Endoscopic palliation of inoperable hilar biliary carcinoma with self-expanding metal stents

AIM: Prosthetic palliation of patients with malignant hilar stenoses shows particular difficulties, especially in advanced lesions. This is a prospective report of the efficacy of endoscopically inserted single metal stent for complex malignant biliary hilar obstruction. METHODS: Sixty-one consecutive patients were recruited. Contrast injection was deliberately limited to the distal end of the malignant tumor stenosis. A single metal stent was inserted across the stricture into the duct that was technically easiest for the drainage. RESULTS: Successful stent insertion was achieved in 59 of 61 (96.7%) patients. In 3 (4.9%) cases stent malfunction occurred. Successful drainage was achieved in 59 (96.7%) patients and complete resolution of jaundice was achieved in 86% of cases. Early complications included 3 (4.9%) cases of cholangitis and 2 (3.2%) cases of stent occlusion. Late occlusion of the stent occurred in 14 patients (22.9%), including 10 (16.3%) cases of cholangitis and 1 case of liver abscess. Median stent patency was 169 days. Median patient survival was 140 days. CONCLUSION: Metal stent insertion is safe, feasible, and achieves adequate drainage in the great majority of patients with non-resectable hilar cholangiocarcinoma.     

Palliation of malignant rectal obstruction with self-expanding metal stents

BACKGROUND: Surgical management of patients with metastatic or recurrent rectal cancer remains controversial. Self-expanding metal stents are increasingly used for palliative treatment of advanced tumors, although long-term results are not yet available. METHODS: Between 1996 and 2003, 521 patients underwent surgery for rectal neoplasms. In the same time period, self-expanding metal stents were used for palliation of 34 patients with malignant rectal obstruction and incurable disease. The outcome of the patients was analyzed retrospectively. RESULTS: Rectal stents were successfully placed in 33 of 34 patients (97%) without major complications. Early failure occurred in 7 patients (21%) because of stent migration, pain, or incontinence. Long-term success with a mean patency of 5.3 months was observed in 26 patients (79%), but restenting was required in 2 patients. Despite the initial success of stenting, a colostomy was created in 2 other patients after 3.4 months and 9.2 months because of incontinence and rectovesical fistula. Overall, 6 of 33 patients (18%) underwent palliative surgery because of early complications (n = 4) or long-term failure of stent treatment (n = 2). CONCLUSIONS: Self-expanding metal stents are useful to avoid a colostomy in selected patients with incurable rectal cancer and limited life expectancy. Nonetheless, a considerable number (18%) of patients will require surgical palliation because of failure of stent treatment.     

Palliation of inoperable esophageal carcinoma

Summary The combined regimen of irradiation and chemotherapy has been successfully used as a preoperative measure to improve the cure rate for squamous cell carcinoma of the esophagus. In the nonresectable patient, we have seen response to this regimen in the form of conversion of the neoplastic stricture into a fibrous one. Dysphagia remained unchanged due to the persistence of a stricture. In this situation, therapeutic endoscopy can be highly effective for relief of dysphagia, as illustrated by a case report, and is proposed as the palliative procedure of choice when the patient has shown response to combined chemotherapy and radiotherapy.     

Insertion of self-expanding metal stents for malignant dysphagia: assessment of a simple endoscopic method

AIM: To assess the efficacy, safety and long-term results of self-expanding metallic prostheses, placed using an entirely endoscopic method, for the relief of dysphagia in oesophageal carcinoma. PATIENTS AND METHODS: A consecutive series of 50 patients (30 men, 20 women), aged 43-91 years (median, 75 years) underwent stent placement (Ultraflex Stent, Boston Scientific, Watertown, MA, USA) under general anaesthesia without fluoroscopic control. RESULTS: Stent placement was successful in all patients. Swallowing improved from dysphagia score 4, 3 or 2 to score 1 (or 0) in all patients available for long-term follow-up (excluding two patients who died, and two who had resection, in the immediate post-stenting period). There were two early deaths that were, or could have been, procedure-related and one early complication, in addition to technical problems in 6 cases, all early in the series. Seven patients required endoscopic laser treatment, on 13 occasions, subsequently for tumour in-growth or over-growth. Of the 46 patients with long-term stents in situ, 36 patients died with a median survival time of 4 months (range 10 days to 24 months). At the time of writing, 10 patients are still alive with a median survival of 4 months (range 1-11 months). CONCLUSIONS: Self-expanding metallic stents provide rapid, safe and effective relief of dysphagia. They can provide long-term palliation (> 1 year) with endoscopic laser treatment for recurrent in-growing/over-growing tumour. Fluoroscopic control is not necessary for the safe and accurate placement of such stents.     

Complication of benign tracheobronchial strictures by self-expanding metal stents

OBJECTIVES: Self-expanding metal stents are used to palliate benign strictures. We examined the complications of this approach. METHODS: Between 1997 and 2002, we observed recurrent airway obstruction and extension of benign inflammatory strictures after the placement of tracheobronchial Microvasive Ultraflex stents and Wallstents (Boston Scientific Corp, Natick, Mass), in 10 patients with postintubation strictures and 5 with other indications; all but 1 patient were referred to us. Patients with tracheal (9), subglottic (1), combined tracheal and subglottic (3), and bronchial (2) strictures had been treated with covered and uncovered Wallstents (6) and Microvasive Ultraflex stents (9). RESULTS: After stent insertion, stricture and granulations within previously normal airway were seen in all patients. New subglottic strictures resulting from the stent caused hoarseness in 4 patients. A bronchoesophageal fistula was found in 1 patient at presentation and a tracheoesophageal fistula in another during extraction of a Wallstent. Primary surgical reconstruction, judged to have been feasible before wire stent insertion in 10 patients, was possible after stenting in only 7 and failed in 2. Palliative tubes were placed in 60% (9/15). Self-expanding metal stents may lengthen luminal damage, incite subglottic strictures, and cause esophagorespiratory fistula in inflammatory airway strictures. The injury is severe, occurs after a short duration of stenting, and precludes definitive surgical treatment or requires more extensive tracheal resection. CONCLUSION: The current generation of self-expanding metal stents should be avoided in benign strictures of trachea and bronchi.     

Management of tracheomediastinal fistula using self-expanding metallic stents

Tracheomediastinal fistula is a rare condition usually associated with a fatal outcome. We report the case of a 65-year-old man with a subcarinal mass causing total destruction of the carina and proximal mainstem bronchi. The mass was diagnosed as a large cell lymphoma, and the decision was made to undertake chemotherapy only after stabilization of the endobronchial tree. The endobronchial defects were successfully palliated with placement of three different types of self-expanding metallic stents using a flexible bronchoscope under conscious sedation. The unique properties of each stent were used for optimum clinical benefit, avoiding any morbidity.     

Palliation of malignant dysphagia using the Nd:YAG laser

A group of 141 patients with biopsy-proved malignant dysphagia, treated with neodymium YAG laser between April 1985 and November 1988, have been prospectively evaluated. Patients treated since November 1988 have not been included to allow minimum follow-up of 18 months. The success of treatment has been assessed in terms of survival, relief of dysphagia, complications, and length of inpatient stay. One- and two-year survival rates were 12.6% and 3.5%, respectively (mean survival 24.7 weeks). Ninety-two percent of patients were returned to a semisolid diet or better. In 4% recanalization was impossible, and 4% swallowed only liquids despite an adequate channel. Tumor histology, site of tumor, and length of previous treatment had no significant influence on outcome. The presence of metastases significantly influenced survival (p=0.007). The principal complications were perforation (6.4%) and tracheoesophageal fistula (2.8%). Laser recanalization provides effective palliation for malignant dysphagia.

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Resumen Ciento cuarenta y un pacientes con disfagia por neoplasmas malignas comprobados por biopsia y tratados con laser YAG Neodimio entre abril de 1985 y noviembre de 1988 fueron valorados en forma prospectiva. No se incluyeron los pacientes que han sido tratados a partir de noviembre de 1988, a fin de lograr un seguimiento minimo de 18 meses. El éxito del tratamiento fue determinado en términos de sobrevida, control de la disfagia, complicaciones y duration de la hospitalización. Las tasas de sobrevida a uno y dos años fueron 12.6% y 3.5% respectivamente (sobrevida media 24.7 meses). Noventa y dos por ciento de los pacientes retornaron a una dieta semisólida, o mejor. Cuatro por ciento resultaron imposibles de recanalizar y 4% apenas pudieron pasar líquidos, a pesar de haberse logrado una canalization adecuada. La histología tumoral, el lugar y la duración de tratamientos previos no demostraron influir significativamente sobre el resultado final, pero la presencia de metastasis apareció como un factor significativo en cuanto a sobrevida (p=0.007). Las complicaciones principales fueron la perforación (6.4%) y la fístula traqueo-esofágica (2.8%). La recanalización con laser aparece como una modalidad efectiva de paliación de la disfagia maligna.

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Résumé Cent quarante et un patients ayant une dysphagie en rapport avec un cancer oesogastrique, prouvé histologiquement, et ayant eu un traitement par laser YAG ont été évalués prospectivement. La date de point a été Novembre 1988. Le succès du traitment a été évalué en termes de survie, de soulagement de la dysphagie, des complications et de durée de séjour hospitalier. La survie à un et à deux ans a été respectivement de 12.6% et de 3.5% (survie moyenne de 24.7 semaines). Quatre-vingt-deux pourcent des patients ont pu manger des aliments semiou presque solides. La reperméabilisation a été impossible dans 4% des cas, et 4% des patients n'ont jamais pu manger d'aliments solides malgré une reperméabilisation satisfaisante. L'histologie et le site de la tumeur, la durée du traitement n'ont pas influencé l'évolution. La présence de métastases a influencé la survie de façon significative (p=0.007). Les complications principales ont été la perforation (6.4%) et la fistule trachéooesophagienne (2.8%). La reperméabilisation par laser est une méthode palliative valable dans la dysphagie d'origine néoplasique.

     

The use of biodegradable (SX-ELLA) oesophageal stents to treat dysphagia due to benign and malignant oesophageal disease

Background

Biodegradable (BD) oesophageal stents have been available commercially only since 2008 and previous published research is limited. Our aim was to review the use of BD stents to treat dysphagia in benign or malignant oesophageal strictures.

Methods

Patients were identified from a prospective interventional radiological database. BD stents were inserted radiologically under fluoroscopic control.

Results

Between July 2008 and February 2011, 25 attempts at placing SX-ELLA biodegradable oesophageal stents were made in 17 males and five females, with a median age of 69 (range = 54–80) years. Two patients required more than one BD stent. Indications were benign strictures (n = 7) and oesophageal cancer (n = 17). One attempt was unsuccessful for a technical success rate of 96% with no immediate complications. Clinical success rate was 76%. Median dysphagia score before stent insertion was 3 (range = 2–4) compared to 2 (range = 0–3) after stent insertion (p = 0.0001).

Conclusion

BD stents provide good dysphagia relief for the life time of the stent. They may help avoid the use of feeding tubes in patients having radical chemoradiotherapy or awaiting oesophagectomy. They do not require removal or interfere with radiotherapy planning via imaging. However, the reintervention rate is high after the stent dissolves.     

Palliation of malignant tracheal strictures using silicone T tubes.

The use of silicone T tubes for intubation of malignant tracheobronchial strictures may provide some degree of palliation of this distressing condition. It was used in seven patients with malignant lesions and two with benign strictures (resulting from tracheal trauma and lung transplantation). Four patients (two with cancer) are still alive and well with the tube in position. All patients noted improvement in dyspnoea and stridor. The main problems were tube migration (one patient), tracheo-oesophageal fistula (one patient), and blockage of the tube by tumour (two patients) or encrusted secretions (three patients). Airway patency was restored when the tube was blocked by cleaning or by laser resection of the tumour. With careful supervision and education of the patient intubation can give useful palliation to patients with distressing upper airways obstruction.     

Randomized clinical trial comparing self-expanding metallic stents with plastic endoprostheses in the palliation of oesophageal cancer

BACKGROUND: There is little evidence of the clinical and cost effectiveness of self-expanding metallic stents in the palliation of oesophageal cancer. The aims of this randomized trial were to evaluate the immediate and medium-term clinical outcomes following palliative intubation, examine patient quality of life, and evaluate costs and benefits from the perspective of the health service. METHODS: Fifty patients with inoperable oesophageal cancer were randomly allocated a metallic stent (n = 25) or plastic endoprosthesis (n = 25). Patients were followed up monthly until death. RESULTS: There was no significant difference in procedure-related complications or mortality rate between the two groups. There was a trend towards significance in favour of metallic stents with respect to quality of life and survival (median survival 62 versus 107 days for plastic prosthesis and metallic stent respectively). The cost of the initial placement of metallic stents was significantly higher than that of plastic endoprostheses ( pound 983 versus pound 296). After 4 weeks, cost differences were no longer significant. CONCLUSION: Metallic stents may contribute to improved survival and quality of life in patients with oesophageal cancer. Although initially more expensive, this cost difference does not last beyond 4 weeks. A larger trial involving approximately 300 patients would be required to detect a quality of life benefit of the magnitude observed in this trial.     

Management of anastomotic leaks after Roux-en-Y bypass using self-expanding polyester stents

BACKGROUND: To analyze the outcomes of a series of endoscopically placed polyester self-expanding polyflex stents (SEPSs) for the management of anastomotic leaks after Roux-en-Y bypass. Anastomotic leaks after gastric bypass cause significant morbidity and mortality. Covered polyester SEPSs might have a role in the treatment of these leaks. METHODS: A retrospective chart review was performed from January 2006 to November 2006 that included all acute and chronic leaks treated with SEPSs. RESULTS: A total of 6 patients were treated with stents, with a mean procedure time of 22 minutes. Of these 6 patients, 5 had acute postoperative leaks and 1 had a chronic fistula. Five patients started oral intake 1-6 days after their procedure. All acute leaks had complete healing at a median of 44 days. The patient with a chronic gastrocutaneous fistula required revisional surgery for fistula closure. In addition, 5 patients had stent migration, and 3 required stent replacement. CONCLUSION: An endoscopically placed SEPS provides a less-invasive alternative to treat acute anastomotic leaks after Roux-en-Y bypass while simultaneously allowing oral intake. The results of this case series have demonstrated this treatment to be safe and effective.     

全覆膜食管金属支架治疗高位食管疾病

目的评价全覆膜食管金属支架在高位食管狭窄和瘘以及术后吻合口狭窄和瘘治疗中的有效性和安全性。方法复旦大学附属中山医院内镜中心2005年5月至2013年7月间,应用16mm全覆膜食管金属支架对84例高位食管狭窄和瘘以及术后吻合口狭窄和瘘进行治疗。其中食管癌性狭窄31例,食管外压性狭窄2例,食管癌放疗后狭窄10例,食管癌术后复发致狭窄4例,吻合口狭窄27例,内镜黏膜下剥离术后食管狭窄1例,食管．气管瘘7例,食管一纵隔瘘1例,食管癌术后残胃瘘1例。狭窄或瘘口上缘距中切牙距离15～20cm者48例,大于20cm者36例。结果84例患者共置入100枚支架,术中无出血和穿孔等并发症发生。支架置入术后患者吞咽困难、呛咳症状均迅速缓解。术后并发症发生率为6．0％（5／84）,其中严重胸痛2例,经止痛药物缓解;气管塌陷1例,予气管切开术;支架移位2例,内镜下应用异物钳对支架位置进行调整。76例（90．5％）患者获得完整随访,5-3％（4／76）的患者出现再狭窄,2．6％（2／76）新发食管．气管瘘;其中5例接受再次内镜下置入全覆膜金属支架术并获成功,另1例经沙氏探条扩张及氩离子凝固术治疗效果满意。结论全覆膜食管金属支架治疗高位食管狭窄和瘘以及术后吻合口狭窄和瘘安全、有效,可考虑作为临床首选。     

Comparison of endoscopic laser therapy and self expanding metal stents for palliation in patients with non-resectable oesophageal carcinoma

Background

There are currently limited data on the comparative success of endoscopic laser therapy (NLT) and self expanding metal stents (SEMS) as palliative measures in patients with non-resectable oesophageal cancer. This study aims to assess and compare the outcomes of these methods of endoscopic palliation.

Placement of self-expanding metal stents for acute malignant large-bowel obstruction: a collective review

Background The purpose of this study was to review our experience with self-expanding metal stents as the initial interventional approach in the management of acute malignant large-bowel obstruction. Methods Twenty-six patients who underwent placement of colonic stents at our institution between June 1994 and June 2000 were identified and reviewed. Results In 14 patients, the stents were placed for palliation, whereas in 12, they were placed as a bridge to surgery. In 22 patients (85%), stent placement was successful on the first occasion. In the remaining four individuals, one was successfully stented at the second occasion, and three required emergency surgery. Nine of the 12 patients (75%) in the bridge-to-surgery group underwent elective colon resection. In the palliative group, four patients (29%) had reobstruction of the stents, and in one (9%), the stent migrated. In the remaining nine patients (64%), the stent was patent until the patient died or until the time of last follow-up (median, 156 days). Conclusions In our experience with 26 patients who developed a complete bowel obstruction as a consequence of a malignant tumor, placement of colonic stents to achieve immediate nonoperative decompression proved to be both safe and effective. Subsequent elective resection was accomplished in the majority of resectable cases.     

Palliation of esophageal carcinoma with intraluminal tubes: experience with 30 patients.

Between 1968 and 1978, 26 patients with carcinomas of the thoracic esophagus and 4 with adenocarcinomas involving the esophagogastric junction were treated by the insertion of indwelling intraluminal (endoesophageal) tubes. Four different types of tube were inserted by the pull-through technique. Thirteen of the 30 patients died in the hospital within 30 days. However, among the 20 patients who did not have neoplasms of the upper third of the thoracic esophagus or who had not had a prior resection, only 5 died. The principal cause of death was aspiration pneumonia. Survival averaged 2.5 months. Four patients survived 5 to 7 months. Deglutition was adequate in most patients but was not as satisfactory as after esophagogastrectomy. Our best results were obtained in patients with carcinoma of the middle or lower third of the esophagus, with or without an esophagorespiratory fistula, who had not had a previous resection.