Palliative endoscopic interventions in esophageal cancer

Outcomes of self-expandable metal stent placement for malignant oesophageal strictures

AIM

To analyse the outcomes of oesophageal stenting for malignant strictures and to study the correlation between the follow-up time and major complications.

MATERIALS AND METHODS

Patients with oesophageal malignancy who underwent stent placement between 2011 and 2016 for dysphagia were included. The data included age, sex, dysphagia, length and location of stenosis, date of stent placement, complications, follow-up time, and survival.

RESULTS

Two hundred and ninety-eight patients were included in the study. Minor complications occurred in 113 patients (37.9%) including chest pain (17.1%), foreign body sensation (25.5%), hiccups (1.68%), and reflux symptoms (27.5%). Major adverse events occurred in 93 (31.1%) patients including pneumonia (25.5%), migration (3%), perforation (0.67%), bleeding (1.68%), and restenosis (22.5%). oesophago-airway fistula occurred in 45 (15.1%) patients. The incidence of recurrent dysphagia, pneumonia, and oesophago-airway fistula increased over 3 months and decreased after another 3 months. The incidence of major complications as a percentage of survivors remained high after 3 months (>40%). Spearman analysis revealed a significant positive correlation between the incidence and the follow-up time over this period (rs=0.907, p<0.01).

CONCLUSION

The major complications of oesophageal stenting increased with time over 3 months and remained high for another 3 months. Therefore, stenting should be considered for palliation in patients with short expected survival (usually <3 months).

Outcome and complications of long-term self-expanding esophageal stenting

Esophageal stenting with self-expanding plastic or covered metal stents is believed to be safe and effective. As data on the outcome of patients with long-term stenting are not available, this study was conducted to evaluate the safety and efficacy of long-term esophageal stenting. From 2002 to 2008, 70 patients with long-term esophageal stenting for various indications from a prospective database were included into further analysis. The median stent period was 297 (124-1980) days during a mean follow-up time of 55 ± 52.4 months. Overall complication rate was 30% with a primary success rate of 97.2%. The stent-related total reintervention rate was 17.1%. There were no correlations between stent characteristics and the risk of complication or migration. No stent-related death was observed. Our data provide evidence that long-period esophageal stenting is safe and effective for various indications.

Self-expanding plastic stent to palliate symptomatic tissue in/overgrowth after self-expanding metal stent placement for esophageal cancer

Self-expanding metal stents (SEMS) are used to treat obstructive malignancies of the esophagus or esophagogastric junction; however, a potential complication is recurrent dysphagia because of tissue in/overgrowth. The placement of a second SEMS is one strategy to re-establish patency of the esophageal lumen. We evaluated the safety and efficacy of an alternative and likely less costly approach: placing a self-expanding plastic stent (SEPS) to manage relapsing dysphagia in patients previously treated with a partially covered SEMS. From December 2007 to January 2009, 13 patients previously treated with a SEMS for malignant dysphagia underwent treatment by inserting a SEPS to palliate relapsing dysphagia, as a result of tissue in/overgrowth. Stenosis was located in the upper esophagus in one patient, in the middle in four patients, and in the lower esophagus in eight patients. Clinical evaluation was performed at the time of stent placement, after 1 week, and then, monthly until death. The SEPS was successfully placed in a single treatment session for all patients. No preliminary dilation was required, and no further treatment was necessary for any patient. Before stenting, the median dysphagia score was 4 (range 3-4), and 1 week later the score was 0 for all patients. The resolution of dysphagia persisted until patient death (from tumor progression). The mean survival after the SEPS insertion was 4 months (range 3-8). This case series supports the use of a SEPS to palliate dysphagia from tissue in/overgrowth of a SEMS. Future clinical trials with larger patient samples are warranted.

Solving the problem of difficult stent removal due to tissue ingrowth in partially uncovered esophageal self-expanding metal stents

Partially uncovered stents provide a better fixation to the esophageal wall than fully covered stents, but indication is limited to palliation because stent removal is compromised by mucosal ingrowth. After an unsuccessful attempt to remove a partially uncovered Evolution stent (Cook Medical Inc, Bloomington, IN) we placed a Polyflex stent (Boston Scientific, Natick, MA) inside the first stent, overlapping at the lower part to press the tissue out of the stent mesh. Both stents were easily removed 3 days later. By adopting this procedure to scheduled stent removals, partially uncovered SEMS may be used to prevent the frequently observed migrations of fully-covered stents in the treatment of esophageal perforation or anastomotic leakage.

Temporary placement of self-expanding oesophageal stents as bridging for neo-adjuvant therapy

BACKGROUND

Placement of self-expanding stents is an effective palliation for dysphagia in non-resectable oesophageal or proximal gastric cancer. The aim of this analysis was to assess the efficacy of temporary stent placement for dysphagia relief during neo-adjuvant treatment for locally advanced disease.

METHODS

A total of 38 patients scheduled for neo-adjuvant chemo(radio)therapy for locally advanced oesophageal cancer (n = 29), cardia cancer (n = 8) or subcardial gastric cancer (n = 1) underwent placement of self-expanding plastic stents (n = 13) or covered metal stents (n = 25) due to severe dysphagia and weight loss.

RESULTS

Instant dysphagia relief was achieved in 37 (97.4%) of 38 patients. Dysphagia scores declined from mean 3.0 +/- 0.7 before stent placement to 0.6 +/- 0.9 at restaging. After completion of the neo-adjuvant therapy 20 (52.6%) of the 38 patients underwent resection of the tumour, 5 patients (13.2%) underwent primary resection without receiving chemotherapy while 12 patients (31.6%) did not undergo surgery. Stent-related complications were observed as perforation (n = 1), mediastinitis (n = 1), tracheo-oesophageal fistula (n = 2), bleeding (n = 1) and jejunal perforation caused by a migrated stent (n = 1). Serum albumin significantly decreased in patients with progressive disease despite successful stenting (40.0 +/- 4.9 mg/dl versus 29.7 +/- 6.4 mg/dl, p < 0.05) while stable albumin levels were found in patients who underwent surgery (39.9 +/- 4.3 mg/dl versus 39.1 +/- 3.8 mg/dl, p = 0.484).

CONCLUSION

Placement of self-expanding stents is highly effective for instant dysphagia relief, enabling adequate oral nutrition during neo-adjuvant therapy, but is limited by a high re-intervention rate.