Palliation of malignant esophageal obstruction due to intrinsic and extrinsic lesions with expandable metal stents

Endoscopic luminal stenting: Current applications and future perspectives

Endoscopic luminal stenting (ELS) represents a minimally invasive option for the management of malignant obstruction along the gastrointestinal tract. Previous studies have shown that ELS can provide rapid relief of symptoms related to esophageal, gastric, small intestinal, colorectal, biliary, and pancreatic neoplastic strictures without compromising cancer patients’ overall safety. As a result, in both palliative and neoadjuvant settings, ELS has largely surpassed radiotherapy and surgery as a first-line treatment modality. Following the abovementioned success, the indications for ELS have gradually expanded. To date, ELS is widely used in clinical practice by well-trained endoscopists in managing a wide variety of diseases and complications, such as relieving non-neoplastic obstructions, sealing iatrogenic and non-iatrogenic perforations, closing fistulae and treating post-sphincterotomy bleeding. The abovementioned development would not have been achieved without corresponding advances and innovations in stent technology. However, the technological landscape changes rapidly, making clinicians’ adaptation to new technologies a real challenge. In our mini-review article, by systematically reviewing the relevant literature, we discuss current developments in ELS with regard to stent design, accessories, techniques, and applications, expanding the research basis that was set by previous studies and highlighting areas that need to be further investigated.

Stenting as a Bridge to Surgery or a Palliative Treatment

Endoscopic stenting of the colorectum has emerged as a viable alternative to surgical interventions in a selected group of patients. The main indication for stenting is bowel obstruction. As such stenting can be used to palliate patients with metastatic disease or bridge patients to surgical intervention. The main advantages of stenting in the emergency setting include lower morbidity and mortality, lower incidence of stoma formation, shorter hospitalization, and better quality of life. For patients with unresectable disease and short life expectancy, stenting can be considered. However, for patients with longer life expectancy, the potential long-term complications of a metal stent such as erosion, migration, or obstruction have engendered debate whether such patients are better served by operative intervention. Stenting as a bridge to surgery is an alternative to surgery in patients who are high risk for emergency surgery but concerns remain regarding its impact on oncologic outcome in potentially curable patients.

Self-expandable metal stent for dysphagia caused by mediastinal masses in patients with lung cancer

BACKGROUND AND STUDY AIMS

We intended to evaluate the role of self-expandable metal stents (SEMS) for palliation of malignant dysphagia in patients with lung cancer.

PATIENTS AND METHODS

During the period between May 2015 and September 2017, 42 SEMS have been placed for malignant dysphagia in patients with lung cancer. Stents have been placed under combined fluoroscopic and endoscopic guidance.

RESULTS

Data from 42 patient were analysed. 35 patients (83%) were males and the mean age was 68,4 years (range 52-80 y). In 26 patients (61%) cause of dysphagia was extraluminal mediastinal lymphadenopathy and in others direct tumour infiltration of the oesophagus. A tracheo-oesophageal fistula (TEF) was seen in 8 patients (19%). Most of the patients (32 patients; 76%) had stage 3 dysphagia (able to swallow liquids only) and the rest (10 patients; 24%) stage 4 (unable to swallow saliva). Thirty stents (71%) were partially covered and 12 (29%) were fully covered. Five (12%) stents have been placed across the oesophagogastric junction due to infiltration of the cardia. There were no immediate complications except for aspiration pneumonia in 3 (7%) and minor bleeding in 2 (5%) patients which resolved spontaneously. Dysphagia score improved in all patients to stage 1 (dysphagia with certain solid food in 16 patients-38%) or stage 2 (able to swallow semi solid in 26 patients-62%). In 3 (7%) patients during the follow-up we encountered tumour overgrowth and in 1 patients the TEF was not sealed so they have been referred for gastrostomy. No other long term complications were recorded. Most of the patients (30 patients- 71%) died during the follow-up, with mean survival of 4 months (range 2-9) after the stent placement.

CONCLUSION

Placing SEMS in patients with lung cancer is safe and highly effective in relieving dysphagia with significant improvement in quality of life.

Fluoroscopic Balloon Dilation for Treating Postoperative Nonanastomotic Strictures in the Proximal Small Bowel: A 15-Year Single-Institution Experience

PURPOSE

To evaluate safety and effectiveness of fluoroscopic balloon dilation (FBD) for treating postoperative nonanastomotic strictures in proximal small bowel.

MATERIALS AND METHODS

Data of 44 patients (26 men and 18 women; mean age, 53.7 y ± 13.0) treated with FBD for postoperative nonanastomotic strictures in the proximal small bowel between January 2000 and February 2016 were retrospectively reviewed. Site of stricture was located in the first portion of duodenum in 8 (18.2%) patients, second portion of duodenum in 8 (18.2%) patients, third portion of duodenum in 1 (2.3%) patient, fourth portion of duodenum in 1 (2.3%) patient, and proximal jejunum in 26 (59.1%) patients. Mean distance between the most anal-side lesion and the oral cavity was 63.9 cm ± 15.0.

RESULTS

Technical success was achieved in 39 (88.6%) patients. Mean stricture length was 3.0 cm ± 1.8. Technical failure because of inability to negotiate the guide wire through the stricture occurred in 5 (13.6%) patients. Complete resolution of obstructive symptoms and resumption of oral intake of soft or solid food within 3 days occurred in 34 patients after 1 (n = 32) or 2 (n = 2) FBD sessions, rendering a clinical success rate of 87.2%. There were no major complications directly related to FBD. Median follow-up period was 1,406 days (interquartile range, 594-2,236 d). Nine (26.5%) patients had recurrence within a median 47 days (interquartile range, 20-212 d).

CONCLUSIONS

FBD may be safe and effective for treating postoperative nonanastomotic strictures in the proximal small bowel.

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

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

Self-expandable metal stents for malignant esophageal obstruction: a comparative study between extrinsic and intrinsic compression

Self-expandable metal stents (SEMSs) are effective for malignant esophageal obstruction, but usefulness of SEMSs in extrinsic lesions is yet to be elucidated. This study is aimed at evaluating the clinical usefulness of SEMSs in the extrinsic compression compared with intrinsic. A retrospective review was conducted for 105 patients (intrinsic, 85; extrinsic, 20) with malignant esophageal obstruction who underwent endoscopic SEMSs placement. Technical and clinical success rates were evaluated and clinical outcomes were compared between extrinsic and intrinsic group. Extrinsic group was mostly pulmonary origin. Overall technical and clinical success rate was 100% and 91%, respectively, without immediate complications. Extrinsic and intrinsic group did not differ significantly in clinical success rate. The median stent patency time was 131.3 ± 85.8 days in intrinsic group while that of extrinsic was 54.6 ± 45.1 due to shorter survival after stent insertion. The 4-, 8-, and 12-week patency rates were 90.5%, 78.8%, and 64.9% respectively in intrinsic group, while stents of extrinsic group remained patent until death. Uncovered, fully covered, and double-layered stent were used evenly and the types did not influence patency in both groups. In conclusion, esophageal SEMSs can safely and effectively be used for malignant extrinsic compression as well as intrinsic.

Palliative enteral feeding for patients with malignant esophageal obstruction: a retrospective study

BACKGROUND

Malignant esophageal obstruction leads to dysphagia, deterioration in quality of life, and malnutrition. Traditional bedside nasogastric (NG) tube placement is very difficult under these circumstances. However, endoscopically assisted NG tube placement under fluoroscopic guidance could be an alternative option for establishing palliative enteral nutrition. This study aimed to compare the clinical outcomes of enteral tube feeding and esophageal stenting for patients with malignant esophageal obstruction and a short life expectancy.

METHODS

Thirty-one patients were divided into 3 groups according to their treatment modality: NG tube (n = 12), esophageal stent group (n = 10), and supportive care with nil per os (NPO) (n = 9). Enteral nutrition, clinical outcomes, length of hospital stay, and median survival were evaluated.

RESULTS

There were no significant baseline differences among the groups, except in age. The tube and stent groups had significantly higher enteral calorie intake (p = 0.01), higher serum albumin (p < 0.01), shorter hospital stay (p = 0.01), and longer median survival (p < 0.01) than the NPO group. The incidence of dislodgement in the tube group was significantly higher than in the stent group (58% vs. 20%, respectively; p = 0.01). However, stenting costs more than NG tube placement.

CONCLUSIONS

Palliative enteral feeding by NG tube is safe, inexpensive, and has a low complication rate. Endoscopically assisted NG tube placement under fluoroscopic guidance could be a feasible palliative option for malignant esophageal obstruction for patients who have a short life expectancy.

Palliative Endoscopic Therapy of Esophageal Cancer

Background

This is a review of endoscopic therapy in the setting of palliative management of patients suffering from esophageal cancer (EC). Unfortunately, many cases of EC present in a stage of disease in which curative therapy is not possible. The maintenance of quality of life includes the ability to swallow and of oral feeding, pain control, and the prevention of bleeding.

Methods

A review of the current literature was performed.

Results

Many endoscopic methods are available for the management of dysphagia, of which dilation, endoluminal tumor destruction, stenting, and brachytherapy are the most common.

Conclusion

Surgical palliation should be avoided as much as possible since the alternatives show at least the same efficacy and have fewer complications.

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.

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.

Stents for benign and malignant esophageal strictures

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

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

Background

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

Material/Methods

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

Results

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

Conclusions

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

Palliative therapy for patients with unresectable esophageal carcinoma

Most patients diagnosed with carcinoma of the esophagus do not undergo therapy with curative intent. The focus of treatment for these patients is to maximize their progression-free survival and palliate the most common sequelae of their disease: dysphagia, malnutrition, pain, and intraluminal tumor bleeding. This article discusses the available treatment options for palliation of patients with unresectable esophageal cancer.

Stenting of the colon in patients with malignant large bowel obstruction: a local experience

PURPOSE

There is an increasing evidence base to support the use of self-expanding metallic gastrointestinal stents. In patients with colorectal cancer, they are used as a bridge to surgery and for palliation. The purposes of this study are to assess technical success, clinical outcome, complication rate and patency following colonic stent insertion in patients with colonic cancer at a local level and to compare our results with the current evidence base.

METHODS

A retrospective, two-centre study was conducted. Twenty-seven patients were included over a 5-year period. Six patients had undergone stent insertion as a bridge to surgery, and 21 had the procedure for palliation.

RESULTS

Initial technical success was achieved in 26 of 27 patients (96%). Of these 26 patients, clinical success was achieved in 24 patients (92%). Five patients (21%) suffered from stent re-occlusion, and one patient (4%) suffered from stent migration. There was one case (4%) of procedure-related perforation. Of the 19 palliative patients in whom clinical success was achieved, 17 (89%) were alive at 30 days, 13 (68%) at 90 (53%) days and 10 at 180 days. Average stent patency was 195 days.

CONCLUSION

WallFlex® self-expanding metallic gastrointestinal stents are a safe and effective means of alleviating obstructive symptoms in patients with colonic cancer requiring palliative treatment or as a bridge to surgery. Our data suggest that although a small percentage of patients are affected by stent re-occlusion, this does not contribute to premature mortality. They improve quality of life in palliative care patients as well as reducing premature morbidity and mortality caused by emergency surgery.

An Auxetic structure configured as oesophageal stent with potential to be used for palliative treatment of oesophageal cancer; development and in vitro mechanical analysis

Oesophageal cancer is the ninth leading cause of malignant cancer death and its prognosis remains poor. Dysphagia which is an inability to swallow is a presenting symptom of oesophageal cancer and is indicative of incurability. The goal of this study was to design and manufacture an Auxetic structure film and to configure this film as an Auxetic stent for the palliative treatment of oesophageal cancer, and for the prevention of dysphagia. Polypropylene was used as a material for its flexibility and non-toxicity. The Auxetic (rotating-square geometry) structure was made by laser cutting the polypropylene film. This flat structure was welded together to form a tubular form (stent), by an adjustable temperature control soldering iron station: following this, an annealing process was also carried out to ease any material stresses. Poisson's ratio was estimated and elastic and plastic deformation of the Auxetic structure was evaluated. The elastic and plastic deformation behaviours of the Auxetic polypropylene film were evaluated by applying repetitive uniaxial tensile loads. Observation of the structure showed that it was initially elastically deformed, thereafter plastic deformation occurred. This research discusses a novel way of fabricating an Auxetic structure (rotating-squares connected together through hinges) on Polypropylene films, by estimating the Poisson's ratio and evaluating the plastic deformation relevant to the expansion behaviour of an Auxetic stent within the oesophageal lumen.

Enteral stents

The American Society for Gastrointestinal Endoscopy (ASGE) Technology Committee provides reviews of existing, new, or emerging endoscopic technologies that have an impact on the practice of GI endoscopy. Evidence-based methodology is used, with a MEDLINE literature search to identify pertinent clinical studies on the topic and a MAUDE (U.S. Food and Drug Administration Center for Devices and Radiological Health) database search to identify the reported complications of a given technology. Both are supplemented by accessing the "related articles" feature of PubMed and by scrutinizing pertinent references cited by the identified studies. Controlled clinical trials are emphasized, but in many cases, data from randomized, controlled trials are lacking. In such cases, large case series, preliminary clinical studies, and expert opinions are used. Technical data are gathered from traditional and Web-based publications, proprietary publications, and informal communications with pertinent vendors. Technology Status Evaluation Reports are drafted by 1 or 2 members of the ASGE Technology Committee, reviewed and edited by the committee as a whole, and approved by the Governing Board of the ASGE. When financial guidance is indicated, the most recent coding data and list prices at the time of publication are provided. For this review, the MEDLINE database was searched through August 2010 for articles related to enteral, esophageal, duodenal, and colonic stents. Technology Status Evaluation Reports are scientific reviews provided solely for educational and informational purposes. Technology Status Evaluation Reports are not rules and should not be construed as establishing a legal standard of care or as encouraging, advocating, requiring, or discouraging any particular treatment or payment for such treatment.

Palliation of malignant esophageal obstruction and fistulas with self expandable metallic stents

AIM: To evaluate the efficacy of self expandable metallic stents (SEMS) in patients with malignant esophageal obstruction and fistulas.

METHODS: SEMS were implanted in the presence of fluoroscopic guidance in patients suffering from advanced and non-resectable esophageal, cardiac and invasive lung cancer between 2002 and 2009. All procedures were performed under conscious sedation. All patients had esophagus obstruction and/or fistula. In all patients who required reintervention, recurrence of dysphagia, hemorrhage, and fistula formation were indications for further endoscopy. Patients’ files were scanned retrospectively and the obtained data were analyzed using SPSS 13.0 for Windows. The χ² test was used for categorical data and was analysis of variance for non-categorical data. Patients’ long-term survival was assessed using the Kaplan-Meier method.

RESULTS: Stents were successfully implanted in 90 patients using fluoroscopic guidance. Reasons for stent implantation in these patients were esophageal stricture (77/90, 85.5%), external pressure (8/90, 8.8%) and tracheo-esophageal fistula (5/90, 5.5%). Dysphagia scores (mean ± SD) were 3.37 ± 0.52 before and 0.90 ± 0.43 after stent implantation (P = 0.002). Intermittent, non-massive hemorrhage due to the erosion caused by the distal end of the stent in the stomach occurred in only one patient who received implementation at cardio-esophageal junction. Mean survival following stenting was 134.14 d (95% confidence interval: 94.06-174.21).

CONCLUSION: SEMS placement is safe and effective in the palliation of dysphagia in selected patients with malignant esophageal strictures.

Self-expandable esophageal stents placement for the palliation of dysphagia as a result of lung cancer

We report our experience with self-expandable metallic stents for the palliation of malignant dysphagia and tracheoesophageal fistulae caused by lung cancer. Esophageal self-expandable metallic stents were deployed in 28 patients with malignant dysphagia as a result of lung cancer between August 2002 and January 2009. Mean age was 62.1 (42-77) with 26 male patients. Twenty-three patients received previous chemo-radiotherapy and two had pneumonectomy. Tracheoesophageal fistulae were coexisting in eight patients. Stents were inserted under fluoroscopic control over guide-wire with the patient under conscious sedation. One stent was used in all patients except one fistula patient with two stents. Immediate improvement after stent insertion was seen in all patients. Fistulae were sealed off in all. No complication was seen except transitional pain in 12 patients (42%). During the follow-up, all patients remained asymptomatic with no clinical appearance of dysphagia symptoms except one patient whom gastrostomy was applied. All patients with fistulae died with a mean survival of 15.4 weeks. Dysphagia patients without fistulae died with mean survival of 6 months except one patient with 1 month follow-up. Self-expandable esophageal metallic stent insertion can manage malignant dysphagia in lung cancer patients with significant survival period via nonsurgical approach.

Esophageal stents for the palliation of malignant dysphagia and fistula recurrence after esophagectomy

BACKGROUND

Despite advances in staging methods, surgical techniques, and adjuvant treatment, recurrent cancer after esophagectomy is a major cause of morbidity and mortality.

OBJECTIVE

Our purpose was to investigate the safety and efficacy of a self-expandable metal stent (SEMS) in patients with dysphagia or fistula caused by recurrent cancer after esophagectomy.

DESIGN

Prospective, observational study with standardized treatment and follow-up.

SETTING

Single university center.

PATIENTS

In 81 patients with recurrent cancer after previous surgical esophagectomy, 100 esophageal SEMSs were inserted for dysphagia (n = 66) or fistula formation (n = 15).

INTERVENTIONS

Stent placement.

MAIN OUTCOME MEASUREMENTS

Technical and functional outcome, complications, and survival.

RESULTS

The SEMSs restored luminal patency in 65 (98%) of 66 patients and sealed malignant fistulae in 14 (93%) of 15 patients. Stent dysfunction occurred in 24 (30%) of 81 patients. They all were successfully managed by subsequent endoscopic intervention. After stent placement, a total of 16 complications were observed. Major complications occurred in 9 (11%) of 81 patients, mild complications occurred in 7 (9%) of 81 patients. The overall 30-day mortality rate after stent insertion was 25%. Progression of the disease resulted in death after a median interval of 70 days (range 1 day to 91 months).

LIMITATIONS

Nonrandomized design.

CONCLUSIONS

SEMS placement in recurrent esophageal cancer after surgical resection offers adequate palliation by relieving dysphagia and sealing off esophageal respiratory fistulae. Therefore, in these patients who have a relatively short life expectancy, SEMS placement should be considered the treatment of choice.

Gastrointestinal and biliary stents

Advances in stent design have led to a substantial increase in the use of stents for a variety of malignant and benign strictures in the gastrointestinal tract and biliary system. Whereas early stents were mostly composed of plastic, the majority of contemporary stents are self-expanding metal stents that are composed of either nitinol or stainless steel. These stents are able to exert an adequate expansile force and, at the same time, are highly flexible and biocompatible. Covered stents have been introduced to minimize tumor ingrowth through the metal mesh but are associated with higher rates for spontaneous migration. This has led to the development of covered stents with uncovered ends and stents with both covered and uncovered layers. Drug-eluting and biodegradable stents are also likely to become available in the near future. Although stents appear to be the preferred form of palliation for some patients with advanced cancer, many patients will benefit from a multidisciplinary approach that usually includes surgeons and oncologists.

The use of self-expandable metallic stents for palliative treatment of inoperable esophageal cancer

Most patients with esophageal carcinoma present in the advanced stage die from tumor invasion and widespread metastases. Because radical regimens are not appropriate for the majority of patients, and their expected survivals are as short as to be measured by months, the main aim of therapy is palliation with minimum morbidity and mortality. Among the palliative modalities are surgery, external radiotherapy or brachytherapy, dilatation, laser, photodynamic therapy, bipolar electrocoagulation tumor probe, and chemical ablation. The placement of self-expandable metallic stents is another method that improves dysphagia for these patients. In this study, the aim was to evaluate retrospectively the effectiveness of metallic stents deployed because of inoperable malignant esophageal stenosis and esophagotracheal fistulas. The results of 170 patients with 202 stents administered because of inoperable malignant esophageal stenosis and esophagorespiratory fistula between January 2000 and October 2008 at the Ataturk University, Department of Thoracic Surgery, were investigated. Despite epidemiological and clinical data, information regarding relief of dysphagia and quality of life were also examined. One hundred seventy patients with stents were between 28 and 91 years old (mean age 63.7 years+/-11.4 years). Ninety-seven were male and 73 were female. Stent indications were advanced tumors with distant metastasis (82 cases, 48.2%), unresectable tumors (51 cases, 30%), patients who cannot tolerate surgery or chemoradiotherapy (18 cases, 10.5%), local recurrence after primary therapy (1 case, 0.5%), esophagorespiratory fistulas from tumor or therapy (14 cases, 8.2%), and refusal of surgery (4 cases, 2.3%). Dysphagia scores evaluated by a modified Takita's grading system improved from 3.4 before the procedure to 2.6 afterward. The overall complication rate without chest pain was 31.7% (occurring in 64 cases). Mean survival was 177.7 days+/-59.3 days (2-993 days). Quality-of-life scores (The European Organization of Research and Treatment of Cancer QLQ C30) improved from 73+/-10.3 (57-85) to 112+/-12.6 (90-125). In therapy of malignant esophageal obstructions, metallic stents provide a significant improvement in dysphagia and require less frequent re-intervention according to other methods of dysphagia palliation such as dilatation, laser, and photodynamic therapy, nearly completely relieve esophagotracheal fistulas and improve quality of life to an important degree.

Clinical outcomes and patency of self-expanding metal stents in patients with malignant upper gastrointestinal obstruction

This study was performed to evaluate clinical outcomes and factors associated with patency of self-expanding metal stents (SEMS) in patients with malignant upper gastrointestinal (UGI) obstruction. In 83 patients with malignant UGI obstruction, 118 SEMS placements were performed. Obstruction sites were esophagus/gastro-esophageal junction (GEJ) and gastric outlet (GO) in 41 and 42 patients, respectively. Technical success was achieved in 99.2% and clinical success in 90.5%, with no procedure-related complications. Re-obstruction and migration occurred in 38.1% during a mean follow-up of 137 days; both occurred significantly more often with GO than esophageal/GEJ obstruction (49.2% vs 23.9%). Patency rates of esophageal/GEJ obstruction were 93.5, 78.1 and 67.0% at 30, 90 and 180 days, respectively, and were significantly higher than those of GO obstruction-71.7, 51.8 and 32.5%. Palliative chemotherapy or radiation therapy was not associated with stent patency. Endoscopic SEMS placement is a safe and effective palliative treatment for malignant UGI obstruction, and complications or stent patency differed according to obstruction site.

Comparison of Wallstent and Ultraflex stents for palliation of malignant left-sided colon obstruction: a retrospective, case-matched analysis

BACKGROUND

Self-expandable metal stents (SEMSs) are accepted palliation for malignant colon obstruction. Outcomes of different stent types is unknown.

OBJECTIVE

Our purpose was to compare outcomes after palliative placement of the Enteral Wallstent (EW) and the Precision Colonic Ultraflex (PCU) stent.

DESIGN

Retrospective study of all SEMS placement during a 7-year period.

SETTING

Tertiary care academic medical center.

PATIENTS

Malignant left-sided colon obstruction in which through-the-scope (TTS) or non-TTS stent placement was possible.

MAIN OUTCOME MEASUREMENTS

Technical and clinical success rates, stent-related complications, reintervention.

RESULTS

Demographics, degree, site, and cause of obstruction were comparable. Technical difficulties were more frequent with EW than PCU (16% vs 9%, P not significant), insufficient stent expansion and stent misplacement being most common. Relief of obstruction occurred in all patients when placement was technically successful. Mean follow-up was 93 days (range 7-691 days). Early (<7 days) stent occlusion (6% vs 0%, P not significant) and migration (4% vs 0%, P not significant) occurred more frequently in the EW group. Self-limited hematochezia was more common with PCU (20% vs 2%, P = .002). Delayed complications (perforation, stent occlusion, migration, and erosion) occurred significantly more often in the EW group (38% vs 20%). Reintervention was needed more frequently for EW, endoscopic (40% vs 17%, P = .01) and operative (46% vs 26%, P = .03).

CONCLUSIONS

Enteral Wallstents and Precision Ultraflex Colonic stents adequately relieve colonic obstruction. Stent dysfunction, stent-related complications, and need for reintervention are higher after EW placement. Precision Colonic Ultraflex stents appear better suited for palliation of left-sided malignant colon obstruction.

Treatment options for esophageal strictures

Esophageal strictures are a problem commonly encountered in gastroenterological practice and can be caused by malignant or benign lesions. Dysphagia is the symptom experienced by all patients, regardless of whether their strictures are caused by malignant or benign lesions. The methods most frequently used for palliation of malignant esophageal strictures are stent placement (particularly in patients with an expected survival of 3 months or less) and brachytherapy (in patients with a life expectancy of more than 3 months). Brachytherapy has been shown to be beneficial in patients with an expected survival of longer than 3 months with regard to (prolonged) dysphagia improvement, complications and quality of life. The mainstay of benign esophageal stricture treatment is dilation. Although dilation usually results in symptomatic relief, recurrent strictures do occur. In order to predict which types of strictures are most likely to recur, it is important to differentiate between esophageal strictures that are simple (i.e. focal, straight strictures with a diameter that allows endoscope passage) and those that are more complex (i.e. long (>2 cm), tortuous strictures with a narrow diameter). These complex strictures are considered refractory when they cannot be dilated to an adequate diameter. Novel treatment modalities for refractory strictures include temporary stent placement and incisional therapy.

Interventional management of malignant colorectal obstruction: use of covered and uncovered stents

Objective

We wanted to evaluate usefulness of uncovered stent in comparison with covered stent for the palliative treatment of malignant colorectal obstruction.

Materials and Methods

Covered (n = 52, type 1 and type 2) and uncovered (n = 22, type 3) stents were placed in 74 patients with malignant colorectal obstruction. Stent insertion was performed for palliative treatment in 37 patients (covered stent: n = 23 and uncovered stent: n = 14). In the palliative group, the data on the success of the procedure, the stent patency and the complications between the two groups (covered versus uncovered stents) were compared.

Results

The technical success rate was 89% (33/37). Symptomatic improvement was achieved in 86% (18/21) of the covered stent group and in 92% (11/12) of the uncovered stent group patients. The period of follow-up ranged from three to 319 days (mean period: 116±85 days). The mean period of stent patency was 157±33 days in the covered stent group and 165±25 days in the uncovered stent group. In the covered stent group, stent migration (n = 11), stent fracture (n = 2) and poor expansion of the stent (n = 2) were noted. In the uncovered stent group, tumor ingrowth into the stents (n = 3) was noted.

Conclusion

Self-expanding metallic stents are effective for relieving malignant colorectal obstruction. The rate of complications is lower in the uncovered stent group than in the covered stent group.

Clinical application of self-expanding metallic stent in the management of acute left-sided colorectal malignant obstruction

AIM: To summarize our experience with the application of self-expanding metallic stent (SEMS) in the management of acute left-sided colorectal malignant obstruction.

METHODS: A retrospective chart review of all patients undergoing placement of SEMS between April 2000 and January 2004 was performed.

RESULTS: Insertion of SEMS was attempted in 26 patients under fluoroscopic guidance with occasional endoscopic assistance. The sites of lesions were located in splenic flexure of two patients, left colon of seven patients, sigmoid colon of eight patients and rectum of nine patients. The intended uses of SEMS were for palliation in 7 patients and as a bridge to elective surgery in 19 patients. In the latter group, placement of SEMS allowed for preoperative systemic and bowel preparation and the following one-stage anastomosis. Successful stent placement was achieved in 22 (85%) of the 26 patients. The clinical bowel obstruction resolved 24 hours after successful stent placement in 21 (95%) patients. Three SEMS-related minor complications occurred, two stents migrated and one caused anal pain.

CONCLUSION: SEMS represents an effective and safe tool in the management of acute malignant colorectal obstruction. As a bridge to surgery, SEMS can provide time for systematic support and bowel preparation and obviate the need for fecal diversion or on-table lavage. As a palliative measure, SEMS can eliminate the need for emergent colostomy.

Palliative esophageal stent placement using endoscopic guidance without fluoroscopy

AIMS

Fluoroscopy is not available in every endoscopic unit. This situation leads to delays in treatment or to transfer of patients to other centres for stent insertion. We assessed safety and effectiveness of expandable esophageal metal stent placement under endoscopic control without fluoroscopy using a thin gastroscope.

PATIENTS AND METHODS

From October 2002 to June 2004, thirty-three consecutive patients have been included for esophageal stent placement under endoscopic control alone with a nasogastroscope (5.9 mm). A proximal release covered stent (Ultraflex; Boston Scientific Microvasive) was used. Indications were malignant esophageal stricture (N = 26), malignant extrinsic compression (N = 2 ) and esophago-respiratory neoplastic fistulae (N = 5).

RESULTS

Stent placement using endoscopic control alone was successful in 30/33 (90%) patients. Complications occurred in 11 patients. Early complications (<7 days) included one death from pulmonary embolism, severe retrosternal pain needing transient morphinic treatment (N = 2) and GERD despite antisecretory therapy (N = 1). Late complications included: food impaction (N = 1), tumour overgrowth-related obstruction of the stent (N = 5) and one late esophago-respiratory fistula at 4 months at the proximal end of the stent. Relief of dysphagia was obtained for all patients at 48 hours and dysphagia score decreased from 3.1 before stent to 1.2 at 1 month (P < 0.05).

CONCLUSION

Expandable esophageal stents can be accurately and safely placed using endoscopy with a thin gastrosocope. This method obviates the requirement of fluoroscopic access, lacking in many centres, and avoids exposure to X-ray.

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Self-expandable metallic stents for palliation of malignant esophageal obstruction: special reference to quality of life and survival of patients

SUMMARY. Self-expandable metallic stents (EMS) provide a common option for malignant esophageal stenosis because of the low complication rate and high dysphagia improvement rate. However, there are few studies on the functional duration of EMS and the extent of improvement of the quality of life. We retrospectively analyzed 18 patients who received EMSs in our division from 1996 to 2002. The median duration of possible food intake and the median survival period were 94.5 and 108 days. The median duration of domiciliary treatment was 56 days. Six of the 18 patients were not discharged from hospital after EMS insertion. The Karnofsky index was found to be a significant determinant of the feasibility of domiciliary treatment. One-third of the patients are incapable of obtaining the benefits of the palliative therapy. EMS deployment should be prudently selected for patients exhibiting low performance status.

New approach to malignant strictures of the esophagus

Primary esophageal cancer is the most common cause of malignant esophageal stricture. Prognosis and treatment outcomes vary with the stage of the disease. Endoscopic ultrasound has a high accuracy rate for local and regional staging. Surgery is curative for early cancer. Endoscopic mucosal resection, photodynamic therapy, or brachytherapy can be used with curative intent for early cancer, especially in patients with comorbid conditions precluding surgery. Unfortunately, the majority of patients with esophageal cancer present with advanced disease. The primary aim in these patients is to alleviate symptoms with a minimum of side effects and reinterventions. Palliative surgery or chemoradiotherapy can be associated with high morbidity and mortality rates. Several endoscopic techniques for palliation are available, and all have the potential of significantly improving swallowing. The choice of a particular endoscopic approach is usually determined by local expertise and characteristics of the stricture.

Antireflux stents in tumors of the cardia

Self-expanding metal esophageal stents (SMES) are highly effective in relieving dysphagia in patients with esophageal carcinoma. As the incidence of cancer at the lower esophagus/cardia continues to increase, SMES also are being deployed across the gastroesophageal junction (GEJ). However, use of SMES in this location makes the stomach and the esophagus, in effect, a common cavity, which predisposes patients to gastroesophageal reflux (GER) and aspiration. Reflux may result from an increase in intra-abdominal pressure or it may occur passively when the patient is recumbent. Acid-suppression medications do not protect against regurgitation and aspiration. We developed a modified antireflux SMES and evaluated its efficacy in vitro, in dogs, and in 11 patients with distal esophageal/GEJ carcinoma. The modification involved extending the polyurethane coating of the stent to 8 cm below the lower edge. In dogs, significantly more reflux episodes occurred with the regular stent (mean, 197 episodes) than with the modified stent (mean, 16 episodes; P = 0.03). In patients who received the modified stent, dysphagia scores were significantly reduced (mean baseline score, 3.4; mean end point score, 1.1; P <0.001). The modified stent prevented GER while allowing belching and vomiting.

EsophaCoil for palliation of dysphagia in unresectable oesophageal carcinoma: short- and long-term results

BACKGROUND AND AIM

Few reports have shown that EsophaCoil is an effective and safe prosthesis for palliation of malignant oesophageal dysphagia. A single centre experience using this type of prosthesis is reported.

PATIENTS AND METHODS

Between January 1995 and September 2000, 42 consecutive patients, 41 with unresectable oesophageal cancer and one with oesophageal stenosis secondary to lung cancer, were treated with 44 EsophaCoils (2 patients received 2 stents). Tumours were located in lower third of oesophagus and/or gastric cardia in 22 cases, in middle third in 18 and in upper third in 2. Mean stricture length was 5.3 cm. Implantation was performed on hospitalized patients.

RESULTS

EsophaCoil placement was successful all 44 times and was followed by complete expansion of the prostheses. There were no major procedure-related complications or deaths. Dysphagia score improved from mean of 2.9 to 1.3 within 24 hours of stent implantation. Median hospital stay was 2.7 days. Late complications occurred in 14 patients (34.2%): 3 migrations into stomach, 7 tissue overgrowth, 2 late perforations and 2 food impactions. Mean survival time was 4.2 months (range 1-10).

CONCLUSIONS

In our experience, full expansion of EsophaCoil was achieved in all cases. This result, was associated with high incidence of retrosternal pain. Relief of dysphagia score was identical to that obtained with other types of Self-Expanding Metal Stent. Coil design prevented tumour ingrowth and allowed retrieval of three migrated stents. Mean survival time was similar to that reported in larger series using different types of Self-Expanding Metal Stent.

Endoscopic therapeutic esophageal interventions

Despite numerous advances in the chemotherapeutic, radiotherapeutic, and surgical treatment of esophageal cancer, most patients require some type of endoscopic palliation for dysphagia during the course of their illness. Numerous modalities exist, including thermal ablation with neodymium:yttrium-aluminum-garnet laser, argon plasma coagulation, electrocautery, nonthermal ablation with alcohol injection or photodynamic therapy, or displacement of tumor with endoscopically placed stents. Each therapy carries with it a unique profile of efficacy and complications. Some therapies may be more appropriate for certain tumor locations and morphologies than others. During the past year, new studies have defined these parameters further. However, it remains essential that the endoscopist have both a thorough knowledge of these various modalities and an ability to chose among them when undertaking endoscopic palliation of this difficult and rapidly rising disease.

Results of expandable metal stents for malignant esophageal obstruction in 100 patients: short-term and long-term follow-up

BACKGROUND

Expandable metal stents palliate malignant dysphagia in most cases, but early complications and outcomes in long-term survivors have not been well described. This report summarizes our experience with expandable metal stents for malignant dysphagia.

METHODS

Over a 48-month period, 127 stents were placed in 100 patients with dysphagia from esophageal cancer (93%) or lung cancer. Most had undergone prior treatment. Dysphagia scores, duration of palliation, complications, and reintervention were evaluated.

RESULTS

Immediate improvement in dysphagia was observed in 85% of patients with no procedure-related deaths. Dysphagia score decreased from 3.3 before stent to 2.3 (p < 0.005). Average interval to reintervention was 80 days. In 40 patients surviving more than 120 days, 31 (78%) required reintervention. Major complications occurred in 3 patients receiving poststent chemoradiation (tracheoesophageal fistula, T1 vertebral body abscess, mediastinal abscess). Other complications included unsatisfactory deployment requiring immediate removal (3 patients), migration (11 patients), pain requiring removal (2 patients), food impaction (10 patients), and tumor ingrowth (37 patients).

CONCLUSIONS

Expandable metal stents offer excellent short-term palliation of malignant dysphagia. In long-term survivors, recurrent dysphagia requiring reintervention is common. In a small subset of patients receiving chemoradiation after stent placement, major complications were observed.

Self-expanding metal esophageal stent with anti-reflux mechanism

BACKGROUND

When deployed across the gastroesophageal junction, self-expanding metal esophageal stents can predispose to gastroesophageal reflux. Our aim was to evaluate the efficacy of a self-expanding metal esophageal stent that was modified to prevent gastroesophageal reflux.

METHODS

The polyurethane coating of a metal Z-stent was extended beyond its lower end to form windsock-type valve. The anti-reflux property of this stent was studied in vitro by submerging the stent under water and measuring the pressure required to invert the valve. Esophageal acid exposure time was measured in 5 dogs with a standard and the modified stent placed across the gastroesophageal junction. The modified stent was also placed in 11 patients with cancer of the gastroesophageal junction who were prospectively followed.

RESULTS

The pressure required to invert the valve was directly proportional to the thickness of the valve membrane (48 +/- 0.4 cm water for a 0.0067-inch thick membrane). Esophageal acid exposure time was significantly less with the modified stent as compared with a standard stent (1% +/- 0.3%, 49% +/- 11%, respectively, p = 0.03). Dysphagia score in patients improved from 3.4 +/- 0.1 to 1.1 +/- 0.2 (p < 0.001). Daytime heartburn and regurgitation scores were less than 1 (score 10 = severe). No patient complained of nocturnal reflux symptoms. Karnofsky performance status scale did not improve significantly.

CONCLUSIONS

The efficacy of the modified stent in relieving dysphagia is comparable with a standard stent. It also effectively prevents gastroesophageal reflux.

Self-expanding metallic stent in the treatment of colonic obstruction caused by advanced malignancies

INTRODUCTION

The treatment of malignant obstruction of the left colon or rectum usually requires emergency surgery on poor-risk patients, and the creation of a stoma is usually inevitable. With the use of self-expanding metallic stents, the prompt relief of large-bowel obstruction without surgery has become possible. This report describes our results in the use of self-expanding metallic stents in the treatment of left-sided colonic obstruction resulting from advanced malignancies.

METHODS

From November 1997 to March 1999, insertion of self-expanding metallic stents was attempted in 24 patients with acute left-sided colonic obstruction caused by primary or recurrent malignancies. All the procedures were performed by colorectal surgeons. The guidewire was inserted through the channel of the endoscope, and its position was confirmed with fluoroscopy. Uncovered Wallstent esophageal endoprostheses were used in all except the first case. The insertion and deployment of the stents were under both endoscopic and fluoroscopic guidance.

RESULTS

There were 24 patients (15 males) with a mean age of 63.6 (range, 36-98) years. Thirteen patients had primary colorectal cancer and 11 had recurrent cancers (colorectal cancer, 5; gastric cancer, 5; other, 1). In the treatment of primary colorectal cancer, seven procedures were palliative, and no subsequent surgery was planned because of extensive liver metastasis or poor medical risk. The other six patients underwent elective resection after mechanical bowel preparation. There was no mortality related to the procedure. Stenting was successful in the relief of obstruction in 23 patients. Perforation of the colon occurred in one patient, and an emergency Hartmann's operation was performed. Migration of the stents occurred in three patients. Only 3 of the 18 patients in the palliation group required the subsequent creation of stomas.

CONCLUSION

The use of the self-expanding metallic stents can achieve rapid and effective nonsurgical means to relieve left-sided colonic obstruction. It provides good palliation for unresectable advanced tumors that cause colonic obstruction. It may also have a role in the temporary relief of obstruction so that subsequent colonic resection can be performed under elective conditions.