Endoluminal Complex Esophageal Management: Stitches, Stents, and Clips

Surgeons performing esophageal surgery should have endoscopic skills to manage endoluminal situations. Meticulous attention to detail, draining infection, sealing leaks, and removing stents before they erode into adjacent structures is critical to achieving a good patient outcome. The objective of this video is to review tools that may be used when endoluminally managing an esophageal leak, perforation, or stricture. The skills needed to deploy the stents, suture leaks closed, and manage infected cavities are described. In this video series (the first video in the series can be viewed by clicking here), multiple cases are reviewed, including ones that demonstrate management skills following the case in order to educate the viewer about the usage of different devices.   

Endoluminal Devices Reviewed

• Esophageal Stents
• Ovesco Endoclips
• Resolutions Clips
• Apollo Endoluminal Suturing Device
• Para-esophageal Irrigation and Drainage Devices
• Anti-migration Devices

Figure 1: Esophageal stent after removal. Portions of the esophagus wall grew into the uncovered portion of the stent.

Figure 2: Bedside arrangement to perform endoluminal esophageal suturing. The overtube, dual-channel endoscope, CO2 insufflator, and Apollo equipment is necessary for such a procedure.

Figure 3: Esophageal leak as seen from a thoracotomy. Hybrid surgeries can be combined with endoluminal techniques for a “belt and suspender” approach.

Tips

• Esophageal stents deployed for a leak should not be left inside the esophagus for more than three weeks to prevent erosion into adjacent structures.
• If a leak does not heal after the first round, the stents should be removed and replaced in a new landing zone.
• All extravasating esophageal leaks should be drained externally. Leaks that cannot be addressed endoluminally should be treated with surgery when appropriate, making sure that the patient stays informed about the off-label nature of many of the devices used in the video.
• Interventionalists treating esophageal leaks and fistulas should have surgical training and understand the principles of fistula management.
• Stents deployed near the aorta or airway should be surrounded by fat or a muscle flap to buttress and avoid erosion.
• Stents should never be deployed against structures that would be fragile if erosion occurred. Clips are typically used for fresh incision closures
• The larger Ovesco clips may close larger perforations, but do not typically close chronic fistulae well.
• The new Apollo endosuturing tool is an excellent device that may be used to both close leaks and secure stents to prevent migration.