Covered, expandable esophageal metallic stent tubes: experiences in 119 patients

Palliative treatment of unresectable esophagogastric junction tumors: balloon dilation combined with chemotherapy and/or radiation therapy and metallic stent placement

PURPOSE

To prospectively evaluate an algorithm for palliative treatment of unresectable esophagogastric junction tumors based on stricture length.

MATERIALS AND METHODS

Eighty-six patients with malignant esophagogastric obstructions were referred to the interventional radiology department for balloon dilation or stent placement due to dysphagia. Balloon dilation was performed in patients (n = 39) with a short segmental (< or =4 cm) stricture, whereas stent placement was performed in patients (n = 47) with a long segmental (>4 cm) stricture. In the balloon group, 16 patients with esophageal carcinoma underwent both chemotherapy and radiation therapy, whereas 23 patients with gastric carcinoma underwent only chemotherapy.

RESULTS

Technical success was achieved in all procedures in all patients (100%). The overall clinical success rate of balloon dilation and stent placement for a malignant esophagogastric junction was 87% (75 of 86 patients). Clinical success was achieved in 29 of the 39 patients in the balloon group (74%) and 98% (46 of the 47 patients in the stent group (98%). The overall complication rate was 21% (18 of 86 patients). Seventeen complications, which consisted of reflux (n = 8), migration (n = 6), tumor overgrowth (n = 2), and tissue hyperplasia (n = 1), occurred after stent placement, whereas one complication (intramural rupture) occurred after balloon dilation. The median symptom-free and survival periods were 120 (95% confidence interval: 114, 263) and 147 (95% confidence interval: 98, 196) days, respectively.

CONCLUSIONS

The treatment strategies seem to be reasonable for palliative therapy in patients with malignant esophagogastric junction obstructions. However, further investigations are needed to minimize the drawbacks of the methods and to determine optimal treatments in patients with unresectable malignant esophagogastric junction obstructions.

Self-expandable esophageal stent loaded with 125I seeds: initial experience in patients with advanced esophageal cancer

PURPOSE

To prospectively compare the response to treatment with a self-expandable esophageal stent loaded with iodine 125 ((125)I) seeds for intraluminal brachytherapy versus the response to treatment with a conventional self-expandable covered stent in patients with advanced esophageal cancer.

MATERIALS AND METHODS

The study protocol was approved by the institutional ethics committee, and informed consent was obtained from each patient. Patients from one institution who had dysphagia caused by inoperable esophageal cancer were randomly assigned to receive treatment with a stent loaded with (125)I seeds (irradiation stent group) or a conventional covered stent (control group). After stent implantation, the outcomes were measured in terms of relief of dysphagia, survival time, and complications related to the procedure. Dysphagia was assigned a grade. A P value of less than .05 was considered to indicate a significant difference.

RESULTS

The stent was successfully placed in the diseased esophagus in all 53 patients (27 patients in the irradiation stent group and 26 patients in the control group). The dysphagia grades significantly improved in both groups within the 1st month after stent placement but were better in the irradiation stent group than in the control group after 2 months (P < .05). The median and mean survival times were better in the irradiation stent group than in the control group, and the differences were significant (P < .001). Hemorrhage occurred in 16 (30%) patients in both groups combined during follow-up.

CONCLUSION

In patients with advanced esophageal cancer, treatment with an esophageal stent loaded with (125)I seeds, compared with that with a conventional covered stent, has potential benefit in that it allows a slightly longer relief of dysphagia and extended survival.

Metallic stent placement in patients with recurrent cancer after gastrojejunostomy

PURPOSE

To assess the technical feasibility and clinical effectiveness of placement of expandable metallic stents in patients with recurrent cancer after a gastrojejunostomy.

MATERIALS AND METHODS

Data from 39 consecutive patients who had undergone metallic stent placement for recurrent malignant obstruction after a gastrojejunostomy were retrospectively analyzed. Thirty patients underwent a distal gastrectomy with a gastrojejunostomy with (n=10) or without (n=20) jejunojejunostomy, two patients underwent distal gastrectomy with a Roux-en-Y gastrojejunostomy, and seven patients underwent a palliative gastrojejunostomy with (n=5) or without (n=2) jejunojejunostomy. A total of 57 metallic stents were used in this study: four bare stents, 29 partially covered stents, and 24 fully covered stents. Types of obstruction were classified into 12 patterns and types of stent placement were classified into 16 patterns.

RESULTS

Stent placement was technically successful in all patients. After stent placement, 35 of the 39 patients (90%) experienced improvement of their symptoms, two showed no change, and the remaining two showed aggravation of symptoms as a result of faulty stent placement. Two patients treated with stent placement only in the afferent loop died of aspiration pneumonia. In one of two patients who underwent stent placement according to pattern 6, afferent loop syndrome occurred 10 days after stent placement and was treated by percutaneous pigtail catheter drainage. Stent migration occurred in four of 24 fully covered stents, but in none of the bare or partially covered stents. Tumor ingrowth occurred in one of four bare stents, tumor overgrowth in one of 29 partially covered stents, and mucosal prolapse in one of 24 fully covered stents; all were treated with a second stent placement.

CONCLUSIONS

Placement of expandable metallic stents in patients with recurrent cancer after a gastrojejunostomy seems to be feasible and effective, but accurate knowledge of the type of surgical procedure performed and determination of the pattern of tumor recurrence are important for successful stent placement.

Novel biodegradable stents for benign esophageal strictures following endoscopic submucosal dissection

The application of metallic stents for benign stenosis is limited due to long-term complications. We report here the results of the implantation of a novel biodegradable poly-L-lactic acid (PLLA) esophageal stent in two patients with benign esophageal stenosis after endoscopic submucosal dissection (ESD). Case 1 was a 64-year-old man who received ESD for an early squamous esophageal cancer in the middle esophagus. The mucosal defect was seven-eighths of the circumference, and the distal margin of the resection scar formed the stenosis. After balloon dilatation, the PLLA esophageal stent was endoscopically placed; for 6 months, he has not experienced any symptoms of re-stenosis. Case 2 consisted of a 62-year-old man who developed an early squamous esophageal cancer in the middle esophagus. The lesion was resected by ESD, and the mucosal defect was seven-eighths of the circumference. The resection scar formed the stenosis, and the PLLA esophageal stent was endoscopically placed. He also has not experienced any symptoms of re-stenosis for 6 months. In conclusion, the PLLA esophageal stent provides a new possibility for the management of benign esophageal strictures after ESD. Due to the biodegradable features of this stent, longer term studies are necessary to investigate the relationship between the expected disappearance of the stent and the patency of the stricture.

Long-term effects of achalasia on esophageal motility following temporary internal metal stent dilation

AIM: To explore the long term effects of achalasia on esophageal motility following temporary internal metal stent dilation.

METHODS: Nineteen patients with achalasia had temporary internal metal stents (20-25 mm diameter) placed under X-ray guidance. After stent dilation over 3-7 d, the stents were removed by endoscopy. We measured lower esophageal sphincter (LES) pressure, LES relaxation rate, and 24-hours pH in the 19 patients and 12 healthy control subjects (HS).

RESULTS: LES residual pressure before stent dilation was markedly higher than at 2 wk and 2 years after stent dilation (47.43 ± 9.84 mmHg vs 12.32 ± 5.87 mmHg, and 14.21 ± 7.34 mmHg; P < 0.05). LES relaxation rate was significantly different before stent dilation that at 2 wk and 2 years after (13.33% vs 76.66%, and 73.46%, P < 0.05). The frequency of gastroesophageal reflux (GER) at 2 years after stent dilation was markedly higher than before and two wk and before stent dilation (66.12% vs 27.72%, 2.95%, P < 0.01); residual pressure and relax rate showed no significant difference between HS and after stent dilation of 2 wk and 2 years.

CONCLUSION: Temporary internal metal stent dilation results in lower LES pressure and a higher rate of GER for patients with achalasia in the long term.

Usefulness of biodegradable stents constructed of poly-l-lactic acid monofilaments in patients with benign esophageal stenosis

AIM: To report 13 patients with benign esophageal stenosis treated with the biodegradable stent.

METHODS: We developed a Ultraflex-type stent by knitting poly-l-lactic acid monofilaments.

RESULTS: Two cases were esophageal stenosis caused by drinking of caustic liquid, 4 cases were due to surgical resection of esophageal cancers, and 7 cases were patients with esophageal cancer who received the preventive placement of biodegradable stents for post-endoscopic mucosal dissection (ESD) stenosis. The preventive placement was performed within 2 to 3 d after ESD. In 10 of the 13 cases, spontaneous migration of the stents occurred between 10 to 21 d after placement. In these cases, the migrated stents were excreted with the feces, and no obstructive complications were experienced. In 3 cases, the stents remained at the proper location on d 21 after placement. No symptoms of re-stenosis were observed within the follow-up period of 7 mo to 2 years. Further treatment with balloon dilatation or replacement of the biodegradable stent was not required.

CONCLUSION: Biodegradable stents were useful for the treatment of benign esophageal stenosis, particularly for the prevention of post-ESD stenosis.

Anastomotic Recurrence of Gastric Cancer after Total Gastrectomy with Esophagojejunostomy: Palliation with Covered Expandable Metallic Stents

PURPOSE

To assess the technical feasibility, safety, and clinical effectiveness of the placement of expandable metallic stents in patients with anastomotic recurrence of gastric cancer after total gastrectomy with esophagojejunostomy.

MATERIALS AND METHODS

The authors retrospectively analyzed data from 32 patients in whom metallic stents were placed for recurrent obstruction after total gastrectomy with esophagojejunostomy. Technical and clinical success and complications with related interventions were evaluated. Overall survival and stent patency rates were calculated according to the Kaplan-Meier method.

RESULTS

Stent placement was technically successful in 30 of the 32 patients (94%). After stent placement, 29 patients (91%) experienced improvement of their symptoms. Fourteen complications occurred after stent placement, and these consisted of pain (n = 5, 16%), stent migration (n = 3, 9%), stent obstruction due to tumor overgrowth (n = 4, 13%), and abutment of the tortuous jejunal wall by the end of the stent (n = 2, 6%). In one of five patients with pain, the stent was removed 4 hours after placement because the pain could not be controlled with analgesics. The median survival and stent patency period were 87.0 and 140.0 days, respectively.

CONCLUSION

Placement of covered metallic stents in patients with anastomotic recurrence of gastric cancer after total gastrectomy with esophagojejunostomy is technically feasible, safe, and clinically effective.

Fate of migrated esophageal and gastroduodenal stents: experience in 70 patients

PURPOSE

To investigate the frequency of esophageal and gastroduodenal stent migration and the fate of such stents.

MATERIALS AND METHODS

The authors studied five types of covered metal stents. Type A stents were nonretrievable polyurethane-covered stents with shouldered ends (n = 169), type B stents were retrievable polyurethane-covered stents with shouldered ends (n = 62), type C stents were retrievable polyurethane-covered stents with flared ends (n = 72), type D stents were retrievable polytetrafluoroethylene-covered stents with shouldered ends (n = 369), and type E stents were separated stents (n = 216). Types A-D stents were esophageal stents, and the type E stent was a gastroduodenal stent. Stents were placed in 888 patients with either benign (n = 43) or malignant (n = 845) causes of stricture. The rate of stent migration was analyzed relative to completeness of migration, the cause of obstruction, stent type, and stent placement location. The fate of migrated stents and the treatment of patients were evaluated.

RESULTS

Stent migration occurred in 70 of the 888 patients (7.9%). Migration occurred in 11 of the 43 patients (25%) with benign cause of strictures and 591 of the 845 patients (7.0%) with malignant cause. The migration rates for types A, B, C, D, and E stents were 10%, 4.8%, 24%, 7.3% and 2.8%, respectively. Of the 70 migrated stents, 45 had complete migration and 25 had partial migration. The anastomotic sites were the areas most commonly associated with migration (16%), but this was not statistically significant. Forty of the 70 migrated stents were removed with retrieval devices under fluoroscopic guidance because they were not passed with stool and possibility of complications related to migrated stents. The remaining 30 stents exited via the rectum (n = 15), remained in the body without complications (n = 12), or were surgically removed because they caused complicated intestinal obstructions (n = 3).

CONCLUSION

The overall migration rate for esophageal and gastroduodenal stents was 7.9%. Most migrated stents were removed nonsurgically, exited the body spontaneously, or remained in the body in an uncomplicated state. Surgical stent removal was necessary in three patients (4.3%) due to complicated intestinal obstructions.

Covered Metallic Stent Placement in the Management of Cervical Esophageal Strictures

PURPOSE

To describe the authors' experience with self-expandable covered metallic stents in 16 patients with malignant and benign cervical esophageal strictures.

MATERIALS AND METHODS

Sixteen expandable covered metallic stents were placed with fluoroscopic guidance in 16 patients (14 men, two women; mean age, 60 years; age range, 26-75 years) with malignant and benign strictures of the cervical esophagus. The causes of strictures were ingestion of corrosive agents (n = 3), biopsy-proved squamous cell carcinoma (n = 12), and postsurgical scarring (n = 1). The mean dysphagia scores at presentation were compared with those after stent placement by using the Wilcoxon signed rank test.

RESULTS

Stent placement was technically successful in all patients. The reduction in the mean dysphagia score after stent placement was statistically significant (P = .0327). All patients complained of mild to severe foreign body sensation, with four reporting severe pain necessitating immediate stent removal. With the exception of one patient with limited follow-up, complications requiring intervention occurred in all patients, including migration in nine patients and tissue hyperproliferation in two. Of the 12 patients with a malignant stricture of the esophagus, four patients eventually underwent gastrostomy for the placement of a feeding tube and one patient underwent surgery. All four patients with a benign cervical stricture failed to achieve long-lasting improvement with temporary stent placement.

CONCLUSIONS

Although the placement of covered metallic stents in the cervical esophagus provides adequate initial palliation, it is associated with poor patient tolerance and a high complication rate.

Removal of a Covered Esophageal Metallic Stent 8 Years after Placement

A covered expandable esophageal metallic stent was placed to treat a corrosive esophageal stricture that was refractory to repeated balloon dilations. The stent was removed 8 years after placement due to severe dysphagia. The stented esophageal area has since maintained long-term patency for 2 years. These results suggest the feasibility of removal of a metallic stent after long-term stent placement.

Gastrotracheal and gastrobronchial fistulas: management with covered expandable metallic stents

PURPOSE

The present study evaluated the clinical results of covered tracheobronchial metallic stent placement in the management of gastrotracheal fistulas (GTFs) and gastrobronchial fistulas (GBFs).

MATERIALS AND METHODS

Sixteen patients with GTFs or GBFs after esophagogastrectomy were treated with one of two types of covered tracheobronchial metallic stents: a hinged stent or a straight stent. These included 12 GTFs and four GBFs. Thirteen hinged stents and three straight stents were placed during the initial procedure. Data regarding the technical success of stent placement, initial clinical success and failure, fistula reopening, and complications were obtained.

RESULTS

Stent placement was technically successful in all patients. The stent completely sealed off the fistula in 12 of 16 patients (75% initial clinical success rate), whereas the remaining four patients (25%) had persistent aspiration symptoms as a result of incomplete GTF or GBF closure (ie, initial clinical failure). During follow-up, the fistula reopened in three of the 12 patients in whom initial clinical success was achieved (25%). Two reopened fistulas were sealed off with stent placement, and one was treated with a nasoenteric feeding tube and a nasogastric decompression tube. All patients died during the 1-year follow-up period; mean survival time was 17 +/- 3.02 weeks (range, 1-42 weeks) after stent placement. Mean survival in patients in whom initial clinical success was achieved was significantly longer than in patients with initial clinical failure (P = .003; log-rank test).

CONCLUSION

Use of covered metallic stents appears to be a safe and moderately effective procedure to occlude GTFs and GBFs.

Postoperative esophageal leak management with the Polyflex esophageal stent

OBJECTIVE

Leak after esophageal anastomosis or perforation repair prolongs hospitalization, prevents oral hydration and nutrition, and can produce localized infection or sepsis. This investigation reviews our experience treating postoperative esophageal leaks with the Polyflex esophageal stent (Boston Scientific, Natick, Mass).

METHODS

Over a 30-month period, patients with a postoperative esophageal leak were treated with the Polyflex stent for leak occlusion. Leak occlusion was confirmed by means of esophagraphy. Patients were followed until their stent was removed and their esophageal leak had resolved.

RESULTS

Twenty-one patients had 27 stents placed for leak occlusion after esophagectomy (n = 5), esophageal perforation (n = 5), surgical (n = 4) or endoscopic (n = 2) antireflux procedure, and esophageal diverticulectomy (n = 3) or myotomy (n = 2). The mean interval between surgical intervention and stent placement was 12 +/- 8 days (range, 3-31 days). Occlusion of the leak occurred in 20 patients. One patient experienced a dehiscence of the surgical esophageal perforation repair requiring esophageal diversion. Stent migration requiring repositioning (n = 3) or replacement (n = 4) occurred in 5 (24%) patients. Twenty (95%) stents were removed without residual leak (mean, 51 +/- 43 days; range, 15-175 days). One patient had a stricture after stent removal that required endoscopic dilatation. One patient in this series died.

CONCLUSIONS

The Polyflex esophageal stent is an effective method for occluding a postoperative esophageal leak. It rapidly eliminates contamination of the mediastinum, pleura, and peritoneum; allows oral hydration and nutrition; and is easily removable. These stents also offer an appealing alternative to traditional esophageal diversion and subsequent reconstruction in patients with a persistent esophageal leak.

Repeated coaxial colonic stenting in the palliative management of benign colonic obstruction

In inflammatory bowel disease, strictures of the colon, causing bowel obstruction, is not uncommon. Usually an operative procedure can deal with these strictures. We describe a case of an unfit patient with pulmonary malignancy having a Crohn's stricture of the recto-sigmoid junction in which repeated coaxial placement of self-expanding metallic stents eliminated the need to perform an operation. This is the first report of multiple coaxial colonic stenting. It shows that there is a place for stents in selected cases of inflammatory bowel disease with a limited life expectancy and that repeated colonic stenting makes colonic stenting possible also in patients requiring stents for longer time periods.

Self-expandable stent loaded with 125I seeds: feasibility and safety in a rabbit model

OBJECTIVE

To evaluate technical feasibility and acute and subacute radiotolerance of a self-expandable stent loaded with (125)I seeds in the rabbit esophagus.

METHODS

A self-expandable stent designed for esophageal application was made of 0.16mm nitinol wire and loaded with (125)I seeds (CIAE-6711). Twenty-seven stents with three different radioactive dosages (n=9 in each dosage group) were implanted in the esophagus of healthy rabbits, while nine stents alone were used as controls. The stents were perorally deployed into the esophagus under fluoroscopic guidance. Radiological follow-up included plain chest film, CT scan, and barium esophagography which were undertaken in all rabbits of each group at 2, 4, and 8 weeks, respectively, which were correlated to histopathological findings. The stented esophageal segments along with their adjacent tissues were harvested for histopathological examinations.

RESULTS

The stent was successfully deployed into the targeted esophageal segment in all rabbits. Neither (125)I seeds dislodged from the stent during the deployment, nor they did during the follow-up period. The greatest (16.2Gy) absorbed dose was found in the tissue 10mm from (125)I seeds at 8 weeks. Slight epithelial hyperplasia on the stent surface and submucosal inflammatory process developed at 2 weeks, which reached the peak at 8 weeks after the procedure. Significant thickness of the esophageal muscular layer was found at 8 weeks only in the groups with (125)I seeds. On radiologic follow-up, moderate strictures on both ends of the stents developed at 4 weeks and became severe at 8 weeks after the procedure in all groups.

CONCLUSION

Deployment of a self-expandable stent loaded with (125)I seeds is technically feasible and safe within the first 8 weeks. Acute and subacute radiotolerance of the treated esophagus and its adjacent tissues by (125)I seeds is well preserved in a healthy rabbit model.

Esophageal Stents: Findings on Esophagography in 46 Patients

OBJECTIVE

The purpose of this report is to assess the findings on esophagography in patients with esophageal stents for palliation of malignant tumors involving the esophagus.

CONCLUSION

Radiologists should be familiar with findings of little importance (stent narrowing, flow of contrast medium around stent, stent kinks, and apparent esophageal narrowing below stent because of incompletely distended hiatal hernias) versus more important findings (polypoid defects above or below stent, narrowing within or below stent, delayed stent emptying, esophageal-airway fistulas, stent migration, and abutting of distal stent against greater curvature of stomach) on esophagography after stent placement to guide endoscopists regarding the need for stent revision.

Self-expandable metallic stent placement for patients with inoperable esophageal carcinoma: investigation of the influence of prior radiotherapy and chemotherapy

PURPOSE

The aim of this study was to evaluate the efficacy and complications of self-expandable metallic stent placement for patients with inoperable esophageal carcinoma after radiotherapy and/or chemotherapy.

MATERIALS AND METHODS

We obtained data from 19 patients with advanced or recurrent esophageal carcinoma between 1996 and 2000. In all patients, a self-expandable metallic stent was placed under fluoroscopic guidance. Dysphagia before and after stent placement was graded. Complications after stent placement were also evaluated. Data were compared between patients with and without prior radiotherapy and/or chemotherapy.

RESULTS

The procedure was technically successful in all but one patient. The dysphagia grade improved in all patients. No life-threatening complications occurred. The other major complications such as mediastinitis occurred in two patients, and pneumonia and funnel phenomenon occurred in one patient each. These patients had a history of radiotherapy and/or chemotherapy prior to stent placement. Eight of the twelve patients with prior radiotherapy and/or chemotherapy compared with one of seven patients without prior therapy had persistent chest pain, which was a statistically significant difference (P < 0.05).

CONCLUSION

Placement of self-expandable metallic stents was effective for patients with advanced or recurrent esophageal carcinoma. However, prior irradiation and/or chemotherapy increased the risk of persistent chest pain after stent placement.

Prior chemoradiotherapy is associated with a higher life-threatening complication rate after palliative insertion of metal stents in patients with oesophageal cancer

BACKGROUND

Self-expanding metal stents are used routinely to palliate dysphagia due to oesophageal cancer.

STUDY AIM

To compare the frequency of life-threatening complications after self-expanding metal stent insertion, depending on whether patients received prior chemoradiotherapy or no treatment.

PATIENTS AND METHODS

During 7 years, 116 consecutive patients were treated at a single centre in a palliative intent by insertion of self-expanding metal stent for dysphagia due to an oesophageal cancer. Patients were retrospectively separated into two groups: patients with chemoradiotherapy before self-expanding metal stent insertion (group 1, n = 56) and patients with no treatment before or after self-expanding metal stent insertion (group 2, n = 60). Life-threatening complications were compared and predictive risk factors of postprocedure complications were identified.

RESULTS

Median dysphagia was significantly improved during the first month (grade 3 to grade 1 in the two groups). Early and late major complications occurred more frequently in group 1 (23.2% vs. 3.3%; P < 0.002 and 21.6% vs. 5.1%; P < 0.02 respectively). Prior chemoradiotherapy was the only independent predictive factor of postprocedure major complications, with an odds ratio of 5.59 (CI 95% 1.7-18.1).

CONCLUSIONS

Life-threatening complications after palliative self-expanding metal stent placement seem to occur more frequently in patients with prior chemoradiotherapy. Prevention of these severe complications should be considered before stenting.

[Palliative endoscopic treatments for esophageal cancers]

Esophageal cancer five-year survival has slightly increased during past 20 years (from 5 to 9%), but remains low. At time of diagnosis, 60% of the patients are only relevant for palliative therapy. Recent advances in therapeutic endoscopy have allowed improving dysphagia and quality of life. Endoscopic techniques are chosen according to tumor characteristics. According to French societies guidelines (FFCD, "Standards-Options-Recommandations" from FNCLCC, SNFGE) endoscopic treatment is a "gold standard" for metastatic patients with poor performance status, as well as oesophago-tracheal fistula. Expandable metal stent are efficient for malignant stenosis with lower morbidity and mortality than plastic prosthesis. Endoscopic placement of a covered self-expanding metal stent is the treatment of choice of an esophago-respiratory fistula. Dilatation is often the first step before other endoscopic therapies or medical treatment such as radiochemotherapy. Single dose brachytherapy could provide better long-term relief of dysphagia and fewer complications than stent placement, but is less widespread. Other techniques like bipolar electrocoagulation have restricted indications especially for circonferential stenosis of cervical esophagus. However, the main problem remains the dysphagia relapse after treatment.

Survival and complications after insertion of self-expandable metal stents for malignant oesophageal stenosis

OBJECTIVE

To report on survival and complications after insertion of self-expandable stents in patients with malignant oesophageal stenosis.

MATERIAL AND METHODS

Data were gathered retrospectively from the medical records of 92 consecutive patients in the period 1994-2003. The study comprised 68 men and 24 women (median age 72 years, range 46-93 years) with stenosis from cancer of the oesophagus (n=61), the gastric cardia (n=26) and the lung (n=5), located mainly above (n=4) or below (n=62) the carina, or at the gastro-oesophageal junction (n=26). One uncovered stent and six different covered stents were used.

RESULTS

Median and mean survival times after stenting (n=92) were 83 (range 4-1102) and 125 days, respectively. Thirty-day mortality was 19% (n=17), and 7% (n=6) survived more than one year. Survival was neither significantly influenced by division of the patients into diagnostic subgroups nor by comparison of the three most frequently used stents. One, two, three and four stents were received by 76, 11, 4 and 1 patient(s), respectively. There was no stent-related mortality, and complications were bleeding 1 (1%), stent migration 7 (8%), recurrent stenosis 8 (9%) from both tumour overgrowth (n=8) and tumour ingrowth (n=2) when using uncovered stents. Thirteen (14%) patients were re-stented because of recurrent stenosis (n=8) including fistula formation to the left main bronchus (n=2) and stent migration (n=5).

CONCLUSIONS

Use of self-expandable stents in patients with inoperable malignant oesophageal stenosis carried few complications and resulted in relatively long survival in comparison with similar studies.

A new esophageal stent design (Niti-S stent) for the prevention of migration: a prospective study in 42 patients

BACKGROUND

Covered, rather than uncovered, metal stents are used for the palliation of dysphagia from esophageal cancer, but a major drawback is the risk of stent migration, which occurs in up to 20% of patients. To overcome this problem, a double-layered stent, the Niti-S stent (Taewong Medical, Seoul, Korea), has been developed. The Niti-S stent consists of an inner polyurethane layer to prevent tumor ingrowth and an outer uncovered nitinol wire tube to allow the mesh of the stent to embed itself in the esophageal wall.

METHODS

Between June 2003 and May 2004, 42 patients with malignant dysphagia caused by inoperable carcinoma of the esophagus or gastric cardia were treated with a Niti-S stent. Patients were prospectively followed and data collection focused on recurrent dysphagia, functional outcome, complications, and survival.

RESULTS

At 4 weeks, the dysphagia score had significantly improved from a median of 3 (liquids only) to 0 (ability to eat a normal diet). Five of 42 (12%) patients with a Niti-S stent developed recurrent dysphagia, mainly due to tissue overgrowth (2 of 42; 5%) and stent migration (3 of 42; 7%). Major complications (perforation, 1; aspiration pneumonia, 2; hemorrhage, 2) occurred in 5 of 42 (12%) patients. Pain following stent placement was observed in 5 of 42 (12%) patients, and symptomatic gastroesophageal reflux occurred in 2 of 42 (5%) patients.

CONCLUSIONS

The Niti-S stent provides symptomatic relief of malignant dysphagia and effectively reduces recurrent dysphagia. Its double-layered design is probably important in preventing migration. In addition, the complete covering of the Niti-S stent may be a factor in preventing tissue overgrowth at both ends of the stent.

Fluoroscopically guided insertion of self-expandable metal esophageal stents for palliative treatment of patients with malignant stenosis of esophagus and cardia: comparison of uncovered and covered stent types

The aim of this retrospective study was to present and compare the results of using two different types of esophageal self-expanding stents (uncovered and covered) for palliative treatment of patients with inoperable malignant stenosis of the esophagus and cardia. Over a period of 8 years, 152 patients underwent fluoroscopically guided insertion of metal esophageal stents. We inserted uncovered esophageal nitinol Strecker stents in 54 patients (group I) and covered esophageal Ultraflex stents in the remaining 98 patients (group II). The stent insertion procedure was successively performed in all patients. Closure of esophageal fistula by covered stents was achieved in 8/8 patients. Mean dysphagia score was significantly decreased in both patient groups at 4 weeks follow-up: from 2.73 before stent insertion to 0.15 in group I, and from 2.67 to 0.05 in group II (on 0-4 scale). Eighty-eight per cent of patients with covered stents and 54% with uncovered type were free of symptoms during follow-up. Complications occurring during follow-up and their comparative frequency in the two groups of patients were as follows (group I: group II%): stent migration (0:10%); tumor or granulation tissue ingrowth (100:53%); overgrowth at the ends of stents (17:30%); restenosis causing recurrent dysphagia (37:8%); and appearance of esophageal fistulas (8:6%). In conclusion, fluoroscopically guided insertion of self-expandable esophageal stents is a safe and comfortable method of palliation for patients suffering with malignant dysphagia. In selection of a stent, covered types should be given priority for prevention of restenosis.

A dual expandable nitinol stent: experience in 102 patients with malignant gastroduodenal strictures

PURPOSE

To investigate the technical feasibility and clinical effectiveness of a dual expandable nitinol stent in the palliative treatment of malignant gastroduodenal strictures.

MATERIALS AND METHODS

The dual stent consisted of two stents, an outer partially covered stent and an inner bare nitinol stent. The outer diameter of the stent delivery system was 3.8 mm. With fluoroscopic guidance, the outer stent was placed into the stricture, followed by coaxial placement of the inner stent. The stent placement was attempted in 102 consecutive patients with malignant gastroduodenal strictures. The underlying causes of malignant strictures were gastric cancer (n = 55), pancreatic cancer (n = 24), gallbladder cancer (n = 7), cholangiocarcinoma (n = 5), duodenal cancer (n = 5), and metastatic cancer (n = 6). All patients presented with symptoms of gastric outlet obstruction.

RESULTS

Stent placement was technically successful and well tolerated in 101 of 102 patients (99%). After stent placement, 85 of the 101 patients (84%) with technical success experienced improvement of their symptoms. Tumor overgrowth occurred in five patients, stent migration in two, mucosal hyperplasia in one, bleeding in one, and jaundice in two. Seventy one of the 101 patients died 5 to 340 days (mean, 71 days) after stent placement from progression of their disease, myocardial infarction, bleeding, or sepsis. The remaining 30 patients are still alive 6 to 227 days (mean, 39 days) after stent placement. The 30-day, 60-day, 90-day, and 180-day survival rates were 78%, 58%, 39%, and 8%, respectively.

CONCLUSION

The dual stent with a 3.8-mm stent delivery system is easy to insert, safe, and reasonably effective for the palliative treatment of malignant gastroduodenal strictures.

The use of a retrievable self-expanding stent in treating childhood benign esophageal strictures

BACKGROUND/PURPOSE

Esophageal stenting is a popular form of treatment of esophageal strictures in adults but is not widely used in children. The aim of the current study was to investigate whether esophageal stents could be used safely and effectively in the treatment of esophageal stenosis in children.

METHODS

Covered retrievable expandable nitinol stents were placed in 8 children with corrosive esophageal stenosis. The stents were removed 1 to 4 weeks after insertion.

RESULTS

The stents were placed in all patients without complications and were later removed successfully. After stent placement, all patients could take solid food without dysphagia. Stent migration occurred in one patient and so the insertion procedure was repeated to reposition the stent. During the 3-month follow-up period after stent removal, all children could eat satisfactorily. After 6 months, 2 children required balloon dilation (3 times in one and 5 times in the other). The dysphagia score improved in all patients.

CONCLUSIONS

The use of the covered retrievable expandable stent is an effective and safe method in treating childhood corrosive esophageal stenosis.

Remember to Crush the Tablets After Esophageal Stent Insertion

The main mode of palliation for inoperable esophageal cancer is by insertion of expandable metallic stents. While major complications include occlusion by tumor ingrowth and migration, impaction by food has been reported in as many as 10% of cases. Although patients are routinely instructed to follow a soft and finely minced diet after insertion of esophageal stents, stent blockage can still occur if patients swallow large-sized tablets. We report a case of stent blockage by 2 large-sized tablets, about which the endoscopist did not forewarn the patient or his family. The tablets were eventually dislodged easily through a repeat endoscopy. We caution about the possibility of such complication after esophageal stenting. We recommend inspection of patients' medication before the stenting procedure as well as instructing patients, their family, and care providers to crush their large-sized tablets before consumption.

Comparison of Temporary and Permanent Stent Placement with Concurrent Radiation Therapy in Patients with Esophageal Carcinoma

PURPOSE

To assess the clinical effectiveness of temporary metallic stent placement with concurrent radiation therapy in patients with esophageal carcinoma by comparing it with permanent stent placement with concurrent radiation therapy.

MATERIALS AND METHODS

Covered retrievable expandable nitinol stents were placed in 47 patients with esophageal carcinoma 1 week before starting radiation therapy; the stents were electively removed 4 weeks after placement in 24 patients (group A), while not electively removed in the other 23 patients (group B). In cases of complications, the stents were also removed from patients in groups A and B. The dysphagia score, complications (severe pain, granulation tissue formation, stent migration, esophagorespiratory fistula, and hematemesis), tumor overgrowth/regrowth, reintervention rates, and dysphagia-progression-free and overall survival rates were compared in the two groups.

RESULTS

Stent placement or removal was technically successful and well tolerated in all patients. The dysphagia score was significantly improved in both groups after stent placement (P < .01). Each of the stent-related complications was less in group A than in group B but there was no significant difference. However, the total number of patients with one or more than one complications and who needed related reinterventions was significantly less in group A than in group B (P = .042 and .030, respectively). Tumor overgrowth/regrowth and the total number of patients who required related reinterventions was not significantly different (P = 1.00 and .517, respectively). Dysphagia-progression-free and overall survival rates were significantly longer in group A than in group B (P = .005 and .001, respectively).

CONCLUSION

Temporary placement of a covered retrievable expandable metallic stent with concurrent radiation therapy for patients with esophageal carcinoma is beneficial for reducing complications and related reinterventions and for increasing resultant survival rates compared with permanent esophageal stent placement.

Cervical oesophageal stent placement via a retrograde transgastric route

During attempted oesophageal stent placement in a patient with cervical oesophageal cancer in whom swallowing of even saliva was impossible, transoral access to the cervical oesophagus was unsuccessful. Under ultrasound and fluoroscopy guidance, percutaneous gastric puncture was performed, and using an angiographic catheter and guidewire, access to the oesophagus by a retrograde transgastric route was successfully achieved. The obstructed segment of the oesophagus was traversed. It was then possible to pull the guidewire through the mouth and place an oesophageal stent via an antegrade approach.

Removal of retrievable esophageal and gastrointestinal stents: experience in 113 patients

OBJECTIVE

Although there are frequent clinical situations in which esophageal and gastrointestinal stents should be removed, nonsurgical stent removal has been difficult. The purpose of our study was to describe the safety and efficacy of removing the retrievable nitinol stents with a retrieval hook.

MATERIALS AND METHODS

Under fluoroscopic guidance, the removal of 119 esophageal, six gastroduodenal, and five rectal retrievable stents was attempted in 113 patients using a retrieval hook. Indications for stent removal included migration (n = 35), severe pain (n = 23), formation of a new stricture (n = 13), incomplete stent expansion (n = 7), airway compression (n = 2), esophagorespiratory fistula (n = 2), malpositioned stent (n = 1), and hematemesis (n = 1). The remaining 46 stents were electively removed.

RESULTS

Of the 130 stents, 127 (97.7%) were successfully removed despite the following difficulties: untied drawstrings (n = 4), separation of the stent (n = 3), and fracture (n = 2) or disconnection (n = 2) of a retrieval hook. The removal procedure failed in three cases (2.3%). The causes of failure were the inability to place the hook into the migrated stent (n = 2) and a tight stricture above the migrated stent (n = 1). The procedure-related complications included minor (n = 4) and major (n = 1) bleeding and intramural rupture (n = 3). One patient died of major bleeding after removal of an esophageal stent.

CONCLUSION

The stent retrieval hook is useful for removing retrievable esophageal and gastrointestinal stents.

Use of a newly designed multifunctional coil catheter for stent placement in the upper gastrointestinal tract

PURPOSE

To evaluate the usefulness of a newly designed multifunctional coil catheter for stent placement in patients with upper gastrointestinal tract strictures.

MATERIALS AND METHODS

Constructed in our research laboratory, the coil catheter was used in 202 consecutive patients with malignant (n = 191) or corrosive (n = 11) upper gastrointestinal tract strictures. The coil catheter was made of a stainless-steel coil (1.3-mm inner diameter, 1.8-mm outer diameter), a 0.4-mm nitinol wire, a polyolefin tube, and a hemostasis valve. Usefulness of the coil catheter was evaluated based on whether the coil catheter could pass the stricture over a guide wire and whether measurement of the stricture length was possible while the guide wire was in place.

RESULTS

The passage of the coil catheter over a guide wire beyond the stricture was technically successful and well tolerated in 199 of 202 patients (99%). Negotiation of a guide wire or a coil catheter through the stricture of the stomach (n = 2) or duodenum (n = 1) under fluoroscopic guidance failed in three patients. In two of these three patients, it was possible to negotiate a guide wire and a coil catheter under combined endoscopic and fluoroscopic guidance; it was not possible in the third. There were no procedure-related complications.

CONCLUSION

The newly designed multifunctional coil catheter is useful in stent placement in patients with upper gastrointestinal tract strictures.

Comparative retrospective study on the use of plastic prostheses and self-expanding metal stents in the palliative treatment of malignant strictures of the esophagus and cardia

Palliative treatment of malignant strictures of the esophagus and cardia is usually carried out by the endoscopic placement of a prosthesis. The aim of this retrospective study was to evaluate short- and long-term outcomes of the use of expandable stents, compared with conventional plastic prostheses. One hundred and thirteen endoscopic intubations were carried out in 120 patients affected by malignant stenosis of the esophagus and cardia using plastic prosthesis and self-expanding metal stents. Dysphagia was scored according to Atkinson and Ferguson's classification and the preoperative median score (3.6) was comparable in both groups. The technical success rate was 94.4% with plastic prosthesis and 93.7% with self-expanding metal stent while the functional success rate was, respectively, 85.2% and 88.8%. Three deaths occurred with plastic prostheses (4.4%), while no deaths were observed with metal stents. A comparative analysis of the results of this study suggests that the endoscopic placement of self-expanding metal stents is effective and safe and has to be preferred to the conventional plastic prosthesis for easier implantation and lower morbidity.

Endoskopische Palliation der malignen Magenausgangsstenose durch selbstexpandierbare Metallstents

INTRODUCTION

Malignant gastric outlet stenosis is caused by tumour obstruction and restricts the oral intake of food, resulting in a seriously reduced quality of life. Endoscopic implantation of self expanding metal stents (SEMS) can clear stenosis in the GI-tract and reestablish and preserve the passage in the GI-tract.

PATIENTS AND METHODS

Between October 2001 and April 2003 seven patients with malignant gastric outlet stenosis have been treated by the implantation of SEMS. Four patients had malignant stenosis in the upper duodenum or gastric antrum, two patients had stenosis because of tumour recurrence in the efferent loop of the jejunum after gastric resection because of gastric carcinoma and one patient had an obstruction 20 cm distal of the oesophagus after gastrectomy because of gastric cancer.

RESULTS

In all patients obstruction was cleared by the implantation of SEMS, and oral intake of food was possible in all patients after two days. No serious complications occurred during or after stent implantation.

CONCLUSION

Stent implantation for the treatment of malignant gastric outlet stenosis is a cost effective procedure, associated with low risk and low stress for the patient, and provides excellent palliation of symptoms in patients with malignant gastric outlet stenosis.

Follow-up evaluation for benign stricture of upper gastrointestinal tract with stent insertion

AIM: To determine the best mothod for benign stricture of the upper gastrointestinal tract (UGIT) with stent insertion by follow-up evaluation.

METHODS: A total of 110 stents insertions were performed in 110 cases of benign stricture of the UGIT. Permanent (group A) and temporary (group B) placement of an expandable metal stent in 30 cases and 80 cases respectively. All cases were completed under fluoroscopy.

RESULTS: In group A, 30 uncovered or antireflux covered or partially covered expandable metal stents were placed permanently. In group A, 5 cases (16.7%) in 3-months, 5 cases (20.0%) in 6-months, 6 cases (25%) in the 1st year, 6 cases (50%) in the 3^rd year, and 4 cases (80%) in the 5^th year exhibited dysphagia relapse. In group B, a partially-covered expandable metal stent was temporarily placed in each patient and removed after 3-7 d via gastroscopy. Follow-up data in this group showed that 8 cases (7.5%) in 3-months, 9 cases (12.0%) in 6-months, 10 cases (15.4%) in the 1^st year, 6 cases (20%) in the 3^rd year, and 3 cases (25%) in the 5^th year exhibited dysphagia relapse. The placement and withdrawal of all stents were all performed successfully. The follow-up of all cases lasted for 3-99 mo (mean 41.6 ± 19.7 mo).

CONCLUSION: The best mothod for benign stricture of UGIT with stent insertion is temporary placement of a partially-covered expandable metal stent.

Temporary partially-covered metal stent insertion in benign esophageal stricture

AIM: To study the therapeutic efficacy of temporary partially-covered metal stent insertion on benign esophageal stricture.

METHODS: Temporary partially-covered metal stent was inserted in 83 patients with benign esophageal stricture. All the patients had various dysphagia scores.

RESULTS: Insertion of 85 temporary partially-covered metal stents was performed successfully in 83 patients with benign esophageal stricture and dysphagia was effectively remitted in all the 83 cases. The dysphagia score was 3.20 ± 0.63 (mean ± SD) and 0.68 ± 0.31 before and after stent insertion, and 0.86 ± 0.48 after stent removal. The mean diameter of the strictured esophageal lumen was 3.37 ± 1.23 mm and 25.77 ± 3.89 mm before and after stent insertion, and 16.15 ± 2.96 mm after stent removal. Follow-up time was from 1 week to 96 months (mean 54.26 ± 12.75 months). The complications were chest pain (n = 37) after stent insertion, and bleeding (n = 12) and reflux (n = 13) after stent removal.

CONCLUSION: Temporary partially-covered metal stent insertion is one of the best methods for treatment of benign esophageal stricture.

Severe complications in advanced esophageal cancer treated with radiotherapy after intubation of esophageal stents: a questionnaire survey of the Japanese Society for Esophageal Diseases

PURPOSE

A questionnaire survey was performed to evaluate the complications and prognosis of esophageal cancer treated with esophageal intubation before or during radiotherapy.

METHODS AND MATERIALS

Clinical data were accumulated on a total of 47 patients treated at 17 institutions in Japan. Five patients had Stage II, 30 Stage III, and 11 Stage IV, and the stage was unknown in 1 patient. Covered expandable metallic stents were inserted in 30 patients, uncovered expandable metallic stents in 13, plastic or silicon prosthesis in 3, and an unknown type in 1 patient. Esophageal stenting was performed before the start of RT for 23 patients and during the course of RT for 24 patients. The reasons for the stenting were severe stricture in 32 patients (Group 1) and esophageal fistula in 15 patients (Group 2).

RESULTS

The most frequent toxicity was formation or worsening of esophageal fistulas in 13 patients (28%), followed by massive hematemesis or GI bleeding in 10 patients (21%). In total, 24 patients (51%), including 10 patients with possible treatment-related deaths (Grade 5), had nonhematologic toxicities of Grade 3-5. The interval from the start of RT to the nonhematologic toxicity ranged from 16 to 312 days (median 78). The incidence of toxicities was higher for Group 1 (59%) than for Group 2 (33%), although the difference was not statistically significant. The median survival time for those with Stage II-III and Stage IV was 5 and 3.5 months, respectively.

CONCLUSIONS

Patients with esophageal intubation before or during RT have a high risk of life-threatening complications, especially for those with severe esophageal stricture. Because long survival is expected for a substantial proportion of patients with locally advanced esophageal cancer after chemoradiotherapy, palliative intubation should be delayed until radiotherapy or chemoradiotherapy appears to have failed.

A randomised prospective comparison of the Flamingo Wallstent and Ultraflex stent for palliation of dysphagia associated with lower third oesophageal carcinoma

BACKGROUND

Covered metallic oesophageal stents offer effective palliation of malignant oesophageal strictures. However, first generation devices were associated with a high rate of migration, particularly when used in the lower oesophagus.

AIM

To compare the rate of complications and palliative effect of two newer covered metallic oesophageal stents.

PATIENTS AND METHODS

We performed a prospective randomised study using two of these newer stent designs in the treatment of malignant lower third oesophageal tumours. Fifty three patients with dysphagia due to inoperable oesophageal carcinoma involving the lower third of the oesophagus were randomly selected to receive either a Flamingo covered Wallstent (Boston Scientific Inc., Watertown, Massachusetts, USA) or an Ultraflex covered stent (Boston Scientific Inc.). Dysphagia was scored on a five point scale, recorded before stent insertion, the day after, and at least one month later at follow up. Technical success, early and late complications (perforation, migration, severe gastro-oesophageal reflux, haematemesis, and reobstruction due to tumour overgrowth) were also recorded.

RESULTS

In both stent groups, a significant improvement in dysphagia score was seen both the next day post stenting and at late follow up (p<0.05). No significant difference was seen in the improvement in dysphagia between the two groups (p>0.1). The frequency of complications encountered in the two groups was similar. Three patients in the Ultraflex group required two stents at primary stenting.

CONCLUSION

The two types of stent are equally effective in the palliation of dysphagia associated with lower third oesophageal malignancy and the complication rates associated with their use are comparable.

New approach to malignant strictures of the esophagus

Primary esophageal cancer is the most common cause of malignant esophageal stricture. Prognosis and treatment outcomes vary with the stage of the disease. Endoscopic ultrasound has a high accuracy rate for local and regional staging. Surgery is curative for early cancer. Endoscopic mucosal resection, photodynamic therapy, or brachytherapy can be used with curative intent for early cancer, especially in patients with comorbid conditions precluding surgery. Unfortunately, the majority of patients with esophageal cancer present with advanced disease. The primary aim in these patients is to alleviate symptoms with a minimum of side effects and reinterventions. Palliative surgery or chemoradiotherapy can be associated with high morbidity and mortality rates. Several endoscopic techniques for palliation are available, and all have the potential of significantly improving swallowing. The choice of a particular endoscopic approach is usually determined by local expertise and characteristics of the stricture.

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

PURPOSE

To compare the effectiveness of an antireflux stent with that of a standard open stent in preventing symptoms of gastroesophageal reflux in patients with inoperable distal esophageal cancer.

MATERIALS AND METHODS

Fifty consecutive patients with inoperable distal esophageal tumors underwent placement of either a standard open or an antireflux stent across the cardia. Stents were allocated randomly before assessment of the stricture. All patients were followed up prospectively by the departmental research nurses. Technical and clinical success, reflux symptoms, complications, and reintervention rates were assessed. P values of observed differences were calculated by using the chi(2) and log-rank tests as appropriate.

RESULTS

The technical success rate was 100%. Improvement in dysphagia was identical in both groups (three points on a five-point scale). Twenty-four (96%) of 25 patients with standard open stents had symptoms of esophageal reflux; 19 (76%) of 25 required treatment. Three (12%) of 25 patients with antireflux stents reported esophageal reflux; one (4%) of 25 required treatment. This difference was significant (P <.001). There was no significant difference in survival, complications, or reintervention rate. One case of late esophageal perforation occurred in each group. One patient died of aspiration within 24 hours after insertion of a standard open stent; no procedure-related deaths occurred with the antireflux stent.

CONCLUSION

This antireflux stent is as safe and effective as the standard open stent in relieving malignant dysphagia and was successful in reducing symptomatic gastroesophageal reflux.

Self-expandable metal stents in the management of cervical oesophageal and/or hypopharyngeal strictures

AIM

To assess the usefulness of self-expandable metal stents in the recanalization of cervical and/or hypopharyngeal strictures.

MATERIALS AND METHODS

We report our experience in 10 patients with inoperable cervical and/or hypopharyngeal strictures treated by implantation of 11 uncovered self-expandable metal stents inserted perorally under fluoroscopic guidance. The stent was placed in the hypopharynx and cervical oesophagus in 3 patients and cervical oesophagus alone in 7. There were 8 men and 2 women, mean age 70.2 years, range 45-85 years. All patients but two had malignant stricture caused by squamous cell carcinoma, in one case there was a benign postoperative stenosis secondary to laryngectomy, and in the last patient a local recurrence from thyroid cancer.

RESULTS

Eleven stents were placed in 10 patients: technical success was achieved in 9 cases while clinical improvement was obtained in 8 cases. Seven of ten patients had a rapid improvement of dysphagia. One patient had a distal misplacement of the prosthesis, while in the other two cases stent position was very proximal and interfered with swallowing. A mean 9-month follow-up was obtained (range 3-24 months). Four patients with malignant stricture developed proliferation of neoplastic tissue after 2-5 months. The only patient treated for a benign stricture developed inside proliferation of granulation tissue after 4 months.

CONCLUSION

Despite several technical difficulties and a high rate of late complications, recanalization of cervical oesophageal strictures by self-expandable metal stents allowed good palliation of symptoms. Stents proved to be effective and well tolerated palliative treatment also for hypopharyngeal stenoses.

Randomized clinical trial comparing self-expanding metallic stents with plastic endoprostheses in the palliation of oesophageal cancer

BACKGROUND

There is little evidence of the clinical and cost effectiveness of self-expanding metallic stents in the palliation of oesophageal cancer. The aims of this randomized trial were to evaluate the immediate and medium-term clinical outcomes following palliative intubation, examine patient quality of life, and evaluate costs and benefits from the perspective of the health service.

METHODS

Fifty patients with inoperable oesophageal cancer were randomly allocated a metallic stent (n = 25) or plastic endoprosthesis (n = 25). Patients were followed up monthly until death.

RESULTS

There was no significant difference in procedure-related complications or mortality rate between the two groups. There was a trend towards significance in favour of metallic stents with respect to quality of life and survival (median survival 62 versus 107 days for plastic prosthesis and metallic stent respectively). The cost of the initial placement of metallic stents was significantly higher than that of plastic endoprostheses ( pound 983 versus pound 296). After 4 weeks, cost differences were no longer significant.

CONCLUSION

Metallic stents may contribute to improved survival and quality of life in patients with oesophageal cancer. Although initially more expensive, this cost difference does not last beyond 4 weeks. A larger trial involving approximately 300 patients would be required to detect a quality of life benefit of the magnitude observed in this trial.

Self-expandable covered metallic esophageal stent impregnated with beta-emitting radionuclide: an experimental study in canine esophagus

PURPOSE

A specially designed self-expandable covered metallic stent impregnated with the beta-emitting radioisotope 166Ho (166Ho, energy: 1.85 and 1.76 MeV, T12: 26.8 h) was developed at our institute for the purpose of intraluminal palliative brachytherapy, as well as for treating malignant esophageal stricture and swallowing difficulty. The aim of this study was to evaluate the tissue response to brachytherapy and the safety of the radioactive metallic stent with regard to the normal canine esophagus before clinical application.

METHODS AND MATERIALS

166Ho was impregnated into the polyurethane membrane (50 micron thickness) covering the outer surface of a self-expandable metallic stent (diameter, 18 mm; length, 40 mm). Stents with radioactivity 4.0-7.8 mCi (Group A, n = 15), 1.0-1.8 mCi (Group B, n = 5), and 0.5-0.7 mCi (Group C, n = 5) were placed in the esophagi of 25 healthy beagle dogs, and the stents were tightly anchored surgically to prevent migration. The estimated radiation dose calculated by Monte Carlo simulation was 194-383 Gy in Group A, 48-90 Gy in Group B, and 23-32 Gy in Group C. The dogs were killed 8-12 weeks after insertion of the stents, and histologic examinations of the esophageal walls were performed.

RESULTS

In Group A, 3 of 15 dogs died of wound infection, so specimens were obtained from only 12 dogs; all 12 cases showed esophageal stricture with mucosal ulceration. Microscopically, severe fibrosis and degeneration of the muscular propria were found in 3 dogs, complete fibrosis of the entire esophageal wall was found in 7 dogs, and esophageal fibrosis with radiation damage within periesophageal soft tissue was found in 2 dogs. However, esophageal perforation did not develop, despite extremely high radiation doses. In Group B, glandular atrophy and submucosal fibrosis were found, but the muscular layer was intact. In Group C, no histologic change was found in 3 dogs, but submucosal inflammation and glandular atrophy with intact mucosa were found in 2 dogs.

CONCLUSIONS

A radioactive, self-expandable covered metallic stent can be used as an alternative therapeutic modality for the palliative treatment of malignant esophageal stricture.

Intervention in gastrointestinal tract: the treatment of esophageal, gastroduodenal and colorectal obstructions with metallic stents

With the development of newer stent designs and delivery systems, metallic stents are currently established component of nonsurgical treatment of gastrointestinal obstructions. The use of metallic stents is not intended to be curative but palliative. This palliation may be intended for the rest of the patient's life with unresectable disease or as a temporary procedure prior to a definitive surgical procedure to allow time to improve the patient's overall medical condition or quick and noninvasive decompression of the intestinal obstruction.

Retrievable covered nitinol stents: experiences in 108 patients with malignant esophageal strictures

PURPOSE

The authors report their experience with three types of retrievable covered nitinol stents in patients with malignant esophageal strictures.

MATERIALS AND METHODS

Three types of retrievable covered nitinol stents were designed. Type A stents were placed in 45 patients, type B stents were placed in 29 patients, and type C stents were placed in 34 patients. The stents were removed with use of a stent retrieval set under fluoroscopic guidance when the stents caused complications. Stent patency, symptom relief, survival rate, and complications were analyzed relative to stent type and radiation therapy.

RESULTS

The timing of radiation and the stent type have significant effects on occurrence of complications such as stent migration and fistula formation (P =.002 and P = 0.029, respectively). Complications were significantly more frequent in patients with the type B stent than those with type A or type C stents (P =.008). Patients who underwent radiation therapy before stent placement or who underwent no radiation therapy experienced substantially less complications than those who underwent radiation therapy after stent placement (P =.005 and P <.001, respectively). The survival period was significantly longer in patients who underwent radiation therapy after stent placement than in the other groups (P =.034). Stents were removed from 15 patients (14%) 2 days to 16 weeks (mean, 4 weeks) after stent placement as a result of severe pain (n = 7), stent migration (n = 6), or stent deformity (n = 2). Stent removal was well tolerated in all patients.

CONCLUSION

Use of retrievable covered nitinol stents seems to be a safe and effective method of treatment in patients with malignant esophageal strictures. However, removal of the stents was needed in 14% of the patients because of complications. Patients who underwent radiation therapy after stent placement and those with the type B stent experienced more complications than other patients.

Malignant gastric outlet obstructions: treatment by means of coaxial placement of uncovered and covered expandable nitinol stents

PURPOSE

To assess whether coaxial placement of uncovered and covered expandable nitinol stents overcomes the disadvantages of the increased migration rate seen with covered stents and the tumor ingrowth seen in uncovered stents in the treatment of malignant gastric outlet obstructions.

MATERIALS AND METHODS

Two types of expandable nitinol stent were designed: an uncovered stent and a covered stent. Under fluoroscopic guidance, the uncovered and covered stents were placed coaxially with complete overlap in 39 consecutive patients with malignant gastric outlet obstruction caused by stomach cancer. Food intake capacity was graded on a scale of 0-4. Stent patency rate was estimated by the Kaplan-Meier method.

RESULTS

Technical success rate was 97% (38 of 39 patients). After stent placement, food intake capacity improved at least one grade in 36 patients. Stent migration occurred in three patients (8%), that is, partial (n = 2) or complete (n = 1) upward migration of the inner covered stent into the stomach. Two of these patients were treated by placement of an additional covered stent. During the mean follow-up period of 134 days (range, 15-569 d), 10 patients developed recurrent symptoms of obstruction with tumor overgrowth being the most common cause. Nine underwent placement of an additional covered stent with good results. The median period of primary stent patency was 157 days (mean, 278 d). The 30-, 60-, and 180-day patency rates were 97%, 91%, and 39%, respectively. Four patients (10%) died within 1 month after the procedure.

CONCLUSION

Coaxial stent placement technique seems to contribute to decreasing the migration rate of the stent and decrease the rate of recurrent obstruction by preventing or delaying tumor ingrowth.