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Yang Y, Yang Y, Hou Z, Wang T, Wu P, Shen L, Li P, Zhang K, Yang L, Sun S. Comprehensive review of materials, applications, and future innovations in biodegradable esophageal stents. Front Bioeng Biotechnol 2023; 11:1327517. [PMID: 38125305 PMCID: PMC10731276 DOI: 10.3389/fbioe.2023.1327517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 11/27/2023] [Indexed: 12/23/2023] Open
Abstract
Esophageal stricture (ES) results from benign and malignant conditions, such as uncontrolled gastroesophageal reflux disease (GERD) and esophageal neoplasms. Upper gastrointestinal endoscopy is the preferred diagnostic approach for ES and its underlying causes. Stent insertion using an endoscope is a prevalent method for alleviating or treating ES. Nevertheless, the widely used self-expandable metal stents (SEMS) and self-expandable plastic stents (SEPS) can result in complications such as migration and restenosis. Furthermore, they necessitate secondary extraction in cases of benign esophageal stricture (BES), rendering them unsatisfactory for clinical requirements. Over the past 3 decades, significant attention has been devoted to biodegradable materials, including synthetic polyester polymers and magnesium-based alloys, owing to their exceptional biocompatibility and biodegradability while addressing the challenges associated with recurring procedures after BES resolves. Novel esophageal stents have been developed and are undergoing experimental and clinical trials. Drug-eluting stents (DES) with drug-loading and drug-releasing capabilities are currently a research focal point, offering more efficient and precise ES treatments. Functional innovations have been investigated to optimize stent performance, including unidirectional drug-release and anti-migration features. Emerging manufacturing technologies such as three-dimensional (3D) printing and new biodegradable materials such as hydrogels have also contributed to the innovation of esophageal stents. The ultimate objective of the research and development of these materials is their clinical application in the treatment of ES and other benign conditions and the palliative treatment of malignant esophageal stricture (MES). This review aimed to offer a comprehensive overview of current biodegradable esophageal stent materials and their applications, highlight current research limitations and innovations, and offer insights into future development priorities and directions.
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Affiliation(s)
- Yaochen Yang
- Department of Gastroenterology, Endoscopic Center, Engineering Research Center of Ministry of Education for Minimally Invasive Gastrointestinal Endoscopic Techniques, Shengjing Hospital of China Medical University, Shenyang, China
- Research Center for Biomedical Materials, Engineering Research Center of Ministry of Education for Minimally Invasive Gastrointestinal Endoscopic Techniques, Shengjing Hospital of China Medical University, Shenyang, China
| | - Yuanyuan Yang
- Department of Gastroenterology, Endoscopic Center, Engineering Research Center of Ministry of Education for Minimally Invasive Gastrointestinal Endoscopic Techniques, Shengjing Hospital of China Medical University, Shenyang, China
| | - Zhipeng Hou
- Research Center for Biomedical Materials, Engineering Research Center of Ministry of Education for Minimally Invasive Gastrointestinal Endoscopic Techniques, Shengjing Hospital of China Medical University, Shenyang, China
| | - Tingting Wang
- Department of Gastroenterology, Endoscopic Center, Engineering Research Center of Ministry of Education for Minimally Invasive Gastrointestinal Endoscopic Techniques, Shengjing Hospital of China Medical University, Shenyang, China
| | - Peng Wu
- Department of Gastroenterology, Endoscopic Center, Engineering Research Center of Ministry of Education for Minimally Invasive Gastrointestinal Endoscopic Techniques, Shengjing Hospital of China Medical University, Shenyang, China
| | - Lufan Shen
- Department of Gastroenterology, Endoscopic Center, Engineering Research Center of Ministry of Education for Minimally Invasive Gastrointestinal Endoscopic Techniques, Shengjing Hospital of China Medical University, Shenyang, China
| | - Peng Li
- Liaoning Research Institute for Eugenic Birth and Fertility, China Medical University, Shenyang, China
| | - Kai Zhang
- Department of Gastroenterology, Endoscopic Center, Engineering Research Center of Ministry of Education for Minimally Invasive Gastrointestinal Endoscopic Techniques, Shengjing Hospital of China Medical University, Shenyang, China
| | - Liqun Yang
- Research Center for Biomedical Materials, Engineering Research Center of Ministry of Education for Minimally Invasive Gastrointestinal Endoscopic Techniques, Shengjing Hospital of China Medical University, Shenyang, China
- Liaoning Research Institute for Eugenic Birth and Fertility, China Medical University, Shenyang, China
| | - Siyu Sun
- Department of Gastroenterology, Endoscopic Center, Engineering Research Center of Ministry of Education for Minimally Invasive Gastrointestinal Endoscopic Techniques, Shengjing Hospital of China Medical University, Shenyang, China
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Fu Y, Zhao H, Li J, Li Y, Gong T, An C, Wang R, Li X. Infigratinib, a Selective Fibroblast Growth Factor Receptor Inhibitor, Suppresses Stent-Induced Tissue Hyperplasia in a Rat Esophageal Model. Cardiovasc Intervent Radiol 2023; 46:1267-1275. [PMID: 37491520 DOI: 10.1007/s00270-023-03502-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Accepted: 06/20/2023] [Indexed: 07/27/2023]
Abstract
PURPOSE Stent-induced tissue hyperplasia remains a challenge for the application of self-expanding metal stents in the management of esophageal stricture. This study aimed to evaluate the efficacy of infigratinib, which is a selective fibroblast growth factor receptor inhibitor, in the prevention of stent-induced tissue hyperplasia in a rat esophageal model. METHODS Twenty-four male Sprague-Dawley rats underwent esophageal stent placement and were randomized to receive 1 ml of vehicle, 5 mg/kg infigratinib in 1 ml of vehicle, or 10 mg/kg infigratinib in 1 ml of vehicle via naso-gastric tube once daily for 28 days. Follow-up fluoroscopy was performed on postoperative day 28, and the stented esophageal tissues were harvested for histological and immunofluorescence examinations. RESULTS All rats survived until euthanasia on postoperative day 28 without procedure-related adverse events. The incidence of stent migration was 12.5%, 12.5% and 25% in the control group, the 5 mg/kg infigratinib group and, the 10 mg/kg infigratinib group, respectively. The percentage of granulation tissue area, the submucosal fibrosis thickness, the number of epithelial layers, the degree of inflammatory cell infiltration, the degree of collagen deposition, the number of fibroblast growth factor receptor 1 (FGFR1)-expressing myofibroblasts, and the number of proliferating myofibroblasts were all significantly lower in both infigratinib groups than in the control group (P < 0.05) but were not significantly different between the two infigratinib groups (P > 0.05). CONCLUSIONS Infigratinib significantly suppresses stent-induced tissue hyperplasia by inhibiting FGFR1-mediated myofibroblast proliferation and profibrotic activities in a rat esophageal model.
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Affiliation(s)
- Yan Fu
- Department of Interventional Therapy, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 17 Panjiayuan Nanli, Chaoyang District, Beijing, 100021, China
| | - He Zhao
- Department of Interventional Therapy, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 17 Panjiayuan Nanli, Chaoyang District, Beijing, 100021, China
| | - Jingui Li
- Department of Interventional Therapy, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 17 Panjiayuan Nanli, Chaoyang District, Beijing, 100021, China
| | - Yawei Li
- Department of Interventional Therapy, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 17 Panjiayuan Nanli, Chaoyang District, Beijing, 100021, China
| | - Tao Gong
- Department of Interventional Therapy, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 17 Panjiayuan Nanli, Chaoyang District, Beijing, 100021, China
| | - Chao An
- Department of Interventional Ultrasound, Chinese PLA General Hospital, 28 Fuxing Road, Beijing, 100853, China
| | - Ruosu Wang
- Department of Interventional Therapy, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 17 Panjiayuan Nanli, Chaoyang District, Beijing, 100021, China
| | - Xiao Li
- Department of Interventional Therapy, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 17 Panjiayuan Nanli, Chaoyang District, Beijing, 100021, China.
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Kailla E, Rezai F, Kansci AK, Akande O, Gossage J. SX-ELLA biodegradable stent for benign oesophageal strictures: a systematic review and proportion meta-analysis. Surg Endosc 2023; 37:2476-2484. [PMID: 36481820 PMCID: PMC10082093 DOI: 10.1007/s00464-022-09767-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 11/06/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND This systematic review aimed to analyse the use of the SX-ELLA biodegradable stent (BDS) for benign oesophageal strictures through the assessment of clinical and technical success, differences in pre- and post-BDS insertion dysphagia scores, rates of stent migration, and safety. METHODS A systematic review was reported according to PRISMA guidelines, with a prospectively registered protocol. The databases PubMed, Embase, SCOPUS, and ClinicalTrials.gov were searched up to March 2022. Studies assessing the use of the SX-ELLA BDS in adults with benign oesophageal strictures were included. A pooled data analysis was conducted to analyse the clinical and technical success associated with BDS use, rate of stent migration, and safety. RESULTS Of the 1509 articles identified, 16 studies treating 246 patients were eligible for inclusion. BDS was clinically successful in 41.9% of cases (95% CI = 35.7 - 48.1%), defined as those who experienced complete symptom resolution following BDS insertion. Technical success was achieved in 97.2% of patients (95% CI = 95.1 - 99.3%). A pooled analysis concluded a decrease in mean dysphagia score of 1.8 points (95% CI = 1.68 - 1.91) following BDS insertion. Re-intervention was required in 89 patients (36.2%, 95% CI = 30.2 - 42.2%), whilst stent migration occurred in 6.5% of patients (95% CI = 3.4 - 9.6%). A total of 37 major clinical complications related to BDS insertion were reported (15.0%, 95% CI = 10.5 - 19.5%). CONCLUSION The pooled data analysis demonstrates the high technical and moderate clinical success of the SX-ELLA biodegradable stent, supporting its use for benign oesophageal strictures in adults. However, greater evidence is required for more robust conclusions to be made in terms of success when compared to alternative methods of intervention, such as endoscopic dilation.
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Affiliation(s)
- Elisha Kailla
- GKT School of Medical Education, King's College London, London, UK
- University of Birmingham Medical School, Birmingham, UK
| | - Fatema Rezai
- GKT School of Medical Education, King's College London, London, UK
| | | | | | - James Gossage
- Department of Upper Gastrointestinal Surgery, St Thomas' Hospital, London, UK.
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Zhang F, Xu J, Zhu Y, Shi Y, Wu B, Wang H, Huang C. Endoscopic ultrasonography guided cutting scar of esophageal stricture after endoscopic injection sclerotherapy. BMC Gastroenterol 2022; 22:343. [PMID: 35840909 PMCID: PMC9284865 DOI: 10.1186/s12876-022-02420-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 07/08/2022] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE To investigate efficacy and safety of endoscopic ultrasonography (EUS) guiding to cut the scar of esophageal stricture after endoscopic injection sclerotherapy (EIS). METHODS The data of 10 patients with oesophageal stricture after esophageal varices EIS in our hospital from September 1, 2021 to December 31, 2021 treated by cutting the scar guided by ultrasonic endoscopy were retrospective, and the efficacy was evaluated. RESULTS The dysphagia was obviously relieved in 9 patients during follow-up, and 1 patient suffered dysphagia again after the treatment. There was no complications of perforation, bleeding and infection among the paitents. CONCLUSION EUS guiding to cut the scar of esophageal stricture after EIS was safe and reliable.
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Affiliation(s)
- Fulong Zhang
- Department of Gastroenterology, HangZhou Xixi Hospital, 2 Hengbu Street, Xihu District, Hangzhou, 310032, China
| | - Jing Xu
- Department of Gastroenterology, HangZhou Xixi Hospital, 2 Hengbu Street, Xihu District, Hangzhou, 310032, China
| | - Yuandong Zhu
- Department of Gastroenterology, HangZhou Xixi Hospital, 2 Hengbu Street, Xihu District, Hangzhou, 310032, China.
| | - Yan Shi
- Department of Gastroenterology, HangZhou Xixi Hospital, 2 Hengbu Street, Xihu District, Hangzhou, 310032, China
| | - Bo Wu
- Department of Gastroenterology, HangZhou Xixi Hospital, 2 Hengbu Street, Xihu District, Hangzhou, 310032, China
| | - Hai Wang
- Department of Gastroenterology, HangZhou Xixi Hospital, 2 Hengbu Street, Xihu District, Hangzhou, 310032, China
| | - Chaojun Huang
- Department of Gastroenterology, HangZhou Xixi Hospital, 2 Hengbu Street, Xihu District, Hangzhou, 310032, China
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Yano T, Yoda Y, Nonaka S, Abe S, Kawata N, Yoshio T, Sasaki T, Tanaka S, Sasaki F, Maekita T, Kitano M, Matsumoto K, Isayama H, Ono H. Pivotal trial of a biodegradable stent for patients with refractory benign esophageal stricture. Esophagus 2022; 19:516-524. [PMID: 35106667 DOI: 10.1007/s10388-022-00909-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 01/25/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Benign esophageal strictures (BES) cause dysphagia and decrease patients' quality of life. Although mechanical dilation is the standard of care for BES, in some patients, dysphagia is unrelieved despite repeated procedures. The biodegradable stent was developed to resolve refractory BES, with reported favorable outcomes, but it is unapproved in Japan. Thus, we evaluated the safety and efficacy of the biodegradable stent (BDS) for patients with refractory BES for regulatory approval. METHODS This was a nonrandomized single-arm prospective trial conducted at eight institutions. We included patients with BES after ≥ 5 times of dilation or ≥ one time of radial incision and cutting whose dysphagia score (DS) was 2 or worse and an endoscope could not admit. The primary endpoint was the proportion of patients whose DS improvement of ≤ 1 was maintained at 3 months. RESULTS Thirty patients (median age: 69 years, male/female: 27:3) were enrolled and treated; BDS placement failed in 1 patient. Fourteen patients maintained their DS improvement until 3 months after placement (proportion of DS improvement at 3 months 46.7% [95% CI: 28.3-65.7]), and the median dysphagia-free survival was 98 days [95% CI: 68-123]. Most adverse events could be managed conservatively; however, a patient with BES after chemoradiotherapy (CRT) developed an esophago-left atrium fistula and died approximately 4 months after stent placement. CONCLUSION The BDS was effective for refractory BES and the safety was acceptable. However, the indication for this procedure in patients RECEIVING CRT for esophageal cancer should be carefully considered.
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Affiliation(s)
- Tomonori Yano
- Department of Gastroenterology and Endoscopy, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kashiwa, Chiba, 288-8577, Japan.
| | - Yusuke Yoda
- Department of Gastroenterology and Endoscopy, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kashiwa, Chiba, 288-8577, Japan
| | - Satoru Nonaka
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| | - Seiichiro Abe
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| | - Noboru Kawata
- Division of Endoscopy, Shizuoka Cancer Center Hospital, Shizuoka, Japan
| | - Toshiyuki Yoshio
- Department of Gastroenterology, Cancer Institute Hospital, Tokyo, Japan
| | - Takashi Sasaki
- Department of Gastroenterology, Cancer Institute Hospital, Tokyo, Japan
| | - Shinwa Tanaka
- Department of Endoscopic Internal Medicine, Kobe University Hospital, Hyogo, Japan
| | - Fumisato Sasaki
- Department of Endoscopic Internal Medicine, Kagoshima University Hospital, Kagoshima, Japan
| | - Takao Maekita
- Department of Gastroenterology, Wakayama Medical University, Wakayama, Japan
| | - Masayuki Kitano
- Department of Gastroenterology, Wakayama Medical University, Wakayama, Japan
| | - Kenshi Matsumoto
- Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Hiroyuki Ono
- Division of Endoscopy, Shizuoka Cancer Center Hospital, Shizuoka, Japan
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Loskot J, Jezbera D, Zmrhalová ZO, Nalezinková M, Alferi D, Lelkes K, Voda P, Andrýs R, Fučíková AM, Hosszú T, Bezrouk A. A Complex In Vitro Degradation Study on Polydioxanone Biliary Stents during a Clinically Relevant Period with the Focus on Raman Spectroscopy Validation. Polymers (Basel) 2022; 14:polym14050938. [PMID: 35267761 PMCID: PMC8912347 DOI: 10.3390/polym14050938] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 02/18/2022] [Accepted: 02/23/2022] [Indexed: 02/06/2023] Open
Abstract
Biodegradable biliary stents are promising treatments for biliary benign stenoses. One of the materials considered for their production is polydioxanone (PPDX), which could exhibit a suitable degradation time for use in biodegradable stents. Proper material degradation characteristics, such as sufficient stiffness and disintegration resistance maintained for a clinically relevant period, are necessary to ensure stent safety and efficacy. The hydrolytic degradation of commercially available polydioxanone biliary stents (ELLA-CS, Hradec Králové, Czech Republic) in phosphate-buffered saline (PBS) was studied. During 9 weeks of degradation, structural, physical, and surface changes were monitored using Raman spectroscopy, differential scanning calorimetry, scanning electron microscopy, and tensile and torsion tests. It was found that the changes in mechanical properties are related to the increase in the ratio of amorphous to crystalline phase, the so-called amorphicity. Monitoring the amorphicity using Raman spectroscopy has proven to be an appropriate method to assess polydioxanone biliary stent degradation. At the 1732 cm−1 Raman peak, the normalized shoulder area is less than 9 cm−1 which indicates stent disintegration. The stent disintegration started after 9 weeks of degradation in PBS, which agrees with previous in vitro studies on polydioxanone materials as well as with in vivo studies on polydioxanone biliary stents.
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Affiliation(s)
- Jan Loskot
- Department of Physics, University of Hradec Králové, Rokitanského 62, 500 03 Hradec Králové, Czech Republic; (J.L.); (D.J.)
| | - Daniel Jezbera
- Department of Physics, University of Hradec Králové, Rokitanského 62, 500 03 Hradec Králové, Czech Republic; (J.L.); (D.J.)
| | - Zuzana Olmrová Zmrhalová
- Center of Materials and Nanotechnologies, Faculty of Chemical Technology, University of Pardubice, Studentska 95, 530 02 Pardubice, Czech Republic;
| | - Martina Nalezinková
- Department of Biology, University of Hradec Králové, Rokitanského 62, 500 03 Hradec Králové, Czech Republic; (M.N.); (A.M.F.)
| | - Dino Alferi
- Department of Medical Biophysics, Faculty of Medicine in Hradec Králové, Charles University, Šimkova 870, 500 03 Hradec Králové, Czech Republic; (D.A.); (K.L.); (P.V.)
| | - Krisztina Lelkes
- Department of Medical Biophysics, Faculty of Medicine in Hradec Králové, Charles University, Šimkova 870, 500 03 Hradec Králové, Czech Republic; (D.A.); (K.L.); (P.V.)
| | - Petr Voda
- Department of Medical Biophysics, Faculty of Medicine in Hradec Králové, Charles University, Šimkova 870, 500 03 Hradec Králové, Czech Republic; (D.A.); (K.L.); (P.V.)
| | - Rudolf Andrýs
- Department of Chemistry, University of Hradec Králové, Rokitanského 62, 500 03 Hradec Králové, Czech Republic;
| | - Alena Myslivcová Fučíková
- Department of Biology, University of Hradec Králové, Rokitanského 62, 500 03 Hradec Králové, Czech Republic; (M.N.); (A.M.F.)
| | - Tomáš Hosszú
- Department of Neurosurgery, Faculty of Medicine in Hradec Králové, Charles University, Sokolská 581, 500 05 Hradec Králové, Czech Republic;
- Department of Neurosurgery, University Hospital Hradec Králové, Sokolská 581, 500 05 Hradec Králové, Czech Republic
| | - Aleš Bezrouk
- Department of Medical Biophysics, Faculty of Medicine in Hradec Králové, Charles University, Šimkova 870, 500 03 Hradec Králové, Czech Republic; (D.A.); (K.L.); (P.V.)
- Correspondence:
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Álvarez Delgado A, Pérez García ML. Managing esophageal strictures following endoscopic resection of superficial neoplastic lesions. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2021; 113:810-812. [PMID: 34818896 DOI: 10.17235/reed.2021.8437/2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Over the last few years early esophageal tumors, whether squamous-cell or associated with Barrett's esophagus, have been excised using endoscopic resection techniques, primarily endoscopic submucosal dissection (ESD). Esophageal surgery-associated morbidity and mortality are thus avoided with similar oncologic outcomes. ESD is not without complications, many of which arise and are endoscopically solved during the procedure itself (bleeding, perforation, etc.). Other complications develop within days or weeks after resection, these including mainly esophageal stricture. Esophageal strictures following ESD are initially managed with endoscopic balloon dilation (EBD). Preventive measures have been suggested to alleviate this complication, primarily by using local or systemic steroids in association with early dilation. Even so, not always may they be prevented. Such complications are called refractory strictures, which require either esophageal stents (in a majority of cases) or surgery.
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Spaander MCW, van der Bogt RD, Baron TH, Albers D, Blero D, de Ceglie A, Conio M, Czakó L, Everett S, Garcia-Pagán JC, Ginès A, Jovani M, Repici A, Rodrigues-Pinto E, Siersema PD, Fuccio L, van Hooft JE. Esophageal stenting for benign and malignant disease: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2021. Endoscopy 2021; 53:751-762. [PMID: 33930932 DOI: 10.1055/a-1475-0063] [Citation(s) in RCA: 77] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
MALIGNANT DISEASE 1: ESGE recommends placement of partially or fully covered self-expandable metal stents (SEMSs) for palliation of malignant dysphagia over laser therapy, photodynamic therapy, and esophageal bypass.Strong recommendation, high quality evidence. 2 : ESGE recommends brachytherapy as a valid alternative, alone or in addition to stenting, in esophageal cancer patients with malignant dysphagia and expected longer life expectancy.Strong recommendation, high quality evidence. 3: ESGE recommends esophageal SEMS placement for sealing malignant tracheoesophageal or bronchoesophageal fistulas. Strong recommendation, low quality evidence. 4 : ESGE does not recommend SEMS placement as a bridge to surgery or before preoperative chemoradiotherapy because it is associated with a high incidence of adverse events. Other options such as feeding tube placement are preferable. Strong recommendation, low quality evidence. BENIGN DISEASE 5: ESGE recommends against the use of SEMSs as first-line therapy for the management of benign esophageal strictures because of the potential for adverse events, the availability of alternative therapies, and their cost. Strong recommendation, low quality evidence. 6: ESGE suggests consideration of temporary placement of self-expandable stents for refractory benign esophageal strictures. Weak recommendation, moderate quality evidence. 7: ESGE suggests that fully covered SEMSs be preferred over partially covered SEMSs for the treatment of refractory benign esophageal strictures because of their very low risk of embedment and ease of removability. Weak recommendation, low quality evidence. 8: ESGE recommends the stent-in-stent technique to remove partially covered SEMSs that are embedded in the esophageal wall. Strong recommendation, low quality evidence. 9: ESGE recommends that temporary stent placement can be considered for the treatment of leaks, fistulas, and perforations. No specific type of stent can be recommended, and the duration of stenting should be individualized. Strong recommendation, low quality of evidence. 10 : ESGE recommends considering placement of a fully covered large-diameter SEMS for the treatment of esophageal variceal bleeding refractory to medical, endoscopic, and/or radiological therapy, or as initial therapy for patients with massive bleeding. Strong recommendation, moderate quality evidence.
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Affiliation(s)
- Manon C W Spaander
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Ruben D van der Bogt
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Todd H Baron
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - David Albers
- Department of Internal Medicine and Gastroenterology, Elisabeth-Krankenhaus Academic Hospital, University of Duisburg-Essen, Essen, Germany
| | - Daniel Blero
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, CUB Erasme Hospital, ULB (Free University of Brussels), Brussels, Belgium
| | - Antonella de Ceglie
- Department of Gastroenterology, Ospedale Civile di Sanremo, Sanremo (IM), Italy
| | - Massimo Conio
- Department of Gastroenterology, Ospedale Santa Corona, Pietra Ligure (SV), Italy
| | - László Czakó
- First Department of Medicine, Faculty of Medicine, University of Szeged, Szeged, Hungary
| | - Simon Everett
- Department of Gastroenterology and Hepatology, Leeds Teaching Hospital NHS Trust, Leeds, UK
| | - Juan-Carlos Garcia-Pagán
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit - Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver) - Hospital Clinic, IDIBAPS and CIBERehd, University of Barcelona, Barcelona, Spain
| | - Angels Ginès
- Gastroenterology Department, Hospital Clinic of Barcelona, IDIBAPS and CIBERehd, University of Barcelona, Barcelona, Spain
| | - Manol Jovani
- Department of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Alessandro Repici
- Endoscopy Unit, IRCCS Istituto Clinico Humanitas, Rozzano, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | | | - Peter D Siersema
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Lorenzo Fuccio
- Gastroenterology Unit, Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
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Hernandez-Mondragon O, Contreras LG, Pineda OM, Blanco-Velasco G, Murcio-Pérez E. Safety and efficacy of biodegradable stents in octogenarian patients with esophageal achalasia. Endosc Int Open 2021; 9:E756-E766. [PMID: 34079856 PMCID: PMC8159585 DOI: 10.1055/a-1386-3214] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 01/05/2021] [Indexed: 02/06/2023] Open
Abstract
Backgrounds and study aims Treatment of octogenarian patients with achalasia with conventional treatments is effective but with compromised safety. Biodegradable stents (BS) are promising. We aimed to evaluate their safety, efficacy and clinical outcomes at early, mid and long-term in this population. Patients and methods Naïve or previously-treated achalasic octogenarian patients underwent to BS placement (BSP) between December, 2010 and November, 2011, and were followed-up for 9-years. A strict follow-up was performed. Results Thirty-two patients were included, (17 men [53.1 %]; median age 82 years [78-92]). BSP was performed in all patients. At 9y, 18/32 (56.2 %) completed protocol. Mean BSP time was 37.5±12.1 min and 34.4 % presented thoracic pain. At 1 m, six BS were migrated (18.7 %), requiring a second BSP fixed with hemoclips. At 3 m, twenty-three (72.8 %) completed degradation process. At 6 m, eighteen (56.2 %) presented clinical dysphagia, of whom 5/32 (15.6 %) presented stenotic-tissue hyperplasia, responding to balloon dilation in all cases. Pre-BSP Eckardt, Timed barium esophagram and integrated relaxation pressure improved post-BSP 6 m values (9 vs 2, p = 0.001; < 50 % = 93.8 % vs > 80 % = 81.5 %, p = 0.003 and 18.8 ± 3.2 vs 11.1 ± 2.6 mmHg, p = 0.001, respectively), and there were no significant changes up to 9y post-BSP. Esophagitis grade A or B was presented between 4.7 % to 11.2 % and controlled with PPI. After 9 years we had clinical success rates of 94.4 %, 72 %, and 65.4 % for time point evaluation, per protocol and intention to treat analysis, respectively. Conclusions BSP represents a feasible alternative option in octogenarian patients with achalasia who are high risk with other treatments, presenting acceptable early, mid-, and long-term outcomes.
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Affiliation(s)
| | - Luis Garcia Contreras
- Instituto Mexicano del Seguro Social – Digestive Endoscopy, Ciudad de Mexico, Mexico
| | - Omar Michel Pineda
- Instituto Mexicano del Seguro Social – Digestive Endoscopy, Ciudad de Mexico, Mexico
| | - Geraro Blanco-Velasco
- Instituto Mexicano del Seguro Social – Digestive Endoscopy, Ciudad de Mexico, Mexico
| | - Enrique Murcio-Pérez
- Instituto Mexicano del Seguro Social – Digestive Endoscopy, Ciudad de Mexico, Mexico,Hospital de Especialidades Centro Medico Nacional Siglo, Mexico City, Mexico
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10
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Boregowda U, Goyal H, Mann R, Gajendran M, Patel S, Echavarria J, Sayana H, Saligram S. Endoscopic management of benign recalcitrant esophageal strictures. Ann Gastroenterol 2021; 34:287-299. [PMID: 33948052 PMCID: PMC8079876 DOI: 10.20524/aog.2021.0585] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 11/02/2020] [Indexed: 11/25/2022] Open
Abstract
Benign esophageal strictures are one of the common clinical conditions managed by endoscopists. Nearly 90% of the benign esophageal strictures respond to endoscopic dilation. However, a small percentage of patients progress to recalcitrant strictures. The benign recalcitrant esophageal strictures are difficult to manage both medically and endoscopically as they do not respond to conventional treatment with proton pump inhibitors and esophageal dilations. Patients with benign recalcitrant esophageal strictures are at a high risk of developing debilitating malnutrition and morbidity due to severe dysphagia. This condition is associated with psychological trauma to patients as treatments are usually prolonged with poor outcomes. Also, this can be a financial burden on the healthcare industry due to several sessions of treatment. In this article, we discuss the classification of benign esophageal strictures, evidence-based treatment strategies, endoscopic procedural techniques, and complications of endoscopic interventions. We aim to guide providers in managing benign esophageal strictures with a focus on endoscopic management of benign recalcitrant esophageal strictures.
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Affiliation(s)
- Umesha Boregowda
- Department of Internal Medicine, Bassett Medical Center, Cooperstown, NY (Umesha Boregowda)
| | - Hemant Goyal
- Department of Medicine, The Wright Center for Graduation Medical Center, Scranton, PA (Hemant Goyal)
| | - Rupinder Mann
- Department of Internal Medicine, Saint Agnes Medical Center, Fresno, CA (Rupinder Mann)
| | - Mahesh Gajendran
- Department of Internal Medicine, Texas Tech University Health Sciences Center, El Paso, TX (Mahesh Gajendran)
| | - Sandeep Patel
- Division of Gastroenterology, University of Texas Health, San Antonio, TX (Sandeep Patel, Juan Echavarria, Hari Sayana, Shreyas Saligram), USA
| | - Juan Echavarria
- Division of Gastroenterology, University of Texas Health, San Antonio, TX (Sandeep Patel, Juan Echavarria, Hari Sayana, Shreyas Saligram), USA
| | - Hari Sayana
- Division of Gastroenterology, University of Texas Health, San Antonio, TX (Sandeep Patel, Juan Echavarria, Hari Sayana, Shreyas Saligram), USA
| | - Shreyas Saligram
- Division of Gastroenterology, University of Texas Health, San Antonio, TX (Sandeep Patel, Juan Echavarria, Hari Sayana, Shreyas Saligram), USA
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11
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van der Bogt RD, Nikkessen S, Bruno MJ, Spaander MC. Stents for benign esophageal strictures. ACTA ACUST UNITED AC 2020. [DOI: 10.1016/j.tige.2020.04.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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12
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Gkolfakis P, Siersema PD, Tziatzios G, Triantafyllou K, Papanikolaou IS. Biodegradable esophageal stents for the treatment of refractory benign esophageal strictures. Ann Gastroenterol 2020; 33:330-337. [PMID: 32624652 PMCID: PMC7315705 DOI: 10.20524/aog.2020.0482] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 02/15/2020] [Indexed: 12/12/2022] Open
Abstract
This review attempts to present the available evidence regarding the use of biodegradable stents in refractory benign esophageal strictures, especially highlighting their impact on clinical success and complications. A comprehensive literature search was conducted in PubMed, using the terms "biodegradable" and "benign"; evidence from cohort and comparative studies, as well as data from one pooled analysis and one meta-analysis are presented. In summary, the results from these studies indicate that the effectiveness of biodegradable stents ranges from more than one third to a quarter of cases, fairly similar to other types of stents used for the same indication. However, their implementation may reduce the need for re-intervention during follow up. Biodegradable stents also seem to reduce the need for additional types of endoscopic therapeutic modalities, mostly balloon or bougie dilations. Results from pooled data are consistent, showing moderate efficacy along with a higher complication rate. Nonetheless, the validity of these results is questionable, given the heterogeneity of the studies included. Finally, adverse events may occur at a higher rate but are most often minor. The lack of high-quality studies with sufficient patient numbers mandates further studies, preferably randomized, to elucidate the exact role of biodegradable stents in the treatment of refractory benign esophageal strictures.
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Affiliation(s)
- Paraskevas Gkolfakis
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium (Paraskevas Gkolfakis)
| | - Peter D. Siersema
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands (Peter Siersema)
| | - Georgios Tziatzios
- Hepatogastroenterology Unit, 2 Department of Internal Medicine, “Attikon” University General Hospital, Medical School, National and Kapodistrian University of Athens, Greece (Georgios Tziatzios, Konstantinos Triantafyllou, Ioannis S. Papanikolaou)
| | - Konstantinos Triantafyllou
- Hepatogastroenterology Unit, 2 Department of Internal Medicine, “Attikon” University General Hospital, Medical School, National and Kapodistrian University of Athens, Greece (Georgios Tziatzios, Konstantinos Triantafyllou, Ioannis S. Papanikolaou)
| | - Ioannis S. Papanikolaou
- Hepatogastroenterology Unit, 2 Department of Internal Medicine, “Attikon” University General Hospital, Medical School, National and Kapodistrian University of Athens, Greece (Georgios Tziatzios, Konstantinos Triantafyllou, Ioannis S. Papanikolaou)
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13
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Mohan BP, Chandan S, Garg R, Mohamed S, Shakhatreh M, Dugyala S, Mashiana HS, Ponnada S, Asokkumar R, Adler DG. Lumen-apposing Metal Stents, Fully Covered Self-expanding Metal Stents, and Biodegradable Stents in the Management of Benign of GI Strictures: A Systematic Review and Meta-Analysis. J Clin Gastroenterol 2019; 53:560-573. [PMID: 31149932 DOI: 10.1097/mcg.0000000000001228] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Refractory benign gastrointestinal (GI) strictures are difficult to treat and placement of a stent is a commonly sought resort. Stents used for this purpose are fully covered self-expanding metal stent (FCSEMS), a biodegradable stent (BDS) and recently, a lumen-apposing metal stent (LAMS). There is no data comparing these stents to this end. METHODS We conducted a comprehensive search of multiple electronic databases and conference proceedings (from inception through October 2018) to identify studies that reported on the performance of FCSEMS, BDS, and LAMS in the treatment of refractory benign GI strictures. Our goals were to evaluate the pooled rate of technical success, clinical success, and adverse events with these stents and compare the outcomes between them. RESULTS A total of 31 studies were analyzed. In total, 14 (342 patients), 11 (226 patients), and 8 studies (192 patients) reported the use of FCSEMS, BDS, and LAMS, respectively. The pooled rate of technical success was 96.5% [95% confidence interval (CI): 93.5-98.1], 91.9% (95% CI: 85.6-95.6), and 97.6% (95% CI: 94.0-99.0) with FCSEMS, BDS, and LAMS respectively. No statistical significance to the difference was noted. The pooled rate of clinical success was 48.4% (95% CI: 37.1-59.8), 34.9% (95% CI: 23.6-48.1), and 78.8% (95% CI: 65.8-87.8) with FCSEMS, BDS, and LAMS, respectively. Statistical significance was noted in LAMS versus FCSEMS (P=0.001) and LAMS versus BDS (P=0.001). LAMS demonstrated statistically better outcomes in regards to stent migration and postprocedure pain when compared with FCSEMS and BDS. CONCLUSION Our study demonstrates that LAMS gives better clinical outcomes in the treatment of refractory benign GI strictures when compared with FCSEMS and BDS. Variability in the site, as well as the length of stricture, indirect comparison, and heterogeneity, were the limitations of our study.
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Affiliation(s)
- Babu P Mohan
- University of Arizona, Banner University Medical Center, Tucson, AZ
| | - Saurabh Chandan
- Division of Gastroenterology and Hepatology, University of Nebraska Medical Center, Omaha, NE
| | - Rajat Garg
- Cleveland Clinic Foundation, Cleveland, OH
| | - Shuaib Mohamed
- University of Arizona, Banner University Medical Center, Tucson, AZ
| | | | - Sushma Dugyala
- University of Arizona, Banner University Medical Center, Tucson, AZ
| | - Harmeet S Mashiana
- Division of Gastroenterology and Hepatology, University of Nebraska Medical Center, Omaha, NE
| | | | - Ravishankar Asokkumar
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore, Singapore
| | - Douglas G Adler
- Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, UT
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14
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Yang K, Cao J, Yuan TW, Zhu YQ, Zhou B, Cheng YS. Silicone-covered biodegradable magnesium stent for treating benign esophageal stricture in a rabbit model. World J Gastroenterol 2019; 25:3207-3217. [PMID: 31333312 PMCID: PMC6626718 DOI: 10.3748/wjg.v25.i25.3207] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 05/14/2019] [Accepted: 06/07/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Stent insertion can effective alleviate the symptoms of benign esophageal strictures (BES). Magnesium alloy stents are a good candidate because of biological safety, but show a poor corrosion resistance and a quick loss of mechanical support in vivo. AIM To test the therapeutic and adverse effects of a silicone-covered magnesium alloy biodegradable esophageal stent. METHODS Fifteen rabbits underwent silicone-covered biodegradable magnesium stent insertion into the benign esophageal stricture under fluoroscopic guidance (stent group). The wall reconstruction and tissue reaction of stenotic esophagus in the stent group were compared with those of six esophageal stricture models (control group). Esophagography was performed at 1, 2, and 3 weeks. Four, six, and five rabbits in the stent group and two rabbits in the control groups were euthanized, respectively, at each time point for histological examination. RESULTS All stent insertions were well tolerated. The esophageal diameters at immediately, 1, 2 and 3 wk were 9.8 ± 0.3 mm, 9.7 ± 0.7 mm, 9.4 ± 0.8 mm, and 9.2 ± 0.5 mm, respectively (vs 4.9 ± 0.3 mm before stent insertion; P < 0.05). Magnesium stents migrated in eight rabbits [one at 1 wk (1/15), three at 2 wk (3/11), and four at 3 wk (4/5)]. Esophageal wall remodeling (thinner epithelial and smooth muscle layers) was found significantly thinner in the stent group than in the control group (P < 0.05). Esophageal injury and collagen deposition following stent insertion were similar and did not differ compared to rabbits with esophageal stricture and normal rabbits (P > 0.05). CONCLUSION Esophageal silicone-covered biodegradable magnesium stent insertion is feasible for BES without causing severe injury or tissue reaction. Our study suggests that insertion of silicone-covered magnesium esophageal stent is a promising approach for treating BES.
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Affiliation(s)
- Kai Yang
- Department of Radiological Intervention, Shanghai Sixth People's Hospital East Campus Affiliated to Shanghai University of Medicine & Health Sciences, Shanghai 201306, China
- Department of Radiological Intervention, Shanghai Sixth People's Hospital East Campus Affiliated to Shanghai Jiao Tong University, Shanghai 201306, China
| | - Jun Cao
- Department of Tumor Intervention, Dahua Hospital, Shanghai 200237, China
| | - Tian-Wen Yuan
- Department of Tumor Intervention, Dahua Hospital, Shanghai 200237, China
| | - Yue-Qi Zhu
- Department of Radiological Intervention, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University, Shanghai 200233, China
| | - Bi Zhou
- Department of Radiological Intervention, Shanghai Sixth People's Hospital East Campus Affiliated to Shanghai University of Medicine & Health Sciences, Shanghai 201306, China
- Department of Radiological Intervention, Shanghai Sixth People's Hospital East Campus Affiliated to Shanghai Jiao Tong University, Shanghai 201306, China
| | - Ying-Sheng Cheng
- Department of Radiological Intervention, Shanghai Sixth People's Hospital East Campus Affiliated to Shanghai University of Medicine & Health Sciences, Shanghai 201306, China
- Department of Radiological Intervention, Shanghai Sixth People's Hospital East Campus Affiliated to Shanghai Jiao Tong University, Shanghai 201306, China
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15
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Richardson T, Naidoo G, Rupasinghe N, Smart H, Bhattacharya S. Biodegradable Stents in Resistant Peptic Oesophageal Stricture: Is It the Right Way to Go? CLINICAL MEDICINE INSIGHTS. GASTROENTEROLOGY 2019; 11:1179552218819492. [PMID: 30627002 PMCID: PMC6309028 DOI: 10.1177/1179552218819492] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 11/14/2018] [Indexed: 12/22/2022]
Abstract
Peptic oesophageal stricture can be considered as the end result of prolonged gastro-oesophageal reflux. The 'gold standard' treatment for peptic stricture is endoscopic dilatation with balloon or bougie. It is predicted that up to 40% of patients remain symptomatic with dysphagia due to refractory (resistant to treatment) or recurrent strictures, needing frequent interventions at short intervals. Such patients have poor nutritional status due to the primary disease and are susceptible to complications related to repeated endoscopic dilatation such as bleeding and perforation. This general review aims to analyse existing published evidence and address the role of biodegradable stents in resistant peptic strictures as an alternative treatment to provide long-term dysphagia-free intervals.
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Affiliation(s)
- Tom Richardson
- Department of Digestive Diseases, Warrington Hospital, Warrington and Halton Hospitals NHS Foundation Trust, Warrington, UK
| | - Gerlin Naidoo
- Department of Digestive Diseases, Warrington Hospital, Warrington and Halton Hospitals NHS Foundation Trust, Warrington, UK
| | - Namal Rupasinghe
- Department of Digestive Diseases, Warrington Hospital, Warrington and Halton Hospitals NHS Foundation Trust, Warrington, UK
| | - Howard Smart
- Endoscopy Unit, Royal Liverpool University Hospital, Liverpool, UK
| | - Sayantan Bhattacharya
- Department of Digestive Diseases, Warrington Hospital, Warrington and Halton Hospitals NHS Foundation Trust, Warrington, UK.,Consultant Upper GI Surgeon, Warrington, UK.,Department of General Surgery, Warrington Hospital, Warrington and Halton Hospitals NHS Foundation Trust, Warrington, UK
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16
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Everett SM. Endoscopic management of refractory benign oesophageal strictures. Ther Adv Gastrointest Endosc 2019; 12:2631774519862134. [PMID: 31460518 PMCID: PMC6702770 DOI: 10.1177/2631774519862134] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Accepted: 06/16/2019] [Indexed: 12/17/2022] Open
Abstract
Refractory benign oesophageal strictures are an infrequent presentation but a cause of significant morbidity and mortality. The treatment of these strictures has changed little in recent years, yet new evidence is emerging for the optimal timing and application of different therapies. In this article, we have carefully reviewed the current literature on the evaluation and management of refractory strictures and provided practical advice as to their management. A number of areas require attention in future research, including carefully designed randomised trials of endoscopic and medical therapies, and a focus on risk factors at a patient and molecular level to facilitate development of medical therapies that can reduce recurrent fibrosis in these patients.
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Affiliation(s)
- Simon M. Everett
- Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds LS9 7TF, UK
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17
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Sami SS, Haboubi HN, Ang Y, Boger P, Bhandari P, de Caestecker J, Griffiths H, Haidry R, Laasch HU, Patel P, Paterson S, Ragunath K, Watson P, Siersema PD, Attwood SE. UK guidelines on oesophageal dilatation in clinical practice. Gut 2018; 67:1000-1023. [PMID: 29478034 PMCID: PMC5969363 DOI: 10.1136/gutjnl-2017-315414] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Revised: 01/03/2018] [Accepted: 01/14/2018] [Indexed: 01/10/2023]
Abstract
These are updated guidelines which supersede the original version published in 2004. This work has been endorsed by the Clinical Services and Standards Committee of the British Society of Gastroenterology (BSG) under the auspices of the oesophageal section of the BSG. The original guidelines have undergone extensive revision by the 16 members of the Guideline Development Group with representation from individuals across all relevant disciplines, including the Heartburn Cancer UK charity, a nursing representative and a patient representative. The methodological rigour and transparency of the guideline development processes were appraised using the revised Appraisal of Guidelines for Research and Evaluation (AGREE II) tool.Dilatation of the oesophagus is a relatively high-risk intervention, and is required by an increasing range of disease states. Moreover, there is scarcity of evidence in the literature to guide clinicians on how to safely perform this procedure. These guidelines deal specifically with the dilatation procedure using balloon or bougie devices as a primary treatment strategy for non-malignant narrowing of the oesophagus. The use of stents is outside the remit of this paper; however, for cases of dilatation failure, alternative techniques-including stents-will be listed. The guideline is divided into the following subheadings: (1) patient preparation; (2) the dilatation procedure; (3) aftercare and (4) disease-specific considerations. A systematic literature search was performed. The Grading of Recommendations Assessment, Develop-ment and Evaluation (GRADE) tool was used to evaluate the quality of evidence and decide on the strength of recommendations made.
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Affiliation(s)
- Sarmed S Sami
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Hasan N Haboubi
- Cancer Biomarker Group, Swansea Medical School, Swansea University, Swansea, UK
| | - Yeng Ang
- Department of GI Sciences, University of Manchester, Manchester, UK
- Salford Royal NHS Foundation Trust, Salford, UK
| | - Philip Boger
- Department of Gastroenterology, Southampton University Hospital, Southampton, UK
| | - Pradeep Bhandari
- Department of Gastroenterology, Portsmouth University Hospitals NHS Trust, Portsmouth, UK
| | - John de Caestecker
- Digestive Diseases Centre, University Hospitals of Leicester, Leicester, UK
| | - Helen Griffiths
- Department of Gastroenterology, Wye Valley NHS Trust, Wye Valley, UK
| | - Rehan Haidry
- Department of Gastroenterology, University College Hospital, London, UK
| | - Hans-Ulrich Laasch
- Department of Radiology, The Christie NHS Foundation Trust, Manchester, UK
| | - Praful Patel
- Department of Gastroenterology, Southampton University Hospital, Southampton, UK
| | - Stuart Paterson
- Department of Gastroenterology, NHS Forth Valley, Stirling, UK
| | - Krish Ragunath
- NIHR Nottingham Digestive Diseases Biomedical Research Centre, Queens Medical Centre, Belfast, UK
| | - Peter Watson
- Faculty of Medicine Health and Life Sciences, Queen's University Belfast, Belfast, UK
| | - Peter D Siersema
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Nijmegen, The Netherlands
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Abstract
OPINION STATEMENT PURPOSE OF REVIEW: Esophageal stents are used in clinical practice for endoscopic treatment of a wide variety of esophageal diseases and conditions. This review provides key principles and a literature update on the utility and limitations of esophageal stenting in clinical practice. RECENT FINDINGS Indications for esophageal stenting can be subdivided into two groups. The first group consists of patients with malignant or benign dysphagia, in which an esophageal stent restores luminal patency. In the past years, temporary stent placement has increasingly been used in the therapeutic management of refractory benign esophageal strictures. When endoscopic repeated bougie dilation and other endoscopic treatment modalities have failed, an esophageal stent could be considered. Based on the literature, a fully covered self-expandable metal stent may be the preferred choice for the treatment of both malignant and benign dysphagia. The second group consists of patients with leakage from the esophageal lumen into the surrounding tissue. Esophageal leakage can be subdivided into three forms, benign esophageal perforations (iatrogenic and spontaneous), anastomotic leakage after reconstructive esophageal surgery, and fistula. In a carefully selected group of patients, a covered esophageal stent may be used for sealing off the leakage, thereby preventing further contamination of the tissue surrounding the defect. The past few years, several validated prediction tools have been developed that may assist clinicians in the selection of patients eligible for esophageal stent placement. Based on retrospective studies and expert opinion, a partially or fully covered self-expandable metal stent may have a role in treatment of esophageal leakage. Research do date supports the utilization of esophageal stents for the treatment of malignant or benign dysphagia and esophageal leakage.
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Affiliation(s)
- Bram D Vermeulen
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Geert Grooteplein-Zuid 8 (route 455), 6500, HB, Nijmegen, the Netherlands.
| | - Peter D Siersema
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Geert Grooteplein-Zuid 8 (route 455), 6500, HB, Nijmegen, the Netherlands
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Yano T, Yoda Y, Nomura S, Toyosaki K, Hasegawa H, Ono H, Tanaka M, Morimoto H, Horimatsu T, Nonaka S, Kaneko K, Sato A. Prospective trial of biodegradable stents for refractory benign esophageal strictures after curative treatment of esophageal cancer. Gastrointest Endosc 2017; 86:492-499. [PMID: 28137598 DOI: 10.1016/j.gie.2017.01.011] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Accepted: 01/13/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Biodegradable stents are reportedly effective for refractory benign esophageal strictures; however, little is known about their use in patients with refractory stricture after endoscopic submucosal dissection (ESD) or chemoradiotherapy (CRT) for esophageal cancer. This study aimed to evaluate the effectiveness of biodegradable stents for these patients. METHODS Patients with refractory benign esophageal stricture with a dysphagia score (DS) of 2 or worse and for whom the passage of a standard size endoscope was not possible were eligible. The primary endpoint was the proportion of those who improved their DSs (% DS improved) at 12 weeks after stent placement, and the secondary endpoints were the proportion of those who improved their DSs at 24 weeks, dysphagia-free survival (DFS), and adverse events. RESULTS Eighteen patients (men:women, 15:3; median age, 72 years; range, 53-80) were enrolled. Twelve patients improved their DS at 12 weeks (% DS improved, 66.7%; 90% CI, 44.6%-84.4%). Also, 8 of 11 patients (72.7%) after esophagectomy, 4 of 6 patients (66.7%) after ESD, and 3 of 4 patients (75%) after CRT improved at 12 weeks. Three patients who were treated with esophagectomy maintained their DS improvement at 24 weeks (% DS improved, 16.7%; 95% CI, 3.6%-41.4%). The median DFS was 14.1 weeks (95% CI, 13.0-19.0). One patient who had ESD and CRT developed an esophagobronchial fistula 3 months after stent placement. CONCLUSIONS Biodegradable stents are effective and tolerable for refractory benign esophageal strictures after treatment for esophageal cancer; however, long-term efficacy was limited, especially after ESD or CRT. (Clinical trial registration number: UMIN000008054.).
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Affiliation(s)
- Tomonori Yano
- Department of Gastroenterology and Endoscopy, National Cancer Center Hospital East, Chiba, Japan
| | - Yusuke Yoda
- Department of Gastroenterology and Endoscopy, National Cancer Center Hospital East, Chiba, Japan
| | - Shogo Nomura
- Office of Clinical Research Support, National Cancer Center Hospital East, Chiba, Japan
| | - Kayo Toyosaki
- Office of Clinical Research Support, National Cancer Center Hospital East, Chiba, Japan
| | - Hiromi Hasegawa
- Office of Clinical Research Support, National Cancer Center Hospital East, Chiba, Japan
| | - Hiroyuki Ono
- Endoscopy Division, Shizuoka Cancer Center, Shizuoka, Japan
| | - Masaki Tanaka
- Endoscopy Division, Shizuoka Cancer Center, Shizuoka, Japan
| | - Hiroyuki Morimoto
- Department of Gastroenterology and Endoscopy, National Cancer Center Hospital East, Chiba, Japan
| | - Takahiro Horimatsu
- Department of Therapeutic Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Satoru Nonaka
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| | - Kazuhiro Kaneko
- Department of Gastroenterology and Endoscopy, National Cancer Center Hospital East, Chiba, Japan
| | - Akihiro Sato
- Office of Clinical Research Support, National Cancer Center Hospital East, Chiba, Japan
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Kochhar R, Samanta J, Basha J, Verma A, Choudhuri G, Lakhtakia S, Reddy DN. Biodegradable Stents for Caustic Esophageal Strictures: Do They Work? Dysphagia 2017; 32:575-582. [PMID: 28444489 DOI: 10.1007/s00455-017-9800-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2016] [Accepted: 04/17/2017] [Indexed: 02/08/2023]
Abstract
Biodegradable (BD) stents have been used for the management of various esophageal strictures (ES) but the experience of its use in caustic strictures is limited. The present study, aimed at evaluating efficacy of BD stents for the treatment of refractory caustic-induced ES, was a retrospective multi-center study conducted at three tertiary care centers in India wherein adult patients with refractory caustic induced strictures underwent placement of a BD stent. Patients were followed up for immediate complications and long term outcome. All 13 patients (39.3 ± 15.1 years) underwent successful BD stent placement. Retrosternal chest pain occurred in 2 patients and stent migration in 1 (7.6%) patient. At 3 months, restenosis with recurrence of dysphagia was seen in nine (69.2%) patients, at 6 months, 10 (77%) patients had dysphagia of whom three underwent surgery and the remaining seven patients required dilatations. At 1 year, one patient remained asymptomatic while nine had dysphagia. The requirement for dilatation was once in 3 months in seven patients & once in a month in two patients. At 2 years, the requirement of dilatations was further reduced to once in 4-6 months in all patients. Over a 3 year follow up three (23%) patients had undergone surgery, one was free of symptoms while nine patients continued to be on periodic dilatation although the requirement had reduced to once in 4-6 months. Efficacy of BD stents in patients with caustic-induced ES is limited and the short term radial force applied by the currently available BD stents is inadequate to provide long term relief in such patients.
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Affiliation(s)
- Rakesh Kochhar
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India.
| | - Jayanta Samanta
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Jahangeer Basha
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Abhai Verma
- Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Gourdas Choudhuri
- Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
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Fully covered self-expanding metallic stent placement for benign refractory esophageal strictures. Indian J Gastroenterol 2017; 36:197-201. [PMID: 28674786 DOI: 10.1007/s12664-017-0764-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Accepted: 05/11/2017] [Indexed: 02/04/2023]
Abstract
AIMS Treatment options for benign refractory esophageal stricture are limited. We retrospectively analyzed data of 11 patients who underwent fully covered self-expanding metallic stent (FC-SEMS) placement for refractory benign esophageal stricture at our institute. METHODS Refractory benign esophageal stricture was defined as inability to dilate a stricture to a diameter of 14 mm after a minimum of five sessions at 2-week intervals or inability to maintain diameter of 14 mm for at least 4 weeks. Eleven patients with refractory benign esophageal stricture (corrosive-6, peptic-3, and post-sclerotherapy-2) underwent FC-SEMS placement. The stent was removed after 4-6 weeks as per manufacturer's recommendation. Patients were followed up for 1 year. RESULTS Three patients with peptic strictures [length of stricture 2, 3, and 3 cm] and two patients with post-sclerotherapy stricture [length 2 and 1.5 cm] had complete response. Two of 6 patients with corrosive stricture (10 cm, 12 cm) developed recurrence of symptoms within 1 month of stent removal, and two after 2 months (8 cm, 3 cm). One patient with corrosive stricture (6 cm) had recurrence after 6 months, and responded to single session of dilatation. One patient with corrosive stricture was asymptomatic for last 12 months. Four stents were migrated. Four patients developed severe retrosternal pain following stent placement, which was managed with analgesics. There were no serious adverse events after placement of stent and removal of stent. CONCLUSIONS Fully covered SEMS is safe and effective for refractory benign non-corrosive esophageal strictures.
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Ray DM, Srinivasan I, Tang SJ, Vilmann AS, Vilmann P, McCowan TC, Patel AM. Complementary roles of interventional radiology and therapeutic endoscopy in gastroenterology. World J Radiol 2017; 9:97-111. [PMID: 28396724 PMCID: PMC5368632 DOI: 10.4329/wjr.v9.i3.97] [Citation(s) in RCA: 7] [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: 07/28/2016] [Revised: 11/12/2016] [Accepted: 01/14/2017] [Indexed: 02/06/2023] Open
Abstract
Acute upper and lower gastrointestinal bleeding, enteral feeding, cecostomy tubes and luminal strictures are some of the common reasons for gastroenterology service. While surgery was initially considered the main treatment modality, the advent of both therapeutic endoscopy and interventional radiology have resulted in the paradigm shift in the management of these conditions. In this paper, we discuss the patient’s work up, indications, and complementary roles of endoscopic and angiographic management in the settings of gastrointestinal bleeding, enteral feeding, cecostomy tube placement and luminal strictures. These conditions often require multidisciplinary approaches involving a team of interventional radiologists, gastroenterologists and surgeons. Further, the authors also aim to describe how the fields of interventional radiology and gastrointestinal endoscopy are overlapping and complementary in the management of these complex conditions.
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Poincloux L, Rouquette O, Abergel A. Endoscopic treatment of benign esophageal strictures: a literature review. Expert Rev Gastroenterol Hepatol 2017; 11:53-64. [PMID: 27835929 DOI: 10.1080/17474124.2017.1260002] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Benign esophageal strictures arise from various etiologies and are frequently encountered. Although endoscopic dilation is still the first-line therapy, recurrent strictures do occur in approximately 10% of the cases and remains a challenge to gastroenterologists. Areas covered: A literature search was performed using PubMed and Google Scholar databases for original and review articles on endoscopic treatment of benign esophageal strictures. This review outlines the main available treatment options and its controversies in the management of refractory benign esophageal strictures. Expert commentary: Adding local steroid injections to dilation can be effective for peptic stenosis and strictures after endoscopic submucosal dissection, but remains uncertain for anastomotic strictures. Intralesional injections of mitomycin-C could be useful in corrosive strictures. Incisional therapy can be a reliable alternative in Schatzki rings and in anastomotic strictures, in experienced hands. By contrast, long-term outcome with endoprosthetic treatment is disappointing, and stent placement should be carefully considered and individualized.
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Affiliation(s)
- Laurent Poincloux
- a Department of Digestive and Hepatobiliary Diseases , Estaing University Hospital , Clermont-Ferrand , France.,b UMR Auvergne University/CNRS 6284 ISIT (Image Sciences for Innovations Techniques) , Clermont-Ferrand , France
| | - Olivier Rouquette
- a Department of Digestive and Hepatobiliary Diseases , Estaing University Hospital , Clermont-Ferrand , France
| | - Armand Abergel
- a Department of Digestive and Hepatobiliary Diseases , Estaing University Hospital , Clermont-Ferrand , France.,b UMR Auvergne University/CNRS 6284 ISIT (Image Sciences for Innovations Techniques) , Clermont-Ferrand , France
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Repici A, Small AJ, Mendelson A, Jovani M, Correale L, Hassan C, Ridola L, Anderloni A, Ferrara EC, Kochman ML. Natural history and management of refractory benign esophageal strictures. Gastrointest Endosc 2016; 84:222-8. [PMID: 26828759 DOI: 10.1016/j.gie.2016.01.053] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Accepted: 01/23/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS The natural history of refractory benign esophageal strictures (RBES) is unclear, and surgery or percutaneous endoscopic gastrostomy (PEG) may be the only viable long-term options. The aim of the present study was to assess the long-term outcomes of patients with RBES. METHODS Clinical data of consecutive patients with RBES treated in the previous 15 years in 2 tertiary-care referral academic centers with specialized interest in esophageal stricture management were retrospectively analyzed. RBES was defined as the persistence and/or recurrence of dysphagia despite at least 5 dilation sessions and/or cycles with dilation to at least 14 mm. Information regarding the use of dilation or stents and the dysphagia-free period between subsequent interventions and adverse events was collected. Clinical success was defined as no need for endoscopic interventions for at least 6 months; unfavorable outcomes were defined as the need for endoscopic treatment at the end of follow-up, surgery, or percutaneous endoscopic gastrostomy (PEG). Predictors of unfavorable outcomes were assessed by multivariate analysis. A linear mixed-effect model was used to measure dysphagia-free period changes over time. RESULTS Overall, 70 patients with RBES (46 male; mean age 60 years) were followed for a mean of 43.9 months (range 3.7-157 months). Caustic, postradiotherapy, surgical, mixed, and postinflammatory etiology accounted for 10%, 14.3%, 31.4%, 40%, and 4.3% of causes, respectively. All patients underwent sequential sessions of pneumatic or bougie dilation, with a median of 15.5 dilation sessions per patient. Self-expandable metal stents (SEMSs) and biodegradable stents were placed in 18 (25.7%) and 14 (20%) patients, respectively. RBES resolution was achieved in only 22 of 70 (31.4%) patients. Two deaths (3%) were related to RBES. The success rate was lower in those who also were treated with endoprosthetics (odds ratio [OR] 3.7; 95% confidence interval [CI], 1.01-18.0). The mean dysphagia-free period was 3.3 months (95% CI, 2.4-4.1) for patients treated with dilation and 2.4 months (95% CI, 1.2-3.6) for those treated with stents (P = .062). Over time, the total dysphagia-free period increased at a rate of 4.1 days (95% CI, 1.7-6.4) per dilation. There was no difference in the rate of change across groups defined by sex (P = .976), age (P = .633), or endoscopic treatment (P = .267). CONCLUSIONS Our multicenter series showed a disappointing long-term outcome for RBES, with only 1 of 3 achieving clinical resolution. The dysphagia-free period was relatively short, affecting the quality of life. Endoprosthetics did not appear to affect the natural history of RBES.
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Affiliation(s)
- Alessandro Repici
- Department of Gastroenterology, Humanitas Research Hospital, Rozzano, Milan, Italy; Humanitas University, Milan, Italy
| | - Aaron J Small
- Gastroenterology Division, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Aaron Mendelson
- Gastroenterology Division, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | | | | | | | | | | | | | - Michael L Kochman
- Gastroenterology Division, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
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Siersema PD. Treatment of refractory benign esophageal strictures: it is all about being "patient". Gastrointest Endosc 2016; 84:229-31. [PMID: 27425797 DOI: 10.1016/j.gie.2016.04.035] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Accepted: 04/26/2016] [Indexed: 12/11/2022]
Affiliation(s)
- Peter D Siersema
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Geert Grooteplein Zuid 10, Nijmegen, The Netherlands
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Sigounas DE, Siddhi S, Plevris JN. Biodegradable esophageal stents in benign and malignant strictures - a single center experience. Endosc Int Open 2016; 4:E618-23. [PMID: 27556067 PMCID: PMC4993895 DOI: 10.1055/s-0042-105433] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Accepted: 03/07/2016] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND AND STUDY AIMS Biodegradable (BD) esophageal stents were recently developed mainly for refractory benign strictures, but experience and available literature are limited. PATIENTS AND METHODS This was a retrospective observational study. All patients who had BD stents inserted due to refractory benign esophageal strictures or malignant strictures, or were awaiting radical radiotherapy/chemotherapy or neo-adjuvant therapy and esophagectomy between March 2011 and July 2015 were included. RESULTS Stent placement was successful in all patients. Ten patients with benign strictures (3 male, median age 80.5 years, IQR: 68.75 - 89.5) were followed-up for a median of 171.5 weeks (IQR: 24 - 177.25). The interval between dilatations prior to the first BD stent placement (median: 34.25 days, IQR: 23.06 - 48.29) was significantly shorter than the interval between the first BD stent placement and the first intervention required (median: 149.5 days, IQR: 94.25 - 209.5) and this difference was statistically significant (P = 0.012). Ten patients with esophageal cancer (8 male, median age: 69 years, IQR: 59.25 - 80.75) were included and they were followed up for a median of 36 weeks (IQR: 26 - 58). Only 1 completed radical radiotherapy successfully, but developed refractory post-radiotherapy stricture. No one proceeded to esophagectomy and 50 % required a self-expanding metal stent (SEMS) at a median of 134 days (IQR: 100 - 263) following stent placement. CONCLUSIONS BD stents were successfully deployed in both benign and malignant strictures. They offered a prolonged dilatation-free interval in benign strictures, yet in the majority of patients, strictures recurred. In malignant strictures, stent patency was similar to that of benign strictures, which suggests a potential value in ensuring adequate oral intake during oncologic therapy. In our cohort, however, use of stents did not contribute to improved outcome.
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Affiliation(s)
- Dimitrios E. Sigounas
- Centre for Liver & Digestive Disorders, The Royal Infirmary, University of Edinburgh, Edinburgh, Scotland, UK
| | - Sandeep Siddhi
- Centre for Liver & Digestive Disorders, The Royal Infirmary, University of Edinburgh, Edinburgh, Scotland, UK
| | - John N. Plevris
- Centre for Liver & Digestive Disorders, The Royal Infirmary, University of Edinburgh, Edinburgh, Scotland, UK,Corresponding author Professor John N. Plevris Centre for Liver & Digestive DisordersThe Royal InfirmaryUniversity of Edinburgh51 Little France CrescentEdinburgh EH16 4SAScotland, UK
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Imaz-Iglesia I, García-Pérez S, Nachtnebel A, Martín-Águeda B, Sánchez-Piedra C, Karadayi B, Demirbaş AR. Biodegradable stents for the treatment of refractory or recurrent benign esophageal stenosis. Expert Rev Med Devices 2016; 13:583-99. [DOI: 10.1080/17434440.2016.1184967] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Yuan T, Yu J, Cao J, Gao F, Zhu Y, Cheng Y, Cui W. Fabrication of a Delaying Biodegradable Magnesium Alloy-Based Esophageal Stent via Coating Elastic Polymer. MATERIALS (BASEL, SWITZERLAND) 2016; 9:384. [PMID: 28773505 PMCID: PMC5503030 DOI: 10.3390/ma9050384] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Revised: 04/18/2016] [Accepted: 05/11/2016] [Indexed: 11/16/2022]
Abstract
Esophageal stent implantation can relieve esophageal stenosis and obstructions in benign esophageal strictures, and magnesium alloy stents are a good candidate because of biodegradation and biological safety. However, biodegradable esophageal stents show a poor corrosion resistance and a quick loss of mechanical support in vivo. In this study, we chose the elastic and biodegradable mixed polymer of Poly(ε-caprolactone) (PCL) and poly(trimethylene carbonate) (PTMC) as the coated membrane on magnesium alloy stents for fabricating a fully biodegradable esophageal stent, which showed an ability to delay the degradation time and maintain mechanical performance in the long term. After 48 repeated compressions, the mechanical testing demonstrated that the PCL-PTMC-coated magnesium stents possess good flexibility and elasticity, and could provide enough support against lesion compression when used in vivo. According to the in vitro degradation evaluation, the PCL-PTMC membrane coated on magnesium was a good material combination for biodegradable stents. During the in vivo evaluation, the proliferation of the smooth muscle cells showed no signs of cell toxicity. Histological examination revealed the inflammation scores at four weeks in the magnesium-(PCL-PTMC) stent group were similar to those in the control group (p > 0.05). The α-smooth muscle actin layer in the media was thinner in the magnesium-(PCL-PTMC) stent group than in the control group (p < 0.05). Both the epithelial and smooth muscle cell layers were significantly thinner in the magnesium-(PCL-PTMC) stent group than in the control group. The stent insertion was feasible and provided reliable support for at least four weeks, without causing severe injury or collagen deposition. Thus, this stent provides a new stent for the treatment of benign esophageal stricture and a novel research path in the development of temporary stents in other cases of benign stricture.
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Affiliation(s)
- Tianwen Yuan
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai Jiao Tong University, 600 Yi Shan Road, Shanghai 200233, China.
| | - Jia Yu
- Department of Orthopedics, The First Affiliated Hospital of Soochow University, Orthopedic Institute, Soochow University, 708 Renmin Road, Suzhou 215006, China.
| | - Jun Cao
- Department of Interventional Oncology, Dahua Hospital, Xuhui District, Shanghai 200237, China.
| | - Fei Gao
- Zhejiang Zylox Medical Device Co., Ltd., No. 1500, Wenyi West Road, Hangzhou 311121, China.
| | - Yueqi Zhu
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai Jiao Tong University, 600 Yi Shan Road, Shanghai 200233, China.
| | - Yingsheng Cheng
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai Jiao Tong University, 600 Yi Shan Road, Shanghai 200233, China.
| | - Wenguo Cui
- Department of Orthopedics, The First Affiliated Hospital of Soochow University, Orthopedic Institute, Soochow University, 708 Renmin Road, Suzhou 215006, China.
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Yang K, Ling C, Yuan T, Zhu Y, Cheng Y, Cui W. Polymeric Biodegradable Stent Insertion in the Esophagus. Polymers (Basel) 2016; 8:158. [PMID: 30979258 PMCID: PMC6432023 DOI: 10.3390/polym8050158] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Revised: 04/03/2016] [Accepted: 04/08/2016] [Indexed: 12/11/2022] Open
Abstract
Esophageal stent insertion has been used as a well-accepted and effective alternative to manage and improve the quality of life for patients diagnosed with esophageal diseases and disorders. Current stents are either permanent or temporary and are fabricated from either metal or plastic. The partially covered self-expanding metal stent (SEMS) has a firm anchoring effect and prevent stent migration, however, the hyperplastic tissue reaction cause stent restenosis and make it difficult to remove. A fully covered SEMS and self-expanding plastic stent (SEPS) reduced reactive hyperplasia but has a high migration rate. The main advantage that polymeric biodegradable stents (BDSs) have over metal or plastic stents is that removal is not require and reduce the need for repeated stent insertion. But the slightly lower radial force of BDS may be its main shortcoming and a post-implant problem. Thus, strengthening support of BDS is a content of the research in the future. BDSs are often temporarily effective in esophageal stricture to relieve dysphagia. In the future, it can be expect that biodegradable drug-eluting stents (DES) will be available to treat benign esophageal stricture, perforations or leaks with additional use as palliative modalities for treating malignant esophageal stricture, as the bridge to surgery or to maintain luminal patency during neoadjuvant chemoradiation.
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Affiliation(s)
- Kai Yang
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai Jiao Tong University, 600 Yi Shan Road, Shanghai 200233, China.
| | - Christopher Ling
- Department of Orthopedics, The First Affiliated Hospital of Soochow University, Orthopedic Institute, Soochow University, 708 Renmin Road, Suzhou 215006, China.
- Nanotechnology Engineering, University of Waterloo, 200 University Ave W, Waterloo, ON N2L 3G1, Canada.
| | - Tianwen Yuan
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai Jiao Tong University, 600 Yi Shan Road, Shanghai 200233, China.
| | - Yueqi Zhu
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai Jiao Tong University, 600 Yi Shan Road, Shanghai 200233, China.
| | - Yingsheng Cheng
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai Jiao Tong University, 600 Yi Shan Road, Shanghai 200233, China.
| | - Wenguo Cui
- Department of Orthopedics, The First Affiliated Hospital of Soochow University, Orthopedic Institute, Soochow University, 708 Renmin Road, Suzhou 215006, China.
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Endoscopic balloon dilatation as an effective treatment for lower and upper benign gastrointestinal system anastomotic stenosis. Surg Laparosc Endosc Percutan Tech 2016; 25:138-42. [PMID: 25122484 DOI: 10.1097/sle.0000000000000090] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Endoscopic balloon dilatation (EBD) is currently accepted as an effective, safe, and first-line treatment of postoperative benign gastrointestinal anastomosis stenosis (BGAS); however, a limited number of publications on the subject exist in the literature. The aim of the study was to retrospectively evaluate the efficiency of endoscopic dilatation in patients with postoperative intestinal anastomotic stenoses at a single surgical center. METHODS Patients with postoperative BGAS treated by EBD at our institution from February 2008 to 2012 were included. The dilatations were all performed using through-the-scope balloons. The balloon was introduced into the stricture using a guidewire under radiologic guidance. Each dilatation session consisted of 2 to 3 two-minute multistep inflations of the balloon until adequate dilatation was achieved. RESULTS Of the 48 patients included in the study, 44 patients (91.7%) fully recovered and 4 (8.3%) did not respond to treatment. The mean follow-up period was 24 months (range, 3 to 57 mo). Four patients who did not respond to the procedure were treated surgically. Two patients (4.1%) with intestinal perforation during EBD were treated conservatively with a stent. CONCLUSIONS EBD has a low rate of complications and a high success rate, is well tolerated, and avoids further surgical procedures for BGAS. Therefore, EBD should be the first choice of treatment for postoperative anastomotic stenoses.
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Kappelle WFW, Siersema PD, Bogte A, Vleggaar FP. Challenges in oral drug delivery in patients with esophageal dysphagia. Expert Opin Drug Deliv 2016; 13:645-58. [DOI: 10.1517/17425247.2016.1142971] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Wouter F. W. Kappelle
- University Medical Center Utrecht, Department of Gastroenterology and Hepatology, Utrecht, The Netherlands
| | - Peter D. Siersema
- University Medical Center Utrecht, Department of Gastroenterology and Hepatology, Utrecht, The Netherlands
| | - Auke Bogte
- University Medical Center Utrecht, Department of Gastroenterology and Hepatology, Utrecht, The Netherlands
| | - Frank P. Vleggaar
- University Medical Center Utrecht, Department of Gastroenterology and Hepatology, Utrecht, The Netherlands
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Caustic Esophageal Stenosis: A Case Report of Endoscopic Dilation With a Dynamic Stent. GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2016; 23:218-223. [PMID: 28868463 PMCID: PMC5580173 DOI: 10.1016/j.jpge.2015.12.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Accepted: 12/17/2015] [Indexed: 12/15/2022]
Abstract
INTRODUCTION The management of esophageal strictures has evolved from surgical treatment to the endoscopic dilation and, more recently, esophageal stenting. CLINICAL CASE We describe a case of a two-year-old boy with a double stenosis of the esophagus resulting from accidental ingestion of strong alkaline liquid. After several unsuccessful endoscopic dilations for three years and even topical mitomicin, it was decided to place a dynamic stent developed by the Digestive Surgery and Endoscopic Unit of the Bambino Gesù Hospital, Rome. The stent is a custom silicon device built coaxially on a nasogastric tube that is inserted after stricture dilations, by endoscopic guidance, and then fixed outside the nose. The device was removed after seven weeks with good clinical outcome (no dysphagia more than a year of follow-up). CONCLUSION This case confirms that the dynamic stent is a simple device that may avoid aggressive surgical substitution in cases of refractory strictures.
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Samanta J, Dhaka N, Sinha SK, Kochhar R. Endoscopic incisional therapy for benign esophageal strictures: Technique and results. World J Gastrointest Endosc 2015; 7:1318-1326. [PMID: 26722613 PMCID: PMC4689794 DOI: 10.4253/wjge.v7.i19.1318] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 09/20/2015] [Accepted: 11/04/2015] [Indexed: 02/05/2023] Open
Abstract
Benign esophageal strictures refractory to the conventional balloon or bougie dilatation may be subjected to various adjunctive modes of therapy, one of them being endoscopic incisional therapy (EIT). A proper delineation of the stricture anatomy is a prerequisite. A host of electrocautery and mechanical devices may be used, the most common being the use of needle knife, either standard or insulated tip. The technique entails radial incision and cutting off of the stenotic rim. Adjunctive therapies, to prevent re-stenosis, such as balloon dilatation, oral or intralesional steroids or argon plasma coagulation can be used. The common strictures where EIT has been successfully used are Schatzki’s rings (SR) and anastomotic strictures (AS). Short segment strictures (< 1 cm) have been found to have the best outcome. When compared with routine balloon dilatation, EIT has equivalent results in treatment naïve cases but better long term outcome in refractory cases. Anecdotal reports of its use in other types of strictures have been noted. Post procedure complications of EIT are mild and comparable to dilatation therapy. As of the current evidence, incisional therapy can be used for management of refractory AS and SR with relatively short stenosis (< 1 cm) with good safety profile and acceptable long term patency.
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Zhou WZ, Song HY, Park JH, Shin JH, Kim JH. Stent placement in benign esophageal strictures. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2015. [DOI: 10.18528/gii1400020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
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Abstract
Background This is a review of endoscopic therapy in the setting of palliative management of patients suffering from esophageal cancer (EC). Unfortunately, many cases of EC present in a stage of disease in which curative therapy is not possible. The maintenance of quality of life includes the ability to swallow and of oral feeding, pain control, and the prevention of bleeding. Methods A review of the current literature was performed. Results Many endoscopic methods are available for the management of dysphagia, of which dilation, endoluminal tumor destruction, stenting, and brachytherapy are the most common. Conclusion Surgical palliation should be avoided as much as possible since the alternatives show at least the same efficacy and have fewer complications.
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Affiliation(s)
- Thomas Rabenstein
- Department of Gastroenterology, Diakonissen Speyer-Mannheim, Diakonissen Krankenhaus Speyer, Speyer, Germany
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Irani S, Kozarek RA. Techniques and principles of endoscopic treatment of benign gastrointestinal strictures. Curr Opin Gastroenterol 2015; 31:339-350. [PMID: 26247823 DOI: 10.1097/mog.0000000000000200] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW The fundamental goal of treating any stenosis is luminal enlargement to ameliorate the underlying obstructive symptoms. Symptoms depend on the etiology and the site of the stricture and may include dysphagia, nausea and vomiting, abdominal pain, obstipation, or frank bowel obstruction. This article compares the various current technologies available for the treatment of gastrointestinal stenoses with regard to ease and site of application, patient tolerance, safety and efficacy data, and cost-benefit ratio. RECENT FINDINGS Recent studies indicate that gastrointestinal dilation and stenting have evolved to a point at which in many if not most situations they can be the first line therapy and potentially the final therapy needed to treat the underlying condition. SUMMARY Following techniques and principles in the management of gastrointestinal strictures would allow for the well tolerated and effective treatment of most patients with the tools currently available today.
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Affiliation(s)
- Shayan Irani
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, USA
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Literature Analysis of the Treatment of Benign Esophageal Disease with Stent. Indian J Surg 2015; 78:6-13. [PMID: 27186033 DOI: 10.1007/s12262-015-1294-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2014] [Accepted: 05/20/2015] [Indexed: 12/31/2022] Open
Abstract
To analyze the efficacy and safety of benign esophageal disease used biodegradable (BD) stent or metal stent. The English literatures of benign esophageal disease that were treated by biodegradable or metal stents implantation were retrieved and summarized. In all 323 benign esophageal disease, the most common etiologies were benign refractory stricture, surgical anastomotic stricture and esophageal fistula/leak/perforation, but the main characteristics between the two groups were not significantly different. One hundred fifty-four cases were completely healed by using BD stents or self-expandable metal stents (SEMS) (47.7 %). Clinical success was achieved in 47.7 % of all patients and there was no significant difference between BD stents (51 %) and SEMS (46.2 %) (P = 0.472), while stent migration occurred more frequently with SEMS (33.9 %) than with BD stent (19.6 %) (P ≤ 0.05), and tissue in- or overgrowth occurred more frequently with SEMS (22.2 %) than with BD stents (8.8 %) (P ≤ 0.05). Furthermore, the time about degradation of BD stents in esophageal was longer than removal of SEMS from the esophagus (P ≤ 0.05). Placement of BD stents or SEMS provides effective and safe relief for benign esophageal disease. Clinical success and mortality were not significantly different. BD stents offers an advantage of fewer complications. Although stent placement is a viable strategy in patients with benign esophageal disease, the ideal treatment strategy and further randomized trials with large number of patients are needed.
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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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Bechara R, Inoue H. Recent advancement of therapeutic endoscopy in the esophageal benign diseases. World J Gastrointest Endosc 2015; 7:481-495. [PMID: 25992187 PMCID: PMC4436916 DOI: 10.4253/wjge.v7.i5.481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Revised: 01/13/2015] [Accepted: 02/09/2015] [Indexed: 02/05/2023] Open
Abstract
Over the past 30 years, the field of endoscopy has witnessed several advances. With the advent of endoscopic mucosal resection, removal of large mucosal lesions have become possible. Thereafter, endoscopic submucosal resection was refined, permitting en bloc removal of large superficial neoplasms. Such techniques have facilitated the development of antireflux mucosectomy, a promising novel treatment for gastroesophageal reflux. The introduction and use of over the scope clips has allowed for endoscopic closure of defects in the gastrointestinal tract, which were traditionally treated with surgical intervention. With the development of per-oral endoscopic myotomy (POEM), the treatment of achalasia and spastic disorders of the esophagus have been revolutionized. From the submucosal tunnelling technique developed for POEM, Per oral endoscopic tumor resection of subepithelial tumors was made possible. Simultaneously, advances in biotechnology have expanded esophageal stenting capabilities with the introduction of fully covered metal and plastic stents, as well as biodegradable stents. Once deemed a primarily diagnostic tool, endoscopy has quickly transcended to a minimally invasive intervention and therapeutic tool. These techniques are reviewed with regards to their application to benign disease of the esophagus.
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van Boeckel PGA, Siersema PD. Refractory esophageal strictures: what to do when dilation fails. CURRENT TREATMENT OPTIONS IN GASTROENTEROLOGY 2015; 13:47-58. [PMID: 25647687 PMCID: PMC4328110 DOI: 10.1007/s11938-014-0043-6] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Benign esophageal strictures arise from a diversity of causes, for example esophagogastric reflux, esophageal resection, radiation therapy, ablative therapy, or the ingestion of a corrosive substance. Most strictures can be treated successfully with endoscopic dilation using bougies or balloons, with only a few complications. Nonetheless, approximately one third of patients develop recurrent symptoms after dilation within the first year. The majority of these patients are managed with repeat dilations, depending on their complexity. Dilation combined with intra lesional steroid injections can be considered for peptic strictures, while incisional therapy has been demonstrated to be effective for Schatzki rings and anastomotic strictures. When these therapeutic options do not resolve the stenosis, stent placement should be considered. Self bougienage can be proposed to a selected group of patients with a proximal stenosis. As a final step surgery is an option, but even then the risk of stricture formation at the anastomotic site remains. This chapter reviews refractory benign esophageal strictures and the treatment options that are currently available.
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Affiliation(s)
- Petra G A van Boeckel
- Department of Gastroenterology and Hepatology, HP: F02.618, University Medical Center, Heidelberglaan 100, 3584, CX, Utrecht, Netherlands,
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van Halsema EE, van Hooft JE. Clinical outcomes of self-expandable stent placement for benign esophageal diseases: A pooled analysis of the literature. World J Gastrointest Endosc 2015. [PMID: 25685270 DOI: 10.4253/wjge.v7.i2.135.] [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
AIM To analyze the outcomes of self-expandable stent placement for benign esophageal strictures and benign esophageal leaks in the literature. METHODS The PubMed, Embase and Cochrane databases were searched for relevant articles published between January 2000 and July 2014. Eight prospective studies were identified that analyzed the outcomes of stent placement for refractory benign esophageal strictures. The outcomes of stent placement for benign esophageal leaks, perforations and fistulae were extracted from 20 retrospective studies that were published after the inclusion period of a recent systematic review. Data were pooled and analyzed using descriptive statistics. RESULTS Fully covered self-expandable metal stents (FC SEMS) (n = 85), biodegradable (BD) stents (n = 77) and self-expandable plastic stents (SEPS) (n = 70) were inserted in 232 patients with refractory benign esophageal strictures. The overall clinical success rate was 24.2% and according to stent type 14.1% for FC SEMS, 32.9% for BD stents and 27.1% for SEPS. Stent migration occurred in 24.6% of cases. The overall complication rate was 31.0%, including major (17.7%) and minor (13.4%) complications. A total of 643 patients were treated with self-expandable stents mainly for postsurgical leaks (64.5%), iatrogenic perforations (19.6%), Boerhaave's syndrome (7.8%) and fistulae (3.7%). FC SEMS and partially covered SEMS were used in the majority of patients. Successful closure of the defect was achieved in 76.8% of patients and according to etiology in 81.4% for postsurgical leaks, 86.0% for perforations and 64.7% for fistulae. The pooled stent migration rate was 16.5%. Stent-related complications occurred in 13.4% of patients, including major (7.8%) and minor (5.5%) complications. CONCLUSION The outcomes of stent placement for refractory benign esophageal strictures were poor. However, randomized trials are needed to put this into perspective. The evidence on successful stent placement for benign esophageal leaks, perforations and fistulae is promising.
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Affiliation(s)
- Emo E van Halsema
- Emo E van Halsema, Jeanin E van Hooft, Department of Gastroenterology and Hepatology, Academic Medical Center, 1105 AZ Amsterdam, The Netherlands
| | - Jeanin E van Hooft
- Emo E van Halsema, Jeanin E van Hooft, Department of Gastroenterology and Hepatology, Academic Medical Center, 1105 AZ Amsterdam, The Netherlands
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WITHDRAWN: Stent Placement in Benign Esophageal Strictures. GASTROINTESTINAL INTERVENTION 2014. [DOI: 10.1016/j.gii.2014.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Park JH, Song HY, Shin JH, Kim JH, Jun EJ, Cho YC, Kim SH, Park J. Polydioxanone biodegradable stent placement in a canine urethral model: analysis of inflammatory reaction and biodegradation. J Vasc Interv Radiol 2014; 25:1257-1264.e1. [PMID: 24912878 DOI: 10.1016/j.jvir.2014.03.023] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Revised: 03/20/2014] [Accepted: 03/21/2014] [Indexed: 11/17/2022] Open
Abstract
PURPOSE To investigate the inflammatory reaction and perform quantitative analysis of biodegradation after placement of a polydioxanone (PDO) biodegradable stent in a canine urethral model. MATERIALS AND METHODS PDO biodegradable stents were placed in the proximal and distal urethra of nine male mongrel dogs. The dogs were euthanized 4 weeks (group A; n = 3), 8 weeks (group B; n = 3), or 12 weeks (group C; n = 3) after stent placement. The luminal diameter of the stent-implanted urethra was assessed by follow-up retrograde urethrography, and histologic findings were obtained after the dogs were killed. Stents were removed after euthanasia, and their surface morphology and molecular weight were evaluated. Hematologic examination was performed to evaluate inflammatory reaction. RESULTS Stent placement was technically successful in all dogs. The average luminal diameter gradually decreased. The average number of epithelial layers (2.93 vs 4.42; P < .001), the average thickness of papillary projection (0.80 mm vs 1.28 mm; P < .001), and the average thickness of submucosal fibrosis (0.34 mm vs 0.49 mm ; P < .001) were significantly increased in group B versus group A. There were no significant differences between group B and group C. The average inflammatory cell infiltration did not differ significantly in the three groups. Molecular weight losses were 54% in group A and 84% in group B. In group C, PDO stents were completely decomposed. CONCLUSIONS An experimental study in a canine urethral model has demonstrated acceptable inflammatory reaction with gradually increasing granulation tissue but no luminal obstruction within 12 weeks.
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Affiliation(s)
- Jung-Hoon Park
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Poongnap 2-dong, Songpa-gu, Seoul 138-736, Republic of Korea
| | - Ho-Young Song
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Poongnap 2-dong, Songpa-gu, Seoul 138-736, Republic of Korea.
| | - Ji Hoon Shin
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Poongnap 2-dong, Songpa-gu, Seoul 138-736, Republic of Korea
| | - Jin Hyoung Kim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Poongnap 2-dong, Songpa-gu, Seoul 138-736, Republic of Korea
| | - Eun Jung Jun
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Poongnap 2-dong, Songpa-gu, Seoul 138-736, Republic of Korea
| | - Young Chul Cho
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Poongnap 2-dong, Songpa-gu, Seoul 138-736, Republic of Korea
| | - Soo Hwan Kim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Poongnap 2-dong, Songpa-gu, Seoul 138-736, Republic of Korea
| | - Jihong Park
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Poongnap 2-dong, Songpa-gu, Seoul 138-736, Republic of Korea
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Ham YH, Kim GH. Plastic and biodegradable stents for complex and refractory benign esophageal strictures. Clin Endosc 2014; 47:295-300. [PMID: 25133114 PMCID: PMC4130882 DOI: 10.5946/ce.2014.47.4.295] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2014] [Revised: 04/15/2014] [Accepted: 04/15/2014] [Indexed: 12/17/2022] Open
Abstract
Endoscopic stent placement is a well-accepted and effective alternative treatment modality for complex and refractory esophageal strictures. Among the currently available types of stents, the partially covered self-expanding metal stent (SEMS) has a firm anchoring effect, preventing stent migration and ensuring effective covering of a narrowed segment. However, hyperplastic tissue reaction driven by the uncovered mesh may prevent easy and safe stent removal. As an alternative, a fully covered SEMS decreases the recurrence of dysphagia caused by hyperplastic tissue ingrowth; however, it has a high migration rate. Likewise, although a self-expanding plastic stent (SEPS) reduces reactive hyperplasia, the long-term outcome is disappointing because of the high rate of stent migration. A biodegradable stent has the main benefit of not requiring stent removal in comparison with SEMS and SEPS. However, it still has a somewhat high rate of hyperplastic reaction, and the long-term outcome does not satisfy expectations. Up to now, the question of which type of stent should be recommended for the effective treatment of complex and refractory benign strictures has no clear answer. Therefore, the selection of stent type for endoscopic treatment should be individualized, taking into consideration the endoscopist's experience as well as patient and stricture characteristics.
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Affiliation(s)
- Young Hee Ham
- Department of Internal Medicine, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Gwang Ha Kim
- Department of Internal Medicine, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
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46
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Endoprosthetics in the treatment of benign esophageal strictures. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2014. [DOI: 10.1016/j.tgie.2014.08.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Lorenzo-Zúñiga V, Moreno-de-Vega V, Marín I, Boix J. Biodegradable stents in gastrointestinal endoscopy. World J Gastroenterol 2014; 20:2212-2217. [PMID: 24605020 PMCID: PMC3942826 DOI: 10.3748/wjg.v20.i9.2212] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Revised: 10/22/2013] [Accepted: 12/04/2013] [Indexed: 02/06/2023] Open
Abstract
Biodegradable stents (BDSs) are an attractive option to avoid ongoing dilation or surgery in patients with benign stenoses of the small and large intestines. The experience with the currently the only BDS for endoscopic placement, made of Poly-dioxanone, have shown promising results. However some aspects should be improved as are the fact that BDSs lose their radial force over time due to the degradable material, and that can cause stent-induced mucosal or parenchymal injury. This complication rate and modest clinical efficacy has to be carefully considered in individual patients prior to placement of BDSs. Otherwise, the price of these stents therefore it is nowadays an important limitation.
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Pasha SF, Acosta RD, Chandrasekhara V, Chathadi KV, Decker GA, Early DS, Evans JA, Fanelli RD, Fisher DA, Foley KQ, Fonkalsrud L, Hwang JH, Jue TL, Khashab MA, Lightdale JR, Muthusamy VR, Sharaf R, Saltzman JR, Shergill AK, Cash B. The role of endoscopy in the evaluation and management of dysphagia. Gastrointest Endosc 2014; 79:191-201. [PMID: 24332405 DOI: 10.1016/j.gie.2013.07.042] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Accepted: 07/29/2013] [Indexed: 02/06/2023]
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49
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van Boeckel PGA, Vleggaar FP, Siersema PD. Biodegradable stent placement in the esophagus. Expert Rev Med Devices 2014; 10:37-43. [DOI: 10.1586/erd.12.45] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Hourneaux de Moura EG, Toma K, Goh KL, Romero R, Dua KS, Felix VN, Levine MS, Kochhar R, Appasani S, Gusmon CC. Stents for benign and malignant esophageal strictures. Ann N Y Acad Sci 2013; 1300:119-143. [PMID: 24117639 DOI: 10.1111/nyas.12242] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
This paper presents commentaries on endotherapy for esophageal perforation/leaks; treatment of esophageal perforation; whether esophageal stents should be used for treating benign esophageal strictures; what determines the optimal stenting period in benign esophageal strictures/leaks; how to choose an esophageal stent; how a new fistula secondary to an esophageal stent should be treated; which strategy should be adopted when a fistula of a cervical anastomosis occurs; intralesional steroids for refractory esophageal strictures; balloon and bougie dilators for esophageal strictures and predictors of response to dilation; whether refractory strictures from different etiologies respond differently to endotherapy; surgical therapy of benign esophageal strictures; and whether stenoses following severe esophageal burns should be treated by esophageal resection or esophageal bypass.
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Affiliation(s)
| | - Kengo Toma
- Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Khean-Lee Goh
- Division of Gastroenterology and GI Endoscopy, University of Malaya, Kuala Lumpur, Malaysia
| | - Ronald Romero
- Division of Gastroenterology and GI Endoscopy, University of Malaya, Kuala Lumpur, Malaysia
| | - Kulwinder S Dua
- Division of Gastroenterology and Hepatology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - Marc S Levine
- Department of Gastrointestinal Radiation, University of Pennsylvania Medical Center, Philadelphia, Pennsylvania.,Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rakesh Kochhar
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sreekanth Appasani
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Carla Cristina Gusmon
- Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universdade de São Paulo, São Paulo, Brazil
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