Recurrent Dysphagia Research Articles

GIST des Ösophagus im linken tracheobronchialen Winkel: Resektion mittels rechtsthorakaler VATS

The vast majority of submucosal oesophageal tumours are leiomyomas. Gastrointestinal stromal tumours (GIST) account for only one percent of all gastrointestinal malignancies, whereby an oesophageal location represents a medical rarity. Although surgical resection is the gold standard, the optimal procedure remains a matter of debate. Conventional oesophageal resection is the most common therapeutic choice to ensure complete removal with an appropriate safety margin and avoid dissemination of neoplastic cells. Anyhow, occasional case reports about enucleation of oesophageal GIST have been published. This video paper for the first time describes the use of right-sided video-assisted thoracoscopic surgery (VATS) as a technique to enucleate an oesophageal GIST within the left tracheobronchial angle. A 68-year-old male patient was evaluated for recurrent haemoptysis and dysphagia and diagnosed with a 1.4 cm sized oesophageal tumour at the left tracheobronchial angle. CT scan showed a submucosal location without signs of invasive growth. After conducting endosonography we suspected a leiomyoma and performed minimally invasive enucleation with right-sided VATS. Employing independent lung ventilation the patient was put into a left lateral position. Four trocars were applied. After incision of the mediastinal pleura the tumour was localised with intraoperative gastroscopy and diaphanoscopy. By mobilisation of the oesophagus and transection of the azygous vein it was possible to bluntly dissect the mass from surrounding oesophageal muscular fibres and safely extract it with a specimen bag. After removal of the thoracic drainage on the first postoperative day the patient was discharged the day after. The further course was uneventful. Histological work-up showed a GIST pT1cN0M0 R0 with a Ki-67 index less than 1 % (UICC I). After 10 months of follow-up the patient is recurrence-free and shows no symptoms. Enucleation of a locally limited oesophageal GIST by right-sided VATS is a feasible and safe surgical procedure with dramatically reduced invasiveness compared to conventional open oesophageal resections.

An Unusual Cause of Dysphagia

Purpose: Lymphocytic esophagitis (LE) is a newly recognized histological pattern of esophageal injury. It is characterized by an increased number of intraepithelial lymphocytes without associated intraepithelial granulocytosis in the peripapillary fields of esophageal tissue. It typically presents with dysphagia and sometimes chest pain. The esophageal endoscopic findings are commonly normal. We present a case of a patient with recurrent dysphagia that was found to have histological evidence of LE. The individual is a 47-year-old man with history of Hodgkin's lymphoma at 23 years of age who was treated with splenectomy followed by chemotherapy and mantle field radiation completed 24 years ago. He currently has no evidence of disease. He presented with recurrent and progressive dysphagia for 2 years. His symptoms were initially alleviated by a proton pump inhibitor but recurred 1.5 years later. He had dysphagia daily and it was mostly to solids but occurred occasionally with liquids. He described a sensation of food getting stuck high in the esophagus for several seconds that ultimately passed down. He was on daily acid suppression therapy at this time. He denied regurgitation, heartburn, acid water brash, cough, or presenting to emergency room for food impaction. He underwent double contrast esophagram that revealed a possible early Zencker's diverticulum and esophageal web. Subsequent upper endoscopy revealed a normal appearing upper and middle third of the esophagus as well as Barrett's esophagus. There was no endoscopic evidence of stenosis, web or Zencker's diverticulum. Pathology of proximal esophagus revealed increased number of intraepithelial lymphocytes and rare granulocytes predominantly in the peripapillary fields. Given the patient's symptoms of dysphagia and intraepithelial lymphocytosis,this was considered to represent lymphocytic esophagitis. He was continued on a proton pump inhibitor twice per day and started on swallowed fluticasone. After 2 months of therapy, he describes an improvement in symptoms though still has occasional mild dysphagia to solids. Despite recently being diagnosed with increasing frequency, the clinical significance of LE, its treatment, and natural history remain poorly understood. Prospective studies are needed to help us better understand this condition.

Obliteration of Schatzki Rings in Patients with Refractory Dysphagia Utilizing Multiple Standard Endoscopic Biopsies

Purpose: The Schatzki ring, a benign lower esophageal structural anomaly, is one of the most common causes of dysphagia and intermittent food impaction. Therapy for Schatzki rings has traditionally utilized esophageal dilation with either bougienage or balloon dilators. No clear advantage has been demonstrated between these dilator types and both are associated with recurrent dysphagia. Alternatively, endoscopic electrosurgical incision of the fibrous, elastic core of Schatzki rings has been shown to be an efficacious treatment modality ever since it was first described almost 30 years ago in two patients who did not respond to conventional bougienage. However, the needle knife is not commonly employed during upper endoscopy, and its use in the treatment of benign esophageal strictures is likely to be technically difficult among most gastroenterologists with a risk of serious complications. In a fashion similar to that of electrosurgical incision, direct disruption of Schatzki rings may be more feasibly achieved with standard endoscopic biopsy forceps. To our knowledge, no study or case series has described ring obliteration by endoscopic biopsy forceps in patients who have refractory dysphagia after Savary dilation or through-the-scope balloon dilation. In our case series, we describe three individuals who underwent Schatzki ring obliteration utilizing multiple biopsies with standard forceps after undergoing conventional esophageal dilation that did not relieve their dysphagia. In the presence of acid suppression, obliteration was performed by obtaining four to five circumferential biopsies from various points of the Schatzki ring; no complications were encountered and dilation was immediately confirmed by the passage of a 13.5 or 15 millimeter through-the-scope balloon without resistance. Two of the patients reported no symptoms of dysphagia at follow-up 6-8 months later. The third patient had recurrent dysphagia that was later discovered to have an oropharyngeal etiology. Based on these outcomes, we suggest that multiple standard biopsies performed at equidistant sites around the Schatzki ring “break” the ring and relieve refractory dysphagia in a manner that is comparatively safer, more cost-effective, and more widely accepted in routine practice than electrosurgical incision.

Lymphocytic Esophagitis Presenting as Severe Dysphagia

Purpose: A 35-year-old African-American male with a history of childhood asthma, eczema, and food, drug and seasonal allergies presented with dysphagia. His symptoms began at age 7 years when he presented with regurgitation and dysphagia. There was no toxic ingestion. He was treated with antacids and H2 blockers. Symptoms were troublesome for years but resolved by age 10 years. He presented again at age 27 years with inability to tolerate solid foods. Upper endoscopy (EGD) at his local hospital was reportedly normal. He underwent manometry and was reportedly diagnosed with achalasia. A surgical myotomy was performed with only minimal improvement in symptoms. The patient presented to our institution with progressive severe solid dysphagia and weight loss. He denied odynophagia, fever, or night sweats. Physical exam: thin male, no oral lesions or lymphadenopathy. Labs: normal hemoglobin, electrolytes, and serum albumin. HIV negative. Barium esophagram: dilated esophagus with severe esophageal dysmotility. Repeat EGD: severely fibrotic and nodular mucosa. Biopsies caused linear tears and bleeding, requiring endoscopic clipping. Pathology showed active esophagitis and an inflammatory infiltrate composed of lymphocytes with admixed neutrophils and eosinophils. Based on the patient's history and pathologic findings, a clinical diagnosis of severe longstanding lymphocytic esophagitis (LE) or eosinophilic esophagitis (EoE) was made. A trial of high-dose PPI and topical budesonide was unsuccessful. Given the severity of the endoscopic findings and lack of response to medical therapy, the patient underwent an esophagectomy. Post-operatively he is able to tolerate a solid diet without recurrent dysphagia. Lymphocytic esophagitis is a poorly-understood entity. The primary symptom is dysphagia, though symptoms can include chest pain, abdominal pain, and heartburn. A wide range of ages at diagnosis has been reported. Patients often have GERD and atopic comorbidities. Endoscopic findings include rings, esophagitis, strictures, furrows, and nodularity. Biopsies are required for diagnosis and show a high number of intraepithelial lymphocytes but no more than rare neutrophils and eosinophils. Appropriate treatment for LE has not yet been defined, though prognosis appears to be good. This patient's pathology does not meet strict histologic criteria for LE. This may reflect a diagnosis of EoE, an overlap syndrome, or LE with post-surgical changes. LE should be considered in the differential diagnosis of dysphagia and more research is needed on the diagnosis, management, and natural history of this disorder.

PTU-170 Oesophageal Perforation Resulting from Band Achalasia – a Delayed Complication of Laparoscopic Adjustable Gastric Banding

IntroductionLaparoscopic adjustable gastric banding (LAGB) is a common bariatric procedure in the UK due to its relative technical ease and reversibility. The technique has been around since the 1990s and...

Su1503 Dysphagia Relief and Adverse Events Associated With Fully Covered Evolution® Esophageal Stents in Malignant Esophageal Strictures: Does Size Matter?

covered 20-mm SEMS which combines bilateral flared ends and three rows of anchoring flaps on the stent body for the prevention of migration. Aim: To evaluate the clinical efficacy and safety of the HANARO-Utrecht stent for the palliation of malignant dysphagia. Methods: Consecutive patients who underwent HANARO-Utrecht stent placement for palliation of malignant dysphagia in four centers from June 2011 until October 2012 were included. Patients were contacted after 2 weeks and monthly thereafter until death. Technical success, recurrent dysphagia, migration, survival and complications were evaluated. Results: Forty patients (29 men (72.5%), mean age 68 11 years) were included. Malignant dysphagia was caused by esophageal cancer (n 32), malignant extrinsic compression (n 5), tumor recurrence after esophagectomy (n 2) and gastric cancer (n 1). Four patients (10%) had an esophageal-respiratory fistula and 26 patients (65%) had undergone previous radiation and/or chemotherapy. Stent placement was technically successful in 38 patients (95%), in 1 patient the stent collapsed during repositioning and a second stent was placed through the stent and in 1 patient the stent was placed more distally than intended despite repositioning. Thirty-four patients (85%) remained dysphagia free during followup (median 59 days, range 2-397), while 6 patients (17%) had recurrent dysphagia after a median of 39 days (range 9-48), due to stent migration (n 5) and tissue overgrowth (n 1). In 4 of these patients, the stent had partially migrated and could be repositioned endoscopically, while in 2 patients a new stent was placed. One patient presented with recurrent partial migration after 59 days, for which repeat repositioning was performed. Fourteen patients are still alive after a median of 59 days (range 15-397) and 26 patients died after a median of 58 days (range 2-210), due to disease progression (n 20), complicated pneumonia (n 3), cardiac disease (n 1), euthanasia (n 1) and acute hypoxemia due to tumor ingrowth in the trachea (n 1). In total, 24 major complications occurred in 18 patients (47%), including severe pain (n 7), severe nausea and/or vomiting (n 6), bleeding (n 4), aspiration pneumonia (n 4), fistula formation (n 2) and tracheal compression (n 1). Conclusion: Despite the specific anti-migration features of the HANARO-Utrecht stent, migration was the main cause of recurrent dysphagia. We also observed a relatively high complication rate, especially severe pain, nausea and vomiting after placement, further improvements in stent design are needed.

Divertículo faringoesofagiano: avaliação dos resultados do tratamento

To evaluate the postoperative outcome of patients with pharyngoesophageal diverticulum submitted to surgical and endoscopic treatments. We retrospectively analyzed 36 patients with pharyngo-esophageal diverticulum treated at the Hospital of the Medical School of Botucatu - UNESP. Patients were divided into two groups, depending on the treatment: group 1 (n = 24): diverticulectomy associated myotomy through a left cervicotomy; group 2 (n = 12): endoscopic diverticulostomy with linear stapler. Operative mortality was zero in both groups. Early complications: group 1 - two patients developed cervical fistula and two, hoarseness; group 2 - none. Late complications: group 1 - none; group 2: recurrence of dysphagia in four patients (p = .01). Mean follow-up was 33 months for group 1 and 28 months for group 2. Both procedures were effective in remission of dysphagia. Surgical treatment showed superiority to endoscopy, with resolution of dysphagia with a single procedure. Endoscopic treatment should be reserved for the elderly and those with comorbidities.

Esophageal Stents in Malignant and Benign Disorders

Endoscopic stent placement is an effective palliative treatment for malignant dysphagia and fistula, leading to rapid symptom relief. However, recurrent dysphagia and other stent-related complications are common, for which reason continuously new design modifications are implemented. Although some of these changes facilitate stent placement, complications remain and occur at similar rates. Recently, stents have also been used in benign esophageal disorders. Covered stents have the ability to effectively seal esophageal perforations and leaks, reducing the need for invasive surgery. This benefit does not pertain to patients with refractory benign esophageal strictures, in whom stents have limited long-term effect and are associated with a high complication rate. The initial results of fully covered metal stents in refractory esophageal variceal bleeding are encouraging, but their definite role remains to be further elucidated. This review provides an overview of indications, techniques, and management of complications of stents in malignant and benign esophageal disease.

Recurrent Dysphagia after Heller Myotomy: Is Esophagectomy Always the Answer?

Esophagectomy has been recommended for patients when recurrent dysphagia develops after Heller myotomy for achalasia. My colleagues and I prefer to correct the specific anatomic problem with redo myotomy and preserve the esophagus. We examined the results of this approach. We analyzed the course of 43 patients undergoing redo Heller myotomy for achalasia between 1994 and 2011 with at least 1-year of follow-up. In 2012, a phone interview and a symptoms questionnaire were completed by 24 patients. Forty-three patients underwent redo Heller myotomy. All patients had dysphagia, 80% had had multiple dilations. Manometry confirmed the diagnosis, lower esophageal sphincter pressure averaged 17 mmHg; 24-hour pH monitoring was not useful because of fermentation; patients were divided into 4 groups according to findings on upper gastrointestinal series. Three patients underwent take down of previous fundoplication only, the remainder 40 had that and a redo myotomy with 3-cm gastric extension. Two mucosal perforations were repaired with primary closure and Dor fundoplication. At a median follow-up of 63 months, 19 of 24 patients reported improvement in dysphagia, with median overall satisfaction rating of 7 (range 3 to 10); 4 patients required esophagectomy for persistent dysphagia. The majority of failures after Heller myotomy present with dysphagia associated with esophageal narrowing. Upper gastrointestinal series is most useful to plan therapy and predicts outcomes. With few exceptions, patients improve substantially with redo myotomy, which can be accomplished laparoscopically with relatively low risk. These findings challenge the previously held concept that all myotomy failures need to be treated by an esophagectomy.

Presentation, Diagnosis, and Management of Achalasia

Presentation, Diagnosis, and Management of Achalasia

Partial Anterior vs Partial Posterior Fundoplication Following Transabdominal Esophagocardiomyotomy for Achalasia of the Esophagus

To review transabdominal esophagocardiomyotomy (surgical treatment of achalasia) of the esophagus and to compare outcomes of partial anterior vs partial posterior fundoplication. An electronic search was conducted among studies published between January 1976 and September 2011 using the keywords achalasia, myotomy, antireflux surgery, and fundoplication. Prospective studies of transabdominal esophagocardiomyotomy were selected. Outcomes selected were recurrent or persistent postoperative dysphagia and an abnormal 24-hour pH test result. Studies were divided into the following 3 groups: myotomy only, myotomy with anterior fundoplication, and myotomy with posterior fundoplication. Studies were weighted by the number of patients and by the follow-up duration. Event rates were calculated using meta-regression of the log-odds with the inverse variance method. Thirty-nine studies with a total of 2998 patients were identified. The odds of postoperative dysphagia were 0.06 (95% CI, 0.03-0.12) for myotomy only, 0.11 (95% CI, 0.09-0.14) for myotomy with anterior fundoplication, and 0.06 (95% CI, 0.04-0.08) for myotomy with posterior fundoplication. The odds of a postoperative abnormal 24-hour pH test result were 0.37 (95% CI, 0.12-1.08) for myotomy only, 0.16 (95% CI, 0.11-0.24) for myotomy with anterior fundoplication, and 0.18 (95% CI, 0.13-0.25) for myotomy with posterior fundoplication. The increased odds of postoperative dysphagia in the group undergoing myotomy with anterior fundoplication compared with the group undergoing myotomy with posterior fundoplication were statistically significant (P < .001). However, the incidence of a postoperative abnormal 24-hour pH test result was statistically similar. Partial posterior fundoplication when combined with an esophagocardiomyotomy may be associated with significantly lower reintervention rates for postoperative dysphagia, while providing similar reflux control compared with partial anterior fundoplication.

Prótesis Choostent como método de paliación de la disfagia secundaria a patología maligna

Use of Choostent prosthetic device for palliation of dysphagia secondary to esophageal cancer Background: Esophageal cancer causes disabling dysphagia and swallowing problems. Aim: To prospectively analyze the outcome of the insertion of a covered self-expanding metallic Choostent type prosthesis as a method of palliation of dysphagia, esophageal fistula or leak secondary to malignant disease of the esophagus or cardia. Material and Methods: A total of 30 consecutive patients aged 75 ± 8.8 years (63% males) with malignant disease of the esophagus or cardia were studied. Results: In 27 patients (90%) the stenosis was located in the esophagus, in two (6.7%) at the gastroesophageal junction and in one (3.3%) at the esophago - jejunal anastomosis due to tumor recurrence. In 24 cases (80%), the indication of the prosthesis was dysphagia, in three (10%) the presence of a tracheo-esophageal fistula and in the remaining three (10%), the suspicion of a perforation. Patients were followed until death. The prosthesis was inserted without incidents in 29 patients (96.6%). One patient had a pneumomediastinum, which evolved favorably. Dysphagia subsided in all patients. Early evolution was satisfactory in 12 patients (66.7%). The most common early complication was a transient chest pain in 3 cases (10%). Four patients (13.3%) died within 30 days post procedure. Of the remaining 26 patients, 14 (53.8%) had late complications (recurrence of dysphagia in 42% and hemorrhage in 11%). The mean interval between stent insertion and death was 169 ± 142.5 days. Conclusions: The Choostent esophageal prosthesis improves dysphagia immediately and safely. However, its use is associated with a high rate of late complications, directly related to prosthetic dysfunction.

Invited Commentary

Invited Commentary

Recurrent Severe Dysphagia Secondary to a Siliconoma after Breast Implant Failure

Recurrent Severe Dysphagia Secondary to a Siliconoma after Breast Implant Failure

Elimination of dysphagia using ultrasound guidance for botulinum toxin injections in cervical dystonia

Dysphagia is a common side effect after botulinum toxin injections for cervical dystonia, with an incidence of 10-40%, depending upon the study and dose used. Our study consisted of 5 preselected women who met criteria for cervical dystonia and subsequent dysphagia after electromyography (EMG)-guided injections. Injections were performed with ultrasound (US) imaging, and the effects on swallowing were examined. Separately, sternocleidomastoid (SCM) thickness in healthy controls and treated patients was measured. There were 34 episodes of dysphagia over 98 injection sessions using EMG guidance for a cumulative rate of 34.7%. Using US plus EMG guidance, there was 0% dysphagia across 27 injection sessions. SCM thickness was <1.1 cm. US combined with EMG guidance eliminated recurrent dysphagia after botulinum toxin treatment, possibly by keeping the injectate within the SCM.

Surgical management of benign strictures of the oesophagus: 18 years of experience

Introduction: Benign strictures of the oesophagus are not uncommon. The majority are due to ingestion of corrosives. Different forms of therapy have been recommended. Repeated stricture dilatation has been advocated; when this fails surgical replacement of the oesophagus may be required. There is little information regarding oesophageal dilatation in Sri Lanka. Aim: To retrospectively analyze an 18 year series of patients with benign strictures of the oesophagus treated in a single surgical unit to determine the safety and long term effectiveness of oesophageal replacement by a variety of techniques. Methods: 110 Patients with benign strictures of the oesophagus were treated in a single surgical unit at the Sri Jayawardenapura General Hospital, Nugegoda, Sri Lanka from 1994 to 2011. Clinical, pathological and operative data were reviewed from medical records and interviews with patients and relatives. Results: The male: female ratio was 1.14. Caustic soda ingestion was the commonest cause. Ninety two patients had undergone dilatation prior to presentation without improvement of dysphagia, while 65 had other procedures performed. Transhiatal resection of the oesophagus was the preferred method. Gastric transposition was performed in 67 while the colon was used as the conduit in the others. Recurrence of dysphagia was seen in 8 (7.6%) while the operative mortality rate was 5.4% Conclusion: Surgical treatment of benign strictures of the oesophagus by oesophageal replacement with the stomach or colon is a good option in patients with strictures that do not respond to dilatation and can be carried out with low mortality and morbidity. Repeated attempts at dilatation are unwarranted in such patients. DOI: http://dx.doi.org/10.4038/sljs.v30i1.4502 The Sri Lanka Journal of Surgery 2012; 30(1):18-25

Single and sequential biodegradable stent placement for refractory benign esophageal strictures: a prospective follow-up study

Although biodegradable stents do not require removal, a single biodegradable stent may only temporarily relieve dysphagia in patients with refractory benign esophageal stricture (RBES). The aim of this study was to evaluate the safety and long term efficacy of single and sequential biodegradable stent placement in patients with RBES. All patients who underwent biodegradable stent placement for RBES between August 2008 and March 2011 were prospectively followed to evaluate recurrent dysphagia and complication rates. In total, 59 stents were placed in 28 patients. Patients had previously been treated with multiple dilations (n = 20) or multiple dilations and non-biodegradable esophageal stenting (n = 8). A total of 13 patients underwent sequential biodegradable stent placement (median 3, range 2 - 8) during the study period. After initial stent placement, the median dysphagia-free period was 90 days (range 14 - 618 days). Clinical success (absence of dysphagia ≥ 6 months after stent placement) was achieved in seven patients (25 %) and major complications occurred in eight patients (29 %). After placement of a second biodegradable stent, the median dysphagia-free period was 55 days (range 25 - 700 days) and clinical success was achieved in 15 % of patients. After placement of a third stent, the median dysphagia-free period was 106 days (range 90 - 150 days), but none of the patients was clinically dysphagia-free. Placement of a single biodegradable stent is only temporarily effective in the vast majority of patients with RBES treated in a tertiary referral center. Sequential stenting may however be an option to avoid serial dilations.

Combination of biodegradable stent placement and single-dose brachytherapy is associated with an unacceptably high complication rate in the treatment of dysphagia from esophageal cancer

For the palliative treatment of dysphagia, esophageal stent placement provides immediate improvement, whereas brachytherapy offers better long-term relief. To evaluate safety and efficacy of concurrent brachytherapy and biodegradable stent placement. Prospective, single-arm study. Two tertiary-care referral centers. Nineteen consecutive patients with significant dysphagia resulting from unresectable esophageal cancer, with a life expectancy of more than 3 months. Single-dose brachytherapy (12 Gy) on day 1 followed by biodegradable stent placement on day 2. Intervention-related major complications (determined by an expert panel) and dysphagia. Nineteen patients (13 men, median age 66 years [interquartile range (IQR) 59-71] years) were included; 7 patients (37%) also received palliative chemotherapy. After inclusion of 19 patients, the study was ended prematurely because the safety threshold was exceeded. In total, 28 major complications occurred in 17 patients (89%). In 9 patients (47%), major complications were determined intervention-related (severe retrosternal pain with or without vomiting [n = 6], hematemesis [n = 1], recurrent dysphagia [n = 2]. Dysphagia scores decreased significantly from a median of 3 (IQR 3-4) to a median of 1 (IQR 0-3) after 1 month (P < .001). Despite adequate luminal patency in 17 patients (89%), normal diet could not be tolerated in 7 patients (37%) because of retrosternal pain and vomiting. Lack of routine endoscopy or contrast esophagram to evaluate recurrent dysphagia during follow-up. Despite restoration of luminal patency, a combined treatment of brachytherapy and biodegradable stent placement cannot be recommended for the palliative treatment of esophageal cancer because of an unacceptably high intervention-related major complication rate.

A comparison of the temporary placement of 3 different self-expanding stents for the treatment of refractory benign esophageal strictures: a prospective multicentre study

BackgroundRefractory benign esophageal strictures (RBESs) have been treated with the temporary placement of different self-expanding stents with conflicting results. We compared the clinical effectiveness of 3 types of stents: self-expanding plastic stents (SEPSs), biodegradable stents, and fully covered self-expanding metal stents (FCSEMSs), for the treatment of RBES.MethodsThis study prospectively evaluated 3 groups of 30 consecutive patients with RBESs who underwent temporary placement of either SEPSs (12 weeks, n = 10), biodegradable stents (n = 10) or FCSEMSs (12 weeks, n = 10). Data were collected to analyze the technical success and clinical outcome of the stents as evaluated by recurrent dysphagia, complications and reinterventions.ResultsStent implantation was technically successful in all patients. Migration occurred in 11 patients: 6 (60%) in the SEPS group, 2 (20%) in the biodegradable group and 3 (30%) in the FCSEMS group (P = 0.16). A total of 8/30 patients (26.6%) were dysphagia-free after the end of follow-up: 1 (10%) in the SEPS group, 3 (30%) in the biodegradable group and 4 (40%) in the FCSEMS group (P = 0.27). More reinterventions were required in the SEPS group (n = 24) than in the biodegradable group (n = 13) or the FCSEMS group (n = 13) (P = 0.24). Multivariate analysis showed that stricture length was significantly associated with higher recurrence rates after temporary stent placement (HR = 1.37; 95% CI = 1.08-1.75; P = 0.011).ConclusionsTemporary placement of a biodegradable stent or of a FCSEMS in patients with RBES may lead to long-term relief of dysphagia in 30 and 40% of patients, respectively. The use of SEPSs seems least preferable, as they are associated with frequent stent migration, more reinterventions and few cases of long-term improvement. Additionally, longer strictures were associated with a higher risk of recurrence.

Ten-year experience of esophageal self-expanding metal stent insertion at a single institution

Palliation of malignant dysphagia can be achieved using self-expanding metal stents (SEMS). This study was conceived to confirm that the insertion of SEMS improved patient symptoms without serious complications and to allow comparison with recent national data. Retrospective case note review of all patients receiving SEMS over a 10-year period between March 1999 and February 2009 was used in this study. There were 138 consecutive patients (50 female), median age of 75 (range 46-90) years, 122 (88.5%) had primary malignant disease of the esophagus or gastroesophageal junction. In total, 250 endoscopic examinations were carried out, with 200 interventional procedures, including the insertion of 156 SEMS. Before stenting, 74.2% of patients had a dysphagia score of 2-3. Following stent insertion, dysphagia scores improved to 0-1 in 90.3% of patients (P < 0.0001, Wilcoxon signed ranks). No complications were encountered in 61 (44%) patients. Chest pain was the most frequent difficulty, encountered in 50 (36%) patients. Tumor overgrowth occurred in 17 (12.3%) patients and food bolus obstruction was seen in 7% of patients. There were no esophageal perforations attributable to SEMS insertion. Overall 30-day mortality for those with esophago-gastric malignancy was 11.6% (16 patients), although the SEMS-related mortality was 2.2% (3 patients). Median survival from SEMS insertion was 3 (IQR 1.5-7) months. Patients requiring re-intervention for tumor overgrowth had a significantly longer median survival of 9.2 months (P= 0.001, log rank). SEMS were well tolerated with overall mortality and complication rates comparable to national data. For the longer survivors, re-intervention for recurrent dysphagia was not unusual.