To determine the safety, feasibility and clinical outcomes of interventional methods for the management of esophagomediastinal fistula, and to investigate the effect of stent placement on fistula healing and the swallowing. Sixty consecutive patients with esophagomediastinal fistula were treated using interventional method and were retrospectively assessed. Patients received 3-tube but without covered stent placement were placed in group A, the remaining patients received covered stent placement with/without 3-tube method were placed in group B. Tubes and stents would be removed once fistula heals. Interventional procedures were technically successful all patients (100%). Esophageal stents and abscess drainage tubes were successfully removed from 14 patients. Three patients underwent stent removal during the perioperative period, resulting in a clinical success rate of 88.5% of 26 patients in group B. A total of 13 complications were found in all patients, including 5 major complications. Patients in group B showed a higher healing rate of abscess cavity and better dysphagia score than group A. During follow up, 17 patients in group A and 11 patients in group B were still alive. Interventional treatment is safe, feasible and efficacious for esophagomediastinal fistula; covered stent placement can promote fistula healing and improve swallowing.

Anastomotic leakage is common and life-threatening complication after esophagectomy. The management of esophageal anastomotic leakage remains challenging. We aimed to determine the safety, feasibility and efficacy of three-tube method and covered metallic stent placement for the management of anastomotic leakage.

Twenty-six consecutive patients with anastomotic leakage were treated using three-tube method and covered metallic stent and the medical records were retrospectively assessed. All patients received placement of abscess drainage tube, jejunal feeding tube and gastrointestinal decompression tube as well as esophageal covered stent, followed by continue abscess drainage, nutritional support and anti-inflammatory treatment. Tubes and esophageal stents will be removed once anastomotic leakage heals.

The procedure was technically successful in 23 patients (95.8%). A total of 31 covered stents were used. Esophageal stents and abscess drainage tubes were successfully removed from 14 patients. The median retention duration was 2.3 months and 2.6 months for stent and abscess drainage tubes, respectively. No perioperative death, esophageal rupture, massive hemorrhage, or other severe complications were observed during procedures. The abscess cavity had markedly decreased in 8 patients or disappeared in 16 cases. During follow-up, 8 patients died of cancer recurrence and 2 patients died of severe pulmonary infection. The 1-, 3-, 5-year survival rates were 60.1, 51.5 and 51.5%, respectively.

Three-tube method and covered metallic stent placement is safe, feasible and efficacious for treatment of anastomotic leakage after esophagectomy.

Esophageal fistula and stricture is rare but life-threatening complication for esophageal cancer. The management of esophageal fistula and stricture remains challenging. We aimed to determine the safety, feasibility and efficacy of covered metallic stent and three tubes placement for the management of esophageal fistula and stricture.

Between May 2012 and March 2018, all patients with esophageal fistula and stricture were treated using three tubes or covered metallic stent placement. Patients in group A received covered stents and three tubes placement. Patients in group B only received three tubes placement. Continue abscess drainage and nutritional support was performed after procedure. Three tubes or esophageal stents were removed once esophageal fistula heals. The related medical records were retrospectively assessed.

Thirty-seven consecutive patients with esophageal fistula and stricture were enrolled, including 26 patients in group A and 11 patients in group B. Stent placement procedure was technically successful in 25 patients (96.2%). A total of 42 covered stents were inserted. Seventeen esophageal stents were successfully removed from 10 patients. The median retention duration was 3.3 months and 3.4 months for stent and abscess drainage tubes, respectively. One perioperative death due to massive hemorrhage was observed 21 days after stent placement. The abscess cavity was decreased or disappeared in 17 cases and 4 cases in group A and group B, respectively. During follow up, patients in group A still showed a significant better condition of normal diet than that in group B (p < 0.05). Fourteen patients died of cancer recurrence, 3 patients died of massive digestive bleeding and 2 patients died of severe pulmonary infection. The median survivals were 14.8 months and 13.2 months for group A and group B, respectively.

Covered metallic stent placement is safe, feasible and efficacious for treatment of esophageal fistula and stricture, with a better condition of normal diet than patients only received three tubes placement.

Anastomotic stenosis and leakage are rare complications after esophagojejunostomy. The management of complications after esophagojejunostomy remains a challenge. We evaluated the outcomes and clinical effectiveness of an alternative interventional protocol.

To determine the safety and efficacy of interventional treatment for the management of complications after esophagojejunostomy.

This study included 24 consecutive patients with complications after esophagojejunostomy treated using interventional protocol. Patients received balloon dilation or stenting for anastomotic stenosis. Patients with anastomotic leakage received three-tube placement or retrievable covered esophageal stent placement, followed by abscess drainage, nutritional support, and anti-inflammatory treatment. The three tubes and esophageal stents were removed after leakage healing and stenosis ceased.

Thirteen patients received three-tube method, and 16 patients received covered stent placement. All procedures were technically successful, except for a failure of Y-type esophageal stent placement in one patient. The median retention time of stent and abscess drainage tube was 67.5 days and 87 days, respectively. No perioperative death, esophageal rupture, or massive hemorrhage was found during procedures. During follow-up, 14 patients died of cancer recurrence, and one died of severe pulmonary infection. The 1-, 3-, 5-year survival rates were 39.5%, 23.7%, and 23.7%, respectively.

Interventional protocol is safe, feasible, and efficacious for treatment of complications after esophagojejunostomy.

We aimed to determine the safety, feasibility and efficacy of interventional radiology method for the management of esophagogastric anastomotic leakage.

We retrospectively assessed the medical records of 23 consecutive patients with esophagogastric anastomotic leakage treated using intervention protocol. Patients received three-tube method (abscess drainage tube, gastrointestinal decompression tube and jejunal feeding tube) with or without temporary covered esophageal stent placement. Abscess drainage, anti-inflammatory treatment and nutritional support were performed thereafter. The esophageal stents and three tubes were removed after leakage healing.

All patient received three-tube method and eight patients received covered stent placement. All operations were technically successful. After a median of 2.4 months, the stents were successfully removed from five patients. No death, esophageal rupture or massive hemorrhage occurred during procedures. The abscess cavity had markedly decreased in seven patients or disappeared in 16 cases. During follow-up, four patients died of cancer recurrence, one died of heart dysfunction and one died of pulmonary infection. The 1-, 3-, 5-year survival rates were 86.4%, 52.3% and 52.3%, respectively.

Interventional radiology protocol is safe, feasible and efficacious for treatment for esophagogastric anastomotic leakage.

The aim of the present study was to evaluate the more effective therapy for the postsurgical gastroesophageal leakage by a head-to-head comparison of endoscopic vacuum therapy (EVT) and endoscopic stent implantation with self-expandable metal stent (E-SEMS). In this hospital-based, retrospective, observative study, the patients were classified into 2 groups. Those treated with EVT were assigned to the EVT group (n = 7), and those treated with E-SMS were assigned to the E-SEMS group (n = 11). We evaluated the clinical characteristics and treatment outcomes between the 2 groups. All 7 patients (100%) were treated with EVT, but only 7 of 11 patients (63.6%) in the stenting group were treated successfully. The median time to clinical success was 19.5 (5-21) days in the EVT group and 27.0 (3-84) days in the E-SEMS group. The median hospital stay was 37.1 (13-128) days in the EVT group and 87.3 (17-366) days in the E-SEMS group. The complicaion rate was lower in the EVT group (0/7, 0.0%) than that in the E-SEMS group (6/11, 54.5%) with statistically significant difference (P = 0.042). EVT is more effective and has fewer adverse effects than E-SMS therapy as a treatment for postsurgical gastroesophageal leakage.

Esophageal perforation is a rare complication of endoscopic retrograde cholangiopancreatography and the perforation is usually too large to close with endoclips. We developed an endoscopic procedure for the perforations.

A gastroscope fitted with a cap was inserted into the esophagus to perform the clip closure. The closure procedure was divided in 3 steps: step 1 is large clip closure; step 2 is small clip closure; and step 3 is the nasogastric tube placement for drainage.

A total of 4 patients underwent a cap-assisted clip closure and the procedures were completed successfully within 30 minutes. The cure was achieved in all the 4 patients after a relatively short period of hospital stay and no patient complained of closure-related complication.

The cap-assisted clip closure procedure is effective, safe, and easy to carry out for the closure of large esophageal perforations. It may also be applied to perform the closure of large perforations at other sites of the digestive tract.

Anastomotic leakage in the upper and lower intestinal tract is associated with high morbidity and mortality. Within the last 10 years endoscopic treatment options have been accepted as sufficient treatment option of these surgical complications. Endoscopic vacuum assisted closure (E-VAC) is a new innovative endoscopic therapeutic option in this field. E-VAC transfers the positive effects of vacuum assisted closure (VAC) on infected cutaneous wounds to infected cavities that can only be reached endoscopically. A sponge connected to a drainage tube is endoscopically placed in the leakage and a continuous vacuum is applied. Sponge and vacuum allow removal of infected fluids and promote granulation of the leakage. This results in clean wound grounds and finally allows wound closure. Meanwhile the method was also successfully used in the treatment of necrotic pancreatitis.

Fully covered self-expanding metal stent (SEMS) placement has been successfully described for the treatment of malignant and benign conditions. The aim of this study is to evaluate our experience of fully covered SEMS placement for post-operative foregut leaks.

Retrospective analysis was done for indications, outcomes and complications of SEMS placed in homogeneous population of 15 patients with post-operative foregut leaks in our tertiary-care centre from December 2008 to December 2010. Stent placement and removal, clinical and radiological evidence of leak healing, migration and other complications were the main outcomes analyzed.

Twenty-three HANAROSTENT(®) SEMS were successfully placed in 14/15 patients (93%) with post-operative foregut leaks for an average duration of 28.73 days (range=1-42 days) per patient and 18.73 days per SEMS. Three (20%) patients needed to be re-stented for persistent leaks ultimately resulting in leak closure. Total 5/15 (33.33%) patients and 7/23 (30.43%) stents showed migration; 5/7 (71.42%) migrated stents could be retrieved endoscopically. There were mucosal ulceration in 2/15 (13.33%) and pain in 1/15 (6.66%) patients.

Stenting with SEMS seems to be a feasible option as a primary care modality for patients with post-operative foregut leaks.

Gastrointestinal leak is a dreaded complication after esophagectomy. Conventional treatments for leak include conservative therapy, surgical reoperation, and even complete gastrointestinal (GI) diversion. The aim of this study was to evaluate the impact of endoluminal stenting in the management of esophagogastric leak after esophagectomy.

Data on 18 (11.3%) of 160 patients who developed postoperative leaks after minimally invasive esophagectomy were reviewed. Indications for esophagectomy included carcinoma (n = 14), Barrett's with high-grade dysplasia (n = 3), and benign stricture (n = 1). Neoadjuvant therapy was used in 57.1% of patients with carcinoma. The first nine patients underwent conventional treatments for leak whereas the latter nine patients underwent endoscopic esophageal covered stenting as primary therapy. There were 5 cervical and 13 intrathoracic anastomotic leaks. Main outcome measures included patient characteristics, types of treatment, length of hospital stay, morbidity, and mortality.

Subjects were 16 males and 2 females with a mean age of 66 years. In the conventional treatment group, leaks were treated with neck drainage (n = 4), GI diversion (n = 2), and thoracoscopic drainage with or without repair or T-tube placement (n = 3). In the endoscopy group, all leaks were treated with endoscopic covered stenting with or without percutaneous drainage (n = 9). Control of leaks occurred in 89% of patients in the conventional treatment group vs. 100% of patients in the endoscopic stenting group. Three patients in the conventional treatment group (33%) required esophageal diversion compared to none of the patients in the endoscopy group. The 60-day or in-hospital mortality was 0% for both groups.

In our clinical practice, there has been a shift in the management of esophagogastric anastomotic leaks to nonsurgical therapy using endoscopic esophageal covered stenting. Endoluminal stenting is a safe and effective alternative in the management of GI leaks.

Self-expandable metals stents (SEMSs) have increasingly been used as a temporary device to bridge chemoradiotherapy in patients with malignant esophageal disease or in patients with benign esophageal defects or stenosis.

To evaluate the outcome of removal of SEMSs in a large cohort of patients with benign and malignant esophageal disease.

Observational study with standardized treatment and follow-up.

Single university center.

Between 2001 and 2010, 95 consecutive patients referred for endoscopic SEMS extraction were included.

Endoscopic stent removal.

Technical and functional outcome and complications.

A total of 124 stent extractions were undertaken in 95 patients; both partially covered (68%) and fully covered (32%) SEMSs were removed. Three patients had 2 overlapping SEMSs in place. Successful primary removal was achieved in 89%; the secondary removal rate was 96%. Uncomplicated primary removal rate was significantly higher for fully covered versus partially covered stents (P = .035) and for single versus overlapping stents (P = .033). Patients with a complicated stent removal had the stent in place significantly longer compared with patients with an uncomplicated primary stent removal (126 days vs 28 days; P = .01). Surgical removal was required in 3 patients (2.4%). Six moderate and severe complications (5%) related to the endoscopic extraction occurred.

Retrospective, nonrandomized study design.

Primary endoscopic removal of an SEMS is feasible in the majority of patients with benign and malignant esophageal disease. A longer time that a stent is in place and the use of partially covered SEMSs both impede removal. Moreover, overlapping SEMSs should be avoided for temporary use because stent disintegration and subsequent complications may occur.

Intrathoracic anastomotic leakage after esophagectomy is associated with high morbidity and mortality. Because of disappointing results after surgical reexploration endoscopic stent implantation was introduced as primary treatment option with improved outcome. Aortoesophageal fistula is a very rare complication and has thus far only anecdotally been reported after esophagectomy. The aim of this retrospective study was to investigate if endoscopic stent implantation increases the incidence of postoperative aortoesophageal fistula by reason of stent-related erosion of the thoracic aorta.

Between January 2004 and October 2010, 213 patients underwent esophageal resection mainly for esophageal cancer. An intrathoracic esophageal anastomotic leak was endoscopically verified in 25 patients. Seventeen patients received endoscopic implantation of a self-expanding stent as primary treatment. In 8 patients a rethoracotomy was mandatory.

After successfully accomplished endoscopic stent placement, complete closure of the anastomotic leak was radiologically proven in all 17 patients. In 13 cases, definitive closure and healing of the leak was achieved and the stent could subsequently be removed. In 1 patient, because of early recurrence of very malignant small cell cancer, the stent remained in situ. Three patients developed an erosion of the thoracic aorta with subsequent massive hemorrhage. The mean time between stent insertion and occurrence of aortoesophageal fistula was 26 days. All 3 patients died of exsanguination with severe hypovolemic shock. Postmortem examination confirmed an aortoesophageal fistula in each case.

While endoscopic stent implantation seems to be effective in the control of intrathoracic anastomotic leakage, nevertheless the incidence of aortoesophageal fistula caused by stent-related aortic erosion exceeds the thus far reported numbers. Awareness of this life-threatening complication after stent insertion is therefore mandatory.

Partially covered self-expanding metal stents (SEMSs) are regularly used for malignant and occasionally for benign esophageal disorders. Safe removal of these stents can be challenging due to embedding of the uncovered stent ends. Our aim is to report the results of removal of embedded, partially covered SEMSs by induction of pressure necrosis using the stent-in-stent technique.

Consecutive patients referred to three endoscopy units in 2007-2009, treated by the stent-in-stent technique, were reviewed. The partially covered SEMSs were inserted for malignant (n=3) or benign (n=16) conditions and were left in situ for a median of 42 days (14-189). When SEMSs were found to be embedded, a fully covered self-expanding plastic stent (SEPS) or fully covered SEMS was placed inside the partially uncovered SEMS. Subsequent removal of both stents was planned after a period of 10-14 days.

In total, 23 stent-in-stent procedures were performed in 19 patients (10 males). Placement of a fully covered stent (SEPS: n=9 and SEMS: n=14) was technically successful in all patients. In 21 of 23 (91%) procedures, both stents were successfully removed in one procedure after a median of 12 days (5-18). In two patients, a repeat stent-in-stent procedure was needed for persistent embedding of the partially uncovered SEMSs. One (5%) procedure was complicated by severe bleeding, which could be treated endoscopically. In seven (36%) patients, the initial disorder had resolved after stent removal and no further endoscopic interventions were needed. Two (10%) patients were treated with chemoradiation or surgery for esophageal cancer after stent removal. In 10 (53%) patients, a repeat endoscopic intervention was required during follow-up because of progressive dysphagia or a persisting leak or fistula.

The stent-in-stent technique is safe and effective for the removal of partially covered SEMSs that are embedded in the esophageal wall.

Anastomotic leakage after esophagectomy is an important determinant of early and late morbidity and mortality. Control of the septic focus is essential when treating patients with anastomotic leakages. Surgical and endoscopic treatment options are limited.

Between 2005 and 2009, we treated 6 patients who experienced an intrathoracic anastomotic leakage after esophageal resection. After all established therapeutic measures had failed, we explored the feasibility of an endoscopically assisted mediastinal vacuum therapy.

We were able to heal intrathoracic esophageal leakages in all 6 patients without any local complications and without the need for reoperation. One patient died because of a progressive pneumonia.

Endoscopic vacuum-assisted closure of anastomotic leakages may help to overcome the limitations that are associated with intermittent endoscopic treatment and conventional drainage therapy. Our preliminary results suggest that this new concept may be suitable for those patients.

Esophageal full-thickness wall repair is an important but unsolved issue in endoscopy. It is unknown how well endoscopic clip closure (ECC) and endoscopic closure with suturing (ECS) perform compared with the criterion standard of thoracoscopic closure (TC).

Comparison of technical success, feasibility, long-term patency, complications, and histological quality of the different closure techniques (ECC, ECS, TC) for esophageal perforations.

Comparative animal study.

Approved animal facility.

Eighteen pigs.

Eighteen pigs were randomized, 6 each into 3 groups (ECC, ECS, TC). After endoscopic wall incision and mediastinoscopy, closure was performed by using 1 of the 3 techniques. After 8 to 12 weeks, pre-euthanasia endoscopic, necropsy, histological, and morphometric analyses were performed.

Long-term survival and histological quality of the repair.

The closure of the esophageal incisions was successful in all pigs. On days 2 and 6, 1 animal died of mediastinitis, 1 in the ECS group because of reflux of gastric contents into the mediastinum before the repair and 1 in the TC group because of leakage of the sutured closure (P = 1.0). No strictures were seen on prenecropsy endoscopy. At necropsy, 1 mediastinal abscess was found in an ECS animal (P = 1.0). Minor complications included periesophageal adhesions and reactive lymph nodes in 3 of 6 (ECC group) and 5 of 6 (TC and ECS groups). Histology showed muscle layer defects up to 12 mm in width and 21 mm in length, with a trend toward smaller defect size of width and length in the ECS group of animals.

Animal study of limited size.

Overall, ECS and ECC performed similarly to TC. ECS showed the smallest histological defects in the long-term repair.

Complications after esophagectomy related to ischemia of the graft are dreaded. Prompt assessment of the situation is essential. The series presented describes our experience regarding the evaluation of gastric tube complications. A score is presented classifying flexible endoscopy and CT-scan findings. A retrospective analysis from the charts of 47 consecutive patients who underwent esophagectomy for cancer was conducted. Patients who underwent upper endoscopy during admittance were entered in this study. Findings on flexible endoscopy and CT scan were systematic scored. According to the findings, different attitudes were taken. Between January 2006 and December 2007, 47 patients underwent esophagectomy for cancer. Eleven (23%) out of 47 patients were suspected to have complications related to the viability of the anastomosis. Median period to deterioration was 5 days. In 3 (27%) patients, stent placement was the only intervention necessary. In 2 (18%) patients, stent placement was combined with drainage of abscesses in the upper mediastinum. Five (46%) patients required a new right thoracotomy, with drainage of mediastinal abscesses and empyema. In 2 patients a limited resection and a new cervical anastomosis with a stent was created. Mean intensive care admission and hospital admittance was 30.2 days and 67.9 days, respectively. Two patients (18%) died during hospital admittance. All cervical anastomosis required postoperative dilatation. No complications related to the use of flexible endoscopy were seen. An aggressive policy is adopted in patients deteriorating following esophagectomy. CT-scanning of the thorax and a flexible endoscopy of the gastric conduit should always be performed. Direct therapy should be adopted without delay.

Endoscopic treatment options for postsurgical intrathoracic leaks include injection of fibrin glue, clip application, and stent placement. Endoscopic vacuum-assisted closure (E-VAC) may be an effective treatment option.

To demonstrate that E-VAC is an effective endoscopic treatment option for closure of major intrathoracic postsurgical leaks.

A prospective, single-center study at an academic medical center.

Eight consecutive patients with major intrathoracic postsurgical leaks.

Endoscopic placement of transnasal draining tubes, armed with a size-adjusted sponge at their distal end, in the necrotic anastomotic cavities, followed by continuous suction. Sponge and drainage were changed twice weekly. Patients were followed-up for 193 +/- 137 days.

Successful leak closure.

Successful closure of leaks was achieved in 7 of 8 patients (88%) after a mean of 23 +/- 8 days. A median of 7 endoscopic interventions was necessary. No major treatment-associated short-term or long-term (follow-up, 193 +/- 137 days) complications were noted.

Small sample size, single-center study, and lack of randomization.

E-VAC is an effective endoscopic treatment modality for major postsurgical intrathoracic leaks. (This study is registered at Clinicaltrials.gov, identifier NCT00876551.).

Leaks of the esophagus are associated with a high mortality rate and need to be treated as soon as possible. Therapeutic options are surgical repair or resection or conservative management with cessation of oral intake and antibiotic therapy. We evaluated an alternative approach that uses self-expandable metallic stents (SEMS).

Between 2002 and 2007, 31 consecutive patients with iatrogenic esophageal perforation (n = 9), intrathoracic anastomotic leak after esophagectomy (n = 16), spontaneous tumor perforation (n = 5), and esophageal ischemia (n = 1) were treated at our institution. All were treated with endoscopic placement of a covered SEMS. Stent removal was performed 4 to 6 weeks after implantation. To exclude continuous esophageal leak after SEMS placement, radiologic examination was performed after stent implantation and removal.

SEMS placement was successful in all patients and a postinterventional esophagogram demonstrated full coverage of the leak in 29 patients (92%). In two patients, complete sealing could not be achieved and they were referred to surgical repair. Stent migration was seen in only one patient (3%). After removal, a second stent with larger diameter was placed and no further complication occurred. Two patients died: one due to myocardial infarction and one due to progressive ischemia of the esophagus and small bowl as a consequence of vascular occlusion. Stent removal was performed within 6 weeks, and all patients had radiologic and endoscopic evidence of esophageal healing.

Implantation of covered SEMS in patients with esophageal leak or perforation is a safe and feasible alternative to operative treatment and can lower the interventional morbidity rate.

Intra-thoracic esophageal leakage after esophageal resection or esophageal perforation is a life-threatening event. The objective of this non-randomized observational study was to evaluate the effects of endoluminal stent treatment in patients with esophageal anastomotic leakages or perforations in a single tertiary care center.

Thirty-two consecutive patients with an intrathoracic esophageal leak, caused by esophagectomy (n = 19), transhiatal gastrectomy (n = 3), laparoscopic fundoplication (n = 2), and iatrogenic or spontaneous perforation (n = 8), undergoing endoscopic stent treatment were evaluated. Hospital stay, mortality and morbidity, sealing rate, extraction rates, complications, and long-term effects were measured.

Median time interval between diagnosis and stent treatment was 3 and 5 days, respectively. Eighteen patients had futile surgical closure of the defect before stenting, while in 14 patients, stent placement was the primary treatment for leakage. Stent placement was technically correct in all patients. Functional sealing was achieved in 78%. Mortality was 15.6%. Stent extraction rate was 70%. Overall method-related complications occurred in nine patients (28%).

Implantation of self-expanding stents after esophageal resection or perforation is a feasible and safe procedure with an acceptable morbidity even if used as last-choice treatment.

Historically, esophageal fistulas, perforations, and benign and malignant strictures have been managed surgically or with the placement of permanent endoprostheses or metallic stents. Recently, a removable, self-expanding, plastic stent has become available. The authors investigated the use of this new stent at their institution.

The study reviewed all the patients who received a Polyflex stent for an esophageal indication at the authors' institution between January 2004 and October 2006. Duration of placement, complications, and treatment efficacy were recorded.

A total of 37 stents were placed in 30 patients (14 women and 16 men) with a mean age of 68 years (range, 28-92 years). Stent placement included 7 for fistulas, 3 for perforations, 1 for an anastomotic leak, 7 for malignant strictures, and 19 for benign strictures (8 anastomotic, 1 caustic, 5 reflux, 2 radiation, and 2 autoimmune esophagitis strictures, and 1 post-Nissen gas bloat stricture). The mean follow-up period was 6 months. Stent deployment was successful for all the patients, and no complications resulted from stent placement or removal. Nine stents migrated spontaneously. Three of three perforations and three of five fistulas sealed. Only one stent was removed because of patient discomfort. One patient with a radiation stricture experienced tracheoesophageal fistulas secondary to pressure necrosis. Of 20 patients with stricture, 18 experienced improvement in their dysphagia.

Self-expanding, removable plastic stents are easily and safely placed and removed from the esophagus. This has facilitated their use in the authors' institution for an increasing number of esophageal conditions. Further studies to help define their ultimate role in benign and malignant esophageal pathology are warranted.

Management of intrathoracic anastomotic leaks remains an interdisciplinary challenge. Established treatment options include percutaneous drainage, endoscopic closure, or even surgical revision. All these procedures are associated with high morbidity and mortality rates.

We report a new, effective endoscopic treatment option for intrathoracic esophageal anastomotic leaks by using an endoscopic vacuum-assisted closure system.

Two patients with intrathoracic anastomotic leaks after esophagectomy and gastrectomy were included.

Surgical reinterventions failed to seal the leaks in 1 patient, whereas in the other patient the anastomotic leakage persisted after endoscopic placement of 2 covered self-expanding metal stents. We endoscopically placed transnasal draining tubes that were armed with a size-adjusted sponge at their distal tip in the necrotic anastomotic cavities. Continuous suction was applied. Sponge and drain were changed twice a week.

No complications were noted during the course of treatment. After a median of 15 days, closure of the wound cavities was achieved in all cases. A median of 5 endoscopic interventions was necessary. Both patients returned gradually to a solid diet without recurrence of the leaks.

Endoscopic vacuum-assisted closure might be an effective alternative in the treatment of upper intestinal anastomotic leaks.

The application of stents in the GI tract has expanded tremendously. Stent placement is the most frequently used treatment modality for palliating dysphagia from esophageal or gastric cardia cancer. Newly designed esophageal stents, including the Polyflex stent and the Niti-S double stent, have been introduced to reduce recurrent dysphagia owing to migration or nontumoral or tumor overgrowth. Stents are also the treatment of choice for esophagorespiratory fistulas, for proximal malignant lesions near the upper esophageal sphincter, for recurrent carcinoma after esophagectomy or gastrectomy and for sealing traumatic or iatrogenic nonmalignant ruptures, such as Boerhaave's syndrome and leakages following surgery. Stents in the latter patient group should be removed within 4-8 weeks after placement to prevent the formation of granulation tissue or hyperplasia at the stent ends. For gastric outlet obstruction, many case series have been published. Only two, small, randomized controlled trials have compared stent placement with gastrojejunostomy to date, and a large, randomized trial is currently being conducted in The Netherlands. Obstructive jaundice caused by a malignancy in the common bile duct can be treated effectively with plastic or metal stent placement. However, a prognostic score needs to be developed that guides a treatment decision towards using either of these stents. Finally, colonic stents are applied successfully for acute malignant obstruction as a 'bridge to surgery' in patients with tumors that are deemed to be resectable, or as a palliative treatment for patients with locally advanced or metastatic disease.