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.     

Fully-covered, self-expandable metal stents (CSEMS) in malignant distal biliary strictures: mid-term evaluation

Background and Aims: Limited data exist regarding fully‐covered, self‐expandable metal stents (CSEMS) with anchoring fins for the management of malignant distal biliary strictures. The aim of this study is to evaluate their safety and patency. Methods: Over a period of 2 years, 70 patients (45 males, 66 ± 13 years) underwent endoscopic retrograde cholangiopancreatography (ERCP) with placement of a 10‐mm (67 patients) or 8‐mm diameter (3 patients) CSEMS for the palliation of distal malignant biliary obstruction (pancreatic [53] or other [17]). Data were collected prospectively for survival and stent patency; complications were evaluated retrospectively. Results: After CSEMS placement, 17 patients proceeded to surgery, and 53 patients were deemed unresectable. Mean survival for non‐surgical candidates was 180 days (range: 15–1091), and 170 days (range: 9–589) for patients who underwent surgical management. CSEMS were left in place and remained patent for a mean of 163 days (range: 15–1091) in non‐surgical candidates, and a mean of 55 days (range: 5–126) in surgical candidates. Complications during placement included wire perforations (4) and proximal deployment requiring repositioning (4), one of which was complicated by a bile leak. Post‐procedure complications were observed in 24 cases (34%) and included post‐ERCP pancreatitis (8, with 2 of them severe), post‐procedure pain (5, with 3 requiring admission), cholecystitis (3), stent occlusion (3), cholangitis (2), proximal migration (1), post‐sphincterotomy bleeding (1), and sepsis leading to death (1). Conclusion: CSEMS appear to provide acceptable short‐term patency rates; however, their limited long‐term patency and high complication rate might limit their widespread use. Further long‐term prospective data are required to confirm this observation.     

Clinical evaluation of double stenting for duodenal and biliary obstructions caused by pancreatic head carcinoma using covered self‐expandable metallic stents

Five patients with non‐resectable pancreatic head carcinoma complicated by duodenal and biliary obstructions were successfully treated by double stenting with covered self‐expandable metallic stents (EMS). Diamond (Boston Scientific, Natick City, MA, USA) stents covered with a polyurethane membrane were used to treat biliary obstructions, whereas covered Ultraflex (Boston Scientific) stents for esophageal stenting were used to treat duodenal obstructions. That is, Diamond stents were initially placed in the biliary tract percutaneously in one patient and endoscopically in the remaining four patients. Subsequently, covered Ultraflex stents were placed in the duodenum. Double stenting with EMS was successfully performed in all five patients without inducing early technical complications. All patients were able to take a liquid diet orally at a mean 1.6 days after the double stenting procedure and were able to eat solid foods thereafter. Sludge‐induced biliary obstructions were detected in two patients 3 and 6 months after the placement of EMS. However, recurrent biliary obstruction was not noted in the remaining three patients. The EMS left in the duodenum were not obstructed during the observation period. The survival period of the patients ranged from 86 to 363 days (mean 172 days). There have not been any reports evaluating the usefulness of double stenting using covered EMS for duodenal and biliary obstructions. Because favorable results were obtained by double stenting in our patients, stenting for duodenal and biliary obstructions caused by non‐resectable pancreatic head carcinoma may become a useful treatment modality substituting for bypass surgery.     

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.     

Home self‐dilatation for esophageal strictures

Esophageal strictures secondary to caustic ingestion, head and neck radiation and at the anastomosis post‐esophagectomy tend to be refractory to one or several dilatations. One option for these strictures is home self‐dilatation. The aim of this study was to assess the efficacy and safety of home self‐dilatation for a refractory esophageal stricture. A retrospective chart review was performed of all patients from 1997 to 2009 that performed home self‐dilatation for an esophageal stricture. Patients with proximal strictures without tortuosity or a shelf proximal to the stricture were selected for self‐dilatation. The patients were taught self‐dilatation by the surgeon and an experienced nurse, and an appropriate sized Maloney dilator was provided to the patient and returned when no longer needed. There were 16 patients (11 male and 5 female) with a median age of 60 years (range 38–78). The stricture was related to the anastomosis after esophagectomy in 12 patients, caustic injury in 3 patients and cervical chemoradiotherapy in 1 patient. Prior to initiation of self‐dilatation patients had a median of four endoscopic dilatations. Self‐dilatation was done with a Maloney dilator ranging in size from 45 to 60 French. The median duration of self‐dilatation was 16 weeks. No patient had a perforation or complication related to self‐dilatation. No patient required stenting or repetitive endoscopic dilatations because of failure of self‐dilatation. Strictures recurred in two patients after cessation of self‐dilatation and both responded to endoscopic dilatation followed by additional self‐dilatation. Self‐dilatation effectively resolves refractory esophageal strictures. It was well tolerated, and there were no complications in this series. Home self‐dilatation should be considered the treatment of choice in appropriate patients with refractory esophageal strictures in the cervical esophagus.     

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.     

Unique usage of a partially covered metal stent for drainage of a pancreatic pseudocyst via endosonography-guided transcystgastrostomy

Pancreatic pseudocysts are frequent complications of pancreatitis episodes. The current therapeutic modalities for drainage of pancreatic pseudocysts include surgical, percutaneous, and endoscopic drainage modalities. Endosonography-assisted endoscopic drainage of these pseudocysts with the placement of multiple plastic or fully covered self-expanding biliary metal stents is becoming more commonly carried out. The present case report discusses the unique and successful drainage of a pancreatic pseudocyst with the placement of a partially covered self-expanding metal stent.     

Fully covered self-expanding metal stents for benign refractory pancreatic duct strictures in chronic pancreatitis

Background: Pancreatic duct (PD) stricture is a common adverse event in chronic pancreatitis (CP). Primary treatment for refractory PD strictures is endotherapy (ET), including the insertion of multiple plastic stents. In addition, fully covered self-expandable metal stents (FC-SEMSs) have also been successfully used. More long-term studies are necessary to clarify the complication rate and efficiency, however.

Methods: This retrospective study was comprised of 17 patients with symptomatic CP and refractory fibrotic main pancreatic duct (MPD) stricture treated with FC-SEMSs between 2010–2018 at the Helsinki University Hospital. Treated strictures were located in the pancreatic head. Technical success was defined as the accurate positioning of the stent and resolution of the MPD stricture. Clinical success was defined as pain relief at the end of the follow-up.

Results: In 12 patients (71%), stricture resolution was accomplished. Clinical success was achieved in 12 patients (71%). The median duration of stenting was 169 days (range 15–804). Ten patients (58.8%) underwent a follow-up of two years or more. Early complications (≤7 days) occurred in two patients (12%): one pancreatitis and one cholestasis. Late complications (≥7 days) included severe abdominal pain (n?=?2, 12%), pancreatitis (n?=?3, 18%), cholestasis (n?=?1, 6%) and stent migration (n?=?7, 35%). Significant differences in stricture resolution and pain improvement were evident in patients with stent migration compared to patients without stent migration [1(14.3%) vs. 11(84.6%), p?=?.004 and 2(28.6%) vs. 11(84.6%), p?=?.022].

Conclusion: FC-SEMS placement is a safe and potentially effective treatment for this challenging group of patients. However, stent migration appears to affect the clinical and technical outcome.