A prospective trial of self-expanding metal stents in the palliation of malignant esophageal obstruction after failure of primary curative therapy

Palliation of malignant dysphagia with a segmented self-expanding metal stent: A STROBE-compliant article

ABSTRACT

Self-expanding metal stents (SEMSs) in different geometric shapes are an established palliative treatment for malignant tumors of the esophagus. Mechanical properties and stent design have an impact on patient comfort, migration rate, and removability. SEMS with a segmented design (segSEMS) have recently become available on the market, promising new biomechanical properties for stent placement in benign and malignant esophageal diseases. In this study, we evaluated recurrent dysphagia, quality of life as well as technical success and complications for segmented SEMS-implantation in a retrospective study in palliative patients with dysphagia caused by malignant tumors of the esophagus.Between May 2017 and December 2018, patients presented to the interdisciplinary department of endoscopy of the University Hospital Cologne underwent segmented SEMS placement for malignant dysphagia. Patient follow-up was evaluated, and complications were monitored. Quality of life and functional improvement were monitored using the EORTC QLQ-C30 and QLQ-OE18.A total of 20 consecutive patients (16 men, 4 women; mean age: 65.5, range: 46-82) participated in the study and were treated with 20 segSEMS in total. The success rate of stent placement was 100%. Stent migration occurred in 3 patients (15.0%). Insertion of segSEMS immediately lead to a 48.0% reduction of dysphagia in the first 2 months (P < .001). Pain while eating (odynophagia) could also be significantly reduced by 39.6% over the first 2 months (P < .001).Implantation of segSEMS is a feasible and effective treatment for dysphagia in palliative patients with malignant tumors of the esophagus, offering immediate relief of symptoms and gain of physical functions.

Esophageal fistula after definitive concurrent chemotherapy and intensity modulated radiotherapy for esophageal squamous cell carcinoma

Background

The literature regarding esophageal fistula after definitive concurrent chemotherapy and intensity modulated radiotherapy (IMRT) for esophageal squamous cell carcinoma (ESCC) remains lacking. We aimed to investigate the risk factors of esophageal fistula among ESCC patients undergoing definitive concurrent chemoradiotherapy (CCRT) via IMRT technique.

Methods

A total of 129 consecutive ESCC patients receiving definitive CCRT with IMRT between 2008 and 2018 were reviewed. The cumulative incidence of esophageal fistula and survival of patients were estimated by the Kaplan–Meier method and compared between groups by the log-rank test. The risk factors of esophageal fistula were determined with multivariate Cox proportional hazards regression analysis.

Results

Median follow-up was 14.9 months (IQR, 7.0–28.8). Esophageal perforation was identified in 20 (15.5%) patients, resulting in esophago-pleural fistula in nine, esophago-tracheal fistula in seven, broncho-esophageal fistula in two, and aorto-esophageal fistula in two patients. The median interval from IMRT to the occurrence of esophageal fistula was 4.4 months (IQR, 3.3–10.1). Patients with esophageal fistula had an inferior median overall survival (10.0 vs. 17.2 months, p = 0.0096). T4 (HR, 3.776; 95% CI, 1.383–10.308; p = 0.010) and esophageal stenosis (HR, 2.601; 95% CI, 1.053–6.428; p = 0.038) at baseline were the independent risk factors for esophageal fistula. The cumulative incidence of esophageal fistula was higher in patients with T4 (p = 0.018) and pre-treatment esophageal stenosis (p = 0.045). There was a trend toward better survival after esophageal fistula among patients receiving repair or stenting for the fistula than those only undergoing conservative treatments (median survival, 5.9 vs. 0.9 months, p = 0.058).

Conclusions

T4 and esophageal stenosis at baseline independently increased the risk of esophageal fistula in ESCC treated by definitive CCRT with IMRT. There existed a trend toward improved survival after the fistula among patients receiving repair or stenting for esophageal perforation.

Efficacy and Adverse Effects of Self-Expandable Metal Stent Placement for Malignant Duodenal Obstruction: The Papilla of Vater as a Landmark

Purpose

Self-expandable metal stents are used for malignant duodenal obstruction. Outcomes between stents placed above and below the papilla of Vater differ, and no study has investigated these differences. We evaluated the efficacy and adverse events of stent placement in these two locations and reported our experience with self-expandable metal stent placement in patients.

Patients and Methods

We retrospectively analyzed the data of patients with unresectable metastatic cancers (n = 101), who underwent successful duodenal self-expandable metal stent placement between 2008 and 2018. Patients were divided into above and below the papilla of Vater groups. Patient demographics, technical and clinical outcomes, post-procedural morbidity, and stent patency were analyzed.

Results

Overall, 71 and 30 patients had intestinal obstruction above (including the papilla itself) and below the papilla of Vater and underwent successful stenting. Common bile duct obstruction was more common in the above-papilla group. Procedure time was similar between the groups, if an appropriate endoscope could facilitate stent placement in the below-papilla group. Both groups achieved symptomatic relief. Median stent patency duration was not significantly different between the groups; three patients had severe gastrointestinal bleeding due to postoperative vascular-enteric fistula.

Conclusion

Self-expandable metal stents can effectively relieve symptoms of duodenal obstructions located above and below the papilla of Vater. Duodenoscopes could facilitate stent placement if the obstruction is located below the papilla of Vater; if gastrointestinal bleeding occurs postoperatively, the possibility of vascular-enteric fistula formation should be considered.

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.

Radioactive feeding tube in the palliation of esophageal malignant obstruction

PURPOSE

A radioactive feeding tube was used to achieve both nutrition and brachytherapy for the treatment for malignant esophageal obstruction. We report the safety and effectiveness of this technique.

METHODS

We conducted a retrospective analysis of 16 consecutive patients who employed this technique from January 2015 to March 2018. The radioactive feeding tube was made by binding the ¹²⁵I seed chain on the feeding tube. Under fluoroscopic guidance, the tube was inserted into the obstructed esophagus, with the seed chain crossing over the segment of malignant esophageal obstruction. Technical success rate, dysphagia score, procedure time and complications were analyzed. Kaplan-Meier analysis was used to analyze the survival time.

RESULTS

The radioactive feeding tube was easy to prepare. The technical success rate was 100%, without serious complications such as bleeding or infection. The median procedure time of tube insertion was 44.0 min. The Kamofsky score and Neuhaus dysphagia grading were significantly improved after tube insertion (p < 0.01). On esophageal radiography, the contrast agent passed through the narrow area smoothly. Complete remission (n = 1) and partial remission (n = 13) of local tumor were obtained in 14 patients, and the local tumor control rate was 87.5% (14/16). During follow-up, four patients survived with no obvious clinical symptom and 10 patients died of cancer. The median survival was 12.0 months.

CONCLUSION

Preparation of the radioactive feeding tube is simple and easy. The insertion of this kind of tube achieves parenteral nutrition and brachytherapy simultaneously and is safe and effective in dysphagia palliation of malignant esophageal stricture. The radiological-radiotherapeutic procedure could be an alternative tool in the case of refusing other treatments by the patients.

A phase III, multicenter, prospective, single-blinded, noninferiority, randomized controlled trial on the performance of a novel esophageal stent with an antireflux valve (with video)

BACKGROUND AND AIMS

Self-expanding metal stents (SEMSs) when deployed across the gastroesophageal junction (GEJ) can lead to reflux with risks of aspiration. A SEMS with a tricuspid antireflux valve (SEMS-V) was designed to address this issue. The aim of this study was to evaluate the efficacy and safety of this stent.

METHODS

A phase III, multicenter, prospective, noninferiority, randomized controlled trial was conducted on patients with malignant dysphagia requiring SEMSs to be placed across the GEJ. Patients were randomized to receive SEMSs with no valve (SEMS-NV) or SEMS-V. Postdeployment dysphagia score at 2 weeks and Gastroesophageal Reflux Disease-Health Related Quality of Life (GERD-HRQL) questionnaire score at 4 weeks were measured. Patients were followed for 24 weeks.

RESULTS

Sixty patients were randomized (SEMS-NV: 30 patients, mean age 67 ± 13 years; SEMS-V: 30 patients, mean age 65 ± 12 years). Baseline dysphagia scores (SEMS-NV, 2.5 ± .8; SEMS-V, 2.5 ± .8) and GERD-HRQL scores (SEMS-NV, 11.1 ± 8.2; SEMS-V, 12.8 ± 8.3) were similar. All SEMSs were successfully deployed. A similar proportion of patients in both arms improved from advanced dysphagia to moderate to no dysphagia (SEMS-NV, 71%; SEMS-V, 74%; 95% confidence interval, 1.93 [-17.8 to 21.7]). The dysphagia scores were also similar across all follow-up time points. Mean GERD-HRQL scores improved by 7.4 ± 10.2 points in the SEMS-V arm and by 5.2 ± 8.3 in the SEMS-NV group (P = .96). The GERD-HRQL scores were similar across all follow-up time points. Aspiration pneumonia occurred in 3.3% in the SEMS-NV arm and 6.9% in the SEMS-V arm (P = .61). Migration rates were similar (SEMS-NV, 33%; SEMS-V, 48%; P = .29). Two SEMS-V spontaneously fractured. There was no perforation, food impaction, or stent-related death in either group.

CONCLUSIONS

The SEMS-V was equally effective in relieving dysphagia as compared with the SEMS-NV. Presence of the valve did not increase the risks of adverse events. GERD symptom scores were similar between the 2 stents, implying either that the valve was not effective or that all patients on proton pump inhibitors could have masked the symptoms of GERD. Studies with objective evaluations such as fluoroscopy and/or pH/impedance are recommended. (Clinical trial registration number: NCT02159898.).

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.

Modified Type of Double-Covered Self-Expandable Segmental Metallic Stents for Palliation of Esophageal Fistula

Purpose: To study the modified type of double-covered self-expandable segmental metallic stents in terms of efficacy, complications, and long-term outcomes. Patients and Methods: A retrospective review of a consecutive series of 24 patients who underwent placement of the modified stent from July 2013 to July 2018 was conducted. Twenty-five modified segmental stents were implanted. Data regarding technical success and complications were collected and analyzed. Results: Stent placement was successful in all patients with no perioperative procedure-related deaths. The median follow-up time was 10.3 months (interquartile range 6.3-23.5 months). Adjustment was required in 9 patients (37.5%) due to stent migration. The mean dysphagia scores before stenting and during follow-up were 3.6 ± 0.7 and 0.9 ± 1.6, respectively (P < .0001). Fifteen modified stents were removed due to complications or cure. Conclusion: Modified double-covered self-expandable segmental metallic stents are safe and effective for palliation of esophageal fistula.

Mmp-9 expression after metallic stent placement in patients with colorectal cancer: association with in-stent restenosis

PURPOSE

To verify the expression of matrix metalloproteinase (MMP)-9 in stent-induced hyperplastic tissue from patients with colorectal cancer who received colorectal stents as a bridge to surgery.

MATERIALS AND METHODS

This prospective study was institutional review board-approved, and informed consent was obtained from all patients. Eleven patients (nine men, two women; mean age, 67 years; age range, 53-82 years) with malignant colorectal obstructions who received a colorectal stent between May and December 2010 were included. Tissue specimens were analyzed for MMP-9 and MMP-2 expression. After resection, the tissue was segmented into three parts: tumor tissue, stent-induced tissue hyperplasia, and normal colon tissue. MMP-9 and MMP-2 expression were determined by using zymography, Western blot analysis, and real-time reverse-transcription (qRT) polymerase chain reaction (PCR). Significance of differences between groups was evaluated with Friedman analysis of variance test. Signed-rank test was used to determine differences between malignant tumor tissue and stent-induced hyperplastic tissue groups.

RESULTS

Stent placement was technically successful in all 11 patients. Stent-induced hyperplastic tissues were found in all patients. Zymography (P = .003) and Western blot analysis (P = .008) showed that expression of MMP-9 was higher in malignant tumor tissue and stent-induced hyperplastic tissue groups compared with normal colorectal tissue group, demonstrating significant differences between groups but no significant differences between malignant tumor and stent-induced hyperplastic tissues. As for results of qRT PCR analysis, the stent-induced hyperplastic tissue group showed increases in messenger RNA expression level of MMP-9 compared with the malignant tumor tissue group (50.42-fold ± 66.30 higher).

CONCLUSION

High expression of MMP-9 is closely associated with stent-induced colorectal tissue hyperplasia in patients with colorectal cancer.

Placement of fully covered self-expandable metal stents in patients with locally advanced esophageal cancer before neoadjuvant therapy

BACKGROUND

Most patients with locally advanced esophageal cancer requiring neoadjuvant therapy have significant dysphagia.

OBJECTIVE

To report our experience in using a fully covered self-expandable metal stent (FCSEMS) to treat malignant dysphagia and for maintenance of nutritional support during neoadjuvant therapy.

DESIGN

Retrospective study.

SETTING

Two tertiary-care referral centers.

PATIENTS

This study involved 55 patients with locally advanced esophageal cancer (50 adenocarcinoma, 5 squamous cell carcinoma). Forty-three patients were men, and the mean age was 65.8 years.

INTERVENTION

EUS followed by FCSEMS placement.

MAIN OUTCOME MEASUREMENTS

Procedural success, dysphagia scores, patient weights, stent migration, and stent-related complications.

RESULTS

All stents were successfully placed. Tumors were located in the middle esophagus (n = 10) and distal esophagus (n = 45). The mean dysphagia score obtained at 1 week after stent placement had improved significantly from baseline (2.4 and 1, respectively; P < .001). Patients maintained their weights at 1 month follow-up when compared with baseline (153 and 149 pounds, respectively; P = .58). Immediate complications included chest discomfort in 13 patients; 2 patients required stent removal because of intractable pain. One patient had stent removal because of significant acid reflux. Stent migration occurred at some point in 17 of 55 patients (31%). There was a delayed perforation in 1 patient. Because of disease progression or the discovery of metastasis after neoadjuvant therapy, only 8 of 55 patients underwent curative surgery.

LIMITATIONS

Retrospective study.

CONCLUSION

Placement of FCSEMSs in patients with locally advanced esophageal cancer significantly improves dysphagia and allows for oral nutrition during neoadjuvant therapy. FCSEMSs appear to be effective for palliating dysphagia. Migration was not associated with injury or harm to the patient and usually represented a positive response to neoadjuvant therapy. Few patients undergoing stenting in this situation ultimately undergo surgery because of disease progression or poor operative candidacy.

The impact of prior radiotherapy on fatal complications after self-expandable metallic stents (SEMS) for malignant dysphagia due to esophageal carcinoma

The esophageal stent has been demonstrated to serve as a safe and effective palliative treatment for advanced inoperable esophageal carcinoma. However, the safety of esophageal stents in patients with prior radiotherapy (RT) remains debated. This article aims to investigate the impact of prior RT on the incidence of fatal complications after self-expandable metallic stents for palliation of malignant dysphagia because of esophageal carcinoma. Between January 2007 and July 2010, 93 patients with malignant dysphagia because of esophageal carcinoma underwent placement of self-expandable metallic stents in our hospital. Patients were retrospectively separated into two groups: patients with RT before stent placement (RT group, n=57) and patients with no treatment before stent placement (no RT group, n=35).The median survival after stent placement was 77 days (7-842 days) in the RT group and 246 days (15-878 days) in the no RT group. Improvement in dysphagia score was similar in both groups. The fatal complications included fatal gastrointestinal hemorrhage and uncontrolled pneumonia. The incidence of fatal gastrointestinal hemorrhage and uncontrolled pneumonia were 28.1% and 5.7% (P=0.009), 28.1% and 5.7% (P=0.009), respectively. Logistic regression analysis showed a significant interaction between prior RT and fatal gastrointestinal hemorrhage (relative risk 7.82, 95% confidence interval 1.54-39.61; P=0.013). Mortality of massive hemorrhage was 5.7% (2/35), 0% (0/4), 12.5% (3/24), and 44.8% (13/29), respectively, in patients who received 0, 1Gy∼49Gy, 50Gy∼60Gy, and >60Gy (χ(2) =17.761; P=0.000). Logistic regression analysis disclosed prior RT did not significantly increase the risk of uncontrolled pneumonia (relative risk 1.47, 95% confidence interval 0.21-10.12; P=0.697).

Colorectal stents: do we have enough evidence?

BACKGROUND

The use of colonic stents has significantly evolved over the last few years. Emergency surgery for colonic obstructions is usually associated with significant mortality, morbidity and often stoma formation. Colonic stents provide an alternative way to relieve colonic obstruction, and hence avoiding the risks associated with emergency surgery. This literature review aims to summarize the important current evidence regarding colorectal stenting and show whether further evaluation of the procedure is required.

RESULTS

The available large number of non-randomized studies suggests that Self-Expandable-Metal-Stents (SEMS) placement for acute colonic obstruction could be considered as safe and effective alternative to surgery in experienced hands either as a bridge to surgery or as a palliative measure. This evidence has led to SEMS being widely adopted. However, randomized evidence has begun to show the defects that are inherent in the low level evidence that has so far supported SEMS use and it may be that reports of randomized controlled trials may clarify the patient population where SEMS placement is appropriate.

CONCLUSION

While we are still waiting for the outcome of the multicentre randomized controlled trials in the UK and Europe, clinicians must be aware of the current evidence limitations and apply SEMS use pragmatically.

Expandable metal stents: principles and tissue responses

Expandable stents are widely used in gastroenterology. The basic principle of all of these devices is that they can be constrained onto a delivery system of small diameter and then deployed in an area of stenosis without the risk of complications due to excessive dilation. Understanding tissue responses to stents is important both for the design of new stents and for clinicians to balance the benefits and risks of covered and uncovered stents. With biodegradable stents and removable stents, understanding tissue responses provides the basis for timing of removal and assessing treatment response.

WITHDRAWN: Interventions for dysphagia in oesophageal cancer

BACKGROUND

The majority of oesophageal and gastro-oesophageal cancers are diagnosed at an advanced stage and palliative treatment is the realistic management option for most patients. The optimal intervention for the palliation of dysphagia in these patients has not been established.

OBJECTIVES

To systematically analyse and summarise the efficacy of different interventions used in the palliation of dysphagia in primary oesophageal carcinoma.

SEARCH STRATEGY

We undertook a search according to the Cochrane Upper Gastrointestinal and Pancreatic Diseases model using the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE, EMBASE and CINAHL and major conference proceedings up to August 2005. The literature search was re-run in August 2006 and March 2007.

SELECTION CRITERIA

Randomised controlled trials (RCTs) in patients with inoperable or unresectable primary oesophageal cancer who underwent palliative treatment. We included rigid plastic intubation, self-expanding metallic stent (SEMS) insertion, brachytherapy, external beam radiotherapy, chemotherapy, oesophageal bypass surgery, chemical and thermal ablation therapy, either head-to-head or in combination. The primary outcome was dysphagia improvement. Secondary outcomes included recurrent dysphagia, technical success, procedure related mortality, 30-day mortality, adverse effects and quality of life.

DATA COLLECTION AND ANALYSIS

One author assessed the eligibility criteria of each study and extracted data regarding outcomes and factors affecting risk of bias.

MAIN RESULTS

We included 2542 patients from 40 studies. SEMS insertion is safer and more effective than plastic tube insertion. Thermal and chemical ablative therapy provide comparable dysphagia palliation but have an increased requirement for re-interventions and adverse effects. Anti-reflux stents provide comparable dysphagia palliation to conventional metal stents. Some anti-reflux stents might reduce gastro-oesophageal reflux compared to conventional metal stents. Brachytherapy might be a suitable alternative to SEMS in providing a survival advantage and possibly a better quality of life.

AUTHORS' CONCLUSIONS

Self-expanding metal stent insertion is safe, effective and quicker in palliating dysphagia compared to other modalities. However, high-dose intraluminal brachytherapy is a suitable alternative and might provide additional survival benefit with a better quality of life. Self-expanding metal stent insertion and brachytherapy provide comparable palliation to endoscopic ablative therapy but are preferable due to the reduced requirement for re-interventions. Rigid plastic tube insertion, dilatation alone or in combination with other modalities, chemotherapy alone, combination chemoradiotherapy and bypass surgery are not recommended for palliation of dysphagia due to a high incidence of delayed complications and recurrent dysphagia.

Palliation of malignant esophageal obstruction and fistulas with self expandable metallic stents

AIM: To evaluate the efficacy of self expandable metallic stents (SEMS) in patients with malignant esophageal obstruction and fistulas.

METHODS: SEMS were implanted in the presence of fluoroscopic guidance in patients suffering from advanced and non-resectable esophageal, cardiac and invasive lung cancer between 2002 and 2009. All procedures were performed under conscious sedation. All patients had esophagus obstruction and/or fistula. In all patients who required reintervention, recurrence of dysphagia, hemorrhage, and fistula formation were indications for further endoscopy. Patients’ files were scanned retrospectively and the obtained data were analyzed using SPSS 13.0 for Windows. The χ² test was used for categorical data and was analysis of variance for non-categorical data. Patients’ long-term survival was assessed using the Kaplan-Meier method.

RESULTS: Stents were successfully implanted in 90 patients using fluoroscopic guidance. Reasons for stent implantation in these patients were esophageal stricture (77/90, 85.5%), external pressure (8/90, 8.8%) and tracheo-esophageal fistula (5/90, 5.5%). Dysphagia scores (mean ± SD) were 3.37 ± 0.52 before and 0.90 ± 0.43 after stent implantation (P = 0.002). Intermittent, non-massive hemorrhage due to the erosion caused by the distal end of the stent in the stomach occurred in only one patient who received implementation at cardio-esophageal junction. Mean survival following stenting was 134.14 d (95% confidence interval: 94.06-174.21).

CONCLUSION: SEMS placement is safe and effective in the palliation of dysphagia in selected patients with malignant esophageal strictures.

A pilot study of fully covered self-expandable metal stents prior to neoadjuvant therapy for locally advanced esophageal cancer

Self-expandable metal stents (SEMS) have been mostly reserved for palliation of dysphagia because of advanced esophageal cancer. Fully covered SEMS (FCSEMS) (ALIMAXX-E, Alveolus Inc, Charlotte, NC, USA) offer the choice of removability if complications occur or maximum therapeutic benefit is achieved. To our knowledge, their use has not been studied in patients undergoing neoadjuvant therapy. The objectives of this study were the following: (i) to evaluate whether FCSEMS are useful in patients receiving neoadjuvant therapy; and (ii) to assess ease of removability and tissue reaction to FCSEMS. FCSEMS (ALIMAXX-E, Alveolus Inc) were deployed in consecutive patients with locally advanced esophageal cancer over a period of 14 months. All patients were referred for neoadjuvant chemoradiation therapy after stenting. Dysphagia scores were assessed at 0 month, 1 month, 3 months, and 6 months. Barium swallow and endoscopy were performed for new symptoms and follow-up. Eleven patients were treated with FCSEMS prior to neoadjuvant therapy (mean age 60.5 years, 55% white, 91% male). All but one stent were successfully placed. Strictures were located in the upper esophagus (n= 1), middle esophagus (n= 4), lower esophagus (n= 2), and gastroesophageal junction (n= 4). Dysphagia was significantly improved at 1 month (mean difference 3.12; 2.53-3.79 95% confidence interval [CI]), 3 months (mean difference 2.86, 2.19-3.53 95% CI), and 6 months (mean difference 2.56, 1.79-3.34 95% CI) compared with baseline. Three patients (27%) experienced chest pain or heartburn immediately following deployment. Only two patients ultimately underwent surgical resection. The others were diagnosed with metastatic disease prior to surgery, had disease progression in spite of neoadjuvant treatment, or died with the stent in place. Three patients developed delayed complications: recurrent dysphagia (n= 2) and tracheal-esophageal fistula (n= 1). Eight (73%) stents were subsequently removed, one because of complication (tracheal-esophageal fistula), one because of migration (recurrent dysphagia), one was incorrectly deployed, and five were felt to have satisfied their purpose. Stents remained in place for a mean duration of 100.36 days (range 0-105, median 84). Removal was characterized as very easy in all cases. Upon removal, ulcerations at the proximal or distal edge of stents were noted in six patients (75%), polyps in four (50%), and granulation in six (75%). One stent (13%) became embedded but was easily lifted from tissue. There were no perforations. Neoadjuvant treatment may have contributed to improvement in dysphagia scores. FCSEMS can be used to re-establish esophageal luminal patency in patients undergoing neoadjuvant therapy for locally advanced esophageal cancer, resulting in significant improvement in dysphagia over baseline. Tissue reaction to stents occurs but does not appear to impair removability.

Interventions for dysphagia in oesophageal cancer

BACKGROUND

The majority of oesophageal and gastro-oesophageal cancers are diagnosed at an advanced stage and palliative treatment is the realistic management option for most patients. The optimal intervention for the palliation of dysphagia in these patients has not been established.

OBJECTIVES

To systematically analyse and summarise the efficacy of different interventions used in the palliation of dysphagia in primary oesophageal carcinoma.

SEARCH STRATEGY

We undertook a search according to the Cochrane Upper Gastrointestinal and Pancreatic Diseases model using the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE, EMBASE and CINAHL and major conference proceedings up to August 2005. The literature search was re-run in August 2006 and March 2007.

SELECTION CRITERIA

Randomised controlled trials (RCTs) in patients with inoperable or unresectable primary oesophageal cancer who underwent palliative treatment. We included rigid plastic intubation, self-expanding metallic stent (SEMS) insertion, brachytherapy, external beam radiotherapy, chemotherapy, oesophageal bypass surgery, chemical and thermal ablation therapy, either head-to-head or in combination. The primary outcome was dysphagia improvement. Secondary outcomes included recurrent dysphagia, technical success, procedure related mortality, 30-day mortality, adverse effects and quality of life.

DATA COLLECTION AND ANALYSIS

One author assessed the eligibility criteria of each study and extracted data regarding outcomes and factors affecting risk of bias.

MAIN RESULTS

We included 2542 patients from 40 studies. SEMS insertion is safer and more effective than plastic tube insertion. Thermal and chemical ablative therapy provide comparable dysphagia palliation but have an increased requirement for re-interventions and adverse effects. Anti-reflux stents provide comparable dysphagia palliation to conventional metal stents. Some anti-reflux stents might reduce gastro-oesophageal reflux compared to conventional metal stents. Brachytherapy might be a suitable alternative to SEMS in providing a survival advantage and possibly a better quality of life.

AUTHORS' CONCLUSIONS

Self-expanding metal stent insertion is safe, effective and quicker in palliating dysphagia compared to other modalities. However, high-dose intraluminal brachytherapy is a suitable alternative and might provide additional survival benefit with a better quality of life. Self-expanding metal stent insertion and brachytherapy provide comparable palliation to endoscopic ablative therapy but are preferable due to the reduced requirement for re-interventions. Rigid plastic tube insertion, dilatation alone or in combination with other modalities, chemotherapy alone, combination chemoradiotherapy and bypass surgery are not recommended for palliation of dysphagia due to a high incidence of delayed complications and recurrent dysphagia.

Delayed complications after placement of self-expanding stents in malignant esophageal obstruction: treatment strategies and survival rate

PURPOSE

Placement of self-expanding metal stents is regarded as a safe and effective treatment in patients with incurable malignant esophagogastric obstruction. However, proceeding and possible benefit of re-interventions in patients with recurrent dysphagia due to delayed complications (>4 weeks after stent insertion) is unclear.

PATIENTS AND METHODS

In 133 patients with malignant stricture of the esophagus or the esophagogastric junction 164 expandable metal stents were placed. About 89 patients were followed up until death. All tumor- or stent-related complications and consequent re-interventions were recorded.

RESULTS

The overall incidence of delayed complications was 53.4% (71 of 133 pts.), with 34 patients (25.6%) experiencing more than one complication. Recurrent dysphagia due to tumor ingrowth (22%) or overgrowth (15%), bolus obstruction (21%), stent migration (9%), and development of esophagorespiratory fistula (9%) was successfully treated by dilatation (24%), placement of a second/third stent (27%), laser therapy (16%), and/or placement of a feeding tube (PEG, 19%). The median survival of patients with endoscopic therapy was significantly longer (222 +/- 26 days) compared to patients without re-intervention (86 +/- 14 days, P < 0.0001).

CONCLUSIONS

Delayed complications after metal stent placement for malignant esophageal stricture are common, but can be treated successfully by endoscopic re-intervention in most cases. Regular interventional therapy may also improve survival.

Stents in the GI tract

The application of stents in the GI tract has expanded tremendously. Stent placement is the most frequently used treatment modality for palliating dysphagia from esophageal or gastric cardia cancer. Newly designed esophageal stents, including the Polyflex stent and the Niti-S double stent, have been introduced to reduce recurrent dysphagia owing to migration or nontumoral or tumor overgrowth. Stents are also the treatment of choice for esophagorespiratory fistulas, for proximal malignant lesions near the upper esophageal sphincter, for recurrent carcinoma after esophagectomy or gastrectomy and for sealing traumatic or iatrogenic nonmalignant ruptures, such as Boerhaave's syndrome and leakages following surgery. Stents in the latter patient group should be removed within 4-8 weeks after placement to prevent the formation of granulation tissue or hyperplasia at the stent ends. For gastric outlet obstruction, many case series have been published. Only two, small, randomized controlled trials have compared stent placement with gastrojejunostomy to date, and a large, randomized trial is currently being conducted in The Netherlands. Obstructive jaundice caused by a malignancy in the common bile duct can be treated effectively with plastic or metal stent placement. However, a prognostic score needs to be developed that guides a treatment decision towards using either of these stents. Finally, colonic stents are applied successfully for acute malignant obstruction as a 'bridge to surgery' in patients with tumors that are deemed to be resectable, or as a palliative treatment for patients with locally advanced or metastatic disease.

Esophageal bypass using a gastric tube and a cardiostomy for malignant esophagorespiratory fistula

Esophageal bypass with a gastric tube and a cardiostomy is a method recently devised for malignant esophagorespiratory fistula. This method separates completely the alimentary and respiratory tracts. Four patients underwent these procedures. No operative deaths occurred, nor was there any anastomotic leakage or disruption of the excluded esophagus. The average survival time was 7 months. However, all patients were allowed to consume food orally up to the last moment of life. This bypass procedure is simple and safe to perform, and is thus a feasible treatment choice for patients with such fistulas.

Polyflex stents for malignant oesophageal and oesophagogastric stricture: a prospective, multicentric study

OBJECTIVE

Dysphagia is the most distressing symptom in patients with cancer-related oesophageal obstruction. Endoscopic palliation aims to restore swallowing, avoid reintervention and to reduce hospitalization. This study reports an experience with a new self-expandable plastic stent (Polyflex) in patients with unresectable oesophageal and oesophagogastric junction cancer.

METHODS

Sixty patients were prospectively collected. The cause of obstruction was oesophageal squamous cell carcinoma (44) and adenocarcinoma (eight), lung cancer (seven) and thyroid tumour (one).

RESULTS

The stent was successfully placed in 59 patients. Early minor complications occurred in 19 patients (32%), and major complications in 13 (22%). Death occurred in three patients owing to pulmonary embolism (one) and massive haemorrhage (two). Recurrent dysphagia for early stent migration was observed in seven patients. Delayed stent migration occurred in five patients and tumour overgrowth in eight patients. The mean dysphagia score of 2.8 improved to a mean score of 1.0 after stenting (P<0.001). Overall median survival time was 4.6 months.

CONCLUSIONS

Our study suggests that Polyflex stents are competitive with metal stents, with similar efficacy but lower cost. Technical improvements, however, are required to make these stents more user friendly. Large randomized clinical studies are needed to guide in the choice among the different available stents.

Prior chemoradiotherapy is associated with a higher life-threatening complication rate after palliative insertion of metal stents in patients with oesophageal cancer

BACKGROUND

Self-expanding metal stents are used routinely to palliate dysphagia due to oesophageal cancer.

STUDY AIM

To compare the frequency of life-threatening complications after self-expanding metal stent insertion, depending on whether patients received prior chemoradiotherapy or no treatment.

PATIENTS AND METHODS

During 7 years, 116 consecutive patients were treated at a single centre in a palliative intent by insertion of self-expanding metal stent for dysphagia due to an oesophageal cancer. Patients were retrospectively separated into two groups: patients with chemoradiotherapy before self-expanding metal stent insertion (group 1, n = 56) and patients with no treatment before or after self-expanding metal stent insertion (group 2, n = 60). Life-threatening complications were compared and predictive risk factors of postprocedure complications were identified.

RESULTS

Median dysphagia was significantly improved during the first month (grade 3 to grade 1 in the two groups). Early and late major complications occurred more frequently in group 1 (23.2% vs. 3.3%; P < 0.002 and 21.6% vs. 5.1%; P < 0.02 respectively). Prior chemoradiotherapy was the only independent predictive factor of postprocedure major complications, with an odds ratio of 5.59 (CI 95% 1.7-18.1).

CONCLUSIONS

Life-threatening complications after palliative self-expanding metal stent placement seem to occur more frequently in patients with prior chemoradiotherapy. Prevention of these severe complications should be considered before stenting.

[Palliative endoscopic treatments for esophageal cancers]

Esophageal cancer five-year survival has slightly increased during past 20 years (from 5 to 9%), but remains low. At time of diagnosis, 60% of the patients are only relevant for palliative therapy. Recent advances in therapeutic endoscopy have allowed improving dysphagia and quality of life. Endoscopic techniques are chosen according to tumor characteristics. According to French societies guidelines (FFCD, "Standards-Options-Recommandations" from FNCLCC, SNFGE) endoscopic treatment is a "gold standard" for metastatic patients with poor performance status, as well as oesophago-tracheal fistula. Expandable metal stent are efficient for malignant stenosis with lower morbidity and mortality than plastic prosthesis. Endoscopic placement of a covered self-expanding metal stent is the treatment of choice of an esophago-respiratory fistula. Dilatation is often the first step before other endoscopic therapies or medical treatment such as radiochemotherapy. Single dose brachytherapy could provide better long-term relief of dysphagia and fewer complications than stent placement, but is less widespread. Other techniques like bipolar electrocoagulation have restricted indications especially for circonferential stenosis of cervical esophagus. However, the main problem remains the dysphagia relapse after treatment.

New developments in palliative therapy

Over the past 5 years, new developments in the palliative treatment of incurable cancer of the oesophagus and gastro-oesophageal junction have been introduced with the aim of palliating dysphagia and improving the survival of patients. Stent placement is currently the most widely used treatment for palliation of dysphagia from oesophageal cancer. A stent offers rapid relief of dysphagia; however, current recurrent dysphagia rates vary between 30 and 40%. Recently introduced new stent designs are likely to reduce recurrent dysphagia by decreasing stent migration and non-tumoral tissue overgrowth. Intraluminal radiotherapy (brachytherapy) has been demonstrated to compare favourably with stent placement in long-term effectiveness and safety. A disadvantage of brachytherapy, however, is that one-fifth of patients need an additional treatment because of persistent tumour growth in the oesophagus. A solution may be to administer brachytherapy not in a single fraction but in multiple fractions. Finally, efforts have been undertaken to improve survival of patients by using chemotherapy. In the future, a multimodal approach--for example by combining stent placement with chemotherapy or radiotherapy--may improve the prognosis of patients without jeopardizing their quality of life.

Self-expandable metallic stent for unresectable malignant strictures in the esophagus and cardia

OBJECTIVE

Self-expandable metallic stent (EMS) placement has been the first choice for dysphagia because of the certainty over its safety, low invasiveness, and immediate efficacy. However, there still remain some problems in relation to the EMS placement site and anticancer therapies before and after EMS placement.

METHODS

Consecutive 78 patients in whom EMS was placed due to the unresectable malignant stricture in the esophagus or cardia from July 1995 to August 2003 in our department were studied.

RESULTS

Gastroesophageal reflux was found in 5 of 8 patients after placement of conventional EMS for the stricture in the gastroesophageal junction. Meanwhile, acid and bile reflux into the esophagus were not detected by pH and bilirubin monitoring, respectively, in 6 patients after placement of the EMS with an anti-reflux mechanism for the stricture in the gastroesophageal junction. The median survival period of all patients after EMS placement was 123 days. The median survival period of 7 patients with radiotherapy only after EMS placement was 138 days and that of 17 patients with radiotherapy before EMS placement was 60 days, which was shorter than that of the former (p<0.05). On the other hand, the median survival period after hospital admission due to dysphagia of these 7 patients was longer than that of 17 patients with radiotherapy only before EMS placement, although, the difference was not significant.

CONCLUSION

EMS with an antireflux mechanism is not commercially available in Japan and approval is urgently required. The indication of radiotherapy associated with EMS placement is to be studied further.

Comparison of Temporary and Permanent Stent Placement with Concurrent Radiation Therapy in Patients with Esophageal Carcinoma

PURPOSE

To assess the clinical effectiveness of temporary metallic stent placement with concurrent radiation therapy in patients with esophageal carcinoma by comparing it with permanent stent placement with concurrent radiation therapy.

MATERIALS AND METHODS

Covered retrievable expandable nitinol stents were placed in 47 patients with esophageal carcinoma 1 week before starting radiation therapy; the stents were electively removed 4 weeks after placement in 24 patients (group A), while not electively removed in the other 23 patients (group B). In cases of complications, the stents were also removed from patients in groups A and B. The dysphagia score, complications (severe pain, granulation tissue formation, stent migration, esophagorespiratory fistula, and hematemesis), tumor overgrowth/regrowth, reintervention rates, and dysphagia-progression-free and overall survival rates were compared in the two groups.

RESULTS

Stent placement or removal was technically successful and well tolerated in all patients. The dysphagia score was significantly improved in both groups after stent placement (P < .01). Each of the stent-related complications was less in group A than in group B but there was no significant difference. However, the total number of patients with one or more than one complications and who needed related reinterventions was significantly less in group A than in group B (P = .042 and .030, respectively). Tumor overgrowth/regrowth and the total number of patients who required related reinterventions was not significantly different (P = 1.00 and .517, respectively). Dysphagia-progression-free and overall survival rates were significantly longer in group A than in group B (P = .005 and .001, respectively).

CONCLUSION

Temporary placement of a covered retrievable expandable metallic stent with concurrent radiation therapy for patients with esophageal carcinoma is beneficial for reducing complications and related reinterventions and for increasing resultant survival rates compared with permanent esophageal stent placement.

Prior radiation and/or chemotherapy has no effect on the outcome of metal stent placement for oesophagogastric carcinoma

OBJECTIVE

It is still unclear whether prior radiation and/or chemotherapy (RTCT) increases the risk of complications after the placement of self-expanding metal stents in patients with inoperable oesophagogastric carcinoma. We evaluated the influence of prior RTCT on the outcome of stent placement in a large group of patients.

METHODS

From October 1994 to December 2000, 200 patients underwent placement of self-expanding metal stents for malignant dysphagia, and were followed prospectively. Forty-nine of these patients had received prior RTCT (chemotherapy n = 35, radiation therapy n = 8, or both n = 6).

RESULTS

At 4 weeks after stenting, the dysphagia score had improved similarly in patients with or without prior RTCT, from a median of 3 to 0 (P < 0.001). The occurrence of major complications (bleeding, perforation, fistula formation, fever and severe pain) was not different between patients with or without prior RTCT (29% vs 21%; relative risk (RR) = 1.15 (95% CI 0.54-2.46; P = 0.72)), as was the occurrence of recurrent dysphagia due to tumour overgrowth, stent migration, or impaction of a food bolus (35% vs 27%; RR = 1.49 (95% CI 0.71-3.13; P = 0.29)). Median survival of both patient groups after stent placement was similar (110 vs 93 days; RR = 0.90 (95% CI 0.60-1.34; P = 0.60) for prior RTCT versus no prior treatment). Only minor complications (mainly mild retrosternal pain) occurred more frequently in patients with prior RTCT (41% vs 15%; RR = 2.12 (95% CI 1.06-4.25; P = 0.035)).

CONCLUSIONS

Both the incidence of life-threatening complications and survival after placement of self-expanding metal stents for oesophagogastric carcinoma are not affected by prior RTCT, but retrosternal pain occurs more frequently in patients who had previously undergone RTCT.

Morbidity and mortality after self-expandable metallic stent placement in patients with progressive or recurrent esophageal cancer after chemoradiotherapy

BACKGROUND

Placemet of self-expandable metallic stents in patients with advance esophageal cancer improves dysphagia and occludes tracheoesophageal fistulas. However, the safety of self-expandable metallic stents for patients who have undergone chemoradiotherapy is controversial. This study evaluated the morbidity and modality after self-expandable metallic stent placement in patients with progressive or recurrent esophageal cancer after chemoradiotherapy.

METHODS

A total of 22 patients in whom self-expandable metallic stents were placed because of progressive or recurrent esophageal cancer after chemoradiotherapy were studied.

RESULTS

All 22 patients had dysphagia, and 13 had a tracheoesophageal fistula. After self-expandable metallic stent placement, the mean dysphagia grade improved from 3.5 to 0.9, and tracheoesophageal fistula was successfully managed in all cases. Seventeen patients had T4 stage disease, and among 8 of them with invasion to the aorta, 6 (75%) died of sudden massive hemorrhage. Median survival for these 6 patients was 31 days (range 13-63 days) compared with 67 days (range 4-262 days) for all patients after self-expandable metallic stent placement.

CONCLUSION

Self-expandable metallic stent placement improved dysphagia and was useful for treatment of tracheoesophageal fistula. However, for patients with T4 lesions that invade to the aorta, self-expandable metallic stent placement after chemoradiotherapy should be considered carefully.

Endoluminal palliation for dysphagia secondary to esophageal carcinoma

There are now a variety of treatment options available to palliate dysphagia in patients with advanced esophageal carcinoma. The decision as to which therapy to recommend for a patient should be based on a though understanding of the therapies and must be individualized for each patient and on the experience of the endoscopist or surgeon. In addition, consideration should be given as to resource availability at a particular institution. External beam radiation currently has little role as primary treatment for dysphagia. Brachytherapy is labor intensive; requires 2 to 3 weekly treatments, highly specialized radiation equipment, and an experienced radiation oncologist; and is therefore limited to tertiary care centers. Endoluminal YAG-laser tumor ablation is feasible at many institutions and provides immediate dysphagia relief but has limited durability (weeks) if not followed by adjuvant therapy, and requires an endoscopist with significant laser experience. PDT is relatively easy to perform and has a lower perforation rate and longer durability than YAG laser therapy but it is relatively costly and less patient friendly due to the morbidity of its attendant 6 weeks of photosensitivity. Advances in stent technology have rendered this a safe, readily available treatment for the palliation of dysphagia. Palliation of dysphagia is an important but difficult goal that may require creative use of a variety of endoscopic interventions, either in combination or serially. Ideally, physicians who palliate dysphagia secondary to esophageal cancer should be facile in both endoscopic ablative and stenting techniques and have a close working relationship with both radiation and medical oncologists.

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.

Improvement of oral ingestion in patients with inoperable esophageal cancer treated with radiotherapy, chemotherapy and insertion of a self-expanding nitinol stent

Radiotherapy, chemotherapy and self-expanding nitinol stent insertion were performed in patients with inoperable esophageal cancer to improve oral ingestion. Twelve patients underwent radiotherapy and chemotherapy. A stent was inserted in patients with dysphagia after radiotherapy and chemotherapy. Patients' capacity for oral ingestion was classified into three categories: grade I patients were able to ingest enough food; grade II patients could ingest food but required nutritional support; and grade II patients found it impossible to ingest anything. After radiotherapy and chemotherapy, the number of grade I patients increased from three to five but seven patients remained in grades II and III. Four grade II and III patients were treated with stents, after which dysphagia was reduced to grade I. In the grade I patients after treatment with radiotherapy and chemotherapy, the duration of grade I was on average 167 days and survival was 191 days. In the patients subjected to stent insertion, grade I lasted 65 days and survival was 149 days. Before the introduction of the stent, grade II patients died, on average, after 91 days. After the introduction of self-expanding nitinol stents, all patients could ingest enough food and were discharged.

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

BACKGROUND

The use of metal stents for the treatment of dysphagia due to esophageal malignancy is an important advance because of ease of delivery and their self-expandable property. Obstruction due to tumor overgrowth is a recognized complication, but nonmalignant obstruction in patients with metal stents is rarely reported.

METHODS

Database records of patients who had esophageal cancer and underwent metal stent insertion were reviewed.

RESULTS

A total of 116 patients were seen between October 1993 and October 1997. Four types of metal stents had been used (Ultraflex, Z Stent, Wallstent, and Esophacoil). Detailed follow-up information was available for 81 patients, who constitute the study sample. Forty-nine (60%) stent obstructions were reported, 26 of the 49 (53%) were due to tumor overgrowth and 23 (47%) were not associated with malignancy. Histologic analysis of the nonmalignant obstructing tissue showed granulation tissue (56%), reactive hyperplasia (22%) and fibrosis (22%).

CONCLUSIONS

Nonmalignant obstruction is a common although infrequently reported complication after placement of metal stents for esophageal cancer. The tissue response of the esophageal mucosa occurred with all 4 types of stents used. No specific characteristic of the stent or prior treatment seems to be related to obstruction of the stent in patients with either nonmalignant obstruction or tumor overgrowth.

Palliation of patients with esophagogastric neoplasms by insertion of a covered expandable modified Gianturco-Z endoprosthesis: experiences in 153 patients

BACKGROUND

We aimed to evaluate the short- and long-term outcomes of treatment by insertion of a covered expandable modified Gianturco-Z endoprosthesis (Song stent) in patients with esophagogastric malignancies.

METHODS

Consecutive patients with esophagogastric malignancies in whom a Song stent was inserted were included. Data were retrieved retrospectively. Dysphagia before and after stent placement was scored on a 5-point scale. Early (less than 30 days) and late complications (more than 30 days) were scored.

RESULTS

Analysis included 164 stents in 153 patients. Indications for stent placement were dysphagia and/or fistulas/perforations. The dysphagia score improved from a mean of 3.7 to 2.2 after stent placement (p < 0.0001). Fistulas/perforations sealed in 87% of cases. Early complications after stent placement occurred in 29.9% of cases. These included stent migration (4.3%), stent obstruction (6. 1%), aspiration pneumonia (4.9%), bleeding (4.3%), perforation (1. 8%), and pain (15.9%). Late complications occurred in 27.8% of cases. These included stent migration (2.6%), stent obstruction (9.6%), aspiration pneumonia (2.6%), bleeding (7.0%), perforation (0.9%), and pain (12.2%). The 30-day mortality was 26%. Death related to stent placement occurred in 3.3%.

CONCLUSION

Insertion of a Song expandable endoprosthesis in patients with esophagogastric malignancies significantly improves dysphagia, is successful in sealing fistulas/perforations, and is associated with acceptable morbidity and mortality rates.

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.

Squamous cell papillomatosis of esophagus following placement of a self-expanding metal stent

The esophageal self-expanding metal stent has gained widespread acceptance for the management of tracheoesophageal fistulas and the palliative management of malignant esophageal strictures. The complications associated with its use can be classified as either immediate or delayed. The most frequent delayed complications include tumor ingrowth, stent migration, reflux of gastric contents, bleeding, and perforation. This case report illustrates an otherwise unrecognized delayed complication of a self-expanding metal stent. Near complete ingrowth of the stent by squamous mucosal hyperplasia occurred within six weeks of the metal stent's placement. This finding supports the hypothesis that mucosal injury and regeneration underlies the etiology of esophageal squamous cell papilloma formation.

Palliation of malignant esophageal obstruction due to intrinsic and extrinsic lesions with expandable metal stents

OBJECTIVE

Metal stents have become the standard of care for esophageal stenting. The aim of this study was to determine the safety and efficacy of metal stents for the palliation of dysphagia caused by extraesophageal malignancies compressing the esophagus, compared with that caused by intrinsic lesions involving the esophagus.

METHODS

Expandable metal stents were placed in 46 consecutive patients with dysphagia caused by malignant extrinsic compression of the esophagus (n=24) and intrinsic esophageal strictures (n=22). Quality of life was determined by a dysphagia score and the Karnofsky performance scale. Patients were followed until death.

RESULTS

Stents were successfully deployed in all 24 patients. Dysphagia scores improved from a median of 3 (range, 3-4; mean, 3.5+/-0.2) to a median of 2 (range, 1-4; mean, 1.6+/-0.4; p < 0.0001) in the extrinsic group, and from a median of 3 (range, 2-4) to a median of 1 (range, 1-3) in the intrinsic group (p < 0.0001). The improvement was significantly greater (p=0.01) in the intrinsic group. There was no significant difference in the Karnofsky score between the two groups.

CONCLUSIONS

Patients with intrinsic lesions have better palliation of dysphagia than those with extrinsic lesions. Future studies with other study designs will need to consider this.

Metal stents for the palliation of inoperable upper gastrointestinal stenoses

We sought to determine the efficacy of metal stents in the palliation of malignant upper gastrointestinal stenoses. Six patients with inoperable malignant obstruction of the upper gastrointestinal tract, intractable nausea and vomiting, and an inability to maintain an oral intake were studied. A metal stent was inserted under endoscopic control and deployed in the stenosis. Stents were successfully deployed in all patients, and there were no immediate complications. All patients were able to eat after the procedure and parenteral nutrition was discontinued in all. Mean survival was 23 +/- 8.6 days. We conclude that metal stents represent a promising approach to the management of selected patients with malignant upper gastrointestinal stenoses and that their use warrants further study.

Palliation of malignant dysphagia from oesophageal cancer. Rotterdam Oesophageal Tumor Study Group

Palliative therapies for advanced oesophageal cancer include surgery, radiation therapy, chemotherapy, endoscopic procedures and combinations of these. Of the non-endoscopic modalities is external beam radiation therapy (EBRT) effective and non-invasive. A disadvantage is that relief of dysphagia only occurs over a period of 4-6 weeks. Brachytherapy is more rapid in locally controlling tumour growth and in relieving dysphagia. One of the more commonly used endoscopic procedures is laser therapy, which provides symptomatic relief with low complication rates. Recurrent dysphagia is a problem necessitating repeated treatment sessions. Self-expanding metal stents offer a high degree of palliation and are associated with fewer complications compared with prosthetic tubes. Longer palliation and perhaps even longer survival might be achieved by the combination of different therapies. Most promising are the combination of EBRT plus brachytherapy or chemoradiation. Now is the time to determine which treatment (combination) is best for individual patients.

Coated self-expanding metal stents versus latex prostheses for esophagogastric cancer with special reference to prior radiation and chemotherapy: a controlled, prospective study

BACKGROUND

Self-expanding metal stents seem to be safer than conventional prostheses for palliation of malignant esophagogastric obstruction. However, recurrent dysphagia caused by tumor ingrowth in uncoated types remains a problem. In addition, prior radiation and/or chemotherapy may entail an increased risk of complications.

METHODS

Seventy-five patients with an esophagogastric carcinoma were randomly assigned to placement of a latex prosthesis under general anesthesia or a coated, self-expanding metal stent under sedation. At entry, patients were stratified for location of the tumor in the esophagus or cardia and for prior radiation and/or chemotherapy.

RESULTS

Technical success and improvement in dysphagia score were similar in both groups. Major complications were more frequent with latex prostheses (47%) than with metal stents (16%) (odds ratio 4.07: 95% CI [1.35, 12.50], p = 0.014). Recurrent dysphagia was not different between latex prostheses (26%) and metal stents (24%). Hospital stay was longer, on average, after placement of latex prostheses than metal stents (6.3 +/- 5.2 versus 4.3 +/- 2.3 days; p = 0.043). Only prior radiation and/or chemotherapy increased the risk of specific device-related complications with respect to the esophagus (12 of 28 [43%] versus 8 of 47 [17%]; odds ratio 3.66: 95% CI [1.24, 10.82], p = 0.029).

CONCLUSIONS

Coated, self-expanding metal stents are associated with fewer complications and shorter hospital stay as compared with latex prostheses, and prior radiation and/or chemotherapy increases the risk of device-related complications with respect to the esophagus.