Airway complications of esophageal self-expandable metallic stent

Delayed bronchial obstruction following esophageal stent placement: A case report and review of the literature

Esophageal adenocarcinoma typically has a poor prognosis at the time of diagnosis. Consequently, palliation of symptoms is vital to disease management with a cornerstone for palliation being esophageal stent placement. Esophageal stents are associated with a variety of complications that may present immediately or long after stent placement is completed. In this report, we present a 58-year-old male who developed shortness of breath 4 months after metallic esophageal stent placement. After further evaluation with a chest radiograph and CT angiogram of the chest, the patient was found to have obstruction of the left mainstem bronchus secondary to mass effect from the esophageal stent. Airway compromise secondary to metallic esophageal stent placement typically occurs immediately after placement of the stent. There are only a few documented cases of this complication occurring at a delayed interval. This case clearly demonstrates this rare complication of esophageal stent placement in the setting of esophageal adenocarcinoma.

Delayed Bronchial Obstruction Following Esophageal Stent Implantation: A Case Report

Airway compression is a rare complication of esophageal stent placement. With the introduction of self-expanding metal stents, the incidence of bronchial obstruction by esophageal stents has decreased. Delayed external airway compression after esophageal stent implantation is rarely reported. We describe a case of left main bronchial obstruction after self-expandable esophageal stent placement. A 70-year-old patient with advanced esophageal cancer visited the emergency room (ER) with worsening cough and dyspnea. He had received palliative concurrent chemoradiotherapy after esophageal self-expanding metal stent (SEMS) insertion three months ago. One month before the ER visit, additional esophageal SEMS placement (stent-in-stent) was performed owing to the development of a tracheoesophageal fistula. After hospitalization, chest radiography revealed a patchy consolidation in the left lower lobe. A diagnosis of pneumonia was made, and the patient was treated with antibiotics. Seven days after antibiotic treatment, the patient developed a fever and severe dyspnea. Auscultation revealed the absence of breath sounds in the left hemithorax. A follow-up chest radiograph showed a white-out of the left hemithorax. Flexible bronchoscopy revealed luminal narrowing of the left main bronchus (LMB) due to external compression. Chest computed tomography further demonstrated compression of the LMB by esophageal stents. This case highlights that esophageal SEMS can present as an emergent and often life-threatening airway obstruction.

Dual Airway and Esophageal Stenting in Advanced Esophageal Cancer With Lesions Near Carina

BACKGROUND

Tracheobronchial stenting either alone or with esophageal stenting is often required for symptom palliation in obstructive or fistulous lesions of the airway due to esophageal cancer. There is limited evidence regarding dual stenting for lesions near the carina due to esophageal cancer. Hence, this study aims to evaluate the technical feasibility, outcomes, and complications of preplanned dual stenting in these patients.

METHODS

This is a prospective observational study carried out over a period of 4 years (January 2015 to July 2019). All patients undergoing dual stenting in the airway and esophagus with obstructive or fistulous lesions near the carina were included. The esophageal stent was placed within 24 hours. Prestenting and poststenting symptoms were compared using a symptom-based visual analog scale, Hugh Jones dyspnea scale and dysphagia scale.

RESULTS

Twenty-nine patients (20 males; mean±SD age, 55.3±12.2 y) underwent dual stenting. Twenty-four patients had central airway obstruction due to: infiltration in 20 (69%) and external compression in 4 (13.7%), respectively. Five (17.3%) patients had tracheoesophageal fistula with no airway obstruction. In 80% of the patients (n=23), silicone stents were placed. There was significant improvement in both dyspnea and dysphagia after dual stenting (P<0.001). Mucus plugging, lower respiratory infection, and granulation tissue were the main complications. Median survival after dual stent was 97 days (range, 17 to 297 d).

CONCLUSION

Dual stenting within the airway and the esophagus is a safe and viable option for palliative relief of symptoms in patients with advanced esophageal cancer.

Reducing complications in upper gastrointestinal endoscopy

This article reviews the principal aspects related to sedation in endoscopy and to the prevention of adverse events in some of the most frequently performed therapeutic upper gastrointestinal (GI) endoscopic procedures (esophageal dilation and stenting, endoscopic resection of upper GI early neoplasia, hemostasis of upper GI bleeding and percutaneous endoscopic gastrostomy insertion). These procedures have an inherent risk of negative outcomes that cannot be entirely avoided. Endoscopic procedures are best performed by well-trained, competent and thoughtful endoscopists in facilities suited to provide for patient safety. Attention to clinical risk management may effectively reduce the frequency and intensity of adverse events, enhance recognition and early detection, and improve responsiveness.

Enteral stents

The American Society for Gastrointestinal Endoscopy (ASGE) Technology Committee provides reviews of existing, new, or emerging endoscopic technologies that have an impact on the practice of GI endoscopy. Evidence-based methodology is used, with a MEDLINE literature search to identify pertinent clinical studies on the topic and a MAUDE (U.S. Food and Drug Administration Center for Devices and Radiological Health) database search to identify the reported complications of a given technology. Both are supplemented by accessing the "related articles" feature of PubMed and by scrutinizing pertinent references cited by the identified studies. Controlled clinical trials are emphasized, but in many cases, data from randomized, controlled trials are lacking. In such cases, large case series, preliminary clinical studies, and expert opinions are used. Technical data are gathered from traditional and Web-based publications, proprietary publications, and informal communications with pertinent vendors. Technology Status Evaluation Reports are drafted by 1 or 2 members of the ASGE Technology Committee, reviewed and edited by the committee as a whole, and approved by the Governing Board of the ASGE. When financial guidance is indicated, the most recent coding data and list prices at the time of publication are provided. For this review, the MEDLINE database was searched through August 2010 for articles related to enteral, esophageal, duodenal, and colonic stents. Technology Status Evaluation Reports are scientific reviews provided solely for educational and informational purposes. Technology Status Evaluation Reports are not rules and should not be construed as establishing a legal standard of care or as encouraging, advocating, requiring, or discouraging any particular treatment or payment for such treatment.

Airway and esophageal stenting in patients with advanced esophageal cancer and pulmonary involvement

Background

Most inoperable patients with esophageal-advanced cancer (EGC) have a poor prognosis. Esophageal stenting, as part of a palliative therapy management has dramatically improved the quality of live of EGC patients. Airway stenting is generally proposed in case of esophageal stent complication, with a high failure rate. The study was conducted to assess the efficacy and safety of scheduled and non-scheduled airway stenting in case of indicated esophageal stenting for EGC.

Methods and Findings

The study is an observational study conducted in pulmonary and gastroenterology endoscopy units. Consecutive patients with EGC were referred to endoscopy units. We analyzed the outcome of airway stenting in patients with esophageal stent indication admitted in emergency or with a scheduled intervention. Forty-four patients (58±\−8 years of age) with esophageal stenting indication were investigated. Seven patients (group 1) were admitted in emergency due to esophageal stent complication in the airway (4 fistulas, 3 cases with malignant infiltration and compression). Airway stenting failed for 5 patients. Thirty-seven remaining patients had a scheduled stenting procedure (group 2): stent was inserted for 13 patients with tracheal or bronchial malignant infiltration, 12 patients with fistulas, and 12 patients with airway extrinsic compression (preventive indication). Stenting the airway was well tolerated. Life-threatening complications were related to group 1. Overall mean survival was 26+/−10 weeks and was significantly shorter in group 1 (6+/−7.6 weeks) than in group 2 (28+/−11 weeks), p<0.001). Scheduled double stenting significantly improved symptoms (95% at day 7) with a low complication rate (13%), and achieved a specific cancer treatment (84%) in most cases.

Conclusion

Stenting the airway should always be considered in case of esophageal stent indication. A multidisciplinary approach with initial airway evaluation improved prognosis and decreased airways complications related to esophageal stent. Emergency procedures were rarely efficient in our experience.

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.

[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.

Airway obstruction complicating esophageal stent placement in two post-pneumonectomy patients

Expandable metallic stents have been used effectively to treat multiple nonsurgical esophageal conditions. Here we describe two cases in postpneumonectomy patients in which expandable esophageal stent placement resulted in respiratory compromise requiring reintervention due to airway compression.

Stents for Esophageal Disease

Esophageal malignancies presenting with dysphagia from luminal obstruction generally are not resectable for cure, and palliative therapy is the primary focus. Self-expandable metal stents (SEMS) have replaced plastic stents as a primary mode of palliation for malignant esophageal obstruction because of the relative ease of insertion, lower initial morbidity, and larger stent diameter. Self-expandable metal stents are ideal for patients with midesophageal tumors. A majority of patients experience relief of dysphagia with SEMS and dietary modification, but the initial cost is high and early morbidity may be significant. The placement of SEMS across the gastroesophageal junction may result in free reflux that may improve with a stent containing a one-way gastric flap valve. The placement of SEMS in the cervical esophagus, although more difficult, less effective, and less well tolerated, also may be successful. Coated SEMS are a treatment of choice for individuals with tracheoesophageal fistula. Delayed complications occur in up to 40% of patients and include stent migration, bleeding, perforation, fistula formation, and occlusion. Most complications can be managed endoscopically and additional stents may be placed for tumor overgrowth. The comparison of three currently available SEMS for esophageal malignancy show no statistically significant differences with regard to ease of placement, effectiveness, complications, and mortality. The use of SEMS for patients with benign disease is still considered experimental.

Stenting of the tracheobronchial tree

Endoscopic treatment of endobronchial obstructions is becoming increasingly important. Tracheobronchial stents often are needed in the treatment of obstructions from submucosal or extrabronchial lesions. Tube stents have been available since the early 1960s but are underused because their insertion requires the use of a rigid bronchoscope. With the recent development of metallic stents, interventional radiologists increasingly are involved in the treatment of tracheobronchial obstructions. Metallic stents, easily placed with flexible bronchoscopy, are growing in popularity. All available tracheobronchial stents have been shown in various clinical series to be able to achieve immediate resolution of respiratory symptoms from various tracheobronchial obstructions. A stent's performance, however, should not be based solely on short-term response. Presently, there is no ideal stent because none is free of complications and none are able to consistently maintain life-long patency. Gianturco stents are associated with serious major complications (bronchial perforations and strut fractures) and are no longer recommended for use in the tracheobronchial tree. The Palmaz stent has also fallen into disfavor, because a strong external force, such as a vigorous cough, can recompress it. The Strecker stent can only be used in smaller airways, but may be useful in the accurate stenting of short segment stenoses because it does not foreshorten on deployment. The Wallstent and Ultraflex are our present metallic stents of choice. Both are easy to deploy, available in covered forms, exert adequate radial force, remain relatively stable in position, and have good longitudinal flexibility for use in tortuous airways. Disadvantages include excessive granulation tissue formation and difficulty of removal once the stent has been epithelialized. Metallic stents should be chosen very carefully for use in benign lesions with ongoing active local inflammation or when temporary stenting is needed. In the absence of an ideal stent, technologic advancements will continue. Potential developments include removable metallic stents, biodegradable stents, and chemically and radioactively coated stents. Unquestionably, the expanding stent market will drive scientific research toward the development of the ideal stent. Clearly, physicians need to be ready to assess these technologic advancements.

Airway stents

Considerable progress has been made since the initial stents were manufactured. Despite the reported side effects, cumulative evidence suggests beneficial effects in properly selected patients. The technology is still in evolution, and design modifications strive to find the perfect stent. The Dumon stent remains the gold standard against which the functions of all other stents are being measured. Unfortunately requirement for the RB for deployment has restricted widespread application at least in the United States. The Wallstent can be inserted using FB and has a great potential among the metal stents. Its biggest drawback is that once inserted it is difficult to remove. Studies with the nitinol Ultraflex and the polyester/silicone Polyflex prototype stent also show promise, although extensive experience and long-term follow-up data are still not available. It is possible that combining the strength of the tube stents with the flexibility of the metal stents may one day help to develop the ideal stent.