Management of inoperable malignant oesophageal strictures with fully covered WallFlex(®) stent: a multicentre prospective study

Performance and Predictors of Migration of Partially and Fully Covered Esophageal Self-Expanding Metal Stents for Malignant Dysphagia

BACKGROUND & AIMS

Self-expanding metal stents (SEMS) are routinely used to palliate malignant dysphagia. However esophageal SEMS can migrate or obstruct due to epithelial hyperplasia. The aim of this study was to evaluate the rates and factors predicting migration and obstruction, and the nutritional outcomes in partially covered (pc) vs. fully covered (fc) SEMS vs. fcSEMS with antimigration fins (AF) placed for malignant dysphagia.

METHODS

A retrospective review of consecutive patients undergoing SEMS placement for malignant dysphagia at three academic medical centers.

RESULTS

Among 357 patients, there were 55 (15.4%) stent migrations, 45 (12.6%) obstructions from epithelial hyperplasia, and 20 (5.6%) food impactions. Median overall survival was 79 days (IQR 41,199). The percent weight change/change in albumin at 30 and 60 days after SEMS placement were -2.24%/-0.544 g/dL and -2.98%/-0.55 g/dL, respectively. Stent migration occurred significantly more often with fcSEMS than pcSEMS (25.3% vs 10.9%; P < .003), but there was no difference when either group was compared to fcSEMS-AF (19.3%). The overall rate of epithelial hyperplasia resulting in stent obstruction was low (12.6%) and not different between stent types. Factors associated with increased risk of SEMS migration on multivariable logistic regression included stricture traversability with a diagnostic endoscope (OR, 2.37; 95% CI, 1.29-4.35) and use of fcSEMS (OR, 2.56; 1.31-5.00) or fcSEMS-AF (OR, 2.30, 1.03-5.14).

CONCLUSIONS

Traversability of a malignant esophageal stenosis predicts SEMS migration. In these patients with a limited overall survival, pcSEMS are associated with lower rates of stent migration and similar rates of obstruction compared to fcSEMS.

Palliation of malignant esophageal obstruction using an anti-migration self-expandable metal stent: Results of a prospective multicenter study

BACKGROUND

Self-expanding metal stents (SEMS) placement is primarily indicated to palliate dysphagia for patients with expected short-term survival. We aimed to assess the migration rate and other stent-related adverse events (AEs) of a fully covered SEMS with an anti-migration system (FCSEMS-AMS) for palliation of malignant dysphagia.

METHODS

This is a prospective study including patients with inoperable esophageal cancer that received a FCSEMS-AMS (Taewoong, Niti-S Beta™), in five tertiary-care endoscopic centers from January 2014 to February 2016.

RESULTS

Fifty-three consecutive patients were enrolled. Tumor location was proximal, mid and distal esophagus±esophago-gastric junction (EGJ) in 6, 14, and 33 cases, respectively. Overall, non-severe AEs were reported in 18 patients (34.0%), 13 of them required an additional endoscopic procedure. Migration occurred in 7 patients (13.2%): 3 from the upper and 4 from the lower esophagus and EGJ. Stent retrieval was necessary in one patient due to intolerable pain. Food bolus impaction and tumor overgrowth occurred in 2 patients (3.8%) and 4 (7.5%) patients respectively. Four patients complained of gastroesophageal reflux as late AEs. Median follow-up was 19.3 months. Dysphagia significantly improved until 3 and 6 months from stent insertion (median score before FCSEMS-AMS: 3, vs median score: 1). Median dysphagia-free time was 10 months.

CONCLUSIONS

Placement of the Taewoong, Niti-S Beta™ stent appeared to be a safe and effective treatment of malignant dysphagia. The anti-migration system reduced the overall migration rate, although it remained high in strictures located in the upper esophagus and when the stent was placed across the EGJ.

A finite element investigation on design parameters of bare and polymer-covered self-expanding wire braided stents

Self-expanding covered braided stents are routinely used across a diverse range of clinical applications, but few computational studies have attempted to replicate their complex behaviour. In this study, a computational framework was developed to predict the functional performance of bare and covered self-expanding wire braided stents, with a systematic evaluation on the effect of various braid and cover parameters presented. Simulated radial force and kink deformation tests show good agreement to experimental data for covered braided stents across a range of braid angles and cover thicknesses. Our results demonstrate that braid angle is a key governing parameter that dictates the radial and kink performance of both bare-metal and covered wire braided stents. It was also demonstrated that addition of a polymeric cover to a wire braided stent causes a stiffer radial response across all braid angles, particularly when thicker and/or stiffer covering systems were considered. This study represents the first experimentally-validated computational model for covered wire braided stent systems and has excellent potential to be used in future design of these devices for a range of applications.

Through-the-scope esophageal stent for the relief of malignant dysphagia: Results of a multicentric study (with video)

BACKGROUND AND AIM

In presence of malignant dysphagia, in patients unfit for surgery, the placement of a self-expandable metal stent (SEMS) represents a safe and effective palliative treatment. Esophageal stents (ES) present an over-the-wire mechanism where the stent is deployed under X-ray control. Recently a through-the-scope (TTS) ES was launched. The aim of our retrospective study is to assess the technical and clinical success of the new TTS-ES.

MATERIALS AND METHODS

Patients with malignant dysphagia caused by esophageal cancer or ab-extrinsic compression, who underwent TTS esophageal stent in six Italian endoscopic referral centers, were retrospectively reviewed.

RESULTS

A total of 40 patients were enrolled. TTS stent placement was successful in 39/40 patients (97.5%). 31 patients had an Ogilvie score of 4, nine an Ogilvie 3. After 2 weeks from stent placement 29 reported Ogilvie score of 0, eight a score of 1. None of the patients developed retrosternal pain requiring drugs. No patient experienced perforation, bleeding or migration. A total of seven patients (18%) developed dysphagia as late adverse event (AE).

CONCLUSION

Through-the-scope ES presented less AEs, in terms of bleeding and perforation, if compared to the previous published data. An anti-migration system could be helpful, especially when the stent is placed for "ab-extrinseco" malignant dysphagia.

Comparison of fully-covered vs partially covered self-expanding metallic stents for palliative treatment of inoperable esophageal malignancy: a systematic review and meta-analysis

Background

This study aimed to compare clinical outcomes following placement of fully covered self-expanding metallic stents (FCSEMS) vs partially covered self-expanding metallic stents (PCSEMS) for palliative treatment of inoperable esophageal cancer.

Methods

We searched PubMed, ScienceDirect, Embase, and CENTRAL (Cochrane Central Register of Controlled Trials) databases from inception up to 10th July 2019. Studies comparing clinical outcomes with FCSEMS vs PCSEMS in patients with inoperable esophageal cancer requiring palliative treatment for dysphagia were included.

Results

Five studies were included in the review. Two hundred twenty-nine patients received FCSEMS while 313 patients received PCSEMS in the five studies. There was no difference in the rates of stent migration between FCSEMS and PCSEMS (Odds ratio [OR] 0.63, 95%CI 0.37–1.08, P = 0.09; I² = 0%). Meta-analysis indicated no significant difference in technical success between the two groups (OR 1.32, 95%CI 0.30–5.03, P = 0.78; I² = 12%). Improvement in dysphagia was reported with both FCSEMS and PCSEMS in the included studies. There was no difference between the two stents for obstruction due to tissue growth (OR 0.81, 95%CI 0.47–1.39, P = 0.44; I² = 2%) or by food (OR 0.41, 95%CI 0.10–1.62, P = 0.20; I² = 29%). Incidence of bleeding (OR 0.57, 95%CI 0.21–1.58, P = 0.28; I² = 0%) and chest pain (OR 1.06, 95%CI 0.44–2.57, P = 0.89; I² = 0%) was similar in the two groups. Sensitivity analysis and subgroup analysis of RCTs and non-RCTs produced similar results. The overall quality of studies was not high.

Conclusion

Our results indicate that there is no difference in stent migration, and stent obstruction, with FCSEMS or PCSEMS when used for palliative treatment of esophageal malignancy.

Through-the-scope placement of a fully covered metal stent for palliation of malignant dysphagia: a prospective cohort study (with video)

BACKGROUND AND AIMS

To further optimize endoscopic stent placement, an esophageal fully covered self-expandable metal stent with a through-the-scope (TTS) delivery system was designed, providing direct endoscopic control during stent placement. The aim of the study was to assess the feasibility and safety of a TTS stent approach for palliation of malignant dysphagia.

METHODS

This multicenter prospective feasibility study included patients with malignant dysphagia undergoing stent placement. The primary outcome was technical success of TTS stent placement. Secondary outcomes included functional outcome, adverse events, and survival. Patients were prospectively evaluated at days 14 and 28, and monthly thereafter, until death or stent removal.

RESULTS

In total, 33 stents were placed in 32 patients. TTS stent placement was feasible in 30 (91%) procedures. In the other 3 procedures (9%), no large-channel endoscope could be introduced because of patient discomfort. In 10 (33%) TTS procedures, technical success was achieved because no fluoroscopy and/or guidewire was used, whereas in 20 (67%) TTS procedures, placement was supported by a guidewire (n = 9), or fluoroscopy and a guidewire (n = 11). After 2 weeks, dysphagia scores had improved in 24 (86%) patients. Median dysphagia-free time was 32 days (interquartile range [IQR], 17-76 days). In 20 (63%) patients, 29 serious adverse events (SAEs) occurred. Recurrent dysphagia occurred in 13 (41%) patients due to migration (n = 5), tissue overgrowth (n = 4), and stent deformation (n = 4). Other SAEs included significant retrosternal pain (n = 4), hemorrhage (n = 2), and esophageal perforation (n = 1). No patient died from a stent-related cause. Median survival was 42 days (IQR, 28-91 days).

CONCLUSION

Placement of an esophageal TTS stent was feasible in most of the patients with malignant dysphagia. However, stent placement was associated with a relatively high adverse event rate, and in more than one-third of patients, stent placement still required fluoroscopy, which limited optimal benefit of the TTS approach. (Clinical trial registration number: NCT03269903.).

A New Fully Covered Irradiation Stent Versus a Partially Covered Irradiation Stent for Unresectable Malignant Dysphagia: A Single-Center Experience

PURPOSE

To assess the efficacy and safety of a newly developed fully covered irradiation stent (FCIS) compared with a partially covered irradiation stent (PCIS) in patients with unresectable malignant dysphagia.

MATERIALS AND METHODS

Data of 195 patients [158 (81.0%) males, median age of 75 years (range 49-89 years)] who underwent FCIS or PCIS placement for unresectable malignant dysphagia from January 2012 to November 2017 were retrospectively analyzed. The median follow-up time was 181 days (range 4-547 days). Outcomes were measured in terms of recurrent dysphagia (primary), technical success, clinical success, overall survival, and adverse events. Recurrent dysphagia was analyzed by Fine-Gray regression model.

RESULTS

The technical success rate was 97.8% (87/89) in the FCIS group and 99.1% (105/106) in the PCIS group (P = 0.59). The clinical success rate was 100.0% in both groups. There was no statistically significant difference in the recurrent dysphagia rate between the FCIS and PCIS groups (21.8% vs. 28.6%; P = 0.12). Compared with PCISs, FCISs were associated with a decrease in tissue/tumor growth rate (11.5% vs. 21.9%; P = 0.01), while stent migration rates were statistically comparable (11.5% vs. 5.7%; P = 0.23). The median overall survivals were comparable between the FCIS and PCIS groups (164 days vs. 162 days; P = 0.70). A dysphagia score of 4 and metastasis were risk factors for survival. No significant differences were observed in the rates of adverse events, including chest pain, fistula formation, hemorrhage, and aspiration pneumonia (P > 0.05).

CONCLUSION

For patients with unresectable malignant dysphagia, this newly developed FCIS can provide efficacy and safety comparable to those of a PCIS. Compared with PCIS, this FCIS is more successful in preventing tissue/tumor growth, with a comparable stent migration rate.

Tracheomalacia as Complication of Stenting for Esophageal Injury After Transsternal Approach to High Thoracic Vertebral Metastasis

BACKGROUND

Esophageal injury is a severe surgical complication of a transsternal approach to high thoracic vertebral metastasis, which can result in mediastinitis and life-threatening consequences. A covered stent can be placed in the esophagus to prevent mediastinal leakage. However, tracheomalacia is a rare complication following esophageal stenting.

CASE DESCRIPTION

A 56-year-old man had a pathologic fracture of the T3 vertebral body with spinal cord compression, myelopathy, and neurogenic bladder. An esophageal injury was noticed during the transsternal approach. Immediate suture repair, drainage tube placement, and subsequent esophageal stenting were carried out. One month after discharge, the endoscopic examination revealed nonhealing of the esophagus, and a new covered stent was replaced. Episodes of severe stridor and dyspnea led to the patient being sent to the emergency department. Computed tomography scan of the chest revealed a focal collapse of the trachea at the thoracic inlet, and tracheomalacia was suspected. The covered stent was removed, despite nonhealing of the esophagus. His stridor, dyspnea, and constant coughing subsided afterwards. The endoscopic examination at 3 months after stent removal showed complete healing of the esophagus.

CONCLUSIONS

Esophageal stenting can be used to prevent mediastinal leakage due to esophageal injury in the transsternal approach for high thoracic vertebral metastasis, but the stent might be a cause of tracheomalacia. Stent removal should be considered if upper airway obstruction occurs. Awareness of the radial force of the stent, esophageal composition (e.g., status post suture repair), and esophageal diameter must be considered for optimal stent tolerance to avoid complications.

Safety and feasibility of esophageal self- expandable metal stent placement without the aid of fluoroscopy

Self-expandable metal stents (SEMSs) are used for the management of certain esophageal conditions such as strictures, perforations, and fistulae. These can be placed using fluoroscopic control, endoscopic control, or a combination of both. We evaluated our institutional experience of placing a SEMS using only endoscopy without the aid of fluoroscopy to determine safety and feasibility using this technique. A retrospective review was performed to identify all patients who underwent esophageal SEMS from January 2010 to June 2015. Placement of SEMS was accomplished under direct endoscopic visualization without the aid of fluoroscopy. Esophageal lesion was initially identified during endoscopy and a fully covered SEMS was passed over the guide wire and deployed under direct vision. Misplacement of the SEMS during the procedure that required replacement with another new SEMS was considered as a failed procedure. Other periprocedural complications caused by placement of SEMS were noted. A total of 172 patients underwent 280 procedures for SEMS placement. Mean age was 66 years. The most common indication for SEMS placement was stricture in 248 (88%) procedures. Periprocedure SEMS misplacement occurred in 12 (4%) patients. However, only 8 (3%) patients needed to have a new SEMS placed during the same procedure. A total of 64 (23%) patients had migration of SEMS. There were no other periprocedure complications leading to adverse events. Self-expandable metal stent can be placed accurately and safely under direct endoscopic visualization without the aid of fluoroscopy.

Endoscopic management of complications of self-expandable metal stents for treatment of malignant esophageal stenosis and tracheoesophageal fistulas

BACKGROUND

Self-expandable metal stent (SEMS) implantation may rapidly improve the symptoms of malignant esophageal stenosis and tracheoesophageal fistulas (TEF). However, dysphagia often returns subsequently and repeated endoscopic intervention may be necessary. The aims of the study were to identify the risk factors of complications, and the frequency and efficacy of repeated endoscopic interventions; and to provide technical recommendations on appropriate stent selection.

METHODS

We analyzed retrospectively the clinical data of 212 patients with locally advanced esophageal cancer who underwent SEMS implantation.

RESULTS

A total of 238 SEMS implantations were performed with 99.06% technical success and 1.26% procedure-related deaths in the enrolled 212 cases. Complications occurred in 84 patients (39.62%) and in 55 cases (25.94%) repeated endoscopic procedures were required. Early reintervention 24-48 h after the stent implantations was necessary due to stent migration (12 cases), arrhythmia (2 cases), intolerable retrosternal pain (1 case) and dyspnea (1 case). An average of 1.98 repeated gastroscopies (range 1-6; median 2), 13.58 weeks (range 1.5-48; median 11) after the stent implantation were performed during the follow-up period: 37 stent repositions, 23 restent implantations, 15 endoscopic esophageal dilations and 7 stent removals. In 48 cases (87.3%) oral feeding of patients was made possible by endoscopic interventions.

CONCLUSIONS

In a quarter of SEMS implantations, complications occur that can be successfully managed by endoscopic interventions. Our experiences have shown that individualized stent choice may substantially reduce the complications rate and make repeated endoscopic interventions easier.

Fully covered stents are similar to semi-covered stents with regard to migration in palliative treatment of malignant strictures of the esophagus and gastric cardia: results of a randomized controlled trial

Introduction

Stent migration is a significant clinical problem in palliation of malignant strictures in the esophagus and gastro-esophageal junction (GEJ). We have compared a newer design of a fully-covered stent to a widely used semi-covered stent using migration >20 mm as the primary outcome variable. Effects on dysphagia, quality of life (QoL) and re-intervention frequency were also investigated.

Methods

Patients with dysphagia due to non-curable esophagus/GEJ cancer were randomized to receive either a more recent design of a fully-covered stent (n = 48) or a conventional semi-covered stent (n = 47). Chest x-ray, dysphagia and QoL were studied at baseline, one week, four weeks and three months thereafter.

Results

There were no significant differences either in stent migration distance or in the migration frequency. Stent migration during the total study period occurred in 37.2 % in the semi-covered group compared to 20.0 % for the fully-covered group. Dysphagia was measured with Watson and Ogilvie scores and with the dysphagia module in the QoL scale (QLQ-OG25). On average, there was a tendency to better dysphagia relief for the fully-covered design as scored with the two latter dysphagia instruments (p= 0.081 and p= 0.067) at three months and towards more re-interventions in the semi-covered group (p= 0.083).

Conclusion

In spite of its somewhat lower intrinsic radial force, the fully-covered stent was comparable to the conventional semi-covered stent with regard to stent migration. The data further suggest a potential benefit of the fully-covered stent in improving dysphagia in patients with longer life expectancy.