Stents for esophageal disease

Abstract

Esophageal malignancies presenting with dysphagia from luminal obstruction generally are not resectable for cure, and palliative therapy is the primary focus. Self-expandable metal stents (SEMS) have replaced plastic stents as a primary mode of palliation for malignant esophageal obstruction because of the relative ease of insertion, lower initial morbidity, and larger stent diameter. Self-expandable metal stents are ideal for patients with midesophageal tumors. A majority of patients experience relief of dysphagia with SEMS and dietary modification, but the initial cost is high and early morbidity may be significant. The placement of SEMS across the gastroesophageal junction may result in free reflux that may improve with a stent containing a one-way gastric flap valve. The placement of SEMS in the cervical esophagus, although more difficult, less effective, and less well tolerated, also may be successful. Coated SEMS are a treatment of choice for individuals with tracheoesophageal fistula. Delayed complications occur in up to 40% of patients and include stent migration, bleeding, perforation, fistula formation, and occlusion. Most complications can be managed endoscopically and additional stents may be placed for tumor overgrowth. The comparison of three currently available SEMS for esophageal malignancy show no statistically significant differences with regard to ease of placement, effectiveness, complications, and mortality. The use of SEMS for patients with benign disease is still considered experimental.

A regional audit of iatrogenic perforation of tumours of the oesophagus and cardia

“…Perforation after placement of self‐expanding metal stents is a rare event 17, 18 but delayed complications have been described in up to 65% 19, 20 . There do not appear to be any published randomized series evaluating different manufacturers stents but in our review of the literature both Nitinol and Ultraflex (Boston Scientific Inc., Watertown, MA, USA) stents are associated with fewer short‐ and long‐term complications whereas Wallstents (Boston Scientific Inc.) have been quoted to have a perforation risk of between 2 and 10% 17, 19–22 . It is wholly appropriate that rigid stints have now been confined to historical series as modern material, techniques and technology have superseded them for both safety and efficacy.…”

“…The advantage of expandable metal stents over plastic stents has been well documented with improved patency rates, fewer immediate and long‐term complications, shorter hospital stay and reduced readmission rates 13–16 . Perforation after placement of self‐expanding metal stents is a rare event 17, 18 but delayed complications have been described in up to 65% 19, 20 . There do not appear to be any published randomized series evaluating different manufacturers stents but in our review of the literature both Nitinol and Ultraflex (Boston Scientific Inc., Watertown, MA, USA) stents are associated with fewer short‐ and long‐term complications whereas Wallstents (Boston Scientific Inc.) have been quoted to have a perforation risk of between 2 and 10% 17, 19–22 .…”

Palliation for Advanced Malignant Colorectal Obstruction by Self-Expanding Metallic Stents: Prospective Evaluation of Outcomes

“…13 SEMSs are an effective option to palliate obstruction resulting from advanced malignant disease of the gastrointestinal tract. Their use in the esophagus 16 and biliary tract 17 has been widely accepted. Since Dohmoto 1 reported the first case of colonic stenting, SEMSs have been shown to provide rapid relief of obstruction, and multiple sessions of treatment are not necessary.…”

Broncho-Oesophageal Fistula Complicating Carcinoma of the Oesophagus

“…There is no cure for malignant broncho-oesophageal fistulae and palliative procedures like oesophageal stenting, oesophageal exclusion, oesophageal bypass, fistula resection and repair may prolong survival 4,10 . Insertion of a coated selfexpandable metal stent is the treatment of choice for an individual with malignant bronchooesophageal fistula 11 . The patient did not live long enough to benefit from any of these procedures.…”