Removable esophageal stents have poor efficacy for the treatment of refractory benign esophageal strictures (RBES)

With the recent availability of removable esophageal stents, endoscopic stenting has been utilized to treat refractory benign esophageal strictures (RBES). The objective of this study was to review the feasibility and effectiveness of removable esophageal stents to treat RBES. Patients who received removable esophageal stents for the treatment of RBES at the institution between 2004–2010 using its stent implantation logs and endoscopic database were retrospectively identified. Patient demographics, stricture etiology and location, stent and procedure characteristics, and clinical outcomes were obtained. Twenty‐five patients with a mean age of 70 (72% male) underwent initial stent placement; 24 were successful. Overall clinical success was achieved in five of the 19 patients (26%) ultimately undergoing stent removal. RBES etiologies included anastomotic (13), radiation (5), peptic (3), chemotherapy (1), scleroderma (1), and unknown (2). Alimaxx‐E (Merit‐Endotek, South Jordan, UT, USA) stents were placed in 20 patients and Polyflex (Boston Scientific, Natick, MA, USA) stents were used in five patients. Immediate complications included failed deployment (1) and chest pain (7). Five patients died prior to stent removal. Stent migration was found in 53% (10/19) of patients who underwent stent removal: nine required additional therapy and one had symptom resolution. Out of the nine patients without stent migration, five required additional therapy and four had symptom resolution. Although placement of removable esophageal stents for RBES is technically feasible, it is frequently complicated by stent migration and chest pain. In addition, few patients achieved long‐term stricture resolution after initial stenting. In this study, most patients ultimately required repeated stenting and/or dilations to maintain relief of dysphagia.     

Eosinophilic esophagitis in children with esophageal atresia

Eosinophilic esophagitis (EoE) has only rarely been reported in esophageal atresia (EA) patients. A retrospective case analysis of all EA patients born at our center between January 1999 and April 2012 was performed. A total of 113 of patients were identified; 10 patients were excluded as a result of inadequate data. Eighteen patients (17%) were diagnosed with EoE. The average number of eosinophilis was 30/high‐power field (HPF) (19/HPF–80/HPF). The median age for diagnosis of EoE was 1 year and 6 months (8 months–8 years and 7 months). Children with EoE had a significantly greater incidence of reflux symptoms, dysphagia, tracheomalacia, and ‘hypoxic spells’ (P < 0.05). EoE patients also underwent significantly more surgery including fundoplication and aortopexy when compared with those without EoE (P < 0.0001). Although the incidence of gastrostomy was greater in the EoE group (33% vs. 13%), this was not statistically significant. Half of the EoE patients had a coexisting atopic condition at time of diagnosis. The commonest condition was asthma 7/18 (38%) followed by specific food allergy 6/18 (33%). EoE was treated in 11 patients with either swallowed fluticasone or budesonide slurry. All improved clinically. Histologically, five had complete resolution and six had partial improvement. Six children with EoE were treated with acid suppression alone. All improved clinically, and 5/6 had subsequent histological resolution. One child who received acid suppression and an exclusion diet also improved. Seven patients (38%) had an esophageal stricture at time of EoE diagnosis. Five were dilated at time of the initial endoscopy, prior to the diagnosis of EoE being available. Two patients had resolution of their strictures on medical treatment of their EoE alone and did not require further dilatation. EoE was seen in 17% of children with EA in this study. EoE should be considered in EA patients with persistent symptoms on standard reflux treatment, increasing dysphagia, and recurrent strictures.     

Anastomotic dilatation after repair of esophageal atresia with distal fistula. Comparison of results after routine versus selective dilatation

After repair of esophageal atresia with distal fistula (EADF), anastomotic dilatations are often required. We abandoned routine dilatations (RD), in 2002, for selective dilatations (SD) only when the symptoms arose. We compared the number of dilatations and long-term results after RD and SD. Eighty-one successive EADF patients from 1989 to 2007 (RD 46, SD 35), with primary anastomosis, native esophagus, and peroral feeding, were included. Spitz classification, birth weight, gestational age, incidence of gastroesphageal reflux, tracheomalacia, and postoperative complications did not differ statistically significantly between the groups whereas the total incidence of associated anomalies in RD group was higher than in SD ( P  < 0.05) In RD group, anastomotic dilatations were begun 3 weeks postoperatively and repeated until the anastomotic diameter was 10 mm. In SD group, dilatations were performed only in symptomatic patients. The number of dilatations, dilatation-related complications, nutritional status, and outcome up to 3 years after repair were compared. The median number of dilatations was seven (2–23) in RD and two (0–16) in SD group ( P  < 0.01). Sixteen (46%) patients in SD group had no dilatations during the first 6 months. The incidence of dysphagia, bolus obstructions, and development of nutritional status were similar between the groups. The incidence of complications/dilatation was 0.6% in RD and 1.0% in SD group. One patient in RD group underwent resection for a recalcitrant anastomotic stricture. After repair, EADF policy of SD resulted in significantly less dilatations than RD with equal long-term results.     

Fully versus partially covered self‐expandable metal stents in benign esophageal strictures

Self‐expandable plastic stents are currently recommended for refractory benign esophageal strictures but they show disappointing results in terms of migration and long‐term efficacy. We report here our experience in the management of benign esophageal strictures with partially covered (PCSEMS) and fully covered self‐expandable metal stents (FCSEMS). We performed a retrospective analysis of self‐expandable metal stent (SEMS) placements for benign esophageal strictures from 1998 to 2011 in Rouen University Hospital. Twenty‐two patients (15 men, 7 women) attempted 40 esophageal SEMS placements (17 PCSEMS, 23 FCSEMS) during this period. All technical complications were migrations. Migration was noted after 3/17 PCSEMS (17.6%) and 4/23 FCSEMS placement (17.4%, P = ns). Clinical complications occurred after 6/17 PCSEMS and 2/23 FCSEMS placements (35.3% vs. 8.7%, P = 0.053). PCSEMS caused two major complications (fistulae) whereas FCSEMS did not cause any major complication (11.7% vs. 0%). Mean dysphagia score was significantly lower after SEMS placement (1.68 vs. 3.08, P < 0.001) with similar results for PCSEMS and FCSEMS. Stent placement resulted in long‐term clinical success for 23.5% of PCSEMS and 34.7% of FCSEMS (P = 0.0505). FCSEMS provide satisfying clinical success rate with an acceptable complication rate and they could constitute a relevant therapeutic option in the management of benign esophageal strictures.     

Treatment of malignant esophageal/cardiac stricture with self‐expanding antireflux metallic stents: A preliminary report from 17 patients

BACKGROUND : Different types of self‐expanding metallic stents are available for the palliative treatment of malignant strictures at the gastroesophageal junction. To overcome some of the disadvantages in the design of these metallic stents, we designed a silicone‐covered self‐expanding antireflux metallic stent that can prevent free gastroesophageal reflux after stent placement. METHODS : Seventeen silicone‐covered antireflux prototypes were used in 17 patients with dysphagia caused by inoperable malignant tumors involving the gastroesophageal junction. RESULTS : Stent implantation was technically successful in all 17 patients. There were no procedure‐related perforations or deaths. As a group, the mean dysphagia grade improved significantly (2.56 ± 0.49 vs 1.00 ± 0.51, P < 0.001) and the mean lumenal diameter was greatly increased (4.11 ± 1.02 vs 14.72 ± 4.01, P < 0.001) after stent placement. Ten patients received ambulatory 24‐h esophageal pH monitoring and compared with the healthy volunteers, there were no postprocedural abnormal gastroesophageal refluxes in any patient. Three patients had substantial chest pain requiring long‐term analgesics. No other complications were observed. CONCLUSIONS : The newly developed self‐expanding antireflux metallic stent is safe and effective for use in the palliation of dysphagia caused by malignant strictures at the gastroesophageal junction. A larger patient population would be required to give valid conclusions.     

Refractory strictures post‐esophageal atresia repair: what are the alternatives?

Esophageal strictures remain the most frequent complication after esophageal atresia (EA) repair despite refinements in operative techniques. With an incidence of anastomotic stricture between 8% and 49%, EA is the most frequent cause of benign esophageal stricture in children. The mainstay of treatment for esophageal stricture is dilatation with a 58–96% success rate. In order to relieve dysphagia, between 1 and 15 dilatations will be required in each EA patient with an esophageal stricture. However dilatations may lead to complications including perforation (0.1–0.4% of all esophageal benign strictures) and sociopsychological morbidity. Fifty percent of EA strictures will improve in 6 months. However, 30% will persist and require repeat dilatations. The present article explores the variety of non‐surgical alternative treatments for anastomotic strictures after EA repair, focusing on triamcinolone acetonide, mitomycin C and esophageal stents. We propose an algorithm for a more standardized therapeutic approach, with the hope that an international panel of experts could meet and establish a consensus.     

Endoprosthetics in the treatment of benign esophageal strictures

Benign esophageal strictures are a common problem in endoscopic practice. The predominant symptom of patients is dysphagia. The initial treatment option for a benign esophageal stricture is dilation. A small subgroup of strictures, that is, those that are long (>2 cm), are tortuous, and have a narrow diameter, or are associated with caustic or postradiotherapy etiology, tend to recur and are therefore called refractory. Temporary stent placement, with either a self-expandable metal stent or a self-expandable plastic stent, can be considered as a treatment option in these patients. From a technical point of view, placement of an expandable stent in benign strictures does not differ from placement in cases of palliation of malignant dysphagia. Deep sedation and careful stent placement, especially in proximal locations, is extremely important. Results of temporary stenting are still inconclusive; long-term clinical resolution of the stricture is achieved in less than 50% of patients. Moreover long-term data on safety and efficacy are scant. These disappointing results are mainly because of hyperplastic tissue ingrowth or overgrowth and stent migration. New stent designs are needed for this indication. Promising initial results show that biodegradable stents may be useful for refractory benign esophageal strictures; however, these preliminary data need to be further elucidated in future studies.     

Development of novel treatment with a bioabsorbable esophageal patch for benign esophageal stricture

Using a large animal model, we examined whether circumferential stricture after esophageal endoscopic submucosal dissection (ESD) can be treated by grafting a bioabsorbable esophageal patch. Circumferential ESD was performed on the thoracic esophagus in pigs (n = 6) to create a stricture, for which one of the following interventions was performed: (1) the stricture site was longitudinally incised, and an artificial esophageal wall (AEW) was grafted after placing a bioabsorbable stent (AEW patch group, n = 3); (2) endoscopic balloon dilation (EBD) was performed every other week after stricture development (EBD group, n = 3). In both groups, esophageal fluoroscopy was performed 8 weeks after the interventions, and the esophagus was excised for histological examination of the patched site. In the AEW patch group, esophageal fluoroscopy revealed favorable passage through the patched site. Histologically, the mucosal epithelium and lamina propria had regenerated as in the normal area. In the EBD group, the circumferential stricture site showed marked thickening, and there were hypertrophic scars associated with epithelial defects on the luminal surface. Histologically, defects of the mucosal epithelium and full‐thickness proliferation of connective tissue were observed. AEW patch grafting was suggested to be a potentially novel treatment strategy for post‐ESD esophageal circumferential stricture.     

Endoscopic balloon dilatation of benign esophageal strictures in childhood: a 15‐year experience

The study aims to evaluate the effectiveness and safety of endoscopic balloon dilatation (EBD) in childhood benign esophageal strictures. The medical records of 38 patients who underwent EBD from 1999 to 2013 were retrospectively reviewed. Demographic features, diagnoses, features of strictures, frequency and number of EBD, complications, outcome, and recurrence data were recorded. Median age was 1.5 years (0–14), and female/male ratio was 17/21 (n = 38). Primary diagnoses were corrosive esophageal stricture (n = 19) and esophageal atresia (n = 19). The length of strictures were less than 5 cm in 78.9% (n = 30). No complication was seen in 86.8% (n = 33). Perforation was seen in 10.5% (n = 4), and recurrent fistula was seen in 2.7% (n = 1). Total treatment lasted for 1 year (1–11). Dysphagia was relieved in 60.5% (n = 23). Recurrence was seen in 31.6% (n = 12). Treatment effectiveness was higher, and complication rates were lower in strictures shorter than 5 cm compared with longer ones (70% vs. 25%, P < 0.05, and 3.4% vs. 37.5%, P < 0.05). Although there was no statistical difference, treatment effectiveness rates were lower and complication and recurrence rates were higher in corrosive strictures compared with anastomotic ones (P > 0.05). EBD is a safe and efficient treatment choice in esophageal strictures, especially in strictures shorter than 5 cm and anastomotic strictures.     

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

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

Silicone-covered biodegradable magnesium stent for treating benign esophageal stricture in a rabbit model

BACKGROUND Stent insertion can effective alleviate the symptoms of benign esophageal strictures(BES).Magnesium alloy stents are a good candidate because of biological safety,but show a poor corrosion resistance and a quick loss of mechanical support in vivo.AIM To test the therapeutic and adverse effects of a silicone-covered magnesium alloy biodegradable esophageal stent.METHODS Fifteen rabbits underwent silicone-covered biodegradable magnesium stent insertion into the benign esophageal stricture under fluoroscopic guidance(stent group).The wall reconstruction and tissue reaction of stenotic esophagus in the stent group were compared with those of six esophageal stricture models(control group).Esophagography was performed at 1,2,and 3 weeks.Four,six,and five rabbits in the stent group and two rabbits in the control groups were euthanized,respectively,at each time point for histological examination.RESULTS All stent insertions were well tolerated.The esophageal diameters at immediately,1,2 and 3 wk were 9.8±0.3 mm,9.7±0.7 mm,9.4±0.8 mm,and 9.2±0.5 mm,respectively(vs 4.9±0.3 mm before stent insertion;P<0.05).Magnesium stents migrated in eight rabbits[one at 1 wk(1/15),three at 2 wk(3/11),and four at 3 wk(4/5)].Esophageal wall remodeling(thinner epithelial and smooth muscle layers)was found significantly thinner in the stent group than in the control group(P<0.05).Esophageal injury and collagen deposition following stent insertion were similar and did not differ compared to rabbits with esophageal stricture and normal rabbits(P>0.05).CONCLUSION Esophageal silicone-covered biodegradable magnesium stent insertion is feasible for BES without causing severe injury or tissue reaction.Our study suggests that insertion of silicone-covered magnesium esophageal stent is a promising approach for treating BES.     

Safety and efficacy of self‐expanding removable metal esophageal stents during neoadjuvant chemotherapy for resectable esophageal cancer

Patients with esophageal cancer may present with dysphagia and weight loss. Resectable lesions require consideration of neoadjuvant chemotherapy, which improves survival but have side effects, which compound already poor intake. Prevention of malnutrition has historically required interventions such as surgical jejunostomy or percutaneous endoscopic gastrostomy, which carry associated morbidity. With established roles in palliation, self‐expanding removable metal stents (SERMS) may provide an alternative intervention in resectable disease. We sought to evaluate outcomes from our unit's introduction of SERMS in dysphagic patients prior to esophagectomy. All dysphagic patients presenting with esophageal cancer and considered for curative surgery between April 2006 and November 2008 were offered preoperative treatment of dysphagia with SERMS during neoadjuvant chemotherapy. Baseline and preoperative outcomes assessed included dysphagia score and nutritional markers. Sixteen patients underwent esophageal stenting during neoadjuvant therapy of whom 7/16 (44%) were female with mean age 63 (53–76). In 12/16 (75%), tumors were located in the lower one third of the esophagus. There was a significant fall in mean dysphagia score from 2.5 (range 1–4) to 1.1 (range 0–3) immediately preoperatively. There was no significant change in serum albumin, weight, or body mass index. Stent‐related morbidity occurred in 4/16 (25%) patients and stomach migration occurred in 7/16 (43.8%). All were resolved endoscopically and there was no stent‐related mortality. Of 10/16 (62.5%) patients ultimately progressing to esophagectomy, 30‐day mortality was 6.3%. Anastomotic leak occurred in one patient (10%) and R1 resection rate was 20%. SERMS are a safe and effective intervention in dysphagic patients undergoing neoadjuvant chemotherapy for esophageal cancer. Complications are minor and readily treatable with endoscopy. Objective parameters suggest nutritional status is maintained and symptoms are improved. SERMS do not appear to compromise resection.     

TEMPORARY USE OF A NEW FULLY‐COVERED SELF‐EXPANDING METAL STENT FOR THE MANAGEMENT OF POST‐ESOPHAGECTOMY STRICTURES

Perioperative morbidity rates following esophagectomy for esophageal cancer remain quite high (26–41%) even at high‐volume centers. Complications may include stricture at the esophagogastric (EG) anastomosis, as well as tracheo‐esophageal or tracheo‐gastric fistula formation. Fully‐covered self‐expanding metal stents (FCSEMS) have only recently been described for use in benign esophageal disease. The use of FCSEMS for the management of postoperative complications following esophagectomy has not been well studied. We report our observations in three consecutive patients that underwent placement and subsequent removal of a new, fully‐covered metal stent (Wallflex^® esophageal stent) for treatment of dysphagia due to a persistent stricture at the EG anastomosis.     

Absorbable and Sell-expanding Esophageal Stent

Abstract: A flexible self-expanding esophageal stent, made entirely of absorbable materials, was recently developed by the authors. The new stent consists of two components: a rolled vicryl sheet (Vicryl woven mesh, Ethicon) which has a 20-mm outer diameter, and a PDS string (PDS II, 1 -0. Ethicon) which runs spirally around the rolled sheet. The stent is almost equal in flexibility to the Ultraflex (Microvasive, USA) and its expanding force exceeds that of the Ultraflex. This stent was uneventfully placed in the porcine esophagus and then fully opened. This absorbable stent, incubated in 37°C saline, showed a gradual diminution of its expanding force over a period of more than two weeks. We conclude that this novel absorbable stent, which has characteristics comparable to those of a metallic stent, as well as certain other advantages, is applicable to clinical cases.     

Double layered self-expanding metal stents for malignant esophageal obstruction, especially across the gastroesophageal junction

AIM: To evaluate the clinical outcomes of double-layered self-expanding metal stents (SEMS) for treatment of malignant esophageal obstruction according to whether SEMS crosses the gastroesophageal junction (GEJ).METHODS: Forty eight patients who underwent the SEMS insertion for malignant esophageal obstruction were enrolled. Patients were classified as GEJ group (SEMS across GEJ, 18 patients) and non-GEJ group (SEMS above GEJ, 30 patients) according to SEMS position. Double layered (outer uncovered and inner covered stent) esophageal stents were placed.RESULTS: The SEMS insertion and the clinical improvement were achieved in all patients in both groups. Stent malfunction occurred in seven patients in the GEJ group and nine patients in the non-GEJ group. Tumor overgrowth occurred in five and eight patients, respectively, food impaction occurred in one patient in each group, and stent migration occurred in one and no patient, respectively. There were no significant differences between the two groups. Reflux esophagitis occurred more frequently in the GEJ group (eight vs five patients, P = 0.036) and was controlled by proton pump inhibitor. Aspiration pneumonia occurred in zero and five patients, respectively, and tracheoesophageal fistula occurred in zero and two patients, respectively.CONCLUSION: Double-layered SEMS are a feasible and effective treatment when placed across the GEJ for malignant esophageal obstruction. Double-layered SEMS provide acceptable complications, especially migration, although reflux esophagitis is more common in the GEJ group.     

Self-expanding plastic esophageal stents versus jejunostomy tubes for the maintenance of nutrition during neoadjuvant chemoradiation therapy in patients with esophageal cancer: a retrospective study

In patients undergoing chemoradiotherapy for esophageal cancer, the inability to eat may severely impair nutritional status. We conducted a retrospective study to compare the efficacy of the Polyflex self-expanding silicone stent (PS) versus a jejunostomy tube (JT) for maintaining nutrition during neoadjuvant chemoradiation therapy in patients with esophageal cancer who were scheduled for resectional surgery. Thirty-six patients were treated either with PS placement (12 patients) or JT placement (24 patients) prior to receiving an 8-week course of chemoradiation therapy. Patients were interviewed weekly until cessation of therapy. Patient data were collected on procedural success and complication rates, nutritional status, and dysphagia scores. PS placement was successful in 11 of 12 patients (92%), and those 11 patients were able to resume oral nutrition. Dysphagia scores improved from a mean of 3 to 1 in the PS group ( P  < 0.005) but did not change significantly in the JT group. PS were removed endoscopically without complications prior to the esophagectomies. Albumin levels and weight increased significantly in both the PS and JT groups. There were no significant differences between groups in the procedural success rates (PS 92% vs. JT 100%, P  = 0.33), complication rates (PS 22% vs. JT 4%, P  = 0.11), mean increase in weight (PS 4.4 kg vs. JT 4.2 kg, P  = 0.59), and mean increase in serum albumin (PS 0.62 g/dL vs. JT 0.44 g/dL, P  = 0.05). PS is a safe and effective alternative to a surgical JT for maintaining nutrition in this subset of patients.     

125I粒子食管支架在晚期食管癌治疗中的价值研究

目的 通过观察125I粒子食管支架对晚期食管癌患者的生存期及生活质量的影响从而评价其疗效.方法 采取前瞻性研究方法,对37例接受125I粒子食管支架治疗的晚期食管癌患者进行随访研究,详细记录患者的生存期,并使用癌症患者生活质量核心量表标准问卷(QLQ-C30)和食管癌专用量表(QLQ-OES18)评价食管支架植入前、植...