Endoscopic therapies for bariatric surgery complications.

PURPOSE OF REVIEW: The aim of this review is to present the current state of the field, highlight recent developments, and describe the clinical outcomes of endoscopic therapies for bariatric surgery complications. RECENT FINDINGS: The field of interventional endoscopy now presents a range of minimally invasive procedures for addressing postbariatric complications. Lumen-opposing metal stents have emerged as a reliable solution for managing gastrojejunal strictures following Roux-en-Y gastric bypass, whether with or without associated leaks. Additionally, they serve as a conduit for performing endoscopic retrograde cholangiopancreatography (ERCP) post-RYGB via EUS-directed ERCP (EDGE). Gastric peroral endoscopic myotomy, originally designed for gastroparesis, has demonstrated effectiveness in treating postgastric sleeve stenosis, particularly the challenging helical stenosis cases. Furthermore, innovative endoscopic antireflux techniques are showing encouraging outcomes in addressing gastroesophageal reflux disease (GERD) following sleeve gastrectomy. Additionally, several modifications have been proposed to enhance the efficacy of transoral outlet reduction (TORe), originally developed to treat weight regain due to gastrojejunal anastomotic issues post-RYGB. SUMMARY: Endoscopic management of bariatric surgery complications is continuously evolving. The development of new techniques and devices allows endoscopists to provide novel, minimally invasive alternatives that were not possible in the near past. Many techniques, however, are limited to expert centers because they are technically demanding, and specialized training in bariatric endoscopy is still required.

Endoluminal bariatric and metabolic therapies: state-of-the-art.

PURPOSE OF REVIEW: The aim of this review is to present the current state of the field, highlight recent developments, and describe the clinical outcomes of these endoluminal bariatric and metabolic procedures. RECENT FINDINGS: The landscape of endoluminal devices and techniques for treating obesity has expanded significantly, with FDA-approved therapies currently available to patients with a body mass index values as high as 50 kg/m 2 . Although notable advancements have been made in this area, there is a need for further emphasis to be placed on the metabolic improvements resulting from these therapies, in addition to the conventional focus on weight loss outcomes. Some of these procedures are now FDA approved for the treatment of metabolic disease as opposed to weight loss. To achieve the most favorable results, it is imperative that all endoluminal interventions are combined with a moderately intensive diet and lifestyle program lasting at least 12 months. SUMMARY: Endoluminal metabolic and bariatric therapy represents a bridge between lifestyle counseling, pharmaceutical interventions, and the most efficacious treatment for obesity, bariatric surgery. By virtue of its minimally invasive approach, this therapy may be an appealing option for patients who are ineligible for, or averse to, bariatric surgery and who have experienced suboptimal outcomes or unable to afford medical treatments. Furthermore, these interventions may be particularly beneficial in the early stages of obesity.

The rat eustachian tube: Anatomical, histological, and radiological features.

Purpose: This study investigated the anatomical and histological characteristics of the rat Eustachian tube (E-tube) and the feasibility of Eustachian tubography in a rat model. Materials and methods: Fifteen male Wistar rats were used in this study, and the bilateral E-tubes of each rat were examined. Ten E-tubes were used for anatomical studies, another ten for histological analysis, and the other ten for Eustachian tubography. Five rats were euthanized and decapitated, and ten E-tubes were dissected to describe the anatomy of the E-tube. Ten E-tube specimens obtained from five other rats were sectioned to investigate E-tube histology. Eustachian tubography was performed on the bilateral E-tubes of the other five rats using the trans-tympanic approach. Results: The rat E-tubes consisted of bony and membranous parts. Cartilage and bone tissue covered only the bony part. The E-tubes' mean diameter and overall length were 2.97 â€‹mm and 4.96 â€‹mm, respectively. The tympanic orifices' mean diameter was 1.21 â€‹mm. The epithelium of E-tubes was mainly composed of pseudostratified ciliated and goblet cells. Eustachian tubography was successfully performed on both sides of the E-tube for each rat. The technical success rate was 100%, the average running time was 4.9 â€‹min, and no procedure-related complications occurred. On tubography images, the E-tube, tympanic cavity, and nasopharynx could be identified because of the visualization of bony landmarks. Conclusion: In this study, we described the anatomical and histological features of rat E-tubes. With the aid of these findings, E-tube angiography was successfully performed using a transtympanic approach. These results will facilitate further investigation of E-tube dysfunction.

Perspectives and Management Strategies for Acute Colonic Intramural Hematoma.

Acute intramural hematoma of the colon is a rarely encountered clinical condition with diverse precipitating factors. Different acute and chronic complications emerge following hematoma formation, mandating high clinical suspicion for early diagnosis and optimum management. CECT represents the cornerstone for the proper demonstration of colonic hematomas and possible detection of complications as well as the underlying etiology. There are multiple strategies for management of intramural hematoma and treatment should be tailored according to the etiology and the clinical condition of the patient, reserving surgical intervention for unstable or complicated cases. Endoscopic management of colonic hematomas offers a promising minimally invasive modality with potential safety and efficacy.

Persistent hiccup: A rare presentation of COVID-19.

BACKGROUND: Hiccups are involuntary diaphragmatic muscle contractions with early glottis closure terminating inspiration. They are classified into two types: acute (<48 hours) and persistent (>48 hours). COVID-19 is the defining health crisis of our generation. Although there are common symptoms of the disease (e.g. fever, cough), several atypical presentations have appeared as the pandemic has evolved. Here, we present a patient with COVID-19 presenting with fever, sore throat, and persistent hiccups. METHODS AND RESULTS: A 48-year-old man presented to the hospital with a seven-day history of persistent hiccups, fever, and sore throat. Physical examination was unremarkable and abdominal ultrasound showed gaseous abdominal distension. Laboratory values were remarkable for elevated C-reactive protein, ferritin, and lactate dehydrogenase levels. Computed tomography of the chest showed bilateral subpleural areas of ground-glass attenuation and crazy-paving pattern. A COVID-19 test was positive, and hydroxychloroquine, oseltamivir, baclofen, and symptomatic treatment were initiated. The hiccups improved, and the patient was discharged home after ten days. CONCLUSION: Physicians should maintain a high level of suspicion and be aware of atypical presentations of COVID-19.

Evaluation of red cell distribution width to platelet ratio as a novel non-invasive index for predicting hepatic fibrosis in patients with chronic hepatitis C.

BACKGROUND AND STUDY AIMS: Assessing the extent of fibrosis is an essential part of therapeutic decisions in patients with chronic hepatitis C (CHC). Liver biopsies are the "gold standard" for evaluating liver fibrosis but have many limitations. Thus, noninvasive predictors of fibrosis have been developed. This study aimed to determine the effectiveness of red cell distribution width (RDW) to platelet ratio as a simple noninvasive method for predicting the hepatic fibrosis stage in patients with CHC. PATIENTS AND METHODS: This cross-sectional study included 197 Egyptian patients with CHC. A routine pretreatment reference needle liver biopsy was performed. Fib-4, transient elastography (TE) by Fibroscan, AST to Platelet Ratio Index (APRI), and RDW to platelet ratio (RPR) were measured. Predictors of significant fibrosis (Metavir score ≥ F2) and advanced fibrosis (Metavir score ≥ F3) were identified. RESULTS: Fib-4, TE, APRI, and RPR values differed significantly when comparing different stages of fibrosis (p < 0.01). Fib-4, TE, APRI, and RPR were reliable diagnostic tools at cutoff values of 1.17, 7.75, 0.18, and 0.07, respectively, for predicting significant fibrosis and cutoff values of 1.99, 8, 1.77, and 0.08, respectively, for predicting advanced fibrosis. Using logistic regression analysis, TE was identified as an independent predictor associated with significant and advanced fibrosis. Fib-4 was significantly associated with advanced fibrosis only. CONCLUSION: The use of Fib-4, TE, APRI, and RPR measurements may decrease the need for liver biopsies for predicting significant and advanced fibrosis. RPR showed fair sensitivity, specificity, positive and negative predictive values, and overall accuracy for predicting significant fibrosis in patients with CHC.

The Establishment of a Fast and Safe Orthotopic Colon Cancer Model Using a Tissue Adhesive Technique.

PURPOSE: We aimed to develop a novel method for orthotopic colon cancer model, using tissue adhesive in place of conventional surgical method. MATERIALS AND METHODS: RFP HCT 116 cell line were used to establish the colon cancer model. Fresh tumor tissue harvested from a subcutaneous injection was grafted into twenty nude mice, divided into group A (suture method) and group B (tissue adhesive method). For the group A, we fixed the tissue on the serosa layer of proximal colon by 8-0 surgical suture. For the group B, tissue adhesive (10 µL) was used to fix the tumor. The mortality, tumor implantation success, tumor metastasis, primary tumor size, and operation time were compared between the two groups. Dissected tumor tissue was analyzed for the histology and immunohistochemistry. Also, we performed tumor marker analysis. RESULTS: We observed 30% increase in graft success and 20% decrease in mortality, by using tissue adhesive method, respectively. The median colon tumor size was significantly increased by 4 mm and operation time was shortened by 6.5 minutes. The H&E showed similar tumor structure between the two groups. The immunohistochemistry staining for cancer antigen 19-9, carcinoembryonic antigen, cytokeratin 20, and Ki-67 showed comparable intensities in both groups. Real-time quantitative reverse transcription analysis showed eight out of nine tumor markers are unchanged in the tissue adhesive group. Western blot indicated the tissue adhesive group expressed less p-JNK (apototic marker) and more p-MEK/p-p38 (proliferation marker) levels. CONCLUSION: We concluded the tissue adhesive method is a quick and safe way to generate orthotopic, colon cancer model.

Localized Photothermal Ablation Therapy of Obstructive Rectal Cancer Using a Nanofunctionalized Stent in a Mouse Model.

The self-expanding metal stent (SEMS) is a versatile, palliative treatment method for unresectable, malignant, non-vascular strictures. Colorectal cancer (CRC) is one of the candidates for the application of the SEMS, in combination with the photothermal ablation (PTA) technique that enhances its therapeutic efficacy. The objective of this study was to investigate the efficacy of stent-mediated PTA therapy in an endoscopy-guided, orthotopic rectal cancer model. A total of 30 of 40 mice with the tumor size of grade 4 were included and were divided into three groups of 10 mice each. Group A underwent a gold nanoparticle (AuNP)-coated SEMS but no near-infrared (NIR) irradiation, group B received an uncoated control SEMS with NIR irradiation, and group C received a AuNP-coated SEMS and NIR irradiation together. Colonoscopy and in vivo imaging, immunohistochemical analysis, and quantitative reverse-transcription polymerase chain reaction of major tumor markers were performed. Stent placement and PTA were technically successful using colonoscopy. The tumor grade reduction after PTA is significant in group C, compared with groups A or B (p < 0.001). Molecular analysis validated this observation with a significantly reduced Mapk1 proliferation marker or increased Jnk expression. Histological analysis confirmed the localized PTA therapy using AuNP-coated SEMS profoundly ablated tumor outgrowth through the stent. Our results indicate that this novel strategy of localized PTA therapy could be a promising option for palliative treatment of CRC and to support prolonged stent patency with a decreased tumor volume.

Brunner's gland adenoma is a rare cause of upper gastrointestinal bleeding: A case report and literature review.

Brunner's gland adenoma is a rare benign tumour that arises from Brunner's glands in the duodenum. Lesions are usually incidentally discovered during oesophagogastroduodenoscopy. However, in some cases, they may present clinically with vague abdominal symptoms or bleeding. We present the case of a 54-year-old male who complained of progressive fatigue and intermittent melena for 3 months. Clinical examination findings were unremarkable. Routine blood tests showed microcytic hypochromic anaemia. Oesophagogastroduodenoscopy showed normal oesophageal and gastric mucosa as well as a pedunculated polyp on the anterior wall of the duodenal bulb. Endoscopic ultrasound (EUS) revealed a duodenal hyperechoic mass arising from the submucosal layer of the anterior wall of the duodenal bulb with central cystic degeneration. Both endoscopic- and EUS-guided biopsies were non-diagnostic. Endoscopic mucosal resection was performed after the patient provided consent. Histopathological examination revealed hyperplastic mucosal lobules containing Brunner's glands and smooth muscle cells; malignant cells or Helicobacter pylori infection were not evident. Brunner's gland adenoma is a rare lesion of the duodenum and should be considered in the differential diagnosis of upper gastrointestinal bleeding. EUS is helpful in the diagnosis and detection of the layer of origin. However, the final diagnosis is usually made after lesion removal.

Local Heat Treatment for Suppressing Gastroduodenal Stent-Induced Tissue Hyperplasia Using Nanofunctionalized Self-Expandable Metallic Stent in Rat Gastric Outlet Model.

Despite the promising results from the placement of covered or uncovered self-expandable metallic stent (SEMS) as a nonsurgical therapeutic option for the malignant gastric outlet obstruction (GOO), the long patency of the stent is still limited because of stent-induced tissue hyperplasia. Here, a local heat treatment using a nanofunctionalized SEMS is proposed for suppressing stent-induced tissue hyperplasia during GOO treatment. Highly efficient photothermal gold nanoparticle (GNP) transducer-coated SEMSs (GNP-SEMSs) were prepared for local heat treatment in rat gastric outlet. The in vivo heating temperature in rat gastric outlet model was evaluated and compared with in vitro heating temperature. Three groups of our developed 45 rat gastric outlet models were used: group A, noncoated SEMS only; group B, GNP-SEMS plus local heating; and group C, GNP-SEMS only to investigate in vivo efficacy of GNP-SEMS mediated local heating. Ten rats per group were sacrificed for 4 weeks, and five rats per group were sacrificed immediately after local heat treatment. The in vivo heating temperature was found to be 10.8% lower than the in vitro heating temperatures. GNP-SEMSs were successfully placed through a percutaneous approach into the rat gastric outlet (n = 45). The therapeutic effects of GNP-SEMS were assessed by histologic examination including hematoxylin-eosin, Masson trichrome, immunohistochemistry (TUNEL and CD31), and immunofluorescence (Ki67), and the results showed significant prevention of tissue hyperplasia following stent placement without adjacent gastrointestinal tissue damage. GNP-SEMS-mediated local heating could be an alternative therapeutic option for the suppression of tissue hyperplasia following stent placement in benign and malignant GOOs.

A Novel Biodegradable Tubular Stent Prevents Pancreaticojejunal Anastomotic Stricture.

Stricture of pancreatic-enteric anastomoses is a major late complication of a pancreaticoduodenectomy for the treatment of a periampullary tumor and can lead to exocrine and endocrine insufficiency such as malnutrition and diabetes mellitus. We investigated the safety and efficacy of a biodegradable tubular stent (BTS) for preventing a pancreaticojejunostomy (PJ) anastomotic stricture in both a rat and porcine model. The BTS was manufactured using a terpolymer comprising poly p-dioxanone, trimethylene carbonate, and glycolide. A cohort of 42 rats was randomized into 7 groups of 6 animals each after BTS placement into the duodenum for the biodegradation assay. A total of 12 pigs were randomized equally into a control and BTS placement group. The effectiveness of the BTS was assessed by comparing radiologic images with histologic results. Surgical procedures and/or BTS placements were technically successful in all animals. The median mass losses of the removed BTS samples from the rat duodenum were 2.1, 6.8, 11.2, 19.4, 26.1, and 56.8% at 1, 2, 3, 4, 6, and 8 weeks, respectively. The BTS had completely degraded at 12 weeks in the rats. In the porcine PJ model, the mean luminal diameter and area of the pancreatic duct in the control group was significantly larger than in the BTS group (all p < 0.05). BTS placement thus appears to be safe and effective procedure for the prevention of PJ anastomotic stricture. These devices have the potential to be used as a temporary stent placement to treat pancreatic-enteric anastomoses, but further investigations are required for optimization in human.

A Novel Intragastric Satiety-Inducing Device to Inhibit Weight Gain in Juvenile Pigs: a Pilot Study.

BACKGROUND AND AIMS: Minimally invasive therapies for obesity are a bridge between lifestyle interventions and bariatric surgery. We developed a novel device to reduce weight gain rate and evaluated its safety and efficacy in juvenile pigs. METHODS: The intragastric satiety-inducing device (ISD) comprises a self-expandable esophageal metal stent connected to a star-shaped disc placed in the stomach fundus. Eight juvenile pigs were randomized into ISD (n = 5) and control (n = 3) groups. Body weight and serum ghrelin hormone were monitored weekly for 6 weeks. One pig was followed up for 4 additional weeks (rebound pig) after ISD removal. Histological examination and immunohistochemistry for the interstitial cells of Cajal (ICCs) were performed. RESULTS: ISD placement was successful in all pigs. Two ISDs (40%) migrated at 4 and 5 weeks after placement. Weight gain rates were significantly lower in the ISD group than in the control group from week 1 to 6 but were higher in the rebound pig than in a control pig from week 7 to 10. Mean ghrelin hormone level was higher in the control group than in the ISD group from week 1 to 6. ISD induced reversible inflammatory changes in the esophagus and stomach fundus. The number of ICCs was lesser in ISD pigs than in control and rebound pigs. CONCLUSIONS: ISD placement is feasible and safe in juvenile pigs. It decreases weight gain rate but induces reversible inflammatory reaction and tissue hyperplasia. Its mechanism may be related to pressure exertion on the stomach fundus or gastric motility alteration.

Radiation Inhibits Lymph Drainage in an Acquired Lymphedema Mouse Hindlimb Model.

Background: Radiation therapy has been applied to prolong the duration of lymphedema. This study aimed to evaluate the effect of radiation on the development of lymphedema in a mouse hindlimb model. Methods and Results: A total of 24 Balb/c mice underwent the right popliteal lymph node excision and the afferent and efferent lymphatics blockage. The radiation group (n = 12) received a single 20 Gy radiation 1 day before surgery in the right hindlimb of each mouse, whereas the control group (n = 12) only received surgery without radiation. The right hindpaw thickness of each mouse was measured twice a week for 4 weeks. Fluorescence microscopy images using fluorescein isothiocyanate-dextran tracer were obtained once weekly. Immunohistochemical (IHC) staining images using anti-lymphatic vessel endothelial hyaluronan receptor-1 (anti-LYVE-1) were obtained at 4 weeks after surgery. The radiation group showed significant increase in the thickness of the right hind paws from 0.5 to 2 weeks compared with the control group. As for fluorescence lymphography, the radiation group showed a lower number of regenerated lymphatics and more congestion of tracers in the operated limb at the surgery sites at 1, 2, 3, and 4 weeks after surgery. For the IHC analysis, the radiation group showed a lower number of regenerated lymphatics per high-power field at the surgery site than the control group. Conclusion: Radiation therapy transiently aggravated the extent of lymphedema by inhibiting regenerated lymphatics in a mouse hindlimb model. However, it did not prolong the duration of lymphedema because the cutaneous interstitial flow contributes to the lymphatic fluid clearance.

Clinical effectiveness and safety of self-expanding metal stent placement following palliative chemotherapy in patients with advanced esophageal cancer.

PURPOSE: To investigate the effect of prior chemotherapy on self-expanding metal stent (SEMS)-related complications in patients with locally advanced primary esophageal cancer. MATERIALS AND METHODS: Data from patients with locally advanced primary esophageal cancer who received SEMS placement with or without prior chemotherapy were retrospectively reviewed. Patients were grouped according to prior palliative therapy: group A (n = 41) had received SEMS only, and group B (n = 64) had received palliative chemotherapy prior to SEMS placement. Patients' age, stricture length, tumor location, and dysphagia score prior to SEMS placement were evaluated. The overall patient cohort had a median follow-up period of 129 days (range 11-463). Outcomes after SEMS placement, including technical and clinical success rates, the occurrence of complications, and overall survival, were compared. RESULTS: There were no significant differences between the two groups regarding patients' age, stricture length, tumor location, and dysphagia score prior to SEMS placement. SEMS placement was technically successful in all patients, with no procedure-related complications reported. Clinical success was achieved in 95.1% of patients in group A and 96.8% of patients in group B. The duration of stent patency was significantly shorter in group B [162 days; 95% confidence interval (CI) 126.6-198.4 vs. group A (339 days; 95% CI 258.8-419.3], p = 0.001. No significant differences were seen between the two groups regarding dysphagia score improvement [group A (3.15 ± 0.57 to 1.17 ± 0.83; p < 0.001) and group B (3.17 ± 0.80 to 1.14 ± 0.79; p < 0.001); p = 0.66], complications [group A (10/41), and group B (24/64); p = 0.094], or overall survival [the median and mean overall survival periods were 105 (95% CI 30-180) and 132 days (95% CI 97-167), respectively, in group A, and 126 (95% CI 88-164) and 156 days (95% CI 132-180), respectively, in group B; p = 0.592]. CONCLUSION: Prior chemotherapy did not increase the risk of complications following SEMS placement in patients with locally advanced esophageal cancer. SEMS patency was significantly longer in patients who did not receive chemotherapy prior to SEMS placement. LEVEL OF EVIDENCE: Level 4, Case Series.

Fluoroscopic self-expandable metallic stent placement for treating post-operative nonanastomotic strictures in the proximal small bowel: a 15-year single institution experience.

OBJECTIVE: To evaluate the efficacy and safety of fluoroscopic self-expandable metallic stent (SEMS) placement for treating postoperative nonanastomotic strictures in the proximal small bowel. METHODS: Data from 8 consecutive patients (mean age, 63.8 ± 6.9 years; 7 males and 1 female) who underwent 17 fluoroscopic SEMS placement procedures in total for treating postoperative nonanastomotic strictures in the proximal jejunum were retrospectively reviewed. The most recent surgery for all the patients was total gastrectomy with esophagojejunostomy. Strictures were located in the proximal jejunum in all patients. The mean length of the strictures was 5.8 ± 2.0 cm. Five patients with comorbidities were poor surgical candidates. Four patients underwent fluoroscopic balloon dilation, three of whom showed no resolution of obstructive symptoms and one demonstrated recurrence of symptoms. RESULTS: Technical and clinical success was achieved in 100% (17/17) SEMS procedures. Complete resolution of obstructive symptoms and improvement in oral intake status occurred within 3 days after all procedures, rendering a clinical success rate of 100% (17/17). No complication occurred during or after the procedures. The median follow-up duration was 167 [interquartile range (IQR), 48-576] days. Stent malfunction occurred after 58.8% (10/17) of the procedures, including six occurrences of stent migration and four of benign tissue hyperplasia. Surgical removal of the migrated stents was performed in two patients. Recurrence of symptoms occurred after 64.7% (11/17) of the procedures. The median stent dwell and recurrence-free times were 32 (IQR, 20-193) and 68 (IQR, 38-513) days, respectively. CONCLUSION: Fluoroscopic SEMS placement may be effective and safe for treating postoperative nonanastomotic strictures, but stent malfunction and recurrence are major drawbacks. ADVANCES IN KNOWLEDGE: SEMS placement is effective and relatively safe in patients with postoperative nonanastomotic strictures in the proximal small bowel. Patients section and counseling is highly encouraged.

Balloon-Expandable Biodegradable Stents Versus Self-Expandable Metallic Stents: A Comparison Study of Stent-Induced Tissue Hyperplasia in the Rat Urethra.

PURPOSE: To compare the degrees of stent-induced tissue hyperplasia of balloon-expandable, biodegradable stents (BEBSs) with those of self-expandable metallic stents (SEMSs) in a rat urethral model. MATERIALS AND METHODS: A total of 20 rats were randomized into two groups. The BEBS group (n = 10) received a poly-l-lactic acid (PLLA) biodegradable stent. The SEMS group (n = 10) received a nitinol bare stent. All rats were killed eight weeks after stent placement. The degree of stent-induced tissue hyperplasia was assessed by comparing the results of retrograde urethrography and histologic examination between the two groups. RESULTS: Stent placement was technically successful in all rats. Two rats in the BEBS group were excluded due to procedure-related death. The mean luminal diameter of stented urethra on urethrograms was not significantly different at 4 and 8 weeks between the two groups. On histologic analysis, the percentage of granulation tissue area (p < 0.001) and the thickness of papillary projection (p < 0.001) were significantly higher in the BEBS group compared with the SEMS group. The inflammatory cell infiltration showed a clear tendency to significance (p = 0.050). There were no statistical differences in the number of epithelial layers and the thickness of submucosal fibrosis between the two groups. CONCLUSION: Formation of stent-induced tissue hyperplasia was significantly evident in the rat urethra with similar degrees between the BEBS and the SEMS. The BEBS was associated with a thicker papillary projection and larger granulation tissue area resulting from higher inflammation compared with the SEMS.

A Novel Full Sense Device to Treat Obesity in a Porcine Model: Preliminary Results.

PURPOSE: To evaluate the technical feasibility, safety, and efficacy of a novel full sense device (FSD) for the treatment of obesity in a porcine model. MATERIALS AND METHODS: The novel FSD comprised a self-expanding metallic esophageal stent connected to a star-shaped nitinol disk. Three types of FSD were used: fully covered (type A), fully covered with barbs (type B), and uncovered with barbs (type C). Nine juvenile pigs were divided into two groups: FSD (n = 6) and control (n = 3). FSD type A was placed in the FSD group. In case of migration, either FSD type B or type C was then randomly placed. Food intake was monitored daily. Weight changes and ghrelin hormone levels were monitored weekly for 12 weeks. RESULTS: FSD placement was technically successful in all pigs. All FSDs except one migrated to the stomach within 1 week after placement. The pig in which the FSD was retained showed decreased food intake in the first week after FSD placement, and there was a difference in the final weight between the FSD pig and control pigs. The percentage of weight gain was 116.6% in the control group and 105.3% in the FSD pig. CONCLUSION: FSD placement under fluoroscopic and endoscopic guidance is technically feasible and safe in a porcine model. The uncovered FSD appears to decrease food intake and reduce the rate of weight gain. However, the high FSD migration rate is not encouraging.

Fully covered self-expandable esophageal metallic stents in patients with inoperable malignant disease who survived for more than 6 months after stent placement.

OBJECTIVES: To investigate the clinical outcomes of fully covered self-expanding metal stent (FCSEMS) placement in patients with malignant esophageal obstruction who survived longer than 6 months. METHODS: From January 2002 to January 2018, 88 FCSEMS were placed in 64 patients (mean age 62.9 ± 11.6 years; 58 males) with inoperable malignant esophageal obstruction with or without esophago-respiratory fistula. Only patients who survived more than 6 months with FCSEMS in place were included. Data regarding technical and clinical success, complications, reinterventions, stent patency, and patient survival were obtained from a prospectively maintained hospital database. RESULTS: The technical and clinical success rates were 100 % (64/64). During follow-up, the median dysphagia score significantly improved (3.09 ± 0.68 to 1.05 ± 0.60, p < 0.001). The complication rate was 48.8 %. Multivariate analysis revealed that only longer stenting duration was associated with complications [hazard ratio = 1.220, 95 % confidence interval (CI) (1.074-2.760), p = 0.039]. The median follow-up duration was 257 days (range, 181-969). The median stent patency duration was 289 days [95% CI (209.9-368.1)]. The median survival was 254 days [95% CI (219.7-288.3)]. CONCLUSIONS: Our data suggest that esophageal FCSEMS placement is an effective option for patients with malignant dysphagia when survival longer than 6 months is expected. The rate of complications increases with time, and SEMS development is needed to keep up with the advancement in oncological treatment. ADVANCES IN KNOWLEDGE: Fully covered esophageal self-expandable stent placement is effective in patients surviving more than 6 months, however, the rate of complications also increases. SEMS development is needed to cope with the advancement in oncological treatment.