Comparison of fully-covered vs partially covered self-expanding metallic stents for palliative treatment of inoperable esophageal malignancy: a systematic review and meta-analysis

Novel nutrition strategies in gastric and esophageal cancer

INTRODUCTION

Advances in treatment strategies for gastric and esophageal cancer have led to improved long-term outcomes, however the local and systemic effects of the primary tumor, neoadjuvant therapies and surgery, result in specific nutritional challenges. Comprehensive nutritional evaluation and support represents a core component of multidisciplinary holistic care for this patient population.

AREAS COVERED

We provide a detailed overview of nutritional challenges in gastric and esophageal cancer, with a focus on malignant obstruction, preoperative optimization and survivorship. We discuss current management strategies and evidence base, and describe future therapeutic targets.

EXPERT OPINION

Data to support the optimal management of malignant dysphagia and obstruction, particularly regarding patient reported outcomes, is currently lacking. The advantages of nutritional optimization in the pre- and immediate postoperative phase are well described, but further research is needed to inform optimal personalised strategies. Emerging data regarding the physiologic regulation of appetite and body weight have provided key insights and informed the development of novel therapeutic targets to improve nutritional status among patients undergoing treatment for oesophageal and gastric cancer.

Successful Treatment of an Esophago-Tracheobronchial Fistula Using Double Stenting to Correct Initial Stent Migration: A Case Report and Literature Review

Background: Esophago-tracheobronchial fistula is a severe and often fatal complication in patients with advanced esophageal cancer, requiring prompt attention. The standard treatment involves the placement of a covered stent, which is relatively simple to perform and effectively seals the fistula. However, stent migration remains a common issue, highlighting the need for improved methods to prevent it. Case Presentation: We developed an innovative double stenting method approach utilizing two types of metal stents for cases where conventional stenting led to early stent dislodgement. This technique combines the benefits of uncovered and fully covered stents while minimizing their limitations. Furthermore, it is straightforward and adaptable. In two cases treated at our facility, this method successfully maintained complete fistula coverage until the patients' deaths, allowing them to consume food orally. Conclusions: Here, we describe the procedure in detail and discuss its significance, as our findings demonstrate the effectiveness of the double stenting technique.

Safety and efficacy of conventional compared to segmented esophageal fully covered self-expanding metal stents: a retrospective multicenter case-control study

BACKGROUND

Segmented self-expanding metal stents (SEMS) are an alternative to conventional unsegmented SEMS in the treatment of esophageal strictures. Due to their segmented design, they may adapt better to the surrounding structures making them less likely to migrate or cause trauma. We examined if there are clinically relevant differences between segmented and conventional esophageal SEMS in benign and malignant stenosis in terms of their functionality and safety.

PATIENTS AND METHODS

We performed a multicenter, retrospective case-control study of segmented and conventional SEMS implantations in esophageal stenosis. Outcome parameters were adverse events such as migration, occlusion, and severe complications (i.e., bleeding and perforation).

RESULTS

79 segmented SEMS were identified and compared to 79 conventional SEMS implantations. Groups were similar in terms of age, gender, and etiology. We observed 13.9% severe complications (SEMS-associated clinically significant bleeding or perforation) in the conventional SEMS group compared to 3.8% in the segmented SEMS group. This difference was statistically significant (p = 0.025). Rates of migration and occlusion were similar between both groups. Likewise, there was no significant difference in terms of short-term (30 days) clinical success.

CONCLUSION

In this first controlled analysis, segmented SEMS were associated with fewer severe clinical complications compared to conventional SEMS.

How to preserve the native or reconstructed esophagus after perforations or postoperative leaks: A multidisciplinary 15-year experience

BACKGROUND

Esophageal perforation or postoperative leak after esophageal surgery remain a life-threatening condition. The optimal management strategy is still unclear.

AIM

To determine clinical outcomes and complications of our 15-year experience in the multidisciplinary management of esophageal perforations and anastomotic leaks.

METHODS

A retrospective single-center observational study was performed on 60 patients admitted at our department for esophageal perforations or treated for an anastomotic leak developed after esophageal surgery from January 2008 to December 2023. Clinical outcomes were analyzed, and complications were evaluated to investigate the efficacy and safety of our multidisciplinary management based on the preservation of the native or reconstructed esophagus, when feasible.

RESULTS

Among the whole series of 60 patients, an urgent surgery was required in 8 cases due to a septic state. Fifty-six patients were managed by endoscopic or hybrid treatments, obtaining the resolution of the esophageal leak/perforation without removal of the native or reconstructed esophagus. The mean time to resolution was 54.95 ± 52.64 days, with a median of 35.5 days. No severe complications were recorded. Ten patients out of 56 (17.9%) developed pneumonia that was treated by specific antibiotic therapy, and in 6 cases (10.7%) an atrial fibrillation was recorded. Seven patients (12.5%) developed a stricture within 12 months, requiring one or two endoscopic pneumatic dilations to solve the problem. Mortality was 1.7%.

CONCLUSION

A proper multidisciplinary approach with the choice of the most appropriate treatment can be the key for success in managing esophageal leaks or perforations and preserving the esophagus.

What can the Interventional Endoscopist Offer in the Management of Upper Gastrointestinal Malignancies?

The therapeutic possibilities of endoscopy have rapidly increased in the last decades and now allow organ-sparing treatment of early upper gastrointestinal malignancy as well as an increasing number of options for symptom palliation. This review contains an overview of the interventional endoscopic procedures in upper gastrointestinal malignancies. It describes endoscopic treatment of early oesophageal and gastric cancers, and the palliative options in managing dysphagia and gastric outlet obstruction. It also provides an overview of the therapeutic possibilities of biliary endoscopy, such as retrograde stenting and radiofrequency biliary ablation. Endoscopic ultrasound-guided therapeutic options are discussed, including biliary drainage, gastrojejunostomy and coeliac axis block. To aid in clinical decision making, the procedures are described in the context of their indication, efficacy, risks and limitations.

Multisegmented esophageal fully covered self-expandable metal stent for palliation of malignant dysphagia: a prospective, multicenter feasibility and safety study

BACKGROUND AND AIMS

A novel multisegmented esophageal fully covered self-expandable metal stent (FCSEMS) was designed to reduce stent migration, which is seen in up to 30% of patients. The goal of this study was to evaluate the safety and efficacy of the multisegmented FCSEMS.

METHODS

This multicenter prospective study aimed to include 30 patients undergoing palliative stent placement. Efficacy, defined as technically successful stent placement and dysphagia scores, and safety, defined as the number of adverse events (AEs) and serious AEs (SAEs), were measured.

RESULTS

The study was prematurely terminated due to safety concerns after including 23 patients (mean ± standard deviation age, 72 ± 10 years; 78% male). Stent placement was technically successful in 21 patients (91%), and dysphagia scores had improved in all patients with successful stent placement. SAEs were reported in 16 (70%) patients. Stent-related mortality occurred in 3 patients (13%).

CONCLUSIONS

The multisegmented FCSEMS successfully treated malignant dysphagia. The study was prematurely terminated, however, because stent placement was associated with a relatively high SAE rate. (Clinical trial registration number: NCT04415463.).

A Successful Treatment of Broncho-Esophageal Fistula with Esophageal Stenting Using Direct Endoscopic Visualization

Broncho-esophageal fistula (BEF) is a severe yet relatively rare connection between the bronchus and esophagus usually caused by esophageal and pulmonary malignancies. We present a case report of a 49-year-old man diagnosed with terminal lung carcinoma who developed a BEF. The thoracic computed tomography scan detected a mass in the left bronchi that partially covers and disrupts the bronchial contour in certain regions and extends to the esophageal wall. After thoroughly evaluating alternative treatment approaches, we opt for the stenting procedure due to the advanced stage of the tumor and the significantly diminished quality of life. The treatment involves the use of a partially covered metal stent that is known to exhibit lower potential to migrate. The treatment is highly successful, resulting in a significant enhancement of the patient's quality of life, a lengthening in his survival, and the ability to pursue additional palliative treatment options. In contrast to the typical prosthesis implantation, our procedure uses a direct endoscopic visualization for the proximal deployment of a partially covered stent, offering a cost-effective and radiation-free alternative that can be particularly beneficial for BEF patients in facilities without radiology services.

The endoscopic management of oesophageal strictures

An oesophageal stricture refers to a narrowing of the oesophageal lumen, which may be benign or malignant. The cardinal feature is dysphagia, and this may result from intrinsic oesophageal disease or extrinsic compression. Oesophageal strictures can be further classified as simple or complex depending on stricture length, location, diameter, and underlying aetiology. Many endoscopic options are now available for treating oesophageal strictures including dilatation, injectional therapy, stenting, stricturotomy, and ablation. Self-expanding metal stents have revolutionised the palliation of malignant dysphagia, but oesophageal dilatation with balloon or bougienage remains first-line therapy for most benign strictures. The increase in endoscopic and surgical interventions on the oesophagus has seen more benign refractory oesophageal strictures that are difficult to treat, and often require advanced endoscopic techniques. In this review, we provide a practical overview on the evidence-based management of both benign and malignant oesophageal strictures, including a practical algorithm for managing benign refractory strictures.

An unconventional retrograde approach for self-expanding metallic stent delivery in oesophagus cancer palliation

Partially covered self-expanding metallic stents (SEMS) are the main recommendation for palliative treatment of malignant dysphagia. Delivering self-expanding metallic stents in stenosing oesophagus neoplasia's are often challenging due to the difficulty on passing a guide wire through the tumour. We describe a case in which the guidewire was only able to franchise the tumour retrogradely, after entering the gastric cavity through the percutaneous endoscopic gastrostomy orifice using an ultra slim scope.

Endoscopic Palliative Therapies for Esophageal Cancer

Endoscopic palliation of dysphagia for patients with inoperable esophageal cancer is complex, highly dependent on local expertise, and best done in a multidisciplinary fashion. Systemic therapy is the standard of care because it has been shown to improve survival. Esophageal stenting has traditionally been the most used endoscopic modality. Some modalities such as laser and photodynamic therapy are rarely used. There has been an increasing amount of data on cryotherapy, especially for patients with mild-to-moderate dysphagia on systemic chemotherapy. This article will discuss the latest evidence guiding the palliation of esophageal cancer.

Spontaneous Endoscopic Esophageal Stent Fracture Post-endoscopic Placement: A Case Report

Endoscopic esophageal stent (EES) placement is an important tool for the non-operative management of esophageal pathologies. A rare and infrequently reported complication of EES placement is stent fracture and subsequent migration of the broken fragments. We report a rare case of a spontaneous EES fracture from Pakistan four weeks following its placement for esophageal perforation management, and an uneventful endoscopic retrieval of the fractured stent pieces. The recommended guidelines from available, albeit limited, research literature are also discussed as part of this case report.

Best Practices in Esophageal, Gastroduodenal, and Colonic Stenting

Endoscopic stenting is an area of endoscopy that has witnessed noteworthy advancements over the last decade, resulting in evolving clinical practices among gastroenterologists around the world. Indications for endoscopic stenting have progressively expanded, becoming a frequent part of the management algorithm for various benign and malignant conditions of the gastrointestinal tract, from esophagus to rectum. In addition to expanded indications, continuous technological enhancements and development of novel endoscopic stents have resulted in an increased success of these approaches and, in some cases, allowed new applications. This review aimed to summarize best practices in esophageal, gastroduodenal, and colonic stenting.

Delayed bronchial obstruction following esophageal stent placement: A case report and review of the literature

Esophageal adenocarcinoma typically has a poor prognosis at the time of diagnosis. Consequently, palliation of symptoms is vital to disease management with a cornerstone for palliation being esophageal stent placement. Esophageal stents are associated with a variety of complications that may present immediately or long after stent placement is completed. In this report, we present a 58-year-old male who developed shortness of breath 4 months after metallic esophageal stent placement. After further evaluation with a chest radiograph and CT angiogram of the chest, the patient was found to have obstruction of the left mainstem bronchus secondary to mass effect from the esophageal stent. Airway compromise secondary to metallic esophageal stent placement typically occurs immediately after placement of the stent. There are only a few documented cases of this complication occurring at a delayed interval. This case clearly demonstrates this rare complication of esophageal stent placement in the setting of esophageal adenocarcinoma.

Efficacy and safety of self-expanding metal stents in patients with inoperable esophageal cancer: a real-life study

BACKGROUND

Dysphagia is the most frequent symptom in patients diagnosed with esophageal cancer. Self-expanding metal stents (SEMS) are the current palliative treatment of choice for dysphagia in patients with non-curable esophageal cancer. This study aimed to evaluate the efficacy and adverse events (AEs) of different types of SEMS for palliation of dysphagia.

METHODS

We performed a retrospective cohort study of patients with advanced esophageal cancer and SEMS placement for dysphagia palliation in a tertiary care center. The primary outcome was the clinical success defined as an improvement in dysphagia (reduction of at least 2 points in the Mellow-Pinkas scoring system for dysphagia) after SEMS placement.

RESULTS

Between January 1999 and May 2020, 295 patients with esophageal cancer were identified. Among them, 75 had a SEMS placement for dysphagia palliation. The mean age of the patients was 61.3 years (standard deviation: 13.4), 69 patients (92%) were men, and the mean Mellow-Pinkas scoring for dysphagia pre- and post-SEMS placement were 3.1 and 1.4 (change from baseline -1.7), respectively. Technical success and clinical success were achieved in 98.6% and 58.9%, respectively. AEs were identified in 35/75 patients (46.7%), and SEMS migration was the most frequent AE in 22/75 patients (29.3%). There were no significant differences in improvement in dysphagia (p = 0.054), weight changes (p = 0.78), and AE (p = 0.73) among fully covered SEMS (fc-SEMS) and partially covered SEMS (pc-SEMS). The median follow-up was 89 days (interquartile range: 29-221).

CONCLUSION

SEMS placement was associated with a rapid improvement in dysphagia, high technical success, and a modest improvement in dysphagia with no major AE among fc-SEMS and pc-SEMS.

Optimal Management of Dysphagia in Patients with Inoperable Esophageal Cancer: Current Perspectives

The majority of patients with esophageal cancer are diagnosed at an advanced, incurable stage. Palliation of symptoms, specifically dysphagia, is a crucial component to improve quality of life and optimize nutritional status. Despite multiple available treatment modalities, there is not one accepted or recommended to be the preferred treatment option. Palliative management is often decided by a multidisciplinary team considering factors including local availability, preference, patient life expectancy, and symptom severity. Systemic therapies such as chemotherapy are the most commonly used palliative modalities. Oncologists are most familiar with radiation for dysphagia palliation, especially for advanced metastatic cancer patients with good performance status. One common approach used by endoscopist is self-expandable metal stents. This is preferred for patients with short-term survival and poor functional status as it provides rapid relief of dysphagia. Cryotherapy is a relatively new endoscopic ablative modality and appears to be a promising option for dysphagia palliation, but more data is needed for wider adoption. This review summarizes the current literature on endoscopic and non-endoscopic treatment options for malignant dysphagia.

Benign thyroid disease and the risk of breast cancer: An updated systematic review and meta-analysis

Background

The correlation between benign thyroid disease (BTD) and breast cancer (BC) has long been discussed. However, the definite relationship and potential mechanism between them are still disputed. The current meta-analysis aimed at performing a comprehensive assessment of the relationship between different types of benign thyroid disease and the risk of breast cancer, furthermore, assessing whether benign thyroid disease exerts an influence on the aggressiveness of breast cancer.

Method

A systematic literature search (PubMed, Web of Science, MEDLINE, and Embase databases) identified studies to evaluate the correlation between BTD and BC risk. Data were analyzed using version 16.0 STATA software, including the odds ratio (OR) and its corresponding 95% confidence intervals (CIs). Publication bias and quality assessment were conducted for the included studies.

Result

Overall, 18 studies involving 422,384 patients with BTD were incorporated. The outcome showed that autoimmune thyroiditis (OR: 2.56, 95%CI: 1.95-3.37, I2 = 0.0%, p=0.460), goiter (OR: 2.13, 95%CI: 1.19-3.79, I2 = 80.6%, p=0.000), and Graves' disease (OR: 5.01, 95%CI: 1.49-16.82, I2 = 0.0%, p=0.358) was connected with a higher risk of BC. Both hypothyroidism (OR: 0.82, 95%CI: 0.64-1.04, I2 = 85.0%, p=0.000) and hyperthyroidism (OR: 1.07, 95%CI: 0.93-1.24, I2 = 24.9%, p=0.206) had no significant association with the risk of BC. Additionally, the pooled analysis showed no apparent correlation between BTD and aggressiveness of BC. However, subgroup analysis indicated a positive relationship between BTD and aggressiveness of BC in the Europe subgroup (HR: 2.05, 95%CI: 1.32-3.17, I2 = 86.4%, p=0.000).

Conclusion

Autoimmune thyroiditis, goiter, and Graves' disease are connected with an increased risk of BC. Furthermore, subgroup analysis suggested that BTD increases the aggressiveness of BC in the European population geographically. Nevertheless, further research is needed to prove these discoveries.

Hypothyroidism has a protective causal association with hepatocellular carcinoma: A two-sample Mendelian randomization study

Objective

Observational studies suggest an association between hypothyroidism and the risk of hepatocellular carcinoma (HCC), but the causality and direction of these effects are still inconclusive. We aim to test whether hypothyroidism is causally associated with the risk of HCC by using Mendelian randomization (MR) analysis.

Methods

Single-nucleotide polymorphisms (SNPs) associated with hypothyroidism were screened via a genome-wide association study (GWAS) on 337,159 individuals of European descent (16,376 cases and 320,783 controls). The SNPs associated with thyroid-stimulating hormone (TSH) and free thyroxine (FT4) were selected from a GWAS of 72,167 individuals of European descent. Summary-level data for HCC (168 cases and 372,016 controls) were extracted from UK Biobank. An inverse-variance-weighted (IVW) method was used as the primary MR analysis. Sensitivity analyses were examined via MR-Egger regression, heterogeneity test, pleiotropy test, and leave-one-out sensitivity test. The assumption that exposure causes outcome was verified using the MR Steiger test.

Results

Two-Sample MR analysis showed inverse associations between genetically predicted hypothyroidism and HCC risk (OR = 0.997, 95% CI, 0.995-0.999; P = 0.016). There were no statistical indications of heterogeneity among instruments (P-het = 0.667). Across five MR methods, genetically predicted hypothyroidism shows a consistent correlation with HCC. The leave-one-out analysis indicated that no single SNP changed the overall estimate (P = 0.016). In addition, the MR Steiger test revealed that hypothyroidism was causal for HCC and not the opposite (P = 0.000). Finally, there was no evidence for a direct causal effect of TSH level and FT4 level on HCC risk.

Conclusion

Our results provide some that genetically determined hypothyroidism decreases the risk of HCC, although the size of the causal estimate is small. Further research is required to comprehend the mechanisms underlying this putative causative association, and follow-up clinical trials need to be conducted to establish whether inducing hypothyroidism could be beneficial for patients who are suffering from HCC. During future treatment of hypothyroidism, close attention to liver function may also be required to prevent a possible increased risk of HCC.

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

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

A Computational Framework Examining the Mechanical Behaviour of Bare and Polymer-Covered Self-Expanding Laser-Cut Stents

PURPOSE

Polymer covered stents have demonstrated promising clinical outcomes with improved patency rates compared to traditional bare-metal stents. However, little is known on the mechanical implication of stent covering. This study aims to provide insight into the role of a polymeric cover on the biomechanical performance of self-expanding laser-cut stents through a combined experimental-computational approach.

METHODS

Experimental bench top tests were conducted on bare and covered versions of a commercial stent to evaluate the radial, axial and bending response. In parallel, a computational framework with a novel covering strategy was developed that accurately predicts stent mechanical performance. Different stent geometries and polymer materials were also considered to further improve understanding on covered stent mechanics.

RESULTS

Results show that stent covering causes increased initial axial stiffness and up to 60% greater radial resistive force at small crimp diameters as the cover folds and self-contacts. The incorporation of a cover allows stent designs without interconnecting struts, thereby providing improved flexibility without compromising radial force. It was also shown that use of a stiffer PET polymeric covering material caused significant alterations to the radial and axial response, with the initial axial stiffness increasing six-fold and the maximum radial resistive force increasing four-fold compared to a PTFE-PU covered stent.

CONCLUSION

This study demonstrates that stent covering has a substantial effect on the overall stent mechanical performance and highlights the importance of considering the mechanical properties of the combined cover and stent.

A novel irradiation stent versus conventional irradiation stent for malignant dysphagia: A prospective randomized controlled trial

AIM

To evaluate whether a novel irradiation stent (NIS) could decrease the rate of recurrent dysphagia, compared to the conventional irradiation stent (CIS) in patients with malignant dysphagia.

MATERIALS AND METHODS

We performed an open-label randomized controlled trial of participants with malignant dysphagia. A total of 94 participants were parallelly allocated into the NIS group or the NIS group between April 2019 and April 2020. The primary endpoint was the rate of recurrent dysphagia. The secondary endpoints included technical success, clinical success, overall survival, and adverse events.

RESULTS

The technical success rate and the clinical success rate was 100.0% (47/47) in both groups. The median follow-up period was 189 days (range 14-422 days). Recurrent dysphagia was observed in 12.8% (6/47) of patients in the NIS group and 31.9% (15/47) in the CIS group (P = 0.026). Tissue/tumor growth occurred in 4 patients (8.5%) after NIS placement and 12 (25.5%) after CIS placement (P = 0.028). Stent migration occurred in 2 patients (4.3%) after NIS placement and 3 (6.4%) after CIS placement (P = 0.646). No food obstruction was found in both groups. The median overall survival was 177 days (95% confidence interval [CI] 139-214) in the NIS group and 168 days (95% CI 153-183) in the CIS group (P = 0.932). The incidence of severe adverse events was comparable between the two groups (21.3% vs. 17.0%, P = 0.600).

CONCLUSIONS

In patients with malignant dysphagia, compared with CIS, NIS could decrease the rate of tissue/tumor growth without increase the rate of stent migration and therefore decrease the rate of recurrent dysphagia.

Esophageal stenting for benign and malignant disease: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2021

MALIGNANT DISEASE

1: ESGE recommends placement of partially or fully covered self-expandable metal stents (SEMSs) for palliation of malignant dysphagia over laser therapy, photodynamic therapy, and esophageal bypass.Strong recommendation, high quality evidence. 2 : ESGE recommends brachytherapy as a valid alternative, alone or in addition to stenting, in esophageal cancer patients with malignant dysphagia and expected longer life expectancy.Strong recommendation, high quality evidence. 3: ESGE recommends esophageal SEMS placement for sealing malignant tracheoesophageal or bronchoesophageal fistulas. Strong recommendation, low quality evidence. 4 : ESGE does not recommend SEMS placement as a bridge to surgery or before preoperative chemoradiotherapy because it is associated with a high incidence of adverse events. Other options such as feeding tube placement are preferable. Strong recommendation, low quality evidence.

BENIGN DISEASE

5: ESGE recommends against the use of SEMSs as first-line therapy for the management of benign esophageal strictures because of the potential for adverse events, the availability of alternative therapies, and their cost. Strong recommendation, low quality evidence. 6: ESGE suggests consideration of temporary placement of self-expandable stents for refractory benign esophageal strictures. Weak recommendation, moderate quality evidence. 7: ESGE suggests that fully covered SEMSs be preferred over partially covered SEMSs for the treatment of refractory benign esophageal strictures because of their very low risk of embedment and ease of removability. Weak recommendation, low quality evidence. 8: ESGE recommends the stent-in-stent technique to remove partially covered SEMSs that are embedded in the esophageal wall. Strong recommendation, low quality evidence. 9: ESGE recommends that temporary stent placement can be considered for the treatment of leaks, fistulas, and perforations. No specific type of stent can be recommended, and the duration of stenting should be individualized. Strong recommendation, low quality of evidence. 10 : ESGE recommends considering placement of a fully covered large-diameter SEMS for the treatment of esophageal variceal bleeding refractory to medical, endoscopic, and/or radiological therapy, or as initial therapy for patients with massive bleeding. Strong recommendation, moderate quality evidence.