Expandable metallic esophageal stents in benign disease: a cause for concern. ACTA ACUST UNITED AC. 1998;8:40-43. [PMID: 9488569 DOI: 10.1097/00019509-199802000-00010]

Diagnosis and management of pharyngoesophageal stenosis: A comprehensive approach to prophylactic, endoscopic, and reconstructive treatment options

BACKGROUND

Pharyngoesophageal stenosis (PES) is a serious complication that substantially impacts functional outcomes and quality of life (QOL) for up to a third of head and neck cancer patients who undergo radiotherapy. Dysphagia is often multifactorial in nature and is a devastating complication of treatment that impacts patients' QOL, general health and overall wellbeing. The authors detail the clinical presentation, risk factors, imaging characteristics, preventive measures, and multimodality treatment options for PES.

METHODS

The authors present a comprehensive management algorithm for PES, including treatment by dilation, stenting, spray cryotherapy and dilation, and reconstructive treatment options utilizing different pedicled and free flaps.

RESULTS

The authors advocate for a thorough assessment of the extent and degree of pharyngoesophageal involvement of PES to determine the optimal management strategy.

CONCLUSIONS

The development of post treatment dysphagia requires appropriate imaging and biopsy, when indicated, to rule out the presence of persistent/recurrent cancer. Multidisciplinary management by a team of physicians well-versed in the range of diagnostic and therapeutic interventions available for PES is critical to its successful management.

A Comprehensive Review of Endoscopic Management of Sleeve Gastrectomy Leaks

BACKGROUND

Bariatric surgery leaks result in significant morbidity and mortality. Experts report variable therapeutic approaches, without uniform guidelines or consensus.

OBJECTIVE

To review the pathogenesis, risk factors, prevention, and treatment of gastric sleeve leaks, with a focus on endoscopic approaches. In addition, the efficacy and success rates of different treatment modalities are assessed.

DESIGN

A comprehensive review was conducted using a thorough literature search of 5 online electronic databases (PubMed, PubMed Central, Cochrane, EMBASE, and Web of Science) from the time of their inception through March 2020. Studies evaluating gastric sleeve leaks were included. MeSH terms related to "endoscopic," "leak," "sleeve," "gastrectomy," "anastomotic," and "bariatric" were applied to a highly sensitive search strategy. The main outcomes were epidemiology, pathophysiology, diagnosis, treatment, and outcomes.

RESULTS

Literature search yielded 2418 studies of which 438 were incorporated into the review. Shock and peritonitis necessitate early surgical intervention for leaks. Endoscopic therapies in acute and early leaks involve modalities with a focus on one of: (i) defect closure, (ii) wall diversion, or (iii) wall exclusion. Surgical revision is required if endoscopic therapies fail to control leaks after 6 months. Chronic leaks require one or more endoscopic, radiologic, or surgical approaches for fluid collection drainage to facilitate adequate healing. Success rates depend on provider and center expertise.

CONCLUSION

Endoscopic management of leaks post sleeve gastrectomy is a minimally invasive and effective alternative to surgery. Their effect may vary based on clinical presentation, timing or leak morphology, and should be tailored to the appropriate endoscopic modality of treatment.

Changing epidemiology of esophageal stent placement for dysphagia: a decade of trends and the impact of benign indications

BACKGROUND AND AIMS

In addition to managing malignant obstruction, esophageal stents (ESs) have evolved to address various benign etiologies of dysphagia. We sought to evaluate national trends and changes in practice of ES placement for both benign and malignant etiologies in hospitalized patients with dysphagia.

METHODS

The National Inpatient Sample (2003-2013) was used to include all adult inpatients (≥18 years of age) with endoscopy-guided ES placement for a symptom of dysphagia. Multivariable analyses for indications that impact temporal trends (3 time periods: 2003-2005, 2006-2009, and 2010-2013) and for hospital outcomes were performed.

RESULTS

A total of 7198 ESs were deployed endoscopically in hospitalized patients with dysphagia. Compared with malignant etiologies, there was a significant increase in ES placement for benign conditions (2013 vs 2003: 32.7% vs 14.5%, respectively; P < .001). Multivariable analysis using 2003 to 2005 as a reference showed that patients with benign etiologies for dysphagia predominantly contributed to the increase of ES placement during the most recent time period (2010-2013: odds ratio, 2.09; 95% confidence interval, 1.40-3.13). Multivariable analysis of hospital outcomes revealed no differences in inpatient mortality, duration of hospital stay, and hospital costs between malignant and benign indications.

CONCLUSIONS

In the preceding decade, ES placement for hospitalized patients with dysphagia has increased, driven largely by an over 8-fold rise in stent placement for benign indications. These findings warrant continued efforts to improve stent technology to decrease the risk of migration and review practice guidelines involving ES placement for benign etiologies.

Efficacy and risk profile of self-expandable stents in the management of pediatric esophageal pathology

PURPOSE

The purpose of this study was to evaluate the efficacy and risk profile of esophageal stents in the management of complicated pediatric esophageal disease.

METHODS

An IRB-approved, single-center, retrospective review was performed on all pediatric patients (n = 13) who underwent esophageal stent placement (2005-2017). Demographic, perioperative, and outcome data were analyzed (p < 0.05).

RESULTS

Forty-one stents were placed due to recalcitrant strictures (n = 36), perforations (n = 2), and/or fistulae (n = 3). Median age at initial stent placement was 23.8 months (range, 50 days to 16 years), and median stent duration was 36 days (range, 3-335). The recurrence rate for strictures after initial stent removal was 100%. Four (31%) children subsequently underwent definitive operative repair. There were 5 deaths, including 2 related to stent placement. Seventy-one percent of stents were associated with an adverse event, most commonly intraluminal migration (56%). Younger children experienced an increased risk for airway compression and retching (p = 0.010).

CONCLUSION

These data suggest that stents are associated with high complication rates and are not effective as definitive therapy for recalcitrant strictures in children. Although there may be a temporizing role for stents in selected patients, further refinements in stent technologies are needed to help manage this difficult patient population.

LEVEL OF EVIDENCE

Level IV.

Endoscopic treatment of benign esophageal strictures: a literature review

Benign esophageal strictures arise from various etiologies and are frequently encountered. Although endoscopic dilation is still the first-line therapy, recurrent strictures do occur in approximately 10% of the cases and remains a challenge to gastroenterologists. Areas covered: A literature search was performed using PubMed and Google Scholar databases for original and review articles on endoscopic treatment of benign esophageal strictures. This review outlines the main available treatment options and its controversies in the management of refractory benign esophageal strictures. Expert commentary: Adding local steroid injections to dilation can be effective for peptic stenosis and strictures after endoscopic submucosal dissection, but remains uncertain for anastomotic strictures. Intralesional injections of mitomycin-C could be useful in corrosive strictures. Incisional therapy can be a reliable alternative in Schatzki rings and in anastomotic strictures, in experienced hands. By contrast, long-term outcome with endoprosthetic treatment is disappointing, and stent placement should be carefully considered and individualized.

Efficacy and safety of a new fully covered self-expandable non-foreshortening metal esophageal stent

BACKGROUND

Fully covered esophageal self-expandable metal stents (SEMSs) are potentially removable but can be associated with high migration rates. For precise positioning, non-foreshortening SEMSs are preferred. Recently, a new fully covered non-foreshortening SEMS with anti-migration features was introduced.

OBJECTIVE

To evaluate the efficacy and safety of this new esophageal SEMS.

DESIGN

Retrospective study.

SETTING

Single, tertiary-care center.

PATIENTS

Consecutive patients with malignant and benign strictures with dysphagia grade of ≥3 and patients with fistulas/leaks were studied.

INTERVENTIONS

Stent placement and removal.

MAIN OUTCOME MEASUREMENTS

Technical success in stent deployment/removal, efficacy in relieving dysphagia and sealing fistulas/leaks, and adverse events.

RESULTS

Forty-three stents were placed in 35 patients (mean [± standard deviation] age 65 ± 11 years; 31 male), 24 for malignant and 11 for benign (5 strictures, 6 leaks) indications. Technical success in precise SEMS placement was 100%. The after-stent dysphagia grade improved significantly (at 1 week: 1.5 ± 0.7; at 4 weeks: 1.2 ± 0.4; baseline: 3.8 ± 0.4; P < .0001). Twenty stents were removed for clinical indications, with technical success of 100%. All leaks sealed after SEMS placement and did not recur after stent removal. All benign strictures recurred after stent removal. Adverse events included migration (14%), chest pain (11%), and dysphagia from tissue hyperplasia (6%). There was no stent-related mortality.

LIMITATIONS

Nonrandomized, single-center study.

CONCLUSION

The new esophageal SEMS was effective in relieving malignant dysphagia, allowed for precise placement, and was easily removable. It was effective in treating benign esophageal fistulas and leaks. Stent-related adverse events were acceptable.

Self-expandable stents for benign esophageal leakages and perforations: long-term single-center experience

OBJECTIVE

To date, there is no standardized treatment for esophageal perforations and leakages caused by underlying benign diseases, and it is still debated whether a conservative, endoscopic treatment or a surgical approach is preferable. However, some cases series have successfully demonstrated the feasibility of a temporary placement of self-expanding stents.

DESIGN

All patients with benign leakages of the esophagus or gastroesophageal junction or fistulas at gastroesophageal anastomosis were collected during the past 12 years and analyzed retrospectively. The patients treated with endoscopic stenting were analyzed for sustained success, complications, time to stenting, lesion size, number of stents used, need for percutaneous drainage.

RESULTS

Eighty-five of eight-eight patients were included in this analysis. Three patients were conservatively managed only. The success rate of stent treatment with an average of 1.3 stents was 79%. Success was highest (94%, n = 30 of 32, no complications or mortality) in iatrogenic lesions that were immediately diagnosed and treated. Spontaneous lesions, including lesions due to Boerhaave's syndrome, were healed in 73% and anastomotic leakages were closed in 71%. Fistula had a lower success rate of 43%. Use of multiple stents sequentially placed was necessary in 23% of the cases. Percutaneous drainage was necessary in 25% of all cases.

CONCLUSION

Temporary stent placement for benign leakages of the esophagus is safe and seems to improve treatment success. Adjacent fluid collections should be drained percutaneously.

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.

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.

Success and complications associated with placement of fully covered removable self-expandable metal stents for benign esophageal diseases (with videos)

BACKGROUND

Fully covered esophageal self-expandable metal stents (FCSEMSs) are thought to induce less mucosal hyperplasia and are potentially removable. They may constitute an attractive alternative for the treatment of benign esophageal diseases.

OBJECTIVE

To evaluate the efficacy and safety of FCSEMSs in the treatment of benign esophageal diseases.

DESIGN

Patients referred for management of benign esophageal disease underwent placement of an FCSEMS and were entered into a prospective database and analyzed retrospectively for clinical response, efficacy, and morbidity.

SETTING

Two tertiary care centers with long-standing experience in the management of benign esophageal strictures.

PATIENTS

Between January 2006 and September 2007, 35 patients (mean age 61 years, range 20-85 years) underwent FCSEMS placement for benign esophageal diseases at 2 tertiary academic medical centers. There were 19 patients with benign esophageal strictures and 16 patients with leaks/perforations.

INTERVENTION

Temporary placement of FCSEMS until stricture resolution.

MAIN OUTCOME MEASUREMENTS

Clinical response, efficacy, and morbidity.

RESULTS

Indications for stent placement were esophageal leak/fistulae (n = 12), refractory benign strictures (n = 10), anastomotic strictures (n = 7), perforations (n = 4), and radiation-induced strictures (n = 2). Immediate complications were chest pain (2 patients), stent migration (2 patients), dysphagia (1 patient), respiratory compromise (1 patient), and arrhythmia (1 patient). Long-term complications included recurrent dysphagia (6 patients), aspiration pneumonia (2 patients), globus sensation (2 patients), abdominal pain (2 patients), and fever (1 patient). Stent migration was observed in 12 patients (34%). After placement, dysphagia scores at 1 month improved significantly from 3.1 ± 1.0 to 1.2 ± 1.3 (P < .0001). A total of 11 of 35 patients (31%) were treated successfully. Specifically, 21% of patients with refractory strictures and 44% of patients with leaks/fistulae had successful long-term outcomes without any need for reinterventions. All stents were retrieved successfully, except for 1 stent, which fractured and was retrieved in 2 pieces without any complications.

CONCLUSION

Use of FCSEMSs for benign esophageal conditions was associated with frequent stent migration and long-term improvement in only one third of patients. Further investigation is required before recommending FCSEMS placement to treat benign diseases of the esophagus and to further characterize the subgroup that might benefit from these interventions.

Short-term esophageal stenting in the management of benign perforations

OBJECTIVES

The standard approach to benign esophageal perforations consists of conservative treatment or surgery. In this study, we investigated the efficacy of short-term stent placement for nonmalignant esophageal perforations.

METHODS

This is a prospective single-center study of patients with benign esophageal perforations in whom a removable self-expandable stent was placed. Data were collected from a prospective database, endoscopy records, and operation reports. To obtain follow-up data, we contacted the patients, their relatives, or their general practitioner.

RESULTS

A total of 33 patients underwent stent insertion owing to an iatrogenic perforation (n=19), Boerhaave's syndrome (n=10), or other causes (n=4); this resulted in an immediate and complete sealing of the lesion in 32 patients (97%). Stents migrated in 11 patients (33%). Four patients required an esophageal resection for failed stent therapy (n=3) and failed stent removal (n=1). The 90-day mortality rate was 15%. A total of 33 endoscopic stent extractions were attempted. Overall, 23 stents were extracted within 6 weeks (group I) and 10 stents between 6 and 84 weeks (group II). Extractions were uncomplicated in all patients in group I (100%) vs. in 5 patients in group II (50%) (P=0.001). Six extraction-related complications occurred in group II, including two self-limiting bleedings, three stent fractures, and one impacted stent.

CONCLUSIONS

In patients with a benign esophageal perforation, temporary stent therapy is effective and provides a good alternative to surgery. Complications due to stent removal can be prevented by removal of the prosthesis within 6 weeks after insertion, without compromising the efficacy of treatment.

Systematic review: the role of self-expanding plastic stents for benign oesophageal strictures

BACKGROUND

Treatment of refractory or recurrent benign oesophageal strictures is demanding and surgery may be the only available option. The role of self-expanding plastic stents (SEPS) in the treatment of these strictures is still controversial because of the conflicting results of various studies.

AIM

To analyse with regard to SEPS: technical and clinical success, factors associated with outcome, and safety.

METHODS

Pooled-data analysis of a systematic review of the literature. Clinical success was defined as no need for further endoscopic or surgical treatment after SEPS removal.

RESULTS

Data of 10 studies with 130 treated patients were included. SEPS insertion was technically successful in 128 of 130 patients (98%, 95% CI = 96-100%). Clinical success was achieved in 68 patients (52%, 95% CI = 44-61%) and this was found to be lower in those with a cervical localization of the stricture (33% vs. 54%; P < 0.05). Early (<4 weeks) migration of the stent was reported in 19 (24%, 95% CI = 14-32%) cases, while post-insertion endoscopic re-intervention was required in 25 (21%, 95% CI = 14-28%). Major clinical complications occurred in 12 patients (9%, 95% CI = 4-14%), resulting in death of one (0.8%) patient.

CONCLUSIONS

Our pooled-data analysis showed a favourable risk/benefit ratio when SEPS are applied in patients with recurrent or refractory benign oesophageal strictures. This supports the use of SEPS before referring patients to surgery, and they are a valuable alternative to repeat endoscopic dilation.

Utility of removable esophageal covered self-expanding metal stents for leak and fistula management

BACKGROUND

Esophageal or gastric leakage from anastomotic wound dehiscence, perforation, staple line dehiscence, or trauma can be a devastating event. Traditional therapy has often consisted of either surgical repair for rapidly diagnosed leaks or diversion for more complicated cases, commonly associated with a delayed diagnosis. This study summarizes our experience treating leaks or fistulas with novel, covered self-expanding metal stents (cSEMS). The primary objective of this study was to determine the efficacy and safety of covered self-expanding metal stents when used to treat complicated leaks and fistulas.

METHODS

Over 15 months, 25 patients with esophageal or gastric leaks were evaluated for stenting as primary treatment. A prospective database was used to collect data. Stents were placed endoscopically, with contrast evaluation used for leak evaluation. Patients who did not improve clinically after stenting or whose leak could not be sealed underwent operative management.

RESULTS

During a mean follow-up of 15 months, 23 of the 25 patients with esophageal or gastric leaks during a 15-month period were managed with endoscopic stenting as primary treatment. Healing occurred in patients who were stented for anastomotic leakage after gastric bypass or sleeve gastrectomy (n = 10). One patient with three esophageal iatrogenic perforations healed with stenting. Eight patients successfully avoided esophageal diversion and healed with stenting and adjunctive therapy. Two of the 4 patients with tracheoesophageal fistulas sealed with the assistance of a new pexy technique to prevent stent migration; 1 additional patient had this same technique used to successfully heal an upper esophageal perforation.

CONCLUSIONS

Esophageal leaks and fistulas can be effectively managed with cSEMS as a primary modality. The potential benefits of esophageal stenting are healing without diversion or reconstruction and early return to an oral diet.

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.

Removable self-expanding plastic esophageal stent as a continuous, non-permanent dilator in treating refractory benign esophageal strictures: a prospective two-center study

BACKGROUND

Refractory benign esophageal strictures (RBES) are difficult to treat requiring frequent dilatations or surgery. Conceptually, while maintaining luminal patency, if a dilator is kept in place continuously for several weeks, the benefits may be longer lasting. An expandable esophageal stent will be ideal in achieving the above. Preliminary results on using a removable self-expanding plastic esophageal stent, Polyflex stent (PS), for treating RBES have been mixed.

AIM

To evaluate the efficacy of PS in the treatment of RBES.

METHODS

Forty patients with RBES [mean age 60 +/- 15 SD yrs, female 14, male 26, Anastomotic 12 (fistula 4), Corrosive 8, Radiation 7, Pill induced 4, Post trauma 3 (fistula 3), Peptic 2, Others 4 (fistula 1)] were prospectively studied. Continuous non-permanent dilation was performed by placing a PS and removing it after 4 wk. The patients were then followed at regular intervals. Pre-insertion baseline data and post-removal information on dysphagia status, complications, and change in outcome were prospectively collected.

RESULTS

The technical success in stent placement and stent removal were 95% and 94%, respectively. Mean post-stent dysphagia score was 0.6 +/- 0.7 SD, which was significantly better than pre-stent scores (3.0 +/- 0.8 SD; P < 0.001). At median follow-up of 53 wk (range 11-156), only 40% (intention to treat 30%) patients were dysphagia-free. However, the overall change in outcome from baseline options (ongoing dilatations, or surgery) was 66% (dysphagia-free 12, did not want removal 2, did not remove 1, preferred long-term stenting 10). The stent was successful in closing the fistula in five of eight (63%) patients. Complications observed were migration eight (22%), severe chest pain four (11%), bleeding three (8%), perforation two (5.5%), GE reflux two (5.5%), impaction two (5.5%), and new fistula one (2.7%). There was one mortality from massive bleeding.

CONCLUSIONS

It was feasible to deploy and remove PS stents in the majority of patients with RBES. Some patients achieved long-term relief without further re-interventions while several others re-strictured and preferred long-term stenting over repeated dilations or surgery. The procedure carries significant risks and hence should only be considered in carefully selected patients.

Advances in research of esophageal stents

Esophageal stents were used initially in the palliative treatment of esophageal carcinoma to improve the life quality of the patients in the advanced stage. Along with the appearance of many new kinds of esophageal stents, esophageal stents have been used in the management of the benign esophageal strictures, and clinical effectiveness has been made. This article reviews the application of the esophageal stents in the benign and malignant esophageal strictures.

Prevention of stricture development after corrosive esophageal burn with a modified esophageal stent in dogs

OBJECTIVE

We sought to test the feasibility and technical ease of a newly designed nitinol-based modified esophageal stent and its effects on preventing postcaustic stricture in mongrel dogs and to try to explain the result at the molecular level.

METHODS

Twenty-four dogs were included in this controlled study. Stenosis index (wall thickness/intraluminal diameter), pathologic features, hydroxyproline quantities, esophageal compliance, and biomechanics were compared between the injured but unstented and stented dogs. Transforming growth factor beta1, Sma/Mad (Smad)3, and Smad7 mRNA expression and protein levels in esophageal tissue were detected by means of reverse transcriptase-polymerase chain reaction and Western blotting, respectively.

RESULTS

The modified esophageal stent was able to be placed and retrieved successfully and conveniently and was not only intact but there was also no macroscopic esophageal mucosal injury after the stent removal 4 months later. In comparison with the injured but unstented group, esophageal compliance, biomechanics, and the stenosis index were significantly better in the stented group. Histopathologic study revealed that collagen bundles were thinner and its orientation tended toward a regular and parallel pattern. Transforming growth factor beta1 and Smad3 mRNA expression and protein levels increased and Smad7 mRNA expression and protein levels decreased significantly in esophageal tissue in the stented group. These variables showed no statistically significant difference 2 months after stent removal.

CONCLUSIONS

The modified esophageal stent might be a promising stent in preventing stricture formation after corrosive esophageal burns clinically.

Retrievable esophageal stents for benign indications

Until recently, esophageal stents have not been a realistic option for the management of benign disease owing to difficulty removing the stents and associated high complication rates. However, progress in esophageal stent design has led to the development of retrievable esophageal stents. Clinical experience has shown promise for the management of benign esophageal diseases with retrievable stents, including refractory strictures, esophageal leaks, fistula and perforations. They have been shown to be safe and effective, though stent migration remains a concern. This article reviews the current designs, indications, efficacy and complications of retrievable esophageal stents.

Self-expanding plastic stents in treatment of benign esophageal conditions

BACKGROUND

Recently, self-expanding plastic stents (SEPSs) have been proposed for the treatment of benign esophageal disease.

OBJECTIVES

Our purpose was to review our experience with SEPSs in patients with benign esophageal conditions.

DESIGN

This was a retrospective case review of patients who underwent SEPS placement for benign esophageal disease, including (1) benign stricture, including reflux disease, ischemia, and idiopathic, (2) radiation-induced strictures, (3) anastomotic strictures, and (4) esophageal leak/fistulae.

PATIENTS

Nineteen male and 11 female patients (average age 52.1 years, range 11-87 years) underwent SEPS placement.

INTERVENTIONS

SEPS placement.

MAIN OUTCOME MEASUREMENTS

Initial complications, stent migration, long-term complications, and treatment success according to clinical symptoms, follow-up endoscopy, or imaging.

RESULTS

Eighty-three of 84 SEPS placements were successful. The most common complications were chest pain, dysphagia, nausea, and vomiting. No deaths were reported from stent placement. Stent migration was more frequent in proximal (30/44 stents, 68.1%) and distal (19/27 stents, 70.4%) compared with mid esophageal (3/10 stents, 30%). Migration was more frequent in stents placed for benign strictures (18/22 stents, 81.8%), anastomotic strictures (18/24 stents, 75%), and fistulae/leak (13/22 stents, 59.1%) compared with radiation-induced strictures (4/14 stents, 28.6%). Only 5 of 83 interventions (6%) resulted in long-term improvement after stent removal.

LIMITATIONS

This was a retrospective review, and patients were selected from a tertiary medical center.

CONCLUSION

Use of SEPSs for benign esophageal conditions resulted in frequent stent migration and few cases of long-term improvement. Further investigation is warranted to identify optimal patient populations and to guide future recommendations for the use of SEPSs.

Fluoroscopically Guided Balloon Dilation of Anastomotic Strictures After Total Gastrectomy: Long-Term Results

OBJECTIVE

The purpose of this study was to evaluate the radiologic and clinical effectiveness and long-term results of fluoroscopically guided balloon dilation of anastomotic strictures after total gastrectomy.

CONCLUSION

Fluoroscopically guided balloon dilation is effective and safe and has encouraging long-term results in the management of benign anastomotic strictures after total gastrectomy.

Salvage of a massive esophago-tracheal fistula resulting from a stenting treatment

We report the successful surgical resolution of a case of massive esophago-tracheal fistula (ETF) caused by a stenting treatment for stricture of an esophago-gastric anastomosis. A 54-year-old man was admitted to our hospital due to serious pneumonia secondary to ETF. He had previously received esophagectomy and post-operative chemo-radiation therapy for esophageal cancer, followed by stenting treatments for a benign stricture of the esophago-gastric anastomosis. For surgical treatment of the resulting ETF, serial operations were required. The first operation, performed under percutaneous cardiopulmonary support, included removal of the stents followed by tracheotomy, were with the coverage of the tracheal defect achieved using both major pectoral muscle flaps. A salivary fistula was also generated and an enteral nutrition tube was placed. Six months after the first operation, a pedicled ileocolic interposition was performed in order to effect reconstruction of the digestive tube, with an additional microvascular anastomosis of the ileocolic and internal thoracic artery and vein. After the second operation, the patient's ability to ingest food was restored, and he was discharged from the hospital. Thus, ETF was successfully treated by successive surgical operations with delicate intra- and post-operative respiratory management.

Endoprosthesis implantation at the pharyngo-esophageal level: Problems, limitations and challenges

AIM: To present our experience with endoscopic placement of an esophageal endoprosthesis in 19 patients.

METHODS: A retrospective evaluation was made for the use of 19 stents positioned at the level of the cervical esophagus: 11 for malignant tumours (7 causing obstruction, 4 complicated by an esophago -tracheal or -cutaneous fistula), and 8 for an acquired benign tracheo-esophageal fistula due to prolonged intubation. The covered Ultraflex stent was used in all cases except two. These two patients had an esophagocutaneous fistula following laryngectomy and a Flamingo Wall stent was used.

RESULTS: Stent implantation was technically successful in all patients. Dysphagia score was improved from 3 to 2 in stenosis patients, while sealing of the fistula was achieved in all cases. The median hospital stay was 3 d for malignant tumour patients and 13.5 d for esophagocutaneous fistula patients. One Ultraflex stent and two Flamingo Wall stents were easily removed 33 d and 3 months respectively after implantation when the fistulas had totally occluded.

CONCLUSION: Endoprosthesis implantation for malignancy and/or fistula of malignant or benign origin at the level of the cervical esophagus is an easy, well tolerated, safe and effective procedure with no complications or mortality.

Fluoroscopically Guided Balloon Dilation for Benign Anastomotic Stricture after Ivor-Lewis Esophagectomy: Experience in 62 Patients

PURPOSE

To evaluate the safety and clinical effectiveness of fluoroscopically guided balloon dilation in 62 patients with benign anastomotic stricture after Ivor-Lewis esophagectomy.

MATERIALS AND METHODS

Between January 1996 and June 2004, fluoroscopically guided balloon dilation was undertaken in 62 patients with benign anastomotic stricture after Ivor-Lewis esophagectomy. Radiologic images and medical records including complications were retrospectively reviewed. The maximum diameters of the balloon catheters used were 18-20 mm. Clinical success was defined by the absence of recurrent dysphagia after balloon dilation until the most recent follow-up. The Fisher exact test was used to assess the relationship of symptomatic recurrence and the balloon size, width of the stricture, and radiation therapy.

RESULTS

There were 115 sessions of balloon dilation in 62 patients (mean, 1.85 sessions per patient). Clinical success was achieved in 59 patients (95%) by means of a single dilation (n = 29) or by multiple dilations (n = 30). One patient with severe stenosis was successfully treated with temporary placement of a covered retrievable stent. Major complications such as esophageal perforation or massive bleeding did not occur. Four patients with mucosal tear (n = 3) or aspiration pneumonia (n = 1) were conservatively treated. Patients with severe stricture had more symptomatic recurrences than those with moderate stricture.

CONCLUSION

Fluoroscopically guided balloon dilation is a safe and successful treatment modality for benign anastomotic stricture after Ivor-Lewis esophagectomy.

Temporary stenting of acquired benign tracheoesophageal fistulas in critically ill ventilated patients

BACKGROUND

To evaluate the use of esophageal stents for temporary sealing of acquired benign tracheoesophageal fistulas developed in critically ill, ventilated patients.

METHODS

This is a retrospective analysis (1992-2003) of the data of 12 mechanically ventilated patients - six of them after major or multiple trauma - being intubated for a median of 30 days before they develop an acquired benign tracheoesophageal fistula. Five of them were in sepsis. Two types of stents were used: the Wilson-Cook esophageal balloon plastic stent in the first four cases and the Ultraflex covered self-expandable stent in the remaining eight. The total procedure was performed at bedside in the intensive care unit, with no special need for supplementary anesthesia or fluoroscopic control.

RESULTS

Stent implantation was technically successful in all patients and fistula occlusion was achieved in every case. There was no stent migration and fistulas remained sealed until death or upon decision for removal. Nine patients died between 5 days and 2 months after stent placement, as a result of their diseases. Three patients were referred for fistula surgical repair 33, 36, and 43 days after stent placement. Before surgery the stents were easily removed under direct vision.

CONCLUSION

Temporary closure of an acquired tracheoesophageal fistula developed in critically ill ventilated patients is an easy, bedside-applicable, safe, and effective palliative procedure, with no complications or mortality.

Temporary partially-covered metal stent insertion in benign esophageal stricture

AIM: To study the therapeutic efficacy of temporary partially-covered metal stent insertion on benign esophageal stricture.

METHODS: Temporary partially-covered metal stent was inserted in 83 patients with benign esophageal stricture. All the patients had various dysphagia scores.

RESULTS: Insertion of 85 temporary partially-covered metal stents was performed successfully in 83 patients with benign esophageal stricture and dysphagia was effectively remitted in all the 83 cases. The dysphagia score was 3.20 ± 0.63 (mean ± SD) and 0.68 ± 0.31 before and after stent insertion, and 0.86 ± 0.48 after stent removal. The mean diameter of the strictured esophageal lumen was 3.37 ± 1.23 mm and 25.77 ± 3.89 mm before and after stent insertion, and 16.15 ± 2.96 mm after stent removal. Follow-up time was from 1 week to 96 months (mean 54.26 ± 12.75 months). The complications were chest pain (n = 37) after stent insertion, and bleeding (n = 12) and reflux (n = 13) after stent removal.

CONCLUSION: Temporary partially-covered metal stent insertion is one of the best methods for treatment of benign esophageal stricture.

Use of self-expandable metallic stents in benign GI diseases

BACKGROUND

The self-expandable metallic stent is of proven benefit in patients with malignant disease; however, its use in patients with benign disease is not well established. There are few data available regarding long-term complications and outcomes with use of self-expandable metallic stents in benign disease and virtually none regarding attempted removal once the acute problem is resolved.

METHODS

Thirteen patients who had a self-expandable metallic stent placed for benign GI disorders were included in a retrospective analysis. Data collected included patient demographics, indication for procedure, type of stent used, complications, and patient outcomes.

RESULTS

Thirteen patients (7 women, 6 men; mean age 67 years, range 34-84 years) had one or more self-expandable metallic stents placed for benign disease and were followed for a mean of 3.4 years (3 weeks to 10 years). Of the 13 patients, 8 had esophageal stents, 4 biliary stents, and 1 had dual stents placed in the pancreaticobiliary tree. Complications developed in 8 (62%) patients; 4 (31%) ultimately died, either from the primary disease process (3) or from stent-related complications (1).

CONCLUSIONS

Self-expandable metallic stent placement is effective treatment for benign esophageal leaks, providing the stent can be removed. It also may be used in either the esophagus or biliary tree in patients who are poor candidates for surgery and short expected survival. However, a self-expandable metallic stent should not be placed in a patient with a benign GI disorder who has a significant life expectancy and is a good candidate for surgery.

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.

Covered metallic stent treatment of a patient with spontaneous rupture of the esophagus

A patient with a potentially fatal condition as a result of esophago-pneumo-broncho fistula was successfully treated with the insertion of a self-expanded covered metallic stent. Severe regurgitation resulted in the removal of the stent 3 months after insertion. Stricture after removal of the stent required pneumatic balloon dilation. The use of a self-expanded covered metallic stent is effective for the treatment of spontaneous esophageal rupture; however, early removal of the stent is recommended.

Expandable metallic stents should not be used in the treatment of benign esophageal strictures

Expandable metallic stents have become popular in recent years for the treatment of esophageal strictures. While they are undoubtedly of great value in the palliation of malignant strictures and tracheo-esophageal fistulas, there is concern over their use for the treatment of benign diseases. We report three cases, in which such problems were seen following stent insertion for benign esophageal strictures. All three patients developed further strictures above the stents, one was complicated by a tracheo-esophageal fistula and two stents (in one patient) migrated distally into the stomach. Two of the patients underwent subsequent esophageal surgery. In both cases, this proved extremely difficult and hazardous because of the intense fibrotic reaction induced by the stents. Expandable mesh stents should not be used for the treatment of benign esophageal strictures without careful consideration of the potential problems, which can include rendering the problem inoperable.

Are self-expanding metal mesh stents useful in the treatment of benign esophageal stenoses and fistulas? An experience of four cases

OBJECTIVE

The aim of this study was to review the long-term results of treating benign esophageal fistula and stenosis using self-expanding metal stents.

METHODS

We treated four patients using covered mesh or coiled stents. We removed the stents electively in two patients (one endoscopically and one during planned partial esophagectomy) and unexpectedly in one patient who developed bleeding. One stent migrated and required laparotomy for removal.

RESULTS

Placement of self-expanding metal stents successfully sealed the benign fistula in two patients and reestablished swallowing in two other patients with complicated achalasia. Two patients were swallowing normally on long-term follow-up, one died of the underlying disease, and one required gastrostomy.

CONCLUSION

Temporary use of self-expanding metal stents as a feasible option for treating benign esophageal stenosis and fistula in patients who have failed other conventional treatments.