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S3-Leitlinie Diagnostik und Therapie der Plattenepithelkarzinome und Adenokarzinome des Ösophagus. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2023; 61:e209-e307. [PMID: 37285869 DOI: 10.1055/a-1771-6953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
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Sasso JGRJ, de Moura DTH, Proença IM, Junior ESDM, Ribeiro IB, Sánchez-Luna SA, Cheng S, Bestetti AM, Kum AST, Bernardo WM, de Moura EGH. Anti-reflux versus conventional self-expanding metal stents in the palliation of esophageal cancer: A systematic review and meta-analysis. Endosc Int Open 2022; 10:E1406-E1416. [PMID: 36262514 PMCID: PMC9576338 DOI: 10.1055/a-1894-0914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 07/05/2022] [Indexed: 11/09/2022] Open
Abstract
Background and study aims Self-expanding metal stents (SEMS) are an effective palliative endoscopic therapy to reduce dysphagia in esophageal cancer. Gastroesophageal reflux disease (GERD) is a relatively common complaint after non-valved conventional SEMS placement. Therefore, valved self-expanding metal stents (SEMS-V) were designed to reduce the rate of GERD symptoms. We aimed to perform a systematic review and meta-analysis comparing the two stents. Material and methods This was a systematic review and meta-analysis including only randomized clinical trials (RCT) comparing the outcomes between SEMS-V and non-valved self-expanding metal stents (SEMS-NV) following the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines. The risk of bias was assessed using the Cochrane Risk of Bias 2 tool. Data were analyzed with Review Manager Software. Quality of evidence was evaluated using Grading of Recommendations Assessment, Development, and Evaluation guidelines. Results Ten randomized clinical trials including a total of 467 patients, 234 in the SEMS-V group and 233 in the SEMS-NV group, were included. There were no statistically significant differences regarding GERD qualitative analysis (RD -0.17; 95 % CI -0.67, 0.33; P = 0.5) and quantitative analysis (SMD -0.22; 95 % CI -0.53, 0.08; P = 0.15) technical success (RD -0.03; 95 % CI -0.07, 0.01; P = 0.16), dysphagia improvement (RD -0.07; 95 % CI -0.19, 0.06; P = 0.30), and adverse events (RD 0.07; 95 % CI -0.07, 0.20; P = 0.32). Conclusions Both SEMS-V and SEMS-NV are safe and effective in the palliation of esophageal cancer with similar rates of GERD, dysphagia relief, technical success, adverse events, stent migration, stent obstruction, bleeding, and improvement of the quality of life.
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Affiliation(s)
- João Guilherme Ribeiro Jordão Sasso
- Serviço de Endoscopia Gastrointestinal, Departamento de Gastroenterologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Diogo Turiani Hourneaux de Moura
- Serviço de Endoscopia Gastrointestinal, Departamento de Gastroenterologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Igor Mendonça Proença
- Serviço de Endoscopia Gastrointestinal, Departamento de Gastroenterologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Epifânio Silvino do Monte Junior
- Serviço de Endoscopia Gastrointestinal, Departamento de Gastroenterologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Igor Braga Ribeiro
- Serviço de Endoscopia Gastrointestinal, Departamento de Gastroenterologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Sergio A. Sánchez-Luna
- Basil I. Hirschowitz Endoscopic Center of Excellence, Division of Gastroenterology and Hepatology, Department of Internal Medicine, The University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama, United States
| | - Spencer Cheng
- Serviço de Endoscopia Gastrointestinal, Departamento de Gastroenterologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Alexandre Moraes Bestetti
- Serviço de Endoscopia Gastrointestinal, Departamento de Gastroenterologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Angelo So Taa Kum
- Serviço de Endoscopia Gastrointestinal, Departamento de Gastroenterologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Wanderley Marques Bernardo
- Serviço de Endoscopia Gastrointestinal, Departamento de Gastroenterologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Eduardo Guimarães Hourneaux de Moura
- Serviço de Endoscopia Gastrointestinal, Departamento de Gastroenterologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
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Kim GH, Shin JH, Zeng CH, Park JH. Recent Updates in Gastrointestinal Stent Placement from the Esophagus to the Colon: A Radiological Perspective. Cardiovasc Intervent Radiol 2022; 45:425-437. [PMID: 35166883 DOI: 10.1007/s00270-022-03067-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 01/24/2022] [Indexed: 11/02/2022]
Abstract
Fluoroscopic-guided stent placement has become an advantageous treatment option for diverse gastrointestinal disorders. In addition to palliative stent placement in patients with inoperable cancers, stenting has gradually expanded to other conditions, including as a bridge to surgery, as well as in patients' benign lesions and anastomotic strictures or leaks. This narrative review describes the indications, efficacy and safety of stent placement from the esophagus to the colon, including current recommendations, recent updates, and novel stents.
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Affiliation(s)
- Gun Ha Kim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Olympic-ro 43-gil, Songpa-gu, Seoul, Korea
| | - Ji Hoon Shin
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Olympic-ro 43-gil, Songpa-gu, Seoul, Korea.
| | - Chu Hui Zeng
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Olympic-ro 43-gil, Songpa-gu, Seoul, Korea
| | - Jung Hoon Park
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Olympic-ro 43-gil, Songpa-gu, Seoul, Korea
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4
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Network meta-analysis of palliative treatments in patients with esophageal cancer. Crit Rev Oncol Hematol 2021; 168:103506. [PMID: 34740823 DOI: 10.1016/j.critrevonc.2021.103506] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 09/14/2021] [Indexed: 11/21/2022] Open
Abstract
We aimed to compare available palliative treatments in terms of survival and to rank these treatments for esophageal cancer. Web of Science, Medline, Scopus, Cochrane Library and Embase were searched. The risk of bias was judged using Cochrane's tools. Statistical heterogeneity was assessed using the Chi2 test and was quantified by I2. The results were summarized using the hazard ratio (HR). The rank probability for each treatment was calculated using the p-score. Nineteen RCTs met the eligibility criteria for this study. Treatments formed three networks including networks A, B, and C. The Ultraflex stent (p-score = 0.93), irradiation stent (p-score = 0.89), and thermal ablative therapy (p-score = 0.85) were the first ranking treatments in networks A, B, and C, respectively. Based on the results of this network meta-analysis, it appears that the ultraflex stent, the irradiation stent, and thermal ablative therapy are the better treatments among the networks.
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Essrani R, Shah H, Shah S, Macfarlan J. Complications Related to Esophageal Stent (Boston Scientific Wallflex vs. Merit Medical Endotek) Use in Benign and Malignant Conditions. Cureus 2020; 12:e7380. [PMID: 32328390 PMCID: PMC7176327 DOI: 10.7759/cureus.7380] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Background In our institutions, there are two types of stents used: the Boston Scientific Wallflex (Marlborough, Massachusetts) and Merit Medical Endotek (South Jordan, Utah). So we performed this retrospective study to compare complication rates in various esophageal disorders to improve our quality of care. Methods Charts were reviewed to capture gender, indications of stent placement, stent length/diameter, age of the patient at the time of stent placement, length of hospital stay, physicians performing a procedure, and complications within 90 days of stent placement. Results A total of 67 patients (71.6% male) underwent stent placement (WallFlex 49.3% and Merit 50.8%) for malignant (68.7%) mainly esophageal obstruction by primary esophageal cancer (89.1%) and benign causes (31.3%) mainly esophageal leak (66.7%). Merit and WallFlex used in malignant conditions were 82.4% and 54.6%, respectively, and in benign conditions, they were 17.7% and 45.5%, respectively. The mean age at which endoscopy was performed was 64. Complications post Merit and WallFlex placement were 79.4% and 60.6%, respectively. Complications with malignant and benign conditions were 73.9% and 61.9%, respectively. Complications with 19, 18, and 23 mm diameters were 75.0%, 66.7%, and 69.4%, respectively. Complications with 120, 150, 100, 15, 12, 10 mm stent lengths were 84.6%, 58.3%, 58.8%, 80.0%, 75.0%, and 33.3%, respectively. Conclusion Our study showed that the Merit stent was mainly used, and the major indication of stent placement was a malignant condition. Major complications were seen when the reason for stent placement was a malignant condition, the diameter was 19 mm, the length was 120 mm, and the use of the Merit stent.
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Affiliation(s)
- Rajesh Essrani
- Internal Medicine, Geisinger Medical Center, Danville, USA.,Internal Medicine, Lehigh Valley Health Network, Allentown, USA
| | - Hiral Shah
- Gastroenterology, Lehigh Valley Health Network, Allentown, USA
| | - Shashin Shah
- Gastroenterology, Lehigh Valley Health Network, Allentown, USA
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Betzel B, Drenth JPH, Siersema PD. Adverse Events of the Duodenal-Jejunal Bypass Liner: a Systematic Review. Obes Surg 2019; 28:3669-3677. [PMID: 30121857 DOI: 10.1007/s11695-018-3441-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
A systematic review was conducted on adverse events (AEs) associated with the use of the duodenal-jejunal bypass liner (DJBL). PubMed, EMBASE, and Cochrane library were searched up to January 2018. The quality of reporting AEs was determined by the McHarm questionnaire and the risk of bias by the Newcastle-Ottawa scale. Thirty-eight studies were included. The comparability of the studies was low and the McHarm questionnaire showed incompleteness for most parameters in all studies. A total of 891 AEs were reported in 1056 patients. Thirty-three AEs (3.7%) were classified as severe, including hepatic abscess and esophageal perforation. The anchor of the DJBL caused or likely caused 85% of the SAEs. To improve the safety margin of the DJBL, adjustments to the anchoring system are needed.
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Affiliation(s)
- Bark Betzel
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, P.O. Box 9101, code 455, Nijmegen, The Netherlands.
| | - Joost P H Drenth
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, P.O. Box 9101, code 455, Nijmegen, The Netherlands
| | - Peter D Siersema
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, P.O. Box 9101, code 455, Nijmegen, The Netherlands
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Dua KS, DeWitt JM, Kessler WR, Diehl DL, Draganov PV, Wagh MS, Kahaleh M, Wong Kee Song LM, Khara HS, Khan AH, Aburajab MM, Ballard D, Forsmark CE, Edmundowicz SA, Brauer BC, Tyberg A, Buttar NS, Adler DG. A phase III, multicenter, prospective, single-blinded, noninferiority, randomized controlled trial on the performance of a novel esophageal stent with an antireflux valve (with video). Gastrointest Endosc 2019; 90:64-74.e3. [PMID: 30684601 DOI: 10.1016/j.gie.2019.01.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 01/09/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Self-expanding metal stents (SEMSs) when deployed across the gastroesophageal junction (GEJ) can lead to reflux with risks of aspiration. A SEMS with a tricuspid antireflux valve (SEMS-V) was designed to address this issue. The aim of this study was to evaluate the efficacy and safety of this stent. METHODS A phase III, multicenter, prospective, noninferiority, randomized controlled trial was conducted on patients with malignant dysphagia requiring SEMSs to be placed across the GEJ. Patients were randomized to receive SEMSs with no valve (SEMS-NV) or SEMS-V. Postdeployment dysphagia score at 2 weeks and Gastroesophageal Reflux Disease-Health Related Quality of Life (GERD-HRQL) questionnaire score at 4 weeks were measured. Patients were followed for 24 weeks. RESULTS Sixty patients were randomized (SEMS-NV: 30 patients, mean age 67 ± 13 years; SEMS-V: 30 patients, mean age 65 ± 12 years). Baseline dysphagia scores (SEMS-NV, 2.5 ± .8; SEMS-V, 2.5 ± .8) and GERD-HRQL scores (SEMS-NV, 11.1 ± 8.2; SEMS-V, 12.8 ± 8.3) were similar. All SEMSs were successfully deployed. A similar proportion of patients in both arms improved from advanced dysphagia to moderate to no dysphagia (SEMS-NV, 71%; SEMS-V, 74%; 95% confidence interval, 1.93 [-17.8 to 21.7]). The dysphagia scores were also similar across all follow-up time points. Mean GERD-HRQL scores improved by 7.4 ± 10.2 points in the SEMS-V arm and by 5.2 ± 8.3 in the SEMS-NV group (P = .96). The GERD-HRQL scores were similar across all follow-up time points. Aspiration pneumonia occurred in 3.3% in the SEMS-NV arm and 6.9% in the SEMS-V arm (P = .61). Migration rates were similar (SEMS-NV, 33%; SEMS-V, 48%; P = .29). Two SEMS-V spontaneously fractured. There was no perforation, food impaction, or stent-related death in either group. CONCLUSIONS The SEMS-V was equally effective in relieving dysphagia as compared with the SEMS-NV. Presence of the valve did not increase the risks of adverse events. GERD symptom scores were similar between the 2 stents, implying either that the valve was not effective or that all patients on proton pump inhibitors could have masked the symptoms of GERD. Studies with objective evaluations such as fluoroscopy and/or pH/impedance are recommended. (Clinical trial registration number: NCT02159898.).
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Affiliation(s)
- Kulwinder S Dua
- Department of Medicine, Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - John M DeWitt
- Department of Medicine, Division of Gastroenterology and Hepatology, Indiana University Hospital, Indianapolis, Indiana, USA
| | - William R Kessler
- Department of Medicine, Division of Gastroenterology and Hepatology, Indiana University Hospital, Indianapolis, Indiana, USA
| | - David L Diehl
- Department of Medicine, Division of Gastroenterology and Hepatology, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - Peter V Draganov
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida, USA
| | - Mihir S Wagh
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Colorado Denver, Aurora, Colorado, USA
| | - Michel Kahaleh
- Department of Medicine, Division of Gastroenterology and Hepatology, Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA
| | - Louis M Wong Kee Song
- Department of Medicine, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Harshit S Khara
- Department of Medicine, Division of Gastroenterology and Hepatology, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - Abdul H Khan
- Department of Medicine, Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Murad M Aburajab
- Department of Medicine, Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Darren Ballard
- Department of Medicine, Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Chris E Forsmark
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida, USA
| | - Steven A Edmundowicz
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Colorado Denver, Aurora, Colorado, USA
| | - Brian C Brauer
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Colorado Denver, Aurora, Colorado, USA
| | - Amy Tyberg
- Department of Medicine, Division of Gastroenterology and Hepatology, Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA
| | - Najtej S Buttar
- Department of Medicine, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Douglas G Adler
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, Utah, USA
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Pandit S, Samant H, Morris J, Alexander SJ. Efficacy and safety of standard and anti-reflux self-expanding metal stent: A Systematic review and meta-analysis of randomized controlled trials. World J Gastrointest Endosc 2019. [DOI: 10.4253/wjge.v11.i4.272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Kaltsidis H, Mansoor W, Park JH, Song HY, Edwards DW, Laasch HU. Oesophageal stenting: Status quo and future challenges. Br J Radiol 2018; 91:20170935. [PMID: 29888981 PMCID: PMC6475941 DOI: 10.1259/bjr.20170935] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 05/22/2018] [Accepted: 06/04/2018] [Indexed: 02/06/2023] Open
Abstract
Oesophageal stents are widely used for palliating dysphagia from malignant obstruction. They are also used with increasing frequency in the treatment of oesophageal perforation, as well as benign strictures from a variety of causes. Improved oncological treatments have led to prolonged survival of patients treated with palliative intent; as a consequence, stents need to function and last longer in order to avoid repeat procedures. There is also increasing need for meticulous procedure planning, careful selection of the device most appropriate for the individual patient and planned follow-up. Furthermore, as more patients are cured, there will be more issues with resultant long-term side-effects, such as recalcitrant strictures due to radiotherapy or anastomotic scarring, which will have to be addressed. Stent design needs to keep up with the progress of cancer treatment, in order to offer patients the best possible long-term result. This review article attempts to illustrate the changing realities in oesophageal stenting, differences in current stent designs and behaviour, as well as the pressing need to refine and modify devices in order to meet the new challenges.
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Affiliation(s)
- Harry Kaltsidis
- Department of Gastroenterology, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Wasat Mansoor
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK
| | - Jung-Hoon Park
- Department of Radiology and Research Institute of Radiology, Asan Medical Center & University of Ulsan College of Medicine, Seoul, Korea
| | - Ho-Young Song
- Department of Radiology and Research Institute of Radiology, Asan Medical Center & University of Ulsan College of Medicine, Seoul, Korea
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van Rossum PSN, Mohammad NH, Vleggaar FP, van Hillegersberg R. Treatment for unresectable or metastatic oesophageal cancer: current evidence and trends. Nat Rev Gastroenterol Hepatol 2018; 15:235-249. [PMID: 29235549 DOI: 10.1038/nrgastro.2017.162] [Citation(s) in RCA: 85] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Approximately half of the patients diagnosed with oesophageal cancer present with unresectable or metastatic disease. Treatment for these patients aims to control dysphagia and other cancer-related symptoms, improve quality of life and prolong survival. In the past 25 years, modestly improved outcomes have been achieved in the treatment of patients with inoperable non-metastatic cancer who are medically not fit for surgery or have unresectable, locally advanced disease. Concurrent chemoradiotherapy offers the best outcomes in these patients. In distant metastatic oesophageal cancer, several double-agent or triple-agent chemotherapy regimens have been established as first-line treatment options. In addition, long-term results of multiple large randomized phase III trials using additional targeted therapies have been published in the past few years, affecting contemporary clinical practice and future research directions. For the local treatment of malignant dysphagia, various treatment options have emerged, and self-expandable metal stent (SEMS) placement is currently the most widely applied method. Besides the continuous search for improved SEMS designs to minimize the risk of associated complications, efforts have been made to develop and evaluate the efficacy of antireflux stents and irradiation stents. This Review outlines the current evidence and ongoing trends in the different modern-day, multidisciplinary interventions for patients with unresectable or metastatic oesophageal cancer with an emphasis on key randomized trials.
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Affiliation(s)
- Peter S N van Rossum
- Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584CX Utrecht, The Netherlands.,Department of Radiation Oncology, University Medical Center Utrecht, Heidelberglaan 100, 3584CX Utrecht, The Netherlands
| | - Nadia Haj Mohammad
- Department of Medical Oncology, University Medical Center Utrecht, Heidelberglaan 100, 3584CX Utrecht, The Netherlands
| | - Frank P Vleggaar
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Heidelberglaan 100, 3584CX Utrecht, The Netherlands
| | - Richard van Hillegersberg
- Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584CX Utrecht, The Netherlands
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11
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Doosti-Irani A, Mansournia MA, Rahimi-Foroushani A, Haddad P, Holakouie-Naieni K. Complications of stent placement in patients with esophageal cancer: A systematic review and network meta-analysis. PLoS One 2017; 12:e0184784. [PMID: 28968416 PMCID: PMC5624586 DOI: 10.1371/journal.pone.0184784] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 08/30/2017] [Indexed: 02/07/2023] Open
Abstract
Background Palliative treatments and stents are necessary for relieving dysphagia in patients with esophageal cancer. The aim of this study was to simultaneously compare available treatments in terms of complications. Methods Web of Science, Medline, Scopus, Cochrane Library and Embase were searched. Statistical heterogeneity was assessed using the Chi2 test and was quantified by I2. The results of this study were summarized in terms of Risk Ratio (RR). The random effects model was used to report the results. The rank probability for each treatment was calculated using the p-score. Results Out of 17855 references, 24 RCTs reported complications including treatment related death (TRD), bleeding, stent migration, aspiration, severe pain and fistula formation. In the ranking of treatments, thermal ablative therapy (p-score = 0.82), covered Evolution® stent (p-score = 0.70), brachytherapy (p-score = 0.72) and antireflux stent (p-score = 0.74) were better treatments in the network of TRD. Thermal ablative therapy (p-score = 0.86), the conventional stent (p-score = 0.62), covered Evolution® stent (p-score = 0.96) and brachytherapy (p-score = 0.82) were better treatments in the network of bleeding complications. Covered Evolution® (p-score = 0.78), uncovered (p-score = 0.88) and irradiation stents (p-score = 0.65) were better treatments in network of stent migration complications. In the network of severe pain, Conventional self-expandable nitinol alloy covered stent (p-score = 0.73), polyflex (p-score = 0.79), latex prosthesis (p-score = 0.96) and brachytherapy (p-score = 0.65) were better treatments. Conclusion According to our results, thermal ablative therapy, covered Evolution® stents, brachytherapy, and antireflux stents are associated with a lower risk of TRD. Moreover, thermal ablative therapy, conventional, covered Evolution® and brachytherapy had lower risks of bleeding. Overall, fewer complications were associated with covered Evolution® stent and brachytherapy.
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Affiliation(s)
- Amin Doosti-Irani
- Department of epidemiology, school of public health, Hamadan University of medical sciences, Hamadan, Iran
- Department of epidemiology and biostatistics, school of public health, Tehran University of medical sciences, Tehran, Iran
| | - Mohammad Ali Mansournia
- Department of epidemiology and biostatistics, school of public health, Tehran University of medical sciences, Tehran, Iran
| | - Abbas Rahimi-Foroushani
- Department of epidemiology and biostatistics, school of public health, Tehran University of medical sciences, Tehran, Iran
| | - Peiman Haddad
- Radiation Oncology Research Center, Cancer Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Kourosh Holakouie-Naieni
- Department of epidemiology and biostatistics, school of public health, Tehran University of medical sciences, Tehran, Iran
- * E-mail:
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12
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Iwasaki H, Mizushima T, Suzuki Y, Fukusada S, Kachi K, Ozeki T, Anbe K, Tsukamoto H, Okumura F, Joh T, Sano H. Factors That Affect Stent-Related Complications in Patients with Malignant Obstruction of the Esophagus or Gastric Cardia. Gut Liver 2017; 11:47-54. [PMID: 27728966 PMCID: PMC5221860 DOI: 10.5009/gnl16172] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Revised: 05/11/2016] [Accepted: 05/18/2016] [Indexed: 12/30/2022] Open
Abstract
Background/Aims Self-expandable metallic stent (SEMS) placement is effective for dysphagia that results from malignant obstruction of the esophagus or gastric cardia; however, stent-related complications may be life-threatening. Thus, the goal of this study was to identify risk factors associated with complications following esophageal stenting. Methods Of the 71 patients who underwent SEMS placement for dysphagia as a result of malignant stricture of the esophagus or gastric cardia, 53 patients with squamous cell carcinoma or adenocarcinoma, without previous SEMS placement, without a fistula, and without recurrent tumor after surgery were retrospectively identified. The occurrence of stent-related complications was used as an endpoint. Results Stent-related complications were identified in 26 patients (49.1%), and major complications occurred in 14 patients (26.4%). The use of an Ultraflex stent (odds ratio [OR], 6.81; 95% confidence interval [CI], 1.54 to 30.00; p=0.011) and prior chemotherapy (OR, 6.13; 95% CI, 1.46 to 25.70; p=0.013) were significantly associated with stent-related complications. Moreover, the use of an Ultraflex stent (OR, 19.60; 95% CI, 2.26 to 170.00; p=0.007) and prior radiation (OR, 25.70; 95% CI, 2.37 to 280.00; p=0.008) significantly increased the risk of major complications. Conclusions The use of an Ultraflex stent and prior radiation and/or chemotherapy may represent risk factors for complications following esophageal SEMS placement.
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Affiliation(s)
- Hiroyasu Iwasaki
- Department of Gastroenterology, Gifu Prefectural Tajimi Hospital, Tajimi, Japan
| | - Takashi Mizushima
- Department of Gastroenterology, Gifu Prefectural Tajimi Hospital, Tajimi, Japan
| | - Yuta Suzuki
- Department of Gastroenterology, Gifu Prefectural Tajimi Hospital, Tajimi, Japan
| | - Shigeki Fukusada
- Department of Gastroenterology, Gifu Prefectural Tajimi Hospital, Tajimi, Japan
| | - Kenta Kachi
- Department of Gastroenterology, Gifu Prefectural Tajimi Hospital, Tajimi, Japan
| | - Takanori Ozeki
- Department of Gastroenterology, Gifu Prefectural Tajimi Hospital, Tajimi, Japan
| | - Kaiki Anbe
- Department of Gastroenterology, Gifu Prefectural Tajimi Hospital, Tajimi, Japan
| | - Hironobu Tsukamoto
- Department of Gastroenterology, Gifu Prefectural Tajimi Hospital, Tajimi, Japan
| | - Fumihiro Okumura
- Department of Gastroenterology, Gifu Prefectural Tajimi Hospital, Tajimi, Japan
| | - Takashi Joh
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Hitoshi Sano
- Department of Gastroenterology, Gifu Prefectural Tajimi Hospital, Tajimi, Japan
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13
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History of the Use of Esophageal Stent in Management of Dysphagia and Its Improvement Over the Years. Dysphagia 2017; 32:39-49. [PMID: 28101666 DOI: 10.1007/s00455-017-9781-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Accepted: 01/01/2017] [Indexed: 01/07/2023]
Abstract
The art and science of using stents to treat dysphagia and seal fistula, leaks and perforations has been evolving. Lessons learnt from the deficiencies of previous models led to several improvements making stent deployment easier, and with some designs, it was also possible to remove the stents if needed. With these improvements, besides malignant dysphagia, newer indications for using stents emerged. Unfortunately, despite several decades of evolution, as yet, there is no perfect stent that "fits all." This article is an overview of how this evolution process happened and where we are currently with using stents to manage patients with dysphagia and with other esophageal disorders.
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Brimhall B, Adler DG. Esophageal stents for the treatment of malignant dysphagia in patients with esophageal cancer. Hosp Pract (1995) 2016; 38:94-102. [PMID: 20890057 DOI: 10.3810/hp.2010.06.301] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Self-expanding metal stents (SEMS) are the current standard for relief of malignant esophageal dysphagia. Self-expanding plastic stents (SEPS) are also used for relief of malignant esophageal dysphagia and as neoadjuvant therapy due to their relative ease of removability. The innovations in design of both SEMS and SEPS have made their use more prevalent in patients with malignant dysphagia. We review the current literature on esophageal stents, including general concepts, indications, contraindications, SEMS and SEPS models, complications and their management, implications of tumor location, cost-effectiveness of stents in comparison with other modalities, and quality of life after stent placement.
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Affiliation(s)
- Bryan Brimhall
- University of Utah, Department of Internal Medicine, Division of Gastroenterology and Hepatology, Salt Lake City, UT 84132, USA
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15
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Irani S, Kozarek RA. Techniques and principles of endoscopic treatment of benign gastrointestinal strictures. Curr Opin Gastroenterol 2015; 31:339-50. [PMID: 26247823 DOI: 10.1097/mog.0000000000000200] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW The fundamental goal of treating any stenosis is luminal enlargement to ameliorate the underlying obstructive symptoms. Symptoms depend on the etiology and the site of the stricture and may include dysphagia, nausea and vomiting, abdominal pain, obstipation, or frank bowel obstruction. This article compares the various current technologies available for the treatment of gastrointestinal stenoses with regard to ease and site of application, patient tolerance, safety and efficacy data, and cost-benefit ratio. RECENT FINDINGS Recent studies indicate that gastrointestinal dilation and stenting have evolved to a point at which in many if not most situations they can be the first line therapy and potentially the final therapy needed to treat the underlying condition. SUMMARY Following techniques and principles in the management of gastrointestinal strictures would allow for the well tolerated and effective treatment of most patients with the tools currently available today.
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Affiliation(s)
- Shayan Irani
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, USA
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16
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Philips P, North DA, Scoggins C, Schlegel M, Martin RC. Gastric-Esophageal Stenting for Malignant Dysphagia: Results of Prospective Clinical Trial Evaluation of Long-Term Gastroesophageal Reflux and Quality of Life-Related Symptoms. J Am Coll Surg 2015; 221:165-73. [DOI: 10.1016/j.jamcollsurg.2015.01.062] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2014] [Accepted: 01/17/2015] [Indexed: 12/31/2022]
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17
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Abstract
Endoscopic stenting is increasingly being used in the management of gastrointestinal luminal obstruction, and has become the current treatment of choice for the palliation of blockage caused by malignant or benign growths. A variety of stents have been developed to enhance the efficacy of the procedure, and improvements are ongoing. In this article, we review the history of, and recent advances in, gastrointestinal stenting. We describe the rationale behind the design as well as the resulting outcome for each stent type.
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Affiliation(s)
- Jin-Seok Park
- Digestive Disease Center, Department of Internal Medicine, Inha University School of Medicine, Incheon, Korea
| | - Seok Jeong
- Digestive Disease Center, Department of Internal Medicine, Inha University School of Medicine, Incheon, Korea. ; National Center of Efficacy Evaluation for the Development of Health Products Targeting Digestive Disorders (NCEED), Incheon, Korea
| | - Don Haeng Lee
- Digestive Disease Center, Department of Internal Medicine, Inha University School of Medicine, Incheon, Korea. ; National Center of Efficacy Evaluation for the Development of Health Products Targeting Digestive Disorders (NCEED), Incheon, Korea. ; Utah-Inha DDS & Advanced Therapeutics Research Center, Incheon, Korea
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18
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Park JS, Jeong S, Lee DH. Recent Advances in Gastrointestinal Stent Development. Clin Endosc 2015; 48:209-15. [PMID: 26064820 PMCID: PMC4461664 DOI: 10.5946/ce.2015.48.3.209] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Accepted: 05/06/2015] [Indexed: 12/17/2022] Open
Abstract
Endoscopic stenting is increasingly being used in the management of gastrointestinal luminal obstruction, and has become the current treatment of choice for the palliation of blockage caused by malignant or benign growths. A variety of stents have been developed to enhance the efficacy of the procedure, and improvements are ongoing. In this article, we review the history of, and recent advances in, gastrointestinal stenting. We describe the rationale behind the design as well as the resulting outcome for each stent type.
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Affiliation(s)
- Jin-Seok Park
- Digestive Disease Center, Department of Internal Medicine, Inha University School of Medicine, Incheon, Korea
| | - Seok Jeong
- Digestive Disease Center, Department of Internal Medicine, Inha University School of Medicine, Incheon, Korea. ; National Center of Efficacy Evaluation for the Development of Health Products Targeting Digestive Disorders (NCEED), Incheon, Korea
| | - Don Haeng Lee
- Digestive Disease Center, Department of Internal Medicine, Inha University School of Medicine, Incheon, Korea. ; National Center of Efficacy Evaluation for the Development of Health Products Targeting Digestive Disorders (NCEED), Incheon, Korea. ; Utah-Inha DDS & Advanced Therapeutics Research Center, Incheon, Korea
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19
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Malgras B, Lo Dico R, Pautrat K, Dohan A, Boudiaf M, Pocard M, Soyer P. Gastrointestinal stenting: Current status and imaging features. Diagn Interv Imaging 2015; 96:593-606. [PMID: 25953525 DOI: 10.1016/j.diii.2015.04.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Accepted: 04/02/2015] [Indexed: 12/13/2022]
Abstract
The use of stents in the gastrointestinal tract has been subjected to major changes. Initially, the use of stents was restricted to malignant strictures in patients with metastatic disease. But thanks to reduction of the morbidity and mortality rates, they are now used with curative intention and in patients with benign diseases after careful selection. However, for patients presenting with colon obstruction due to an advanced colon carcinoma, the mortality and morbidity are still high. The purpose of this review is to provide an overview of indications, techniques and further developments of the stents in the gastrointestinal tract and to highlight the predominant role of multidetector row computed tomography (MDCT) in the detection of potential complications.
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Affiliation(s)
- B Malgras
- Department of Surgical Oncology, hôpital Lariboisière, AP-HP, 2, rue Ambroise-Paré, 75475 Paris cedex 10, France.
| | - R Lo Dico
- Department of Surgical Oncology, hôpital Lariboisière, AP-HP, 2, rue Ambroise-Paré, 75475 Paris cedex 10, France
| | - K Pautrat
- Department of Surgical Oncology, hôpital Lariboisière, AP-HP, 2, rue Ambroise-Paré, 75475 Paris cedex 10, France
| | - A Dohan
- Department of Abdominal and Interventional Imaging, hôpital Lariboisière, AP-HP, 2, rue Ambroise-Paré, 75475 Paris cedex 10, France; Sorbonne Paris Cité, université Diderot - Paris 7, 10, avenue de Verdun, 75010 Paris, France; UMR Inserm 965, hôpital Lariboisière, 2, rue Ambroise-Paré, 75010 Paris, France
| | - M Boudiaf
- Department of Abdominal and Interventional Imaging, hôpital Lariboisière, AP-HP, 2, rue Ambroise-Paré, 75475 Paris cedex 10, France
| | - M Pocard
- Department of Surgical Oncology, hôpital Lariboisière, AP-HP, 2, rue Ambroise-Paré, 75475 Paris cedex 10, France; Sorbonne Paris Cité, université Diderot - Paris 7, 10, avenue de Verdun, 75010 Paris, France; UMR Inserm 965, hôpital Lariboisière, 2, rue Ambroise-Paré, 75010 Paris, France
| | - P Soyer
- Department of Abdominal and Interventional Imaging, hôpital Lariboisière, AP-HP, 2, rue Ambroise-Paré, 75475 Paris cedex 10, France; Sorbonne Paris Cité, université Diderot - Paris 7, 10, avenue de Verdun, 75010 Paris, France; UMR Inserm 965, hôpital Lariboisière, 2, rue Ambroise-Paré, 75010 Paris, France
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20
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North DA, Schlegel M, Martin RCG. Gastroesophageal Reflux Disease-related Symptom Assessment in Subjects with Malignant Dysphagia Receiving Esophageal Stents. Am Surg 2014. [DOI: 10.1177/000313481408001230] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Concerns remain over the ability to stent across of the lower esophageal sphincter (LES) for esophageal adenocarcinoma and the effects of gastroesophageal (GE) reflux. Thus, the aim of this study was to demonstrate minimal quality-of-life (QOL) side effects in patients undergoing esophageal stenting across the LES. An Institutional Review Board–approved prospective clinical trial evaluated the results of the Gastrointestinal Symptom questionnaire that includes a validated GE reflux disease (GERD) assessment (GERD-HRQL) and a dysphagia assessment. Consecutive patients were enrolled in this clinical trial, with 81 per cent male, 19 per cent female, median age of 62 years, with adenocarcinoma of the GE junction as their diagnosis. The median dysphagia score was 3 (only liquids can be tolerated) prestent and was improved to a median score of 0 (ability to eat all foods) poststent ( P = 0.01). The median GERD score was 0 (none) prestent and did not change with a median score of 0 (none) poststent ( P = 0.2). All GERD-related questions were unchanged prestent and poststent in all categories, specifically: frequency of GERD, time of day of reflux, pain behind breastbone, and pain medications. There was also no difference in regurgitation frequency (median prestent 1 vs poststent 0, P = 0.08), texture (prestent 2 [semisolid] vs poststent 1 [liquid]). There was only a statistical change in the ability to belch (prestent 0 [no ability] to poststent 1 [ability]), P = 0.02) and the ability to vomit. Esophageal stenting across the GE junction for dysphagia relief in esophageal malignancies does not adversely effect a patient's QOL in regard to reflux-related symptoms.
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Affiliation(s)
- D. Alan North
- Department of Surgery, University of Louisville, Louisville, Kentucky
| | - Melissa Schlegel
- Department of Surgery, University of Louisville, Louisville, Kentucky
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21
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Dai Y, Li C, Xie Y, Liu X, Zhang J, Zhou J, Pan X, Yang S. Interventions for dysphagia in oesophageal cancer. Cochrane Database Syst Rev 2014; 2014:CD005048. [PMID: 25354795 PMCID: PMC8106614 DOI: 10.1002/14651858.cd005048.pub4] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Most patients with oesophageal and gastro-oesophageal carcinoma are diagnosed at an advanced stage and require palliative intervention. Although there are many kinds of interventions, the optimal one for the palliation of dysphagia remains unclear. This review updates the previous version published in 2009. OBJECTIVES The aim of this review was to systematically analyse and summarise the efficacy of different interventions used in the palliation of dysphagia in primary oesophageal and gastro-oesophageal carcinoma. SEARCH METHODS To find new studies for this updated review, in January 2014 we searched, according to the Cochrane Upper Gastrointestinal and Pancreatic Diseases model, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE, EMBASE and CINAHL; and major conference proceedings (up to January 2014). SELECTION CRITERIA Only randomised controlled trials (RCTs) were included in which patients with inoperable or unresectable primary oesophageal cancer underwent palliative treatment. Different interventions like rigid plastic intubation, self-expanding metallic stent (SEMS) insertion, brachytherapy, external beam radiotherapy, chemotherapy, oesophageal bypass surgery, chemical and thermal ablation therapy, either head-to-head or in combination, were included. The primary outcome was dysphagia improvement. Secondary outcomes included recurrent dysphagia, technical success, procedure related mortality, 30-day mortality, adverse effects and quality of life. DATA COLLECTION AND ANALYSIS Data collection and analysis were performed in accordance with the methods of the Cochrane Upper Gastrointestinal and Pancreatic Diseases Review Group. MAIN RESULTS We included 3684 patients from 53 studies. SEMS insertion was safer and more effective than plastic tube insertion. Thermal and chemical ablative therapy provided comparable dysphagia palliation but had an increased requirement for re-interventions and for adverse effects. Anti-reflux stents provided comparable dysphagia palliation to conventional metal stents. Some anti-reflux stents might have reduced gastro-oesophageal reflux and complications. Newly-designed double-layered nitinol (Niti-S) stents were preferable due to longer survival time and fewer complications compared to simple Niti-S stents. Brachytherapy might be a suitable alternative to SEMS in providing a survival advantage and possibly a better quality of life, and might provide better results when combined with argon plasma coagulation or external beam radiation therapy. AUTHORS' CONCLUSIONS Self-expanding metal stent insertion is safe, effective and quicker in palliating dysphagia compared to other modalities. However, high-dose intraluminal brachytherapy is a suitable alternative and might provide additional survival benefit with a better quality of life. Some anti-reflux stents and newly-designed stents lead to longer survival and fewer complications compared to conventional stents. Combinations of brachytherapy with self-expanding metal stent insertion or radiotherapy are preferable due to the reduced requirement for re-interventions. Rigid plastic tube insertion, dilatation alone or in combination with other modalities, and chemotherapy alone are not recommended for palliation of dysphagia due to a high incidence of delayed complications and recurrent dysphagia.
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Affiliation(s)
- Yingxue Dai
- Department of Child, Adolescent and Maternal Health, Hua Xi School of Public Health, Sichuan University, 17 Ren min nan lu san duan, Chengdu, Sichuan, China, 610041
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22
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Qian L, Wang B, Li K, Yu L, Ding J, Zhang H, Ding X, Shi R. Long-term efficacy of pneumatic dilation and esophageal stenting for the treatment of achalasia. Digestion 2014; 88:209-16. [PMID: 24217292 DOI: 10.1159/000355207] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2013] [Accepted: 08/21/2013] [Indexed: 02/04/2023]
Abstract
AIMS To compare the efficacy and safety of pneumatic dilation with stenting for the treatment of achalasia. METHODS Achalasia patients treated with pneumatic dilation or stenting were included in this analysis. Clinical symptoms were assessed by the Eckardt score. An esophagram and esophageal manometry were performed at the pretreatment and posttreatment follow-up visits. Data such as patient demographics and complications were collected. A drop in the Eckardt score to ≤3 was defined as treatment success. RESULTS There were 151 patients treated with pneumatic dilation (n = 76) or stenting (n = 75). The 1-, 12- and 24-month therapeutic success rates were 100, 92 and 79%, respectively, in the dilation group and 100, 93 and 87%, respectively, in the stenting group. The decrease of Eckardt score in the stenting group was significantly notable (p < 0.05) compared to that of the dilation group at the long-term follow-up visits. The maximum esophageal diameter was comparable at baseline and became statistically significant [25 mm (22-30) vs. 22 mm (19-27), p = 0.004] at posttreatment month 24. The recurrence rate was 21% in the dilation group and 13% in the stenting group. The complications of either treatment were usually mild, transient and statistically insignificant. CONCLUSION Esophageal stenting had a comparable short-term but better long-term efficacy in comparison with pneumatic dilation.
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Affiliation(s)
- Lijuan Qian
- Department of Gastroenterology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, PR China
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23
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Hirdes MM, Siersema P. Endoprosthetics for malignant esophageal disease. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2014. [DOI: 10.1016/j.tgie.2014.07.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Hourneaux de Moura EG, Toma K, Goh KL, Romero R, Dua KS, Felix VN, Levine MS, Kochhar R, Appasani S, Gusmon CC. Stents for benign and malignant esophageal strictures. Ann N Y Acad Sci 2013; 1300:119-143. [PMID: 24117639 DOI: 10.1111/nyas.12242] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
This paper presents commentaries on endotherapy for esophageal perforation/leaks; treatment of esophageal perforation; whether esophageal stents should be used for treating benign esophageal strictures; what determines the optimal stenting period in benign esophageal strictures/leaks; how to choose an esophageal stent; how a new fistula secondary to an esophageal stent should be treated; which strategy should be adopted when a fistula of a cervical anastomosis occurs; intralesional steroids for refractory esophageal strictures; balloon and bougie dilators for esophageal strictures and predictors of response to dilation; whether refractory strictures from different etiologies respond differently to endotherapy; surgical therapy of benign esophageal strictures; and whether stenoses following severe esophageal burns should be treated by esophageal resection or esophageal bypass.
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Affiliation(s)
| | - Kengo Toma
- Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Khean-Lee Goh
- Division of Gastroenterology and GI Endoscopy, University of Malaya, Kuala Lumpur, Malaysia
| | - Ronald Romero
- Division of Gastroenterology and GI Endoscopy, University of Malaya, Kuala Lumpur, Malaysia
| | - Kulwinder S Dua
- Division of Gastroenterology and Hepatology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - Marc S Levine
- Department of Gastrointestinal Radiation, University of Pennsylvania Medical Center, Philadelphia, Pennsylvania.,Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rakesh Kochhar
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sreekanth Appasani
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Carla Cristina Gusmon
- Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universdade de São Paulo, São Paulo, Brazil
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Jee SR, Cho JY, Kim KH, Kim SG, Cho JH. Evidence-based recommendations on upper gastrointestinal tract stenting: a report from the stent study group of the korean society of gastrointestinal endoscopy. Clin Endosc 2013; 46:342-54. [PMID: 23964331 PMCID: PMC3746139 DOI: 10.5946/ce.2013.46.4.342] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2012] [Revised: 01/02/2013] [Accepted: 01/03/2013] [Indexed: 12/16/2022] Open
Abstract
Endoscopic stents have evolved dramatically over the past 20 years. With the introduction of uncovered self-expanding metal stents in the early 1990s, they are primarily used to palliate symptoms of malignant obstruction in patients with inoperable gastrointestinal (GI) cancer. At present, stents have emerged as an effective, safe, and less invasive alternative for the treatment of malignant GI obstruction. Clinical decisions about stent placement should be made based on the exact understanding of the patient's condition. These recommendations based on a critical review of the available data and expert consensus are made for the purpose of providing endoscopists with information about stent placement. These can be helpful for management of patients with inoperable cancer or various nonmalignant conditions in the upper GI tract.
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Affiliation(s)
- Sam Ryong Jee
- Department of Internal Medicine, Inje University Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
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26
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Partially versus fully covered self-expanding metal stents for benign and malignant esophageal conditions: a single center experience. Surg Endosc 2013; 27:2185-92. [PMID: 23370964 DOI: 10.1007/s00464-012-2738-x] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2012] [Accepted: 12/04/2012] [Indexed: 02/06/2023]
Abstract
BACKGROUND Fully covered self-expanding metal stents (FCSEMS), unlike partially covered SEMS (PCSEMS), have been used to treat benign as well as malignant conditions. We aimed to evaluate the outcome of PCSEMS and FCSEMS in patients with both benign and malignant esophageal diseases. METHODS Data were reviewed of all patients who underwent SEMS placement for malignant or benign conditions between January 1995 and January 2012. Patients with cancer were followed for at least 3 months, until death or surgery. Patients with benign conditions had stents removed between 4 and 12 weeks. Patient demographics, location and type of lesion, stent placement and removal, clinical success, and adverse events were analyzed. RESULTS A total of 252 patients (mean ± standard deviation age 68.5 ± 14 years; 171 male) received 321 SEMS (209 PCSEMS, 112 FCSEMS) for malignant (78 %) and benign (22 %) conditions. Stent placement and removal was successful in 97.6 and 95.6 % procedures. Successful relief of malignant dysphagia was noted in 140 of 167 patients (83.8 %) and control of benign fistulas, leaks, and perforations was noted in 21 of 25 patients (84 %), but only 8 of 15 patients (53 %) with recalcitrant benign strictures had effective treatment. Fifty-six patients (22.2 %) experienced at least one stent-related adverse events. Migration was frequent, occurring in 61 of 321 stent placements (19 %), and more frequently with FCSEMS than PCSEMS (37.5 vs. 9.1 %, p < 0.001). FCSEMS, benign conditions, and distal location were the variables independently associated with migration (p < 0.001, p = 0.022, and p = 0.008). Patients with PCSEMS were more likely to have tissue in- or overgrowth than FCSEMS (53.4 vs. 29.1 %, p = 0.004). CONCLUSIONS Both PCSEMS and FCSEMS can be used in benign and malignant conditions; they are both effective for relieving malignant dysphagia and for closing leaks and perforations, but they seem less effective for relieving benign recalcitrant strictures. Stent migration is more common with FCSEMS, which may limit its use for the palliation of malignant dysphagia.
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Abstract
Gastrointestinal (GI) stent has been developed for palliation of obstructive symptoms in various diseases causing obstruction of GI tract. Self-expanding metal stent (SEMS) has replaced old type of plastic stent, and endoscopic insertion of stent has replaced fluoroscopy-guided insertion. Nowadays, newly-designed SEMSs have been developed for prevention of complications such as stent migration and re-obstruction, and indications of stent recently have been widened into benign conditions as well as malignant obstruction. In this review, the types, method of insertion, indications and clinical outcomes of stent in the upper GI tract would be discussed.
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Affiliation(s)
- Sang Gyun Kim
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
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28
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Ben-Menachem T, Decker GA, Early DS, Evans J, Fanelli RD, Fisher DA, Fisher L, Fukami N, Hwang JH, Ikenberry SO, Jain R, Jue TL, Khan KM, Krinsky ML, Malpas PM, Maple JT, Sharaf RN, Dominitz JA, Cash BD. Adverse events of upper GI endoscopy. Gastrointest Endosc 2012; 76:707-18. [PMID: 22985638 DOI: 10.1016/j.gie.2012.03.252] [Citation(s) in RCA: 221] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2012] [Accepted: 03/20/2012] [Indexed: 12/13/2022]
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29
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Kumagai H, Nio K, Shirakawa T, Uchino K, Kusaba H, Isobe T, Komoda M, Tamura S, Maeyama R, Nagai E, Akashi K, Baba E. Improvement of quality of life and survival using self-expandable metal stent placement for severe malignant stenosis of the gastric body: a case report. J Med Case Rep 2012; 6:315. [PMID: 22992342 PMCID: PMC3485130 DOI: 10.1186/1752-1947-6-315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2012] [Accepted: 07/19/2012] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Advanced gastric carcinoma often decreases quality of life because of upper gastrointestinal tract stenosis. Self-expandable metal stents have been thought to be an effective, minimally invasive treatment for stenosis. However, the effectiveness of self-expandable metal stent placement for carcinomatous stenosis of the gastric body and antrum has not been clarified, and there have been few reports of such cases. CASE PRESENTATION A 74-year-old Japanese woman developed stenosis of the gastric body and antrum caused by advanced gastric cancer during first-line chemotherapy. She developed weight loss and poor nutrition due to inadequate intake. Self-expandable metal stent placement for stenosis of the gastric body and antrum ameliorated her symptoms rapidly and improved her general condition and quality of life. Eight days after self-expandable metal stent placement, second-line chemotherapy could be administered safely. Oral intake and nutritional status were maintained for 117 days after self-expandable metal stent placement, and she died of gastric cancer 176 days after self-expandable metal stent placement and initiation of second-line chemotherapy. CONCLUSIONS Self-expandable metal stent placement for carcinomatous stenosis in the gastric body and antrum could be an effective therapeutic strategy for patients with inadequate oral uptake. It may provide rapid improvement of the patient's general condition and oral intake with minimal complications, comparatively long-term symptom relief, and a survival benefit by allowing second-line chemotherapy.
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Affiliation(s)
- Hozumi Kumagai
- Department of Hematology and Oncology, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
| | - Kenta Nio
- Department of Hematology and Oncology, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
| | - Tsuyoshi Shirakawa
- Department of Hematology and Oncology, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
| | - Keita Uchino
- Department of Medical Oncology, Kyushu Medical Center, 1-8-1 Jigyohama, Chuo-ku, Fukuoka, 810-0065, Japan
| | - Hitoshi Kusaba
- Department of Hematology and Oncology, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
| | - Taichi Isobe
- Department of Hematology and Oncology, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
| | - Masato Komoda
- Department of Hematology and Oncology, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
| | - Shingo Tamura
- Department of Hematology and Oncology, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
| | - Ryo Maeyama
- Department of Surgery and Oncology, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Eishi Nagai
- Department of Surgery and Oncology, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Koichi Akashi
- Department of Hematology and Oncology, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
| | - Eishi Baba
- Department of Hematology and Oncology, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
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Hu XJ, Zhang H, Shao GA, Wang SQ, Liu GF, Xu YY, Lu H. Antireflux stents versus conventional stents for management of stenosis of distal esophageal and gastric cardia: An systematic review. Shijie Huaren Xiaohua Zazhi 2012; 20:2270-2275. [DOI: 10.11569/wcjd.v20.i24.2270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the efficacy and safety of anti-reflux stents versus conventional stents for the management of stenosis of distal esophageal and gastric cardia in patients with esophageal cancer.
METHODS: Randomized controlled trials (RCTs)that evaluated anti-reflux stents versus conventional stents in the treatment of stenosis of distal esophageal and gastric cardia in patients with esophageal cancer were electronically searched from the PubMed (1978-2011), EMbase (1966-2011), CBM (1978-2011), Cochrane Library (2011, Issue 11) and CNKI (1979-2011) databases, and relevant published and unpublished data and their references (either in English or Chinese), were also searched manually. The data were extracted and the methodological quality of the incorporated studies was evaluated by two reviewers independently. The RevMan 5.1 software was used for meta-analysis.
RESULTS: Five RCTs involving 234 patients were included. Meta-analysis showed that anti-reflux stents and conventional stents had no significant differences in terms of the incidences of pain (RR = 0.41, 95% CI: 0.16, 1.06), stent migration (RR = 1.02, 95% CI: 0.50, 2.11), obstruction (RR = 1.02, 95% CI: 0.52, 1.99), gastroesophageal reflux (RR = 1.68, 95% CI: 0.52, 5.48), bleeding (RR = 1.39, 95% CI: 0.44, 4.40), and perforation of the esophagus and stomach (RR = 0.70, 95% CI: 0.25, 2.00).
CONCLUSION: The overall curative efficacy of anti-reflux stents for the stenosis of distal esophageal and gastric cardia in patients with esophageal cancer is not better than that of conventional stents. Because of the generally low quality and a small number of studies in the incorporated research, the above conclusion remains to be validated by carrying out more randomized controlled trials with multiple center samples and enough follow-up time.
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Shim CS. Esophageal stent for cervical esophagus and esophagogastric junction. Clin Endosc 2012; 45:235-9. [PMID: 22977809 PMCID: PMC3429743 DOI: 10.5946/ce.2012.45.3.235] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2012] [Revised: 07/25/2012] [Accepted: 07/25/2012] [Indexed: 11/14/2022] Open
Abstract
Tumors in the cervical portion of the esophagus have traditionally been more difficult to manage. The implantation in the cervical esophagus is a technically demanding procedure. The implantation of modified self-expandable metal stents (SEMSs) was very effective perorally under endoscopic and fluoroscopic guidance. Experience with SEMS has revealed an increased risk of migration when either covered stents are used or a stent is implanted across the gastroesophageal junction. The modified, covered, esophageal stents appear to prevent stent migration and improve dysphagia in patients with malignant tumor stenosis at the esophagogastric junction. Besides heartburn, regurgitation is sometimes very distressing to patients and may lead to fatal aspiration due to reflux after stenting in esophagogastric junction. These symptoms can be reduced by the use of valved stent. The long S-shape valve is very effective in preventing acid reflux and valve inversion.
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Affiliation(s)
- Chan Sup Shim
- Digestive Disease Center, Konkuk University Medical Center, Seoul, Korea
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Kim MD, Park SB, Kang DH, Lee JH, Choi CW, Kim HW, Chung CU, Jeong YI. Double layered self-expanding metal stents for malignant esophageal obstruction, especially across the gastroesophageal junction. World J Gastroenterol 2012; 18:3732-7. [PMID: 22851867 PMCID: PMC3406427 DOI: 10.3748/wjg.v18.i28.3732] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2011] [Revised: 02/01/2012] [Accepted: 04/13/2012] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the clinical outcomes of double-layered self-expanding metal stents (SEMS) for treatment of malignant esophageal obstruction according to whether SEMS crosses the gastroesophageal junction (GEJ).
METHODS: Forty eight patients who underwent the SEMS insertion for malignant esophageal obstruction were enrolled. Patients were classified as GEJ group (SEMS across GEJ, 18 patients) and non-GEJ group (SEMS above GEJ, 30 patients) according to SEMS position. Double layered (outer uncovered and inner covered stent) esophageal stents were placed.
RESULTS: The SEMS insertion and the clinical improvement were achieved in all patients in both groups. Stent malfunction occurred in seven patients in the GEJ group and nine patients in the non-GEJ group. Tumor overgrowth occurred in five and eight patients, respectively, food impaction occurred in one patient in each group, and stent migration occurred in one and no patient, respectively. There were no significant differences between the two groups. Reflux esophagitis occurred more frequently in the GEJ group (eight vs five patients, P = 0.036) and was controlled by proton pump inhibitor. Aspiration pneumonia occurred in zero and five patients, respectively, and tracheoesophageal fistula occurred in zero and two patients, respectively.
CONCLUSION: Double-layered SEMS are a feasible and effective treatment when placed across the GEJ for malignant esophageal obstruction. Double-layered SEMS provide acceptable complications, especially migration, although reflux esophagitis is more common in the GEJ group.
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Hirdes MMC, Vleggaar FP, Siersema PD. Stent placement for esophageal strictures: an update. Expert Rev Med Devices 2012; 8:733-55. [PMID: 22029470 DOI: 10.1586/erd.11.44] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
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.
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Battersby NJ, Bonney GK, Subar D, Talbot L, Decadt B, Lynch N. Outcomes following oesophageal stent insertion for palliation of malignant strictures: A large single centre series. J Surg Oncol 2012; 105:60-5. [PMID: 22161899 DOI: 10.1002/jso.22059] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Self-expanding metal stents (SEMS) are an accepted intervention for malignant dysphagia. Stents vary in ease of insertion, removability, migration and occlusion rates. This series reports the complications, morbidity and mortality associated with several SEMS. METHOD A prospective database of patients undergoing fluoroscopic guided oesophageal stent insertion for malignancy between June 2001 and June 2009 was analysed. Patient demographics, intervention outcomes and tumour variables were correlated with stent failure and patient survival. Multivariate analysis was performed to evaluate predictors for stent failure. RESULTS Two hundred and seventy-three stents were deployed using nine different types of SEMS. The median Mellow-Pinkas dysphagia score significantly improved from 3 to 1 post-stent insertion (P < 0.001), with a technical success rate of 98%. Stent complications occurred in 95 (36%) patients [recurrent dysphagia n = 49 (19%), migration n = 24 and occlusion n = 25]. Multivariate analysis demonstrates that the covered Niti S stent fails significantly more than the double-layered Niti S stent (OR = 4, P < 0.005). CONCLUSION Oesophageal stent insertion provides good palliation for malignant dysphagia, however recurrent dysphagia remains a problem. This major complication occurs more frequently with covered Niti S stents than double-layered Niti S stents. This finding may aid the stent choice used in advanced oesophageal malignancy.
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Affiliation(s)
- Nicholas J Battersby
- Department of Upper GI Surgery, Stockport NHS Foundation Trust, Stepping Hill Hospital, Stockport, Cheshire, UK.
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Dubecz A, Watson TJ, Raymond DP, Jones CE, Matousek A, Allen J, Salvador R, Polomsky M, Peters JH. Esophageal stenting for malignant and benign disease: 133 cases on a thoracic surgical service. Ann Thorac Surg 2012; 92:2028-32; discussion 2032-3. [PMID: 22115214 DOI: 10.1016/j.athoracsur.2011.08.033] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2009] [Revised: 08/09/2011] [Accepted: 08/11/2011] [Indexed: 10/15/2022]
Abstract
BACKGROUND Esophageal stenting is increasingly being utilized to treat a variety of benign and malignant esophageal conditions. The aim of our study was to review our experience with self-expanding metal, plastic, and hybrid stents in the treatment of esophageal disease on a thoracic surgical service. METHODS The study population consisted of 126 patients undergoing placement of 133 stents at a single institution from 2000 to 2008. Data were reviewed retrospectively for patient characteristics, indications, complications, reinterventions, and efficacy. RESULTS Most stents were placed for palliation of dysphagia due to advanced esophageal cancer (90 of 133; 68%) or extrinsic compression from lung cancer (13 of 133; 9.8%). A total of 123 self-expanding metal stents (SEMS), 7 self-expanding plastic stents (SEPS), and 3 hybrid stents were placed. Of the SEMS, 57 were uncovered and 66 were covered. Malignant obstruction was typically palliated with SEMS, while covered stents were chosen for perforations or anastomotic leaks. The median length of stay was 1 day. Complications occurred in 38.3% of stent placements, with a single perioperative mortality resulting from massive hemorrhage on postoperative day 4. Most complications resulted from stent impaction (12.8%), migration (9.7%), or tumor ingrowth (5.3%). Tumor ingrowth was uncommon with uncovered stents (2 of 57; 3.5%). Stent migration was common with SEPS (4 of 7; 57%), or hybrid stents (2 of 3; 67%). Survival was short in patients with underlying malignancy (median 104 days for esophageal cancer and 48 days for lung cancer), with 20% of patients surviving less than 1 month. CONCLUSIONS Esophageal stent placement is safe and reliable. The goals of therapy are typically met with a single intervention. The majority of patients require no further interventions, though life expectancy often is short and patient selection may be difficult. Most complications are due to stent obstruction, though stent migration is an issue particularly with SEPS and hybrid stents. Esophageal surgeons should be adept at stent placement.
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Affiliation(s)
- Attila Dubecz
- Division of Thoracic and Foregut, Department of Surgery, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA.
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Hirdes MM, Vleggaar FP, Laasch HU, Siersema PD. Technical feasibility and safety of a new, implantable reflux control system to prevent gastroesophageal reflux in patients with stents placed through the lower esophageal sphincter (with video). Gastrointest Endosc 2012; 75:174-8. [PMID: 22196815 DOI: 10.1016/j.gie.2011.08.037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2011] [Accepted: 08/18/2011] [Indexed: 12/11/2022]
Abstract
BACKGROUND When an esophageal stent is placed through the lower esophageal sphincter (LES), gastroesophageal reflux symptoms may persist despite high-dose proton pump inhibitor therapy. A recently developed, short segment, uncovered nitinol stent with a tricuspid-like valve can be placed inside a previously placed esophageal stent. OBJECTIVE To evaluate the technical feasibility and safety of a reflux control system (RCS) in distally placed esophageal stents. DESIGN A prospective case series. SETTING Two tertiary-care referral centers. PATIENTS This study involved 10 patients who had an "open" stent placed through the LES and 1 patient with severe bile reflux after esophagojejunostomy. INTERVENTION Placement of an RCS with fluoroscopic and (in selected cases) endoscopic guidance, from April to October 2010. MAIN OUTCOME MEASUREMENTS Technical success of RCS placement and complications. RESULTS Placement of an RCS was successful on the first attempt in all patients; complete expansion to the wall of the host stent was confirmed by fluoroscopy in all cases. In 3 patients, the host stent migrated in <1 month with the RCS still inside. In 8 patients, the RCS was in place for a median of 134 days (range 33-225 days). Three patients died because of malignant disease progression. Eight RCSs were removed endoscopically, together with the host stent without complications. RCS migration did not occur. LIMITATIONS Small number of patients, nonrandomized design, lack of pH measurements. CONCLUSION Placement of an RCS in a host stent is technically feasible and safe. An RCS can be considered in symptomatic patients with open esophageal stents to prevent gastroesophageal reflux.
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Affiliation(s)
- Meike M Hirdes
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, The Netherlands.
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Abstract
Esophageal strictures are a common problem in gastroenterological practice. In general, the management of malignant or benign esophageal strictures is different and requires a different treatment approach. In daily clinical practice, stent placement is a commonly used modality for the palliation of incurable malignant strictures causing dysphagia, whereas, if available, intraluminal brachytherapy can be considered in patients with a good performance status. Recurrent dysphagia frequently occurs in malignant cases. In case of tissue in- or overgrowth, a second stent is placed. If stent migration occurs, the stent can be repositioned or a second (preferably partially covered) stent can be placed. Food obstruction of the stent lumen can be resolved by endoscopic cleansing. The cornerstone of the management of benign strictures is still dilation therapy (Savary-Gilliard bougie or balloon). There are a subgroup of strictures that are refractory or recur and an alternative approach is required. In order to prevent stricture recurrence, steroid injections into the stricture followed by dilation can be considered. In case of anastomotic strictures or Schatzki rings, incisional therapy is a safe method in experienced hands. Temporary stent placement is a third option before considering self-bougienage or surgery as a salvage treatment. In this review, the most frequently used endoscopic treatment modalities for malignant and benign stricture management will be discussed based on the available literature, and some practical information for the management in daily clinical practice will be provided.
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Gray RT, O'Donnell ME, Scott RD, McGuigan JA, Mainie I. Self-expanding metal stent insertion for inoperable esophageal carcinoma in Belfast: an audit of outcomes and literature review. Dis Esophagus 2011; 24:569-74. [PMID: 21418125 DOI: 10.1111/j.1442-2050.2011.01188.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Successful palliation of dysphagia in patients with inoperable esophageal carcinoma has a major effect on quality of life. Self-expanding metal stents (SEMS) are currently recommended for rapid symptomatic relief when life expectancy is less than 3 months. We assessed complication and reintervention rates along with survival outcomes in patients with inoperable esophageal carcinoma undergoing stent insertion. A retrospective audit was performed from April 2007 to June 2009 for all inoperable primary esophageal carcinoma patients who had an esophageal stent inserted for dysphagia. Case notes were reviewed for clinical, pathological, stent and complication details, while ICD-10 causes of death were obtained from the Department of Health and Social Services, Northern Ireland. Fifty-six stents were inserted into 53 patients (66.0% male, mean age of 70 years). Inoperability was defined by metastatic spread (n= 34, 64.2%), locally advanced disease (n= 7, 13.2%), and severe medical comorbidities (n= 12, 22.6%). The median time from diagnosis to stent insertion was 109 (interquartile range [IQR] 43-187) days. Fifty stents (94.3%) were successfully deployed, while three patients (5.7%) required an additional stent as the primary stent had not bridged the tumor (proximal deployment = 2, suboptimal stent length = 1). Post-SEMS dysphagia scores were significantly better than pre-SEMS scores (2.90 vs. 1.54, P < 0.001). There were 27 complications identified in 23 (43.4%) patients (major complications = 9, minor complications = 14). Twelve patients (22.6%) required additional endoscopic procedures. The 30-day mortality rate was 11.3% (n= 6). Only one patient (1.9%) remains alive with a cumulative median survival rate of 84 (IQR 38-156) days. Esophageal stent insertion in this group of patients still presents a clinical challenge, with complication and endoscopic reintervention rates of 43.4 and 22.6%, respectively. Our results are comparable with previously published series, and as a palliative modality stent insertion remains appropriate when expected survival is less than 3 months. A range of SEMS is currently available with broadly similar efficacy and safety profiles. Data regarding the newly available fully covered SEMS suggest that they should be avoided.
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Affiliation(s)
- R T Gray
- Department of Thoracic Surgery, Royal Victoria Hospital, Department of Surgery, Belfast City Hospital Faculty of Life and Health Sciences, University of Ulster, Northern Ireland, UK.
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Varadarajulu S, Banerjee S, Barth B, Desilets D, Kaul V, Kethu S, Pedrosa M, Pfau P, Tokar J, Wang A, Song LMWK, Rodriguez S. Enteral stents. Gastrointest Endosc 2011; 74:455-64. [PMID: 21762904 DOI: 10.1016/j.gie.2011.04.011] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2011] [Accepted: 04/06/2011] [Indexed: 02/08/2023]
Abstract
The American Society for Gastrointestinal Endoscopy (ASGE) Technology Committee provides reviews of existing, new, or emerging endoscopic technologies that have an impact on the practice of GI endoscopy. Evidence-based methodology is used, with a MEDLINE literature search to identify pertinent clinical studies on the topic and a MAUDE (U.S. Food and Drug Administration Center for Devices and Radiological Health) database search to identify the reported complications of a given technology. Both are supplemented by accessing the "related articles" feature of PubMed and by scrutinizing pertinent references cited by the identified studies. Controlled clinical trials are emphasized, but in many cases, data from randomized, controlled trials are lacking. In such cases, large case series, preliminary clinical studies, and expert opinions are used. Technical data are gathered from traditional and Web-based publications, proprietary publications, and informal communications with pertinent vendors. Technology Status Evaluation Reports are drafted by 1 or 2 members of the ASGE Technology Committee, reviewed and edited by the committee as a whole, and approved by the Governing Board of the ASGE. When financial guidance is indicated, the most recent coding data and list prices at the time of publication are provided. For this review, the MEDLINE database was searched through August 2010 for articles related to enteral, esophageal, duodenal, and colonic stents. Technology Status Evaluation Reports are scientific reviews provided solely for educational and informational purposes. Technology Status Evaluation Reports are not rules and should not be construed as establishing a legal standard of care or as encouraging, advocating, requiring, or discouraging any particular treatment or payment for such treatment.
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Martinez JC, Puc MM, Quiros RM. Esophageal stenting in the setting of malignancy. ISRN GASTROENTEROLOGY 2011; 2011:719575. [PMID: 21991527 PMCID: PMC3168502 DOI: 10.5402/2011/719575] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/23/2011] [Accepted: 06/15/2011] [Indexed: 12/28/2022]
Abstract
Esophageal cancer is often diagnosed at an advanced stage, with many patients
found to have locoregional or metastatic disease at time of diagnosis. Because
of this, cure may be unlikely, leading treatment efforts to focus more on
symptom palliation and improving patient quality of life. The majority of
patients with advanced disease suffer from some degree of dysphagia. Palliative
efforts are therefore directed at relieving dysphagia, allowing patients to
manage their oropharyngeal secretions, reduce aspiration risk, and maintain
caloric intake orally. A variety of endoscopic treatment modalities have been
utilized with these objectives in mind, with options determined by the location
and size of the tumor, as well as the patient's expected prognosis. In this
article, we review the use of endoscopically-placed stents for palliation in
patients with advanced esophageal cancer. We discuss the history of stent use in
such cases, as well as more recent developments in stent technology. We give an
overview of some of the more commonly used stents in practice, discuss the
technique of insertion, and survey the short- and long-term outcomes of stent
placement.
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Abstract
Esophageal cancer is diagnosed in about 400,000 patients each year worldwide, and its incidence is increasing faster than that of any other malignancy. This makes it the ninth most common malignancy and sixth on the list of cancer mortality causes. Most patients with esophageal cancer present at a stage that is too advanced for curative therapy, and many die within a few months. Treatment of dysphagia is the main goal of palliative care in more than 50% of incurable cases. Although many different palliative options for malignant dysphagia are available, expandable stent placement is the most commonly performed treatment modality.
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Abstract
Partially covered self-expandable esophageal stents have been associated with unacceptable complications when used for benign esophageal disorders. With the introduction of removable or potentially removable fully covered stents and biodegradable stents, interest in using expandable stents for benign indications has been revived. Although expandable stents can offer a minimally invasive alternative to surgery, they can be associated with serious complications; hence, this approach should be considered in carefully selected patients, preferably on a protocol basis.
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Affiliation(s)
- Kulwinder S Dua
- Division of Gastroenterology and Hepatology, Department of Medicine, Medical College of Wisconsin, 9200 West Wisconsin Avenue, Milwaukee, WI 53226, USA.
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Sreedharan A, Harris K, Crellin A, Forman D, Everett SM. WITHDRAWN: Interventions for dysphagia in oesophageal cancer. Cochrane Database Syst Rev 2011:CD005048. [PMID: 21328271 DOI: 10.1002/14651858.cd005048.pub3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND The majority of oesophageal and gastro-oesophageal cancers are diagnosed at an advanced stage and palliative treatment is the realistic management option for most patients. The optimal intervention for the palliation of dysphagia in these patients has not been established. OBJECTIVES To systematically analyse and summarise the efficacy of different interventions used in the palliation of dysphagia in primary oesophageal carcinoma. SEARCH STRATEGY We undertook a search according to the Cochrane Upper Gastrointestinal and Pancreatic Diseases model using the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE, EMBASE and CINAHL and major conference proceedings up to August 2005. The literature search was re-run in August 2006 and March 2007. SELECTION CRITERIA Randomised controlled trials (RCTs) in patients with inoperable or unresectable primary oesophageal cancer who underwent palliative treatment. We included rigid plastic intubation, self-expanding metallic stent (SEMS) insertion, brachytherapy, external beam radiotherapy, chemotherapy, oesophageal bypass surgery, chemical and thermal ablation therapy, either head-to-head or in combination. The primary outcome was dysphagia improvement. Secondary outcomes included recurrent dysphagia, technical success, procedure related mortality, 30-day mortality, adverse effects and quality of life. DATA COLLECTION AND ANALYSIS One author assessed the eligibility criteria of each study and extracted data regarding outcomes and factors affecting risk of bias. MAIN RESULTS We included 2542 patients from 40 studies. SEMS insertion is safer and more effective than plastic tube insertion. Thermal and chemical ablative therapy provide comparable dysphagia palliation but have an increased requirement for re-interventions and adverse effects. Anti-reflux stents provide comparable dysphagia palliation to conventional metal stents. Some anti-reflux stents might reduce gastro-oesophageal reflux compared to conventional metal stents. Brachytherapy might be a suitable alternative to SEMS in providing a survival advantage and possibly a better quality of life. AUTHORS' CONCLUSIONS Self-expanding metal stent insertion is safe, effective and quicker in palliating dysphagia compared to other modalities. However, high-dose intraluminal brachytherapy is a suitable alternative and might provide additional survival benefit with a better quality of life. Self-expanding metal stent insertion and brachytherapy provide comparable palliation to endoscopic ablative therapy but are preferable due to the reduced requirement for re-interventions. Rigid plastic tube insertion, dilatation alone or in combination with other modalities, chemotherapy alone, combination chemoradiotherapy and bypass surgery are not recommended for palliation of dysphagia due to a high incidence of delayed complications and recurrent dysphagia.
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Affiliation(s)
- Aravamuthan Sreedharan
- Department of Gastroenterology, United Lincolnshire Hospitals NHS Trust, Lincoln County Hospital, Greetwell Road, Lincoln, Lincolnshire, UK, LN2 2YE
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Sgourakis G, Gockel I, Radtke A, Dedemadi G, Goumas K, Mylona S, Lang H, Tsiamis A, Karaliotas C. The use of self-expanding stents in esophageal and gastroesophageal junction cancer palliation: a meta-analysis and meta-regression analysis of outcomes. Dig Dis Sci 2010; 55:3018-30. [PMID: 20440646 DOI: 10.1007/s10620-010-1250-1] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2009] [Accepted: 04/12/2010] [Indexed: 12/16/2022]
Abstract
BACKGROUND The objective of this study was to examine the impact of self-expanding stents versus locoregional treatment modalities in the setting of esophageal cancer palliation. METHODS The present meta-analysis pooled the effects of outcomes of 1,027 patients enrolled in 16 randomized controlled trials. RESULTS The meta-analysis revealed an advantage to the use of stents compared to locoregional modality treatments with respect to the number of patients requiring reinterventions, although the latter treatment arm had a higher 1-year survival. No difference was observed between the use of the antireflux stents and conventional stents in relieving reflux. Previous chemoradiotherapy had no impact on complications, procedural deaths, and overall patient survival. Differences in outcomes among stents were minimal. CONCLUSIONS Conventional self-expanding stents and anti-reflux stents are equally effective. Although the risk difference for 1-year survival favoured locoregional palliative treatment modalities, the latter were associated with a higher number of patients requiring reintervention.
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Affiliation(s)
- George Sgourakis
- 2nd Surgical Department and Surgical Oncology Unit, Korgialenio-Benakio Red Cross Hospital, 11 Mantzarou Str., Neo Psychiko, Athens, Greece.
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Park JJ, Lee YC, Kim BK, Kim JH, Park JC, Kim YJ, Lee SK, Song SY, Chung JB. Long-term clinical outcomes of self-expanding metal stents for treatment of malignant gastroesophageal junction obstructions and prognostic factors for stent patency: effects of anticancer treatments. Dig Liver Dis 2010; 42:436-40. [PMID: 19767253 DOI: 10.1016/j.dld.2009.07.020] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2009] [Revised: 07/23/2009] [Accepted: 07/28/2009] [Indexed: 12/11/2022]
Abstract
BACKGROUND Self-expanding metal stent has emerged as an effective treatment option for malignant gastroesophageal junction obstruction. However, data on the clinicopathologic factors associated with stent patency are still lacking. AIM To investigate the long-term clinical outcomes and prognostic factors, including treatment modalities, affecting stent patency in patients with malignant gastroesophageal junction obstruction given self-expanding metal stent insertions. METHODS A total 89 patients who underwent self-expanding metal stent insertion for malignant gastroesophageal junction obstruction were enrolled. We analysed technical and clinical success rates, complications, and prognostic factors affecting stent patency. RESULTS Self-expanding metal stent insertion was successful in all patients and clinical improvement was achieved in 93.3%. Stent malfunction occurred in 32.9% of patients. The median overall survival time and stent patency time were 143 (95% CI: 99-187) and 190 days (95% CI: 108-272), respectively. In multivariate analysis, radiation therapy after stent placement significantly prolonged stent patency (OR: 0.221; 95% CI: 0.055-0.884; p=0.033). A higher migration rate was observed in those patients given chemotherapy after covered self-expanding metal stent placement (no anticancer treatment: 10.0%, chemotherapy: 42.9%, chemoradiation therapy: 9.1%, p=0.042). CONCLUSIONS Self-expanding metal stent is a feasible and effective treatment for malignant gastroesophageal junction obstruction. Radiation therapy after stent placement significantly prolongs overall stent patency and chemotherapy increases the migration rate of covered stents.
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Affiliation(s)
- Jae Jun Park
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea
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Blomberg J, Wenger U, Lagergren J, Arnelo U, Agustsson T, Johnsson E, Toth E, Lagergren P. Antireflux stent versus conventional stent in the palliation of distal esophageal cancer. A randomized, multicenter clinical trial. Scand J Gastroenterol 2010; 45:208-16. [PMID: 19968614 DOI: 10.3109/00365520903443860] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Patients with incurable distal esophageal or cardia cancer often need palliative stenting to relieve their dysphagia but stents passing through the cardia can cause reflux and aspiration, leading to a reduced health-related quality of life (HRQL). This study addressed the hypothesis that antireflux stenting improves HRQL compared to conventional stenting. MATERIAL AND METHODS In a single-blind, multicenter, randomized trial in patients with inoperable esophageal or cardia cancer requiring palliative stenting passing through the cardia, 65 patients were stented. Patients received either an antireflux stent (Esophageal Z-Stent with Dua antireflux valve; n = 28) or a conventional stent (Esophageal Z-stent, Ultraflex or Wallstent; n = 37). Validated questionnaires (European Organization for Research and Treatment of Cancer QLQ-C30 and QLQ-OES18) were used to collect information on HRQL at baseline and 1 and 3 months after stenting. Main outcome measurements were differences in HRQL scores between baseline and 1 and 3 months after stenting. RESULTS Scores for most aspects of HRQL were similar in the two groups, and no statistically significant differences were found. Some general symptoms however showed clinically relevant improvement in the antireflux stent group, while esophageal-specific symptoms such as dysphagia seemed clinically better, and symptoms of reflux were clinically reduced in the conventional stent group but not in the antireflux stent group. CONCLUSION This study, although limited in size, provided no obvious support for using the antireflux stent in preference to the conventional stent in the palliation of distal esophageal or cardia cancer from an HRQL perspective.
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Affiliation(s)
- John Blomberg
- Upper GastroIntestinal Research, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
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A new metal stent with a controlled-release system for palliation of malignant dysphagia: a prospective, multicenter study. Gastrointest Endosc 2010; 71:455-60. [PMID: 20003967 DOI: 10.1016/j.gie.2009.09.046] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2009] [Accepted: 09/25/2009] [Indexed: 02/08/2023]
Abstract
BACKGROUND Self-expanding metal stents are frequently used for the palliation of malignant dysphagia. Recently, a new stent design, the Evolution stent (Cook Medical, Limerick, Ireland), was developed. The stent has an internal and external silicone coating to resist tissue ingrowth and uncoated dual flanges on both ends to prevent migration. Its controlled-release system may allow full control and precise positioning of the stent. OBJECTIVE To determine the safety and clinical effectiveness of the Evolution stent for the palliation of dysphagia in patients with malignant strictures located in the esophagus (n = 33 [75%]) or gastric cardia (n = 11 [25%]). METHODS All patients who underwent placement of an esophageal Evolution stent from February to December 2008 received follow-up telephone calls 14 days after treatment and thereafter monthly until death. Data on technical and clinical outcome, complications, and recurrent dysphagia were collected. RESULTS A total of 44 patients (32 [73%] men, median age 74 years [range 48-91 years]) were treated with the Evolution stent. The median tumor length was 6 cm (range 1-11 cm). Stent placement was technically successful in 41 patients. Dysphagia improved from a median of 3 (ability to swallow liquids only) to 1 (ability to eat some solid foods) 4 weeks after stent placement. Major complications occurred in 4 (9%) patients, ie, pneumonia (3 patients) and hemorrhage (1 patient). Two (5%) patients died of pneumonia. Minor complications included gastroesophageal reflux and mild retrosternal pain in 11 (25%) and 4 (9%) patients, respectively. Recurrent dysphagia developed in 11 (25%) patients as a result of tissue ingrowth or overgrowth (6 patients; 14%), food impaction (3 patients; 7%), or stent migration (2 patients; 5%). CONCLUSIONS The Evolution stent is safe and effective for the palliation of dysphagia from esophageal and gastric cardia cancer. Randomized trials are needed to compare this device with other stent designs.
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Abstract
These recommendations provide an evidence-based approach to the role of esophageal stents in the management of benign and malignant diseases. These guidelines have been developed under the auspices of the American College of Gastroenterology and its Practice Parameters Committee and approved by the Board of Trustees. The following guidelines are based on a critical review of the available scientific literature on the topic identified in Medline and PubMed (January 1992-December 2008) using search terms that included stents, self-expandable metal stents, self-expandable plastic stents, esophageal cancer, esophageal adenocarcinoma, esophageal squamous cell carcinoma, esophageal stricture, perforations, anastomotic leaks, tracheoesophageal fistula, and achalasia. These guidelines are intended for use by health-care providers and apply to adult, but not pediatric, patients. As with other practice guidelines, these guidelines are not intended to replace clinical judgment but rather to provide general guidelines applicable to the majority of patients. Clinicians need to integrate recommendations with their own clinical judgment, and with individual patient circumstances, values, and preferences. They are intended to be flexible, in contrast to standards of care, which are inflexible policies designed to be followed in every case. Specific recommendations are based on relevant published information. The quality of evidence and strength of recommendations have been assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system, which is a system that has been adopted by multiple national and international societies. The GRADE system is based on a sequential assessment of quality of evidence, followed by assessment of the balance between benefits vs. downsides (harms, burden, and costs) and subsequent judgment regarding the strength of recommendation.
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Affiliation(s)
- Prateek Sharma
- Division of Gastroenterology and Hepatology, Veterans Affairs Medical Center and University of Kansas School of Medicine, Kansas City, Missouri 64128-2295, USA.
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Abstract
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.
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Sreedharan A, Harris K, Crellin A, Forman D, Everett SM. Interventions for dysphagia in oesophageal cancer. Cochrane Database Syst Rev 2009:CD005048. [PMID: 19821338 DOI: 10.1002/14651858.cd005048.pub2] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND The majority of oesophageal and gastro-oesophageal cancers are diagnosed at an advanced stage and palliative treatment is the realistic management option for most patients. The optimal intervention for the palliation of dysphagia in these patients has not been established. OBJECTIVES To systematically analyse and summarise the efficacy of different interventions used in the palliation of dysphagia in primary oesophageal carcinoma. SEARCH STRATEGY We undertook a search according to the Cochrane Upper Gastrointestinal and Pancreatic Diseases model using the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE, EMBASE and CINAHL and major conference proceedings up to August 2005. The literature search was re-run in August 2006 and March 2007. SELECTION CRITERIA Randomised controlled trials (RCTs) in patients with inoperable or unresectable primary oesophageal cancer who underwent palliative treatment. We included rigid plastic intubation, self-expanding metallic stent (SEMS) insertion, brachytherapy, external beam radiotherapy, chemotherapy, oesophageal bypass surgery, chemical and thermal ablation therapy, either head-to-head or in combination. The primary outcome was dysphagia improvement. Secondary outcomes included recurrent dysphagia, technical success, procedure related mortality, 30-day mortality, adverse effects and quality of life. DATA COLLECTION AND ANALYSIS One author assessed the eligibility criteria of each study and extracted data regarding outcomes and factors affecting risk of bias. MAIN RESULTS We included 2542 patients from 40 studies. SEMS insertion is safer and more effective than plastic tube insertion. Thermal and chemical ablative therapy provide comparable dysphagia palliation but have an increased requirement for re-interventions and adverse effects. Anti-reflux stents provide comparable dysphagia palliation to conventional metal stents. Some anti-reflux stents might reduce gastro-oesophageal reflux compared to conventional metal stents. Brachytherapy might be a suitable alternative to SEMS in providing a survival advantage and possibly a better quality of life. AUTHORS' CONCLUSIONS Self-expanding metal stent insertion is safe, effective and quicker in palliating dysphagia compared to other modalities. However, high-dose intraluminal brachytherapy is a suitable alternative and might provide additional survival benefit with a better quality of life. Self-expanding metal stent insertion and brachytherapy provide comparable palliation to endoscopic ablative therapy but are preferable due to the reduced requirement for re-interventions. Rigid plastic tube insertion, dilatation alone or in combination with other modalities, chemotherapy alone, combination chemoradiotherapy and bypass surgery are not recommended for palliation of dysphagia due to a high incidence of delayed complications and recurrent dysphagia.
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Affiliation(s)
- Aravamuthan Sreedharan
- Department of Gastroenterology, United Lincolnshire Hospitals NHS Trust, Lincoln County Hospital, Greetwell Road, Lincoln, Lincolnshire, UK, LN2 2YE
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