Treatment of esophagorespiratory fistulas with silicone-coated self-expanding metal stents

Surgical strategies for benign acquired tracheoesophageal fistula

OBJECTIVES

Tracheoesophageal fistula (TEF) is characterized by abnormal connectivity between the posterior wall of the trachea or bronchus and the adjacent anterior wall of the oesophagus. Benign TEF can result in serious complications; however, there is currently no uniform standard to determine the appropriate surgical approach for repairing TEF.

METHODS

The PubMed database was used to search English literature associated with TEF from 1975 to October 2023. We employed Boolean operators and relevant keywords: 'tracheoesophageal fistula', 'tracheal resection', 'fistula suture', 'fistula repair', 'fistula closure', 'flap', 'patch', 'bioabsorbable material', 'bioprosthetic material', 'acellular dermal matrix', 'AlloDerm', 'double patch', 'oesophageal exclusion', 'oesophageal diversion' to search literature. The evidence level of the literature was assessed based on the GRADE classification.

RESULTS

Nutritional support, no severe pulmonary infection and weaning from mechanical ventilation were the 3 determinants for timing of operation. TEFs were classified into 3 levels: small TEF (<1 cm), moderate TEF (≥1 but <5 cm) and large TEF (≥5 cm). Fistula repair or tracheal segmental resection was used for the small TEF with normal tracheal status. If the anastomosis cannot be finished directly after tracheal segmental resection, special types of tracheal resection, such as slide tracheoplasty, oblique resection and reconstruction, and autologous tissue flaps were preferred depending upon the site and size of the fistula. Oesophageal exclusion was applicable to refractory TEF or patients with poor conditions.

CONCLUSIONS

The review primarily summarizes the main surgical techniques employed to repair various acquired TEF, to provide references that may contribute to the treatment of TEF.

The utility of 3D-printed airway stents to improve treatment strategies for central airway obstructions

Airway stents are commonly used in the management of patients suffering from central airway obstruction (CAO). CAO may occur directly from airway strictures, obstructing airway cancers, airway fistulas or tracheobronchomalacia, resulting from the weakening and dynamic collapse of the airway wall. Current airway stents are constructed from biocompatible medical-grade silicone or from a nickel-titanium (nitinol) alloy with fixed geometry. The stents are inserted via the mouth during a bronchoscopic procedure. Existing stents have many shortcomings including the development of obstructing granulation tissue in the weeks and months following placement, mucous build up within the stent, and cough. Furthermore, airway stents are expensive and, if improperly sized for a given airway, may be easily dislodged (stent migration). Currently, in Australia, it is estimated that approximately 12,000 patients will develop CAO annually, many of whom will require airway stenting intervention. Of all stenting procedures, the rate of failure is currently reported to be at 22%. With a growing incidence of lung cancer prevalence globally, the need for updating airway stent technology is now greater than ever and personalizing stents using 3D-printing technology may offer the best chance of addressing many of the current limitations in stent design. This review article will assess what represents the gold standard in stent manufacture with regards to treatment of tracheobronchial CAO, the challenges of current airway stents, and outlines the necessity and challenges of incorporating 3D-printing technology into personalizing airway stents today.

Current treatment of tracheoesophageal fistula

Tracheoesophageal fistulas (TEFs) often occur with esophageal or bronchial carcinoma. Currently, we rely on implantation of delicate devices, such as self-expanding and silicone stents, in the esophagus or trachea to cover the fistula and expand the stenosis in order to relieve patient pain. However, because each case is different, our approach may not be effective for every patient. Consequently, new devices and technology have emerged to address these situations, such as degradable stents, Amplatzer^® devices, endobronchial one-way umbrella-shaped valves, and transplantation of mesenchymal stem cells. Although some studies have shown such alternatives can be reasonable solutions in special cases, further development of other new and effectual techniques is of utmost importance.

Endoscopic Management of Esophagorespiratory Fistulas: A Multicenter Retrospective Study of Techniques and Outcomes

BACKGROUND AND AIMS

Esophagorespiratory fistulas (ERF) are a devastating complication of benign and malignant etiologies. ERF are associated with high mortality, short survival, and poor quality of life. We performed a multicenter analysis of patients with ERF undergoing endoscopic treatment.

METHODS

Multicentre retrospective study.

RESULTS

We analyzed 25 patients undergoing 35 procedures over an 8-year period. Our data showed high technical success rates (97.1% of procedures) and with good, but not ideal, clinical success rates (60% of procedures, 80% of patients), which were defined as fistula closure confirmed by radiographic or repeat endoscopic evaluation and/or a lack of recurrent episodes of clinical aspiration to focus on durable ERF closure as opposed to only initial success. Proximal ERF were the most difficult to manage with the lowest overall clinical success rates, highest rates of recurrent aspiration despite endoscopic therapy, highest adverse events, and shortest survival times. Adverse events occurred in 40.0% of our patients and were all minor. Treatment allowed for diet advancement in 75% of patients.

CONCLUSION

This represents the largest recent collection of US data and the first multicenter study evaluating the clinical success of multiple treatment modalities while stratifying data by fistula etiology and esophageal location. The endoscopic approaches detailed in this study offer a minimally invasive and safe choice for intervention with the potential to improve quality of life despite overall suboptimal clinical success and survivorship rates for in with ERF.

Erosion of esophageal stent into left main bronchus causing airway compromise

Covered or uncovered self-expanding metal stents are currently used for the palliative treatment of neoplastic esophageal strictures or compressions and esophageal leaks or fistulas due to malignancies. Erosion of esophageal stents into the respiratory tract is a rare complication and that too has been reported mostly as an early complication within few days or weeks. Here, we present the case of a 31-year-old female, who presented with a late complication of an esophageal stent eroding into the left main bronchus causing respiratory distress. She was stented for a benign corrosive esophageal stricture following caustic soda ingestion 3 years ago. She underwent a thoracotomy and closure of esophagobronchial fistula along with laparoscopic esophagectomy and gastric pull through. Postoperatively, patient developed an anastomotic leak which was corrected by placing a temporary stent.

Esophageal bypass operation prior to definitive chemoradiotherapy in advanced esophageal cancer with tracheobronchial invasion

BACKGROUND

In T4 esophageal cancer with tracheobronchial invasion, an esophagorespiratory fistula (ERF) often occurs during or after chemoradiotherapy. We have performed esophageal bypass operations prior to definitive chemoradiotherapy for these patients to increase the chemoradiotherapy completion rate by minimizing the potential effect of an ERF. The aim of this study was to examine the clinical outcome of esophageal bypass surgery prior to chemoradiotherapy.

METHODS

Between 1997 and 2010, 17 patients underwent esophageal bypass surgery followed by definitive chemoradiotherapy for esophageal cancer with tracheobronchial invasion (bypass group). Ten patients in the same circumstances were treated with chemoradiotherapy alone (control group). Overall survival, the clinical effect of chemoradiotherapy, the ERF incidence rate, and the safety of esophageal bypass surgery were assessed.

RESULTS

The overall response rate to chemoradiotherapy was 64.7% in the bypass group and 90.0% in the control group. Except for 2 patients with ERF at initial diagnosis, 4 (26.7%) of the 15 patients developed ERF in the bypass group, and 3 (30.0%) of the 10 patients developed ERF in the control group during or after chemoradiotherapy. The 2-year and 3-year overall survival rates were 17.6% and 17.6% in the bypass group and 20.0% and 0% in the control group, respectively (p = 0.924); long-term survival of more than 3 years was seen only in the bypass group.

CONCLUSIONS

Esophageal bypass surgery prior to definitive chemoradiotherapy could be performed safely, and this strategy contributed to long-term survival in the patients who achieved a good response to chemoradiotherapy but developed an ERF.

Bronchoesophageal fistula

Bronchoesophageal fistula (BEF) is an undesirable consequence of esophageal cancer. A BEF is encountered in 5% to 15% of patients with esophageal cancer. It is generally a life-threatening complication because of the development of recurrent pulmonary infection and sepsis. We present a case with esophageal cancer and acquired BEF. The fistula allowed herniation of the esophageal wall into the endobronchial lumen, causing significant obstruction of the airway lumen, findings not reported previously.

Comparative study of esophageal stent and feeding gastrostomy/jejunostomy for tracheoesophageal fistula caused by esophageal squamous cell carcinoma

BACKGROUND

A malignant tracheoesophageal/bronchoesophageal fistula (TEF) is a life-threatening complication of esophageal squamous cell carcinoma. A feeding gastrostomy/jejunostomy had been the most common treatment method for patients with TEF before the era of stenting. The aim of this retrospective study is to compare the prognosis of esophageal squamous cell carcinoma patients with TEF treated with an esophageal metallic stent to those treated with a feeding gastrostomy/jejunostomy.

METHODS

We retrospectively reviewed a total of 1011 patients with esophageal squamous cell carcinoma between 1996 and 2011 at Kaohsiung Chang Gung Memorial Hospital, and 86 patients with TEF (8.5%) were identified. The overall survival and other clinical data were compared between 30 patients treated with an esophageal metallic stent and 35 patients treated with a feeding gastrostomy/jejunostomy.

RESULTS

Among the 65 patients receiving either an esophageal metallic stent or a feeding gastrostomy/jejunostomy, univariate analysis showed that treatment modality with an esophageal metallic stent (P = 0.007) and radiotherapy treatment after fistula diagnosis (P = 0.04) were predictive of superior overall survival. In the multivariate comparison, treatment modality with an esophageal metallic stent (P = 0.026, odds ratio: 1.859) represented the independent predictive factor of superior overall survival. There were no significant differences between groups in mean decrease in serum albumin or mean body weight loss. Compared to the feeding gastrostomy/jejunostomy group, a significantly higher proportion of patients in the stenting group (53% versus 14%, P = 0.001) were able to receive chemotherapy within 30 days after fistula diagnosis, indicating better infection control in the stenting group.

CONCLUSIONS

Compared with a feeding gastrostomy/jejunostomy, an esophageal metallic stent significantly improves overall survival in patients with malignant TEF in our retrospective analysis. Esophageal metallic stent placement may be considered the first-line of treatment for patients with malignant TEF.

Interventional management of esophagorespiratory fistula

An esophagorespiratory fistula (ERF) is an often fatal consequence of esophageal or bronchogenic carcinomas. The preferred treatment is placement of esophageal and/or airway stents. Stent placement must be performed as quickly as possible since patients with ERFs are at a high risk for aspiration pneumonia. In this review, choice of stents and stenting area, fistula reopening and its management, and the long-term outcome in the interventional management of malignant ERFs are considered. Lastly, a review of esophagopulmonary fistulas will also be provided.

Palliative treatment of malignant esophagopulmonary fistulas with covered expandable metallic stents

OBJECTIVE

The objective of our study was to evaluate the safety and clinical effectiveness of covered expandable metallic stents for palliative treatment of malignant esophagopulmonary fistulas.

MATERIALS AND METHODS

Between November 1990 and January 2008, 14 patients with fistulas between the esophagus and pulmonary parenchyma were treated with covered expandable metallic esophageal stents. The fistulas were caused by esophageal (n = 9) or bronchogenic (n = 5) carcinomas. At the time of stent placement, all patients had aspiration pneumonia and 11 had lung abscesses (79%). Technical and clinical success, fistula reopening, complications, and survival rates were evaluated.

RESULTS

Stent placement was technically successful in all cases, and there were no immediate procedural complications. Complete fistula sealing resulting in resolution of aspiration symptoms (i.e., clinical success) occurred in 12 patients (86%). During follow-up (mean survival, 100.9 +/- 79.9 days; median survival, 65.5 days; range, 16-275 days), the fistula reopened in two of 12 clinical success patients. One patient (7%) experienced complications resulting from dyspnea due to tracheal compression by the esophageal stent. Although 13 patients died of aspiration pneumonia and the remaining patient died of cancer bleeding, none of the mortalities was related to the stent placement procedure.

CONCLUSION

The use of covered expandable metallic stents appears to be safe and feasible for the palliative treatment of malignant esophagopulmonary fistulas.

Double stenting of oesophagus and airways in palliative treatment of patients with oesophageal cancer is efficient but associated with a high morbidity

BACKGROUND

Double stenting of oesophagus and airways may be required in palliative treatment of patients with locally advanced oesophageal cancer.

AIM

To assess feasibility, efficacy and complications occurring in patients with locally advanced oesophageal cancer receiving both oesophagus and airways stenting.

METHODS

In one single centre between 1997 and 2005, among 180 patients with locally advanced oesophageal cancer treated by the palliative placement of a self-expanding metal stent, patients requiring double stenting of oesophagus and airways were identified. Clinical efficacy, complications and survival were retrospectively collected.

RESULTS

Fifteen patients (8.3% of 180) required a double stenting at follow-up. Symptomatic efficacy of oesophagus and airways stenting was 86.7% for dysphagia and 100% for dyspnoea. Median survival after the second stent insertion was 99 days. Life-threatening early complications occurred in three patients after double stenting (20%), including two deaths following oesophageal perforation and massive haemoptysis, respectively. Procedure-related mortality was 13.3%.

CONCLUSIONS

Double stenting of oesophagus and airways is feasible in patients with locally advanced oesophageal cancer, with a relevant clinical efficacy. However, early major complications including procedure-related death may occur in as many as 20% of patients. This treatment should be reserved to very selected patients with severe symptoms and end-stage disease.

Temporary stenting of acquired benign tracheoesophageal fistulas in critically ill ventilated patients

BACKGROUND

To evaluate the use of esophageal stents for temporary sealing of acquired benign tracheoesophageal fistulas developed in critically ill, ventilated patients.

METHODS

This is a retrospective analysis (1992-2003) of the data of 12 mechanically ventilated patients - six of them after major or multiple trauma - being intubated for a median of 30 days before they develop an acquired benign tracheoesophageal fistula. Five of them were in sepsis. Two types of stents were used: the Wilson-Cook esophageal balloon plastic stent in the first four cases and the Ultraflex covered self-expandable stent in the remaining eight. The total procedure was performed at bedside in the intensive care unit, with no special need for supplementary anesthesia or fluoroscopic control.

RESULTS

Stent implantation was technically successful in all patients and fistula occlusion was achieved in every case. There was no stent migration and fistulas remained sealed until death or upon decision for removal. Nine patients died between 5 days and 2 months after stent placement, as a result of their diseases. Three patients were referred for fistula surgical repair 33, 36, and 43 days after stent placement. Before surgery the stents were easily removed under direct vision.

CONCLUSION

Temporary closure of an acquired tracheoesophageal fistula developed in critically ill ventilated patients is an easy, bedside-applicable, safe, and effective palliative procedure, with no complications or mortality.

Esophagorespiratory fistula: long-term results of palliative treatment with covered expandable metallic stents in 61 patients

PURPOSE

To evaluate long-term clinical results of palliative treatment of esophagorespiratory fistulas (ERFs) with covered expandable metallic stents.

MATERIALS AND METHODS

Sixty patients with ERFs due to esophageal or bronchogenic carcinoma and one patient with ERF due to pressure necrosis caused by initial esophageal stent placement for esophageal carcinoma were treated with covered expandable esophageal or tracheobronchial metallic stents. Information about technical success of stent placement, initial clinical success and failure, fistula reopening, and complications was obtained. Survival curves for both patient groups with initial clinical success and failure were obtained and compared with Kaplan-Meier methods and log-rank test.

RESULTS

Stent placement was technically successful in all patients, with no immediate procedural complications. The stent completely sealed off the fistula in 49 (80%) of 61 patients so that they had no further aspiration symptoms (initial clinical success). Twelve (20%) of 61 patients had persistent aspiration symptoms due to incomplete ERF closure (initial clinical failure). During follow-up, the fistula reopened in 17 (35%) of 49 patients with initial clinical success: In eight patients, the reopened ERF was sealed off successfully with stent placement or balloon dilation. In two patients with reopened ERF caused by food impaction, the reopened fistula resolved spontaneously. Seven patients did not undergo further treatment. All patients died during follow-up, and mean survival was 13.4 weeks (range, 1-56 weeks) after stent placement. Mean survival in patients with initial clinical success was significantly longer than that in patients with initial clinical failure (15.1 vs 6.2 weeks, P <.05).

CONCLUSION

Covered expandable metallic stents were placed in 61 patients with ERFs, but the initial clinical success rate was poor and the rate of reopening was high; however, interventional treatment was effective for sealing off reopened ERFs.

Management of Tracheoesophageal Fistulas in Adults

The approach to treatment of adult patients with tracheoesophageal fistulas depends on whether the fistula is congenital or acquired in origin. Most adults have acquired tracheoesophageal fistulas, and treatment depends on whether the fistula is a result of a benign process or a malignancy, with the latter usually primary esophageal cancer. For patients with benign tracheoesophageal fistulas, treatment is almost always initially supportive followed by definitive surgical correction. In general, depending on the size and location of the tracheal aspect of the fistula, surgical therapy involves primary repair of the fistula and, if necessary, resection and reconstruction of the trachea. For patients with malignant tracheoesophageal fistulas, treatment depends on whether the patient is resectable and/or medically fit for surgical therapy. However, most patients with malignant trach-eoesophageal fistulas have advanced disease and can only be treated with palliative measures. The current standard of palliative therapy for patients with malignant tracheoesophageal fistulas is the endoscopic or radiologic placement of covered self-expanding metallic stents (SEMS), which allow closure of the fistula. All three types of commercially available covered SEMS have been used in this capacity with success. Other, less common treatment options for selected patients with malignant tracheoesophageal fistulas include chemotherapy and radiation, surgical bypass, esophageal exclusion, and fistula resection and repair.

Methods of palliation of esophageal and gastric cancer

Esophageal and gastric malignancies are common worldwide. Less than half are amenable to curative treatment at the time of diagnosis because of advanced or metastatic disease. Palliation is often required for symptoms, such as dysphagia, gastrointestinal bleeding, aspiration caused by tracheoesophageal fistula, nausea and emesis secondary to gastric outlet obstruction, and malnutrition. This article reviews the gastric outlet obstruction, and malnutrition. This article reviews the medical, endoscopic, and surgical options for palliative treatment.

Self-expanding metal stents for complicated and recurrent esophagogastric cancer

BACKGROUND

Fewer complications are encountered with the use of self-expanding metal stents compared with semirigid prostheses in the palliation of patients with malignant esophagogastric obstructions. Metal stents can also be used to treat patients with complicated and/or recurrent esophagogastric carcinoma.

METHODS

Covered metal stents were placed in 57 patients for the following reasons: esophagorespiratory fistula (n = 16), recurrent carcinoma in a gastric tube interposition (n = 21), recurrent carcinoma after partial (n = 4) or total (n = 6) gastrectomy, or a carcinoma near the upper esophageal sphincter (n = 10).

RESULTS

The procedure was technically successful in 55 of 57 (96%) patients. Dysphagia score improved from a mean of 3.6 to 1.6 (p < 0.001). Major complications occurred in 13 (23%) patients. In all cases, esophagorespiratory fistulas were occluded. Tumor recurred in 5 of 16 patients with a fistula, 8 of 21 patients after gastric tube interposition, 3 of 10 patients after gastrectomy, and 2 of 10 patients with a tumor immediately distal to the upper esophageal sphincter. Median survival was 61 days. Prior radiation, chemotherapy, or both increased the risk of specific stent-related complications in relation to the (neo)esophagus (6 of 16 [38%] versus 4 of 41 [10%]: odds ratio, 5.5: 95% CI [1.3, 24], p = 0.018).

CONCLUSIONS

Self-expanding metal stents are effective and relatively safe for palliation of patients with malignancy and dysphagia caused by fistula formation, postoperative recurrence, and tumors near the upper esophageal sphincter. Placement should be considered at an early stage in these conditions.

Self-expandable coated stent after intraluminal treatment of esophageal cancer: a risky procedure?

BACKGROUND

Stenting is a well established palliative treatment for stenotic malignant disease of the esophagus. Because of its merely mechanical potential other tumoricidal techniques are often done before stenting.

METHODS

We did esophageal stenting in 11 patients (9 men and 2 women) using a self-expanding coated stent system. Three tumors were localized in the proximal, four in the middle, and four in the distal third of the esophagus. In 9 patients tumors were locally or functional nonresectable, 1 patient refused an operation, and 1 had a recurrence after esophagojejunostomy. One patient had had pretreatment by repetitive dilatation and local hyperthermia, 9 had had photodynamic therapy followed by endoluminal iridium 192 high-dose rate brachyradiotherapy, and 1 patient was admitted with esophagotracheal fistula. The interval between the last endoluminal treatment and stent insertion was between 3 and 29 days (mean, 11 days).

RESULTS

In 7 patients (63.7%) no complications were observed. Four patients (36.3%) died of major complications within 1 week. Postmortem examination confirmed that the pressure of the fully expanding stent to the esophageal wall caused the rupture.

CONCLUSION

The use of self-expanding coated stents in pretreated esophageal tumors is associated with a high risk of perforation due to pressure of the indwelling tube in a less resistant esophageal wall.

Esophageal fistula sealing: choice of stent, practical management, and cost

BACKGROUND

Three models of covered metal stents are available to seal esophageal fistulas.

METHODS

Stainless steel covered stents were inserted in 5 patients (group I); nitinol covered stents were inserted in 12 patients (group II) with malignant (n = 14) or benign (n = 3) esophageal fistulas.

RESULTS

Stent positioning was satisfactory in all cases. Fistula sealing was complete in 1 of 5 (20%) and 12 of 12 (100%) patients of groups I and II, respectively (p < 0.005). Continued esophageal leakage was initially related to the passage of fluids alongside the stent covering (n = 3) and to early stent migration (n = 1). Complications related to stent placement were observed in 2 of 17 (12%) patients and were fatal. During follow-up (mean 153 +/- 143 days), esophageal fistulas relapsed after initial sealing in 5 of 13 (38%) patients. Further treatment (glue or fibrin sealant injection, additional stent insertion) was attempted in 7 cases of persistent or relapsing esophageal fistula, with sealing obtained in 5 of them. The costs per patient and per day free from symptoms due to the esophageal fistula were $106 and $57 in groups I and II, respectively.

CONCLUSION

Nitinol covered stents more frequently provided complete esophageal fistula sealing, as compared with stainless steel covered stents. Further treatments tailored to the mechanisms of fistula persistence or relapse often provided sealing.

Comparison of conventional and wire mesh expandable prostheses and surgical bypass in patients with malignant esophagorespiratory fistulas

BACKGROUND

Patients who present with malignant esophagorespiratory fistula continue to provide a significant palliative challenge to gastroenterologists and surgeons.

METHODS

This retrospective series reviewed 29 patients treated with conventional prostheses (13 patients), expandable wire mesh-coated prostheses (12 patients), and surgical bypass with esophageal exclusion (4 patients) between 1982 and 1995.

RESULTS

Improvement in dysphagia scores were comparable in all three groups. Fistula occlusion was more successful with expandable prostheses (92%) compared conventional prostheses (77%); however, reinterventions were required more commonly with expandable prostheses, which were also significantly more expensive on a unit cost basis. In selected patients in whom prosthesis placement either was inappropriate or failed, surgical bypass and esophageal exclusion was undertaken. These patients demonstrated good palliation with minimal morbidity and no mortality.

CONCLUSIONS

Both conventional and expandable prostheses are safe and reasonably straightforward treatment modalities for patients with esophagorespiratory fistulas. Because of ease of insertion and large luminal diameter, expandable metal prostheses will see increasing use in treatment of these difficult patients; however, conventional prostheses will remain a good alternative, especially in patients with extrinsic esophageal compression. When stent placement is either unsuccessful or inadvisable, physiologically fit patients can undergo surgical bypass and esophageal exclusion with good palliation and minimal morbidity and mortality.

Palliative treatment of malignant esophagorespiratory fistulas with Gianturco-Z stents. A prospective clinical trial and review of the literature on covered metal stents

OBJECTIVE

Esophagorespiratory fistulas, especially in the upper third of the esophagus, are a complication of malignant esophageal tumors, which are difficult to manage. The efficacy of polyurethane-covered, self-expanding metal stents for palliation of malignant esophagorespiratory fistulas was investigated prospectively.

METHODS

Eleven patients with malignant esophagorespiratory fistulas resp. perforations were treated with Gianturco-Z stents. In five patients the lesion was located in the proximal part of the esophagus. Because of the fistula all patients suffered from dysphagia even for liquids.

RESULTS

No technical problems during the implantation procedure of the stents occurred. In the control radiography with water-soluble contrast media, the fistulas were completely sealed in 10 of 11 patients. Therefore the dysphagia score improved from 3.0 to 0.6. Nearly all Gianturco-Z stents (10/11) showed a sufficient expansion within 24 h after placement. Severe early or late complications were not encountered, with the exception of tumor overgrowth in one patient about 9 months after stent placement. In five patients, short term (3-6 days) retrosternal pain was observed, and one patient complained of slight foreign body sensation. By August 1997 all 11 patients had died of advanced disease, with a median survival time of 121 days (range, 22-300 days).

CONCLUSIONS

Gianturco-Z stents are highly effective for palliative treatment of esophagorespiratory fistula resp. perforations and have a low complication rate. Due to the fact that this stent shows no retraction during the release, a precise positioning is possible, especially in the case of tumors and fistulas in the upper third of the esophagus. It seems that use of the Gianturco-Z stent can be considered a good therapeutic method for palliative endoscopic treatment of this high risk patient group.

Expandable metallic prostheses for malignant obstructions of gastric outlet and proximal small bowel

BACKGROUND

Data are limited on use of expandable metal stents for treatment of malignant gastric outlet obstruction. Accordingly, we report our experience using these stents to palliate malignant obstructions of the gastric outlet, duodenum, and proximal jejunum.

METHODS

Eight patients with malignant strictures causing gastric obstruction underwent endoscopy with fluoroscopic guidance to delineate tumor borders and length followed by expandable metallic prosthesis placement (Wallstent, Z-Stent, Ultraflex, and Endocoil).

RESULTS

Symptoms were relieved in seven patients, five of whom had previous surgeries (Whipple, Billroth II, esophagojejunostomy, and gastrojejunostomy) for malignancy. One patient underwent surgical resection of a presumed malignant stricture containing a previously placed Wallstent after a 45-pound weight gain.

CONCLUSIONS

Expandable metallic prostheses placed in patients with malignant obstruction of the gastric outlet, duodenum, or proximal jejunum, before or after surgery, effectively palliate obstructive symptoms and may also serve to improve nutrition.

Use of the 25 mm flanged esophageal Z stent for malignant dysphagia: a prospective multicenter trial

BACKGROUND

An initial multicenter study using a 21 mm flanged esophageal Z stent demonstrated excellent palliation but an 11% immediate complication rate at placement and a 27% migration rate at 1 month. This North American multicenter trial prospectively studied a 25 mm flanged Z stent to define its palliative ability and whether the increased diameter affected placement or migration problems.

METHODS

Fifty patients who had esophageal Z stents at seven university or regional referral hospitals were prospectively studied. Indications for prosthesis placement, previous therapy, patient demographics, incidence of concomitant tracheoesophageal fistula, and degree of dysphagia were defined, as were procedural and subsequent stent-related problems, survival times, the ability to occlude a tracheoesophageal fistula, and subsequent degree of dysphagia.

RESULTS

Twenty-four patients had infiltrating malignancy (16 exophytic and 10 extrinsic), 9 of whom had concomitant tracheoesophageal fistulas. Ten patients (20%) had misplaced stents requiring retrieval and replacement, 12 patients (24%) had subsequent stent-related problems including exsanguination (2), aspiration (3), tumor overgrowth (3), and postplacement migration (4) (8%). There was statistically significant improvement in prestent versus poststent dysphagia and two thirds of patients had complete occlusion of their tracheoesophageal fistula.

CONCLUSIONS

Redesign of the esophageal Z stent has decreased the migration rate without increasing placement or subsequent erosion problems. Its efficacy appears comparable to the currently marketed Z stent for the palliation of malignant dysphagia and occlusion of tracheoesophageal fistula.

Esophageal self-expandable metallic stents--indications, practice, techniques, and complications: results of a national survey

BACKGROUND

The gastroenterology community's experience with esophageal self-expandable metallic stents (SEMS) is unknown.

METHODS

In order to assess indications, perioperative management, and self-reported complications associated with SEMS placement, a survey was mailed to ASGE members.

RESULTS

Of 3414 surveys mailed, 212 (6.2%) were completed and returned. One hundred twenty-eight physicians had experience with a total of 434 SEMS. Most physicians practiced in the private sector (72%), and 75% had placed 3 or fewer SEMS. Perceived ease of placement was the most common reason for choosing a SEMS (55%). Fluoroscopic and endoscopic guidance was used by 83% of respondents, and 81% allowed liquid diet after correct position and patency had been confirmed; 56% of respondents discharged their patients within 24 hours of SEMS placement. The rates of failure for full expansion (7.1%), stent misplacement (4.8%), and failure to deploy (3%) were higher than previously reported. Acute patient complications and delayed bleeding occurred less frequently than in reported series but mortality rates were similar.

CONCLUSIONS

Ease of placement is the main reason for choosing a SEMS. Differences in complication rates, compared to previous studies on SEMS, may be related to operator experience and protocol requirements. When compared to plastic stents, complications were less frequent.

Mathematical formulation for computing the performance of self expanding helical stents

Stents are cylindrical devices implanted inside pathologic tubular passages within the body. The stents, which are made of metal or plastic, keep the passage open for flow (of blood, urine, air etc.) by applying radial pressure on the passage walls. In most cases the stents are selected empirically for each application. We introduce here a mathematical formula for computing the radial pressure induced by self expanding helical stents. The formula was verified experimentally for an urological stent using a special device. The results correlate well with the theoretical predictions (R = 0.997; y = 1.017 x -0.06 kg; SEE = 0.034, for forces and R = 0.9988; y = 1.04 x +8.7 mmHg; SEE = 25.3 for pressures). This formula can potentially serve as an analytical tool for selecting the most suitable stent for a given application.

Silicone-covered Wallstent prototypes for palliation of malignant esophageal obstruction and digestive-respiratory fistulas

BACKGROUND

Endoscopic palliation of malignant esophageal obstruction with uncovered self-expanding metal stents has been shown to have fewer complications than with conventional plastic stents. The addition of a membrane might prevent tumor ingrowth and allow treatment of digestive-respiratory fistulas. We report the clinical experience with a prototype silicone membrane-covered self-expanding metal stent.

METHODS

Twenty-three silicone membrane-covered Wallstent prototypes were used in 21 patients with dysphagia due to inoperable malignant tumors involving the esophagus and cardia.

RESULTS

Stent implantation was technically successful in all patients. There were no procedure-related perforations or deaths. The prototype stent was successful in sealing seven of the eight (87.5%) digestive-respiratory fistulas. As a group, the mean dysphagia grade improved significantly after stent placement (4.8 +/- 0.9 vs 3.4 +/- 1.6, p < 0.0005). However, 9 of 21 (42.9%) patients experienced no improvement in their dysphagia. Complications occurred in 13 of 21 (61.9%) patients. Tumor ingrowth was not observed in any patient.

CONCLUSIONS

The prototype covered self-expanding metal stent was effective in sealing digestive-respiratory fistulas and provided palliation of dysphagia in slightly more than one half of the patients studied. A great deal has been learned from the preliminary experience, which has led to design modifications. The utility of the commercially available device should be evaluated in further prospective clinical trials.

Treatment of esophageal obstruction with covered, self-expanding esophageal Wallstents

BACKGROUND

Conventional endoluminal plastic prostheses used for relieving esophageal obstruction allow variable palliation. Covered, expandable metal stents provide an 18-mm lumen to allow improved deglutition.

METHODS

From December 1994 to December 1995, 20 patients underwent placement of self-expanding, silicone-covered Wallstents (Schneider, Plymouth, MN) for esophageal obstruction. Fifteen patients had obstruction secondary to carcinoma and 5 patients had benign esophageal stricture. There were 13 men and 7 women, ranging in age from 54 to 94 years. All patients underwent esophageal dilation using a flexible gastroscope and Savary bougies. After dilation to 42F or 45F, placement of the stent was performed under fluoroscopic control.

RESULTS

Follow-up was complete in all patients, ranging from 4 weeks to 12 months. Technical success was achieved in all patients. There was one postoperative death (bronchoesophageal fistula) and one migration of the stent requiring removal (peptic stricture). The remaining stents were well tolerated, even in the cervical region (4 patients). All patients successfully intubated were able to eat well, including solid foods.

CONCLUSIONS

Covered, self-expanding esophageal Wallstents are technically simple and safe to insert and appear to provide durable, excellent palliation of esophageal obstruction due to either benign or malignant conditions. A larger patient population is required to make firm conclusions.

Erosion of the right mainstem bronchus by an esophageal stent

Self-expanding metallic stents (SEMSs) are used to palliate malignant esophageal strictures. We describe a patient who had an extensive mediastinal tumor for which he was receiving irradiation therapy; chest pain, hemoptysis, and recurrent Gram-negative pneumonia developed in this patient after stent placement. Fiberoptic bronchoscopy revealed protrusion of the SEMS into the tracheobronchial tree, a novel complication for this new type of stent.