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Upper gastrointestinal perforations, fistula, and anastomotic leaks are severe conditions with high mortality. Temporary endoscopic placement of fully covered self-expanding metal stent (fSEMS) has emerged as treatment option. Stent migration is a major drawback of currently used stents. Migration is often attributed to a relatively too small stent diameter as esophageal stents were initially intended for the treatment of strictures. This study aimed to investigate the safety and efficacy of a large-diameter fSEMS for treatment of these conditions. Data were retrospectively collected from patients who received this stent in the Netherlands between March 2011 and August 2013. Clinical success was defined as sufficient leak closure after stent removal as confirmed by endoscopy or X-ray with oral contrast without surgical intervention or placement of another type of stent. Adverse events were graded according a standardized grading system. Stent placement was performed in 34 patients for the following indications: perforation (n = 6), anastomotic leak (n = 26), and fistula (n = 2). Technical success rate was 97% (33/34). Clinical success rate was 44% (15/34) after one stent and 50% (17/34) after an additional stent. There were no severe adverse events and stent-related mortality. The overall adverse event rate was 50% (all graded 'moderate'). There were 14 (41%) stent migrations (complete n = 8, partial n = 6). Other adverse events were bleeding (n = 2) and aspiration pneumonia (n = 1). Reinterventions for failure of the large-diameter fSEMS were placement of another type of fSEMS (n = 4), surgical repair (n = 3), or esophagectomy (n = 1). Eleven patients (32%) died in-hospital because of persisting intrathoracic sepsis (n = 10) or preexistent bowel ischemia (n = 1). This study suggests that temporary placement of a large-diameter fSEMS for the treatment of upper gastrointestinal perforations, fistula, and anastomotic leaks is safe in terms of severe adverse events and stent-related mortality. The larger diameter does not seem to prevent stent migration

This paper describes the sedimentary architecture, chronostratigraphy and palaeogeography of the late Middle and Late Pleistocene (Marine Isotope Stage/MIS 6-2) incised Rhine-valley fill in the central Netherlands based on six geological transects, luminescence dating, biostratigraphical data and a 3D geological model. The incised-valley fill consists of a ca. 50 m thick and 10-20 km wide sand-dominated succession and includes a well-developed sequence dating from the Last Interglacial: known as the Eemian in northwest Europe. The lower part of the valley fill contains coarse-grained fluvio-glacial and fluvial Rhine sediments that were deposited under Late Saalian (MIS 6) cold-climatic periglacial conditions and during the transition into the warm Eemian interglacial (MIS 5e-d). This unit is overlain by fine-grained fresh-water flood-basin deposits, which are transgressed by a fine-grained estuarine unit that formed during marine high-stand. This ca. 10 m thick sequence reflects gradual drowning of the Eemian interglacial fluvial Rhine system and transformation into an estuary due to relative sea-level rise. The chronological data suggests a delay in timing of regional Eemian interglacial transgression and sea-level high-stand of several thousand years, when compared to eustatic sea-level. As a result of this glacio-isostatic controlled delay, formation of the interglacial lower deltaic system took only place for a relative short period of time: progradation was therefore limited. During the cooler Weichselian Early Glacial period (MIS 5d-a) deposition of deltaic sediments continued and extensive westward progradation of the Rhine system occurred. Major parts of the Eemian and Weichselian Early Glacial deposits were eroded and buried as a result of sea-level lowering and climate cooling during the early Middle Weichselian (MIS 4-3). Near complete sedimentary preservation occurred along the margins of the incised valley allowing the detailed reconstruction presented here. © 2015 Elsevier Ltd.