Esophageal Self-expandable Metal Stents Research Articles

Fever of Undetermined Origin: Cervical Diskitis-Osteomyelitis Associated With Esophageal Self-Expanding Metal Stent

Conflicts of interest The authors disclose no conflicts. © 2013 by the AGA Institute 1542-3565/$36.00 http://dx.doi.org/10.1016/j.cgh.2013.05.039 Aof an esophageal self-expanding metal stent (SEMS). She was diagnosed with squamous cell carcinoma of the upper esophagus 6 months previously at another facility. She underwent placement of the partially covered SEMS at that time. She subsequently underwent chemotherapy and radiation therapy, with follow-up positron emission tomography–computed tomography (CT) showing no evidence of residual disease. About 2 weeks after completion of therapy, she started experiencing intolerance to liquids in the form of coughing episodes, followed by onset of fevers. Work-up for fever at the outside facility was unrevealing. Endoscopic removal of the SEMS was unsuccessful, and she was referred to our facility. Upon review of systems, she also reported upper back pain for the past few weeks. A barium esophagogram did not reveal any leak, fistula, obstruction, or perforation. A CT scan of the thorax suggested erosion of the posterior aspect of the SEMS into the C7 and T1 vertebral bodies (Figure A, sagittal CT view). Endoscopic views of the SEMS were unremarkable. The SEMS was removed under general anesthesia using a double-channel therapeutic gastroscope and 2 rat-tooth forceps, with no evidence of perforation noted after stent removal (Figure B). A barium esophagogram obtained after stent removal showed no evidence of a leak or fistula. Subsequent magnetic resonance imaging of the C-spine and T-spine showed enhancement of the C7, T1, T2, and T3 vertebral bodies, suggestive of diskitis-osteomyelitis (Figure C, sagittal T2-weighted magnetic resonance image). Blood cultures were negative. The patient’s fevers abated with appropriate antibiotic therapy. At the last follow-up evaluation 3 months later, she remained asymptomatic without any back pain or fevers. Esophageal SEMS have become an integral part of the management of malignant dysphagia. The patient’s initial symptoms of cough and intolerance to oral intake were suspicious for a tracheoesophageal fistula. However, barium esophagogram before and after stent removal failed to show the same. Her symptoms were likely caused by cervical spine involvement, esophageal dysmotility, and/or reflux. Cases of spondylodiscitis and osteomyelitis associated with esophageal stents, both plastic stents and SEMS, for benign indications as well as malignant indications have been reported previously. Although most cases have occurred in association with overt stent-induced perforation, there was no evidence of perforation in the current case. It is possible that a small perforation may have sealed by the time of fluoroscopic and endoscopic study at our institution. Given the widespread use of SEMS for palliation of dysphagia, clinicians need to be aware of the above described delayed complication associated with their use.

Resolution of an esophageal leak and posterior gastric wall necrosis with esophageal self-expandable metal stents

The use of weight reduction surgeries has increased over the years with a higher proportion of these surgeries being sleeve gastrectomies, this has been associated with some complications including staple line leaks. We report a 32-year-old male who had undergone a laparoscopic gastric band surgery and subsequently a laparoscopic sleeve gastrectomy, this was complicated by both an staple line leak at the gastroesophageal junction as well as a large (> 4 cm) posterior gastric wall defect due to gastric wall necrosis. We used two co-axially inserted self-expandable stents (SEMS) in the management of this patient, 5 stents were used over repeated endoscopy sessions and 20 wk. Both defects had resolved without the need for surgical intervention.This is the first reported case were SEMS are used for both a staple line leak as well as a gastric wall defect. We also review the literature on the use of SEMS in the management of leaks post weight reduction surgeries.

Esophageal self-expanding metallic stent (SEMS) migration: it's a topsy-turvy world

Esophageal self-expanding metallic stent (SEMS) migration: it's a topsy-turvy world

Placement of an esophageal self-expandable metal stent through a percutaneous endoscopic gastrostomy tract, for endoscopic therapy of upper gastrointestinal bleeding

Placement of an esophageal self-expandable metal stent through a percutaneous endoscopic gastrostomy tract, for endoscopic therapy of upper gastrointestinal bleeding

Covered esophageal self-expandable metal stents in the nonoperative management of postoperative colorectal anastomotic leaks

Covered esophageal self-expandable metal stents in the nonoperative management of postoperative colorectal anastomotic leaks

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.

Sp807 Unusual Case of Esophageal Disruption Treated with Self-Expanding Metal Esophageal Stents

A 24-year-old quadriplegic (auto accident) male presented with dysphagia, odynophagia, neck pain, fevers and chills of 4 weeks duration. CT scan showed a cervical para-spinal abscess with a fistulous communication with the esophagus. Neck exploration with abscess drainage and cervical plate removal was performed. Despite two surgical attempts, a persistent defect was present on esophagram. Further surgical intervention was deemed impossible due to infection. Patient was stabilized with conservative management. Two months later, while on G-tube feedings, the patient was referred to GI for any possible intervention so as to allow peroral intake.

Tu1594 Technical Aspects of Endoscopic Removal of Stents Placed for Benign Esophageal Diseases

Tu1594 Technical Aspects of Endoscopic Removal of Stents Placed for Benign Esophageal Diseases

Tu1595 Esophageal Self-Expandable Metal Stents Material and Mesh Grid Density Are the Biggest Determinants of Radiation Dose Enhancement in the Setting of Esophageal Radiotherapy

With the continued increase in the incidence of esophageal neoplasia the use of self-expandable metal stents (SEMSs) as an adjunct to chemoradiation for the treatment and palliation of malignant esophageal neoplasia continues to rise. The optimal esophageal stent design and material to minimize radiation dose enhancement and post-radiation complications in this setting is unknown.

Mo1440 The Use of Covered Esophageal Self-Expanding Metal Stents (CSEMS) for the Management of Post-Operative Colo-Rectal Anastomotic Leaks

Mo1440 The Use of Covered Esophageal Self-Expanding Metal Stents (CSEMS) for the Management of Post-Operative Colo-Rectal Anastomotic Leaks

Placement of a covered stent for palliation of a cavitated colon cancer by using a novel over-the-scope technique (with video)

Covered self-expandable metal stents (SEMSs) dedicated for colonic use are unavailable in the United States.1 Closure of colonic fistulae and leaks is feasible using covered esophageal SEMSs, but their short-length, non–through-the-scope (TTS) delivery systems are difficult to pass through tortuous anatomy. We describe a novel over-the-scope (OTS) technique to place an esophageal partially covered SEMS (PC-SEMS) in the colon.

Effect of stents on radiation dosimetry for esophageal cancer.

48 Background: To evaluate how self-expanding metal stents (SEMS) affect esophageal cancer radiation planning target volumes (PTVs) and dose delivered to surrounding organs-at-risk (OARs). Methods: Ten patients were evaluated for whom a SEMS was placed before radiation. A CT scan obtained before stent placement was fused to the post-stent CT simulation scan. Three methods were used to represent pre-stent PTVs: 1) Image Fusion (IF) - PTVs were contoured based on the pre-stent CT, 2) Volume Approximation (VA) - the post-stent PTV was altered to approximate the pre-stent PTV based on differences in esophageal volumes between scans, and 3) Diameter Approximation (DA) - the post-stent PTV was altered based on differences in esophageal diameters. PTVs and OARs were contoured per RTOG 1010 protocol using Eclipse Treatment Planning software. Post-stent dosimetry for each patient was compared to approximated pre-stent dosimetry. Results: For the IF, VA, and DA methods, the post-stent PTVs were larger than pre-stent PTVs by an average of 155, 68, and 67 cm3, respectively. Pre-stent heart and lung doses were less than post-stent using VA and DA; however, IF only yielded a significantly lower heart V40 (Table). Liver, spinal cord, and kidney doses were not significantly different between planning methods. Conclusions: Placement of an esophageal SEMS increased the PTV size for radiation planning, causing a statistically significant increase in heart and lung radiation doses, although the absolute dose increase was relatively small. Most patients receiving stents will have no increased risk of radiation-induced toxicity. In patients where one anticipates difficulty meeting crucial dose constraints, it may be preferable to consider avoidance of stenting before radiotherapy. [Table: see text]

Fully covered removable nitinol self-expandable metal stents (SEMS) in malignant strictures of the esophagus: a multicenter analysis

Fully covered esophageal self-expandable metallic stents (SEMS) often are used for palliation of malignant dysphagia. However, experience and data on these stents are still limited. The purpose of this multicenter study was to evaluate the efficacy and safety of fully covered nitinol SEMS in patients with malignant dysphagia. 37 patients underwent placement of a SEMS during a 3 year period. Five patients underwent SEMS placement as a bridge to surgery: one for tracheoesophageal fistula in the setting of squamous cell carcinoma of the esophagus, one for perforation in setting of esophageal adenocarcinoma, 27 for unresectable esophageal cancer (16 adenocarcinoma, 11 squamous cell carcinoma), two for lung cancer, and one for breast-cancer-related esophageal strictures. SEMS placement was successful in all 37 patients. Immediate complications after stent deployment included chest pain (n = 6), severe heartburn (n = 1), and upper gastrointestinal bleeding requiring SEMS revision (n = 1). Dysphagia scores improved significantly from 3.2 ± 0.4 before stent placement to 1.4 ± 1.0 at 1 month (P < 0.0001), 1.1 ± 1.2 (P < 0.0001) at 3 months, and 1.3 ± 1.4 (P = 0.0018) at 6 months. The stent was removed in 11 patients (30%) for the following indications: resolution of stricture (n = 3), stent malfunction (n = 5), and stent migration (n = 3). After stent removal, three patients were restented, three underwent dilation, and two underwent PEG placement. Mean survival for the 37 patients after stent placement was 146.3 ± 143.6 (range, 13-680) days. Our study suggests that fully covered SEMS placement improve dysphagia scores in patients with malignant strictures, particularly in the unresectable population. Further technical improvements in design to minimize long-term malfunction and migration are required.

Stent-in-stent technique for removal of a metal stent embedded in the colon wall by using a fully covered, self-expandable metal esophageal stent (with video)

Stent-in-stent technique for removal of a metal stent embedded in the colon wall by using a fully covered, self-expandable metal esophageal stent (with video)

Esophageal self-expandable metal stent for an anastomotic colorectal stricture

required total colectomy with ileorectal anastomosis in November 2009. She subsequently developed partial bowel obstruction requiring multiple balloon dilations of a pinpoint anastomotic stricture. A repeat endoscopy was performed and the stricture was first dilated up to 10mm with a CRE balloon dilator (Boston Scientific, Natick, Massachusetts, USA; ● Fig. 1a,b). A fully covered, metal, 18 × 80-mm esophageal Bonastent (Standard Sci Tech Inc., Seoul, South Korea) was then deployed across the stricture (● Fig. 1c,d) under fluoroscopic guidance (● Fig. 2). The patient tolerated the procedure well, without any complications. She was continuing to do extremely well when she returned for follow-up visits 1 month and 3 months later, with a barium enema showing a patent stent. She has declined to have the stent removed because she is finally symptom free. This case is unusual in that an esophageal stent was used to treat a colonic stricture. In patients with advanced malignancies, colonic stenting can provide palliative care by relieving acute colonic obstruction [1]. More recently, self-expanding metal stents (SEMS) have been placed in patients with benign colorectal disease [2]. The use of SEMS may be associated with a longer lasting dilatation and a lower rate of recurrence in cases of anastomotic stricture [2]. The majority of the previously reported cases have used colonic stents, either covered or uncovered [3]. However, for rectosigmoid lesions, esophageal stents may be another useful option because they are covered and the relatively short distance from the anus offers greater mechanical advantage in terms of manipulation of the stents [3,4]. One clinical trial that compared the migration rates of several stents in malignant colonic strictures reported that the Bonastent had the lowest rate of migration. This was attributed to its larger diameter and flared ends [4]. In conclusion, covered SEMS with flared ends can be used to relieve obstructions caused by anastomotic strictures. Further experience with these novel SEMS is required before they can be recommended for more generalized use.

Endoscopic removal of an embedded partially covered esophageal self-expandable metallic stent by overtube technique

Endoscopic removal of an embedded partially covered esophageal self-expandable metallic stent by overtube technique

Migration of esophageal self-expandable metal stent to the pleural cavity

Migration of esophageal self-expandable metal stent to the pleural cavity

Use of endoscopic nasobiliary drainage tube for treating mediastinitis caused by insertion of an esophageal self-expanding metal stent

Use of endoscopic nasobiliary drainage tube for treating mediastinitis caused by insertion of an esophageal self-expanding metal stent

Safety and efficacy of self-expanding removable metal esophageal stents during neoadjuvant chemotherapy for resectable esophageal cancer

Patients with esophageal cancer may present with dysphagia and weight loss. Resectable lesions require consideration of neoadjuvant chemotherapy, which improves survival but have side effects, which compound already poor intake. Prevention of malnutrition has historically required interventions such as surgical jejunostomy or percutaneous endoscopic gastrostomy, which carry associated morbidity. With established roles in palliation, self-expanding removable metal stents (SERMS) may provide an alternative intervention in resectable disease. We sought to evaluate outcomes from our unit's introduction of SERMS in dysphagic patients prior to esophagectomy. All dysphagic patients presenting with esophageal cancer and considered for curative surgery between April 2006 and November 2008 were offered preoperative treatment of dysphagia with SERMS during neoadjuvant chemotherapy. Baseline and preoperative outcomes assessed included dysphagia score and nutritional markers. Sixteen patients underwent esophageal stenting during neoadjuvant therapy of whom 7/16 (44%) were female with mean age 63 (53-76). In 12/16 (75%), tumors were located in the lower one third of the esophagus. There was a significant fall in mean dysphagia score from 2.5 (range 1-4) to 1.1 (range 0-3) immediately preoperatively. There was no significant change in serum albumin, weight, or body mass index. Stent-related morbidity occurred in 4/16 (25%) patients and stomach migration occurred in 7/16 (43.8%). All were resolved endoscopically and there was no stent-related mortality. Of 10/16 (62.5%) patients ultimately progressing to esophagectomy, 30-day mortality was 6.3%. Anastomotic leak occurred in one patient (10%) and R1 resection rate was 20%. SERMS are a safe and effective intervention in dysphagic patients undergoing neoadjuvant chemotherapy for esophageal cancer. Complications are minor and readily treatable with endoscopy. Objective parameters suggest nutritional status is maintained and symptoms are improved. SERMS do not appear to compromise resection.

Sa1568 Immediate, Early and Late Complications in Esophageal SEMS

The various indications for placement of esophageal self-expandable metal stent (SEMS) include fistulas, tears, perforations, and stenoses; both of malignant and benign etiology. International series describe a complication rate of 7 - 70%, including both minor and major events. Evaluate the immediate, early, and late complications of esophageal SEMS. From June 1996 to December 2010, 157 esophageal SEMS were placed. Complications were evaluated during the immediacy of placement (less than 24 hours), at an established early period (1 to 30 days), and throughout a late period (more than 30 days). Follow-up was possible in 67% of patients. Mean patient age was 66.4 years, with a male predominance of 76.7%. Indication for SEMS placement was of malignant etiology in 75.7%. Mean length of stenosis was 7.5cm. Forty-four percent of patients developed minor complications. Immediate complications were seen in 3.8%, being the most frequent: airway aspiration - 2 patients (50%), and proximal migration - 1 patient (25%). Early complications presented in 21.2%: proximal migration - 6 (27.3%), distal migration - 5 (22.7%), and decubitus ulceration - 5 (22.7%), among others. Late complications occurred in 44.2%: tumor overgrowth - 14 (30.4%), severe pain - 10 (21.7%), distal migration - 10 (21.7%), and food impaction - 3 (6.5%), were the most prevalent. No major complications were seen, associated with stent placement; and no patients died due to complications related to the procedure. Mean patient survival was 5.2 months. The incidence of immediate, early, and late complications, seen in our patients, is similar to what is described in larger series. We therefore concur that SEMS continue to be an adequate treatment option for the management of esophageal stenoses, fistulas, or perforations; both of benign or malignant etiology.