Sealing of esophageal perforation or ruptures with expandable metallic stents: A prospective controlled study on treatment efficacy and limitations

Esophageal perforations are surgical emergencies with high mortality rates. A variety of treatment strategies have been advocated. No single strategy has however, been fully applicable to deal with most situations. The aim of this study was to investigate if treatment with covered expandable metallic stents could offer a feasible option for the management of a leaking esophagus regardless of cause. Twenty-two consecutive patients with perforation or leakage from the intrathoracic esophagus were endoscopically treated with placement of a covered expandable metallic stent. Nine patients had esophageal cancer and 13 had benign underlying disease of whom two had a leakage from a surgical anastomosis. The leakage could be sealed in all but one patient. This patient died after an open esophageal diversion procedure. Twelve patients had an uneventful recovery, whereas three patients needed percutaneous drainage of abscesses and one drainage of the pleural cavity through a small thoracotomy. One patient required a conventional thoracotomy to drain the mediastinum. In total five (23%) patients died from the perforation within 30 days. Two of the deaths were unrelated and three (14%) related to the perforation. In patients with benign disease stents were removed or replaced after 3 weeks. In total 17 stents were successfully removed. Leakage from a damage esophagus can be effectively covered by expandable metallic stents seemingly regardless of the underlying cause and is likely to offer a good chance of survival even in severely ill patients.     

Endoscopic treatment of thoracic esophageal anastomotic leaks by using silicone-covered, self-expanding polyester stents

BACKGROUND: Surgery, as well as conservative treatment, in patients with clinically apparent intrathoracic esophageal anastomotic leaks often is associated with poor results and carries a high morbidity and mortality. The successful treatment of esophageal anastomotic insufficiencies and perforations when using covered, self-expanding metallic stents is described. METHODS: The feasibility and the outcome of endoscopic treatment of intrathoracic anastomotic leakages when using silicone-covered self-expanding polyester stents were investigated. Twelve consecutive patients presented with clinically apparent intrathoracic esophageal anastomotic leak caused by resection of an epiphrenic diverticulum (n = 1), esophagectomy for esophageal cancer (n = 9), or gastrectomy for gastric cancer (n = 2), were endoscopically treated in our department. The extent of the dehiscences ranged from about 20% to 70% of the anastomotic circumference. After endoscopic lavage and debridement of the leakage at 2-day intervals (mean duration, 8.6 days), a large-diameter polyester stent (Polyflex; proximal/distal diameters 25/21 mm) was placed to seal the leakage. Simultaneously, the periesophageal mediastinum was drained by chest drains. OBSERVATIONS: All 12 patients were successfully treated endoscopically without the need for reoperation. A complete closure of the leakage was obtained in 11 of 12 patients after stent removal (median time to stent retrieval, 4 weeks, range 2-8 weeks). In one patient, a persistent leak was sealed endoscopically after stent removal by using 3 clips. Distal stent migration was obtained in two patients. CONCLUSIONS: The placement of silicone-covered self-expanding polyester stents seems to be a successful minimally invasive treatment option for clinically apparent intrathoracic esophageal anastomotic leaks.     

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.     

Effect of stent size on complications and recurrent dysphagia in patients with esophageal or gastric cardia cancer

BACKGROUND: Stents are commonly used for the palliation of dysphagia from esophageal or gastric cardia cancer. A major drawback of stents is the occurrence of recurrent dysphagia. Large-diameter stents were introduced for the prevention of migration but may be associated with more complications. OBJECTIVE: To compare small- and large-diameter stents for improvement of dysphagia, complications, and recurrent dysphagia. DESIGN: Evaluation of 338 prospectively followed patients with dysphagia from obstructing esophageal or gastric cardia cancer who were treated with an Ultraflex stent (n = 153), a Gianturco Z-stent (n = 89), or a Flamingo Wallstent (n = 96) of either a small diameter (n = 265) or a large diameter (n = 73) during the period 1996 to 2004. SETTING: Single academic center. PATIENTS: Patients with an inoperable malignant obstruction of the esophagus or the gastric cardia, or recurrent dysphagia after prior radiation, with curative or palliative intent for esophageal cancer. INTERVENTIONS: Stent placement. MAIN OUTCOME MEASUREMENTS: Dysphagia score (on a scale from 0 [no dysphagia] to 4 [complete dysphagia]), complications, and recurrent dysphagia. Analysis was by chi2 test, log-rank test, and Cox regression analysis. RESULTS: Improvement in dysphagia was similar between patients with a small- or a large-diameter stent (P = .35). The occurrence of major complications, such as hemorrhage, perforation, fistula, and fever, was increased in patients with a large-diameter Gianturco Z-stent compared with those treated with a small-diameter stent (4 [40%] vs 16 [20%]; adjusted hazard ratio [HR] 5.03, 95% confidence interval [CI] 1.33-19.11) but not in patients with a large-diameter Ultraflex stent or a Flamingo Wallstent. Moreover, minor complications, particularly pain, were associated with prior radiation and/or chemotherapy in patients with a large- or a small-diameter Gianturco Z-stent (HR 4.27, 95% CI 1.44-12.71) but not in those with an Ultraflex stent or a Flamingo Wallstent. Dysphagia from stent migration, tissue overgrowth, and food bolus obstruction reoccurred more frequently in patients with a small-diameter stent than in those with a large-diameter stent (Ultraflex stent: 54 [42%] vs 3 [13%], adjusted HR 0.16, 95% CI 0.04-0.74; Gianturco Z-stent: 21 [27%] vs 1 [10%], adjusted HR 0.97, 95% CI 0.11-8.67; and Flamingo Wallstent: 21 [37%] vs 6 [15%], adjusted HR 0.40, 95% CI 0.03-4.79). LIMITATIONS: Nonrandomized study design. CONCLUSIONS: Large-diameter stents reduce the risk of recurrent dysphagia from stent migration, tissue overgrowth, or food obstruction. Increasing the diameter in some stent types may, however, increase the risk of stent-related complications to the esophagus.     

Thirty-four cases of esophageal perforation: the experience of a district general hospital in the UK

Esophageal perforation is uncommon and traditionally has a high rate of morbidity and mortality. Our aim was to perform a 13-year retrospective review of the cases managed in our district general hospital. Thirty-four cases of esophageal perforation diagnosed between 1995 and 2008 were retrospectively analyzed. There were 20 males and 14 females with a median age of 64 (range 23–86) years. The etiology of the perforations were Boerhaave's syndrome ( n = 19), therapeutic endoscopy ( n = 9), diagnostic endoscopy ( n = 2), gastric lavage injury ( n = 1), foreign body ( n = 1), blunt chest trauma ( n = 1), and spontaneous tumor perforation ( n = 1). Only 11 cases (32%) had evidence of surgical emphysema upon examination. In 50% of cases, another clinical diagnosis was initially suspected. Twenty-four were treated surgically and 10 cases managed non-operatively. Surgical treatment included thoracotomy with primary repair ( n = 9), T-tube drainage ( n = 7), emergency esophagectomy ( n = 1), or intra-operative stent insertion ( n = 1). Four cases had primary repair and fundal wrap via abdominal approach without thoracotomy. Two patients were treated with washout and drainage only. Eight patients died overall (in-hospital mortality 23.5%). Esophageal perforations are often initially misdiagnosed and the majority do not have surgical emphysema. There are a wide variety of methods to manage esophageal perforation. Management tailored to the location and size of perforation, degree of contamination, and underlying cause appears to result in a reasonable prognosis.     

Multimodal endoscopic treatment for delayed severe esophageal stricture caused by incomplete stent removal

The usefulness of a covered self‐expandable metallic stent for benign esophageal stricture and perforation was well established. In case of benign disease, early stent removal was recommended within 6–8 weeks after placement. A case with severe esophageal stricture caused by incomplete stent removal 7 years after stent placement for spontaneous esophageal rupture was reported. Residual stent fragments could be removed by step‐by‐step multimodal endoscopic treatment, producing satisfactory luminal diameter of the esophagus. In particular, stent trimming with argon plasma coagulation was safe and effective strategy. The endoscopic stent removal is minimally invasive and should be attempted before surgical intervention; however, it is most important to ensure early stent removal before tissue ingrowth or overgrowth can develop.     

Endoscopic debridement of paraesophageal, mediastinal abscesses: a prospective case series

BACKGROUND: Mediastinal abscesses after esophageal perforation or postoperative leakage nearly always require surgical intervention. METHODS: Patients with paraesophageal abscesses were treated with EUS-guided or endoscopic mediastinal puncture if the abscess was >2 cm and sepsis was present. Abscess cavities were entered with a 9.5-mm endoscope after balloon dilation to allow irrigation and drainage. Debris was removed with a Dormia basket. Concomitant pleural effusions were treated with transthoracic drains. Patients received intravenous antibiotics and enteral/parenteral nutrition. RESULTS: Twenty patients fulfilled the entry criteria. Simple drainage was sufficient in 4 cases, and puncture was impossible in one case. Of the 15 treated patients (age 39-76 years, 5 women) the etiology of perforation was Boerhaave's syndrome (n = 8), anastomotic leak (n = 3), and iatrogenic perforation (n = 4). Debridement was successful in all cases and required a median of 5 daily sessions (range 3-10). All patients became apyrexial, with a C-reactive protein < 5 mg/L within a median of 4 days (range 2-8 days). Esophageal defects were closed with endoclips (n = 7), fibrin glue (n = 4), metal stents (n = 1), or spontaneously healed (n = 3). One patient died from a massive pulmonary embolism one day after successful debridement (mortality 7%). No other complications were seen. Median follow-up was 12 months (range 3-40 months). CONCLUSIONS: Nonoperative endoscopic transesophageal debridement of mediastinal abscesses appears safe and effective.     

Knitted nitinol stent insertion for various intestinal stenoses with a modified delivery system

BACKGROUND: Insertion of metallic stents for esophageal stenoses is well established, but these stents are technically difficult to place elsewhere in the GI tract. Moreover, major complications have occurred when metal stents with sharp ends have been placed in these locations. The currently available flexible, blunt-ended, knitted nitinol stent is intended for use only in the esophagus. Because its short delivery system cannot reach segments of the gut distal to the esophagus, the delivery device was modified to facilitate intestinal access, and its performance was evaluated in the treatment of malignant intestinal obstructions. METHODS: The Ultraflex delivery system was modified by connecting an additional plastic tube and a suture cord; the length was increased from 95 cm to 150 cm or more. Stents used were 18 to 23 mm in diameter, and 10 to 15 cm in length. A knitted metal stent was inserted by using the modified delivery system in 10 patients (7 men, 3 women, mean age 68 years); 8 with gastric outlet, 1 with jejunal, and 1 with proximal colonic obstruction. RESULTS: Metal stent insertion was successful in all patients with significant relief of symptoms and restoration of the ability to eat. The patient with a jejunal stent required placement of a second stent because of bending of the initial stent. No major complications (migration or perforation) occurred. CONCLUSION: This technique appears to facilitate placement of a metal stent with blunt ends in the duodenum, small intestine, and proximal colon. Manufacturers should offer blunt-ended stents with long delivery devices.     

Natural course of inoperable esophageal cancer treated with metallic expandable stents: quality of life and cost-effectiveness analysis

BACKGROUND AND AIM: The aim of this study was to evaluate the efficacy and safety of endoscopic therapy with self-expanding metallic endoprostheses in the management of malignant esophageal obstruction or stenosis and the cost-effectiveness of the method in patients suffering from primary esophageal carcinoma. All patients with inoperable esophageal cancers treated with either laser palliation or endoprosthesis insertion were studied retrospectively. METHOD: Between May 1997 and December 2002 obstruction of the esophagus was diagnosed in 78 patients (52 male, 26 female, age range 53-102 years, mean 72.3 years). The etiology of obstruction was squamous cell carcinoma (n = 42) and adenocarcinoma of the esophagus (n = 36). The site of obstruction was in the upper (n = 1), in the middle (n = 38) and in the lower esophagus (n = 39). In 16 cases the gastroesophageal junction was also involved. Four patients had broncho-esophageal fistulas. In all cases the tumor was considered non-resectable. A total of 89 Ultraflex metal stents were introduced endoscopically. In 46 patients dilation with Savary dilators prior to stent placement was required. RESULTS: Stents were placed successfully in all patients. After 48 h, all patients were able to tolerate solid or semisolid food. During the follow-up period eight patients developed dysphagia due to food impaction (treated successfully endoscopically). Eleven patients presented with recurrent dysphagia 4-16 weeks after stenting due to tumor overgrowth and were treated with placement of a second stent. The median survival time was 18 weeks. There was no survival difference between squamous cell and esophageal adenocarcinoma. A cost-effective analysis was performed, comparing esophageal stenting with laser therapy. The mean survival and the cost were similar. A small difference of 156 Euro was noted (3.103 Euro and 2.947 Euro for each group of patients, respectively). A significant improvement in quality of life was noted in patients that underwent stenting (96% and 75%vs 71% and 57% for the first 2 months). CONCLUSION: Placement of self-expanding metal stents is a safe and cost effective treatment modality that improve the quality of life, as compared with other palliative techniques, for patients with inoperable malignant esophageal obstructions. In cases of expansion of the mass a second stent can be used; however, the overall survival of these patients, is poor.     

125Ⅰ粒子覆膜支架对正常兔食管组织的放射性损伤实验研究

目的 观察125I粒子覆膜食管支架对于正常兔食管组织的放射性损伤.方法 将实验用兔分两组,每组各6只,实验组置入125I粒子支架(单颗粒子剂量22.2MBq ×3颗粒子),对照组植入无放射粒子的支架.于支架植入后2、4、8周分别取实验组和对照组兔2只,行食管造影,观察支架、粒子移位情况,处死后取标本行肉眼、显微镜观察.结果 支架释放过程及术后随访未发现125I粒子脱落.所有动物未发现穿孔等严重并发症.实验组术后2周,食管中部仅为轻微的病理学损伤,鳞状上皮明显增生.黏膜卜炎性细胞浸润.术后4周,出现肉芽组织增生,少量纤维组织增生.术后8周,肉芽组织、纤维结缔组织进一步增生.粒子相对处的食管组织损伤程度明显轻于粒子接触处食管组织.对照组支架中间部分食管与正常食管组织相似,可见食管鳞状卜皮轻增生.支架两端实验组和对照组局部增生食管组织覆盖支架,可见肉芽组织、纤维结缔组织明显增牛.结论 125I粒子支架置人正常兔食管壁组织造成病理性改变,主要表现为肉芽组织、纤维结缔组织增生,无出血、穿孔.     

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.     

Use of self-expandable metallic stents in benign GI diseases

BACKGROUND: The self-expandable metallic stent is of proven benefit in patients with malignant disease; however, its use in patients with benign disease is not well established. There are few data available regarding long-term complications and outcomes with use of self-expandable metallic stents in benign disease and virtually none regarding attempted removal once the acute problem is resolved. METHODS: Thirteen patients who had a self-expandable metallic stent placed for benign GI disorders were included in a retrospective analysis. Data collected included patient demographics, indication for procedure, type of stent used, complications, and patient outcomes. RESULTS: Thirteen patients (7 women, 6 men; mean age 67 years, range 34-84 years) had one or more self-expandable metallic stents placed for benign disease and were followed for a mean of 3.4 years (3 weeks to 10 years). Of the 13 patients, 8 had esophageal stents, 4 biliary stents, and 1 had dual stents placed in the pancreaticobiliary tree. Complications developed in 8 (62%) patients; 4 (31%) ultimately died, either from the primary disease process (3) or from stent-related complications (1). CONCLUSIONS: Self-expandable metallic stent placement is effective treatment for benign esophageal leaks, providing the stent can be removed. It also may be used in either the esophagus or biliary tree in patients who are poor candidates for surgery and short expected survival. However, a self-expandable metallic stent should not be placed in a patient with a benign GI disorder who has a significant life expectancy and is a good candidate for surgery.     

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.     

Implantation of self-expanding metallic stent for patients with malignant stricture after failure of definitive chemoradiotherapy for T3 or T4 esophageal squamous cell carcinomas

BACKGROUND/AIMS: Definitive chemoradiotherapy can have curative potential in unresectable patients with malignant stricture due to locally advanced esophageal carcinoma, however, dysphagia is the principal problem in patients who had recurrence or who did not respond to chemoradiotherapy. In this prospective study, we investigated the efficacy and feasibility of metallic stent implantation for patients with dysphagia after chemoradiotherapy failed. METHODOLOGY: Concurrent chemoradiotherapy was performed in 40 patients with severe dysphagia due to esophageal squamous cell carcinomas accompanied by T3 or T4 disease containing M1 lymph node (LYM) disease. A self-expanding metallic stent was inserted for patients with malignant stricture of the thoracic esophagus after failure of chemoradiotherapy using identical protocols. RESULTS: Of 40 patients, 13 (33%) achieved a complete response. However, 12 patients complained of severe dysphagia again after chemoradiotherapy despite a good performance status. Esophageal stricture of these 12 patients was caused by stable disease (n = 4), local progression (n = 5), and compression of metastatic lymph node (n = 3). Metallic stents were successfully inserted for all 12 patients, and dysphagia improved in 10 (83%) of these 12 patients. Life-threatening complication (17%) of sepsis in two patients was found in an early phase after stent insertion, although approximately 200 days had passed in a dysphagia-free state after chemoradiotherapy. CONCLUSIONS: Implantation of self-expanding metallic stent for patients with malignant stricture after failure of chemoradiotherapy is effective, however, serious complication can occur in the early phase.     

Novel Biodegradable Stents for Benign Esophageal Strictures Following Endoscopic Submucosal Dissection

The application of metallic stents for benign stenosis is limited due to long-term complications. We report here the results of the implantation of a novel biodegradable poly-l-lactic acid (PLLA) esophageal stent in two patients with benign esophageal stenosis after endoscopic submucosal dissection (ESD). Case 1 was a 64-year-old man who received ESD for an early squamous esophageal cancer in the middle esophagus. The mucosal defect was seven-eighths of the circumference, and the distal margin of the resection scar formed the stenosis. After balloon dilatation, the PLLA esophageal stent was endoscopically placed; for 6 months, he has not experienced any symptoms of re-stenosis. Case 2 consisted of a 62-year-old man who developed an early squamous esophageal cancer in the middle esophagus. The lesion was resected by ESD, and the mucosal defect was seven-eighths of the circumference. The resection scar formed the stenosis, and the PLLA esophageal stent was endoscopically placed. He also has not experienced any symptoms of re-stenosis for 6 months. In conclusion, the PLLA esophageal stent provides a new possibility for the management of benign esophageal strictures after ESD. Due to the biodegradable features of this stent, longer term studies are necessary to investigate the relationship between the expected disappearance of the stent and the patency of the stricture.     

Stents or Open Operation for Palliation of Colorectal Cancer: A Retrospective,Cohort Study of Perioperative Outcome and Long-term Survival

PURPOSE: Expandable, metallic stents provide a new modality of palliation for patients with noncurable metastatic colorectal adenocarcinoma. This study was designed to compare the use of expandable metallic stents as a palliative measure to traditional open surgical management, with particular reference to length of stay, and survival.METHODS: Patients admitted between 1997 and 2002 with left-sided (splenic flexure and distal), colorectal adenocarcinoma and nonresectable metastatic disease (Stage 4) were treated with expandable metal stents or open surgery (resection, bypass, or stoma). The group of patients having stents inserted were compared with regard to perioperative outcome and survival to those having open surgical procedures.RESULTS: Twenty-two of 25 patients had colonic stents successfully inserted and 19 patients underwent open surgery. The two groups were comparable: stent: median age, 66 (range, 37–88) years; 13 males; and open operation: median age, 68 (range, 51–85) years; 12 males. The tumors were primary in 22 stents procedures and 18 open operations. The site of obstruction was: splenic flexure, 2 stent vs. 0 open operation; descending colon, 2 stent vs. 2 open operation; sigmoid colon, 12 stent vs. 6 open operation; rectum, 9 stent vs. 11 open operation. The American Society of Anesthesiologists (ASA) class was: ASA 1, 0 stent vs. 0 open operation; ASA 2, 6 stent vs. 9 open operation; ASA 3, 15 stent vs. 7 open operation; ASA 4, 4 stent vs. 3 open operation. The open operations were laparotomy only (n = 2), bypass (n = 1), stoma (n = 7), resection with anastomosis (n = 4), resection without anastomosis (n = 5). The complications after open operation were urinary (n = 2), stroke (n = 1), cardiac (n = 2), respiratory (n = 2), deep vein thrombosis (n = 1), anastomotic leak (n = 1). There were no stent-related complications. The mean length of stay was significantly shorter in the stent group (4 vs. 10.4 days; P < 0.0001). There was no difference in survival between the two groups (median survival: stent group, 7.5 months; open operation, 3.9 months; log-rank P value = 0.2156).CONCLUSIONS: Patients treated with stents are discharged earlier than after open surgery. Stents do not affect survival. Expandable metal stents provide an acceptable alternative and may be better than traditional open surgical techniques.Reprints are not available.Presented at the Annual Scientific Meeting of the Royal Australian College of Surgeons, Brisbane, Australia, May 5 to 9, 2003.     

Current management of esophageal perforation: 20 years experience

Esophageal perforations are surgical emergencies associated with high morbidity and mortality rates. No single strategy has been sufficient to deal with the majority of situations. We aim to postulate a therapeutic algorithm for this complication based on 20 years of experience and also on data from published literature. We performed a retrospective clinical review of 44 patients treated for esophageal perforation at our hospital between January 1989 and May 2008. We reviewed the characteristics of these patients, including age, gender, accompanying diseases, etiology of perforation, diagnosis, location, time interval between perforation and diagnosis, treatment of the perforation, morbidity, hospital mortality, and duration of hospitalization. Perforation occurred in the cervical esophagus in 14 patients (31.8%), thoracic esophagus in 18 patients (40.9%), and abdominal esophagus in 12 patients (27.3%). Management of the esophageal perforation included primary closure in 23 patients (52.3%), resection in 7 patients (15.9%), and nonsurgical therapy in 14 patients (31.8%). In the surgically treated group, the mortality rate was 3 of 30 patients (10%), and 2 of 14 patients (14.3%) in the conservatively managed group. Four of the 14 nonsurgical patients were inserted with covered self-expandable stents. The specific treatment of an esophageal perforation should be selected according to each individual patient. To date, the most effective treatment would appear to be operative management. With improvements in endoscopic procedures, the morbidity and mortality rates of esophageal perforations are significantly decreased. We suggest that minimally invasive techniques for the repair of esophageal perforations will be very important in the future treatment of this condition.     

Endoscopic removal of metallic airway stents

BACKGROUND: Complications of metallic airway stents include granulation tissue formation, fracture of struts, migration, and mucous plugging. When these complications result in airway injury or obstruction, it may become necessary to remove the stent. There have been few reports detailing techniques and complications associated with endoscopic removal of metallic airway stents. We report our experience with endoscopic removal of 30 such stents over a 3-year period. METHODS: We conducted a retrospective review of 25 patients who underwent endoscopic stent removal from March 2001 to April 2004. The patients ranged in age from 17 to 80 years (mean, 56.3 years). There were 10 male and 15 female patients. The stents had been placed for nonmalignant disease in 20 patients (80%) and malignant disease in 5 patients (20%). All procedures were done under general anesthesia with a rigid bronchoscope. Special attention was focused on the technique of stent removal and postoperative complications. RESULTS: Thirty metallic airway stents were successfully removed from 25 consecutive patients over a 3-year period. The basic method of removal involved the steady application of traction to the stent with alligator forceps. In all cases, an instrument such as the barrel of the rigid bronchoscope or a Jackson dilator was employed to help separate the stent from the airway wall before removal was attempted. In some instances, the airway wall was pretreated with thermal energy prior to stent removal. Complications were as follows: retained stent pieces (n = 7), mucosal tear with bleeding (n = 4), re-obstruction requiring temporary silicone stent placement (n = 14), need for postoperative mechanical ventilation (n = 6), and tension pneumothorax (n = 1). CONCLUSIONS: Although metallic stents may be safely removed endoscopically, complications are common and must be anticipated. Other investigators have described airway obstruction and death as a result of attempted stent removal. Placement and removal of metallic airway stents should only be performed at centers that are prepared to deal with the potentially life-threatening complications.     

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.     

INSERTION OF METALLIC STENTS FOR MALIGNANT GASTRIC OUTLET AND DUODENAL STENOSES

Recently, an indication of gastrointestinal stenting is not only esophageal stenosis but it extends from the esophagus to the gastric outlet and duodenum. However, there are some problems such as shortness of the device for esophageal stenting, angulations of stenotic sites, and so on, when we perform the stenting for stenoses of the gastric outlet and duodenum. Until now, some refinements of stent insertion technique have been attempted to solve these problems. In this paper, we report three cases in which self‐expanding metallic stents were placed for stenoses of the gastric outlet and duodenum with refinements of stent insertion technique. Our attempts in these patients were an extension of stenting device to insert stents easily, and placement of covered metallic stent inside non‐covered metallic stent or a fixation of covered metallic stent to the gastrointestinal wall by means of endoclips to avoid dislocation of stents. Stents were inserted successfully in all patients, and the nutrition of these patients was improved after the placement of stents. Further refinements of stents and stent insertion technique are expected to achieve easy manipulation.