Malignant Esophageal Strictures Research Articles

Self-expandable metal stents for malignant dysphagia.

The use of self-expandable metal stents in relieving dysphagia for patients with incurable malignant oesophageal strictures was retrospectively evaluated. Between September 1993 and August 1996, 66 male and 16 female patients with a median age of 72 years received self-expandable metal stents for malignant dysphagia. Six patients had concurrent tracheo-oesophageal fistulas. All patients were stented under sedation and stent insertion was performed under fluoroscopic guidance. Stent placement was successful in 80 patients (98%). There were seven early complications (inaccurate positioning (n = 3), migration (n = 1), incomplete expansion (n = 1), intractable pain (n = 1), and perforation (n = 1)). Two complications were lethal and three were treated endoscopically. Mean dysphagia grade improved from 3.2+/-0.7 to 1.8+/-0.9 (P < 0.05) after implantation. All tracheo-esophageal fistulas were successfully occluded. Upon a median follow-up of 8 weeks (range: 2-20 weeks), 30 complications developed in 21 patients (tumour overgrowth (n = 15), food bolus obstruction (n = 7), tumour ingrowth (n = 2), buckling of stent (n = 2), tracheo-esophageal fistula (n = 2), bleeding (n = 1), and gastric wall herniation through metal coils (n = 1)). Median survival was 13 weeks (range: 1-82 weeks). Self-expandable metal stents provide useful palliation in patients with incurable malignant dysphagia.

Palliation of malignant esophageal strictures: initial results with self-expanding uncovered nitinol coil stents.

The purpose of this study was to determine the efficacy of the uncovered coil stents in patients with malignant dysphagia. Coiled spring-shaped uncovered self-expanding metallic Esophacoil stents (Instent, Eden Prairie, Minnesota) were placed in 11 patients (9 men and 2 women; age range 38-77 years, mean age 60.5 years) with malignant esophageal strictures and dysphagia, under fluoroscopic guidance. Dysphagia was graded on a scale of 0 to 4 (0 = no dysphagia; 1 = dysphagia to normal solids; 2 = dysphagia to soft solids; 3 = dysphagia to solids and liquids; 4 = complete dysphagia, inability to swallow saliva). Two patients had received radiation therapy, 4 had had chemotherapy, and 5 had had a combination of both radiation and chemotherapy before stent palliation. Control clinical examinations and endoscopic or barium swallow studies were performed every 4 weeks until the patient died. The stents were well tolerated by all patients and were effective in 9 of 11 patients with malignant dysphagia. Complications of the procedure included incomplete opening of the stent in 1 case, migration in 1 case, transient pain in 8 cases, reflux in 3 cases and minor gastrointestinal bleeding in 2 cases. Stent migration in 1 case resulted in surgical intervention and incomplete opening of the stent allowed only partial improvement of dysphagia in 1 case. The quality of life significantly improved in all other patients. Mean survival time of the patients was 73 days (range 34-125 days) and no significant tumor ingrowth was detected during the follow-up period. Insertion of an Esophacoil has a good palliative effect on dysphagia in patients with malignant esophageal strictures with few complications. Although the stent is uncovered, tumor ingrowth and overgrowth were not observed in our study, possibly because of previous treatments.

The Esophacoil Stent for Malignant Esophageal Obstruction

Esophageal cancer is the seventh most common cause of cancer-related deaths in men in the United States. For a disease in which 60% of patients are incurable at presentation, palliative therapy is the main treatment option. Palliative measures include surgery, radiation therapy, chemotherapy, photodynamic therapy, endoscopic dilation, endoscopic ablation, and the use of endoscopic prostheses. This article reviews the characteristics, technique, efficacy, and complications of the Esophacoil stent for malignant esophageal strictures.

Techniques for dilation of malignant esophageal strictures

Multiple dilating systems and numerous subtle variations of technique are available to the clinician attempting to palliate the patient with a malignant esophageal stricture. Whether red rubber Maloney bougienage, wire-guided polyvinyl dilators, or radial balloon dilating systems are used, careful attention to the details of methodology should enhance patient response while reducing risk of complications. The specific technique and dilating system used in a particular patient is determined by the characteristics of the stricture, the level of comfort, and tolerance of the patient, as well as the expense, expertise, and clinical judgement of the operator.

Biopsy-negative malignant esophageal stricture: diagnosis by endoscopic ultrasound

Endoscopic ultrasound (EUS) of the esophagus has been used primarily in staging biopsy-proven cancers. Its use as a primary diagnostic modality for esophageal malignancy has not been previously described. We report our recent experience in four patients with dysphagia and endoscopic biopsies negative for malignancy, including one patient with clinical and manometric features suggestive of achalasia. In all cases, EUS revealed a large infiltrating tumor invading through the esophageal wall into the surrounding tissues, and in one case into the aorta. Computed tomography suggested the possibility of a tumor in only one of the cases. Two patients underwent esophagectomy and were found to have adenocarcinoma. Two patients underwent repeat biopsy with alternative aggressive biopsy techniques and were found to have squamous cell carcinoma. We conclude that EUS is useful in the diagnosis of esophageal cancer and should be performed in selected patients with esophageal strictures whose biopsies are negative for malignancy; i.e., those with suspicious endoscopic or radiographic appearance, atypical presentation ( e.g., profound weight loss, short duration of symptoms, or advanced age), and failure to respond to treatment.

EsophaCoil: long-term results in 81 patients

Background: Cancer of the esophagus and gastric cardia cause progressive dysphagia. Half of patients are not amenable to surgical resection; of those who are, about 20% will suffer either from local recurrence or anastomotic strictures. Self-expandable metallic stents of diverse characteristics have been used in these clinical conditions. However, expandable metallic stents have several drawbacks: low radial force, migration, epithelial trauma, and tumor ingrowth. We herein report our long-term experience with EsophaCoil, a self-expandable esophageal metallic coil, in 81 patients. Methods: From January 1993 to July 1996, 84 stents were placed in 81 consecutive patients (53 men and 28 women, mean age 69.8 years (range 40 to 90 years). 41 patients had esophageal squamous cell carcinoma, 32 adenocarcinoma of the esophagus and cardia, 5 mediastinal metastasis, 1 sarcoma, and 2 had benign esophageal strictures. Five patients had bronchoesophageal fistulas. Mean dysphagia score before treatment was 3.5, mean stricture length 6 cm. Most patients were hospitalized for at least 24 hours after stent implantation. Patients were followed and early and late complications were recorded. Results: Stents were successfully placed in all patients. Dysphagia improved in 96% of patients (score dropped from 3.5 to 1.2). Mean patient survival after stent insertion was 4 months (range 0.5 to 20 months). Bronchoesophageal fistulas were closed in all 5 cases. Early complications occurred in 11 patients. These were severe in 3 (esophageal perforation) and mild in 8 patients (precordial pain lasting 24 to 48 hours). Late complications occurred in 18 patients and included migration to the stomach (5 patients), stent breakage (5 among the first 20 cases), food impaction (5), tumor overgrowth (2), and bleeding (1). Conclusions: In a long-term follow-up, EsophaCoil was effective in the palliative treatment of dysphagia caused by malignant esophageal strictures, including cases of fistulas, having low malfunction and migration rates. No tumor ingrowth was seen. (Gastrointest Endosc 1998;48:376-82.)

Self-expandable metallic stents in the palliation of rectosigmoidal carcinoma: a follow-up study

Background: Currently applied endoscopic palliative treatment of advanced rectosigmoidal carcinoma is hampered by the cost of the equipment, the need for repeated, often painful treatment sessions, and the occurrence of complications. Metallic expandable stents are effective in the palliation of malignant esophageal and biliary stenoses. We evaluated the use of a new type of self-expandable nitinol stent in the palliation of rectosigmoidal carcinoma. Methods: In 10 patients with advanced obstructing rectosigmoidal carcinoma, initial Nd:YAG laser treatment was performed if necessary to allow passage of a gastroscope. Subsequently, a self-expanding nitinol stent with flanged ends was inserted under combined fluoroscopic and endoscopic control. Endoscopic and clinical follow-up was carried out at regular intervals. Results: After 2 ± 0.4 sessions of initial laser therapy, minimal lumen diameter was 9 ± 1 mm. Stent insertion was successful in 9 patients, increasing minimal lumen diameter to 14 ± 1.2 mm ( p < 0.005). In one patient, stent deployment was complicated by a sigmoid perforation, requiring surgery. After insertion, colorectal stents remained adequately positioned and free of obstruction for 103 ± 31 days. Patient survival after stent placement was 204 ± 43 days. Stent migration occurred in 3 patients, after 38 ± 10 days. Obstruction of the stent because of tumor ingrowth was observed in only one patient, after 268 days. Conclusion: Insertion of self-expandable nitinol stents in patients with rectosigmoidal carcinoma is technically feasible. Metallic stents are effective in the palliation of malignant rectosigmoid obstruction; they provide an alternative to repeated palliative laser therapy or palliative surgery. (Gastrointest Endosc 1998;48:267-1.)

Improved endoscopic stenting for malignant dysphagia using Tygon plastic prostheses.

Endoscopic palliative treatment of malignant esophageal stenosis using conventional plastic stents has been reported to be associated with a considerable risk of perforation. Stenoses with a distance of less than 2cm from the upper esophageal sphincter (UES) have generally been excluded from treatment. Using self-expandable metal stents, procedure-related complications are rare. However, the rates of late complications necessitating retreatment appear to be as high as those of plastic stents. This study describes our stent placement technique and our results using a modified Tygon plastic stent. Over a two-year period, 71 consecutive patients with incurable malignant esophageal stenosis were prospectively studied. Tygon plastic stents of diameter 9-14 mm were individually tailored according to length and location of the stenosis. Prior to stenting, stepwise bougienage was performed, if necessary over several sessions. After endoscopic placement of a guide wire, the stent was inserted over a bougie without fluoroscopic monitoring. A total of 71 patients (54 men and 17 women, median age 69, range 34-93), were treated with Tygon plastic stents (14 mm: 19 patients; 12 mm: 50 patients; 9 mm: 2 patients). Median length of the strictures and of the stents were 7 (range 2-18) and 10 (range 6-25) cm, respectively. Four patients had an associated esophago-respiratory fistula. After a median of 2 (range 1-5) bougienage sessions, stent insertion was technically successful in all patients. Forty-one stents were placed across the cardia, 13 were positioned 0.5-1 cm below the UES. Three patients had to undergo retreatment within 24 hours because of pain or stent migration and the stents were repositioned or exchanged. No procedure-related perforation, hemorrhage or respiratory problems were observed. During a median follow-up of 63 (range 2-388) days, 82% of the patients died. Improvement or stabilization of dysphagia allowing for oral nutrition could be achieved in 89%. Dislocation occurred in eight patients, bolus obstruction in five patients and tumor overgrowth in four patients. Three of the four fistulas could be covered by the stent. In one patient with a fistula located at the level of the UES, a stent was placed but migrated after 5 days. Overall, 27 patients (38%) required reinterventions, mainly for dysphagia or nutritional problems. In our experience, Tygon plastic stents with a diameter of 9-14 mm can be safely placed after stepwise, less extensive bougienage. Effective palliation is possible even for lesions located close to the UES. Perforation can be avoided. Reintervention rates seem to be comparable to those seen with self-expanding metal stents.

Malignant dysphagia: palliation with esophageal stents--long-term results in 100 patients.

To evaluate the long-term palliative effect of self-expanding nitinol esophageal stents in patients with malignant dysphagia. One hundred patients with severe dysphagia secondary to malignant esophageal strictures were treated with self-expanding nitinol stents. The strictures were caused by squamous carcinoma (n = 43), adenocarcinoma (n = 28), anastomotic tumor recurrence (n = 14), and mediastinal tumor (n = 15). One hundred six stents were successfully positioned in 100 patients. Attempts to insert a second, coaxial stent were unsuccessful in two patients; a second stent was placed incorrectly in another patient. Statistically significant (P < .001) reduction of dysphagia was noted after expansion of the stents. Complications consisted of incomplete expansion secondary to stent twisting (n = 4), stent migration (n = 4), tumor ingrowth (n = 17), tumor overgrowth (n = 3), food impaction (n = 5), fracture of stent wires (n = 2), benign strictures at stent edges (n = 2), tumor bleeding (n = 3), and esophagorespiratory fistula (n = 5). The primary patency rate was 75% (77 of 102 stents); the secondary patency rate was 94% (96 of 102 stents). The survival time (mean, 6.2 months; range, 0.1-47 months) varied with the diagnosis. Placement of self-expanding nitinol stents is safe and has a good long-term palliative effect on dysphagia in patients with malignant esophageal strictures.

How safe is endoscopic dilatation in benign and malignant oesophageal strictures?

How safe is endoscopic dilatation in benign and malignant oesophageal strictures?

The Use of Stents in the Management of Malignant Esophageal Strictures

The majority of patients with intrinsic or extrinsic obstructing esophageal malignancies are not treatable for cure because of an advanced tumor stage at the time of diagnosis or a recurrence after primary curative therapy. Palliative treatment is mainly directed at relieving dysphagia, which is a frequent cause of patient distress and malnutrition. The approach should be rapidly effective, safe, and well tolerated; the period of hospitalization should be limited in view of a life expectancy of only a few months.

Radiation and Chemotherapy in the Management of Malignant Esophageal Strictures

The management of malignant and esophageal strictures with radiation and chemotherapy is reviewed. There is no evidence to support the use of adjuvant radiation. Studies demonstrate that concurrent chemotherapy and radiation are superior to radiation alone. The trials of preoperative combined chemotherapy and radiation are discussed, and it is suggested that further studies are needed before such treatment could be accepted as standard therapy. The roles of radiation and chemotherapy in palliative management are briefly discussed, and some potential areas for further study are proposed.

Nonthermal Ablation of Malignant Esophageal Strictures: Photodynamic Therapy, Endoscopic Intratumoral Injections, and Novel Modalities

Several novel nonthermal ablative modalities for the palliation of malignant esophageal stenoses have been developed over the past decade. In this article, the authors review techniques and clinical experience with photodynamic therapy as well as the intratumoral injection of alcohol, cytotoxins, and immunomodulators.

Endoscopic Application of Nd:YAG Laser in General Surgery: Technique and Results

Summary The aim of this retrospective study was to evaluate the value of Nd:YAG laser application in general surgery. From 1981 to 1996 1009 endoscopic therapies with Nd:YAG laser were performed in 580 patients. Lasers were applied to achieve recanalisation of benign and malignant stenosis in the gastrointestinal tract. 57 patients were treated for malignant esophageal stenosis. One perforation occurred. Quality of life could be improved in 50%. Mean survival was 7 months. Malignant stenosis of the rectum was treated in 279 patients. Two perforations of the rectum developed. Improvement of symptoms could be achieved in 52% of patients. Mean survival was 16 months. In conclusion Nd:YAG laser therapy proved to be an efficient instrument in palliative treatment of stenosing esophageal and rectal cancer and in selected benign diseases.

Potential risks and artifacts of magnetic resonance imaging of self-expandable esophageal stents

Background: Several types of coated and uncoated self-expandable stents composed of various metals are available for palliation of malignant esophageal stenoses and fistulas. We encountered poor visualization of the mediastinum and skeletal axis with magnetic resonance imaging in a patient with a Gianturco self-expandable stent. Methods: To evaluate potential problems, such as stent migration in the magnetic field of the magnetic resonance scanner (MRI) and artifacts in the images, we studied four types of expandable stents: the Ultraflex (titanium alloy), the covered Wall stent (nitinol), the Gianturco stent (Cook), and the modified Gianturco stent (Song)—the last two being made of stainless steel. Results: An appreciable attraction force and torque, as measured ex vivo by suspending the stent in a Perspex device, was found for both Gianturco stents. In particular, the Gianturco (Cook) stent is pulled toward the head with a force of 7 g; however, it is uncertain whether this is a potential risk for dislodgement. In addition, gross artifacts in the images, studied by putting the stents in a cylindric phantom filled with a diluted gadolinium solution, made the magnetic resonance useless for imaging in a wide area around the Gianturco stents of stainless steel. No problems with magnetic resonance image quality were encountered for the titanium-based Ultraflex and Wall stents. Conclusions: Specific information on the type of stent is necessary before a magnetic resonance imaging examination is planned. (Gastrointest Endosc 1997;46:424-9.)

Particular aspects and limits of palliation of secondary malignant esophageal strictures.

The value of palliative intubation in the secondary malignant stricture of the thoracic esophagus is discussed. One hundred and eleven patients with secondary involvement of the esophagus due to primary inoperable (in 64) or recurrent bronchial tumor (after lobectomy or pneumonectomy in 34) and mediastinal tumor (in 9) or metastases after mastectomy of breast cancer (in 4) underwent a limited invasive surgical intubation with a personally designed, composite tube in the past 15 years. The distal part of the tube is detachable, which allows insertion of the tube only into the esophagus. The overall hospital mortality was 9.9%. Esophageal perforation and intraabdominal septic complication were never recorded. Nonfatal complication rate was low (5.4%). All survivors have resumed on oral soft diet. By this technique, all attempts of tube insertion were successful, although in 33% of the cases various esophageal axis deviations or tortuosity were present. Reintubation for tube dislodgement was necessary in 7.2% of the patients. Stenotic tracheobronchial invasion, vena cava superior syndrome, bronchial stump fistula as well as cardiac arrhythmias are the main contraindications of the palliative intubation in such cases. In the remaining group of patients with secondary invasion of the esophagus by intrathoracic malignancies, intubation may be considered a unique type of management with acceptable risk.

Benign and malignant esophageal strictures: treatment with a polyurethane-covered retrievable expandable metallic stent.

To evaluate the clinical effectiveness of a polyurethane-covered, retrievable, self-expandable metallic stent and hook catheter in the treatment of esophageal strictures. Stents were constructed of 0.4-mm stainless steel wire in a cylindric zig-zag configuration of six to nine bends. Four to eight stents were connected in tandem by dipping in a polyurethane solution. A nylon loop was hooked inside to each bend of the proximal portion of the stent and strung with a thread. Under fluoroscopic guidance, 22 stents were placed in 16 patients with a malignant stricture and five patients with a benign stricture. The stent was removed with a hook catheter 2 months after placement in patients with a benign stricture and when complications occurred in patients with a malignant stricture. All patients had dysphagia with ingestion of soft foods or liquids. Stent placement was technically successful and well tolerated in 20 patients. In one patient, the stent was misplaced but relocated successfully. After stent placement, all patients were able to ingest solid and/or soft foods without dysphagia. After stent removal, strictures showed improvement but recurred in two patients. Use of polyurethane-covered, retrievable expandable stents seems to be a feasible and effective method of treatment of benign and malignant esophageal strictures.

Prognostic factors in patients with malignant esophageal stenosis and palliative treatment with self-expanding mesh stents

Prognostic factors in patients with malignant esophageal stenosis and palliative treatment with self-expanding mesh stents

SELF‐EXPANDABLE OESOPHAGEAL STENTS IN THE MANAGEMENT OF BENIGN PEPTIC OESOPHAGEAL STRICTURES IN THE ELDERLY

SUMMARYSelf‐expandable oesophageal stents are being increasingly used in the management of malignant oesophageal strictures. Most benign peptic oesophageal strictures can be successfully managed using endoscopic oesophageal dilatation combined with long‐term Proton pump inhibition therapy. Although endoscopic oesophageal dilatation can be performed on an outpatient basis, it often requires repeated hospital visits. There is a small risk of oesophageal perforation, while cardiorespiratory complications may be encountered during the use of intravenous sedation in an elderly population. The use of self‐expandable Strecker stents in three elderly patients with benign peptic oesophageal strictures is described.

Bleeding esophageal varices treated with the seed six-shooter versus single-shot ligation: A comparison of results

TREATMENT OF MALIGNANT ESOPHAGEAL STRICTURE AND TRACHEO-ESOPHAGEAL FISTULA WITH SELF-EXPANDING METAL STENTS. F,A. Roelding, K, Dan, K. Sneian, A.G. Bohorfoush HI, R. Shaker, MCW Dysphagia Institute, Depamnents of Medicine and Radiology, Medical College of Wisconsin and VAMC, Milwaukee, Wl. Self-expanding metal gents (SEMS) are now being increasingly used in palliation of malignant esophageal obstruction and tracbeo-esophageal fistula (TEF). The aim of this study was to review our experience with the new generation of SEMS in management of patients who had failed other treatment modalities of palliation. Patients & Methods: Between 8/94 and 8/96 14 patients (12 male; age 68 range 47-81 ) were referred for palliation of dysphagia (13) and/or TEF (3) after other modalities (surgery, chemotherapy, radiotherapy) of palliation had failed. A total of 17 SEMS were deployed: 3 Ultraflex (Mierovasive), 3 Wallstent (Schneider), 5 EsophagoCoil 0nstent), 6 EZS (Wilson-Ccok). Pro-insertion dilatations were performed (diameter:44~5F) to allow adequate stent expansion after deployment. Palliation was assessed by dysphagia score (0: normal, to 4: inability to swallow saliva) and alleviation of TEF symptoms; then corroborated by esophagogram done within 24 hrs in all patients. Results: SEMS were successfully placed in all patients. In 12/14 patients the dysphagia was immediately relieved as docnmented by esophagogram and a significant decrease in dysphagia score from 3.5• to 1.4• (p<0.001). In one patient (proximal esophageal stricture with laser-induced TEF) dysphagla could not be relieved as the proximal extent of the stricture was near the LIES. However, the stent successfully bridged the TEF. In another patient post-deploymera dysphagia relief was not seen as the stoat had migrated proximally. Successful palliation of TEF was immediately achieved in all patients using covered stents. Three patients returned within a mean of 31 days (range:l-38) with recurrent symptoms secondary to stent migration (1), overgrowth (1) and TEF (1). In these patients additional SEMS were placed and symptoms suCCessfully palliated. Continued intractable chest pain in one patient necessitated removal of the Esopb.agoCoil stem. Two patients (gastroesophage, al junction cancer with trans-GEJ stent placement) required continned therapy with a proton-pump inhibitor to alleviate reflux symptoms. Conelnsion: SEMS provide safe, immediate and effective palliation of malignant esophageal obstruction and TEF in the majority of patients.