Through-the-scope esophageal stent for the relief of malignant dysphagia: Results of a multicentric study (with video)

A Comprehensive Analysis of Reported Adverse Events and Device Failures Associated with Esophageal Self-Expandable Metal Stents: An FDA MAUDE Database Study

INTRODUCTION

Esophageal Stents are used to maintain esophageal lumen patency in esophageal strictures caused by intrinsic and/or extrinsic malignancies and the occlusion of concomitant esophageal fistulas. While data on the efficacy and safety of esophageal stents exist, comprehensive evaluation of adverse events is limited. The aim of this study is to investigate the reported adverse events and device failures associated with esophageal self-expandable metal stents (SEMS) using the FDA's Manufacturer and User Facility Device Experience (MAUDE) database.

METHODS

Post-marketing surveillance data for the esophageal SEMSs were analyzed using the FDA's MAUDE database from January 2014 to December 10, 2023. The outcomes of interest were patient-related adverse events and device failures. Statistical analysis was performed using Microsoft Excel 2010 and SPSS. Pooled numbers and percentages were calculated for each adverse event. Continuous variables underwent analysis using a two-tailed student t test, and significance was set to p ≤ 0.05.

RESULTS

During the study period, 548 MAUDE reports revealed 873 device failures and 186 patient-related adverse events. The most common device issues were stent activation, positioning, or separation problems (4 n = 403; 46.2%), followed by device detachment or migration (n = 109, 12.5%), and material problems (n = 93, 10.7%). Patient complications included dysphagia/odynophagia (10%), perforation, pain, and bleeding (each 7.6%). The most common device failures in over-the-wire (OTW) stents and through-the-scope (TTS) stents were activation, positioning, or separation problems (TTS: n = 183, 52.6% vs OTW: n = 220, 41.9%). Compared to OTW stents, TTS stents had higher migration and breakage (13.5% vs. 11.8%, p = 0.24), and (9.2% vs. 6.7%, p = 0.08) respectively, while OTW stents had more challenges with stent advancement or removal (5.1% vs. 0.3%, p < 0.001 and 4.6% vs 3.4%, p = 0.19, respectively) and material problems (14.7% vs. 4.6%, p < 0.001). Activation, positioning, and separation problems were the most frequent device failures in fully covered (FC) and partially covered (PC) stents (FC: n = 62, 32.8%, PC: n = 168, 43.5%). FC stents had higher migration rates (20.6% vs 9.8%, p < 0.001), while PC stents exhibited more material problems (17.4% vs. 5.8%, p < 0.001) and difficulties with advancing the stents (6.7% vs. 0%, p < 0.001).

CONCLUSION

Our examination showed a prevalence of reported device complications associated with stent activation, positioning, and separation problems. Dysphagia or odynophagia emerged as the most frequently reported patient complication. Furthermore, our analysis, provides insights into TTS vs. OTW and FC vs. PC esophageal SEMSs, enabling endoscopists and manufacturers to better understand adverse events and potentially optimize device design for future iterations.

The endoscopic management of oesophageal strictures

An oesophageal stricture refers to a narrowing of the oesophageal lumen, which may be benign or malignant. The cardinal feature is dysphagia, and this may result from intrinsic oesophageal disease or extrinsic compression. Oesophageal strictures can be further classified as simple or complex depending on stricture length, location, diameter, and underlying aetiology. Many endoscopic options are now available for treating oesophageal strictures including dilatation, injectional therapy, stenting, stricturotomy, and ablation. Self-expanding metal stents have revolutionised the palliation of malignant dysphagia, but oesophageal dilatation with balloon or bougienage remains first-line therapy for most benign strictures. The increase in endoscopic and surgical interventions on the oesophagus has seen more benign refractory oesophageal strictures that are difficult to treat, and often require advanced endoscopic techniques. In this review, we provide a practical overview on the evidence-based management of both benign and malignant oesophageal strictures, including a practical algorithm for managing benign refractory strictures.

Endoscopic Management of Refractory Benign Esophageal Strictures

Benign esophageal strictures are commonly encountered in clinical practice. The principal etiologies of benign esophageal strictures include long term acid reflux, caustic injuries, eosinophilic esophagitis, anastomotic strictures or endoscopic therapy. Dysphagia is most prominently present in esophageal strictures along with a variety of other symptoms which depend on the stricture etiology. Benign esophageal strictures can be categorized into two groups: simple or complex depending on their structure. Most strictures can be treated successfully with endoscopic dilation by bougies or balloons dilators. In some cases, treatment is more challenging, involving a higher risk of the patient developing recurrent or refractory strictures. To improve symptoms in these patients, other endoscopic treatments such as steroid injection, incisional therapy and stent placement should be considered. In this manuscript, we provide a comprehensive review of the main treatment options currently available to manage recurrent benign esophageal strictures.

Meta-analysis of efficacy and complications of intraluminal radioactive stent and common covered stent in treatment of advanced esophageal cancer

BACKGROUND

The main symptom of advanced esophageal cancer is dysphagia. Because there is no indication for surgery, in order to improve the patient's symptoms and quality of life, esophageal stent therapy has become the main palliative treatment. Based on the results of many studies, it can be speculated that intraluminal radioactive stent is better since it combines the function of ordinary stent and brachytherapy.

AIM

To evaluate the difference in the curative effect and complications between intraluminal radioactive stent (iodine 125 particle scaffold) and common covered stent in patients with mid-advanced esophageal cancer.

METHODS

A computer search of the electronic databases PubMed (1989/2020-03), Web of Science (2000/2020-03), Wiley Online Library (1992/2020-03), CNKI database (1978/2020-03), Wanfang database (1997/2020-03), and VIP database (2000/2020-03) and a manual search of Cochrance library were performed to retrieve articles using the method recommended by the Cochrance System Evaluator's Manual (version 4.2.2). The Oxford's 2011 evidence level assessment was used to evaluate the quality of the included articles, and Meta-analysis was performed using Revman 5.3 software.

RESULTS

Ten articles were finally included, with a total of 943 patients involved. Among the patients, 449 were implanted with an intraluminal radioactive stent and 494 were implanted with a common covered stent. A meta-analysis of 10 articles showed that the average survival time of the intraluminal radioactive stent group was 3.91 mo longer than that of the common covered stent group (95%CI: 1.68-6.13, Z = 3.44, P = 0.0006), and the median survival time was 3.12 mo longer 95%CI: 1.78-4.47, Z = 4.57, P = 0.0001). The dysphagia scores of the two groups of patients were significantly reduced within 1 and 3 mo after the stent was placed (P < 0.05), but there was no statistical difference between the two groups (P > 0.05). After stenting, there was no statistically significant difference in the incidence of pain (odds ratio [OR] = 0.89, 95%CI: 0.65-1.21, Z = 0.77, P = 0.44), bleeding (OR = 0.80, 95%CI: 0.52-1.22, Z = 1.03, P = 0.30), perforation (OR = 1.16, 95%CI: 0.55-2.43, Z = 0.39, P = 0.70), or stent displacement (R = 0.66, 95%CI: 0.31-1.38, Z = 1.10, P = 0.27) between the intraluminal radioactive stent group and the common covered stent group; but there was a statistical difference in the incidence of restenosis [OR = 0.61 , 95%CI (0.42-0.87), Z = 3.73 P = 0.006] between them.

CONCLUSION

The use of intraluminal radioactive stent in the treatment of advanced esophageal cancer can prolong the average survival time and median survival time of patients, and signficantly reduce the incidence of restenosis after surgery; however, the two types of stents have no significant difference in relieving the symptoms of dysphagia within 1-3 mo or in reducing postoperative complications such as pain, hemorrhage, perforation, and stent displacement.