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Chen W, Huang P, Gu X, Liu X, Ying X, Yang J. Efficacy and safety of sequential cutting of nasobiliary tubes as an alternative to stent placement after nasobiliary drainage for the treatment of hilar malignant biliary stricture: a retrospective cohort study. Therap Adv Gastroenterol 2025; 18:17562848251319809. [PMID: 39963248 PMCID: PMC11831652 DOI: 10.1177/17562848251319809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2024] [Accepted: 01/24/2025] [Indexed: 02/20/2025] Open
Abstract
Background The rising incidence of hilar malignant bile duct strictures poses challenges for diagnosis and treatment. While endoscopic treatment is essential for relieving obstruction, it carries a high risk of postoperative cholangitis. Sequential cutting of nasobiliary tubes as an alternative to stent placement after nasobiliary drainage may emerge as an effective strategy to mitigate these complications. Objectives This study aimed to evaluate the efficacy and safety of nasobiliary tube cutting after nasobiliary drainage versus conventional stent placement in reducing postoperative cholangitis in patients with hilar malignant biliary strictures. Design A retrospective cohort study. Methods From 2015 to 2023, 208 patients were divided into two groups: nasobiliary tube cutting group (n = 103) and conventional stent group (n = 105). The primary outcome was postoperative cholangitis, with secondary outcomes including drainage success, bilirubin reduction, re-interventions, complications, and hospital stay. Results Cholangitis occurred in 11.7% of the nasobiliary tube cutting group and 26.7% of the conventional stent group (p = 0.006). Successful drainage was achieved in 84 patients (81.6%) in the nasobiliary tube cutting group and 78 patients (74.3%) in the conventional stent group, with no statistically significant difference (p = 0.207). Patients whose total bilirubin reduction >50% within 7 days were significantly higher in the nasobiliary tube cutting group (48.5% vs 27.6%, p = 0.002). There were no significant differences between the groups in the number of endoscopic retrograde cholangiopancreatography procedures or re-interventions required (p > 0.05). Except for postoperative cholangitis, other postoperative complications were comparable between the groups (p > 0.05). The postoperative hospital stay was significantly longer in the nasobiliary tube cutting group, with a median duration of 10.0 (7.0, 14.0) days compared to 7.0 (5.5, 12.5) days in the conventional stent group (p = 0.024). Bismuth-Corlette Type IV was identified as an independent risk factor for cholangitis (OR = 3.207, 95%CI: 1.253-8.210, p = 0.015). Conclusion For patients with hilar malignant biliary stricture, sequential cutting of nasobiliary tubes as an alternative to stent placement after nasobiliary drainage may reduce the incidence of postoperative cholangitis and achieve early successful drainage, but it may result in a prolonged postoperative hospital stay. Bismuth-Corlette Type IV is an independent risk factor for the development of postoperative cholangitis.
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Affiliation(s)
- Wangyang Chen
- Department of Gastroenterology, Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
- Key Laboratory of Integrated Traditional Chinese and Western Medicine for Biliary and Pancreatic Diseases of Zhejiang Province, Hangzhou, Zhejiang Province, China
- Hangzhou Institute of Digestive Diseases, Hangzhou, Zhejiang Province, China
| | - Peiyao Huang
- Department of Gastroenterology, The Fourth Affiliated Hospital, Zhejiang University School of Medicine, Yiwu, Zhejiang Province, China
- Key Laboratory of Integrated Traditional Chinese and Western Medicine for Biliary and Pancreatic Diseases of Zhejiang Province, Hangzhou, Zhejiang Province, China
- Hangzhou Institute of Digestive Diseases, Hangzhou, Zhejiang Province, China
| | - Xinyi Gu
- The Fourth School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, Zhejiang Province, China
- Key Laboratory of Integrated Traditional Chinese and Western Medicine for Biliary and Pancreatic Diseases of Zhejiang Province, Hangzhou, Zhejiang Province, China
- Hangzhou Institute of Digestive Diseases, Hangzhou, Zhejiang Province, China
| | - Xiaodie Liu
- The Fourth School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, Zhejiang Province, China
- Key Laboratory of Integrated Traditional Chinese and Western Medicine for Biliary and Pancreatic Diseases of Zhejiang Province, Hangzhou, Zhejiang Province, China
- Hangzhou Institute of Digestive Diseases, Hangzhou, Zhejiang Province, China
| | - Xiuzhiye Ying
- The Fourth School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, Zhejiang Province, China
- Key Laboratory of Integrated Traditional Chinese and Western Medicine for Biliary and Pancreatic Diseases of Zhejiang Province, Hangzhou, Zhejiang Province, China
- Hangzhou Institute of Digestive Diseases, Hangzhou, Zhejiang Province, China
| | - Jianfeng Yang
- Department of Gastroenterology, Affiliated Hangzhou First People’s Hospital, School of Medicine, Westlake University, #261 Huansha Road, Hangzhou, Zhejiang Province 310006, China
- Key Laboratory of Integrated Traditional Chinese and Western Medicine for Biliary and Pancreatic Diseases of Zhejiang Province, Hangzhou, Zhejiang Province, China
- Hangzhou Institute of Digestive Diseases, Hangzhou, Zhejiang Province, China
- Zhejiang Provincial Key Laboratory of Clinical Cancer Pharmacology and Toxicology Research, Hangzhou, Zhejiang Province, China
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Arntz S, Roller L. Delayed bronchial obstruction following esophageal stent placement: A case report and review of the literature. Radiol Case Rep 2023; 18:3113-3116. [PMID: 37416321 PMCID: PMC10319639 DOI: 10.1016/j.radcr.2023.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 05/28/2023] [Accepted: 06/02/2023] [Indexed: 07/08/2023] Open
Abstract
Esophageal adenocarcinoma typically has a poor prognosis at the time of diagnosis. Consequently, palliation of symptoms is vital to disease management with a cornerstone for palliation being esophageal stent placement. Esophageal stents are associated with a variety of complications that may present immediately or long after stent placement is completed. In this report, we present a 58-year-old male who developed shortness of breath 4 months after metallic esophageal stent placement. After further evaluation with a chest radiograph and CT angiogram of the chest, the patient was found to have obstruction of the left mainstem bronchus secondary to mass effect from the esophageal stent. Airway compromise secondary to metallic esophageal stent placement typically occurs immediately after placement of the stent. There are only a few documented cases of this complication occurring at a delayed interval. This case clearly demonstrates this rare complication of esophageal stent placement in the setting of esophageal adenocarcinoma.
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Ardeshna DR, Hussain FS, Balasubramanian G, Papachristou GI, Lara LF, Groce JR, Han S, Lee PJ, Jalil S, Hinton A, Krishna SG. Adverse Events With Esophageal Stenting: A Call to Optimize Device and Endoscopic Placement. TECHNIQUES AND INNOVATIONS IN GASTROINTESTINAL ENDOSCOPY 2023; 25:11-20. [DOI: 10.1016/j.tige.2022.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/25/2023]
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Bacopanos E, Jansen S, Hockley J. Aortoduodenal Fistula from Duodenal Stenting for Malignant Gastric Obstruction. EJVES Vasc Forum 2022; 57:1-4. [PMID: 36249716 PMCID: PMC9563612 DOI: 10.1016/j.ejvsvf.2022.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 08/11/2022] [Accepted: 08/24/2022] [Indexed: 12/04/2022] Open
Abstract
Introduction Aortoduodenal fistula (ADF) is a rare cause of upper gastrointestinal (GI) bleeding and is usually fatal without intervention. A high index of suspicion is required to identify and successfully manage this condition. Report Three cases of ADF following duodenal stent insertion for gastric outflow obstruction secondary to metastatic adenocarcinoma are presented. All presented with upper GI bleeding and underwent emergency percutaneous endovascular aortic stent graft repair (EVAR), with temporary aortic balloon occlusion in one case. All were successful in achieving haemostasis. The first case, although initially complicated by acute stent thrombosis of the right iliac limb, was discharged to a rehabilitation facility and survived for two years. The second patient died two days after the procedure from sepsis related complications. The third was discharged home six days post-procedure with a three month follow up. Conclusion A high suspicion for ADF in patients with previous duodenal stents is required for prompt diagnosis and management. EVAR may increase short to midterm life expectancy.
Aortoduodenal fistula following duodenal stent for malignant gastric obstruction Cases underwent percutaneous endovascular stent graft repair and achieved haemostasis In cases of ADF secondary to duodenal stenting, tube endografting may prolong life.
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Delayed Bronchial Obstruction Following Esophageal Stent Implantation: A Case Report. Medicina (B Aires) 2022; 58:medicina58020231. [PMID: 35208554 PMCID: PMC8876190 DOI: 10.3390/medicina58020231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 01/25/2022] [Accepted: 02/01/2022] [Indexed: 11/17/2022] Open
Abstract
Airway compression is a rare complication of esophageal stent placement. With the introduction of self-expanding metal stents, the incidence of bronchial obstruction by esophageal stents has decreased. Delayed external airway compression after esophageal stent implantation is rarely reported. We describe a case of left main bronchial obstruction after self-expandable esophageal stent placement. A 70-year-old patient with advanced esophageal cancer visited the emergency room (ER) with worsening cough and dyspnea. He had received palliative concurrent chemoradiotherapy after esophageal self-expanding metal stent (SEMS) insertion three months ago. One month before the ER visit, additional esophageal SEMS placement (stent-in-stent) was performed owing to the development of a tracheoesophageal fistula. After hospitalization, chest radiography revealed a patchy consolidation in the left lower lobe. A diagnosis of pneumonia was made, and the patient was treated with antibiotics. Seven days after antibiotic treatment, the patient developed a fever and severe dyspnea. Auscultation revealed the absence of breath sounds in the left hemithorax. A follow-up chest radiograph showed a white-out of the left hemithorax. Flexible bronchoscopy revealed luminal narrowing of the left main bronchus (LMB) due to external compression. Chest computed tomography further demonstrated compression of the LMB by esophageal stents. This case highlights that esophageal SEMS can present as an emergent and often life-threatening airway obstruction.
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Das KK, Hasak S, Elhanafi S, Visrodia KH, Ginsberg GG, Ahmad NA, Hollander T, Lang G, Kushnir VM, Mullady DK, Abu Dayyeh BK, Buttar NS, Wong Kee Song LM, Kochman ML, Chandrasekhara V. Performance and Predictors of Migration of Partially and Fully Covered Esophageal Self-Expanding Metal Stents for Malignant Dysphagia. Clin Gastroenterol Hepatol 2021; 19:2656-2663.e2. [PMID: 32898705 DOI: 10.1016/j.cgh.2020.09.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 08/24/2020] [Accepted: 09/02/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Self-expanding metal stents (SEMS) are routinely used to palliate malignant dysphagia. However esophageal SEMS can migrate or obstruct due to epithelial hyperplasia. The aim of this study was to evaluate the rates and factors predicting migration and obstruction, and the nutritional outcomes in partially covered (pc) vs. fully covered (fc) SEMS vs. fcSEMS with antimigration fins (AF) placed for malignant dysphagia. METHODS A retrospective review of consecutive patients undergoing SEMS placement for malignant dysphagia at three academic medical centers. RESULTS Among 357 patients, there were 55 (15.4%) stent migrations, 45 (12.6%) obstructions from epithelial hyperplasia, and 20 (5.6%) food impactions. Median overall survival was 79 days (IQR 41,199). The percent weight change/change in albumin at 30 and 60 days after SEMS placement were -2.24%/-0.544 g/dL and -2.98%/-0.55 g/dL, respectively. Stent migration occurred significantly more often with fcSEMS than pcSEMS (25.3% vs 10.9%; P < .003), but there was no difference when either group was compared to fcSEMS-AF (19.3%). The overall rate of epithelial hyperplasia resulting in stent obstruction was low (12.6%) and not different between stent types. Factors associated with increased risk of SEMS migration on multivariable logistic regression included stricture traversability with a diagnostic endoscope (OR, 2.37; 95% CI, 1.29-4.35) and use of fcSEMS (OR, 2.56; 1.31-5.00) or fcSEMS-AF (OR, 2.30, 1.03-5.14). CONCLUSIONS Traversability of a malignant esophageal stenosis predicts SEMS migration. In these patients with a limited overall survival, pcSEMS are associated with lower rates of stent migration and similar rates of obstruction compared to fcSEMS.
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Affiliation(s)
- Koushik K Das
- Division of Gastroenterology, Washington University, St. Louis, Missouri.
| | - Stephen Hasak
- Division of Gastroenterology, Washington University, St. Louis, Missouri
| | - Sherif Elhanafi
- Division of Gastroenterology, Texas Tech University Health Sciences Center, El Paso, Texas
| | - Kavel H Visrodia
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts
| | - Gregory G Ginsberg
- Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Nuzhat A Ahmad
- Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Thomas Hollander
- Division of Gastroenterology, Washington University, St. Louis, Missouri
| | - Gabriel Lang
- Division of Gastroenterology, Washington University, St. Louis, Missouri
| | - Vladimir M Kushnir
- Division of Gastroenterology, Washington University, St. Louis, Missouri
| | - Daniel K Mullady
- Division of Gastroenterology, Washington University, St. Louis, Missouri
| | - Barham K Abu Dayyeh
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Navtej S Buttar
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | | | - Michael L Kochman
- Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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Stent Applications for Palliative Treatment in Advanced Stage Esophageal Cancers. Gastroenterol Res Pract 2021; 2021:8034948. [PMID: 34707656 PMCID: PMC8545594 DOI: 10.1155/2021/8034948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 09/08/2021] [Accepted: 09/25/2021] [Indexed: 11/17/2022] Open
Abstract
Methods We examined cases of endoscopic stenting for palliative treatment of advanced stage esophageal cancers between January 2014 and July 2019. Age, gender, location of mass, adverse events, survival time, and stent type were evaluated. Outcomes of fully covered and uncovered self-expanding stents were compared with regard to adverse events, including stent migration and occlusion. Results The mean age of the patients was 66.4 ± 1, 52 were male, and 8 were female. Patients were followed up for a mean of 133 days. The most common complication due to stenting was migration. 13 patients developed adverse events. Migration was the most common adverse event, occurring in 8 (13%) patients. Although the migration rate of fully covered stents was higher than uncovered stents, there was no statistically significant difference (p = 0.47). Stent occlusion was observed in 4 patients. In three cases, it was due to the tumor; an uncovered stent was placed again in these cases. Food-related occlusion developed in one patient. There was no statistical difference in terms of overall adverse event rate when comparing fully covered stents to uncovered stents (p = 0.68). Conclusion Endoscopic stenting is a viable palliative method with low morbidity and mortality in experienced centers. Though there are relative advantages with covered versus uncovered stents in individual cases, the overall adverse event rate is low and relatively similar.
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8
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Comparison of different types of covered self-expandable metal stents for malignant colorectal obstruction. Surg Endosc 2020; 35:4124-4133. [PMID: 32789723 DOI: 10.1007/s00464-020-07869-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 08/05/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Stent migration is one of the main drawbacks of covered self-expandable metal stent (SEMSs), occurring in up to 40% of malignant colorectal obstruction management cases. Various types of covered SEMSs have been developed to reduce this risk. We aimed to compare the effectiveness and complication rates of the flare-type covered SEMS (Flare) with those of the double-layered covered SEMS (ComVi). METHODS We performed a prospective, randomized study in four tertiary referral centers between July 2016 and April 2018. Patients with malignant colorectal obstruction were eligible for the study. The primary outcome was migration rate as observed within the first month. Rates of technical success, clinical success, and complications within the first month were also assessed. RESULTS A total of 60 patients were included (mean age, 70.5 ± 12.5 years; male, 31 [51.7%]). Flare and ComVi stents were applied in 30 patients each. The Flare and ComVi groups showed comparable technical success rates (90% [27/30] vs. 96.7% [29/30], p = 0.605) and clinical success rates (85.2% [23/27] vs. 75.9% [22/29], p = 0.589). Migration occurred in three (11.1%) and four (13.8%) cases in the Flare and ComVi groups, respectively, without significant difference (p = 0.99), and the risk of other complications, including perforation and re-obstruction, did not differ between the two groups. CONCLUSIONS Our study indicates that both flare-shape and double-layered covered SEMSs are equally effective options for the management of malignant colorectal obstruction with low migration rates when compared with previously reported migration risk of covered SEMS.
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Chan MQ, Balasubramanian G, Modi RM, Papachristou GI, Strobel SG, Groce JR, Hinton A, Krishna SG. Changing epidemiology of esophageal stent placement for dysphagia: a decade of trends and the impact of benign indications. Gastrointest Endosc 2020; 92:56-64.e7. [PMID: 32105711 DOI: 10.1016/j.gie.2020.02.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 02/08/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS In addition to managing malignant obstruction, esophageal stents (ESs) have evolved to address various benign etiologies of dysphagia. We sought to evaluate national trends and changes in practice of ES placement for both benign and malignant etiologies in hospitalized patients with dysphagia. METHODS The National Inpatient Sample (2003-2013) was used to include all adult inpatients (≥18 years of age) with endoscopy-guided ES placement for a symptom of dysphagia. Multivariable analyses for indications that impact temporal trends (3 time periods: 2003-2005, 2006-2009, and 2010-2013) and for hospital outcomes were performed. RESULTS A total of 7198 ESs were deployed endoscopically in hospitalized patients with dysphagia. Compared with malignant etiologies, there was a significant increase in ES placement for benign conditions (2013 vs 2003: 32.7% vs 14.5%, respectively; P < .001). Multivariable analysis using 2003 to 2005 as a reference showed that patients with benign etiologies for dysphagia predominantly contributed to the increase of ES placement during the most recent time period (2010-2013: odds ratio, 2.09; 95% confidence interval, 1.40-3.13). Multivariable analysis of hospital outcomes revealed no differences in inpatient mortality, duration of hospital stay, and hospital costs between malignant and benign indications. CONCLUSIONS In the preceding decade, ES placement for hospitalized patients with dysphagia has increased, driven largely by an over 8-fold rise in stent placement for benign indications. These findings warrant continued efforts to improve stent technology to decrease the risk of migration and review practice guidelines involving ES placement for benign etiologies.
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Affiliation(s)
- Megan Q Chan
- Division of Gastroenterology, Hepatology, and Nutrition, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
| | - Gokulakishnan Balasubramanian
- Division of Gastroenterology, Hepatology, and Nutrition, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
| | - Rohan M Modi
- Division of Gastroenterology, Hepatology, and Nutrition, University of Virginia, Charlottesville, Virginia, USA
| | - Georgios I Papachristou
- Division of Gastroenterology, Hepatology, and Nutrition, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
| | - Sebastian G Strobel
- Division of Gastroenterology, Hepatology, and Nutrition, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
| | - Jeffery R Groce
- Division of Gastroenterology, Hepatology, and Nutrition, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
| | - Alice Hinton
- Division of Biostatistics, College of Public Health, The Ohio State University, Columbus, Ohio, USA
| | - Somashekar G Krishna
- Division of Gastroenterology, Hepatology, and Nutrition, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
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Martin EJ, Bruggeman AR, Nalawade VV, Sarkar RR, Qiao EM, Rose BS, Murphy JD. Palliative Radiotherapy Versus Esophageal Stent Placement in the Management of Patients With Metastatic Esophageal Cancer. J Natl Compr Canc Netw 2020; 18:569-574. [DOI: 10.6004/jnccn.2019.7524] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Accepted: 12/11/2019] [Indexed: 11/17/2022]
Abstract
Background:Patients with advanced esophageal cancer often experience pain and dysphagia, yet the optimal palliative management remains unclear. This retrospective study evaluated outcomes and adverse effects of palliative radiotherapy (RT) compared with esophageal stenting among a cohort of U.S. veterans with metastatic esophageal cancer.Patients and Methods:We identified 1,957 veterans in the United States with metastatic esophageal cancer who received palliative RT to the esophagus or esophageal stenting, and assessed the risks of severe adverse effects, including esophageal fistula formation, perforation, obstruction, hemorrhage, and esophagitis. We determined palliative efficacy by evaluating pain and dysphagia scores before and after intervention. Multivariable analyses were used to control for potential confounding factors.Results:In our cohort, 1,593 patients underwent RT and 364 underwent esophageal stenting. The cumulative incidence of any severe adverse effect at 6 months was higher among patients who received stents compared with those who received RT (21.7% vs 12.4%;P<.0010). In multivariable analysis, patients who received stents had an increased risk of any severe adverse effect, including fistula, perforation, and hemorrhage (allP<.0500). Multivariable analysis also showed that, compared with stenting, RT was associated with more rapid and durable pain relief (P<.0010) with no difference in relief of dysphagia over time when accounting for pretreatment dysphagia scores (P=.1029).Conclusions:Compared with esophageal stenting, RT was associated with a decreased risk of adverse effects, greater pain relief, and equivalent relief of moderate to severe dysphagia over time. Unmeasured patient- or tumor-related factors could have influenced the choice of intervention, thereby impacting our study outcomes. To our knowledge, this is the largest study to date analyzing the comparative risks and benefits of palliative RT and esophageal stenting among patients with metastatic esophageal cancer.
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Affiliation(s)
- Emily J. Martin
- 1Department of Medicine, University of California, Los Angeles, Los Angeles, California; and
| | - Andrew R. Bruggeman
- 2Department of Radiation Medicine and Applied Sciences, University of California, San Diego, San Diego, California
| | - Vinit V. Nalawade
- 2Department of Radiation Medicine and Applied Sciences, University of California, San Diego, San Diego, California
| | - Reith R. Sarkar
- 2Department of Radiation Medicine and Applied Sciences, University of California, San Diego, San Diego, California
| | - Edmund M. Qiao
- 2Department of Radiation Medicine and Applied Sciences, University of California, San Diego, San Diego, California
| | - Brent S. Rose
- 2Department of Radiation Medicine and Applied Sciences, University of California, San Diego, San Diego, California
| | - James D. Murphy
- 2Department of Radiation Medicine and Applied Sciences, University of California, San Diego, San Diego, California
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Chan MQ, Balasubramanian G. Esophageal Dysphagia in the Elderly. CURRENT TREATMENT OPTIONS IN GASTROENTEROLOGY 2019; 17:534-553. [PMID: 31741211 DOI: 10.1007/s11938-019-00264-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW With a globally aging population, dysphagia is a growing health concern among elderly. Increasing reflux disease has contributed to an increased prevalence of dysphagia from peptic strictures and esophageal cancer. Dysphagia can lead to malnutrition and aspiration pneumonia, causing considerable morbidity and mortality. This review article focuses on recent advances in the approach and management of esophageal dysphagia. RECENT FINDINGS Endoscopic functional luminal imaging probe is a novel test that complements upper endoscopy, esophagram, and esophageal manometry for evaluation of esophageal dysphagia. Opioid induced esophageal dysfunction (OIED) is an emerging clinical entity that can mimic achalasia. Strictures refractory to dilation can be treated with intralesional steroid injections, electrosurgical incision, or esophageal stents. Peroral endoscopic myotomy (POEM) is gaining in popularity for treatment of achalasia and other spastic disorders of esophagus. Treatment of esophageal dysphagia may include proton pump inhibitors, endoscopic dilation, or surgery and requires a personalized approach based on risks and benefits. POEM is a valuable therapy for achalasia, but further studies are needed to evaluate its use, and other alternatives, for treatment of OIED and spastic esophageal disorders.
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Affiliation(s)
- Megan Q Chan
- Department of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, 395 W. 12th Avenue, 2nd floor, Columbus, OH, USA
| | - Gokulakishnan Balasubramanian
- Department of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, 395 W. 12th Avenue, 2nd floor, Columbus, OH, USA.
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12
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Ribeiro MSI, da Costa Martins B, Simas de Lima M, Franco MC, Safatle-Ribeiro AV, de Sousa Medeiros V, Bastos VR, Kawaguti FS, Aissar Sallum RA, Ribeiro U, Maluf-Filho F. Self-expandable metal stent for malignant esophagorespiratory fistula: predictive factors associated with clinical failure. Gastrointest Endosc 2018; 87:390-396. [PMID: 28964748 DOI: 10.1016/j.gie.2017.09.020] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2017] [Accepted: 09/21/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Malignant esophagorespiratory fistulas (MERFs) usually are managed by the placement of self-expandable metal stents (SEMSs) but with conflicting results. This study aimed to identify risk factors associated with clinical failure after SEMS placement for the treatment of MERFs. METHODS This was a retrospective analysis of a prospectively maintained database used at a tertiary-care cancer hospital, with patients treated with SEMS placement for MERFs between January 2009 and February 2016. Logistic regression was used to identify predictive factors for clinical outcomes and to estimate the odds ratio (OR) and the 95% confidence interval (CI). The Kaplan-Meier method was used for survival analysis, and comparisons were made by using the log-rank test. RESULTS A total of 71 patients (55 male, mean age 59 years) were included in the study, and 70 were considered for the final analysis (1 failed stent insertion). Clinical failure occurred in 44% of patients. An Eastern Cooperative Oncology Group (ECOG) performance status of 3 or 4 and fistula development during esophageal cancer treatment were associated with an increased risk of clinical failure. ECOG status of 3 or 4, pulmonary infection at the time of SEMS placement, and prior radiation therapy were predictive factors associated with lower overall survival. Dysphagia scores improved significantly 15 days after stent insertion. The overall stent-related adverse event rate was 30%. Stent migration and occlusion caused by tumor overgrowth were the most common adverse events. CONCLUSION SEMS placement is a reasonable treatment option for MERFs; however, ECOG status of 3 or 4 and fistula development during esophageal cancer treatment may be independent predictors of clinical failure after stent placement.
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Affiliation(s)
| | - Bruno da Costa Martins
- Department of Gastroenterology, Cancer Institute of Sao Paulo, University of Sao Paulo, Sao Paulo, Brazil
| | - Marcelo Simas de Lima
- Department of Gastroenterology, Cancer Institute of Sao Paulo, University of Sao Paulo, Sao Paulo, Brazil
| | - Matheus Cavalcante Franco
- Department of Gastroenterology, Cancer Institute of Sao Paulo, University of Sao Paulo, Sao Paulo, Brazil
| | | | - Vitor de Sousa Medeiros
- Department of Gastroenterology, Cancer Institute of Sao Paulo, University of Sao Paulo, Sao Paulo, Brazil
| | - Victor Rossi Bastos
- Department of Gastroenterology, Cancer Institute of Sao Paulo, University of Sao Paulo, Sao Paulo, Brazil
| | - Fabio Shiguehissa Kawaguti
- Department of Gastroenterology, Cancer Institute of Sao Paulo, University of Sao Paulo, Sao Paulo, Brazil
| | | | - Ulysses Ribeiro
- Department of Gastroenterology, Cancer Institute of Sao Paulo, University of Sao Paulo, Sao Paulo, Brazil
| | - Fauze Maluf-Filho
- Department of Gastroenterology, Cancer Institute of Sao Paulo, University of Sao Paulo, Sao Paulo, Brazil
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Delay of surgery after stent placement for resectable malignant colorectal obstruction is associated with higher risk of recurrence. Int J Colorectal Dis 2017; 32:513-516. [PMID: 27853888 DOI: 10.1007/s00384-016-2705-4] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/10/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND Self-expanding metal stents can be used as bridge to elective surgery for acute malignant colonic obstruction. However, the impact on long-term oncological outcome and the optimal timing of surgery are still unknown. METHOD This was a retrospective multicenter study performed at four colorectal centers. Patients undergoing stent placement as bridge to surgery, between January 2010 and December 2013, were included in the study. Primary outcomes were survival and recurrence rates along with location of the metastases. Additionally, we recorded time from stent placement to elective surgery. Secondary outcomes were postoperative complication rates. Complications were classified according to the Clavien-Dindo classification score. A logistic regression model was used to describe impact of delayed stent removal on risk of recurrence. RESULTS This study included 112 patients, with a median follow-up of 43 months. Survival rate was 70%. We found a recurrence rate of 37%, primarily local recurrences (17%). Procedure-related complications at the stent placement were seen in 18%, and complications after subsequent elective surgery were seen in 39%. A significantly higher risk of recurrence with increased time from stent placement to elective surgery (OR 5.1 [1.6-15.8], p = 0.005) was found. CONCLUSION Delay of elective surgery after stent placement may have a negative influence on long-term oncologic outcomes.
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Ishtiaq J, Sutton J, Ahmed W. A novel management of post-oesophagectomy gastro-pleural fistula. J Gastrointest Oncol 2016; 7:E93-E97. [PMID: 28078131 DOI: 10.21037/jgo.2016.09.12] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Oesophageal anastomotic leak and fistula are major and life-threatening complications of oesophagectomy with resultant increased mortality. Non-operative approach of such cases should be the initial strategy. Re-operative surgery and/or stent insertion are considered if conservative measures failed. Although oesophageal stenting is a safe option for the leaks, stent migration and failure to completely cover large anastomotic leaks are the main complications and pitfalls of the procedure. These can be overcome by using multiple or larger stents. We describe a case of a 73-year-old man who underwent a laparoscopic oesophagectomy for an oesophageal adenocarcinoma. The procedure was complicated by a large gastro-pleural fistula and anastomotic leak, resulting into a chronic empyema. The initial conservative treatment and a conventional oesophageal stent insertion failed to heal the fistula and to resolve the empyema. Re-operative surgery was ruled out because of the patient's poor general health and high surgical risk. Due to the changed oesophago-gastric anatomy and a potential risk of migration of the additional conventional stent, a mega stent was deployed with successful closure of the oesophageal leak. Post-stenting contrast studies and an out-patient follow up review of the case confirmed no further anastomotic leakage.
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Affiliation(s)
- Javaid Ishtiaq
- Gastroenterology, Sandwell and West Birmingham Hospitals NHS Trust, Lyndon, West Bromwich, West Midlands, UK
| | | | - Waqar Ahmed
- Gastroenterology, Ysbyty Gwynedd, Bangor, Gwynedd, UK
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DaVee T, Irani S, Leggett CL, Berzosa Corella M, Grooteman KV, Wong Kee Song LM, Wallace MB, Kozarek RA, Baron TH. Stent-in-stent technique for removal of embedded partially covered self-expanding metal stents. Surg Endosc 2016; 30:2332-2341. [PMID: 26416379 DOI: 10.1007/s00464-015-4475-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Accepted: 06/27/2015] [Indexed: 12/18/2022]
Abstract
BACKGROUND Removal of embedded partially covered self-expanding metal stents (PCSEMS) is associated with an increased risk of adverse events compared with removal of fully covered self-expanding stents (FCSES) due to tissue ingrowth. Successful removal of embedded PCSEMS has been described by the stent-in-stent (SIS) technique. AIMS To report the first US experience from three high-volume quaternary care centers on the safety and efficacy of the SIS technique for removal of embedded PCSEMS. METHODS Retrospective study of outcomes for consecutive patients who underwent the SIS for removal of embedded PCSEMS over a 5-year period. RESULTS Twenty-seven embedded PCSEMS were successfully removed using the SIS technique (100 %) from 25 patients (11 males), median age 65 (range 37-80). All stents were successfully removed in one endoscopic session (no repeat SIS procedures were required for persistently embedded stents). The embedded PCSEMS had been in situ for a median of 76 days (range 26-501). Median SIS dwell time (FCSES in situ of PCSEMS) was 13 days (interquartile range 8-16 days; range 4-212 days). One adverse event (self-limited bleeding) occurred during a median follow-up period of 3 months (range 1-32). No patients died, required surgery, or had long-term disability due to adverse events attributed to the SIS technique. Twelve patients required additional interventions following SIS procedure for persistence or recurrence of the underlying pathology. CONCLUSION When performed by experienced endoscopists, safe and effective removal of embedded PCSEMS can be achieved via the SIS technique.
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Affiliation(s)
- Tomas DaVee
- Gastroenterology, Vanderbilt University, Nashville, TN, USA
| | - Shayan Irani
- Gastroenterology, Virginia Mason Medical Center, Seattle, WA, USA
| | | | | | | | | | | | | | - Todd H Baron
- Gastroenterology, University of North Carolina, Chapel Hill, NC, USA.
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Abstract
BACKGROUND AND STUDY AIMS Migration is the most common complication of the fully covered metallic self-expanding esophageal stent (FCSEMS). Recent studies have demonstrated migration rates between 30% and 60%. The aim of this study was to determine the effect of fixation of the FCSEMS by endoscopic suturing on migration rate. PATIENT AND METHODS Patients who underwent stent placement for esophageal strictures and leaks over the last year were captured and reviewed retrospectively. Group A, cases, were patients who underwent suture placement and group B, controls, were patients who had stents without sutures. Basic demographics, indications, and adverse events (AEs) were collected. Kaplan-Meier analysis and Cox regression modeling were conducted to determine estimates and predictors of stent migration in patients with and without suture placement. RESULTS Thirty-seven patients (18 males, 48.65%), mean age 57.2 years (±16.3 y), were treated with esophageal FCSEMS. A total of 17 patients received sutures (group A) and 20 patients received stents without sutures (group B). Stent migration was noted in a total of 13 of the 37 patients (35%) [2 (11%) in group A and 11 (55%) in group B]. Using Kaplan-Meier analysis and log-rank analysis, fixation of the stent with suturing reduced the risk of migration (P=0.04). There were no AEs directly related to suture placement. CONCLUSIONS Anchoring of the upper flare of the FCSEMS with endoscopic sutures is technically feasible and significantly reduces stent migration rate when compared with no suturing, and is a safe procedure with very low AEs rates.
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Abstract
Upper gastrointestinal (GI) stents are increasingly being used to manage upper GI obstructions. Initially developed for palliative treatment of esophageal cancer, upper GI stents now play an emerging role in benign strictures of the upper GI tract. Because recurrent obstruction and stent-related complications are common, new modifications of stents have been implemented. Self-expandable metal stents (SEMS) have replaced older plastic stents. In addition, newly designed SEMS have been developed to prevent complications. This review provides an overview of the various types, indications, methods, complications, and clinical outcomes of upper GI stents in a number of malignant and benign disorders dividing the esophagus and gastroduodenum.
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Affiliation(s)
- Hyoun Woo Kang
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, Korea
| | - Sang Gyun Kim
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
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Kang HW, Kim SG. Upper Gastrointestinal Stent Insertion in Malignant and Benign Disorders. Clin Endosc 2015; 48:187-93. [PMID: 26064817 PMCID: PMC4461661 DOI: 10.5946/ce.2015.48.3.187] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2015] [Accepted: 04/22/2015] [Indexed: 02/06/2023] Open
Abstract
Upper gastrointestinal (GI) stents are increasingly being used to manage upper GI obstructions. Initially developed for palliative treatment of esophageal cancer, upper GI stents now play an emerging role in benign strictures of the upper GI tract. Because recurrent obstruction and stent-related complications are common, new modifications of stents have been implemented. Self-expandable metal stents (SEMS) have replaced older plastic stents. In addition, newly designed SEMS have been developed to prevent complications. This review provides an overview of the various types, indications, methods, complications, and clinical outcomes of upper GI stents in a number of malignant and benign disorders dividing the esophagus and gastroduodenum.
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Affiliation(s)
- Hyoun Woo Kang
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, Korea
| | - Sang Gyun Kim
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
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Kim SJ, Kim HW, Park SB, Kang DH, Choi CW, Song BJ, Hong JB, Kim DJ, Park BS, Son GM. Colonic perforation either during or after stent insertion as a bridge to surgery for malignant colorectal obstruction increases the risk of peritoneal seeding. Surg Endosc 2015; 29:3499-506. [PMID: 25676202 DOI: 10.1007/s00464-015-4100-6] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Accepted: 01/26/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Endoscopic colorectal stenting may be performed as a bridge to surgery in patients with malignant colorectal obstruction, and has been reported to be associated with a high rate of successful primary anastomosis, low rate of stoma formation, and shorter hospital stay. However, the results of recent studies suggest that colorectal stenting could potentially worsen the prognosis. This study aimed to compare outcomes between patients who underwent colorectal stenting as a bridge to surgery and patients who underwent curative surgery only for malignant colorectal obstruction. METHODS This study included patients with malignant colorectal obstruction and symptomatic bowel dilatation who were treated by stenting as a bridge to surgery (stent group, n = 27) or surgical resection only (surgery-only group, n = 29) between May 2009 and May 2012. The short-term outcomes evaluated were the primary anastomosis rate, length of hospital stay, and rates of emergency and open surgery. The long-term outcomes evaluated were overall survival (OS) and recurrence-free survival (RFS). RESULTS The primary outcomes were similar in the two groups. There were no significant differences between the stent and surgery-only groups in 3-year OS (85.2 vs. 82.8%; p = 0.655) or 3-year RFS (80.7 vs. 78.6%; p = 0.916). The odds ratio for seeded metastasis after perforation either during or after stent placement was 46.0 (95% CI, 2.0-1,047.8; p = 0.016). CONCLUSIONS Colorectal stenting as a bridge to surgery showed no significant short- or long-term benefits compared with surgery only, and was associated with peritoneal seeding after perforation. Stenting before surgery should therefore only be considered in patients with a high risk of complications associated with emergency surgery.
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Affiliation(s)
- Su Jin Kim
- Department of Internal Medicine, Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Beomeo-ri, Mulgeum-eup, Yangsan-si, Gyeongsangnam-do, Yangsan, 626-770, Korea.
| | - Hyung Wook Kim
- Department of Internal Medicine, Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Beomeo-ri, Mulgeum-eup, Yangsan-si, Gyeongsangnam-do, Yangsan, 626-770, Korea.
| | - Su Bum Park
- Department of Internal Medicine, Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Beomeo-ri, Mulgeum-eup, Yangsan-si, Gyeongsangnam-do, Yangsan, 626-770, Korea
| | - Dae Hwan Kang
- Department of Internal Medicine, Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Beomeo-ri, Mulgeum-eup, Yangsan-si, Gyeongsangnam-do, Yangsan, 626-770, Korea
| | - Cheol Woong Choi
- Department of Internal Medicine, Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Beomeo-ri, Mulgeum-eup, Yangsan-si, Gyeongsangnam-do, Yangsan, 626-770, Korea
| | - Byeong Jun Song
- Department of Internal Medicine, Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Beomeo-ri, Mulgeum-eup, Yangsan-si, Gyeongsangnam-do, Yangsan, 626-770, Korea
| | - Joung Boom Hong
- Department of Internal Medicine, Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Beomeo-ri, Mulgeum-eup, Yangsan-si, Gyeongsangnam-do, Yangsan, 626-770, Korea
| | - Dong Jun Kim
- Department of Internal Medicine, Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Beomeo-ri, Mulgeum-eup, Yangsan-si, Gyeongsangnam-do, Yangsan, 626-770, Korea
| | - Byung Soo Park
- Department of Surgery, Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Gyung Mo Son
- Department of Surgery, Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
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Jovani M, Genco C, Bravatà I, Repici A. Stents in the management of benign colorectal strictures. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2014. [DOI: 10.1016/j.tgie.2014.06.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Martins BDC, Retes FA, Medrado BF, de Lima MS, Pennacchi CMPS, Kawaguti FS, Safatle-Ribeiro AV, Uemura RS, Maluf-Filho F. Endoscopic management and prevention of migrated esophageal stents. World J Gastrointest Endosc 2014. [PMID: 24567792 DOI: 10.4253/wjge.v6.i2.49.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
The use of self-expandable metallic stents has increased recently to palliate inoperable esophageal neoplasia and also in the management of benign strictures. Migration is one of the most common complications after stent placement and the endoscopist should be able to recognize and manage this situation. Several techniques for managing migrated stents have been described, as well as new techniques for preventing stent migration. Most stents have a "lasso" at the upper flange which facilitates stent repositioning or removal. An overtube, endoloop and large polypectomy snare may be useful for the retrieval of stents migrated into the stomach. External fixation of the stent with Shim's technique is efficient in preventing stent migration. Suturing the stent to the esophageal wall, new stent designs with larger flanges and double-layered stents are promising techniques to prevent stent migration but they warrant validation in a larger cohort of patients.
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Affiliation(s)
- Bruno da Costa Martins
- Bruno da Costa Martins, Felipe Alves Retes, Bruno Frederico Medrado, Marcelo Simas de Lima, Caterina Maria Pia Simione Pennacchi, Fabio Shiguehissa Kawaguti, Adriana Vaz Safatle-Ribeiro, Ricardo Sato Uemura, Fauze Maluf-Filho, Department of Gastroenterology, Endoscopy Division, Cancer Institute of the University of São Paulo, São Paulo 01246-000, Brazil
| | - Felipe Alves Retes
- Bruno da Costa Martins, Felipe Alves Retes, Bruno Frederico Medrado, Marcelo Simas de Lima, Caterina Maria Pia Simione Pennacchi, Fabio Shiguehissa Kawaguti, Adriana Vaz Safatle-Ribeiro, Ricardo Sato Uemura, Fauze Maluf-Filho, Department of Gastroenterology, Endoscopy Division, Cancer Institute of the University of São Paulo, São Paulo 01246-000, Brazil
| | - Bruno Frederico Medrado
- Bruno da Costa Martins, Felipe Alves Retes, Bruno Frederico Medrado, Marcelo Simas de Lima, Caterina Maria Pia Simione Pennacchi, Fabio Shiguehissa Kawaguti, Adriana Vaz Safatle-Ribeiro, Ricardo Sato Uemura, Fauze Maluf-Filho, Department of Gastroenterology, Endoscopy Division, Cancer Institute of the University of São Paulo, São Paulo 01246-000, Brazil
| | - Marcelo Simas de Lima
- Bruno da Costa Martins, Felipe Alves Retes, Bruno Frederico Medrado, Marcelo Simas de Lima, Caterina Maria Pia Simione Pennacchi, Fabio Shiguehissa Kawaguti, Adriana Vaz Safatle-Ribeiro, Ricardo Sato Uemura, Fauze Maluf-Filho, Department of Gastroenterology, Endoscopy Division, Cancer Institute of the University of São Paulo, São Paulo 01246-000, Brazil
| | - Caterina Maria Pia Simione Pennacchi
- Bruno da Costa Martins, Felipe Alves Retes, Bruno Frederico Medrado, Marcelo Simas de Lima, Caterina Maria Pia Simione Pennacchi, Fabio Shiguehissa Kawaguti, Adriana Vaz Safatle-Ribeiro, Ricardo Sato Uemura, Fauze Maluf-Filho, Department of Gastroenterology, Endoscopy Division, Cancer Institute of the University of São Paulo, São Paulo 01246-000, Brazil
| | - Fabio Shiguehissa Kawaguti
- Bruno da Costa Martins, Felipe Alves Retes, Bruno Frederico Medrado, Marcelo Simas de Lima, Caterina Maria Pia Simione Pennacchi, Fabio Shiguehissa Kawaguti, Adriana Vaz Safatle-Ribeiro, Ricardo Sato Uemura, Fauze Maluf-Filho, Department of Gastroenterology, Endoscopy Division, Cancer Institute of the University of São Paulo, São Paulo 01246-000, Brazil
| | - Adriana Vaz Safatle-Ribeiro
- Bruno da Costa Martins, Felipe Alves Retes, Bruno Frederico Medrado, Marcelo Simas de Lima, Caterina Maria Pia Simione Pennacchi, Fabio Shiguehissa Kawaguti, Adriana Vaz Safatle-Ribeiro, Ricardo Sato Uemura, Fauze Maluf-Filho, Department of Gastroenterology, Endoscopy Division, Cancer Institute of the University of São Paulo, São Paulo 01246-000, Brazil
| | - Ricardo Sato Uemura
- Bruno da Costa Martins, Felipe Alves Retes, Bruno Frederico Medrado, Marcelo Simas de Lima, Caterina Maria Pia Simione Pennacchi, Fabio Shiguehissa Kawaguti, Adriana Vaz Safatle-Ribeiro, Ricardo Sato Uemura, Fauze Maluf-Filho, Department of Gastroenterology, Endoscopy Division, Cancer Institute of the University of São Paulo, São Paulo 01246-000, Brazil
| | - Fauze Maluf-Filho
- Bruno da Costa Martins, Felipe Alves Retes, Bruno Frederico Medrado, Marcelo Simas de Lima, Caterina Maria Pia Simione Pennacchi, Fabio Shiguehissa Kawaguti, Adriana Vaz Safatle-Ribeiro, Ricardo Sato Uemura, Fauze Maluf-Filho, Department of Gastroenterology, Endoscopy Division, Cancer Institute of the University of São Paulo, São Paulo 01246-000, Brazil
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Rolanda C, Caetano AC, Dinis-Ribeiro M. Emergencies after endoscopic procedures. Best Pract Res Clin Gastroenterol 2013; 27:783-98. [PMID: 24160934 DOI: 10.1016/j.bpg.2013.08.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2013] [Revised: 07/25/2013] [Accepted: 08/11/2013] [Indexed: 02/08/2023]
Abstract
Endoscopy adverse events (AEs), or complications, are a rising concern on the quality of endoscopic care, given the technical advances and the crescent complexity of therapeutic procedures, over the entire gastrointestinal and bilio-pancreatic tract. In a small percentage, not established, there can be real emergency conditions, as perforation, severe bleeding, embolization or infection. Distinct variables interfere in its occurrence, although, the awareness of the operator for their potential, early recognition, and local organized facilities for immediate handling, makes all the difference in the subsequent outcome. This review outlines general AEs' frequencies, important predisposing factors and putative prophylactic measures for specific procedures (from conventional endoscopy to endoscopic cholangio-pancreatography and ultrasonography), with comprehensive approaches to the management of emergent bleeding and perforation.
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Affiliation(s)
- Carla Rolanda
- Department of Gastroenterology, Hospital Braga, Braga, Portugal; Life and Health Sciences Research Institute (ICVS), School of Health Sciences, University of Minho, Braga, Portugal; ICVS/3B's - PT Government Associate Laboratory, Braga/Guimarães, Portugal.
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Jee SR, Cho JY, Kim KH, Kim SG, Cho JH, The Stent Study Group of the Korean Society of Gastrointestinal Endoscopy. Evidence-based recommendations on upper gastrointestinal tract stenting: a report from the stent study group of the korean society of gastrointestinal endoscopy. Clin Endosc 2013; 46:342-354. [PMID: 23964331 PMCID: PMC3746139 DOI: 10.5946/ce.2013.46.4.342] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2012] [Revised: 01/02/2013] [Accepted: 01/03/2013] [Indexed: 12/16/2022] Open
Abstract
Endoscopic stents have evolved dramatically over the past 20 years. With the introduction of uncovered self-expanding metal stents in the early 1990s, they are primarily used to palliate symptoms of malignant obstruction in patients with inoperable gastrointestinal (GI) cancer. At present, stents have emerged as an effective, safe, and less invasive alternative for the treatment of malignant GI obstruction. Clinical decisions about stent placement should be made based on the exact understanding of the patient's condition. These recommendations based on a critical review of the available data and expert consensus are made for the purpose of providing endoscopists with information about stent placement. These can be helpful for management of patients with inoperable cancer or various nonmalignant conditions in the upper GI tract.
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Affiliation(s)
- Sam Ryong Jee
- Department of Internal Medicine, Inje University Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Joo Young Cho
- Institute for Digestive Research, Digestive Disease Center, Soonchunhyang University Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Kyung Ho Kim
- Department of Internal Medicine, Hallym University College of Medicine, Seoul, Korea
| | - Sang Gyun Kim
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Jun-Hyung Cho
- Institute for Digestive Research, Digestive Disease Center, Soonchunhyang University Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
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Woo SM, Kim DH, Lee WJ, Park KW, Park SJ, Han SS, Kim TH, Koh YH, Kim HB, Hong EK. Comparison of uncovered and covered stents for the treatment of malignant duodenal obstruction caused by pancreaticobiliary cancer. Surg Endosc 2013; 27:2031-9. [PMID: 23288317 DOI: 10.1007/s00464-012-2705-6] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2012] [Accepted: 11/04/2012] [Indexed: 12/14/2022]
Abstract
BACKGROUND Few clinical studies to date have compared different types of self-expandable metallic stents (SEMS) and their outcomes in patients with pure duodenal obstruction caused by pancreaticobiliary cancer. The aim of this study was to compare the clinical effectiveness and side effects of uncovered and covered SEMS for the palliation of duodenal obstruction caused by pancreaticobiliary cancer. METHODS We retrospectively analyzed all patients with pancreaticobiliary cancer who underwent upper endoscopy with SEMS placement for malignant duodenal obstruction at the National Cancer Center of Korea between April 2003 and December 2010. The technical and clinical success rates of the procedure, complications, and durations of stent patency and overall survival were evaluated. RESULTS We identified 70 patients with a mean age of 51.2 years (range = 39-81 years); of these, 46 (65.7 %) had pancreatic cancer, 9 (12.9 %) had bile duct cancer, 11 (15.7 %) had gallbladder cancer, and 4 (5.7 %) had cancer of the ampulla of Vater. Twenty-four patients (34.3 %) received covered SEMSs and 46 (65.7 %) received uncovered SEMSs. Technical and clinical success rates were similar for the covered and uncovered stent groups. The complication rate was higher in the covered than in the uncovered group (62.5 vs. 34.8 %, P = 0.025), due primarily to a significantly higher stent migration rate (20.8 vs. 0 %, P = 0.004). Perforation as a late complication occurred in four patients, two in each group (8.3 vs. 4.3 %, P = 0.425). Stent patency tended to be shorter for covered than for uncovered duodenal stents (13.7 ± 8.6 weeks vs. not reached, P = 0.069). CONCLUSIONS The use of uncovered stents may be a preferred option for duodenal obstruction secondary to pancreaticobiliary malignancies, since they were effective in preventing stent migration and tended to have longer patency than covered stents. Careful attention should be paid to signs and symptoms of perforation during follow-up.
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Affiliation(s)
- Sang Myung Woo
- Center for Liver Cancer, National Cancer Center, 111 Junbalsan-ro, Ilsandong-gu, Goyang, Gyeonggi, 410-769, South Korea.
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25
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Ghazal AHA, El-Shazly WG, Bessa SS, El-Riwini MT, Hussein AM. Colonic endolumenal stenting devices and elective surgery versus emergency subtotal/total colectomy in the management of malignant obstructed left colon carcinoma. J Gastrointest Surg 2013; 17:1123-9. [PMID: 23358847 DOI: 10.1007/s11605-013-2152-2] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2012] [Accepted: 01/16/2013] [Indexed: 01/31/2023]
Abstract
BACKGROUND Traditionally, left-sided acute bowel obstruction is treated by a staged procedure because immediate resection and anastomosis in a massive distended and unprepared colon carries a high complication rate. Total abdominal colectomy is a one-stage procedure that will remove synchronous proximal neoplasms, reduce the risk of subsequent metachronous tumor, and avoid stoma. Colorectal stents are being used for palliation and as a bridge to surgery in obstructing colorectal carcinoma, making elective surgery straightforward, enabling easily mobilization and resection of the colon with a possible trend toward reduction in postoperative complication rates compared to emergency surgery. The purpose of this work was to compare the procedures of endoscopic stenting followed by elective colectomy versus total abdominal colectomy and ileorectal anastomosis in the management of acute obstructed carcinoma of the left colon as regards feasibility, safety, and clinical outcomes METHODS From January 2009 through May 2012, 60 patients were randomized to either emergency stenting followed by elective resection (ESER group) or total abdominal colectomy and ileorectal anastomosis (TACIR group). RESULTS Twenty nine patients (96.7 %) had successful stenting and underwent elective surgery 7-10 days later (ESER group). Postoperative complications were encountered in four patients in the ESER group compared to 15 patients in the TACIR group (p = 0.012). Anastomotic leakage was encountered in one patient (3.3 %) in the TACIR group. There were no operative mortalities in the present study. Within the first three postoperative months, the TACIR group patients had significantly more frequent bowel motions per day compared to the ESER group patients although (p = 0.013). In both study groups, the follow-up duration ranged from 6 to 40 months with a median of 18 months. Recurrent disease was encountered in five patients (17.2 %) in the ESER group compared to four patients (13.3 %) in the TACIR group (p = 0.228). CONCLUSION Both techniques are feasible, safe, and produce comparable oncological outcomes. However, endoscopic stenting followed by elective resection was associated with significantly less postoperative complications and bowel motions per day.
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Affiliation(s)
- Abdel-Hamid A Ghazal
- General Surgery Department, Faculty of Medicine, University of Alexandria, Alexandria, Egypt.
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Colonic stent placement: a "double contrast technique": slightly novel approach. Tech Coloproctol 2013; 17:597-9. [PMID: 23558595 DOI: 10.1007/s10151-013-1003-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2012] [Accepted: 03/08/2013] [Indexed: 10/27/2022]
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Ben-Menachem T, Decker GA, Early DS, Evans J, Fanelli RD, Fisher DA, Fisher L, Fukami N, Hwang JH, Ikenberry SO, Jain R, Jue TL, Khan KM, Krinsky ML, Malpas PM, Maple JT, Sharaf RN, Dominitz JA, Cash BD. Adverse events of upper GI endoscopy. Gastrointest Endosc 2012; 76:707-18. [PMID: 22985638 DOI: 10.1016/j.gie.2012.03.252] [Citation(s) in RCA: 245] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2012] [Accepted: 03/20/2012] [Indexed: 12/13/2022]
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Gupta S, Kacker LK. Postchemotherapy expulsion of oesophageal endoluminal stent with vomiting: a rare occurrence. BMJ Case Rep 2012; 2012:bcr-2012-006882. [PMID: 23010465 DOI: 10.1136/bcr-2012-006882] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Self-expandable metallic stents (SEMS) are currently the most widely used modality for palliation of dysphagia from oesophageal malignancy. However, placement of SEMS is associated with a number of complications. We report a rare late complication of SEMS placed for relief of malignant dysphagia (Locally advanced Carcinoma mid-esophagus) in a 65-year-old man. SEMS was expelled out intact with vomiting following complete response to disease after three cycles of chemotherapy. Check on endoscopy done the day after, patient's growth had shown partial response to chemotherapy with scope easily negotiable upto Gastroesophageal junction with area of scarring and healed ulceration and stent imprint on the oesophageal wall. Partial response of the disease to chemotherapy and lack of expected fibrosis between stent and oesophageal wall resulted in loss of scaffolding for the stent and its subsequent expulsion in vomiting and relief in patient's dysphagia.
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Affiliation(s)
- Sameer Gupta
- Surgical Oncology, CSMMU, Lucknow, Uttar Pradesh, India.
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Freeman RK, Ascioti AJ, Mahidhara RJ. Palliative therapy for patients with unresectable esophageal carcinoma. Surg Clin North Am 2012; 92:1337-51. [PMID: 23026285 DOI: 10.1016/j.suc.2012.07.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Most patients diagnosed with carcinoma of the esophagus do not undergo therapy with curative intent. The focus of treatment for these patients is to maximize their progression-free survival and palliate the most common sequelae of their disease: dysphagia, malnutrition, pain, and intraluminal tumor bleeding. This article discusses the available treatment options for palliation of patients with unresectable esophageal cancer.
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Affiliation(s)
- Richard K Freeman
- Department of Thoracic and Cardiovascular Surgery, St Vincent Hospital, Indianapolis, IN 46260, USA.
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Kim MD, Park SB, Kang DH, Lee JH, Choi CW, Kim HW, Chung CU, Jeong YI. Double layered self-expanding metal stents for malignant esophageal obstruction, especially across the gastroesophageal junction. World J Gastroenterol 2012; 18:3732-7. [PMID: 22851867 PMCID: PMC3406427 DOI: 10.3748/wjg.v18.i28.3732] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2011] [Revised: 02/01/2012] [Accepted: 04/13/2012] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the clinical outcomes of double-layered self-expanding metal stents (SEMS) for treatment of malignant esophageal obstruction according to whether SEMS crosses the gastroesophageal junction (GEJ).
METHODS: Forty eight patients who underwent the SEMS insertion for malignant esophageal obstruction were enrolled. Patients were classified as GEJ group (SEMS across GEJ, 18 patients) and non-GEJ group (SEMS above GEJ, 30 patients) according to SEMS position. Double layered (outer uncovered and inner covered stent) esophageal stents were placed.
RESULTS: The SEMS insertion and the clinical improvement were achieved in all patients in both groups. Stent malfunction occurred in seven patients in the GEJ group and nine patients in the non-GEJ group. Tumor overgrowth occurred in five and eight patients, respectively, food impaction occurred in one patient in each group, and stent migration occurred in one and no patient, respectively. There were no significant differences between the two groups. Reflux esophagitis occurred more frequently in the GEJ group (eight vs five patients, P = 0.036) and was controlled by proton pump inhibitor. Aspiration pneumonia occurred in zero and five patients, respectively, and tracheoesophageal fistula occurred in zero and two patients, respectively.
CONCLUSION: Double-layered SEMS are a feasible and effective treatment when placed across the GEJ for malignant esophageal obstruction. Double-layered SEMS provide acceptable complications, especially migration, although reflux esophagitis is more common in the GEJ group.
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Abstract
This article reviews the principal aspects related to sedation in endoscopy and to the prevention of adverse events in some of the most frequently performed therapeutic upper gastrointestinal (GI) endoscopic procedures (esophageal dilation and stenting, endoscopic resection of upper GI early neoplasia, hemostasis of upper GI bleeding and percutaneous endoscopic gastrostomy insertion). These procedures have an inherent risk of negative outcomes that cannot be entirely avoided. Endoscopic procedures are best performed by well-trained, competent and thoughtful endoscopists in facilities suited to provide for patient safety. Attention to clinical risk management may effectively reduce the frequency and intensity of adverse events, enhance recognition and early detection, and improve responsiveness.
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Affiliation(s)
- Gianluca Rotondano
- Division of Gastroenterology and Digestive Endoscopy, Hospital Maresca, Torre del Greco, Italy.
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Moura EGH, Ferreira FC, Cheng S, Moura DTH, Sakai P, Zilberstain B. Duodenal stenting for malignant gastric outlet obstruction: prospective study. World J Gastroenterol 2012; 18:938-943. [PMID: 22408353 PMCID: PMC3297053 DOI: 10.3748/wjg.v18.i9.938] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2011] [Revised: 11/16/2011] [Accepted: 12/31/2011] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate the results of duodenal stenting for palliation of gastroduodenal malignant obstruction by using a gastric outlet obstruction score (GOOS). METHODS A prospective, non-randomized study was performed at a tertiary center between August 2005 and April 2010. Patients were eligible if they had malignant gastric outlet obstruction (GOO) and were not candidates for surgical treatment. Medical history and patient demographics were collected at baseline. Scheduled interviews were made on the day of the procedure and 15, 30, 90 and 180 d later or unscheduled as necessary. RESULTS Fifteen patients (6 male, 9 female; median age 61 years) with GOO who had undergone duodenal stenting were evaluated. Ten patients had metastasis at baseline (66.6%) and 14 were unable to accept oral intake (93.33%), including 7 patients who were using a feeding tube. Laboratory data showed biliary obstruction in eight cases (53.33%); all were submitted to biliary drainage. Two patients developed obstructive symptoms due to tumor ingrowth after 30 d and another due to tumor overgrowth after 180 d. Two cases of stent migration occurred. A good response to treatment was observed, with a mean time of approximately 1 d (19 h) until toleration of a liquid diet and slightly more than 2 d for both soft solids (51 h) and a solid food/normal diet (55 h). The mean time to first failure to maintain liquid intake (GOOS ≥ 1) was 93 d. During follow-up, the mean time to first failure to maintain the previously achieved GOOS of 2-3 (solid/semi-solid food), considered technical failure, was 71 d. On the basis of oral intake a GOOS is defined: 0 for no oral intake; 1 for liquids only; 2 for soft solids only; 3 for low-residue or full diet. CONCLUSION Enteral stenting to alleviate gastroduodenal malignant obstruction improves quality of life in patients with limited life expectancy, which can be evaluated by using a GOO scoring system.
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Baron TH, Wong Kee Song LM, Repici A. Role of self-expandable stents for patients with colon cancer (with videos). Gastrointest Endosc 2012; 75:653-62. [PMID: 22341111 DOI: 10.1016/j.gie.2011.12.020] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2011] [Accepted: 12/19/2011] [Indexed: 02/06/2023]
Affiliation(s)
- Todd H Baron
- Department of Medicine, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota 55905, USA
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Early massive bleeding after duodenal self-expandable metal stent placement for palliation of malignant gastric outlet obstruction (with video). Gastrointest Endosc 2011; 74:1426-7. [PMID: 21429490 DOI: 10.1016/j.gie.2010.12.034] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2010] [Accepted: 12/28/2010] [Indexed: 12/11/2022]
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Repici A, de Paula Pessoa Ferreira D. Expandable metal stents for malignant colorectal strictures. Gastrointest Endosc Clin N Am 2011; 21:511-33, ix. [PMID: 21684468 DOI: 10.1016/j.giec.2011.04.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The surgical management of malignant colorectal obstruction is still controversial and has higher associated mortality and complication rates compared with elective surgery. Placement of self-expanding metallic stents (SEMS) has been proposed as an alternative therapeutic approach for colonic decompression of patients with acute malignant obstruction. SEMS placement may be used both as a bridge to surgery in patients who are good candidates for curative resection and for palliation of those patients presenting with advanced stage disease or with severe comorbid medical illnesses.
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Affiliation(s)
- Alessandro Repici
- Digestive Endoscopy Unit, IRCCS Istituto Clinico Humanitas, Via Manzoni 56, 20089 Rozzano, Milano, Italy.
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Irani S, Kozarek R. Esophageal stents: past, present, and future. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2010; 12:178-190. [DOI: 10.1016/j.tgie.2011.01.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Lazaraki G, Katsinelos P, Nakos A, Chatzimavroudis G, Pilpilidis I, Paikos D, Tzilves D, Katsos I. Malignant esophageal dysphagia palliation using insertion of a covered Ultraflex stent without fluoroscopy: a prospective observational study. Surg Endosc 2010; 25:628-35. [PMID: 20644961 DOI: 10.1007/s00464-010-1236-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2009] [Accepted: 01/23/2010] [Indexed: 01/20/2023]
Abstract
BACKGROUND This study aimed to investigate the efficacy and safety of placing self-expandable metal stents (SEMSs) without fluoroscopy for palliation of malignant esophageal or esophagogastric strictures. METHODS From January 2003 to June 2008, a prospective observational study investigated the placement of covered proximal-release Ultraflex stents without fluoroscopy in nonoperable malignant esophageal and esophagogastric strictures. The technical success as well as the early and late complications (perforation, migration, severe gastroesophageal reflux, hematemesis, and reobstruction due to tissue ingrowth or overgrowth) were recorded. Dysphagia before and after stent placement was scored on a 5-point scale. All the patients were observed monthly in the outpatient clinic or by telephone contact until death. RESULTS The study enrolled 89 patients (16 women; mean age, 69.54±7.1 years) with dysphagia due to inoperable esophageal or esophagogastric malignant strictures (29 squamous cell cancers, 52 adenocarcinomas, and 8 obstructive malignant extrinsic compressions). The mean stricture length was 6.2±2.8 cm. Endoscopic deployment was achieved for 83 patients (93.2%), with accurate stent positioning in all the patients except one. An adequate relief of symptoms was noted for 82 of the patients (92.1%). During the follow-up period, 36 patients (43.4%) had recurrent dysphagia, caused by tumor overgrowth in 32 cases and stent migration in 4 cases, after an average time of 82 days (range 67-216 days). A stent-in-stent procedure was performed in 27 cases. For two patients, a third stent-in-stent needed to be placed after 85 and 216 days, respectively. CONCLUSION In most cases, SEMSs can be accurately and safely positioned without fluoroscopy for palliative treatment of malignant esophageal dysphagia.
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Affiliation(s)
- Georgia Lazaraki
- Department of Gastrointestinal Oncology, Theagenion Cancer Hospital, Al. Simeonidi 2 str, 54007, Thessaloniki, Greece.
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Schembre D. Advances in esophageal stenting: the evolution of fully covered stents for malignant and benign disease. Adv Ther 2010; 27:413-25. [PMID: 20586003 DOI: 10.1007/s12325-010-0042-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2010] [Indexed: 12/13/2022]
Abstract
Self-expanding metal stents have become a leading palliative therapy for dysphagia resulting from esophageal, proximal gastric, and mediastinal cancers. Increasingly, fully covered self-expanding plastic stents and now fully covered metal stents have been used to treat a variety of benign esophageal conditions as well as cancer. Several stent designs are available in the United States and many more internationally. Each design has advantages and limitations. Knowledge of the indications for esophageal stenting and the common side effects associated with different designs allows physicians to choose the best stent for a given condition as well as to anticipate complications such as stent migration or restenosis. Compared with partially covered stents, newer, fully covered metal stents may promote less granulation tissue and subsequent stenosis and may be removable even after several weeks. However, the tradeoff may be more frequent migration. Interest in fully covered metal stents in place of fully covered plastic stents for use in strictures and leaks has also grown, despite the lack of a formal indication for metal stents in benign disease. Unfortunately, rigorous studies of newer stent designs are currently lacking.
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Katsanos K, Sabharwal T, Adam A. Stenting of the upper gastrointestinal tract: current status. Cardiovasc Intervent Radiol 2010; 33:690-705. [PMID: 20521050 DOI: 10.1007/s00270-010-9862-6] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2009] [Accepted: 04/01/2010] [Indexed: 12/16/2022]
Abstract
Minimally invasive image-guided insertion of self-expanding metal stents in the upper gastrointestinal tract is the current treatment of choice for palliation of malignant esophageal or gastroduodenal outlet obstructions. A concise review is presented of contemporary stenting practice of the upper gastrointestinal tract, and the procedures in terms of appropriate patient evaluation, indications, and contraindications for treatment are analyzed, along with available stent designs, procedural steps, clinical outcomes, inadvertent complications, and future technology. Latest developments include biodegradable polymeric stents for benign disease and radioactive or drug-eluting stents for malignant obstructions.
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Affiliation(s)
- Konstantinos Katsanos
- Department of Interventional Radiology, School of Medicine, Patras University Hospital, 26500 Patras, Greece
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40
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Park JJ, Lee YC, Kim BK, Kim JH, Park JC, Kim YJ, Lee SK, Song SY, Chung JB. Long-term clinical outcomes of self-expanding metal stents for treatment of malignant gastroesophageal junction obstructions and prognostic factors for stent patency: effects of anticancer treatments. Dig Liver Dis 2010; 42:436-40. [PMID: 19767253 DOI: 10.1016/j.dld.2009.07.020] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2009] [Revised: 07/23/2009] [Accepted: 07/28/2009] [Indexed: 12/11/2022]
Abstract
BACKGROUND Self-expanding metal stent has emerged as an effective treatment option for malignant gastroesophageal junction obstruction. However, data on the clinicopathologic factors associated with stent patency are still lacking. AIM To investigate the long-term clinical outcomes and prognostic factors, including treatment modalities, affecting stent patency in patients with malignant gastroesophageal junction obstruction given self-expanding metal stent insertions. METHODS A total 89 patients who underwent self-expanding metal stent insertion for malignant gastroesophageal junction obstruction were enrolled. We analysed technical and clinical success rates, complications, and prognostic factors affecting stent patency. RESULTS Self-expanding metal stent insertion was successful in all patients and clinical improvement was achieved in 93.3%. Stent malfunction occurred in 32.9% of patients. The median overall survival time and stent patency time were 143 (95% CI: 99-187) and 190 days (95% CI: 108-272), respectively. In multivariate analysis, radiation therapy after stent placement significantly prolonged stent patency (OR: 0.221; 95% CI: 0.055-0.884; p=0.033). A higher migration rate was observed in those patients given chemotherapy after covered self-expanding metal stent placement (no anticancer treatment: 10.0%, chemotherapy: 42.9%, chemoradiation therapy: 9.1%, p=0.042). CONCLUSIONS Self-expanding metal stent is a feasible and effective treatment for malignant gastroesophageal junction obstruction. Radiation therapy after stent placement significantly prolongs overall stent patency and chemotherapy increases the migration rate of covered stents.
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Affiliation(s)
- Jae Jun Park
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea
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Small AJ, Coelho-Prabhu N, Baron TH. Endoscopic placement of self-expandable metal stents for malignant colonic obstruction: long-term outcomes and complication factors. Gastrointest Endosc 2010; 71:560-72. [PMID: 20189515 DOI: 10.1016/j.gie.2009.10.012] [Citation(s) in RCA: 195] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2009] [Accepted: 10/08/2009] [Indexed: 02/07/2023]
Abstract
BACKGROUND Self-expandable metal stents (SEMSs) are used for colonic obstruction palliatively and preoperatively. OBJECTIVE Determine long-term efficacy, incidence of complications, and risk factors of SEMS placement for colonic obstruction. DESIGN Retrospective review of SEMSs placed for malignant colorectal obstruction from 1999 to 2008. SETTING Tertiary-care center. PATIENTS This study involved 168 patients who underwent SEMS placement for palliation and 65 patients who underwent SEMS placement as a "bridge to surgery." INTERVENTION Colonic SEMS placement. MAIN OUTCOME MEASUREMENTS Stricture location, stent-induced complications, time to adverse events, need for reintervention. RESULTS Technical and immediate clinical success rates were 96% and 99% in the palliative group and 95% and 98% in the preoperative group. Forty-one patients (24.4%) in the palliative group had complications including perforation (9%), occlusion (9%), migration (5%), and erosion/ulcer (2%). Mean stent patency was 145 days in the palliative group. One hundred eight of 122 patients (88.5%) were free of obstruction from implantation until death. Preoperatively placed stents remained in situ for a mean of 25.4 days and remained patent until surgery in 73.8% of patients. Complications were present preoperatively in 23.1% of patients; 94% underwent elective colectomy. Univariate analysis identified males, complete obstruction, stent diameter < or = 22 mm, stricture dilation during SEMS insertion, and operator experience as significant risk factors for complication. In the palliative group, intraluminal lesions (27% vs 19%), bevacizumab (35% vs 23%), and distal colon placement of the stent (27% vs 13%) were also associated with higher complication rates as compared to extraluminal lesions, patients not treated with bevacizumab, and stents in the proximal colon, respectively. Bevacizumab therapy nearly tripled the risk of perforation. LIMITATIONS Retrospective analysis, single institution. CONCLUSION Colorectal SEMS placement is relatively safe and effective but with a complication rate of nearly 25%. Patient characteristics and technical variables appear to affect the outcome of SEMS therapy.
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Affiliation(s)
- Aaron J Small
- Department of Medicine, Weill Medical College of Cornell University, New York, New York, USA
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Abstract
These recommendations provide an evidence-based approach to the role of esophageal stents in the management of benign and malignant diseases. These guidelines have been developed under the auspices of the American College of Gastroenterology and its Practice Parameters Committee and approved by the Board of Trustees. The following guidelines are based on a critical review of the available scientific literature on the topic identified in Medline and PubMed (January 1992-December 2008) using search terms that included stents, self-expandable metal stents, self-expandable plastic stents, esophageal cancer, esophageal adenocarcinoma, esophageal squamous cell carcinoma, esophageal stricture, perforations, anastomotic leaks, tracheoesophageal fistula, and achalasia. These guidelines are intended for use by health-care providers and apply to adult, but not pediatric, patients. As with other practice guidelines, these guidelines are not intended to replace clinical judgment but rather to provide general guidelines applicable to the majority of patients. Clinicians need to integrate recommendations with their own clinical judgment, and with individual patient circumstances, values, and preferences. They are intended to be flexible, in contrast to standards of care, which are inflexible policies designed to be followed in every case. Specific recommendations are based on relevant published information. The quality of evidence and strength of recommendations have been assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system, which is a system that has been adopted by multiple national and international societies. The GRADE system is based on a sequential assessment of quality of evidence, followed by assessment of the balance between benefits vs. downsides (harms, burden, and costs) and subsequent judgment regarding the strength of recommendation.
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Affiliation(s)
- Prateek Sharma
- Division of Gastroenterology and Hepatology, Veterans Affairs Medical Center and University of Kansas School of Medicine, Kansas City, Missouri 64128-2295, USA.
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Novel removable internally fully covered self-expanding metal esophageal stent: feasibility, technique of removal, and tissue response in humans. Am J Gastroenterol 2009; 104:1374-81. [PMID: 19491851 DOI: 10.1038/ajg.2009.133] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVES Internally fully covered self-expandable metal stents (FCSEMSs) have recently become available offering the possibility of removal. However, to our knowledge, the feasibility, techniques for endoscopic removal, and tissue reaction to FCSEMS have not been reported in humans. Our aims are (1) to report reasons for and success of FCSEMS removal in consecutive patients, (2) to describe methods of esophageal stent retrieval, and (3) to describe stent reactions induced by FCSEMS in humans. METHODS Removable FCSEMSs (ALIMAXX-E, Alveolus Inc., Charlotte, NC) were placed in consecutive patients requiring palliation of dysphagia symptoms with locally advanced esophageal or gastro-esophageal junction cancers, refractory benign esophageal strictures, postoperative mediastinal leaks, or tracheoesophageal fistulas. Dysphagia scores were assessed at 1, 3, and 6 months. Esophagogram and endoscopy follow-up were performed routinely at 1 month or to assess new symptoms. RESULTS A total of 36 stents were placed in 31 patients over 16 months (mean age 62.8 years, 61% white, 58% male). Indications included the following: malignant strictures (n=17), refractory benign strictures (n=7), tracheoesophageal fistulas (n=8), postoperative mediastinal leaks (n=2), and iatrogenic perforations (n=2). Dysphagia scores improved (decreased) significantly at 1 (mean difference 2.09; 95% confidence interval (CI) 1.65-2.52, P=0.0001), 3 (mean difference 2.1; 95% CI 1.57-2.62, P=0.0001), and 6 months (mean difference of 2; 95% CI 1.28-2.73, P<0.0001). Clinical success rates for various indications were: malignant strictures 88%, refractory benign strictures 29%, tracheoesophageal fistula 88%, postoperative mediastinal leaks 100%, and iatrogenic perforations 50%. Sixty one percent (n=22) of the stents were removed (removal was successful in 100% of cases attempted). Twenty three percent (n=5 stents in four patients) were removed due to chest pain or abdominal pain. The stents satisfied their purposes in all of these four patients. The remainder were removed on schedule or had satisfied their purpose and/or migrated. Fifty percent of removed stents had ulcers (median size=2 cm) at the distal edge of the stent, whereas 23% had ulcers at the proximal edge of the stent. Pseudo-polyps formed at either the proximal or distal edge of the stent in four patients. Tissue reaction was severe in only two patients. Stents were embedded in four cases but were easily lifted from tissue. Our preferred method of retrieval was the double-channel therapeutic endoscope with two rat-tooth forceps or rat-tooth forceps with a snare. CONCLUSIONS FCSEMSs palliate dysphagia from both benign and malignant conditions and seal postoperative tracheoesophageal fistulas and mediastinal leaks. Tissue reaction to the stents was common but remained clinically insignificant in the majority of patients. Close follow-up of patients with FCSEMS is required and repeat endoscopy with stent retrieval might be necessary with the development of new symptoms or complications from the stent.
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Repici A, Rando G. Expandable Stents for Malignant Dysphagia. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2008. [DOI: 10.1016/j.tgie.2008.07.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Paganin F, Schouler L, Cuissard L, Noel JB, Becquart JP, Besnard M, Verdier L, Rousseau D, Arvin-Berod C, Bourdin A. Airway and esophageal stenting in patients with advanced esophageal cancer and pulmonary involvement. PLoS One 2008; 3:e3101. [PMID: 18769726 PMCID: PMC2518104 DOI: 10.1371/journal.pone.0003101] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2008] [Accepted: 07/23/2008] [Indexed: 11/28/2022] Open
Abstract
Background Most inoperable patients with esophageal-advanced cancer (EGC) have a poor prognosis. Esophageal stenting, as part of a palliative therapy management has dramatically improved the quality of live of EGC patients. Airway stenting is generally proposed in case of esophageal stent complication, with a high failure rate. The study was conducted to assess the efficacy and safety of scheduled and non-scheduled airway stenting in case of indicated esophageal stenting for EGC. Methods and Findings The study is an observational study conducted in pulmonary and gastroenterology endoscopy units. Consecutive patients with EGC were referred to endoscopy units. We analyzed the outcome of airway stenting in patients with esophageal stent indication admitted in emergency or with a scheduled intervention. Forty-four patients (58±\−8 years of age) with esophageal stenting indication were investigated. Seven patients (group 1) were admitted in emergency due to esophageal stent complication in the airway (4 fistulas, 3 cases with malignant infiltration and compression). Airway stenting failed for 5 patients. Thirty-seven remaining patients had a scheduled stenting procedure (group 2): stent was inserted for 13 patients with tracheal or bronchial malignant infiltration, 12 patients with fistulas, and 12 patients with airway extrinsic compression (preventive indication). Stenting the airway was well tolerated. Life-threatening complications were related to group 1. Overall mean survival was 26+/−10 weeks and was significantly shorter in group 1 (6+/−7.6 weeks) than in group 2 (28+/−11 weeks), p<0.001). Scheduled double stenting significantly improved symptoms (95% at day 7) with a low complication rate (13%), and achieved a specific cancer treatment (84%) in most cases. Conclusion Stenting the airway should always be considered in case of esophageal stent indication. A multidisciplinary approach with initial airway evaluation improved prognosis and decreased airways complications related to esophageal stent. Emergency procedures were rarely efficient in our experience.
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Baron TH. Optimizing endoscopic placement of expandable stents throughout the GI tract. Expert Rev Gastroenterol Hepatol 2008; 2:399-409. [PMID: 19072388 DOI: 10.1586/17474124.2.3.399] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Expandable stents have now become accepted for the relief of malignant obstruction throughout the GI tract and biliary system. Almost all expandable stents are composed of metal. More recently, an expandable plastic stent has been developed for the treatment of benign esophageal conditions. The clinical response to these devices is dependent on proper stent placement and anatomical location. Proper stent placement, in turn, is dependent on being familiar with the characteristics of the devices, having knowledge of the length of the stricture and anatomy, and the location of the obstruction within the GI tract. This review summarizes the available devices and techniques for optimal placement of expandable stents.
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Affiliation(s)
- Todd H Baron
- Department of Medicine, Division of Gastroenterology & Hepatology, Mayo Clinic College of Medicine, 200 First Street SW, Charlton 8, Rochester, MN 55905, USA.
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Abstract
Advanced esophageal carcinoma has a rather dismal prognosis with dysphagia to solids and liquids as a common symptom. Self-expanding metal stents provide immediate and durable relief of dysphagia. Recently, self-expanding plastic stents have been developed for refractory benign esophageal strictures but may have applications in malignant strictures as well. In this issue of The American Journal of Gastroenterology, a multicenter, prospective, randomized, comparative trial evaluates the safety and efficacy of self-expanding metal versus plastic stents for palliation of dysphagia due to esophageal cancer. While the stents compared equivalently for symptom relief, complications were observed more commonly in the plastic stent group.
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