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