Covered Self-Expandable Metallic Stents Could be Used Successfully in the Palliation of Malignant Cervical Esophageal Strictures: Preliminary Report

Clinical Efficacy of Stent in Patients with Cervical Esophageal and/or Hypopharyngeal Stenosis after Total Laryngectomy

We retrospectively analyzed 17 patients with esophageal stent who underwent cervical esophageal and/or hypopharyngeal stenosis after total laryngectomy (TL) from January 2014 to January 2018. The success rate of stent implantation was 100%. Dysphagia in 16 patients improved to class 0 or 1 (16/17, 94.12%) after stent implantation and in 1 patient was improved to class 2 (1/17, 5.88%). Two patients died of tumor progression at 7 months and 11 months after stent implantation, respectively, but both could eat semi-solid/solid food before death. Dysphagia was resolved in the remaining 15 patients, and there was no recurrence of dysphagia including feeding obstruction during follow-up. Therefore, this case series concludes that the esophageal stent position after TL can be much higher than that of patients with normal pharyngeal structures. Esophageal stent implantation is a feasible and effective treatment for patients with laryngopharyngeal/esophageal stenosis following TL.

Feasibility, efficacy and safety of stent insertion as a palliative treatment for malignant strictures in the cervical segment of the esophagus and the hypopharynx

BACKGROUND

50% of esophageal cancers are inoperable at the time of diagnosis, and around 15% involve the cervical esophagus. The hypopharynx is often involved by these malignancies as well. Palliation of cervical esophageal malignancies through stent insertion is considered limited due to technical challenges, poor patient tolerance and high complication rate. The aim of this study is to review our experience with stent insertion in the cervical segment of the esophagus and to evaluate outcome differences between stent insertions involving or sparing the hypopharynx.

METHODS

We retrospectively reviewed data on 69 consecutive patients that underwent stent insertion for malignant strictures in the cervical esophagus at our Department. Patients were divided according to involvement or sparing of the lower hypopharynx. Dysphagia severity was measured with the Mellow-Pinkas scale before the procedure and on monthly follow-ups. Any complication and its management were recorded. The main outcome parameters were as follows: dysphagia improvement, rate of successful dysphagia palliation (i.e., a reduction of the score to 0 or 1 after stent insertion) and complication rate. Multivariable analysis was carried out to assess the influence of patient- and procedure-related factors on the outcome of the procedure.

RESULTS

Stent insertion was achieved in 100% patients. At 4 weeks, dysphagia score improved from a median of 3-0 (p < 0.001), and a successful palliation was achieved in 76.8% patients. The 30-day mortality rate was 14.5%. Successful palliation throughout the follow-up was achieved in 72.9% of the surviving patients. Complications occurred in 31.9% patients. Dilation before stent insertion was associated with a less efficient short-term dysphagia palliation (OR 6.77, 95% CI 1.46-31.29, p = 0.02).

CONCLUSIONS

Stent insertion is a safe and effective palliative treatment for malignant cervical esophageal strictures. Results are consistent even in patients with hypopharyngeal lesions. Dilation should be avoided before stent insertion.

Symptom relief effect of palliative high dose rate intracavitary radiotherapy for advanced esophageal cancer with dysphagia

Intracavitary radiotherapy (ICRT) for the palliative treatment of advanced esophageal cancer with dysphagia is currently performed at the University of Tokyo Hospital (Tokyo, Japan). In the present study, 24 patients exhibiting advanced esophageal cancer with dysphagia received palliative ICRT. ICRT, which was delivered 5 mm below the esophageal mucous membrane, with the exception of one case, was administered at a dose of 6 Gy/fraction. Specific patients additionally underwent definitive or palliative external beam radiation therapy for esophageal cancer a minimum of three months prior to ICRT. The effect of treatment on symptom alleviation was examined by comparing the dysphagia score prior to and following ICRT, with the patients’ medical records and a questionnaire used to calculate a dysphagia score ranging from zero (no dysphagia) to four (total dysphagia). In consideration of the individual efficacy of the treatment, the maximum number of repeated ICRT fractions was four (median, 1.7 times). A trend in the improvement of the symptom of dysphagia was observed in response to esophageal ICRT, with the average dysphagia score markedly decreasing from 2.54 to 1.65, however, the difference was not significant (P=0.083). Furthermore, pain was the most frequent side-effect of the esophageal ICRT and no patients exhibited severe complications. Thus, esophageal ICRT at a dose of 6 Gy/fraction may present an effective strategy for relieving the symptom of dysphagia in cases of advanced esophageal cancer.

Efficacy and safety of a new fully covered self-expandable non-foreshortening metal esophageal stent

BACKGROUND

Fully covered esophageal self-expandable metal stents (SEMSs) are potentially removable but can be associated with high migration rates. For precise positioning, non-foreshortening SEMSs are preferred. Recently, a new fully covered non-foreshortening SEMS with anti-migration features was introduced.

OBJECTIVE

To evaluate the efficacy and safety of this new esophageal SEMS.

DESIGN

Retrospective study.

SETTING

Single, tertiary-care center.

PATIENTS

Consecutive patients with malignant and benign strictures with dysphagia grade of ≥3 and patients with fistulas/leaks were studied.

INTERVENTIONS

Stent placement and removal.

MAIN OUTCOME MEASUREMENTS

Technical success in stent deployment/removal, efficacy in relieving dysphagia and sealing fistulas/leaks, and adverse events.

RESULTS

Forty-three stents were placed in 35 patients (mean [± standard deviation] age 65 ± 11 years; 31 male), 24 for malignant and 11 for benign (5 strictures, 6 leaks) indications. Technical success in precise SEMS placement was 100%. The after-stent dysphagia grade improved significantly (at 1 week: 1.5 ± 0.7; at 4 weeks: 1.2 ± 0.4; baseline: 3.8 ± 0.4; P < .0001). Twenty stents were removed for clinical indications, with technical success of 100%. All leaks sealed after SEMS placement and did not recur after stent removal. All benign strictures recurred after stent removal. Adverse events included migration (14%), chest pain (11%), and dysphagia from tissue hyperplasia (6%). There was no stent-related mortality.

LIMITATIONS

Nonrandomized, single-center study.

CONCLUSION

The new esophageal SEMS was effective in relieving malignant dysphagia, allowed for precise placement, and was easily removable. It was effective in treating benign esophageal fistulas and leaks. Stent-related adverse events were acceptable.