Self-expanding metal esophageal stent with anti-reflux mechanism

A phase III, multicenter, prospective, single-blinded, noninferiority, randomized controlled trial on the performance of a novel esophageal stent with an antireflux valve (with video)

BACKGROUND AND AIMS

Self-expanding metal stents (SEMSs) when deployed across the gastroesophageal junction (GEJ) can lead to reflux with risks of aspiration. A SEMS with a tricuspid antireflux valve (SEMS-V) was designed to address this issue. The aim of this study was to evaluate the efficacy and safety of this stent.

METHODS

A phase III, multicenter, prospective, noninferiority, randomized controlled trial was conducted on patients with malignant dysphagia requiring SEMSs to be placed across the GEJ. Patients were randomized to receive SEMSs with no valve (SEMS-NV) or SEMS-V. Postdeployment dysphagia score at 2 weeks and Gastroesophageal Reflux Disease-Health Related Quality of Life (GERD-HRQL) questionnaire score at 4 weeks were measured. Patients were followed for 24 weeks.

RESULTS

Sixty patients were randomized (SEMS-NV: 30 patients, mean age 67 ± 13 years; SEMS-V: 30 patients, mean age 65 ± 12 years). Baseline dysphagia scores (SEMS-NV, 2.5 ± .8; SEMS-V, 2.5 ± .8) and GERD-HRQL scores (SEMS-NV, 11.1 ± 8.2; SEMS-V, 12.8 ± 8.3) were similar. All SEMSs were successfully deployed. A similar proportion of patients in both arms improved from advanced dysphagia to moderate to no dysphagia (SEMS-NV, 71%; SEMS-V, 74%; 95% confidence interval, 1.93 [-17.8 to 21.7]). The dysphagia scores were also similar across all follow-up time points. Mean GERD-HRQL scores improved by 7.4 ± 10.2 points in the SEMS-V arm and by 5.2 ± 8.3 in the SEMS-NV group (P = .96). The GERD-HRQL scores were similar across all follow-up time points. Aspiration pneumonia occurred in 3.3% in the SEMS-NV arm and 6.9% in the SEMS-V arm (P = .61). Migration rates were similar (SEMS-NV, 33%; SEMS-V, 48%; P = .29). Two SEMS-V spontaneously fractured. There was no perforation, food impaction, or stent-related death in either group.

CONCLUSIONS

The SEMS-V was equally effective in relieving dysphagia as compared with the SEMS-NV. Presence of the valve did not increase the risks of adverse events. GERD symptom scores were similar between the 2 stents, implying either that the valve was not effective or that all patients on proton pump inhibitors could have masked the symptoms of GERD. Studies with objective evaluations such as fluoroscopy and/or pH/impedance are recommended. (Clinical trial registration number: NCT02159898.).

Oesophageal stenting: Status quo and future challenges

Oesophageal stents are widely used for palliating dysphagia from malignant obstruction. They are also used with increasing frequency in the treatment of oesophageal perforation, as well as benign strictures from a variety of causes. Improved oncological treatments have led to prolonged survival of patients treated with palliative intent; as a consequence, stents need to function and last longer in order to avoid repeat procedures. There is also increasing need for meticulous procedure planning, careful selection of the device most appropriate for the individual patient and planned follow-up. Furthermore, as more patients are cured, there will be more issues with resultant long-term side-effects, such as recalcitrant strictures due to radiotherapy or anastomotic scarring, which will have to be addressed. Stent design needs to keep up with the progress of cancer treatment, in order to offer patients the best possible long-term result. This review article attempts to illustrate the changing realities in oesophageal stenting, differences in current stent designs and behaviour, as well as the pressing need to refine and modify devices in order to meet the new challenges.

Evaluation of valve function in antireflux biliary metal stents

Background

To overcome duodenobiliary reflux induced by biliary stents, antireflux valve (ARV) biliary stents have been developed and showed improvement in stent patency. However, negative study results have also been reported because stent patency may be decreased by the malfunction of ARV itself. Given such mixed results, the true efficacy of ARV remains unknown and the mechanism of its dysfunction needs to be clearly elucidated. The aim of this study was to investigate the exact mechanism of ARV dysfunction using in vitro phantom models.

Methods

Two experimental models were designed to evaluate two important environmental factors suspected to cause ARV malfunction, i.e. bile flow and pH. Three types of ARV metal stents from different companies were used for the experiments: a funnel type ARV, a windsock type ARV, and a wine glass-shaped ARV. Ten stents of each type were tested (five stents in the bile flow phantom model, and another five stents in the duodenal pH environmental model). To determine ARV malfunction, ARV-induced flow resistance was measured using a custom-made testing device. All stents from the two models were removed every 2 weeks for 12 weeks after stent insertion and were evaluated on morphological and functional changes of the ARV.

Results

Only ARV of wine glass-shaped ARV was morphologically changed due to silicone bond detachment in the bile flow model. All types of ARV were morphologically changed in the pH model. The morphological changes of ARV influenced the flow resistance. The antegrade pressure gradients were increased over time in the pH model (p < 0.05).

Conclusions

Morphological change of the ARVs may induce dysfunction of ARV metal stents, which is mainly due to duodenal pH environment. In the future, development of new ARV that is not affected by duodenal environmental factors can be expected to improve stent patency.

Electronic supplementary material

The online version of this article (10.1186/s12876-018-0878-8) contains supplementary material, which is available to authorized users.

Self-Expandable Metallic Stent Placement for the Palliation of Esophageal Cancer

Esophageal stents have been used to palliate patients with dysphagia caused by esophageal cancer. Early rigid plastic prostheses have been associated with a high risk of complications. However, with the development of self-expanding stents, it has developed into a widely accepted method for treating malignant esophageal strictures and esophagorespiratory fistulas (ERFs). The present review covers various aspects of self-expanding metallic stent placement for palliating esophageal cancer, including its types, placement procedures, indications, contraindications, complications, and some of innovations that will become available in the future.

Optimal radial force and size for palliation in gastroesophageal adenocarcinoma: a comparative analysis of current stent technology

BACKGROUND

The optimal use of esophageal stents for malignant and benign esophageal strictures continues to be plagued with variability in pain tolerance, migration rates, and reflux-related symptoms. The aim of this study was to evaluate the differences in radial force exhibited by a variety of esophageal stents with respect to the patient's esophageal stricture.

METHODS

Radial force testing was performed on eight stents manufactured by four different companies using a hydraulic press and a 5000 N force gage. Radial force was measured using three different tests: transverse compression, circumferential compression, and a three-point bending test. Esophageal stricture composition and diameters were measured to assess maximum diameter, length, and proximal esophageal diameter among 15 patients prior to stenting.

RESULTS

There was a statistically significant difference in mean radial force for transverse compression tests at the middle (range 4.25-0.66 newtons/millimeter N/mm) and at the flange (range 3.32-0.48 N/mm). There were also statistical differences in mean radial force for circumferential test (ranged from 1.19 to 10.50 N/mm, p < 0.001) and the three-point bending test (range 0.08-0.28 N/mm, p < 0.001). In an evaluation of esophageal stricture diameters and lengths, the smallest median diameter of the stricture was 10 mm (range 5-16 mm) and the median proximal diameter normal esophagus was 25 mm (range 22-33 mm), which is currently outside of the range of stent diameters.

CONCLUSIONS

Tested stents demonstrated significant differences in radial force, which provides further clarification of stent pain and intolerance in certain patients, with either benign or malignant disease. Similarly, current stent diameters do not successfully exclude the proximal esophagus, which can lead to obstructive-type symptoms. Awareness of radial force, esophageal stricture composition, and proximal esophageal diameter must be known and understood for optimal stent tolerance.

History of the Use of Esophageal Stent in Management of Dysphagia and Its Improvement Over the Years

The art and science of using stents to treat dysphagia and seal fistula, leaks and perforations has been evolving. Lessons learnt from the deficiencies of previous models led to several improvements making stent deployment easier, and with some designs, it was also possible to remove the stents if needed. With these improvements, besides malignant dysphagia, newer indications for using stents emerged. Unfortunately, despite several decades of evolution, as yet, there is no perfect stent that "fits all." This article is an overview of how this evolution process happened and where we are currently with using stents to manage patients with dysphagia and with other esophageal disorders.

Antireflux versus conventional self-expanding metallic Stents (SEMS) for distal esophageal cancer: results of a multicenter randomized trial

INTRODUCTION

Self-expanding metal stents (SEMS) are commonly used in the palliation of dysphagia in patients with inoperable esophageal carcinoma. However, they predispose to gastroesophageal reflux when deployed across the gastroesophageal junction. The aims of this study were to: 1) assess the influence of the antireflux valve on trans-prosthetic reflux (primary outcome); and 2) compare the results of SEMS with and without antireflux valve in terms of reflux symptoms, quality of life (QOL), improvement of dysphagia and adverse events (secondary outcomes).

PATIENTS AND METHODS

Thirty-eight patients were enrolled in nine centers. Carcinomas were locally advanced (47 %) or metastatic. After randomization, patients received either a covered SEMS with antireflux valve (n = 20) or a similar type of SEMS with no antireflux device but assigned to standard proton pump inhibitor therapy and postural advice (n = 18). Trans-prosthetic reflux was assessed at day 2 using a radiological score based on barium esophagography performed after Trendelenburg maneuver and graded from 0 (no reflux) to 12 (maximum). Monthly telephone interviews were conducted for Organisation Mondiale de la Santé (OMS) scoring from 0 (excellent) to 5 (poor), QOL assessment (based on the Reflux-Qual Simplifié scoring system) from 0 (poor) to 100 (excellent), dysphagia scoring from 0 (no dysphagia) to 5 (complete dysphagia) and regurgitation scoring from 0 (no regurgitation) to 16 (maximum).

RESULTS

No difference was noted in terms of age, sex, size of lesion, prosthesis length or need for dilation prior to SEMS placement. No difficulty in placing SEMS nor complications were noted. Radiological scores of reflux were found to be significantly lower in patients with an antireflux stent compared to the conventional stent and associated measures. The regurgitation scores were significantly decreased in patients with antireflux stents during the first 2 months after stent placement and thereafter, they were similar in the two groups. QOL and dysphagia were improved in both groups. Survival rates were comparable in the two groups.

CONCLUSIONS

No difference was observed between the two types of SEMS regarding the palliation of dysphagia and improvement of QOL. However, SEMS with an antireflux valve were more effective in preventing trans-prosthetic gastroesophageal reflux but at the cost of an increased likehood of minor adverse events (migrations and/or obstruction of the SEMS).

Oesophageal stenting for benign and malignant strictures: a systematic approach

Oesophageal stenting is now standard treatment for managing both benign and malignant stenosis of the oesophagus. There is a wide choice in oesophageal stents currently available on the market, with variations in the stent material, size and design. Most oesophageal stents are made from metal alloy compounds for use in malignant strictures, although there are stents made of durable polymers, and now of biodegradable (BD) material, for use in both benign and malignant strictures. With the development of self-expanding plastic stents, self-expanding metal stents and BD stents, stent placement for oesophageal pathologies can be safe and cost-effective. Oesophageal stenting has several challenges for a therapeutic endoscopist which is determined by the location of stricture or tumour, the anatomy of the stenosis and the nature of stent selected. Strictures that have narrow or tortuous lumens can be particularly difficult to stent as the luminal diameter must allow access of at least a 0.035 inch guide wire. This review covers the indications and outcomes of different stents in clinical situations to help rational decision-making.

Interventions for dysphagia in oesophageal cancer

BACKGROUND

Most patients with oesophageal and gastro-oesophageal carcinoma are diagnosed at an advanced stage and require palliative intervention. Although there are many kinds of interventions, the optimal one for the palliation of dysphagia remains unclear. This review updates the previous version published in 2009.

OBJECTIVES

The aim of this review was to systematically analyse and summarise the efficacy of different interventions used in the palliation of dysphagia in primary oesophageal and gastro-oesophageal carcinoma.

SEARCH METHODS

To find new studies for this updated review, in January 2014 we searched, according to the Cochrane Upper Gastrointestinal and Pancreatic Diseases model, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE, EMBASE and CINAHL; and major conference proceedings (up to January 2014).

SELECTION CRITERIA

Only randomised controlled trials (RCTs) were included in which patients with inoperable or unresectable primary oesophageal cancer underwent palliative treatment. Different interventions like rigid plastic intubation, self-expanding metallic stent (SEMS) insertion, brachytherapy, external beam radiotherapy, chemotherapy, oesophageal bypass surgery, chemical and thermal ablation therapy, either head-to-head or in combination, were included. The primary outcome was dysphagia improvement. Secondary outcomes included recurrent dysphagia, technical success, procedure related mortality, 30-day mortality, adverse effects and quality of life.

DATA COLLECTION AND ANALYSIS

Data collection and analysis were performed in accordance with the methods of the Cochrane Upper Gastrointestinal and Pancreatic Diseases Review Group.

MAIN RESULTS

We included 3684 patients from 53 studies. SEMS insertion was safer and more effective than plastic tube insertion. Thermal and chemical ablative therapy provided comparable dysphagia palliation but had an increased requirement for re-interventions and for adverse effects. Anti-reflux stents provided comparable dysphagia palliation to conventional metal stents. Some anti-reflux stents might have reduced gastro-oesophageal reflux and complications. Newly-designed double-layered nitinol (Niti-S) stents were preferable due to longer survival time and fewer complications compared to simple Niti-S stents. Brachytherapy might be a suitable alternative to SEMS in providing a survival advantage and possibly a better quality of life, and might provide better results when combined with argon plasma coagulation or external beam radiation therapy.

AUTHORS' CONCLUSIONS

Self-expanding metal stent insertion is safe, effective and quicker in palliating dysphagia compared to other modalities. However, high-dose intraluminal brachytherapy is a suitable alternative and might provide additional survival benefit with a better quality of life. Some anti-reflux stents and newly-designed stents lead to longer survival and fewer complications compared to conventional stents. Combinations of brachytherapy with self-expanding metal stent insertion or radiotherapy are preferable due to the reduced requirement for re-interventions. Rigid plastic tube insertion, dilatation alone or in combination with other modalities, and chemotherapy alone are not recommended for palliation of dysphagia due to a high incidence of delayed complications and recurrent dysphagia.

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.

Stents for benign and malignant esophageal strictures

This paper presents commentaries on endotherapy for esophageal perforation/leaks; treatment of esophageal perforation; whether esophageal stents should be used for treating benign esophageal strictures; what determines the optimal stenting period in benign esophageal strictures/leaks; how to choose an esophageal stent; how a new fistula secondary to an esophageal stent should be treated; which strategy should be adopted when a fistula of a cervical anastomosis occurs; intralesional steroids for refractory esophageal strictures; balloon and bougie dilators for esophageal strictures and predictors of response to dilation; whether refractory strictures from different etiologies respond differently to endotherapy; surgical therapy of benign esophageal strictures; and whether stenoses following severe esophageal burns should be treated by esophageal resection or esophageal bypass.

Evidence-based recommendations on upper gastrointestinal tract stenting: a report from the stent study group of the korean society of gastrointestinal endoscopy

Endoscopic stents have evolved dramatically over the past 20 years. With the introduction of uncovered self-expanding metal stents in the early 1990s, they are primarily used to palliate symptoms of malignant obstruction in patients with inoperable gastrointestinal (GI) cancer. At present, stents have emerged as an effective, safe, and less invasive alternative for the treatment of malignant GI obstruction. Clinical decisions about stent placement should be made based on the exact understanding of the patient's condition. These recommendations based on a critical review of the available data and expert consensus are made for the purpose of providing endoscopists with information about stent placement. These can be helpful for management of patients with inoperable cancer or various nonmalignant conditions in the upper GI tract.

The evaluation of esophageal stenting complications in palliative treatment of dysphagia related to esophageal cancer

Background

Esophageal cancer is the seventh-most frequent cause of cancer-related deaths and it is usually diagnosed at an inoperable stage. In palliative treatment, endoscopic and non-endoscopic methods are applied to reduce dysphagia in patients with neoplastic esophageal obstruction. Because of severe complications, non-endoscopic treatment (surgery, radiotherapy, brachytherapy and chemotherapy) is applied rarely. Within the endoscopic methods, only the use of endoprostheses yields long-term effects. The aim of this study was to evaluate the safety and efficacy of implantation of self-expandable esophageal stents in palliative treatment of dysphagia related to esophageal cancer.

Material/Methods

A total number of 46 patients (41 males and 5 females) were qualified to palliative implantation of coated self-expandable stent. The mean age of the patients was 67 years (from 51 to 78 years). In all patients, Evolution-type coated self-expandable stents were used. In all cases, 24 hours after the implantation, radiological examination was performed to assess the stent location.

Results

Severe, possibly life-threatening, complications constituted 28% of all the complications and occurred in 9% of the patients. Less severe complications occurred in 17% of the observed patients and were not life-threatening.

Conclusions

In patients with neoplastic esophageal stenosis, stenting with coated, self-expandable nitinol prostheses is a safe, effective and fast method of palliative dysphagia treatment.

Esophageal stent for cervical esophagus and esophagogastric junction

Tumors in the cervical portion of the esophagus have traditionally been more difficult to manage. The implantation in the cervical esophagus is a technically demanding procedure. The implantation of modified self-expandable metal stents (SEMSs) was very effective perorally under endoscopic and fluoroscopic guidance. Experience with SEMS has revealed an increased risk of migration when either covered stents are used or a stent is implanted across the gastroesophageal junction. The modified, covered, esophageal stents appear to prevent stent migration and improve dysphagia in patients with malignant tumor stenosis at the esophagogastric junction. Besides heartburn, regurgitation is sometimes very distressing to patients and may lead to fatal aspiration due to reflux after stenting in esophagogastric junction. These symptoms can be reduced by the use of valved stent. The long S-shape valve is very effective in preventing acid reflux and valve inversion.

Double layered self-expanding metal stents for malignant esophageal obstruction, especially across the gastroesophageal junction

AIM: To evaluate the clinical outcomes of double-layered self-expanding metal stents (SEMS) for treatment of malignant esophageal obstruction according to whether SEMS crosses the gastroesophageal junction (GEJ).

METHODS: Forty eight patients who underwent the SEMS insertion for malignant esophageal obstruction were enrolled. Patients were classified as GEJ group (SEMS across GEJ, 18 patients) and non-GEJ group (SEMS above GEJ, 30 patients) according to SEMS position. Double layered (outer uncovered and inner covered stent) esophageal stents were placed.

RESULTS: The SEMS insertion and the clinical improvement were achieved in all patients in both groups. Stent malfunction occurred in seven patients in the GEJ group and nine patients in the non-GEJ group. Tumor overgrowth occurred in five and eight patients, respectively, food impaction occurred in one patient in each group, and stent migration occurred in one and no patient, respectively. There were no significant differences between the two groups. Reflux esophagitis occurred more frequently in the GEJ group (eight vs five patients, P = 0.036) and was controlled by proton pump inhibitor. Aspiration pneumonia occurred in zero and five patients, respectively, and tracheoesophageal fistula occurred in zero and two patients, respectively.

CONCLUSION: Double-layered SEMS are a feasible and effective treatment when placed across the GEJ for malignant esophageal obstruction. Double-layered SEMS provide acceptable complications, especially migration, although reflux esophagitis is more common in the GEJ group.

Stent placement for esophageal strictures: an update

The use of stents for esophageal strictures has evolved rapidly over the past 10 years, from rigid plastic tubes to flexible self-expanding metal (SEMS), plastic (SEPS) and biodegradable stents. For the palliative treatment of malignant dysphagia both SEMS and SEPS effectively provide a rapid relief of dysphagia. SEMS are preferred over SEPS, as randomized controlled trials have shown more technical difficulties and late migration with plastic stents. Despite specific characteristics of recently developed stents, recurrent dysphagia due to food impaction, tumoral and nontumoral tissue overgrowth, or stent migration, remain a major challenge. The efficacy of stents with an antireflux valve for patients with distal esophageal cancer varies between different stent designs. Concurrent treatment with chemotherapy and/or radiotherapy seems to be safe and effective. In the future, it can be expected that removable stents will be used as a bridge to surgery to maintain luminal patency during neoadjuvant treatment. For benign strictures, new stent designs, such as fully covered SEMS and biodegradable stents, may potentially reduce complications during stent removal.

Technical feasibility and safety of a new, implantable reflux control system to prevent gastroesophageal reflux in patients with stents placed through the lower esophageal sphincter (with video)

BACKGROUND

When an esophageal stent is placed through the lower esophageal sphincter (LES), gastroesophageal reflux symptoms may persist despite high-dose proton pump inhibitor therapy. A recently developed, short segment, uncovered nitinol stent with a tricuspid-like valve can be placed inside a previously placed esophageal stent.

OBJECTIVE

To evaluate the technical feasibility and safety of a reflux control system (RCS) in distally placed esophageal stents.

DESIGN

A prospective case series.

SETTING

Two tertiary-care referral centers.

PATIENTS

This study involved 10 patients who had an "open" stent placed through the LES and 1 patient with severe bile reflux after esophagojejunostomy.

INTERVENTION

Placement of an RCS with fluoroscopic and (in selected cases) endoscopic guidance, from April to October 2010.

MAIN OUTCOME MEASUREMENTS

Technical success of RCS placement and complications.

RESULTS

Placement of an RCS was successful on the first attempt in all patients; complete expansion to the wall of the host stent was confirmed by fluoroscopy in all cases. In 3 patients, the host stent migrated in <1 month with the RCS still inside. In 8 patients, the RCS was in place for a median of 134 days (range 33-225 days). Three patients died because of malignant disease progression. Eight RCSs were removed endoscopically, together with the host stent without complications. RCS migration did not occur.

LIMITATIONS

Small number of patients, nonrandomized design, lack of pH measurements.

CONCLUSION

Placement of an RCS in a host stent is technically feasible and safe. An RCS can be considered in symptomatic patients with open esophageal stents to prevent gastroesophageal reflux.

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.

Esophageal stenting

Malignant obstruction of the esophagus is a debilitating condition, with dysphagia as its main symptom. Many patients present with advanced disease and palliative treatment is the only possibility. Since their widespread introduction 10 years ago, self-expanding metal stents have become accepted as an extremely effective method of palliating malignant dysphagia. Early reports suggesting very low complications have been superseded by results from randomized trials. It is now evident that the complication rate is significant and the need for reintervention can be as high as 50%. Modifications in stent design should reduce this reintervention rate. There are a large number of stent designs now available and it is essential that the interventional radiologist understand the particular strengths and weaknesses of each design, so that the correct choice of stent can be made for a particular patient. The most recent designs include antireflux stents and removable stents. Both represent significant advances and should reduce stent-related complications.

Expandable stents for benign esophageal disease

Partially covered self-expandable esophageal stents have been associated with unacceptable complications when used for benign esophageal disorders. With the introduction of removable or potentially removable fully covered stents and biodegradable stents, interest in using expandable stents for benign indications has been revived. Although expandable stents can offer a minimally invasive alternative to surgery, they can be associated with serious complications; hence, this approach should be considered in carefully selected patients, preferably on a protocol basis.

WITHDRAWN: Interventions for dysphagia in oesophageal cancer

BACKGROUND

The majority of oesophageal and gastro-oesophageal cancers are diagnosed at an advanced stage and palliative treatment is the realistic management option for most patients. The optimal intervention for the palliation of dysphagia in these patients has not been established.

OBJECTIVES

To systematically analyse and summarise the efficacy of different interventions used in the palliation of dysphagia in primary oesophageal carcinoma.

SEARCH STRATEGY

We undertook a search according to the Cochrane Upper Gastrointestinal and Pancreatic Diseases model using the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE, EMBASE and CINAHL and major conference proceedings up to August 2005. The literature search was re-run in August 2006 and March 2007.

SELECTION CRITERIA

Randomised controlled trials (RCTs) in patients with inoperable or unresectable primary oesophageal cancer who underwent palliative treatment. We included rigid plastic intubation, self-expanding metallic stent (SEMS) insertion, brachytherapy, external beam radiotherapy, chemotherapy, oesophageal bypass surgery, chemical and thermal ablation therapy, either head-to-head or in combination. The primary outcome was dysphagia improvement. Secondary outcomes included recurrent dysphagia, technical success, procedure related mortality, 30-day mortality, adverse effects and quality of life.

DATA COLLECTION AND ANALYSIS

One author assessed the eligibility criteria of each study and extracted data regarding outcomes and factors affecting risk of bias.

MAIN RESULTS

We included 2542 patients from 40 studies. SEMS insertion is safer and more effective than plastic tube insertion. Thermal and chemical ablative therapy provide comparable dysphagia palliation but have an increased requirement for re-interventions and adverse effects. Anti-reflux stents provide comparable dysphagia palliation to conventional metal stents. Some anti-reflux stents might reduce gastro-oesophageal reflux compared to conventional metal stents. Brachytherapy might be a suitable alternative to SEMS in providing a survival advantage and possibly a better quality of life.

AUTHORS' CONCLUSIONS

Self-expanding metal stent insertion is safe, effective and quicker in palliating dysphagia compared to other modalities. However, high-dose intraluminal brachytherapy is a suitable alternative and might provide additional survival benefit with a better quality of life. Self-expanding metal stent insertion and brachytherapy provide comparable palliation to endoscopic ablative therapy but are preferable due to the reduced requirement for re-interventions. Rigid plastic tube insertion, dilatation alone or in combination with other modalities, chemotherapy alone, combination chemoradiotherapy and bypass surgery are not recommended for palliation of dysphagia due to a high incidence of delayed complications and recurrent dysphagia.

Quality of life in patients with esophageal stenting for the palliation of malignant dysphagia

Incidence of esophageal cancer (EC) is rising more rapidly in the Western world than that of any other cancer. Despite advances in therapy, more than 50% of patients have incurable disease at the time of presentation. This precludes curative treatment and makes palliative treatment a more realistic option for most of these patients. Dysphagia is the predominant symptom in more than 70% of patients with EC and although several management options have been developed in recent years to palliate this symptom, the optimum management is not established. Self-expanding metal stents (SEMS) are a well-established palliation modality for dysphagia in such patients. Health-related quality of life (HRQoL) is becoming a major issue in the evaluation of any therapeutic or palliative intervention. To date, only a few published studies can be found on Medline examining HRQoL in patients with advanced EC treated with SEMS implantation. The aim of this study was to review the impact on HRQoL of SEMS implantation as palliative treatment in patients with EC. All Medline articles regarding HRQoL in patients with advanced EC, particularly those related to SEMS, were reviewed. In most studies, relief of dysphagia was the only aspect of HRQoL being measured and SEMS implantation was compared with other palliative treatments such as brachytherapy and laser therapy. SEMS insertion provides a swift palliation of dysphagia compared to brachytherapy and no evidence was found to suggest that stent implantation is different to laser treatment in terms of improving dysphagia, recurrent dysphagia and better HRQoL, although SEMS insertion has a better technical success rate and also reduces the number of repeat interventions.

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.

Long-term clinical outcomes of self-expanding metal stents for treatment of malignant gastroesophageal junction obstructions and prognostic factors for stent patency: effects of anticancer treatments

BACKGROUND

Self-expanding metal stent has emerged as an effective treatment option for malignant gastroesophageal junction obstruction. However, data on the clinicopathologic factors associated with stent patency are still lacking.

AIM

To investigate the long-term clinical outcomes and prognostic factors, including treatment modalities, affecting stent patency in patients with malignant gastroesophageal junction obstruction given self-expanding metal stent insertions.

METHODS

A total 89 patients who underwent self-expanding metal stent insertion for malignant gastroesophageal junction obstruction were enrolled. We analysed technical and clinical success rates, complications, and prognostic factors affecting stent patency.

RESULTS

Self-expanding metal stent insertion was successful in all patients and clinical improvement was achieved in 93.3%. Stent malfunction occurred in 32.9% of patients. The median overall survival time and stent patency time were 143 (95% CI: 99-187) and 190 days (95% CI: 108-272), respectively. In multivariate analysis, radiation therapy after stent placement significantly prolonged stent patency (OR: 0.221; 95% CI: 0.055-0.884; p=0.033). A higher migration rate was observed in those patients given chemotherapy after covered self-expanding metal stent placement (no anticancer treatment: 10.0%, chemotherapy: 42.9%, chemoradiation therapy: 9.1%, p=0.042).

CONCLUSIONS

Self-expanding metal stent is a feasible and effective treatment for malignant gastroesophageal junction obstruction. Radiation therapy after stent placement significantly prolongs overall stent patency and chemotherapy increases the migration rate of covered stents.

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.

A new metal stent with a controlled-release system for palliation of malignant dysphagia: a prospective, multicenter study

BACKGROUND

Self-expanding metal stents are frequently used for the palliation of malignant dysphagia. Recently, a new stent design, the Evolution stent (Cook Medical, Limerick, Ireland), was developed. The stent has an internal and external silicone coating to resist tissue ingrowth and uncoated dual flanges on both ends to prevent migration. Its controlled-release system may allow full control and precise positioning of the stent.

OBJECTIVE

To determine the safety and clinical effectiveness of the Evolution stent for the palliation of dysphagia in patients with malignant strictures located in the esophagus (n = 33 [75%]) or gastric cardia (n = 11 [25%]).

METHODS

All patients who underwent placement of an esophageal Evolution stent from February to December 2008 received follow-up telephone calls 14 days after treatment and thereafter monthly until death. Data on technical and clinical outcome, complications, and recurrent dysphagia were collected.

RESULTS

A total of 44 patients (32 [73%] men, median age 74 years [range 48-91 years]) were treated with the Evolution stent. The median tumor length was 6 cm (range 1-11 cm). Stent placement was technically successful in 41 patients. Dysphagia improved from a median of 3 (ability to swallow liquids only) to 1 (ability to eat some solid foods) 4 weeks after stent placement. Major complications occurred in 4 (9%) patients, ie, pneumonia (3 patients) and hemorrhage (1 patient). Two (5%) patients died of pneumonia. Minor complications included gastroesophageal reflux and mild retrosternal pain in 11 (25%) and 4 (9%) patients, respectively. Recurrent dysphagia developed in 11 (25%) patients as a result of tissue ingrowth or overgrowth (6 patients; 14%), food impaction (3 patients; 7%), or stent migration (2 patients; 5%).

CONCLUSIONS

The Evolution stent is safe and effective for the palliation of dysphagia from esophageal and gastric cardia cancer. Randomized trials are needed to compare this device with other stent designs.

Clinical outcomes of using a conservative approach of late esophageal stent placement in palliation of malignant dysphagia

BACKGROUND

Esophageal stents have been used as first-line treatment for palliation of malignant dysphagia, but this is associated with significant complications. The present study evaluated clinical outcomes and survival in patients with malignant dysphagia with esophageal stent placement who did not respond to prior chemoradiation or endoscopic modalities.

PATIENTS AND METHODS

Patients with esophageal cancer, who had esophageal stents, were retrospectively reviewed from the electronic medical records. The patient demographics, type of stent placed, dysphagia scores, stent-related complications, and survival were recorded.

RESULTS

Thirty-five patients with esophageal cancer received a total of 41 stents. There were 25 males and 10 females with mean age of 69.8 years. Twenty-two patients had esophageal adenocarcinoma, ten patients had squamous cell carcinoma, and three had poorly differentiated tumor. Esophageal malignancy was early stage (I, II) in 10 patients and advanced (III, IV) in 24 patients. Three patients had upper esophageal involvement, eight patients had mid-esophageal involvement; distal esophageal malignancy was present in 24 patients with 10 patients having gastroesophageal junction involvement. Six patients presented with tracheoesophageal fistula. Nine patients had prior esophagectomy. Thirty-three patients had chemoradiation, and 32 patients had other endoscopic therapies previously. Twelve of the 35 (33%) patients developed stent-related complications; nine patients had dysphagia due to various causes; one patient each developed aspiration, intractable hiccups, and intractable vomiting after stent placement, respectively. Nine patients underwent a repeat esophagogastroduodenoscopy. Development of stent-related complications was not significantly associated with poor survival.

CONCLUSIONS

The clinical outcomes for patients with esophageal stent placement for malignant dysphagia after chemoradiation and other endoscopic treatments is not worse than that reported in patients where esophageal stent placement was used as first-line treatment.

Role of esophageal stents in benign and malignant diseases

These recommendations provide an evidence-based approach to the role of esophageal stents in the management of benign and malignant diseases. These guidelines have been developed under the auspices of the American College of Gastroenterology and its Practice Parameters Committee and approved by the Board of Trustees. The following guidelines are based on a critical review of the available scientific literature on the topic identified in Medline and PubMed (January 1992-December 2008) using search terms that included stents, self-expandable metal stents, self-expandable plastic stents, esophageal cancer, esophageal adenocarcinoma, esophageal squamous cell carcinoma, esophageal stricture, perforations, anastomotic leaks, tracheoesophageal fistula, and achalasia. These guidelines are intended for use by health-care providers and apply to adult, but not pediatric, patients. As with other practice guidelines, these guidelines are not intended to replace clinical judgment but rather to provide general guidelines applicable to the majority of patients. Clinicians need to integrate recommendations with their own clinical judgment, and with individual patient circumstances, values, and preferences. They are intended to be flexible, in contrast to standards of care, which are inflexible policies designed to be followed in every case. Specific recommendations are based on relevant published information. The quality of evidence and strength of recommendations have been assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system, which is a system that has been adopted by multiple national and international societies. The GRADE system is based on a sequential assessment of quality of evidence, followed by assessment of the balance between benefits vs. downsides (harms, burden, and costs) and subsequent judgment regarding the strength of recommendation.

Recent advances in the use of stents for esophageal disease

The use of self-expanding metal esophageal stents has evolved dramatically over the last 20 years. Stents themselves have morphed from simple open-mesh wire devices to a variety of partially and fully covered metal and plastic protheses designed to resist in-growth and migration. Indications include grown considerably from simply palliating malignant dysphagia to the treatment of benign conditions such as refractory strictures, perforations, and fistulas, bridging tumors through neoadjuvant therapy and even serving as support for mucosal healing after ablative therapies. This article describes the current experience with esophageal stenting for malignant and benign conditions and examines new innovations in stent design and applications.

Interventions for dysphagia in oesophageal cancer

BACKGROUND

The majority of oesophageal and gastro-oesophageal cancers are diagnosed at an advanced stage and palliative treatment is the realistic management option for most patients. The optimal intervention for the palliation of dysphagia in these patients has not been established.

OBJECTIVES

To systematically analyse and summarise the efficacy of different interventions used in the palliation of dysphagia in primary oesophageal carcinoma.

SEARCH STRATEGY

We undertook a search according to the Cochrane Upper Gastrointestinal and Pancreatic Diseases model using the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE, EMBASE and CINAHL and major conference proceedings up to August 2005. The literature search was re-run in August 2006 and March 2007.

SELECTION CRITERIA

Randomised controlled trials (RCTs) in patients with inoperable or unresectable primary oesophageal cancer who underwent palliative treatment. We included rigid plastic intubation, self-expanding metallic stent (SEMS) insertion, brachytherapy, external beam radiotherapy, chemotherapy, oesophageal bypass surgery, chemical and thermal ablation therapy, either head-to-head or in combination. The primary outcome was dysphagia improvement. Secondary outcomes included recurrent dysphagia, technical success, procedure related mortality, 30-day mortality, adverse effects and quality of life.

DATA COLLECTION AND ANALYSIS

One author assessed the eligibility criteria of each study and extracted data regarding outcomes and factors affecting risk of bias.

MAIN RESULTS

We included 2542 patients from 40 studies. SEMS insertion is safer and more effective than plastic tube insertion. Thermal and chemical ablative therapy provide comparable dysphagia palliation but have an increased requirement for re-interventions and adverse effects. Anti-reflux stents provide comparable dysphagia palliation to conventional metal stents. Some anti-reflux stents might reduce gastro-oesophageal reflux compared to conventional metal stents. Brachytherapy might be a suitable alternative to SEMS in providing a survival advantage and possibly a better quality of life.

AUTHORS' CONCLUSIONS

Self-expanding metal stent insertion is safe, effective and quicker in palliating dysphagia compared to other modalities. However, high-dose intraluminal brachytherapy is a suitable alternative and might provide additional survival benefit with a better quality of life. Self-expanding metal stent insertion and brachytherapy provide comparable palliation to endoscopic ablative therapy but are preferable due to the reduced requirement for re-interventions. Rigid plastic tube insertion, dilatation alone or in combination with other modalities, chemotherapy alone, combination chemoradiotherapy and bypass surgery are not recommended for palliation of dysphagia due to a high incidence of delayed complications and recurrent dysphagia.

Application progress of stent placement in esophageal malignant and benign stenosis

Stent placement is widely used for palliation of dysphagia caused by advanced esophageal carcinoma. As the development of technology, many new stents are being used for clinical therapy. Some stents are added with anti-reflux valve or retrievable device, some are loaded with ¹²⁵I; the biodegradable stent are even invented. Improvement of sents can decrease many complications while elevate survival rates. Several nonsurgical palliative modalities including endoluminal laser therapy, photodynamic therapy, electrocoagulation and brachytherapy are available to recanalize malignant stenosis, but the fastest palliative method is stent placement. Reports about treating benign esophageal stricture with stents are increasing, and temporary and biodegradable stents have a better effect.

[Pathological characteristics of esophago-respiratory fistulas of esophageal tumor origin]

Esophago-respiratory fistulas, evolving as a result of esophageal tumors, are serious and lethal complications on account of the constant respiratory contamination and the inability to swallow. They can develop either as the complication of the end stage disease or sometimes even in the first stage of the malignancy. The objective was to reveal the characteristics of the disease. In a prospective single-center study in the period between 1984 and 2004, 243 fistulas were diagnosed. Their data were analyzed using multivariate analysis. The mean age of patients with fistula was 56.9 years, the male-to-female ratio was 4.3:1. The average time of the complaints was 5.2 months, while the time of manifestation of the fistula was 7.5 months. Dysphagia was diagnosed in 97.5% of the patients, fever in 36.9%, and cachexia in 59.5%, respectively. The average loss of weight was 10.4 kg and the average size of the tumor was 7.7 cm. Endoscopic intubation was performed in 176 cases. The average survival was 3.4 months. Patients with fistula were divided into two groups, where the characteristics of the disease were significantly different. Only in 66.3% was the fistula a late complication. In the other 33.7% of the cases the fistula was diagnosed in younger patients at the early stage of the disease, with a more aggressive, less differentiated histology. In these patients the weight loss, the grade of dysphagia and the size of the tumor were smaller, the possibilities of treatment were fewer, and survival were shorter.

Randomised comparison of the FerX Ella antireflux stent and the ultraflex stent: proton pump inhibitor combination for prevention of post-stent reflux in patients with esophageal carcinoma involving the esophago-gastric junction

BACKGROUND AND AIM

Metal stents placed across the gastroesophageal junction in patients with malignant dysphagia frequently present with reflux symptoms. We compared an antireflux stent with a standard open stent used in combination with proton pump inhibitor medication.

METHODS

Forty-nine patients with dysphagia due to inoperable carcinoma in the lower third of the esophagus were randomly selected to receive either a antireflux valve stent (FerX-Ella) (n = 22) or a covered standard open stent (Ultraflex), which was combined with proton pump inhibitors such as omeprazole (n = 26). The technical success, the presence of reflux, and complications were recorded.

RESULTS

Reflux was seen in 3/22 patients (13.6%) in the FerX-Ella group and in 2/26 patients (7.7%) in the Ultraflex and proton pump inhibitor combination group (P-value not significant). In both groups, a significant improvement in the dysphagia score was seen and no statistically significant difference was detected between the two groups (P = 0.84). The FerX-Ella stents migrated more frequently (32%) than the Ultraflex stents (23%). This also necessitated surgical intervention more frequently in the FerX-Ella group (2/22, 9.1%) compared to the Ultraflex group (1/26, 3.8%).

CONCLUSION

The antireflux stent had no demonstrable advantages compared to the combination of standard open stent and proton pump inhibitor medication.

Stents in the GI tract

The application of stents in the GI tract has expanded tremendously. Stent placement is the most frequently used treatment modality for palliating dysphagia from esophageal or gastric cardia cancer. Newly designed esophageal stents, including the Polyflex stent and the Niti-S double stent, have been introduced to reduce recurrent dysphagia owing to migration or nontumoral or tumor overgrowth. Stents are also the treatment of choice for esophagorespiratory fistulas, for proximal malignant lesions near the upper esophageal sphincter, for recurrent carcinoma after esophagectomy or gastrectomy and for sealing traumatic or iatrogenic nonmalignant ruptures, such as Boerhaave's syndrome and leakages following surgery. Stents in the latter patient group should be removed within 4-8 weeks after placement to prevent the formation of granulation tissue or hyperplasia at the stent ends. For gastric outlet obstruction, many case series have been published. Only two, small, randomized controlled trials have compared stent placement with gastrojejunostomy to date, and a large, randomized trial is currently being conducted in The Netherlands. Obstructive jaundice caused by a malignancy in the common bile duct can be treated effectively with plastic or metal stent placement. However, a prognostic score needs to be developed that guides a treatment decision towards using either of these stents. Finally, colonic stents are applied successfully for acute malignant obstruction as a 'bridge to surgery' in patients with tumors that are deemed to be resectable, or as a palliative treatment for patients with locally advanced or metastatic disease.

The current management of esophageal cancer

The divergence in epidemiology between the East and West has made interpretation of data in the literature more difficult and has affected the choice of the most appropriate surgical technique and treatment strategies. The management of esophageal cancer certainly has evolved, and many more options are available. Stage-directed strategies and individualization of treatment are important considerations. Surgeons play a central role in directing management of this disease by advising how best to integrate surgical therapy with nonoperative programs. Surgeons should aim at improving their results further, so that the best results of surgery are compared with seemingly "safer" nonsurgical therapies. Low death rates have been achieved in specialized centers, but there still is much room for improvement in morbidity rates. Even with the best surgical resection and chemoradiation therapy, distant failure remains a barrier to improved survival rates. Therapeutic improvements will require more effective systemic drugs and a better ability to predict responders with precision. Management strategies will evolve further, with improvements in molecular techniques, imaging methods, and introduction of more novel tumoricidal agents. The challenge for the future is to test strategies critically in a scientific, unbiased manner and to explore other innovative treatments.

Endoscopic stenting of esophageal cancer: the clinical impact

PURPOSE OF REVIEW

To summarize the most relevant articles with regard to endoscopic stenting of esophageal cancer published in 2006.

RECENT FINDINGS

In 2006, there were two studies on esophageal stents with experimental designs and adequate size to contribute to an evaluation of esophageal stent technology. A study on an antireflux stent will not measurably change the current use of this device, but emphasizes the need for additional investigation. A study on a self-expanding plastic stent was the largest study to date demonstrating a self-expanding plastic stent to be comparable to self-expanding metal stents. Other published studies in 2006 on esophageal stents include review articles, case reports and small case series that are not addressed in this review.

SUMMARY

Self-expanding metal stents remain an important option for the treatment of patients with tracheoesophageal fistulae and esophageal malignancies. Recent innovations are dominated by a shift toward self-expanding esophageal stents that are potentially removable. Such potentially removable stents allow for expanded clinical applications and will be the focus of publications in 2007.

Antireflux stents for palliation of malignant esophagocardial stenosis

Placement of self-expanding metal stents (SEMS) for palliation of malignant stenoses at the gastroesophageal junction is often associated with stent migration and reflux symptoms. SEMS with an antireflux mechanism have been developed to overcome the latter problem. The aim of this study was to evaluate the safety and efficacy of antireflux Z-stents. Patients with advanced squamous cell or adenocarcinoma of the distal esophagus or cardia suffering from dysphagia received an antireflux Z-stent. Technical success, complications of the procedure, clinical symptoms before and after stent placement, reinterventions and survival were recorded. Follow-up was accomplished by patient interviews and a standardized questionnaire for primary care physicians. Eighteen consecutive patients received an antireflux Z-stent. Seventeen of 18 stents were placed technically successful in a single endoscopic procedure. Mean dysphagia score improved from 2.2 to 0.6. Four patients (22%) had permanent reflux symptoms, an additional nine (50%) were taking proton pump inhibitors on a regular basis. In 10 patients, a re-intervention was necessary mainly due to dislocation of the stent. To ensure adequate nutrition three and two patients received a percutaneous gastrostomy and a jejunostomy, respectively. Median survival from stent insertion was 54 days (range, 3-201). Although placement of an antireflux Z-stent is technically feasible, its application is hampered by frequent stent migration and insufficient prevention of gastroesophageal reflux. Further technical improvements of stents or alternative methods like brachytherapy are required for satisfactory palliation of malignant gastroesophageal stenosis.

Superiority of anti-reflux stent compared with conventional stents in the palliative management of patients with cancer of the lower esophagus and esophago-gastric junction: results of a randomized clinical trial

Palliation of inoperable esophageal cancer with covered stents aims to relieve progressive dysphagia and improve health-related quality of life (HRQoL). Introducing a stent across the esophagogastric junction in lower third tumors may predispose to unchecked gastro-esophageal reflux (GER). Esophageal stents incorporating an anti-reflux valve have been introduced to address this problem. We prospectively compared an anti-reflux stent with a standard stent in the palliation of inoperable lower third esophageal tumors. Forty-nine consecutive patients with malignant dysphagia were randomized to receive a standard (n = 25, group 1) or an anti-reflux stent (n = 24, group 2). HRQoL was assessed before stenting, at 1 week and at 2 months, utilizing European Organization for Research and Treatment of Cancer questionnaires QLQ-C30, QLQ-OES24 and reflux questionnaires. Esophageal pH testing was performed within 1 week of the stent insertion. Detailed statistical analysis was employed to assess general QoL, symptoms and pH scores in both groups. Both groups reported significantly improved QoL, health and dysphagia scores at 1 week and 2 months after stenting. Group 2 patients reported significantly (P < 0.05) better DeMeester symptom, general reflux scores, and normal pH profile at 1 week. At 2 months DeMeester symptom scores were significantly (P < 0.05) better in group 2 compared with group 1. Standard and anti-reflux stents afford comparable relief from dysphagia and improved quality of life in patients with inoperable lower third esophageal cancer. Anti-reflux stents, however, controlled symptomatic and physiologically relevant reflux and should therefore be considered as optimal palliation in this cohort.

Evolving role of self-expanding metal stents in the treatment of malignant dysphagia and fistulas

BACKGROUND

Self-expanding metal stents (SEMS) are touted as the cornerstone of endoscopic palliation of unresectable esophageal cancer. However, usage at MD Anderson has fallen in recent years, despite a greater volume of patients with esophageal cancer.

OBJECTIVE

To compare our more recent experience with that of earlier reported institutional experience and to assess how esophageal stent use has evolved.

DESIGN

A retrospective chart review.

SETTING

A tertiary referral cancer center.

PATIENTS

Ninety-seven patients with malignant dysphagia who had SEMS placed from 2000 to 2003.

INTERVENTIONS

Placement of SEMS for malignant disease.

MAIN OUTCOMES MEASUREMENTS

Dysphagia scores, overall survival, and complication rates.

RESULTS

Dysphagia scores improved in 86%, and tracheoesophageal fistula symptoms improved in 90%. Complications were seen in a majority of the patients and major complications in 37%. Ten patients had hematemesis, migrations occurred in 5, and early unexpected deaths in 2. Adenocarcinoma and female sex were factors associated with increased odds of a major complication. Prior chemoradiation, age, stricture location, and length were not associated with complications. Median survival was 77 days.

LIMITATIONS

Noncomparative retrospective single-center study.

CONCLUSIONS

SEMS fall short of an ideal palliative method, because complications that require additional intervention are frequent. Usage has declined despite higher numbers of patients with esophageal cancer. However, for patients with tracheoesophageal fistulas, SEMS are the treatment of choice. For patients who are not candidates for chemoradiation or who failed to achieve adequate palliation with such therapy, SEMS offer a viable, albeit imperfect, endoscopic approach.

Minimizing endoscopic complications: endoluminal stents

Almost all endoluminal stents used by gastroenterologists in the United States are self-expandable metal stents, and they are placed most commonly for relief of malignant luminal obstruction. Recently, a plastic self-expandable stent was approved for treating refractory benign esophageal strictures. Endoluminal stent placement is associated with myriad of complications. Some of these complications can be avoided or minimized by the endoscopist, whereas others are beyond the endoscopist's control. This article covers the various complications that can occur following self-expandable stent placement and provides recommendations on how to minimize these complications.

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.