Outcome and complications of long-term self-expanding esophageal stenting

Risk factors of stent migration in esophageal cancer patients who underwent fully-covered self-expanding metal stents for malignant dysphagia or tracheoesophageal fistula

BACKGROUND

More than 50% of esophageal cancer patients are diagnosed with advanced diseases and commonly experience dysphagia, some of whom even have tracheoesophageal fistula. Self-expandable metal stent (SEMS) is one of the recommended palliative methods, although complications such as chest pain and stent migration are not uncommon. The goal of this study was to examine the predictors of stent migration.

METHODS

We conducted a retrospective cohort study to include patients with esophageal cancer and dysphagia/tracheoesophageal fistula. Clinicopathological information, stent characteristics and patient outcomes were collected for analysis, while side-effects of SEMS were recorded, potential predictors were examined, and patients' nutritional outcomes were compared in the migration and non-migration groups.

RESULTS

A total of 54 patients with esophageal cancer who received fully covered SEMS between 2013 and 2022 were included. We found tumor across the esophagogastric junction (adjusted odds ratio (OR) = 32.64, P = 0.01) and the female sex (adjusted OR = 12.5, P = 0.02) were significant predictors for stent migration. There was a decreasing tendency in body mass index/body weight in migration and non-migration groups, but the former had a steeper downslope.

CONCLUSION

Fully covered SEMS is a safe and effective strategy to palliate dysphagia or fistula. Tumor across esophagogastric junction and the female sex were higher risk predictors of stent migration. A careful patient selection would optimize the effects of SEMS placement, especially in those with short-expected lifespan.

Nutritional Status and the Outcomes of Endoscopic Stenting in Benign and Malignant Diseases of Esophagus

BACKGROUND

Endoscopic stenting (ES) is a widely known method for palliative dysphagia treatment in esophageal strictures. Esophageal cancer is often associated with advanced malnutrition, which may increase the risk of complications of the procedure. The aim of this study was to evaluate complication rates and the impact of nutritional status on the outcomes of ES.

PATIENTS AND METHODS

A single-center retrospective study was conducted at Copernicus Hospital in Gdańsk, Poland. Adult patients who underwent endoscopic stenting between February 2014 and December 2018 were included. The influence of patient characteristics (age, sex, indications for esophageal stenting, and location of stenosis) and nutritional status (BMI, NRS 2002, GLIM, and dysphagia score) on complication rates and survival were analyzed.

RESULTS

Eighty-one patients (69% men) were enrolled in the study. In 69%, the indication for ES was malignancy (mainly esophageal cancer). The median dysphagia score significantly decreased from 2.8 to 0.6 after the procedure (p < 0.001). Complications were observed in 27% (n = 22) of the patients. Early complications were bleeding (2.5%), stent unexpansion (2.5%), and stent migration during the procedure (3.7%). There were no early fatal complications of the procedure. Late complications included: stent migration (6.2%), tissue overgrowth (6.2%), food impaction (2.2%), fistula formation (3.7%), bleeding (3.7%), and stent malposition (1.2%). A total of 76% of the participants scored ≥ 3 points in nutritional screening (NRS2002) and 70% were diagnosed with severe malnutrition (GLIM -stage 2). A stent diameter of < 2.2 cm compared with ≥ 2.2 was associated with a higher rate of migrations (15.5% vs. 2.5%). The median survival time in the malignant group was 90 days. Histopathological diagnosis and patients' nutritional status (BMI, NRS 2002, GLIM, and dysphagia score) had no significant effect on complication rates and survival after esophageal stent insertion.

CONCLUSIONS

Endoscopic stenting is a relatively safe procedure for the palliative treatment of esophageal strictures. Severe malnutrition, although common, does not affect the outcomes of the procedure.

Recent Updates in Gastrointestinal Stent Placement from the Esophagus to the Colon: A Radiological Perspective

Fluoroscopic-guided stent placement has become an advantageous treatment option for diverse gastrointestinal disorders. In addition to palliative stent placement in patients with inoperable cancers, stenting has gradually expanded to other conditions, including as a bridge to surgery, as well as in patients' benign lesions and anastomotic strictures or leaks. This narrative review describes the indications, efficacy and safety of stent placement from the esophagus to the colon, including current recommendations, recent updates, and novel stents.

A Novel and Simple Method of Managing Thoracic Esophageal Perforation: The "ASSIST" Approach

INTRODUCTION

Thoracic esophageal perforation (TEP) remains a therapeutic challenge that carries with it a high mortality. Because of its rare occurrence and management is complex, most patients are referred to higher level of care. Management is variable, ranging from a stent placement to an esophagectomy. Unfortunately, stent capabilities may not be readily available and the different surgical approaches can be complex, time-consuming, and demanding on a septic patient. Given these challenges, we conceived a simple 6-step (1) Antibiotics, (2) Suture the cervical esophagus with a 0- chromic, (3) Suture the abdominal esophagus with a 3-0 chromic, (4) Insert nasogastric tube above the sutured cervical esophagus, (5) Support nutrition with a jejunostomy, and (6) Tubes (placement of bilateral chest tubes).

METHODS

Six consecutive septic patients with TEP who underwent an ASSIST approach were evaluated. On day 14, patients were taken to the OR for an esophagogastroduodenoscopy to open the cervical and hiatal esophageal closure. Patients then underwent a repeat barium swallow prior to resuming per oral (PO) intake.

RESULTS

Sepsis resolved in all patients. One patient died of advanced cirrhosis. None of the living patients required additional surgery and all resumed a normal diet.

CONCLUSIONS

The "ASSIST" method is a viable option for managing septic patients with thoracic esophageal perforation. This novel approach does not require a high level of technical expertise and conceivably be performed by most centers without the need for immediate transfer to specialized facilities.

The addition of flexible endoscopic suturing to stenting for the management of transmural esophageal wall defects: a single tertiary center experience

BACKGROUND AND AIMS

Endoscopic stenting is the standard of care for full thickness esophageal wall defects. The aim of this study is to evaluate outcomes of endoscopic closure of esophageal defects using stenting, with or without endoscopic suturing.

METHODS

This is a single-center retrospective study of patients with esophageal wall defects who underwent endoscopic interventions. Outcomes of stenting with or without endoscopic suturing of the defect were assessed. Univariate and multivariate logistic regression models were used to examine factors associated with successful defect closure.

RESULTS

One hundred and fourteen patients with esophageal wall defects underwent 254 endoscopies with an overall complete closure rate of 75.8%. Twenty-three (20.2%) patients underwent primary closure using endoscopic suturing and subsequent esophageal stenting, while 91 (79.8%) underwent esophageal stenting only. The dual modality group (versus the stent-only group) had similar defect closure rates (84.2 vs. 73.8%, p = 0.55) and time to stent migration (37 vs. 12.5 days, p = 0.07), but was associated with longer procedure times (60 vs. 36 min, p < 0.01) and fewer additional endoscopic procedures (13.6 vs. 43.2%, p = 0.01). Stent suturing significantly decreased migration (35.5 vs. 58.5%, p = 0.04), was associated with fewer additional endoscopies (15.4 vs. 50%, p < 0.01) and reduced need for additional stents (7.7 vs. 34.3%, p < 0.01). On multivariate analysis, chronic defects (> four weeks old) were 81% less likely to close compared to acute (≤ 4 weeks) defects (OR 0.19, CI 0.04-0.77, p = 0.02), and large diameter stents (23 mm) were associated with higher odds of defect closure (OR 3.36, CI 1.02-11.4, p = 0.04).

CONCLUSION

Endoscopic treatment of esophageal wall defects is safe, effective, and more likely to be successful in acute defects using larger caliber stents. Stent suturing reduces migration, need for additional endoscopic procedures, and stent exchanges. Further comparative studies with larger cohorts are needed to validate our results.

Fully covered self-expandable esophageal metallic stents in patients with inoperable malignant disease who survived for more than 6 months after stent placement

OBJECTIVES

To investigate the clinical outcomes of fully covered self-expanding metal stent (FCSEMS) placement in patients with malignant esophageal obstruction who survived longer than 6 months.

METHODS

From January 2002 to January 2018, 88 FCSEMS were placed in 64 patients (mean age 62.9 ± 11.6 years; 58 males) with inoperable malignant esophageal obstruction with or without esophago-respiratory fistula. Only patients who survived more than 6 months with FCSEMS in place were included. Data regarding technical and clinical success, complications, reinterventions, stent patency, and patient survival were obtained from a prospectively maintained hospital database.

RESULTS

The technical and clinical success rates were 100 % (64/64). During follow-up, the median dysphagia score significantly improved (3.09 ± 0.68 to 1.05 ± 0.60, p < 0.001). The complication rate was 48.8 %. Multivariate analysis revealed that only longer stenting duration was associated with complications [hazard ratio = 1.220, 95 % confidence interval (CI) (1.074-2.760), p = 0.039]. The median follow-up duration was 257 days (range, 181-969). The median stent patency duration was 289 days [95% CI (209.9-368.1)]. The median survival was 254 days [95% CI (219.7-288.3)].

CONCLUSIONS

Our data suggest that esophageal FCSEMS placement is an effective option for patients with malignant dysphagia when survival longer than 6 months is expected. The rate of complications increases with time, and SEMS development is needed to keep up with the advancement in oncological treatment.

ADVANCES IN KNOWLEDGE

Fully covered esophageal self-expandable stent placement is effective in patients surviving more than 6 months, however, the rate of complications also increases. SEMS development is needed to cope with the advancement in oncological treatment.

Palliative interventions for patients with incurable locally advanced or metastatic thoracic esophageal carcinoma

BACKGROUND

The aim of this study was to assess the clinical outcomes of palliative interventions for patients with incurable locally advanced or metastatic esophageal carcinoma.

METHODS

A total of 131 patients with thoracic esophageal carcinoma who underwent palliative interventions were enrolled. Insertion of a self-expandable metallic stent (SEMS), tube enterostomy for enteral nutrition (EN), and palliative esophagectomy (PE) were performed in 38, 65, and 28 patients, respectively. The clinicopathological characteristics and clinical outcomes of each group were retrospectively reviewed.

RESULTS

Patients in the EN group frequently received chemoradiotherapy (P < 0.01). SEMS insertion, but not PE or EN, improved the mean dysphagia score after the intervention (P < 0.01). For the SEMS, EN, and PE groups, the occurrence of intervention-related complications was 31.6, 10.8, and 96.4%, respectively, the median survival time was 88, 208, and 226 days (P < 0.01), and the mean ratio of duration of home care to survival time was 28.9, 38.5, and 39.6% (P = 0.95).

CONCLUSIONS

SEMS insertion effectively relieved obstructive symptoms, but had no survival benefit. Tube enterostomy showed a low complication rate and has the potential to improve survival in combination with additional treatment, with no palliation of obstructive symptoms.

Performance status is a predictive factor of dysphagia improvement after esophageal stenting in patients with malignant esophageal strictures and fistulas

BACKGROUND

Malignant strictures and fistulas of the esophagus adversely affect quality of life (QOL) and prognosis, and stenting is considered a useful therapy for improving QOL. However, the predictive factors for improving dysphagia after esophageal stenting are unclear. This retrospective cohort study aimed to evaluate patients with esophageal malignant strictures and fistulas who underwent stenting and investigate the factors for dysphagia improvement after stenting.

METHODS

Twenty-four patients with malignant esophageal strictures and fistulas were treated with a self-expandable metallic stent over a period of 5 years and 6 months. The main outcome was improvement in the dysphagia score. We divided the patients into dysphagia improved and non-improved groups after esophageal stenting. Sex, age, cause of stenting (primary or non-primary esophageal cancers), prior treatments, such as chemotherapy and radiation, type of esophageal stents (covered or non-covered), dysphagia score before stenting, and Eastern Cooperative Oncology Group (ECOG) performance status (PS) of the patients before stenting were evaluated. Student's t test and Fisher's exact test were used for continuous and categorical variables, respectively. Factors with a P value < 0.2, age, and sex were included and evaluated using a multiple logistic regression model. Statistical significance was defined as a P value < 0.05.

RESULTS

Stent placements succeeded in all cases without fatal complications. The dysphagia score improved in 15 patients. Twelve patients had primary lesions, and another 12 had non-primary lesions. The reasons for stenting were malignant strictures in 20 patients and esophageal fistulas in 4 patients. There were no significant differences in any factors, except PS before stenting (P = 0.003), between the improved and non-improved groups. Multiple logistic regression analysis results demonstrated that improvement in the dysphagia score was significantly associated with PS before stenting (adjusted odds ratio = 0.035, 95% CI 0.003-0.44, P = 0.009).

CONCLUSIONS

Esophageal stenting is safe and effective in patients with malignant esophageal strictures and fistulas. PS is an independent factor for dysphagia improvement after stenting.

Self-expandable metal stents are a valid option in long-term survivors of advanced esophageal cancer

BACKGROUND

self-expandable metal stents are often used for the palliative treatment of dysphagia in patients with advanced esophageal cancer and an anticipated limited survival. Due to previous reports of a high rate of adverse event when used long-term, concerns have been raised with regard to the use of self-expandable metal stents in patients with a longer survival.

AIM

assess the role of esophageal self-expandable metal stents in patients with advanced esophageal cancer that have survived longer than six months.

METHODS

retrospective study of patients with advanced esophageal cancer with a self-expandable metal stent and a stent placement time greater than six months.

RESULTS

forty-two patients were followed up for 298 days. There was a clinical improvement in all patients. However, 59% of patients experienced an adverse event. The median stent patency was 236 days. Endoscopic management was attempted in all self-expandable metal related adverse events, with a clinical success rate of 100%. However, the previously treated adverse event recurred in seven patients. Multivariate analysis showed that strictures that were traversable with an ultrathin gastroscope were associated with a higher risk of adverse events (p = 0.035).

CONCLUSIONS

long-term esophageal stenting in patients with advanced esophageal cancer is associated with a high prevalence of adverse events without an impact on mortality; most cases can be managed endoscopically.

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.

Self-expandable metal stent for malignant esophagorespiratory fistula: predictive factors associated with clinical failure

BACKGROUND AND AIMS

Malignant esophagorespiratory fistulas (MERFs) usually are managed by the placement of self-expandable metal stents (SEMSs) but with conflicting results. This study aimed to identify risk factors associated with clinical failure after SEMS placement for the treatment of MERFs.

METHODS

This was a retrospective analysis of a prospectively maintained database used at a tertiary-care cancer hospital, with patients treated with SEMS placement for MERFs between January 2009 and February 2016. Logistic regression was used to identify predictive factors for clinical outcomes and to estimate the odds ratio (OR) and the 95% confidence interval (CI). The Kaplan-Meier method was used for survival analysis, and comparisons were made by using the log-rank test.

RESULTS

A total of 71 patients (55 male, mean age 59 years) were included in the study, and 70 were considered for the final analysis (1 failed stent insertion). Clinical failure occurred in 44% of patients. An Eastern Cooperative Oncology Group (ECOG) performance status of 3 or 4 and fistula development during esophageal cancer treatment were associated with an increased risk of clinical failure. ECOG status of 3 or 4, pulmonary infection at the time of SEMS placement, and prior radiation therapy were predictive factors associated with lower overall survival. Dysphagia scores improved significantly 15 days after stent insertion. The overall stent-related adverse event rate was 30%. Stent migration and occlusion caused by tumor overgrowth were the most common adverse events.

CONCLUSION

SEMS placement is a reasonable treatment option for MERFs; however, ECOG status of 3 or 4 and fistula development during esophageal cancer treatment may be independent predictors of clinical failure after stent placement.

Feasibility of esophageal stent fixation with an over-the-scope-clip for malignant esophageal strictures to prevent migration

BACKGROUND AND STUDY AIMS

 Fixation of an esophageal self-expandable metal stent (SEMS) with an over-the-scope-clip (OTSC) system for a benign stricture to prevent migration has been reported. However, the efficacy of SEMS fixation with an OTSC for malignant esophageal stricture remains unclear. The aim of this retrospective study was to evaluate the feasibility of SEMS fixation with an OTSC for a malignant esophageal stricture.

PATIENTS AND METHODS

Twelve patients who underwent esophageal SEMS placement and fixation with an OTSC for a malignant esophageal stricture were included in this retrospective study. The primary endpoint was technical success. The secondary endpoint was clinical success, which was defined as an improvement of at least 1 grade in the dysphagia score 1 week after SEMS placement or changes in the dysphagia score from before SEMS placement to 1 week after SEMS placement.

RESULTS

 The technical success rate was 100 %. The clinical success rate was 92.3 %. In 6 mild stricture cases in which a standard peroral endoscope could be used, no migration of the SEMS was observed. The median dysphagia score before and at 1 week after SEMS placement was 3 (range 2 - 4) and 0 (0 - 4), respectively, which indicated improvement at 1 week after SEMS placement compared with before SEMS placement ( P  = 0.002). There were no adverse events associated with placement of SEMS and deployment of an OTSC.

CONCLUSIONS

SEMS fixation with an OTSC is feasible for prevention of migration due to a malignant esophageal stricture.

Adverse events of self-expandable esophageal metallic stents in patients with long-term survival from advanced malignant disease

BACKGROUND AND AIMS

Self-expandable metallic stents are considered the best palliative treatment of dysphagia for patients with advanced esophageal cancer. Adverse events (AEs) are a major concern, especially in patients with better prognosis and longer survival. The present study aimed to evaluate the AEs of patients who survived longer than 6 months with esophageal stents in place.

METHODS

This is a retrospective analysis of a prospectively collected database including all patients submitted to esophageal stent placement for the palliation of malignant diseases during the period from February 2009 to February 2014 at a tertiary care academic center who had stents longer than 6 months.

RESULTS

Sixty-three patients were included. Mean follow-up was 10.7 months. Clinical success was achieved in all patients, and the median stent patency was 7.1 months. AEs occurred in 40 patients (63.5%), totaling 62 AEs (mean, 1.5 AEs per patient). Endoscopic management of AEs was successful in 84.5% of cases, with a mean of 1.6 reinterventions per patient. The univariate analysis revealed that performance status, age, and post-stent radiotherapy presented a trend to higher risk of AEs. The multivariate analysis revealed that only performance status was associated with AEs (P = .025; hazard ratio, 4.1).

CONCLUSIONS

AEs are common in patients with long-term esophageal stenting for malignancy. However, AEs were not related to higher mortality rate, and most AEs could be successfully managed by endoscopy. Only performance status was a risk factor for AEs. Our data suggest that metallic stenting is a valid option for the treatment of malignant esophageal conditions, even when survival longer than 6 months is expected.

Novel stent in the palliation of malignant esophageal strictures: a retrospective study

The placement of metal stents is often used as a palliative treatment for malignant esophageal stenosis. We designed a novel stent that has been used clinically since 2011, and we therefore performed a retrospective study to compare the therapeutic effects of this novel metal stent to a conventional partially covered metal stent in patients with malignant esophageal strictures. The records of 201 consecutive patients who underwent placement of either the conventional partially covered metal stents (Group A, n = 92) or the new metal stents (Group B, n = 109) in the Endoscopy Center of General Hospital of Chengdu Military Command from October 2008 to March 2013 were reviewed. The median dysphagia score significantly improved in both groups 1 week following stent placement (P < 0.001). No significant differences were observed in success rate (P = 0.910) or the complication rate (P = 0.426) between groups. Six months after stent placement, recurrent dysphagia due to stent migration, tissue ingrowth or overgrowth or food obstruction occurred in 45% and 29% of patients in the conventional stent and new stent groups, respectively. The results of this retrospective study indicate that the new modified self-expandable metal stents (SEMS) is at least as safe and effective as the conventional partially covered SEMS in treatment of malignant esophageal strictures.

Unintentional Long-Term Esophageal Stenting due to a Complete Response in a Patient with Stage UICC IV Adenocarcinoma of the Gastroesophageal Junction

Endoscopic stent implantation is a common short-treatment option in palliative settings in patients with esophageal cancer. Advanced disease is associated with low survival rates; therefore, data on the long-term outcome are limited. So far, cases of long-term remission or even cure of metastasized adenocarcinoma of the gastroesophageal junction or stomach (AGS) have only been reported from Asia. A 51-year-old male patient primarily diagnosed with metastasized adenocarcinoma of the gastroesophageal junction (GEJ) [type I, cT3cN+cM1 (hep), CEA positive, UICC stage IV] received palliative esophageal stenting with a self-expandable metal stent. As disease progressed after four cycles with epirubicin, oxaliplatin, and capecitabin, treatment was changed to 5-FU and Irinotecan. The patient did not return after 5 cycles of FOLFIRI, but presented 4 years later with mild dysphagia. Endoscopy surprisingly revealed no relevant stenosis or stent migration. Repeated histological analyses of a residual mass at the GEJ did not detect malignancy. Since the initially diagnosed hepatic metastases were no longer detectable by computed tomography, cure from esophageal cancer was assumed. Dysphagia was ascribed to esophageal motility disorder by a narrowed esophageal lumen after long-term stenting. Thus, endoscopic stent implantation is an important method in palliative treatment of dysphagia related to AGS. New systemic treatment strategies like trastuzumab in Her2neu positive cases or new VEGF-inhibitors like ramucirumab will lead to more long-time survivors with AGS. In conclusion, future endoscopic treatment strategies in AGS represent a challenge for the development of new stent techniques in either extraction or programmed complete dissolution.

Gastrointestinal stenting: Current status and imaging features

The use of stents in the gastrointestinal tract has been subjected to major changes. Initially, the use of stents was restricted to malignant strictures in patients with metastatic disease. But thanks to reduction of the morbidity and mortality rates, they are now used with curative intention and in patients with benign diseases after careful selection. However, for patients presenting with colon obstruction due to an advanced colon carcinoma, the mortality and morbidity are still high. The purpose of this review is to provide an overview of indications, techniques and further developments of the stents in the gastrointestinal tract and to highlight the predominant role of multidetector row computed tomography (MDCT) in the detection of potential complications.

Small bowel perforation due to a migrated esophageal stent: Report of a rare case and review of the literature

•

Palliation of dysphagia with esophageal stenosis via esophageal stent placement is an effective procedure.

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Migration is one of the most common complication after stent placement.

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The lumen of stent is often allow to the passage in the intestine, so symptoms may develop much later.

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Intestinal perforation is a rare but serious complication of stent migration.

Introduction

Endoscopic esophageal stent placement is used to treat benign strictures, esophageal perforations, fistulas and for palliative therapy of esophageal cancer. Although stent placement is safe and effective method, complications are increasing the morbidity and mortality rate. We aimed to present a patient with small bowel perforation as a consequence of migrated esophageal stent.

Presentation of case

A 77-years-old woman was admitted with complaints of abdominal pain, abdominal distension, and vomiting for two days. Her past medical history included a pancreaticoduodenectomy for pancreatic tumor 11 years ago, a partial esophagectomy for distal esophageal cancer 6 months ago and an esophageal stent placement for esophageal anastomotic stricture 2 months ago. On abdominal examination, there was generalized tenderness with rebound. Computed tomography showed the stent had migrated. Laparotomy revealed a perforation localized in the ileum due to the migrated esophageal stent. About 5 cm perforated part of gut resected and anastomosis was done. The patient was exitus fifty-five days after operation due to sepsis.

Discussion

Small bowel perforation is a rare but serious complication of esophageal stent migration. Resection of the esophagogastric junction facilitates the migration of the stent. The lumen of stent is often allow to the passage in the gut, so it is troublesome to find out the dislocation in an early period to avoid undesired results. In our case, resection of the esophagogastric junction was facilitated the migration of the stent and late onset of the symptoms delayed the diagnosis.

Conclusion

Patients with esophageal stent have to follow up frequently to preclude delayed complications. Additional technical procedures are needed for the prevention of stent migration.

Covered self-expanding metal stents for the treatment of refractory esophageal nonvariceal bleeding: a case series

INTRODUCTION

This study aimed to assess the safety and effectiveness of covered self-expanding metal stents for the treatment of nonvariceal esophageal bleeding in patients for whom routine therapies have failed.

PATIENTS AND METHODS

A retrospective analysis was conducted on patients with esophageal bleeding in our hospital. Data on hemostatic effects and complications were collected from patients who underwent esophageal stenting.

RESULTS

In total, 4 patients were treated with five stents. In all 4 patients, the placement of esophageal stents immediately stopped the ongoing bleeding. One patient experienced recurrent bleeding 4 days after the removal of the first stent. Hemostasis was achieved after the insertion of a second stent. No stent-related complications occurred during or after stent implantation in the other 3 patients.

CONCLUSIONS

The implantation of a covered self-expandable metal stent is a safe and effective alternative to treat acute, nonvariceal esophageal bleeding after routine therapies have failed.

Treatment of esophageal leaks, fistulae, and perforations with temporary stents: evaluation of efficacy, adverse events, and factors associated with successful outcomes

BACKGROUND

Factors associated with successful endoscopic therapy with temporary stents for esophageal leaks, fistulae, and perforations (L/F/P) are not well known.

OBJECTIVES

To evaluate the safety, efficacy, and outcomes of esophageal stenting in these patients and identify factors associated with successful closure.

DESIGN

Retrospective.

SETTING

Academic tertiary referral center.

PATIENTS

All patients with attempted stent placement for esophageal L/F/P between January 2003 and May 2012.

INTERVENTION

Esophageal stent placement and removal.

MAIN OUTCOME MEASUREMENTS

Factors predictive of therapeutic success defined as complete closure after index stent removal (primary closure) or after further endoscopic stenting (secondary closure).

RESULTS

Sixty-seven patients with 132 attempted stents for esophageal L/F/P were considered; 13 patients were excluded. Among the remaining 54 patients, 117 stents were placed for leaks (29 patients; 64 stents), fistulae (15 patients; 36 stents), and perforations (10 patients; 17 stents). Procedural technical success was achieved in all patients (100%). Primary closure was successful in 40 patients (74%) and secondary closure in an additional 5 (83% overall). On short-term (<3 months) follow-up, 27 patients (50%) were asymptomatic, whereas 22 (41%) had technical adverse events, including stent migration in 15 patients (28%). Factors associated with successful primary closure include a shorter time between diagnosis of esophageal L/F/P and initial stent insertion (9.03 vs 22.54 days; P = .003), and a smaller luminal opening size (P = .002).

LIMITATIONS

Retrospective, single-center study.

CONCLUSIONS

Temporary stents are safe and effective in treating esophageal L/F/P. Defect opening size and time from diagnosis to stent placement appear to be candidate predictors for successful closure.

Endoscopic management and prevention of migrated esophageal stents

The use of self-expandable metallic stents has increased recently to palliate inoperable esophageal neoplasia and also in the management of benign strictures. Migration is one of the most common complications after stent placement and the endoscopist should be able to recognize and manage this situation. Several techniques for managing migrated stents have been described, as well as new techniques for preventing stent migration. Most stents have a "lasso" at the upper flange which facilitates stent repositioning or removal. An overtube, endoloop and large polypectomy snare may be useful for the retrieval of stents migrated into the stomach. External fixation of the stent with Shim's technique is efficient in preventing stent migration. Suturing the stent to the esophageal wall, new stent designs with larger flanges and double-layered stents are promising techniques to prevent stent migration but they warrant validation in a larger cohort of patients.

Establishing a rabbit model of malignant esophagostenosis using the endoscopic implantation technique for studies on stent innovation

Background

Stents are recommended in patients with dysphagia caused by esophageal stricture, but an ideal stent does not currently exist. Thus, studies on new esophageal stents are necessary, and suitable animal models are desperately needed for these studies. The aim of this study was to establish a model of malignant esophageal stricture in rabbit for studies on stent innovation.

Methods

A total of 38 New Zealand white rabbits were used in this study. Using the endoscopic submucosal injection technique, VX2 fragments were inoculated into the submucosal layer of the rabbit thoracic esophagus, and an endoscopic follow-up was subsequently performed to observe the tumor development and progression. The self-expandable metal stents were randomly deployed in rabbits with severe esophageal stricture to investigate the safety and feasibility of the animal models for stenting.

Results

An endoscopic implantation procedure for VX2 tumors was completed in 34/38 rabbits, and tumor development was confirmed in 30/34 animals. The success rate of the endoscopic implantation and tumor development were 89.4% (95% CI, 79.6% to 99.2%) and 88.2% (95% CI, 76.9% to 99.5%) respectively. During the endoscopic follow-up period, severe esophageal stricture occurred in 22/30 rabbits with a rate of 73.3% (95% CI, 57.5% to 89.1%), and 12/22 models received stent placement. During and after stent implantation, no severe stent-related complication or mortality occurred in the animal models. The rabbits that received stent placement survived longer than those without stent implantation (the mean survival time: 53.9 days versus 40.3 days, P = 0.016).

Conclusion

The endoscopic method is a safe and effective method for establishing a malignant esophagostenosis model in rabbits. This model can simulate the human body environment for stent deployment and is an excellent tool for the study of stent innovation for the treatment of esophageal cancer.

Auxetic oesophageal stents: structure and mechanical properties

Oesophageal cancer is the ninth leading cause of malignant cancer death and its prognosis remains poor, ranking as the sixth most frequent cause of death in the world. This research work aims to adopt an Auxetic (rotating-squares) geometry device, that had previously been examined theoretically and analysed by Grima and Evans (J Mater Sci Lett 19(17):1563-1565, 2000), to produce a novel Auxetic oesophageal stent and stent-grafts relevant to the palliative treatment of oesophageal cancer and also for the prevention of dysphagia. This paper discusses the manufacture of a small diameter Auxetic oesophageal stent and stent-graft. The oral deployment of such an Auxetic stent would be simplest if a commercial balloon dilatational catheter was used as this obviates the need for an expensive dedicated delivery system. A novel manufacturing route was employed in this research to develop both Auxetic films and Auxetic oesophageal stents, which ranged from conventional subtractive techniques to a new additive manufacturing method. Polyurethane was selected as a material for the fabrication of Auxetic films and Auxetic oesophageal stents because of its good biocompatibility and non-toxicological properties. The Auxetic films were later used for the fabrication of seamed Auxetic oesophageal stents. The flexible polyurethane tubular grafts were also attached to the inner luminal side of the seamless Auxetic oesophageal stents, in order to prevent tumour in-growth. Scanning electron microscopy was used to conduct surface morphology study by using different Auxetic specimens developed from different conventional and new additive manufacturing techniques. Tensile testing of the Auxetic films was performed to characterise their mechanical properties. The stent expansion tests of the Auxetic stents were done to analyse the longitudinal extension and radial expansion of the Auxetic stent at a range of radial pressures applied by the balloon catheter, and to also identify the pressure values where the Auxetic stent fails. Finite element models of both Auxetic film and Auxetic stent were developed, and the results were compared with experimental results with a good agreement. The tensile testing of the Auxetic polyurethane films revealed that the Poisson's ratio of the sample ranged between -0.87 and -0.963 at different uniaxial tensile load values. From the stent expansion test, it was found that the Auxetic oesophageal stent radially expanded from 0.5 to 5.73 mm and longitudinally extended from 0.15 to 1.83 mm at a range of applied pressure increments (0.5-2.7 bar) from the balloon catheter.

Recent progress in treatment of achalasia

Achalasia is a rare primary esophageal motility disorder characterized by impaired relaxation of the lower esophageal sphincter, absent or decreased esophageal peristaltic waves and synchronous contractions. As the exact pathogenesis of the disease remains unclear, treatment options focus on the alleviation of the functional obstruction caused by lower esophageal sphincter and prevention of gastroesophageal reflux disease at the same time. Treatment modalities include pharmacological therapy, interventional therapy, surgical treatment and spinal rotation massage. This article reviews the latest progress in treatment of achalasia, with particular emphasis on the evolution of main treatments which include endoscopic pneumatic dilation, Heller myotomy and per-oral endoscopic myotomy (POEM).