients who received a Polyflex stent for an esophageal indication at the authors’ institution between January 2004 and October 2006. Duration of placement, complications, and treatment efficacy were recorded. Results A total of 37 stents were placed in 30 patients (14 women and 16 men) with a mean age of 68 years (range, 28–92 years). Stent placement included 7 for fistulas, 3 for perforations, 1 for an anastomotic leak, 7 for malignant strictures, and 19 for benign strictures (8 anastomotic, 1 caustic, 5 reflux, 2 radiation, and 2 autoimmune esophagitis strictures, and 1 post-Nissen gas bloat stricture). The mean follow-up period was 6 months. Stent deployment was successful for all the patients, and no complications resulted from stent placement or removal. Nine stents migrated spontaneously. Three of three perforations and three of five fistulas sealed. Only one stent was removed because of patient discomfort. One patient with a radiation stricture experienced tracheoesophageal fistulas secondary to pressure necrosis. Of 20 patients with stricture, 18 experienced improvement in their dysphagia. Conclusion Self-expanding, removable plastic stents are easily and safely placed and removed from the esophagus. This has facilitated their use in the authors’ institution for an increasing number of esophageal conditions. Further studies to help define their ultimate role in benign and malignant esophageal pathology are warranted.     

Collagen matrix staple line reinforcement in gastric bypass

BackgroundStaple line leaks and bleeding, anastomotic strictures, and marginal ulcers are significant complications of Roux-en-Y gastric bypass (RYGB) for morbid obesity. Reinforcing the staple lines with bovine collagen matrix reinforcement (CMR) might safely decrease the incidence of leaks and bleeding without causing other complications. Our objective was to determine the effect in RYGB of reinforcing the linear and circular gastric staple lines with CMR on the outcomes including abdominal septic events, blood transfusions, and the incidence of stricture and marginal ulceration of the gastrojejunostomy in a private bariatric surgery practice at 2 Surgical Review Committee Center of Excellence community hospitals.MethodsWe performed a retrospective review of prospectively collected data comparing consecutive outcomes of 505 patients undergoing RYGB without CMR from 2005 to 2006 to 568 patients with CMR of the linear and circular gastric staple lines from 2007 to 2009.ResultsThe application of CMR was associated with a significant reduction from 4% to 1% in the incidence of abdominal septic events, including frank staple line leakage, purulent drainage, and abscess. The number of patients needing transfusion showed a trend downward. The frequency of stricture (1%) and marginal ulceration (2%) was unchanged. No gastrogastric fistulas were identified in either group. No evidence of migration of collagen matrix material appeared after CMR. The 90-day mortality rate for each group was .2% and was unrelated to staple line complications.ConclusionThe use of CMR was associated with a significant reduction in the incidence of abdominal septic complications and a trend toward fewer patients needing transfusion. The frequency of stricture and marginal ulceration was unchanged by the use of CMR.     

Treatment of Gastric Leaks with Coated Self-Expanding Stents after Sleeve Gastrectomy

Background Duodenal switch (DS) is one of the most effective techniques for the treatment of morbid obesity and its co-morbidities, with mortality rate <1%, but with 9.4% morbidity rates (6.5% due to leaks). In our experience, leaks of the staple-line after sleeve gastrectomy (SG) are the most frequent sites of fistula formation and conservative treatment usually takes a long time.We present our experience in the treatment of gastric leaks with coated self-expandable stents (CSES). Methods 6 patients had gastric leaks at the gastroesophageal (GE) junction after SG or DS. One patient had a symptomatic gastro-bronchial fistula. Stents were placed by the interventional radiologist under fluoroscopic control and removed endoscopically. In one case, we used an uncoated Wallstent. In two patients, percutaneous microcoil embolization of the fistula was added. Results The patient treated with the Wallstent required a total gastrectomy 6 months after placement of the uncovered stent. In the other 5 patients, coated stents were successfully removed and the gastric leaks completely sealed. Conclusions CSES are proposed as an alternative therapeutic option for the management of GE junction leaks in bariatric surgery with good results in terms of morbidity and survival.     

The efficacy of self-expanding metal stents for palliation of malignant esophageal strictures and fistulas.

OBJECTIVES: Esophageal strictures and esophagorespiratory fistulas are complications of malignant esophageal tumors, which are difficult to manage. The efficacy of self-expanding metal stents (SEMS) for palliation of malignant esophageal strictures and fistulas was investigated prospectively. METHODS: Forty-three SEMS were inserted in 41 patients with malignant esophageal stricture or fistula. Our series included 32 men and nine women, of whom median age was 61.4 years. Twenty nine stents were inserted for stricture, ten for esophago-tracheal fistula, and four esophago-pleural fistula. Stents were inserted endoscopically under fluoroscopic control. RESULTS: SEMS implantation was technically successful in 40 of 41 patients. A second stenting was needed in two patients. Median dysphagia score improved from 3.4 to 1.3. The covered SEMS was succesful in completely sealing 85.7% of the fistulas. Complication occurred in 11 (26.8%) patients. Especially in the case of tumor stenoses in the distal esophagus, complication rate was higher (44%). In total six patients (14.6%) died after stent placement during early postoperative period. Procedure-related mortality was 4.8% (2/41). CONCLUSIONS: We conclude that treatment of malignant esophageal obstructions, including esophagorespiratory fistulas, with SEMS is an alternative palliative procedure. Furthermore SEMS implantation seems more safe in the case of tumor stenoses locating in the middle esophagus.     

Clinical results using bioabsorbable staple line reinforcement for circular staplers

Although linear surgical staple line reinforcement has been shown to increase anastomotic tensile strength in animal models and reduce the incidence of staple line bleeding and anastomotic leaks in colorectal surgery, the benefits of staple line reinforcement on circular stapled anastomoses in bariatric surgery remain unreported in the literature. The purpose if this study was to compare the incidence of anastomotic bleeding, leak, and stricture in patients undergoing laparoscopic gastric bypass with circular staple line reinforcements with those with no circular staple line reinforcements. Since May 2006, 138 consecutive patients (Group B) have undergone laparoscopic Roux-en-Y divided gastric bypass with a 25-mm circular stapled gastrojejunal anastomosis using GORE SEAMGUARD bioabsorbable circular staple line reinforcement (CBSG) with a mean follow up of 9 months. The incidence of anastomotic bleeding, leak, and stricture was compared with 255 similar patients (Group A) who underwent surgery before May 2006 without gastrojejunal reinforcement with a mean follow up of 22 months. The rates of anastomotic bleeding, leak, and stricture for Group B versus Group A were 0.7 per cent versus 1.1 per cent (P = 0.64); 0.7 per cent versus 1.9 per cent (P = 0.34); and 0.7 per cent versus 9.3 per cent (P = 0.0005), respectively. The use of CBSG reduced the incidence of anastomotic stricture by 93 per cent and the incidence of a composite end point of all anastomotic complications by 85 per cent. Our results indicate that the use of circular staple line reinforcement at the gastrojejunal anastomosis in patients undergoing laparoscopic gastric bypass significantly decreases the incidence of anastomotic stricture and a composite end point of all anastomotic complications. On this basis, strong consideration should be given to the routine use of CBSG staple line reinforcement in patients undergoing laparoscopic divided gastric bypass with a circular stapled gastrojejunal anastomosis.     

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.     

Anastomotic leaks after bariatric surgery: it is the host response that matters

BACKGROUND: Anastomotic leaks after bariatric surgery can lead to severe complications and adverse outcomes. We tested the hypothesis that not all patients with an anastomotic leak after bariatric surgery present with clinical symptoms and that their outcome is dependent on the aggressiveness of the host inflammatory response. METHODS: This was a retrospective analysis of prospectively collected clinical data from 2384 bariatric surgeries from 1983 to 2006. All anastomotic leaks were identified from the database, and the vital signs, hematologic and biochemical data, mode of diagnosis, treatment, and outcome were recorded and analyzed. RESULTS: We identified 55 anastomotic leaks (2.3%) at a median of 4 days (range 1-26) after surgery. In 37 patients (67.3%), the leaks were identified at a median of 5 days (range 1-26) postoperatively because of clinical signs and symptoms of a systemic inflammatory response (SIRS leaks). In contrast, in 18 patients (32.7%), the leaks were identified at a median of 1.5 days (range 1-16) postoperatively only after routine contrast studies (non-SIRS leaks). Treatment included antibiotics and open drainage in 41.8%, laparoscopic drainage in 21.8%, computed tomography-guided drainage in 12.7%, conservative treatment in 14.5%, and other in 9.2%. All 6 deaths (4 men and 2 women, 10.9%) occurred in the SIRS group. Using logistic regression analysis, temperature (inflammatory response) and body mass index were independent predictors of mortality. CONCLUSION: The results of our study have shown that one third of patients with anastomotic leaks after bariatric surgery present with minimal clinical symptoms (non-SIRS) and are only detected if contrast studies are performed. Such leaks are unlikely to lead to death. Two thirds of patients with anastomotic leaks present with a systemic inflammatory response to the leak. Such leaks require urgent treatment that might not always prevent death.     

Use of Polyflex stents in treatment of acute esophageal and gastric leaks after bariatric surgery.

BACKGROUND: This study examined the feasibility of using Polyflex stents in the treatment of enteric leaks after various bariatric operations. Chronic and acute leaks were treated. METHODS: We performed a retrospective case series review. Four patients received 6 Polyflex stents to treat complications of bariatric surgery. Two presented with early sepsis before stenting. One presented with abdominal pain. One presented with a chronic persistent fistula with an associated abscess. Stenting was performed under endoscopy with fluoroscopic guidance. The stents were left in place for 6 weeks. RESULTS: All patients tolerated a clear liquid diet within 24 hours of stenting and were able to be advanced to a pureed diet. All patients improved clinically after stenting. Three patients with acute leaks sealed their leaks after stent placement. One patient with a chronic leak persisted and required operative closure after a second stent was placed and failed. All patients experienced short-term nausea, as well as early satiety that lasted the duration of the stenting. One patient experienced hypersialisis while the stent was in place. Two stents migrated, although this had no effect on leak closure. One patient had an anastomotic stenosis successfully treated with a second stent. CONCLUSIONS: Polyflex stents are useful in bypassing acute upper intestinal leaks after various bariatric operations. They provide a temporary bridge for wound healing with continued oral intake. Stenting provides a minimally invasive option in the management of acute leaks and, in our experience, had no serious associated morbidity.     

Use of self-expandable metal stents for the treatment of esophageal perforations and anastomotic leaks

Background  Esophageal perforations and extensive anastomotic leaks after esophageal resection or gastrectomy are surgical emergencies with high mortality rates. In recent years, the use of self-expanding metallic stents (SEMS) has emerged as a promising treatment alternative for bridging and sealing the damage. This study aimed to evaluate the role of covered SEMS for the management of esophageal perforations and anastomotic leaks. Methods  All esophageal stent placement procedures (174 procedures for 157 patients) at the authors’ unit between January 1999 and April 2008 were assessed by a retrospective chart review. Of the 157 patients, 10 (6.4%) were treated with SEMS for sealing of an iatrogenic esophageal perforation (n = 4), a spontaneous esophageal rupture in Boerhaave’s syndrome (n = 4), or an anastomotic leakage (n = 2). Results  The median time from perforation or anastomotic leak to stent insertion was 13 days (range, 2 h to 48 days). The esophageal leak was totally sealed for 8 (80%) of 10 patients. The overall mortality rate was 50% (n = 5), and three (30%) of the five deaths were related to the perforation (n = 2) or leakage (n = 1). In both of the perforation cases, the diagnosis and treatment were substantially delayed. One patient with an anastomotic leak after gastrectomy died of the complication despite successful operative and SEMS treatment. Two of the deaths were unrelated to the perforation. In both cases, the cause of death was a disseminated malignant disease. Conclusions  Traumatic perforations and anastomotic leaks can be treated effectively with covered SEMS together with adequate drainage of the thoracic cavity even in cases of severely ill patients with inveterate esophageal perforations and leaks.     

Successful management of gastrojejunal strictures after gastric bypass: is timing important?

BackgroundEndoscopic balloon dilation is an effective treatment of gastrojejunal (GJ) strictures after Roux-en-Y gastric bypass (RYGB), although its success might depend on the point at which they occur postoperatively. We hypothesized that “late” strictures (≥90 d after RYGB) might be less amenable to balloon dilations than “early” strictures occurring within 90 days postoperatively.MethodsA review of a prospectively maintained database at a bariatric center was conducted to identify all patients who underwent upper endoscopy (UE) for investigation of gastrointestinal symptoms after RYGB. Those who were diagnosed with a GJ anastomotic stricture at endoscopy were selected for additional evaluation. The patients were classified into 1 of 3 groups, according to the point at which they presented with stricture symptoms (group 1, 0–90 d after RYGB; group 2, 91–365 d after RYGB; and group 3, >1 yr after RYGB). All strictures were dilated using through-the-scope controlled radial expansion balloons.ResultsFrom July 2006 to July 2009, 929 RYGB procedures were performed in our bariatric unit. Our surgical endoscopy team performs approximately 1500 UE investigations annually. Most investigations were for preoperative assessment of bariatric patients; however, a proportion is indicated for the investigation of postoperative weight regain and complications of foregut surgery, as well as endoluminal surgery. In the present study period, 591 gastric bypass patients underwent UE for investigation of gastrointestinal symptoms postoperatively. In total, 72 patients were diagnosed with a symptomatic GJ anastomotic stricture and underwent balloon dilation. Almost two thirds (63.9%) of the dilations were performed within 90 days after RYGB; 98% of these “early” strictures resolved with dilation. In comparison, of the “late” strictures, only 61% (16 of 26 patients) resolved and 38.5% (n = 10) required revisional surgery for additional management.ConclusionEndoscopic balloon dilation is effective in treating early GJ strictures after RYGB. Late strictures are less amenable to endoscopic dilation and often require revisional surgery. Patients presenting with upper gastrointestinal symptoms after RYGB warrant early investigation with UE to investigate for a GJ stricture, which if present, should be promptly dilated.     

进展期胃癌全胃切除"围巾式"食管-空肠吻合术(附121例报告)

目的 介绍“围巾式”食管-空肠吻合术预防术后吻合口瘘的临床经验。方法 分析1997年1月至2005年12月连续121例进展期胃癌全胃切除“围巾式”食管-空肠吻合术的临床结果。结果 手术死亡率1．65％（2／121）。存活的119例中，术后均未发生吻合口瘘和反流性食管炎。2000年12月以前，有4例（3．36％）术后发生吻合口狭窄，经胃镜下扩张治愈；改进技术后再无吻合口狭窄发生。结论 “围巾式”食管-空肠吻合术可减少进展期胃癌全胃切除术后吻合口并发症，安全、有效。     

Self-expanding Polyflex plastic stents in esophageal disease: various indications,complications, and outcomes

Background Esophageal stenting has become an important technique in the treatment of different clincal problems such as malignant or benign stenosis, anastomotic leaks after surgery, or fistulas. In this study we present our experience with the self-expanding Polyflex plastic stent in various indications, arising complications, and patient’s outcomes. Methods Over a three-year period, 35 patients underwent self-expanding Polyflex plastic stent placement for esophageal stenosis (n = 23) with 22 malignant, and for perforations, fistulas, or anastomotic leaks after surgery (n = 12). The short-term efficacy and long-term outcomes were analyzed. Results In patients with stenosis, implantation was performed without any complications in 91% (21/23). In one patient perforation occurred while passing the stenosis; in another patient the stent dislocated during the insertion procedure. Dysphagia score improved from 3.0 to 1.0 after stenting. In all patients with perforations, fistulas, or anastomotic leaks (n = 12), stents were placed successfully without any complication. Complete sealing of the mucosal defect was proven by radiography in 92% (n = 11) and healing was seen in 42% (n = 5). If indicated, stent removal was performed without any complications. Stent migration (n = 13; 37%) was the most common long-term complication. Conclusions The placement of self-expanding Polyflex plastic stents is a highly sufficient and cost-effective treatment for malignant and benign esophageal disorders. Because the long-term results were highly favorable, self-expanding plastic stent placement could be used as the initial treatment for various conditions.     

Treatment of gastric leaks after Roux-en-Y gastric bypass: a paradigm shift

BackgroundDuring the past decade, nonoperative treatment of leaks after bariatric surgery has been deemed acceptable in selected patients. The setting of our study was 2 university affiliated hospitals.MethodsWe reviewed gastric leaks in 1069 consecutive bariatric operations that were performed by 1 surgeon during the past 8 years, including 836 primary laparoscopic Roux-en-Y gastric bypass (RYGB), 114 primary open RYGBs, and 119 revisional procedures. Drains were used routinely in the laparoscopic and revision groups and selectively in the open group. Perforations and jejunojejunostomy leaks were excluded.ResultsThere were no leaks after open RYGB, 8 leaks (.95%) after laparoscopic RYGB, and 5 leaks (4.2%) after the revisional procedures. Of the 13 leaks, 7 occurred at the gastrojejunostomy, 6 at the staple line of the upper pouch, and none in the excluded stomach. Of the 8 postlaparoscopic RYGB leaks, 3 required reoperation versus 2 of 5 postrevision leaks. There were no perioperative deaths. All but 2 patients in the nonoperative group were treated with endoscopic injection of fibrin sealant (EIFS). Of the 4 leaks in the laparoscopic RYGB group, 2 treated by EIFS closed after 1 treatment; however, all leaks in the revision group required >1 EIFS treatment. The mean length of stay was 36 ± 34 days in the operative group and 33 ± 7 days in the EIFS patients. Operation for failure of EIFS was not required in any patient.ConclusionEIFS provides safe and successful treatment of patients who develop gastric leaks after bariatric operations. We recommend EIFS for all patients with endoscopically accessible leaks who can safely be treated nonoperatively.     

Early migration of fully covered double-layered metallic stents for post-gastric bypass anastomotic strictures

INTRODUCTIONLaparoscopic Roux-en-Y gastric bypass (LRYGB) is well recognized for its efficiency in morbidly obese patients. Anastomotic strictures present in 5–15% of cases and have a significant impact on the patient's quality of life. Endoscopic balloon dilation is the recommended treatment but management of refractory cases is challenging.PRESENTATION OF CASETwo patients with anastomotic stenoses refractory to dilations were treated with fully covered esophageal stents. Both cases presented early stent migration. The first patient finally underwent surgical revision of the anastomosis. For the second patient, a double-layered stent was installed after the first incident. After the migration of this second stent, three sessions of intralesional injection of triamcinolone acetonide were performed. Both patients were free of obstructive symptoms at a follow-up of 9 months.DISCUSSIONTreatment of post-gastric bypass strictures with stents is based on years of successful experience with endoscopic stenting of malignant esophageal strictures, gastric outlet obstruction in addition to anastomotic stenoses after esophageal cancer surgery. The actual prosthesis are however inadequate for the particularities of the LRYGB anastomosis with a high migration rate. Intralesional corticosteroid injection therapy has been reported to be beneficial in the management of refractory benign esophageal strictures and seems to have prevented recurrence of the stenosis in this post-LRYGB.CONCLUSIONStents are aimed at preventing a complex surgical reintervention but are not yet specifically designed for that indication. Local infiltration of corticosteroids at the time of dilation may prevent recurrence of the anastomotic stricture.     

Treating sleeve gastrectomy leak with endoscopic stenting: the kuwaiti experience and review of recent literature

Background

Obesity today is a leading cause of global morbidity and mortality, and bariatric surgeries such as laparoscopic sleeve gastrectomy (LSG) are increasingly playing a key role in its management. Such operations, however, carry many difficult and sometimes fatal complications, including leaks. This study aims at evaluating the effectiveness of endoscopic stenting in treating gastric leaks post-LSG.

Methods

A retrospective study was conducted to the patients who were admitted with post-LSG gastric leak at Al-Amiri Hospital Kuwait from October 2008 to December 2012 and were subsequently treated with stenting. The patients were stented endoscopically with self-expandable metal stent (SEMS), and a self-expandable plastic stent (SEPS) was used to facilitate stent removal.

Results

A total of 17 patients with post-LSG leaks underwent endoscopic stenting. The median age was 34 years (range 19–56), 53 % of the patients were male, and mean body mass index (BMI) was 43 kg/m ² . The median duration of SEMS placement per patient was 42 days (range 28–84). The SEPS-assisted retrieval process took a median duration of 11 days (range 14–35). Successful treatment of gastric leak was evident in 13 (76 %) patients, as evident by gastrografin swallow 1 week after stent removal. In addition, a shorter duration between the LSG and the time of stent placement was associated with a higher success rate of leak seal.

Conclusions

The use of SEMS appears to be a safe and effective method in the treatment of post-LSG leaks, with a success rate of 76 %. The time frame of intervention after surgery is critical, as earlier stent placement is associated with favorable outcomes. Finally, SEPS is often required to facilitate SEMS removal, and further modification of stents and its delivery system may improve results.     

Complications after esophagogastrectomy using stapling instruments

We studied 195 patients undergoing esophageal resection using stapling instruments during a period of over 8.5 years. Of these, 178 (91.2%) underwent operation for malignant disease. Operative death occurred in 19 patients (9.7%). Nine (4.6%) postoperative complications, excluding stricture formation, were related to the use of stapling instruments, including two operative deaths (1.0%). Anastomotic leaks and gastrotomy staple line leaks were the most common complications (four each). In 7 patients (3.6%) the circular stapler tore the esophagus; anastomotic leaks subsequently developed in 43% of these patients. After we began oversewing gastrotomy staple lines in 1984, we experienced only one gastrotomy leak due to a technical error. Postoperative stricture formation occurred soon after resection and responded well to one or two dilations. It is better to err on the side of choosing too small a stapling head when performing an esophageal anastomosis because this may reduce the incidence of leaks, and further strictures are easily dealt with.     

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.