Esophageal Self-expandable Metal Stents Research Articles

394. ESOPHAGEAL STENTING IN ESOPHAGEAL CANCER PATIENTS WITH PERFORATION AND FISTULA

Abstract Background Esophageal perforation and fistula to the respiratory system are serious problems in esophageal cancer patients. Esophageal self-expandable metal stent (SEMS) placement has become a popular treatment for this problem. This retrospective study aimed to evaluate the factors associated with clinical outcomes following the placement of a SEMS in esophageal cancer patients with perforation and fistula. Methods Data from 43 esophageal cancer patients with perforation and fistula who underwent esophageal SEMS placement at Prince of Songkla University Hospital between January 2008 and June 2023 were reviewed. Statistical analyses, including chi-square tests and Kaplan-Meier methods, were employed for comparisons and survival calculations. Results The SEMS location was the middle esophagus in 76.8% and 11.6% in each of the lower and upper esophagus. The disease was stage IV in 62.8% and stage III in 37.2%. 46.5% had a history of chemoradiotherapy. The perforation and fistula penetrated into the left bronchus in 39.5%, right bronchus 18.6%, trachea 16.3%, lung 14% and mediastinum 11.6%. The SEMS technique was successful in all patients. The median stent patency was 38.5 days. Tumor overgrowth was the major cause of stent obstruction. The median overall survival was 40 days. Initial success of the SEMS placement was the only predictor of better survival. Conclusion Esophageal SEMS placement in esophageal cancer perforation and fistula cases is technically uncomplicated. Although these advanced esophageal cancer patients had a poor prognosis, the esophageal SEMS provided symptom relief and improved quality of life for their remaining time.

Palliative use of self-expanding metal stents in initially anticancer treatment-intolerant patients with esophageal cancer

BackgroundThe post-insertion clinical course of esophageal self-expandable metal stents (SEMS) in initially frail patients with esophageal carcinoma (EC) with dysphagia remains unclear. This study aimed to assess dysphagia improvement and evaluate prognosis in initially frail patients with advanced EC following SEMS insertion.MethodsWe retrospectively reviewed EC patients with EC who underwent esophageal SEMS insertion at our institution between January 2014 and March 2023. Inclusion criteria comprised Eastern Cooperative Oncology Group Performance Status (ECOG PS) ≥ 3 or ECOG PS 2 for individuals aged ≥ 75 years and recommendation for best supportive care by a multidisciplinary team.ResultsForty-six patients met the inclusion criteria. Among them, 37 patients (80.4%) were ≥ 75 years old, and 21 patients (45.7%) exhibited ECOG PS 3 or 4. Dysphagia score (DS) ≥ 3 was observed in 27 patients (58.7%). All esophageal SEMS insertions were successfully completed. Post-procedure, there were two fatal cases of aspiration pneumonia and one perforation incident. DS improved to ≤ 1 in 25 patients (54.3%), with multivariate analysis indicating DS 3–4 and Glasgow Prognostic Score (GPS) 1–2 as negative predictive factors. The median overall survival was 4.1 months (95% confidence interval 1.8–6.5).ConclusionsEsophageal SEMS insertion effectively alleviated dysphagia in initially frail EC patients, yet prognosis remained poor, with occurrences of some fatal adverse events. Careful selection of candidates for esophageal SEMS insertions is crucial in this demographic, particularly considering the challenges in improving dysphagia for patients with DS 3–4 and GPS 1–2.

Esophageal Self-Expandable Metal Stents Can Fracture in the Distal Third When Used for Post-Bariatric Surgery Complications: A Single Center Experience and Review of the Literature with Video

Background: Esophageal self-expandable metal stents (SEMS) are an important endoscopic tool. These stents have now been adapted successfully to manage post-bariatric surgery complications such as anastomotic leaks and strictures. In centers of expertise, this has become the primary standard-of-care treatment given its minimally invasive nature, and that it results in early oral feeding, decreased hospitalization, and overall favorable outcomes. Self-expandable metal stents (SEMS) fractures are a rare complication of unknown etiology. We aimed to investigate possible causes of SEMS fractures and highlight a unique endoscopic approach utilized to manage a fractured and impaled SEMS. Methods: This is a retrospective study of consecutive patients who underwent esophageal SEMS placement between 2015–2021 at a tertiary referral center to identify fractured SEMS. Patient demographics, stent characteristics, and possible etiologies of fractured SEMS were identified. A comprehensive literature review was also conducted to evaluate all prior cases of fractured SEMS and to hypothesize fracture theories. Results: There were seven fractured esophageal SEMS, of which six were used to manage post-bariatric surgery complications. Five SEMS were deployed with their distal ends in the gastric antrum and proximal ends in the distal esophagus. All stents fractured within 9 weeks of deployment. Most stents (5/7) were at least 10 cm in length with fractures commonly occurring in the distal third of the stents (6/7). The wires of a fractured SEMS were embedded within the esophagogastric junction in one case, prompting the use of an overtube that was synchronously advanced while steadily extracting the stent. Discussion: We suggest the following four etiologies of SEMS fractures: anatomical, physiological, mechanical, and chemical. Stent curvature at the stomach incisura can lead to strain- and stress-related fatigue due to mechanical bending with exacerbation from respiratory movements. Physiologic factors (gastric body contractions) can result in repetitive squeezing of the stent, adding to metal fatigue. Intrinsic properties (long length and low axial force) may be contributing factors. Lastly, the stomach acidic environment may cause nitinol-induced chemical weakness. Despite the aforementioned theories, SEMS fracture etiology remains unclear. Until more data become available, it may be advisable to remove these stents within 6 weeks.

A Comprehensive Analysis of Reported Adverse Events and Device Failures Associated with Esophageal Self-Expandable Metal Stents: An FDA MAUDE Database Study.

Esophageal Stents are used to maintain esophageal lumen patency in esophageal strictures caused by intrinsic and/or extrinsic malignancies and the occlusion of concomitant esophageal fistulas. While data on the efficacy and safety of esophageal stents exist, comprehensive evaluation of adverse events is limited. The aim of this study is to investigate the reported adverse events and device failures associated with esophageal self-expandable metal stents (SEMS) using the FDA's Manufacturer and User Facility Device Experience (MAUDE) database. Post-marketing surveillance data for the esophageal SEMSs were analyzed using the FDA's MAUDE database from January 2014 to December 10, 2023. The outcomes of interest were patient-related adverse events and device failures. Statistical analysis was performed using Microsoft Excel 2010 and SPSS. Pooled numbers and percentages were calculated for each adverse event. Continuous variables underwent analysis using a two-tailed student t test, and significance was set to p ≤ 0.05. During the study period, 548 MAUDE reports revealed 873 device failures and 186 patient-related adverse events. The most common device issues were stent activation, positioning, or separation problems (4 n = 403; 46.2%), followed by device detachment or migration (n = 109, 12.5%), and material problems (n = 93, 10.7%). Patient complications included dysphagia/odynophagia (10%), perforation, pain, and bleeding (each 7.6%). The most common device failures in over-the-wire (OTW) stents and through-the-scope (TTS) stents were activation, positioning, or separation problems (TTS: n = 183, 52.6% vs OTW: n = 220, 41.9%). Compared to OTW stents, TTS stents had higher migration and breakage (13.5% vs. 11.8%, p = 0.24), and (9.2% vs. 6.7%, p = 0.08) respectively, while OTW stents had more challenges with stent advancement or removal (5.1% vs. 0.3%, p < 0.001 and 4.6% vs 3.4%, p = 0.19, respectively) and material problems (14.7% vs. 4.6%, p < 0.001). Activation, positioning, and separation problems were the most frequent device failures in fully covered (FC) and partially covered (PC) stents (FC: n = 62, 32.8%, PC: n = 168, 43.5%). FC stents had higher migration rates (20.6% vs 9.8%, p < 0.001), while PC stents exhibited more material problems (17.4% vs. 5.8%, p < 0.001) and difficulties with advancing the stents (6.7% vs. 0%, p < 0.001). Our examination showed a prevalence of reported device complications associated with stent activation, positioning, and separation problems. Dysphagia or odynophagia emerged as the most frequently reported patient complication. Furthermore, our analysis, provides insights into TTS vs. OTW and FC vs. PC esophageal SEMSs, enabling endoscopists and manufacturers to better understand adverse events and potentially optimize device design for future iterations.

Hemostatic powder for the management of hemorrhage from esophageal self-expanding metal stents: A case report.

Hemostatic powder for the management of hemorrhage from esophageal self-expanding metal stents: A case report.

Endoscopic self-expandable metal stent versus endoscopy vacuum therapy for traumatic esophageal perforations: a retrospective cohort study

BackgroundTraumatic esophageal perforations (TEP) are a grave medical condition and require immediate intervention. Techniques such as Esophageal Self-Expandable Metal Stent (E-SEMS) and Endoscopic Vacuum Therapy (EVT) show promise in reducing tissue damage and controlling esophageal leakage. The present study aims to compare the application of EVT to E-SEMS placement in TEP.MethodsRetrospective cohort study valuated 30 patients with TEP. The E-SEMS and EVT groups were assessed for time of hospitalization, treatment duration, costs, and clinical outcome.ResultsPatients treated with EVT (24.4 ± 13.2) demonstrated significantly shorter treatment duration (p < 0.005) compared to the group treated with E-SEMS (45.8 ± 12.9) and patients submitted to E-SEMS demonstrated a significant reduction (p = 0.02) in the time of hospitalization compared to the EVT (34 ± 2 vs 82 ± 5 days). Both groups demonstrated a satisfactory discharge rate (E-SEMS 93.7% vs EVT 71.4%) but did not show statistically significant difference (p = 0.3155). E-SEMS treatment had a lower mean cost than EVT (p < 0.05). Descriptive statistics were utilized, arranged in table form, where frequencies, percentages, mean, median, and standard deviation of the study variables were calculated and counted. The Fisher's Exact Test was used to evaluate the relationship between two categorical variables. To evaluate differences between means and central points, the parametric t-test was utilized. Comparisons with p value up to 0.05 were considered significant.ConclusionE-SEMS showed a shorter time of hospitalization, but a longer duration of treatment compared to EVT. The placement of E-SEMS and EVT had the same clinical outcome. Treatment with E-SEMS had a lower cost compared with EVT.

Prevention of Migration of Esophageal Self-Expandable Metallic Stents Using Endoscopic Clips.

Background and Objectives: Esophageal stenting with self-expandable metallic stents (SEMS), for both benign and malignant reasons, has been widely practiced for decades, but migration still remains the most common complication of the procedure. In this report we aim to review our experience and results in stent fixation with clips. Materials and Methods: We present 18 patients who underwent esophageal stenting for both benign and malignant reasons. The SEMSs used were partially covered and were fixated with two to four through the scope hemostatic clips in the proximal end of the prothesis. The procedure was performed only on patients with a high risk of migration of the stent. Results: Migration occurred in only one of the above-mentioned patients and was treated with stent repositioning. The other adverse events that occurred were related to tumor growth in patients with malignant diseases. Conclusions: Clip fixation of an esophageal self-expandable metallic stent in cases considered high-risk for migration is a safe procedure. It reduces the migration rate significantly for both benign and malignant indications.

Safety and efficacy analysis of the removal of refractory esophageal self-expandable metal stents by stent-in-stent technique

To evaluate the safety and efficacy of esophageal stent-in-stent (SIS) in patients with refractory esophageal self-expandable metal stents (SEMS). Case series study. Retrospective analysis was made on the patients with refractory esophageal SEMS treated with SIS technology in Zhongda Hospital Affiliated to Southeast University from June 2015 to June 2021. The success rate of stent removal and the incidence of adverse events were analyzed. A total of 12 patients were included, including 7 males and 5 females, aged 50-73 (62.7±8.5) years. The clinical success rate of the internal stents was 12/12, with the median retention time of [M(Q1, Q3), 64.5 (52.0, 90.8)] days. The postoperative displacement rate and severe stenosis incidence were 1/12 and 3/12, respectively. The esophageal stents were successfully removed in one endoscopic session in all patients. A small amount of mucous membrane extravasation occurred in all patients after SIS, and no patients died after 90 days of follow-up.

Fluoroscopic Removal of Embedded Esophageal Self-Expanding Metal Stents: Stent-in-Stent Combined with Guidewire Lasso Technique.

We report the use of the guidewire lasso technique for the removal of an embedded esophageal self-expanding metal stent (SEMS), following a failure of distal to proximal invagination by removal hook caused by stent incorporation. During a removal procedure of an embedded SEMS using the hook retrieval device, the strut fractured and the stent retained. Attempts to pull up the retained stent using hook were not effective. Thus, the lasso technique with a guidewire over the retained stent was performed and successfully removed with no procedure-related complications. The patient is alive without dysphagia after 3 months follow-up.

Spinal cord compression related to an esophageal self-expandable metal stent

Spinal cord compression related to an esophageal self-expandable metal stent

Endoscopic removal of a retained esophageal stent using the stent-in-stent technique

Video 1Stent-in-stent technique for removal of retained esophageal self-expanding metal stent.

Endoscopic extraction of a gastric foreign body by means of an esophageal self-expanding metal stent.

Endoscopic extraction of a gastric foreign body by means of an esophageal self-expanding metal stent.

Percutaneous Endoscopic Necrosectomy-A Review of the Literature.

In this article, an attempt was made to clarify the role of percutaneous endoscopic necrosectomy (PEN) in the interventional treatment of pancreatic necrosis. A comprehensive review of the current literature was performed to identify publications on the role of PEN in patients with consequences of acute necrotizng pancreatitis. The aim of the study was to review the literature on minimal invasive necrosectomy, with emphasis on PEN using esophageal self-expanding metal stents (SEMS). The described results come from 15 studies after a review of the current literature. The study group comprised 52 patients (36 men and 16 women; mean age, 50.87 (13–75) years) with walled-off pancreatic necrosis, in whom PEN using a self-expandable esophageal stent had been performed. PEN was successfully completed in all 52 patients (100%). PEN complications were observed in 18/52 (34.62%) patients. Clinical success was achieved in 42/52 (80.77%) patients, with follow-up continuing for an average of 136 (14–557) days. In conclusion, the PEN technique is potentially effective, with an acceptable rate of complications and may be implemented with good clinical results in patients with pancreatic necrosis.

Inversion technique under fluoroscopy for removal of self-expanding nitinol esophageal stent after long-term placement: review of 107 consecutive cases.

Removal of self-expanding esophageal metal stents that have been implanted for a long time can be difficult and risky. In this paper, we describe the use of the "inversion technique" under fluoroscopy for removal of self-expandable nitinol esophageal stents that have been placed for long periods and evaluate the effectiveness and safety of the method. Retrospective analysis of patients who underwent removal of self-expanding nitinol esophageal stents by the inversion technique under fluoroscopy at our center. Demographic characteristics, type of esophageal stents, stent retention time, reasons for stent removal, and related complications were collected from the case records and analyzed. A total of 112 metal esophageal stents (62 fully covered esophageal stents and 50 partially covered esophageal stents) were extracted from the 107 patients included in the study. Indications for stent implantation were malignant esophageal stenosis (27 patients), benign esophageal stenosis (42 patients), and esophageal fistula (38 patients). Median duration of stent retention was 77days (29-727days). All stents were removed successfully without major complications such as esophageal rupture, massive hemorrhage, asphyxia, or cardiorespiratory arrest. Inversion technique under fluoroscopy appears to be a safe, effective, and quick procedure for removal of self-expanding nitinol esophageal stent after long-term placement.

Use of a self-expanding metal stent to treat acute esophageal perforation in a 4-year-old child

Esophageal perforations are associated with a high morbidity and mortality in the pediatric population. Most cases are managed conservatively with antibiotics, nutritional supplementation, and percutaneous drainage of fluid collections. Direct surgical repair is reserved for patients with hemodynamic instability or evidence of clinical worsening due to the high risk of postoperative complications. Utilization of stents in the treatment of acute esophageal perforation has become well-established in adults, but evidence remains lacking in the pediatric population. We present the case of a 4-year old male with an acute esophageal perforation who was successfully treated with an esophageal self-expanding metal stent (SEMS) in lieu of direct surgical repair. He failed extubation on postoperative day (POD) 6 due to tracheal compression by the oversized stent but exhibited good healing with successful extubation on POD 13. This case report demonstrates that esophageal stents may be a promising alternative to surgical repair in the pediatric population. Further studies and trials should be performed to compare the effectiveness of esophageal stenting to direct surgical repair. Modification and downsizing of the adult SEMS design for pediatric anatomy is recommended to prevent complications such as tracheal compression and prolonged intubation.

Fluoroscopic removal of fractured, retained, embedded Z self-expanding metal stent using a guidewire lasso technique: A case report

BACKGROUNDThere are few reports of a fractured esophageal self-expanding metallic stent (SEMS) and the lasso retrieval technique, forming a guidewire loop by directing the guidewire back up the external stent for retrieval. CASE SUMMARYA 74-year-old man complained of dysphagia approximately 6 mo after radical resection of esophageal cancer. Benign anastomotic stenosis was diagnosed, and a 20 mm in diameter and 60 mm in length esophageal covered SEMS was inserted after repeated balloon dilatation. About 13.5 mo after stenting, dysphagia recurred and esophagography showed severe stenosis above the proximal stent and stent removal was performed. One-third of the stent was removed and the fractured stent remained in the proximal esophagus. A suction tube was introduced through the guidewire and then the guidewire was grabbed, acting like a “lasso” on tightening. The remaining fractured stent was successfully removed by slowly pulling back the guidewire, with no fragments of stent wires retained.CONCLUSIONThe guidewire lasso technique is a simple, effective method of removing esophageal SEMS in rare cases of stent fracture.

Сравнительный анализ стентирования и гастростомии у больных со злокачественной патологией пищевода и пищеводно-желудочного перехода

Objective — to analyze the results of esophageal stenting in comparison with gastrostomy in patients with malignant dysphagia. Material and methods. The first group consists of 100 men and 42 women with malignant dysphagia, who underwent stenting of the esophagus and cardia with self-expanding metal stents. The group consists of 142 people aged 43 to 90 years. Stenting of the esophagus in this group was performed with the aim of resolving malignant stenosis of the esophagus in 71 patients: malignant stenosis of the esophageal-gastric junction in 59 patients and extraorgan compression of the esophagus from the outside in 12 patients. The second group consisted of 164 people in the age group from 33 to 89 years — 140 men and 24 women who underwent gastrostomy by the laparotor method according to Topprover in order to resolve malignant dysphagia. Gastrostomy was imposed on 110 patients due to malignant stenosis of the esophagus: with malignant stenosis of the esophageal-gastric junction in 44 patients and as a result of external compression in 10 patients. Results. Complications in patients after stenting in the remote period occurred in 17 cases. In the group of patients who underwent gastrostomy, complications requiring gastrostomy replacement occurred in 23 patients. Death occurred in one patient as a result of specific complications after gastrostomy. Life expectancy as a percentage, regardless of the pathology of the disease, does not have a large spread in the comparison groups and is approximately the same. The results of studies on life expectancy depending on the type of treatment (stenting-gastrostomy) and the location of the tumor lesion did not reveal statistically significant differences. Conclusions. Comparison of the results of implantation of self-expanding metal esophageal stents and gastrostomy by the laparotomic method in malignant dysphagia of the esophagus and esophagogastric junction was performed for the first time. In the course of the study, it was revealed that in the studied groups of patients, life expectancy in percentage terms, regardless of the pathology of the disease, does not have a wide spread and is approximately the same. There are no statistically significant differences in life expectancy depending on the type of treatment (stenting-gastrostomy) and the location of the tumor lesion in the analysis of variance according to the criterion of the least significant difference. Esophageal stenting with self-expanding metal stents is the least traumatic and effective method of choosing the resolution of malignant dysphagia of the esophagus and gastroesophageal junction with low complication rates, which allows to restore adequate nutrition, thereby improving the quality of life in incurable patients.

EUS-guided drainage using lumen apposing metal stent and percutaneous endoscopic necrosectomy as dual approach for the management of complex walled-off necrosis: a case report and a review of the literature

BackgroundEndoscopic ultrasound-guided drainage is suggested as the first approach in the management of symptomatic and complex walled-off pancreatic necrosis. Dual approach with percutaneous drainage could be the best choice when the necrosis is deep extended till the pelvic paracolic gutter; however, the available catheter could not be large enough to drain solid necrosis neither to perform necrosectomy, entailing a higher need for surgery. Therefore, percutaneous endoscopic necrosectomy through a large bore percutaneous self-expandable metal stent has been proposed.Case presentationIn this study, we present the case of a 61-year-old man admitted to our hospital with a history of sepsis and persistent multiorgan failure secondary to walled-off pancreatic necrosis due to acute necrotizing pancreatitis. Firstly, the patient underwent transgastric endoscopic ultrasound-guided drainage using a lumen-apposing metal stent and three sessions of direct endoscopic necrosectomy. Because of recurrence of multiorgan failure and the presence of the necrosis deeper to the pelvic paracolic gutter at computed tomography scan, we decided to perform percutaneous endoscopic necrosectomy using an esophageal self-expandable metal stent. After four sessions of necrosectomy, the collection was resolved without complications. Therefore, we perform a revision of the literature, in order to provide the state-of-art on this technique. The available data are, to date, derived by case reports and case series, which showed high rates both of technical and clinical success. However, a not negligible rate of adverse events has been reported, mainly represented by fistulas and abdominal pain.ConclusionDual approach, using lumen apposing metal stent and percutaneous self-expandable metal stent, is a compelling option of treatment for patients affected by symptomatic, complex walled-off pancreatic necrosis, allowing to directly remove large amounts of necrosis avoiding surgery. Percutaneous endoscopic necrosectomy seems a promising technique that could be part of the step-up-approach, before emergency surgery. However, to date, it should be reserved in referral centers, where a multidisciplinary team is disposable.

ID: 3520803 SELF-EXPANDABLE METAL STENTING FOR ESOPHAGEAL FISTULA CLOSURE: INCREASING THE ODDS OF SUCCESS.

Esophageal self-expanding metal stent (SEMS) can be considered for treatment of anastomotic leaks and fistulas. We aim to assess predictors for SEMS success in the closure of fistulas and anastomotic leaks.

Double hitch stitch is a novel technique for fixation of tracheal stent in a case of tracheoesophageal fistula: a case report

BackgroundCaudal tracheal stent migration can be potentially life threatening by causing distal luminal obstruction. We present a rare double hitch stitch procedure (for prevention of migration of tracheal stent), which is an external fixation technique in a case of tracheoesophageal fistula with tracheal and esophageal self-expandable metallic stent (SEMS).Case presentationA 50-year-old male patient who presented with cough and dyspnea was a known case of carcinoma of the esophagus with esophageal stent in situ. Computed tomography (CT) scan showed tracheoesophageal fistula with esophageal stent (esophageal SEMS) migrating into the trachea. Tracheal stenting was done with SEMS. Patient was followed up after 1 month with recurrent complaints of cough on deglutition. On follow-up bronchoscopy, migration of stent was observed. A rare procedure of double hitch stitch was performed with fixation of the tracheal stent (tracheal SEMS) using a percutaneous anchoring stitch, embedded in the subcutaneous tissue. Follow-up bronchoscopy after 1 month of the procedure showed no migration of stent.ConclusionFor the treatment of large tracheoesophageal fistula, stenting of both the trachea and the esophagus along with the double hitch stitch proved to be lifesaving. Stent migration prevention using “double hitch-stitch” is simple, safe, and successful, without any complications.