The role of endoscopic stents in the management of chronic anastomotic and staple line leaks and chronic strictures after bariatric surgery

BackgroundThe use of endoluminal stents has been proposed for the management of fistulas and anastomotic strictures after bariatric surgery. The objective of our study was to determine the success of endoscopically placed, self-expandable metal stents (SEMS) in bariatric patients specifically with either chronic persistent anastomotic or staple line leaks/fistulas or chronic, persistent anastomotic strictures.MethodsWe treated 21 patients including 5 with chronic staple line leaks/fistulas (4 from the gastric sleeve after biliopancreatic diversion with duodenal switch [BPD/DS] and 1 after removal of an eroding laparoscopic adjustable gastric band) and 16 with chronic anastomotic strictures (15 at the gastrojejunostomy after Roux-en-Y gastric bypass and 1 at the duodenoileal anastomosis after BPD/DS). Patients with early leaks or anastomotic strictures were excluded.ResultsAll but one of these patients had been referred to our institution after chronic treatment elsewhere was unsuccessful with prior stent placement for fistulas or multiple endoscopic dilations for strictures. Their bariatric operations had been performed a mean of 386 days beforehand. Stent placement was performed successfully in all patients without complications but was successful in only 4 of 21 patients (19%)—2 with chronic fistulas and 2 with chronic anastomotic strictures. Stent migration occurred in 10 patients (47%); the migrated stents were removed/replaced endoscopically in 7 patients but required elective operative removal in 3 with concomitant correction of the leak, fistula, or anastomotic stricture; none were operated emergently.ConclusionOnly 4 of 21 patients with a chronic persistent leak or anastomotic stricture were treated definitively using a SEMS. Although endoluminal stents may not lead to resolution of a chronic leak or stricture, SEMS may suppress ongoing sepsis and allow patients to undergo nutritional resuscitation orally before operative correction.     

A retrospective analysis of early and late outcome of biodegradable stent placement in the management of refractory anastomotic colorectal strictures

Background

Benign colorectal strictures are treated conventionally by endoscopic dilation. Experience using SEMS for benign colonic strictures is limited, and outcomes to date have been disappointing. Refractory colorectal strictures remain challenging to be treated with surgery. Polydioxanone-based stent are biodegradable (BD) stent CE approved for esophageal strictures. This study was designed to investigate retrospectively the safety and the efficacy of these stents for the management of strictures refractory to multiple sessions of dilation.

Methods

Patients with postsurgical benign strictures located within 20 cm from anal verge, refractory to mechanical or pneumatic dilation (at least 3 sessions) were included in this analysis. Clinical success was defined as the absence of occlusive symptoms and the ability to pass through the stricture with a regular size colonoscope. All patients were predilated before stent placement. Stents were released under fluoroscopic control. All patients were under stool softeners for 3 months. Follow-up was scheduled with endoscopic and fluoroscopic controls within 90 days from stent deployment and afterwards by telephone interview and/or ambulatory consultation.

Results

Eleven patients (7 males, mean age 62.3 ± 8.5 years) were included. Technical success was achieved in all the patients. Stent migration was observed in four patients within the first 2 weeks after stent placement. Stent migration was followed by recurrence of stricture and obstructive symptoms in all the cases. Among the seven patients who completed the process of stent biodegradation, five of them had complete resolution of the stricture and relief of symptoms. Two of 11 patients required surgical treatment during the follow-up period (mean 19.8 (range 42–15) months). The overall success rate of the BD stent was 45 %.

Conclusions

This retrospective analysis of a limited number of patients demonstrated that nondedicated esophageal BD stents are associated with high risk of migration and clinical success in less than 50 % of patients. Dedicated stents with large diameter and antimigration findings could potentially improve the outcome of patients with refractory benign colorectal strictures.     

Endoscopic Dilation of Gastrojejunal Anastomotic Strictures After Laparoscopic Gastric Bypass. Predictors of Initial Failure

Background and aims  

Laparoscopic Roux-en-Y gastric bypass (LRYGB) is the most frequent technique performed in bariatric surgery. Gastrojejunal anastomotic stricture is one of the most common postoperative complications. The aims of this study were to evaluate the efficacy and safety of endoscopic balloon dilation in the treatment of the gastrojejunal anastomotic strictures after LRYGB and to look for predicting factors that would indicate the need of repeated dilations.     

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.     

Percutaneous placement of permanent metal stents for treatment of ureteroenteric anastomotic strictures

PURPOSE: To evaluate the efficacy of permanent metal stent placement in the treatment of ureteroenteric anastomotic strictures following failed balloon dilation or laser endoureterotomy. PATIENTS AND METHODS: Metal stents were placed in six ureteroenteric anastomotic strictures in four patients presenting with recurrent obstruction after balloon dilation or laser endoureteromy. Patients were evaluated at 1 week postoperatively with antegrade ureterography and at 3 to 6 months with renal ultrasound or CT scans. Serum creatinine assays and physical examination were performed at serial postoperative clinic visits. RESULTS: At 1-week follow-up, antegrade studies demonstrated a patent anastomosis in all six strictures. With a mean follow-up of 10 months (range 7-12 months), no stricture recurrence has been seen. All patients have been clinically stable, without episodes of pyelonephritis, flank pain, or need for indwelling stents or nephrostomy tube placement. Serum creatinine concentrations have been stable in all patients. CONCLUSIONS: Metal stents offer a useful treatment option in patients who develop ureteroenteric anastomotic strictures after urinary diversion. Further, such stents may be used in patients failing balloon dilation or laser endoureterotomy. Further study to assess the long-term durability of metal stent placement is needed.     

Efficacy and risk profile of self-expandable stents in the management of pediatric esophageal pathology

PurposeThe purpose of this study was to evaluate the efficacy and risk profile of esophageal stents in the management of complicated pediatric esophageal disease.MethodsAn IRB-approved, single-center, retrospective review was performed on all pediatric patients (n = 13) who underwent esophageal stent placement (2005–2017). Demographic, perioperative, and outcome data were analyzed (p < 0.05).ResultsForty-one stents were placed due to recalcitrant strictures (n = 36), perforations (n = 2), and/or fistulae (n = 3). Median age at initial stent placement was 23.8 months (range, 50 days to 16 years), and median stent duration was 36 days (range, 3–335). The recurrence rate for strictures after initial stent removal was 100%. Four (31%) children subsequently underwent definitive operative repair. There were 5 deaths, including 2 related to stent placement. Seventy-one percent of stents were associated with an adverse event, most commonly intraluminal migration (56%). Younger children experienced an increased risk for airway compression and retching (p = 0.010).ConclusionThese data suggest that stents are associated with high complication rates and are not effective as definitive therapy for recalcitrant strictures in children. Although there may be a temporizing role for stents in selected patients, further refinements in stent technologies are needed to help manage this difficult patient population.Level of evidenceLevel IV     

Low Anastomotic Stricture Rate After Roux-en-Y Gastric Bypass Using a 21-mm Circular Stapling Device

Background

Laparoscopic Roux-en-Y gastric bypass (LRYGB) has been established as a safe and effective procedure for morbid obesity management. Amongst some of the postoperative complications are gastrojejunal (GJ) anastomotic strictures, with an incidence of 3 to 27?% in some series. This study evaluates the incidence of GJ strictures using a 21-mm circular stapling device and its response to treatment with endoscopic balloon dilation.

Methods

A retrospective chart review was conducted of patients who underwent LRYGB between January 2007 and September 2010. We used our previously published technique of retrocolic, retrogastric Roux-en-Y bypass, using a 21-mm circular stapler to construct the gastrojejunostomy. Postoperatively, patients with persistent food intolerance underwent an endoscopy. Those found to have a GJ stricture (defined as inability to pass the endoscope beyond he anastomotic site) underwent pneumatic dilation with a 12-mm balloon.

Results

A total of 338 patients underwent LRYGB. Median follow-up was 57.6?weeks (8?C137). Twenty-two patients underwent an endoscopy due to food intolerance. Sixteen patients (4.7?%, 16/338) were identified with GJ stricture and received at least one endoscopic dilation. The other six patients had a normal endoscopic evaluation. GJ strictures presented at an average of 35?days (13 to 90?days) postoperatively. Four patients underwent two endoscopic interventions, and one underwent three endoscopic interventions.

Conclusions

We hereby demonstrate that the construction of GJ anastomosis with a 21-mm circular stapler is associated with a low stricture rate using our standardized technique. Strictures are amenable to balloon dilatation with subsequent long-term resolution of symptoms.     

The use of self-expanding silicone stents in esophageal cancer care: optimal pre-, peri-, and postoperative care

Background  Preoperative nutritional supplementation, management of esophageal leaks, and postoperative anastomotic strictures still remain common problems in the management of esophageal cancer. Jejunal feeding tubes, total parenteral nutrition (TPN) with nasogastric suction, and repeated esophageal dilations remain the most common treatments, respectively. The aim of this study was to evaluate the use of removable silicone stents in (1) the preoperative nutritional optimization during neoadjuvant therapy, (2) the management of perioperative anastomotic leak, and (3) the management of postoperative anastomotic strictures. Methods  Review of our prospectively maintained esophageal database identified 15 patients who had removable self-expanding silicone stents placed in the management of one of these three management problems from July 2004 to August 2006. Results  Preoperative therapy: Five patients underwent initial stent placement in preparation for neoadjuvant therapy. Dysphagia relief was seen in 100% of patients, with optimal caloric needs taken within 24 h of placement. All patients tolerated neoadjuvant therapy without delay from dehydration or malnutrition. One stent migration was found at the time of operation, which was removed without sequelae. Perioperative therapy: Five patients developed delayed (>10 days) esophageal leaks that were managed with removable esophageal stent and percutaneous drainage (in three patients). All patients had successful exclusion of the leak on the day of the procedure with resumption of oral intake on the evening of procedure. All five healed leaks without sequelae. Postoperative therapy: Five patients developed postoperative anastomotic strictures that required dilation and placement of removable esophageal stent. The median number of dilations was 1 (range 1–2), with all stents placed for approximate 3 months duration. All patients had immediate dysphagia relief after stent placement. Conclusion  Removable esophageal stents are novel treatment option to optimize relief of symptoms and return the patients back to a more normal oral intake. Continued evaluation is needed to consider stent use as first-line therapy.     

Prospective evaluation of a new self-expanding plastic stent for inoperable esophageal strictures

BACKGROUND: High stent cost is considered the major drawback of self-expanding metal stents for dysphagia palliation in patients with inoperable esophageal strictures. We report our experience with a self-expanding plastic (Polyflex) stent, the cost of which is half that of the metal stents. METHODS: Between September 1999 and April 2001, 16 dysphagic patients (15 men; mean age, 69.4 +/- 14.5 years; range, 49-100 years; mean dysphagia score, 3.31 +/- 0.6) with esophageal strictures who underwent Polyflex stent placement (insertion device diameter, 12-14 mm; postexpansion inner stent diameter, 16-21 mm; stent length, 9, 12, and 15 cm) were studied prospectively. The strictures were caused by postsurgical recurrence of gastric/esophageal cancer at the anastomotic site in five patients, primary esophageal cancer in four patients, esophagocardia junction cancer in four patients, metastatic mediastinal lymph nodes from a primary lung cancer invading the esophagus in 1 patient, and benign peptic stricture in two elderly patients. All the patients were prospectively followed until death. RESULTS: Stent insertion was technically successful in 12 patients (75%). Stent placement failed in four patients (25%) because of failure to pass the delivery catheter across the stricture in three patients and failure of the stent to open in one patient. Early and late stent migration occurred in two patients and 1 patient, respectively. Tumor overgrowth occurred in 1 patient. The mean dysphagia score 7 days after stent placement was 1.1 +/- 0.9. Mean survival was 100.6 +/- 71.2 days (range, 8-225 days). CONCLUSION: Self-expanding Polyflex stents are safe and effective for inoperable esophageal strictures and have an acceptable technical success rate. Further experience, better selection criteria, and design improvements should improve results.     

Self-expanding esophageal stents for the management of benign refractory esophageal strictures in children: A systematic review and review of outcomes at a single center

BackgroundThis study aimed to evaluate our outcomes and complication rate following placement of self-expanding esophageal stents in children for the management of refractory esophageal strictures and comparing these to the existing literature.MethodsOutcomes following placement of stents in consecutive patients under 18 years at a single center from 2003 to 2018 were reviewed. A PRISMA-guided systematic review was conducted identifying studies with 5 or more children evaluating self-expanding stents published from 1975 to 2018. Endpoints for both the retrospective and systematic reviews were the requirement for further intervention and stent-associated complications.Results25 patients received 65 stents. There were 12 caustic injury-related strictures (48%), 9 anastomotic strictures (36%), and 4 esophagitis-related strictures (16%). Four patients were lost to follow-up. 19/21 patients (90%) required further intervention, and 8/21 (38%) had esophageal replacement. Nine studies, all case series, were included in the systematic review. 97 patients received 160 stents for esophageal strictures and/or perforation. 36 out of 69 patients (52%) with strictures required no further treatment post-stenting, and 22/29 (76%) of esophageal perforations closed with stenting.ConclusionsEsophageal stents may have a role as a bridge to definitive surgery and for the management of esophageal leaks, but complete stricture resolution post-stenting is unlikely.Type of StudyTreatment Study (Case Series with no Comparison Group)Level of EvidenceLevel IV     

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.     

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.     

The efficacy and safety of ureteral dilation and long-term type ureteral stent for patients with ureteral obstruction

ObjectiveThis study was conducted to investigate the efficacy and safety of ureteral dilation and placement of a long-term ureteral stent for patients with various types of ureteral obstructions.MethodsWe retrospectively reviewed the records of 39 patients presenting with ureteral obstruction secondary to malignant strictures (n = 9) or nonmalignant strictures (n = 30). The mean age of these patients was 55.8 ± 16.1 years (range, 13–87 years). All patients underwent retrograde ureteral balloon dilation and placement of one to three ureteral stents. Stent patency rate and complications including febrile urinary tract infection, stent encrustation, and stent fragmentation were recorded.ResultsA total of 117 ureteral stents were implanted during the 83 procedures. Three stents were placed in seven patients and two stents in 20 patients. The patency rate was 95.2% with a mean 75-day follow-up. There was no encrustation in 104 stents and Grade 1 in 13 stents. The patency rate was similar between the patients with malignant strictures and those with nonmalignant strictures (100% vs. 94.7%, p = 0.57). However, three episodes of febrile urinary tract infection were noted only in patients with malignant strictures. The improvement of hydronephrosis and complications were also comparable between those patients with ureteral stents indwelling for >90 days and those for <90 days. No stent fragmentation was found in any of the patients.ConclusionWe demonstrated that ureteral dilation and placement of a single or multiple ureteral stents was effective and safe for patients with ureteral obstruction.     

钛镍记忆合金网状支架治疗食管贲门狭窄

作者使用形状记忆合金支架治疗９５例食管恶性狭窄,３５例吻合口瘢痕狭窄。所有病例均失去手术机会,使用扩张、化疗、放疗、激光等治疗也无效。治疗后,吞咽困难从３．７１±０．４５（３～４级）降到１．０８±０．５９（０～２级）（Ｐ＜０．０１）。并发症发生４９例（３１．５％）,其中胸痛３６例,出血５例,肿瘤过度生长４例,支架移位２例,食物堵塞２例。通过近三年的临床应用和疗效观察,作者认为,食管贲门狭窄放置钛镍记忆合金支架是一种有效、安全、简单方法。     

尿流改道术后输尿管肠代膀胱吻合口狭窄的腔内治疗

目的 探讨腔内技术治疗尿流改道术后输尿管肠代膀胱吻合口狭窄的临床应用价值.方法 膀胱癌尿流改道术后输尿管肠代膀胱吻合口狭窄患者9例,狭窄段长度1～3 cm,均采用腔内技术治疗,顺行经皮肾处理8例,逆行输尿管镜处理1例;术中使用高压气囊配合筋膜扩张器扩张,术后留置双J管.结果 随访0.5～5.0年.1例吻合口闭锁患者术后3个月仍为重度积水,患者拒绝开放手术而长期留置肾造瘘管;8例患者肾积水减轻,再次逆行扩张狭窄段并留置双J管,其中5例经2～3次扩张换管,拔除双J管后复查肾积水稳定于轻度状态;3例拔除双J管后腰痛不适,需要长期留置双J管.结论 尿流改道术后输尿管肠代膀胱吻合口狭窄腔内技术治疗效果良好,可避免开放手术的风险.     

Outcome of endoscopic balloon dilation of strictures after laparoscopic gastric bypass

Objective  Stricture formation at the gastrojejunal anastomosis is a relatively common complication after laparoscopic Roux-en-Y gastric bypass (LRYGB). The objective of this study was to report the incidence of stomal strictures after LRYGB in our institution and report our experience with their management by endoscopic balloon dilatation. Methods  This is a retrospective study of 1012 patients who underwent LRYGB from January 2001 to May 2004. Patients with nausea and vomiting after the surgery, suspected of having gastrojejunal (GJ) anastomotic stricture, had upper endoscopy. Stomas less than 10 mm in diameter, or those not allowing passage of the scope were considered significant strictures and were treated with balloon dilations. Dilations were performed with a through-the-scope (TTS) balloon, with sizes ranging from 6 to 18 mm. The following data were collected from these patients: age, sex, body mass index (BMI), comorbidities, size of balloon catheter, time from surgery until symptoms onset, number of endoscopies needed to relief symptoms, and complications of the procedure. Results  Sixty-one patients (46 females and 15 males) were found to have anastomotic strictures, corresponding to an incidence of 6%. In total, 134 upper endoscopies were performed, with 128 dilatations. The average age was 41.7 years (range: 19–68 years); mean preoperative BMI was 45 kg/m² (range: 42–61 kg/m²). Mean time from surgery to symptoms onset was 2 months (range: 1–6 months). The number of dilations per patient was as follows: a single dilation in 28% of patients, two dilations in 33%, three dilations in 26%, four dilations in 11.5%, and five dilations in 1.5% of patients. All the patients responded to dilation without need for formal surgical revision. However, after balloon dilatation three patients (4.9%), all females, had bowel perforation by radiological criteria (free air on X-ray), which corresponded to 2.2% of all dilatations. The maximum balloon size used in this group was 13.5 mm. All three patients had exploratory laparoscopy without finding of perforation site. They were treated with bowel rest, intravenous antibiotics for 7 days, and drain placement. No factors were identified to predict a risk of perforation. Conclusion  This is the largest study to evaluate the outcome of endoscopic dilatations of GJ strictures after RYGB. Endoscopic balloon dilation is a safe and effective treatment for anastomotic strictures. However, it carries a small risk of perforation. Further case studies are needed to determine risk factors for perforation and if the patients can be managed conservatively in this setting.     

Intraoperative Endoscopic Assessment of the Pouch and Anastomosis During Laparoscopic Roux-en-Y Gastric Bypass

As an advanced surgical procedure, laparoscopic Roux-en-Y gastric bypass (LRYGB) is associated with considerable morbidity, especially in the learning curve period. The aim of this study was to evaluate the role of endoscopy during LRYGB surgery in assessing the gastric pouch and anastomosis for air leak, bleeding, and structure at the beginning of a bariatric surgery program. Patients who underwent LRYGB for morbid obesity between May 2008 and May 2009 were included in this study. After the completion of the anastomosis, an endoscopic examination was carried out. The transection line and anastomosis site were examined for bleeding and patency and inspected for air leak under laparoscopic vision. Thirteen morbidly obese patients (mean body mass index, 48.0 ± 6.8 kg/m²) were evaluated by endoscopic examination during the LRYGB operation. None of the cases had bleeding at the transection line or anastomosis site. In two patients, air leak test was positive and the anastomosis was reinforced with additional sutures. All the patients, including those with positive air leak test, were discharged from the hospital with no leak complications. After a mean follow-up of 9.1 ± 5.5 months, except for the patient who underwent balloon dilatation, no other patient had anastomotic stricture. Intraoperative endoscopy is invaluable in the assessment of bleeding, anastomotic patency, and air leak during LRYGB, and it might be a helpful auxiliary tool to decrease morbidity during the learning curve period. Also, it helps solve intraoperative problems during the surgery so that postoperative complications might be prevented.     

URETEROILEAL ANASTOMOTIC STRICTURES: AN INNOVATIVE APPROACH WITH METALLIC STENTS

Purpose

We report our experience with the use of self-expandable metallic stents to bypass anastomotic strictures after ureteroileal urinary diversion.

Materials and Methods

We evaluated 3 men and 1 woman with invasive bladder carcinoma who underwent radical cystectomy and ileal conduit urinary diversion. Ureteroenteric anastomotic strictures developed after a mean of 16 months. Self-expandable metallic stents were successfully placed (bilaterally in 2) comprising 6 stented ureters that bypassed strictures. Mean patient age was 64 years and mean followup was 12 months.

Results

No restenosis was observed in 3 patients during followup. The stricture recurred 1 month after stent placement in the remaining patient and additional intervention was necessary, consisting of placement of a totally coaxial overlapping metal stent. No sepsis or other complication was observed. One patient died of metastatic disease 12 months after stent placement.

Conclusions

We propose the use of metal stents as an adequate, safe and effective alternative treatment for anastomotic strictures after ureteroileal diversion.     

Partially covered esophageal stents cause bowel injury when used to treat complications of bariatric surgery

Background

We hypothesized that an esophageal nitinol stent that is mainly silicone-covered but partially uncovered may allow tissue ingrowth and decrease the migration rate seen with fully covered stents and still allow safe stent removal. The aim of this study was to evaluate the first human results of using partially covered stents for anastomotic complications of bariatric surgery.

Methods

This was a retrospective evaluation of all patients with staple-line complications after bariatric surgery who received a partly covered stent at a single tertiary-care bariatric center. The stents varied in length from 10 to 15 cm and in diameter from 18 to 23 mm.

Results

From April 2009 to April 2010, eight patients received partially covered stents on 14 separate occasions. The indications were gastrojejunal stricture in four, acute leak in two, acute leak followed by a later stricture in one, and a perforated anastomotic ulcer in one patient. Single stents were placed in 12 sessions and two overlapping stents in two sessions. At the time of stent deployment, one patient had the uncovered proximal end of the stent in the stomach, with all others in the distal esophagus. Immediate symptom improvement occurred in 12/14 stent placements. Oral nutrition was initiated for 10/14 stent treatments within 48 h. Stents were removed after 25 ± 10 days. Minor stent displacement occurred with 9/13 stents, with the proximal end of the stent moving into the stomach, though the site of pathology remained covered. The stents were difficult to remove when tissue ingrowth was present. One patient required laparoscopic removal and one required two endoscopy sessions for removal. At the time of removal of ten stents, where the proximal end was found in the stomach, four had gastric ulceration, three had gastric mucosa replaced by granulation tissue, and three had normal gastric mucosa. In four cases where the proximal portion of the stent stayed in the esophagus, the esophageal deployment zone had abnormalities: three with granulation tissue and one with denuding of the esophageal mucosa. The distal uncovered portion of the stent in the Roux limb never became embedded in the mucosa and caused minimal injury.

Conclusions

A partially covered stent was successful in keeping the site of the pathology covered and provided rapid symptom improvement and oral nutrition in most patients. The proximal end of the stent generally moved from the esophagus to the stomach, probably due to esophageal peristalsis. The proximal uncovered portion of the stent causes significant bowel mucosal injury and sometimes becomes embedded in the esophagus or the stomach, making removal difficult. We no longer use partially covered stents.