Esophageal stent placement without fluoroscopy

BACKGROUND: Access to fluoroscopic equipment is limited in some regions where esophageal cancer is common. This report describes a simple method for placement of expandable esophageal stents without fluoroscopy. METHODS: Patients with dysphagia due to unresectable esophageal cancer underwent esophageal stent placement under endoscopic control alone. A colored mark on the stent delivery catheter was used to properly position the undeployed stent with respect to the proximal end of the tumor. RESULTS: Stent placement was attempted in 70 patients and was successful in every case. There were no immediate complications of stent placement. Mean dysphagia score decreased from 3.3 before stent placement to 0.5 at follow-up. There was a trend toward lower dysphagia scores in patients who received coated stents. CONCLUSION: Expandable esophageal stents can be accurately and safely placed under direct endoscopic control, without fluoroscopy.     

Treatment of malignant esophageal obstruction with silicone-coated metallic self-expanding stents.

Six patients with high-grade malignant esophageal obstruction were treated with silicone-coated metallic self-expanding esophageal stents (Z stents). Endoscopic placement of stents was well tolerated. All patients achieved excellent palliation, defined by a decrease of at least two dysphagia grades, which was sustained. Complications occurred during follow-up in four patients and included stent migration, silicone disruption with tumor ingrowth, food impaction, and perforation (discovered at autopsy) at the distal stent site. Three of the four complications were promptly treated by endoscopic or radiologic intervention. Recent modification in stent design and placement technique will hopefully reduce complications. The self-expanding stent has several theoretical advantages over the rigid plastic stent and Nd:YAG laser for palliation of obstructing esophageal malignancy.     

Endoscopic clips prevent self-expandable metallic stent migration

BACKGROUND/AIMS: Self-expandable metallic stents (SEMS) have been used for many years in the palliation of esophageal cancer symptoms. Stent migration is one of the most recognized complications of SEMS. To prevent SEMS migration, this study reported the use of endoscopic clips, and carefully analyzed the patients who underwent implantation. METHODOLOGY: From January 2000 to December 2002, nine patients consecutively underwent SEMS implantation. After successful placement of the SEMS and to maintain its position, endoscopic clips were used to fix the branch of the upper end of the stent to the esophageal mucosa. RESULTS: Stent implantation was technically successful in all patients, three of whom had strictures and six of whom had digestive-respiratory fistulas. No stent migration was observed in any of the patients, and dysphagia improved significantly after stent placement. Five patients did, however, experience delayed complications, two in the form of obstructions, two with recurrent fistulas, and one with a perforation. CONCLUSIONS: In conclusion, this new technique is recommended as endoscopic clipping can diminish the risks of stent migration, in particular those associated with esophago-respiratory fistulas without luminal obstruction.     

Large diameter fully covered self‐expanding metal stent placement for palliation of proximal malignant esophageal strictures

In patients with malignant esophageal strictures within 6 cm from the upper esophageal sphincter, self‐expanding metal stents placement represents a challenge because there is an increased risk of complications. The aim of this study was to assess the safety and effectiveness of large‐diameter WallFlex^® fully covered self‐expanding metal stents for palliation of patients with proximal malignant esophageal strictures. From March 2010 to December 2012, 12 patients with proximal strictures (4–6 cm from the upper esophageal sphincter) and six with very proximal strictures (<4 cm from the upper esophageal sphincter) were palliated with this fully covered self‐expanding metal stent and included in the study. Technical success was 100% and clinical success was 94%. The mean baseline dysphagia score was 3.2, and 1 week after stenting it improved significantly to 1.3 (P < 0.001). Early complications occurred in four patients, more frequently in patients with very proximal strictures as compared with patients with proximal strictures (P = 0.02). Late complications occurred in five patients, and there were no differences between patients with very proximal strictures or proximal strictures (P = 0.245). The mean survival after stent placement was 119 days, and no differences between patients with very proximal strictures versus proximal strictures were found (P = 0.851). There was no stent‐related mortality or 30‐day mortality. Our results suggested that a large‐diameter fully covered self‐expanding metal stent is an effective and secure device for palliation of patients with proximal malignant esophageal strictures.     

Self-expanding plastic stents for inoperable malignant strictures of the cervical esophagus

Dysphagia and respiratory complications are the major problems in patients suffering from malignant strictures of the cervical esophagus. In inoperable cases, interventional palliation is the cornerstone of treatment. The aim of this study was to evaluate the use of self-expanding plastic stents (SEPS) in this group of patients. In a retrospective study, 23 patients suffering from various malignant obstructive diseases of the cervical esophagus, including squamous cell carcinoma ( n = 10), laryngeal cancer ( n = 7), lung cancer with esophageal invasion ( n = 5), and metastatic breast cancer ( n = 1), underwent SEPS placement, under endoscopic and fluoroscopic guidance. Tracheoesophageal fistula was documented in five patients. Technical success rate, improvement of dysphagia grade, and stent-related complications were evaluated after stent placement. Stent insertion was successfully achieved in all cases, namely in 20 patients at the first stent placement attempt and in three patients after a second attempt. Dysphagia grade was notably improved after 24 h. In two cases, major complications occurred. These were successfully treated without the need of stent extraction. Barium swallowing studies demonstrated complete sealing of all fistulas. Foreign-body sensation that gradually disappeared within the first week after stent placement was observed in eight patients. Recurrence of dysphagia occurred in three patients, due to hyperplastic tissue proliferation ( n = 2) and tumor overgrowth ( n = 1). Late migration of the stent was detected in one case after 67 days. SEPS placement is an effective and safe palliative treatment for malignant strictures of the cervical esophagus. Main advantages include easy retrievability and reduced rates of reinterventions.     

Palliative endoscopic treatments for esophageal cancers

Esophageal cancer five-year survival has slightly increased during past 20 years (from 5 to 9%), but remains low. At time of diagnosis, 60% of the patients are only relevant for palliative therapy. Recent advances in therapeutic endoscopy have allowed improving dysphagia and quality of life. Endoscopic techniques are chosen according to tumor characteristics. According to French societies guidelines (FFCD, "Standards-Options-Recommandations" from FNCLCC, SNFGE) endoscopic treatment is a "gold standard" for metastatic patients with poor performance status, as well as oesophago-tracheal fistula. Expandable metal stent are efficient for malignant stenosis with lower morbidity and mortality than plastic prosthesis. Endoscopic placement of a covered self-expanding metal stent is the treatment of choice of an esophago-respiratory fistula. Dilatation is often the first step before other endoscopic therapies or medical treatment such as radiochemotherapy. Single dose brachytherapy could provide better long-term relief of dysphagia and fewer complications than stent placement, but is less widespread. Other techniques like bipolar electrocoagulation have restricted indications especially for circonferential stenosis of cervical esophagus. However, the main problem remains the dysphagia relapse after treatment.     

Palliative treatment of advanced esophageal cancer. Comparative study: auto-expandable metal stent and isoperistaltic esophagogastric bypass

Advanced squamous cell carcinoma of the esophagus (SCCE) is usually a disease of dismal prognosis. Palliation of dysphagia is the main goal of its treatment. This trial compared surgical to endoscopic palliation of dysphagia. Forty patients(32:8a, age 39-79y) suffering from TNM stage III or IV SCCE were divided into two groups: 20 patients were submitted to esophagogastric bypass (surgical group), and 20 patients had an endoscopically placed auto-expandable metal stent (EsophaCoil "In stent", Minnesota, USA)(endoscopic group). Both groups were similar regarding demographic data and nutritional status. The palliation of dysphagia, the incidence of early and late complications, the life quality (Karnofsky Index), the survival, the length of inpatient stay and the costs were evaluated in both groups. There was no difference between surgical and endoscopic groups regarding palliation of dysphagia, frequency of complications, quality of life, and survival. Early and late most common postsurgical complications were anastomotic leak and stenosis, respectively. The most common post-endoscopic complications were both late: benign hyperplasia and tumour overgrowth. None of the surgical or endoscopic complications were related to mortality. Hospital length stay and the costs were significantly higher in the surgical group (15.5 days vs 3 days, P < 0.001; U$ 4.690,45 +/- 1.360,28 vs U$ 2.618,24 +/- 944,98 P < 0.001). In conclusion, the endoscopic placement of an esophageal metal stent for the palliation of malignant dysphagia in patients with irresectable disease is equally effective as surgical bypass at lower costs and reduced length of inpatient stay.     

Esophageal stents for malignant strictures close to the upper esophageal sphincter

BACKGROUND: Self-expanding stents are a well-accepted palliative treatment modality for strictures resulting from esophageal carcinoma. However, the use of stents close to the upper esophageal sphincter (UES) is considered to be limited by patient intolerance caused by pain and globus sensation and an increased risk of complications, particularly tracheoesophageal fistula formation and aspiration pneumonia. OBJECTIVE: Our purpose was to determine the efficacy and safety of stent placement in patients with a malignant obstruction close to the UES. DESIGN: Evaluation of 104 patients with dysphagia from a malignant stricture close to the UES treated in the period 1996-2006. SETTING: Single university center. PATIENTS: Patients with primary esophageal carcinoma (n = 66) or recurrent cancer after gastric tube interposition (n = 38) within 8 cm distance distal of the UES. Twenty-four (23%) patients also had a tracheoesophageal fistula. INTERVENTIONS: Stent placement. MAIN OUTCOME MEASUREMENTS: Functional and technical outcome, survival, complications, and recurrent dysphagia. Analyses were performed by chi(2) test, Kaplan-Meier curves, and log-rank testing. RESULTS: Mean distance from the UES to the upper tumor margin was 4.9 +/- 2.6 cm and to the upper stent margin 3.1 +/- 2.3 cm. The procedure was technically successful in 100 of 104 (96%) patients. Fistula sealing was achieved in 19 of 24 (79%) patients. After 4 weeks, dysphagia had improved from a median score of 3 (liquids only) to 1 (some difficulties with solids). Total complications were seen in 34 of 104 (33%) patients. Of these, major complications (aspiration pneumonia [9], hemorrhage [8], fistula [7], and perforation [2]) occurred in 22 (21%) patients, whereas pain after stent placement was observed in 16 (15%) patients. Recurrent dysphagia occurred in 29 (28%) patients and was mainly caused by tissue ingrowth or overgrowth (n = 10), food bolus obstruction (n = 7), stent migration (n = 3), or other reasons (n = 11), such as persistent fistula (n = 5), difficulty with swallowing (n = 4), and dislocation of the stent (n = 2). Eight (8%) patients complained of globus sensation; however, in none of the patients was stent removal indicated. LIMITATIONS: Retrospective design. CONCLUSIONS: Stent placement is safe and effective for the palliation of dysphagia and sealing of fistulas in patients with a malignant stricture close to the UES. On the basis of these results, stent placement may be considered for palliation in this group of patients with an otherwise dismal prognosis.     

A randomized prospective comparison of self-expandable plastic stents and partially covered self-expandable metal stents in the palliation of malignant esophageal dysphagia

OBJECTIVES: Self-expanding metal stents (SEMS) provide effective palliation in patients with malignant dysphagia, although severe complications and mortality may result. We performed a prospective controlled trial to compare a new self-expanding polyester mesh stent (Polyflex) with SEMS (Ultraflex). METHODS: One hundred one patients with unresectable esophageal carcinoma were randomized to placement of a Polyflex (N=47) or a partially covered Ultraflex (N=54) stent. Patients with esophagogastric junction (EGJ) malignancy were excluded. RESULTS: Placement was successful in 46 (98%) patients with the Polyflex and 54 (100%) patients with the Ultraflex stent. In one patient, the Polyflex stent could not be placed. After 1 wk, dysphagia was improved by at least 1 grade in 100% of the Polyflex group and in 94% of the Ultraflex group. Major complications were observed in 48% of the Polyflex group and 33% of the Ultraflex group. Intraprocedural perforation occurred in 1 Polyflex and 1 Ultraflex patient. Two Polyflex patients had postprocedural hemorrhage. Twenty (44%) patients with a Polyflex stent and 18 (33%) with an Ultraflex stent had recurrent dysphagia because of tumor overgrowth, stent migration, hyperplastic granulomatous reaction, or food bolus impaction. Multivariate analysis showed a significantly higher complication rate with Polyflex than with Ultraflex stents (odds ratio 2.3, 95% CI 1.2-4.4). However, median survival was 134 days with Polyflex and 122 days with Ultraflex stents (P=NS). CONCLUSIONS: No difference was seen in palliation of dysphagia between the two stents. Significantly more complications, especially late stent migration, were observed in the Polyflex group.     

Insertion of expandable metallic stents in esophageal cancer without fluoroscopy is safe and effective: a 5-year experience

BACKGROUND: Self-expanding metallic stent (SEMS) placement is an important method of dysphagia palliation for patients with inoperable esophageal cancer. In most institutions, it is performed with fluoroscopic guidance; however, in 2001, we described a novel, direct-vision approach to SEMS placement, which does not require fluoroscopy. Here we report an audit of our experience over the last 5 years when using this methodology. OBJECTIVE: To describe our 5-year experience of 98 patients in whom esophageal stents were inserted when using the direct-vision technique and compare outcomes with published series of radiography-guided stents. DESIGN: Retrospective review of single-center experience. SETTING: English National Health Service Cancer Centre Hospital. PATIENTS: All patients who underwent esophageal stent insertion for a primary esophageal malignancy. INTERVENTIONS: SEMS insertion by direct endoscopic vision. RESULTS: Ninety-eight patients underwent SEMS insertion for malignant dysphagia during the study period, 92% of which were inserted without fluoroscopy. The technique had a low complication rate, which was consistent with published fluoroscopic data, and the median survival beyond stent insertion was 100 days (interquartile range, 62, 256; range, 4-921 days). In 59 patients, no further endoscopic palliative procedure was required. LIMITATIONS: Retrospective data collection. CONCLUSIONS: This series confirms direct-vision SEMS placement as a safe and efficacious method of malignant dysphagia palliation, providing definitive treatment in almost two thirds of cases.     

Delayed Complications after Placement of Self-Expanding Stents in Malignant Esophageal Obstruction: Treatment Strategies and Survival Rate

Purpose Placement of self-expanding metal stents is regarded as a safe and effective treatment in patients with incurable malignant esophagogastric obstruction. However, proceeding and possible benefit of re-interventions in patients with recurrent dysphagia due to delayed complications (>4 weeks after stent insertion) is unclear. Patients and methods In 133 patients with malignant stricture of the esophagus or the esophagogastric junction 164 expandable metal stents were placed. About 89 patients were followed up until death. All tumor- or stent-related complications and consequent re-interventions were recorded. Results The overall incidence of delayed complications was 53.4% (71 of 133 pts.), with 34 patients (25.6%) experiencing more than one complication. Recurrent dysphagia due to tumor ingrowth (22%) or overgrowth (15%), bolus obstruction (21%), stent migration (9%), and development of esophagorespiratory fistula (9%) was successfully treated by dilatation (24%), placement of a second/third stent (27%), laser therapy (16%), and/or placement of a feeding tube (PEG, 19%). The median survival of patients with endoscopic therapy was significantly longer (222 ± 26 days) compared to patients without re-intervention (86 ± 14 days, P < 0.0001). Conclusions Delayed complications after metal stent placement for malignant esophageal stricture are common, but can be treated successfully by endoscopic re-intervention in most cases. Regular interventional therapy may also improve survival.     

Fully covered,retrievable self-expanding metal stents (Niti-S) in palliation of malignant dysphagia: Long-term results of a prospective study

Abstract

Background. In the palliative treatment of malignant dysphagia, fully covered, retrievable metal stents are not commonly used, mainly due to the high risk of migration. Therefore, we performed a prospective study to evaluate the clinical efficacy of a fully covered, retrievable self-expanding metal stent (Niti-S). Method. Between October 1998 and February 2009, 100 consecutive patients with malignant esophageal obstruction treated with the fully covered Niti-S stent (Niti-S, Taewoong Medical, Seoul, South Korea) were included. Data collected contained functional outcome, feasibility of endoscopic stent retrieval, recurrent dysphagia, complications, and survival. Result. At 4 weeks after stent placement, dysphagia significantly improved in all patients (p = 0.000). Recurrent dysphagia occurred in 19 of 100 patients treated with Niti-S stents (19%) mainly due to tumor overgrowth (7/100, 7%), stent migration (6/100, 6%), and food impaction (6/100, 6%). Endoscopic stent retrieval was successful in all the attempted 17 patients (17/100, 17%) – 7 overgrowth, 6 stent migration, 2 stent degradation, and 2 severe pain. Major complications were 2 hemorrhage, 2 severe pain, and 1 tracheal compression (5/100, 5%), and minor complications were 10 retrosternal pain and 7 symptomatic gastroesophageal reflux (17/100, 17%). After a median follow-up of 142 days, 97 patients had expired. There was no stent-related mortality or 30-day mortality. Conclusion. The fully covered, retrievable Niti-S stent has proved its effectiveness for palliation of malignant dysphagia and feasibility of endoscopic retrieval. We estimate its dog-bone shaped flanges at both ends and it being completely covered provide good resistance to migration and overgrowth.     

A new design metal stent (Flamingo stent) for palliation of malignant dysphagia: a prospective study. The Rotterdam Esophageal Tumor Study Group

BACKGROUND: Metal stents are not superior to conventional endoprostheses with respect to the incidence of recurrent dysphagia because of tumor ingrowth with uncovered stents and migration with their covered counterparts. To overcome these limitations, a partially covered (inside-out covering) metal stent with a conical shape and a varying braiding angle of the mesh along its length, the Flamingo stent, has been developed. METHODS: From March 1997 to October 1997, 40 consecutive patients with dysphagia due to malignant tumors had either a small diameter (proximal/distal diameter 24/16 mm; n = 21) or a large diameter Flamingo stent (proximal/distal diameter 30/20 mm; n = 19) placed. RESULTS: There was statistically significant improvement in dysphagia, but improvement was not greater with large diameter stents compared to small diameter stents (p = 0.21). Major complications (bleeding [4], perforation [1], fever [1] and fistula [1]) occurred in 7 (18%) patients. Large diameter stents tended to be associated with more major complications than small diameter stents (5 vs. 2; p = 0.07). Pain following stent placement was observed in 9 (22%) patients and occurred more frequently in those who had prior radiation and/or chemotherapy (p = 0.02). Recurrent dysphagia (mainly due to tumor overgrowth) occurred in 10 (25%) patients. CONCLUSIONS: Flamingo stents are effective for palliation of malignant dysphagia, but the large diameter stent seems to be associated with more complications involving the esophagus than the small diameter stent. Because recurrent dysphagia is mainly due to tumor progression, further technical developments in stent design are needed.     

Impact of a self-expanding, plastic esophageal stent on various esophageal stenoses, fistulas, and leakages: a single-center experience in 39 patients

BACKGROUND: In this study, we describe our experience with the use of a self-expanding, covered, plastic esophageal stent (SEPS). The majority of placements were difficult to treat situations, i.e., proximal or extremely proximal stent release or emergency cases in the intensive care unit. METHODS: Thirty-nine patients were treated by insertion of a SEPS by endoscopic or radiologic guidance for the following: malignant stenosis (n = 22), malignant fistula (n = 8), benign stenosis after treatment for malignant disease (n = 6), benign fistula (n = 2), and perforation or leakage after surgery of the esophagus (n = 5). RESULTS: Stent placement was technically feasible in all patients. In patients with a stenosis, esophageal passage was achieved in 92.8%. Fistulas, perforations, and leakages were sealed in 73.3%. In 6 patients (15.4%), the stent was electively removed because of the completion of the therapy. Complications included respiratory insufficiency, mediastinal emphysema, and tracheal impression in one patient each; a new fistula in two patients; bleeding in 3 patients; stent-induced ulcers in two patients; and stent migration in 8 patients. CONCLUSIONS: The therapeutical success and the complication rate after SEPS placement are similar to that reported for self-expanding metal stents. In addition, the SEPS can be readily removed, and the costs are significantly lower.     

New design esophageal stents for the palliation of dysphagia from esophageal or gastric cardia cancer: a randomized trial

BACKGROUND & AIM: Stents are often used for the palliation of inoperable esophageal or gastric cardia cancer. One of the drawbacks of the currently used stents is the high percentage of recurrent dysphagia due to stent migration and tissue growth. New stents have been designed to overcome this unwanted sequela of stent placement. In the present study, we investigated whether results of stent placement could be improved with newer stent designs. METHODS: Between June 2004 and May 2006, 125 patients with dysphagia from inoperable carcinoma of the esophagus or gastric cardia were randomized to placement of an Ultraflex stent (N = 42), Polyflex stent (N = 41), or Niti-S stent (N = 42). Patients were followed by scheduled telephone calls at 14 days after treatment, and then monthly for 6 months or until death. Technical and functional outcome, complications, recurrent dysphagia, and survival were analyzed with, chi(2) tests, Kaplan-Meier curves, and log-rank tests. RESULTS: Stent placement was technically successful in all patients with an Ultraflex stent, in 34/41 (83%) patients with a Polyflex stent, and in 40/42 (95%) patients treated with a Niti-S stent (P= 0.008). Dysphagia score improved from a median of 3 (liquids only) to 1 (ability to eat some solid food) in all patients. There were no differences in complications among the three stent types. Recurrent dysphagia, caused by tissue in- or overgrowth, migration, or food obstruction, was significantly different between patients with an Ultraflex stent and patients with a Polyflex stent or Niti-S stent (22 [52%]vs 15 [37%]vs 13 [31%], P= 0.03). Stent migration occurred more frequently with Polyflex stents, whereas tissue in- or overgrowth was more frequently seen with Ultraflex stents, and to a lesser degree, Niti-S stents. No differences were found in survival (median survival: Ultraflex stent 132 days vs Polyflex stent 102 days vs Niti-S stent 159 days) among the three stent types. CONCLUSIONS: All three stents are safe and offer adequate palliation of dysphagia from esophageal or gastric cardia cancer. Nonetheless, Polyflex stents seem the least preferable in this patient group, as placement of this device is technically demanding and associated with a high rate of stent migrations.     

The impact of prior radiotherapy on fatal complications after self‐expandable metallic stents (SEMS) for malignant dysphagia due to esophageal carcinoma

The esophageal stent has been demonstrated to serve as a safe and effective palliative treatment for advanced inoperable esophageal carcinoma. However, the safety of esophageal stents in patients with prior radiotherapy (RT) remains debated. This article aims to investigate the impact of prior RT on the incidence of fatal complications after self‐expandable metallic stents for palliation of malignant dysphagia because of esophageal carcinoma. Between January 2007 and July 2010, 93 patients with malignant dysphagia because of esophageal carcinoma underwent placement of self‐expandable metallic stents in our hospital. Patients were retrospectively separated into two groups: patients with RT before stent placement (RT group, n = 57) and patients with no treatment before stent placement (no RT group, n = 35).The median survival after stent placement was 77 days (7–842 days) in the RT group and 246 days (15–878 days) in the no RT group. Improvement in dysphagia score was similar in both groups. The fatal complications included fatal gastrointestinal hemorrhage and uncontrolled pneumonia. The incidence of fatal gastrointestinal hemorrhage and uncontrolled pneumonia were 28.1% and 5.7% (P = 0.009), 28.1% and 5.7% (P = 0.009), respectively. Logistic regression analysis showed a significant interaction between prior RT and fatal gastrointestinal hemorrhage (relative risk 7.82, 95% confidence interval 1.54–39.61; P = 0.013). Mortality of massive hemorrhage was 5.7% (2/35), 0% (0/4), 12.5% (3/24), and 44.8% (13/29), respectively, in patients who received 0, 1Gy～49Gy, 50Gy～60Gy, and >60Gy (χ² = 17.761; P = 0.000). Logistic regression analysis disclosed prior RT did not significantly increase the risk of uncontrolled pneumonia (relative risk 1.47, 95% confidence interval 0.21–10.12; P = 0.697).     

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.     

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.     

A new esophageal stent design (Niti-S stent) for the prevention of migration: a prospective study in 42 patients

BACKGROUND: Covered, rather than uncovered, metal stents are used for the palliation of dysphagia from esophageal cancer, but a major drawback is the risk of stent migration, which occurs in up to 20% of patients. To overcome this problem, a double-layered stent, the Niti-S stent (Taewong Medical, Seoul, Korea), has been developed. The Niti-S stent consists of an inner polyurethane layer to prevent tumor ingrowth and an outer uncovered nitinol wire tube to allow the mesh of the stent to embed itself in the esophageal wall. METHODS: Between June 2003 and May 2004, 42 patients with malignant dysphagia caused by inoperable carcinoma of the esophagus or gastric cardia were treated with a Niti-S stent. Patients were prospectively followed and data collection focused on recurrent dysphagia, functional outcome, complications, and survival. RESULTS: At 4 weeks, the dysphagia score had significantly improved from a median of 3 (liquids only) to 0 (ability to eat a normal diet). Five of 42 (12%) patients with a Niti-S stent developed recurrent dysphagia, mainly due to tissue overgrowth (2 of 42; 5%) and stent migration (3 of 42; 7%). Major complications (perforation, 1; aspiration pneumonia, 2; hemorrhage, 2) occurred in 5 of 42 (12%) patients. Pain following stent placement was observed in 5 of 42 (12%) patients, and symptomatic gastroesophageal reflux occurred in 2 of 42 (5%) patients. CONCLUSIONS: The Niti-S stent provides symptomatic relief of malignant dysphagia and effectively reduces recurrent dysphagia. Its double-layered design is probably important in preventing migration. In addition, the complete covering of the Niti-S stent may be a factor in preventing tissue overgrowth at both ends of the stent.