Reply to Zhang et al.

We are grateful for the opportunity to respond to the Letter to the Editor entitled “Prevention of stent migration: Which option would patients prefer?” by Zhang et al. The authors suggested that endoscopic clips, rather than endoscopic suturing, should be the first-line option for stent fixation in consideration of procedure time, safety, and cost-efficacy [1] [2].

The efficacy of endoscopic clipping for the prevention of stent migration is unclear. Whereas a study by Vanbiervliet et al. [2] demonstrated that anchoring the fully covered metal stent to the esophageal wall with endoscopic clips decreased the risk of stent migration, another study including more than 72 patients with clip placement for stent fixation found no difference in migration rates between the stents that were clipped and those that were not [3]. In a proof of biomechanical principles study, endoscopic suturing significantly increased the force needed to displace the stent (mean force 20.4 Newtons [N]; P < 0.01) compared with clip fixation using endoclips or stent placement without fixation in an ex vivo setting. The application of clips to fix the stents onto the esophageal wall did not significantly enhance stent attachment (mean 6.1 N vs. mean 4.8 N) [4].

Zhang et al. cited a study comparing endoscopic clips with endoscopic suturing for mucosotomy closure after peroral endoscopic myotomy (POEM) [1]. Although the instrument cost was not significantly higher for endoscopic suturing (US$ 873 ± 39) compared with clips (US$ 703 ± 327; P = 0.17), the closure time was significantly shorter with endoscopic clips (16 ± 12 minutes) than suturing (33 ± 11 minutes; P = 0.04). Endoscopic suturing was also more expensive in operative room cost compared with conventional clip closure. It should be noted that the force required for mucosal closure is lower than that needed to keep the stent in place. In addition, the reported average time for endoscopic suturing for stent fixation was only 12 minutes [5] compared with 33 minutes for mucosotomy closure during POEM. Thus, the results from this study do not apply to stent fixation for the prevention of stent migration.

Zhang et al. also raised a concern about injury to the thoracic aorta by needle puncture from endoscopic suturing. To date, more than 140 cases of endoscopic suturing for stent fixation have been performed without any report of injury to thoracic organs or vasculature [6] [7] [8]. In fact, endoscopic suturing for stent fixation provides deeper mucosal anchoring and does not generally create full-thickness fixation. In the ex vivo study, after endoscopic suturing for stent fixation, no fixation sutures (0/12) were found to penetrate the entire esophageal wall [4]. In addition, during endoscopic suturing, puncturing in proximity to pulsatile structures is generally avoided.

In conclusion, there have been no convincing data suggesting that stent fixation with endoscopic clips is superior to endoscopic suturing. Prospective studies comparing different fixation techniques and their impact on clinical outcomes are necessary. Until then, endoscopic suturing for stent fixation should be considered in patients with benign upper gastrointestinal conditions undergoing fully covered metal stent placement, when expertise is available.

• References

• 1 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
• 2 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
• 3 Seven G, Irani S, Ross AS. et al. Partially versus fully covered self-expanding metal stents for benign and malignant esophageal conditions: a single center experience. Surg Endosc 2013; 27: 2185-2192
• 4 Rieder E, Dunst CM, Martinec DV. et al. Endoscopic suture fixation of gastrointestinal stents: proof of biomechanical principles and early clinical experience. Endoscopy 2012; 44: 1121-1126
• 5 Kantsevoy SV, Bitner M. Esophageal stent fixation with endoscopic suturing device (with video). Gastrointest Endosc 2012; 76: 1251-1255
• 6 Sharaiha RZ, Kumta NA, DeFilippis EM. et al. A large multicenter experience with endoscopic suturing for management of gastrointestinal defects and stent anchorage in 122 patients: a retrospective review. J Clin Gastroenterol 2016; 50: 388-392
• 7 Yang J, Siddiqui AA, Kowalski TE. et al. Esophageal stent fixation with endoscopic suturing device improves clinical outcomes and reduces complications in patients with locally advanced esophageal cancer prior to neoadjuvant therapy: a large multicenter experience. Surg Endosc 2016; DOI: 10.1007/s00464-016-5131-3. (erratum at DOI: 10.1007/s00464-016-5259-1)
• 8 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: 802-808