Clinical efficacy and safety of palliative esophageal stenting without fluoroscopy: a systematic review and meta-analysis

Abstract

Background and study aims Despite advances in curative treatments for esophageal cancer, many patients often present with advanced disease. Dysphagia resulting in significant weight loss and malnutrition leads to poor quality of life. Palliative esophageal stenting with self-expanding metal stents (SEMS) helps alleviate symptoms and prolongs survival. However, access to fluoroscopy may be limited at certain centers causing delay in patient care. Methods We searched multiple databases from inception to November 2019 to identify studies evaluating the efficacy and safety of endoscopic palliative esophageal stenting and selected only those studies where fluoroscopic guidance was not used. Our primary aim was to calculate the overall technical as well as clinical success. Using meta-regression analysis, we also evaluated the effect of tumor location and obstruction length on overall technical and clinical success. Results A total of 1778 patients from 17 studies were analyzed. A total of 2036 stents were placed without the aid of fluoroscopy. The pooled rate of technical success was 94.7 % (CI 89.9–97.3, PI 55–99; I2 = 85) and clinical success was 82.1 % (CI 67.1–91.2, PI 24–99; I2 = 87). Based on meta-regression analysis both the length of obstruction and tumor location did not have any statistically significant effect on technical and clinical success. The pooled rate of adverse events was 4.1 % (CI 2.4–7.2; I2 = 72) for stent migration, 8.1 % (CI 4.1–15.4; I2 = 89) for tumor overgrowth and 1.2 % (CI 0.7–2; I2 = 0) for perforation. The most frequent clinical adverse event was retro-sternal chest pain. Conclusion Palliative esophageal stenting without fluoroscopy using SEMS is both safe and effective in patients with advanced esophageal cancer.

Adverse events associated with EGD and EGD-related techniques

“…In a recent metaanalysis of palliative esophageal stent placement without fluoroscopy in 1778 patients from 17 studies, the pooled perforation rate was 1.2%, indicating the safety of this approach. 85 In the same study, retrosternal chest pain was found to be the most common AE reported (10.4%). In a retrospective review of 442 patients undergoing SEMS placement for dysphagia because of unresectable esophageal cancer, perforation occurred in .9% of patients.…”

The Role of Self-Expandable Metallic Stents in the Treatment of Malignant Strictures in all Segments of the Gastrointestinal Tract

“…[9] SEMS placement for a malignant oesophageal stricture is considered a technical success, while the post-operative regression of dysphagia and the tolerance of enteral feeding are considered a clinical success. Chandan et al (2020) have recently conducted a meta-analysis and reported the technical and clinical success rates of oesophageal SEMS placement as 94.7% (95% CI 89.9-97.3) and 82.1% (95% CI 67.1-91.2), respectively. [10] In our sample, the technical success rate was 100%, probably because we used both fluoroscopy and endoscopy for the procedure.…”

Predictors of adverse events and early mortality after esophageal stent placement in a low resource setting: a series of 3823 patients in Kenya

“…Similar to other studies regarding SEMS placement 8 24 , both the technical and clinical success rates were high. A recent meta-analysis from Chandan et al demonstrated the safety and efficacy of SEMS placement without fluoroscopy and reported rates of technical and clinical success of 94.7 % and 82.1 %, respectively 16 . Notably, our series has twice as many patients as the meta-analysis and further demonstrates the importance of high-volume centers in improving outcomes.…”

“…In many parts of the world, SEMS have traditionally been placed under fluoroscopy. However, there have also been multiple reports of SEMS stent placement under endoscopic visualization without fluoroscopy 14 15 16 , and at our institution, we further refined this and now place stents using a modified technique that utilizes measurements without either fluoroscopy or direct endoscopic visualization during stent deployment 15 .…”

“…Dilation is often required to assess tumor length before SEMS placement without fluoroscopy. In a meta-analysis concerning SEMS placement without fluoroscopy, numerous investigators reported on the use of esophageal dilation before deployment with either Savary or balloon dilators 16 . However, there is no consensus on the optimal size of dilation.…”