Silicone-covered self-expanding metallic stents for the palliation of malignant esophageal obstruction and esophagorespiratory fistulas: experience in 32 patients and a review of the literature

Efficacy and risk profile of self-expandable stents in the management of pediatric esophageal pathology

PURPOSE

The purpose of this study was to evaluate the efficacy and risk profile of esophageal stents in the management of complicated pediatric esophageal disease.

METHODS

An IRB-approved, single-center, retrospective review was performed on all pediatric patients (n = 13) who underwent esophageal stent placement (2005-2017). Demographic, perioperative, and outcome data were analyzed (p < 0.05).

RESULTS

Forty-one stents were placed due to recalcitrant strictures (n = 36), perforations (n = 2), and/or fistulae (n = 3). Median age at initial stent placement was 23.8 months (range, 50 days to 16 years), and median stent duration was 36 days (range, 3-335). The recurrence rate for strictures after initial stent removal was 100%. Four (31%) children subsequently underwent definitive operative repair. There were 5 deaths, including 2 related to stent placement. Seventy-one percent of stents were associated with an adverse event, most commonly intraluminal migration (56%). Younger children experienced an increased risk for airway compression and retching (p = 0.010).

CONCLUSION

These data suggest that stents are associated with high complication rates and are not effective as definitive therapy for recalcitrant strictures in children. Although there may be a temporizing role for stents in selected patients, further refinements in stent technologies are needed to help manage this difficult patient population.

LEVEL OF EVIDENCE

Level IV.

Migration resistance of esophageal stents: The role of stent design

OBJECTIVE

Stenting is one of the major treatments for malignant esophageal cancer. However, stent migration compromises clinical outcomes. A flared end design of the stent diminishes its migration. The goal of this work is to quantitatively characterize stent migration to develop new strategies for better clinical outcomes.

METHODS

An esophageal stent with flared ends and a straight counterpart were virtually deployed in an esophagus with asymmetric stricture using the finite element method. The resulted esophagus shape, wall stress, and migration resistance force of the stent were quantified and compared.

RESULTS

The lumen gain for both the flared stent and the straight one exhibited no significant difference. The flared stent induced a significantly larger contact force and thus a larger stress onto the esophagus wall. In addition, more migration resistance force was required to pull the flared stent through the esophagus. This force was inversely related to the occurrence rate of stent migration. A doubled strut diameter also increased the migration resistance force by approximately 56%. An increased friction coefficient from 0.1 to 0.3 also boosted the migration resistance force by approximately 39%.

SUMMARY

The mechanical advantage of the flared stent was unveiled by the significantly increased contact force, which provided the anchoring effect to resist stent migration. Both the strut diameter and friction coefficient positively correlated with the migration resistance force, and thus the occurrence of stent migration.

Esophageal Cancer: Recent advances

Esophageal carcinoma has, over the past decade, undergone a sea of change, not only in its pathological distribution, but also in the diagnosis, staging and subsequent management. Although the advent of better imaging techniques has helped in diagnosing patients at an earlier period, the majority of them have unresectable disease at the time of presentation. Despite aggressive treatment protocols involving either one or a combination of the options of surgery, radiation, and chemotherapy, the five-year survival remains dismal in the order of 10 to 15%. The two most commonly used surgical techniques for resecting the esophagus, the Ivor Lewis and the trans-hiatal esophagectomy, have similar results in terms of morbidity, mortality and, more importantly, five-year survival following resection. There has been an increasing interest in the surgical treatment of carcinoma esophagus by a minimally invasive approach, as meta-analysis of clinical series have shown that a faster recovery time without any statistically significant difference in the in-hospital mortality or morbidity when compared to conventional surgery. Nonrandomized studies suggest that patients receiving neoadjuvant chemo-radiation have a five year survival advantage compared with those treated with surgery alone, especially if they had a complete histological response to the preoperative regimen. Lastly, palliative procedures, form the mainstay of management of patients with non-resectable disease.

Long-term efficacy of pneumatic dilation and esophageal stenting for the treatment of achalasia

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.

Late complications of nickel-titanium alloy stent in tracheal stenosis

OBJECTIVES/HYPOTHESIS

To investigate and treat the late complications of using nickel-titanium alloy stents in laryngotracheal, bronchial, and esophageal stenosis patients who developed severe laryngotracheal stenosis (SLS).

STUDY DESIGN

Retrospective clinical study.

METHODS

Thirteen patients with SLS or tracheoesophageal fistula secondary to insertion of a nickel-titanium alloy stent for treatment of laryngotracheal, bronchial, or esophageal stenosis treated between May 2004 and March 2010 were retrospectively analyzed. Of the 13 total patients, nine had one stent placed, and four had two stents placed. The late complications observed were glottic and/or subglottic extension of cervical tracheal stenosis (n = 6), new stricture of the thoracic trachea (n = 4), severe left bronchial stricture with massive left pulmonary collapse (n = 1), and cervical tracheoesophageal fistula (n = 2).

RESULTS

Six patients with glottic and/or subglottic to cervical tracheal stenosis underwent successful laryngotracheal reconstruction. Two patients with subglottic and upper thoracic tracheal stenosis were successfully treated by staged operation for the stenosis. Two patients with subglottic and distal thoracic tracheal stenosis are still undergoing treatment. One patient with severe left bronchial stricture and massive left pulmonary collapse has been treated but has not achieved full recovery. One patient with cervical tracheoesophageal fistula underwent successful repair but died later from metastatic disease. One patient with tracheoesophageal fistula died from massive hemorrhage and asphyxiation induced by the stent, which had not been removed.

CONCLUSIONS

The nickel-titanium alloy stents should be used with extreme caution in patients with laryngotracheal, bronchial, or esophageal stenosis treatment that can be corrected by surgical therapy.

13-year follow-up of a prospective comparison of the long-term clinical efficacy of temporary self-expanding metallic stents and pneumatic dilatation for the treatment of achalasia in 120 patients

OBJECTIVE

The purpose of this article is to compare the efficacy of self-expanding metallic stents and pneumatic dilation for the long-term clinical treatment of achalasia.

SUBJECTS AND METHODS

Patients diagnosed with achalasia (n = 120) were allocated for treatment with pneumatic dilation (n = 30; group A) or a temporary self-expanding metallic stent with a diameter of 20 mm (n = 30; group B), 25 mm (n = 30; group C), or 30 mm (n = 30; group D). Data on clinical symptoms, complications, and long-term clinical outcomes were collected, and follow-up was performed at 6 months and at 1, 3-5, 5-8, 8-10, and more than 10 years after surgery.

RESULTS

Pneumatic dilation and stent placement were technically successful in all patients. The follow-up at more than 10 years revealed that the clinical remission rate in group D (83.3%) was higher than that in groups A (0%), B (0%), and C (28.6%), and the overall cumulative clinical failure rate in group D (13%) was lower than that in groups A (76.7%), B (53.3%), and C (26.7%). Patients in group D exhibited reduced dysphagia scores and lower esophageal sphincter pressures and had normal levels of barium height and width during the follow-up periods, whereas these markers increased with time in the other groups. The duration of primary patency in group D was also longer than that in groups A, B, and C.

CONCLUSION

A temporary self-expanding metallic stent with a diameter of 30 mm has superior clinical efficacy for the treatment of achalasia compared with pneumatic dilation or self-expanding metallic stents with diameters of 20 or 25 mm.

Temporary self-expanding metallic stents for achalasia: A prospective study with a long-term follow-up

AIM: To compare the efficacy of self-expanding metallic stents (SEMSs) for the long-term clinical treatment of achalasia.

METHODS: Ninety achalasic patients were treated with a temporary SEMS with a diameter of 20 mm (n = 30, group A), 25 mm (n = 30, group B) or 30 mm (n = 30, group C). Data on clinical symptoms, complications and treatment outcomes were collected, and follow-up was made at 6 mo and at 1, 3-5, 5-8, 8-10 and > 10 years, postoperatively.

RESULTS: Stent placement was successful in all patients. Although chest pain occurrence was high, stent migration was less in group C than in groups A and B. The clinical remission rate at 5-8, 8-10 and > 10 years in group C was higher than that in the other two groups. The treatment failure rate was lower in group C (13%) than in groups A (53%) and B (27%). SEMSs in group C resulted in reduced dysphagia scores and lowered esophageal sphincter pressures, as well as normal levels of barium height and width during all the follow-up time periods. Conversely, these parameters increased over time in groups A and B. The primary patency in group C was longer than in groups A and B.

CONCLUSION: A temporary SEMS with a diameter of 30 mm is associated with a superior long-term clinical efficacy in the treatment of achalasia compared with a SEMS with a diameter of 20 mm or 25 mm.

Antireflux stent versus conventional stent in the palliation of distal esophageal cancer. A randomized, multicenter clinical trial

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.

Self-expanding metal stents in palliation of malignant dysphagia: outcome of 124 Egyptian patients

Most cases of esophageal carcinoma are inoperable at presentation. Currently, the best method for palliation of malignant dysphagia, with or without esophago-respiratory fistula, is an insertion of esophageal self-expanding metal stents (SEMS) across the malignant esophageal stricture. Herein we present our experience in the use of SEMS in palliation of patients with malignant dysphagia and/or ERF. The study included 124 patients (79 males and 45 females) with advanced esophageal malignancy. The mean age was 54 (43-87) years. Nine patients had malignant ERF. All patients were subjected to SEMS insertion under both endoscopic and fluoroscopic guidance. SEMS insertion was successful in all patients. Nine patients had two stents. Median dysphagia score improved from 3.5 to 1.2. ERF was sealed in eight out of the nine patients. Complications related to stent implementation were reported in 41 patients. In conclusion, insertion of the SEMS is a reliable, effective, simple and safe method for palliation of malignant dysphagia with or without ERF.

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.

Long-term safety and outcome of a temporary self-expanding metallic stent for achalasia: a prospective study with a 13-year single-center experience

To prospectively evaluate the long-term clinical safety and efficacy of a newly designed self-expanding metallic stent (SEMS) in the treatment of patients with achalasia. Seventy-five patients with achalasia were treated with a temporary SEMS with a 30-mm diameter. The SEMSs were placed under fluoroscopic guidance and removed by gastroscopy 4–5 days after stent placement. Follow-up data focused on dysphagia score, technique and clinical success, clinical remissions and failures, and complications and was performed at 6 months, 1 year, and within 3 to 5 years, 5 to 8 years, 8 to 10 years, and >10 years postoperatively. Stent placement was technically successful in all patients. Complications included stent migration (n = 4, 5.33%), chest pain (n = 28, 38.7%), reflux (n = 15, 20%), and bleeding (n = 9, 12%). No perforation or 30-day mortality occurred. Clinical success was achieved in all patients 1 month after stent removal. The overall remission rates at 6 months, 1, 1–3, 3–5, 5–8, 8–10, and >10 year follow-up periods were 100%, 96%, 93.9%, 90.9%, 100%, 100%, and 83.3%, respectively. Stent treatment failed in six patients, and the overall remission rate in our series was 92%. The median and mean primary patencies were 2.8 ± 0.28 years (95% CI: 2.25–3.35) and 4.28 ± 0.40 years (95% CI: 3.51–5.05), respectively. The use of temporary SEMSs with 30-mm diameter proved to be a safe and effective approach for managing achalasia with a long-term satisfactory clinical remission rate.

Fixation of a covered self-expandable metal stent by means of a polypectomy snare: an easy method to prevent stent migration

Management of oesophageal leaks is controversial. Covered self-expandable-metallic stents have been used for several conditions, but migration of the stents is frequent. We report the case of a patient with post-surgery oesophageal fistula in which, to prevent dislocation, a covered self-expandable-metallic stent was fixed externally using a polypectomy snare.

Endoscopic management for broncholithiasis with bronchoesophageal fistula

We report a case of broncholithiasis with bronchoesophageal fistula that was successfully managed endoscopically using endoscopic laser therapy and a covered self-expandable metallic stent.

Palliation of malignant aerodigestive fistulae with self-expanding metallic stents

Malignant aerodigestive fistulae are rare but devastating sequelae of thoracic cancers, most commonly associated with esophageal cancer. Survival following development of a malignant aerodigestive fistula is measured in weeks. Palliation is the primary goal of therapy and to this end, we report the use of self-expanding metallic stents (SEMS) as treatment. Between May 1999 and January 2004, 12 patients were treated for malignant aerodigestive fistulae. The underlying diagnosis was esophageal cancer for 10 patients, and non-small cell lung cancer for two others. All patients were symptomatic and fistulae were diagnosed by esophagoscopy in seven, bronchoscopy in two, and esophagram in three. Seven covered Wallstents (seven esophageal) and eight covered Ultraflex (five tracheal and three esophageal) were used. A single stent was placed in eight patients (seven esophageal and one tracheal). Three patients required esophageal and tracheal stents and one patient needed two tracheal stents. General anesthesia was required in 50% of the patients. There were no procedure-related complications. Symptoms were palliated in 100% of patients and oral intake was reinstituted in 42% (5/12). All the patients were discharged from hospital after SEMS placement and one patient returned for an uneventful tracheal stent replacement secondary to mucus impaction 2 months later. SEMS placement is an effective strategy to palliate malignant aerodigestive fistulae. Complications are rare and symptoms are alleviated in most patients.

Fate of migrated esophageal and gastroduodenal stents: experience in 70 patients

PURPOSE

To investigate the frequency of esophageal and gastroduodenal stent migration and the fate of such stents.

MATERIALS AND METHODS

The authors studied five types of covered metal stents. Type A stents were nonretrievable polyurethane-covered stents with shouldered ends (n = 169), type B stents were retrievable polyurethane-covered stents with shouldered ends (n = 62), type C stents were retrievable polyurethane-covered stents with flared ends (n = 72), type D stents were retrievable polytetrafluoroethylene-covered stents with shouldered ends (n = 369), and type E stents were separated stents (n = 216). Types A-D stents were esophageal stents, and the type E stent was a gastroduodenal stent. Stents were placed in 888 patients with either benign (n = 43) or malignant (n = 845) causes of stricture. The rate of stent migration was analyzed relative to completeness of migration, the cause of obstruction, stent type, and stent placement location. The fate of migrated stents and the treatment of patients were evaluated.

RESULTS

Stent migration occurred in 70 of the 888 patients (7.9%). Migration occurred in 11 of the 43 patients (25%) with benign cause of strictures and 591 of the 845 patients (7.0%) with malignant cause. The migration rates for types A, B, C, D, and E stents were 10%, 4.8%, 24%, 7.3% and 2.8%, respectively. Of the 70 migrated stents, 45 had complete migration and 25 had partial migration. The anastomotic sites were the areas most commonly associated with migration (16%), but this was not statistically significant. Forty of the 70 migrated stents were removed with retrieval devices under fluoroscopic guidance because they were not passed with stool and possibility of complications related to migrated stents. The remaining 30 stents exited via the rectum (n = 15), remained in the body without complications (n = 12), or were surgically removed because they caused complicated intestinal obstructions (n = 3).

CONCLUSION

The overall migration rate for esophageal and gastroduodenal stents was 7.9%. Most migrated stents were removed nonsurgically, exited the body spontaneously, or remained in the body in an uncomplicated state. Surgical stent removal was necessary in three patients (4.3%) due to complicated intestinal obstructions.

Self-expanding stents in oesophageal cancer

The main therapeutic concern in patients with inoperable oesophageal cancer is palliation of dysphagia. Self-expandable metal stents are widely used because they are safer than conventional plastic stents, offer rapid relief from dysphagia and may seal off tracheo-oesophageal fistulae. Self-expanding metal stents, particularly when uncovered, are, however, associated with the disadvantage of tumour ingrowth. Self-expandable plastic stents are entirely covered and easy to reposition in case of migration and usually induce less inflammatory proliferation at their flanges when compared with metal stents. The major disadvantage of the current version of plastic stents is the large diameter and stiffness of the stent delivery system when compared with metal stents. Therefore, plastic stents are more difficult to place in patients with angulated strictures or with tumours located in the cervical oesophagus near the upper sphincter.

An antireflux stent versus conventional stents for palliation of distal esophageal or cardia cancer: a randomized clinical study

BACKGROUND

Self-expandable metal stents placed across the esophagogastric junction for palliative treatment of malignant strictures may lead to gastroesophageal reflux and pulmonary aspiration. This study compared the effects of a Dua antireflux stent with those of a conventional stent.

METHODS

Patients with incurable cancer of the distal esophagus or gastric cardia were randomly assigned to receive an antireflux stent (n = 19) or a standard stent (n = 22) at nine Swedish hospitals during the period September 1, 2003 to July 31, 2005. Complications were recorded at clinical follow-up visits. Survival rates were assessed through linkage to the Population Register. Dysphagia, reflux symptoms, esophageal pain, dyspnea, and global quality of life were assessed as changes in mean scores between baseline and 1 month after stent insertion through validated questionnaires.

RESULTS

No technical problems occurred during stent placement in the 41 enrolled patients. Fewer patients with complications were observed in the antireflux stent group (n = 3) than in the standard group (n = 8), but no statistically significant difference was shown (p = 0.14). The survival rates were similar in the two groups (p = 0.99; hazard ratio, 1.0; 95% confidence interval, 0.5-2.0). The groups did not differ significantly in terms of studied esophageal or respiratory symptoms or quality of life. Clinically relevant improvement in dysphagia occurred in both groups. Dyspnea decreased after antireflux stent insertion (mean score change, -11), and increased after insertion of standard stent (mean score change, +21).

CONCLUSIONS

Antireflux stents may be used without increased risk of complications, mortality, esophageal symptoms, or reduced global quality of life. These results should encourage large-scale randomized trials that can establish potentially beneficial effects of antireflux stents.

[Palliative endoscopic treatments for esophageal cancers]

Esophageal cancer five-year survival has slightly increased during past 20 years (from 5 to 9%), but remains low. At time of diagnosis, 60% of the patients are only relevant for palliative therapy. Recent advances in therapeutic endoscopy have allowed improving dysphagia and quality of life. Endoscopic techniques are chosen according to tumor characteristics. According to French societies guidelines (FFCD, "Standards-Options-Recommandations" from FNCLCC, SNFGE) endoscopic treatment is a "gold standard" for metastatic patients with poor performance status, as well as oesophago-tracheal fistula. Expandable metal stent are efficient for malignant stenosis with lower morbidity and mortality than plastic prosthesis. Endoscopic placement of a covered self-expanding metal stent is the treatment of choice of an esophago-respiratory fistula. Dilatation is often the first step before other endoscopic therapies or medical treatment such as radiochemotherapy. Single dose brachytherapy could provide better long-term relief of dysphagia and fewer complications than stent placement, but is less widespread. Other techniques like bipolar electrocoagulation have restricted indications especially for circonferential stenosis of cervical esophagus. However, the main problem remains the dysphagia relapse after treatment.

Bronchoesophageal fistula due to broncholithiasis: a case series

OBJECTIVE

To describe the clinical presentation, diagnostic evaluation, and treatment of bronchoesophageal (BE) fistula due to broncholithiasis, a rare cause of chronic cough with specific therapeutic implications.

METHODS

Retrospective chart review of 9 patients diagnosed with BE fistulae at our tertiary-care institution between 1964 and 2002.

RESULTS

The median age of patients (3 men, 6 women) was 56 years (range, 34-72 years). Six patients had never smoked. Eight presented with intractable cough typically worse after drinking that was relieved by lying on either side; 1 patient presented with dysphagia. Six patients reported lithoptysis, and most had a history of recurrent pneumonia. Chest findings were nonspecific. Diagnosis was established by radiocontrast studies of the esophagus (5 patients), surgical procedures (3), or bronchoscopy (1). Fistulae were right-sided in 7 patients and left-sided in 2. All patients had surgical repair of the fistulae; 6 patients experienced symptom resolution.

CONCLUSION

BE fistula caused by broncholithiasis most commonly affects the right bronchial tree and should be considered in patients with chronic cough associated with drinking, lithoptysis, or recurrent pneumonia. The diagnosis is usually established by radiocontrast studies of the esophagus or incidentally during operations. Surgical repair is required.

Self-expandable metallic stents for palliation of malignant esophageal obstruction: special reference to quality of life and survival of patients

SUMMARY. Self-expandable metallic stents (EMS) provide a common option for malignant esophageal stenosis because of the low complication rate and high dysphagia improvement rate. However, there are few studies on the functional duration of EMS and the extent of improvement of the quality of life. We retrospectively analyzed 18 patients who received EMSs in our division from 1996 to 2002. The median duration of possible food intake and the median survival period were 94.5 and 108 days. The median duration of domiciliary treatment was 56 days. Six of the 18 patients were not discharged from hospital after EMS insertion. The Karnofsky index was found to be a significant determinant of the feasibility of domiciliary treatment. One-third of the patients are incapable of obtaining the benefits of the palliative therapy. EMS deployment should be prudently selected for patients exhibiting low performance status.

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.

Comparative retrospective study on the use of plastic prostheses and self-expanding metal stents in the palliative treatment of malignant strictures of the esophagus and cardia

Palliative treatment of malignant strictures of the esophagus and cardia is usually carried out by the endoscopic placement of a prosthesis. The aim of this retrospective study was to evaluate short- and long-term outcomes of the use of expandable stents, compared with conventional plastic prostheses. One hundred and thirteen endoscopic intubations were carried out in 120 patients affected by malignant stenosis of the esophagus and cardia using plastic prosthesis and self-expanding metal stents. Dysphagia was scored according to Atkinson and Ferguson's classification and the preoperative median score (3.6) was comparable in both groups. The technical success rate was 94.4% with plastic prosthesis and 93.7% with self-expanding metal stent while the functional success rate was, respectively, 85.2% and 88.8%. Three deaths occurred with plastic prostheses (4.4%), while no deaths were observed with metal stents. A comparative analysis of the results of this study suggests that the endoscopic placement of self-expanding metal stents is effective and safe and has to be preferred to the conventional plastic prosthesis for easier implantation and lower morbidity.

Are metal stents effective for palliation of malignant dysphagia and fistulas?

BACKGROUND

One of the available treatments for unresectable oesophagogastric malignancies is the insertion of metal stents.

AIMS

We evaluated prospectively 147 patients suffering from malignant dysphagia and/or fistula, after inserting a self-expandable metal stent.

PATIENTS AND METHODS

The study included 147 patients (87 males, mean age 73 years). Dysphagia before and after stent placement was scored. Patients were divided in two groups according to dysphagia grade: group A (grade 0, 1) and group B (grades 2, 3, 4). Three types of stents were used: the Ultraflex stent (covered and uncovered) and the Flamingo one (covered). The total number of self-expandable metal stents placed was 183. A total of 92 of them were inserted following the combined endoscopic and fluoroscopic approach (42 by injecting lipiodol), while 91 were placed under endoscopic control only. Early and late complications were evaluated.

RESULTS

Mean dysphagia score in group A, 1 day and 1 month after the procedure, was slightly reduced from 0.8 to 0.5/0.6 (p=NS), respectively. However, there was a statistically significant improvement (p<0.001) of mean dysphagia score in group B, from 2.4 initially to 1.1/1.4. Early complications occurred in 37 cases, late ones in 51. According to severity, minor complications occurred in 24 patients, major in 42, while life-threatening ones in 22. Survival ranged from 1 to 611 days and 1-week mortality was 9%. Stent-related death occurred in six patients.

CONCLUSIONS

All kinds of endoscopic methods used for stenting in the present study were easy to perform even on an out-patient basis. Insertion of self-expandable metal stents is effective in patients with dysphagia scores > or = 2. It might not clinically improve patients with dysphagia score <2, so selection of patients for stenting is essential to avoid unnecessary procedures. Moreover, their high cost, high complication rates and low overall survival may improve following better selection criteria.

Antireflux stents in tumors of the cardia

Self-expanding metal esophageal stents (SMES) are highly effective in relieving dysphagia in patients with esophageal carcinoma. As the incidence of cancer at the lower esophagus/cardia continues to increase, SMES also are being deployed across the gastroesophageal junction (GEJ). However, use of SMES in this location makes the stomach and the esophagus, in effect, a common cavity, which predisposes patients to gastroesophageal reflux (GER) and aspiration. Reflux may result from an increase in intra-abdominal pressure or it may occur passively when the patient is recumbent. Acid-suppression medications do not protect against regurgitation and aspiration. We developed a modified antireflux SMES and evaluated its efficacy in vitro, in dogs, and in 11 patients with distal esophageal/GEJ carcinoma. The modification involved extending the polyurethane coating of the stent to 8 cm below the lower edge. In dogs, significantly more reflux episodes occurred with the regular stent (mean, 197 episodes) than with the modified stent (mean, 16 episodes; P = 0.03). In patients who received the modified stent, dysphagia scores were significantly reduced (mean baseline score, 3.4; mean end point score, 1.1; P <0.001). The modified stent prevented GER while allowing belching and vomiting.

New approach to radial expansive force measurement of self expandable esophageal metal stents

The accurate measurement of radial expansive force is crucial for optimal design and implantation of self expandable esophageal metal stents. In the present study, a new method of measurement under experimental conditions simulating actual stent implantation has been developed. This method offers precise and reproducible measurements and can be applied to a wide variety of stent types. In particular, the method enables one to measure expansive pressure as well as the true radial expansive force up to the radial compression ratio of 72%, covering the range of compression often encountered in a partially obstructed lumen. The test results for various kinds of metal stents are presented and compared. Based on these results, three important points of observation critical in explaining and predicting the expansion characteristics of stents have been reported. Further understanding and characterization of these findings will be necessary for developing new stents with outstanding clinical efficacy.

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.

EsophaCoil for palliation of dysphagia in unresectable oesophageal carcinoma: short- and long-term results

BACKGROUND AND AIM

Few reports have shown that EsophaCoil is an effective and safe prosthesis for palliation of malignant oesophageal dysphagia. A single centre experience using this type of prosthesis is reported.

PATIENTS AND METHODS

Between January 1995 and September 2000, 42 consecutive patients, 41 with unresectable oesophageal cancer and one with oesophageal stenosis secondary to lung cancer, were treated with 44 EsophaCoils (2 patients received 2 stents). Tumours were located in lower third of oesophagus and/or gastric cardia in 22 cases, in middle third in 18 and in upper third in 2. Mean stricture length was 5.3 cm. Implantation was performed on hospitalized patients.

RESULTS

EsophaCoil placement was successful all 44 times and was followed by complete expansion of the prostheses. There were no major procedure-related complications or deaths. Dysphagia score improved from mean of 2.9 to 1.3 within 24 hours of stent implantation. Median hospital stay was 2.7 days. Late complications occurred in 14 patients (34.2%): 3 migrations into stomach, 7 tissue overgrowth, 2 late perforations and 2 food impactions. Mean survival time was 4.2 months (range 1-10).

CONCLUSIONS

In our experience, full expansion of EsophaCoil was achieved in all cases. This result, was associated with high incidence of retrosternal pain. Relief of dysphagia score was identical to that obtained with other types of Self-Expanding Metal Stent. Coil design prevented tumour ingrowth and allowed retrieval of three migrated stents. Mean survival time was similar to that reported in larger series using different types of Self-Expanding Metal Stent.

Successful endoscopical sealing of malignant esophageotracheal fistulae by using a covered self-expandable stenting system

OBJECTIVE

Any treatment of tracheo-esophageal fistulae in end-stage malignant stenosis of the esophagus must be weighed against associated morbidity and mortality. In a prospective study we investigated benefits and risks of the use of one type of coated, self-expandable stent.

PATIENTS AND METHODS

We treated four male and two female patients, (mean age 68.3 years, range: 38-90 years), with malignant esophago-tracheal fistula non-resectable due to advanced tumour stage and/or functional reasons. All were in a poor general condition suffering from aspiration pneumonia and malnutrition. Four out of the six patients had had one or multiple extra- or endoluminal palliative treatments at a mean interval of 191 days (range: 7 days-15 ms) since the last intervention. The fistulae were sealed by using a covered, self-expandable stent (ULTRAFLEX esophageal stent system, Microinvasive, Boston Scientific Corporation, Boston, MA).

RESULTS

Stenting did not cause any technical problems and all fistulae were successfully sealed in a one-step procedure. The median hospital stay was 4.6 days (range: 3-9 days). Except for one late stent induced recurrent fistula treated by re-stenting and tracheostomy, we did not observe any stent associated complications. Five patients died of tumour generalization. The median survival of the patients who died was 78 days (range: 35-129 days). One patient is alive and well at 120 days after stenting.

CONCLUSION

In spite of the small number of patients the results suggest that this type of stent represents a safe and efficient approach for palliative endoscopic treatment of this high risk group. Local pretreatment does not preclude the successful use of the self-expandable coated stent.

A comparison of 3 types of covered metal stents for the palliation of patients with dysphagia caused by esophagogastric carcinoma: a prospective, randomized study

BACKGROUND

There are currently 3 types of covered metal stents available in Europe for palliation of patients with malignant dysphagia. Their relative merits have not been compared in a prospective, randomized study.

METHODS

One hundred consecutive patients with esophagogastric carcinoma were randomized to placement of an Ultraflex stent, a Flamingo Wallstent, or a Gianturco-Z stent. Malignant strictures of the esophagus were treated by insertion of a small-diameter stent (n = 71), whereas those involving the gastric cardia were treated with a large-diameter stent (n = 29).

RESULTS

At 4 weeks, dysphagia had improved in all patient groups (p < 0.001), but the degree of improvement did not differ among the 3 groups (p = 0.14). There were differences among the 3 stent types with respect to major complications (Ultraflex stent: 8/34 [24%], Flamingo Wallstent: 6/33 [18%], and Gianturco-Z stent: 12/33 [36%]), but these were not statistically significant (p = 0.23). Nine patients (26%) with an Ultraflex stent, 11 (33%) with a Flamingo Wallstent, and 8 (24%) with a Gianturco-Z stent had recurrent dysphagia (p = 0.73), mainly because of tumor overgrowth or stent migration; 12 of 13 episodes of migration involved small-diameter stents in the esophagus.

CONCLUSIONS

All 3 covered metal stents evaluated offer the same degree of palliation of patients with malignant dysphagia. Placement of Gianturco-Z stents was associated with more complications as compared with Ultraflex stents and Flamingo Wallstents. Although stent migration is reduced by increasing stent diameter, tumor overgrowth remains an intractable problem that requires a new approach.

A prospective, randomized, controlled trial of covered expandable metal stents in the palliation of malignant esophageal obstruction at the gastroesophageal junction

OBJECTIVE

Palliation of malignant esophageal obstruction is an important clinical problem. Expandable metal stents are a major advance in therapy, but many stents become obstructed because of tumor ingrowth. The aim of this study was to compare a new, membrane-covered expandable metal stent to conventional prostheses in a randomized controlled trial.

METHODS

Sixty-two patients with malignant inoperable esophageal obstruction at the gastroesophageal junction participated in the study. Patients were randomly assigned to covered or uncovered stents. The principal outcome measure was the need for reintervention because of recurrent dysphagia or migration. Secondary endpoints were relief of dysphagia measured by a dysphagia score (grade 0 = no dysphagia, grade 1 = able to eat solid food, grade 2 = semisolids only, grade 3 = liquids only, grade 4 = complete dysphagia) and the rate of complications and functional status. All patients were observed at monthly intervals until death or for 6 months.

RESULTS

One week after stenting the dysphagia score improved significantly in both the uncovered (n = 32, 3 +/- 0.1 to 1 +/- 0.1 [means +/- SEMs], p < 0.001) and covered (n = 30, 3 +/- 0.1 to 1 +/- 0.2 [means +/- SEMs], p < 0.001) stents. Obstructing tumor ingrowth was significantly more likely in the uncovered stent group (9/30) than in the covered group (1/32) (p = 0.005). Significant stent migration occurred in 2/30 patients with uncovered stents, as compared with 4/32 patients in the covered group (p = 0.44). Reinterventions for tumor ingrowth were significantly greater in the uncovered stent group (27%), as compared with 0% in the covered group (p = 0.002). Life table analysis showed similar survival in both groups.

CONCLUSION

Membrane-covered stents have significantly better palliation than conventional bare metal stents because of decreased rates of tumor ingrowth that necessitate endoscopic reintervention for dysphagia.

Self-expanding metal esophageal stent with anti-reflux mechanism

BACKGROUND

When deployed across the gastroesophageal junction, self-expanding metal esophageal stents can predispose to gastroesophageal reflux. Our aim was to evaluate the efficacy of a self-expanding metal esophageal stent that was modified to prevent gastroesophageal reflux.

METHODS

The polyurethane coating of a metal Z-stent was extended beyond its lower end to form windsock-type valve. The anti-reflux property of this stent was studied in vitro by submerging the stent under water and measuring the pressure required to invert the valve. Esophageal acid exposure time was measured in 5 dogs with a standard and the modified stent placed across the gastroesophageal junction. The modified stent was also placed in 11 patients with cancer of the gastroesophageal junction who were prospectively followed.

RESULTS

The pressure required to invert the valve was directly proportional to the thickness of the valve membrane (48 +/- 0.4 cm water for a 0.0067-inch thick membrane). Esophageal acid exposure time was significantly less with the modified stent as compared with a standard stent (1% +/- 0.3%, 49% +/- 11%, respectively, p = 0.03). Dysphagia score in patients improved from 3.4 +/- 0.1 to 1.1 +/- 0.2 (p < 0.001). Daytime heartburn and regurgitation scores were less than 1 (score 10 = severe). No patient complained of nocturnal reflux symptoms. Karnofsky performance status scale did not improve significantly.

CONCLUSIONS

The efficacy of the modified stent in relieving dysphagia is comparable with a standard stent. It also effectively prevents gastroesophageal reflux.

A prospective trial of a new self-expanding plastic stent for malignant esophageal obstruction

OBJECTIVE

We studied a new expandable plastic stent in the palliation of malignant esophageal obstruction.

METHODS

Eight patients with malignant esophageal obstruction and dysphagia were studied. An expandable covered plastic stent made of polyester netting and covered with a silicone membrane was inserted and released into the stenosis. Relief of dysphagia and functional status were measured.

RESULTS

The stent was successfully inserted in all eight patients. The median dysphagia score dropped from 3 (able to eat liquids only) to 1 (some dysphagia with solid food), and seven of the eight patients had an improvement of at least two grades of dysphagia. Mean survival was 87 days (range 17-226). Stent migration occurred in one patient after 50 days; stent occlusion due to tumor ingrowth was not seen.

CONCLUSIONS

A low cost (approximately $400) expandable plastic stent has been developed that is safe and effective in the palliation of malignant esophageal obstruction. Large randomized trials comparing this stent to expandable metal stents are warranted.

Palliative treatment of malignant esophageal stenosis: the role of self-expanding stent endoscopic implantation

Endoscopic tube implantations were carried out in 40 patients with malignant stenosis of the esophagus and gastric cardia using self-expanding metallic stents. The indications for endoscopic intubation were the advanced stage of the tumor in 27 cases and risk factors that made resection inadvisable in 13 cases. In three patients, it proved impossible to implant a stent endoscopically because we were not able to pass the guide wire through the stenosis, whereas correct stent placement was achieved in 37 cases. Functional results were good in 33 patients, but four patients did not show any improvement of symptoms. Complications occurred in nine patients (24.3%): two bleedings, three neoplastic obstructions, one food obstruction, and three distal dislodgements of the prosthesis were observed, but could be readily corrected. No deaths occurred. The median survival time was 151 days (range 25-545 days). This study suggests that endoscopic placement of metallic self-expanding stents is safe and is to be preferred to plastic stents for easier implantation and lower morbidity.