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Endolumenal Stent Suture-Fixation Compared to Endoscopic Clips for Prevention of Esophageal Stent Migration During Prolonged Dilatation in Recurrent Achalasia
Erwin Rieder*, Reza Asari, Johannes Lenglinger, Sebastian F. Schoppmann
Surgery, Medical University of Vienna, Vienna, Austria
Background: Treatment of esophageal achalasia such as myotomy or pneumatic dilatation appears to be effective in many patients. However, due to several reasons some patients present with treatment failure and recurrent symptoms. We have started to use short-term implantation of a self-expandable metal stent (SEMS) in patients with recurrent achalasia. The aim of this study was to assess the effectiveness of prolonged stent dilatation in this specific group of patients. As migration of stents placed at the lower esophageal sphincter (LES) is expected to be high, we further evaluated the use of endolumenal stent suture-fixation (ESSF) compared to endoscopic clip attachment to prevent stent migration.
Patients and Methods: Patients diagnosed with recurrent achalasia were allocated for prolonged dilatation using short-term SEMS implantation. Under general anesthesia, in supine position, and with fluoroscopic guidance large diameter fully covered esophageal stents (30 mm x 80 mm, Niti-S stent, Taewong Medical, Seoul, Korea) were placed across the esophagogastric junction. To prevent migration, stents were attached to the esophageal wall with either two or three endoscopic clips (group A: n=4) or by ESSF (group B: n=4) using an endoscopic suturing system (OverStitchTM, Apollo Endosurgery, Austin, TX). Patients were put on double-dose PPI. After gastrografin esophagogram on the following morning, patients were scheduled to have stent removal after four to seven days.
Results: Eight patients (median resting LES pressure of 43 mmHg, residual LES pressure of 47 mmHg) were treated by prolonged dilatation. Patients had an initial median Eckardt score of 4 (range: 4-9). Stent placement was performed without complications in all patients. The esophagograms on the first day found, that the large diameter esophageal stents have migrated into the stomach in three of the four patients in group A (75%) where clip attachment were used. On the other hand, ESSF (group B) prevented early stent migration in all patients when endolumenal sutures were used. At the 3-month follow up Eckardt score had improved in all but one patient (median 2, range: 1-5). Postinterventional manometry has been scheduled after 6-months.
Conclusion: Prolonged dilatation of the LES might be an interesting therapeutic alternative to treat patients with recurrent achalasia. Additionally, in contrast to endoscopic clip attachment ESSF appears promising to prevent early stent migration at difficult locations.
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