A prospective, randomized, controlled trial of covered expandable metal stents in the palliation of malignant esophageal obstruction at the gastroesophageal junction

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

A Successful Treatment of Broncho-Esophageal Fistula with Esophageal Stenting Using Direct Endoscopic Visualization

Broncho-esophageal fistula (BEF) is a severe yet relatively rare connection between the bronchus and esophagus usually caused by esophageal and pulmonary malignancies. We present a case report of a 49-year-old man diagnosed with terminal lung carcinoma who developed a BEF. The thoracic computed tomography scan detected a mass in the left bronchi that partially covers and disrupts the bronchial contour in certain regions and extends to the esophageal wall. After thoroughly evaluating alternative treatment approaches, we opt for the stenting procedure due to the advanced stage of the tumor and the significantly diminished quality of life. The treatment involves the use of a partially covered metal stent that is known to exhibit lower potential to migrate. The treatment is highly successful, resulting in a significant enhancement of the patient's quality of life, a lengthening in his survival, and the ability to pursue additional palliative treatment options. In contrast to the typical prosthesis implantation, our procedure uses a direct endoscopic visualization for the proximal deployment of a partially covered stent, offering a cost-effective and radiation-free alternative that can be particularly beneficial for BEF patients in facilities without radiology services.

The endoscopic management of oesophageal strictures

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

Esophageal Stenting: How I Do It

Endoscopic esophageal stent placement is an effective palliative treatment for malignant strictures and has also been successfully used for benign indications, including esophageal refractory strictures and iatrogenic leaks and perforations. Despite several decades of evolution and the wide variety of esophageal stents available to choose from, an ideal stent that is both effective and without adverse events such as stent migration, tissue ingrowth, or pressure necrosis has yet to be developed. This paper is an overview of how this evolution happened, and it also addresses the characteristics of some of the currently available stents, like their material and construction, delivery device, radial and axial force pattern, covering and size which may help to understand and avoid the occurrence of adverse events. The insertion delivery systems and techniques of placement of an esophageal self-expandable metal stent are reviewed, as well as some tips and tricks regarding placement and management of adverse events.

Endoscopic Stenting for Malignant Dysphagia in Patients with Esophageal Cancer

Malignant dysphagia is a common problem in patients with esophageal cancer. Endoscopic stenting can resolve dysphagia caused by malignant stricture; however, controversy exists regarding the use of esophageal stenting for the treatment of malignant stricture, including whether stenting or radiotherapy is superior, whether stenting before or after radiotherapy is safe, whether stenting before or after chemotherapy is safe, and whether low-radial-force stents are safer than conventional stents. Among treatment options for malignant dysphagia, stenting may have some disadvantages in terms of pain relief and the risk of adverse events compared with radiotherapy and in terms of survival compared with gastrostomy. Additionally, the risk of stent-related adverse events is significantly associated with prior radiotherapy. The risk of perforation is especially high when a radiation dose of >40 Gy is delivered to the esophagus after stenting, whereas perforation is not associated with prior chemotherapy or additional chemotherapy after stenting. Nevertheless, stenting remains an important palliative option, especially for patients with a short life expectancy and a strong desire for oral intake, because stenting can facilitate a more rapid improvement in dysphagia than radiotherapy or gastrostomy. The application of a low-radial-force stent should be considered to reduce the risk of adverse events, especially in patients with prior radiotherapy.

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.

The Role of Self-Expandable Metallic Stents in the Treatment of Malignant Strictures in all Segments of the Gastrointestinal Tract

Objectives

Management of malignant gastrointestinal (GI) obstruction presents a significant challenge. Most patients are in a profoundly decompensated state due to underlying malignancy and are not ideal candidates for invasive surgical procedures. Self-expandable metallic stents (SEMSs) are used to provide permanent or temporary patency in all endoscopically accessible stenosis of the GI tract. In this study, it is aimed to analyse the characteristics and the efficacy of patients with malignant stenosis treated with SEMS, in all segments of the GI tract.

Material and Methods

The sample consisted of 60 patients who underwent SEMS replacement, between 10 March 2014 and 16 December 2020, to treat malignant-related strictures in the GI tract at the Gastroenterology Department of the Health Sciences University Umraniye Training and Research Hospital. The data of the patients, hospital data processing database and electronic endoscopic database records were retrospectively scanned and recorded. The general characteristics of the patients and the treatment-related features were analysed.

Results

The mean age of patients who were placed SEMS was 69.7 ± 13.7 years. Uncovered (15%, n: 9), fully covered (13.3%, n: 8), or partially covered (71.6%, n: 43) SEMS were successfully placed in all patients. Clinical success in patients with SEMS was 85.7% in the esophagus, 100% in the small intestine and 90.9% in the stomach and colon. About 11.4% migration, 14.2% pain, 11.4% overgrowth and 5.7% ingrowth were detected in patients who had SEMS placed in the oesophagus. Pain was detected in 9.1% and ingrowth in 18.2% of patients who had SEMS placed in the stomach. Pain was detected in 18.2% of the patients who had SEMS placed in the colon and migration was found in 9.1%.

Conclusion

SEMS implant is a minimally invasive effective method in the palliative treatment of malignant strictures of the GI tract.

Utilization and Outcomes of Radiation in Stage IV Esophageal Cancer

Introduction

For patients with stage IV esophageal cancer, esophageal radiation may be used selectively for local control and palliation. We aimed to understand patterns of radiation administration among patients with stage IV esophageal cancer and any potential survival associations.

Methods

In this retrospective cohort study, the National Cancer Database was queried for patients with metastatic stage IV esophageal cancer diagnosed between 2016 and 2019. Patterns of radiation use were identified. Survival was determined through Kaplan-Meier analysis of propensity score-matched pairs of patients who did and did not receive radiotherapy and time-to-event models.

Results

Overall, 12,088 patients with stage IV esophageal cancer were identified, including 32.7% who received esophageal radiation. The median age was 65 (interquartile range [IQR]: 58-73) years, and 82.6% were male. Among the irradiated patients, the median total radiation dose was 35 (IQR: 30-50) Gy administered in a median of 14 (IQR: 10-25) fractions given in 22 (IQR: 14-39) days. Overall, esophageal radiation was not associated with better survival (log-rank p = 0.41). When stratified by radiation dose, a survival advantage (over no radiation) was found in the 1144 patients (29% of the irradiated patients) who received 45 to 59.9 Gy (time ratio = 1.28, 95% confidence interval: 1.20-1.37, p < 0.001) and the 88 patients (2.2%) who received 60 to 80 Gy (time ratio = 1.37, 95% confidence interval: 1.11-1.69, p = 0.003).

Conclusions

One-third of the patients with metastatic stage IV esophageal cancer in the National Cancer Database received esophageal radiation. Most received a radiation dose that, although consistent with palliative regimens, was not associated with a survival advantage. Further study is warranted to understand the indications for radiation in stage IV esophageal cancer and potentially reevaluate the most appropriate radiation dose for palliation.

The Outcomes of Nutritional Support Techniques in Patients with Gastrointestinal Cancers

Gastrointestinal cancers represent a major cause of morbidity and mortality worldwide. A significant issue regarding the therapeutic management of these patients consists of metabolic disturbances and malnutrition. Nutritional deficiencies have a negative impact on both the death rates of these patients and the results of surgical or oncological treatments. Thus, current guidelines recommend the inclusion of a nutritional profile in the therapeutic management of patients with gastrointestinal cancers. The development of digestive endoscopy techniques has led to the possibility of ensuring the enteral nutrition of cancer patients without oral feeding through minimally invasive techniques and the avoidance of surgeries, which involve more risks. The enteral nutrition modalities consist of endoscopy-guided nasoenteric tube (ENET), percutaneous endoscopic gastrostomy (PEG), percutaneous endoscopic gastrostomy with jejunal tube extension (PEG-J), direct percutaneous endoscopic jejunostomy (DPEJ) or endoscopic ultrasound (EUS)-guided gastroenterostomy.

Endoscopic Management of Esophageal Cancer

Advances in technology and improved understanding of the pathobiology of esophageal cancer have allowed endoscopy to serve a growing role in the management of this disease. Precursor lesions can be detected using enhanced diagnostic modalities and eradicated with ablation therapy. Furthermore, evolution in endoscopic resection has provided larger specimens for improved diagnostic accuracy and offer potential for cure of early esophageal cancer. In patients with advanced esophageal cancer, endoluminal therapy can improve symptom burden and provide therapeutic options for complications such as leaks, perforations, and fistulas. The purpose of this review article is to highlight the role of endoscopy in the diagnosis, treatment, and palliation of esophageal cancer.

Characterization and preliminary in vivo evaluation of a self-expandable hydrogel stent with anisotropic swelling behavior and endoscopic deliverability for use in biliary drainage

We demonstrate the potential of a novel self-expandable biliary stent comprised of poly(vinyl alcohol) (PVA) hydrogel with anisotropic swelling behavior and endoscopic deliverability in vivo, using a porcine stent model. The mechanism underlying the anisotropic swelling behavior and endoscopic deliverability (i.e., flexibility) was investigated by scanning electron microscopy (SEM), small-angle X-ray scattering (SAXS), evaluation of the water content and swelling ratio, and three-point bending tests. The in vivo experiment using a porcine stent model indicated that the tube-shaped PVA hydrogel could effectively expand the biliary tract, without disturbing bile flow. SEM and SAXS showed that PVA hydrogels prepared by drying under extension showed structural orientation along the extension axis, leading to anisotropic swelling. The water content of the PVA hydrogel was found to be crucial for maintaining flexibility as well as endoscopic deliverability. In conclusion, this study demonstrated the novel concept of using a hydrogel stent as a self-expandable biliary stent.

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.

AGA Clinical Practice Update on the Optimal Management of the Malignant Alimentary Tract Obstruction: Expert Review

BACKGROUND & AIMS

The purpose of this expert review is to describe the current methodologies available to manage malignant alimentary tract obstructions as well the evidence behind the various methods (including their efficacy and safety), indications, and appropriate timing of interventions.

METHODS

This is not a formal systematic review but is based on a review of the literature to provide best practice advice statements. No formal rating of the quality of evidence or strength of recommendation is carried out. BEST PRACTICE ADVICE 1: For all patients with alimentary tract obstruction, the decision about specific interventions should be made in a multidisciplinary setting including oncologists, surgeons, and endoscopists and take into account the characteristics of the obstruction, patient's expectations, prognosis, expected subsequent therapies, and functional status. BEST PRACTICE ADVICE 2: For patients who present with esophageal obstruction from esophageal cancer and who are potential candidates for resection or chemoradiation, clinicians should not routinely insert a self-expanding metal stent (SEMS) without multidisciplinary review because of high rates of stent migration, higher morbidity and mortality, and potentially lower R0 (microscopically negative margins) resection rates. BEST PRACTICE ADVICE 3: For patients who present with esophageal obstruction from esophageal cancer who are potential candidates for resection and who have concerns of malnutrition, clinicians may consider the use of enteral feeding tubes (via nasogastric or percutaneous route). Clinicians should be aware of the potential risk of abdominal wall tumor seeding as well as making subsequent gastric conduit formation difficult with percutaneous endoscopic gastrostomy placement. BEST PRACTICE ADVICE 4: For patients who present with esophageal obstruction from esophageal cancer who are not candidates for resection, clinicians should consider either SEMS insertion or brachytherapy as sole therapy or in combination. Clinicians should not consider the use of laser therapy or photodynamic therapy because of the lack of evidence of better outcomes and superior alternatives. BEST PRACTICE ADVICE 5: For patients with malignant esophageal obstruction who are undergoing SEMS placement, clinicians should use a fully covered or partially covered SEMS and not an uncovered SEMS, with consideration of a stent-anchoring/fixation method. BEST PRACTICE ADVICE 6: For patients with gastric outlet obstruction who have a life expectancy greater than 2 months, have good functional status, and who are surgically fit, surgical gastrojejunostomy should be considered. BEST PRACTICE ADVICE 7: For patients with gastric outlet obstruction who are undergoing surgical gastrojejunostomy, a laparoscopic approach is favored over an open approach because of lower blood loss and shorter hospital stay. BEST PRACTICE ADVICE 8: For patients with gastric outlet obstruction who are not candidates for gastrojejunostomy (surgical or endoscopic ultrasound-guided), clinicians should consider the insertion of an enteral stent. BEST PRACTICE ADVICE 9: Enteral stents should not be used in patients with multiple luminal obstructions or severely impaired gastric motility because of the limited benefit in these scenarios. Clinicians can consider placement of a venting gastrostomy in these patients. BEST PRACTICE ADVICE 10: Depending on the experience of the endoscopist, endoscopic ultrasound-guided gastrojejunostomy is an acceptable alternative to surgical gastrojejunostomy and enteral stent placement. Clinicians should be aware that there are currently no dedicated Food and Drug Administration-approved devices for endoscopic ultrasound-guided gastrojejunostomy. BEST PRACTICE ADVICE 11: For patients with malignant colonic obstruction who are candidates for resection, insertion of SEMS is a reasonable choice as a "bridge to surgery" to allow for one-stage, elective resection. BEST PRACTICE ADVICE 12: For patients with malignant colonic obstruction who are not candidates for resection, either SEMS placement or a diverting colostomy are reasonable choices depending on the patient's goals and functional status. BEST PRACTICE ADVICE 13: SEMS is a reasonable option for patients with proximal (or right-sided) malignant obstructions, both as a "bridge to surgery" and in the palliative setting. BEST PRACTICE ADVICE 14: SEMS placement is a reasonable alternative for patients with extracolonic malignancy who are not candidates for surgery, although their placement is more technically challenging, clinical success rates are more variable, and complications (including stent migration) are more frequent.

Palliation of malignant esophageal obstruction using an anti-migration self-expandable metal stent: Results of a prospective multicenter study

BACKGROUND

Self-expanding metal stents (SEMS) placement is primarily indicated to palliate dysphagia for patients with expected short-term survival. We aimed to assess the migration rate and other stent-related adverse events (AEs) of a fully covered SEMS with an anti-migration system (FCSEMS-AMS) for palliation of malignant dysphagia.

METHODS

This is a prospective study including patients with inoperable esophageal cancer that received a FCSEMS-AMS (Taewoong, Niti-S Beta™), in five tertiary-care endoscopic centers from January 2014 to February 2016.

RESULTS

Fifty-three consecutive patients were enrolled. Tumor location was proximal, mid and distal esophagus±esophago-gastric junction (EGJ) in 6, 14, and 33 cases, respectively. Overall, non-severe AEs were reported in 18 patients (34.0%), 13 of them required an additional endoscopic procedure. Migration occurred in 7 patients (13.2%): 3 from the upper and 4 from the lower esophagus and EGJ. Stent retrieval was necessary in one patient due to intolerable pain. Food bolus impaction and tumor overgrowth occurred in 2 patients (3.8%) and 4 (7.5%) patients respectively. Four patients complained of gastroesophageal reflux as late AEs. Median follow-up was 19.3 months. Dysphagia significantly improved until 3 and 6 months from stent insertion (median score before FCSEMS-AMS: 3, vs median score: 1). Median dysphagia-free time was 10 months.

CONCLUSIONS

Placement of the Taewoong, Niti-S Beta™ stent appeared to be a safe and effective treatment of malignant dysphagia. The anti-migration system reduced the overall migration rate, although it remained high in strictures located in the upper esophagus and when the stent was placed across the EGJ.

[Endoscopic Management of Dysphagia]

Dysphagia is difficulty in swallowing that can be caused by a number of disorders that involve either the oropharynx or the esophagus. Specific endoscopic treatment for dysphagia depends on its etiology, whether the dysphagia is caused by mechanical narrowing or a motor disorder. Variable endoscopic treatment strategies can be used to manage dysphagia. Patient with dysfunction of the upper esophageal sphincter may benefit from esophageal dilationor injection of botulinum toxin. Pneumatic balloon dilation, injection of botulinum toxin, peroral endoscopic myotomy can be considered as treatment options for esophageal motility disorders. Endoscopic dilation is the treatment choice of esophageal stricture, while intraluminal steroid injection and temporary stent can be considered in refractory benign esophageal stricture. Self-expandable metal stent insertion can be considered for dysphagia with malignant cause.

Endoscopic recanalization of complete esophageal obstruction

BACKGROUND AND AIMS

Complete esophageal obstruction (CEO) is a rare complication after radiochemotherapy that dramatically impairs quality of life. Within this study, we assessed the outcome of two different endoscopic techniques for lumen restoration in patients with CEO.

METHODS

17 patients were included. Esophageal recanalization was performed in an antegrade approach (Group A) or through combined antegrade and retrograde recanalization and dilatation (CARD, Group B). Technical success, complications, and dysphagia development during follow-up (FU) were compared between the groups.

RESULTS

In Group A (n = 6), esophageal recanalization was performed by a single endoscopist with a median duration of 47 min. In two patients, antegrade recanalization led to formation of a false lumen (i.e., submucosal tunneling) followed by mediastinitis. In Group B, 21 CARD procedures were performed in 11 patients with a technical success rate of 100%. Procedure time was longer compared to Group A; however, no intra- or postprocedural complications were observed in Group B.

CONCLUSIONS

In our experience and cohort, CARD was a successful procedure for recanalization of CEO, which exhibits a more favorable safety profile over antegrade recanalization. Further randomized studies to evaluate the treatment of CEO with CARD are needed.

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

BACKGROUND AND AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Complications Related to Esophageal Stent (Boston Scientific Wallflex vs. Merit Medical Endotek) Use in Benign and Malignant Conditions

Background In our institutions, there are two types of stents used: the Boston Scientific Wallflex (Marlborough, Massachusetts) and Merit Medical Endotek (South Jordan, Utah). So we performed this retrospective study to compare complication rates in various esophageal disorders to improve our quality of care. Methods Charts were reviewed to capture gender, indications of stent placement, stent length/diameter, age of the patient at the time of stent placement, length of hospital stay, physicians performing a procedure, and complications within 90 days of stent placement. Results A total of 67 patients (71.6% male) underwent stent placement (WallFlex 49.3% and Merit 50.8%) for malignant (68.7%) mainly esophageal obstruction by primary esophageal cancer (89.1%) and benign causes (31.3%) mainly esophageal leak (66.7%). Merit and WallFlex used in malignant conditions were 82.4% and 54.6%, respectively, and in benign conditions, they were 17.7% and 45.5%, respectively. The mean age at which endoscopy was performed was 64. Complications post Merit and WallFlex placement were 79.4% and 60.6%, respectively. Complications with malignant and benign conditions were 73.9% and 61.9%, respectively. Complications with 19, 18, and 23 mm diameters were 75.0%, 66.7%, and 69.4%, respectively. Complications with 120, 150, 100, 15, 12, 10 mm stent lengths were 84.6%, 58.3%, 58.8%, 80.0%, 75.0%, and 33.3%, respectively. Conclusion Our study showed that the Merit stent was mainly used, and the major indication of stent placement was a malignant condition. Major complications were seen when the reason for stent placement was a malignant condition, the diameter was 19 mm, the length was 120 mm, and the use of the Merit stent.

Three-dimensional printed 5-fluorouracil eluting polyurethane stents for the treatment of oesophageal cancers

3D printing is introduced as rapid and facile approach to prepare personalized drug-eluting stents for the treatment of oesophageal cancers.

Esophageal Dysphagia in the Elderly

PURPOSE OF REVIEW

With a globally aging population, dysphagia is a growing health concern among elderly. Increasing reflux disease has contributed to an increased prevalence of dysphagia from peptic strictures and esophageal cancer. Dysphagia can lead to malnutrition and aspiration pneumonia, causing considerable morbidity and mortality. This review article focuses on recent advances in the approach and management of esophageal dysphagia.

RECENT FINDINGS

Endoscopic functional luminal imaging probe is a novel test that complements upper endoscopy, esophagram, and esophageal manometry for evaluation of esophageal dysphagia. Opioid induced esophageal dysfunction (OIED) is an emerging clinical entity that can mimic achalasia. Strictures refractory to dilation can be treated with intralesional steroid injections, electrosurgical incision, or esophageal stents. Peroral endoscopic myotomy (POEM) is gaining in popularity for treatment of achalasia and other spastic disorders of esophagus. Treatment of esophageal dysphagia may include proton pump inhibitors, endoscopic dilation, or surgery and requires a personalized approach based on risks and benefits. POEM is a valuable therapy for achalasia, but further studies are needed to evaluate its use, and other alternatives, for treatment of OIED and spastic esophageal disorders.

Stenting in Palliation of Unresectable Esophageal Cancer

Background

The aim of this study was to analyze the safety and effectiveness of stenting using partially covered self-expandable stents in palliation of dysphagia in patients with unresectable esophageal cancer.

Methods

Retrospective analysis of hospital records of all patients who underwent esophageal stenting in the period 2008–2015 was performed. The study included patients with unresectable esophageal and esophagogastric cancer.

Results

There were 442 patients included. Mean age was 56 years (range 28–89), and 379 were males. In 40 (9.0%) patients, stenting was performed in the cervical, in 150 (39.3%)—in the middle thoracic, in 141 (31.9%)—in lower thoracic esophagus and in 111 (25.1%)—in the esophagogastric junction. Stenting resulted in significant alleviation of dysphagia grade (3.0 vs. 1.0, p = 0.00001). During the follow-up, 55 (12.4%) patients experienced recurrent dysphagia due to tumor or granulation tissue overgrowth, and in 18 (4.1%) patients, migration of the stent occurred, for which an independent risk factor was adjuvant chemo- and/or radiation therapy (p = 0.001). Minor complications included chest pain (54.5%), delayed complete stent expansion (12.0%), feeling of a foreign body (25.3%), hiccup (1.6%), gastroesophageal reflux (45.6%) and post-discharge pneumonia (2.5%). A feeling of a foreign body in the esophagus was significantly more common after stenting of the cervical esophagus (p = 0.0001), and hiccup was more common after stenting of the esophagogastric junction (p = 0.02). Major complications included bleeding (1.3%), respiratory insufficiency (0.7%), esophageal perforation (0.9%) and irregular heartburn (2.3%). Overall procedure-related mortality was 0.4%. The median survival time was 117.8 days (range 2–732).

Conclusions

Stenting is an effective procedure in relieving dysphagia in patients with unresectable malignant esophageal stenosis and is associated with low rate of postoperative and long-term complications.

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.

Clinical Feasibility and Safety of Endoscopic Self-Expandable Metal Stent Placement for Upper Gastrointestinal Pathologies

We aimed to review our experiences to evaluate the practicality, safety, and effectiveness of endoscopic stent placement for the palliation of malignant obstructions of the upper gastrointestinal system (GIS) and the treatment of postoperative complications such as failure of anastomoses and fistulae. Endoscopic stent placement is increasingly used in the upper GIS for the management of both high grade malignancies causing obstruction and benign pathologies such as anastomosis failures, gastrointestinal fistulae, and strictures. Hospital records, clinical data, and endoscopy reports of 61 patients who had undergone endoscopic stenting between the years 2012 and 2015 were analyzed retrospectively. For all patients, self-expandable metal covered stents were used. Data involving technical and clinical success rates, complication, morbidity, and mortality rates of the endoscopic stenting procedure was collected and simple statistical analyses were made. Endoscopic stenting was successful in 60 of 61 patients (98.3%). Overall technical success rate was found to be 98.3%; clinical success rate, 86.6%; complication rate, 4.9%. No stent related mortality was observed in our series. Endoscopic stents can be effectively and safely used in the treatment of various lesions of the upper GIS.

Small Bowel Perforation Secondary to Esophageal Stent Migration: A Comparative Review of Six Cases

Esophageal stent placement is used to treat benign strictures, esophageal perforations, fistulas and for palliative therapy of esophageal cancer. Although it is a safe and effective method, complications are increasing the morbidity and mortality rate. Small bowel perforation as a result of esophageal stent migration is a remarkably rare occurrence. We report one case from our clinical experience and undertake a review of the previously reported cases retrieved from the PubMed. A total of six cases were found accessible. Abdominal pain was the common clinical presentation. The mean time from stent placement to perforation was 3.4 months (range, two weeks to 12 months). The jejunum was the frequently perforated portion of the small bowel. Surgical intervention was the mainstay of treatment. This comparative review illustrates that clinicians should remain vigilant for small bowel perforation in patients with esophageal stent placement. Further studies are required to delineate the magnitude and scope of this association.

Low skeletal muscle mass in stented esophageal cancer predicts poor survival: A retrospective observational study

BACKGROUND

In esophageal cancer, nutritional challenges are extremely common. Malignant obstruction resulting from esophageal cancer (EC) is often treated by the insertion of expandable stents, but little is known as to the role and evolution of sarcopenia in this patient population. The aim of this article was to determine the effects of body mass parameters on survival of advanced EC patients who received a stent for palliation of malignant obstruction.

METHODS

This was a retrospective observational study of 238 EC patients who had a stent inserted for palliation of malignant obstruction between 2005 and 2013. Skeletal muscle mass was calculated from abdominal computed tomography scans, and the patients were divided into sarcopenic and non-sarcopenic groups. A follow-up computed tomography scan was available in 118 patients. The primary outcome was survival, and complication rates and the need for an alternative enteral feeding route were secondary outcomes.

RESULTS

Sarcopenia occurred in 199 (85%) patients. Median survival was 146 (range: 76-226) days in the sarcopenia group and 152 (range: 71-249) days in the non-sarcopenic group (P = 0.61). Complication rates between the groups were not significantly different (P = 0.85). In Cox regression analysis, the skeletal muscle index was inversely correlated with overall survival (hazard ratio 0.98, 95% confidence interval 0.97-0.99; P = 0.033).

CONCLUSIONS

Sarcopenia, defined by consensus thresholds, at the time of stent insertion cannot effectively predict poor survival in this patient cohort, but a lower skeletal muscle index correlates with poor prognosis as a continuous variable.

Treatment for unresectable or metastatic oesophageal cancer: current evidence and trends

Approximately half of the patients diagnosed with oesophageal cancer present with unresectable or metastatic disease. Treatment for these patients aims to control dysphagia and other cancer-related symptoms, improve quality of life and prolong survival. In the past 25 years, modestly improved outcomes have been achieved in the treatment of patients with inoperable non-metastatic cancer who are medically not fit for surgery or have unresectable, locally advanced disease. Concurrent chemoradiotherapy offers the best outcomes in these patients. In distant metastatic oesophageal cancer, several double-agent or triple-agent chemotherapy regimens have been established as first-line treatment options. In addition, long-term results of multiple large randomized phase III trials using additional targeted therapies have been published in the past few years, affecting contemporary clinical practice and future research directions. For the local treatment of malignant dysphagia, various treatment options have emerged, and self-expandable metal stent (SEMS) placement is currently the most widely applied method. Besides the continuous search for improved SEMS designs to minimize the risk of associated complications, efforts have been made to develop and evaluate the efficacy of antireflux stents and irradiation stents. This Review outlines the current evidence and ongoing trends in the different modern-day, multidisciplinary interventions for patients with unresectable or metastatic oesophageal cancer with an emphasis on key randomized trials.

Esophageal Stenting in Clinical Practice: an Overview

OPINION STATEMENT

PURPOSE OF REVIEW: Esophageal stents are used in clinical practice for endoscopic treatment of a wide variety of esophageal diseases and conditions. This review provides key principles and a literature update on the utility and limitations of esophageal stenting in clinical practice.

RECENT FINDINGS

Indications for esophageal stenting can be subdivided into two groups. The first group consists of patients with malignant or benign dysphagia, in which an esophageal stent restores luminal patency. In the past years, temporary stent placement has increasingly been used in the therapeutic management of refractory benign esophageal strictures. When endoscopic repeated bougie dilation and other endoscopic treatment modalities have failed, an esophageal stent could be considered. Based on the literature, a fully covered self-expandable metal stent may be the preferred choice for the treatment of both malignant and benign dysphagia. The second group consists of patients with leakage from the esophageal lumen into the surrounding tissue. Esophageal leakage can be subdivided into three forms, benign esophageal perforations (iatrogenic and spontaneous), anastomotic leakage after reconstructive esophageal surgery, and fistula. In a carefully selected group of patients, a covered esophageal stent may be used for sealing off the leakage, thereby preventing further contamination of the tissue surrounding the defect. The past few years, several validated prediction tools have been developed that may assist clinicians in the selection of patients eligible for esophageal stent placement. Based on retrospective studies and expert opinion, a partially or fully covered self-expandable metal stent may have a role in treatment of esophageal leakage. Research do date supports the utilization of esophageal stents for the treatment of malignant or benign dysphagia and esophageal leakage.

Fully covered stents versus partially covered stents for palliative treatment of esophageal cancer: Is there a difference?

INTRODUCTION AND AIMS

Malignant dysphagia is difficulty swallowing resulting from esophageal obstruction due to cancer. The goal of palliative treatment is to reduce the dysphagia and improve oral dietary intake. Self-expandable metallic stents are the current treatment of choice, given that they enable the immediate restoration of oral intake. The aim of the present study was to describe the results of using totally covered and partially covered esophageal stents for palliating esophageal cancer.

MATERIALS AND METHODS

A retrospective study was conducted on patients with inoperable esophageal cancer treated with self-expandable metallic stents. The 2 groups formed were: group A, which consisted of patients with a fully covered self-expandable stent (SX-ELLA^®), and group B, which was made up of patients with a partially covered self-expandable stent (Ultraflex^®).

RESULTS

Of the 69-patient total, 50 were included in the study. Group A had 19 men and 2 women and their mean age was 63.6 years (range 41-84). Technical success was achieved in 100% (n=21) of the cases and clinical success in 90.4% (n=19). Group B had 24 men and 5 women and their mean age was 67.5 years (range 43-92). Technical success was achieved in 100% (n=29) of the cases and clinical success in 89.6% (n=26). Complications were similar in both groups (33.3 vs. 51.7%).

CONCLUSION

There was no difference between the 2 types of stent for the palliative treatment of esophageal cancer with respect to technical success, clinical success, or complications.

Complications of stent placement in patients with esophageal cancer: A systematic review and network meta-analysis

Background

Palliative treatments and stents are necessary for relieving dysphagia in patients with esophageal cancer. The aim of this study was to simultaneously compare available treatments in terms of complications.

Methods

Web of Science, Medline, Scopus, Cochrane Library and Embase were searched. Statistical heterogeneity was assessed using the Chi² test and was quantified by I². The results of this study were summarized in terms of Risk Ratio (RR). The random effects model was used to report the results. The rank probability for each treatment was calculated using the p-score.

Results

Out of 17855 references, 24 RCTs reported complications including treatment related death (TRD), bleeding, stent migration, aspiration, severe pain and fistula formation. In the ranking of treatments, thermal ablative therapy (p-score = 0.82), covered Evolution® stent (p-score = 0.70), brachytherapy (p-score = 0.72) and antireflux stent (p-score = 0.74) were better treatments in the network of TRD. Thermal ablative therapy (p-score = 0.86), the conventional stent (p-score = 0.62), covered Evolution® stent (p-score = 0.96) and brachytherapy (p-score = 0.82) were better treatments in the network of bleeding complications. Covered Evolution® (p-score = 0.78), uncovered (p-score = 0.88) and irradiation stents (p-score = 0.65) were better treatments in network of stent migration complications. In the network of severe pain, Conventional self-expandable nitinol alloy covered stent (p-score = 0.73), polyflex (p-score = 0.79), latex prosthesis (p-score = 0.96) and brachytherapy (p-score = 0.65) were better treatments.

Conclusion

According to our results, thermal ablative therapy, covered Evolution® stents, brachytherapy, and antireflux stents are associated with a lower risk of TRD. Moreover, thermal ablative therapy, conventional, covered Evolution® and brachytherapy had lower risks of bleeding. Overall, fewer complications were associated with covered Evolution® stent and brachytherapy.

Factors That Affect Stent-Related Complications in Patients with Malignant Obstruction of the Esophagus or Gastric Cardia

Background/Aims

Self-expandable metallic stent (SEMS) placement is effective for dysphagia that results from malignant obstruction of the esophagus or gastric cardia; however, stent-related complications may be life-threatening. Thus, the goal of this study was to identify risk factors associated with complications following esophageal stenting.

Methods

Of the 71 patients who underwent SEMS placement for dysphagia as a result of malignant stricture of the esophagus or gastric cardia, 53 patients with squamous cell carcinoma or adenocarcinoma, without previous SEMS placement, without a fistula, and without recurrent tumor after surgery were retrospectively identified. The occurrence of stent-related complications was used as an endpoint.

Results

Stent-related complications were identified in 26 patients (49.1%), and major complications occurred in 14 patients (26.4%). The use of an Ultraflex stent (odds ratio [OR], 6.81; 95% confidence interval [CI], 1.54 to 30.00; p=0.011) and prior chemotherapy (OR, 6.13; 95% CI, 1.46 to 25.70; p=0.013) were significantly associated with stent-related complications. Moreover, the use of an Ultraflex stent (OR, 19.60; 95% CI, 2.26 to 170.00; p=0.007) and prior radiation (OR, 25.70; 95% CI, 2.37 to 280.00; p=0.008) significantly increased the risk of major complications.

Conclusions

The use of an Ultraflex stent and prior radiation and/or chemotherapy may represent risk factors for complications following esophageal SEMS placement.

Safety and feasibility of esophageal self- expandable metal stent placement without the aid of fluoroscopy

Self-expandable metal stents (SEMSs) are used for the management of certain esophageal conditions such as strictures, perforations, and fistulae. These can be placed using fluoroscopic control, endoscopic control, or a combination of both. We evaluated our institutional experience of placing a SEMS using only endoscopy without the aid of fluoroscopy to determine safety and feasibility using this technique. A retrospective review was performed to identify all patients who underwent esophageal SEMS from January 2010 to June 2015. Placement of SEMS was accomplished under direct endoscopic visualization without the aid of fluoroscopy. Esophageal lesion was initially identified during endoscopy and a fully covered SEMS was passed over the guide wire and deployed under direct vision. Misplacement of the SEMS during the procedure that required replacement with another new SEMS was considered as a failed procedure. Other periprocedural complications caused by placement of SEMS were noted. A total of 172 patients underwent 280 procedures for SEMS placement. Mean age was 66 years. The most common indication for SEMS placement was stricture in 248 (88%) procedures. Periprocedure SEMS misplacement occurred in 12 (4%) patients. However, only 8 (3%) patients needed to have a new SEMS placed during the same procedure. A total of 64 (23%) patients had migration of SEMS. There were no other periprocedure complications leading to adverse events. Self-expandable metal stent can be placed accurately and safely under direct endoscopic visualization without the aid of fluoroscopy.

Per-oral endoscopic tunneling for restoration of the esophagus: a novel endoscopic submucosal dissection technique for therapy of complete esophageal obstruction

BACKGROUND AND AIMS

Total aphagia from complete esophageal obstruction (CEO) can be seen in patients with head-neck or thoracic malignancies undergoing chemoradiation or surgery. Combined antegrade and retrograde endoscopy (via gastrostomy tube [G-tube] tract) is often performed for esophageal reconstruction but is limited by the length of the obstructed esophagus. We describe per-oral endoscopic tunneling for restoration of the esophagus (POETRE) for patients with longer segments of esophageal obstruction. The aim of this study was to assess the efficacy and safety of POETRE for CEO.

METHODS

All patients with CEO undergoing endoscopy with POETRE from October 2013 to September 2015 were enrolled in this single-center prospective study. Clinical, endoscopic, and radiologic records were maintained as required for clinical care and for the study. Dysphagia score was recorded before and after POETRE. Adverse events were assessed based on the American Society for Gastrointestinal Endoscopy criteria.

RESULTS

Four patients (3 men; mean age, 72.3 years) underwent POETRE for CEO ≥3 cm in length. Esophageal reconstruction was technically successful in all patients (100%). Antegrade submucosal tunneling was performed in 2 of 4 patients (50%), and retrograde tunneling was performed in the other 2 patients, all with simultaneous dual endoscope and fluoroscopic guidance. The mean dysphagia score of 4 before the procedure improved to 2.5 after POETRE during follow-up (mean, 27.8 weeks). All patients required subsequent serial endoscopic dilations as needed after POETRE. One adverse event (pneumonia) was seen (25%).

CONCLUSIONS

We present a novel ESD technique, POETRE, for therapy of complete esophageal obstruction. This approach is specifically useful for lumen restoration in patients with longer segments of esophageal obstruction. (Clinical trial registration number: NCT00968552.).

Fully covered stents are similar to semi-covered stents with regard to migration in palliative treatment of malignant strictures of the esophagus and gastric cardia: results of a randomized controlled trial

Introduction

Stent migration is a significant clinical problem in palliation of malignant strictures in the esophagus and gastro-esophageal junction (GEJ). We have compared a newer design of a fully-covered stent to a widely used semi-covered stent using migration >20 mm as the primary outcome variable. Effects on dysphagia, quality of life (QoL) and re-intervention frequency were also investigated.

Methods

Patients with dysphagia due to non-curable esophagus/GEJ cancer were randomized to receive either a more recent design of a fully-covered stent (n = 48) or a conventional semi-covered stent (n = 47). Chest x-ray, dysphagia and QoL were studied at baseline, one week, four weeks and three months thereafter.

Results

There were no significant differences either in stent migration distance or in the migration frequency. Stent migration during the total study period occurred in 37.2 % in the semi-covered group compared to 20.0 % for the fully-covered group. Dysphagia was measured with Watson and Ogilvie scores and with the dysphagia module in the QoL scale (QLQ-OG25). On average, there was a tendency to better dysphagia relief for the fully-covered design as scored with the two latter dysphagia instruments (p= 0.081 and p= 0.067) at three months and towards more re-interventions in the semi-covered group (p= 0.083).

Conclusion

In spite of its somewhat lower intrinsic radial force, the fully-covered stent was comparable to the conventional semi-covered stent with regard to stent migration. The data further suggest a potential benefit of the fully-covered stent in improving dysphagia in patients with longer life expectancy.

Outcome and risk factors assessment for adverse events in advanced esophageal cancer patients after self-expanding metal stents placement

Self-expanding metal stents (SEMS) are the treatment of choice for advanced esophageal cancers. Literature is scarce on risk factors predictors for adverse events after SEMS placement. Assess risk factors for adverse events after SEMS placement in advanced esophageal cancer and evaluate survival after SEMS placement. Cross-sectional study of patients with advanced esophageal cancer referred for SEMS placement, during a period of 3 years. Ninety-seven patients with advanced esophageal cancer placed SEMS. Adverse events were more common when tumors were located at the level of the distal esophagus/cardia (47% vs 23%, P = 0.011, OR 3.1), with statistical significance being kept in the multivariate analysis (OR 3.1, P = 0.018). Time until adverse events was lower in the tumors located at the level of the distal esophagus/cardia (P = 0.036). Survival was higher in patients who placed SEMS with curative intent (327 days [126-528] vs. 119 days [91-147], P = 0.002) and in patients submitted subsequently to surgery compared with those who did just chemo/radiotherapy or who did not do further treatment (563 days [378-748] vs. 154 days [133-175] vs. 46 days [20-72], P < 0.001). Subsequent treatment kept statistical significance in the multivariate analysis (HR 3.4, P < 0.001). SEMS allow palliation of dysphagia in advanced esophageal cancer and are associated with an increased out-of-hospital survival, as long as there are conditions for further treatments. Tumors located at the level of the distal esophagus/cardia are associated with a greater number of adverse events, which also occur earlier.

Small caliber covered self-expanding metal stents in the management of malignant dysphagia

BACKGROUND

Use of large caliber [≥18 mm body diameter (BD)] self-expanding metal stents (SEMS) for management of malignant dysphasia is associated with substantial adverse event (AE) and mortality rates (MRs). We sought to determine dysphagia response, stent migration rates, and AE and MRs, for small caliber covered SEMS (sccSEMS) with BDs between 10-16 mm in malignant dysphagia.

METHODS

Thirty-one patients underwent direct endoscopic placement of 50 sccSEMS between January 2008 and March 2011. Patients were monitored for change in dysphagia score (DS), stent migration, AEs, and death through May 2011.

RESULTS

DS improved in 30 of 31 patients (97%). The median DS decreased from 3 to 2 (P<0.0001). The median effective duration of first sccSEMS placement was 116 (95% CI: 75-196) days. Major and minor AE rates were 6.5% and 19.4% respectively. No stent related deaths were encountered. The overall migration rate was 36% (18/50). The anticipated migration rate was 45.7% (16/35) and the unanticipated migration rate was 13.3% (2/15) (P=0.052). Positive effective clinical outcome occurred in 93.5% (29/31) of cases.

CONCLUSIONS

In malignant dysphagia, direct endoscopic sccSEMS placement provided acceptable dysphagia control and migration rates with substantial reductions in stent related AEs and MRs compared to those reported for large caliber SEMS.

Palliation of Concomitant Tracheobronchial and Esophageal Disease Using a Combined Airway and Esophageal Approach

BACKGROUND

Neoplastic involvement of the mediastinum can contribute to both airway and esophageal pathology. That can manifest as combined esophageal and airway stenosis, or tracheobronchoesophageal fistula. Conventional palliative treatment of these problems consists of endoluminal stent insertion. The double stenting approach consists of insertion of a tracheobronchial and an esophageal stent in parallel and allows concomitant symptomatic relief of both the airway and esophageal pathology.

METHODS

The study consists of a retrospective case series of patients who underwent a double stenting procedure for concomitant airway and esophageal disease between August 2009 and September 2014. The type of airway stent chosen was determined based on the pathology and the level of the lesion (simple tubular in the mid trachea or mainstem bronchus, Y-stent for carina).

RESULTS

Thirty-nine patients were treated using the double stenting approach during a combined procedure over 5 years: 15 patients with tracheobronchoesophageal fistula and 24 with stenosis. Immediate relief of symptoms, defined as resuming oral intake and breathing without an external tracheal device, was observed in 25 patients (64%). Thirty-two patients (82%) were discharged from hospital, and 7 patients died in hospital (18%). Of these 7 deaths, 6 patients died of pulmonary complications. Inhospital complications occurred in 11 patients (28%). Of the patients discharged from the hospital, 14 died during a mean follow-up period of 54 days. Mean and median survival were 49 and 24 days, respectively (range, 1 to 448), and median hospital stay was 3 days (range, 1 to 46).

CONCLUSIONS

Treatment of combined airway and esophageal pathology using a double stenting approach is safe, feasible, provides reasonable immediate palliation of symptoms, and is associated with acceptable morbidity. It is a palliative procedure that allows for early hospital discharge of patients who are diagnosed with an incurable malignancy.

Stenting as a palliative method in the management of advanced squamous cell carcinoma of the oesophagus and gastro-oesophageal junction

Advanced squamous cell carcinoma of the oesophagus and gastroesophageal junction usually requires palliative treatment, and the method of choice is stenting. There are several types of stents currently available, including: self-expandable metallic stents (fully or partially covered); self-expandable plastic stents; biodegradable stents. Each of the mentioned stents has its advantages and limitations, and requires a proper, patient-tailored selection. Due to the close anatomical relationship between the oesophagus and bronchial tree, some patients may require bilateral stenting. Oesophageal stenting may not only be considered as a palliative procedure, but can also be implemented to alleviate dysphagia during preoperative chemotherapy and/or radiotherapy.

Endoscopy in patients on antiplatelet or anticoagulant therapy, including direct oral anticoagulants: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guidelines

The risk of endoscopy in patients on antithrombotics depends on the risks of procedural haemorrhage versus thrombosis due to discontinuation of therapy. P2Y12 RECEPTOR ANTAGONISTS CLOPIDOGREL, PRASUGREL, TICAGRELOR: For low-risk endoscopic procedures we recommend continuing P2Y12 receptor antagonists as single or dual antiplatelet therapy (low quality evidence, strong recommendation); For high-risk endoscopic procedures in patients at low thrombotic risk, we recommend discontinuing P2Y12 receptor antagonists five days before the procedure (moderate quality evidence, strong recommendation). In patients on dual antiplatelet therapy, we suggest continuing aspirin (low quality evidence, weak recommendation). For high-risk endoscopic procedures in patients at high thrombotic risk, we recommend continuing aspirin and liaising with a cardiologist about the risk/benefit of discontinuation of P2Y12 receptor antagonists (high quality evidence, strong recommendation).

WARFARIN

The advice for warfarin is fundamentally unchanged from British Society of Gastroenterology (BSG) 2008 guidance.

DIRECT ORAL ANTICOAGULANTS DOAC

For low-risk endoscopic procedures we suggest omitting the morning dose of DOAC on the day of the procedure (very low quality evidence, weak recommendation); For high-risk endoscopic procedures, we recommend that the last dose of DOAC be taken ≥48 h before the procedure (very low quality evidence, strong recommendation). For patients on dabigatran with CrCl (or estimated glomerular filtration rate, eGFR) of 30-50 mL/min we recommend that the last dose of DOAC be taken 72 h before the procedure (very low quality evidence, strong recommendation). In any patient with rapidly deteriorating renal function a haematologist should be consulted (low quality evidence, strong recommendation).

Treatment of gastric outlet obstruction that results from unresectable gastric cancer: Current evidence

Malignant gastric outlet obstruction (GOO) is a common condition that results from locally advanced malignancies in the upper gastrointestinal tract, such as pancreatic, gastric, and other carcinomas. Two types of procedures for malignant GOO, namely, gastrojejunostomy (GJ) with laparotomy or a laparoscopic approach and endoscopic stenting (ES), are currently available. Although numerous previous reports have clarified the benefits and drawbacks of each procedure, whether GJ or ES should be used in patients with GOO that results from gastric cancer who may have a longer life expectancy than patients with other malignancies has not been determined. In this review, which focuses on gastric cancer-induced GOO, we analyzed the two systematic reviews and a meta-analysis that compared GJ and ES and outlined the current status of GOO treatment. We also provide an updated review that includes laparoscopic GJ. Various data from 13 studies in one review and 6 studies in another review were analyzed. Although the main results of the present review indicated that both GJ and ES were efficacious treatments in patients with GOO that resulted from gastric cancer, current evidence suggests that GJ may be the preferable procedure given its good performance status and improved prognosis in gastric cancer patients.