Expandable Metallic Stent Placement Research Articles

Tracheal Compression by the Stomach Following Gastric Pull-Up: Diagnosis With CT and Treatment With Expandable Metallic Stent Placement

Surgical treatment of recurrent achalasia includes esophagectomy with gastric pull-up. A MEDLINE search yielded no articles describing an adverse effect of this surgery on pulmonary function. We report the first case of acute ventilatory failure caused by gastric pull-up. An evaluation by flexible bronchoscopy, spirometry with flow-volume loops, and dynamic CT scanning revealed extrinsic compression of the trachea by the stomach causing obstruction. Endotracheal placement of a self- expanding stent resulted in the rapid extubation of the patient with normalization of the flow-volume loop and dramatic improvement in the FVC, FEV(1), and peak expiratory flow.

Hemodynamic changes after self-expandable metallic stent therapy for vena cava syndrome.

We examined changes in hemodynamics after self-expandable metallic stent placement in the vena cava. The rapid increase in venous return immediately after expandable metallic stent placement influenced the hemodynamics of the circulatory system.

Expandable metallic stent placement in upper tracheal stenosis: value of laryngeal masks.

Expandable metallic stent placement in upper tracheal stenosis: value of laryngeal masks.

A comparison of migration rates after esophageal expandable metallic stent placement

A comparison of migration rates after esophageal expandable metallic stent placement

Delayed Complications after Esophageal Stent Placement for Treatment of Malignant Esophageal Obstructions and Esophagorespiratory Fistulas

To evaluate delayed complications after esophageal expandable metallic stent placement. From April 1993 to December 1997, 90 expandable metallic stents were placed in 82 consecutive patients with inoperable malignant esophageal obstruction (n = 49) or malignant esophagorespiratory fistula (n = 33). Stents used included covered Gianturco-Rosch Z stents (n = 20), Wallstents (covered, n = 31; uncovered, n = 13), and Ultraflex stents (covered, n = 8; uncovered, n = 10). Patients were followed prospectively and monitored for delayed complications, defined as major (hemorrhage, tracheal compression, stent migration, perforation or fistula formation, granulomatous obstruction, tumor ingrowth and overgrowth, funnel phenomenon, and stent covering disruption) or minor (reflux, chest pain, and food impaction). Mean survival was 4.5 months after stent placement (range, 3 weeks to 26 months). The overall incidence of delayed complications was 64.6%, with 17 patients (20.7%) experiencing more than one complication. The rates of delayed complications in patients with Z stents, Wallstents, and Ultraflex stents were 75.0%, 68.1%, and 44.4%, respectively (P <.05). Most complications were life-threatening and occurred more frequently when stents were placed in the proximal third of the esophagus, compared with more distally (P <.05). Thirteen patients (15.9%) died from complications directly related to stent placement. Esophageal stent placement for malignant obstruction or fistula is associated with a substantial incidence of delayed complications.

A Case of Treatment with Expandable Metallic Stent Placement for Duodenal Stenosis due to Invasion of Pancreas Carcinoma

A-71-year-old man was admitted to our hospital because of abdominal pain and abdominal fullness due to duodenal stenosis. 6 months ago, he visited our hospital because of obstructive jaundice due to pancreas head carcinoma, and biliary stent was inserted following percutaneous transhepatic biliary drainage. On this admission, endoscopic and X-ray study showed severe stenosis at the 2nd portion of duodenum. An expandable metallic stent (EMS) was not enough long for passage through the narrowing space of duidenum. We make a new delivery system use of teflon tube. After cutting handlebar, teflon tube connected with outer tube of EMS. And the new delivery system was 150 cm length and detained at the senotic lesion. 5 days after treatment with EMS, he was able to take a diet for about 3 months. We think that EMS therapy for duodenal stenosis is useful to the improvement of quality of life.

7153 Endoscopic palliation of malignant gastric-outlet obstruction.

Introduction: Combined gastrojejunostomy and choledochoduodenostomy are routinely performed as treatment for malignant gastric-outlet obstruction. This procedure has significant morbidity and mortality and necessitates a considerable hospital stay.We describe a less invasive endoscopic treatments, with self-expanding metal stents. Patients and Methods: Three female patients, presenting with clinical findings of gastric outlet obstruction, confirmed by upper GI-endoscopy and/or upper GI X-ray, had endoscopic placement of expandable metal stents (Microvasive, 6 cm, 22 mm). In two patients , combined stenting of the duodenum and common bile duct was performed as a one step procedure. All patients had primary or metastatic malignancy involving the pylorus or duodenum. The mean age of the patients was 75 years. The first patient (71 years) had a breast carcinoma with metastasis in hilar lymph nodes, invading the common bile duct and subsequently causing gastric-outlet obstruction. The second patient (80 years) had a tumor in the head of the pancreas with liver metastasis, obstructive jaundice and secondary gastric-outlet obstruction. The third patient (74 years) had a cancer of the stomach, obstructing the pyloric region. No surgical procedure was performed because of the high age of the patients and the poor prognosis, suspected by the presence of metastatic disease. Results: Stent placement was successful in all patients. The procedure was followed by immediate clinical improvement, without complications. In case of a double endoscopic stenting procedure, transpyloric dilation was carried out, using a 18 mm balloon, in order to achieve access to the duodenum. After insertion of a biliary Wallstent, a guidewire was introduced in the third part of the duodenum. Subsequently, a Wallstent Enteral was released in the bulboduodenal region. All patients had excellent palliation with normal oral feeding within 24 to 48 hours. Two patients died after a mean of 7 weeks and could tolerate oral feeding well until 2-3 days before they died. The third patient is still alive after 6 weeks, without any complaint, and normal oral feeding so far. Conclusion: An endoscopically placed Wallstent provides effective palliation for malignant gastric-outlet obstruction. The procedure is easy to perform, non-invasive and well tolerated, with significant improvement in quality of live. Introduction: Combined gastrojejunostomy and choledochoduodenostomy are routinely performed as treatment for malignant gastric-outlet obstruction. This procedure has significant morbidity and mortality and necessitates a considerable hospital stay.We describe a less invasive endoscopic treatments, with self-expanding metal stents. Patients and Methods: Three female patients, presenting with clinical findings of gastric outlet obstruction, confirmed by upper GI-endoscopy and/or upper GI X-ray, had endoscopic placement of expandable metal stents (Microvasive, 6 cm, 22 mm). In two patients , combined stenting of the duodenum and common bile duct was performed as a one step procedure. All patients had primary or metastatic malignancy involving the pylorus or duodenum. The mean age of the patients was 75 years. The first patient (71 years) had a breast carcinoma with metastasis in hilar lymph nodes, invading the common bile duct and subsequently causing gastric-outlet obstruction. The second patient (80 years) had a tumor in the head of the pancreas with liver metastasis, obstructive jaundice and secondary gastric-outlet obstruction. The third patient (74 years) had a cancer of the stomach, obstructing the pyloric region. No surgical procedure was performed because of the high age of the patients and the poor prognosis, suspected by the presence of metastatic disease. Results: Stent placement was successful in all patients. The procedure was followed by immediate clinical improvement, without complications. In case of a double endoscopic stenting procedure, transpyloric dilation was carried out, using a 18 mm balloon, in order to achieve access to the duodenum. After insertion of a biliary Wallstent, a guidewire was introduced in the third part of the duodenum. Subsequently, a Wallstent Enteral was released in the bulboduodenal region. All patients had excellent palliation with normal oral feeding within 24 to 48 hours. Two patients died after a mean of 7 weeks and could tolerate oral feeding well until 2-3 days before they died. The third patient is still alive after 6 weeks, without any complaint, and normal oral feeding so far. Conclusion: An endoscopically placed Wallstent provides effective palliation for malignant gastric-outlet obstruction. The procedure is easy to perform, non-invasive and well tolerated, with significant improvement in quality of live.

4751 Management of malignant duodenal strictures caused by pancreatic carcinoma with expandable stents.

Pancreatic carcinoma is the second leading gastrointestinal cancer in the United States. Curative surgical procedures are rare at the time of initial Dx (< than 15%). Palliative endoscopic treatment options therefore take on a major role in pts with unresectable lesions. These include biliary and pancreatic endoscopic prosthesis for obstructed ducts as well as EUS-guided celiac plexus neurolysis for refractory abdominal pain. A less well known complication but equally important is treatment of high-grade duodenal strictures resulting in gastric outlet obstruction. AIM: To determine the effectiveness and complication rate of expandable metal stents in the treatment of malignant duodenal strictures. METHODS: Eleven pts, 8-W, 3-M, (age range 72-86, mean 76) underwent placement of enteral wall stents (Boston Scientific). All patients had unresectable pancreatic carcinomas involving the head of the pancreas. These pts were previously treated with biliary endoprosthesis (11) and pancreatic endoprosthesis (2). Time between biliary endoprosthesis and presentation of duodenal obstruction was 5 months to 13 months (mean 8.7 months). RESULTS: All pts underwent successful placement of expandable metal stents (size 20 mm diameter, Length 90 mm=4, 60 mm=7). None of the strictures were initially traversable with standard upper endoscope and required placement of an 0.35" guidewire beyond the stricture under fluoroscopic control to assist in deployment/positioning of the wall stent. Mean follow-up was 12.5 months (range 7-18 months). There were 2 complications related to wall stents, both perforations at the level of the proximal stent margin (1) and distal stent margin (1) presenting at 5 weeks and 12 weeks after deployment respectively. The perforations were felt to be directly related to the bare barbs at each end of the wall stent design. Both pts underwent successful surgical palliation. Survival, post duodenal wall stents, was 6.8 months (Range 4-13 months). Two pts are alive with good palliation of their duodenal obstruction. CONCLUSION: Expandable metallic stents are effective and provide a reasonably good palliative option for unresectable pancreatic carcinoma with duodenal strictures. The relative high rate of complication would require further modification in stent design.

4749 Endoscopic versus surgical palliation of malignant gastric outlet obstruction: a retrospective analysis.

Background: Palliation of malignant gastric outlet obstruction is usually achieved surgically. Recently, endoscopic palliation using expandable metal stents has been employed with good anecdotal success. Aim: To compare clinical success rates, hospitalization days, and treatment costs of endoscopic versus surgical approaches to palliation of malignant gastric outlet obstruction. Methods: Over the last 12 months, 10 consecutive patients underwent placement of expandable metal stents (enteral Wallstent, 20 or 22mm diameter) for palliation of malignant gastric oultet obstruction. These patients were compared with an equal number of patients who underwent open surgical gastrojejunostomy. The surgical patients were randomly selected from a surgical billing database from the last four years. Patients and/or families in both groups were interviewed by phone using a symptom questionnaire. Successful palliation was defined as ability to maintain adequate oral intake without need for parenteral supplementation. Medical records were reviewed to determine hospital days from the time of intervention to initial discharge. Cost of palliation was determined by adding hospital day and procedural costs. The distribution of underlying malignancies was similar in the two groups. Nonparametric methods were used to compare hospital days and costs between the two groups. Results: No statistically significant difference in clinical success rates was demonstrable given small sample sizes. Endoscopically treated patients had significantly shorter hospitalizations (p

Use of a palmaz stent for tracheomalacia: Case report of an infant with esophageal atresia

A male infant with congenital cardiac anomalies and esophageal atresia with tracheoesophageal fistula (EA-TEF) showed intractable respiratory symptoms after delayed primary repair of EA-TEF. Computed tomography demonstrated that the trachea was compressed by the enlarged aorta. Artificial ventilation was necessary even after aortopexy performed at 2 months of age. At 140 days of age, an expandable metallic stent (Palmaz stent) was inserted through a rigid bronchoscope into the trachea under fluoroscopic control. His respiratory status improved dramatically, and he was extubated in 18 hours. Although the follow-up period has been 9 months, the short-term result is satisfactory. The expandable metallic stent placement should be considered in patients with EA-TEF who show intractable respiratory symptoms caused by tracheomalacia.

Palliation of jaundice in unresectable pancreatic carcinoma: radiologic-guided interventions

The percutaneous transhepatic placement of an uncovered expandable metallic stent is an effective and safe means of palliating the symptoms of obstructive jaundice resulting from unresectable carcinoma of the pancreas. This approach is indicated when endoscopic placement is not possible.

Pulmonary Function Improves After Expandable Metal Stent Placement for Benign Airway Obstruction

To determine whether expandable metal stent placement for benign airway lesions improves pulmonary function. Case series. University medical center. Nine patients who underwent balloon-mediated expandable metal stent deployment for airway obstruction due to benign etiologies. All nine patients had expandable stents deployed for benign airway lesions using fiberoptic bronchoscopy and fluoroscopic guidance. Pulmonary function improved after stent placement. The mean FVC increased by 388 mL (95% confidence interval [CI], 30 to 740 mL), the mean peak expiratory flow (PEF) increased by 1,288 mL (95% CI, 730 to 1,840 mL), the mean FEV1 increased by 550 mL (95% CI, 240 to 860 mL), and the mean forced expiratory flow between 25% and 50% of vital capacity (FEF25-75%) increased by 600 mL (95% CI, 110 to 1,090 mL). Corresponding relative measurements included increases in FVC (12%), PEF (95%), FEV1 (38%), and FEF25-75% (87%). The complete characterization of a benign airway obstruction generally required a multimodal approach. Expandable metal stent placement appears to be an effective therapy for benign airway obstruction.

Expandable metallic stent placement for nutcracker phenomenon

A 40-year-old woman presented with asymptomatic gross hematuria caused by the nutcracker phenomenon. Despite treatment with hemostatic agents and injection of silver nitrate into the renal pelvis, the hematuria had continued, and severe anemia (hematocrit 17%) had developed. We performed expandable metallic stent (EMS) placement across the left renal vein. Although mild hematuria continued, the anemia resolved after this interventional radiotherapy. EMS placement is a minimally invasive therapy for the nutcracker phenomenon.

Results of expandable metal stent placement in lung transplant recipients: MA Baz, JG Caridi, MS Guevara, ED Friskel, JA Alexander, ED Staples. Dept of Medicine, Radiology and Surgery, University of Florida, Gainesville, Florida, USA

Results of expandable metal stent placement in lung transplant recipients: MA Baz, JG Caridi, MS Guevara, ED Friskel, JA Alexander, ED Staples. Dept of Medicine, Radiology and Surgery, University of Florida, Gainesville, Florida, USA

Self-expandable metal stents for malignant gastric outlet obstruction: a modified technique.

Endoscopic palliative treatment may be effective in the management of malignant gastric outlet obstruction. However, experience in this area is limited, and the techniques vary widely. In this retrospective study, a uniform technique using nearly identical self-expandable metal stents was employed to assess technical feasibility, safety, and outcome. Eight patients presenting with clinical findings of gastric outlet obstruction confirmed by upper gastrointestinal radiography underwent endoscopic placement of expandable metal stents. All patients had primary or metastatic malignancy involving the pylorus or duodenum. Endoscopic and Gastrografin-enhanced upper gastrointestinal radiographic evaluations were carried out immediately after stent placement. Complications and clinical outcomes were assessed in each patient. Five patients had extrinsic compression of the descending duodenum due to pancreatic cancer, two had pyloric stenosis from metastatic cancer, and one patient had primary duodenal cancer. Stent placement was successful in all patients, and was followed by clinical improvement. There was one death within 30 days, related to pneumonia. Endoscopic self-expandable stent placement appears to be a reasonable therapeutic alternative in patients with malignant gastric outlet obstruction.

The use of expandable metallic stents for acute tracheal stenosis in the growing lamb

Purpose: Expandable metallic stents (Palmaz stents) have been used in the treatment of tracheobronchial obstruction in children and adults. The authors investigated their utility in the management of acute airway stenosis in a growing animal model. Methods: A model for tracheal stenosis was developed in young lambs (mean age, 4 weeks; mean weight, 8.6 kg). Via an anterior tracheotomy, a circumferential mucosal injury to the trachea was produced with electrocautery in 31 lambs. In the control group (n = 10) no further intervention was used. In the treatment groups, either serial balloon dilatation of the stricture was performed (n = 6), or expandable metallic stents were inserted across the stricture (n = 15). All animals were monitored daily for signs of respiratory distress. Body weights, fluoroscopic airway measurements and rigid bronchoscopy were performed at least weekly. Results: The average weekly rate of airway growth was 8.2% ± 5.5% of the tracheal cross-sectional area (CSA). All animals displayed severe stenosis (mean, 90.2% ± 7.5% of CSA) within 13.1 ± 4 days after the injury. All animals in the control group had severe respiratory distress, weight loss and died within 14.6 ± 2.8 days after injury. Serial balloon dilatation of the stricture alone failed to relieve symptoms in all six animals in this group, who died within 20 ± 1 days after the injury, despite two to three dilatations each. With placement of expandable metallic stents, only 3 of 15 lambs died (two of pneumonia, one of iatrogenic perforation). The remaing 12 remained symptom-free and gained weight during a 2-month follow-up period. However, fluoroscopic examination showed partial collapse of the stents in all of these animals (mean, 44.7% ± 21.6% of CSA) requiring an average of 2 ± 0.7 bronchoscopic dilatations. Pathological evaluation showed more pronounced granulation tissue in the stented animals. Conclusions: The authors conclude that expandable metallic stents provide an effective tool in the management of acute tracheal stenosis. However, airway growth, tissue reaction, and the mechanical properties of the stent require close monitoring and stent adjustment.

A CASE REPORT OF TRACHEAL OBSTRUCTION DUE TO RECURRENT ESOPHAGEAL CANCER SUCCESSFULLY TREATED WITH AN EXPANDABLE METALLIC STENT

A 72-year-old man who underwent a curative resection for a thoracic esophageal cancer in June 1996, developed dyspnea in March 1997. Chest CT revealed recurrence and infiltration at the tracheal bifurcation, causing complete obstruction of the left main bronchus and atelectasis of the left lower lobe. Although radiotherapy was initiated immediately, his dyspnea became more severe, so an expandable metallic stent (EMS) was placed at the site of obstruction on April 1. On the next day after setting, dilatation of the tracheal lumen was achieved to the maximum diameter of EMS without pain or persistent cough. There was a striking improvement in his dyspnea and atelectasis. Four months after the EMS placement, the patient died from exacerbation of pleural effusion and intra-airway bleeding due to perforation of a mediastinal blood vessel by progression of the local lesion. EMS placement for airway obstruction had been suggested to be associated with the risks of hemorrhage on insertion of the dilator and fistula formation to adjacent structures throught long-term pressure from the expandable stent, but it was actually less invasive and dramatically improved the quality of life in this case. EMS insertion is particularly useful in patients with terminal cancer, and should be more widely used in the future.

Expandable metallic stent placement in patients with benign esophageal strictures: results of long-term follow-up.

To evaluate the long-term effectiveness of expandable esophageal metallic stents in benign esophageal strictures. The authors performed long-term follow-up of 14 expandable metallic stents in 12 patients (aged 16-72 years) with benign esophageal strictures. All 12 patients had initially undergone placement of one stent; two patients received an additional stent because of recurrent dysphagia. No procedural complications occurred. Delayed complications occurred in all patients. New strictures formed in six stents (five patients), migration occurred in seven stents (six patients), and both migration and formation of new strictures occurred in one stent (one patient). New stricture formation caused recurrence of dysphagia and necessitated further treatment. Three of four stents that migrated within 2 months after placement but none of the four stents that migrated more than 2 months after placement caused recurrence of dysphagia. Six patients died of unrelated causes 6-20 months after stent placement. The remaining six patients are still alive 24-48 (mean, 35) months after stent placement. The long-term effectiveness of expandable metallic stents in benign esophageal strictures is not encouraging because of the high delayed-complication rate. That the patients with migration showed improvement of dysphagia, however, may warrant further investigation of temporary placement of a retrievable covered stent.

Expandable Metallic Stents for Tracheobronchial Stenoses in Esophageal Cancer

Tracheobronchial stenosis in patients with esophageal cancer can be life threatening. Few reports have discussed use of expandable metallic stents for central airway stenoses in patients with esophageal cancer. Twelve patients with esophageal cancer underwent placement of expandable metallic stents for respiratory distress caused by tracheobronchial stricture. Single or double metallic stents were placed in the stenotic airways under fluoroscopic guidance. Improvement in respiratory symptoms and clinical outcome were assessed. Most stenoses were located in the trachea or the left main bronchus. From one to four expandable metallic stents were placed in each stricture site, with immediate relief of respiratory symptoms in 8 patients. One patient with tracheomalacia in alive 3 years after stent placement and another is alive 6 months after stent insertion. The other 10 patients lived from 10 to 70 days (mean; survival, 35 days) after stent placement. Death was due to progression of disease. Although metallic stents are useful for relieving respiratory distress in patients with advanced esophageal cancer, additional therapies should be considered.

Budd-Chiari syndrome caused by obstruction of the hepatic inferior vena cava: immediate and 2-year treatment results of transluminal angioplasty and metallic stent placement.

To assess the usefulness of percutaneous transluminal angioplasty (PTA) and expandable metallic stent (EMS) placement for treatment of Budd-Chiari syndrome (BCS). Thirty-two patients with BCS were treated by PTA alone or by PTA and EMS placement. Among the 32 patients, a membranous obstruction was found in 24 and a segmental stenosis or occlusion in 8 patients. The follow-up period for PTA was 38-68 months (mean 52.2 months); for EMS it was 20-36 months (mean 24.3 months). Twenty-one patients underwent PTA as the primary treatment. Of these, one patient died of disseminated intravascular coagulation shortly after the procedure; 20 had good to excellent initial angiographic and clinical results. Of the 20, restenosis or reocclusion developed in 10 patients (48%), all before 27 months; 8 patients (38%) became symptomatic, and 2 remained symptom-free for a total recurrent obstruction rate of 50%. The EMS group of 17 patients included 11 patients who underwent primary stenting and 6 patients with secondary stenting after recurrence following primary PTA; restenosis was demonstrated in only 2 patients (12%). We conclude that PTA alone produces excellent short-term results and about 50% sustained patency after 2 years in patients with BCS; therefore it should remain the procedure of first choice. Stents should be reserved for primary or secondary PTA failures.