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

Outcome, survival, and costs in patients undergoing intubation for carcinoma of the esophagus

BACKGROUND

In this prospective study a consecutive series of 70 patients undergoing insertion of a Wilson-Cook endoprosthesis for palliation of esophageal carcinoma was examined.

METHODS

The tube was inserted endoscopically using intravenous sedation and a pulsion technique.

RESULTS

The patients had a mean (SEM) age of 70.7 (1.5) years and 44 (63%) were men. Two patients died in hospital and 2 died after discharge, giving a procedure-related mortality of 2.8% and a 30-day mortality of 5.7%. Nine patients experienced complications, giving a morbidity rate of 12.8% following the initial procedure. Twenty patients required a second or further procedure. The indications were tube migration in 22 cases, obstruction in 10, and fistula formation in 2 patients. Thirty-day mortality in this group was significantly greater than after a first procedure (7 patients, 20.1%; P <0.05). The median survival following insertion of a Wilson-Cook endoprosthesis was 16 weeks.

CONCLUSIONS

This study describes a safe, effective method for insertion of an endoprosthesis, with a low morbidity and mortality. The average cost for endoscopic insertion of a Wilson-Cook endoprosthesis in this unit is $1,600, and in view of the short median survival in this group of patients, the introduction of costly self-expanding stents is not warranted without demonstrable benefits in a controlled, prospective, randomized clinical trial.

Covered gianturco stents for malignant biliary obstruction: preliminary clinical evaluation

PURPOSE

To evaluate the effectiveness of covered Gianturco stents in patients with malignant biliary obstruction.

MATERIALS AND METHODS

Three types of partially polyurethane-covered stents were implanted in 19 patients with malignant biliary obstruction located distal to the hilar confluence. A transhepatic approach was employed in all but one patient, in whom the stent was placed through a T-tube tract.

RESULTS

Stent placement was possible in all patients. In 15 patients, the implanted stents were expanded to a mean of 81% of their original diameter. In the remaining four patients, the stents expanded to less than 40% of the original diameter, and balloon dilation and additional bare stent placement were required. All patients except one, who had impairment of liver function due to multiple liver metastases, showed relief of jaundice after stent placement. At follow-up, which ranged from 5 to 57 weeks (mean, 24.7 weeks), one stent (5%) was occluded after 26 weeks due to tumor growth above the upper stent edge, and required secondary intervention. Complications in three patients included stent migration in one (5%) and cholangitis in two (11%).

CONCLUSION

Preliminary results suggest that placement of covered Gianturco stents is feasible, the complication rate is acceptable, and short-term patency appears promising.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Nonvascular stents

Stents or endoprostheses have evolved since their introduction. Initially used only in the vascular system, the use of stents has expanded to use in the biliary, urinary, and gastrointestinal tracts and in the tracheo-bronchial tree. Current use of stents includes treatment of both benign and malignant conditions, with the greatest impact in the palliation of malignant strictures. The biomechanics and types of stents used in each region is reviewed. The indications, insertion techniques, results, and complications of stents in each of the aforementioned regions are also reviewed.

Erosion of the right mainstem bronchus by an esophageal stent

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

Use of a Strecker oesophageal stent in the treatment of benign oesophageal stricture

The use of self-expanding prostheses in the management of malignant oesophageal strictures has become well established. The majority of benign peptic oesophageal strictures can be successfully managed using endoscopic or fluoroscopically guided balloon oesophageal dilatation combined with long-term drug therapy, particularly using proton pumper inhibitors. Although endoscopic oesophageal dilatation can be performed on an outpatient basis, it requires repeated hospital visits. There is a small risk of oesophageal perforation whilst cardio-respiratory complications may be encountered during the use of intravenous sedation in an elderly population. The use of a self-expanding Strecker stent in a 98 year old woman with a benign oesophageal stricture is described.

Treatment of malignant esophageal obstructions with covered metallic Z stents: long-term results in 52 patients

PURPOSE

To prospectively evaluate the clinical efficacy of silicone-covered Gianturco-Rösch self-expandable Z (GRZ) stents in the treatment of malignant esophageal obstruction.

PATIENTS AND METHODS

GRZ stents were placed in 52 patients (39 men, 13 women) with severe dysphagia due to high-grade malignant esophageal obstruction.

RESULTS

Stent placement was technically successful, and immediate relief of dysphagia was achieved in 50 of 52 patients (96%), with long-term relief in 47 patients (90%). Fifty-one patients (98%) died during follow-up (range, 1 week to 33 months; mean, 4.3 months). Late complications were most prevalent and included stent migration (n = 5), food impaction (n = 2), chest pain (n = 2), membrane disruption with tumor ingrowth (n = 1), granulomatous reaction above the stent (n = 1), esophageal perforation with mediastinitis (n = 1), and upper gastrointestinal hemorrhage (n = 4). Twelve complications were easily managed with medical, endoscopic, or radiologic intervention. Four deaths may have been related to stent placement (early mortality rate, 7.7%).

CONCLUSION

GRZ stents provide relatively safe and effective long-term palliation in patients with severe, malignant esophageal obstruction.

Management of oesophageal fistula by radiologically-guided instillation of tissue adhesive

Two cases are presented in which healing of oesophageal fistula was achieved by the radiologically-guided placement of tissue adhesive (enbucrilate, Histoacryl). With this relatively simple procedure, further surgical intervention under general anaesthesia was avoided.