Introduction

Malignant oesophageal strictures can cause airway compromise and fistula formation¹. Combined oesophageal and airway stenting is a potential treatment yet no guidelines exist². This study aims to describe the outcomes of same-session oesophageal and airway endoscopic stenting for malignant strictures and propose an algorithm for intervention.

Aims & Methods

A retrospective study on patients undergoing same-session gastroenterology (GI) and respiratory endoscopy at University College London Hospital, 2019-2023. All procedures were with anaesthetic-led propofol sedation. Endoscopic decision making was based on preprocedure multidisciplinary team meeting (MDM) and intra-procedure clinical assessment. Data collected included malignancy type, luminal narrowing, complications, and mortality.

Results

26 patients were identified. Mean age was 63 years. Cancer type was oesophageal (81%) or lung (19%). The most common referral indication was dysphagia (42%); airway compromise was often seen on imaging (65%). Stent insertion was oesophageal only (35%), airway only (19%) and dual (27%) (Table 1). Airway stenting was common (80%) if airway stenosis was >50%. No airway stenting occurred if stenosis was <50%. After oesophageal stenting, repeat bronchoscopy showed increased airway stenosis in 4 patients (25%). The only intraoperative complication was one oesophageal perforation. New tracheooesophageal fistula was the most common post-intervention complication (15%). Median time from malignancy diagnosis to death was 7.9 weeks.

Conclusion

We present the first algorithm (Figure 1) for endoscopic stenting in patients with malignant oesophageal stricture and airway involvement. We suggest upper GI and respiratory MDM to plan same-session endoscopy with decision-making framed by patient-centred goals given their poor prognosis.

References

1. Khan A, Hashim Z, Neyaz Z, Agarwal A, Mohindra S, Nath A. Dual Airway and Esophageal Stenting in Advanced Esophageal Cancer With Lesions Near Carina. J Bronchology Interv Pulmonol.2020;27(4):286-293. doi:10.1097/LBR.0000000000000672
2. Bi Y, Ren J, Chen H, Bai L, Han X, Wu G. Combined airway and esophageal stents implantation formalignant tracheobronchial and esophageal disease. Medicine. 2019;98(3):e14169.doi:10.1097/MD.0000000000014169

Introduction

Transmural oesophageal defects are associated with significant morbidity and mortality. Repeat surgery is often complicated and undesirable with variable outcomes. Increasingly, endoscopic interventions including clip closure devices, temporary full covered self-expanding metal stents (FcSEMS) and endoscopic suturing are being used to treat this problem. Endoscopic vacuum therapy (EVT) relies on a sponge-based device that is placed either within a cavity or the oesophageal lumen to provide continuous negative pressure over the defect which enhances drainage and tissue micro-perfusion.
The VacStent GI^TM (MicroTech) device is an innovative endoscopic solution which synergistically incorporates the advantages of a fcSEMS while synchronously employing the principles of EVT.

Aims & Methods

We retrospectively analysed patients undergoing treatment for transmural oesophageal defects with the VacStent GI^TM (MicroTech) device between October 2023 and Febuary 2025 at two upper GI surgical centres (UCLH and University Hospitals of Derby).
All patients had cross-sectional imaging and any chest contamination was drained before stent insertion. Defects involving the cricopharnyx and/or those more than 5cm were excluded. Continuous negative pressure of 125 mmHg was used for the first 24 hours after stent placement and then reduced to 75 mmHg. The VacStent was exchanged every 7-10 days until defect closure. All cases were performed in endoscopy with a minimum of propofol sedation and were discussed as part of specialist MDT.
The primary outcome was clinical success, defined as the endoscopic and radiological evidence of defect closure. Secondary outcomes included technical success, number of stent exchanges, serious adverse device effect (SADE) and time to defect closure.

Results

The VacStent GI^TM (MicroTech) device was used 33 times in 16 patients with a median age of 65 years (IQR 57-75). The study population comprised 75% male and 25% females. 2/16 (12.5%) had defects secondary to boerhaaves syndrome, 4/16 (25%) had iatrogenic defects and, 10/16 (62.5%) had anastomotic leaks (1=benign:9=malignant).
Clinical success was achieved in 10/16 (62.5%) patients with a technical success rate of 100%. Median time to defect closure following index VacStent implantation was 10 days (IQR 6-15) with a median of 1 VacStent exchange (IQR 0-2). The median defect size was 10mm (IQR 6-14). Cases of VacStent failure appear to be related to defects more than 4cm and those within a conduit (Table 1). There was a single adverse event related to severe bleeding due to the stent becoming embedded to the oesophageal lumen – after the VACStent was removed, a temporary fully covered stent was placed to tamponade any bleeding and later removed uneventfully.

Conclusion

In conclusion, our experience has demonstrated that VacStent is a safe and effective treatment option for oesophageal defect closure achieving this in 62.5% of patients. This is a challenging cohort of patients that usually have limited treatment options. Multi-disciplinary collaboration and early recognition of both appropriate and inappropriate defect dimensions and aetiology is critical to enhancing success rates. Ongoing experience with a more diverse and larger patient population will further clarify the position of the VacStent device in the EVT treatment paradigm.

Introduction

Oesophageal stent placement is a nonsurgical alternative for palliation of malignant obstruction. It is now established as a major treatment for dysphagia resulting from inoperable oesophageal cancer.

Aims & Methods

A retrospective study of all patients undergone oesophageal stent insertion at a single endoscopy unit under fluoroscopy from July 2015 to Nov 2022 was undertaken.
Aim: Evidence of immediate or late complications, repeat interventions, and for survival statistics after stent insertion.

Results

95 oesophageal stents were placed in 7 years. There were 28% Female (28/95) and 69% Males (68/95), mean age 73 (Range 47-91). The mean Indication dysphagia due to oesophageal stricture. Histology revealed: 64 adenocarcinoma, 22 squamous cell carcinoma, 5 high grade dysplasia. Location of malignancy:81 distal oesophagus, 6 proximal oesophagus, 5 Gastro-oesophageal junction and 3 Mid oesophagus. Types of stent used: 84 Fully Covered, 2 Uncovered.
No immediate complications reported apart from 2 stents moved on reintubation or extubation. The endoscopy was repeated in 43 patients.
Late complications 13% (13/95): 6 patients had Tumour overgrowth, 6 patients had Stent migration and one patient had a Food bolus. The 30 days mortality is 13%.

Conclusion

Palliative Oesophageal stent insertion in our hospital proved to be an effective treatment for patients with malignant dysphagia.
Outcomes compare favourably with published data in terms of complications and mortality.
It is a relatively safe procedure with no immediate complications and a low rate of serious acute complications.
Steps to improve post-procedure monitoring with prospective collection of data could be useful in future service development.

References

Esophageal stenting for benign and malignant disease: European Society of Gastrointestinal Endoscopy (ESGE) Guideline – Update 2021

Introduction

The Cryoballoon Focal Ablation System (CbFAS) (Pentax Medical Inc) is an innovative device designed for the endoscopic ablation of Barrett's-related neoplasia. This system has been shown to provide advantages such as reduced stricture rates and improved patient tolerance compared to the conventional standard of care, radiofrequency ablation (RFA).
We report early outcomes from a prospective UK first multi-centre registry of consecutive patients who underwent Cryoablation for the endoscopic eradication (EET) of Barrett’s-related neoplasia.

Aims & Methods

Patients were prospectively enrolled from two tertiary referral centres for Barrett’s Oesophagus (BE). Inclusion criteria included patients with a BE segment no longer than 5cm with histologically-proven dysplasia on biopsy or endoscopic resection specimens suitable for EET of BE after MDT review. Cryoablation sessions were conducted at 3-month intervals until endoscopic eradication was complete. The standardised protocol involved administering 8 seconds per ablation for all enrolled patients with the CbFAS. Our primary outcome was complete eradication of BE. Secondary outcomes included the number of ablations performed, adverse events, device malfunction, stricture rate, patient tolerance, and endoscopist satisfaction which was evaluated using a 10-point Likert scale (1=poor, 10=excellent).

Results

Between January 2020 and December 2023, a total of 16 patients (35 treatment sessions) were treated. The median BE length was C0M2. Complete eradication of BE was achieved in 89% (8/9) of patients who had completed treatment. No instances of device malfunction or intraoperative adverse events were recorded. A stricture rate of 12.5% (2/16) was observed, both of which were successfully managed through endoscopic dilatation. All patients were recorded as tolerating the procedure well with sedation. The median endoscopist satisfaction score was 9 (+/- 2.4) with only one recorded instance of difficulty attributed to balloon positioning.

Conclusion

These preliminary results from the UK cryoablation registry suggest that cryoablation with the CbFAS is a safe and effective therapy for BE-related dysplasia. The stricture rate appears to be comparable to that observed with RFA and similar studies. With the planned enrolment of further centres and suitable patients, this registry will further enhance our understanding of the long-term efficacy and safety profile of cryoablation using the CbFAS.

Introduction

A decade ago, endoscopic surveillance (ES) for Barrett’s oesophagus (BO) was recommended to improve the outcome of oesophageal adenocarcinoma through early recognition and prevention¹. The yield of ES to detect dysplasia may depend on guideline adherence and quality of endoscopy^2,3,4.

Aims & Methods

The aim is to assess whether dedicated (expert) ES (DS) is more effective than conventional (non-dedicated) ES (NS) by means of Key Performance Indicators (KPI), Dysplasia Detection Rate (DDR), use of advanced imaging and complication rate.
This multicentre (5 UK hospitals) retrospective study includes real-world ES data from 1303 procedures conducted within the last 8 years. The endoscopy and histology reports and clinical notes of consecutive procedures were accessed. The data were collected in spreadsheets and then analysed with SPSS-23. Two services were reported demographically and compared with appropriate statistical tests and logistic regression to test factors associated with DDR.

Results

Data from 680 DS and 623 NS procedures were included, comprising 906 (69.5%) males and 397 (30.5%) females (M:F=2.3:1.0). The age ranged from 14-90 yrs with a mean of 63.7 (SD±12.5) yrs. The maximum length of the BO was 18 cm with a mean of 4.1 cm (SD±3.0). There were significant differences in all the KPIs (Prague classification, Barrett’s island description, hiatus hernia delineation, visible lesion documentation, Paris classification, Seattle protocol adherence and inspection time) favoring the DS (P<0.001). Other comparisons: narrow band imaging (NBI, P<0.001), acetic acid chromoendoscopy (AAC, P<0.001), sedation (P=0.02) and acquisition of target biopsies (, P<0.001) were also significantly higher in DS while the complication rate was significantly lower (P=0.05). Importantly, the DDR was significantly higher in DS (58/680 (8.5%)) than in NS (16/623 (2.6%)) with a P<0.001. Regression analysis showed: increasing age, male sex, lesion description and Paris classification documentation were associated with higher DDR (Table 1), while other indicators showed no significant association.

Table 1. Factors associated with dysplasia detection

Conclusion

Surveillance for BO through a dedicated service with high quality endoscopy can produce a higher diagnostic yield with improved DDR and a lower complication rate. Given these benefits, large-scale prospective studies are warranted to assess the true impact on mortality, morbidity, cost benefit and patient-reported outcomes, ensuring that surveillance service provides a meaningful clinical benefit, particularly with risk stratification concerning the factors associated with disease progression.

References

1. Fitzgerald et al. (2013). BSG guidelines on Barrett’s oesophagus. Gut, 63(1), 7–42. doi:10.1136/gutjnl-2013-305372.
2. Britton et al. (2019). Improving accuracy in Barrett’s surveillance. Frontline Gastroenterol, 10(2), 128–134. doi:10.1136/flgastro-2018-101019.
3. Ratcliffe et al. (2023). Surveillance service improves dysplasia detection. Frontline Gastroenterol, 15(1), 21–27. doi:10.1136/flgastro-2023-102425.
4. Ratcliffe et al. (2023). Dedicated Barrett’s surveillance vs. standard care. iGIE, 3(1), 58–65. doi:10.1016/j.igie.2023.11.003.

Introduction

A Zenker diverticulum is an acquired sac-like outpouching of the mucosa and submucosa that occurs at the pharyngo-oesophageal junction. When symptomatic, it is characterised by oropharyngeal dysphagia and regurgitation. Multiple treatment options are available with various success. Commonly a flexible endoscopic diverticulotomy is performed but is associated with a high risk of recurrence. Zenker peroral endoscopic myotomy (Z-POEM) represents are exciting endoscopic strategy that involves third space endoscopy by tunnelling through the submucosa to enable a more complete myotomy. Early studies have shown a high success rate and favourable safety profile, but it is mainly limited to small retrospective cohorts outside the UK. Here, we report our experience on Z-POEM at two UK tertiary referral centres.

Aims & Methods

We conducted a retrospective cases series among patients undergoing Z-POEM between April 2021 to March 2023 at University College London Hospital and Cleveland Clinic London. Patient demographics, technical success, clinical success, and adverse events were all recorded. Technical success was defined as successful completion of all steps of the Z-POEM procedure. Clinical success was defined as a reduction in Dakkak and Bennett (DB) dysphagia score to ≤ 1 (or 0 if the pre-treatment score was 1) at three- and six-months post-procedure without need for repeat intervention.

Results

In total, 33 patients underwent Z-POEM. The median age was 76 years old (IQR 70-79), 13 patients (39.4%) were female, and the median Charlson comorbidity Index was 3 (IQR 3-4.5). Pre-procedure, the median DB score was 2 (IQR 2-3) and the mean pouch size was 3.98 cm (95% CI: +/- 0.6). Seven patients had previously undergone attempted endoscopic stapling and one open surgery. All procedures were performed under a general anaesthetic. The mean procedural time was 48.9 minutes (95% CI: +/- 7.9), median length of stay one day, and the technical success rate was 100%. The overall clinical success (minimum one month follow-up) was 83.3% with a median follow-up of 8 months (IQR 4-13). At 3-months, 6-months, and 12-months post-procedure, the clinical success was 87.0% (n=23), 77.8% (n=18), and 66.7% (n=12), respectively. Three patients had improved DB scores but opted for repeat intervention for persistent symptoms. Two underwent successful repeat Z-POEM to extend the myotomy and one underwent a diverticulotomy of remaining muscle fibres. One patient is awaiting work-up for a planned repeat Z-POEM. During follow-up, there were two adverse events (7.4%) due to post-operative chest infections. Two patients died, which were both unrelated to the Z-POEM procedure.

Conclusion

Z-POEM is a novel minimally invasive procedure that is associated with low adverse events and high success rates. Our early outcomes are promising and consistent with other observational cohorts. Those with persistent symptoms can be treated successfully with reintervention, which improves the clinical efficacy to >90% at one year. The marker of success appears to be completeness of the initial myotomy, and patients should be aware of the possibility and efficacy of reintervention.

Introduction

Advanced oesophageal cancers (OC) exhibit poor median survival rates, and often self-expandable metal stents (SEMS) are used to address malignant dysphagia. Previous studies purport to a high prevalence of adverse events post stent insertion, without an impact on mortality. We aimed to review mortality outcomes of oesophageal stenting in both squamous cell carcinoma (SCC) and adenocarcinomas (AC).

Aims & Methods

One hundred and eighty-six patients who were diagnosed with OC between September 2010 - February 2021 were included. We retrospectively analysed the data for patient demographics, histology, oncological management, oesophageal stenting, and mortality, notably overall survival (OS). Survival probability was calculated using Kaplan-Meier survival curves and compared using Log-rank testing with statistical significance determined by p value <0.05.

Results

From the 186 OC diagnoses made. Male: Female 136 (73%) and 50 (27%). Mean age at diagnosis was 73 years (range 32-98). Histological findings showed 132 patients had AC (71%), and 54 patients had SCC (29%). Mean OS from date of diagnosis for AC and SCC were 21.6 and 10.6 months respectively.

SEMS were inserted for 98 patients (53%); 37 (38%) for SCC and 61 (62%) for AC. Mean OS for patients with stenting vs not stenting was 11.1 and 26.4 months respectively. Median OS for stenting was 8 months (95% CI, 6.0 - 10.0) vs 10 months for not stenting (95% CI, 7.0 -16.0) with a p<0.0005) (See Figure 1). 30-day mortality post stent insertion was 23%.
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For patients who underwent oesophageal stent insertion, mean OS for AC and SCC 11.9 months (95% CI, 8.989 to 14.913) and 10.1 months (95% CI, 6.709 to 13.561) respectively. Median OS for stent population for SCC and AC were 6 months (95% CI, 5.0 -8.0) and 9 months (95% CI, 6.0 -12.0) respectively (p = 0.3765).

Conclusion

Patients with OC who underwent stent insertion had overall poor survival outcome. This could reflect advanced stage of OS. Stenting is often useful for malignant dysphagia in patients who harbor inoperable disease. Analysis of stent adverse events would be useful.

Disclosure

Nil