Treatment of esophageal obstruction from mediastinal compressive tumor with covered, self-expanding metallic Z-stents

Esophageal self-expandable metal stent placement for the palliation of dysphagia due to lung cancer

BACKGROUND

This study aims to report our experience with esophageal self-expendable metal stents for the palliation of malignant dysphagia and tracheoesophageal fistulas caused by lung cancer.

METHODS

Esophageal self-expandable metal stents were deployed in 56 patients (55 males, 1 female; mean age 63.5 years; range, 42 to 79 years) with malignant dysphagia due to lung cancer between August 2002 and May 2018. Of the patients, 34 had received previous chemoradiotherapy, eight only chemotherapy, and three only radiotherapy, while four had pneumonectomy. Tracheoesophageal fistula was coexisting in 12 patients (21%). Stents were inserted under fluoroscopic control over guide-wire in 28 patients and under flexible endoscopic control in the remaining 28 patients. One stent was used in all patients, except two patients with tracheoesophageal fistula, one patient who had an external compression causing downward migration of stent, and two patients who had tumor progression.

RESULTS

Dysphagia improved in all patients after stent insertion. Tracheoesophageal fistula was sealed off in all patients. All patients remained asymptomatic without dysphagia symptoms during the follow-up period except for two patients who underwent gastrostomy. All patients with tracheoesophageal fistula died. Their mean duration of survival was 2.8 months. Of the patients with tracheoesophageal fistula, one died of mediastinitis, one died of esophageal perforation, while the others died of cancer-related reasons. Of the dysphagia patients without tracheoesophageal fistula, all died except for two patients. Mean duration of survival in this group was 4.3 months.

CONCLUSION

Dysphagia in lung cancer may have many underlying reasons. Self-expandable metal stents may provide satisfactory relief of dysphagia symptoms with minimal morbidity after a single procedure in patients with limited lifespan.

Stenting of the upper gastrointestinal tract: current status

Minimally invasive image-guided insertion of self-expanding metal stents in the upper gastrointestinal tract is the current treatment of choice for palliation of malignant esophageal or gastroduodenal outlet obstructions. A concise review is presented of contemporary stenting practice of the upper gastrointestinal tract, and the procedures in terms of appropriate patient evaluation, indications, and contraindications for treatment are analyzed, along with available stent designs, procedural steps, clinical outcomes, inadvertent complications, and future technology. Latest developments include biodegradable polymeric stents for benign disease and radioactive or drug-eluting stents for malignant obstructions.

Comparison of double-layered and covered Niti-S stents for palliation of malignant dysphagia

BACKGROUND AND AIM

Covered metal stents have been accepted as the treatment of choice for malignant dysphagia caused by esophageal and gastric cardia cancer, but stent migration is a major shortcoming. A double-layered Niti-S stent was therefore introduced to obviate this problem. We aimed to compare double-layered and covered Niti-S stents regarding safety, efficacy, and feasibility in the treatment of malignant dysphagia.

METHODS

Thirty-seven consecutive patients with malignant dysphagia due to inoperable esophageal or gastric cardia cancer were enrolled in a prospective, randomized study. The main outcomes were technical success, improvement in dysphagia score after stent insertion, and complications.

RESULTS

Technical success was achieved at a similar rate in both groups (covered, 19/19 [100%]vs double layered, 16/17 [94%]). A week after stent insertion, the mean dysphagia score improved significantly in the covered and double-layered groups compared to baseline (from 2.95 +/- 0.52 and 2.88 +/- 0.33 to 1.00 +/- 0.47 and 1.06 +/- 0.24, respectively; P < 0.001). There was no difference in the survival of the patients in the two groups. The overall complications, including stent migration and tumor overgrowth, occurred more frequently with covered stents (11/19 [58%]) than double-layered stents (2/17 [12%]; P = 0.006).

CONCLUSION

Newly-developed, self-expanding metal stents, (covered and double-layered Niti-S stents) were equally effective and feasible treatments for malignant dysphagia. However, double-layered Niti-S stents are preferable due to their favorable safety profile.

Clinical outcomes and patency of self-expanding metal stents in patients with malignant upper gastrointestinal obstruction

This study was performed to evaluate clinical outcomes and factors associated with patency of self-expanding metal stents (SEMS) in patients with malignant upper gastrointestinal (UGI) obstruction. In 83 patients with malignant UGI obstruction, 118 SEMS placements were performed. Obstruction sites were esophagus/gastro-esophageal junction (GEJ) and gastric outlet (GO) in 41 and 42 patients, respectively. Technical success was achieved in 99.2% and clinical success in 90.5%, with no procedure-related complications. Re-obstruction and migration occurred in 38.1% during a mean follow-up of 137 days; both occurred significantly more often with GO than esophageal/GEJ obstruction (49.2% vs 23.9%). Patency rates of esophageal/GEJ obstruction were 93.5, 78.1 and 67.0% at 30, 90 and 180 days, respectively, and were significantly higher than those of GO obstruction-71.7, 51.8 and 32.5%. Palliative chemotherapy or radiation therapy was not associated with stent patency. Endoscopic SEMS placement is a safe and effective palliative treatment for malignant UGI obstruction, and complications or stent patency differed according to obstruction site.

New design esophageal stents for the palliation of dysphagia from esophageal or gastric cardia cancer: a randomized trial

BACKGROUND & AIM

Stents are often used for the palliation of inoperable esophageal or gastric cardia cancer. One of the drawbacks of the currently used stents is the high percentage of recurrent dysphagia due to stent migration and tissue growth. New stents have been designed to overcome this unwanted sequela of stent placement. In the present study, we investigated whether results of stent placement could be improved with newer stent designs.

METHODS

Between June 2004 and May 2006, 125 patients with dysphagia from inoperable carcinoma of the esophagus or gastric cardia were randomized to placement of an Ultraflex stent (N = 42), Polyflex stent (N = 41), or Niti-S stent (N = 42). Patients were followed by scheduled telephone calls at 14 days after treatment, and then monthly for 6 months or until death. Technical and functional outcome, complications, recurrent dysphagia, and survival were analyzed with, chi(2) tests, Kaplan-Meier curves, and log-rank tests.

RESULTS

Stent placement was technically successful in all patients with an Ultraflex stent, in 34/41 (83%) patients with a Polyflex stent, and in 40/42 (95%) patients treated with a Niti-S stent (P= 0.008). Dysphagia score improved from a median of 3 (liquids only) to 1 (ability to eat some solid food) in all patients. There were no differences in complications among the three stent types. Recurrent dysphagia, caused by tissue in- or overgrowth, migration, or food obstruction, was significantly different between patients with an Ultraflex stent and patients with a Polyflex stent or Niti-S stent (22 [52%]vs 15 [37%]vs 13 [31%], P= 0.03). Stent migration occurred more frequently with Polyflex stents, whereas tissue in- or overgrowth was more frequently seen with Ultraflex stents, and to a lesser degree, Niti-S stents. No differences were found in survival (median survival: Ultraflex stent 132 days vs Polyflex stent 102 days vs Niti-S stent 159 days) among the three stent types.

CONCLUSIONS

All three stents are safe and offer adequate palliation of dysphagia from esophageal or gastric cardia cancer. Nonetheless, Polyflex stents seem the least preferable in this patient group, as placement of this device is technically demanding and associated with a high rate of stent migrations.

[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.

A new esophageal stent design (Niti-S stent) for the prevention of migration: a prospective study in 42 patients

BACKGROUND

Covered, rather than uncovered, metal stents are used for the palliation of dysphagia from esophageal cancer, but a major drawback is the risk of stent migration, which occurs in up to 20% of patients. To overcome this problem, a double-layered stent, the Niti-S stent (Taewong Medical, Seoul, Korea), has been developed. The Niti-S stent consists of an inner polyurethane layer to prevent tumor ingrowth and an outer uncovered nitinol wire tube to allow the mesh of the stent to embed itself in the esophageal wall.

METHODS

Between June 2003 and May 2004, 42 patients with malignant dysphagia caused by inoperable carcinoma of the esophagus or gastric cardia were treated with a Niti-S stent. Patients were prospectively followed and data collection focused on recurrent dysphagia, functional outcome, complications, and survival.

RESULTS

At 4 weeks, the dysphagia score had significantly improved from a median of 3 (liquids only) to 0 (ability to eat a normal diet). Five of 42 (12%) patients with a Niti-S stent developed recurrent dysphagia, mainly due to tissue overgrowth (2 of 42; 5%) and stent migration (3 of 42; 7%). Major complications (perforation, 1; aspiration pneumonia, 2; hemorrhage, 2) occurred in 5 of 42 (12%) patients. Pain following stent placement was observed in 5 of 42 (12%) patients, and symptomatic gastroesophageal reflux occurred in 2 of 42 (5%) patients.

CONCLUSIONS

The Niti-S stent provides symptomatic relief of malignant dysphagia and effectively reduces recurrent dysphagia. Its double-layered design is probably important in preventing migration. In addition, the complete covering of the Niti-S stent may be a factor in preventing tissue overgrowth at both ends of the stent.

Comparative observation on different intervention procedures in benign stricture of gastrointestinal tract

AIM: To determine the most effective intervention procedure by evaluation of mid and long-term therapeutic efficacy in patients of stricture of the gastrointestinal tract (GIT).

METHODS: Different intervention procedures were used to treat benign stricture of GIT in 180 patients including pneumatic dilation (group A, n = 80), permanent (group B, n = 25) and temporary (group C, n = 75) placement of expandable metallic stents.

RESULTS: The diameters of the strictured GIT were significantly greater after the treatment of all procedures employed (P < 0.01). For the 80 patients in group A, 160 dilations were performed (mean, 2.0 times per patient). Complications in group A included chest pain (n = 20), reflux (n = 16), and bleeding (n = 6). Dysphagia relapse occurred in 24 (30%) and 48 (60%) patients respectively during 6-and-12 momth follow-up periods in group A. In group B, 25 uncovered or partially covered or antireflux covered expandable metallic stents were placed permantly, complications included chest pain (n = 10), reflux (n = 15), bleeding (n = 3), and stent migration (n = 4), and dysphagia relapse occurred in 5 (20%) and 3 patients (25%) during the 6- and -12 month follow-up periods, respectively. In group C, the partially covered expandable metallic stents were temporarily placed in 75 patients and removed after 3 to 7 days via gastroscope, complications including chest pain (n = 30), reflux (n = 9), and bleeding (n = 12), and dysphagia relapse occurred in 9 (12%) and 8 patients (16%) during the 6-and-12 month follow-up periods, respectively. The placement and withdrawal of stents were all successfully performed. The follow-up of all patients lasted for 6 to 96 months (mean 45.3 ± 18.6 months).

CONCLUSION: The effective procedures for benign GIT stricture are pneumatic dilation and temporary placement of partially-covered expandable metallic stents. Temporary placement of partially-covered expandable metallic stents is one of the best methods for benign GIT strictures in mid and long-term therapeutic efficacy.

Follow-up evaluation for benign stricture of upper gastrointestinal tract with stent insertion

AIM: To determine the best mothod for benign stricture of the upper gastrointestinal tract (UGIT) with stent insertion by follow-up evaluation.

METHODS: A total of 110 stents insertions were performed in 110 cases of benign stricture of the UGIT. Permanent (group A) and temporary (group B) placement of an expandable metal stent in 30 cases and 80 cases respectively. All cases were completed under fluoroscopy.

RESULTS: In group A, 30 uncovered or antireflux covered or partially covered expandable metal stents were placed permanently. In group A, 5 cases (16.7%) in 3-months, 5 cases (20.0%) in 6-months, 6 cases (25%) in the 1st year, 6 cases (50%) in the 3^rd year, and 4 cases (80%) in the 5^th year exhibited dysphagia relapse. In group B, a partially-covered expandable metal stent was temporarily placed in each patient and removed after 3-7 d via gastroscopy. Follow-up data in this group showed that 8 cases (7.5%) in 3-months, 9 cases (12.0%) in 6-months, 10 cases (15.4%) in the 1^st year, 6 cases (20%) in the 3^rd year, and 3 cases (25%) in the 5^th year exhibited dysphagia relapse. The placement and withdrawal of all stents were all performed successfully. The follow-up of all cases lasted for 3-99 mo (mean 41.6 ± 19.7 mo).

CONCLUSION: The best mothod for benign stricture of UGIT with stent insertion is temporary placement of a partially-covered expandable metal stent.

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.

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.

An update in the palliative management of malignant dysphagia

BACKGROUND

Oesophageal cancer is generally associated with late presentation and poor prognosis. Therefore palliative surgery has been largely superseded by less invasive non-surgical techniques. Once palliation is indicated, the aims of the management should be: the maintenance of oral intake, minimizing hospital stay, relief of pain, elimination of reflux and regurgitation and the prevention of aspiration.

METHODS

This study was a review of all published English language data on the palliation of malignant dysphagia between 1994-1999. The Medline and Bids databases were searched and other references were derived from the material perused.

RESULTS AND CONCLUSIONS

Palliative treatment for oesophageal cancer should be individualized and relate to tumour stage, size and location, the patient's medical condition and his/her personal wishes. The palliative treatment largely includes self-expanding metal stents (SEMS), laser (including photodynamic therapy (PDT)) or a combination of the two to relieve symptoms, this may be employed with or without other treatments such as radiotherapy/chemotherapy (RT/CT) with the aim of reducing tumour bulk and possibly prolonging survival. A multi-disciplinary approach is vital in patients with advanced oesophageal cancer.

A new design metal stent (Flamingo stent) for palliation of malignant dysphagia: a prospective study. The Rotterdam Esophageal Tumor Study Group

BACKGROUND

Metal stents are not superior to conventional endoprostheses with respect to the incidence of recurrent dysphagia because of tumor ingrowth with uncovered stents and migration with their covered counterparts. To overcome these limitations, a partially covered (inside-out covering) metal stent with a conical shape and a varying braiding angle of the mesh along its length, the Flamingo stent, has been developed.

METHODS

From March 1997 to October 1997, 40 consecutive patients with dysphagia due to malignant tumors had either a small diameter (proximal/distal diameter 24/16 mm; n = 21) or a large diameter Flamingo stent (proximal/distal diameter 30/20 mm; n = 19) placed.

RESULTS

There was statistically significant improvement in dysphagia, but improvement was not greater with large diameter stents compared to small diameter stents (p = 0.21). Major complications (bleeding [4], perforation [1], fever [1] and fistula [1]) occurred in 7 (18%) patients. Large diameter stents tended to be associated with more major complications than small diameter stents (5 vs. 2; p = 0.07). Pain following stent placement was observed in 9 (22%) patients and occurred more frequently in those who had prior radiation and/or chemotherapy (p = 0.02). Recurrent dysphagia (mainly due to tumor overgrowth) occurred in 10 (25%) patients.

CONCLUSIONS

Flamingo stents are effective for palliation of malignant dysphagia, but the large diameter stent seems to be associated with more complications involving the esophagus than the small diameter stent. Because recurrent dysphagia is mainly due to tumor progression, further technical developments in stent design are needed.

Palliation of malignant esophageal obstruction due to intrinsic and extrinsic lesions with expandable metal stents

OBJECTIVE

Metal stents have become the standard of care for esophageal stenting. The aim of this study was to determine the safety and efficacy of metal stents for the palliation of dysphagia caused by extraesophageal malignancies compressing the esophagus, compared with that caused by intrinsic lesions involving the esophagus.

METHODS

Expandable metal stents were placed in 46 consecutive patients with dysphagia caused by malignant extrinsic compression of the esophagus (n=24) and intrinsic esophageal strictures (n=22). Quality of life was determined by a dysphagia score and the Karnofsky performance scale. Patients were followed until death.

RESULTS

Stents were successfully deployed in all 24 patients. Dysphagia scores improved from a median of 3 (range, 3-4; mean, 3.5+/-0.2) to a median of 2 (range, 1-4; mean, 1.6+/-0.4; p < 0.0001) in the extrinsic group, and from a median of 3 (range, 2-4) to a median of 1 (range, 1-3) in the intrinsic group (p < 0.0001). The improvement was significantly greater (p=0.01) in the intrinsic group. There was no significant difference in the Karnofsky score between the two groups.

CONCLUSIONS

Patients with intrinsic lesions have better palliation of dysphagia than those with extrinsic lesions. Future studies with other study designs will need to consider this.

Palliation of malignant dysphagia from oesophageal cancer. Rotterdam Oesophageal Tumor Study Group

Palliative therapies for advanced oesophageal cancer include surgery, radiation therapy, chemotherapy, endoscopic procedures and combinations of these. Of the non-endoscopic modalities is external beam radiation therapy (EBRT) effective and non-invasive. A disadvantage is that relief of dysphagia only occurs over a period of 4-6 weeks. Brachytherapy is more rapid in locally controlling tumour growth and in relieving dysphagia. One of the more commonly used endoscopic procedures is laser therapy, which provides symptomatic relief with low complication rates. Recurrent dysphagia is a problem necessitating repeated treatment sessions. Self-expanding metal stents offer a high degree of palliation and are associated with fewer complications compared with prosthetic tubes. Longer palliation and perhaps even longer survival might be achieved by the combination of different therapies. Most promising are the combination of EBRT plus brachytherapy or chemoradiation. Now is the time to determine which treatment (combination) is best for individual patients.

Coated self-expanding metal stents versus latex prostheses for esophagogastric cancer with special reference to prior radiation and chemotherapy: a controlled, prospective study

BACKGROUND

Self-expanding metal stents seem to be safer than conventional prostheses for palliation of malignant esophagogastric obstruction. However, recurrent dysphagia caused by tumor ingrowth in uncoated types remains a problem. In addition, prior radiation and/or chemotherapy may entail an increased risk of complications.

METHODS

Seventy-five patients with an esophagogastric carcinoma were randomly assigned to placement of a latex prosthesis under general anesthesia or a coated, self-expanding metal stent under sedation. At entry, patients were stratified for location of the tumor in the esophagus or cardia and for prior radiation and/or chemotherapy.

RESULTS

Technical success and improvement in dysphagia score were similar in both groups. Major complications were more frequent with latex prostheses (47%) than with metal stents (16%) (odds ratio 4.07: 95% CI [1.35, 12.50], p = 0.014). Recurrent dysphagia was not different between latex prostheses (26%) and metal stents (24%). Hospital stay was longer, on average, after placement of latex prostheses than metal stents (6.3 +/- 5.2 versus 4.3 +/- 2.3 days; p = 0.043). Only prior radiation and/or chemotherapy increased the risk of specific device-related complications with respect to the esophagus (12 of 28 [43%] versus 8 of 47 [17%]; odds ratio 3.66: 95% CI [1.24, 10.82], p = 0.029).

CONCLUSIONS

Coated, self-expanding metal stents are associated with fewer complications and shorter hospital stay as compared with latex prostheses, and prior radiation and/or chemotherapy increases the risk of device-related complications with respect to the esophagus.