Enteral stents in the management of gastrointestinal leaks, perforations and fistulae

Gastrointestinal leaks and fistulae are grave conditions associated with substantial morbidity and mortality. Expandable stents have shown significant success in the management of leaks and fistulae, providing an efficacious minimally invasive approach in patients who are frequently poor surgical candidates. Most reports, however, are limited by their small size or the pooling of different stents, techniques and locations of leaks and fistulae. Despite the numerous alterations in stent design, migration remains the pivotal drawback of this technique. In this article, we review the current status of expandable stents in the management of gastrointestinal leaks and fistulae, available anti-migration techniques and evolving innovations in stent design.

Endoscopic management of postsurgical leaks

Postsurgical leaks are a major complication with significant mobidity and mortality. Conventional conservative and surgical approaches are highly morbid with limited success. Over the last decade several endoscopic techniques have proved effective with a favorable safety profile. Nevertheless, most data still come from retrospective series, and many studies included heterogenous patient groups pooling complex surgical leaks with minor endoscopic perforations. This review focuses on the endoscopic management of the more difficult postsurgical leaks. Stents and over-the-scope clips are currently the key endoscopic techniques for leak closure, but emerging techniques such as vacuum sponge therapy and endoscopic internal drainage have proved to be at least as effective. The current trend is to use these different techniques interchangeably or simultaneously rather than assuming a single standardized approach.

External laryngeal manipulation done by the laryngoscopist makes the best laryngeal view for intubation

External laryngeal manipulation [ELM] is used to get better laryngeal view during direct laryngoscopy. This study was designed to test the hypothesis that ELM done by the intubating anesthetist [laryngoscopist] offers the best laryngeal view for tracheal intubation. A total of 160 patients underwent different surgical procedures were included in this study. Percentage of glottic opening [POGO] score and Cormack and Lehane scale were used as outcome measures for comparison between different laryngoscopic views. Four views were described; basic laryngoscopic view and then views after ELM done by the assistant, by the laryngoscopist and fi nally by the assistant after the guidance from the laryngoscopist respectively. The last three views compared with the basic laryngoscopic view. ELM done by the laryngoscopist or by the assistant after guidance from the laryngoscopist showed significant improvement of Cormack grades and POGO scores compared with basic laryngoscopic view. Number of patients with Cormack grade1 increased from 39 after direct laryngoscopy to 97 and 96 patients [P < 0.001 by Fisher's exact test], after ELM done by the laryngoscopist and that done by the assistant after guidance from the anesthetist respectively. Furthermore, the number of patients with POGO scores of 100% increased from 39 after direct laryngoscopy to 78 and 61 [P < 0.01] patients after ELM done by the laryngoscopist and that done by the assistant after guidance from the anesthetist respectively. It appeared from this study that ELM done by the anesthetist makes the best laryngeal view for tracheal intubation