Esophagorespiratory fistula associated with esophageal cancer: treatment with a Gianturco stent tube

The use of self-expandable metallic stents in the airways in the adult population

The airway stents restore patency in the face of luminal compromise from intrinsic and/or extrinsic pathologies. Luminal compromise beyond 50% often leads to debilitating symptoms such as dyspnea. Silicone stents remain the most commonly placed stents worldwide and have been the "gold standard" for the treatment of benign and malignant airway stenoses over the past 20 years. Nevertheless, silicone stents are not the ideal stents in all situations. Metallic stents can serve better in some selected conditions. Unlike silicone stents, there are large and increasing varieties of metallic stents available on the market. The lack of prospective or comparative studies between various types of metallic stents makes the choice difficult and expert-opinion based. International guidelines are sorely lacking in this area.

Evidence-based recommendations on upper gastrointestinal tract stenting: a report from the stent study group of the korean society of gastrointestinal endoscopy

Endoscopic stents have evolved dramatically over the past 20 years. With the introduction of uncovered self-expanding metal stents in the early 1990s, they are primarily used to palliate symptoms of malignant obstruction in patients with inoperable gastrointestinal (GI) cancer. At present, stents have emerged as an effective, safe, and less invasive alternative for the treatment of malignant GI obstruction. Clinical decisions about stent placement should be made based on the exact understanding of the patient's condition. These recommendations based on a critical review of the available data and expert consensus are made for the purpose of providing endoscopists with information about stent placement. These can be helpful for management of patients with inoperable cancer or various nonmalignant conditions in the upper GI tract.

Esophageal stents in malignant and benign disorders

Endoscopic stent placement is an effective palliative treatment for malignant dysphagia and fistula, leading to rapid symptom relief. However, recurrent dysphagia and other stent-related complications are common, for which reason continuously new design modifications are implemented. Although some of these changes facilitate stent placement, complications remain and occur at similar rates. Recently, stents have also been used in benign esophageal disorders. Covered stents have the ability to effectively seal esophageal perforations and leaks, reducing the need for invasive surgery. This benefit does not pertain to patients with refractory benign esophageal strictures, in whom stents have limited long-term effect and are associated with a high complication rate. The initial results of fully covered metal stents in refractory esophageal variceal bleeding are encouraging, but their definite role remains to be further elucidated. This review provides an overview of indications, techniques, and management of complications of stents in malignant and benign esophageal disease.

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.

Role of esophageal stents in benign and malignant diseases

These recommendations provide an evidence-based approach to the role of esophageal stents in the management of benign and malignant diseases. These guidelines have been developed under the auspices of the American College of Gastroenterology and its Practice Parameters Committee and approved by the Board of Trustees. The following guidelines are based on a critical review of the available scientific literature on the topic identified in Medline and PubMed (January 1992-December 2008) using search terms that included stents, self-expandable metal stents, self-expandable plastic stents, esophageal cancer, esophageal adenocarcinoma, esophageal squamous cell carcinoma, esophageal stricture, perforations, anastomotic leaks, tracheoesophageal fistula, and achalasia. These guidelines are intended for use by health-care providers and apply to adult, but not pediatric, patients. As with other practice guidelines, these guidelines are not intended to replace clinical judgment but rather to provide general guidelines applicable to the majority of patients. Clinicians need to integrate recommendations with their own clinical judgment, and with individual patient circumstances, values, and preferences. They are intended to be flexible, in contrast to standards of care, which are inflexible policies designed to be followed in every case. Specific recommendations are based on relevant published information. The quality of evidence and strength of recommendations have been assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system, which is a system that has been adopted by multiple national and international societies. The GRADE system is based on a sequential assessment of quality of evidence, followed by assessment of the balance between benefits vs. downsides (harms, burden, and costs) and subsequent judgment regarding the strength of recommendation.

Palliative treatment of malignant esophagopulmonary fistulas with covered expandable metallic stents

OBJECTIVE

The objective of our study was to evaluate the safety and clinical effectiveness of covered expandable metallic stents for palliative treatment of malignant esophagopulmonary fistulas.

MATERIALS AND METHODS

Between November 1990 and January 2008, 14 patients with fistulas between the esophagus and pulmonary parenchyma were treated with covered expandable metallic esophageal stents. The fistulas were caused by esophageal (n = 9) or bronchogenic (n = 5) carcinomas. At the time of stent placement, all patients had aspiration pneumonia and 11 had lung abscesses (79%). Technical and clinical success, fistula reopening, complications, and survival rates were evaluated.

RESULTS

Stent placement was technically successful in all cases, and there were no immediate procedural complications. Complete fistula sealing resulting in resolution of aspiration symptoms (i.e., clinical success) occurred in 12 patients (86%). During follow-up (mean survival, 100.9 +/- 79.9 days; median survival, 65.5 days; range, 16-275 days), the fistula reopened in two of 12 clinical success patients. One patient (7%) experienced complications resulting from dyspnea due to tracheal compression by the esophageal stent. Although 13 patients died of aspiration pneumonia and the remaining patient died of cancer bleeding, none of the mortalities was related to the stent placement procedure.

CONCLUSION

The use of covered expandable metallic stents appears to be safe and feasible for the palliative treatment of malignant esophagopulmonary fistulas.

Characteristics of esophagorespiratory fistulas resulting from esophageal cancers: a single-center study on 243 cases in a 20-year period

BACKGROUND

Esophagorespiratory fistulas are serious complications of esophageal tumors. The main goal of this study was to reveal their characteristics.

METHODS

In the period between 1984 and 2004, 243 fistulas were diagnosed among the 1993 patients with esophageal cancer. Comparing the characteristic data of patients with and without fistula (demographics, symptoms, duration time of symptoms, morphologic features, histology, metastases, staging), multivariance analysis showed significant differences (P < 0.05). Patients with fistula were divided into two additional groups (I, n = 82; II, n = 161 cases) with cluster analysis. The difference between these two groups was also significant.

RESULTS

It was possible to perform a palliative endoscopic intubation in 176 cases, while 62 patients could be treated only supportively. The average survival was 3.4 and 1.2 months, respectively. Fistula was a late complication of tumor in two thirds (66.3%) of the cases, while in 33.7% it was diagnosed in younger patients at the early stage of the disease, with a more aggressive, less differentiated histology. In these patients the weight loss, the grade of dysphagia, and the size of the tumor were smaller, the possibilities of treatment were fewer, and survival time was shorter (2.1 vs. 3.1 months).

CONCLUSIONS

These tumors seem to be specific forms of esophageal cancers. For a better quality of life and longer survival time for these patients, there should be earlier diagnosis and endoscopic intubation as the best palliative treatment should be performed.

Management of airway involvement of oesophageal cancer using covered retrievable nitinol stents

AIM

To assess the efficacy and safety of covered retrievable nitinol stents in oesophageal cancer patients with airway involvement.

MATERIALS AND METHODS

Under fluoroscopic guidance, covered retrievable nitinol airway stents were placed in 23 oesophageal cancer patients with airway stricture and/or oesophagorespiratory fistula (ERF) over a long period of 12 years. Six patients only had aspiration by ERF and three patients had both airway stricture and asymptomatic ERF. Technical aspects, dyspnoea improvement, and/or resolution of ERF symptoms, complications, reinterventions, and survival data were evaluated.

RESULTS

A total of 27 airway stents (14 tracheal, 11 bronchial, and two hinged) were placed successfully in 23 patients with airway stricture or ERF. Dyspnoea score decreased significantly after stent placement (p<0.001). ERF were sealed off in all nine patients. Complications included stent migration or expectoration (n=4), haemoptysis (n=2), sputum retention (n=7), and tumour overgrowth (n=1). All three migrated stents were easily removed. Twenty-one patients died, with the median survival period of 76 days (range 2-197 days).

CONCLUSION

Placement of covered retrievable expandable nitinol stents was safe and effective for the palliative treatment of airway strictures and/or ERF, with a reasonable range of complications, in patients with advanced oesophageal cancer.

Airway and esophageal stenting in patients with advanced esophageal cancer and pulmonary involvement

Background

Most inoperable patients with esophageal-advanced cancer (EGC) have a poor prognosis. Esophageal stenting, as part of a palliative therapy management has dramatically improved the quality of live of EGC patients. Airway stenting is generally proposed in case of esophageal stent complication, with a high failure rate. The study was conducted to assess the efficacy and safety of scheduled and non-scheduled airway stenting in case of indicated esophageal stenting for EGC.

Methods and Findings

The study is an observational study conducted in pulmonary and gastroenterology endoscopy units. Consecutive patients with EGC were referred to endoscopy units. We analyzed the outcome of airway stenting in patients with esophageal stent indication admitted in emergency or with a scheduled intervention. Forty-four patients (58±\−8 years of age) with esophageal stenting indication were investigated. Seven patients (group 1) were admitted in emergency due to esophageal stent complication in the airway (4 fistulas, 3 cases with malignant infiltration and compression). Airway stenting failed for 5 patients. Thirty-seven remaining patients had a scheduled stenting procedure (group 2): stent was inserted for 13 patients with tracheal or bronchial malignant infiltration, 12 patients with fistulas, and 12 patients with airway extrinsic compression (preventive indication). Stenting the airway was well tolerated. Life-threatening complications were related to group 1. Overall mean survival was 26+/−10 weeks and was significantly shorter in group 1 (6+/−7.6 weeks) than in group 2 (28+/−11 weeks), p<0.001). Scheduled double stenting significantly improved symptoms (95% at day 7) with a low complication rate (13%), and achieved a specific cancer treatment (84%) in most cases.

Conclusion

Stenting the airway should always be considered in case of esophageal stent indication. A multidisciplinary approach with initial airway evaluation improved prognosis and decreased airways complications related to esophageal stent. Emergency procedures were rarely efficient in our experience.

[Pathological characteristics of esophago-respiratory fistulas of esophageal tumor origin]

Esophago-respiratory fistulas, evolving as a result of esophageal tumors, are serious and lethal complications on account of the constant respiratory contamination and the inability to swallow. They can develop either as the complication of the end stage disease or sometimes even in the first stage of the malignancy. The objective was to reveal the characteristics of the disease. In a prospective single-center study in the period between 1984 and 2004, 243 fistulas were diagnosed. Their data were analyzed using multivariate analysis. The mean age of patients with fistula was 56.9 years, the male-to-female ratio was 4.3:1. The average time of the complaints was 5.2 months, while the time of manifestation of the fistula was 7.5 months. Dysphagia was diagnosed in 97.5% of the patients, fever in 36.9%, and cachexia in 59.5%, respectively. The average loss of weight was 10.4 kg and the average size of the tumor was 7.7 cm. Endoscopic intubation was performed in 176 cases. The average survival was 3.4 months. Patients with fistula were divided into two groups, where the characteristics of the disease were significantly different. Only in 66.3% was the fistula a late complication. In the other 33.7% of the cases the fistula was diagnosed in younger patients at the early stage of the disease, with a more aggressive, less differentiated histology. In these patients the weight loss, the grade of dysphagia and the size of the tumor were smaller, the possibilities of treatment were fewer, and survival were shorter.

Palliation of malignant aerodigestive fistulae with self-expanding metallic stents

Malignant aerodigestive fistulae are rare but devastating sequelae of thoracic cancers, most commonly associated with esophageal cancer. Survival following development of a malignant aerodigestive fistula is measured in weeks. Palliation is the primary goal of therapy and to this end, we report the use of self-expanding metallic stents (SEMS) as treatment. Between May 1999 and January 2004, 12 patients were treated for malignant aerodigestive fistulae. The underlying diagnosis was esophageal cancer for 10 patients, and non-small cell lung cancer for two others. All patients were symptomatic and fistulae were diagnosed by esophagoscopy in seven, bronchoscopy in two, and esophagram in three. Seven covered Wallstents (seven esophageal) and eight covered Ultraflex (five tracheal and three esophageal) were used. A single stent was placed in eight patients (seven esophageal and one tracheal). Three patients required esophageal and tracheal stents and one patient needed two tracheal stents. General anesthesia was required in 50% of the patients. There were no procedure-related complications. Symptoms were palliated in 100% of patients and oral intake was reinstituted in 42% (5/12). All the patients were discharged from hospital after SEMS placement and one patient returned for an uneventful tracheal stent replacement secondary to mucus impaction 2 months later. SEMS placement is an effective strategy to palliate malignant aerodigestive fistulae. Complications are rare and symptoms are alleviated in most patients.

Removal of a Covered Esophageal Metallic Stent 8 Years after Placement

A covered expandable esophageal metallic stent was placed to treat a corrosive esophageal stricture that was refractory to repeated balloon dilations. The stent was removed 8 years after placement due to severe dysphagia. The stented esophageal area has since maintained long-term patency for 2 years. These results suggest the feasibility of removal of a metallic stent after long-term stent placement.

Gastrotracheal and gastrobronchial fistulas: management with covered expandable metallic stents

PURPOSE

The present study evaluated the clinical results of covered tracheobronchial metallic stent placement in the management of gastrotracheal fistulas (GTFs) and gastrobronchial fistulas (GBFs).

MATERIALS AND METHODS

Sixteen patients with GTFs or GBFs after esophagogastrectomy were treated with one of two types of covered tracheobronchial metallic stents: a hinged stent or a straight stent. These included 12 GTFs and four GBFs. Thirteen hinged stents and three straight stents were placed during the initial procedure. Data regarding the technical success of stent placement, initial clinical success and failure, fistula reopening, and complications were obtained.

RESULTS

Stent placement was technically successful in all patients. The stent completely sealed off the fistula in 12 of 16 patients (75% initial clinical success rate), whereas the remaining four patients (25%) had persistent aspiration symptoms as a result of incomplete GTF or GBF closure (ie, initial clinical failure). During follow-up, the fistula reopened in three of the 12 patients in whom initial clinical success was achieved (25%). Two reopened fistulas were sealed off with stent placement, and one was treated with a nasoenteric feeding tube and a nasogastric decompression tube. All patients died during the 1-year follow-up period; mean survival time was 17 +/- 3.02 weeks (range, 1-42 weeks) after stent placement. Mean survival in patients in whom initial clinical success was achieved was significantly longer than in patients with initial clinical failure (P = .003; log-rank test).

CONCLUSION

Use of covered metallic stents appears to be a safe and moderately effective procedure to occlude GTFs and GBFs.

New developments in palliative therapy

Over the past 5 years, new developments in the palliative treatment of incurable cancer of the oesophagus and gastro-oesophageal junction have been introduced with the aim of palliating dysphagia and improving the survival of patients. Stent placement is currently the most widely used treatment for palliation of dysphagia from oesophageal cancer. A stent offers rapid relief of dysphagia; however, current recurrent dysphagia rates vary between 30 and 40%. Recently introduced new stent designs are likely to reduce recurrent dysphagia by decreasing stent migration and non-tumoral tissue overgrowth. Intraluminal radiotherapy (brachytherapy) has been demonstrated to compare favourably with stent placement in long-term effectiveness and safety. A disadvantage of brachytherapy, however, is that one-fifth of patients need an additional treatment because of persistent tumour growth in the oesophagus. A solution may be to administer brachytherapy not in a single fraction but in multiple fractions. Finally, efforts have been undertaken to improve survival of patients by using chemotherapy. In the future, a multimodal approach--for example by combining stent placement with chemotherapy or radiotherapy--may improve the prognosis of patients without jeopardizing their quality of life.

A fast placement technique for covered tracheobronchial stents in patients with complicated esophagorespiratory fistulas

PURPOSE

To test an endotracheal placement procedure for malignant esophagorespiratory fistula when endoesophageal placement is inapplicable.

METHODS

We report on patients with malignant esophagorespiratory fistula to which endoesophageal approaches were complicated with a complete obstruction of the hypopharynx, a collapsible tracheobronchus, or a previously placed endoesophageal stents. Gore-Tex membrane-covered Z-stents were deployed in the trachea using a coaxial introducer system in three patients. A Dumon tube was deployed in the bronchus over the bronchofiberscope in one patient.

RESULTS

All fistula were completely sealed by the endotracheal or endobronchial stenting. Symptomatic and clinical improvements were immediate obtained.

CONCLUSION

Endotracheal or endobronchial covered stent placement is thought to be an effective alternative method for sealing esophagorespiratory fistula.

Quality improvement guidelines for placement of esophageal stents

Esophageal cancer is now the sixth leading cause of death from cancer worldwide. During the past three decades, important changes have occurred in the epidemiologic patterns associated with this disease. Due to the distensible characteristics of the esophagus, patients may not recognize any symptoms until 50% of the luminal diameter is compromised, explaining why cancer of the esophagus is generally associated with late presentation and poor prognosis. Esophageal cancer has a poor outcome, with an overall 5 year survival rate of less than 10%, and fewer than 50% of patients are suitable for resection at presentation. As a result palliation is the best option in this group of patients. The aims of palliation are maintenance of oral intake, minimizing hospital stay, relief of pain, elimination of reflux and regurgitation, and prevention of aspiration. For palliative care, current treatment options include thermal ablation, photodynamic therapy, radiotherapy, chemotherapy, chemical injection therapy, argon beam or bipolar electrocoagulation therapy, enteral feeding (nasogastric tube/percutaneous endoscopic gastrostomy), and intubation (self-expanding metal stents (SEMS) or semi-rigid prosthetic tubes) with different success and complications rates.

Preparation of the Patient for Palliative Procedures

The primary intent of surgical procedures traditionally has been the achievement of cure. Palliative surgery is emerging as an equally legitimate strategy of care; its goals are symptom relief and enhanced quality of life based on the patient's preferences. The key to successful palliative surgery is understanding patient and family dynamics, interdisciplinary team approaches, and producing a consistent and rational treatment plan. Far from condemning a patient, palliative surgery has a potential place in many treatment plans for enhanced quality of life and longevity.

Esophagorespiratory fistula: long-term results of palliative treatment with covered expandable metallic stents in 61 patients

PURPOSE

To evaluate long-term clinical results of palliative treatment of esophagorespiratory fistulas (ERFs) with covered expandable metallic stents.

MATERIALS AND METHODS

Sixty patients with ERFs due to esophageal or bronchogenic carcinoma and one patient with ERF due to pressure necrosis caused by initial esophageal stent placement for esophageal carcinoma were treated with covered expandable esophageal or tracheobronchial metallic stents. Information about technical success of stent placement, initial clinical success and failure, fistula reopening, and complications was obtained. Survival curves for both patient groups with initial clinical success and failure were obtained and compared with Kaplan-Meier methods and log-rank test.

RESULTS

Stent placement was technically successful in all patients, with no immediate procedural complications. The stent completely sealed off the fistula in 49 (80%) of 61 patients so that they had no further aspiration symptoms (initial clinical success). Twelve (20%) of 61 patients had persistent aspiration symptoms due to incomplete ERF closure (initial clinical failure). During follow-up, the fistula reopened in 17 (35%) of 49 patients with initial clinical success: In eight patients, the reopened ERF was sealed off successfully with stent placement or balloon dilation. In two patients with reopened ERF caused by food impaction, the reopened fistula resolved spontaneously. Seven patients did not undergo further treatment. All patients died during follow-up, and mean survival was 13.4 weeks (range, 1-56 weeks) after stent placement. Mean survival in patients with initial clinical success was significantly longer than that in patients with initial clinical failure (15.1 vs 6.2 weeks, P <.05).

CONCLUSION

Covered expandable metallic stents were placed in 61 patients with ERFs, but the initial clinical success rate was poor and the rate of reopening was high; however, interventional treatment was effective for sealing off reopened ERFs.

Management of Tracheoesophageal Fistulas in Adults

The approach to treatment of adult patients with tracheoesophageal fistulas depends on whether the fistula is congenital or acquired in origin. Most adults have acquired tracheoesophageal fistulas, and treatment depends on whether the fistula is a result of a benign process or a malignancy, with the latter usually primary esophageal cancer. For patients with benign tracheoesophageal fistulas, treatment is almost always initially supportive followed by definitive surgical correction. In general, depending on the size and location of the tracheal aspect of the fistula, surgical therapy involves primary repair of the fistula and, if necessary, resection and reconstruction of the trachea. For patients with malignant tracheoesophageal fistulas, treatment depends on whether the patient is resectable and/or medically fit for surgical therapy. However, most patients with malignant trach-eoesophageal fistulas have advanced disease and can only be treated with palliative measures. The current standard of palliative therapy for patients with malignant tracheoesophageal fistulas is the endoscopic or radiologic placement of covered self-expanding metallic stents (SEMS), which allow closure of the fistula. All three types of commercially available covered SEMS have been used in this capacity with success. Other, less common treatment options for selected patients with malignant tracheoesophageal fistulas include chemotherapy and radiation, surgical bypass, esophageal exclusion, and fistula resection and repair.

Comparative retrospective study on the use of plastic prostheses and self-expanding metal stents in the palliative treatment of malignant strictures of the esophagus and cardia

Palliative treatment of malignant strictures of the esophagus and cardia is usually carried out by the endoscopic placement of a prosthesis. The aim of this retrospective study was to evaluate short- and long-term outcomes of the use of expandable stents, compared with conventional plastic prostheses. One hundred and thirteen endoscopic intubations were carried out in 120 patients affected by malignant stenosis of the esophagus and cardia using plastic prosthesis and self-expanding metal stents. Dysphagia was scored according to Atkinson and Ferguson's classification and the preoperative median score (3.6) was comparable in both groups. The technical success rate was 94.4% with plastic prosthesis and 93.7% with self-expanding metal stent while the functional success rate was, respectively, 85.2% and 88.8%. Three deaths occurred with plastic prostheses (4.4%), while no deaths were observed with metal stents. A comparative analysis of the results of this study suggests that the endoscopic placement of self-expanding metal stents is effective and safe and has to be preferred to the conventional plastic prosthesis for easier implantation and lower morbidity.

Retrievable covered nitinol stents: experiences in 108 patients with malignant esophageal strictures

PURPOSE

The authors report their experience with three types of retrievable covered nitinol stents in patients with malignant esophageal strictures.

MATERIALS AND METHODS

Three types of retrievable covered nitinol stents were designed. Type A stents were placed in 45 patients, type B stents were placed in 29 patients, and type C stents were placed in 34 patients. The stents were removed with use of a stent retrieval set under fluoroscopic guidance when the stents caused complications. Stent patency, symptom relief, survival rate, and complications were analyzed relative to stent type and radiation therapy.

RESULTS

The timing of radiation and the stent type have significant effects on occurrence of complications such as stent migration and fistula formation (P =.002 and P = 0.029, respectively). Complications were significantly more frequent in patients with the type B stent than those with type A or type C stents (P =.008). Patients who underwent radiation therapy before stent placement or who underwent no radiation therapy experienced substantially less complications than those who underwent radiation therapy after stent placement (P =.005 and P <.001, respectively). The survival period was significantly longer in patients who underwent radiation therapy after stent placement than in the other groups (P =.034). Stents were removed from 15 patients (14%) 2 days to 16 weeks (mean, 4 weeks) after stent placement as a result of severe pain (n = 7), stent migration (n = 6), or stent deformity (n = 2). Stent removal was well tolerated in all patients.

CONCLUSION

Use of retrievable covered nitinol stents seems to be a safe and effective method of treatment in patients with malignant esophageal strictures. However, removal of the stents was needed in 14% of the patients because of complications. Patients who underwent radiation therapy after stent placement and those with the type B stent experienced more complications than other patients.

The role of parallel stent insertion in patients with esophagorespiratory fistulas

BACKGROUND

Patients with malignant esophagorespiratory fistulas have a poor prognosis. Treatment is palliative and involves restoration of the ability to ingest food and prevention of aspiration by insertion of esophageal or tracheobronchial stents. Because insertion of a single stent may be insufficient for palliation, a series of patients who underwent parallel stent insertion were studied.

METHODS

Thirteen patients with esophagorespiratory fistulas who required parallel stents were studied retrospectively. Palliation was evaluated by assessing dyspnea, dysphagia, and coughing associated with eating and/or drinking before and after insertion of stents.

OBSERVATIONS

Insertion of the first stent (n = 13) resulted in complete relief of symptoms attributed to an esophagorespiratory fistula in 46% and in a reduction in symptoms in 54% of patients. The interval between insertion of the first and second stents ranged from 1 to 182 days (mean 46 days). Insertion of the second stent (n = 12) resulted in complete relief of symptoms in 42% and a reduction in symptoms in 58% of the patients.

CONCLUSION

Parallel stent insertion may be indicated in patients with symptoms caused by malignant esophagorespiratory fistula.

Successful endoscopical sealing of malignant esophageotracheal fistulae by using a covered self-expandable stenting system

OBJECTIVE

Any treatment of tracheo-esophageal fistulae in end-stage malignant stenosis of the esophagus must be weighed against associated morbidity and mortality. In a prospective study we investigated benefits and risks of the use of one type of coated, self-expandable stent.

PATIENTS AND METHODS

We treated four male and two female patients, (mean age 68.3 years, range: 38-90 years), with malignant esophago-tracheal fistula non-resectable due to advanced tumour stage and/or functional reasons. All were in a poor general condition suffering from aspiration pneumonia and malnutrition. Four out of the six patients had had one or multiple extra- or endoluminal palliative treatments at a mean interval of 191 days (range: 7 days-15 ms) since the last intervention. The fistulae were sealed by using a covered, self-expandable stent (ULTRAFLEX esophageal stent system, Microinvasive, Boston Scientific Corporation, Boston, MA).

RESULTS

Stenting did not cause any technical problems and all fistulae were successfully sealed in a one-step procedure. The median hospital stay was 4.6 days (range: 3-9 days). Except for one late stent induced recurrent fistula treated by re-stenting and tracheostomy, we did not observe any stent associated complications. Five patients died of tumour generalization. The median survival of the patients who died was 78 days (range: 35-129 days). One patient is alive and well at 120 days after stenting.

CONCLUSION

In spite of the small number of patients the results suggest that this type of stent represents a safe and efficient approach for palliative endoscopic treatment of this high risk group. Local pretreatment does not preclude the successful use of the self-expandable coated stent.

Palliative treatment of malignant esophageal stenosis: the role of self-expanding stent endoscopic implantation

Endoscopic tube implantations were carried out in 40 patients with malignant stenosis of the esophagus and gastric cardia using self-expanding metallic stents. The indications for endoscopic intubation were the advanced stage of the tumor in 27 cases and risk factors that made resection inadvisable in 13 cases. In three patients, it proved impossible to implant a stent endoscopically because we were not able to pass the guide wire through the stenosis, whereas correct stent placement was achieved in 37 cases. Functional results were good in 33 patients, but four patients did not show any improvement of symptoms. Complications occurred in nine patients (24.3%): two bleedings, three neoplastic obstructions, one food obstruction, and three distal dislodgements of the prosthesis were observed, but could be readily corrected. No deaths occurred. The median survival time was 151 days (range 25-545 days). This study suggests that endoscopic placement of metallic self-expanding stents is safe and is to be preferred to plastic stents for easier implantation and lower morbidity.

Use of metallic stents and balloons in the esophagus and gastrointestinal tract

The majority of malignant and benign strictures in the esophagus and GI tract can be treated with use of minimally invasive alternatives to surgery such as balloon dilation or metallic stents. Virtually any obstructing lesion in the esophagus, stomach, duodenum, colon, and rectum can be treated with these methods with use of interventional radiologic or endoscopic techniques. In general, metallic stents are reserved for malignant strictures and balloon dilation is indicated for benign lesions. Patients with malignant esophageal fistulas and perforations can be palliated effectively and promptly by sealing the fistula or leak by deployment of a covered stent. Patients with malignant disease may benefit from a treatment regime that includes metallic stent placement, chemotherapy, radiation therapy and/or brachytherapy, although the efficacy of such combined therapies has yet to be defined. Further refinements to stent design are required. The ideal stent would be resistant to tumor ingrowth and migration. Placing a coating material on uncovered stents to prevent tumor ingrowth may achieve these aims. Finally, a biodegradable stent that dissolves before the development of intimal hyperplasia might enable stents to be used to treat benign strictures.

Covered retrievable expandable nitinol stents in patients with benign esophageal strictures: initial experience

PURPOSE

To investigate the safety and clinical effectiveness of covered retrievable expandable nitinol stents in 25 patients with a benign esophageal stricture.

MATERIALS AND METHODS

Under fluoroscopic guidance, covered retrievable expandable nitinol stents were placed in 25 patients with a benign esophageal stricture and were removed with a retrieval hook 1-8 weeks later.

RESULTS

Stent placement was successful in all patients, with no procedural complications. After stent placement, all patients could ingest solid food. The stents were successfully removed from all but two patients. One patient passed the stent via the rectum, and the other regurgitated a high cervical stent. After stent removal, one patient developed a small esophagobronchial fistula, which spontaneously sealed within 1 week of stent removal. After stent removal or migration, all patients could ingest solid food. During follow-up (mean, 13 months; range, 2-25 months) after stent removal or migration, 12 patients maintained their improvement in dysphagia and needed no further treatment. Thirteen patients with recurrence were treated by means of repeat balloon dilation.

CONCLUSION

Use of retrievable expandable nitinol stents seems to be a safe and effective method of treatment in selected patients with benign esophageal strictures.

Endobronchial stenting as a palliation for advanced esophageal cancer

Three cases of airway invasion of esophageal cancer treated palliatively by endobronchial stenting are reported. In case 1 (a 60-year-old male) expandable metallic stents were inserted into the totally occluded left main bronchus. In case 2 (a 45-year-old male) a Dumon stent was inserted into the totally occluded left main bronchus. Both patients recovered from performance status 4 to performance status 1 or 0 and were in good condition before they died of cancer, 150 and 54 days after stenting in cases 1 and 2, respectively. In case 3, a Dumon stent was inserted into the left main bronchus before total occlusion. The patient recovered from performance status 3 or 2 to performance status 1 or 0 and survived 40 days after stenting with no signs of airway obstruction. Endobronchial stenting is a useful palliation for keeping the performance status at a good level in patients with esophageal cancer obstructing or narrowing the main airway.

Interventional radiology and the use of metal stents in nonvascular clinical practice: a systematic overview

PURPOSE

The intent of this systematic overview was to describe the clinical role of metal stents in nonvascular health care interventions and the level of evidence supporting their use.

MATERIALS AND METHODS

Structured searches of Medline were conducted and limited to original peer-reviewed articles published in English.

RESULTS

Clinical practice involving metal stents was reported in more than 109 clinical series involving 4,753 patients. Stents were placed mainly for palliation of malignant biliary, esophageal, and airway obstruction in patients who were untreatable or had surgically unresectable lesions. Assessment of these interventions has so far centered on safety and technical success. Efficacy, quality of life, and costing factors were not routinely reported. Randomized trial evidence was available but limited; six randomized trials involving metal stents have been reported. Three trials involved biliary malignant obstruction, and all three reported metal stent (132 patients) palliation to be superior to plastic stent palliation (136 patients) based on longer patency and lower reintervention costs. Safety and complication differences between stents, however, were inconsistent across trials. In three trials involving esophageal malignant obstruction, metal stent (82 patients) palliation was reported to be superior to plastic stent (41 patients), based on lower complication and reintervention rates, and superior to laser therapy (18 patients), based on better dysphagia relief.

CONCLUSION

Use of metal stents has been reported for obstructed ducts and passageways of most body systems. There is, however, limited controlled trial evidence confirming the advantages of their use over plastic stents or other forms of treatment.

Upper gastrointestinal tract malignant obstruction: initial results of palliation with a flexible covered stent

The authors treated 21 patients with inoperable upper gastrointestinal tract malignant obstruction from the esophagus to the duodenum by means of intubation with a flexible covered stent with fluoroscopic guidance. Stent placement was successful and relief of dysphagia was immediate in 18 (86%) patients, without serious complication. The average dysphagia score decreased from 2.6 (dysphagia to liquids) to 1.0 (dysphagia to normal solid food). Placement of a flexible covered stent provides easy, safe, and effective palliation of upper gastrointestinal malignant obstruction.

Treatment of a malignant esophageal perforation with a prototype conical Wallstent

A 60-year-old man with a malignant esophageal perforation could not be treated by conventional covered metallic stents because the upper esophagus was dilated. The perforation was eventually closed by deployment of a prototype, conical covered Wallstent.

The clinical effectiveness of the Gianturco oesophageal stent in malignant oesophageal obstruction

Between January 1994 and December 1996 72 patients were treated with 76 Gianturco oesophageal stents for oesophageal obstruction or perforation. The patients were followed prospectively in order to determine the effectiveness in improving dysphagia, to establish long term patency, survival times and complications. The mean dysphagia score prior to stenting was 3, improving to a mean score of 1 after stenting. Swallowing failed to improve in three patients. No serious complications were seen at stent insertion. Patients tolerated the procedure well with no complications in 63%. The most frequent immediate complication was chest pain occurring in 15 patients (21%). This settled in all patients with appropriate analgesia, however, four patients required long-term pain relief. In no cases was the chest pain due to perforation. Re-intervention was required in 16.7% of patients, the commonest cause being tumour overgrowth, and this was seen primarily in patients with long survival. The migration rate was low, despite the fact that 45 of 76 stents had been placed with the distal end in the stomach. Only four stents (5.6%) migrated completely, all of which had been deployed across the cardia. In our series the use of the Gianturco oesophageal stents for provided effective palliation of malignant oesophageal obstruction.

Three dimensional imaging of tracheobronchial system using spiral CT

The purpose of this study was to evaluate the clinical efficacy of 3D reconstruction of the tracheobronchial system using spiral CT. A total of 25 patients with tracheobronchial abnormalities, stenosis (n = 21) and fistula with esophagus (n = 4), underwent a single breathhold spiral CT (5 mm collision, 5 mm)/s increment). With respect to localization, extent and degree of stenosis and size of fistula were compared with findings at bronchoscopy. The CT location and extent of stenoses were consistent with bronchoscopic findings in all 21 patients. The diameter and shape of the lesions were not evaluated in five patients with severe stenoses. In patients with fistula, 3D CT image demonstrates the location and size of fistula in all four patients. Spiral CT serves to demonstrate accurate and useful 3D reconstruction images for planning and monitoring therapy.

Palliative treatment of malignant esophagorespiratory fistulas with Gianturco-Z stents. A prospective clinical trial and review of the literature on covered metal stents

OBJECTIVE

Esophagorespiratory fistulas, especially in the upper third of the esophagus, are a complication of malignant esophageal tumors, which are difficult to manage. The efficacy of polyurethane-covered, self-expanding metal stents for palliation of malignant esophagorespiratory fistulas was investigated prospectively.

METHODS

Eleven patients with malignant esophagorespiratory fistulas resp. perforations were treated with Gianturco-Z stents. In five patients the lesion was located in the proximal part of the esophagus. Because of the fistula all patients suffered from dysphagia even for liquids.

RESULTS

No technical problems during the implantation procedure of the stents occurred. In the control radiography with water-soluble contrast media, the fistulas were completely sealed in 10 of 11 patients. Therefore the dysphagia score improved from 3.0 to 0.6. Nearly all Gianturco-Z stents (10/11) showed a sufficient expansion within 24 h after placement. Severe early or late complications were not encountered, with the exception of tumor overgrowth in one patient about 9 months after stent placement. In five patients, short term (3-6 days) retrosternal pain was observed, and one patient complained of slight foreign body sensation. By August 1997 all 11 patients had died of advanced disease, with a median survival time of 121 days (range, 22-300 days).

CONCLUSIONS

Gianturco-Z stents are highly effective for palliative treatment of esophagorespiratory fistula resp. perforations and have a low complication rate. Due to the fact that this stent shows no retraction during the release, a precise positioning is possible, especially in the case of tumors and fistulas in the upper third of the esophagus. It seems that use of the Gianturco-Z stent can be considered a good therapeutic method for palliative endoscopic treatment of this high risk patient group.

Expandable metallic prostheses for malignant obstructions of gastric outlet and proximal small bowel

BACKGROUND

Data are limited on use of expandable metal stents for treatment of malignant gastric outlet obstruction. Accordingly, we report our experience using these stents to palliate malignant obstructions of the gastric outlet, duodenum, and proximal jejunum.

METHODS

Eight patients with malignant strictures causing gastric obstruction underwent endoscopy with fluoroscopic guidance to delineate tumor borders and length followed by expandable metallic prosthesis placement (Wallstent, Z-Stent, Ultraflex, and Endocoil).

RESULTS

Symptoms were relieved in seven patients, five of whom had previous surgeries (Whipple, Billroth II, esophagojejunostomy, and gastrojejunostomy) for malignancy. One patient underwent surgical resection of a presumed malignant stricture containing a previously placed Wallstent after a 45-pound weight gain.

CONCLUSIONS

Expandable metallic prostheses placed in patients with malignant obstruction of the gastric outlet, duodenum, or proximal jejunum, before or after surgery, effectively palliate obstructive symptoms and may also serve to improve nutrition.

Use of the 25 mm flanged esophageal Z stent for malignant dysphagia: a prospective multicenter trial

BACKGROUND

An initial multicenter study using a 21 mm flanged esophageal Z stent demonstrated excellent palliation but an 11% immediate complication rate at placement and a 27% migration rate at 1 month. This North American multicenter trial prospectively studied a 25 mm flanged Z stent to define its palliative ability and whether the increased diameter affected placement or migration problems.

METHODS

Fifty patients who had esophageal Z stents at seven university or regional referral hospitals were prospectively studied. Indications for prosthesis placement, previous therapy, patient demographics, incidence of concomitant tracheoesophageal fistula, and degree of dysphagia were defined, as were procedural and subsequent stent-related problems, survival times, the ability to occlude a tracheoesophageal fistula, and subsequent degree of dysphagia.

RESULTS

Twenty-four patients had infiltrating malignancy (16 exophytic and 10 extrinsic), 9 of whom had concomitant tracheoesophageal fistulas. Ten patients (20%) had misplaced stents requiring retrieval and replacement, 12 patients (24%) had subsequent stent-related problems including exsanguination (2), aspiration (3), tumor overgrowth (3), and postplacement migration (4) (8%). There was statistically significant improvement in prestent versus poststent dysphagia and two thirds of patients had complete occlusion of their tracheoesophageal fistula.

CONCLUSIONS

Redesign of the esophageal Z stent has decreased the migration rate without increasing placement or subsequent erosion problems. Its efficacy appears comparable to the currently marketed Z stent for the palliation of malignant dysphagia and occlusion of tracheoesophageal fistula.