Endoscopic stenting-Where are we now and where can we go?

Abstract

Self expanding metal stents (SEMS) play an important role in the management of malignant obstructing lesions in the gastrointestinal tract. Traditionally, they have been used for palliation in malignant gastric outlet and colonic obstruction and esophageal malignancy. The development of the polyflex stent, which is a removable self expanding plastic stent, allows temporary stent insertion for benign esophageal d i s e a s e a n d p o s s i b l y fo r p a t i e n t s u n d e r g o i n g neoadjuvant chemotherapy prior to esophagectomy. Potential complications of SEMS insertion include perforation, tumour overgrowth or ingrowth, and stent migration. Newer stents are being developed with the aim of increasing technical and clinical success rates, while reducing complication rates. Other areas of development include biodegradable stents for benign disease and radioactive or drug-eluting stents for malignant disease. It is hoped that, in the future, newer stents will improve our management of these difficult conditions and, possibly, provide prognostic as well as symptomatic benefit in the setting of malignant obstruction.© 2008 The WJG Press. All rights reserved. [9] and improvements in quality of life, dysphagia, and eating scales [10] for brachytherapy. It has been suggested that, as stent re-intervention is likely to be increased for those who live longer, SEMS should be considered for those with a poorer prognosis, and chemo/radiotherapy, with temporary stent placement, for those with a longer life expectancy [2] . A Korean group inserted a removable nitinol stent in 47 patients who had concur rent radiotherapy and extracted the stent in 24 patients after 4 wk, leaving the stent in place in the remaining patients [11] . The complication and re-intervention rates were significantly lower in the group in which the stent was extracted, while the dysphagia-progression-free and overall survival rates were significantly longer. No randomized trials have yet been conducted with the Polyflex stent, which is the only removable stent licensed in the USA in this setting. Further randomized trials of SEMS in combination with other treatment modalities would help determine the optimal management strategy in terms of symptom control and overall survival. Drugeluting and radioactive stents may also have a future role in the management of esophageal malignancy; these have been tested with success in animal models [12,13] . In cases where the distal margin of the stent crosses the gastro-esophageal (GE) junction there are now SEMS available with an anti-reflux mechanism. Survival has been shown to be reduced in patients in whom the stent crossed the GE junction [14] . A study which compared an open stent with the Z-stent with Dua antireflux valve found that 96% of patients with the open stent had reflux symptoms, compared with 12% with the antireflux mechanism [15] . Several other SEMS with antireflux mechanisms have been manufactured. Further work will be required to determine the overall efficacy and complic...

Endoscope-assisted brachytherapy for pancreatic cancer: From tumor killing to pain relief and drainage

“…The trial proved that the combination of radioactive stents and metallic and/or plastic stents was technically feasible and tolerable in patients with advanced tumors around the pancreatic-head area. According to the reviews on endoscopic stenting, 31,32 newer stents will improve management of these difficult-to-treat diseases and provide prognostic as well as symptomatic benefit in the setting of malignant obstruction.…”

Emergency Self- Expanding Metal Stenting for Malignant Colonic Obstruction: An Opportunity for Operation in a More Favorable Condition

“…In these patients, traditional emergency resection may proceed with no initial detailed work-up, despite the fact that patients might have other preoperative comorbidities and complications. Emergency surgery, for decompression in especially elderly patients, on an unprepared basis, was already shown to carry important rates of morbidity (32-64%) and risks of mortality (15-34%) (3,4). In these patients, the replacement of the colorectal self-expandable metal stent (SEMS) can be a good option as a remedy of acute obstruction or as a bridge to surgery.…”

Self-Expandable Metallic Stents in Oesophago-Respiratory Fistulas Treatment in Neoplasms—Case Reports and Literature Review

“…SEMS implantation is an effective, safe and relatively simple method of choice in palliative treatment of patients with EFR [4−8]. SEMS have been used for ERF since the early 1990s, when they replaced rigid plastic stents [4,5]. SEMS insertion effectively closes fistulas in 88.9-96% of patients [4, 6, 9−12].…”