Surgical Endoscopy

, Volume 25, Issue 7, pp 2350–2357 | Cite as

Feasibility and safety of endoscopic transesophageal access and closure using a Maryland dissector and a self-expanding metal stent

  • Daniel von RentelnEmail author
  • Melina C. Vassiliou
  • Karel Caca
  • Arthur Schmidt
  • Richard I. Rothstein
Endoluminal Surgery



Secure access and reliable closure is paramount in the setting of transesophageal mediastinal endoscopic surgery. The purpose of this study was to develop a secure transesophageal access technique and to evaluate the feasibility, safety, and efficacy of a novel covered, self-expanding, retractable stent for closure of 15-mm esophageal defects.


Fifteen-millimeter esophagotomies were created in 18 domestic pigs using needle knife puncture and balloon dilatation or a blunt dissection technique. Six animals were randomly assigned to open surgical repair and six animals to endoscopic closure using a self-expanding, covered, nitinol stent (Danis SX-ELLA stent, ELLA-CS) in a nonsurvival setting. Pressurized leak tests were performed on all closures. Six animals underwent transesophageal endoscopic mediastinal interventions and survived for 17 days. Stents were extracted at day 10.


Nonsurvival experiments revealed two bleeding complications associated with the needle–knife access technique, while blunt-dissection mediastinal access was not associated with any complications. Leak test results were not different for stent compared to surgical closures. All survival animals were found to have complete closure and adequate healing of the esophagotomies. No leakage or infectious complication occurred.


Blunt dissection achieves safe access into the mediastinum. Stent closure achieves similar leak test results compared to surgical closure and results in adequate sealing and wound healing of 15-mm esophageal defects.


Natural orifice transluminal endoscopic surgery NOTES Transesophageal endoscopic surgery Thoracoscopy Interventional endoscopy Esophageal perforation Mediastinal lymph node biopsy Self-expanding metal stent SEMS 



Daniel von Renteln acknowledges ASGE support (Cook Medical Don Wilson Award 2009) for an endoscopy and research fellowship at Dartmouth Hitchcock Medical Center.


Daniel von Renteln, Melina C. Vassiliou, Karel Caca, and Arthur Schmidt have no conflicts of interest or financial ties relevant to this report to disclose. Richard I. Rothstein is a consultant for Ethicon Endo-Surgery, Inc. Endotherapeutic material (stents and endoscopic instruments) for this study was provided by Ella-CS and Ethicon Endo-Surgery free of charge.

Supplementary material

Video 1 Demonstration of the flexible Maryland dissector. The instrument can be passed through the 3.7-mm channel of an endoscope (MOV 6534 kb)

Video 2 Creation of transesophageal mediastinal access using the flexible Maryland, pleural biopsies, and stent insertion (MOV 20638 kb)

Video 3 Stent extraction and inspection of the esophagotomy site (MOV 5723 kb)


  1. 1.
    Das A, Sivak MV Jr, Chak A (2001) Cervical esophageal perforation during EUS: a national survey. Gastrointest Endosc 53:599–602PubMedCrossRefGoogle Scholar
  2. 2.
    Eloubeidi MA, Tamhane A, Lopes TL, Morgan DE, Cerfolio RJ (2009) Cervical esophageal perforations at the time of endoscopic ultrasound: a prospective evaluation of frequency, outcomes, and patient management. Am J Gastroenterol 104:53–56PubMedCrossRefGoogle Scholar
  3. 3.
    Mickisch O, Manegold BC (1992) Esophageal perforation in attempted ERCP. Z Gastroenterol 30:428–430PubMedGoogle Scholar
  4. 4.
    Sahai AV (2002) Balloon-assisted esophageal intubation to prevent cervical perforation during EUS. Gastrointest Endosc 55:140–141PubMedCrossRefGoogle Scholar
  5. 5.
    Stermer E, Levy N (1993) Esophageal perforation during ERCP. Gastrointest Endosc 39:603PubMedCrossRefGoogle Scholar
  6. 6.
    Fujishiro M, Yahagi N, Kakushima N, Kodashima S, Muraki Y, Ono S, Kobayashi K, Hashimoto T, Yamamichi N, Tateishi A, Shimizu Y, Oka M, Ogura K, Kawabe T, Ichinose M, Omata M (2006) Successful nonsurgical management of perforation complicating endoscopic submucosal dissection of gastrointestinal epithelial neoplasms. Endoscopy 38:1001–1006PubMedCrossRefGoogle Scholar
  7. 7.
    Fujishiro M, Yahagi N, Kakushima N, Kodashima S, Muraki Y, Ono S, Yamamichi N, Tateishi A, Shimizu Y, Oka M, Ogura K, Kawabe T, Ichinose M, Omata M (2006) Endoscopic submucosal dissection of esophageal squamous cell neoplasms. Clin Gastroenterol Hepatol 4:688–694PubMedCrossRefGoogle Scholar
  8. 8.
    Ishihara R, Iishi H, Uedo N, Takeuchi Y, Yamamoto S, Yamada T, Masuda E, Higashino K, Kato M, Narahara H, Tatsuta M (2008) Comparison of EMR and endoscopic submucosal dissection for en bloc resection of early esophageal cancers in Japan. Gastrointest Endosc 68:1066–1072PubMedCrossRefGoogle Scholar
  9. 9.
    Kakushima N, Yahagi N, Fujishiro M, Kodashima S, Nakamura M, Omata M (2006) Efficacy and safety of endoscopic submucosal dissection for tumors of the esophagogastric junction. Endoscopy 38:170–174PubMedCrossRefGoogle Scholar
  10. 10.
    Ono S, Fujishiro M, Niimi K, Goto O, Kodashima S, Yamamichi N, Omata M (2009) Long-term outcomes of endoscopic submucosal dissection for superficial esophageal squamous cell neoplasms. Gastrointest Endosc 69:AB123–AB123CrossRefGoogle Scholar
  11. 11.
    Yamamoto H (2005) Endoscopic submucosal dissection of early cancers and large flat adenomas. Clin Gastroenterol Hepatol 3:S74–S76PubMedCrossRefGoogle Scholar
  12. 12.
    Bethge N, Kleist DV, Vakil N (1996) Treatment of esophageal perforation with a covered expandable metal stent. Gastrointest Endosc 43:161–163PubMedCrossRefGoogle Scholar
  13. 13.
    Bleier BS, Gratton MA, Leibowitz JM, Palmer JN, Newman JG, Cohen NA (2008) Laser-welded endoscopic endoluminal repair of iatrogenic esophageal perforation: an animal model. Otolaryngol Head Neck Surg 139:713–717PubMedCrossRefGoogle Scholar
  14. 14.
    Blocksom JM, Sugawa C, Tokioka S, Williams M (2004) The Hemoclip: a novel approach to endoscopic therapy for esophageal perforation. Dig Dis Sci 49:1136–1138PubMedCrossRefGoogle Scholar
  15. 15.
    Dormann AJ, Wigginghaus B, Deppe H, Huchzermeyer H (2001) Successful treatment of esophageal perforation with a removable self-expanding plastic stent. Am J Gastroenterol 96:923–924PubMedCrossRefGoogle Scholar
  16. 16.
    Ferri L, Lee JK, Law S, Wong KH, Kwok KF, Wong J (2005) Management of spontaneous perforation of esophageal cancer with covered self expanding metallic stents. Dis Esophagus 18:67–69PubMedCrossRefGoogle Scholar
  17. 17.
    Freeman RK, Van Woerkom JM, Ascioti AJ (2007) Esophageal stent placement for the treatment of iatrogenic intrathoracic esophageal perforation. Ann Thorac Surg 83:2003–2007 discussion 2007–2008PubMedCrossRefGoogle Scholar
  18. 18.
    Gerke H, Crowe GC, Iannettoni MD (2007) Endoscopic closure of cervical esophageal perforation caused by traumatic insertion of a mucosectomy cap. Ann Thorac Surg 84:296–298PubMedCrossRefGoogle Scholar
  19. 19.
    Johnsson E, Lundell L, Liedman B (2005) Sealing of esophageal perforation or ruptures with expandable metallic stents: a prospective controlled study on treatment efficacy and limitations. Dis Esophagus 18:262–266PubMedCrossRefGoogle Scholar
  20. 20.
    Leers JM, Vivaldi C, Schafer H, Bludau M, Brabender J, Lurje G, Herbold T, Holscher AH, Metzger R (2009) Endoscopic therapy for esophageal perforation or anastomotic leak with a self-expandable metallic stent. Surg Endosc 23(10):2258–2262PubMedCrossRefGoogle Scholar
  21. 21.
    Martinek J, Kovacova S, Nosek V, Verner T, Vasicek M, Spicak J (2008) Successful endoscopic treatment (clipping) of esophageal perforation during balloon dilatation in a patient with achalasia. Endoscopy Suppl 2:E61–E62CrossRefGoogle Scholar
  22. 22.
    Mumtaz H, Barone GW, Ketel BL, Ozdemir A (2002) Successful management of a nonmalignant esophageal perforation with a coated stent. Ann Thorac Surg 74:1233–1235PubMedCrossRefGoogle Scholar
  23. 23.
    Scott-Mackie PL, Morgan RA, Mason R, Adam A (1998) Treatment of a malignant esophageal perforation with a prototype conical Wallstent. Cardiovasc Intervent Radiol 21:501–502PubMedCrossRefGoogle Scholar
  24. 24.
    Shimamoto C, Hirata I, Umegaki E, Katsu K (2000) Closure of an esophageal perforation due to fish bone ingestion by endoscopic clip application. Gastrointest Endosc 51:736–739PubMedCrossRefGoogle Scholar
  25. 25.
    Sriram PV, Rao GV, Reddy ND (2006) Successful closure of spontaneous esophageal perforation (Boerhaave’s syndrome) by endoscopic clipping. Indian J Gastroenterol 25:39–41PubMedGoogle Scholar
  26. 26.
    Sung HY, Kim JI, Cheung DY, Cho SH, Park SH, Han JY, Kim JK, Han SW, Choi KY, Chung IS (2007) Successful endoscopic hemoclipping of an esophageal perforation. Dis Esophagus 20:449–452PubMedCrossRefGoogle Scholar
  27. 27.
    von Renteln D, Walz B, Riecken B, Kayser T, Caca K (2009) Endoscopic management of acute esophageal dissection by using a covered, self-expanding metal stent (with video). Gastrointest Endosc 69:577–580CrossRefGoogle Scholar
  28. 28.
    White RE, Mungatana C, Topazian M (2003) Expandable stents for iatrogenic perforation of esophageal malignancies. J Gastrointest Surg 7:715–719 discussion 719–720PubMedCrossRefGoogle Scholar
  29. 29.
    Zhou JH, Gong TQ, Jiang YG, Wang RW, Zhao YP, Tan QY, Ma Z, Lin YD, Deng B (2009) Management of delayed intrathoracic esophageal perforation with modified intraluminal esophageal stent. Dis Esophagus 22(5):434–438PubMedCrossRefGoogle Scholar
  30. 30.
    Tang SJ, Singh S, Wait MA, Mullican MA, Scott DJ (2009) Endotherapy for a 5-cm mid-esophageal perforation with tandem stenting above the lower esophageal sphincter (with videos). Surg Endosc 23(12):2836–2841CrossRefGoogle Scholar
  31. 31.
    Sanchez-Pernaute A, Aguirre EP, Talavera P, Valladares LD, de la Serna JP, Mantilla CS, de Leon AR, Torres A (2009) Laparoscopic approach to esophageal perforation secondary to pneumatic dilation for achalasia. Surg Endosc 23:1106–1109PubMedCrossRefGoogle Scholar
  32. 32.
    Salminen P, Gullichsen R, Laine S (2009) Use of self-expandable metal stents for the treatment of esophageal perforations and anastomotic leaks. Surg Endosc 23:1526–1530PubMedCrossRefGoogle Scholar
  33. 33.
    Ott C, Ratiu N, Endlicher E, Rath HC, Gelbmann CM, Scholmerich J, Kullmann F (2007) Self-expanding Polyflex plastic stents in esophageal disease: various indications, complications, and outcomes. Surg Endosc 21:889–896PubMedCrossRefGoogle Scholar
  34. 34.
    Lo AY, Surick B, Ghazi A (1993) Nonoperative management of esophageal perforation secondary to balloon dilatation. Surg Endosc 7:529–532 discussion 533PubMedCrossRefGoogle Scholar
  35. 35.
    Landen S, El Nakadi I (2002) Minimally invasive approach to Boerhaave’s syndrome: a pilot study of three cases. Surg Endosc 16:1354–1357PubMedCrossRefGoogle Scholar
  36. 36.
    Fischer A, Thomusch O, Benz S, von Dobschuetz E, Baier P, Hopt UT (2006) Nonoperative treatment of 15 benign esophageal perforations with self-expandable covered metal stents. Ann Thorac Surg 81:467–472PubMedCrossRefGoogle Scholar
  37. 37.
    Siersema PD, Homs MY, Haringsma J, Tilanus HW, Kuipers EJ (2003) Use of large-diameter metallic stents to seal traumatic nonmalignant perforations of the esophagus. Gastrointest Endosc 58:356–361PubMedCrossRefGoogle Scholar
  38. 38.
    Morgan RA, Ellul JP, Denton ER, Glynos M, Mason RC, Adam A (1997) Malignant esophageal fistulas and perforations: management with plastic-covered metallic endoprostheses. Radiology 204:527–532PubMedGoogle Scholar
  39. 39.
    Gee DW, Willingham FF, Lauwers GY, Brugge WR, Rattner DW (2008) Natural orifice transesophageal mediastinoscopy and thoracoscopy: a survival series in swine. Surg Endosc 22:2117–2122PubMedCrossRefGoogle Scholar
  40. 40.
    Willingham FF, Gee DW, Lauwers GY, Brugge WR, Rattner DW (2008) Natural orifice transesophageal mediastinoscopy and thoracoscopy. Surg Endosc 22:1042–1047PubMedCrossRefGoogle Scholar
  41. 41.
    Fritscher-Ravens A, Patel K, Ghanbari A, Kahle E, von Herbay A, Fritscher T, Niemann H, Koehler P (2007) Natural orifice transluminal endoscopic surgery (NOTES) in the mediastinum: long-term survival animal experiments in transesophageal access, including minor surgical procedures. Endoscopy 39:870–875PubMedCrossRefGoogle Scholar
  42. 42.
    Turner BG, Gee DW, Cizginer S, Konuk Y, Karaca C, Willingham F, Mino-Kenudson M, Morse C, Rattner DW, Brugge WR (2010) Feasibility of endoscopic transesophageal thoracic sympathectomy (with video). Gastrointest Endosc 71:171–175PubMedCrossRefGoogle Scholar
  43. 43.
    Inoue H, Minami H, Kobayashi Y, Sato Y, Kaga M, Suzuki M, Satodate H, Odaka N, Itoh H, Kudo S (2010) Peroral endoscopic myotomy (POEM) for esophageal achalasia. Endoscopy 42:265–271PubMedCrossRefGoogle Scholar
  44. 44.
    Inoue H, Kudo SE (2010) Per-oral endoscopic myotomy (POEM) for consecutive 43 cases of esophageal achalasia. Nippon Rinsho 68:1749–1752PubMedGoogle Scholar
  45. 45.
    Pauli EM, Mathew A, Haluck RS, Ionescu AM, Moyer MT, Shope TR, Rogers AM (2008) Technique for transesophageal endoscopic cardiomyotomy (Heller myotomy): video presentation at the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2008, Philadelphia, PA. Surg Endosc 22:2279–2280PubMedCrossRefGoogle Scholar
  46. 46.
    Pasricha PJ, Hawari R, Ahmed I, Chen J, Cotton PB, Hawes RH, Kalloo AN, Kantsevoy SV, Gostout CJ (2007) Submucosal endoscopic esophageal myotomy: a novel experimental approach for the treatment of achalasia. Endoscopy 39:761–764PubMedCrossRefGoogle Scholar
  47. 47.
    Perretta S, Dallemagne B, Alleman P, Marescaux J (2010) Heller myotomy and intraluminal fundoplication: a NOTES technique. Surg Endosc 24(11):2903PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2010

Authors and Affiliations

  • Daniel von Renteln
    • 1
    • 2
    Email author
  • Melina C. Vassiliou
    • 3
  • Karel Caca
    • 1
  • Arthur Schmidt
    • 1
  • Richard I. Rothstein
    • 2
  1. 1.Department of GastroenterologyMedizinische Klinik I, Klinikum LudwigsburgLudwigsburgGermany
  2. 2.Department of Gastroenterology and HepatologyDartmouth-Hitchcock Medical CenterLebanonUSA
  3. 3.Department of SurgeryMontreal General Hospital, McGill UniversityMontrealCanada

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