Clinical Case Summary

39-year-old male, diagnosed with a gastroesophageal junction adenocarcinoma underwent a hybrid thoraco-laparoscopic oesophagectomy in October 2021.
On post-op day 13 patient developed fever not responding to antibiotics. Contrast enhanced computed tomography (CECT) of chest & abdomen with contrast swallow, identified an anastomotic leakage with a right side chest collection. Over-the-scope clip and oesophageal fully covered metal stent was used to attempt closure without success.
An 11mm atrial septal defect (ASD) closure device, which is a self-expanding, double umbrella shaped device made of nitinol wire mesh, was used to close the 5mm defect seen at the anastomotic site. Feeding was continued via nasojejunal tube.
CECT done 2 weeks and 6 months after insertion showed no contrast leak or evidence of recurrence. Oesophagogastroduodenoscopy done at 6 months showed the ASD closure device to have dislodged from the site and remain free in the stomach. The site of leak had completely closed. Patient remained asymptomatic, without any evidence of recurrence on CECT done 3 years after surgery.
This clinical case describes the novel, off label use of an ASD closure device to treat post-oesophagectomy anastomotic leakage , where other conventional endoscopic treatment methods have failed. Reports on similar application of this device in endoscopic treatment of anastomotic leakage are scarce worldwide (1-3), and long term patient outcomes upto 3 years have not been reported.
This method is more costly than alternate endoscopic treatment methods for anastomotic leakage. However, the unique structure of the ASD closure device which promotes tissue growth, and the availability of multiple disk and waist size variations contributes to a higher success rate than other conventional endoscopic treatment methods. Therefore the use of ASD closure devices can be considered where other alternatives have failed, when a minimally invasive treatment option is sought.

References

1. Repici A, Presbitero P, Carlino A, Strangio G, Rando G, Pagano N, et al. First human case of esophagus-tracheal fistula closure by using a cardiac septal occluder (with video). Gastrointest Endosc. 2010 Apr;71(4):867–9.
2. Subtil JC, Valenti V, Cienfuegos JA, Calabuig J, Hernández-Lizoain JL, Muñoz-Navas M. Successful endoscopic closure of multiple tracheoesophageal fistulas following implantation of two atrial septal defect occluders. Endoscopy. 2016;48:E346–7.
3. Coppola F, Boccuzzi G, Rossi G, Gaia S, Cosimato M, Recchia S. Cardiac septal umbrella for closure of a tracheoesophageal fistula. Endoscopy. 2010;42(SUPPL. 2).

Introduction

In the treatment of esophageal carcinoma, abdomino-thoracic esophagectomy is the curative therapeutic option, often combined with perioperative (radio-)chemotherapy. This procedure is associated with high complication rates and significant mortality. Anastomotic leakage, with a pooled incidence of 11% (ranging from 0% to 49%)¹, constitutes a major postoperative complication. New therapeutic options, such as the EndoVac (Stent) system, offer promising approaches for its management. The aim of this study was to identify risk factors for the occurrence of anastomotic leaks and to evaluate the effectiveness of various treatment methods.

Aims & Methods

We present data from 2022–2024 collected at the University Medical Center Göttingen, a high-volume center for esophageal surgery. A total of 242 patients who underwent abdomino-thoracic esophagectomy, either as primary treatment or after neoadjuvant therapy, were included. Structured data collection and analysis were carried out using Excel and GraphPad Prism.

Results

In this patient cohort, 79.3% were male (n=192) and 20.7% female (n=50), with a mean age of 65.4 years and a mean BMI of 26.1 kg/m² at the time of surgery. The most common pre-existing conditions were 56.6% arterial hypertension (n=137), 7,9% COPD (n=19), 21% diabetes mellitus (n=51), as well as coronary artery disease (CAD) and peripheral arterial disease (PAD), each 8.2% (n=20). Histologically, 80.1% (n=194) adenocarcinomas and 19.4% (n=47) squamous cell carcinomas. 88.8% of patients received neoadjuvant therapy (n=215): 35.5% radiochemotherapy (n=86) and 53% chemotherapy (n=129). Of all patients, 24.8% (n=60) underwent primary open surgery and 75,3% (n=182) had minimally invasive hybrid procedures. By 2024, minimally invasive approaches had increased to 83.3% (n=86).
Anastomotic leakage occurred in 25 patients (10.3%), with clinical manifestation appearing on average 8 days postoperatively (range: 1–29 days). An association with the occurrence of anastomotic leakage was observed for nicotine abuse (OR 1.35; 95% CI: 0.60–3.11), alcohol consumption (OR 1.69; 95% CI: 0.66–4.24), coronary artery disease (CAD), and peripheral arterial disease (PAD) (each OR 2.37; 95% CI: 0.80–7.81); however, none reached statistical significance in Fisher’s exact test (all p > 0.05). Complete remission (24.4%, n=59) was significantly associated with an increased risk of leakage (OR 3.51; 95% CI: 1.53–7.86; p = 0.005).
All 25 anastomotic leaks were initially treated with EndoVac, healing successfully in 21 cases (96%). Four patients (16%) required revision surgery. An EndoVacStent was implanted in 52% of cases (n=13), with 20% receiving only an EndoVacStent (n=5) and 32% treated with a combination of sponge and stent (n=8). The average duration of EndoVac therapy was 15 days (range: 1–42 days), with the system being exchanged three times on average. In-hospital mortality was 1.6% (n=4).

Conclusion

In summary, the EndoVac and EndoVacStent systems have proven to be safe and effective treatment options for anastomotic leakage. Patients with complete remission showed an increased susceptibility to anastomotic leakage. Our data supports the importance of studies like ESORES (DRKS00022050)² and PRESTO (NCT05713838)³, investigating non-operative treatment approaches for clinical complete remission cases followed by a watch-and-wait strategy.

References

1. Sivesh K Kamarajah, Aaron Lin, Thahesh Tharmaraja, Yashvi Bharwada, James R Bundred, Dmitri Nepogodiev, Richard P T Evans, Pritam Singh, Ewen A Griffiths, Risk factors and outcomes associated with anastomotic leaks following esophagectomy: a systematic review and meta-analysis, Diseases of the Esophagus, Volume 33, Issue 3, March 2020, doz089, https://doi.org/10.1093/dote/doz089
2. ESORES – A prospective registry study for patients with esophageal cancer and clinical complete response after neoadjuvant therapy. German Clinical Trials Register (DRKS00022050). https://www.drks.de/DRKS00022050
3. PRESTO – Prospective evaluation of watch-and-wait strategies in complete responders to neoadjuvant therapy for esophageal cancer. ClinicalTrials.gov (NCT05713838).
https://clinicaltrials.gov/ct2/show/NCT05713838

Introduction

Prophylactic wound closure after Endoscopic Submucosal Dissection (ESD) is suggested in high-risk patients to reduce delayed AEs (e.g. bleeding). The closure of large wounds can be challenging with standard endoscopic devices (e.g. endoclips) and dedicated devices are needed. Endoscopic Hand-Suturing (EHS) can be a therapeutic option to close extensive gastrointestinal defects. The current study presents the EHS experience from two Italian centers, aiming to assess the feasibility and clinical effectiveness of the EHS technique.

Aims & Methods

Data from two high-volume endoscopic Italian centers were retrospectively collected. Patients with an ESD wound closed using the SutuArt (Olympus Medical Systems, Tokyo, Japan) device were enrolled in the study (Figure1). Demographics, technical data, success rate, suturing speed, and AEs were recorded

Results

Between June 2023 and August 2024 10 patients were enrolled in the study, demographics in Table 1. All patients were at high-risk for delayed bleeding after gastric or colorectal ESD (figure2). The mean lesion size was 34mm (range 15-45). In all cases SutuArt (Olympus Medical Systems, Tokyo, Japan) needle holder with V-LOC 180, size 3-0 threads (Medtronic) were used. All procedures were performed by two expert endoscopists. ESD-wound closure was successfully achieved in 90% of cases. The mean suturing time was 42 min (range: 25–65 min, SD=23.3 min) meanwhile the mean ESD time was 86 minutes (range: 15–185min, SD=38min). Suturing significantly increased the total procedure time (120min Vs 86min, p<0.001). In one case, the wound closure failed due to suture breakage, resulting in needle entrapment within the mesorectum, with the impossibility of retrieving it. No other AEs were reported.

Conclusion

ESD-defects closure with EHS is feasible and safe with promising outcomes. However, this technique is significantly time-consuming. Probably extended training may be required for endoscopists performing suturing, and further studies are needed to assess the real-life applicability and the cost-effectiveness of this technique.

Introduction

Esophageal stricture after endoscopic submucosal dissection (ESD) remains a significant clinical challenge, particularly when the post-ESD mucosal defect involves ≥75% of the esophageal circumference. Various preventive strategies, including local or systemic corticosteroids, have been explored to mitigate this risk, but their efficacy is often limited by incomplete drug coverage, suboptimal timing of administration, or considerable side effects. This study aimed to investigate a new prophylactic strategy to prevent post-ESD esophageal strictures in cases of large circumferential mucosal defects.

Aims & Methods

This was a prospective single-arm trial conducted at a large regional medical center in Southwest China. Patients were considered eligible if they met all of the following criteria: (1) early esophageal cancer confirmed by postoperative pathology; (2) an ESD-induced mucosal defect involving ≥75% of the esophageal circumference; (3) no evidence of local or distant metastasis; and (4) no contraindications to corticosteroid therapy. All eligible patients received a combined steroid regimen to prevent stricture formation. Specifically, the first triamcinolone injection was administered intraoperatively immediately after complete lesion resection. Using a 23G endoscopic needle, triamcinolone (8 mg/mL) was injected submucosally at multiple points around the resection bed, spaced approximately 1 cm apart in four quadrants (0.5-1 mL per site; total of 20-40 injections). The second injection, following the same protocol, was given on postoperative day 4. Oral prednisone was started on day 5 post-ESD at 30 mg/day for 2 weeks, then reduced to 25 mg/day for the next 2 weeks, followed by a taper of 5 mg per week until discontinuation at 8 weeks. Clinically significant stricture was defined by both an inability to pass a standard 9.9 mm endoscope and a dysphagia severity of Stooler grade ≥3. Scheduled follow-up endoscopies at 3, 6, 12, and 24 months were performed to assess stricture formation and detect any residual or recurrent disease. Dysphagia symptoms were also assessed via telephone interviews at 2, 4, 6, 8, 12, and 24 months using the Stooler grading.

Results

Between September 2024 and March 2025, ten patients meeting the inclusion criteria (6 women and 4 men; mean age 67.5 years) were enrolled and treated with the combined steroid regimen. Six patients had full circumferential mucosal defects after ESD, while the remaining four had near-circumferential defects ranging from approximately five-sixths to eight-ninths of the esophageal circumference. The median longitudinal length of the post-ESD mucosal defects was 7.5 cm (range 4-12 cm), and the median resected area was 3375 mm² (range 1500-5250 mm²). No procedure-related complications were observed within 30 days post-ESD. Over a median follow-up period of 5 months (range 2-7 months), only one patient (10%) developed an esophageal stricture. This stricture was successfully managed with a single endoscopic dilation at 2 months after ESD. All other patients exhibited good mucosal healing and remained free of significant strictures throughout the follow-up.

Conclusion

This combined approach of intraoperative and postoperative local steroid injections coupled with a short-term oral corticosteroid taper appears to be a safe and preliminarily effective strategy for preventing esophageal strictures after ESD when large circumferential mucosal defects are present. Further validation in large-scale, multicenter randomized controlled trials is warranted to confirm its efficacy and safety.

Introduction

Peroral Endoscopic Myotomy (POEM) is an effective treatment for esophageal motility disorders, particularly achalasia. POEM also demonstrated a good safety and efficacy profile in patients with prior treatment failure (PTF). However, long-term data of POEM for this selective group have been underexplored. This study aims to compare long-term outcomes of POEM in patients with and without PTF.

Aims & Methods

This is a retrospective analysis of a prospectively maintained cohort of patients who underwent POEM for esophageal motility disorders at a single high-volume center between March 2012 and March 2024. Patients who had completed at least 6 months of follow-up were included. Baseline data included demographics, type of esophageal motility disorder, esophageal shape, and pre-POEM Eckardt score (ES). Procedural data included procedural time, adverse events and length of hospitalization. Follow-up data included clinical failure (defined as ES ≥ 4), gastroesophageal reflux disease (GERD) symptoms, erosive esophagitis > B grade at esophagogastroduodenoscopy (EGD) and acid exposure time (AET) > 6% at pH-impedance monitoring. Survival analysis was performed using Kaplan-Meier curves and Cox proportional hazards regression to identify factors associated with clinical failure. A 1:1 PSM without replacement was performed, and weighted regression analyses were used to evaluate outcomes.

Results

595 patients underwent POEM during the study period. A total of 564 patients (median age 57 years, 57.3% male) with at least 6 months of follow-up after POEM for esophageal motility disorders (12.7% achalasia I, 76.6% achalasia II, 6.4% achalasia III, 4.2% other non-achalasia disorders) were included in the analysis. One-hundred eight (19.1%) patients had undergone previous treatments (37% Heller myotomy, 39% pneumatic balloon dilation, 15% POEM, 9% Botulinum toxin injection). No significant difference was observed in terms of median procedural time (70 minutes (IQR 55;85) vs 71 minutes (IQR 56;86)) and adverse events (4.6% vs 1.8%) between primary POEM patients and those with PTF (P = ns). Globally, over a median follow-up of 36 months (range 6-60), 72 (12.7%) clinical failures were reported. After matching, 130 patients (65 per group) were analyzed for clinical failure. In the matched cohort, clinical failure occurred more frequently in PTF patients compared to controls (24.6% vs 10.8%). In a weighted Cox regression model, PTF was associated with a significantly higher risk of clinical failure (HR 2.20; 95% CI 1.05–5.36; p = 0.04). Regarding reflux-related outcomes, no statistically significant differences were observed between groups after matching: clinical reflux (38.2% vs 30.3%, p = 0.41), severe esophagitis (34.2% vs 24.7%, p = 0.29), and pathological AET >6% (45.9% vs 45.9%, p = 1.00).

Conclusion

POEM remains a highly effective, safe and durable treatment option for esophageal motility disorders with optimal long-term outcomes. However, patients with PTF undergoing POEM had a significantly higher risk of clinical failure. These findings highlight the need for closer monitoring and potential enhanced interventions for these patients.

Introduction

Lower esophageal (Schatzki´s) rings are a common cause of solid impactation dysphasia. Standard treatments involve passage of a single large bougie to disrupt the ring but symptoms recur in the majority of patients. Electrosurgical incision of the ring may provide a longer duration of symptom improvement. Acid suppression has been shown to decrease the recurrence rate of peptic strictures but are few datas on the treatment of Schatzki`s ring

Aims & Methods

To compare the efficacy of bougie dilatation plus Esomeprazole to surgical incision plus esomeprazole in symptomatic patients with Schatzki`s ring
A prospective randomized trial study, from May 2013 to Abril 2025, was performed in a referred Gastrointestinal hospital in Brazil. A total of 84 patients underwent for endoscopic evaluation of dysphagia were found to have a Schatzki`s ring. They were randomized to Bougie dilatation using a 54 French Dilator or electrosurgical incision a standard needle knife incision with 4 longitudinal incisions placed radially around the Schatzki`s ring. All patients were placed on Esomeprazole 40mg/daily for 8 weeks. Paired data were analyzed using Wilcoxon rank (dysphasia score) and paired t-test (GERD scores) within groups

Results

Thirty-nine patients underwent bougie dilatation and thirty-eight electrosurgical incisions. Patients were followed up for 18 months. Seven patients did not come for followed up. Two episodes of bleeding during electrosurgical incision were controlled using epinephrine injection. Symptoms free were significantly longer in incision group (8.82 months) compared to bougie dilatation group (4.93 months) (p = 0,02). The improvement in dysphasia scores were significant within each group comparing baseline to each time interval. The incision group experienced a significant improvement of dysphasia symptoms at 6 weeks compared to the bougie dilatation group (p = 0,05). GERD scores improved significantly in both groups at all time intervals in the bougie dilatation group and at all time intervals in the incision group. There were no significantly difference in GERD scores between the groups.

Conclusion

Electrosurgical incision of lower esophageal (Schatzki`s) ring is safe and offers longer free symptoms free compared to bougie dilatation. The addition of Esomeprazole offered significant improvement in GERD scores in both groups.

Clinical Case Summary

A 48-year-old man was diagnosed with a 2.0x2.5 cm protrusion in the descending duodenal bulb (A). Endoscopic ultrasonography and CT scans confirmed the mass arising from the muscularis propria (B). After discussion, we chose endoscopic full-thickness resection (EFTR). A dual knife was used to incise the mucosal cap covering the lesion and gradually separating it from the muscularis propria. After resection, there is a significant full-thickness defect of approximately 1.5x2.5 cm (C). Attempts to close the wound using titanium clips were unsuccessful due to the wound's large size. The narrow space and tender wall also complicated the use of nylon ropes and titanium clips, which increased the risk of clip detachment or mucosal injury. To overcome this challenge, we innovatively used a long transparent cap from a ligation device to enhance suction. By suctioning both sides of the mucosa into the cap, we were able to manipulate the clips with enhanced suction to achieve complete closure. A thorough examination and insufflation confirmed satisfactory wound closure and luminal dilation (D) (Video). The patient was discharged five days postoperatively without any adverse events. Histopathological examination confirmed complete resection of a low-risk GIST.