Spontaneous esophageal perforation traditionally mandates urgent surgical treatment. Lately, esophageal stents have been used to reduce the associated morbidity and mortality. The current systematic review aimed to assess the efficacy of stents as a primary treatment option in this scenario. A systematic search was conducted in PubMed/MEDLINE, Scopus and the Cochrane Library for studies published in the English language between 2000 and 2023. We included observational studies reporting on the use of stents, alongside conservative measures and drainage procedures, in patients with spontaneous esophageal perforations. Primary outcomes were sealing rate (persistent leak occlusion) and failure rate (mortality or conversion to a major surgical operation). Secondary outcomes included patients’ presentation, sepsis, drainage procedures, and reinterventions. Results for primary outcomes were presented as pooled rates with 95% confidence intervals (CIs), using a random-effects model. Methodological quality was assessed using the MINORS score. Eighteen studies involving 171 patients were included. Sealing rate was 86% (95%CI 77-93%) and failure rate was 14% (95%CI 7-22%). Weighted mortality rate was 6% (95%CI 2-13%), while conversion to surgical treatment was 2% (95%CI 0-9%). Late presentation was not related to a statistically significant increase in treatment failure (odds ratio 1.85, 95%CI 0.37-9.30; P=0.72). Drainage procedures were required for the majority of patients, with a high rate of surgical and endoscopic reinterventions. Our results imply that stents may offer an effective and safe alternative treatment for patients with spontaneous esophageal perforations. Additional endoscopic and surgical drainage procedures are frequently needed.

Hepatocellular carcinoma (HCC) is an increasingly common malignancy worldwide. Transarterial chemoembolization (TACE) is a procedure that was developed to treat HCC patients deemed unsuitable candidates for surgical resection or transplantation and has shown a survival benefit for patients with unresectable HCC. Similarly, radiofrequency ablation (RFA) and microwave ablation (MWA) have been shown to treat HCC successfully, although the rates of success are size-dependent. Head-to-head studies of TACE vs. RFA have shown some superiority of ablation vs. TACE in prolonging survival, with the greatest survival benefit conferred to individuals undergoing dual TACE and ablation therapy. The chapter will discuss the merits of combination treatment vs. monotherapy.