Esophageal Stenting for Leaks and Strictures: A Benign Intervention for a Benign Indication?

Abstract

As esophageal stents have evolved in composition, so alsohave indications for their placement [1]. Stents wereavailable initially only as rigid plastic or rubber stents, usedfor the treatment of malignant dysphagia. This rigid designresulted in difficult placement and frequent complications.In response to this, self-expanding metal stents (SEMS)were developed. Although better tolerated and easier toplace, these stents were plagued by tissue ingrowth throughtheir open mesh. In response to this, a covering membranewas added to stents to minimize tissue ingrowth. While apartially covered stent is sufficient to prevent tumoringrowth and occlude esophageal fistulas in malignantdysphagia, this design was inadequate for benign indica-tions due to concerns for the stent becoming imbedded atits distal and proximal uncovered ends with in some casesformation of new strictures [2].More recently, fully covered stents have been availableand have been used in a variety of benign indications(Table 1). The most widely studied stent is the Poly-flex stent (Boston Scientific, Natick, MA, USA), a self-expanding plastic stent (SEPS) which was introduced in2001 and remains the only stent with FDA approval for lateremovability. The Alimaxx-E stent (Merit Endotek, SouthJordan, UT, USA), used in the current study by Senousyand colleagues, was introduced in 2005. It is a hybrid fullycovered self-expanding metal stent (FCSEMS) constructedof nitinol and fully covered with polyurethane, with 20outer metal struts to resist migration. Although thisFCSEMS is only FDA-approved for immediate removal,the ability to resist tissue ingrowth has led to its use inbenign indications with a delayed removal. More recently,other esophageal FCSEMSs have become available in theUnited States but none are approved for delayed removal(Table 1).In this issue, Senousy and colleagues report on theirexperience using the Alimaxx-E stent for benign esophagealindications. In a retrospective study conducted over a 6-yearperiod, 14 patients were treated in total for esophageal fis-tulas (n = 7) and benign esophageal strictures (BES, n = 7)[3]. Given the important clinical differences between thesetwo groups, it is best to consider them separately.A heterogeneous group of difficult benign strictureswere treated in this study, including strictures due toradiation therapy, photodynamic therapy, post-surgicalanastomosis, and peptic disease. Impressively, all patientshad clinical resolution of their dysphagia after this short-term intervention; however, it is important to note thatlong-term follow-up in this retrospective study was notstandardized. Thus, despite this positive result, a majorconcern is the durability of this effect, as many of thesedifficult strictures may recur late after stent removal [4, 5].In a recently published study of 31 patients with the sameFCSEMS placement, stent placement was performed for arefractory BES in 7 patients [6]. With 6 months follow-upafter stent placement, stricture resolution was seen in only29% of patients. A recently published prospective study of40 patients with rigorous follow-up utilized a SEPS whichwas removed 4 weeks after initial placement. A similarlypoor long-term success rate (30%) was seen at 1 year forthese patients with refractory BES [7].A difficulty in studying interventions for patients withBES is the lack of a uniform definition. Recently, criteriahave been proposed to facilitate discussion about man-agement of difficult benign esophageal strictures, andwidespread adoption should be considered [8]. In this