Prevention of stent migration: Which option would patients prefer?

We read with great interest the article by Ngamruengphong et al. “Endoscopic suturing for the prevention of stent migration in benign upper gastrointestinal conditions: a comparative multicenter study” [1]. The authors introduced an endoscopic suturing device (OverStitch; Apollo Endosurgery, Austin, Texas, USA) for the prevention of stent migration in patients with benign upper gastrointestinal diseases. After stent deployment, the endoscopic suturing device bites through the stent and esophageal mucosa to complete the suture. Compared with the patients who did not undergo stent fixation, the stent migration rate was lower in the endoscopic suturing group (33 % vs. 16 %; P = 0.03), suggesting that endoscopic suturing decreases the migration rate of fully covered metal stents.

We have concerns about which of the two options patients would prefer, especially when procedure safety and cost-effectiveness are also considered. On review of previous published articles and our own experience, we think that metallic clip fixation may be the preferred method.

In the Ngamruengphong study, the authors proposed that the conventional metallic clips grasp only small amounts of superficial tissue and cannot provide strong and long-lasting stent fixation, whereas the endoscopic suturing method also anchors the stent to the esophageal mucosal layer. As we know, most stents need to be removed in benign conditions, and therefore ease of stent removal is an important consideration. Thus, full-thickness or mucosal-muscular fixation, including the over-the-scope clip system, is not appropriate for patients with benign disease. In addition, endoscopists may require more training in order to perform endoscopic suturing safely, as there is a risk to patients if the thoracic aorta, which is close to the esophageal wall, is punctured by the suturing needle.

Metallic clips (e. g. HX-600 – 135 [Olympus, Tokyo, Japan] or the Resolution clip [Boston Scientific, Marlborough, Massachusetts, USA]) close the mucosal layer and were first used to anchor esophageal stents in 2001 to prevent stent migration [2]. In a comparative study by Vanbiervliet et al., 2 – 4 clips were used to anchor the stent to the esophageal wall after stent deployment [3]. The results showed that metallic clips reduced stent migration in patients with esophageal stricture, fistulas or perforations, with a migration rate of 13 % (3/23). The rate was similar to the result for endoscopic suturing. In another study comparing the cost-effectiveness between endoscopic suturing and metallic clip closure in patients receiving per-oral endoscopic myotomy, both techniques produced a reliable closure effect, but the procedure time was longer and cost was higher in the endoscopic suturing group [4]. The cost of the instruments was similar for endoscopic suturing and endoscopic clips (US$ 873 ± 39 vs. US$ 703 ± 327; P = 0.169); however, the OverStitch suturing procedure was significantly more expensive and the total cost of closure showed a trend toward lower cost with clips (US$ 1502 ± 849 vs. US$ 2521 ± 575; P = 0.073) [4].

In summary, metallic clips may be comparable to endoscopic suturing for the prevention of stent migration. Clips may be the preferred first choice in terms of procedure time and cost-efficiency. However, for patients who have experienced previous stent migration, endoscopic suturing should be considered.

• References

• 1 Ngamruengphong S, Sharaiha RZ, Sethi A. et al. Endoscopic suturing for the prevention of stent migration in benign upper gastrointestinal conditions: a comparative multicenter study. Endoscopy 2016; 48: 1-4
• 2 Sriram PV, Das G, Rao GV. et al. Another novel use of endoscopic clipping: to anchor an esophageal endoprosthesis. Endoscopy 2001; 33: 724-726
• 3 Vanbiervliet G, Filippi J, Karimdjee BS. et al. The role of clips in preventing migration of fully covered metallic esophageal stents: a pilot comparative study. Surg Endosc 2012; 26: 53-59
• 4 Pescarus R, Shlomovitz E, Sharata AM. et al. Endoscopic suturing versus endoscopic clip closure of the mucosotomy during a per-oral endoscopic myotomy (POEM): a case-control study. Surg Endosc 2016; 30: 2132-2135