Stent Perforation Research Articles

S1970 Utility of Covered Metal Stents in Esophageal Penetrating Injuries

INTRODUCTION: Management of esophageal perforations and leaks is traditionally managed via a surgical approach, however, here we show that self-expanding metal stents (SEMS) can be used to successfully treat esophageal injuries. CASE DESCRIPTION/METHODS: Case 1: A 27-yo man presented for GSW to the chest and went for surgical repair of the proximal esophagus. The esophageal defect was oversewn, but on day 7 an esophagram revealed an anterior leak. On EGD, there were 2 medium-sized perforations 30 cm from the incisors that were covered with a 12 cm × 20 mm fully covered stent under fluoroscopic guidance and anchored with two hemostatic clips. One week later the stent was exchanged because one perforation was still present. At two-weeks after the first EGD, the perforations had completely healed that was confirmed with esophagram. Case 2: A 21 year-old-woman presented for GSW to the neck who was found to have a T1 spinal cord injury with severe damage to the soft tissue. An esophageal perforation was found on a later esophagram and surgical repair failed to close the leak. EGD showed a perforation at 20 cm from the incisors that was treated with a 12 cm × 20 mm fully covered stent under fluoroscopic guidance and anchored with two hemostatic clips. She had a repeat EGD with stent exchange, but at week-two the tract had epithelialized that was further treated with APC and closure with 3 clips. DISCUSSION: Esophageal perforations are a life-threatening complication. If not corrected within the first 24 hours, morbidity and mortality increases significantly due to increased risk for fulminant mediastinitis and pleural contamination.1 Successful closure of benign esophageal perforations with stents is approximately 82%-100%.1 In a study of 15 patients, early (∼45 minutes) versus late (∼123 hours) esophageal stenting decreased hospital stay to 5 days compared to 44 days in the late group related to complications of sepsis and multiorgan failure.4 Serious complications from esophageal stenting are stent perforation, stent-related bleeding, and strictures which occurred at 2%, 0.8%, and 3.2%, respectively. In that same study, 73/340 experienced stent migration.5 A study of 44 patients comparing rates of esophageal migration with and without anchoring clips, migration occurred in 3/23 patients with hemostatic clips versus 12/21 without hemostatic clips.6 Here are two cases of esophageal perforation where fully covered esophageal SEMS were used without complication of stent migration due to anchoring clips.Figure 1.: Esophageal perforation.Figure 2.: SEMS covering perforation.Figure 3.: Healed perforation after SEMS.

Bridging Stent Placement in Vena Cava Syndrome With Tumor Thrombotic Extension in the Right Atrium.

Venous stent placement of symptomatic occlusion of the superior and inferior vena cava is considered the treatment of choice in malignant disease because this technique can restore patency and achieve a relief of symptoms. However, tumor thrombus extension into the right atrium harbors the potential risk of stent migration and perforation. One strategy to avoid this potential life-threatening complication could be the placement of a bridging stent from the superior vena cava-to-inferior vena cava. This case reports describes the superior vena cava-to-inferior vena cava bridging stent technique in 2 patients with malignant occlusion of the superior and inferior vena cava. Special considerations such as technical details of the devices and potential complications are discussed.

Evaluation of the Accero Stent for Stent-Assisted Coiling of Unruptured Wide-Necked Intracranial Aneurysm Treatment with Short-Term Follow-Up.

Background: Stent-assisted coiling is an effective method of treating intracranial aneurysms. The aim of the study was to assess the safety and efficacy of the new Accero stent for the treatment of intracranial aneurysms. Materials and Methods: It was a retrospective, single-center study. Eighteen unruptured intracranial aneurysms were treated using the stent-assisted coiling method with the Accero stent. Patient demographics, aneurysm characteristics, procedural parameters, grade of occlusion, complications, and clinical results were analyzed. Follow-up magnetic resonance (MR) was performed 6 months after intervention. Results: Seventeen patients with 18 incidental unruptured aneurysms were electively treated with coiling and the Accero stent. The aneurysms were located on internal carotid artery (ICA), middle cerebral artery (MCA) and basilar artery (BA). All stents were deployed successfully. Immediate complete occlusion rate Raymond-Roy occlusion classification (RROC) class I was achieved in 13 cases and class II in 4 cases. Complications occurred in 2/17 treatments and included guidewire stent perforation with subarachnoid hemorrhage (SAH) and stent deformation. Vascular spasm in the subarachnoid hemorrhage (SAH) patient subsided before discharge. Ninety days after intervention, the modified Rankin Scale (mRS) value was 0. RROC class I was observed in 88.23% of cases in follow-up. Conclusion: The Accero stent provides excellent support for coil mass. It constitutes an efficacious device with good initial occlusion rate for treating wide-necked unruptured intracranial aneurysms.

A newly designed uncovered biliary stent for palliation of malignant obstruction: results of a prospective study

BackgroundBiliary decompression can reduce symptoms and improve quality of life in patients with malignant biliary obstruction. Endoscopically placed stents have become the standard of care for biliary drainage with the aim of improving hepatic function, relieving jaundice, and reducing adverse effects of obstruction. The purpose of this study was to evaluate the performance characteristics of a newly-designed, uncovered metal biliary stent for the palliation of malignant biliary obstruction.MethodsThis post-market, prospective study included patients with biliary obstruction due to a malignant neoplasm treated with a single-type, commercially available uncovered self-expanding metal stent (SEMS). Stents were placed as clinically indicated for palliation of jaundice and to potentially facilitate neo-adjuvant chemotherapy. The main outcome measure was freedom from recurrent biliary obstruction (within the stent) requiring re-intervention within 1, 3, and 6 months of stent insertion. Secondary outcome measures included device-related adverse events and technical success of stent deployment.ResultsSEMS were placed in 113 patients (73 men; mean age, 69); a single stent was inserted in 106 patients, and 2 stents were placed in 7 patients. Forty-eight patients survived and/or completed the 6 month study protocol. Freedom from symptomatic recurrent biliary obstruction requiring re-intervention was achieved in 108 of 113 patients (95.6, 95%CI = 90.0–98.6%) at study exit for each patient. Per interval analysis yielded the absence of recurrent biliary obstruction in 99.0% of patients at 1 month (n = 99; 95%CI = 97.0–100%), 96.6% of patients at 3 months (n = 77; 95%CI = 92.7–100%), and 93.3% of patients at 6 months (n = 48; 95%CI = 86.8–99.9%). In total, only 5 patients (4.4%) were considered failures of the primary endpoint. Most of these failures (4/5) were due to stent occlusion from tumor ingrowth or overgrowth. Overall technical success rate of stent deployment was 99.2%. There were 2 cases of stent-related adverse events (1.8%). There were no cases of post-procedure stent migration, stent-related perforation, or stent-related deaths.ConclusionsThis newly designed and marketed biliary SEMS system appears to be effective at relieving biliary obstruction and preventing re-intervention within 6 months of insertion in the overwhelming majority of patients. The device has an excellent safety profile, and associated high technical success rate during deployment.Trial registrationThe study was registered on clinicaltrials.gov on 14 October 2013 and the study registration number is NCT01962168. University of Massachusetts Medical School did not participate in the study.

Outcomes of Stenting as a Bridge to Surgery in Malignant Colonic Obstruction, With Emphasis on Perforation Rate and Clinical Success

BACKGROUND Colonic stent placement in acute malignant obstruction has proven to be an alternative for emergency surgery. It has been associated with reduced stoma creation and postoperative morbidity. Concerns have risen that manipulation of the tumor and risk of perforation might result in lower disease-free survival. Therefore, we investigated the long-term outcomes of stenting as a bridge to surgery in these patients, with emphasis on clinical success of the stenting procedure. METHODS We performed a comparative study in the Rijnstate Hospital in Arnhem, The Netherlands. Data were collected from patients who underwent colonic stenting procedures or acute surgical resection due to malignant obstruction performed between 2007 and 2015. Patients treated with palliative intent were excluded. RESULTS We included 92 patients, 66 underwent stent placement and 26 had an acute surgical resection. Technical and clinical success rates of the stenting procedures were 94% and 82%, respectively. No significant differences in demographic, tumor or stenting characteristics were found for patients with clinically (un)successful stent placement or stent-related perforations. Patients with unsuccessful stent procedures or perforation had higher rates of open procedures and rescue colostomy. Survival rates were similar for patients who underwent stent placements compared with acute resection. We found no significant differences in survival between patients with successful compared with unsuccessful procedures or perforation. CONCLUSIONS Survival rates of patients who underwent colonic stenting are similar to those of patients who had an acute resection. No negative effects on survival were observed for clinically failed stenting procedures or stent-related perforations.

Curative management of malignant left-sided colorectal obstruction

Left-sided malignant colonic obstruction remains a challenging surgical problem despite recent advances. We aim to provide a concise overview of the relevant surgical options for this condition in the curative setting. A literature search of MedLine, PubMed, and Embase was performed to elucidate the latest evidence in the management of malignant left-sided colorectal obstruction, focusing on the risks and benefits of each approach and the appropriate patient selection. Primary resection and anastomosis are the intervention of choice for low-risk patients in the curative setting. Delayed resection with a bridge to surgery should be considered in unwell patients requiring medical optimization. While stenting has gained popularity, the risk of stent perforation carries a poor prognosis and must be carefully considered. Hartmann's procedure should be considered in high-risk elderly patients. Subtotal colectomy is preferred over segmental colectomy when there is extensive proximal colon damage but results in more frequent bowel actions postoperatively.

Recto-Gluteal Fistula from Colonic Stent Migration and Perforation in a Patient with Metastatic Colorectal Cancer Treated with Folfox and Bevacizumab: A Case Report

Recto-Gluteal Fistula from Colonic Stent Migration and Perforation in a Patient with Metastatic Colorectal Cancer Treated with Folfox and Bevacizumab: A Case Report

EVALUATION OF STRENGTH CHARACTERISTICS OF CORONARY STENTS IN THE CREATED MODEL OF “MYOCARDIAL BRIDGE”

Introduction. Presently there is no unified tactics to treat patients with aberrantly localized coronary arteries of “muscular bridge” type. There are controversial data regarding the benefit of coronary artery stenting due to often stent breakage or perforation of tunneled vessel. There are no major randomized studies regarding this issue. In this regard the goal of this research was to assess strength characteristics of stents in the model of muscular growth that we restored.Materials and methods. The originally developed model enabled to determine the strength limit of coronary stents under conditions that are maximum close to the physiological ones. The stents were placed into a polytetrafluoroethylene tube, the bridge-imitating oscillation frequency was configured to 250 beats per minute. The results of the experiment were recorded on USB-camera each 30 minutes in order to register mechanical defects of the stent.Results and discussion. The stent consisting of cells that are joined with V-shaped connections, showed first signs of strut deformity on the 10th day. Complete breakage happened on the 17th day after implantation. After 2 months observation the stent preserved mechanical firmness without V-shaped connections.Conclusion. Thus, it is not quite correct to support the hypothesis on infeasibility of stent implantation into the coronary artery with a muscular bridge. Taking into consideration the findings it is possible to suppose that the structure, design, form and content of stents predetermine the possibility to implant it into coronary artery with muscular bridge, but require individual approach to every particular patient.

Gastroduodenal Stent-Related Complications and Management

AbstractPlacement of a gastroduodenal self-expandable metallic stent (SEMS) is a safe and well-established procedure for the palliative care of malignant gastric outlet obstruction. There have been reported complications related to the SEMS procedure such as stent occlusion, migration of the stent, biliary obstruction, bleeding, and bowel perforation. Early detection and proper management of the complications are crucial to maintain the quality of life and prolong the life expectancy of the patients. In this article, we will discuss the diagnosis and treatment of SEMS-related complications.

Collaborating with interventional pulmonology in managing a massive tracheoesophageal fistula that extends from cricoid to carina: a case report

Tracheoesophageal fistulas (TEF) present a perioperative management challenge. A 62 year-old man with esophageal carcinoma presented with a large tracheoesophageal fistula extending most of the trachea. Previously, the patient had two overlapping esophageal and one tracheal stent placed, but he developed progressive tracheal disruption due to esophageal stent perforation near the level of the cricoid. This case describes the anesthetic management of tracheal stent placement for an expanding TEF. Management included a spontaneous breathing inhalation induction followed by ventilation through a supraglottic device—laryngeal mask airway (LMA). Finally, during rigid bronchoscopy, a combination of bag ventilation and jet ventilation was utilized.

A case of esophageal stent perforation managed by a covered stent

Esophageal carcinoma is the sixth most common cause for cancer mortality. Dysphagia and obstruction in patients with this cancer are considered two of the most distressing and debilitating symptoms. Patients with locally advanced and metastatic tumors are treated with palliative intent. The use of self-expanding stents under these circumstances may allow for the avoidance of more invasive procedures such as placement of gastrostomy and jejunostomy. But these outpatient procedures also carry with it the risk of complication, stent perforation being one of them. This presentation is being done to report such a case of stent perforation which was managed in a novel way.

The Role of Esophageal Stents in the Management of Esophageal Anastomotic Leaks and Benign Esophageal Perforations

The aim of this review was to assess the safety and effectiveness of esophageal stents in the management of benign esophageal perforation and in the management of esophageal anastomotic leaks. Benign esophageal perforation and postoperative esophageal anastomotic leak are often encountered. Endoscopic placement of esophageal stent across the site of leakage might help control the sepsis and reduce the mortality and morbidity. All the published case series reporting the use of metallic and plastic stents in the management of postoperative anastomotic leaks, spontaneous esophageal perforations, and iatrogenic esophageal perforations were identified from MEDLINE, EMBASE, and PubMed (1990-2012). Primary outcomes assessed were technical success rates and complete healing rates. Secondary outcomes assessed were stent migration rates, stent perforation rates, duration of hospital stay, time to stent removal, and mortality rates. A pooled analysis was performed and subgroup analysis was performed for plastic versus metallic stents and anastomotic leaks versus perforations separately. A total of 27 case series with 340 patients were included. Technical and clinical success rates of stenting were 91% and 81%, respectively. Stent migration rates were significantly higher with plastic stents than with metallic stents (40/148 vs 13/117 patients, respectively; P = 0.001). Patients with metallic stents had significantly higher incidence of postprocedure strictures (P = 0.006). However, patients with plastic stents needed significantly higher number of reinterventions (P = 0.005). Mean postprocedure hospital stay varied from 8 days to 51 days. There was no significant difference in the primary or secondary outcomes when stenting was performed for anastomotic leaks or perforations. Endoscopic management of esophageal anastomotic leaks and perforations with the use of esophageal stents is technically feasible. It seems to be safe and effective when performed along with mediastinal or pleural drainage. Esophageal stent can, therefore, be considered as a treatment option in the management of patients who present early after esophageal perforation or anastomotic leak with limited mediastinal or pleural contamination.

Magnets in the GI tract

Magnets in the GI tract

THE ROLE OF OESOPHAGEAL STENTS IN THE MANAGEMENT OF OESOPHAGEAL ANASTOMOTIC LEAKS AND BENIGN OESOPHAGEAL PERFORATIONS

IntroductionEndoscopic placement of oesophageal stent across the benign oesophageal perforation and postoperative oesophageal anastomotic leak might help to control the sepsis and reduce the associated mortality and morbidity.Aims/BackgroundThe aim of...

Suprarenal stent perforation after endovascular abdominal aortic aneurysm repair

A 66-year-old man with an abdominal aortic aneurysm previously repaired with an endovascular stent graft presented to our facility with worsening midabdominal and back pain. Previous postoperative surveillance computed tomography scans were unremarkable, showing excellent stent-wall apposition and a shrinking aneurysm sac; however, imaging done on his arrival identified a contained rupture at the level of the celiac artery containing a perforating suprarenal stent. We repaired this rupture with a surgeon-modified fenestrated stent graft. To our knowledge, this is the first reported case of penetration of the native aorta by a suprarenal stent in the absence of infection or trauma.

Colorectal stents for the management of malignant colonic obstructions.

Colorectal cancer is one of the most common cancer in the western world. Acute colonic obstruction is one of the common presentations of colon cancer. Emergency surgical decompression is the traditional treatment of choice but is associated with high morbidity and mortality. In recent years colonic stents have been used to relieve the obstruction. The aim was to compare the colonic stenting versus emergency surgical decompression with regards to benefits and risks. Searches were carried out May 2010 in the Cochrane Colorectal Cancer Specialised Register, the Cochrane Central Register of Controlled Trials, Ovid MEDLINE, Ovid EMBASE and Ovid CINAHL. Randomised clinical trials comparing colonic stenting versus surgical decompression for obstructing colorectal cancers were considered for inclusion. Data on the characteristics of the trial, methodological quality of the trials, mortality, morbidity, technical and clinical success rate, operating time, hospital stay and other measured secondary outcomes from each trial were collected. And the data were analysed with both the fixed-effect and the random-effects models using RevMan Analysis. For each outcome, odds ratio (OR) with 95% confidence intervals (CI) based on available data analysis was calculated. Five randomised trials were identified with a total of 207 participants, 102 to colorectal stenting and 105 to emergency surgery. There was statistically significant higher clinical success rate in the emergency surgery group. The average time of clinical relief of obstruction was 0.66 day in the colonic stent group and was 3.55 days in the emergency surgery group. The stent insertion was successful in 86.02% of attempted stent placements. There was no statistically significant difference in the 30-day mortality between two groups. The 30 day mortality rate was similar, 2.3% in both groups. The stent related perforation rate was 5.88%. The stent migration rate was 2.13%. The stent obstruction rate was 2.13%. There was no statistically significant difference in overall complication rate in both groups. The complication rate was 39.22% in the colonic stent group and was 45.71% in the emergency surgery group. The mean hospital stay was 11.53 days in the colonic stent group and was 17.15 days in the emergency surgery group. The mean procedure/operating time was 113.93 minutes in the colonic stent group compared to 143.85 minutes in the emergency surgery group. The median blood loss was 50 ml in the colonic stent group and 350 ml in the emergency surgery group. The use of colonic stent in malignant colorectal obstruction seems to have no advantage over emergency surgery. The clinical success rate was statistically higher in emergency surgery group. However, use of colorectal stents seems to be as safe in the malignant colorectal obstruction as the emergency surgery with no statistically significant difference in the mortality and morbidity. Colorectal stents are associated with acceptable stent perforation, migration and obstruction rates. The advantages of colorectal stent includes shorter hospital stay and procedure time and less blood loss. However, due to the variability in the sample size and trial designs in the included studies, further randomised trials with bigger sample size and well defined trial design are needed to achieve the robust evidence.

Endoscopic magnetic gastroenteric anastomosis for palliation of malignant gastric outlet obstruction: a prospective multicenter study

Palliation of malignant gastric outlet obstruction remains challenging. Although there are 2 established treatment options, ie, surgical gastrojejunostomy and endoscopic duodenal stent insertion, there is an ongoing search for a technique that would combine the safety and rapid effect of duodenal stent placement with the long-term efficacy and low reintervention rate of a surgical gastrojejunostomy. To investigate the safety and success rate of endoscopic creation of a gastroenteric anastomosis formed by magnetic compression and stent placement. Prospective, multicenter cohort study. Four referral centers. The expected number of patients with symptomatic malignant gastric outlet obstruction to be included at the participating hospitals during a year was 40. Because of a serious adverse device event, the study was terminated after inclusion of 18 patients. Creation of an endoscopic gastroenteric anastomosis by using the Cook Magnetic Anastomosis Device with transanastomotic deployment of a self-expandable stent. Primary endpoints were safety and success rate associated with the creation of an endoscopic gastrojejunostomy by using a magnetic anastomotic device with transanastomotic deployment of a self-expandable stent. Because of a serious adverse event, the study was terminated prematurely. A success rate of 66.7% (12 of 18 patients) was achieved; 1 serious adverse event (stent perforation) occurred leading to the death of the patient. Three patients (25%) experienced an adverse device effect (stent migration). Small sample size, lack of a control group. Endoscopic creation of a gastroenteric anastomosis by magnetic compression is feasible and safe; however, the necessity of a stent led to serious morbidity and even mortality in this study. The current system can therefore not be recommended for clinical use.

Direct Erosion and Prolapse of Esophageal Stents into the Tracheobronchial Tree Leading to Life-threatening Airway Compromise

Covered or uncovered self-expanding metal stents are currently used for the palliative treatment of neoplastic esophageal obstructions or compressions and malignant esophageal leaks or fistulas. This small series, from three different European hospitals, highlights the unusual but significant complication of esophageal stent perforation followed by erosion and prolapse of the endoprosthesis into the tracheobronchial tree causing acute airway compromise or aspiration. Possible causal mechanisms and means of treatment are discussed to raise physician awareness of this life-threatening complication.

Late colonic stent perforation following chemotherapy

A 67-year-old patient was diagnosed as having a tumor at the splenic flexure of the colon with multiple liver metastases. They were treated with four consecutive cycles of FOX chemotherapy (leucovorin, 5-fluorouracil, and oxaliplatin). A computed tomography (CT) scan of the abdomen showed regression of liver metastases; however, the patient had obstipation, and prestenotic dilation of the colon was observed. A Wallstent enteral endoprosthesis (Boston Scientific International, Natick, MA, USA) was placed, with subsequent normal passage of stool ([Fig. 1]). Following the procedure the patient continued with chemotherapy. One month later, the patient was admitted with nausea, vomiting, and diarrhea. Gastroscopy revealed that the proximal end of the Wallstent endoprosthesis had perforated the stomach. The endoscope could pass through the endoprosthesis, and in this way it reached the descending colon ([Fig. 2]).

Catastrophic Complication of Stent Perforation in a Uremic Patient with Acute Myocardial Infarction

Catheter-induced coronary artery dissection is a rare but devastating complication of coronary angiography and percutaneous coronary intervention (PCI). Complications during PCI include coronary artery dissection, intramural hematoma, coronary artery perforation, and occlusion of branch vessels. Stent perforation is more unusual and potentially fatal. Here, we report a 68-year-old uremic woman who underwent primary PCI for her acute myocardial infarction. Unfortunately, dissection of the left proximal coronary artery by a guide catheter, followed by stent implantation, resulted in stent perforation through the middle left coronary artery and severe laceration of the left coronary orifice. Cardiogenic shock leading to cardiac arrest occurred. Emergency coronary artery bypass grafting and aortomy for left coronary orifice repair were conducted. The patient's postoperative course was uneventful, and she was discharged 15 days after surgery. From the successful outcome in this patient, we speculate that both better selection of patients and lesions for angioplasty and surgical standby may prove to be life-saving and effectively decrease subsequent mortality for patients experiencing devastating complications during PCI.