Silicone-covered self-expanding metallic stents for the palliation of malignant esophageal obstruction and esophagorespiratory fistulas: experience in 32 patients and a review of the literature

Double stenting for esophageal and tracheobronchial stenoses

BACKGROUND

We examined the complications and outcomes of placing stents for both esophageal and tracheobronchial stenoses.

METHODS

We placed stents for both esophageal and tracheobronchial stenoses in 8 patients (7 with esophageal cancer and 1 with lung cancer). Covered or noncovered metallic stents were used for the esophageal stenoses, except in 1 patient treated with a silicone stent. Silicone stents were used for the tracheobronchial stenoses. The grades of esophageal and tracheobronchial stenoses were scored.

RESULTS

All patients experienced improvement of grades of both dysphagia and respiratory symptoms after stent therapy. The complications were: (1) 2 patients suffered respiratory distress after placement of the esophageal stent because of compression of the trachea by the stent; and (2) 3 patients developed new esophago-tracheobronchial fistulae, and 2 patients had recurring fistula symptoms because of growth of preexisting fistulae after the stent placement, which were caused by pressure from the 2 stents. Despite the fistulae, the 5 patients treated with covered metallic stents did not complain of fistula symptoms, but 2 patients treated with noncovered metallic or silicone stents did complain.

CONCLUSIONS

For patients with both esophageal and tracheobronchial stenoses, a stent should be introduced into the tracheobronchus first. Because placement of stents in both the esophagus and tracheobronchus has a high risk of enlargement of the fistula, a covered metallic stent is preferable for esophageal cancer involving the tracheobronchus.

An update in the palliative management of malignant dysphagia

BACKGROUND

Oesophageal cancer is generally associated with late presentation and poor prognosis. Therefore palliative surgery has been largely superseded by less invasive non-surgical techniques. Once palliation is indicated, the aims of the management should be: the maintenance of oral intake, minimizing hospital stay, relief of pain, elimination of reflux and regurgitation and the prevention of aspiration.

METHODS

This study was a review of all published English language data on the palliation of malignant dysphagia between 1994-1999. The Medline and Bids databases were searched and other references were derived from the material perused.

RESULTS AND CONCLUSIONS

Palliative treatment for oesophageal cancer should be individualized and relate to tumour stage, size and location, the patient's medical condition and his/her personal wishes. The palliative treatment largely includes self-expanding metal stents (SEMS), laser (including photodynamic therapy (PDT)) or a combination of the two to relieve symptoms, this may be employed with or without other treatments such as radiotherapy/chemotherapy (RT/CT) with the aim of reducing tumour bulk and possibly prolonging survival. A multi-disciplinary approach is vital in patients with advanced oesophageal cancer.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

A new design metal stent (Flamingo stent) for palliation of malignant dysphagia: a prospective study. The Rotterdam Esophageal Tumor Study Group

BACKGROUND

Metal stents are not superior to conventional endoprostheses with respect to the incidence of recurrent dysphagia because of tumor ingrowth with uncovered stents and migration with their covered counterparts. To overcome these limitations, a partially covered (inside-out covering) metal stent with a conical shape and a varying braiding angle of the mesh along its length, the Flamingo stent, has been developed.

METHODS

From March 1997 to October 1997, 40 consecutive patients with dysphagia due to malignant tumors had either a small diameter (proximal/distal diameter 24/16 mm; n = 21) or a large diameter Flamingo stent (proximal/distal diameter 30/20 mm; n = 19) placed.

RESULTS

There was statistically significant improvement in dysphagia, but improvement was not greater with large diameter stents compared to small diameter stents (p = 0.21). Major complications (bleeding [4], perforation [1], fever [1] and fistula [1]) occurred in 7 (18%) patients. Large diameter stents tended to be associated with more major complications than small diameter stents (5 vs. 2; p = 0.07). Pain following stent placement was observed in 9 (22%) patients and occurred more frequently in those who had prior radiation and/or chemotherapy (p = 0.02). Recurrent dysphagia (mainly due to tumor overgrowth) occurred in 10 (25%) patients.

CONCLUSIONS

Flamingo stents are effective for palliation of malignant dysphagia, but the large diameter stent seems to be associated with more complications involving the esophagus than the small diameter stent. Because recurrent dysphagia is mainly due to tumor progression, further technical developments in stent design are needed.

Interventional radiology and the use of metal stents in nonvascular clinical practice: a systematic overview

PURPOSE

The intent of this systematic overview was to describe the clinical role of metal stents in nonvascular health care interventions and the level of evidence supporting their use.

MATERIALS AND METHODS

Structured searches of Medline were conducted and limited to original peer-reviewed articles published in English.

RESULTS

Clinical practice involving metal stents was reported in more than 109 clinical series involving 4,753 patients. Stents were placed mainly for palliation of malignant biliary, esophageal, and airway obstruction in patients who were untreatable or had surgically unresectable lesions. Assessment of these interventions has so far centered on safety and technical success. Efficacy, quality of life, and costing factors were not routinely reported. Randomized trial evidence was available but limited; six randomized trials involving metal stents have been reported. Three trials involved biliary malignant obstruction, and all three reported metal stent (132 patients) palliation to be superior to plastic stent palliation (136 patients) based on longer patency and lower reintervention costs. Safety and complication differences between stents, however, were inconsistent across trials. In three trials involving esophageal malignant obstruction, metal stent (82 patients) palliation was reported to be superior to plastic stent (41 patients), based on lower complication and reintervention rates, and superior to laser therapy (18 patients), based on better dysphagia relief.

CONCLUSION

Use of metal stents has been reported for obstructed ducts and passageways of most body systems. There is, however, limited controlled trial evidence confirming the advantages of their use over plastic stents or other forms of treatment.

A comparison study on physical properties of self-expandable esophageal metal stents

BACKGROUND

Currently available esophageal expandable stents differ in design, material, and method of deployment. We compared the expansile force and the susceptibility to buckling force in five commercially available stents.

METHODS

The Esophacoil, Wallstent, Ultraflex, Gianturco-Z and Song stents were tested. The middle sections of fully expanded stents were subjected to compression force using a universal tensile testing machine. The distortion of the stent was measured electronically and the expansile force was calculated. Bending moments were applied to the ends of the stents until buckling occurred in the inner parts. The buckling radius was measured as the radius of the inner curvature of the stent when this occurred.

RESULTS

The stents tested were significantly different in their expansile forces and buckling radii. Song stent and Gianturco-Z stent were similar due to their similar designs. Esophacoil was the strongest with regard to withstanding compressive force and angulation force, followed by Wallstent. Ultraflex stent was the weakest in expansile force but withstood angulation force better than the Song and Gianturco stents.

CONCLUSION

Esophageal stents differ greatly in their elasticity and resistance to angulation. Knowledge of their mechanical properties will be another helpful factor to consider in selecting the appropriate stent in addition to the geometry and consistency of the tumor.

Extraction of migrated self-expanding esophageal metal stents

BACKGROUND

When self-expanding metal stents are used in the palliative treatment of malignant stenoses complications can occur and require the endoscopic extraction of the stent.

METHODS

Three Gianturco-Z stents and two EsophaCoil stents had to be extracted because of migration (4 patients) and strangulation of healthy esophageal tissue between the coil loops during EsophaCoil stent release (1 patient). Because of the strong expansion force of the Gianturco-Z stent, the plastic sheath of a polypectomy snare was replaced by the steel sheath of a basket used for mechanical lithotripsy of bile duct stones. The sufficient resistance of the steel sheath allowed the stents to be compressed. The EsophaCoil stents were gradually retracted with a polypectomy snare over a plastic tube.

RESULTS

All stents could be extracted successfully. There were no severe complications related to extraction.

CONCLUSION

By means of the endoscopic extraction techniques described above, it is possible to safely remove self-expanding esophageal stents.

The use of oesophageal, self-expanding, metal stents

Self-expanding metal stents have become increasingly popular in the effort to relieve the distressing symptoms associated with malignant oesophageal disruption. Despite numerous medical reports on the effectiveness of oesophageal stents, an extensive literature search revealed no nursing research on this subject. Through personal experience and reflection, the authors identified some distressing complications associated with oesophageal stenting. Their concerns resulted in a retrospective audit to assess the relief of dysphagia and identify any complications experienced by 37 patients who had received oesophageal stents. The results of this audit are inconsistent with previous medical studies, and question the effectiveness of these devices in the relief of symptoms associated with oesophageal disruption. In fact, the authors were perturbed by the number of complications identified after stenting, especially haematemesis, malaena and haemoptysis. The authors recognize that this subject requires a larger, multi-centre study. They have identified that a thorough nutritional assessment of patients with stents would be beneficial, and that education of both nursing staff and patients about these stents was a necessity.

Esophageal fistula sealing: choice of stent, practical management, and cost

BACKGROUND

Three models of covered metal stents are available to seal esophageal fistulas.

METHODS

Stainless steel covered stents were inserted in 5 patients (group I); nitinol covered stents were inserted in 12 patients (group II) with malignant (n = 14) or benign (n = 3) esophageal fistulas.

RESULTS

Stent positioning was satisfactory in all cases. Fistula sealing was complete in 1 of 5 (20%) and 12 of 12 (100%) patients of groups I and II, respectively (p < 0.005). Continued esophageal leakage was initially related to the passage of fluids alongside the stent covering (n = 3) and to early stent migration (n = 1). Complications related to stent placement were observed in 2 of 17 (12%) patients and were fatal. During follow-up (mean 153 +/- 143 days), esophageal fistulas relapsed after initial sealing in 5 of 13 (38%) patients. Further treatment (glue or fibrin sealant injection, additional stent insertion) was attempted in 7 cases of persistent or relapsing esophageal fistula, with sealing obtained in 5 of them. The costs per patient and per day free from symptoms due to the esophageal fistula were $106 and $57 in groups I and II, respectively.

CONCLUSION

Nitinol covered stents more frequently provided complete esophageal fistula sealing, as compared with stainless steel covered stents. Further treatments tailored to the mechanisms of fistula persistence or relapse often provided sealing.

Esophageal stent with antireflux valve for tumors involving the cardia: work in progress

PURPOSE

To describe an esophageal stent with a polyester mesh cover and an antireflux valve, and to assess its efficacy in the treatment of patients with inoperable tumors of the gastric cardia.

MATERIALS AND METHODS

Thirteen patients with adenocarcinoma of the cardia, two patients with squamous cell carcinoma, and three patients with recurrent carcinoma of the gastric fundus after surgery were treated by placement of an esophageal stent with an antireflux valve. The spiral Z stent has a porous, polyester mesh cover and an antireflux sleeve made of pliable polyurethane at its lower end.

RESULTS

Placement of the stent was successful in all patients, and their dysphagia disappeared or significantly improved. All were able to swallow solid food, and no patient reported significant reflux or "gas bloat" syndrome prior to death or the end of follow-up. Two patients only complained of minor heartburn. Follow-up barium swallow studies showed the absence of significant gastroesophageal reflux in all patients. No stent migration occurred.

CONCLUSION

The esophageal stent with antireflux valve has been effective in the treatment of malignant obstruction of the cardia and allowed good esophageal passage without migration and major gastroesophageal reflux.

EsophaCoil: long-term results in 81 patients

BACKGROUND

Cancer of the esophagus and gastric cardia cause progressive dysphagia. Half of patients are not amenable to surgical resection; of those who are, about 20% will suffer either from local recurrence or anastomotic strictures. Self-expandable metallic stents of diverse characteristics have been used in these clinical conditions. However, expandable metallic stents have several drawbacks: low radial force, migration, epithelial trauma, and tumor ingrowth. We herein report our long-term experience with EsophaCoil, a self-expandable esophageal metallic coil, in 81 patients.

METHODS

From January 1993 to July 1996, 84 stents were placed in 81 consecutive patients (53 men and 28 women, mean age 69.8 years (range 40 to 90 years). 41 patients had esophageal squamous cell carcinoma, 32 adenocarcinoma of the esophagus and cardia, 5 mediastinal metastasis, 1 sarcoma, and 2 had benign esophageal strictures. Five patients had bronchoesophageal fistulas. Mean dysphagia score before treatment was 3.5, mean stricture length 6 cm. Most patients were hospitalized for at least 24 hours after stent implantation. Patients were followed and early and late complications were recorded.

RESULTS

Stents were successfully placed in all patients. Dysphagia improved in 96% of patients (score dropped from 3.5 to 1.2). Mean patient survival after stent insertion was 4 months (range 0.5 to 20 months). Bronchoesophageal fistulas were closed in all 5 cases. Early complications occurred in 11 patients. These were severe in 3 (esophageal perforation) and mild in 8 patients (precordial pain lasting 24 to 48 hours). Late complications occurred in 18 patients and included migration to the stomach (5 patients), stent breakage (5 among the first 20 cases), food impaction (5), tumor overgrowth (2), and bleeding (1).

CONCLUSIONS

In a long-term follow-up, EsophaCoil was effective in the palliative treatment of dysphagia caused by malignant esophageal strictures, including cases of fistulas, having low malfunction and migration rates. No tumor ingrowth was seen.

Delayed esophageal hemorrhage caused by a metal stent: treatment with embolization

We report a case of life-threatening esophageal hemorrhage after metal stent implantation successfully treated by arterial embolization. An 85-year-old woman was admitted in shock secondary to massive hematemesis and melena. Recent medical history revealed esophageal cancer treated 8 weeks previously by endoesophageal radiotherapy (40 Gy) and endoscopic placement of a covered Wall-stent prosthesis. Selective arteriography of the fifth posterior right intercostal artery showed massive contrast extravasation in the esophagus. Embolization was performed with 150-250-micron polyvinyl alcohol particles. Follow-up at 5 months was uneventful. Arteriography and embolization are advised when severe hemorrhage occurs after esophageal implantation of metal stents.

Expandable metallic esophageal stents in benign disease: a cause for concern

Over a 2-year period at our institution, 6 patients underwent metallic stent treatment, 5 for malignant conditions and 1 for a benign condition of the esophagus. The use of expandable metallic stents for benign strictures has paralleled malignant indications but is limited and less understood from a clinical standpoint. A review of current literature in the treatment of benign strictures is presented. Treatment of benign strictures is associated with high morbidity and mortality as demonstrated by the cumulative experience of 21 patients. Migration, hyperplastic tissue obstruction at the terminal ends, reflux, and complications of perforation occur at a prohibitive rate. We conclude that expandable metallic stents should be reserved for palliative treatment of esophageal malignant obstructions and tracheoesophageal fistulas. Pharmacological management, necessary dilatations and operative corrections (antireflux procedures, esophagectomy) are recommended treatments for benign strictures.

Comparison of conventional and wire mesh expandable prostheses and surgical bypass in patients with malignant esophagorespiratory fistulas

BACKGROUND

Patients who present with malignant esophagorespiratory fistula continue to provide a significant palliative challenge to gastroenterologists and surgeons.

METHODS

This retrospective series reviewed 29 patients treated with conventional prostheses (13 patients), expandable wire mesh-coated prostheses (12 patients), and surgical bypass with esophageal exclusion (4 patients) between 1982 and 1995.

RESULTS

Improvement in dysphagia scores were comparable in all three groups. Fistula occlusion was more successful with expandable prostheses (92%) compared conventional prostheses (77%); however, reinterventions were required more commonly with expandable prostheses, which were also significantly more expensive on a unit cost basis. In selected patients in whom prosthesis placement either was inappropriate or failed, surgical bypass and esophageal exclusion was undertaken. These patients demonstrated good palliation with minimal morbidity and no mortality.

CONCLUSIONS

Both conventional and expandable prostheses are safe and reasonably straightforward treatment modalities for patients with esophagorespiratory fistulas. Because of ease of insertion and large luminal diameter, expandable metal prostheses will see increasing use in treatment of these difficult patients; however, conventional prostheses will remain a good alternative, especially in patients with extrinsic esophageal compression. When stent placement is either unsuccessful or inadvisable, physiologically fit patients can undergo surgical bypass and esophageal exclusion with good palliation and minimal morbidity and mortality.

Palliative treatment of malignant esophagorespiratory fistulas with Gianturco-Z stents. A prospective clinical trial and review of the literature on covered metal stents

OBJECTIVE

Esophagorespiratory fistulas, especially in the upper third of the esophagus, are a complication of malignant esophageal tumors, which are difficult to manage. The efficacy of polyurethane-covered, self-expanding metal stents for palliation of malignant esophagorespiratory fistulas was investigated prospectively.

METHODS

Eleven patients with malignant esophagorespiratory fistulas resp. perforations were treated with Gianturco-Z stents. In five patients the lesion was located in the proximal part of the esophagus. Because of the fistula all patients suffered from dysphagia even for liquids.

RESULTS

No technical problems during the implantation procedure of the stents occurred. In the control radiography with water-soluble contrast media, the fistulas were completely sealed in 10 of 11 patients. Therefore the dysphagia score improved from 3.0 to 0.6. Nearly all Gianturco-Z stents (10/11) showed a sufficient expansion within 24 h after placement. Severe early or late complications were not encountered, with the exception of tumor overgrowth in one patient about 9 months after stent placement. In five patients, short term (3-6 days) retrosternal pain was observed, and one patient complained of slight foreign body sensation. By August 1997 all 11 patients had died of advanced disease, with a median survival time of 121 days (range, 22-300 days).

CONCLUSIONS

Gianturco-Z stents are highly effective for palliative treatment of esophagorespiratory fistula resp. perforations and have a low complication rate. Due to the fact that this stent shows no retraction during the release, a precise positioning is possible, especially in the case of tumors and fistulas in the upper third of the esophagus. It seems that use of the Gianturco-Z stent can be considered a good therapeutic method for palliative endoscopic treatment of this high risk patient group.

Expandable metallic prostheses for malignant obstructions of gastric outlet and proximal small bowel

BACKGROUND

Data are limited on use of expandable metal stents for treatment of malignant gastric outlet obstruction. Accordingly, we report our experience using these stents to palliate malignant obstructions of the gastric outlet, duodenum, and proximal jejunum.

METHODS

Eight patients with malignant strictures causing gastric obstruction underwent endoscopy with fluoroscopic guidance to delineate tumor borders and length followed by expandable metallic prosthesis placement (Wallstent, Z-Stent, Ultraflex, and Endocoil).

RESULTS

Symptoms were relieved in seven patients, five of whom had previous surgeries (Whipple, Billroth II, esophagojejunostomy, and gastrojejunostomy) for malignancy. One patient underwent surgical resection of a presumed malignant stricture containing a previously placed Wallstent after a 45-pound weight gain.

CONCLUSIONS

Expandable metallic prostheses placed in patients with malignant obstruction of the gastric outlet, duodenum, or proximal jejunum, before or after surgery, effectively palliate obstructive symptoms and may also serve to improve nutrition.

Endoprostheses for colonic strictures

BACKGROUND

Patients who present with large bowel obstruction often undergo emergency surgical intervention with its attendant risk of morbidity and death. A colostomy may be inevitable and this detracts from the patient's quality of life, especially when palliation is the only option.

METHODS

This review examines the possibility of a more conservative approach using metallic stents to relieve colonic obstruction, either as the first stage of a curative surgical procedure or for palliation without surgery. The various stents available are examined.

RESULTS

Case reports show that relief of obstruction can be achieved in over 80 per cent of patients, allowing subsequent elective surgery or achieving palliation for several months. Complications are rare but include colonic perforation, particularly when predilatation of the stricture has to be performed. Such complications are generally recognized early and patients can proceed to surgery and colostomy, as would previously have been conventional treatment; on occasion a small leak may be treated conservatively with success. The advent of newer endoprostheses which do not require active dilatation may improve the rate of successful deployment and lessen the risk of perforation.

CONCLUSION

The development of new endoprostheses has allowed their adaptation for use in the colon and, perhaps, the distal small bowel. The technology is evolving rapidly and warrants serious consideration in selected patients with large bowel obstruction before embarking on surgery. There is an urgent need for a controlled trial to establish whether such intervention for malignant strictures, potentially curable by surgery, leads to an increased risk of metastatic disease.

Restenting malignant oesophageal strictures

BACKGROUND

Self-expanding metal stents are used to palliate malignant strictures of the oesophagus. This study was designed to identify the characteristics of patients requiring restenting of malignant oesophageal strictures.

METHODS

Fifty-three stents were inserted in 42 patients. Thirty-two patients did not require further stenting (once-stented group). Ten patients received second stents for recurrent oesophageal obstruction (restented group), with one patient requiring restenting a second time. Comparisons were drawn between the once-stented and restented groups with regard to survival, patient, tumour and procedural characteristics.

RESULTS

There were no significant differences with regard to tumour grade, tumour type, involvement of the cardia, procedural difficulties or the need for postprocedural oesophageal dilatation between the two groups. Survival from initial stenting was significantly greater in the restented group (median 24 (range 4-43) weeks) than in the once-stented group (median 9.5 (range 1-84) weeks) (P < 0.05). The mean length of stents used in the once-stented group was significantly greater than that of the initial stents used in the restented group (12 versus 10 cm, P = 0.032).

CONCLUSION

Inserting a covered stent through a previously inserted uncovered stent is an uncomplicated and well tolerated technique which maintains palliation from obstructing oesophageal carcinoma. The need for restenting cannot be predicted on the basis of tumour characteristics alone.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Endoscopic therapy of esophageal cancer

In the management of esophageal cancer, endoscopy has evolved from a tool used to provide biopsy confirmation of suspected tumor to an integral part of the staging and ongoing treatment of patients. Endoscopic ultrasound is currently the most accurate means for T and N staging. Improved endoscopic techniques like dye staining and aggressive biopsy protocols can identify very early stage tumors in high-risk groups and allow curative surgery. Patients with early-stage tumors who are not surgical candidates can also be treated with endoscopic mucosectomy, photodynamic therapy, or Nd:YAG laser and still have a chance of long-term cure. Palliation of advanced tumors remains the major role of endoscopy in patients with esophageal cancer. A variety of techniques have proven effective over the years, including dilatation, laser, and rigid prostheses. Newer developments like bipolar probes, injection therapy, photodynamic therapy, and brachytherapy offer potential applications. The development and continuing improvements in both coated and uncoated expandable metal stents have been perhaps the greatest recent advance in endoscopic palliation of malignant dysphagia and esophagorespiratory fistulas. With the increasing array of endoscopic treatments and palliative techniques, emphasis must be placed on considering functional status; tumor characteristics like stage, location, and shape; patient wishes; and local expertise in tailoring treatment plans for each situation.

Use of the 25 mm flanged esophageal Z stent for malignant dysphagia: a prospective multicenter trial

BACKGROUND

An initial multicenter study using a 21 mm flanged esophageal Z stent demonstrated excellent palliation but an 11% immediate complication rate at placement and a 27% migration rate at 1 month. This North American multicenter trial prospectively studied a 25 mm flanged Z stent to define its palliative ability and whether the increased diameter affected placement or migration problems.

METHODS

Fifty patients who had esophageal Z stents at seven university or regional referral hospitals were prospectively studied. Indications for prosthesis placement, previous therapy, patient demographics, incidence of concomitant tracheoesophageal fistula, and degree of dysphagia were defined, as were procedural and subsequent stent-related problems, survival times, the ability to occlude a tracheoesophageal fistula, and subsequent degree of dysphagia.

RESULTS

Twenty-four patients had infiltrating malignancy (16 exophytic and 10 extrinsic), 9 of whom had concomitant tracheoesophageal fistulas. Ten patients (20%) had misplaced stents requiring retrieval and replacement, 12 patients (24%) had subsequent stent-related problems including exsanguination (2), aspiration (3), tumor overgrowth (3), and postplacement migration (4) (8%). There was statistically significant improvement in prestent versus poststent dysphagia and two thirds of patients had complete occlusion of their tracheoesophageal fistula.

CONCLUSIONS

Redesign of the esophageal Z stent has decreased the migration rate without increasing placement or subsequent erosion problems. Its efficacy appears comparable to the currently marketed Z stent for the palliation of malignant dysphagia and occlusion of tracheoesophageal fistula.

Esophageal self-expandable metallic stents--indications, practice, techniques, and complications: results of a national survey

BACKGROUND

The gastroenterology community's experience with esophageal self-expandable metallic stents (SEMS) is unknown.

METHODS

In order to assess indications, perioperative management, and self-reported complications associated with SEMS placement, a survey was mailed to ASGE members.

RESULTS

Of 3414 surveys mailed, 212 (6.2%) were completed and returned. One hundred twenty-eight physicians had experience with a total of 434 SEMS. Most physicians practiced in the private sector (72%), and 75% had placed 3 or fewer SEMS. Perceived ease of placement was the most common reason for choosing a SEMS (55%). Fluoroscopic and endoscopic guidance was used by 83% of respondents, and 81% allowed liquid diet after correct position and patency had been confirmed; 56% of respondents discharged their patients within 24 hours of SEMS placement. The rates of failure for full expansion (7.1%), stent misplacement (4.8%), and failure to deploy (3%) were higher than previously reported. Acute patient complications and delayed bleeding occurred less frequently than in reported series but mortality rates were similar.

CONCLUSIONS

Ease of placement is the main reason for choosing a SEMS. Differences in complication rates, compared to previous studies on SEMS, may be related to operator experience and protocol requirements. When compared to plastic stents, complications were less frequent.

Silicone-covered Wallstent prototypes for palliation of malignant esophageal obstruction and digestive-respiratory fistulas

BACKGROUND

Endoscopic palliation of malignant esophageal obstruction with uncovered self-expanding metal stents has been shown to have fewer complications than with conventional plastic stents. The addition of a membrane might prevent tumor ingrowth and allow treatment of digestive-respiratory fistulas. We report the clinical experience with a prototype silicone membrane-covered self-expanding metal stent.

METHODS

Twenty-three silicone membrane-covered Wallstent prototypes were used in 21 patients with dysphagia due to inoperable malignant tumors involving the esophagus and cardia.

RESULTS

Stent implantation was technically successful in all patients. There were no procedure-related perforations or deaths. The prototype stent was successful in sealing seven of the eight (87.5%) digestive-respiratory fistulas. As a group, the mean dysphagia grade improved significantly after stent placement (4.8 +/- 0.9 vs 3.4 +/- 1.6, p < 0.0005). However, 9 of 21 (42.9%) patients experienced no improvement in their dysphagia. Complications occurred in 13 of 21 (61.9%) patients. Tumor ingrowth was not observed in any patient.

CONCLUSIONS

The prototype covered self-expanding metal stent was effective in sealing digestive-respiratory fistulas and provided palliation of dysphagia in slightly more than one half of the patients studied. A great deal has been learned from the preliminary experience, which has led to design modifications. The utility of the commercially available device should be evaluated in further prospective clinical trials.

A newly-designed shape-memory coil stent for esophageal stricture: a preliminary report

A newly designed coil esophageal endoprosthesis was developed using a thermal shape-memory titanium-nickel alloy. The major advantages of this stent lie in (a) its small diameter while in its compressed state in ice water and (b) the large lumen which is achieved once it has been warmed to body temperature. The technical feasibility and tissue compatibility of this stent were tested on four beagle dogs: two with an anastomotic stricture and two with a stenosis induced by the injection of monoethanolamine oleate. The teflon-coated stent was inserted under fluoroscopy and removed 4 weeks after implantation. No signs of esophageal reobstruction were observed in any of the animals after implantation or extraction of the stent, although the dog which had received the first stent without teflon coating developed obstruction caused by granulation tissue. Our preliminary experience strongly suggests that the shape-memory alloy stent with teflon coating may be used in the endoscopic treatment of anastomotic stenosis after esophagectomy, as well as of esophageal obstruction caused by carcinoma.

Prospective multicenter trial of esophageal Z-stent placement for malignant dysphagia and tracheoesophageal fistula

BACKGROUND

Conventional esophageal prosthesis placement has been associated with a 6% to 8% perforation rate and numerous postplacement complications. Expandable esophageal stents have been developed to preclude the above but there are few studies that have prospectively defined clinical results and subsequent stent-related complications.

METHODS

All patients who underwent esophageal Z-stent placement at nine university or referral hospitals were prospectively assessed. Data collected included patient demographics, acute and subacute placement problems, the ability to occlude airway fistulas, prestent and poststent dysphagia scores, and patient survival.

RESULTS

Fifty-four of 56 patients (96%) with refractory dysphagia or malignant esophagoairway fistulae had 73 Z-stents successfully inserted. Initial distal deployment occurred in 13% of the patients and an additional 17% required balloon dilation to achieve maximal diameter. Acute placement complications occurred in 11% of patients and included severe pain (3), bleeding from necrotic tumor (2), and hiatal hernia intussusception (1). No perforations occurred. Eight of 11 patients (73%) had complete tracheoesophageal fistula occlusion and mean dysphagia score (+/- SD) improved from 2.6 (0.7) to 1.1 (1.2) (p < 0.01). Fifteen stents (27%) had delayed migration at a mean of 1 month and 3 required surgery for retrieval. Three patients had ultimate stent erosion resulting in bleeding in 2 (exsanguination 1) or fistula (treated with a conventional stent).

CONCLUSIONS

The authors conclude that esophageal Z-stents can be placed safely and successfully in the majority of patients. The tendency of distal deployment during placement and subsequent migration problems at a time distant from placement in a patient subset deserve attention and are currently being addressed.

Treatment of a ruptured anastomotic esophageal stricture following bougienage with a Dacron-covered nitinol stent

A patient suffering from esophagorespiratory fistula after bougienage of a benign stricture at the site of the anastomosis between a jejunal interposition and the esophagus was referred for interventional treatment. A prototype nitinol stent centrally covered with Dacron was implanted under regional anesthesia and fluoroscopic guidance. The self-expanding prosthesis dilated the stenosis completely and closed the fistula, with consequent improvement in respiratory and nutritional status and thus the general quality of life. The patient was able to eat and drink normally until death 3 months later due to progression of his underlying malignant disease.

Treatment of esophageal obstruction with covered, self-expanding esophageal Wallstents

BACKGROUND

Conventional endoluminal plastic prostheses used for relieving esophageal obstruction allow variable palliation. Covered, expandable metal stents provide an 18-mm lumen to allow improved deglutition.

METHODS

From December 1994 to December 1995, 20 patients underwent placement of self-expanding, silicone-covered Wallstents (Schneider, Plymouth, MN) for esophageal obstruction. Fifteen patients had obstruction secondary to carcinoma and 5 patients had benign esophageal stricture. There were 13 men and 7 women, ranging in age from 54 to 94 years. All patients underwent esophageal dilation using a flexible gastroscope and Savary bougies. After dilation to 42F or 45F, placement of the stent was performed under fluoroscopic control.

RESULTS

Follow-up was complete in all patients, ranging from 4 weeks to 12 months. Technical success was achieved in all patients. There was one postoperative death (bronchoesophageal fistula) and one migration of the stent requiring removal (peptic stricture). The remaining stents were well tolerated, even in the cervical region (4 patients). All patients successfully intubated were able to eat well, including solid foods.

CONCLUSIONS

Covered, self-expanding esophageal Wallstents are technically simple and safe to insert and appear to provide durable, excellent palliation of esophageal obstruction due to either benign or malignant conditions. A larger patient population is required to make firm conclusions.

General management of gastrointestinal fistulas. Recognition, stabilization, and correction of fluid and electrolyte imbalances

Gastrointestinal fistulas are unfortunate complications of a number of disease states, such as inflammatory bowel disease and tumors, or may result from complications of surgical intervention. Fistulas may be associated with significant morbidity and mortality, much of which is a result of fluid losses and electrolyte imbalances. Thus, attention to these issues is a critical component of the management of patients with gastrointestinal fistulas. The management of gastrointestinal fistulas is divided into three phases: diagnosis/recognition, stabilization/investigation, and treatment. The major goal of the stabilization phase is the correction of fluid losses and electrolyte abnormalities. This phase must be carried out expeditiously to reduce the associated complications. Knowledge of the electrolyte content of various secretions of the gastrointestinal tract is essential to guide this phase of management. Early control of infectious foci, with drainage of abscesses if present, is of great importance. Esophageal fistulas most commonly result from instrumentation of the esophagus and are diagnosed by radiographic imaging studies. Nonoperative therapy is an option in select patients, but aggressive surgical intervention is often required. Dehydration is often associated with these injuries and must be corrected. Gastric and duodenal fistulas are most commonly iatrogenic and may be associated with significant fluid losses. Careful measurement of the fistula effluent is important. Nutritional support is begun following correction of fluid and electrolyte abnormalities. Pancreatic fistulas are often high volume fistulas and are associated with significant skin breakdown if they are cutaneous. The use of a somatostatin analogue may decrease the volume of the fistula to allow healing. Small intestinal fistulas often result from postoperative complications and require careful attention to electrolyte abnormalities. Spontaneous closure often obviates surgical intervention. Colonic fistulas are less often associated with complications than are other fistulas of the gastrointestinal tract. The stabilization phase in the management of patients with gastrointestinal fistulas is a critical time during which careful attention to fluid and electrolyte losses can result in reduced morbidity and mortality from these difficult management problems.

Erosion of the right mainstem bronchus by an esophageal stent

Self-expanding metallic stents (SEMSs) are used to palliate malignant esophageal strictures. We describe a patient who had an extensive mediastinal tumor for which he was receiving irradiation therapy; chest pain, hemoptysis, and recurrent Gram-negative pneumonia developed in this patient after stent placement. Fiberoptic bronchoscopy revealed protrusion of the SEMS into the tracheobronchial tree, a novel complication for this new type of stent.

Malignant tracheo-esophageal fistula: use of esophageal endoprosthesis

Malignant tracheo-esophageal fistula (TEF) is a serious complication of cancer arising usually in the esophagus, lung, or tracheobronchial tree. Repeated aspiration and pneumonia lead to rapid deterioration and death. The prognosis is dismal and curative resections are curiosities. Surgical bypass of the lesion has been performed but is associated with 25-61% mortality. Other treatments have been employed, such as enterostomies, esophageal endoprostheses, and supportive care. The reported mortality of palliative procedures using endoprostheses, surgical bypass, or exclusion in almost identical. A retrospective review of the data over the past decade revealed a trend toward insertion of endoprostheses. Insertion of endoprostheses can be performed in an endoscopy suite, under sedation, and has fewer major complications than occur with a surgical approach. The periprocedure mortality rate for these patients is 15%, compared to a 29-47% perioperative mortality for patients undergoing surgery. Even so, patients after surgical procedures could survive for 8 months or more, which is better than survival after endoprosthesis intubation. We conclude that insertion of an esophageal endoprosthesis should be the usual preferred option for palliative treatment of malignant TEF. However, for special candidates a surgical procedure is a valid option.

Self-expanding metal stents for palliation of malignant obstruction in the upper gastrointestinal tract. Comparative assessment of three stent types implemented in 96 implantations

Self-expanding metal stents provide a new option for the palliative treatment of malignant stenoses from tumors of the esophagus. Our present study provides a comparative assessment of clinical experience gained consecutively in the implementation of three stent versions in a total of 87 patients and 96 implantations. Thirty-one Wallstents (Scheider, Lusanne, Switzerland) (five coated) were implanted in 23 patients, 35 Ultraflex stents (Boston Scientific, Boston, MA, U.S.A.) (uncoated) in another 34 patients, and 30 Gianturco-Z stents (Cook, Winston-Salem, NC, U.S.A.) (all coated) in a group of 30 patients. In the three patient groups there were no significant differences as to the degree of dysphagia, number of pretreatments, length of the tumor stenosis, tumor location, or histological classification. Seven patients who had been treated with Gianturco-Z stents presented with an esophagorespiratory fistula. Technically, all 96 implantation procedures were successful. Complete sealing of the fistulas was verified by radiography in all patients who had developed fistulas. Severe early complications in the form of stent migration were encountered in only three of 96 implantations (3%). Within the early period after stent placement in five patients of the Wallstent group (22%), 13 patients of the Ultraflex group (37%), and three patients of the Gianturco group (10%), retreatments were necessary due to stent dislocation and/or insufficient stent expansion. The degree of dysphagia improved distinctly and with a comparable development in all three patient groups. The rate of reintervention (percentage of patients) due to major and minor problems in the follow-up period amounted to 43% (Wallstents), 35% (Ultraflex stents), and 21% (Gianturco-Z stents). In view of the low number of complications (3%) in the early stage of implantation, self-expanding metal stents provide an improved approach for palliative therapy of malignant stenoses of the esophagus. Nevertheless, further technological improvements are necessary to reduce the great frequency of unavoidable reinterventions (20-43%) in the follow-up period.

Plastic prosthesis versus expandable metal stents for palliation of inoperable esophageal thoracic carcinoma: a controlled prospective study

BACKGROUND

Rapid palliation of malignant dysphagia is usually possible with endoscopic implantation of a plastic prosthesis, but this device has a high rate of complications. Recently, expandable metal stents, a new class of endoprosthesis, have become available and may reduce complication rates.

METHODS

Thirty nine patients affected by esophageal thoracic cancer were randomly assigned to treatment with either a plastic stent (20 patients) or expandable metal stent (19 patients). The degree of palliation (expressed as dysphagia score) and incidence of complications (short- and long-term) were compared in both treatment groups.

RESULTS

Technical success, as a percentage of successful intubation, was similar in both treatment groups (90% vs 94.7%, p = NS) and dysphagia scores improved significantly and similarly in both treatment groups. Nevertheless, complications and mortality related to implantation were significantly less frequent with metal stents than with plastic prostheses (complications: 0% vs 21%, p < 0.001; mortality: 0% vs. 15.8%, p < 0.001). Late complications included obstruction by food in both treatment groups (four cases with plastic stents vs four cases with metal stents), tube migration only with plastic prostheses (two cases) and tumor ingrowth only with metal stents (two cases).

CONCLUSIONS

Expandable metal stents can be considered an effective and safer alternative to conventional plastic prostheses in the treatment of esophageal obstruction caused by inoperable cancer.

Treatment of esophageal obstruction from mediastinal compressive tumor with covered, self-expanding metallic Z-stents

BACKGROUND

Mediastinal malignancies may involve the esophagus, leading to esophageal stenosis and dysphagia. Rigid and self-expanding esophageal stents have been used for effective palliation, but their use in extrinsic, compressive lesions is controversial.

METHODS

A retrospective review of self-expanding Gianturco-Rösch Z-stents that were successfully placed in 13 patients with malignant esophageal obstruction due to extrinsic lesions.

RESULTS

All patients had an improvement in dysphagia of at least two dysphagia grades. The mean dysphagia grade fell from 3.15 to 0.62. Mean survival was 2.2 months. Early (within 48 hours) procedure-related complications occurred in 4 of 13 patients and consisted of minor, transient chest pain that resolved within 6 hours (3 patients) and endoscopic stent dislodgment into the stomach (1 patient). Late complications (> 48 hours) occurred in 2 patients and consisted of a partial proximal stent migration and the development of a benign stricture proximal to the stent. There was no procedural or stent related mortality.

CONCLUSIONS

Esophageal obstruction and malignant dysphagia from extrinsic, compressive mediastinal malignancies can be effectively and safely palliated with self-expanding Gianturco- Rösch Z-stents.

Biochemical effects of oral sodium phosphate

Our objective was to monitor serum and urine biochemical changes after oral sodium phosphate cleansing in a prospectively designed study. The study subjects were seven healthy, asymptomatic adults. Sodium phosphate 45 ml diluted in 45 ml water was given orally at baseline and 12 hr later. Calcium, ionized calcium, phosphorus, sodium, potassium, creatinine, and PTH were analyzed at 2, 4, 6, 9, 12, 14, 16, 18, 21 and 24 hr after the first challenge. Urinary calcium, phosphorus, sodium, potassium, and cyclic AMP were analyzed at baseline and every 2 hr after oral sodium phosphate. Blood pressure, pulse, and respiratory rate were recorded every 2 hr and symptom questionnaires using visual analog scales were completed. A marked rise in phosphorus (peak range 3.6-12.4 mg/dl, P < 0.001) and falls in calcium (P < 0.001) and ionized calcium (P < 0.001) were seen. Rises seen in PTH and urinary cAMP confirmed the physiologic significance of the biochemical effect. There were no significant changes in other serum and urine laboratory or clinical assessments. Reported significant symptoms included bloating, cramps, abdominal pain, and nausea. Significant hypocalcemia and hyperphosphatemia after oral sodium phosphate raises concern about its use in normal individuals. Oral sodium phosphate should not be administered in patients with cardiopulmonary, renal, or hepatic disease.

Expandable versus conventional esophageal prostheses: easier insertion may not preclude subsequent stent-related problems

BACKGROUND

Although expandable esophageal endoprostheses may be easier to insert and are associated with fewer procedure-related perforations, data comparing clinical results with these stents to those obtained with conventional prostheses are sparse.

METHODS

We reviewed the records of all patients undergoing esophageal stent placement at our institution between October 1983 and July 1995 to define relative risks, clinical results, and need for reintervention prior to death, contrasting conventional to a variety of expandable esophageal endoprostheses.

RESULTS

Over the period of review, 47 patients had conventional prostheses (CP) and 38 had expandable prostheses (EP) placed. Fifteen of 44 patients with CP and 14 of 38 with EP for malignancy also had esophago-airway fistulas. Insertion complications, prestent and poststent dysphagia scores, and complete fistula occlusion rates were comparable. Subacute complications were higher in the patients receiving EP (80%) than in those receiving CP (60%), possibly related to the prospective accumulation of data in patients receiving EP. Survival data were virtually identical and approximated 3 months for either group.

CONCLUSIONS

Although both CP and EP improve dysphagia and occlude tracheoesophageal fistulae, patients ill enough to require a prosthesis do poorly regardless of prosthesis design. Moreover, although EP may be easier to insert than CP, stent- and patient-related problems persist and may require additional intervention.

Prior radiation and chemotherapy increase the risk of life-threatening complications after insertion of metallic stents for esophagogastric malignancy

BACKGROUND

Self-expanding metallic stents (SEMS) are effective in relieving the symptoms of obstructing esophagogastric malignancy. While complications with SEMS have been described, factors influencing such occurrence have not been defined.

METHODS

Self-expanding Gianturco-Rosch Z-stents were placed successfully in 59 patients with obstructing esophagogastric malignancies.

RESULTS

Early procedure-related complications occurred in 6 patients (10%) and were usually minor. Twenty-three late complications occurred in 22 patients (37.5%). Life-threatening complications occurred in 9 patients (15%), including gastrointestinal bleeding (7), perforation (1), and tracheoesophageal fistula (1) and contributed to all five deaths. Eight of 22 patients with prior radiation and/or chemotherapy (36.4%) had life-threatening complications compared to 1 of 37 (2.5%) without prior therapy (p = 0.001). Stent-related mortality occurred in 5 of 22 (23%) patients with prior therapy compared to none of the 37 without prior therapy (p = 0.005). Multivariate analysis confirmed the association between prior radiation and/or chemotherapy and life-threatening complications (p = 0.012; odds ratio, 32.63) and also an association with female gender (p = 0.032; odds ratio, 13.9). There was no association with tumor location or length, histologic type, age, prestent dysphagia grade, or previous surgical resection.

CONCLUSION

Patients with prior radiation and/or chemotherapy have an increased risk of severe complications following placement of SEMS.