Palliation of esophageal carcinoma with a new self-expanding plastic stent

BACKGROUND AND STUDY AIMS

Self-expandable metallic covered stents (SEMS) are widely used for the palliation of esophageal cancer. In the long term, a drawback of these stents is the occurrence of nontumoral occlusion at their proximal or distal parts. New self-expanding plastic stents (SEPS) may combine the advantages of SEMS with those of previously used plastic stents. Our aim was to study prospectively the implantation of such stents in a series of patients with fairly long life expectancy, focusing on safety, feasibility and long-term effectiveness.

PATIENTS AND METHODS

Between June 1999 and December 2000, in a prospective cohort study, 33 patients were treated with Polyflex stents for palliation of esophageal stenoses, and were followed up until death. The inclusion criteria demanded the presence of a nonresectable or nonoperable, histologically proven, malignant stricture of the esophagus causing significant dysphagia.

RESULTS

Stent insertion was successful in all cases. The mean duration of follow-up of the patients was 149.7 days (range 25 - 469). A complete follow-up until death was documented for all patients (n = 33). During the entire follow-up, no stent occlusion was observed which was caused by either nontumoral or tumoral ingrowth, or by nontumoral overgrowth. Stent occlusions were caused only by tumoral overgrowth, and occurred at a rate of 12.1 % (n = 4). The stent migration rate was 6.0 % (n = 2), and the re-intervention rate overall was 21.1 % (n = 7).

CONCLUSIONS

These results show that SEPS are effective for the palliation of dysphagia in patients with esophageal malignancies. The immediate results are similar to those observed with SEMS, and the observed low rate of late obstruction suggests that their long-term efficacy might be superior to that of SEMS. This device warrants evaluation in a controlled prospective trial.

Self-expanding metallic stents for continuous dilatation of benign stenoses in gastrointestinal tract - first results of long-term follow-up in interim stent application in pyloric and colonic obstructions

The use of self-expandable metallic stents (SEMS) is an established palliative treatment of malignant stenosis in the gastrointestinal tract. There is wide experience with the palliation of malignant esophageal obstruction and fistulae, but the application of stents in benign stenosis is rarely reported and exclusively deals with obstruction of the esophagus. No data has been available for benign gastric outlet and rectosigmoid obstruction until now. For the first time we report about 4 cases, in which we temporarily implanted a SEMS (Ultraflex(R) stent, Boston Scientific Microvasive(R)) in benign stenosis of the pylorus or rectosigmoid between 09.97-07.98. The indications for stent implantation were failure of established dilatation therapy and/or refusal of surgical treatment, and/or surgical high-risk patients. Our idea was to prolong the duration of the dilatation by interim implantation (range 8 days - 12 weeks) of a SEMS. There where no peri-interventional complications or dislocations. In one case endoscopic removal was not possible, peranal surgical approach allowed the removal of the stent. During follow-up (range 34-39 months) 2 patients needed one bougienage directly after stent removal. Endoscopic examinations showed no recurrence of any stenosis in all patients. We conclude that interim application of SEMS in benign stenosis of the gastrointestinal tract may be a possible therapeutic tool in selected patients. Further trials with greater numbers of patients dealing with the questions of duration of stay of SEMS and choice of stent type are needed.

[Ulcerative esophagitis and colitis as rare manifestations of Adamantiades-Behcet disease]

We report the case of a 39-year-old German women who suffered from chronic inflammatory bowel disease which had not been exactly classified for 6 years. In the course of the disease she developed recurrent iritis, nodular skleritis, oral and genital ulcer, erythema nodosum and axillary folliculitis. For the first time retrosternal pain occurred. Endoscopy of the upper gastrointestinal tract showed mid esophageal ulcer formation. Colonoscopy demonstrated ulcerative colitis with no involvement of rectal mucosa. Histologically a cutaneous vasculitis in the lower limb was seen and diagnosis of Adamantiades-Behçet disease with marked gastrointestinal involvement and rare manifestation in the esophagus was established. A therapy with prednisolone, azathioprine and mesalazine was started. Under this regimen stomatitis, esophagitis and cutaneous vasculitis resolved, while the colitis showed partial remission now for up to one year.

Modified percutaneous endoscopic gastrostomy (PEG) with gastropexy--early experience with a new introducer technique

OBJECTIVE

The Cliny PEG 13 has been available since 1999 for clinical use in the modified introducer technique in combination with endoscopically controlled gastropexy. Data on indication, insertion technique and safety have not yet been reported in the literature.

METHODS

During the time period from January 1999 to June 2000, from a total of 457 patients receiving a PEG 27 (5.9%) subjects, in whom the insertion of a PEG by means of pull-through technique was impossible or only in combination with an intervention e.g. bougienage were included in this prospective study. Each patient received a Cliny PEG 13 by means of introducer technique with endoscopically controlled double gastropexy. Tumor patients with severe stenosis made up more than 90% of the cases. The insertion and 30 day follow-up were performed using a standardized protocol. Method-related and unrelated complications were recorded.

RESULTS

PEG insertion was successful in all patients without additional intervention. We did not see any method-related complications. The peri-interventional local infection rate was 3.7%. One patient died during the 30-day follow-up period as a result of progression of the underlying disease. No further complications occurred in long term follow-up.

CONCLUSIONS

Our results show that the Cliny PEG 13 is a safe technique and an alternative to other methods and surgical procedures in patients in whom a PEG was not applicable by means of the pull-through technique. Larger case numbers and the use in other patient collectives will have to prove these initial results.

Antibiotic prophylaxis in percutaneous endoscopic gastrostomy (PEG)--results from a prospective randomized multicenter trial

OBJECTIVE

To determine the efficacy of antibiotic prophylaxis in percutaneous endoscopic gastrostomy (PEG) as a part of a standardized regimen.

METHODS

An open prospective randomised multicenter study in 216 patients. 106 received ceftriaxone 1 g i.v. 30 min preinterventionally and 110 no study medication. A standardized protocol was followed for PEG preparation, insertion, and aftercare; all patients received a 15 French gastrostomy tube. Follow-up of local and systemic infection and clinical course was continued to postintervention day 10. An aggregate erythema and exudation score > 3 or the presence of pus was taken as indicative of peristomal infection. The pharmacoeconomics of antibiotic use were also examined.

RESULTS

In no-prophylaxis patients, wound infection rates were 23.6% on day 4 and 24.5% on day 10 vs. 7.6% (p < 0.05) and 11.4% (p < 0.05), respectively, in prophylaxis patients. Results were disproportionally better in tumor patients in comparison with neurological patients. Patients systemic infection rates were 11.8% vs. 1.9% in noprophylaxis vs. prophylaxis (p < 0.05), and overall infection rates 36.3% vs. 13.3%, respectively (p < 0.05). Pneumonia was more frequent in patients with underlying neurological disease and reduced in the prophylaxis group. Antibiotic and application costs were similar in both groups (p = 0.400).

CONCLUSIONS

Single-dose ceftriaxone 1 g is a effective prophylaxis against local and systemic infection after PEG and should be a part of a standard regimen.

Self-expandable metallic stents in malignant gastric outlet obstructions--an alternative approach using modified techniques

Malignant gastric outlet obstructions are commonly present in an advanced tumor stage. Surgery and other therapy options are often accompanied with substantial problems and reduced quality of life. We therefore investigated the endoscopic palliation with self-expandable metallic stents. This report documents the clinical benefit of new stent systems. During a period of eleven months we implanted eleven self-expandable metallic stents (one Ultraflex Esophageal Stent/five Ultraflex Duodenal Diamond Stents/five Enteral Wallstents) in eight patients with malignant gastric outlet stenoses (five female/three male, average age 66 years, range 42-85 years). The procedure was performed under analgosedation and in seven cases on an outpatient bases. The stenosis could be dilated in all cases without complications, allowing semi-liquid oral feeding at the procedure day. Three patients needed a second stent in the follow-up. Stent dislocation appeared in one case after one month--the stent protruded per vias naturales. The stent struts broke in two patients after one and four months post stent implantation. A new stent could be inserted without complications in both cases. The used products enabled a fast and precise positioning of the metallic stent in malignant gastric outlet stenosis. We experienced some problems with the Ultraflex Duodenal Diamond Stent. This didn't occur with the Enteral Wallstent. Additionally with the Enteral Wallstent we could solve the diamond stent complications. Due to the small diameter (10 French) the Enteral Wallstent system can be positioned wire guided in the stenosis through the working channel of the endoscope. Stent release is performed fluoroscopically and with the use of endoscopic guidance retaining the instrument in the stomach. In our point of view, this metallic stent is an optimal device for the palliative treatment of malignant gastric outlet obstructions.

A single dose of ceftriaxone administered 30 minutes before percutaneous endoscopic gastrostomy significantly reduces local and systemic infective complications

OBJECTIVE

The aim of this study was to determine the efficacy of antibiotic prophylaxis in percutaneous endoscopic gastrostomy (PEG).

METHODS

An open prospective, randomised, multicenter study was conducted in 141 patients; 72 received ceftriaxone 1 g i.v. 30 min preintervention, and 69 received no study medication. A standardized protocol was followed for PEG preparation, insertion, and aftercare; all patients received a 15-Fr gastrostomy tube. Follow-up of local and systemic infection and clinical course was continued to postintervention day 10. An aggregate erythema and exudation score >3 or the presence of pus was taken as indicative of peristomal infection. The pharmacoeconomics of antibiotic use were also examined.

RESULTS

In no-prophylaxis patients, wound infection rates were 25% on day 4 and 26.4% on day 10, versus 10.1% (p = 0.03) and 14.5% (p = 0.10), respectively, in prophylaxis patients. Results were disproportionally better in tumor patients: systemic infection rates were 16.7% versus 5.8% in no-prophylaxis versus prophylaxis patients (p = 0.045), and overall infection rates 38.9% versus 17.4%, respectively (p = 0.046). Pneumonia was more frequent in patients with underlying neurological disease. Antibiotic costs were the same in both groups (p = 0.792).

CONCLUSIONS

Single dose ceftriaxone 1 g is an effective prophylaxis against local and systemic infection after PEG.

[Primary palliative treatment of malignant gastric outlet obstruction with a self-expanding metal stent]

BACKGROUND AND OBJECTIVE

A high operative mortality, diffuse local tumor growth and abnormal wound healing are significant risk factors in the palliative surgical treatment of gastric outlet obstruction caused by a malignant tumor. This study was undertaken to evaluate the use of self-expanding metal stents as an alternative.

PATIENTS AND METHODS

Over a period of 33 months, nine previously unoperated patients (three women, six men; mean age 71.4 [66-76] years) with gastric outlet obstruction by a malignant tumor underwent endoscopic implantation of an uncoated self-expanding nitinol Ultraflex stent. The stent's length was 7 and 10 cm, respectively, the length of the carrier catheter was 92 cm. The stent was implanted after balloon dilatation of the stenosis and marking the distal tumor margin with lipiodol injected over a guide-wire under fluoroscopic control.

RESULTS

The implantation was successful in only two of the first five patients, but after modifying the method of stent release in three of the four subsequent patients. All patients reported an improved quality of life. One patient died after 10 days of the underlying malignancy. There were no complications associated with the implantation.

CONCLUSIONS

Insertion of a self-expanding metal stent can provide palliation in patients with inoperable gastric outlet stenosis due to malignant tumour. The number of successful implantations can probably be increased by optimizing some of the devices used, for example by lengthening the carrier catheter.

[Normal values for 24-hour manometry of the esophagus]

OBJECTIVE

To obtain normal values of 24-hour manometry of the oesophagus.

SUBJECTS AND METHODS

Oesophageal pressures were measured in 41 healthy volunteers who had given informed consent. Recordings were made for 24 hours via a two-channel catheter in 27 and via a 4-channel one in 14 subjects. The catheter orifices were 5 and 15 cm respectively 5, 10, 15 and 20 cm above the lower oesophageal sphincter.

RESULTS

Median of contractions was 1523 at 5 cm and 1500 at 15 cm (1635 at 10 cm and 2135 at 20 cm) contraction amplitudes were 31 mm Hg at 5 cm, 26 mm Hg at 15 cm; 26 mm Hg at 10 cm and 37 mm Hg at 20 cm. On average 44% of the contractions were propulsive, 17% simultaneous and 30% nonpropulsive, the remainder not clearly defined. Neither age nor sex had a significant influence on the results. Motor activity was reduced during sleep. During eating the number of contractions, their amplitude and propulsive force increased.

CONCLUSION

The listed measurements, by defining normal values, make it possible to diagnose hypo- and hypermotility of the oesophagus during long-time manometry. Two-point measurement is sufficient for assessing the smooth-muscle component.