Fully-covered metal stents with endoscopic suturing vs. partially-covered metal stents for benign upper gastrointestinal diseases: a comparative study

Abstract

Background and study aims Self-expandable metallic stents (SEMS) have been increasingly used in benign conditions (e. g. strictures, fistulas, leaks, and perforations). Fully covered SEMS (FSEMS) were introduced to avoid undesirable consequences of partially covered SEMS (PSEMS), but come with higher risk of stent migration. Endoscopic suturing (ES) for stent fixation has been shown to reduce migration of FSEMS. Our aim was to compare the outcomes of FSEMS with ES (FS/ES) versus PSEMS in patients with benign upper gastrointestinal conditions. Patients and methods We retrospectively identified all patients who underwent stent placement for benign gastrointestinal conditions at seven US tertiary-care centers. Patients were divided into two groups: FSEMS with ES (FS/ES group) and PSEMS (PSEMS group). Clinical outcomes between the two groups were compared. Results A total of 74 (FS/ES 46, PSEMS 28) patients were included. On multivariable analysis, there was no significant difference in rate of stent migration between FS/ES (43 %) and PSEMS (15 %) (adjusted odds ratio 0.56; 95 % CI 0.15 – 2.00). Clinical success was similar [68 % vs. 64 %; P = 0.81]. Rate of adverse events (AEs) was higher in PSEMS group [13 (46 %) vs. 10 (21 %); P = 0.03). Difficult stent removal was higher in the PSEMS group (n = 5;17 %) vs. 0 % in the FS/ES group; P = 0.005. Conclusions The proportion of stent migration of FS/ES and PSEMS are similar. Rates of other stent-related AEs were higher in the PSEMS group. PSEMS was associated with tissue ingrowth or overgrowth leading to difficult stent removal, and secondary stricture formation. Thus, FSEMS with ES for stent fixation may be the preferred modality over PSEMS for the treatment of benign upper gastrointestinal conditions.

Migrated Esophageal Stent Endoscopic Extraction through Gastrostomy Site in a Patient with Severe Esophageal Stricture

“…These stents reduce undesirable consequences of PCSEMS such as bleeding, fistulae, new strictures, and embedment leading to challenging stent removal [4]. Consequently, these stents have higher risk of migration due to limited tissue reaction (9%-31% PCSEMS vs. 26-36% FCSEMS) [5,6]. Despite the high migration rate, esophageal stents continue to be used due to their clinical success (24.4-40.5%) [2,7].…”

“…Therefore, FCSEMS are used in conjunction with stent fixation such as endoscopic suturing by anchoring to full thickness of the esophagus, over-the-scope clips (OTSCs), or TTS endoclips by securing to mucosa only. Recent studies have validated the effectiveness of endoscopic suturing and OTSCs in reducing migration rate [6,8,9]. However, TTS endoclips are reported to be inefficient due to limited opening widths, closure strength and depth of penetration [5,9].…”

Improving stent efficiency by understanding stent-related adverse events

“…As such, fully covered SEMS lack the additional adhesive quality conferred by tissue embedding, which is afforded to partially covered or uncovered SEMS. Partially covered SEMS were found to have similar rates of migration as sutured fully covered SEMS in a study by Ngamruengphong et al [27]. Intriguingly, randomized controlled trials comparing fully covered and partially covered SEMS used in malignant esophageal obstruction did not have difference in frequency of poststent obstruction/migration, nor time to recurrent obstruction [28,29].…”

Endoscopic management of gastrointestinal leaks and fistulae: What option do we have?

“…Fixation techniques are used in 80% of expert centers, particularly in case of previous stent migration, when incomplete sealing between stent and esophageal wall is present or when stents are placed across jejunal anastomoses[ 12 ]. In a multicenter retrospective study, Ngamruengphong et al [ 51 ] evaluated 74 patients underwent to stent deployment for benign UGI conditions (strictures, leaks, fistulae and perforations). All subjects were treated either with PCSEMS (28 pts) or with FCSEMS sutured to the esophageal wall with the Overstitch suturing device (Apollo Endosurgery, Austin, TX, United States).…”