Periodic endoscopic observation of postoperative esophageal stricture due to excessive tissue hyperproliferation after stent placement

TGF-β1 inhibitor P144 protects against benign restenosis after esophageal stenting through TGF-β1/Smads signaling pathway inhibition

BACKGROUND AND STUDY AIMS

Esophageal restenosis is a serious complication after esophageal stent placement, which influences the clinical prognosis of stent implantation and the patient's quality of life. TGF-β1/Smads signaling pathway plays an important role in the development of the eosinophilic esophagitis and scar repair after skin trauma. However, the role of TGF-β1/Smads in the development of esophageal restenosis after esophageal stent placement remains unknown. Our study aimed to investigate whether TGF-β1/Smads plays an important role in the development of esophageal restenosis after esophageal stent, and whether the exogenous TGF-β1 inhibitor supplement could ameliorate the esophageal restenosis after esophageal stent.

MATERIAL AND METHODS

We established the model of esophageal restenosis after esophageal stenting in rats, and determined the expression levels of TGF-β1/Smads signaling pathway and the relevant markers of fibroblast activation by immunochemistry (IHC), Western Blot and real time qPCR. Those all the indicators were also determined in esophageal fibroblast when exposed to rhTGF-β1 with or without TGF-β1 inhibitor P144.

RESULTS

The serum level of IL-1β and TNFα were significantly increased in stent implantation group compared to blank control group, and obviously ameliorated when treated with P144. The TGF-β1/Smads signaling pathway and the relevant markers of fibroblast activation were significantly increased in stent implantation group compared to blank control group, and obviously ameliorated when treated with P144. Those all the indicators were significantly increased when exposed to rhTGF-β1, and obviously decreased when treated with P144.

CONCLUSIONS

TGF-β1 Inhibitor P144 could protect against benign restenosis after esophageal stenting by down-regulating the expression levels of relevant markers of fibroblast activation through TGF-β1/Smads signaling pathway inhibition, and may be used as a novel therapy for benign restenosis after esophageal stenting.

Recurrent Benign Urethral Strictures Treated with Covered Retrievable Self-Expandable Metallic Stents: Long-Term Outcomes over an 18-Year Period

PURPOSE

To assess the long-term outcomes of covered retrievable self-expandable metallic stent (REMS) placement for recurrent benign urethral stricture and to compare the outcomes associated with 3 types of covered REMSs.

MATERIALS AND METHODS

A retrospective study was performed in 54 male patients in whom 114 REMSs were placed between November 1998 and December 2016. These included 26 polyurethane-covered REMSs in 13 patients (group A), 47 internally polytetrafluoroethylene (PTFE)-covered REMSs in 21 patients (group B), and 41 externally PTFE-covered REMSs in 20 patients (group C). The outcomes were analyzed and compared between the groups.

RESULTS

Overall clinical success was achieved in 14 of the 54 patients (24%) at 5-year follow-up (group A, 12%; group B, 19%; group C, 40%). The overall complication rate was 60.5%, and the complication rate was significantly higher in group B than in groups A or C (group A vs B, P = .018; group B vs C, P = .002). The median stent indwelling time and maintained patency period were 3.1 months and 108 months, respectively. In multivariate analysis, stent indwelling time was the only significant factor associated with maintained patency.

CONCLUSIONS

The long-term outcome of covered REMSs has not achieved the desired success rate for the standard treatment of recurrent urethral stricture. However, externally PTFE-covered REMSs showed a better long-term outcome than the other studied types.

Plastic tube-assisted gastroscopic removal of embedded esophageal metal stents: A case report

A patient with stent embedding after placement of an esophageal stent for an esophagobronchial fistula was treated with an ST-E plastic tube inserted into the esophagus to the upper end of the stent using gastroscopy. The gastroscope was guided into the esophagus through the ST-E tube, and an alligator forceps was inserted into the esophagus through the ST-E tube alongside the gastroscope. Under gastroscopy, the stent wire was grasped with the forceps and pulled into the ST-E tube. When resistance was met during withdrawal, the gastroscope was guided further to the esophageal section where the stent was embedded. Biopsy forceps were guided through a biopsy hole in the gastroscope to the embedded stent to remove silicone membranes and connection threads linking the Z-shaped wire mesh. While the lower section of the Z-shaped stent was fixed by the biopsy forceps, the alligator forceps were used to pull the upper section of the metal wire until the Z-shaped metal loops elongated. The wire mesh of the stent was then removed in stages through the ST-E tube. Care was taken to avoid bleeding and perforation. Under the assistance of an ST-E plastic tube, an embedded esophageal metal stent was successfully removed with no bleeding or perforation. The patient experienced an uneventful recovery after surgery. Plastic tube-assisted gastroscopic removal of embedded metal stents can be minimally invasive, safe, and effective.

Endoscopic removal of self-expandable metal stents from the esophagus (with video)

BACKGROUND

Self-expandable metals stents (SEMSs) have increasingly been used as a temporary device to bridge chemoradiotherapy in patients with malignant esophageal disease or in patients with benign esophageal defects or stenosis.

OBJECTIVE

To evaluate the outcome of removal of SEMSs in a large cohort of patients with benign and malignant esophageal disease.

DESIGN

Observational study with standardized treatment and follow-up.

SETTING

Single university center.

PATIENTS

Between 2001 and 2010, 95 consecutive patients referred for endoscopic SEMS extraction were included.

INTERVENTIONS

Endoscopic stent removal.

MAIN OUTCOME MEASUREMENTS

Technical and functional outcome and complications.

RESULTS

A total of 124 stent extractions were undertaken in 95 patients; both partially covered (68%) and fully covered (32%) SEMSs were removed. Three patients had 2 overlapping SEMSs in place. Successful primary removal was achieved in 89%; the secondary removal rate was 96%. Uncomplicated primary removal rate was significantly higher for fully covered versus partially covered stents (P = .035) and for single versus overlapping stents (P = .033). Patients with a complicated stent removal had the stent in place significantly longer compared with patients with an uncomplicated primary stent removal (126 days vs 28 days; P = .01). Surgical removal was required in 3 patients (2.4%). Six moderate and severe complications (5%) related to the endoscopic extraction occurred.

LIMITATIONS

Retrospective, nonrandomized study design.

CONCLUSIONS

Primary endoscopic removal of an SEMS is feasible in the majority of patients with benign and malignant esophageal disease. A longer time that a stent is in place and the use of partially covered SEMSs both impede removal. Moreover, overlapping SEMSs should be avoided for temporary use because stent disintegration and subsequent complications may occur.

Temporary metallic stent placement in the treatment of refractory benign esophageal strictures: results and factors associated with outcome in 55 patients

The purpose of this study was to evaluate the effectiveness of temporary metallic stenting in 55 patients with treatment-resistant benign esophageal strictures and to identify factors associated with clinical outcomes. Under fluoroscopic guidance, covered retrievable stents were placed in 55 patients with benign esophageal strictures and were removed with retrieval hook 1 week to 6 months after placement. Stent placement was successful in all patients, and the mean dysphagia score was reduced from 2.8 to 1.3 (p<0.001). The most common complications were tissue hyperproliferation (31%), severe pain (24%), and stent migration (25%). During follow-up (mean: 38 months), recurrence of the stricture necessitating balloon dilation was seen in 38 (69%) of 55 patients. Maintained patency rates after temporary stenting at 1, 3, and 6 months and 1, 2, and 4 years were 58%, 43%, 38%, 33%, 26%, and 21%, respectively. In multivariate analysis, length (p=0.003) of the stricture was the only significant factor associated with maintained patency after temporary stenting. In conclusion, temporary metallic stenting for refractory benign esophageal strictures may be effective during the period of stent placement, but is disadvantaged by the high recurrence rates after stent removal, particularly in patients with a long length of stricture (>7 cm).

Treatment of large, oesophageal perforations and mediastinitis with a covered, removable metallic endoprosthesis and mediastinal drainage

A bevont fémstentek benignus nyelőcső-stenosisban és -perforatioban való alkalmazása, a stent okozta szöveti reakció és a stent eltávolítás nehézségei miatt, kezdeti stádiumban van. A szerzők nyelőcső-perforatioban egy újabb, bevont fémstent terápiás hatását és eltávolítására kidolgozott módszerük hatékonyságát vizsgálták 3 beteg kapcsán. Három beteg közül kettőnél corrosiv nyelőcsőstenosis tágításakor perforatio lépett fel. Emiatt az egyiknél mediastinalis drenázs és jejunostomia, másiknál primér sutura és drenázs történt. Ezt követően mindkettőben septicus állapot, mediastinitis alakult ki. Ennek hátterében egyiknél perforatio mellett mediastinalis drén okozta nyelőcsőfistula, a másiknál nyelőcsővarrat-elégtelenség állt. A nyelőcső falának defektusát 8, illetve 10 nappal a perforatio, műtét után bevont fémstenttel hidalták át. A harmadik beteg inoperabilis nyelőcsőtumora okozta stenosisának tágítása, stentelési kísérlete során nyelőcsőruptura lépett fel, melyet két órán belül bevont fémstenttel zárta. Parenteralis táplálást, széles spectrumú antibioticus kezelést alkalmaztak. Három nap múlva ellenőrizve mindhárom stent tölcsére tökéletesen zárt. Nasogastricus szonda-, majd per os táplálásra tértek át. Átmeneti mediastinalis drenázs után a stenteket 35, illetve 74 nappal a stentimplantatio után endoscoposan távolították el. Ez idő alatt a nyelőcsőfal-defectusok, a perforatios nyílások záródtak. A stent felső szélénél jelentkező stenosist mindkét betegnél tágították. A 3. betegnél a tumoros nyelőcsőruptura korai, végleges stentelése után szövődmény nem lépett fel. Itt drenázsra nem volt szükség. Nagy nyelőcső-perforatio – kísérő septicus állapot, mediastinitis esetén is – sikeresen gyógyítható bevont, eltávolítható fémstenttel és megfelelő mediastinalis drenázzsal.

Removal of a Covered Esophageal Metallic Stent 8 Years after Placement

A covered expandable esophageal metallic stent was placed to treat a corrosive esophageal stricture that was refractory to repeated balloon dilations. The stent was removed 8 years after placement due to severe dysphagia. The stented esophageal area has since maintained long-term patency for 2 years. These results suggest the feasibility of removal of a metallic stent after long-term stent placement.

The role of capsule endoscopy in the work-up of obscure gastrointestinal bleeding

OBJECTIVE

To evaluate the role of capsule endoscopy in the detection of causes of obscure gastrointestinal bleeding.

METHODS

Fifteen patients, nine males and six females, mean age 46 years (range 20-75 years), were investigated. All patients had undergone upper and lower gastrointestinal endoscopy with no evidence of causes of bleeding. Indication for capsule endoscopy was overt bleeding in 10 patients (eight with melaena and two with rectal bleeding) and anaemia in five patients.

RESULTS

Diagnosis was made in four out of 10 patients with overt bleeding (40%) and in four out of five (80%) in the group with anaemia. The overall detection rate was 53%. Of the eight patients with melaena, two had angiodysplasia, one showed a diffuse inflammation of the jejunum and ileum probably related to associated portal hypertension, and five had a normal examination. Of the two patients with rectal bleeding, one had a polyp in the terminal ileum and the other a normal examination. Of the five patients with anaemia, one had jejunal carcinoma, three had Crohn's disease and one had a normal endoscopy.

CONCLUSION

Wireless capsule endoscopy is safe, effective, non-invasive, and provides definitive diagnosis in about one-half of patients presenting with obscure gastrointestinal bleeding and previous negative endoscopic examinations.

Stenting in esophageal strictures

The interventional management of esophageal strictures remains, to date, an important clinical challenge. Stenting is probably the best palliation modality in patients with incurable esophagogastric carcinoma. Conversely, the use of esophageal stents is still relatively uncommon for the treatment of refractory benign strictures. In the last few years, several new stents have become available as a result of significant advances that have been made in terms of design and materials. This review focuses on the endoscopic use of esophageal stents in malignant and benign esophageal strictures, revisiting the different types of expandable stents presently available, the techniques, the results, and the complications of stent insertion and giving some practical advices. Future developments in the field of esophageal stenting are also discussed.