Prevention Of Stent Migration Research Articles

VACStent: Combining the benefits of endoscopic vacuum therapy and covered stents for upper gastrointestinal tract leakage.

Background and study aims Endoscopic treatment has markedly improved the high morbidity and mortality in patients with upper gastrointestinal tract leakage. Most procedures employ either covered self-expanding metal stents (SEMS) or endoscopic vacuum therapy (EVT), both with good clinical success but also with concomitant significant shortcomings inherent in each technique. A newly developed device, the VACStent, combines the fully covered SEMS with a polyurethane sponge cylinder anchored on the outside. This allows endoluminal EVT while keeping the intestinal lumen patent. The benefit is prevention of stent migration because the suction force of the sponge-cylinder immobilizes the VACStent on the intestinal wall, while at the same time, the attached external vacuum pump suctions off any secretions and improves healing with negative-pressure wound treatment (NPWT). Patients and methods In this pilot study, the first patients to receive the VACStent were assessed. Outcomes included the applicability and stability of the VACStent system together with the clinical course. Results Three patients with different clinical courses were managed with the VACStent. The first patient suffered anastomotic leakage following subtotal esophagectomy and was successfully treated with two postoperative VACStents for 12 days. The second patient received a covered SEMS for 14 days for acute Boerhaave syndrome. Due to persistent leakage, management was converted to EVT. Seven days, later a VACStent was inserted to allow oral nutrition while the leak finally closed. In the third patient, a LINX Reflux Management System had to be removed for erosion, leaving the gastroesophageal junction (GEJ) with a full-thickness gap. After VACstent insertion, successful closure was achieved within 4 days. Conclusions These clinical cases demonstrate the applicability and efficacy of the VACstent in management of esophageal and anastomotic leakage. With its vacuum sponge, the stent fosters wound healing while the covered SEMS keeps the passage patent for nutrition.

Comparison of big funnel and individualized stents for management of stomach cancer with gastric outlet obstruction.

Previous studies reported a similar rate of complications, including stent migration and obstruction, between individualized stents and the standard uncovered stents in gastric outlet obstruction (GOO) caused by distal stomach cancer. The objective of this study was to evaluate the efficacy and safety of funnel stents for management of GOO caused by distal stomach cancer. This study was designed as a multicenter, controlled, prospective, and randomized clinical trial involving 4 hospitals. The individualized stent group (44 cases) received cup and funnel covered stents, and the funnel group (44 cases) received only funnel covered stents for management of GOO caused by distal gastric cancer. All patients with GOO were treated with cup and funnel stents according to their assigned groups. The rate of GOO resolution was 100% in the funnel group and 97.7% in the individualized stent group. Stent obstruction caused by tumor ingrowth was observed in 1 patient in the individualized stent group, and proximal partial stent migration was observed in 1 patient in each group. Stent obstruction caused by tumor ingrowth was observed in 1 patient in the individualized stent group. There was no statistical difference in stent migration, obstruction, and survival between groups. Big funnel stents and individualized stents resulted in similar shaping effect and prevention of stent migration and obstruction, suggesting that funnel shaped stents can be used to treat cup or funnel shaped GOO caused by distal stomach cancer.

Predictive Factors for the Migration of Endoscopic Self-Expanding Metal Stents Placed in the Foregut

With recent advancements in endoscopy, self-expandable metal stents (SEMS) have been used to treat gastrointestinal leaks, perforations, and strictures. Stent migration frequently complicates management and often requires additional treatments to reach resolution. Our study aimed to determine predictive factors for stent migration. Consecutive procedures involving SEMS placed with and without fixation after upper gastrointestinal surgery between 2009 and 2014 were retrospectively reviewed. Demographic, surgical history, rate of stent migration, and stent characteristic data were collected. Rates of stent migration were compared. We reviewed 214 consecutive procedures involving stents placed in the foregut. Median duration of stent placement was 4.0 ± 10.3 weeks. Forty-three (20%) stents migrated after placement. Of those, 27 (63%) required stent replacement. Eleven (5%) procedures utilized stent fixation and 203 (95%) did not. Fixation techniques included endoscopic clips (9%), endoscopic sutures (73%), and transnasal sutures (18%). Stent migration rate was not different between those with and those without fixation ( P = .2). Rate of migration was significantly higher in procedures involving fully covered stents ( P < .001). Migration occurred after esophagectomy and gastric bypass ( P < .001 and P < .05, respectively) and in patients with diabetes ( P < .01). A challenge with SEMS use is stent migration. Diabetes and using fully covered stents were associated with migration as were SEMS used to treat complications of esophagectomy and gastric bypass. Stent fixation was not associated with the prevention of stent migration. No pattern was found that favors an approach to reduce stent migration.

Endoscopic Ultrasound-Guided Pseudocyst Drainage Using a Novel Lumen-Apposing Metal Stent (AXIOS) in Two Pediatric Patients

Introduction: Pancreatic fluid collections are uncommon in children, but when they occur they can lead to serious complications. Endoscopic drainage of pseudocysts has been well established in adults, but there has been a limited experience in children. We present the first experience of pseudocyst drainage using a novel lumen-apposing metal stent (AXIOS) in 2 pediatric patients. Case 1: A 7-year-old girl presented with a past medical history of familial pancreatitis with a 7-cm pseudocyst. The patient underwent endoscopic ultrasound (EUS)-guided drainage with a 19 G needle, which confirmed a pseudocyst with a high amylase and low CEA. The pseudocyst reoccurred and imaging confirmed a 7 x 5 cm cyst in the tail of the pancreas that extended to the mediastinum. After a third reoccurrence the pseudocyst was treated with cystenterostomy drainage with a novel fully covered metal stent (AXIOS). A 10 mm x 10 mm AXIOS stent was placed at the gastroesophageal junction. The tract of the stent was dilated to 6 mm and a ultrathin Olympus endoscope was passed into the pseudocyst and necrotic tissue was removed. One month follow-up magnetic resonance imaging (MRI) and EUS confirmed complete pseudocyst resolution. The AXIOS stent was easily removed with a snare without complications. There has been no recurrence of the pseudocyst after 4 months. Case 2: A 6-year-old girl with metastatic neuroblastoma presented with a 7.6-cm pancreatic body pseudocyst on computed tomograph (CT). An EUS demonstrated a 6 cm x 7.6 cm pseudocyst in the pancreatic body with a metastatic mass in the pancreas causing pancreatic duct obstruction. Cyst fluid aspiration had a high fluid amylase levels and a low CEA. After initial drainage, the pseudocyst reoccurred so it was treated with cystenterostomy drainage with a lumen-apposing fully covered metal stent (AXIOS). A 10 mm x 10 mm AXIOS stent was placed in the body of the stomach. One month follow-up CT and EUS confirmed resolution and the stent was successfully removed without complications. Discussion: The current management for pseudocysts in children is predicated on adult techniques, because of limited pediatric studies. The different techniques include open, percutaneous, laparoscopic, and endoscopic drainage. Recent studies have shown that endoscopic drainage is equivalent to surgical or laparoscopic techniques. Endoscopic transmural drainage of pseudocysts with stent placement is crucial to avoid cyst recurrence. The use of a lumen-apposing fully covered metal stent (AXIOS) has been shown to be safe and effective in adults allowing for complete pseudocyst resolution and prevention of stent migration. These 2 cases show that EUS-guided AXIOS stent placement is effective and safe in pediatric patients.

Endoscopic repositioning of oesophageal stent migrated in the stomach and the prevention of stent migration

Endoscopic repositioning of oesophageal stent migrated in the stomach and the prevention of stent migration

516 生体組織融着技術を用いたステントの位置ずれ防止:小型コイルによるステントの誘導加熱と引張強度評価(OS5 オーガナイズドセッション《ライフサポートにおける工学技術》)

516 生体組織融着技術を用いたステントの位置ずれ防止:小型コイルによるステントの誘導加熱と引張強度評価(OS5 オーガナイズドセッション《ライフサポートにおける工学技術》)

What is the preferred shape for an esophageal stent flange?

Self-expandable metallic stents (SEMS) for the gastrointestinal tract have different types of flanges at either the oral end or both ends to prevent stent migration. The effect of flange shape on the properties of SEMS, to our knowledge, has not been evaluated. The aim of this study was to measure the strain that a SEMS imposes on the adjacent wall and the anti-migration force (AF) exerted by three stents, each with a different flange shape. Stents with one of three different flanges (flared, dumbbell, and barrel) were designed and then their strain and AF values were measured with apparatuses devised in our laboratory. Although the average maximal strain values at the flange were similar (508.4 µm/m, 513.3 µm/m and 486.4 µm/m for flared, dumbbell and barrel, respectively), strain values for each position differed among the three different types of stents. Strain values for the flared shape increased toward the stent end, reaching the maximum value. Maximal strain values for the dumbbell and barrel shapes were observed near the flange's midpoint. Maximal AF values differed significantly according to flange shape. Thus, the median maximal AF values were 1.85 newton, 1.35 newton, and 1.13 newton, for barrel, dumbbell and flared shapes, respectively. The performance of braided esophageal SEMS with barrel shaped flanges is superior to that of SEMS with dumbbell or flared flanges, based on the strain on the adjacent wall and the prevention of stent migration.

Management of delayed intrathoracic esophageal perforation with modified intraluminal esophageal stent

In this article, we reviewed our experience of treatment of the delayed intrathoracic nonmalignant esophageal perforation employing modified intraluminal esophageal stent. Between February 1990 and August 2006, eight patients were included in this study. Five patients experienced sepsis. The interval time between perforation and stent placement ranged from 36 h to 27 days (average, 8.6 days). Esophageal stenting and throracotomy for foreign body removal were performed in four patients. The remaining four patients underwent stent placement and thoracostomy. Nutrition was initiated through gastrostomy after 7 to 10 days after the stenting. The stent was removed after the patients resumed oral intake of food and the esophagogram showed that perforation was closed. There was no death in this group. Signs of sepsis remitted 1 week after stent placement. Complications included stress ulcer, stimulative cough, and pneumonia each. Stent removal ranged 32 to 120 days (average 66.7) after its placement. The stent was kept in place for 4 months to prevent formation of esophageal stricture in one patient with caustic esophageal burns. The follow-up was completed in all the patients. The mean follow-up period was 59 months (range 12-180). One patient with caustic esophageal burn underwent cicatricial esophagectomy and gastric transposition 3 years later due to the esophageal stricture. Barium swallow demonstrated that there was a diverticulum-like outpouching in one patient and slight esophageal stricture at T2 and T3 level in another. One patient developed reflux esophagitis 5 years after stent removal. All the patients finally had a normal intake of food. Modified esophageal stenting is an effective method to manage the delayed intrathoracic esophageal perforation. Prevention of stent migration and its convenient adjustment might be the major advantages of this method.

Lessons Learned Establishing an Animal Model for Endoscopic Stent Placement to Treat Gastrojejunal Anastomotic Leaks After Gastric Bypass

Anastomotic leaks after Roux-en-Y gastric bypass (RYGB) cause significant morbidity and mortality. Placement of enteral stents may be an improvement to the current treatment, which is withholding of oral intake and total parenteral nutrition. We established an open RYGB porcine model with a leak at the gastrojejunostomy in three pigs. A pilot study was then performed in five pigs, where Polyflex stents were placed across the leaking anastomosis and fixed with transmural sutures to the Roux limb. After 2 weeks, endoscopy, fluoroscopy, and necropsy were performed. One pig without stent died on the second postoperative day (POD) due to a volvulus unrelated to the leak. In the other two pigs, leaks with large abscesses were found at necropsy. Stents were placed in five pigs but required open surgical manipulation of the delivery system. One pig died on POD 3 due to a perforation in the posterior gastric wall likely caused by the rigid delivery system. One pig died from gastrojejunostomy leakage on POD 5. The leaks were healed in the remaining three pigs after 2 weeks. In one pig, a perforation of the jejunum 4 cm distal to the anastomosis was found. Stent migration to some extent was seen in all pigs. Stent placement and fixation were feasible but had a high complication rate for treatment of a leaking gastrojejunal anastomosis in the open porcine model. The stent may have contributed to healing the leak in some pigs. Further studies should focus on improving stent delivery, sealing of the leak, and prevention of stent migration.