James H. Tabibian, MD, PhD, from the Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA shares this VideoGIE case “Endoluminal stenting via the suture-assisted flange engagement technique.”
Gastrointestinal endoscopists are now more than ever encountering clinical scenarios where they are asked to provide endoscopic diversion or bridging of a leak site with fully-covered self-expanding metallic stents (cSEMSs). In some cases, the length of the conduit needed may exceed that of commercially available cSEMSs, which currently have a maximum unconstrained length of 15 cm. Additional issues which may exist when needing to bridge such long distances include unfavorable buckling forces (precluding successful overlapping of the cSEMS) and insufficient wall:stent apposition and resulting in stent migration. To overcome these issues, we developed a technique for extended alimentary tract bridging with tandem cSEMS via the suture-assisted flange engagement (SAFE) technique which we have used in a variety of circumstances (eg, Ivor-Lewis anastomotic disruption, duodenal leak in the setting of necrotizing pancreatitis).
Figure 1. C, Fluoroscopic view of 2 contiguous cSEMSs via the suture-assisted flange engagement (SAFE) technique. D, Radiographic image of the 28-cm esophagoduodenal cSEMS conduit.
In brief, the sheath of a cSEMS (eg, a 15 cm WallFlex [Boston Scientific, Marlborough, MA]) is slightly retracted ex vivo to expose its distal flange loops, through which a continuous purse-string suture is fashioned to constrain the flange diameter. This is reinforced with interrupted sutures, and the flange is re-sheathed. The modified cSEMS is then deployed with its proximal (ie, unsutured) flange above the anastomosis and, if possible, EndoCinch-sutured (Bard, Billerica, MA) in place. Next, a second cSEMS is deployed through the first cSEMS with its proximal flange carefully positioned within the constrained distal flange of the first stent (Figure 1C). This ~28 cm stent conduit (Fig. 1D) can then be atraumatically removed after the desired duration of endoscopic stenting.
To summarize, the SAFE technique provides endoscopists a means to safely and effectively provide extended-range endoscopic stent conduits beyond the capabilities of currently availabe cSEMSs and thereby facilitate underlying tissue healing.
This VideoGIE shares with GI endoscopists a practical, safe, and effective technique to treat alimentary tract disruptions, leaks, and fistulae which otherwise cannot be adequately managed with currently available metallic (or other) stents.
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