Radiological evaluation of covered self-expandable metallic stents used for palliation in patients with malignant esophageal strictures

Purpose: To study the role of self-expandable metallic stents in malignant esophageal strictures in terms of patency, improved dysphagia score, and possible associated complications.

Material and Methods: Twenty-two patients with inoperable carcinoma of the esophagus underwent stent placement. Four different varieties of covered stents were used. Stenting was performed under fluoroscopic guidance and local pharyngeal anesthesia. During follow-up, patients were examined clinically and radiologically to assess the effectiveness of stents in relieving dysphagia, to check the stent position, patency, and possible complications.

Results: Fluoroscopic placement of the stent was successful and well tolerated in all patients without any serious complications. Accurate stent placement was possible in 95% of cases. The mean dysphagia score prior to stenting was 3.5 and poststent 1.2, with an improvement of 2.3 degrees. In two patients with associated fistulas, complete closure was seen after stent insertion. There was poor stent expansion in three patients. Significant tumor overgrowth occurred in two patients, and a second overlapping stent was deployed in one case. Three patients developed food impaction, which needed endoscopic removal of impacted food in two cases.

Conclusion: Fluoroscopic placement of self-expandable metallic stents is a safe and effective method of palliating severe dysphagia and fistulas in patients with inoperable esophageal carcinoma. However, complications such as tumor overgrowth and food impaction may require reintervention after stent placement.     

Malignant esophagogastric junction obstruction: palliative treatment with an antireflux valve stent

The authors assessed the efficacy of an antireflux valve stent in the palliation of malignant esophagogastric junction (EGJ) obstruction after in vitro testing of the stent. Seventeen patients with inoperable malignant EGJ obstruction were treated. Antireflux valves, made of three polyurethane leaflets, were attached to the distal part of the stent to prevent reflux. When the flow rate of normal saline was 100 mL/sec in the forward direction, the valve fully opened at a pressure of 10 mm Hg. When the flow rate of normal saline was 0.35 mL/sec in the backward direction, the valve nearly completely closed at a pressure of 10 mm Hg. Stent placement was successful in all patients without complications. The median dysphagia score decreased significantly, from 3.0 (dysphagia to liquids) to 1.0 (dysphagia to normal solid food) (P < .0005). No patients experienced reflux symptoms. There was one case of stent migration. A valve stent that can prevent major reflux is an effective device for the palliation of malignant EGJ obstruction.     

Esophagogastric neoplasms: palliation with a modified gianturco stent.

Self-expanding metallic stents of a modified Gianturco design were used for palliative treatment of malignant esophagogastric strictures. Over a 10-month period, 10 stents were placed in nine patients. All patients with severe dysphagia due to malignant strictures in whom all other treatment options had failed were candidates for these stents. Neither extensive length of esophageal involvement nor complete esophageal obstruction was a contraindication. All stents were placed with fluoroscopic guidance without any technical failures or procedural morbidity or mortality. Mild reflux occurred in three patients in whom the stent tubes straddled the distal esophageal sphincter. Five patients were still alive after 1-8 months. The remaining four patients died 6-28 weeks after stent placement; all stents were patent at the time of death. These stents are easy to insert, safe, and reasonably effective for short-term palliative treatment of esophagogastric neoplasms.     

带膜支架在食管狭窄中的临床应用

目的：本文回顾性分析了金属带膜支架对恶性食管狭窄、吻合口狭窄及食管气管瘘和吻合口瘘的治疗功效,方法：36例吞咽困难患者放置了Gianturco-Z和自彭式金属带膜支架。其中包括恶性食管梗阻（32例）、吻合口狭窄（4例）,合并食管气管瘘（3例）和吻合口瘘（1例）。结果：37根支架被成功释放。吞咽困难在33例患者中获得明显缓解,平均吞咽困难积分从3．02减低到0．81。3例食管气管瘘和1例吻合口瘘完全堵住。并发症包括胸骨后疼痛（23例）、支架移位（21例）、上消化道出血（12例）、返流性食道炎（1例）和气管受压迫（1例）。结论：金属带膜支架是治疗食道梗阻、食管气管瘘及吻合口瘘安全、有效的方法。     

Palliation of malignant dysphagia with expanding metallic stents

PURPOSE: The authors describe their experience with expanding metallic stents for the palliation of malignant dysphagia. MATERIALS AND METHODS: During a 52-month period, 138 stents were inserted in 121 patients with malignant esophageal obstruction. The average age was 74 years; there were 78 men and 43 women. Data regarding the degree of initial dysphagia, presence of an esophago-respiratory fistula, effect of stent placement on swallowing ability, complications at the time of stent placement, and long-term survival were obtained. RESULTS: An improvement in dysphagia symptoms was recorded in more than 95% of patients. The average survival after stent placement was 24 weeks. Complications necessitating further intervention occurred in 26 patients. CONCLUSION: Insertion of self-expanding metallic endoprostheses for the palliation of malignant esophageal obstruction is an effective therapy that can be carried out with relative ease. Successful palliation of symptoms can be expected in more than 95% of cases.     

Palliative treatment of inoperable malignant esophageal strictures with conically shaped covered self-expanding stents

Purpose: To investigate the effectiveness of conically shaped covered self-expanding (Flamingo) stents in palliative treatment of malignant esophagogastric strictures in terms of patency, improved dysphagia score and survival.Material and Methods: Flamingo stents were placed under fluoroscopic guidance between August 1998 and December 1999 for palliation of malignant dysphagia in 33 cases. There were 21 males and 12 females aged 40-80 years (average 64.2 years).Results: Stent placement was successful in all patients, with good symptomatic control and no procedure-related complications. Spontaneous esophago-respiratory fistula and perforation accompanying malignant esophageal stricture in a total of 4 cases (12.2%) were successfully closed. In 1 case, tumor ingrowth was detected from the distal uncovered segment of the stent. In 2 cases with esophago-respiratory fistula, gastrointestinal bleeding occurred. The cause of hemorrhage could not be found by angiography. The mean survival time in 17 patients, later deceased, was 129 days (range 9-360), and the mean observation time in 16 patients still alive is 180 days (range 18-365).Conclusion: Flamingo stents provide an effective and safe choice of palliative therapy in inoperable malignant esophagogastric strictures.     

Delayed complications after esophageal stent placement for treatment of malignant esophageal obstructions and esophagorespiratory fistulas

PURPOSE: To evaluate delayed complications after esophageal expandable metallic stent placement. MATERIALS AND METHODS: From April 1993 to December 1997, 90 expandable metallic stents were placed in 82 consecutive patients with inoperable malignant esophageal obstruction (n = 49) or malignant esophagorespiratory fistula (n = 33). Stents used included covered Gianturco-Rosch Z stents (n = 20), Wallstents (covered, n = 31; uncovered, n = 13), and Ultraflex stents (covered, n = 8; uncovered, n = 10). Patients were followed prospectively and monitored for delayed complications, defined as major (hemorrhage, tracheal compression, stent migration, perforation or fistula formation, granulomatous obstruction, tumor ingrowth and overgrowth, funnel phenomenon, and stent covering disruption) or minor (reflux, chest pain, and food impaction). RESULTS: Mean survival was 4.5 months after stent placement (range, 3 weeks to 26 months). The overall incidence of delayed complications was 64.6%, with 17 patients (20.7%) experiencing more than one complication. The rates of delayed complications in patients with Z stents, Wallstents, and Ultraflex stents were 75.0%, 68.1%, and 44.4%, respectively (P <.05). Most complications were life-threatening and occurred more frequently when stents were placed in the proximal third of the esophagus, compared with more distally (P <.05). Thirteen patients (15.9%) died from complications directly related to stent placement. CONCLUSION: Esophageal stent placement for malignant obstruction or fistula is associated with a substantial incidence of delayed complications.     

Palliative treatment of inoperable malignant esophageal strictures with metal stents: one center's experience with four different stents

PURPOSE: Our center's experience with Ultraflex, Flamingo, SR stent and Flexstent for the palliation of malignant esophageal strictures is reported, and current pertinent literature is reviewed. MATERIAL AND METHODS: Stents have been placed under fluoroscopic guidance between August 1993 and February 2002 for the palliation of malignant dysphagia in 116 patients. 59 patients received Ultraflex, 33 patients received Flamingo Wallstent, 20 patients received the SR stent and four patients received Flexstent. RESULTS: Stent placement was successful in all the patients, with good symptomatic control in 123 out of 126 patients (98%) and no procedure-related complications. Four esophagorespiratory fistulas were successfully closed with covered Flamingo stents. Repeat intervention was necessary in 30 patients (51%) who received the Ultraflex stent, secondary to tumor ingrowth, overgrowth, ulceration, fistula and incomplete expansion. Two patients (6%) who received Flamingo Wallstent died due to gastrointestinal bleeding and one patient had proximal migration. Four patients (20%) who received the SR stent had complete migration of the stent. CONCLUSION: Covered stents were found to provide better long-term palliation compared to uncovered stents. The covered Flamingo Wallstent seems to be the best choice of stent for lesions where crossing the esophagogastric junction is not necessary. For lesions where it is mandatory to cross the junction it may be preferable to use a stent with an antireflux mechanism.     

Comparison of temporary and permanent stent placement with concurrent radiation therapy in patients with esophageal carcinoma

PURPOSE: To assess the clinical effectiveness of temporary metallic stent placement with concurrent radiation therapy in patients with esophageal carcinoma by comparing it with permanent stent placement with concurrent radiation therapy. MATERIALS AND METHODS: Covered retrievable expandable nitinol stents were placed in 47 patients with esophageal carcinoma 1 week before starting radiation therapy; the stents were electively removed 4 weeks after placement in 24 patients (group A), while not electively removed in the other 23 patients (group B). In cases of complications, the stents were also removed from patients in groups A and B. The dysphagia score, complications (severe pain, granulation tissue formation, stent migration, esophagorespiratory fistula, and hematemesis), tumor overgrowth/regrowth, reintervention rates, and dysphagia-progression-free and overall survival rates were compared in the two groups. RESULTS: Stent placement or removal was technically successful and well tolerated in all patients. The dysphagia score was significantly improved in both groups after stent placement (P < .01). Each of the stent-related complications was less in group A than in group B but there was no significant difference. However, the total number of patients with one or more than one complications and who needed related reinterventions was significantly less in group A than in group B (P = .042 and .030, respectively). Tumor overgrowth/regrowth and the total number of patients who required related reinterventions was not significantly different (P = 1.00 and .517, respectively). Dysphagia-progression-free and overall survival rates were significantly longer in group A than in group B (P = .005 and .001, respectively). CONCLUSION: Temporary placement of a covered retrievable expandable metallic stent with concurrent radiation therapy for patients with esophageal carcinoma is beneficial for reducing complications and related reinterventions and for increasing resultant survival rates compared with permanent esophageal stent placement.     

暂时性金属内支架治疗贲门失弛缓症对食管动力的影响

目的 探讨暂时性金属内支架治疗贲门失弛缓症对食管动力的影响。方法 29例贲门失弛缓症患者在X线透视下置入国产可扩张带膜金属内支架，术后3～7d由胃镜取出。治疗前后均测定下食管括约肌(lower esophageal sphincter LES)静息压、松弛率及食管内24h pH监测。12名健康人测定LES静息压、松弛率。结果 支架扩张前LES静息压显著高于扩张后；扩张前LES松弛率显著高于扩张后；扩张后LES静息压和松弛率与健康人相比差异无显著性。扩张后胃食管反流(GER)率显著高于扩张前。结论 暂时性金属内支架扩张术能显著降低贲门失弛缓症患者的LES压力，但GER也显著增加。     

Interventional radiology and the use of metal stents in nonvascular clinical practice: a systematic overview.

PURPOSE: The intent of this systematic overview was to describe the clinical role of metal stents in nonvascular health care interventions and the level of evidence supporting their use. MATERIALS AND METHODS: Structured searches of Medline were conducted and limited to original peer-reviewed articles published in English. RESULTS: Clinical practice involving metal stents was reported in more than 109 clinical series involving 4,753 patients. Stents were placed mainly for palliation of malignant biliary, esophageal, and airway obstruction in patients who were untreatable or had surgically unresectable lesions. Assessment of these interventions has so far centered on safety and technical success. Efficacy, quality of life, and costing factors were not routinely reported. Randomized trial evidence was available but limited; six randomized trials involving metal stents have been reported. Three trials involved biliary malignant obstruction, and all three reported metal stent (132 patients) palliation to be superior to plastic stent palliation (136 patients) based on longer patency and lower reintervention costs. Safety and complication differences between stents, however, were inconsistent across trials. In three trials involving esophageal malignant obstruction, metal stent (82 patients) palliation was reported to be superior to plastic stent (41 patients), based on lower complication and reintervention rates, and superior to laser therapy (18 patients), based on better dysphagia relief. CONCLUSION: Use of metal stents has been reported for obstructed ducts and passageways of most body systems. There is, however, limited controlled trial evidence confirming the advantages of their use over plastic stents or other forms of treatment.     

Palliative treatment of neoplastic strictures by self-expanding nitinol Strecker stent

The purpose of this study was to evaluate technical and clinical results of self-expanding esophageal stent implanted in patients with malignant esophageal strictures and clinically significant dysphagia. From June 1992 to September 1994, 27 patients with inoperable tumors of the esophagus or gastric cardiac were treated by placement of 37 self-expanding nitinol stents. Water-soluble contrast and endoscopy studies were performed after the procedure and during the follow-up period. Successful stenting of the stricture was achieved in 27 patients. The mean dysphagia grade dropped from 2.3 to 1 (SD ± 0.54) immediately after the procedure. After the insertion of the stent, 16 patients died in a period of time ranging from 0 to 13 months (mean 5.6 months), whereas at the end of the study 11 patients were alive 4–15 months after the procedure (mean 8.3 months). No major complications were observed. The results of this study are encouraging because esophageal stent placement was technically easy and clinically effective. Correspondence to: F. Maspes     

Covered retrievable expandable nitinol stents in patients with benign esophageal strictures: initial experience

PURPOSE: To investigate the safety and clinical effectiveness of covered retrievable expandable nitinol stents in 25 patients with a benign esophageal stricture. MATERIALS AND METHODS: Under fluoroscopic guidance, covered retrievable expandable nitinol stents were placed in 25 patients with a benign esophageal stricture and were removed with a retrieval hook 1-8 weeks later. RESULTS: Stent placement was successful in all patients, with no procedural complications. After stent placement, all patients could ingest solid food. The stents were successfully removed from all but two patients. One patient passed the stent via the rectum, and the other regurgitated a high cervical stent. After stent removal, one patient developed a small esophagobronchial fistula, which spontaneously sealed within 1 week of stent removal. After stent removal or migration, all patients could ingest solid food. During follow-up (mean, 13 months; range, 2-25 months) after stent removal or migration, 12 patients maintained their improvement in dysphagia and needed no further treatment. Thirteen patients with recurrence were treated by means of repeat balloon dilation. CONCLUSION: Use of retrievable expandable nitinol stents seems to be a safe and effective method of treatment in selected patients with benign esophageal strictures.     

Palliation of malignant esophageal strictures: initial results with self-expanding uncovered nitinol coil stents

The purpose of this study was to determine the efficacy of the uncovered coil stents in patients with malignant dysphagia. Coiled spring-shaped uncovered self-expanding metallic Esophacoil stents (Instent, Eden Prairie, Minnesota) were placed in 11 patients (9 men and 2 women; age range 38–77 years, mean age 60.5 years) with malignant esophageal strictures and dysphagia, under fluoroscopic guidance. Dysphagia was graded on a scale of 0 to 4 (0 = no dysphagia; 1 = dysphagia to normal solids; 2 = dysphagia to soft solids; 3 = dysphagia to solids and liquids; 4 = complete dysphagia, inability to swallow saliva). Two patients had received radiation therapy, 4 had had chemotherapy, and 5 had had a combination of both radiation and chemotherapy before stent palliation. Control clinical examinations and endoscopic or barium swallow studies were performed every 4 weeks until the patient died. The stents were well tolerated by all patients and were effective in 9 of 11 patients with malignant dysphagia. Complications of the procedure included incomplete opening of the stent in 1 case, migration in 1 case, transient pain in 8 cases, reflux in 3 cases and minor gastrointestinal bleeding in 2 cases. Stent migration in 1 case resulted in surgical intervention and incomplete opening of the stent allowed only partial improvement of dysphagia in 1 case. The quality of life significantly improved in all other patients. Mean survival time of the patients was 73 days (range 34–125 days) and no significant tumor ingrowth was detected during the follow-up period. Insertion of an Esophacoil has a good palliative effect on dysphagia in patients with malignant esophageal strictures with few complications. Although the stent is uncovered, tumor ingrowth and overgrowth were not observed in our study, possibly because of previous treatments. Received: 22 July 1998; Revision received: 30 November 1998; Accepted: 21 December 1998     

国产金属内支架置入治疗良恶性食管狭窄(附25例分析)

目的 :采用国产金属内支架置入治疗良恶性食管狭窄。方法 :2 5例良恶性食管狭窄患者 ,均在 X线监视下 ,经口将导丝安全通过狭窄段 ,行球囊扩张后置入金属支架。结果 :全部病例均顺利置入支架 ,不仅有效地缓解了进食困难 ,改善了营养状况 ,同时还使食管气管瘘及食管纵隔瘘患者瘘口封闭 ,为其减轻感染及进一步治疗造成狭窄的原发病提供了时机。结论 :食管内支架置入术是治疗良恶性食管狭窄的一种安全有效地方法、应用国产金属内支架 ,既可减轻患者经济负担 ,又可达到进口支架同样的效果而成首选。     

防反流覆膜支架在晚期食管下段癌及贲门-胃底癌治疗中的临床应用

目的：评价防反流覆膜支架在晚期食管下段癌及贲门-胃底癌治疗中的临床疗效。方法：选择晚期食管下段癌和贲门-胃底癌38例为治疗组,35例为对照组,在胃镜介导下对治疗组放置防反流覆膜支架,对照组放置普通覆膜支架,术后观察支架植入成功率、梗阻改善状况及反流状况。结果：治疗组和对照组支架成功率均为100％,梗阻均有明显改善,但两组支架植入后食管反流状况有一定的差异。结论：胃镜下放置防反流覆膜支架是治疗晚期食管癌和贲门-胃底癌理想的方法之一,不但能解决癌性梗阻,提高患者的生存质量,还能防止支架植入后胃液反流并发症的出现。     

加膜支架对食管气管瘘的临床应用

目的：探讨加膜食管支架对食管并发食管－气管瘘的实用价值。方法：X线引导下为18例患者置入18个另膜支架，并在其中6个支架加膜部分的外周包裹了一薄层明胶海绵，以防支架与食管壁间形成不规则腔隙。同时对装置进行了改良。结果：支架置入顺利，中中无严重并发症发生。术后呛咳即刻消失，吞咽困难明显缓解，由要前平均3．4级降至0．9级。结论：加膜支架治疗食管癌并发食管－气管瘘安全有效，改良加膜支架有效地防止了支架与食管壁之间不规则腔隙的形成。     

99mTc-sulfur colloid gastroesophageal scintigraphy with late lung imaging to evaluate patients with posterior laryngitis.

The aim of this study was to use gastroesophageal and pulmonary scintigraphy to evaluate the prevalence of gastroesophageal reflux and airway involvement among patients with posterior laryngitis. METHODS: The study included a total of 201 patients (131 females, 70 males; age range, 15-77 y; mean age +/- SD, 49 +/- 16 y). All patients had posterior laryngitis documented by laryngoscopy and symptoms such as a dry cough, painful swallowing, and hoarseness. A control population of 20 healthy volunteers (13 females, 7 males; age range, 19-74 y; mean age, 53 +/- 13 y) was also evaluated. After a 12-h fast, all subjects underwent gastroesophageal scintigraphy through administration of 300 mL orange juice labeled with 185 MBq 99mTc-sulfur colloid. After 18 h, planar anteroposterior thoracic images were acquired with the subjects supine. RESULTS: Sixty-seven percent of patients (134/201) had scans positive for gastroesophageal reflux; of these, 30 (22%) had distal reflux and 104 (78%) had proximal reflux. In addition, the scans of 31 patients were positive for proximal reflux-associated pulmonary uptake. The frequency, duration, and degree of reflux episodes were significantly greater in patients with proximal reflux than in patients with distal reflux (P < 0.001). The 67 patients in whom reflux was not detected had diseases or reflux-associated cofactors that could account for laryngeal symptoms. No statistically significant difference in symptoms or esophageal motility parameters could be identified among the patient groups, but patients with proximal reflux had significantly prolonged gastric emptying times compared with healthy volunteers. CONCLUSION: Most patients with posterior laryngitis had detectable proximal gastroesophageal reflux. Exposure of the proximal part of the esophagus to acid, by setting the stage for microaspiration of gastric material into the larynx, remains a major cause of damage to the laryngeal mucosa. Slowed gastric emptying may be a predisposing factor. Moreover, symptoms such as a dry cough, painful swallowing, or hoarseness may not be reliable predictors of the presence of gastroesophageal reflux or of associated airway involvement.     

Nitinol Esophageal Stents: New Designs and Clinical Indications

Purpose To evaluate the clinical use of covered and noncovered, knitted nitinol stents in patients presenting new stent indications. Methods Self-expandable, knitted nitinol stents were implanted in four patients for treatment of dysphagia. In two patients who had malignant strictures and had esophago-respiratory fistulae and in one patient with an esophagocutaneous fistula, polytetrafluoroethylene (PTFE)-covered stents were implanted. One patient received a noncovered stent, but a retrograde approach through a percutaneous endoscopic gastrostomy (PEG) fistula had to be chosen for recanalization of an esophageal occulusion. Two patients received stents for treatment of benign strictures. Results Recanalization of the stricture and stent implantation were performed under fluoroscopic control without any procedure-related morbidity or mortality. Dysphagia improved in all patients and the esophageal fistulae could be sealed off by covered stents. During a maximum follow-up of 18 months, there was no stent migration or esophageal perforation. Complications observed were stent stenosis due to food impaction (1/4) and benign stent stenosis (2/2). Most complications could be treated by the interventional radiologist. Conclusion Self-expandable, covered Nitinol stents provide an option for the treatment of dysphagia combined with esophageal fistulae. In combination with interventional radiology techniques, even complex strictures are accessible. For benign strictures, the value of stent treatment has not yet been proven.     

胃肠道狭窄或梗阻内支架置入术后常见并发症及其处理

目的：探讨肝肠道或梗阻内支架置入术后常见并发症及处理办法。对象与方法：６０例胃肠道狭窄或阻病人，其中食管狭窄或梗阻３９例，胃十二指肠梗阻或狭窄２１例。在Ｘ光线监视下共放置支架６６只，其中带模２７只，不带３９只。结果：６０例病人中，所有支架安放１－３次成功。疼痛１２例，轻微胀痛１０例，中度胀痛１例，重度疼痛，地轻中度胀痛给予止痛片等对症处理：重度疼产能，药物控制无效者，给予硬膜外麻醉止痛。胃财狭窄９