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

doi:10.1016/S0720-048X(02)00154-7

European Journal of Radiology

Volume 43, Issue 3, September 2002, Pages 196-203

https://doi.org/10.1016/S0720-048X(02)00154-7 Get rights and content

Abstract

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.

Introduction

Progressive dysphagia of the esophagus and cardia tumors may cause death due to starvation in the absence of treatment. Surgery can be performed in only 50% of the patients because of late clinical presentation and early extramural spread [1]. Palliative treatment of dysphagia is of vital importance in the other half of the patient population.

Surgical and radiation therapy are not used frequently in the palliative treatment of malignant dysphagia due to their high morbidity and mortality as well as prolonged hospitalization [2], [3]. Chemotherapy, although not useful when used alone, has been reported to reduce the number of sessions when performed in conjunction with laser therapy [4]. Endoscopic laser therapy, based on the principle of tumor destruction with thermal energy, may restore almost normal swallowing with a low complication risk [4]. However, laser therapy has to be repeated periodically, and although laser procedure-related risk of perforation is less than 1%, esophageal dilatation preceding laser therapy which may be necessary in 30% of the patients has a 6–8% risk of perforation on its own [5], [6].

Rigid plastic endoprostheses placed with surgical or endoscopic guidance have high morbidity and mortality rates as well as limited effectiveness in the palliation of dysphagia due to their rigid nature and narrow lumen [7].

Metallic stents which have a high ratio of expanded diameter to introduction diameter compared to plastic stents are currently an established modality for the endoluminal palliation of stenosis within tubular organs of the body which include blood vessels, gastrointestinal tract, airways, bile ducts and ureters. Stent placement within the esophagus is being used effectively in the treatment of malignant dysphagia and is now a well-established procedure. The procedure is a relatively simple one and technical success is almost 100%, and improvement in dysphagia score ranges from 83 to 100% [8].

We started using metallic stents for the palliation of malignant esophageal strictures in 1993. The original uncovered Ultraflex (Boston Scientific, Watertown, MA) was the first dedicated esophageal stent which was available in our market. Then came Wallstent, the covered Wallstent, and the conical shaped Falmingo Wallstent (Boston Scientific), the SR (Song retrievable) covered stent (Stentech, Seoul, Korea) became available in 2000, and a covered metal stent with an antireflux mechanism the Flexstent (Garson Medical Stent Research Institute, Changzoui, China) became recently available.

We report our center's experience with Ultraflex, Flamingo, SR and our preliminary experience with the antireflux Flexstent stent.

Section snippets

Patients

Between August 1993 and February 2002, 116 patients with inoperable esophagus and gastric cardia tumors diagnosed by clinical or computed tomographic criteria underwent placement of metal stents under fluoroscopic guidance. Patients who had a tumor within 2 cm of the upper esophageal sphincter were excluded.

82 patients of this series were males (71%) and 34 were females (29) with an age range of 23–83 (average 61). Histopathological diagnosis was squamous cell carcinoma in 75 patients (63%) and

Results

Stent insertion was technically successful in all the patients, and no procedure-related complications occurred. The stents usually showed some waisting at the site of stricture immediately after insertion but expanded fully after a few days. All the patients had some dull chest pain following insertion for a few days.

The severity of dysphagia decreased at least one grade in 123 of 126 (98%) patients. There was no relief of dysphagia in one patient (1%) who received an Ultraflex stent and two

Discussion

In patients with esophageal cancer, dysphagia is by far the most common complaint developing when the lumen of the esophagus has been reduced by 50–75% of its normal circumference [9]. By that time, malignant invasion of periesophageal lymph nodes or surrounding mediastinal structures has usually occurred. Therefore, most patients have advanced and unresectable tumors at the time of diagnosis, and the goal of therapy in these patients is limited to the restoration of oral food intake and

Conclusion

Despite multiple recent advances in stent design the quest for the ideal stent continues. Esophageal stents should be flexible enough to allow nontraumatic deployment, and they should be stable in a peristaltic organ. They should have an internal diameter large enough to relieve symptomatology secondary to obstruction and allow normal alimentation. Sufficient radial force allowing them to open slowly in a stricture is a definite advantage, which obviates the use of balloon dilatation, which may

References (19)

R.R. Saxon et al.
Treatment of malignant esophagorespiratory fistulas with silicon-covered metallic Z stents
J. Vasc. Interv. Radiol.
(1995)
S. Moha mmed et al.
Palliation of malignant tracheoesophageal fistula using covered metal stents
Clin. Radiol.
(1996)
J.M. Muller et al.
Surgical therapy of esophageal carcinoma
Br. J. Surg.
(1990)
M. Albertsson et al.
Evaluation of the palliative effect of radiotherapy for esophageal carcinoma
Acta Oncol.
(1989)
R. Earlam et al.
Esophageal squamous cell carcinoma: a critical review of surgery
Br. J. Surg.
(1980)
M.S. Highley et al.
Combination chemotherapy with epirubicin, cisplatin and 5-fluorouracil for the palliation of advanced gastric and esophageal adenocarcinoma
Br. J. Surg.
(1994)
M. Tyrrell et al.
Incidence and management of laser associated esophageal perforation
Br. J. Surg.
(1995)
M.H. Jaffe et al.
Esophageal malignancy: imaging results and complications of combined endoscopic–radiologic palliation
Radiology
(1987)
A.L. Ogilvie et al.
Palliative intubation of esophagogastric neoplasm at fiberoptic endoscopy
Gut
(1982)

There are more references available in the full text version of this article.

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Percutaneous Gastrostomy Compared with Esophageal Stent Placement for the Treatment of Esophageal Cancer with Dysphagia
2021, Journal of Vascular and Interventional Radiology
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In the present study, the rates of complications and additional treatment for stent insertion were 46.9% and 10.6%, respectively. These findings were consistent with previous reports (22,23). The incidence of complications and additional treatments for PG in the present study were 14.4% and 10.6%; compared with previous studies (24–28), the complication rates and need for additional treatments were relatively low.
To compare the outcomes of self-expandable metal stent placement and percutaneous gastrostomy (PG) for the treatment of patients with esophageal cancer (EC) and dysphagia.
This retrospective observational study consisted of 113 patients with EC and dysphagia who underwent either stent placement (n = 47) or PG (n = 66) at a single center between June 2014 and June 2018.
There were 63 men and 50 women, with a mean age of 76.5 years (standard deviation 4.9 years). The 2 groups had similar baseline characteristics, except that the PG group had a higher percentage of patients with cervical EC (22.7% vs 2.1%, P < .001). The PG group had better maintenance of nutritional status in terms of reduction in serum albumin level (P = .039) and weight loss (P = .041). Compared with the stent group, the PG group demonstrated a lower incidence of local severe pain (0% vs 21.3%, P < .001) and lower incidence of dislodgment of device (1.5% vs 19.1%, P = .002). The PG group demonstrated longer overall survival compared with the stent group for Stages II and III (201 vs 185 days, P = .034) and Stage IV (122 vs 86 days, P = .001).
Compared with stent insertion, PG is associated with better maintenance of nutritional status, fewer complications, and better survival. Thus, PG may be the preferred choice for treating malnutrition in patients with EC and dysphagia.
Palliative Therapy for Patients with Unresectable Esophageal Carcinoma
2012, Surgical Clinics of North America
Citation Excerpt :
In patients with malignant dysphagia in the presence of a tracheoesophageal fistula, closure of the fistula is successful in 70% to 100% of patients.55–57 However, subsequent tumor ingrowth or overgrowth is common with disease progression and up to 50% of patients require additional interventions for recurrent dysphagia or complications related to the stent.53 Studies suggest that esophageal stents are also effective for the treatment of dysphagia caused by compression of the esophagus by extraesophageal malignancies.
In vivo evaluation of 5-fluorouracil-containing self-expandable nitinol stent in rabbits: Efficiency in long-term local drug delivery
2010, Journal of Pharmaceutical Sciences
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Self-expandable metallic stents have been used for palliative relief from dysphagia for several decades, and proved to be effective in reducing morbidity and mortality.4–6 However, the failure of this endoluminal stent frequently occurred resulting from ingrowth and overgrowth of the device by tumor cells.7–11 The overgrowth and ingrowth may result in restenosis and shortening the effective lifespan of the treatment.
This 5-fluorouracil (5-FU)-containing stent is fabricated by coating a film, composed of one 5-FU-containing ethylene-vinyl acetate (EVA) copolymer layer and one drug-free EVA protective layer, around a commercial self-expandable nitinol stent. The stents with various drug loadings were implanted into rabbit esophagus, and then 5-FU concentrations in the stent-touching and adjacent segments (including mucosa layer and muscle layer of each segment) of esophagus, serum, and liver were investigated throughout the experiment period. Quantitative analysis of 5-FU was performed by HPLC or LC-MS/MS, while the morphologies of esophageal mucosae by scanning electron microscopy (SEM). The results show that the 5-FU concentration in stent-touching esophageal tissue is overwhelmingly higher than that in serum or liver at all the investigation time points until 45 days. The 5-FU concentration in the stent- touching segment is higher than those in the other segments of esophagus, while the 5-FU concentration in mucosa layer is higher than that in muscle layer for the same segment. With the increase of drug loading, the drug concentrations in esophageal tissues and serum increase, and cellular desquamation of stent-touching epithelial surface become increasingly severe by SEM. Based on the results, the 5-FU-loaded esophageal stent operates long-term local drug delivery with great efficiency.
Oesophageal stenting in a district general hospital
2009, Surgeon
Background: Oesophageal carcinoma is the ninth most common malignancy in the UK with five year survival rate of only 8%. Most patients with dysphagia present at an advanced stage. Endoscopic stent insertion is a valid method of palliation. We present the outcomes of patients stented at a district general hospital. Method: This is a retrospective study of patients presenting to a district general hospital with inoperable oesophageal obstruction resulting in stent insertion from December 2000 to September 2006. Case notes were reviewed for demographics, diagnosis, treatment, complication and outcome. Results: Fifty-seven patients were stented endoscopically by a single surgeon during the study period for incurable oesophageal obstruction. Forty were male and 17 female (mean age 71.9 range 39–92). Most common causes were advanced adenocarcinoma (34; 60%) and squamous cell carcinoma (16; 28%). Other rarer causes were benign stricture of the oesophagus, lung carcinoma, non-Hodgkin's lymphoma and salivary gland tumour. Of the 50 patients with oesophageal carcinoma, strictures were in the lower third (in 68%), middle third (in 30%) and proximal third (in 2%). Twenty-four (42%) patients developed a complication, including overgrowth (14; 25%), migration (8; 14%), tracheo-oesophageal fistula (2; 4%) and perforation (1; 2%). There was an overall improvement in dysphagia in 41 (72%). Conclusion: Endoscopic stenting for advanced oesophageal obstruction is a well-tolerated procedure, which is acceptable to patients. Despite a significant complication rate, it allows the relief of dysphagia in most patients and therefore should be considered for all patients in this category.
A type of esophageal stent coating composed of one 5-fluorouracil-containing EVA layer and one drug-free protective layer: In vitro release, permeation and mechanical properties
2007, Journal of Controlled Release
A type of esophageal stent coating was investigated, which consists of one 5-fluorouracil (5-FU)-containing ethylene-vinyl acetate (EVA) copolymer layer and one drug-free EVA protective layer. The amount of 5-FU permeated through the protective layer (100 μm) is thousands of times lower than that of 5-FU released from the drug-loaded layer, indicating that the coating releases drug molecules in a unidirectional fashion. The barrier of the protective layer can be attributed to a tiny flux of 5-FU through the EVA film. In vitro release profiles of the stent coatings with various drug contents were investigated in pH 6.5 phosphate buffer solution. The results show that, the burst effect is not obvious for the coatings with 20–50% of 5-FU and the release profiles can be characterized by a first faster release rate phase followed by a decrease in release rate. The release data in the early and late stages can all be well fitted with zero-order kinetics, and the possible reasons for the release profiles were discussed. The rate of 5-FU permeation through porcine esophageal mucosa from the coatings can be adjusted by changing drug content of the coatings. The increase of drug content of the coatings significantly leads to the decrease of the maximum elongation, maximum tensible strength and maximum tear strength, and the increase of the modulus of elasticity. The coatings with 20–60% of drug attached to a stent can endure repeated binding and liberation via a stent introducer.
Estimation of 5-fluorouracil-loaded ethylene-vinyl acetate stent coating based on percolation thresholds
2007, International Journal of Pharmaceutics
The drug percolation thresholds of 5-fluorouracil-loaded ethylene-vinyl acetate stent coatings were estimated to characterize their drug release behavior and mechanical properties. The stent coatings were prepared using 5-fluorouracil (5-FU) as antitumor drug and ethylene-vinyl acetate (EVA) as matrix forming material in different ratios. In vitro release assays were carried out exposing only one side of coating to pH 6.5 PBS. Based on the release profiles, the drug percolation thresholds were estimated as 0.21 of total porosity (corresponding to ca. 32%, w/w of the drug), which is in approximately agreement with the atomic force microscopy (AFM) result. Based on the coating tensible break strength and tear break strength data, the mechanical percolation thresholds of drug were obtained as 39.7 ± 0.3 and 37.5 ± 1.4% (w/w) of drug content, respectively.

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

Abstract

Introduction

Section snippets

Patients

Results

Discussion

Conclusion

J. Vasc. Interv. Radiol.

Clin. Radiol.

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Incidence and management of laser associated esophageal perforation

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