History of the Use of Esophageal Stent in Management of Dysphagia and Its Improvement Over the Years

Esophageal Stenting: How I Do It

Endoscopic esophageal stent placement is an effective palliative treatment for malignant strictures and has also been successfully used for benign indications, including esophageal refractory strictures and iatrogenic leaks and perforations. Despite several decades of evolution and the wide variety of esophageal stents available to choose from, an ideal stent that is both effective and without adverse events such as stent migration, tissue ingrowth, or pressure necrosis has yet to be developed. This paper is an overview of how this evolution happened, and it also addresses the characteristics of some of the currently available stents, like their material and construction, delivery device, radial and axial force pattern, covering and size which may help to understand and avoid the occurrence of adverse events. The insertion delivery systems and techniques of placement of an esophageal self-expandable metal stent are reviewed, as well as some tips and tricks regarding placement and management of adverse events.

Endoscopic luminal stenting: Current applications and future perspectives

Endoscopic luminal stenting (ELS) represents a minimally invasive option for the management of malignant obstruction along the gastrointestinal tract. Previous studies have shown that ELS can provide rapid relief of symptoms related to esophageal, gastric, small intestinal, colorectal, biliary, and pancreatic neoplastic strictures without compromising cancer patients’ overall safety. As a result, in both palliative and neoadjuvant settings, ELS has largely surpassed radiotherapy and surgery as a first-line treatment modality. Following the abovementioned success, the indications for ELS have gradually expanded. To date, ELS is widely used in clinical practice by well-trained endoscopists in managing a wide variety of diseases and complications, such as relieving non-neoplastic obstructions, sealing iatrogenic and non-iatrogenic perforations, closing fistulae and treating post-sphincterotomy bleeding. The abovementioned development would not have been achieved without corresponding advances and innovations in stent technology. However, the technological landscape changes rapidly, making clinicians’ adaptation to new technologies a real challenge. In our mini-review article, by systematically reviewing the relevant literature, we discuss current developments in ELS with regard to stent design, accessories, techniques, and applications, expanding the research basis that was set by previous studies and highlighting areas that need to be further investigated.

Inversion technique under fluoroscopy for removal of self-expanding nitinol esophageal stent after long-term placement: review of 107 consecutive cases

BACKGROUND

Removal of self-expanding esophageal metal stents that have been implanted for a long time can be difficult and risky.

PURPOSE

In this paper, we describe the use of the "inversion technique" under fluoroscopy for removal of self-expandable nitinol esophageal stents that have been placed for long periods and evaluate the effectiveness and safety of the method.

METHODS

Retrospective analysis of patients who underwent removal of self-expanding nitinol esophageal stents by the inversion technique under fluoroscopy at our center. Demographic characteristics, type of esophageal stents, stent retention time, reasons for stent removal, and related complications were collected from the case records and analyzed.

RESULTS

A total of 112 metal esophageal stents (62 fully covered esophageal stents and 50 partially covered esophageal stents) were extracted from the 107 patients included in the study. Indications for stent implantation were malignant esophageal stenosis (27 patients), benign esophageal stenosis (42 patients), and esophageal fistula (38 patients). Median duration of stent retention was 77 days (29-727 days). All stents were removed successfully without major complications such as esophageal rupture, massive hemorrhage, asphyxia, or cardiorespiratory arrest.

CONCLUSION

Inversion technique under fluoroscopy appears to be a safe, effective, and quick procedure for removal of self-expanding nitinol esophageal stent after long-term placement.

Balloon dilatation complications during esophagogastric anastomotic stricture treatment under fluoroscopy: Risk factors, prevention, and management

BACKGROUND

Balloon dilatation (BD) is a common treatment for esophagogastric anastomotic stricture (EAS), but with complications. This study investigates the risk factors, prevention, and management of BD complications to provide clinical guidance.

METHODS

We retrospectively analyzed the clinical data of 378 patients with EAS treated by BD from March 2011 to June 2021. The association between esophagogastric anastomotic rupture outcome and patient and stricture characteristics and treatment were analyzed by logistic regression.

RESULTS

BD was performed 552 times and technical success, 98.0%; overall clinical success, 97.8%; major adverse events, 1.3%; minor adverse events, 9.4%; mortality, 0.3%. Logistic regression showed that age (p = 0.080), sex (p = 0.256), interval from surgery to stricture development (p = 0.817), number of dilatations (p = 0.054), cause of stricture (p ≥ 0.168), and preoperative chemotherapy (p = 0.679) were not associated with anastomotic rupture. Balloon diameter (p < 0.001), preoperative radiotherapy (p = 0.003), and chemoradiotherapy (p = 0.021) were correlated with anastomotic rupture. All patients with type I and II ruptures resumed oral feeding without developing into type III rupture. Type III rupture occurred in six cases, who resumed oral feeding after 7-21 days of nasal feeding and liquid feeding. One patient died of massive bleeding after BD.

CONCLUSIONS

Symptomatic treatment for type I and II ruptures and transnasal decompression and jejunal nutrition tubes for type III rupture, are suggested pending rupture healing. Tumor recurrence, preoperative radiotherapy, and balloon diameter affected the anastomotic rupture outcome.

I-125 seed-loaded versus normal stent insertion for obstructive esophageal cancer: a meta-analysis

Introduction

Malignant esophageal obstruction is usually caused by esophageal and other chest cancers. More than 80% of cases of obstructive esophageal cancer (OEC) have lost the chance of curative resection. Stent insertion is a first-line palliative approach used to treat incurable OEC.

Aim

To gauge the relative clinical efficacy of I-125 seed-loaded stent (ISS) versus normal stent (NS) insertion as a treatment for OEC.

Material and methods

Querying of the PubMed, Embase, and Cochrane Library databases was conducted to find all relevant studies published up to November 2020. The meta-analysis was undertaken using RevMan v5.3.

Results

We identified 158 studies initially, eight (4 randomized controlled trials and 4 retrospective studies) of which were used in this meta-analysis. We found that the two groups exhibited the comparable pooled Δdysphagia scores (MD = 0.02; p = 0.80), stent restenosis rates (OR = 0.97; p = 0.89), stent migration rates (OR = 0.81; p = 0.63), severe chest pain rates (OR = 1.05; p = 0.81), hemorrhage rates (OR = 1.53; p = 0.16), aspiration pneumonia rates (OR = 0.72; p = 0.38), and fistula formation rates (OR = 1.47; p = 0.44). The pooled time-to-restenosis and survival were both significantly longer in the ISS group (p = 0.04 and < 0.0001, respectively). Significant heterogeneity was detected in the endpoints of Δdysphagia scores and survival (I² = 73% and 86%, respectively). Funnel plot analysis indicated an absence of publication bias related to the selected study endpoints.

Conclusions

For patients with OEC, our meta-analysis indicated that ISS insertion could provide longer stent patency and survival than NS insertion.

Esophageal Dysphagia in the Elderly

PURPOSE OF REVIEW

With a globally aging population, dysphagia is a growing health concern among elderly. Increasing reflux disease has contributed to an increased prevalence of dysphagia from peptic strictures and esophageal cancer. Dysphagia can lead to malnutrition and aspiration pneumonia, causing considerable morbidity and mortality. This review article focuses on recent advances in the approach and management of esophageal dysphagia.

RECENT FINDINGS

Endoscopic functional luminal imaging probe is a novel test that complements upper endoscopy, esophagram, and esophageal manometry for evaluation of esophageal dysphagia. Opioid induced esophageal dysfunction (OIED) is an emerging clinical entity that can mimic achalasia. Strictures refractory to dilation can be treated with intralesional steroid injections, electrosurgical incision, or esophageal stents. Peroral endoscopic myotomy (POEM) is gaining in popularity for treatment of achalasia and other spastic disorders of esophagus. Treatment of esophageal dysphagia may include proton pump inhibitors, endoscopic dilation, or surgery and requires a personalized approach based on risks and benefits. POEM is a valuable therapy for achalasia, but further studies are needed to evaluate its use, and other alternatives, for treatment of OIED and spastic esophageal disorders.