Endoscopic stenting of esophageal cancer: the clinical impact

Self-expanding segmental radioactive metal stents for palliation of malignant esophageal strictures

BACKGROUND

Traditional metal stents are not always suitable for patients with circuitous malignant esophageal stricture.

PURPOSE

We aimed to report the safety and effectiveness of stent insertion using self-expanding segmental radioactive metal stent in the palliation of malignant esophageal stricture.

MATERIAL AND METHODS

We conducted a retrospective analysis of 22 consecutive patients who underwent insertion of segmental radioactive metal stents from November 2016 to March 2019. Technical success, dysphagia score, and complications were analyzed. Kaplan-Meier analysis was used to analyze the survival time.

RESULTS

The stenting procedure was successful in all 22 patients with no procedure-related deaths. Twenty-four segmental radioactive metal stents were successfully implanted. A total of 6 (27.3%) complications were found, mainly 5 (22.7%) stent migrations. The median follow-up period was 3.3 months. Stent removal was required in 4 (12.5%) patients due to complete stent migration. The mean dysphagia score decreased significantly after stent insertion (P<0.0001). During follow up, 13 patients survived with no obvious clinical symptom and nine patients died. The mean survival was 9.9 months.

CONCLUSION

The stenting procedure using self-expanding segmental radioactive metal stents is safe and effective in dysphagia palliation of malignant esophageal stricture.

Radioactive feeding tube in the palliation of esophageal malignant obstruction

PURPOSE

A radioactive feeding tube was used to achieve both nutrition and brachytherapy for the treatment for malignant esophageal obstruction. We report the safety and effectiveness of this technique.

METHODS

We conducted a retrospective analysis of 16 consecutive patients who employed this technique from January 2015 to March 2018. The radioactive feeding tube was made by binding the ¹²⁵I seed chain on the feeding tube. Under fluoroscopic guidance, the tube was inserted into the obstructed esophagus, with the seed chain crossing over the segment of malignant esophageal obstruction. Technical success rate, dysphagia score, procedure time and complications were analyzed. Kaplan-Meier analysis was used to analyze the survival time.

RESULTS

The radioactive feeding tube was easy to prepare. The technical success rate was 100%, without serious complications such as bleeding or infection. The median procedure time of tube insertion was 44.0 min. The Kamofsky score and Neuhaus dysphagia grading were significantly improved after tube insertion (p < 0.01). On esophageal radiography, the contrast agent passed through the narrow area smoothly. Complete remission (n = 1) and partial remission (n = 13) of local tumor were obtained in 14 patients, and the local tumor control rate was 87.5% (14/16). During follow-up, four patients survived with no obvious clinical symptom and 10 patients died of cancer. The median survival was 12.0 months.

CONCLUSION

Preparation of the radioactive feeding tube is simple and easy. The insertion of this kind of tube achieves parenteral nutrition and brachytherapy simultaneously and is safe and effective in dysphagia palliation of malignant esophageal stricture. The radiological-radiotherapeutic procedure could be an alternative tool in the case of refusing other treatments by the patients.

A novel fully covered self-expandable segmental metallic stents for the treatment of refractory esophageal stenosis

Background

The conventional esophageal stent is not flexible enough for refractory or circuitous esophageal stenosis. After stent placement, the bending stress may stimulate tissue proliferation in both ends of the stent, causing restenosis, severe bleeding or fistula. A fully covered self-expandable segmental stent was designed and used to overcome such shortcoming. This study aims to study the safety and effectiveness of the fully covered self-expandable segmental metallic stents placement in palliation of dysphasia in patients with refractory esophageal stenosis.

Methods

Retrospective study of hospital records of a consecutive series of 24 patients who underwent placement of fully covered segmental stent from March 2015 to April 2018 was conducted. All procedure was performed under local anesthesia and fluoroscopic guidance. Esophagography was performed by orally take of iodine contrast agent. A 5F catheter and a stiff guide wire were introduced in the esophagus. A fully covered segmental stent was delivered and implanted along the stiff guide wire. The upper endoscopy and chest computed tomography scan were used for the assessment of the location and length of stenosis on admission and during follow-up. The technical success and complications were collected and analyzed.

Results

Stent placement was successful in all patients without procedure-related deaths. Twenty-four covered segmental stents were implanted. A total of eight major complications (33.3%) were found, and stent migration was the most common complication (16.7%). The median follow-up time was 4.5 months (interquartile range: 0.8-14.0 months). Adjustment was required in 3 patients (12.5%) due to stent migration. The mean dysphagia score before stenting and end of follow-up was 3.3±0.5 and 1.0±1.6 (P<0.0001). Four covered segmental stents were removed due to stent migration or intolerance.

Conclusions

Stenting using novel fully covered self-expandable segmental metallic stent is safe and effective in dysphagia palliation of refractory esophageal stenosis.

Modified Type of Double-Covered Self-Expandable Segmental Metallic Stents for Palliation of Esophageal Fistula

Purpose: To study the modified type of double-covered self-expandable segmental metallic stents in terms of efficacy, complications, and long-term outcomes. Patients and Methods: A retrospective review of a consecutive series of 24 patients who underwent placement of the modified stent from July 2013 to July 2018 was conducted. Twenty-five modified segmental stents were implanted. Data regarding technical success and complications were collected and analyzed. Results: Stent placement was successful in all patients with no perioperative procedure-related deaths. The median follow-up time was 10.3 months (interquartile range 6.3-23.5 months). Adjustment was required in 9 patients (37.5%) due to stent migration. The mean dysphagia scores before stenting and during follow-up were 3.6 ± 0.7 and 0.9 ± 1.6, respectively (P < .0001). Fifteen modified stents were removed due to complications or cure. Conclusion: Modified double-covered self-expandable segmental metallic stents are safe and effective for palliation of esophageal fistula.

Esophageal stenting for malignant and benign disease: 133 cases on a thoracic surgical service

BACKGROUND

Esophageal stenting is increasingly being utilized to treat a variety of benign and malignant esophageal conditions. The aim of our study was to review our experience with self-expanding metal, plastic, and hybrid stents in the treatment of esophageal disease on a thoracic surgical service.

METHODS

The study population consisted of 126 patients undergoing placement of 133 stents at a single institution from 2000 to 2008. Data were reviewed retrospectively for patient characteristics, indications, complications, reinterventions, and efficacy.

RESULTS

Most stents were placed for palliation of dysphagia due to advanced esophageal cancer (90 of 133; 68%) or extrinsic compression from lung cancer (13 of 133; 9.8%). A total of 123 self-expanding metal stents (SEMS), 7 self-expanding plastic stents (SEPS), and 3 hybrid stents were placed. Of the SEMS, 57 were uncovered and 66 were covered. Malignant obstruction was typically palliated with SEMS, while covered stents were chosen for perforations or anastomotic leaks. The median length of stay was 1 day. Complications occurred in 38.3% of stent placements, with a single perioperative mortality resulting from massive hemorrhage on postoperative day 4. Most complications resulted from stent impaction (12.8%), migration (9.7%), or tumor ingrowth (5.3%). Tumor ingrowth was uncommon with uncovered stents (2 of 57; 3.5%). Stent migration was common with SEPS (4 of 7; 57%), or hybrid stents (2 of 3; 67%). Survival was short in patients with underlying malignancy (median 104 days for esophageal cancer and 48 days for lung cancer), with 20% of patients surviving less than 1 month.

CONCLUSIONS

Esophageal stent placement is safe and reliable. The goals of therapy are typically met with a single intervention. The majority of patients require no further interventions, though life expectancy often is short and patient selection may be difficult. Most complications are due to stent obstruction, though stent migration is an issue particularly with SEPS and hybrid stents. Esophageal surgeons should be adept at stent placement.

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.

Covered nitinol stents for the treatment of esophageal strictures and leaks

AIM: To compare 2 different types of covered esophageal nitinol stents (Ultraflex and Choostent) in terms of efficacy, complications, and long-term outcome.

METHODS: A retrospective review of a consecutive series of 65 patients who underwent endoscopic placement of an Ultraflex stent (n = 33) or a Choostent (n = 32) from June 2001 to October 2009 was conducted.

RESULTS: Stent placement was successful in all patients without hospital mortality. No significant differences in patient discomfort and complications were observed between the Ultraflex stent and Choostent groups. The median follow-up time was 6 mo (inter-quartile range 3-16 mo). Endoscopic reintervention was required in 9 patients (14%) because of stent migration or food obstruction. No significant difference in the rate of reintervention between the 2 groups was observed (P = 0.8). The mean dysphagia score 1 mo after stent placement was 1.9 ± 0.3 for the Ultraflex stent and 2.1 ± 0.4 for the Choostent (P = 0.6). At 1-mo follow-up endoscopy, the cover membrane of the stent appeared to be damaged more frequently in the Choostent group (P = 0.34). Removal of the Choostent was possible up to 8 wk without difficulty.

CONCLUSION: Ultraflex and Choostent proved to be equally reliable for palliation of dysphagia and leaks. Removal of the Choostent was easy and safe under mild sedation.

Thoracic complications and emergencies in oncologic patients

Oncology patients often experience urgent or emergent medical complications that are a direct or indirect result of the underlying malignant condition and are first identified or clarified on radiologic imaging studies. The aim of this review is to identify, discuss, and illustrate some of the major thoracic complications in patients with primary intrathoracic or extrathoracic neoplasms; particular focus is placed on issues in which radiologic imaging may have a significant impact on patient management, including superior vena cava (SVC) syndrome, post-obstructive pneumonia, diaphragmatic paralysis, pleural effusions, pericardial disease, tracheo-esophageal fistula, deep venous thrombosis, and pulmonary embolism.

A new approach to endoscopic treatment of tumors of the esophagogastric junction with individually designed self-expanding metal stents

The incidence of adenocarcinoma of the esophago-gastric junction is constantly increasing. Curative treatment is no longer possible at the time of diagnosis in more than 50% of patients with esophageal carcinoma, and palliative treatment focusing on eliminating dysphagia is required. Endoscopic therapy with stent implantation is an established method of achieving this. It can be carried out quickly, with a low rate of early complications, and leads to fast symptomatic improvement, assessed using the dysphagia score. The relatively high rate of late complications such as stent migration, hemorrhage, and gastroesophageal mucosal prolapse has led to recent debate on the role of metal stents in palliative therapy. We present here a new type of stent design for transcardial application, which is intended to prevent bleeding due to mechanical mucosal lesions caused by the distal end of the stent extending into the stomach. The further intention of this case report is to force the discussion on individually designed nitinol stents in special anatomic conditions.