Introduction

Fully covered self-expandable metal stents (FCSEMS) used for benign and malignant esophageal conditionsare prone to migration, which can impact efficacy but also lead to adverse events. Fixation of proximal end of FCSEMS have shown to reduce stent migration in individual studies. In this systematic review and meta-analysis, we aim to compare rates of stent migration of FCSEMS undergoing fixation (any technique) versus not.

Aims & Methods

PubMed, Embase and Cochrane databases were queried to identify prospective/retrospective studies that compared outcomes of FCSEMS undergoing fixation (FCSEMS-F) versus no fixation (FCSEMS-NF). FCSEMS-F group included use of methods such as sutures, hemoclips and the specific over the scope clip (OTSC). The primary outcome was pooled estimates of the rate of stent migration. Secondary outcomes included clinical success, mean time to stent migration and overall adverse events (chest or abdominal pain, nausea+/-vomiting, tear or perforation, bleeding). Subgroup Analysis was performed to compare stent migration when FCSEMS fixation was performed with endoscopic suturing vs no fixation. Clinical success was defined as resolution of a stricture or closure of a fistula/leak/perforation as documented by clinical and endoscopic/radiological follow-up after stent removal. Odds ratios (RR) with 95% confidence intervals (CI) were calculated for dichotomous variables using the random effects model. Study heterogeneity was assessed using i² statistics.

Results

We identified 9 studies of FCSEMS placement comparing fixation versus no-fixation methods including a total 727 patients with 899 stent procedures: FCSEMS-F group (269 patient, 291 stents, mean age 60.4 years) and FCSEMS-NF group (458 patients, 608 stents, mean age 61.7 years). The stent migration rate for all procedures was 16.1% in FCSEMS-F group compared to 32.8% in FCSEMS-NF group (9 studies, OR 0.36, 95% CI 0.20 -0.64,i²= 53%). Clinical success was achieved in 68.9% procedures in FCSEMS-F group compared to 56.1% in FCSEMS-NF group (3 studies, OR 1.94, 95% CI 1.10 – 3.41, i²=0%). Mean time to stent migration was longer for FCSEMS-F (29.4 +/- 11.2 days) compared to FCSEMS-NF (21.6 +/- 11days) with a mean difference of 7.8 days (95% CI 5.4 – 10.2; SE 1.2, p< 0.0001). There was no difference in overall adverse events between the 2 groups. In a sub-group analysis for FCSEMS patients undergoing fixation with endoscopic suturing versus no fixation, the rate of stent migration was significantly lower in the sutured group (16.3% vs 32.8%, OR 0.37,95% CI 0.19 – 0.72, i²= 55%).

Conclusion

Fixation of FCSEMS (sutured in particular) offer significant advantages in terms of lower stent migration rates, longer duration to stent migration and higher clinical success without any difference in adverse events when compared to esophageal stents not undergoing fixation. Randomized studies comparing various fixation methods is needed to further guide the exact method for stent fixation.

Disclosure

No Relevant Financial Disclosures

Introduction

Lumen-apposing metal stents (LAMS) have increasingly been used for the management of gastrojejunal anastomotic strictures following Roux-en-Y gastric bypass, although through-the-scope balloon dilation (TTS-BD) remains the first-line therapy.

Aims & Methods

This systematic review and meta-analysis aimed to evaluate the effectiveness and safety of LAMS for gastrojejunal anastomotic strictures after Roux-en-Y gastric bypass using a single-arm meta-analysis. Additionally, we conducted pairwise meta-analyses of studies comparing LAMS and TTS-BD. We systematically searched PubMed, Embase, and the Cochrane Librarydatabases. The primary outcome was clinical success. Secondary outcomes included the need for surgery, overall adverse events, and the most common adverse event. Pooled estimates with 95% confidence intervals (CIs) were calculated for single-arm analyses. For the pairwise meta-analysis of comparative studies, pooled risk ratios (RRs) with 95% CIs were calculated for binary outcomes.

Results

We included nine studies, comprising 189 patients treated with LAMS for gastrojejunal anastomotic strictures following Roux-en-Y gastric bypass. Most patients were female, with the mean age ranging from 43.6 to 62.0 years. The pooled clinical success rate with LAMS was 76.39% (95% CI 61.67–86.67%). The pooled rates for need for surgery and overall adverse events were 15.03% (95% CI 7.46–27.97%) and 18.93% (95% CI 11.21–30.16%), respectively. Stent migration was the most frequently reported adverse event associated with LAMS, occurring in 14.83% of cases (95% CI 7.49–27.25%).Among the included studies, four compared LAMS with TTS-BD, encompassing a total of 200 patients (92 treated with LAMS and 108 with TTS-BD). LAMS was associated with a higher clinical success rate (RR 1.49; 95% CI 1.07–2.07; P=0.02; I2=0%) and a higher risk of overall adverse events (RR 4.31; 95% CI 1.03–17.97; P=0.04; I2=37%) compared to TTS-BD. The need for surgery was similar between groups (RR 0.82; 95% CI 0.05–12.68; P=0.89; I2=88%).

Conclusion

LAMS placement showed to be an effectivetreatment for gastrojejunal anastomotic strictures following Roux-en-Y gastric bypass. However, compared to TTS-BD, LAMS was associated with a higher rate of overall adverse events, most commonly stent migration.

Table 1. LAMS size

References

1. Agrawal R, et al. Safety and Efficacy of LAMS for Management of Late Refractory Gastro-jejunal Strictures in Patients with Roux-en-Y Gastric Bypass. Dig Dis Sci. 2025.
2. Hathorn K, et al. Gastrojejunal Anastomotic Stenosis: A Matched Cohort Study Comparing Efficacy and Safety of LAMS Placement to Standard Balloon Dilation. Gastrointest Endosc. 2020.
3. Ichkhanian Y. Balloon Dilation vs. Lumen Apposing Metal Stent for the Management of Post RYGB Gastro-jejunal Anastomotic Stricture (GJAS): A Multicenter Comparative Study. Gastrointest Endosc. 2022.
4. Jirapinyo P, et al. Efficacy of LAMS in the Treatment of Gastrojejunal Anastomotic Stenosis. Gastrointest Endosc. 2018.
5. Packey C. Role for LAMS in the Management of Short-Length Gastrointestinal Strictures. Gastrointest Endosc. 2018.
6. Samuels JM, et al. Use of LAMS in Treating Gastrojejunal Anastomotic Strictures in Bariatric Patients. Surg Endosc. 2023.
7. Sawas T. Endoscopic Stenting for Symptomatic Gastrojejunal Anastomotic Stricture Provides Durable Clinical Response After Failed Balloon Dilation. Gastrointest Endosc. 2020.
8. Shamaa O. Management of Gastro-Jejunal Anastomotic Strictures: Comparing Endoscopic Outcomes in Primary vs Conversion Roux-en-Y Gastric Bypass Patients. Am J Gastroenterol. 2024.
9. Skidmore AP. Use of LAMS in the Management of Gastro Jejunostomy Stricture Following Roux-en-Y Gastric Bypass for Obesity: A Prospective Series. BMC Surg. 2021.

Introduction

Esophageal stenting (ES) is an important intervention for the management of malignant and benign dysphagia, with migration representing a common drawback. This systematic review with meta-analysis aimed to assess the benefit of ES fixation over non-fixated stenting.

Aims & Methods

A systematic research was performed in MEDLINE, Cochrane, Scopus and ClinicalTrials.gov databases until January 2023 for comparative studies evaluating the migration rates of ES after anchoring or not. The primary outcome included the difference of migration rates for fixated and non-fixated ES, with the rate of adverse events being the secondary outcome. A subgroup analysis was stratified the results based on different fixation techniques; suturing, over the scope clipping (OTSC) and trough the scope clipping (TTSC). Meta-analyses were based on random effects model and the results were reported as odds ratios (OR), with 95% Confidence Intervals (95%CI).

Results

Ten studies (1014 patients) were included to our analysis. The rates of stent migration were significantly lower after fixation [OR=0.20 (95%CI: 0.11-0.37; I²=59%)]. The rates of adverse events were similar between the fixation and control groups [OR=0.65 (95%CI: 0.28-1.52; I²=55%)]. In the subgroup analysis, all anchoring techniques preserved the superiority over non-fixated stents [suturing OR= 0.23 (95%CI: 0.10-0.53); OTSC OR= 0.31 (95%CI: 0.17- 0.58); TTSC OR=0.10 (95%CI: 0.03-0.38)], however only OTSC and TTSC groups achieved non-significant heterogeneity (I²=0%). No difference between techniques was recorded considering the migration rates.

Conclusion

Esophageal stent fixation is associated with significantly lower migration rates compared to the non-fixated stents regardless type and stenting indication.

Introduction

Postoperative anastomotic leaks and fistulae in the upper digestive tract are severe complications that can lead to significant morbidity and mortality. Traditionally, surgical intervention has been the primary approach to address these complications. However, self-expanding metal stents (SEMS) have emerged as a less invasive alternative, offering a potential pathway to achieve closure of these leaks and fistulae. Despite their growing use, the efficacy and safety profile of SEMS in this context is not fully understood.

Aims & Methods

This study aims to evaluate the success rates, safety, and predictive factors of therapeutic success for SEMS in managing postoperative upper digestive tract leaks and fistulae, drawing on a 10-year experience at a tertiary center. We conducted a retrospective review of patients with postoperative anastomotic leak or fistula who underwent endoscopic SEMS placement at our tertiary center between 2014 and 2022, and prospectively from 2022 onwards. Therapeutic success was defined as complete closure of the leak/fistula, while failure indicated non-closure.

Results

We included a total of 43 patients (69.8% male) with a median age of 61 years (IQR 17). There were no statistically significant differences regarding distribution by gender, age, Charlson comorbidity index, benign vs malignant disease, time from surgery to endoscopic treatment and leak size between the different types of stents (p>0.05). The technical efficacy was 100%, with a therapeutic success rate of 55.8%. Bariatric stents exhibited the highest success rate (85.7%), followed by fully covered SEMS (60.0%) and partially covered SEMS (46.2%) (p = 0.166). Success was significantly higher in patients with a smaller leak size (10 mm vs. 12 mm, p<0.05). Therapeutic failure was associated with greatest need for endoscopic adjuvants (57.9% vs. 37.5%, p=0.183). The overall mortality rate was 34.9%.

Conclusion

This study indicates that self-expanding metal stents (SEMS) offer a viable and safe treatment option for postoperative upper digestive tract leaks and fistulae. With a technical efficacy of 100% and a therapeutic success rate of 55.8%, SEMS demonstrated promising results. The success rate was influenced by stent type, with bariatric stents showing the highest rate, followed by fully covered SEMS and partially covered SEMS. Smaller leak size emerged as a significant predictor of therapeutic success, emphasizing the importance of early detection and timely intervention. Although the overall mortality rate was 34.9%, this study's outcomes suggest that SEMS can play a crucial role in managing these complications, with early diagnosis and prompt stent placement being pivotal for success. Further research is needed to better understand the factors contributing to therapeutic success and to optimize endoscopic strategies for patients with upper digestive tract leaks and fistulae.

Introduction

Self-expandable metallic stent (SEMS) placement is a palliative treatment for inoperable esophageal malignancies to improve the quality of life. Traditional methods rely on fluoroscopy and endoscopy, but anatomical landmarks can simplify the procedure.

Aims & Methods

To evaluate the technical success, safety and reproducibility of using vertebral column and diaphragm landmarks for SEMS placement.
This retrospective observational study included 801 patients with inoperable esophageal malignancies undergoing SEMS placement for dysphagia due to malignant esophageal strictures, by using vertebral column and diaphragm as landmarks, from 1^st January 2006 to 31^st December 2024. The primary endpoint was to assess the technical success, safety and reproducibility of this unique technique for SEMS placement.
Methodology for Stent Placement in Esophageal Tumors:
1. For Proximal or Mid-Esophageal Tumor, following algorithm was followed: Step 1: Identify key anatomical landmarks using fluoroscopy. Step 2: With the scope in place, under fluoroscopic guidance, identify the vertebra in line with the distal extent of the tumor using the diaphragm as a reference, followed by identification of vertebra at the proximal extent of the tumor. Count the vertebrae between the distal and proximal extent of the tumor. Assign a length of 2.5 cm per vertebral body. Ascertain the desired size of SEMS by calculating the total length of the stricture by counting the vertebrae, adding one vertebral body above and below the tumor for proper stent placement. Step 3: Using fluoroscopy, position the stent. Place the distal end of the stent at the distal vertebral marker. Position the proximal end of the stent at the proximal vertebral marker. Release the stent at the appropriate position to ensure full coverage of the stricture.
2. For Tumor Extending Beyond the Gastro-Esophageal Junction (GEJ), following algorithm was followed: Step 1: Identify the proximal extent of the tumor. Align the proximal extent of the tumor with the vertebra, using the diaphragm as a reference for precise alignment. Measure the distance from the proximal end of the tumor to the proximal stomach using the scope to decide the required size of the stent. Step 2: Place the stent under fluoroscopic guidance. Position the upper end of the stent at the identified vertebra. Extend the distal end of the stent into the stomach, past the GE junction to ensure proper coverage. Release the stent.

Results

408 (50.9%) patients were females. The age range was 18-95 years (mean50±Standard deviation15). Predominant presenting complaint was dysphagia (85.39%). Average duration of dysphagia was 3.84 months. 594 (74.16%) patients had squamous cell carcinoma, whereas 207 (25.84%) patients were diagnosed with adenocarcinoma on histopathology. 365 (45.57%) patients had tumor confined to the lower one-third of esophagus. Major cause of inoperability was distant metastasis (52.81%). 240 (30%) patients had involvement of GEJ. Average length of malignant stricture was 8.4 cm. 139 (17.40%) patients required dilatation by using savary gilliard dilators before SEMS placement. TEF was present in 48 (6%) patients. Range of length of SEMS was 8-18 cm (12.5±2.26). Technical success was achieved in 100% cases. No major immediate complications occurred. Minor complications were rare.

Conclusion

Using vertebral column and diaphragm landmarks is a reliable, safe, simplified and reproducible approach for SEMS placement in patients with inoperable esopahgeal malignancies.

References

1. Lander S, Lander E, Gibson MK. Esophageal Cancer: Overview, Risk Factors, and Reasons for the Rise. Curr Gastroenterol Rep. 2023 Nov;25(11):275-279. doi: 10.1007/s11894-023-00899-0. Epub 2023 Oct 9. PMID: 37812328.

2. Li J, Xu J, Zheng Y, Gao Y, He S, Li H, Zou K, Li N, Tian J, Chen W, He J. Esophageal cancer: Epidemiology, risk factors and screening. Chin J Cancer Res. 2021 Oct 31;33(5):535-547. doi: 10.21147/j.issn.1000-9604.2021.05.01. PMID: 34815628; PMCID: PMC8580797.

3. Asghar MS, Khan NA, Kazmi SJH, Hassan M, Rasheed U, Jawed R, Yaseen R, Naqvi SAA. Clinical, epidemiological, and diagnostic characteristics of esophageal carcinoma in a Pakistani population. Ann Saudi Med. 2021 Mar-Apr;41(2):91-100. doi: 10.5144/0256-4947.2021.91. Epub 2021 Apr 1. PMID: 33818145; PMCID: PMC8020643.

Introduction

Oesophageal leaks and fistulae are a major complication of upper gastrointestinal surgery leading to high rates of postoperative morbidity and mortality. Self-expanding metal stents (SEMS) are the endoscopic mainstay of treatment. Recently, endoscopic vacuum therapy (EVT) as emerged as a promising alternative. The present study intends to evaluate the success rate and safety of EVT versus SEMS in upper gastrointestinal tract surgical leaks/fistulae in a referral centre.

Aims & Methods

We included all patients undergoing EVT in 2022-2023 (n=5) versus all patients submitted to SEMS from 2014 to 2022 (n=39) due to upper gastrointestinal tract surgical leak/fistulae.

Results

There were no statistically significant differences regarding distribution by gender, age, benign vs malignant disease, time from complication diagnosis to endoscopic treatment, time from surgery to endoscopic treatment and leak size (p>0.05).
The success rate, defined as complete closure of the surgical leak/fistulae, was reached in all patients submitted to EVT and in 56.4% of patients with SEMS (p=0.14). Two patients undergoing EVT were previously submitted to unsuccessful SEMS treatment. The median number of endoscopic treatment sessions were significantly superior for EVT [4 (IQR:3) vs 2 (IQR:1); p<0.01].
Technique related complications, readmission and mortality rates were superior in SEMS vs EVT (76.9% vs 0%; 51.3% vs 20%; 35.9% vs 0%, respectively), although these differences were only statistically significant for complication rate (p<0.01). None of the deaths were related to stent placement.

Conclusion

Although with a higher number of treatment sessions, our experience showed that EVT is a safe and effective alternative to endoscopic stenting, with higher success rate (100% vs 56.4%) and lower complication, readmission, and mortality rates. Our data shows that EVT has the potential to become the new gold standard in the endoscopic treatment of oesophageal leaks and fistulae.

Introduction

Sleeve gastrectomy (SG) is currently the most commonly performed bariatric surgery worldwide, attributed to its technical simplicity, effectiveness, and favorable safety profile. Despite these advantages, postoperative gastric leaks remain a serious complication, occurring in up to 5% of cases. Endoscopic stenting is a widely adopted management approach; however, the impact of stent size, small stents (SS) versus megastents (MS) on clinical outcomes remains unclear

Aims & Methods

This systematic review and meta-analysis adhered to PRISMA 2020 guidelines. A comprehensive search of PubMed, Scopus, Embase, Web of Science, and CENTRAL was conducted for studies published until January 2025. Twenty-two studies met inclusion criteria, encompassing 273 patients with SG-related leaks treated via endoscopic stenting. Primary outcome was successful leak closure. Secondary outcomes included complication rates, stent duration, number of interventions, and hospitalization length

Results

Leaks were categorized as early (58%), acute (20%), late (12%), and chronic (10%). The pooled failure rate of stenting was 20.4% (95% CI: 13–28%), with moderate heterogeneity (I² ≈ 30.2%). Subgroup analysis showed failure rates of 22.1% for SS and 17.2% for MS. The relative risk (RR) for failure with MS compared to SS was 0.78 (95% CI: 0.54–1.14; p > 0.05), indicating no statistically significant difference. Stent migration occurred in 23.4% of cases, more often with MS (30%) than SS (16%), though this difference was also not statistically significant. MS showed a significantly shorter mean stent duration (32.6 vs. 55.1 days; p < 0.05) and required fewer interventions (1.9 vs. 2.4). Sensitivity analysis and funnel plots confirmed result robustness with minimal publication bias

Conclusion

Although both small and mega endoscopic stents are effective in managing SG-related leaks, megastents may offer modest clinical advantages, particularly shorter treatment durations and fewer procedures. However, the lack of statistically significant differences in primary outcomes underscores the need for further high-quality comparative studies to define optimal stent choice