Segmental amputation of esophagus with bronchial-wall rupture during removal of a stent for benign esophageal stricture

A highly flexible paclitaxel-loaded poly(ε-caprolactone) electrospun fibrous-membrane-covered stent for benign cardia stricture

In benign esophageal strictures, inflammation reaction and tissue hyperplasia after stent placement greatly limit the stent retention time and affect subsequent scar formation, which is one of the main influences on long-term recurrence rate. A newly developed biodegradable electrospun drug-fiber-coated stent (DFCS) was fabricated to inhibit inflammation and scar formation. The electrospun paclitaxel/poly(ε-caprolactone) (PCL) fibers integrally covered the bare stent using the rotating collection method. The paclitaxel entrapment did not significantly affect the physical properties of electrospun PCL fibrous membranes. The mechanical results demonstrated that electrospun fibers containing paclitaxel covering the stent maintained the original mechanical characteristics of the stent, and no membrane tearing or ablation was observed after hundreds of repeated compressions. Paclitaxel release profiles were controlled mainly via diffusion of drug through the drug content, and stable release of paclitaxel continued up to 32 days at pH 4.0. Higher inhibition of smooth muscle cell proliferation rates was observed on fibrous membranes with higher paclitaxel content. DFCS showed a significant decrease in tissue inflammation and collagen fiber proliferation, and was easily removed from the esophageal part, which had almost no damage to the tissues in the dog model. Therefore, DFCSs may have great potential to markedly attenuate stent-induced inflammation and scar formation in esophageal stenosis therapy.

Self-expanding plastic stent removed after radiochemotherapy for advanced esophageal cancer

Endoscopic evaluation after chemoradiotherapy (CR) is impossible with an esophageal stent in place. The main study objective was to evaluate self-expanding plastic stent (SEPS) removal post-CR. Secondary end-points were the improvement of dysphagia and patients' quality of life. From October 2008 to March 2011, 20 dysphagic patients who suffered from advanced esophageal cancer were enrolled in a multicenter, prospective study. SEPS was inserted prior to CR and then removed endoscopically. SEPS efficiency (dysphagia score) and tolerance, as well as the patients' quality of life (European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire validated for the esophagus), were monitored. Continuous variables were compared using a paired t-test analysis for matched data. A P-value of less than 0.05 was considered statistically significant. Twenty patients (15 men and 5 women), aged 61.5 years (±9.88) (range 43-82 years), with adenocarcinoma (n = 12) and squamous cell carcinoma (n = 8), were enrolled. SEPS were successfully inserted in all patients (100%). There was one perforation and three episodes of migration. All of these complications were medically treated. The mean dysphagia score at the time of stent placement was 2.79 (0.6). Mean dysphagia scores obtained on day 1 and day 30 post-SEPS placement were 0.7 (0.9) (P < 0.0001) and 0.45 (0.8) (P < 0.0001), respectively. Quality of Life Questionnaire validated for the esophagus score showed an improvement in dysphagia (P = 0.01) and quality of oral feeding (P = 0.003). All SEPS were removed endoscopically without complications. In two patients, the stent was left in place due to metastatic disease. SEPS are extractable after CR of esophageal cancer. Early stenting by SEPS prior to and during CR may reduce dysphagia and improve quality of oral alimentation.

Safety of endoscopic removal of self-expandable stents after treatment of benign esophageal diseases

BACKGROUND

Temporary placement of self-expandable stents has been increasingly used for the management of benign esophageal diseases.

OBJECTIVE

To evaluate the safety of endoscopic removal of esophageal self-expandable stents placed for the treatment of benign esophageal diseases.

DESIGN

Multicenter retrospective study.

SETTING

Six tertiary care centers in the United States and Europe.

PATIENTS

A total of 214 patients with benign esophageal diseases undergoing endoscopic stent removal.

INTERVENTION

Endoscopic stent removal.

MAIN OUTCOME MEASUREMENTS

Endoscopic techniques for stent removal, time to stent removal, and adverse events related to stent removal.

RESULTS

A total of 214 patients underwent a total of 329 stent extractions. Stents were mainly placed for refractory strictures (49.2%) and fistulae (49.8%). Of the removed stents, 52% were fully covered self-expandable metal stents (FCSEMSs), 28.6% were partially covered self-expandable metal stents (PCSEMSs), and 19.5% were self-expandable plastic stents. A total of 35 (10.6%) procedure-related adverse events were reported, including 7 (2.1%) major adverse events. Multivariate analysis revealed that use of PCSEMSs (P < .001) was a risk factor for adverse events during stent removal. Favorable factors for successful stent removal were FCSEMSs (P ≤ .012) and stent migration (P = .010). No significant associations were found for stent indwelling time (P = .145) and stent embedding (P = .194).

LIMITATIONS

Retrospective analysis, only tertiary care centers.

CONCLUSIONS

With an acceptable major adverse event rate of 2.1%, esophageal stent removal in the setting of benign disease was found to be a safe and feasible procedure. FCSEMSs were more successfully removed than self-expandable plastic stents and PCSEMSs. Adverse events caused by stent removal were not time dependent.

Stent placement for esophageal strictures: an update

The use of stents for esophageal strictures has evolved rapidly over the past 10 years, from rigid plastic tubes to flexible self-expanding metal (SEMS), plastic (SEPS) and biodegradable stents. For the palliative treatment of malignant dysphagia both SEMS and SEPS effectively provide a rapid relief of dysphagia. SEMS are preferred over SEPS, as randomized controlled trials have shown more technical difficulties and late migration with plastic stents. Despite specific characteristics of recently developed stents, recurrent dysphagia due to food impaction, tumoral and nontumoral tissue overgrowth, or stent migration, remain a major challenge. The efficacy of stents with an antireflux valve for patients with distal esophageal cancer varies between different stent designs. Concurrent treatment with chemotherapy and/or radiotherapy seems to be safe and effective. In the future, it can be expected that removable stents will be used as a bridge to surgery to maintain luminal patency during neoadjuvant treatment. For benign strictures, new stent designs, such as fully covered SEMS and biodegradable stents, may potentially reduce complications during stent removal.

Recent advances in the use of stents for esophageal disease

The use of self-expanding metal esophageal stents has evolved dramatically over the last 20 years. Stents themselves have morphed from simple open-mesh wire devices to a variety of partially and fully covered metal and plastic protheses designed to resist in-growth and migration. Indications include grown considerably from simply palliating malignant dysphagia to the treatment of benign conditions such as refractory strictures, perforations, and fistulas, bridging tumors through neoadjuvant therapy and even serving as support for mucosal healing after ablative therapies. This article describes the current experience with esophageal stenting for malignant and benign conditions and examines new innovations in stent design and applications.

Retrievable esophageal stents for benign indications

Until recently, esophageal stents have not been a realistic option for the management of benign disease owing to difficulty removing the stents and associated high complication rates. However, progress in esophageal stent design has led to the development of retrievable esophageal stents. Clinical experience has shown promise for the management of benign esophageal diseases with retrievable stents, including refractory strictures, esophageal leaks, fistula and perforations. They have been shown to be safe and effective, though stent migration remains a concern. This article reviews the current designs, indications, efficacy and complications of retrievable esophageal stents.