Effectiveness of open versus antireflux stents for palliation of distal esophageal carcinoma and prevention of symptomatic gastroesophageal reflux

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.

Anti-reflux versus conventional self-expanding metal stents in the palliation of esophageal cancer: A systematic review and meta-analysis

Background and study aims  Self-expanding metal stents (SEMS) are an effective palliative endoscopic therapy to reduce dysphagia in esophageal cancer. Gastroesophageal reflux disease (GERD) is a relatively common complaint after non-valved conventional SEMS placement. Therefore, valved self-expanding metal stents (SEMS-V) were designed to reduce the rate of GERD symptoms. We aimed to perform a systematic review and meta-analysis comparing the two stents. Material and methods  This was a systematic review and meta-analysis including only randomized clinical trials (RCT) comparing the outcomes between SEMS-V and non-valved self-expanding metal stents (SEMS-NV) following the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines. The risk of bias was assessed using the Cochrane Risk of Bias 2 tool. Data were analyzed with Review Manager Software. Quality of evidence was evaluated using Grading of Recommendations Assessment, Development, and Evaluation guidelines. Results  Ten randomized clinical trials including a total of 467 patients, 234 in the SEMS-V group and 233 in the SEMS-NV group, were included. There were no statistically significant differences regarding GERD qualitative analysis (RD -0.17; 95 % CI -0.67, 0.33; P  = 0.5) and quantitative analysis (SMD -0.22; 95 % CI -0.53, 0.08; P  = 0.15) technical success (RD -0.03; 95 % CI -0.07, 0.01; P  = 0.16), dysphagia improvement (RD -0.07; 95 % CI -0.19, 0.06; P  = 0.30), and adverse events (RD 0.07; 95 % CI -0.07, 0.20; P  = 0.32). Conclusions  Both SEMS-V and SEMS-NV are safe and effective in the palliation of esophageal cancer with similar rates of GERD, dysphagia relief, technical success, adverse events, stent migration, stent obstruction, bleeding, and improvement of the quality of life.

Network meta-analysis of palliative treatments in patients with esophageal cancer

We aimed to compare available palliative treatments in terms of survival and to rank these treatments for esophageal cancer. Web of Science, Medline, Scopus, Cochrane Library and Embase were searched. The risk of bias was judged using Cochrane's tools. Statistical heterogeneity was assessed using the Chi² test and was quantified by I². The results were summarized using the hazard ratio (HR). The rank probability for each treatment was calculated using the p-score. Nineteen RCTs met the eligibility criteria for this study. Treatments formed three networks including networks A, B, and C. The Ultraflex stent (p-score = 0.93), irradiation stent (p-score = 0.89), and thermal ablative therapy (p-score = 0.85) were the first ranking treatments in networks A, B, and C, respectively. Based on the results of this network meta-analysis, it appears that the ultraflex stent, the irradiation stent, and thermal ablative therapy are the better treatments among the networks.

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.

Therapeutic effect of decellularized extracellular matrix-based hydrogel for radiation esophagitis by 3D printed esophageal stent

Radiation esophagitis, the most common acute adverse effect of radiation therapy, leads to unwanted consequences including discomfort, pain, an even death. However, no direct cure exists for patients suffering from this condition, with the harmful effect of ingestion and acid reflux on the damaged esophageal mucosa remaining an unresolved problem. Through the delivery of the hydrogel with stent platform, we aimed to evaluate the regenerative capacity of a tissue-specific decellularized extracellular matrix (dECM) hydrogel on damaged tissues. For this, an esophagus-derived dECM (EdECM) was developed and shown to have superior biofunctionality and rheological properties, as well as physical stability, potentially providing a better microenvironment for tissue development. An EdECM hydrogel-loaded stent was sequentially fabricated using a rotating rod combined 3D printing system that showed structural stability and protected a loaded hydrogel during delivery. Finally, following stent implantation, the therapeutic effect of EdECM was examined in a radiation esophagitis rat model. Our findings demonstrate that EdECM hydrogel delivery via a stent platform can rapidly resolve an inflammatory response, thus promoting a pro-regenerative microenvironment. The results suggest a promising therapeutic strategy for the treatment of radiation esophagitis.

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 Review of Self-Expanding Esophageal Stents for the Palliation Therapy of Inoperable Esophageal Malignancies

Esophageal cancer is a very deadly disease, killing more than 15,000 people in the United States annually. Almost 400,000 new cases happen in the worldwide every year. More than 50% esophageal cancer patients are diagnosed at an advanced stage when they need an esophageal stent to open the blocked esophagus for feeding and drinking. Esophageal stents have evolved in stages over the years. Current clinically used stents commonly include stainless steel or nitinol self-expandable metallic stent (SEMS) and self-expandable plastic stent (SEPS). There are many choices of different types of stents and sizes, with fierce competition among manufacturers. However, current stent technology, whether uncovered, partially covered, fully covered SEMS or SEPS, has their own advantages to solve the dysphagia, stricture, and fistula problems, but they also cause some clinical complications. The ideal stent remains elusive. New 3D printing technique may bring new promising potential to manufacturing personalized esophageal stents. Drug-eluting stents could be the new avenue to do more than just pry open a stricture or cover a defect in the esophageal lumen, a possibility of proving local anticancer therapy simultaneously. Additionally, the lack of esophageal cancer animal models also hinders the progress of stent development. This paper reviews these topics for a comprehensive understanding of this field. In a conclusion, the ultimate goal of the future esophageal stent would have multifunction to treat the underlying conditions and restore esophageal function to near normal.

3D-printed flexible polymer stents for potential applications in inoperable esophageal malignancies

Palliation therapy for dysphagia using esophageal stents is the current treatment of choice for those patients with inoperable esophageal malignancies. However, the metallic and plastic stents currently used in the clinical setting may cause complications, such as tumor ingrowth and stent migration into the stomach. To effectively reduce/overcome these complications, we designed a tubular, flexible polymer stent with spirals. The parameters of the spirals were computationally optimized by using a finite element analysis. The designed polymer stents with optimized spirals were then printed by a 3D printing technique. 3D-printed tubular polymer stents without spirals served as controls. The self-expansion and anti-migration properties of the printed stent were characterized in an ex vivo normal porcine esophagus. The biodegradability test of the stent was performed in a neutral buffer and acidic gastric buffer. The cytotoxicity of the new stent was examined through the viability test of human esophagus epithelial cells. Results showed the self-expansion force of the 3D-printed polymer stent with spirals was higher than the stent without spirals. The anti-migration force of the 3D-printed stent with spirals was significantly higher than that of the stent without spirals. Furthermore, the stent with spirals significantly decreased the migration distance compared to the non-spiral 3D-printed polymer stent. Degradation study showed that the polymer materials started to degrade after six weeks and the compressive strength of the stent was not significantly decreased with time. In vitro cell viability results further indicated that the polymer stent does not have any cytotoxicity. Together, these results showed that the 3D-printed stent with spirals has potential applications in the treatment of inoperable esophageal malignancies. STATEMENT OF SIGNIFICANCE: In this study, we developed a new 3D-printed flexible tubular polymeric stent with spirals. The mechanical properties of the 3D-printed polymer stent are modulated by changing the ratios of PLA to TPU. The stent is flexible enough to be compressed in a clinically available stent delivery system, and can self-expand after it is released. The self-expansion force of the stent with spirals is higher than that of non-spiral stents. The spirals on the outside of the stent significantly increased the anti-migration force compared to non-spiral stents in an ex vivo normal pig esophagus. Together, the 3D-printed stent with spirals will bring promising potential in the treatment of inoperable esophagus malignancies or benign strictures.

Oesophageal stenting: Status quo and future challenges

Oesophageal stents are widely used for palliating dysphagia from malignant obstruction. They are also used with increasing frequency in the treatment of oesophageal perforation, as well as benign strictures from a variety of causes. Improved oncological treatments have led to prolonged survival of patients treated with palliative intent; as a consequence, stents need to function and last longer in order to avoid repeat procedures. There is also increasing need for meticulous procedure planning, careful selection of the device most appropriate for the individual patient and planned follow-up. Furthermore, as more patients are cured, there will be more issues with resultant long-term side-effects, such as recalcitrant strictures due to radiotherapy or anastomotic scarring, which will have to be addressed. Stent design needs to keep up with the progress of cancer treatment, in order to offer patients the best possible long-term result. This review article attempts to illustrate the changing realities in oesophageal stenting, differences in current stent designs and behaviour, as well as the pressing need to refine and modify devices in order to meet the new challenges.

Complications of stent placement in patients with esophageal cancer: A systematic review and network meta-analysis

Background

Palliative treatments and stents are necessary for relieving dysphagia in patients with esophageal cancer. The aim of this study was to simultaneously compare available treatments in terms of complications.

Methods

Web of Science, Medline, Scopus, Cochrane Library and Embase were searched. Statistical heterogeneity was assessed using the Chi² test and was quantified by I². The results of this study were summarized in terms of Risk Ratio (RR). The random effects model was used to report the results. The rank probability for each treatment was calculated using the p-score.

Results

Out of 17855 references, 24 RCTs reported complications including treatment related death (TRD), bleeding, stent migration, aspiration, severe pain and fistula formation. In the ranking of treatments, thermal ablative therapy (p-score = 0.82), covered Evolution® stent (p-score = 0.70), brachytherapy (p-score = 0.72) and antireflux stent (p-score = 0.74) were better treatments in the network of TRD. Thermal ablative therapy (p-score = 0.86), the conventional stent (p-score = 0.62), covered Evolution® stent (p-score = 0.96) and brachytherapy (p-score = 0.82) were better treatments in the network of bleeding complications. Covered Evolution® (p-score = 0.78), uncovered (p-score = 0.88) and irradiation stents (p-score = 0.65) were better treatments in network of stent migration complications. In the network of severe pain, Conventional self-expandable nitinol alloy covered stent (p-score = 0.73), polyflex (p-score = 0.79), latex prosthesis (p-score = 0.96) and brachytherapy (p-score = 0.65) were better treatments.

Conclusion

According to our results, thermal ablative therapy, covered Evolution® stents, brachytherapy, and antireflux stents are associated with a lower risk of TRD. Moreover, thermal ablative therapy, conventional, covered Evolution® and brachytherapy had lower risks of bleeding. Overall, fewer complications were associated with covered Evolution® stent and brachytherapy.

Self-Expandable Metallic Stent Placement for the Palliation of Esophageal Cancer

Esophageal stents have been used to palliate patients with dysphagia caused by esophageal cancer. Early rigid plastic prostheses have been associated with a high risk of complications. However, with the development of self-expanding stents, it has developed into a widely accepted method for treating malignant esophageal strictures and esophagorespiratory fistulas (ERFs). The present review covers various aspects of self-expanding metallic stent placement for palliating esophageal cancer, including its types, placement procedures, indications, contraindications, complications, and some of innovations that will become available in the future.

History of the Use of Esophageal Stent in Management of Dysphagia and Its Improvement Over the Years

The art and science of using stents to treat dysphagia and seal fistula, leaks and perforations has been evolving. Lessons learnt from the deficiencies of previous models led to several improvements making stent deployment easier, and with some designs, it was also possible to remove the stents if needed. With these improvements, besides malignant dysphagia, newer indications for using stents emerged. Unfortunately, despite several decades of evolution, as yet, there is no perfect stent that "fits all." This article is an overview of how this evolution process happened and where we are currently with using stents to manage patients with dysphagia and with other esophageal disorders.

Recurrence after surgery in esophago-gastric junction adenocarcinoma: Current management and future perspectives

Recurrent esophago-gastric junction adenocarcinoma is not a rare event and its correct management is still debated. Many approaches for the treatment of these patients exist, but only few studies compare the different techniques. Most of the studies are retrospectives series and describe the experiences of single institutions in the treatment of recurrent esophageal and esophago-gastric junction cancers. Nowadays surgery is still the main and only curative treatment. Other alternative palliative therapies could be endoscopic stent placement and balloon dilation, photodynamic therapy, thermal tumor ablation (laser photoablation and Argon plasma coagulation), radiation therapy and brachytherapy, and chemotherapy. The aim of this review is to investigate the different rates, patterns and timings of recurrence of this tumor, and to explain the various approaches used for the treatment of recurrent esophago-gastric junction cancer.

Esophageal stents for the treatment of malignant dysphagia in patients with esophageal cancer

Self-expanding metal stents (SEMS) are the current standard for relief of malignant esophageal dysphagia. Self-expanding plastic stents (SEPS) are also used for relief of malignant esophageal dysphagia and as neoadjuvant therapy due to their relative ease of removability. The innovations in design of both SEMS and SEPS have made their use more prevalent in patients with malignant dysphagia. We review the current literature on esophageal stents, including general concepts, indications, contraindications, SEMS and SEPS models, complications and their management, implications of tumor location, cost-effectiveness of stents in comparison with other modalities, and quality of life after stent placement.

Techniques and principles of endoscopic treatment of benign gastrointestinal strictures

PURPOSE OF REVIEW

The fundamental goal of treating any stenosis is luminal enlargement to ameliorate the underlying obstructive symptoms. Symptoms depend on the etiology and the site of the stricture and may include dysphagia, nausea and vomiting, abdominal pain, obstipation, or frank bowel obstruction. This article compares the various current technologies available for the treatment of gastrointestinal stenoses with regard to ease and site of application, patient tolerance, safety and efficacy data, and cost-benefit ratio.

RECENT FINDINGS

Recent studies indicate that gastrointestinal dilation and stenting have evolved to a point at which in many if not most situations they can be the first line therapy and potentially the final therapy needed to treat the underlying condition.

SUMMARY

Following techniques and principles in the management of gastrointestinal strictures would allow for the well tolerated and effective treatment of most patients with the tools currently available today.

Recent Advances in Gastrointestinal Stent Development

Endoscopic stenting is increasingly being used in the management of gastrointestinal luminal obstruction, and has become the current treatment of choice for the palliation of blockage caused by malignant or benign growths. A variety of stents have been developed to enhance the efficacy of the procedure, and improvements are ongoing. In this article, we review the history of, and recent advances in, gastrointestinal stenting. We describe the rationale behind the design as well as the resulting outcome for each stent type.

Recent Advances in Gastrointestinal Stent Development

Endoscopic stenting is increasingly being used in the management of gastrointestinal luminal obstruction, and has become the current treatment of choice for the palliation of blockage caused by malignant or benign growths. A variety of stents have been developed to enhance the efficacy of the procedure, and improvements are ongoing. In this article, we review the history of, and recent advances in, gastrointestinal stenting. We describe the rationale behind the design as well as the resulting outcome for each stent type.

Gastroesophageal Reflux Disease-related Symptom Assessment in Subjects with Malignant Dysphagia Receiving Esophageal Stents

Concerns remain over the ability to stent across of the lower esophageal sphincter (LES) for esophageal adenocarcinoma and the effects of gastroesophageal (GE) reflux. Thus, the aim of this study was to demonstrate minimal quality-of-life (QOL) side effects in patients undergoing esophageal stenting across the LES. An Institutional Review Board–approved prospective clinical trial evaluated the results of the Gastrointestinal Symptom questionnaire that includes a validated GE reflux disease (GERD) assessment (GERD-HRQL) and a dysphagia assessment. Consecutive patients were enrolled in this clinical trial, with 81 per cent male, 19 per cent female, median age of 62 years, with adenocarcinoma of the GE junction as their diagnosis. The median dysphagia score was 3 (only liquids can be tolerated) prestent and was improved to a median score of 0 (ability to eat all foods) poststent ( P = 0.01). The median GERD score was 0 (none) prestent and did not change with a median score of 0 (none) poststent ( P = 0.2). All GERD-related questions were unchanged prestent and poststent in all categories, specifically: frequency of GERD, time of day of reflux, pain behind breastbone, and pain medications. There was also no difference in regurgitation frequency (median prestent 1 vs poststent 0, P = 0.08), texture (prestent 2 [semisolid] vs poststent 1 [liquid]). There was only a statistical change in the ability to belch (prestent 0 [no ability] to poststent 1 [ability]), P = 0.02) and the ability to vomit. Esophageal stenting across the GE junction for dysphagia relief in esophageal malignancies does not adversely effect a patient's QOL in regard to reflux-related symptoms.

Bleeding after expandable nitinol stent placement in patients with esophageal and upper gastrointestinal obstruction: incidence, management, and predictors

BACKGROUND

Placement of self-expandable nitinol stents is useful for the treatment of esophageal and upper gastrointestinal (GI) obstruction. However, complications such as stent migration, tumor overgrowth, and bleeding occur. Although stent migration and tumor overgrowth are well documented in previous studies, the occurrence of bleeding has not been fully evaluated.

PURPOSE

To evaluate the incidence, management strategies, and predictors of bleeding after placement of self-expandable nitinol stents in patients with esophageal and upper GI obstruction.

MATERIAL AND METHODS

We retrospectively reviewed the medical records and results of computed tomography and endoscopy of 1485 consecutive patients with esophageal and upper GI obstructions who underwent fluoroscopically guided stent placement.

RESULTS

Bleeding occurred in 25 of 1485 (1.7%) patients 0 to 348 days after stent placement. Early stent-related bleeding occurred in 10 patients (40%) and angiographic embolization was used for 5/10. Late bleeding occurred in 15 patients (60%) and endoscopic hemostasis was used for 7/15. Twenty-two of 25 (88%) patients with bleeding had received prior radiotherapy and/or chemotherapy.

CONCLUSION

Bleeding is a rare complication after placement of expandable nitinol stents in patients with esophageal and upper GI obstruction, but patients with early bleeding may require embolization for control. Care must be exercised on placing stents in patients who have received prior radiotherapy or chemotherapy.

Interventions for dysphagia in oesophageal cancer

BACKGROUND

Most patients with oesophageal and gastro-oesophageal carcinoma are diagnosed at an advanced stage and require palliative intervention. Although there are many kinds of interventions, the optimal one for the palliation of dysphagia remains unclear. This review updates the previous version published in 2009.

OBJECTIVES

The aim of this review was to systematically analyse and summarise the efficacy of different interventions used in the palliation of dysphagia in primary oesophageal and gastro-oesophageal carcinoma.

SEARCH METHODS

To find new studies for this updated review, in January 2014 we searched, according to the Cochrane Upper Gastrointestinal and Pancreatic Diseases model, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE, EMBASE and CINAHL; and major conference proceedings (up to January 2014).

SELECTION CRITERIA

Only randomised controlled trials (RCTs) were included in which patients with inoperable or unresectable primary oesophageal cancer underwent palliative treatment. Different interventions like 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, were included. 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

Data collection and analysis were performed in accordance with the methods of the Cochrane Upper Gastrointestinal and Pancreatic Diseases Review Group.

MAIN RESULTS

We included 3684 patients from 53 studies. SEMS insertion was safer and more effective than plastic tube insertion. Thermal and chemical ablative therapy provided comparable dysphagia palliation but had an increased requirement for re-interventions and for adverse effects. Anti-reflux stents provided comparable dysphagia palliation to conventional metal stents. Some anti-reflux stents might have reduced gastro-oesophageal reflux and complications. Newly-designed double-layered nitinol (Niti-S) stents were preferable due to longer survival time and fewer complications compared to simple Niti-S stents. Brachytherapy might be a suitable alternative to SEMS in providing a survival advantage and possibly a better quality of life, and might provide better results when combined with argon plasma coagulation or external beam radiation therapy.

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. Some anti-reflux stents and newly-designed stents lead to longer survival and fewer complications compared to conventional stents. Combinations of brachytherapy with self-expanding metal stent insertion or radiotherapy are preferable due to the reduced requirement for re-interventions. Rigid plastic tube insertion, dilatation alone or in combination with other modalities, and chemotherapy alone are not recommended for palliation of dysphagia due to a high incidence of delayed complications and recurrent dysphagia.

How are palliative care cancer populations characterized in randomized controlled trials? A literature review

CONTEXT

The difficulties in defining a palliative care patient accentuate the need to provide stringent descriptions of the patient population in palliative care research.

OBJECTIVES

To conduct a systematic literature review with the aim of identifying which key variables have been used to describe adult palliative care cancer populations in randomized controlled trials (RCTs).

METHODS

The data sources used were MEDLINE (1950 to January 25, 2010) and Embase (1980 to January 25, 2010), limited to RCTs in adult cancer patients with incurable disease. Forty-three variables were systematically extracted from the eligible articles.

RESULTS

The review includes 336 articles reporting RCTs in palliative care cancer patients. Age (98%), gender (90%), cancer diagnosis (89%), performance status (45%), and survival (45%) were the most frequently reported variables. A large number of other variables were much less frequently reported.

CONCLUSION

A substantial variation exists in how palliative care cancer populations are described in RCTs. Few variables are consistently registered and reported. There is a clear need to standardize the reporting. The results from this work will serve as the basis for an international Delphi process with the aim of reaching consensus on a minimum set of descriptors to characterize a palliative care cancer population.

Stents for benign and malignant esophageal strictures

This paper presents commentaries on endotherapy for esophageal perforation/leaks; treatment of esophageal perforation; whether esophageal stents should be used for treating benign esophageal strictures; what determines the optimal stenting period in benign esophageal strictures/leaks; how to choose an esophageal stent; how a new fistula secondary to an esophageal stent should be treated; which strategy should be adopted when a fistula of a cervical anastomosis occurs; intralesional steroids for refractory esophageal strictures; balloon and bougie dilators for esophageal strictures and predictors of response to dilation; whether refractory strictures from different etiologies respond differently to endotherapy; surgical therapy of benign esophageal strictures; and whether stenoses following severe esophageal burns should be treated by esophageal resection or esophageal bypass.

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.

Improvement of quality of life and survival using self-expandable metal stent placement for severe malignant stenosis of the gastric body: a case report

INTRODUCTION

Advanced gastric carcinoma often decreases quality of life because of upper gastrointestinal tract stenosis. Self-expandable metal stents have been thought to be an effective, minimally invasive treatment for stenosis. However, the effectiveness of self-expandable metal stent placement for carcinomatous stenosis of the gastric body and antrum has not been clarified, and there have been few reports of such cases.

CASE PRESENTATION

A 74-year-old Japanese woman developed stenosis of the gastric body and antrum caused by advanced gastric cancer during first-line chemotherapy. She developed weight loss and poor nutrition due to inadequate intake. Self-expandable metal stent placement for stenosis of the gastric body and antrum ameliorated her symptoms rapidly and improved her general condition and quality of life. Eight days after self-expandable metal stent placement, second-line chemotherapy could be administered safely. Oral intake and nutritional status were maintained for 117 days after self-expandable metal stent placement, and she died of gastric cancer 176 days after self-expandable metal stent placement and initiation of second-line chemotherapy.

CONCLUSIONS

Self-expandable metal stent placement for carcinomatous stenosis in the gastric body and antrum could be an effective therapeutic strategy for patients with inadequate oral uptake. It may provide rapid improvement of the patient's general condition and oral intake with minimal complications, comparatively long-term symptom relief, and a survival benefit by allowing second-line chemotherapy.

The evaluation of esophageal stenting complications in palliative treatment of dysphagia related to esophageal cancer

Background

Esophageal cancer is the seventh-most frequent cause of cancer-related deaths and it is usually diagnosed at an inoperable stage. In palliative treatment, endoscopic and non-endoscopic methods are applied to reduce dysphagia in patients with neoplastic esophageal obstruction. Because of severe complications, non-endoscopic treatment (surgery, radiotherapy, brachytherapy and chemotherapy) is applied rarely. Within the endoscopic methods, only the use of endoprostheses yields long-term effects. The aim of this study was to evaluate the safety and efficacy of implantation of self-expandable esophageal stents in palliative treatment of dysphagia related to esophageal cancer.

Material/Methods

A total number of 46 patients (41 males and 5 females) were qualified to palliative implantation of coated self-expandable stent. The mean age of the patients was 67 years (from 51 to 78 years). In all patients, Evolution-type coated self-expandable stents were used. In all cases, 24 hours after the implantation, radiological examination was performed to assess the stent location.

Results

Severe, possibly life-threatening, complications constituted 28% of all the complications and occurred in 9% of the patients. Less severe complications occurred in 17% of the observed patients and were not life-threatening.

Conclusions

In patients with neoplastic esophageal stenosis, stenting with coated, self-expandable nitinol prostheses is a safe, effective and fast method of palliative dysphagia treatment.

Antireflux stents versus conventional stents for management of stenosis of distal esophageal and gastric cardia: An systematic review

AIM: To evaluate the efficacy and safety of anti-reflux stents versus conventional stents for the management of stenosis of distal esophageal and gastric cardia in patients with esophageal cancer.

METHODS: Randomized controlled trials (RCTs)that evaluated anti-reflux stents versus conventional stents in the treatment of stenosis of distal esophageal and gastric cardia in patients with esophageal cancer were electronically searched from the PubMed (1978-2011), EMbase (1966-2011), CBM (1978-2011), Cochrane Library (2011, Issue 11) and CNKI (1979-2011) databases, and relevant published and unpublished data and their references (either in English or Chinese), were also searched manually. The data were extracted and the methodological quality of the incorporated studies was evaluated by two reviewers independently. The RevMan 5.1 software was used for meta-analysis.

RESULTS: Five RCTs involving 234 patients were included. Meta-analysis showed that anti-reflux stents and conventional stents had no significant differences in terms of the incidences of pain (RR = 0.41, 95% CI: 0.16, 1.06), stent migration (RR = 1.02, 95% CI: 0.50, 2.11), obstruction (RR = 1.02, 95% CI: 0.52, 1.99), gastroesophageal reflux (RR = 1.68, 95% CI: 0.52, 5.48), bleeding (RR = 1.39, 95% CI: 0.44, 4.40), and perforation of the esophagus and stomach (RR = 0.70, 95% CI: 0.25, 2.00).

CONCLUSION: The overall curative efficacy of anti-reflux stents for the stenosis of distal esophageal and gastric cardia in patients with esophageal cancer is not better than that of conventional stents. Because of the generally low quality and a small number of studies in the incorporated research, the above conclusion remains to be validated by carrying out more randomized controlled trials with multiple center samples and enough follow-up time.

Double layered self-expanding metal stents for malignant esophageal obstruction, especially across the gastroesophageal junction

AIM: To evaluate the clinical outcomes of double-layered self-expanding metal stents (SEMS) for treatment of malignant esophageal obstruction according to whether SEMS crosses the gastroesophageal junction (GEJ).

METHODS: Forty eight patients who underwent the SEMS insertion for malignant esophageal obstruction were enrolled. Patients were classified as GEJ group (SEMS across GEJ, 18 patients) and non-GEJ group (SEMS above GEJ, 30 patients) according to SEMS position. Double layered (outer uncovered and inner covered stent) esophageal stents were placed.

RESULTS: The SEMS insertion and the clinical improvement were achieved in all patients in both groups. Stent malfunction occurred in seven patients in the GEJ group and nine patients in the non-GEJ group. Tumor overgrowth occurred in five and eight patients, respectively, food impaction occurred in one patient in each group, and stent migration occurred in one and no patient, respectively. There were no significant differences between the two groups. Reflux esophagitis occurred more frequently in the GEJ group (eight vs five patients, P = 0.036) and was controlled by proton pump inhibitor. Aspiration pneumonia occurred in zero and five patients, respectively, and tracheoesophageal fistula occurred in zero and two patients, respectively.

CONCLUSION: Double-layered SEMS are a feasible and effective treatment when placed across the GEJ for malignant esophageal obstruction. Double-layered SEMS provide acceptable complications, especially migration, although reflux esophagitis is more common in the GEJ group.

Palliation of malignant upper gastrointestinal obstruction with self-expandable metal stent

OBJECTIVE

To assess the technical success, ability to eat, complications and clinical outcomes of patients with self-expandable metal stent (SEMS) placed for malignant upper gastrointestinal (GI) obstruction.

MATERIALS AND METHODS

Data was collected retrospectively on patients who underwent SEMS placement for palliation of malignant upper GI obstruction by reviewing hospital charts from June 1998 to May 2011. Main outcome measurements were technical success, gastric outlet obstruction scoring system (GOOSS) score before and after treatment, complications, and survival.

RESULTS

A total of 82 patients underwent SEMS placement with malignant upper GI obstruction. The initial SEMS placement was successful in 77 patients (93.9%). The mean GOOSS score was 0.56 before stenting and 1.92 (p < 0.001) after treatment. Complications arose in 12 patients (14.6%): stent migration in 1 patient (1.2%), perforation in 1 (1.2%), and obstruction of stent due to tumor ingrowth in 10 (12.2%). The median survival time after stenting was 52 days (6-445).

CONCLUSION

SEMS placement is an effective and safe treatment for palliation of malignant upper GI obstruction. It provides lasting relief in dysphagia and improves the QOL of patients.

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.

Technical feasibility and safety of a new, implantable reflux control system to prevent gastroesophageal reflux in patients with stents placed through the lower esophageal sphincter (with video)

BACKGROUND

When an esophageal stent is placed through the lower esophageal sphincter (LES), gastroesophageal reflux symptoms may persist despite high-dose proton pump inhibitor therapy. A recently developed, short segment, uncovered nitinol stent with a tricuspid-like valve can be placed inside a previously placed esophageal stent.

OBJECTIVE

To evaluate the technical feasibility and safety of a reflux control system (RCS) in distally placed esophageal stents.

DESIGN

A prospective case series.

SETTING

Two tertiary-care referral centers.

PATIENTS

This study involved 10 patients who had an "open" stent placed through the LES and 1 patient with severe bile reflux after esophagojejunostomy.

INTERVENTION

Placement of an RCS with fluoroscopic and (in selected cases) endoscopic guidance, from April to October 2010.

MAIN OUTCOME MEASUREMENTS

Technical success of RCS placement and complications.

RESULTS

Placement of an RCS was successful on the first attempt in all patients; complete expansion to the wall of the host stent was confirmed by fluoroscopy in all cases. In 3 patients, the host stent migrated in <1 month with the RCS still inside. In 8 patients, the RCS was in place for a median of 134 days (range 33-225 days). Three patients died because of malignant disease progression. Eight RCSs were removed endoscopically, together with the host stent without complications. RCS migration did not occur.

LIMITATIONS

Small number of patients, nonrandomized design, lack of pH measurements.

CONCLUSION

Placement of an RCS in a host stent is technically feasible and safe. An RCS can be considered in symptomatic patients with open esophageal stents to prevent gastroesophageal reflux.

Endoscopic management of difficult or recurrent esophageal strictures

Esophageal strictures are a common problem in gastroenterological practice. In general, the management of malignant or benign esophageal strictures is different and requires a different treatment approach. In daily clinical practice, stent placement is a commonly used modality for the palliation of incurable malignant strictures causing dysphagia, whereas, if available, intraluminal brachytherapy can be considered in patients with a good performance status. Recurrent dysphagia frequently occurs in malignant cases. In case of tissue in- or overgrowth, a second stent is placed. If stent migration occurs, the stent can be repositioned or a second (preferably partially covered) stent can be placed. Food obstruction of the stent lumen can be resolved by endoscopic cleansing. The cornerstone of the management of benign strictures is still dilation therapy (Savary-Gilliard bougie or balloon). There are a subgroup of strictures that are refractory or recur and an alternative approach is required. In order to prevent stricture recurrence, steroid injections into the stricture followed by dilation can be considered. In case of anastomotic strictures or Schatzki rings, incisional therapy is a safe method in experienced hands. Temporary stent placement is a third option before considering self-bougienage or surgery as a salvage treatment. In this review, the most frequently used endoscopic treatment modalities for malignant and benign stricture management will be discussed based on the available literature, and some practical information for the management in daily clinical practice will be provided.

Enteral stents

The American Society for Gastrointestinal Endoscopy (ASGE) Technology Committee provides reviews of existing, new, or emerging endoscopic technologies that have an impact on the practice of GI endoscopy. Evidence-based methodology is used, with a MEDLINE literature search to identify pertinent clinical studies on the topic and a MAUDE (U.S. Food and Drug Administration Center for Devices and Radiological Health) database search to identify the reported complications of a given technology. Both are supplemented by accessing the "related articles" feature of PubMed and by scrutinizing pertinent references cited by the identified studies. Controlled clinical trials are emphasized, but in many cases, data from randomized, controlled trials are lacking. In such cases, large case series, preliminary clinical studies, and expert opinions are used. Technical data are gathered from traditional and Web-based publications, proprietary publications, and informal communications with pertinent vendors. Technology Status Evaluation Reports are drafted by 1 or 2 members of the ASGE Technology Committee, reviewed and edited by the committee as a whole, and approved by the Governing Board of the ASGE. When financial guidance is indicated, the most recent coding data and list prices at the time of publication are provided. For this review, the MEDLINE database was searched through August 2010 for articles related to enteral, esophageal, duodenal, and colonic stents. Technology Status Evaluation Reports are scientific reviews provided solely for educational and informational purposes. Technology Status Evaluation Reports are not rules and should not be construed as establishing a legal standard of care or as encouraging, advocating, requiring, or discouraging any particular treatment or payment for such treatment.

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.

Expandable stents for malignant esophageal disease

Esophageal cancer is diagnosed in about 400,000 patients each year worldwide, and its incidence is increasing faster than that of any other malignancy. This makes it the ninth most common malignancy and sixth on the list of cancer mortality causes. Most patients with esophageal cancer present at a stage that is too advanced for curative therapy, and many die within a few months. Treatment of dysphagia is the main goal of palliative care in more than 50% of incurable cases. Although many different palliative options for malignant dysphagia are available, expandable stent placement is the most commonly performed treatment modality.

Expandable stents for benign esophageal disease

Partially covered self-expandable esophageal stents have been associated with unacceptable complications when used for benign esophageal disorders. With the introduction of removable or potentially removable fully covered stents and biodegradable stents, interest in using expandable stents for benign indications has been revived. Although expandable stents can offer a minimally invasive alternative to surgery, they can be associated with serious complications; hence, this approach should be considered in carefully selected patients, preferably on a protocol basis.

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.

Quality of life in patients with esophageal stenting for the palliation of malignant dysphagia

Incidence of esophageal cancer (EC) is rising more rapidly in the Western world than that of any other cancer. Despite advances in therapy, more than 50% of patients have incurable disease at the time of presentation. This precludes curative treatment and makes palliative treatment a more realistic option for most of these patients. Dysphagia is the predominant symptom in more than 70% of patients with EC and although several management options have been developed in recent years to palliate this symptom, the optimum management is not established. Self-expanding metal stents (SEMS) are a well-established palliation modality for dysphagia in such patients. Health-related quality of life (HRQoL) is becoming a major issue in the evaluation of any therapeutic or palliative intervention. To date, only a few published studies can be found on Medline examining HRQoL in patients with advanced EC treated with SEMS implantation. The aim of this study was to review the impact on HRQoL of SEMS implantation as palliative treatment in patients with EC. All Medline articles regarding HRQoL in patients with advanced EC, particularly those related to SEMS, were reviewed. In most studies, relief of dysphagia was the only aspect of HRQoL being measured and SEMS implantation was compared with other palliative treatments such as brachytherapy and laser therapy. SEMS insertion provides a swift palliation of dysphagia compared to brachytherapy and no evidence was found to suggest that stent implantation is different to laser treatment in terms of improving dysphagia, recurrent dysphagia and better HRQoL, although SEMS insertion has a better technical success rate and also reduces the number of repeat interventions.

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.

The use of self-expanding stents in esophageal and gastroesophageal junction cancer palliation: a meta-analysis and meta-regression analysis of outcomes

BACKGROUND

The objective of this study was to examine the impact of self-expanding stents versus locoregional treatment modalities in the setting of esophageal cancer palliation.

METHODS

The present meta-analysis pooled the effects of outcomes of 1,027 patients enrolled in 16 randomized controlled trials.

RESULTS

The meta-analysis revealed an advantage to the use of stents compared to locoregional modality treatments with respect to the number of patients requiring reinterventions, although the latter treatment arm had a higher 1-year survival. No difference was observed between the use of the antireflux stents and conventional stents in relieving reflux. Previous chemoradiotherapy had no impact on complications, procedural deaths, and overall patient survival. Differences in outcomes among stents were minimal.

CONCLUSIONS

Conventional self-expanding stents and anti-reflux stents are equally effective. Although the risk difference for 1-year survival favoured locoregional palliative treatment modalities, the latter were associated with a higher number of patients requiring reintervention.

Esophageal stents for the palliation of malignant dysphagia and fistula recurrence after esophagectomy

BACKGROUND

Despite advances in staging methods, surgical techniques, and adjuvant treatment, recurrent cancer after esophagectomy is a major cause of morbidity and mortality.

OBJECTIVE

Our purpose was to investigate the safety and efficacy of a self-expandable metal stent (SEMS) in patients with dysphagia or fistula caused by recurrent cancer after esophagectomy.

DESIGN

Prospective, observational study with standardized treatment and follow-up.

SETTING

Single university center.

PATIENTS

In 81 patients with recurrent cancer after previous surgical esophagectomy, 100 esophageal SEMSs were inserted for dysphagia (n = 66) or fistula formation (n = 15).

INTERVENTIONS

Stent placement.

MAIN OUTCOME MEASUREMENTS

Technical and functional outcome, complications, and survival.

RESULTS

The SEMSs restored luminal patency in 65 (98%) of 66 patients and sealed malignant fistulae in 14 (93%) of 15 patients. Stent dysfunction occurred in 24 (30%) of 81 patients. They all were successfully managed by subsequent endoscopic intervention. After stent placement, a total of 16 complications were observed. Major complications occurred in 9 (11%) of 81 patients, mild complications occurred in 7 (9%) of 81 patients. The overall 30-day mortality rate after stent insertion was 25%. Progression of the disease resulted in death after a median interval of 70 days (range 1 day to 91 months).

LIMITATIONS

Nonrandomized design.

CONCLUSIONS

SEMS placement in recurrent esophageal cancer after surgical resection offers adequate palliation by relieving dysphagia and sealing off esophageal respiratory fistulae. Therefore, in these patients who have a relatively short life expectancy, SEMS placement should be considered the treatment of choice.

Long-term clinical outcomes of self-expanding metal stents for treatment of malignant gastroesophageal junction obstructions and prognostic factors for stent patency: effects of anticancer treatments

BACKGROUND

Self-expanding metal stent has emerged as an effective treatment option for malignant gastroesophageal junction obstruction. However, data on the clinicopathologic factors associated with stent patency are still lacking.

AIM

To investigate the long-term clinical outcomes and prognostic factors, including treatment modalities, affecting stent patency in patients with malignant gastroesophageal junction obstruction given self-expanding metal stent insertions.

METHODS

A total 89 patients who underwent self-expanding metal stent insertion for malignant gastroesophageal junction obstruction were enrolled. We analysed technical and clinical success rates, complications, and prognostic factors affecting stent patency.

RESULTS

Self-expanding metal stent insertion was successful in all patients and clinical improvement was achieved in 93.3%. Stent malfunction occurred in 32.9% of patients. The median overall survival time and stent patency time were 143 (95% CI: 99-187) and 190 days (95% CI: 108-272), respectively. In multivariate analysis, radiation therapy after stent placement significantly prolonged stent patency (OR: 0.221; 95% CI: 0.055-0.884; p=0.033). A higher migration rate was observed in those patients given chemotherapy after covered self-expanding metal stent placement (no anticancer treatment: 10.0%, chemotherapy: 42.9%, chemoradiation therapy: 9.1%, p=0.042).

CONCLUSIONS

Self-expanding metal stent is a feasible and effective treatment for malignant gastroesophageal junction obstruction. Radiation therapy after stent placement significantly prolongs overall stent patency and chemotherapy increases the migration rate of covered stents.

Antireflux stent versus conventional stent in the palliation of distal esophageal cancer. A randomized, multicenter clinical trial

OBJECTIVE

Patients with incurable distal esophageal or cardia cancer often need palliative stenting to relieve their dysphagia but stents passing through the cardia can cause reflux and aspiration, leading to a reduced health-related quality of life (HRQL). This study addressed the hypothesis that antireflux stenting improves HRQL compared to conventional stenting.

MATERIAL AND METHODS

In a single-blind, multicenter, randomized trial in patients with inoperable esophageal or cardia cancer requiring palliative stenting passing through the cardia, 65 patients were stented. Patients received either an antireflux stent (Esophageal Z-Stent with Dua antireflux valve; n = 28) or a conventional stent (Esophageal Z-stent, Ultraflex or Wallstent; n = 37). Validated questionnaires (European Organization for Research and Treatment of Cancer QLQ-C30 and QLQ-OES18) were used to collect information on HRQL at baseline and 1 and 3 months after stenting. Main outcome measurements were differences in HRQL scores between baseline and 1 and 3 months after stenting.

RESULTS

Scores for most aspects of HRQL were similar in the two groups, and no statistically significant differences were found. Some general symptoms however showed clinically relevant improvement in the antireflux stent group, while esophageal-specific symptoms such as dysphagia seemed clinically better, and symptoms of reflux were clinically reduced in the conventional stent group but not in the antireflux stent group.

CONCLUSION

This study, although limited in size, provided no obvious support for using the antireflux stent in preference to the conventional stent in the palliation of distal esophageal or cardia cancer from an HRQL perspective.

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.

Clinical outcomes of using a conservative approach of late esophageal stent placement in palliation of malignant dysphagia

BACKGROUND

Esophageal stents have been used as first-line treatment for palliation of malignant dysphagia, but this is associated with significant complications. The present study evaluated clinical outcomes and survival in patients with malignant dysphagia with esophageal stent placement who did not respond to prior chemoradiation or endoscopic modalities.

PATIENTS AND METHODS

Patients with esophageal cancer, who had esophageal stents, were retrospectively reviewed from the electronic medical records. The patient demographics, type of stent placed, dysphagia scores, stent-related complications, and survival were recorded.

RESULTS

Thirty-five patients with esophageal cancer received a total of 41 stents. There were 25 males and 10 females with mean age of 69.8 years. Twenty-two patients had esophageal adenocarcinoma, ten patients had squamous cell carcinoma, and three had poorly differentiated tumor. Esophageal malignancy was early stage (I, II) in 10 patients and advanced (III, IV) in 24 patients. Three patients had upper esophageal involvement, eight patients had mid-esophageal involvement; distal esophageal malignancy was present in 24 patients with 10 patients having gastroesophageal junction involvement. Six patients presented with tracheoesophageal fistula. Nine patients had prior esophagectomy. Thirty-three patients had chemoradiation, and 32 patients had other endoscopic therapies previously. Twelve of the 35 (33%) patients developed stent-related complications; nine patients had dysphagia due to various causes; one patient each developed aspiration, intractable hiccups, and intractable vomiting after stent placement, respectively. Nine patients underwent a repeat esophagogastroduodenoscopy. Development of stent-related complications was not significantly associated with poor survival.

CONCLUSIONS

The clinical outcomes for patients with esophageal stent placement for malignant dysphagia after chemoradiation and other endoscopic treatments is not worse than that reported in patients where esophageal stent placement was used as first-line treatment.

Role of esophageal stents in benign and malignant diseases

These recommendations provide an evidence-based approach to the role of esophageal stents in the management of benign and malignant diseases. These guidelines have been developed under the auspices of the American College of Gastroenterology and its Practice Parameters Committee and approved by the Board of Trustees. The following guidelines are based on a critical review of the available scientific literature on the topic identified in Medline and PubMed (January 1992-December 2008) using search terms that included stents, self-expandable metal stents, self-expandable plastic stents, esophageal cancer, esophageal adenocarcinoma, esophageal squamous cell carcinoma, esophageal stricture, perforations, anastomotic leaks, tracheoesophageal fistula, and achalasia. These guidelines are intended for use by health-care providers and apply to adult, but not pediatric, patients. As with other practice guidelines, these guidelines are not intended to replace clinical judgment but rather to provide general guidelines applicable to the majority of patients. Clinicians need to integrate recommendations with their own clinical judgment, and with individual patient circumstances, values, and preferences. They are intended to be flexible, in contrast to standards of care, which are inflexible policies designed to be followed in every case. Specific recommendations are based on relevant published information. The quality of evidence and strength of recommendations have been assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system, which is a system that has been adopted by multiple national and international societies. The GRADE system is based on a sequential assessment of quality of evidence, followed by assessment of the balance between benefits vs. downsides (harms, burden, and costs) and subsequent judgment regarding the strength of recommendation.