Esophageal Self-expandable Metal Stents Research Articles

Successful endoscopic removal of three embedded esophageal self-expanding metal stents

In the report, we describe a case of refractory benign esophageal strictures from esophageal cancer after an operation for the placement of three partially covered self-expanding metal stents (SEMSs), which were all embedded in the esophageal wall. Using the stent-in-stent technique, the three embedded SEMSs were successfully removed without significant complications. To the best of our knowledge, few cases of the successful removal of multiple embedded esophageal SEMSs have been reported in the literature. This case also highlights that the stent-in-stent technique is effective for removing multiple embedded esophageal SEMSs.

Esophageal stenting for benign and malignant disease: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline.

This Guideline is an official statement of the European Society of Gastrointestinal Endoscopy (ESGE), endorsed by the European Society for Radiotherapy and Oncology (ESTRO), the European Society of Digestive Endoscopy (ESDO), and the European Society for Clinical Nutrition and Metabolism (ESPEN). The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was adopted to define the strength of recommendations and the quality of evidence. Main recommendations for malignant disease 1 ESGE recommends placement of partially or fully covered self-expandable metal stents (SEMSs) for palliative treatment of malignant dysphagia over laser therapy, photodynamic therapy, and esophageal bypass (strong recommendation, high quality evidence). 2 For patients with longer life expectancy, ESGE recommends brachytherapy as a valid alternative or in addition to stenting in esophageal cancer patients with malignant dysphagia. Brachytherapy may provide a survival advantage and possibly a better quality of life compared to SEMS placement alone. (Strong recommendation, high quality evidence.) 3 ESGE recommends esophageal SEMS placement as the preferred treatment for sealing malignant tracheoesophageal or bronchoesophageal fistula (strong recommendation, low quality evidence). 4 ESGE does not recommend the use of concurrent external radiotherapy and esophageal stent treatment. SEMS placement is also not recommended as a bridge to surgery or prior to preoperative chemoradiotherapy. It is associated with a high incidence of adverse events and alternative satisfactory options such as placement of a feeding tube are available. (Strong recommendation, low quality evidence.) Main recommendations for benign disease 1 ESGE recommends against the use of self-expandable stents (SEMSs) as first-line therapy for the management of benign esophageal strictures because of the potential for adverse events, the availability of alternative therapies, and costs (strong recommendation, low quality evidence). 2 ESGE suggests consideration of temporary placement of SEMSs as therapy for refractory benign esophageal strictures (weak recommendation, moderate evidence). Stents should usually be removed at a maximum of 3 months (strong recommendation, weak quality evidence). 3 ESGE suggests that fully covered SEMSs be preferred over partially covered SEMSs for the treatment of refractory benign esophageal strictures, because of their lack of embedment and ease of removability (weak recommendation, low quality evidence). 4 For the removal of partially covered esophageal SEMSs that are embedded, ESGE recommends the stent-in-stent technique (strong recommendation, low quality evidence). 5 ESGE recommends that temporary stent placement can be considered for treating esophageal leaks, fistulas, and perforations. The optimal stenting duration remains unclear and should be individualized. (Strong recommendation, low quality evidence.) 6 ESGE recommends placement of a SEMS for the treatment of esophageal variceal bleeding refractory to medical, endoscopic, and/or radiological therapy, or as initial therapy for patients with massive esophageal variceal bleeding (strong recommendation, moderate quality evidence).

Early pain detection and management after esophageal metal stent placement in incurable cancer patients: A prospective observational cohort study.

Background and study aims: Studies of esophageal self-expandable metal stents (SEMS) mainly focus on efficacy and recurrent dysphagia. Retrosternal pain has been described in up to 14 % of these patients, however, prospective daily pain assessment has not yet been performed. We conducted a prospective study to evaluate the occurrence and management of pain after esophageal SEMS deployment. Patients and methods: A total of 65 patients who underwent SEMS placement for incurable malignant esophageal stenosis were included. Patients used a diary to record intensity of pain twice daily for 2 weeks, according to the Numeric Rating Scale (NRS). A pain score ≥ 4 was used to determine whether patients experienced significant pain. If pain occurred, acetaminophen was used and, in cases of ongoing pain, an opiate was prescribed. Dose, duration, and kind of analgesic were noted. Results: The rate of significant pain increased from 0 % at baseline to 60 % on Day 1 (P < 0.001), followed by 37 % and 25 % on Days 7 and 14, respectively. The rate of analgesics use increased from 20 % at baseline to 78 % on Day 1 (P < 0.001), followed by 72 % and 62 % on Days 7 and 14, respectively. The use of opiates increased from 14 % at baseline to 42 % on Day 1 (P < 0.001). No variables associated with SEMS related pain were found. Conclusions: Two-thirds of patients experience significant pain after esophageal SEMS insertion and analgesics, including opiates, are frequently required. Patients need to be informed and preventive prescription of analgesia should be considered in order to improve quality of life.

Tu1215 Impact of Self-Expanding Metal Esophageal Stent (SEMS) in Esophageal Anastomosis Leakages - A Retrospective Single Center Case Series

Tu1215 Impact of Self-Expanding Metal Esophageal Stent (SEMS) in Esophageal Anastomosis Leakages - A Retrospective Single Center Case Series

Tu1249 Retrospective Analysis of Endoscopic Suture Anchoring of Esophageal Fully-Covered Self-Expandable Metal Stents (FCSEMS)

Tu1249 Retrospective Analysis of Endoscopic Suture Anchoring of Esophageal Fully-Covered Self-Expandable Metal Stents (FCSEMS)

Tu1246 Stent Migration Following Endoscopic Suture Fixation of Esophageal Self-Expandable Metal Stents: A Systematic Review and Meta-Analysis

Tu1246 Stent Migration Following Endoscopic Suture Fixation of Esophageal Self-Expandable Metal Stents: A Systematic Review and Meta-Analysis

Predictors of esophageal self-expandable metal stent migration: An academic center study

Predictors of esophageal self-expandable metal stent migration: An academic center study

Endoscopic stents in the management of anastomotic complications after foregut surgery: new applications and techniques

BackgroundAnastomotic complications after foregut surgery include leaks, fistulas, and late strictures. The management of these complications can be challenging, and it may be desirable to avoid complex reoperation. ObjectivesWe aim to describe the indications and outcomes of the use of esophageal self-expanding metal stents in the management of postoperative anastomotic complications after foregut surgery. SettingTertiary-referral academic medical center. MethodsWe performed a retrospective review of a prospectively managed database. Data was collected on patient demographic characteristics, work-up, intraprocedure findings, and outcomes. ResultsFrom October of 2009 to November of 2014, 47 patients (mean age 51.1, 36 women and 11 men) underwent endoscopic stent placement for anastomotic complications following upper gastrointestinal (UGI) surgery. The median time from index operation to endoscopic stent placement was 52 days (range 1–5280 days). Indications were sleeve leak or stenosis, gastrojejunal leak or stenosis after Roux-en-Y gastric bypass (RYGB), pouch staple-line leak after RYGB, enterocutaneous fistula, perforation after endoscopic dilation, upper gastrointestinal bleeding after peroral endoscopic myotomy (POEM), and peptic stricture after POEM. Symptomatic improvement occurred in 76.6% of patients, and early oral intake was initiated in 66% of patients. 14 patients (29.8%) went on to require definitive surgical intervention for persistent symptomatology. The average follow-up was 354.1 days (range 25–1912 days). ConclusionThis paper describes the use of endoscopic stent therapy for a variety of pathologies after upper gastrointestinal surgery. We demonstrate that, in the appropriate setting, it is an effective and less-invasive therapeutic approach.

Stent type used does not impact complication rate or placement time but can decrease treatment cost for benign and malignant esophageal lesions.

To evaluate if differences exist between self-expanding esophageal metal stents (SEMS) and self-expanding esophageal plastic stents (SEPS) when used for benign or malignant esophageal disorders with regard to safety, efficacy, clinical outcomes, placement ease and cost. A retrospective analysis was performed to evaluate outcome in patients having SEPS/SEMS placed for malignant or benign esophageal conditions from January 2005 to April 2012. Inclusion criteria was completed SEMS/SEPS placement. Outcomes assessed included technical success of and time required for stent placement, procedure-related complications, need for repeat intervention, hospital stay, mortality and costs. Forty-three patients underwent stent placement for either benign/malignant esophageal disease during the study period. Thirty patients had SEMS (25 male, mean age 59.6 years old) and 13 patients had SEPS (10 male, mean age 61.7 years old). Placement outcome as well as complication rate (SEPS 23.1%, SEMS 25.2%) and in-hospital mortality (SEPS 7.7%, SEMS 6.7%) after placement did not differ between stent types. Migration was the most frequent complication reported occurring equally between types (SEPS 66.7%, SEMS 57.1%). SEPS was less costly than SEMS, decreasing institutional cost by $255/stent. SEPS and SEMS have similar outcomes when used for benign or malignant esophageal conditions. However, SEPS use results in decreased costs without impacting care.

Safety of endoscopic self-expanding metallic stent placement in esophageal cancer without fluoroscopy

Background: Esophageal self-expanding metal stent (SEMS) placement is traditionally done under fluoroscopic guidance. But few authors have shown that esophageal SEMS can be placed without fluoroscopy. The study aimed to assess the safety and success of SEMS placement in patients with carcinoma esophagus under endoscopic guidance without fluoroscopy. Methods: All patients who underwent esophageal stenting for palliation of malignant dysphagia over a 4 year period were reviewed retrospectively. Consecutive patients were identified from the endoscopy report books and inpatient admission files of medical gastroenterology department, Victoria hospital. In one hundred and ten patients with inoperable carcinoma esophagus, SEMS was placed. The procedure consisted of proximal release SEMS insertion under endoscopic guidance without the use of fluoroscopy. They were followed at one week and one month after deployment. All the complications related to the procedure were recorded. Results: 110 patients underwent endoscopic esophageal SEMS insertion for palliation of malignant dysphagia. Stent was successfully placed in all the patients. The mean age of patients was 57.38±21.21 years (range: 31 to 84 years). Dilatation of stricture before SEMS placement was needed in 33 patients (30%). No patient had esophageal perforation or stent migration. Conclusions: Esophageal stent insertion in carcinoma esophagus under endoscopic guidance without fluoroscopy is successful, safe and effective for palliation of dysphagia.

Large tracheobronchial fistula due to esophageal stent migration: Let it be!

We report tracheal-bronchial migration of a covered esophageal self-expanding metal stent used to relieve dysphagia in a patient with advanced esophageal cancer. The stent eroded the trachea and completely occluded the main left bronchus. Surgery was contraindicated due to her poor clinical condition, and insertion of another stent in the trachea, esophagus, or both was contraindicated due to extension of the fistula. Esophageal exclusion with a combination of cervical esophagostomy and an enteral feeding tube was the only feasible treatment to minimize spoilage by aspirated saliva and provide enteral nutrition.

Tu1598 Placement of Fully-Covered Self-Expanding Metal Esophageal Stents for Relief of Dysphagia Is Safe and Effective in Patients Receiving Neoadjuvant Cheomoradiation

For patients with locally advanced esophageal cancer undergoing neoadjuvant therapy, the traditional management of malignant dysphagia has been the use of enteral feeding tubes or parenteral nutrition. The use of fully-covered self-expanding metal stents (FCSEMS) has become an acceptable alternative option in this population. However, it is unknown what the safety and efficacy is in the use of FCSEMS in patients undergoing neoadjuvant chemoradiation. AIMS: To assess the safety and efficacy of FCSEMS in patients with locally advanced esophageal cancer undergoing neoadjuvant chemoradiation.

A New Method for Distal Repositioning of a Misplaced Esophageal Stent

Figure 1 The endoscope is inserted through the distal end of Several techniques for managing migrated and misplaced self-expanding esophageal metal stents have been described.1--5 However, most of these techniques apply only when there is distal stent dislodgment. When there is proximal stent migration or misplacement, and unless there is a lasso at the distal flange, trying to reposition the stent distally through the stenotic tumor can be challenging. Although it may be tried by grasping distal tines with forceps or inflating a dilating balloon within the stent and applying gentle pressure, it seldom results. We herein report an endoscopic approach for an easy and safe reposition of proximal dislodged esophageal metal stents that, as far as we are aware, was never described before. The stent is removed by grasping the lasso on the proximal end of the stent with an alligator jaw grasping forceps. Outside the patient, the lasso is released and the stent is turned upside down. The endoscope is then introduced through the distal end of the stent until the proximal end, where the lasso is re-grasped by the forceps and pulled back, allowing the upper flange of the stent to collapse over the tip of the endoscope (Fig. 1). The body of the stent is generously lubricated with aqueous jelly and stretched along the endoscope. The patient is reintubated with gently passage of the endoscope and the stent through the pharynx

Efficacy and safety of a new fully covered self-expandable non-foreshortening metal esophageal stent

Fully covered esophageal self-expandable metal stents (SEMSs) are potentially removable but can be associated with high migration rates. For precise positioning, non-foreshortening SEMSs are preferred. Recently, a new fully covered non-foreshortening SEMS with anti-migration features was introduced. To evaluate the efficacy and safety of this new esophageal SEMS. Retrospective study. Single, tertiary-care center. Consecutive patients with malignant and benign strictures with dysphagia grade of≥3 and patients with fistulas/leaks were studied. Stent placement and removal. Technical success in stent deployment/removal, efficacy in relieving dysphagia and sealing fistulas/leaks, and adverse events. Forty-three stents were placed in 35 patients (mean [± standard deviation] age 65 ± 11 years; 31 male), 24 for malignant and 11 for benign (5 strictures, 6 leaks) indications. Technical success in precise SEMS placement was 100%. The after-stent dysphagia grade improved significantly (at 1 week: 1.5 ± 0.7; at 4 weeks: 1.2 ± 0.4; baseline: 3.8 ± 0.4; P< .0001). Twenty stents were removed for clinical indications, with technical success of 100%. All leaks sealed after SEMS placement and did not recur after stent removal. All benign strictures recurred after stent removal. Adverse events included migration (14%), chest pain (11%), and dysphagia from tissue hyperplasia (6%). There was no stent-related mortality. Nonrandomized, single-center study. The new esophageal SEMS was effective in relieving malignant dysphagia, allowed for precise placement, and was easily removable. It was effective in treating benign esophageal fistulas and leaks. Stent-related adverse events were acceptable.

Pancreatic Necrosectomy Using Covered Esophageal Stents

Endoscopic necrosectomy for necrotizing pancreatitis has been increasingly used as an alternative to surgical or percutaneous interventions. The use of fully covered esophageal self-expandable metallic stents may provide a safer and more efficient route for internal drainage. The aim of this study was to evaluate the safety and efficacy of endoscopic treatment of pancreatic necrosis with these stents. A retrospective study at 2 US academic hospitals included patients with infected pancreatic necrosis from July 2009 to November 2012. These patients underwent transgastric placement of fully covered esophageal metallic stents draining the necrosis. After necrosectomy, patients underwent regular sessions of endoscopic irrigation and debridement of cystic contents. The efficacy endpoint was successful resolution of infected pancreatic necrosis without the need for surgical or percutaneous interventions. Seventeen patients were included with the mean age of 41±12 years. A mean of 5.3±3.4 sessions were required for complete drainage and the follow-up period was 237.6±165 days. Etiology included gallstone pancreatitis (6), alcohol abuse (6), s/p distal pancreatectomy (2), postendoscopic retrograde cholangiopancreatography pancreatitis (1), medication-induced pancreatitis (1), and hyperlipidemia (1). Mean size of the necrosis was 14.8 cm (SD 5.6 cm), ranging from 8 to 19 cm. Two patients failed endoscopic intervention and required surgery. The only complication was a perforation during tract dilation, which was managed conservatively. Fifteen patients (88%) achieved complete resolution. Endoscopic necrosectomy with covered esophageal metal stents is a safe and successful treatment option for infected pancreatic necrosis.

Tracheal penetration and tracheoesophageal fistula caused by an esophageal self-expanding metallic stent.

Tracheal penetration of esophageal self-expanding metallic stents (SEMS) with/without tracheoesophageal fistula (TEF) formation is a rare occurrence. We report the case of a 66-year-old female patient with advanced esophageal squamous cell carcinoma who had undergone palliative esophageal stenting on three occasions for recurrent esophageal stent obstruction. On evaluation of symptoms of breathing difficulty and aspiration following third esophageal stent placement, tracheal erosion and TEF formation due to the tracheal penetration by esophageal stent were diagnosed. The patient was successfully managed by covered tracheal SEMS placement under flexible bronchoscopy.

Endoscopic Removal of an Esophageal Stent After Diffuse Hyperplastic Tissue Ingrowth

Endoscopic placement of esophageal Self-Expandable Metal Stents (SEMS) is a therapeutic option for post-surgical esophageal leaks. Partially covered SEMS are mainly designed for malignant esophageal strictures, but are used off-label to close post-surgical leaks due to their lower migration rate than fully covered SEMS, and better adherence to the esophageal wall. Partially covered esophageal SEMS can achieve post-surgical fistula healing, but their removal is difficult due to tissue ingrowth through the uncovered part. A challenging case of a difficult removal of a partially covered esophageal SEMS (remove the indefinite article) is (below) presented.

A case of an iatrogenic esophageal perforation salvaged by anterograde–retrograde rendezvous approach and stenting

Esophageal self-expandable metal stent placement is an effective treatment for palliation of malignant dysphagia, which has a low insertion-related complication rate. However, stent-related perforation can be a life-threatening event. We experienced a patient with advanced esophageal cancer who developed an iatrogenic esophageal perforation resulting from incorrect stent insertion. After removal of the original stent, we attempted to perform antegrade insertion of a second covered stent, but failed because we were not able to find the true lumen to the stomach. Due to his poor general condition and the high risk of surgical esophageal repair, we attempted esophageal stent placement using the combined antegrade–retrograde rendezvous technique using the gastrostomy route. By the performance of esophageal stenting using the rendezvous technique, we were able to avoid risky surgical esophageal repair. We expect that the rendezvous technique may be feasible therapy for patients with iatrogenic esophageal perforation when conventional antegrade endoscopic treatment fails.

Fractured esophageal self-expandable metallic stent in a patient with advanced lung cancer: a case report and review of the literature

Self-expandable metallic stents (SEMS) are the currently recommended treatment modality for palliation of dysphagia resulting from unresectable malignant esophageal obstruction. The most common post-SEMS-placement complications are migration, perforation, bleeding, and tumor ingrowth or overgrowth. We report herein a patient with advanced lung cancer invading the esophagus with the very rare late complication of spontaneous stent fracture 8 months after esophageal SEMS placement, together with a comprehensive review of the related literature. To the best of our knowledge, this is the first report describing the spontaneous fracture of an esophageal SEMS inserted for the palliative treatment of malignant esophageal obstruction due to extrinsic invasion by lung cancer.

Single-session ERCP in patients with previous Roux-en-Y gastric bypass using percutaneous-assisted transprosthetic endoscopic therapy: a case series

Endoscopic retrograde cholangiopancreatography (ERCP) remains technically challenging following Roux-en-Y gastric bypass (RYGB). Various techniques have been described to access the excluded stomach. We describe our experience using percutaneous-assisted transprosthetic endoscopic therapy (PATENT) to perform antegrade ERCP. Balloon enteroscopy was used to access the excluded stomach. Direct retrograde percutaneous endoscopic gastrostomy (RPEG) was performed and an esophageal self-expandable metal stent (SEMS) was deployed within the gastrostomy tract. A duodenoscope was advanced through the SEMS and antegrade ERCP was performed. Following ERCP, a gastrostomy tube was placed through the SEMS to maintain patency. Five patients underwent successful antegrade ERCP using PATENT. All patients had a diagnosis of sphincter of Oddi dysfunction. Biliary sphincterotomy was performed in all patients and liver enzymes normalized in four patients with preprocedural elevations. In conclusion, antegrade ERCP employing PATENT is feasible and can be performed during a single endoscopic session in patients with previous RYGB.