Palliation of inoperable esophageal carcinoma with the Wallstent endoprosthesis

The insidious presentation and challenging management of esophageal perforation following diagnostic and therapeutic interventions

Diagnostic and therapeutic interventions on the esophagus or adjacent organs are responsible for nearly half of all esophageal perforations. If not recognized at the time of the injury, iatrogenic esophageal perforations can present insidiously and lead to delay in diagnosis, thereby increasing morbidity and mortality. Acute clinical awareness is vital for prompt diagnosis, which is usually confirmed with contrast esophagography and contrast-enhanced computed tomography. After establishment of diagnosis, treatment should be promptly initiated and include fluid-volume resuscitation, cessation of oral intake, nasogastric tube insertion, broad-spectrum antibiotics and analgesia. Primary repair, when feasible, is the treatment of choice. Additional procedures beyond primary repair, such as relief of concomitant obstruction, may be necessary if there is underlying esophageal pathology. Drainage alone can be performed for perforations of the cervical esophagus that cannot be visualized. Esophageal T-tube placement or exclusion and diversion techniques are appropriate in clinically unstable patients and in cases where primary repair is precluded either due to preexisting esophageal disease or extensive esophageal damage. Esophagectomy should be performed in patients with malignancy, end-stage benign esophageal disease or extensive esophageal damage that precludes repair. Endoscopic techniques, including stenting, clipping or vacuum therapy, can be used in select cases. Finally, nonoperative management should be reserved for patients with contained esophageal perforations, limited extraluminal soilage and no evidence of systemic inflammation.

Self-expanding metal stents in palliation of malignant dysphagia: outcome of 124 Egyptian patients

Most cases of esophageal carcinoma are inoperable at presentation. Currently, the best method for palliation of malignant dysphagia, with or without esophago-respiratory fistula, is an insertion of esophageal self-expanding metal stents (SEMS) across the malignant esophageal stricture. Herein we present our experience in the use of SEMS in palliation of patients with malignant dysphagia and/or ERF. The study included 124 patients (79 males and 45 females) with advanced esophageal malignancy. The mean age was 54 (43-87) years. Nine patients had malignant ERF. All patients were subjected to SEMS insertion under both endoscopic and fluoroscopic guidance. SEMS insertion was successful in all patients. Nine patients had two stents. Median dysphagia score improved from 3.5 to 1.2. ERF was sealed in eight out of the nine patients. Complications related to stent implementation were reported in 41 patients. In conclusion, insertion of the SEMS is a reliable, effective, simple and safe method for palliation of malignant dysphagia with or without ERF.

A new esophageal stent design (Niti-S stent) for the prevention of migration: a prospective study in 42 patients

BACKGROUND

Covered, rather than uncovered, metal stents are used for the palliation of dysphagia from esophageal cancer, but a major drawback is the risk of stent migration, which occurs in up to 20% of patients. To overcome this problem, a double-layered stent, the Niti-S stent (Taewong Medical, Seoul, Korea), has been developed. The Niti-S stent consists of an inner polyurethane layer to prevent tumor ingrowth and an outer uncovered nitinol wire tube to allow the mesh of the stent to embed itself in the esophageal wall.

METHODS

Between June 2003 and May 2004, 42 patients with malignant dysphagia caused by inoperable carcinoma of the esophagus or gastric cardia were treated with a Niti-S stent. Patients were prospectively followed and data collection focused on recurrent dysphagia, functional outcome, complications, and survival.

RESULTS

At 4 weeks, the dysphagia score had significantly improved from a median of 3 (liquids only) to 0 (ability to eat a normal diet). Five of 42 (12%) patients with a Niti-S stent developed recurrent dysphagia, mainly due to tissue overgrowth (2 of 42; 5%) and stent migration (3 of 42; 7%). Major complications (perforation, 1; aspiration pneumonia, 2; hemorrhage, 2) occurred in 5 of 42 (12%) patients. Pain following stent placement was observed in 5 of 42 (12%) patients, and symptomatic gastroesophageal reflux occurred in 2 of 42 (5%) patients.

CONCLUSIONS

The Niti-S stent provides symptomatic relief of malignant dysphagia and effectively reduces recurrent dysphagia. Its double-layered design is probably important in preventing migration. In addition, the complete covering of the Niti-S stent may be a factor in preventing tissue overgrowth at both ends of the stent.

Evolving options in the management of esophageal perforation

Esophageal perforation remains a devastating event that is difficult to diagnose and manage. The majority of injuries are iatrogenic and the increasing use of endoscopic procedures can be expected to lead to an even higher incidence of esophageal perforation in coming years. Accurate diagnosis and effective treatment depend on early recognition of clinical features and accurate interpretation of diagnostic imaging. Outcome is determined by the cause and location of the injury, the presence of concomitant esophageal disease, and the interval between perforation and initiation of therapy. The overall mortality associated with esophageal perforation can approach 20%, and delay in treatment of more than 24 hours after perforation can result in a doubling of mortality. Surgical primary repair, with or without reinforcement, is the most successful treatment option in the management of esophageal perforation and reduces mortality by 50% to 70% compared with other interventional therapies.

Antireflux stents in tumors of the cardia

Self-expanding metal esophageal stents (SMES) are highly effective in relieving dysphagia in patients with esophageal carcinoma. As the incidence of cancer at the lower esophagus/cardia continues to increase, SMES also are being deployed across the gastroesophageal junction (GEJ). However, use of SMES in this location makes the stomach and the esophagus, in effect, a common cavity, which predisposes patients to gastroesophageal reflux (GER) and aspiration. Reflux may result from an increase in intra-abdominal pressure or it may occur passively when the patient is recumbent. Acid-suppression medications do not protect against regurgitation and aspiration. We developed a modified antireflux SMES and evaluated its efficacy in vitro, in dogs, and in 11 patients with distal esophageal/GEJ carcinoma. The modification involved extending the polyurethane coating of the stent to 8 cm below the lower edge. In dogs, significantly more reflux episodes occurred with the regular stent (mean, 197 episodes) than with the modified stent (mean, 16 episodes; P = 0.03). In patients who received the modified stent, dysphagia scores were significantly reduced (mean baseline score, 3.4; mean end point score, 1.1; P <0.001). The modified stent prevented GER while allowing belching and vomiting.

A comparison of 3 types of covered metal stents for the palliation of patients with dysphagia caused by esophagogastric carcinoma: a prospective, randomized study

BACKGROUND

There are currently 3 types of covered metal stents available in Europe for palliation of patients with malignant dysphagia. Their relative merits have not been compared in a prospective, randomized study.

METHODS

One hundred consecutive patients with esophagogastric carcinoma were randomized to placement of an Ultraflex stent, a Flamingo Wallstent, or a Gianturco-Z stent. Malignant strictures of the esophagus were treated by insertion of a small-diameter stent (n = 71), whereas those involving the gastric cardia were treated with a large-diameter stent (n = 29).

RESULTS

At 4 weeks, dysphagia had improved in all patient groups (p < 0.001), but the degree of improvement did not differ among the 3 groups (p = 0.14). There were differences among the 3 stent types with respect to major complications (Ultraflex stent: 8/34 [24%], Flamingo Wallstent: 6/33 [18%], and Gianturco-Z stent: 12/33 [36%]), but these were not statistically significant (p = 0.23). Nine patients (26%) with an Ultraflex stent, 11 (33%) with a Flamingo Wallstent, and 8 (24%) with a Gianturco-Z stent had recurrent dysphagia (p = 0.73), mainly because of tumor overgrowth or stent migration; 12 of 13 episodes of migration involved small-diameter stents in the esophagus.

CONCLUSIONS

All 3 covered metal stents evaluated offer the same degree of palliation of patients with malignant dysphagia. Placement of Gianturco-Z stents was associated with more complications as compared with Ultraflex stents and Flamingo Wallstents. Although stent migration is reduced by increasing stent diameter, tumor overgrowth remains an intractable problem that requires a new approach.

Self-expanding metal esophageal stent with anti-reflux mechanism

BACKGROUND

When deployed across the gastroesophageal junction, self-expanding metal esophageal stents can predispose to gastroesophageal reflux. Our aim was to evaluate the efficacy of a self-expanding metal esophageal stent that was modified to prevent gastroesophageal reflux.

METHODS

The polyurethane coating of a metal Z-stent was extended beyond its lower end to form windsock-type valve. The anti-reflux property of this stent was studied in vitro by submerging the stent under water and measuring the pressure required to invert the valve. Esophageal acid exposure time was measured in 5 dogs with a standard and the modified stent placed across the gastroesophageal junction. The modified stent was also placed in 11 patients with cancer of the gastroesophageal junction who were prospectively followed.

RESULTS

The pressure required to invert the valve was directly proportional to the thickness of the valve membrane (48 +/- 0.4 cm water for a 0.0067-inch thick membrane). Esophageal acid exposure time was significantly less with the modified stent as compared with a standard stent (1% +/- 0.3%, 49% +/- 11%, respectively, p = 0.03). Dysphagia score in patients improved from 3.4 +/- 0.1 to 1.1 +/- 0.2 (p < 0.001). Daytime heartburn and regurgitation scores were less than 1 (score 10 = severe). No patient complained of nocturnal reflux symptoms. Karnofsky performance status scale did not improve significantly.

CONCLUSIONS

The efficacy of the modified stent in relieving dysphagia is comparable with a standard stent. It also effectively prevents gastroesophageal reflux.

A new design metal stent (Flamingo stent) for palliation of malignant dysphagia: a prospective study. The Rotterdam Esophageal Tumor Study Group

BACKGROUND

Metal stents are not superior to conventional endoprostheses with respect to the incidence of recurrent dysphagia because of tumor ingrowth with uncovered stents and migration with their covered counterparts. To overcome these limitations, a partially covered (inside-out covering) metal stent with a conical shape and a varying braiding angle of the mesh along its length, the Flamingo stent, has been developed.

METHODS

From March 1997 to October 1997, 40 consecutive patients with dysphagia due to malignant tumors had either a small diameter (proximal/distal diameter 24/16 mm; n = 21) or a large diameter Flamingo stent (proximal/distal diameter 30/20 mm; n = 19) placed.

RESULTS

There was statistically significant improvement in dysphagia, but improvement was not greater with large diameter stents compared to small diameter stents (p = 0.21). Major complications (bleeding [4], perforation [1], fever [1] and fistula [1]) occurred in 7 (18%) patients. Large diameter stents tended to be associated with more major complications than small diameter stents (5 vs. 2; p = 0.07). Pain following stent placement was observed in 9 (22%) patients and occurred more frequently in those who had prior radiation and/or chemotherapy (p = 0.02). Recurrent dysphagia (mainly due to tumor overgrowth) occurred in 10 (25%) patients.

CONCLUSIONS

Flamingo stents are effective for palliation of malignant dysphagia, but the large diameter stent seems to be associated with more complications involving the esophagus than the small diameter stent. Because recurrent dysphagia is mainly due to tumor progression, further technical developments in stent design are needed.

Upper gastrointestinal tract malignant obstruction: initial results of palliation with a flexible covered stent

The authors treated 21 patients with inoperable upper gastrointestinal tract malignant obstruction from the esophagus to the duodenum by means of intubation with a flexible covered stent with fluoroscopic guidance. Stent placement was successful and relief of dysphagia was immediate in 18 (86%) patients, without serious complication. The average dysphagia score decreased from 2.6 (dysphagia to liquids) to 1.0 (dysphagia to normal solid food). Placement of a flexible covered stent provides easy, safe, and effective palliation of upper gastrointestinal malignant obstruction.