Polyflex self-expanding,removable plastic stents: assessment of treatment efficacy and safety in a variety of benign and malignant conditions of the esophagus

Background Historically, esophageal fistulas, perforations, and benign and malignant strictures have been managed surgically or with the placement of permanent endoprostheses or metallic stents. Recently, a removable, self-expanding, plastic stent has become available. The authors investigated the use of this new stent at their institution. Methods The study reviewed all the patients who received a Polyflex stent for an esophageal indication at the authors’ institution between January 2004 and October 2006. Duration of placement, complications, and treatment efficacy were recorded. Results A total of 37 stents were placed in 30 patients (14 women and 16 men) with a mean age of 68 years (range, 28–92 years). Stent placement included 7 for fistulas, 3 for perforations, 1 for an anastomotic leak, 7 for malignant strictures, and 19 for benign strictures (8 anastomotic, 1 caustic, 5 reflux, 2 radiation, and 2 autoimmune esophagitis strictures, and 1 post-Nissen gas bloat stricture). The mean follow-up period was 6 months. Stent deployment was successful for all the patients, and no complications resulted from stent placement or removal. Nine stents migrated spontaneously. Three of three perforations and three of five fistulas sealed. Only one stent was removed because of patient discomfort. One patient with a radiation stricture experienced tracheoesophageal fistulas secondary to pressure necrosis. Of 20 patients with stricture, 18 experienced improvement in their dysphagia. Conclusion Self-expanding, removable plastic stents are easily and safely placed and removed from the esophagus. This has facilitated their use in the authors’ institution for an increasing number of esophageal conditions. Further studies to help define their ultimate role in benign and malignant esophageal pathology are warranted.     

Use of the Polyflex stent in the palliative therapy ofesophageal carcinoma

BACKGROUND: Several prospective randomized trials have shown that self-expanding stents have advantages over conventional plastic tubes. Nevertheless, the optimal stent has not yet been developed. The Polyflex stent is a completely new model that represents an improvement over the old metal stents. We have used this stent in a prospective study and herein our present preliminary results. METHODS: In 14 patients with nonresectable esophageal carcinoma, the Polyflex stent was implanted to reduce dysphagia. The grade of dysphagia, the complications following intervention, and the patients' total survival time were documented prospectively every 4 weeks. RESULTS: The implantation of the stent was successful in all cases. The grade of the dysphagia was reduced from 3.0 to 0.5 after stent implantation. One patient died during the hospital stay from a non-stent-induced complication. Stent dislocation occurred once, and tumor overgrowth at the stent margins was observed twice. The mean survival time was 6.2 months, and the reintervention rate was 21.3%. CONCLUSION: The new Polyflex stent, which is based on a completely new design, can be implanted without any difficulty and has had very good short- and long-term results. Therefore, it is a worthy alternative to the metal stents in current use.     

Self-expanding Polyflex plastic stents in esophageal disease: various indications,complications, and outcomes

Background Esophageal stenting has become an important technique in the treatment of different clincal problems such as malignant or benign stenosis, anastomotic leaks after surgery, or fistulas. In this study we present our experience with the self-expanding Polyflex plastic stent in various indications, arising complications, and patient’s outcomes. Methods Over a three-year period, 35 patients underwent self-expanding Polyflex plastic stent placement for esophageal stenosis (n = 23) with 22 malignant, and for perforations, fistulas, or anastomotic leaks after surgery (n = 12). The short-term efficacy and long-term outcomes were analyzed. Results In patients with stenosis, implantation was performed without any complications in 91% (21/23). In one patient perforation occurred while passing the stenosis; in another patient the stent dislocated during the insertion procedure. Dysphagia score improved from 3.0 to 1.0 after stenting. In all patients with perforations, fistulas, or anastomotic leaks (n = 12), stents were placed successfully without any complication. Complete sealing of the mucosal defect was proven by radiography in 92% (n = 11) and healing was seen in 42% (n = 5). If indicated, stent removal was performed without any complications. Stent migration (n = 13; 37%) was the most common long-term complication. Conclusions The placement of self-expanding Polyflex plastic stents is a highly sufficient and cost-effective treatment for malignant and benign esophageal disorders. Because the long-term results were highly favorable, self-expanding plastic stent placement could be used as the initial treatment for various conditions.     

The palliation of dysphagia secondary to esophageal-cardial carcinoma with self-expandable metal prostheses. The authors' personal experience with 92 patients]

BACKGROUND: Endoscopic insertion of a stent is an important option in the palliative management of esophageal obstruction and esophagorespiratory fistula. Plastic stents have been available for over 20 years. A new class of self-expanding metal stents for palliation of esophageal and cardial cancer is now available. METHODS: Between September 1992 and October 1997, 92 patients underwent implantation of self-expanding metal stents for palliation of dysphagia due to inoperable esophageal or cardial cancer (65 patients) or for locally recurrent carcinoma after surgery (12 patients), laser-therapy (11 patients) or radiotherapy (4 patients). RESULTS: Successful stent implantation was achieved in 89/92 patients (96.7%). After stent implantation the dysphagia score improved from 3.0, on average, to 0.5, on average. Early complications were observed in 4.5% and peroperative mortality was 2.1%. Late complications were observed in 25.6%, with a mortality rate of 1.1%. The mean survival time was 6.9 months. CONCLUSIONS: Self-expanding metal stents are a new effective alternative for palliation of dysphagia due to esophageal and cardial cancers.     

The use of self-expanding silicone stents in esophageal cancer care: optimal pre-, peri-, and postoperative care

Background  Preoperative nutritional supplementation, management of esophageal leaks, and postoperative anastomotic strictures still remain common problems in the management of esophageal cancer. Jejunal feeding tubes, total parenteral nutrition (TPN) with nasogastric suction, and repeated esophageal dilations remain the most common treatments, respectively. The aim of this study was to evaluate the use of removable silicone stents in (1) the preoperative nutritional optimization during neoadjuvant therapy, (2) the management of perioperative anastomotic leak, and (3) the management of postoperative anastomotic strictures. Methods  Review of our prospectively maintained esophageal database identified 15 patients who had removable self-expanding silicone stents placed in the management of one of these three management problems from July 2004 to August 2006. Results  Preoperative therapy: Five patients underwent initial stent placement in preparation for neoadjuvant therapy. Dysphagia relief was seen in 100% of patients, with optimal caloric needs taken within 24 h of placement. All patients tolerated neoadjuvant therapy without delay from dehydration or malnutrition. One stent migration was found at the time of operation, which was removed without sequelae. Perioperative therapy: Five patients developed delayed (>10 days) esophageal leaks that were managed with removable esophageal stent and percutaneous drainage (in three patients). All patients had successful exclusion of the leak on the day of the procedure with resumption of oral intake on the evening of procedure. All five healed leaks without sequelae. Postoperative therapy: Five patients developed postoperative anastomotic strictures that required dilation and placement of removable esophageal stent. The median number of dilations was 1 (range 1–2), with all stents placed for approximate 3 months duration. All patients had immediate dysphagia relief after stent placement. Conclusion  Removable esophageal stents are novel treatment option to optimize relief of symptoms and return the patients back to a more normal oral intake. Continued evaluation is needed to consider stent use as first-line therapy.     

The efficacy of self-expanding metal stents for palliation of malignant esophageal strictures and fistulas.

OBJECTIVES: Esophageal strictures and esophagorespiratory fistulas are complications of malignant esophageal tumors, which are difficult to manage. The efficacy of self-expanding metal stents (SEMS) for palliation of malignant esophageal strictures and fistulas was investigated prospectively. METHODS: Forty-three SEMS were inserted in 41 patients with malignant esophageal stricture or fistula. Our series included 32 men and nine women, of whom median age was 61.4 years. Twenty nine stents were inserted for stricture, ten for esophago-tracheal fistula, and four esophago-pleural fistula. Stents were inserted endoscopically under fluoroscopic control. RESULTS: SEMS implantation was technically successful in 40 of 41 patients. A second stenting was needed in two patients. Median dysphagia score improved from 3.4 to 1.3. The covered SEMS was succesful in completely sealing 85.7% of the fistulas. Complication occurred in 11 (26.8%) patients. Especially in the case of tumor stenoses in the distal esophagus, complication rate was higher (44%). In total six patients (14.6%) died after stent placement during early postoperative period. Procedure-related mortality was 4.8% (2/41). CONCLUSIONS: We conclude that treatment of malignant esophageal obstructions, including esophagorespiratory fistulas, with SEMS is an alternative palliative procedure. Furthermore SEMS implantation seems more safe in the case of tumor stenoses locating in the middle esophagus.     

A retrospective analysis of early and late outcome of biodegradable stent placement in the management of refractory anastomotic colorectal strictures

Background

Benign colorectal strictures are treated conventionally by endoscopic dilation. Experience using SEMS for benign colonic strictures is limited, and outcomes to date have been disappointing. Refractory colorectal strictures remain challenging to be treated with surgery. Polydioxanone-based stent are biodegradable (BD) stent CE approved for esophageal strictures. This study was designed to investigate retrospectively the safety and the efficacy of these stents for the management of strictures refractory to multiple sessions of dilation.

Methods

Patients with postsurgical benign strictures located within 20 cm from anal verge, refractory to mechanical or pneumatic dilation (at least 3 sessions) were included in this analysis. Clinical success was defined as the absence of occlusive symptoms and the ability to pass through the stricture with a regular size colonoscope. All patients were predilated before stent placement. Stents were released under fluoroscopic control. All patients were under stool softeners for 3 months. Follow-up was scheduled with endoscopic and fluoroscopic controls within 90 days from stent deployment and afterwards by telephone interview and/or ambulatory consultation.

Results

Eleven patients (7 males, mean age 62.3 ± 8.5 years) were included. Technical success was achieved in all the patients. Stent migration was observed in four patients within the first 2 weeks after stent placement. Stent migration was followed by recurrence of stricture and obstructive symptoms in all the cases. Among the seven patients who completed the process of stent biodegradation, five of them had complete resolution of the stricture and relief of symptoms. Two of 11 patients required surgical treatment during the follow-up period (mean 19.8 (range 42–15) months). The overall success rate of the BD stent was 45 %.

Conclusions

This retrospective analysis of a limited number of patients demonstrated that nondedicated esophageal BD stents are associated with high risk of migration and clinical success in less than 50 % of patients. Dedicated stents with large diameter and antimigration findings could potentially improve the outcome of patients with refractory benign colorectal strictures.     

Self-expanding metallic stents in the treatment of benign colorectal disease: indications and outcomes

OBJECTIVE: The use of stents for benign colorectal obstruction is considered controversial because of a lack of data and perceived high failure and complication rates. The aim of this study was to evaluate the indications and outcomes following stent placement for benign colorectal disease in a UK district general hospital and to review the published literature. PATIENTS AND METHODS: Between 1997 and 2004, 11 of 90 attempted stent insertions were performed for benign colorectal disease (diverticular disease, 4; anastomotic strictures, 4; idiopathic rectal stricture, 1; rectal endometriosis, 1; caecal volvulus, 1). Complications and outcomes were analysed from a prospective database. RESULTS: Stent insertion was successful in nine patients. Early complications occurred in two patients (both with diverticular disease): one patient failed to decompress and needed a colostomy and laparotomy was performed in a second patient who developed peritonitis after five days although no stent perforation of the bowel was identified. Two patients were successfully decompressed and underwent subsequent elective surgery with full bowel preparation. Stent placement resulted in symptomatic improvement in three out of four patients with anastomotic strictures (allowing closure of defunctioning stomas) and in the one patient with an idiopathic rectal stricture. Stent migration occurred in two of these patients without recurrence of symptoms. Stent fracture occurred in one patient, who remained symptomatic. CONCLUSIONS: Self-expanding metallic stents are an effective treatment for benign colorectal obstructions, especially anastomotic strictures with long-term patency. Stents should be avoided in acute diverticular disease because of a higher incidence of complications.     

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。     

Esophageal Stenting and Radiotherapy: A Multimodal Approach for the Palliation of Symptomatic Malignant Dysphagia

Background

Esophageal stents provide immediate palliation of malignant dysphagia; however, radiotherapy (RT) is a superior long-term option. We review the outcomes of combined esophageal stenting and RT for patients with malignant dysphagia.

Methods

We retrospectively reviewed patients with esophageal stents placed for palliation of malignant dysphagia from esophageal stricture, esophageal extrinsic compression, or malignant tracheoesophageal fistula (TEF). We excluded patients with radiation-induced TEF in the absence of tumor. We analyzed and compared outcomes between patients with no RT, RT before stent placement, and RT after stent placement.

Results

We placed stents in 45 patients for esophageal stricture from esophageal cancer (n?=?30; 66.7?%), malignant TEF (n?=?8; 17.7?%), and esophageal compression from airway, mediastinal, or metastatic malignancies (n?=?7; 15.6?%). Twenty patients (44.4?%) had no RT; 25 patients had RT before stent placement (n?=?16; 35.6?%), RT after stent placement (n?=?8; 17.8?%), or both (n?=?1; 2.2?%). Median follow-up was 30?days. Complications requiring stent revision were similar with or without RT. Subjective symptom relief was achieved in 68.9?% of all patients, with no differences noted between groups (p?=?0.99). The 30-day mortality was 15.6?%. Patients with RT after stent placement had a longer median survival compared to those without RT (98 vs. 38?days).

Conclusions

Esophageal stent placement with RT is a safe approach for malignant dysphagia.     

Treatment of benign ureterointestinal anastomotic strictures with permanent ureteral Wallstent after Camey and Wallace urinary diversion: long-term follow-up

BACKGROUND AND PURPOSE: Ureterointestinal anastomotic stricture follows urinary diversion in 4% to 8% of patients and may lead to a progressive deterioration of renal function. There are problems with all current management techniques: surgical revision, endourologic incision, nephrostomy drainage, external ureteral stents, and dilation with a high-pressure angioplasty balloon. The authors present their long-term results with permanent ureteral Wallstents for the treatment of benign ureterointestinal stricture. PATIENTS AND METHODS: Eight patients with 10 strictures were treated by placement of self-expanding permanent indwelling stents via percutaneous nephrostomy between September 1993 and January 1998. The mean age of the group was 59.2 years. Development of strictures occurred a mean of 20.9 months after urinary diversion. There were seven complete and three partial strictures. Of 49 patients treated by the Camey procedure, 7 patients (14%) developed 9 (18%) strictures. Of 28 patients having the Wallace procedure, 1 patient (3.5%) developed one stricture. After recanalization of the distal ureter by a Terumo guidewire and dilation with a high-pressure angioplasty balloon, a Wallstent was placed across the stricture via a percutaneous approach. RESULTS: The endourologic placement of the Wallstent was well tolerated by all patients. The hospital stay averaged 2 days. Seven patients with nine strictures after the Camey procedure are doing well with a follow-up of 7 to 68 months (mean 22.4 months). One major complication was observed in one patient necessitating an additional procedure (lithotripsy) because of stone formation at the lower part of the stent extending into the neobladder in order to maintain patency after 68 months. The other patient, who had a Wallace procedure, is doing well 1 year 8 months afterward. CONCLUSION: An endourologic ureteral Wallstent approach to ureterointestinal stricture is a successful alternative, providing satisfactory management of the problem in most patients. No complication such as stent migration, hematuria, pain, or recurrent stricture was observed.     

Palliation of dysphagia from inoperable oesophageal carcinoma using Atkinson tubes or self-expanding metal stents

Until recently, intubation for the palliation of malignant dysphagia has relied upon the insertion of a variety of plastic tubes. Self-expanding metal stents are reported to have a lower complication rate. We have compared the results of Atkinson tube insertion with self-expanding metal stents in patients with inoperable oesophageal carcinoma. From 1990 to 1994 Atkinson tubes were inserted for the palliation of dysphagia from oesophageal cancer, from 1994 onwards self-expanding metal stents were used. Complications, mortality and hospital stay were compared in both groups of patients. In all, 87 patients with inoperable oesophageal carcinoma were treated, 46 with an Atkinson tube and 41 with metal stents. Complications occurred at similar rates in both groups (56% Atkinson tubes, 44% metal stents). There was a significantly higher perforation rate associated with Atkinson tube insertion (8 patients, 17%) compared with metal stents (1 patient, 2.4%, P = 0.02, chi 2). The length of stay was also significantly higher in the Atkinson tube group (median 10 days) compared with the metal stent group (3 days, P < 0.01, Mann-Whitney U test). Mortality rates were similar in both groups. The use of metal stents for the palliation of dysphagia in inoperable oesophageal carcinoma results in a lower perforation rate and a reduced length of stay and they represent a significant advantage over Atkinson tubes.     

Fully covered removable nitinol self-expandable metal stents (SEMS) in malignant strictures of the esophagus: a multicenter analysis

Background

Fully covered esophageal self-expandable metallic stents (SEMS) often are used for palliation of malignant dysphagia. However, experience and data on these stents are still limited. The purpose of this multicenter study was to evaluate the efficacy and safety of fully covered nitinol SEMS in patients with malignant dysphagia.

Methods

37 patients underwent placement of a SEMS during a 3?year period. Five patients underwent SEMS placement as a bridge to surgery: one for tracheoesophageal fistula in the setting of squamous cell carcinoma of the esophagus, one for perforation in setting of esophageal adenocarcinoma, 27 for unresectable esophageal cancer (16 adenocarcinoma, 11 squamous cell carcinoma), two for lung cancer, and one for breast-cancer-related esophageal strictures.

Results

SEMS placement was successful in all 37 patients. Immediate complications after stent deployment included chest pain (n?=?6), severe heartburn (n?=?1), and upper gastrointestinal bleeding requiring SEMS revision (n?=?1). Dysphagia scores improved significantly from 3.2?±?0.4 before stent placement to 1.4?±?1.0 at 1?month (P?P?P?=?0.0018) at 6?months. The stent was removed in 11 patients (30%) for the following indications: resolution of stricture (n?=?3), stent malfunction (n?=?5), and stent migration (n?=?3). After stent removal, three patients were restented, three underwent dilation, and two underwent PEG placement. Mean survival for the 37 patients after stent placement was 146.3?±?143.6 (range, 13–680) days.

Conclusions

Our study suggests that fully covered SEMS placement improve dysphagia scores in patients with malignant strictures, particularly in the unresectable population. Further technical improvements in design to minimize long-term malfunction and migration are required.     

Tannenbaum and metal stents in the palliative treatment of malignant distal bile duct obstruction: a comparative study of patency and cost effectiveness

Background Stent clogging is the major limitation of palliative treatment for malignant biliary obstruction. Metal stents have much better patency than plastic stents, but are more expensive. Preliminary data suggest that the recently designed plastic (Tannenbaum) stent has better duration of patency than the polyethylene stent. This study aimed to compare the efficacy and cost effectiveness between the Tannenbaum stent without side holes and the uncovered metal stent for patients with malignant distal common bile duct obstruction. Methods In this study, 47 patients (median age, 73 years, range, 56–86 years) with inoperable malignant distal common bile duct strictures were prospectively randomized to receive either a Tannenbaum stent (n = 24) or an uncovered self-expandable metal stent (n = 23). The patients were clinically evaluated, and biochemical tests were analyzed if necessary until their death or surgery for gastric outlet obstruction. Cumulative first stent patency and patient survival were compared between the two groups. Cost-effectiveness analysis also was performed for the two study groups. Results The two groups were comparable in terms of age, gender, and diagnosis. The median first stent patency was longer in the metal group than in the Tannenbaum stent group (255 vs 123.5 days; p = 0.002). There was no significant difference in survival between the two groups. The total cost associated with the Tannenbaum stents was lower than for the metal stents (17,700 vs 30,100 euros; p = 0.001), especially for patients with liver metastases (3,000 vs 6,900 euros; p < 0.001). Conclusions Metal stent placement is an effective treatment for inoperable malignant distal common bile duct obstruction, but Tannenbaum stent placement is a cost-saving strategy, as compared with metal stent placement, especially for patients with liver metastases and expected short survival time.     

Self-expanding esophageal stents for the management of benign refractory esophageal strictures in children: A systematic review and review of outcomes at a single center

BackgroundThis study aimed to evaluate our outcomes and complication rate following placement of self-expanding esophageal stents in children for the management of refractory esophageal strictures and comparing these to the existing literature.MethodsOutcomes following placement of stents in consecutive patients under 18 years at a single center from 2003 to 2018 were reviewed. A PRISMA-guided systematic review was conducted identifying studies with 5 or more children evaluating self-expanding stents published from 1975 to 2018. Endpoints for both the retrospective and systematic reviews were the requirement for further intervention and stent-associated complications.Results25 patients received 65 stents. There were 12 caustic injury-related strictures (48%), 9 anastomotic strictures (36%), and 4 esophagitis-related strictures (16%). Four patients were lost to follow-up. 19/21 patients (90%) required further intervention, and 8/21 (38%) had esophageal replacement. Nine studies, all case series, were included in the systematic review. 97 patients received 160 stents for esophageal strictures and/or perforation. 36 out of 69 patients (52%) with strictures required no further treatment post-stenting, and 22/29 (76%) of esophageal perforations closed with stenting.ConclusionsEsophageal stents may have a role as a bridge to definitive surgery and for the management of esophageal leaks, but complete stricture resolution post-stenting is unlikely.Type of StudyTreatment Study (Case Series with no Comparison Group)Level of EvidenceLevel IV     

Our experience with the use of a plastic prosthesis and self-expanding stents in the palliative treatment of malignant neoplastic stenoses of the esophagus and cardia. Comparative analysis of results

Rapid palliation of malignant dysphagia is usually possible by means of the endoscopic implantation of a plastic prosthesis, but this device has a high morbidity rate. Recently, expandable metal stents have become available and may reduce the morbidity and mortality rates. The aim of this retrospective study was to evaluate self-expanding metal stents compared with conventional plastic prosthesis in malignant strictures of the oesophagus and cardia. One hundred and thirteen endoscopic tube implantations were carried out in 120 patients with malignant stenosis of the oesophagus and cardia using a plastic prosthesis over the period 1980-1993 (72 cases) and self-expanding metal stents over the period 1993-2001 (48 cases). The underlying causes of strictures were oesophageal or cardial cancer in 108 cases and oesophageal invasion by lung cancer in 12. The indications for endoscopic intubation were advanced tumour stage and/or risk factors which made resection inadvisable. The stents used in the conventional group were the Celestin pulsion tube in 18, the Atkinson prosthesis in 23 and the Wilson-Cook tube in 27, while the Ultraflex stent was always employed in the other group. Dysphagia was scored according to the Atkinson and Ferguson classification and the preoperative median score (3.6) was comparable in the two groups. The technical success rate was 94.4% with the plastic prosthesis (68/72) and 93.7% with the self-expanding metal stents (45/48) because in 4 and 3 patients, respectively, it proved impossible to implant the stent. After intubation the dysphagia score was improved in both groups (median score = 0.9) and the functional success rates were 85.2% (58/68) and 88.8% (40/45), respectively, while 10 and 5 patients showed no improvement of symptoms. The early complication rate was 5.9% (4/68) in the conventional stent group (1 perforation, 2 severe bleedings and 1 stent proximal migration) and nil in the other group. Late complications occurred in 14 (20.6%) (7 food obstruction, 4 neoplastic obstructions and 3 dislodgements) and 9 patients (20%) (3 neoplastic obstructions, 1 food obstruction, 3 distal migrations and 2 bleedings), respectively, but all the complications were easily corrected. Three deaths occurred with the plastic prosthesis (4.4%), while the mortality was nil with the metal stents. The median survival times were 183 (range: 58-486) and 151 days (range; 25-545), respectively. Our experience suggests that endoscopic placement of self-expanding metal stents is effective and safe for the management of dysphagia in malignant strictures of the oesophagus and cardia and has to be preferred to conventional plastic prostheses for easier implantation. The technical and functional success rates are similar in both groups, but the acute complication and mortality rates of the Ultraflex prosthesis are lower as compared to the traditional prosthesis.     

The use of a retrievable self-expanding stent in treating childhood benign esophageal strictures

Background/Purpose

Esophageal stenting is a popular form of treatment of esophageal strictures in adults but is not widely used in children. The aim of the current study was to investigate whether esophageal stents could be used safely and effectively in the treatment of esophageal stenosis in children.

Methods

Covered retrievable expandable nitinol stents were placed in 8 children with corrosive esophageal stenosis. The stents were removed 1 to 4 weeks after insertion.

Results

The stents were placed in all patients without complications and were later removed successfully. After stent placement, all patients could take solid food without dysphagia. Stent migration occurred in one patient and so the insertion procedure was repeated to reposition the stent. During the 3-month follow-up period after stent removal, all children could eat satisfactorily. After 6 months, 2 children required balloon dilation (3 times in one and 5 times in the other). The dysphagia score improved in all patients.

Conclusions

The use of the covered retrievable expandable stent is an effective and safe method in treating childhood corrosive esophageal stenosis.     

New indications in the treatment of advanced esophageal cancer using self-expanding stent

In the past four years we performed palliative reconstruction in 69 patients with Tygon or Polyflex self-expanding stents. The procedure was performed in 35 patients because of mid-third oesophageal cancer, in 18 patients because of cancer of the cardia, in 7 patients because of mediastinal tumour and in 8 patients because of oesophago-respiratory fistula. The procedures improved the swallowing greatly, the oesophago-respiratory fistulae closed. During endoscopic intubation of cardia tumours the risk of perforation is high, while it is lower in case of open operative pull-through method. Insertion of Polyflex self-expanding stent under X-ray is safe. Improvement of the stents helps not only safer use, but it encourages its use in new indications, such as iatrogen benign perforation, corrosive oesophageal stricture, long preoperative period, when the swallowing for better nutrition is essential. The procedures improve the quality of life and improve survival time because of the restored swallowing, closed oesophago-respiratory fistula with the prevention of aspiration.     

Are expandable metallic stents better than conventional methods for treating difficult intrahepatic biliary strictures with recurrent hepatolithiasis?

BACKGROUND: Conventional methods for treating patients with recurrent hepatolithiasis associated with complicated intrahepatic biliary strictures include balloon dilatation of the intrahepatic biliary strictures, lithotripsy, and the clearance of difficult stones as completely as possible, with the placement of an external-internal stent for at least 6 months. After these modalities are used, symptomatic refractory strictures remain. Recently we used internal Gianturco-Rosch metallic Z stents to treat patients who had refractory strictures. OBJECTIVE: To compare therapeutic results and complications of an internal expandable metallic Z stent with those of repeated external-internal stent placement. STUDY DESIGN: Case-control study. SETTING: A referral center. PATIENTS: From January 1992 to December 1996, 18 patients with recurrent hepatolithiasis and complicated intrahepatic biliary strictures underwent percutaneous dilatation of stricture and transhepatic percutaneous cholangioscopic lithotomy for recurrent stones. After their stones were completely cleared, their biliary strictures failed to dilate satisfactorily. The patients were randomly enrolled into 2 groups: group A (7 patients), who received an expandable metallic Z stent, and group B (11 patients), who had repeated placement of external-internal stents. INTERVENTIONS: Percutaneous stricture dilatation, electrohydraulic lithotripsy, balloon dilatation, percutaneous transhepatic cholangioscopic lithotomy, and biliary stenting by a Silastic external-internal catheter or a modified Gianturco-Rosch expandable metallic Z stent (for an internal stent). MAIN OUTCOME MEASURES: The number of procedures, days in hospital, procedure-related complications, incidents of stone recurrence and recurrence of cholangitis, readmissions to the hospital, treatment sessions required, and mortality rate. Patients' limitations in ordinary activities were also compared. RESULTS: The follow-up period ranged from 28 to 60 (40.7+/-12.7 [mean +/- SD]) months in group A and from 28 to 49 (36.0+/-7.2) months in group B. Fewer group A patients (3 [43%]) than group B patients (8 [73%]) tended to have recurrent cholangitis and to require readmission to the hospital, but this was not statistically significant (P = .33). When their cumulative probability of a first episode of cholangitis during follow-up was compared, however, it was significantly lower in patients treated with a metallic stent (P = .04). Compared with group B patients, group A patients had less frequent recurrence of stones (0% vs 64%; P = .01), fewer procedures for the clearance of biliary stones or sludge (1.7+/-2.2 vs 6.4+/-4.3; P = .03), and shorter hospital stays (8.0+/-11.5 days vs 17.0+/-12.0 days; P = .07). No patients in group A experienced limitation in ordinary activities, whereas 7 patients in group B did (P<.02). CONCLUSIONS: Compared with the repeated placement of external-internal stents, the use of a metallic internal stent effectively decreases stone recurrence, simplifies further procedures, and is more convenient. Its use is suggested as an alternative choice in the treatment of recurrent hepatolithiasis with refractory intrahepatic biliary strictures.     

钛镍记忆合金网状支架治疗食管贲门狭窄

作者使用形状记忆合金支架治疗９５例食管恶性狭窄,３５例吻合口瘢痕狭窄。所有病例均失去手术机会,使用扩张、化疗、放疗、激光等治疗也无效。治疗后,吞咽困难从３．７１±０．４５（３～４级）降到１．０８±０．５９（０～２级）（Ｐ＜０．０１）。并发症发生４９例（３１．５％）,其中胸痛３６例,出血５例,肿瘤过度生长４例,支架移位２例,食物堵塞２例。通过近三年的临床应用和疗效观察,作者认为,食管贲门狭窄放置钛镍记忆合金支架是一种有效、安全、简单方法。