Nonmalignant obstruction is a common problem with metal stents in the treatment of esophageal cancer

Endoscopic luminal stenting: Current applications and future perspectives

Endoscopic luminal stenting (ELS) represents a minimally invasive option for the management of malignant obstruction along the gastrointestinal tract. Previous studies have shown that ELS can provide rapid relief of symptoms related to esophageal, gastric, small intestinal, colorectal, biliary, and pancreatic neoplastic strictures without compromising cancer patients’ overall safety. As a result, in both palliative and neoadjuvant settings, ELS has largely surpassed radiotherapy and surgery as a first-line treatment modality. Following the abovementioned success, the indications for ELS have gradually expanded. To date, ELS is widely used in clinical practice by well-trained endoscopists in managing a wide variety of diseases and complications, such as relieving non-neoplastic obstructions, sealing iatrogenic and non-iatrogenic perforations, closing fistulae and treating post-sphincterotomy bleeding. The abovementioned development would not have been achieved without corresponding advances and innovations in stent technology. However, the technological landscape changes rapidly, making clinicians’ adaptation to new technologies a real challenge. In our mini-review article, by systematically reviewing the relevant literature, we discuss current developments in ELS with regard to stent design, accessories, techniques, and applications, expanding the research basis that was set by previous studies and highlighting areas that need to be further investigated.

Niti-S Esophageal Covered stent (double anti-reflux type). An observational patient registry|post-market clinical follow-up study

Background: Relieving dysphagia is the main goal of palliative care in advanced esophageal cancer. We aimed to evaluate the safety and clinical performance of the Niti-S esophageal double covered, anti-reflux stent (Taewoong Medical, Seoul, Korea) in inoperable carcinoma of the esophagus or gastric cardia. Methods: This was a retrospective patient registry/post-market clinical follow-up study of all patients with esophageal malignant strictures undergoing self-expandable metal stent (SEMS) placement with the Niti-S Esophageal covered stent, double antireflux in a community hospital (AZ St Maarten Mechelen, Belgium) between March 2013 and July 2021. Results: In twenty-nine patients, thirty self-expandable metal stents (SEMS) were placed. The median dysphagia score before stent placement was 3 and 0 after stent placement (p < 0.001). Stent migration did not occur. Two patients (7%) had new onset reflux symptoms. The most common adverse event was retrosternal pain (5 patients, 17%). One patient (3%) had recurrent dysphagia due to proximal tumoral overgrowth and two patients (7%) because of proximal benign tissue overgrowth. There were no perforations, fistula formations or episodes of food impaction. Conclusion: The Niti-S esophageal double covered, antireflux stent (Taewoong Medical, Seoul, Korea) is an effective and safe treatment option for malignant esophageal stenosis.

Recent Updates in Gastrointestinal Stent Placement from the Esophagus to the Colon: A Radiological Perspective

Fluoroscopic-guided stent placement has become an advantageous treatment option for diverse gastrointestinal disorders. In addition to palliative stent placement in patients with inoperable cancers, stenting has gradually expanded to other conditions, including as a bridge to surgery, as well as in patients' benign lesions and anastomotic strictures or leaks. This narrative review describes the indications, efficacy and safety of stent placement from the esophagus to the colon, including current recommendations, recent updates, and novel stents.

Characterization of Partially Covered Self-Expandable Metallic Stents for Esophageal Cancer Treatment: In Vivo Degradation

Partially covered self-expandable metallic esophageal stent (SEMS) placement is the most frequently applied palliative treatment in esophageal cancer. Structural characterization of explanted 16 nitinol-polyurethane SEMS (the group of 6 females, 10 males, age 40-80) was performed after their removal due to dysfunction. The adverse bulk changes in the polymer structure were identified using differential scanning calorimetry (DSC), differential mechanical thermal analysis (DMTA), and attenuated total reflectance infrared spectroscopy (ATR-IR) and discussed in terms of melting point shift (9 °C), glass-transition shift (4 °C), differences in viscoelastic behavior, and systematic decrease of peaks intensities corresponding to C-H, C═O, and C-N polyurethane structural bonds. The scanning electron and confocal microscopic observations revealed all major types of surface degradation, i.e., surface cracks, peeling off of the polymer material, and surface etching. The changes in the hydrophobic polyurethane surfaces were also revealed by a significant decrease in wettability (74°) and the corresponding increase of the surface free energy (31 mJ/m²). To understand the in vivo degradation, the in vitro tests in simulated salivary and gastric fluids were performed, which mimic the environments of proximal and distal ends, respectively. It was concluded that the differences in the degradation of the proximal and distal ends of prostheses strongly depend on the physiological environment, in particular stomach content. Finally, the necessity of the in vivo tests for SEMS degradation is pointed out.

Self-expanding segmental radioactive metal stents for palliation of malignant esophageal strictures

BACKGROUND

Traditional metal stents are not always suitable for patients with circuitous malignant esophageal stricture.

PURPOSE

We aimed to report the safety and effectiveness of stent insertion using self-expanding segmental radioactive metal stent in the palliation of malignant esophageal stricture.

MATERIAL AND METHODS

We conducted a retrospective analysis of 22 consecutive patients who underwent insertion of segmental radioactive metal stents from November 2016 to March 2019. Technical success, dysphagia score, and complications were analyzed. Kaplan-Meier analysis was used to analyze the survival time.

RESULTS

The stenting procedure was successful in all 22 patients with no procedure-related deaths. Twenty-four segmental radioactive metal stents were successfully implanted. A total of 6 (27.3%) complications were found, mainly 5 (22.7%) stent migrations. The median follow-up period was 3.3 months. Stent removal was required in 4 (12.5%) patients due to complete stent migration. The mean dysphagia score decreased significantly after stent insertion (P<0.0001). During follow up, 13 patients survived with no obvious clinical symptom and nine patients died. The mean survival was 9.9 months.

CONCLUSION

The stenting procedure using self-expanding segmental radioactive metal stents is safe and effective in dysphagia palliation of malignant esophageal stricture.

Outcomes of self-expandable metal stent placement for malignant oesophageal strictures

AIM

To analyse the outcomes of oesophageal stenting for malignant strictures and to study the correlation between the follow-up time and major complications.

MATERIALS AND METHODS

Patients with oesophageal malignancy who underwent stent placement between 2011 and 2016 for dysphagia were included. The data included age, sex, dysphagia, length and location of stenosis, date of stent placement, complications, follow-up time, and survival.

RESULTS

Two hundred and ninety-eight patients were included in the study. Minor complications occurred in 113 patients (37.9%) including chest pain (17.1%), foreign body sensation (25.5%), hiccups (1.68%), and reflux symptoms (27.5%). Major adverse events occurred in 93 (31.1%) patients including pneumonia (25.5%), migration (3%), perforation (0.67%), bleeding (1.68%), and restenosis (22.5%). oesophago-airway fistula occurred in 45 (15.1%) patients. The incidence of recurrent dysphagia, pneumonia, and oesophago-airway fistula increased over 3 months and decreased after another 3 months. The incidence of major complications as a percentage of survivors remained high after 3 months (>40%). Spearman analysis revealed a significant positive correlation between the incidence and the follow-up time over this period (rs=0.907, p<0.01).

CONCLUSION

The major complications of oesophageal stenting increased with time over 3 months and remained high for another 3 months. Therefore, stenting should be considered for palliation in patients with short expected survival (usually <3 months).

A novel fully covered self-expandable segmental metallic stents for the treatment of refractory esophageal stenosis

Background

The conventional esophageal stent is not flexible enough for refractory or circuitous esophageal stenosis. After stent placement, the bending stress may stimulate tissue proliferation in both ends of the stent, causing restenosis, severe bleeding or fistula. A fully covered self-expandable segmental stent was designed and used to overcome such shortcoming. This study aims to study the safety and effectiveness of the fully covered self-expandable segmental metallic stents placement in palliation of dysphasia in patients with refractory esophageal stenosis.

Methods

Retrospective study of hospital records of a consecutive series of 24 patients who underwent placement of fully covered segmental stent from March 2015 to April 2018 was conducted. All procedure was performed under local anesthesia and fluoroscopic guidance. Esophagography was performed by orally take of iodine contrast agent. A 5F catheter and a stiff guide wire were introduced in the esophagus. A fully covered segmental stent was delivered and implanted along the stiff guide wire. The upper endoscopy and chest computed tomography scan were used for the assessment of the location and length of stenosis on admission and during follow-up. The technical success and complications were collected and analyzed.

Results

Stent placement was successful in all patients without procedure-related deaths. Twenty-four covered segmental stents were implanted. A total of eight major complications (33.3%) were found, and stent migration was the most common complication (16.7%). The median follow-up time was 4.5 months (interquartile range: 0.8-14.0 months). Adjustment was required in 3 patients (12.5%) due to stent migration. The mean dysphagia score before stenting and end of follow-up was 3.3±0.5 and 1.0±1.6 (P<0.0001). Four covered segmental stents were removed due to stent migration or intolerance.

Conclusions

Stenting using novel fully covered self-expandable segmental metallic stent is safe and effective in dysphagia palliation of refractory esophageal stenosis.

Stenting in Palliation of Unresectable Esophageal Cancer

Background

The aim of this study was to analyze the safety and effectiveness of stenting using partially covered self-expandable stents in palliation of dysphagia in patients with unresectable esophageal cancer.

Methods

Retrospective analysis of hospital records of all patients who underwent esophageal stenting in the period 2008–2015 was performed. The study included patients with unresectable esophageal and esophagogastric cancer.

Results

There were 442 patients included. Mean age was 56 years (range 28–89), and 379 were males. In 40 (9.0%) patients, stenting was performed in the cervical, in 150 (39.3%)—in the middle thoracic, in 141 (31.9%)—in lower thoracic esophagus and in 111 (25.1%)—in the esophagogastric junction. Stenting resulted in significant alleviation of dysphagia grade (3.0 vs. 1.0, p = 0.00001). During the follow-up, 55 (12.4%) patients experienced recurrent dysphagia due to tumor or granulation tissue overgrowth, and in 18 (4.1%) patients, migration of the stent occurred, for which an independent risk factor was adjuvant chemo- and/or radiation therapy (p = 0.001). Minor complications included chest pain (54.5%), delayed complete stent expansion (12.0%), feeling of a foreign body (25.3%), hiccup (1.6%), gastroesophageal reflux (45.6%) and post-discharge pneumonia (2.5%). A feeling of a foreign body in the esophagus was significantly more common after stenting of the cervical esophagus (p = 0.0001), and hiccup was more common after stenting of the esophagogastric junction (p = 0.02). Major complications included bleeding (1.3%), respiratory insufficiency (0.7%), esophageal perforation (0.9%) and irregular heartburn (2.3%). Overall procedure-related mortality was 0.4%. The median survival time was 117.8 days (range 2–732).

Conclusions

Stenting is an effective procedure in relieving dysphagia in patients with unresectable malignant esophageal stenosis and is associated with low rate of postoperative and long-term complications.

Double-step invagination technique-A novel approach to retrieve embedded esophageal self-expanding metal stent

Self-expanding metal stenting is an established treatment modality in the management of esophageal growth and stricture. Reactive tissue ingrowth at the uncovered portion of the self-expanding metal stent (SEMS) anchors it in position, preventing its migration. When removal of such an embedded SEMS is clinically indicated, the procedure of endoscopic retrieval is fraught with serious complications. Temporary deployment of a larger fully covered "rescue" SEMS within the embedded SEMS has been reported to be useful in the extraction of the embedded SEMS. When the regression of embedding tissue, is only partially achieved by such "rescue" fully covered SEMS, further extraction of the embedded SEMS can prove to be technically challenging. Here we report two cases where a novel technique, namely the "double-step invagination technique," was useful in retrieving such embedded esophageal SEMS.

Computationally Designed 3D Printed Self-Expandable Polymer Stents with Biodegradation Capacity for Minimally Invasive Heart Valve Implantation: A Proof-of-Concept Study

The evolution of minimally invasive implantation procedures and the in vivo remodeling potential of decellularized tissue-engineered heart valves require stents with growth capacity to make these techniques available for pediatric patients. By means of computational tools and 3D printing technology, this proof-of-concept study demonstrates the design and manufacture of a polymer stent with a mechanical performance comparable to that of conventional nitinol stents used for heart valve implantation in animal trials. A commercially available 3D printing polymer was selected, and crush and crimping tests were conducted to validate the results predicted by the computational model. Finally, the degradability of the polymer was assessed via accelerated hydrolysis.

Novel stent in the palliation of malignant esophageal strictures: a retrospective study

The placement of metal stents is often used as a palliative treatment for malignant esophageal stenosis. We designed a novel stent that has been used clinically since 2011, and we therefore performed a retrospective study to compare the therapeutic effects of this novel metal stent to a conventional partially covered metal stent in patients with malignant esophageal strictures. The records of 201 consecutive patients who underwent placement of either the conventional partially covered metal stents (Group A, n = 92) or the new metal stents (Group B, n = 109) in the Endoscopy Center of General Hospital of Chengdu Military Command from October 2008 to March 2013 were reviewed. The median dysphagia score significantly improved in both groups 1 week following stent placement (P < 0.001). No significant differences were observed in success rate (P = 0.910) or the complication rate (P = 0.426) between groups. Six months after stent placement, recurrent dysphagia due to stent migration, tissue ingrowth or overgrowth or food obstruction occurred in 45% and 29% of patients in the conventional stent and new stent groups, respectively. The results of this retrospective study indicate that the new modified self-expandable metal stents (SEMS) is at least as safe and effective as the conventional partially covered SEMS in treatment of malignant esophageal strictures.

Endoscopic treatment of benign esophageal strictures: a literature review

Benign esophageal strictures arise from various etiologies and are frequently encountered. Although endoscopic dilation is still the first-line therapy, recurrent strictures do occur in approximately 10% of the cases and remains a challenge to gastroenterologists. Areas covered: A literature search was performed using PubMed and Google Scholar databases for original and review articles on endoscopic treatment of benign esophageal strictures. This review outlines the main available treatment options and its controversies in the management of refractory benign esophageal strictures. Expert commentary: Adding local steroid injections to dilation can be effective for peptic stenosis and strictures after endoscopic submucosal dissection, but remains uncertain for anastomotic strictures. Intralesional injections of mitomycin-C could be useful in corrosive strictures. Incisional therapy can be a reliable alternative in Schatzki rings and in anastomotic strictures, in experienced hands. By contrast, long-term outcome with endoprosthetic treatment is disappointing, and stent placement should be carefully considered and individualized.

Stenting as a palliative method in the management of advanced squamous cell carcinoma of the oesophagus and gastro-oesophageal junction

Advanced squamous cell carcinoma of the oesophagus and gastroesophageal junction usually requires palliative treatment, and the method of choice is stenting. There are several types of stents currently available, including: self-expandable metallic stents (fully or partially covered); self-expandable plastic stents; biodegradable stents. Each of the mentioned stents has its advantages and limitations, and requires a proper, patient-tailored selection. Due to the close anatomical relationship between the oesophagus and bronchial tree, some patients may require bilateral stenting. Oesophageal stenting may not only be considered as a palliative procedure, but can also be implemented to alleviate dysphagia during preoperative chemotherapy and/or radiotherapy.

Engineering Stent Based Delivery System for Esophageal Cancer Using Docetaxel

Esophageal cancer patients are often diagnosed as "advanced" cases. These patients are subjected to palliative stenting using self-expanding metallic stents (SEMS) to maintain oral alimentation. Unfortunately, SEMS get reoccluded due to tumor growth, in and over the stent struts. To investigate potential solutions to this problem, docetaxel (DTX) delivery films were prepared using PurSil AL 20 (PUS), which can be used as a covering material for the SEMS. Drug-polymer miscibility and interactions were studied. Bilayer films were prepared by adhering the blank film to the DTX loaded film in order to maintain the unidirectional delivery to the esophagus. In vitro release and the local DTX delivery were studied using in vitro permeation experiments. It was found that DTX and PUS were physically and chemically compatible. The bilayer films exhibited sustained release (>30 days) and minimal DTX permeation through esophageal tissues in vitro. The rate-determining step for the DTX delivery was calculated. It was found that >0.9 fraction of rate control lies with the esophageal tissues, suggesting that DTX delivery can be sustained for longer periods compared to the in vitro release observed. Thus, the bilayer films can be developed as a localized sustained delivery system in combination with the stent.

Gastrointestinal stenting: Current status and imaging features

The use of stents in the gastrointestinal tract has been subjected to major changes. Initially, the use of stents was restricted to malignant strictures in patients with metastatic disease. But thanks to reduction of the morbidity and mortality rates, they are now used with curative intention and in patients with benign diseases after careful selection. However, for patients presenting with colon obstruction due to an advanced colon carcinoma, the mortality and morbidity are still high. The purpose of this review is to provide an overview of indications, techniques and further developments of the stents in the gastrointestinal tract and to highlight the predominant role of multidetector row computed tomography (MDCT) in the detection of potential complications.

Refractory esophageal strictures: what to do when dilation fails

Benign esophageal strictures arise from a diversity of causes, for example esophagogastric reflux, esophageal resection, radiation therapy, ablative therapy, or the ingestion of a corrosive substance. Most strictures can be treated successfully with endoscopic dilation using bougies or balloons, with only a few complications. Nonetheless, approximately one third of patients develop recurrent symptoms after dilation within the first year. The majority of these patients are managed with repeat dilations, depending on their complexity. Dilation combined with intra lesional steroid injections can be considered for peptic strictures, while incisional therapy has been demonstrated to be effective for Schatzki rings and anastomotic strictures. When these therapeutic options do not resolve the stenosis, stent placement should be considered. Self bougienage can be proposed to a selected group of patients with a proximal stenosis. As a final step surgery is an option, but even then the risk of stricture formation at the anastomotic site remains. This chapter reviews refractory benign esophageal strictures and the treatment options that are currently available.

Preventive effects of ¹²⁵I seeds on benign restenosis following esophageal stent implantation in a dog model

The present study aimed to evaluate the effects of iodine-125 (¹²⁵I) seeds on the proliferation of primary esophageal fibroblasts in dogs, and to assess the safety and preventive efficacy of ¹²⁵I seed-pre-loaded esophageal stents in benign restenosis following implantation. Primary fibroblasts were cultured with various ¹²⁵I seed activities, which were then evaluated using cell proliferation and apoptosis assays as well as cell cycle analysis using Annexin V/propidium iodide (PI) double staining and PI staining. Prior to sacrification, animals were submitted to esophageal radiography under digital subtraction angiography. Esophageal tissues were collected and examined for macroscopic, microscopic and pathological alterations. The results demonstrated a significant and dose-dependent inhibition of fibroblast proliferation and increased apoptosis following exposure to ¹²⁵I seeds. G0/G1 fibroblast populations increased in a dose-dependent manner following treatment with ¹²⁵I seeds, in contrast to cells in S phase. Four weeks following implantation, α-smooth muscle actin and proliferating cell nuclear antigen expression levels in the experimental group were significantly lower compared with those in the control group; in addition, eight weeks following implantation, esophageal inner diameters were increased in the experimental group. ¹²⁵I seeds inhibited proliferation of dog esophageal fibroblasts via cell cycle arrest and apoptosis. In conclusion, ¹²⁵I seed-pre-loaded esophageal stents inhibited benign hyperplasia in the upper edge of the stent to a certain extent, which relieved benign restenosis following implantation with a good safety profile.

Removable esophageal stents have poor efficacy for the treatment of refractory benign esophageal strictures (RBES)

With the recent availability of removable esophageal stents, endoscopic stenting has been utilized to treat refractory benign esophageal strictures (RBES). The objective of this study was to review the feasibility and effectiveness of removable esophageal stents to treat RBES. Patients who received removable esophageal stents for the treatment of RBES at the institution between 2004-2010 using its stent implantation logs and endoscopic database were retrospectively identified. Patient demographics, stricture etiology and location, stent and procedure characteristics, and clinical outcomes were obtained. Twenty-five patients with a mean age of 70 (72% male) underwent initial stent placement; 24 were successful. Overall clinical success was achieved in five of the 19 patients (26%) ultimately undergoing stent removal. RBES etiologies included anastomotic (13), radiation (5), peptic (3), chemotherapy (1), scleroderma (1), and unknown (2). Alimaxx-E (Merit-Endotek, South Jordan, UT, USA) stents were placed in 20 patients and Polyflex (Boston Scientific, Natick, MA, USA) stents were used in five patients. Immediate complications included failed deployment (1) and chest pain (7). Five patients died prior to stent removal. Stent migration was found in 53% (10/19) of patients who underwent stent removal: nine required additional therapy and one had symptom resolution. Out of the nine patients without stent migration, five required additional therapy and four had symptom resolution. Although placement of removable esophageal stents for RBES is technically feasible, it is frequently complicated by stent migration and chest pain. In addition, few patients achieved long-term stricture resolution after initial stenting. In this study, most patients ultimately required repeated stenting and/or dilations to maintain relief of dysphagia.

Application of argon plasma coagulation in treatment of esophageal strictures

AIM: To assess the application value of argon plasma coagulation in the treatment of esophageal strictures.

METHODS: A comparative study of 112 patients with short-segment esophageal stenosis or in-stent restenosis was performed. The relief of dysphagia was compared between an argon plasma coagulation group and a simple bougie dilatation group or between an argon plasma coagulation group and a second stenting group.

RESULTS: The response rates in the argon plasma coagulation group was significantly better than those in the simple bougie dilatation group during follow-up periods of 3 months (68.57% vs 42.86%, P < 0.05) and 6 months (34.29% vs 10.71%, P < 0.05). The response rates in the argon plasma coagulation group and second stenting group were not statistically significant during follow-up periods of 1 and 3 months, but the response rate in the second stenting group was better after 6 months (50.00% vs 21.74%, P < 0.05).

CONCLUSION: Endoscopic argon plasma coagulation can effectively relieve short-segment esophageal stenosis and restenosis after stenting, representing a safe and effective method.

Bioreducible polymer-delivered siRNA targeting MMP-9: suppression of granulation tissue formation after bare metallic stent placement in a rat urethral model

PURPOSE

To evaluate the effectiveness of small interfering RNA (siRNA) targeting matrix metalloproteinase 9 (MMP-9) in suppressing granulation tissue formation caused by bare metallic stent placement in a rat urethral model.

MATERIALS AND METHODS

All experiments were approved by the committee of animal research. In 20 Sprague-Dawley male rats (weight range, 300-350 g), a self-expanding metallic bare stent was inserted in the urethra with fluoroscopic guidance. One group of 10 rats (group A) was treated with MMP-9 siRNA/bioreducible branched polyethylenimine-disulfide cross-linked-indocyanine green (bioreducible BPEI-SS-ICG), while the other group of 10 rats (group B) received control siRNA/bioreducible BPEI-SS-ICG treatment. All rats were sacrificed at 4 weeks. The therapeutic effectiveness of the MMP-9 siRNA/bioreducible BPEI-SS-ICG complex was assessed by comparing the two results of retrograde urethrography, histologic examination, and quantification of MMP-9 by using zymography and Western blot analysis between the two groups. The Mann-Whitney U test was used to evaluate differences.

RESULTS

Stent placement was successful in all rats without a single case of migration at follow-up. Retrograde urethrography performed 4 weeks after stent placement demonstrated significantly larger luminal diameters of the urethra within the stents in group A compared with those in group B (P = .011). Histologic analysis revealed that the mean percentage of granulation tissue area (P < .001), mean number of epithelial layers (P < .001), and mean thickness of submucosal fibrosis (P < .001) were significantly decreased in group A compared with group B. Meanwhile, the mean density of inflammatory cell infiltration did not significantly differ between the two groups (P = .184). Quantitative analysis disclosed MMP-9 levels to be lower in group A relative to group B, indicating positive inhibition of MMP-9 by MMP-9 siRNA/bioreducible BPEI-SS-ICG.

CONCLUSION

MMP-9 siRNA/bioreducible BPEI-SS-ICG is effective for inhibiting granulation tissue formation after bare metallic stent placement in a rat urethral model.

Self-expanding metal stents or nonstent endoscopic therapy: which is better for anastomotic leaks after total gastrectomy?

BACKGROUND

Anastomotic leaks are a life-threatening complication of gastrectomies with high mortality after surgical reintervention. Endoscopic therapy using fibrin glue injection, endoclip, and other devices is an alternative to surgical intervention for anastomotic leaks. Recently, self-expanding metal stents (SEMS) were introduced to treat anastomotic leaks. The purpose of this study was to assess the clinical characteristics and therapeutic outcomes of SEMS and nonstent endoscopic therapy (NSET) for treatment of anastomotic leaks after total gastrectomy with the aim of assisting endoscopists in choosing a treatment method.

METHODS

Between July 2002 and March 2013, 13 patients treated with SEMS and 14 patients treated with NSET for anastomotic leaks after total gastrectomy were enrolled onto the study. Enrolled patients received 16 SEMS placement sessions and 21 NSET sessions.

RESULTS

No significant differences in baseline characteristics or clinical characteristics related to leakage were detected in patients with SEMS compared to NSET. The successful sealing rate at the first attempt by SEMS was significantly better than that of NSET (80.0 vs. 28.6 %, P = 0.036), whereas the successful sealing rate after multiple endoscopic treatments was not statistically different (80.0 vs. 64.3 %, P = 0.653). The main reason for reintervention with SEMS was complications and with NSET was nonseal (P = 0.004). Clinical outcomes including length of hospital stay, endoscopic treatment-related mortality, and all-cause mortality were not significantly different between the 2 groups.

CONCLUSIONS

In terms of efficacy by single effort, SEMS was superior to other methods for treating anastomotic leaks after total gastrectomy. However, complications with SEMS should be considered when choosing an endoscopic treatment method.

Evidence-based recommendations on upper gastrointestinal tract stenting: a report from the stent study group of the korean society of gastrointestinal endoscopy

Endoscopic stents have evolved dramatically over the past 20 years. With the introduction of uncovered self-expanding metal stents in the early 1990s, they are primarily used to palliate symptoms of malignant obstruction in patients with inoperable gastrointestinal (GI) cancer. At present, stents have emerged as an effective, safe, and less invasive alternative for the treatment of malignant GI obstruction. Clinical decisions about stent placement should be made based on the exact understanding of the patient's condition. These recommendations based on a critical review of the available data and expert consensus are made for the purpose of providing endoscopists with information about stent placement. These can be helpful for management of patients with inoperable cancer or various nonmalignant conditions in the upper GI tract.

Stent placement for esophageal strictures: an update

The use of stents for esophageal strictures has evolved rapidly over the past 10 years, from rigid plastic tubes to flexible self-expanding metal (SEMS), plastic (SEPS) and biodegradable stents. For the palliative treatment of malignant dysphagia both SEMS and SEPS effectively provide a rapid relief of dysphagia. SEMS are preferred over SEPS, as randomized controlled trials have shown more technical difficulties and late migration with plastic stents. Despite specific characteristics of recently developed stents, recurrent dysphagia due to food impaction, tumoral and nontumoral tissue overgrowth, or stent migration, remain a major challenge. The efficacy of stents with an antireflux valve for patients with distal esophageal cancer varies between different stent designs. Concurrent treatment with chemotherapy and/or radiotherapy seems to be safe and effective. In the future, it can be expected that removable stents will be used as a bridge to surgery to maintain luminal patency during neoadjuvant treatment. For benign strictures, new stent designs, such as fully covered SEMS and biodegradable stents, may potentially reduce complications during stent removal.

Fully covered self-expandable metal stents (SEMS), partially covered SEMS and self-expandable plastic stents for the treatment of benign esophageal ruptures and anastomotic leaks

Background

Benign esophageal ruptures and anastomotic leaks are life-threatening conditions that are often treated surgically. Recently, placement of partially and fully covered metal or plastic stents has emerged as a minimally invasive treatment option. We aimed to determine the clinical effectiveness of covered stent placement for the treatment of esophageal ruptures and anastomotic leaks with special emphasis on different stent designs.

Methods

Consecutive patients who underwent placement of a fully covered self-expandable metal stent (FSEMS), a partially covered SEMS (PSEMS) or a self-expanding plastic stent (SEPS) for a benign esophageal rupture or anastomotic leak after upper gastrointestinal surgery in the period 2007-2010 were included. Data on patient demographics, type of lesion, stent placement and removal, clinical success and complications were collected

Results

A total of 52 patients received 83 esophageal stents (61 PSEMS, 15 FSEMS, 7 SEPS) for an anastomotic leak (n = 32), iatrogenic rupture (n = 13), Boerhaave's syndrome (n = 4) or other cause (n = 3). Endoscopic stent removal was successful in all but eight patients treated with a PSEMS due to tissue ingrowth. Clinical success was achieved in 34 (76%, intention-to-treat: 65%) patients (PSEMS: 73%, FSEMS: 83%, SEPS: 83%) after a median of 1 (range 1-5) stent and a median stenting time of 39 (range 7-120) days. In total, 33 complications in 24 (46%) patients occurred (tissue in- or overgrowth (n = 8), stent migration (n = 10), ruptured stent cover (all Ultraflex; n = 6), food obstruction (n = 3), severe pain (n = 2), esophageal rupture (n = 2), hemorrhage (n = 2)). One (2%) patient died of a stent-related cause.

Conclusions

Covered stents placed for a period of 5-6 weeks may well be an alternative to surgery for treating benign esophageal ruptures or anastomotic leaks. As efficacy between PSEMS, FSEMS and SEPS is not different, stent choice should depend on expected risks of stent migration (SEPS and FSEMS) and tissue in- or overgrowth (PSEMS).

Fully covered self-expandable metal stents (SEMS), partially covered SEMS and self-expandable plastic stents for the treatment of benign esophageal ruptures and anastomotic leaks

BACKGROUND

Benign esophageal ruptures and anastomotic leaks are life-threatening conditions that are often treated surgically. Recently, placement of partially and fully covered metal or plastic stents has emerged as a minimally invasive treatment option. We aimed to determine the clinical effectiveness of covered stent placement for the treatment of esophageal ruptures and anastomotic leaks with special emphasis on different stent designs.

METHODS

Consecutive patients who underwent placement of a fully covered self-expandable metal stent (FSEMS), a partially covered SEMS (PSEMS) or a self-expanding plastic stent (SEPS) for a benign esophageal rupture or anastomotic leak after upper gastrointestinal surgery in the period 2007-2010 were included. Data on patient demographics, type of lesion, stent placement and removal, clinical success and complications were collected

RESULTS

A total of 52 patients received 83 esophageal stents (61 PSEMS, 15 FSEMS, 7 SEPS) for an anastomotic leak (n=32), iatrogenic rupture (n=13), Boerhaave's syndrome (n=4) or other cause (n=3). Endoscopic stent removal was successful in all but eight patients treated with a PSEMS due to tissue ingrowth. Clinical success was achieved in 34 (76%, intention-to-treat: 65%) patients (PSEMS: 73%, FSEMS: 83%, SEPS: 83%) after a median of 1 (range 1-5) stent and a median stenting time of 39 (range 7-120) days. In total, 33 complications in 24 (46%) patients occurred (tissue in- or overgrowth (n=8), stent migration (n=10), ruptured stent cover (all Ultraflex; n=6), food obstruction (n=3), severe pain (n=2), esophageal rupture (n=2), hemorrhage (n=2)). One (2%) patient died of a stent-related cause.

CONCLUSIONS

Covered stents placed for a period of 5-6 weeks may well be an alternative to surgery for treating benign esophageal ruptures or anastomotic leaks. As efficacy between PSEMS, FSEMS and SEPS is not different, stent choice should depend on expected risks of stent migration (SEPS and FSEMS) and tissue in- or overgrowth (PSEMS).

Self-expanding metal stents (SEMS) for patients with advanced esophageal cancer in Malawi: an effective palliative treatment

BACKGROUND AND OBJECTIVES

Esophageal cancer is common in Malawi and most patients are inoperable at time of diagnosis. The aim of this study was to prospectively evaluate palliative treatment with self-expanding metal stents (SEMS) in Malawi, a low-income country with limited medical resources.

METHODS

Data of patients with advanced inoperable esophageal cancer were prospectively collected. Tumor and patient specifics, risk factors, dysphagia scores, complications, and survival were assessed. Follow-up data for 1 year or until death were collected from 118/143 patients (83%) during clinic visits, home visits, or via cell phone.

RESULTS

One hundred forty-three patients were treated with 154 SEMS. Median survival was 210 days (95% CI: 150-262 days). Fourteen of 118 patients with complete follow-up (11.9%) survived more than 1 year with longest documented survival of 406 days. The median dysphagia score improved from 3 at the time of presentation to 0 at the time of death. Early complications occurred in 4.2% (6/143), late complications in 11.9% of patients (14/118). The procedure related mortality was 2.1% (3/143).

CONCLUSIONS

SEMS is an appropriate palliative treatment in a resource-limited environment. For the vast majority of patients a single intervention provides lasting improvement of dysphagia.

A comparison of temporary self-expanding plastic and biodegradable stents for refractory benign esophageal strictures

BACKGROUND & AIMS

It is a challenge to manage refractory benign esophageal strictures (RBES). We compared the efficacy and safety of self-expanding plastic stents (SEPSs) with placement of biodegradable stents for the treatment of RBES.

METHODS

We studied 2 groups of consecutive patients with RBES who received temporary placement (6 weeks) of SEPSs (n = 20) or biodegradable stents (n = 18). Data were collected with respect to clinical outcome, complications, recurrent dysphagia, and reinterventions.

RESULTS

SEPSs were removed in 16 (80%) patients. Stent placement was not successful in 1 patient, while stent removal was not performed in another 3 patients. Six (30%) patients with an SEPS were dysphagia-free after a median follow-up of 385 days (range, 77-924 days). Ten (50%) developed recurrent dysphagia. Major complications occurred in 2 patients (10%; 1 with hemorrhage and 1 with perforation). Six patients (33%) with a biodegradable stent were dysphagia-free after a median follow-up of 166 days (range 21-559 days) (P = .83 compared with SEPS). Twelve patients (67%) had recurrent dysphagia. Major complications occurred in 4 patients (22%; 2 with hemorrhage, 2 with severe retrosternal pain) with a biodegradable stent (P = .30 compared with SEPS). Reinterventions were less frequently indicated after biodegradeble stent than after SEPS placement (15 [mean, 0.8 ± 0.6 per stent placed] vs 21 [mean, 1.3 ± 0.4 per stent placed], respectively; P = .03).

CONCLUSIONS

Placement of SEPSs or biodegradable stents provides long-term relief of dysphagia in 30% and 33%, respectively, of patients with RBES. Biodegradable stents require fewer procedures than SEPSs, offering an advantage. Although stent placement is a viable strategy in patients with RBES, the ideal strategy still needs to be defined.

Esophageal stenting

Malignant obstruction of the esophagus is a debilitating condition, with dysphagia as its main symptom. Many patients present with advanced disease and palliative treatment is the only possibility. Since their widespread introduction 10 years ago, self-expanding metal stents have become accepted as an extremely effective method of palliating malignant dysphagia. Early reports suggesting very low complications have been superseded by results from randomized trials. It is now evident that the complication rate is significant and the need for reintervention can be as high as 50%. Modifications in stent design should reduce this reintervention rate. There are a large number of stent designs now available and it is essential that the interventional radiologist understand the particular strengths and weaknesses of each design, so that the correct choice of stent can be made for a particular patient. The most recent designs include antireflux stents and removable stents. Both represent significant advances and should reduce stent-related complications.

Fully covered, retrievable self-expanding metal stents (Niti-S) in palliation of malignant dysphagia: long-term results of a prospective study

BACKGROUND

In the palliative treatment of malignant dysphagia, fully covered, retrievable metal stents are not commonly used, mainly due to the high risk of migration. Therefore, we performed a prospective study to evaluate the clinical efficacy of a fully covered, retrievable self-expanding metal stent (Niti-S).

METHOD

Between October 1998 and February 2009, 100 consecutive patients with malignant esophageal obstruction treated with the fully covered Niti-S stent (Niti-S, Taewoong Medical, Seoul, South Korea) were included. Data collected contained functional outcome, feasibility of endoscopic stent retrieval, recurrent dysphagia, complications, and survival.

RESULT

At 4 weeks after stent placement, dysphagia significantly improved in all patients (p = 0.000). Recurrent dysphagia occurred in 19 of 100 patients treated with Niti-S stents (19%) mainly due to tumor overgrowth (7/100, 7%), stent migration (6/100, 6%), and food impaction (6/100, 6%). Endoscopic stent retrieval was successful in all the attempted 17 patients (17/100, 17%)--7 overgrowth, 6 stent migration, 2 stent degradation, and 2 severe pain. Major complications were 2 hemorrhage, 2 severe pain, and 1 tracheal compression (5/100, 5%), and minor complications were 10 retrosternal pain and 7 symptomatic gastroesophageal reflux (17/100, 17%). After a median follow-up of 142 days, 97 patients had expired. There was no stent-related mortality or 30-day mortality.

CONCLUSION

The fully covered, retrievable Niti-S stent has proved its effectiveness for palliation of malignant dysphagia and feasibility of endoscopic retrieval. We estimate its dog-bone shaped flanges at both ends and it being completely covered provide good resistance to migration and overgrowth.

Systematic review: temporary stent placement for benign rupture or anastomotic leak of the oesophagus

BACKGROUND

Placement of self-expanding metal stents (SEMS) or plastic stents (SEPS) has emerged as a minimally invasive treatment option for benign oesophageal ruptures and leaks; however, it is not clear which stent type should be preferred.

AIM

To assess clinical effectiveness and safety of treating benign oesophageal ruptures and anastomotic leaks with temporary placement of a stent with special emphasis on different stent designs.

METHODS

A pooled analysis was performed after searching PubMed and EMBASE databases for studies regarding placement of fully covered and partially covered SEMS (FSEMS and PSEMS) and SEPS for this indication. Data were pooled and evaluated for clinical outcome, complications and survival.

RESULTS

Twenty-five studies, including 267 patients with complete follow-up on outcome, were identified. Clinical success was achieved in 85% of patients and was not different between stent types (SEPS 84%, FSEMS 85% and PSEMS 86%, P = 0.97). Time of stent placement was longest for SEPS (8 weeks) followed by FSEMS and PSEMS (both 6 weeks). In total, 65 (34%) patients had a stent-related complication. Stent migration occurred more often with SEPS [n = 47 (31%)] and FSEMS [n = 7 (26%)] than with PSEMS [n = 2 (12%), P ≤ 0.001], whereas there was no significant difference in tissue in- and overgrowth between PSEMS [12% vs. 7% (FSEMS) and 3% (SEPS), P = 0.68].

CONCLUSIONS

Although there is a lack of randomised controlled trials, it seems that covered stent placement for a period of 6-8 weeks is safe and effective for benign oesophageal ruptures and anastomotic leaks to heal. As efficacy between different stent types is not significantly different, stent choice should depend on expected risk of stent migration (self-expanding plastic stents and fully covered self-expanding metal stents) and, to a minor degree, on expected risk of tissue in- or overgrowth (partially covered self-expanding metal stents).

Stents for proximal esophageal cancer: a case-control study

BACKGROUND

Self-expandable metal stents (SEMSs) are an established palliative therapy for esophageal cancer. SEMS placement for cancers near the upper esophageal sphincter (UES) is controversial because of a perceived increased risk of complications.

OBJECTIVE

To compare outcomes after patients stented for proximal esophageal cancer (PC) and distal esophageal cancer (DC).

DESIGN

Matched case-control study from a prospective database.

SETTING

Tertiary referral center, Tenwek Hospital, Bomet, Kenya.

PATIENTS

All patients with PC located within 6 cm of the UES were matched with randomly selected controls with DC.

INTERVENTIONS

Outcomes of PC cases were compared with those of DC controls.

MAIN OUTCOME MEASUREMENTS

Dysphagia score, complications, median survival.

RESULTS

A total of 151 patients with PC were identified and were randomly matched with DC controls. Ninety-three case-control pairs had adequate follow-up information available. Mean dysphagia scores (scale 0-4) improved from 3.4 and 3.3 before stenting for PC and DC, respectively, to 1.5 after stenting for both groups (P = .93). Early complications occurred in 6.5% of PC cases and 9.7% of DC controls (P = .44). Late complications occurred in 20.4% of PC cases and 15.1% of DC controls (P = .25). Median survival was 210 days for PC cases and 272 days for DC controls (P = .25). Outcomes were similar for the subgroup of PC cases whose cancer extended to within 2 cm of the UES.

LIMITATION

An important limitation is the absence of adequate follow-up data for 58 of the 151 case-control pairs.

CONCLUSIONS

SEMSs effectively palliate dysphagia in PC cases, whereas complication and survival rates are not statistically different from those of DC controls.

Success and complications associated with placement of fully covered removable self-expandable metal stents for benign esophageal diseases (with videos)

BACKGROUND

Fully covered esophageal self-expandable metal stents (FCSEMSs) are thought to induce less mucosal hyperplasia and are potentially removable. They may constitute an attractive alternative for the treatment of benign esophageal diseases.

OBJECTIVE

To evaluate the efficacy and safety of FCSEMSs in the treatment of benign esophageal diseases.

DESIGN

Patients referred for management of benign esophageal disease underwent placement of an FCSEMS and were entered into a prospective database and analyzed retrospectively for clinical response, efficacy, and morbidity.

SETTING

Two tertiary care centers with long-standing experience in the management of benign esophageal strictures.

PATIENTS

Between January 2006 and September 2007, 35 patients (mean age 61 years, range 20-85 years) underwent FCSEMS placement for benign esophageal diseases at 2 tertiary academic medical centers. There were 19 patients with benign esophageal strictures and 16 patients with leaks/perforations.

INTERVENTION

Temporary placement of FCSEMS until stricture resolution.

MAIN OUTCOME MEASUREMENTS

Clinical response, efficacy, and morbidity.

RESULTS

Indications for stent placement were esophageal leak/fistulae (n = 12), refractory benign strictures (n = 10), anastomotic strictures (n = 7), perforations (n = 4), and radiation-induced strictures (n = 2). Immediate complications were chest pain (2 patients), stent migration (2 patients), dysphagia (1 patient), respiratory compromise (1 patient), and arrhythmia (1 patient). Long-term complications included recurrent dysphagia (6 patients), aspiration pneumonia (2 patients), globus sensation (2 patients), abdominal pain (2 patients), and fever (1 patient). Stent migration was observed in 12 patients (34%). After placement, dysphagia scores at 1 month improved significantly from 3.1 ± 1.0 to 1.2 ± 1.3 (P < .0001). A total of 11 of 35 patients (31%) were treated successfully. Specifically, 21% of patients with refractory strictures and 44% of patients with leaks/fistulae had successful long-term outcomes without any need for reinterventions. All stents were retrieved successfully, except for 1 stent, which fractured and was retrieved in 2 pieces without any complications.

CONCLUSION

Use of FCSEMSs for benign esophageal conditions was associated with frequent stent migration and long-term improvement in only one third of patients. Further investigation is required before recommending FCSEMS placement to treat benign diseases of the esophagus and to further characterize the subgroup that might benefit from these interventions.

Stent-in-stent technique for removal of embedded esophageal self-expanding metal stents

OBJECTIVES

Partially covered self-expanding metal stents (SEMSs) are regularly used for malignant and occasionally for benign esophageal disorders. Safe removal of these stents can be challenging due to embedding of the uncovered stent ends. Our aim is to report the results of removal of embedded, partially covered SEMSs by induction of pressure necrosis using the stent-in-stent technique.

METHODS

Consecutive patients referred to three endoscopy units in 2007-2009, treated by the stent-in-stent technique, were reviewed. The partially covered SEMSs were inserted for malignant (n=3) or benign (n=16) conditions and were left in situ for a median of 42 days (14-189). When SEMSs were found to be embedded, a fully covered self-expanding plastic stent (SEPS) or fully covered SEMS was placed inside the partially uncovered SEMS. Subsequent removal of both stents was planned after a period of 10-14 days.

RESULTS

In total, 23 stent-in-stent procedures were performed in 19 patients (10 males). Placement of a fully covered stent (SEPS: n=9 and SEMS: n=14) was technically successful in all patients. In 21 of 23 (91%) procedures, both stents were successfully removed in one procedure after a median of 12 days (5-18). In two patients, a repeat stent-in-stent procedure was needed for persistent embedding of the partially uncovered SEMSs. One (5%) procedure was complicated by severe bleeding, which could be treated endoscopically. In seven (36%) patients, the initial disorder had resolved after stent removal and no further endoscopic interventions were needed. Two (10%) patients were treated with chemoradiation or surgery for esophageal cancer after stent removal. In 10 (53%) patients, a repeat endoscopic intervention was required during follow-up because of progressive dysphagia or a persisting leak or fistula.

CONCLUSIONS

The stent-in-stent technique is safe and effective for the removal of partially covered SEMSs that are embedded in the esophageal wall.

Role of esophageal stents in the nutrition support of patients with esophageal malignancy

Endoluminal stents are commonly used for palliative treatment of dysphagia in patients with advanced esophageal malignancies. The most frequently used esophageal stents are self-expanding metal stents. Removable self-expanding plastic stents have recently been used in the management of esophageal cancer patients treated with curative intent. Esophageal stents effectively alleviate dysphagia in most patients, and stent placement is associated with a low rate of complications. This article reviews the use of self-expanding esophageal stents in patients with esophageal cancer. Nutrition considerations following stent placement are addressed.

A new partially covered metal stent for palliation of malignant dysphagia: a prospective follow-up study

BACKGROUND

Metal stents are frequently used for palliation of malignant dysphagia. Recently, a new stent design, the partially covered Wallflex stent (Boston Scientific, Natick, Mass), has been introduced.

OBJECTIVE

To determine clinical effectiveness and safety of the esophageal Wallflex stent for the palliation of dysphagia.

DESIGN

A prospective follow-up study evaluating a new stent design.

SETTING

Three tertiary-care referral centers.

PATIENTS

This study involved 37 patients with cancer of the esophagus or gastric cardia.

INTERVENTIONS

Stent placement.

MAIN OUTCOME MEASUREMENTS

Data were collected regarding technical and clinical outcome, complications, recurrent dysphagia, and survival.

RESULTS

A total of 37 patients (median age, 67 years; range, 48-84 years; 22 men [59%]) had a Wallflex stent placed. Stent placement was technically successful in all but 1 patient. Dysphagia improved from a median dysphagia score of 3 (ability to swallow liquids only) to 1 (ability to eat some solid foods) 4 weeks after stent placement. Major complications occurred in 3 patients (8%; pneumonia in 1, severe pain in 2), and 1 patient (3%) died from a complication (pneumonia). Minor complications included mild retrosternal pain in 10 patients (27%) and regurgitation in 7 patients (19%). In total, 8 patients (22%) developed recurrent dysphagia because of stent migration (n = 2 [6%]), food impaction (n = 2 [6%]), or tissue ingrowth or overgrowth (n = 4 [10%]).

LIMITATIONS

Nonrandomized study design.

CONCLUSIONS

Placement of a partially covered Wallflex stent is safe and effective for the palliation of malignant dysphagia, with migration and tissue in- and overgrowth rates comparable to those of similarly designed stents. Retrosternal pain may occur more often with this stent than with other stent designs.

A rat esophageal model to investigate stent-induced tissue hyperplasia

PURPOSE

To evaluate the feasibility of stent placement and the formation of tissue hyperplasia caused by stent placement in a rat esophageal model.

MATERIALS AND METHODS

Twenty Sprague-Dawley rats were divided into four groups to assess differing stent diameters and design (group I, 4 mm diameter and a large mesh gap; group II, 5 mm diameter and a large mesh gap; group III, 5 mm diameter and a small mesh gap; and group IV, barbs added to the group III stents). Follow-up, 1-week, and 3-week esophagograms were obtained. Rats were euthanized 3 weeks after stent placement. Microscopic findings were evaluated in groups with an incidence of less than 50% stent migration.

RESULTS

Stent placement was technically successful in all rats, and there were no procedure-related complications. No esophageal perforation occurred during follow-up. The incidence of stent migration was 100%, 60%, 40%, and 0% in groups I through IV, respectively. The esophagi with stent migration showed only a small amount of tissue hyperplasia; however, esophagi without stent migration showed gross tissue hyperplasia through the mesh. The microscopic findings were evaluated in groups III and IV. The degree of inflammatory cell infiltration, papillary projection thickness, granulation tissue area, and percentage of the granulation tissue area were higher in group IV than in group III; however, there was no statistical significance.

CONCLUSIONS

Esophageal stent placement was feasible in a rat model, and formation of tissue hyperplasia was evident in rats without stent migration. With barbed stents, there was the least incidence of stent migration without esophageal perforation.

Self-expanding plastic stent to palliate symptomatic tissue in/overgrowth after self-expanding metal stent placement for esophageal cancer

Self-expanding metal stents (SEMS) are used to treat obstructive malignancies of the esophagus or esophagogastric junction; however, a potential complication is recurrent dysphagia because of tissue in/overgrowth. The placement of a second SEMS is one strategy to re-establish patency of the esophageal lumen. We evaluated the safety and efficacy of an alternative and likely less costly approach: placing a self-expanding plastic stent (SEPS) to manage relapsing dysphagia in patients previously treated with a partially covered SEMS. From December 2007 to January 2009, 13 patients previously treated with a SEMS for malignant dysphagia underwent treatment by inserting a SEPS to palliate relapsing dysphagia, as a result of tissue in/overgrowth. Stenosis was located in the upper esophagus in one patient, in the middle in four patients, and in the lower esophagus in eight patients. Clinical evaluation was performed at the time of stent placement, after 1 week, and then, monthly until death. The SEPS was successfully placed in a single treatment session for all patients. No preliminary dilation was required, and no further treatment was necessary for any patient. Before stenting, the median dysphagia score was 4 (range 3-4), and 1 week later the score was 0 for all patients. The resolution of dysphagia persisted until patient death (from tumor progression). The mean survival after the SEPS insertion was 4 months (range 3-8). This case series supports the use of a SEPS to palliate dysphagia from tissue in/overgrowth of a SEMS. Future clinical trials with larger patient samples are warranted.

Malignant esophageal dysphagia palliation using insertion of a covered Ultraflex stent without fluoroscopy: a prospective observational study

BACKGROUND

This study aimed to investigate the efficacy and safety of placing self-expandable metal stents (SEMSs) without fluoroscopy for palliation of malignant esophageal or esophagogastric strictures.

METHODS

From January 2003 to June 2008, a prospective observational study investigated the placement of covered proximal-release Ultraflex stents without fluoroscopy in nonoperable malignant esophageal and esophagogastric strictures. The technical success as well as the early and late complications (perforation, migration, severe gastroesophageal reflux, hematemesis, and reobstruction due to tissue ingrowth or overgrowth) were recorded. Dysphagia before and after stent placement was scored on a 5-point scale. All the patients were observed monthly in the outpatient clinic or by telephone contact until death.

RESULTS

The study enrolled 89 patients (16 women; mean age, 69.54±7.1 years) with dysphagia due to inoperable esophageal or esophagogastric malignant strictures (29 squamous cell cancers, 52 adenocarcinomas, and 8 obstructive malignant extrinsic compressions). The mean stricture length was 6.2±2.8 cm. Endoscopic deployment was achieved for 83 patients (93.2%), with accurate stent positioning in all the patients except one. An adequate relief of symptoms was noted for 82 of the patients (92.1%). During the follow-up period, 36 patients (43.4%) had recurrent dysphagia, caused by tumor overgrowth in 32 cases and stent migration in 4 cases, after an average time of 82 days (range 67-216 days). A stent-in-stent procedure was performed in 27 cases. For two patients, a third stent-in-stent needed to be placed after 85 and 216 days, respectively.

CONCLUSION

In most cases, SEMSs can be accurately and safely positioned without fluoroscopy for palliative treatment of malignant esophageal dysphagia.

A new metal stent with a controlled-release system for palliation of malignant dysphagia: a prospective, multicenter study

BACKGROUND

Self-expanding metal stents are frequently used for the palliation of malignant dysphagia. Recently, a new stent design, the Evolution stent (Cook Medical, Limerick, Ireland), was developed. The stent has an internal and external silicone coating to resist tissue ingrowth and uncoated dual flanges on both ends to prevent migration. Its controlled-release system may allow full control and precise positioning of the stent.

OBJECTIVE

To determine the safety and clinical effectiveness of the Evolution stent for the palliation of dysphagia in patients with malignant strictures located in the esophagus (n = 33 [75%]) or gastric cardia (n = 11 [25%]).

METHODS

All patients who underwent placement of an esophageal Evolution stent from February to December 2008 received follow-up telephone calls 14 days after treatment and thereafter monthly until death. Data on technical and clinical outcome, complications, and recurrent dysphagia were collected.

RESULTS

A total of 44 patients (32 [73%] men, median age 74 years [range 48-91 years]) were treated with the Evolution stent. The median tumor length was 6 cm (range 1-11 cm). Stent placement was technically successful in 41 patients. Dysphagia improved from a median of 3 (ability to swallow liquids only) to 1 (ability to eat some solid foods) 4 weeks after stent placement. Major complications occurred in 4 (9%) patients, ie, pneumonia (3 patients) and hemorrhage (1 patient). Two (5%) patients died of pneumonia. Minor complications included gastroesophageal reflux and mild retrosternal pain in 11 (25%) and 4 (9%) patients, respectively. Recurrent dysphagia developed in 11 (25%) patients as a result of tissue ingrowth or overgrowth (6 patients; 14%), food impaction (3 patients; 7%), or stent migration (2 patients; 5%).

CONCLUSIONS

The Evolution stent is safe and effective for the palliation of dysphagia from esophageal and gastric cardia cancer. Randomized trials are needed to compare this device with other stent designs.

A new fully covered stent with antimigration properties for the palliation of malignant dysphagia: a prospective cohort study

BACKGROUND

Fully covered stents are designed to resist tissue ingrowth that is often seen with partially covered stents. An issue with fully covered stents is the risk of migration.

OBJECTIVE

We aimed to determine efficacy, recurrent dysphagia, and complications of the SX-ELLA stent Esophageal HV, which is fully covered to resist tissue ingrowth and has an antimigration ring to withstand migration.

DESIGN

Prospective cohort study.

SETTING

Two tertiary referral centers.

PATIENTS

Forty-four patients with malignant esophageal strictures from inoperable or metastatic esophageal or gastric cardia cancer (n = 42) or lung cancer (n = 2).

INTERVENTIONS

Placement of an SX-ELLA stent.

MAIN OUTCOME MEASURES

Functional outcome, recurrent dysphagia, complications, and survival.

RESULTS

Dysphagia improved from a median score of 3 (liquids only) before stent placement to 1 (ability to eat some solid food) 4 weeks later (P < .001). Twelve of 44 (Kaplan Meier analysis = 40%) patients developed 18 episodes of recurrent dysphagia of which 6 were caused by stent migration and 2 by tissue overgrowth. In total, 14 episodes of major complications developed in 10 of 44 (Kaplan Meier analysis = 29%) patients, 8 of which were caused by hemorrhage. After a median follow-up of 15 months, 39 patients had died (median survival 110 days), 5 (11%) from hemorrhage.

LIMITATIONS

Nonrandomized study design.

CONCLUSIONS

Dysphagia caused by esophageal cancer can be successfully palliated by placement of a new, fully covered esophageal stent (SX-ELLA). Although this single-wire braided stent with an antimigration ring is supposed to be less traumatic and to reduce migration, this was not substantiated in this study. Further improvements of stent features are needed to achieve the goals set for this study.

A fully-covered stent (Alimaxx-E) for the palliation of malignant dysphagia: a prospective follow-up study

BACKGROUND

The majority of the currently available metal stents are partially covered to reduce migration risk. However, one of the remaining issues is tissue ingrowth through the uncovered stent parts.

OBJECTIVE

To determine efficacy, recurrent dysphagia, and complications of a fully covered stent, ie, the Alimaxx-E stent, and to compare two stent delivery systems, ie, one introducing the stent over a guidewire and one introducing the stent over a small-caliber endoscope.

DESIGN

A prospective, follow-up study evaluating a new stent design, with randomization for type of introduction system.

SETTING

Three tertiary referral centers.

PATIENTS

Forty-five patients with inoperable or metastatic esophageal or gastric cardia cancer.

INTERVENTIONS

Stent placement.

MAIN OUTCOME MEASUREMENTS

(1) Functional outcome, recurrent dysphagia, complications, and mortality of the Alimaxx-E stent; (2) functional aspects of the delivery system.

RESULTS

At 4 weeks after stent placement, the dysphagia score improved in all patients (P < .001). Twenty-two of 45 patients (49%) developed among them 28 episodes of recurrent dysphagia, predominantly stent migration (n = 16). Major complications occurred in 9 of 45 patients (20%), with all 5 early (<1 week) complications (severe pain [n = 3], hemorrhage [n = 1], and fever [n = 1]) occurring in patients in whom the stent was introduced over the endoscope (P = .02). During follow-up, 44 patients died, 3 (7%) from hemorrhage.

LIMITATION

The Alimaxx-E stent was not randomly compared with other stent designs.

CONCLUSIONS

Placement of Alimaxx-E stents is safe and produces long-term relief of dysphagia, particularly when introduced over a guidewire. The migration rate of the Alimaxx-E stent is, however, unacceptably high, and an adapted stent design is needed.

Stents as sole therapy for oesophageal cancer: a prospective analysis of outcomes after placement

BACKGROUND

Therapies for inoperable oesophageal cancer include chemoradiotherapy and placement of a self-expanding metal stent (SEMS). Few data are available regarding SEMS as sole therapy for patients with inoperable disease who have not already received, or are unfit for, chemoradiotherapy. The aim of this study was to determine survival, adequacy of palliation, and complications after SEMS placement as sole therapy for inoperable oesophageal cancer in a resource-limited setting.

METHODS

Data were prospectively gathered on all patients with oesophageal cancer treated with SEMS between Jan 1, 1999, and May 20, 2008, at a hospital in Kenya where chemoradiotherapy is unavailable. Dysphagia scores, morbidity, mortality, and survival were assessed. Follow-up was done during clinic visits, home visits, and by mobile phone.

FINDINGS

1000 stents were placed in 951 patients. Long-term follow-up was obtained for 334 patients (35%) with a median survival of 250 days (IQR 130-431, 95%CI 217-301). Mean dysphagia scores improved from 3.3 (SD 0.6) pre-SEMS (n=697) to 1.0 (SD 1.3) for patients (n=78) still alive and 1.8 (SD 1.2) at time of death (n=165). Survival of 17 patients with follow-up who had perforation during tumour dilation (treated with SEMS) was 283 days (IQR 227-538) similar to the 317 patients with follow-up data who did not have a perforation (245 days, 124-430). 20 patients with a tracheo-oesophageal fistula lived a median of 142 days (IQR 73-329). Early complications occurred in 6% (54 of 951 patients) and late complications occurred in 19% (62 of 334 patients). SEMS-related mortality was 0.3% (three of 951).

INTERPRETATION

SEMS effectively palliate inoperable oesophageal cancer. Survival may be longer than previously reported when SEMS are placed in all patients with inoperable oesophageal cancer, as in our study, rather than those failing or unfit for chemoradiotherapy. SEMS seem to be an appropriate technology for palliation of oesophageal cancer in resource-limited settings. Given the proportion of patients lost to follow up, these findings merit further confirmation.

Removable self-expanding plastic esophageal stent as a continuous, non-permanent dilator in treating refractory benign esophageal strictures: a prospective two-center study

BACKGROUND

Refractory benign esophageal strictures (RBES) are difficult to treat requiring frequent dilatations or surgery. Conceptually, while maintaining luminal patency, if a dilator is kept in place continuously for several weeks, the benefits may be longer lasting. An expandable esophageal stent will be ideal in achieving the above. Preliminary results on using a removable self-expanding plastic esophageal stent, Polyflex stent (PS), for treating RBES have been mixed.

AIM

To evaluate the efficacy of PS in the treatment of RBES.

METHODS

Forty patients with RBES [mean age 60 +/- 15 SD yrs, female 14, male 26, Anastomotic 12 (fistula 4), Corrosive 8, Radiation 7, Pill induced 4, Post trauma 3 (fistula 3), Peptic 2, Others 4 (fistula 1)] were prospectively studied. Continuous non-permanent dilation was performed by placing a PS and removing it after 4 wk. The patients were then followed at regular intervals. Pre-insertion baseline data and post-removal information on dysphagia status, complications, and change in outcome were prospectively collected.

RESULTS

The technical success in stent placement and stent removal were 95% and 94%, respectively. Mean post-stent dysphagia score was 0.6 +/- 0.7 SD, which was significantly better than pre-stent scores (3.0 +/- 0.8 SD; P < 0.001). At median follow-up of 53 wk (range 11-156), only 40% (intention to treat 30%) patients were dysphagia-free. However, the overall change in outcome from baseline options (ongoing dilatations, or surgery) was 66% (dysphagia-free 12, did not want removal 2, did not remove 1, preferred long-term stenting 10). The stent was successful in closing the fistula in five of eight (63%) patients. Complications observed were migration eight (22%), severe chest pain four (11%), bleeding three (8%), perforation two (5.5%), GE reflux two (5.5%), impaction two (5.5%), and new fistula one (2.7%). There was one mortality from massive bleeding.

CONCLUSIONS

It was feasible to deploy and remove PS stents in the majority of patients with RBES. Some patients achieved long-term relief without further re-interventions while several others re-strictured and preferred long-term stenting over repeated dilations or surgery. The procedure carries significant risks and hence should only be considered in carefully selected patients.

Liquid (188)Re-filled balloon dilation for the treatment of refractory benign airway strictures: preliminary experience

PURPOSE

To present the preliminary results of beta irradiation with use of liquid rhenium 188 ((188)Re)-filled balloon dilation in the treatment of refractory benign airway strictures.

MATERIALS AND METHODS

Ten sessions of beta irradiation by using liquid (188)Re-filled balloon dilation were prospectively performed in nine patients with refractory bronchial strictures between 2003 and 2006. Indications for treatment were dyspnea caused by repeat stricture or no response to previous treatment (ie, balloon dilation and/or temporary stent placement or laser therapy) in seven patients and dyspnea caused by exuberant granulation tissue formation at the distal end of the placed stent in two. To assess the treatment efficacy, the authors calculated and compared the mean intervals of interventional treatments before and after dilation with (188)Re and mercaptoacetyltriglycine (MAG(3))-filled balloons.

RESULTS

Liquid (188)Re-filled balloon dilation was successfully performed in all nine patients, with no procedure-related complications. Immediately after the procedure, all patients showed resolution of their dyspnea. Five patients remained asymptomatic at 5-25-month follow-up. Four patients experienced dyspnea caused by recurrent stricture 1-10 months after dilation. The mean intervals between interventional treatments increased significantly from 3.1 months +/- 2.1 before (188)Re-MAG(3)-filled balloon dilation to 10.8 months +/- 8.8 after (188)Re-MAG(3)-filled balloon dilation in all nine patients (Wilcoxon signed rank test, P = .025).

CONCLUSIONS

beta irradiation with liquid (188)Re-filled balloon dilation can be safely used for refractory benign airway strictures. A large study with longer follow-up is needed to draw a definite conclusion.