Esophageal Self-expandable Metal Stents Research Articles

TECHNICAL DIFFICULTIES AND PROCEDURAL COMPLICATIONS IN CLOSING MALIGNANT ESOPHAGEAL-RESPIRATORY FISTULAS.

SUMMARYThe aim of the study was to outline technical difficulties and procedural complications of using partially covered esophageal self-expandable metal stents (SEMSs) in malignant esophageal respiratory fistulas (ERFs) as a palliative treatment option. In this study, 150 patients with malignant dysphagia underwent treatment with SEMSs. A total of 36 ERFs were detected through endoscopic or clinical assessment. Complete fistula sealing with SEMSs was possible in 35 of the 36 patients. The majority of fistulas were diagnosed in male patients with advanced esophageal cancer. All of them presented with prolonged dysphagia and cachexia. Stent migration or tumoral overgrowth was identified in 6 cases with recurrent dysphagia, and required a second stent insertion. SEMSs were highly efficient in 98% of the patients studied with ERFs, with successfully sealed ERFs after the first attempt, with an overall median survival rate of 92 days. The technique of esophageal SEMS placement is simple and can be rapidly mastered. Patients with ERFs have a respiratory shunt that makes intubation difficult and is often avoided. Restoring oral feeding increased the patient quality of life. SEMS placement is generally safe, but has few associated postoperative complications.

Adaptation of endovascular technique of self-expandable metal esophageal stent implantation in palliative treatment of malignant dysphagia in the course of esophageal and bronchial cancers: A one-center study.

Esophageal stent implantation is an alternative for microjejunostomy or total parenteral nutrition in the palliative treatment of malignant dysphagia in the course of esophageal and advanced bronchial cancers infiltrating the esophagus. The procedure of implanting an esophageal self-expanding metal stent (SEMS) is performed with gastroscopic guidance under general anesthesia. To analyze the efficacy and safety of a simplified technique (without gastroscopic guidance in local anesthesia) of esophageal SEMS implantation in patients with malignant dysphagia in the course of esophageal and bronchial cancers. This is a retrospective analysis of consecutive procedures of uncovered esophageal SEMS implantation performed with a simplified adaptation of the endovascular technique (Seldinger wire) in patients with esophageal and bronchial cancers and poor performance status. The procedures were done in a single surgical center over an 8-year period in 27 patients who were referred from oncology departments with esophageal stenosis confirmed using gastroscopy and who were being treated for malignant dysphagia. The study endpoints were effectiveness (a decrease in dysphagia from grade 3 or 4 to grade 1 after the procedure) and complications related to the procedures (including restenosis and stent migration). In all 27 patients, the SEMS were effectively implanted, enabling enteral nutrition after the procedure. No early complications related to the procedure were observed. A single patient developed restenosis 14 days after the procedure, which required re-stenting. The simplified method for SEMS implantation described herein may be considered an option in the palliative treatment of patients with malignant dysphagia in the course of esophageal and bronchial cancers and poor performance status, especially in facilities with limited access to endoscopy.

Performance and Predictors of Migration of Partially and Fully Covered Esophageal Self-Expanding Metal Stents for Malignant Dysphagia

Self-expanding metal stents (SEMS) are routinely used to palliate malignant dysphagia. However esophageal SEMS can migrate or obstruct due to epithelial hyperplasia. The aim of this study was to evaluate the rates and factors predicting migration and obstruction, and the nutritional outcomes in partially covered (pc) vs. fully covered (fc) SEMS vs. fcSEMS with antimigration fins (AF) placed for malignant dysphagia. A retrospective review of consecutive patients undergoing SEMS placement for malignant dysphagia at three academic medical centers. Among 357 patients, there were 55 (15.4%) stent migrations, 45 (12.6%) obstructions from epithelial hyperplasia, and 20 (5.6%) food impactions. Median overall survival was 79 days (IQR 41,199). The percent weight change/change in albumin at 30 and 60 days after SEMS placement were -2.24%/-0.544 g/dL and -2.98%/-0.55 g/dL, respectively. Stent migration occurred significantly more often with fcSEMS than pcSEMS (25.3% vs 10.9%; P < .003), but there was no difference when either group was compared to fcSEMS-AF (19.3%). The overall rate of epithelial hyperplasia resulting in stent obstruction was low (12.6%) and not different between stent types. Factors associated with increased risk of SEMS migration on multivariable logistic regression included stricture traversability with a diagnostic endoscope (OR,2.37; 95% CI, 1.29-4.35) and use of fcSEMS (OR, 2.56; 1.31-5.00) or fcSEMS-AF (OR, 2.30, 1.03-5.14). Traversability of a malignant esophageal stenosis predicts SEMS migration. In these patients with a limited overall survival, pcSEMS are associated with lower rates of stent migration and similar rates of obstruction compared to fcSEMS.

Clinical score predicting a successful endoscopic approach of esophageal anastomotic leaks: external validation.

Recently, a clinical prediction rule has been proposed to predict the chance of successful endoscopic stenting in benign esophageal anastomotic leakage, perforation and fistula. We aimed to validate this score in a cohort of patients with anastomotic leaks managed with self-expanding metal esophageal stents, by assessing technical and clinical success rates and comparing the agreement between the predicted and the actual clinical success. A multicenter retrospective cohort study including patients submitted to endoscopic stenting due to anastomotic leak was conducted. Variables of the score (leak size, location and C-reactive protein) were collected and the chance of success (≤50, 50-70 and ≥70%) and its accuracy was assessed. Fifty-three patients, submitted to esophageal stenting after cancer (n = 47) and bariatric surgery were included. Clinical success was achieved in 62% of patients. The area under the ROC curve to differentiate between successful and failed therapies showed a good discriminative power of the score (AUC 0.705; P < 0.01). For a predicted chance of success >50%, the positive predictive value was 72.5%; for a chance of success ≤50%, the negative predictive value was 69.2%. The application of this predictive model in patients with anastomotic leaks proved to be valid in a different cohort from that in which it was derived. Its usefulness in clinical practice may be anticipated, favoring stenting in patients with a chance of success >50%. However, we must be cautious in patients with a lower probability of success and a case-by-case decision should be made.

Palliative Endoscopic Esophageal Stenting for Malignant Esophageal Tumour Complications: A Clinical Case and Single Centre Experience in Latvia

Abstract Esophageal stenting is used in patients with malignant esophageal tumours to reduce dysphagia and inanition. The objective of this study was to analyse the main reasons for esophageal stenting in Rīga East Clinical University Hospital (RECUH) and their association with dysphagia and mortality. A cross-sectional study of all patients hospitalised in RECUH who received esophageal self-expanding metal stents (SEMS) from October 2013 to December 2015 was performed. A total of 29 patients, 24 (82.8%) male and 5 (17.2%) female, with mean age 63.7 ± 11.3 years, underwent the procedure. The most common indications for stenting were tumour-related stenosis (52.9%) and fistulae (17.6%). Mean time from establishing the diagnosis of esophageal cancer to stent placement was 338.6 days. Median survival after stenting was 4.8 months. A complex case of a patient requiring placement of three palliative stents illustrates the challenges of esophageal cancer care. Esophageal stent placement is an effective palliative method for treating tumour-related symptoms but carries risks of stent complications and fistula development over time. SEMS are being successfully used in cancer patient treatment in Latvia.

1687 Argon Plasma Coagulation-Based Removal of Partially-Covered Esophageal Self-Expanding Metal Stent for Anastomotic Leaks Despite Extended Embedment - Challenging Current Standards of Care

INTRODUCTION: Benign esophageal anastomotic leaks can be effectively treated by the placement of esophageal stents. Endoscopic therapy for esophageal anastomotic leaks remains non-standardized. Partially covered self-expanding metal stents (PSEMS) are superior to fully covered stents in the treatment of anastomotic leaks by providing a better seal and therefore promoting quicker healing with shorter time to oral intake. However, the removal of partially covered SEMS is technically challenging due to these stents’ inherent risk of stimulating mucosal hyperplasia and without special technique will lead to esophageal perforation, avulsion or fistula formation during attempted removal. Generally, anastomotic leaks require at least 4 weeks of stent dwelling for clinical success with an average treatment time of 6–8 weeks with recommendations for stent removal by 3 months. CASE DESCRIPTION/METHODS: A 69-year-old man with esophageal adenocarcinoma of the distal esophagus status post neoadjuvant chemoradiation followed by Ivor-Lewis esophagectomy with pyloroplasty presented to the hospital with hematemesis and found to have developed two anastomotic leaks within one month of surgery. He was treated with PSEMS measuring 12.5 cm × 20 mm (25 mm at ends). Three months after placement, elective EGD revealed previously placed stent covering the anastamosis with tissue ingrowth at the uncovered ends. Coagulation using argon plasma at 0.8 liters/minute and 55 watts was performed to free the uncovered ends of the stent by destruction of ingrown tissue. The proximal end was freed, however, some tissue remained over the distal end even after extensive attempts at coagulation and debridement. Two days later, the procedure was repeated with continued fulguration to ablate the remaining ingrown tissue at the uncovered ends using argon plasma and a soft over-the-scope cap was used to remove the necrosed tissue. Stent was eventually removed with rat-tooth forceps. DISCUSSION: There are many described methods for partially covered esophageal stent removal. We propose a safe and effective method for the removal of partially covered esophageal SEMS with the use of Argon Plasma Coagulation, a soft over-the-scope cap and rat-tooth forceps after an extended stent dwelling time of three months. With this efficient, safe and effective method of stent removal, it is essential that the use of partially covered esophageal SEMS be standard of care in the temporary management of anastomotic leaks. Watch the video: http://bit.ly/2SooiEC.

Novel use of esophageal self-expandable metal stents to perform EUS-fine-needle aspiration cytology from retroperitoneal lymph nodes in acase of carcinoma of the esophagus.

A 40-year-old man presented with dysphagia of 2 months’ duration. Gastroscopy revealed ulceroproliferative growth in the mid-thoracic and lower-thoracic esophagus (Fig. 1). A biopsy specimen showed squamous cell carcinoma. The patient underwent positron emission tomography (PET) CT for staging of the disease.

Case Control Study of Post-endoscopic Variceal Ligation Bleeding Ulcers in Severe Liver Disease: Outcomes and Management

Background and Aims: The management of post-endoscopic variceal ligation (EVL) bleeding ulcers (PEBUs) is currently based on local expertise and patients liver disease status. The present retrospective study investigated associations between the endoscopic morphology of PEBUs and patient outcomes.Methods: Patients underwent EVL (primary or secondary), from January 2015 to January 2018, in two tertiary care hospitals in India (ILBS New Delhi and Dharamshila Narayana New Delhi). Mortality rates were determined at post-EVL day five and week six. PEBUs were typified based on Jamwal & Sarin classification system as follows: A, ulcer with active spurting; B, ulcer with ooze; C, ulcer base with visible vessel or clot; and D, clean or pigmented base.Results: Of 3854 EVL procedures, 141 (3.6%) patients developed PEBU, and 46/141 (32.6%) suffered mortality. Among the former, the PEBU types A, B, C, and D accounted for 17.7, 26.2, 36.3, and 19.8%, respectively. Of those who died, 39.1, 30.4, 21.7, and 8.8% had PEBU types A, B, C, and D. Treatments included transjugular intrahepatic portosystemic shunts (TIPS), esophageal self-expandable metal stent (SEMS), glue and sclerosant injection, Sengstaken-Blakemore tube placement and liver transplant. On univariate analysis, no correlation with hepatic venous pressure gradient, TIPS placement, size of varices, or number of bands was found. The Model for End-Stage Liver Disease (MELD)-sodium score correlated positively with outcome. After adjusting for MELD-sodium score, mortality was best predicted by type-A ulcer (p = 0.024; OR 8.95, CI 1.34–59.72).Conclusions: PEBU occurred in 3.6% of a large EVL cohort. Stratifying patients based on PEBU type can help predict outcomes, independent of the MELD-sodium score. Classifying PEBUs by endoscopic morphology may inform treatment strategies, and warrants further validation.

Esophageal self-expandable metal stent placement for the palliation of dysphagia due to lung cancer.

This study aims to report our experience with esophageal self-expendable metal stents for the palliation of malignant dysphagia and tracheoesophageal fistulas caused by lung cancer. Esophageal self-expandable metal stents were deployed in 56 patients (55 males, 1 female; mean age 63.5 years; range, 42 to 79 years) with malignant dysphagia due to lung cancer between August 2002 and May 2018. Of the patients, 34 had received previous chemoradiotherapy, eight only chemotherapy, and three only radiotherapy, while four had pneumonectomy. Tracheoesophageal fistula was coexisting in 12 patients (21%). Stents were inserted under fluoroscopic control over guide-wire in 28 patients and under flexible endoscopic control in the remaining 28 patients. One stent was used in all patients, except two patients with tracheoesophageal fistula, one patient who had an external compression causing downward migration of stent, and two patients who had tumor progression. Dysphagia improved in all patients after stent insertion. Tracheoesophageal fistula was sealed off in all patients. All patients remained asymptomatic without dysphagia symptoms during the follow-up period except for two patients who underwent gastrostomy. All patients with tracheoesophageal fistula died. Their mean duration of survival was 2.8 months. Of the patients with tracheoesophageal fistula, one died of mediastinitis, one died of esophageal perforation, while the others died of cancer-related reasons. Of the dysphagia patients without tracheoesophageal fistula, all died except for two patients. Mean duration of survival in this group was 4.3 months. Dysphagia in lung cancer may have many underlying reasons. Self-expandable metal stents may provide satisfactory relief of dysphagia symptoms with minimal morbidity after a single procedure in patients with limited lifespan.

Successful Endoscopic Esophageal Stent Placement for Esophageal Anastomotic Leak

An anastomotic leak is one of the leading causes of death following gastric bypass surgery and sleeve gastrectomy. In patients who undergo sleeve gastrectomy, the most common site for these leaks is the proximal one-third of the stomach, near the gastroesophageal junction. Evaluation by Upper GI (UGI) contrast study will show extravasation at the site of the leak. Treatment options include surgical management, conservative management with percutaneous drainage, or endoluminal stent placement. This case report presents an endoscopic challenge that was overcome with the replacement of an esophageal stent and subsequent resolution of an esophageal anastomotic leak. A 60 year-old Hispanic female with a past medical history of morbid obesity status-post laparoscopic sleeve gastrectomy presented to the emergency department with a one day history of subjective fever, chills, right upper quadrant abdominal pain, and one episode of non-bloody diarrhea. A UGI series would reveal a proximal gastric anastomotic leak. An EGD was subsequently performed which revealed a fistula approximately 35cm from the incisors; as such, a 25mm diameter/12cm length self-expandable metal esophageal stent was deployed and appropriate placement was confirmed endoscopically and by fluoroscopy (Figure 1). After removal of the esophageal stent, there was persistence of the anastomotic leak, so a new 28mm diameter/12cm length self-expandable metal esophageal stent was placed to cover the fistula. Approximately 6 weeks after the deployment of the 2ndesophageal stent, an EGD was repeated to remove the stent (Figure 2) and a UGI series revealed no extravasation of contrast from the site of the previous anastomotic leak.2966_A Figure 1 No Caption available.2966_B Figure 2 No Caption available.Multiple sources have cited more favorable outcomes with early recognition and prompt management of anastomotic leaks. Criteria for removal of a patient's esophageal stent vary slightly from clinician to clinician, but some common factors include: (1) lack of a leak on esophagram, (2) lack of fever, (3) lack of leukocytosis, (4) absence of an ipsilateral pleural effusion, and (5) resolution of ileus. Despite aggressive therapy, mortality rate of postoperative esophageal leaks remain as high as 20%, with treatment delays being associated with higher mortality rates. Although our experience with esophageal stent placement has evolved and matured, there are unfortunately still complications that arise during and after the procedure.

Esophageal Metal Stents with Concurrent Chemoradiation Therapy for Locally Advanced Esophageal Cancer: Safe or Not?

The purpose of this study was to review the risks and benefits of concurrent chemoradiation therapy (CCRT) with esophageal self-expandable metal stents (SEMS) for the treatment of locally advanced esophageal cancer. Between January 2014 and December 2016, the data from 46 locally advanced esophageal cancer patients who received CCRT at our institution were retrospectively reviewed. Eight patients who received CCRT concomitant with SEMS placement (SEMS plus CCRT group) and thirty-eight patients who received CCRT without SEMS placement (CCRT group) were identified. The risk of developing esophageal fistula and the overall survival of the two groups were analyzed. The rate of esophageal fistula formation during or after CCRT was 87.5% in the SEMS plus CCRT group and 2.6% in the CCRT group. The median doses of radiotherapy in the SEMS plus CCRT group and the CCRT group were 47.5 Gy and 50 Gy, respectively. SEMS combined with CCRT was associated with a greater risk of esophageal fistula formation than CCRT alone (hazard ratio [HR], 72.30; 95% confidence interval [CI], 8.62-606.12; p < .001). The median overall survival times in the SEMS plus CCRT and CCRT groups were 6 months and 16 months, respectively. Overall survival was significantly worse in the SEMS plus CCRT group than in the CCRT group (HR, 5.72; 95% CI, 2.15-15.21; p < .001). CCRT concomitant with SEMS for locally advanced esophageal cancer results in earlier life-threatening morbidity and a higher mortality rate than treatment with CCRT alone. Further prospective and randomized studies are warranted to confirm these observations. Patients treated with SEMS placement followed by CCRT had higher risk of esophageal fistula formation and inferior overall survival rate compared with patients treated with CCRT alone. SEMS placement should be performed cautiously in patients who are scheduled to receive CCRT with curative intent.

Esophageal pulmonary fistula \u2013 a rare complication of radiation therapy: a\xa0case report

BackgroundEsophageal respiratory fistulae are abnormal communications between the esophagus and the respiratory system. They are either congenital or acquired. Most acquired esophageal respiratory fistulae are of the esophageal tracheal and esophageal bronchial type and are caused by infections or malignant neoplasms, whereas esophageal pulmonary fistulae are rare.Case presentationWe report a case of a 72-year-old Caucasian man with squamous cell carcinoma of the lung presenting with abrupt-onset dyspnea during localized mediastinal radiotherapy. His laboratory test results suggested major respiratory infection. A chest x-ray revealed left apical lung radiopacity along with excavated lesions, consistent with secondary tumor infection. No clinical improvement was observed despite antibiotic treatment. A contrast-enhanced computed tomographic scan of the chest confirmed persistent lung infection with unfavorable progression and air in the mediastinum; the latter suggested a fistula from the upper third of the esophagus to the upper left pulmonary lobe. Videofluoroscopy confirmed the diagnosis of an acquired esophageal pulmonary fistula. The patient underwent endoscopy, and an esophageal self-expandable metallic stent was deployed.ConclusionsEsophageal pulmonary fistulae must be suspected whenever patients undergoing local mediastinal radiotherapy present with acute pulmonary complications, particularly pneumonia resistant to antibiotic treatment. Esophageal pulmonary fistulae are diagnosed by means of radiological imaging. Because esophageal respiratory fistulae are acute life-threatening conditions, prompt treatment with an endoscopically placed covered stent proves vital.

Self-expandable metal stents are a valid option in long-term survivors of advanced esophageal cancer

self-expandable metal stents are often used for the palliative treatment of dysphagia in patients with advanced esophageal cancer and an anticipated limited survival. Due to previous reports of a high rate of adverse event when used long-term, concerns have been raised with regard to the use of self-expandable metal stents in patients with a longer survival. assess the role of esophageal self-expandable metal stents in patients with advanced esophageal cancer that have survived longer than six months. retrospective study of patients with advanced esophageal cancer with a self-expandable metal stent and a stent placement time greater than six months. forty-two patients were followed up for 298 days. There was a clinical improvement in all patients. However, 59% of patients experienced an adverse event. The median stent patency was 236 days. Endoscopic management was attempted in all self-expandable metal related adverse events, with a clinical success rate of 100%. However, the previously treated adverse event recurred in seven patients. Multivariate analysis showed that strictures that were traversable with an ultrathin gastroscope were associated with a higher risk of adverse events (p = 0.035). long-term esophageal stenting in patients with advanced esophageal cancer is associated with a high prevalence of adverse events without an impact on mortality; most cases can be managed endoscopically.

Efficacy and Safety of Fully Covered Self-Expanding Metal Stents for Malignant Esophageal Obstruction.

Malignant dysphagia can result in poor nutritional status with severe weight loss. Rapid relief from dysphagia can be achieved with esophageal self-expanding metal stents (SEMSs), a minimally invasive method. In this study, we evaluated the usefulness of SEMSs for malignant dysphagia. Between 2012 and 2015, 119 patients with malignant dysphagia underwent esophageal SEMS insertion with endoscopic assistance. Their demographics and clinical outcomes were collected. Factors associated with stent-related complications and patient survival were evaluated. All data were retrospectively analyzed. The mean age of the 119 patients was 64.9±11.6years, and 25 (21%) were female. Seventy-five patients (63.0%) had squamous carcinoma, majority of which were located in the lower thoracic esophagus (n=42), followed by middle thoracic esophagus (n=19) and upper esophagus (n=10). Eighty patients (67.2%) underwent SEMS insertion at diagnosis. Technical and clinical success rates were 99.2 and 89.9%, respectively. Complications occurred in 47 patients (39.5%); the most common complication was migration (36.3%), followed by pain and obstruction. The median stent patency time was 145days (95% confidence interval 55.19-234.81days). Gastric cancer (odds ratio 3.51, 95% confidence interval 1.21-10.15; p=0.021) and a 20-mm-wide stent (odds ratio 2.922, 95% confidence interval 1.237-6.904; p=0.015) were risk factors for complications. SEMSs are effective in palliation of malignant dysphagia. However, stent-related complications should be borne in mind, particularly in patients with gastric cancer with esophageal invasion and with larger width stents.

Feasibility of esophageal stent fixation with an over-the-scope-clip for malignant esophageal strictures to prevent migration.

Background and study aims Fixation of an esophageal self-expandable metal stent (SEMS) with an over-the-scope-clip (OTSC) system for a benign stricture to prevent migration has been reported. However, the efficacy of SEMS fixation with an OTSC for malignant esophageal stricture remains unclear. The aim of this retrospective study was to evaluate the feasibility of SEMS fixation with an OTSC for a malignant esophageal stricture. Patients and methods Twelve patients who underwent esophageal SEMS placement and fixation with an OTSC for a malignant esophageal stricture were included in this retrospective study. The primary endpoint was technical success. The secondary endpoint was clinical success, which was defined as an improvement of at least 1 grade in the dysphagia score 1 week after SEMS placement or changes in the dysphagia score from before SEMS placement to 1 week after SEMS placement. Results The technical success rate was 100 %. The clinical success rate was 92.3 %. In 6 mild stricture cases in which a standard peroral endoscope could be used, no migration of the SEMS was observed. The median dysphagia score before and at 1 week after SEMS placement was 3 (range 2 – 4) and 0 (0 – 4), respectively, which indicated improvement at 1 week after SEMS placement compared with before SEMS placement ( P = 0.002). There were no adverse events associated with placement of SEMS and deployment of an OTSC. Conclusions SEMS fixation with an OTSC is feasible for prevention of migration due to a malignant esophageal stricture.

Esophageal Self-Expandable Metal Stents Combined With Concurrent Chemoradiation Therapy for Locally Advanced Esophageal Cancer: Is It Safe?

Esophageal Self-Expandable Metal Stents Combined With Concurrent Chemoradiation Therapy for Locally Advanced Esophageal Cancer: Is It Safe?

Covered Esophageal Stenting Is Effective for Symptomatic Gastric Lumen Narrowing and Related Complications Following Laparoscopic Sleeve Gastrectomy.

Laparoscopic sleeve gastrectomy (LSG) is gaining popularity in treating morbid obesity. Prior studies showed a 3.5% risk of gastric sleeve stenosis (GSS). There is no consensus on how to treat these patients, and the role of endoscopic therapy has been addressed in only a few studies. We aim to assess the efficacy and safety of endoscopic stenting in the management of GSS following LSG. Retrospective data were reviewed from July 2009 to November 2013. Patients were referred for endoscopic therapy for symptoms or imaging findings suggestive of gastric leak or narrowing following LSG. Endoscopic therapy included the use of fully covered self-expanding esophageal metal stents (FCSEMS) in addition to over-the-scope clip system (OTSC) when necessary. All 27 patients were females with mean age of 40years; six patients were excluded from the study. Major symptom was nausea and vomiting in 57% of the patients. Five of 21 patients had concomitant leaks. All 21 patients underwent FCSEMS placement, and four out of five patients (80%) with concomitant leak had OTSC. The success rate in both groups for resolution of stricture and leak was 100%, and no surgical intervention was required. There were no immediate or delayed complications of endoscopic therapy. Median follow-up of 6months was available for 20/21 patients. Among patients with gastric leak, 80% had resolution of their symptoms compared with 93% of patients with GSS. Endoscopic therapy for LSG-related GSS or leaks with FCSEMS is highly effective and safe.

Stent migration following endoscopic suture fixation of esophageal self-expandable metal stents: a systematic review and meta-analysis.

Covered self-expandable metal stents (SEMS) are utilized for the management of benign and malignant esophageal conditions; however, covered SEMS are prone to migration. Endoscopic suture fixation may mitigate the migration risk of covered esophageal SEMS. Hence, we conducted a systematic review and meta-analysis to evaluate the effectiveness and safety of endoscopic suture fixation for covered esophageal SEMS. Following PRISMA guidelines, we performed a systematic review from 2011 to 2016 to identify studies (case control/case series) reporting the technical success and migration rate of covered esophageal SEMS following endoscopic suture fixation. We searched multiple electronic databases and conference proceedings. We calculated pooled rates (and 95% confidence intervals [CI]) of technical success and stent migration using a random effects model. We identified 14 studies (212 patients) describing covered esophageal SEMS placement with endoscopic suture fixation. When reported, SEMS indications included leak/fistula (n=75), stricture (n=65), perforation (n=10), and achalasia (n=4). The pooled technical success rate was 96.7% (95% CI 92.3-98.6), without heterogeneity (I 2=0%). We identified 29 SEMS migrations at rate of 15.9% (95% CI 11.4-21.6), without heterogeneity (I 2=0%). Publication bias was observed, and using the trim-and-fill method, a more conservative estimate for stent migration was 17.0%. Suture-related adverse events were estimated to occur in 3.7% (95% CI 1.6-8.2) of cases. Endoscopic suture fixation of covered esophageal SEMS appears to reduce stent migration when compared to published rates of non-anchored SEMS. However, SEMS migration still occurs in approximately 1 out of 6 cases despite excellent immediate technical success and low risk of suture-related adverse events.

Do esophageal stents have a role in Boerhaave syndrome? Case reports

Spontaneous esophageal rupture or Boerhaave syndrome results from exponentially increased intra-esophageal pressure against closed glottis leading to transmural esophageal injury. There are no classical signs and symptoms for diagnosis. Vomiting, pain, and subcutaneous emphysema are the usual triad of presentation. It may also present as nonspecific chest discomfort to rapidly progressive subcutaneous emphysema. Covered endoscopic self-expanding and removable esophageal metal stents are rapidly emerging minimally invasive techniques to manage this condition with good success. We report two cases of Boerhaave syndrome who were treated endoscopically with covered self-expanding metallic esophageal stents.

Self-Expanding Metal Stents Improve Swallowing and Maintain Nutrition During Neoadjuvant Therapy for Esophageal Cancer.

Patients with locally advanced esophageal cancer can have significant dysphagia. Nutritional support during neoadjuvant therapy is often delivered via nasoenteric or percutaneous feeding tubes. These approaches do not allow for per-oral feeding. Evaluate the safety and efficacy of fully covered self-expanding metal esophageal stents for nutritional support during neoadjuvant therapy. This was a pilot, prospective study at a single tertiary center. From March 2012 to May 2013, consecutive patients with esophageal cancer eligible for neoadjuvant therapy were enrolled. Metal stents were placed prior to starting neoadjuvant therapy. Data were collected at baseline and predetermined intervals until an endpoint (surgery or disease progression). Outcomes included dysphagia grade, satisfaction of swallowing score, nutritional status (weight, serum albumin), impact on surgery, and adverse events. Fourteen stents were placed in 12 patients (59.1±9.5years, 11 men, 1 woman). Dysphagia grade (pre 3.4±0.5 vs post 0.2±0.4, p<0.0001) and swallowing scores (20.2±5.9 vs 6.3±4.7, p<0.0001) significantly improved after stent placement. Improvements were sustained throughout neoadjuvant therapy. Body weight and serum albumin levels remained stable. Adverse events included severe chest pain (2), food impaction (1), and delayed stent migration (2). Five patients underwent surgical resection. No significant chemoradiation or operative adverse events occurred due to the presence of a stent. During neoadjuvant therapy for esophageal cancer, self-expanding metal stents are safe and effective in relieving dysphagia and maintaining nutrition. They allow patients to eat orally, thereby improving patient satisfaction. The presence of an in situ stent did not interfere with surgery.