101
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Benítez Roldán A, López-Cepero Andrada J, López Silva ME. [Post-surgical esophageal fistula: closure with self-expanding polyester prosthesis]. GASTROENTEROLOGIA Y HEPATOLOGIA 2001; 24:461. [PMID: 11722825 DOI: 10.1016/s0210-5705(01)79003-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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102
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Lee SH. The role of oesophageal stenting in the non-surgical management of oesophageal strictures. Br J Radiol 2001; 74:891-900. [PMID: 11675304 DOI: 10.1259/bjr.74.886.740891] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
The role of oesophageal stenting continues to evolve, with several new stents currently on the market. These stents possess anti-reflux valves, internal plastic coatings and retrievable threads. In patients with malignant dysphagia, management should ideally take place within multi-disciplinary teams such that accurate tumour staging occurs prior to treatment. Multi-modality therapy can not only improve dysphagia and response rates but may also improve survival. Several non-surgical palliative techniques are available to recanalize malignant obstruction, including oesophageal stenting. Other therapeutic modalities include the use of endoluminal laser therapy, photodynamic therapy, argon beam and bipolar electrocoagulation, ethanol injection and intracavity brachytherapy. Their use often depends on local availability and expertise. Although the initial costs of metal stents are high, the overall costs compare favourably with other forms of palliative therapy that often require multiple procedures with repeated inpatient hospitalization. Treatment of refractory benign strictures with oesophageal stents remains uncommon and several recent reports using retrievable stents appear to improve outcome, although more work is required in this area.
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Affiliation(s)
- S H Lee
- Department of Radiology, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK
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103
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Austin AS, Khan Z, Cole AT, Freeman JG. Placement of esophageal self-expanding metallic stents without fluoroscopy. Gastrointest Endosc 2001; 54:357-9. [PMID: 11522978 DOI: 10.1067/mge.2001.117153] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND Fluoroscopy is routinely used to guide the placement of self-expanding metallic stents for the palliative treatment of patients with esophageal malignancy. This is a description of a novel method of stent placement without fluoroscopy. METHODS This technique relies on a clear endoscopic view of the proximal radiopaque marker on the stent. This was achieved by the application of an external white marker at this level. A gastroscope was passed, allowing guidewire deployment and measurement of stricture length. The endoscope was reinserted and placed alongside the guidewire giving direct visualization of the proximal margin of the stricture. The stent delivery device was positioned, keeping the white mark visible proximal to the stricture, and the stent was deployed. RESULTS Thirty consecutive patients with inoperable esophageal malignancy underwent endoscopic placement of self-expanding metal stents. Deployment in satisfactory position without fluoroscopy was successful in 23 of 30 (77%); there were no complications. CONCLUSIONS The majority of esophageal stents can be accurately positioned without fluoroscopy.
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Affiliation(s)
- A S Austin
- Department of Medicine, Derby City General Hospital NHS Trust, United Kingdom
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104
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Siersema PD, Hop WC, van Blankenstein M, van Tilburg AJ, Bac DJ, Homs MY, Kuipers EJ. A comparison of 3 types of covered metal stents for the palliation of patients with dysphagia caused by esophagogastric carcinoma: a prospective, randomized study. Gastrointest Endosc 2001; 54:145-53. [PMID: 11474382 DOI: 10.1067/mge.2001.116879] [Citation(s) in RCA: 199] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND There are currently 3 types of covered metal stents available in Europe for palliation of patients with malignant dysphagia. Their relative merits have not been compared in a prospective, randomized study. METHODS One hundred consecutive patients with esophagogastric carcinoma were randomized to placement of an Ultraflex stent, a Flamingo Wallstent, or a Gianturco-Z stent. Malignant strictures of the esophagus were treated by insertion of a small-diameter stent (n = 71), whereas those involving the gastric cardia were treated with a large-diameter stent (n = 29). RESULTS At 4 weeks, dysphagia had improved in all patient groups (p < 0.001), but the degree of improvement did not differ among the 3 groups (p = 0.14). There were differences among the 3 stent types with respect to major complications (Ultraflex stent: 8/34 [24%], Flamingo Wallstent: 6/33 [18%], and Gianturco-Z stent: 12/33 [36%]), but these were not statistically significant (p = 0.23). Nine patients (26%) with an Ultraflex stent, 11 (33%) with a Flamingo Wallstent, and 8 (24%) with a Gianturco-Z stent had recurrent dysphagia (p = 0.73), mainly because of tumor overgrowth or stent migration; 12 of 13 episodes of migration involved small-diameter stents in the esophagus. CONCLUSIONS All 3 covered metal stents evaluated offer the same degree of palliation of patients with malignant dysphagia. Placement of Gianturco-Z stents was associated with more complications as compared with Ultraflex stents and Flamingo Wallstents. Although stent migration is reduced by increasing stent diameter, tumor overgrowth remains an intractable problem that requires a new approach.
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Affiliation(s)
- P D Siersema
- Departments of Gastroenterology and Hepatology and Epidemiology and Biostatistics, University Hospital Rotterdam-Dijkzigt, Rotterdam, The Netherlands
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105
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Lee JM, Han YM, Kim CS, Lee SY, Lee ST, Yang DH. Fluoroscopic-guided covered metallic stent placement for gastric outlet obstruction and post-operative gastroenterostomy anastomotic stricture. Clin Radiol 2001; 56:560-7. [PMID: 11446754 DOI: 10.1053/crad.2001.0700] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
AIM To evaluate the feasibility and safety of fluoroscopic-guided covered metallic stent placements in providing palliative care for patients with inoperable malignant gastric outlet obstruction. MATERIALS AND METHODS Under fluoroscopic guidance, placement of self-expandable, covered stents was attempted in 20 patients with inoperable or recurrent gastric cancer (age range 36-79 years). All patients had inoperable gastric outlet obstruction, 13 with native anatomy and seven with post-operative anatomy (gastrointestinal anastomotic sites). All patients had intolerance to oral alimentation and/or vomiting after ingestion. Success was defined both technically and clinically. RESULTS The placement of the stent was technically successful in 18 patients and failed in two patients (technical success: 90%). The cause of the technical failures was an inability to negotiate the guide wire through the obstruction sites in spite of the use of both fluoroscopic and endoscopic guidance. After stent placement, 15 patients were able to ingest at least liquids and had a markedly decreased incidence of vomiting (clinical success: 75%). During the mean follow-up of 6 weeks, there have been no stent reocclusion and no life-threatening complications except migration of two stents in one patient. CONCLUSION Fluoroscopically guided covered metallic stent placement appears to be valuable for the palliative treatment of malignant obstruction of gastric outlet and post-operative gastrointestinal anastomoses.
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Affiliation(s)
- J M Lee
- Department of Radiology, Chonbuk National University Hospital, Chonbuk, Korea.
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106
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Invited commentary. Ann Thorac Surg 2001. [DOI: 10.1016/s0003-4975(01)02684-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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107
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Christie NA, Buenaventura PO, Fernando HC, Nguyen NT, Weigel TL, Ferson PF, Luketich JD. Results of expandable metal stents for malignant esophageal obstruction in 100 patients: short-term and long-term follow-up. Ann Thorac Surg 2001; 71:1797-801; discussion 1801-2. [PMID: 11426750 DOI: 10.1016/s0003-4975(01)02619-4] [Citation(s) in RCA: 104] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Expandable metal stents palliate malignant dysphagia in most cases, but early complications and outcomes in long-term survivors have not been well described. This report summarizes our experience with expandable metal stents for malignant dysphagia. METHODS Over a 48-month period, 127 stents were placed in 100 patients with dysphagia from esophageal cancer (93%) or lung cancer. Most had undergone prior treatment. Dysphagia scores, duration of palliation, complications, and reintervention were evaluated. RESULTS Immediate improvement in dysphagia was observed in 85% of patients with no procedure-related deaths. Dysphagia score decreased from 3.3 before stent to 2.3 (p < 0.005). Average interval to reintervention was 80 days. In 40 patients surviving more than 120 days, 31 (78%) required reintervention. Major complications occurred in 3 patients receiving poststent chemoradiation (tracheoesophageal fistula, T1 vertebral body abscess, mediastinal abscess). Other complications included unsatisfactory deployment requiring immediate removal (3 patients), migration (11 patients), pain requiring removal (2 patients), food impaction (10 patients), and tumor ingrowth (37 patients). CONCLUSIONS Expandable metal stents offer excellent short-term palliation of malignant dysphagia. In long-term survivors, recurrent dysphagia requiring reintervention is common. In a small subset of patients receiving chemoradiation after stent placement, major complications were observed.
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Affiliation(s)
- N A Christie
- Section of Thoracic Surgery, University of Pittsburgh, Pennsylvania, USA
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108
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Do YS, Choo SW, Suh SW, Kang WK, Rhee PL, Kim K, Shim YM, Park KB, Han YH, Choo IW. Malignant esophagogastric junction obstruction: palliative treatment with an antireflux valve stent. J Vasc Interv Radiol 2001; 12:647-51. [PMID: 11340148 DOI: 10.1016/s1051-0443(07)61493-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
The authors assessed the efficacy of an antireflux valve stent in the palliation of malignant esophagogastric junction (EGJ) obstruction after in vitro testing of the stent. Seventeen patients with inoperable malignant EGJ obstruction were treated. Antireflux valves, made of three polyurethane leaflets, were attached to the distal part of the stent to prevent reflux. When the flow rate of normal saline was 100 mL/sec in the forward direction, the valve fully opened at a pressure of 10 mm Hg. When the flow rate of normal saline was 0.35 mL/sec in the backward direction, the valve nearly completely closed at a pressure of 10 mm Hg. Stent placement was successful in all patients without complications. The median dysphagia score decreased significantly, from 3.0 (dysphagia to liquids) to 1.0 (dysphagia to normal solid food) (P < .0005). No patients experienced reflux symptoms. There was one case of stent migration. A valve stent that can prevent major reflux is an effective device for the palliation of malignant EGJ obstruction.
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Affiliation(s)
- Y S Do
- Department of Radiology, Sungkyunkwan University School of Medicine, Samsung Medical Center, 50 Ilwon-dong, Kangnam-ku, Seoul 135-710, Korea
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109
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Mosca F, Stracqualursi A, Portale TR, Consoli A, Latteri S. Palliative treatment of malignant esophageal stenosis: the role of self-expanding stent endoscopic implantation. Dis Esophagus 2001; 13:301-4. [PMID: 11284978 DOI: 10.1046/j.1442-2050.2000.00137.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Endoscopic tube implantations were carried out in 40 patients with malignant stenosis of the esophagus and gastric cardia using self-expanding metallic stents. The indications for endoscopic intubation were the advanced stage of the tumor in 27 cases and risk factors that made resection inadvisable in 13 cases. In three patients, it proved impossible to implant a stent endoscopically because we were not able to pass the guide wire through the stenosis, whereas correct stent placement was achieved in 37 cases. Functional results were good in 33 patients, but four patients did not show any improvement of symptoms. Complications occurred in nine patients (24.3%): two bleedings, three neoplastic obstructions, one food obstruction, and three distal dislodgements of the prosthesis were observed, but could be readily corrected. No deaths occurred. The median survival time was 151 days (range 25-545 days). This study suggests that endoscopic placement of metallic self-expanding stents is safe and is to be preferred to plastic stents for easier implantation and lower morbidity.
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Affiliation(s)
- F Mosca
- Unit of Thoracic and General Surgery, Department of Surgery, University of Catania, Catania, Italy
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110
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Wang MQ, Sze DY, Wang ZP, Wang ZQ, Gao YA, Dake MD. Delayed complications after esophageal stent placement for treatment of malignant esophageal obstructions and esophagorespiratory fistulas. J Vasc Interv Radiol 2001; 12:465-74. [PMID: 11287534 DOI: 10.1016/s1051-0443(07)61886-7] [Citation(s) in RCA: 128] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
PURPOSE To evaluate delayed complications after esophageal expandable metallic stent placement. MATERIALS AND METHODS From April 1993 to December 1997, 90 expandable metallic stents were placed in 82 consecutive patients with inoperable malignant esophageal obstruction (n = 49) or malignant esophagorespiratory fistula (n = 33). Stents used included covered Gianturco-Rosch Z stents (n = 20), Wallstents (covered, n = 31; uncovered, n = 13), and Ultraflex stents (covered, n = 8; uncovered, n = 10). Patients were followed prospectively and monitored for delayed complications, defined as major (hemorrhage, tracheal compression, stent migration, perforation or fistula formation, granulomatous obstruction, tumor ingrowth and overgrowth, funnel phenomenon, and stent covering disruption) or minor (reflux, chest pain, and food impaction). RESULTS Mean survival was 4.5 months after stent placement (range, 3 weeks to 26 months). The overall incidence of delayed complications was 64.6%, with 17 patients (20.7%) experiencing more than one complication. The rates of delayed complications in patients with Z stents, Wallstents, and Ultraflex stents were 75.0%, 68.1%, and 44.4%, respectively (P <.05). Most complications were life-threatening and occurred more frequently when stents were placed in the proximal third of the esophagus, compared with more distally (P <.05). Thirteen patients (15.9%) died from complications directly related to stent placement. CONCLUSION Esophageal stent placement for malignant obstruction or fistula is associated with a substantial incidence of delayed complications.
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Affiliation(s)
- M Q Wang
- Division of Cardiovascular and Interventional Radiology, Stanford University Medical Center, Stanford, CA 94305, USA
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111
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Ackroyd R, Watson DI, Devitt PG, Jamieson GG. Expandable metallic stents should not be used in the treatment of benign esophageal strictures. J Gastroenterol Hepatol 2001; 16:484-7. [PMID: 11354292 DOI: 10.1046/j.1440-1746.2001.02367.x] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Expandable metallic stents have become popular in recent years for the treatment of esophageal strictures. While they are undoubtedly of great value in the palliation of malignant strictures and tracheo-esophageal fistulas, there is concern over their use for the treatment of benign diseases. We report three cases, in which such problems were seen following stent insertion for benign esophageal strictures. All three patients developed further strictures above the stents, one was complicated by a tracheo-esophageal fistula and two stents (in one patient) migrated distally into the stomach. Two of the patients underwent subsequent esophageal surgery. In both cases, this proved extremely difficult and hazardous because of the intense fibrotic reaction induced by the stents. Expandable mesh stents should not be used for the treatment of benign esophageal strictures without careful consideration of the potential problems, which can include rendering the problem inoperable.
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Affiliation(s)
- R Ackroyd
- University of Adelaide, Department of Surgery, Royal Adelaide Hospital, South Australia, Australia
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112
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Morgan R, Adam A. Use of metallic stents and balloons in the esophagus and gastrointestinal tract. J Vasc Interv Radiol 2001; 12:283-97. [PMID: 11287504 DOI: 10.1016/s1051-0443(07)61906-x] [Citation(s) in RCA: 63] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
The majority of malignant and benign strictures in the esophagus and GI tract can be treated with use of minimally invasive alternatives to surgery such as balloon dilation or metallic stents. Virtually any obstructing lesion in the esophagus, stomach, duodenum, colon, and rectum can be treated with these methods with use of interventional radiologic or endoscopic techniques. In general, metallic stents are reserved for malignant strictures and balloon dilation is indicated for benign lesions. Patients with malignant esophageal fistulas and perforations can be palliated effectively and promptly by sealing the fistula or leak by deployment of a covered stent. Patients with malignant disease may benefit from a treatment regime that includes metallic stent placement, chemotherapy, radiation therapy and/or brachytherapy, although the efficacy of such combined therapies has yet to be defined. Further refinements to stent design are required. The ideal stent would be resistant to tumor ingrowth and migration. Placing a coating material on uncovered stents to prevent tumor ingrowth may achieve these aims. Finally, a biodegradable stent that dissolves before the development of intimal hyperplasia might enable stents to be used to treat benign strictures.
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Affiliation(s)
- R Morgan
- Department of Radiology, St. George's Hospital, London, UK.
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113
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Golder M, Tekkis PP, Kennedy C, Lath S, Toye R, Steger AC. Chest pain following oesophageal stenting for malignant dysphagia. Clin Radiol 2001; 56:202-5. [PMID: 11247697 DOI: 10.1053/crad.2000.0609] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
AIM The palliative use of self-expanding metallic stents has been widely reported to relieve dysphagia in cases of oesophageal carcinoma. Little has been documented on the severity of chest pain following oesophageal stenting. The aim of this study was to investigate the association of pain with oesophageal stenting for malignant dysphagia. METHODS Fifty-two patients with inoperable oesophageal carcinoma underwent stent placement between 1995-1999. Daily opioid analgesic requirements (mg of morphine equivalent doses) were monitored for 3 days before and 7 days after stenting. The degree of palliation was expressed as a dysphagia score (0-3). Hospital stay, readmission days, stent complications and patient survival time were also recorded. RESULTS Twenty-six patients (50%) required opioid analgesia for chest pain (median dose: 80 mg morphine/day) within 48 h of the procedure compared to 11 (21.2%) patients before stenting (P = 0.0041). A significant increase was evident in the analgesic consumption following stent deployment (P < 0.001). The dysphagia score improved by a median value of 1 (CI 0.25)P < 0.001, with a re-intervention rate of 11.5%. The median survival time was 40 days post stenting (range 1-120). CONCLUSION A significant proportion of patients developed chest pain after oesophageal stenting, requiring high dose opioid analgesia. As the origin of the pain is still unknown, pre-emptive analgesia may a play role in reducing stent-related morbidity and possibly in-hospital stay.
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Affiliation(s)
- M Golder
- Department of General Surgery, University Hospital Lewisham, London, UK
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114
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Affiliation(s)
- O Kohl
- Department of Internal Medicine, Division of Cardiology and Angiology, University Hospital Giebetaen, Germany
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115
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De Palma GD, Iovino P, Catanzano C. Distally migrated esophageal self-expanding metal stents: wait and see or remove? Gastrointest Endosc 2001; 53:96-8. [PMID: 11154500 DOI: 10.1067/mge.2001.110731] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Extraction of a migrated esophageal stent may be extremely difficult with a substantial risk of complications including esophageal perforation and hemorrhage. METHODS Retrospectively 242 patients were evaluated who underwent implantation of self-expanding metal stents (SEMS) and 13 (5.4%) were identified with distal stent migration. In all cases of stent dislocation into the stomach, extraction of the stent was not attempted and a new stent was inserted. RESULTS Twelve patients had dysphagia. One patient underwent surgery because of stent impaction in the colon, 3 had unrecognized passage of the stent per rectum, and 9 had evidence of the stent into the stomach. Further severe complications were not observed in any patient and all stents remained into the stomach. CONCLUSION Complications arising from migrated esophageal stents are uncommon. Further studies are warranted to determine which patients with migrated SEMS warrant stent retrieval.
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Affiliation(s)
- G D De Palma
- Department of Surgery and Advanced Technologies, Service of Digestive Endoscopy, University of Naples Federico II, School of Medicine, Naples, Italy
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116
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Fukuda T, Hirota S, Matsumoto S, Yoshikawa T, Motohara T, Nishida Y, Sugimura K. Periodic endoscopic observation of postoperative esophageal stricture due to excessive tissue hyperproliferation after stent placement. Gastrointest Endosc 2001; 53:111-4. [PMID: 11154505 DOI: 10.1067/mge.2001.110736] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- T Fukuda
- Department of Radiology, Kobe University School of Medicine, Kobe, Japan
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117
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Roy-Choudhury SH, Nicholson AA, Wedgwood KR, Mannion RA, Sedman PC, Royston CM, Breen DJ. Symptomatic malignant gastroesophageal anastomotic leak: management with covered metallic esophageal stents. AJR Am J Roentgenol 2001; 176:161-5. [PMID: 11133560 DOI: 10.2214/ajr.176.1.1760161] [Citation(s) in RCA: 84] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVE Gastroesophageal anastomotic leak after cancer resection has a mortality rate of up to 60% and significant morbidity, whatever the mode of treatment. We assessed the efficacy of esophageal stenting as a therapeutic option to reduce the mortality and morbidity associated with symptomatic intrathoracic anastomotic leakage. SUBJECTS AND METHODS During a 52-month period, 14 patients had placement of stents for clinically significant postoperative leaks: 10 patients had an esophagogastrectomy and four patients had a total gastrectomy with esophagojejunal anastomosis. Thirteen of 14 patients had tumors that were histologically staged as T3 N1 M0 or worse. Significant anastomotic leaks were revealed by a contrast-enhanced study at 3-28 days after surgery. Stents were inserted in patients in whom the leakage was debilitating or initial conservative treatment had failed. Stenting outcome in terms of clinical and radiologic healing, hospital stay, survival, and complications was assessed. RESULTS No procedural morbidity or 30-day mortality occurred. Immediate postprocedural leak occlusion was obtained in all patients. Clinical healing of the leak occurred in 13 (92.8%) of 14 patients, with a median healing time of 6 days. Of the 13 patients, healing occurred within 10 days in 10 patients (76.9%). Eight of these 10 early closures received a knitted nitinol stent (p = 0.02). One patient (7%) died as a consequence of leakage at 135 days. Median survival for all 14 patients was 11 months (Kaplan-Meier method). Complications included five episodes of food blockages in three patients, which required endoscopic clearance, and one case of stent-related upper gastrointestinal hemorrhage. No patients developed anastomotic stricture or occlusive epithelial hyperplasia. CONCLUSION Covered esophageal stenting appears to reduce the mortality and morbidity of symptomatic anastomotic leakage after surgery for gastroesophageal cancer. Knitted nitinol stents may be best suited to this purpose.
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Affiliation(s)
- S H Roy-Choudhury
- Department of Radiology, Hull and East Yorkshire Hospitals NHS Trust, Anlaby Rd., Kingston Upon Hull, East Yorkshire, HU3 2JZ, United Kingdom
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118
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Lee JM, Han YM, Lee SY, Kim CS, Yang DH, Lee SO. Palliation of postoperative gastrointestinal anastomotic malignant strictures with flexible covered metallic stents: preliminary results. Cardiovasc Intervent Radiol 2001; 24:25-30. [PMID: 11178709 DOI: 10.1007/s002700000385] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE To evaluate the efficacy of the placement of covered metallic stents for palliation of gastrointestinal anastomotic strictures secondary to recurrent gastric cancer. METHODS Under fluoroscopic guidance, placement of one or two self-expandable covered metallic stents was attempted perorally in 11 patents (aged 48-76 years) with anastomotic stenoses due to recurrent gastric malignancies. The strictures involved both the afferent and efferent loops in three patients. All patients had poor peroral food intake with severe nausea and vomiting after ingestion. The technical and clinical success was evaluated. RESULTS Placement of the covered stent was technically successful in 13 of 15 (87%) attempts in ten patients. After the procedure, 9 of 11 (82%) patients overall were able to ingest at least a liquid diet and had markedly decreased incidence of vomiting. During the follow-up of 2-31 weeks (mean 8.5 weeks) there were no major complications. CONCLUSION These preliminary results suggest that flexible, covered stents may provide effective palliation of malignant anastomotic stricture secondary to recurrent gastric cancer.
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Affiliation(s)
- J M Lee
- Department of Diagnostic Radiology, Chonbuk National University Hospital, 634-18 Keumam-Dong, Chonju-shi, Chonbuk 561-712, Korea.
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119
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Miyayama S, Matsui O, Kifune K, Yamashiro M, Yamamoto T, Kitagawa K, Kasahara Y, Asada Y, Iida Y, Miura S. Malignant colonic obstruction due to extrinsic tumor: palliative treatment with a self-expanding nitinol stent. AJR Am J Roentgenol 2000; 175:1631-7. [PMID: 11090392 DOI: 10.2214/ajr.175.6.1751631] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE The purpose of this study was to evaluate the usefulness of self-expanding nitinol stents for palliative treatment of malignant colorectal obstruction caused by unresectable extrinsic tumor, colorectal metastasis, or peritoneal seeding. SUBJECTS AND METHODS One covered stent and 10 uncovered stents were deployed in eight patients with colorectal obstruction due to extrinsic tumor under fluoroscopic guidance. The sites of obstruction were located in the rectum (n = 5), in the rectosigmoid colon (n = 2), and from the transverse colon to the descending colon (n = 1). Clinical usefulness and complications were analyzed. RESULTS Stents were placed successfully in all patients. Minor modifications of the delivery system were required in the tortuous rectosigmoid and lower rectum strictures. Symptoms of obstruction were initially resolved in all but one patient. In that patient, the presence of other points of obstruction was suspected. Bowel obstruction recurred in two patients: one obstruction was due to migration of a covered stent 4 days after the procedure, and the other obstruction was due to peritoneal seeding 33 days after the procedure. Both required colostomy or ileostomy. All patients died 12-111 days after stent placement (mean, 56 days). In five patients (63%), colonic obstruction was palliated by placing a stent until the patients' death between 39 and 111 days after stent placement (mean, 62 days). Six complications occurred in four patients and included stent migration (n = 1), anal bleeding (n = 2), anal pain that required analgesia (n = 1), and fever (n = 2). CONCLUSION; This self-expandable nitinol stent adequately palliated 63% of patients with colonic obstruction due to extrinsic tumor in this small series. Patient selection is very important to the success of this treatment.
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Affiliation(s)
- S Miyayama
- Department of Diagnostic Radiology, Fukuiken Saiseikai Hospital, 7-1, Funabashi, Wadanaka-cho, Fukui 918-8503, Japan
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120
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Song HY, Jung HY, Park SI, Kim SB, Lee DH, Kang SG, Il Min Y. Covered retrievable expandable nitinol stents in patients with benign esophageal strictures: initial experience. Radiology 2000; 217:551-7. [PMID: 11058659 DOI: 10.1148/radiology.217.2.r00nv03551] [Citation(s) in RCA: 142] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE To investigate the safety and clinical effectiveness of covered retrievable expandable nitinol stents in 25 patients with a benign esophageal stricture. MATERIALS AND METHODS Under fluoroscopic guidance, covered retrievable expandable nitinol stents were placed in 25 patients with a benign esophageal stricture and were removed with a retrieval hook 1-8 weeks later. RESULTS Stent placement was successful in all patients, with no procedural complications. After stent placement, all patients could ingest solid food. The stents were successfully removed from all but two patients. One patient passed the stent via the rectum, and the other regurgitated a high cervical stent. After stent removal, one patient developed a small esophagobronchial fistula, which spontaneously sealed within 1 week of stent removal. After stent removal or migration, all patients could ingest solid food. During follow-up (mean, 13 months; range, 2-25 months) after stent removal or migration, 12 patients maintained their improvement in dysphagia and needed no further treatment. Thirteen patients with recurrence were treated by means of repeat balloon dilation. CONCLUSION Use of retrievable expandable nitinol stents seems to be a safe and effective method of treatment in selected patients with benign esophageal strictures.
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Affiliation(s)
- H Y Song
- Department of Diagnostic Radiology, University of Ulsan College of Medicine, Seoul, Korea.
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121
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Jung GS, Song HY, Kang SG, Huh JD, Park SJ, Koo JY, Cho YD. Malignant gastroduodenal obstructions: treatment by means of a covered expandable metallic stent-initial experience. Radiology 2000; 216:758-63. [PMID: 10966707 DOI: 10.1148/radiology.216.3.r00au05758] [Citation(s) in RCA: 132] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
PURPOSE To investigate the technical feasibility and clinical effectiveness of a polyurethane-covered expandable nitinol stent in the treatment of malignant gastroduodenal obstructions. MATERIALS AND METHODS The stent was constructed in-house by weaving a single thread of 0.2-mm nitinol wire in a tubular configuration and was covered with polyurethane solution by means of a dipping method. With fluoroscopic guidance, the stent was placed in 19 consecutive patients with malignant gastric outlet obstruction (n = 15) or duodenal obstruction (n = 4). All patients had severe nausea and recurrent vomiting, and their obstructions were inoperable. RESULTS Stent placement was technically successful in all but one patient. After stent placement, symptoms improved in all but one patient, who had another stenosis at the proximal jejunum. One patient with stent placement in the second portion of the duodenum became jaundiced. During the mean follow-up of 11 weeks, stent migration occurred in five patients 1-4 days after the procedure. All patients with stent migration were treated by means of placing a second, uncovered nitinol stent. Two of these five patients showed recurrence of stricture because of tumor ingrowth; they underwent coaxial placement of a third, covered nitinol stent with good results. CONCLUSION Placement of a polyurethane-covered expandable nitinol stent seems to be technically feasible and effective for palliative treatment of inoperable malignant gastroduodenal obstructions. Stent migration, however, is problematic and requires further investigation.
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Affiliation(s)
- G S Jung
- Department of Diagnostic Radiology, College of Medicine, Kosin University, Pusan, South Korea
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122
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Abstract
OBJECTIVE Achalasia is treated with pneumatic dilation or myotomy, and botulinum toxin injections are occasionally used. We review our community's experience with expandable metal stents in six patients who failed medical treatment or were poor surgical candidates. METHODS Eight stents were placed in six patients between July 1995 and November 1997. Four patients had achalasia and two pseudoachalasia. Four patients underwent successive botulinum toxin injections. One patient only agreed to periodic Maloney dilatations or a stent. Pneumatic dilation was performed in one patient and considered high risk in the rest. All were poor surgical candidates. Three different stents were used: Gianturco Rosch Z stent, Wallstent I, and Wallstent II. RESULTS One-month mortality and morbidity were 33% and 50%, respectively. Two patients were asymptomatic on a liquid diet for > or =6 months but required repeat endoscopy for recurrent dysphagia because of food bolus impaction and proximal stent migration in each. CONCLUSIONS Expandable metal stents in achalasia or pseudoachalasia do not provide sustained symptom relief, and their use is associated with unacceptably high morbidity and mortality. We do not recommend the use of these devices in patients who have failed medical therapy or who are poor surgical candidates.
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Affiliation(s)
- S Mukherjee
- Department of Medicine, State University of New York Health Science Center at Syracuse, USA
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123
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Watson GMT, Grundy A. Non‐vascular hollow organ gastrointestinal intervention. IMAGING 2000. [DOI: 10.1259/img.12.3.120209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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124
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Kim HC, Han JK, Kim TK, Do KH, Kim HB, Park JH, Choi BI. Duodenal perforation as a delayed complication of placement of an esophageal stent. J Vasc Interv Radiol 2000; 11:902-4. [PMID: 10928530 DOI: 10.1016/s1051-0443(07)61809-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Affiliation(s)
- H C Kim
- Department of Radiology and the Institute of Radiation Medicine, Seoul National University College of Medicine, Korea
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125
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Tanaka T, Maeda M, Uchida H, Yoshioka T, Matsuo Y, Makutani S, Yoshimura H, Kichikawa K, Ohishi H. Clinical results of the internally covered spiral Z stent for malignant esophagogastric obstruction and the reduction of stent migration. J Vasc Interv Radiol 2000; 11:771-6. [PMID: 10877425 DOI: 10.1016/s1051-0443(07)61639-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Affiliation(s)
- T Tanaka
- Department of Radiology and Oncoradiology, Nara Medical University, Japan
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126
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Mauro MA, Koehler RE, Baron TH. Advances in gastrointestinal intervention: the treatment of gastroduodenal and colorectal obstructions with metallic stents. Radiology 2000; 215:659-69. [PMID: 10831681 DOI: 10.1148/radiology.215.3.r00jn30659] [Citation(s) in RCA: 164] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Metallic stents are currently an established component of the endoluminal treatment of stenoses within the blood vessels, bile ducts, esophagus, trachea, and bronchi. With the development of newer stent designs and delivery systems and the general momentum toward minimally invasive therapies, metallic stent placement has expanded into the nonsurgical therapy for gastroduodenal and colorectal obstructions. The use of metallic stents within the stomach, duodenum, or colon is intended not to be curative but to provide nonsurgical palliation for the symptoms of gastric or colonic obstruction. This palliation may be intended for the life of the patient in the case of unresectable disease or as a temporizing procedure prior to a definitive surgical procedure. In the latter clinical scenario, the benefits of a minimally invasive intestinal decompression procedure include (a) quick and noninvasive relief of the intestinal obstruction in an acutely ill patient that obviates a more extensive procedure; (b) allowance of time to improve a patient's overall medical condition and thus to allow a patient to better tolerate the definitive surgical procedure; and (c) reduction of the complexity of the definitive procedure by eliminating the need for staged procedures and allowing the definitive procedure to be performed at one setting.
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Affiliation(s)
- M A Mauro
- Department of Radiology and Surgery, University of North Carolina School of Medicine, Chapel Hill, NC 2759, USA
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127
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Kubba AK, Krasner N. An update in the palliative management of malignant dysphagia. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2000; 26:116-29. [PMID: 10744928 DOI: 10.1053/ejso.1999.0754] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
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.
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Affiliation(s)
- A K Kubba
- Dept of Surgery, University of Nottingham, Liverpool, UK
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128
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Abstract
Self-expanding metallic stents have assumed increasing importance in the palliative treatment of malignant dysphagia in recent years. This is most commonly the result of inoperable oesophageal cancer, but may also be the result of extrinsic compression on the oesophagus by other malignant masses. Stents are also occasionally used as a last resort in benign disease.
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Affiliation(s)
- M G Cowling
- Department of Radiology, St Mary's Hospital, London
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129
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Raltz SL, Kozarek RA. Do age, gender, or tumor location affect outcomes when using metallic stents in the palliative treatment of esophageal carcinoma? Gastroenterol Nurs 1999; 22:249-53. [PMID: 10855121 DOI: 10.1097/00001610-199911000-00005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
UNLABELLED Metallic esophageal stents are marketed as easier to insert with fewer placement and subsequent stent-related problems. Accordingly, we retrospectively/prospectively reviewed our experience placing metallic esophageal stents in malignant strictures. METHODS The research design was a one-group pre- and post-test quasi-experimental design including all patients who underwent metallic stent placement at Virginia Mason Medical Center in Seattle between August 1987 and August 1997. Data included descriptive statistics of patient demographics, pre- and post-dysphagia scores, acute and subacute complications, repeated interventions, and patient survival outcomes. Descriptive statistics, paired t-test assessing pre- and post-dysphagia scores, and 2-way ANOVA were used to analyze the statistical relationship between complications and 1) stent location, 2) patient gender, and 3) patient age. FINDINGS Seventy-five metallic stents were placed in 63 patients. Improvement in pre- and post-dysphagia scores was statistically significant. Factor analysis was not statistically significant for complications and stent location, complications and gender, and complications and age. CONCLUSIONS Metallic esophageal stents showed statistically significant improvement for patient dysphagia. Complications of stent placement did not correlate with location of stent, age, or gender.
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Affiliation(s)
- S L Raltz
- Section of Gastroenterology, Virginia Mason Medical Center, Seattle, Washington 98111, USA
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130
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Eubanks PJ, Hu E, Nguyen D, Procaccino F, Eysselein VE, Klein SR. Case of Boerhaave's syndrome successfully treated with a self-expandable metallic stent. Gastrointest Endosc 1999; 49:780-3. [PMID: 10343228 DOI: 10.1016/s0016-5107(99)70301-9] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- P J Eubanks
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, California, USA
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131
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Pron G, Common A, Simons M, Ho CS. Interventional radiology and the use of metal stents in nonvascular clinical practice: a systematic overview. J Vasc Interv Radiol 1999; 10:613-28. [PMID: 10357489 DOI: 10.1016/s1051-0443(99)70092-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
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.
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Affiliation(s)
- G Pron
- Department of Medical Imaging, University of Toronto, Ontario
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132
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Rollhauser C, Fleischer DE. Late migration of a self-expandable metal stent and successful endoscopic management. Gastrointest Endosc 1999; 49:541-4. [PMID: 10202078 DOI: 10.1016/s0016-5107(99)70062-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- C Rollhauser
- Division of Gastroenterology, Georgetown University Medical Center, Washington, DC, USA
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133
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Abstract
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.
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Affiliation(s)
- A May
- Department of Medicine II, HSK Wiesbaden, Wiesbaden; Department of Medicine I, Friedrich-Alexander-University of Erlangen-Nuremberg, Erlangen-Nuremberg, Germany
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134
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Park HS, Do YS, Suh SW, Choo SW, Lim HK, Kim SH, Shim YM, Park KC, Choo IW. Upper gastrointestinal tract malignant obstruction: initial results of palliation with a flexible covered stent. Radiology 1999; 210:865-70. [PMID: 10207494 DOI: 10.1148/radiology.210.3.r99mr13865] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
The authors treated 21 patients with inoperable upper gastrointestinal tract malignant obstruction from the esophagus to the duodenum by means of intubation with a flexible covered stent with fluoroscopic guidance. Stent placement was successful and relief of dysphagia was immediate in 18 (86%) patients, without serious complication. The average dysphagia score decreased from 2.6 (dysphagia to liquids) to 1.0 (dysphagia to normal solid food). Placement of a flexible covered stent provides easy, safe, and effective palliation of upper gastrointestinal malignant obstruction.
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Affiliation(s)
- H S Park
- Department of Radiology, College of Medicine, Sungkyunkwan University, Samsung Medical Center, Kangnam-ku, Seoul, Korea
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135
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Cowling MG, Mason RC, Adam AN. Esophageal and upper GI stenting. Tech Vasc Interv Radiol 1999. [DOI: 10.1016/s1089-2516(99)80057-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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136
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Abstract
A patient is presented who had previously undergone an esophagectomy for an adenocarcinoma of distal esophagus. He experienced repeated strictures at the esophagogastric anastomosis at 22 cm. After multiple dilatations, a self-expanding metal stent was placed. Four months later the upper edge of the stent eroded through the esophagus into the trachea, forming a tracheoesophageal fistula. Muscle flap repair was successful.
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137
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O'Sullivan GJ, Grundy A. Palliation of malignant dysphagia with expanding metallic stents. J Vasc Interv Radiol 1999; 10:346-51. [PMID: 10102201 DOI: 10.1016/s1051-0443(99)70041-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
PURPOSE The authors describe their experience with expanding metallic stents for the palliation of malignant dysphagia. MATERIALS AND METHODS During a 52-month period, 138 stents were inserted in 121 patients with malignant esophageal obstruction. The average age was 74 years; there were 78 men and 43 women. Data regarding the degree of initial dysphagia, presence of an esophago-respiratory fistula, effect of stent placement on swallowing ability, complications at the time of stent placement, and long-term survival were obtained. RESULTS An improvement in dysphagia symptoms was recorded in more than 95% of patients. The average survival after stent placement was 24 weeks. Complications necessitating further intervention occurred in 26 patients. CONCLUSION Insertion of self-expanding metallic endoprostheses for the palliation of malignant esophageal obstruction is an effective therapy that can be carried out with relative ease. Successful palliation of symptoms can be expected in more than 95% of cases.
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Affiliation(s)
- G J O'Sullivan
- Department of Radiology, St. George's Hospital and Medical School, London, England
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138
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Cowling M. Oesophageal stents for the management of malignant strictures and fistulae. MINIM INVASIV THER 1999. [DOI: 10.3109/13645709909153157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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139
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Köcher M, Dlouhy M, Neoral C, Buriankova E, Gryga A, Duda M, Aujesky R. Esophageal stent with antireflux valve for tumors involving the cardia: work in progress. J Vasc Interv Radiol 1998; 9:1007-10. [PMID: 9840050 DOI: 10.1016/s1051-0443(98)70441-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
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.
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Affiliation(s)
- M Köcher
- Radiologicka Klinika FN, Olomouc, Czech Republic
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140
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Nicholson DA. Tracheal and oesophageal stenting for carcinoma of the upper oesophagus invading the tracheo-bronchial tree. Clin Radiol 1998; 53:760-3. [PMID: 9817095 DOI: 10.1016/s0009-9260(98)80320-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Two cases of combined tracheal and oesophageal stenting for carcinoma of the upper oesophagus invading the tracheo-bronchial tree are described. Case 1 describes the complication of respiratory distress following insertion of a high oesophageal stent. This caused severe stridor which required tracheal stenting. In case 2 prophylactic stenting of the airway prior to oesophageal stenting was performed as a staging CT demonstrated severe compromise of the distal trachea/bronchus in a patient who was experiencing both dysphagia and dyspnoea. In both cases the respiratory and dyspnoeic symptoms were relieved. These cases illustrate the effective use of tracheal/bronchial and oesophageal metal stents in palliating patients with combined respiratory and dysphagic symptoms secondary to oesophageal malignancy. When treating high oesophageal tumours tracheal compromise should be considered and prophylactic stenting of the airway prior to oesophageal stenting performed to avoid further airway compromise when the oesophageal stent expands.
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141
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Laasch HU, Nicholson DA, Kay CL, Attwood S, Bancewicz J. The clinical effectiveness of the Gianturco oesophageal stent in malignant oesophageal obstruction. Clin Radiol 1998; 53:666-72. [PMID: 9766720 DOI: 10.1016/s0009-9260(98)80293-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Between January 1994 and December 1996 72 patients were treated with 76 Gianturco oesophageal stents for oesophageal obstruction or perforation. The patients were followed prospectively in order to determine the effectiveness in improving dysphagia, to establish long term patency, survival times and complications. The mean dysphagia score prior to stenting was 3, improving to a mean score of 1 after stenting. Swallowing failed to improve in three patients. No serious complications were seen at stent insertion. Patients tolerated the procedure well with no complications in 63%. The most frequent immediate complication was chest pain occurring in 15 patients (21%). This settled in all patients with appropriate analgesia, however, four patients required long-term pain relief. In no cases was the chest pain due to perforation. Re-intervention was required in 16.7% of patients, the commonest cause being tumour overgrowth, and this was seen primarily in patients with long survival. The migration rate was low, despite the fact that 45 of 76 stents had been placed with the distal end in the stomach. Only four stents (5.6%) migrated completely, all of which had been deployed across the cardia. In our series the use of the Gianturco oesophageal stents for provided effective palliation of malignant oesophageal obstruction.
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Affiliation(s)
- H U Laasch
- Department of Diagnostic Radiology, Hope Hospital, Salford, UK
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142
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Kos X, Trotteur G, Dondelinger RF. Delayed esophageal hemorrhage caused by a metal stent: treatment with embolization. Cardiovasc Intervent Radiol 1998; 21:428-30. [PMID: 9853152 DOI: 10.1007/s002709900293] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
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.
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Affiliation(s)
- X Kos
- Department of Medical Imaging, University Hospital Sart Tilman, Liège, Belgium
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143
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Ohmura K, Nagashima R, Takeda H, Takahashi T. Temporary stenting with metallic endoprosthesis for refractory esophageal stricture secondary to cylindrical resection of carcinoma. Gastrointest Endosc 1998; 48:214-7. [PMID: 9717794 DOI: 10.1016/s0016-5107(98)70170-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- K Ohmura
- Second Department of Internal Medicine, Yamagata University School of Medicine, Iida-Nishi, Japan
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144
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Abstract
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.
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145
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Siersema PD, Dees J, van Blankenstein M. Palliation of malignant dysphagia from oesophageal cancer. Rotterdam Oesophageal Tumor Study Group. SCANDINAVIAN JOURNAL OF GASTROENTEROLOGY. SUPPLEMENT 1998; 225:75-84. [PMID: 9515757 DOI: 10.1080/003655298750027272] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Palliative therapies for advanced oesophageal cancer include surgery, radiation therapy, chemotherapy, endoscopic procedures and combinations of these. Of the non-endoscopic modalities is external beam radiation therapy (EBRT) effective and non-invasive. A disadvantage is that relief of dysphagia only occurs over a period of 4-6 weeks. Brachytherapy is more rapid in locally controlling tumour growth and in relieving dysphagia. One of the more commonly used endoscopic procedures is laser therapy, which provides symptomatic relief with low complication rates. Recurrent dysphagia is a problem necessitating repeated treatment sessions. Self-expanding metal stents offer a high degree of palliation and are associated with fewer complications compared with prosthetic tubes. Longer palliation and perhaps even longer survival might be achieved by the combination of different therapies. Most promising are the combination of EBRT plus brachytherapy or chemoradiation. Now is the time to determine which treatment (combination) is best for individual patients.
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Affiliation(s)
- P D Siersema
- Dept. of Gastroenterology and Hepatology (Internal Medicine II), University Hospital Rotterdam-Dijkzigt, The Netherlands
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146
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Wayman J, Bliss R, Richardson DL, Griffin SM. Self-expanding metal stents in the palliation of small bowel stenosis secondary to recurrent gastric cancer. Gastrointest Endosc 1998; 47:286-90. [PMID: 9540884 DOI: 10.1016/s0016-5107(98)70328-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- J Wayman
- Department of Interventional Radiology, The Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
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147
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Sherwood P, Duggan A, Shek F, Clarke D, Freeman J. Esophagojejunal stenting for recurrent gastric carcinoma. Gastrointest Endosc 1998; 47:192-4. [PMID: 9512290 DOI: 10.1016/s0016-5107(98)70358-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- P Sherwood
- Derby City General Hospital, Derby, United Kingdom
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148
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Abstract
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.
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Affiliation(s)
- N R Lagattolla
- Department of Surgery, Eastbourne District General Hospital, UK
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149
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Cowling MG, Hale H, Grundy A. Management of malignant oesophageal obstruction with self-expanding metallic stents. Br J Surg 1998; 85:264-6. [PMID: 9501832 DOI: 10.1046/j.1365-2168.1998.00562.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The use of self-expanding metal stents for palliation of malignant dysphagia is increasing. Experience in 70 patients was reviewed with respect to the value of stenting and management of the complications encountered. METHODS Oesophageal stents were inserted in 70 patients (42 men) of mean age 73 years with malignant oesophageal obstruction. Data regarding stent insertion and degree of dysphagia were gathered prospectively. RESULTS Seventy-six stents were placed in 70 patients. By the end of the study 57 patients had died and 13 were still alive. Three patients died within 3 days of stent insertion and dysphagia was relieved in 64 of the 67 patients remaining. Stent migration, tumour ingrowth and overgrowth, and food impaction were encountered during follow-up in eight patients. CONCLUSION Insertion of self-expanding metal stents for the palliation of malignant oesophageal obstruction is a successful therapy which can be carried out with relative ease. Palliation of dysphagia with an appropriate stent can be expected in up to 95 per cent of patients.
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Affiliation(s)
- M G Cowling
- Department of Diagnostic Radiology, St George's Hospital and Medical School, London, UK
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150
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Siersema PD, Hop WC, Dees J, Tilanus HW, van Blankenstein M. Coated self-expanding metal stents versus latex prostheses for esophagogastric cancer with special reference to prior radiation and chemotherapy: a controlled, prospective study. Gastrointest Endosc 1998; 47:113-20. [PMID: 9512274 DOI: 10.1016/s0016-5107(98)70342-6] [Citation(s) in RCA: 169] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- P D Siersema
- Department of Gastroenterology, University Hospital Rotterdam-Dijkzigt, The Netherlands
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