Restenting malignant oesophageal strictures

Esophageal stents for the treatment of malignant dysphagia in patients with esophageal cancer

Self-expanding metal stents (SEMS) are the current standard for relief of malignant esophageal dysphagia. Self-expanding plastic stents (SEPS) are also used for relief of malignant esophageal dysphagia and as neoadjuvant therapy due to their relative ease of removability. The innovations in design of both SEMS and SEPS have made their use more prevalent in patients with malignant dysphagia. We review the current literature on esophageal stents, including general concepts, indications, contraindications, SEMS and SEPS models, complications and their management, implications of tumor location, cost-effectiveness of stents in comparison with other modalities, and quality of life after stent placement.

Palliative therapy for patients with unresectable esophageal carcinoma

Most patients diagnosed with carcinoma of the esophagus do not undergo therapy with curative intent. The focus of treatment for these patients is to maximize their progression-free survival and palliate the most common sequelae of their disease: dysphagia, malnutrition, pain, and intraluminal tumor bleeding. This article discusses the available treatment options for palliation of patients with unresectable esophageal cancer.

Palliation of malignant esophageal obstruction and fistulas with self expandable metallic stents

AIM: To evaluate the efficacy of self expandable metallic stents (SEMS) in patients with malignant esophageal obstruction and fistulas.

METHODS: SEMS were implanted in the presence of fluoroscopic guidance in patients suffering from advanced and non-resectable esophageal, cardiac and invasive lung cancer between 2002 and 2009. All procedures were performed under conscious sedation. All patients had esophagus obstruction and/or fistula. In all patients who required reintervention, recurrence of dysphagia, hemorrhage, and fistula formation were indications for further endoscopy. Patients’ files were scanned retrospectively and the obtained data were analyzed using SPSS 13.0 for Windows. The χ² test was used for categorical data and was analysis of variance for non-categorical data. Patients’ long-term survival was assessed using the Kaplan-Meier method.

RESULTS: Stents were successfully implanted in 90 patients using fluoroscopic guidance. Reasons for stent implantation in these patients were esophageal stricture (77/90, 85.5%), external pressure (8/90, 8.8%) and tracheo-esophageal fistula (5/90, 5.5%). Dysphagia scores (mean ± SD) were 3.37 ± 0.52 before and 0.90 ± 0.43 after stent implantation (P = 0.002). Intermittent, non-massive hemorrhage due to the erosion caused by the distal end of the stent in the stomach occurred in only one patient who received implementation at cardio-esophageal junction. Mean survival following stenting was 134.14 d (95% confidence interval: 94.06-174.21).

CONCLUSION: SEMS placement is safe and effective in the palliation of dysphagia in selected patients with malignant esophageal strictures.

Survival and complications after insertion of self-expandable metal stents for malignant oesophageal stenosis

OBJECTIVE

To report on survival and complications after insertion of self-expandable stents in patients with malignant oesophageal stenosis.

MATERIAL AND METHODS

Data were gathered retrospectively from the medical records of 92 consecutive patients in the period 1994-2003. The study comprised 68 men and 24 women (median age 72 years, range 46-93 years) with stenosis from cancer of the oesophagus (n=61), the gastric cardia (n=26) and the lung (n=5), located mainly above (n=4) or below (n=62) the carina, or at the gastro-oesophageal junction (n=26). One uncovered stent and six different covered stents were used.

RESULTS

Median and mean survival times after stenting (n=92) were 83 (range 4-1102) and 125 days, respectively. Thirty-day mortality was 19% (n=17), and 7% (n=6) survived more than one year. Survival was neither significantly influenced by division of the patients into diagnostic subgroups nor by comparison of the three most frequently used stents. One, two, three and four stents were received by 76, 11, 4 and 1 patient(s), respectively. There was no stent-related mortality, and complications were bleeding 1 (1%), stent migration 7 (8%), recurrent stenosis 8 (9%) from both tumour overgrowth (n=8) and tumour ingrowth (n=2) when using uncovered stents. Thirteen (14%) patients were re-stented because of recurrent stenosis (n=8) including fistula formation to the left main bronchus (n=2) and stent migration (n=5).

CONCLUSIONS

Use of self-expandable stents in patients with inoperable malignant oesophageal stenosis carried few complications and resulted in relatively long survival in comparison with similar studies.

Fluoroscopically guided insertion of self-expandable metal esophageal stents for palliative treatment of patients with malignant stenosis of esophagus and cardia: comparison of uncovered and covered stent types

The aim of this retrospective study was to present and compare the results of using two different types of esophageal self-expanding stents (uncovered and covered) for palliative treatment of patients with inoperable malignant stenosis of the esophagus and cardia. Over a period of 8 years, 152 patients underwent fluoroscopically guided insertion of metal esophageal stents. We inserted uncovered esophageal nitinol Strecker stents in 54 patients (group I) and covered esophageal Ultraflex stents in the remaining 98 patients (group II). The stent insertion procedure was successively performed in all patients. Closure of esophageal fistula by covered stents was achieved in 8/8 patients. Mean dysphagia score was significantly decreased in both patient groups at 4 weeks follow-up: from 2.73 before stent insertion to 0.15 in group I, and from 2.67 to 0.05 in group II (on 0-4 scale). Eighty-eight per cent of patients with covered stents and 54% with uncovered type were free of symptoms during follow-up. Complications occurring during follow-up and their comparative frequency in the two groups of patients were as follows (group I: group II%): stent migration (0:10%); tumor or granulation tissue ingrowth (100:53%); overgrowth at the ends of stents (17:30%); restenosis causing recurrent dysphagia (37:8%); and appearance of esophageal fistulas (8:6%). In conclusion, fluoroscopically guided insertion of self-expandable esophageal stents is a safe and comfortable method of palliation for patients suffering with malignant dysphagia. In selection of a stent, covered types should be given priority for prevention of restenosis.