Although ECC was the fastest technique, it could not achieve full-thickness repair of the esophageal wall. Moreover, larger gaping defects could not be bridged by the jaws of the clips. In contrast, ECS anchors were deployed across the entire esophageal wall and showed well-healed scares with the smallest remaining gaps. One of the disadvantages inhibitor CHIR99021 of T-bars is that placing them beyond the gastrointestinal wall cannot be performed under direct vision. So, the needle tip may harm or inadvertedly place a T-bar into an unwanted structure as reported in a previous study [30]. The novel over-the-scope clip (OTSC) system showed promising results for gastrostomy closure [31] and has been used in for closure of postoperative leaks following gastrectomy and primary repair after spontaneous acute esophageal perforation [32].

Cardiac septal occluders might be a valuable alternative. Repici et al. have recently reported the first human case of esophagus-tracheal fistula closure by using a cardiac septal occluder with good results [33]. Other prototype suturing/apposition devices might be of future use in esophagotomy closure, namely, Padlock-G clips (Aponos Medical, Kingston, NH, USA) [34], NDO Plicator (NDO Surgical Inc., Mansfield, MA, USA) [35], g-Cath/g-Prox (Usgi Medical Inc, San Clemente, CA, USA) [36], flexible Endostich (Covidien, North Haven, Conneticut, USA) [37], OverStich (Apollo Endosurgery, Austin, TX, USA) [38], Direct Drive Endoscopic System (DDES Boston Scientific, Natick, MA, USA) [39], Anubis-scope (Karl Storz, Tuttlingen, Germany) [40],and Endo-Samurai (Olympus, Tokyo, Japan) [41].

Von Reitein et al. presented a prototype self-expanding metal stent (SX-ELLA stent, ELLA-CS, Hradec Kralove, Czech Republic) for direct incision esophagotomy closure without any suture [22]. Fifteen-millimeter direct incision esophagotomies were created in 12 domestic pigs using a prototype endoscopic Maryland dissector (Ethicon Endosurgery, Cincinnati, OH, USA). Six animals were randomly assigned to open surgical repair and six animals to endoscopic closure using the self-expanding, covered, nitinol stent in a nonsurvival setting. Pressurized leak test results were not different for stent compared to surgical closures. Six animals underwent transesophageal endoscopic mediastinal interventions and survived for 17 days. Stents were extracted at day 10.

All survival animals were found to have complete closure and adequate healing of the esophagotomies, without leakage or infectious complications. Finally, the hybrid approach presented Dacomitinib by Rolanda et al. might be useful for safe esophagotomy closure. Using a thoracoscope with a 5mm working channel, the authors inserted a needle-holder and performed an end-to-end esophageal anastomosis with gastroscopic intruments assistance [18]. 4.