Esophageal stenting for benign and malignant disease: European Society of Gastrointestinal Endoscopy (ESGE) Guideline – Update 2021

Main recommendations

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.

Abbreviations

BDS: biodegradable stent

CI: confidence interval

CRP: C-reactive protein

EBRT: external beam radiation therapy

ECOG: Eastern Cooperative Oncology Group

ESGE: European Society of Gastrointestinal Endoscopy

ESPEN: European Society of Parenteral and Enteral Nutrition

FCSEMS: fully covered self-expandable metal stent

GRADE: Grading of Recommendations Assessment, Development and Evaluation

LAMS: lumen-apposing metal stent

OD: odds ratio

PCSEMS: partially covered self-expandable metal stent

RBES: refractory benign esophageal stricture

RCT: randomized controlled trial

SEMS: self-expandable metal stent

SEPS: self-expandable plastic stent

TIPS: transjugular intrahepatic portosystemic shunting

1 Introduction

Esophageal cancer is the seventh most common cancer type worldwide, with a global incidence of 604 100 new cases in 2020 [1] [2] [3]. The main symptoms of esophageal cancer include dysphagia, with concomitant weight loss and odynophagia [4]. Because patients with esophageal cancer are usually asymptomatic in the early stages, more than half of patients are diagnosed at an advanced stage of the disease and are not eligible for treatment with curative intent [5].

One of the main goals of palliative treatment is to relieve dysphagia and improve nutritional intake. A variety of therapeutic options are available, including external beam radiation therapy (EBRT), brachytherapy, and esophageal stent placement. Esophageal stent placement is preferable in patients with an expected short-term survival because of its rapid relief of dysphagia symptoms [6]. Different stent designs are available, varying in stent material (plastic, metal), covering, diameter, and antimigration features. Partially covered self-expandable metal stents (PCSEMSs) and fully covered self-expandable metal stents (FCSEMSs) are most often used in current practice.

In addition to their use for the palliation of dysphagia, esophageal stents can be used for the treatment of benign esophageal diseases. Stents are usually removed after several weeks as this timeframe allows for the resolution of disease and safe stent removal. FCSEMSs have been mostly used for the treatment of benign disorders. In recent years, biodegradable stents (BDSs) have gained increasing attention for obviating the need for stent removal.

This is an update of the clinical guideline on the use of esophageal stents for benign and malignant disease issued in 2016 by the European Society of Gastrointestinal Endoscopy (ESGE) [7]. In this guideline update, the current evidence will be discussed and recommendations on the use of esophageal stents will be provided.

2 Methods

The ESGE Guidelines Committee (chair, J.v.H.) commissioned this guideline update and appointed a Guideline leader (M.S.). Key questions (Table  1s, see online-only Supplementary Material) were prepared by a coordinating team (M.S., R.v.d.B., L.F., T.B., J.v.H.) and were approved by all guideline participants. Each guideline participant was assigned to a research question in one of two areas: malignant disease (taskforce leader, L.F.) and benign disease (taskforce leader, T.B.).

A literature search of MEDLINE and the Cochrane library was conducted in August 2020 using the PICO structure (where P stands for population/patient, I for intervention/indicator, C for comparator/control, and O for outcome). The quality of collected studies was graded according to the Grading Recommendations Assessment, Development and Evaluation (GRADE) system and retrieved study outcomes were translated into evidence tables. Evidence tables and proposed guideline recommendations were collected by the Guideline leader and circulated 2 weeks before the digital face-to-face meeting held on 22 October 2020. During the digital face-to-face meeting, outcomes of the PICOs were discussed and consensus was reached on guideline recommendations.

In November 2020, a draft was prepared by M.S. and R.v.d.B. and sent to the guideline team. The revised draft was reviewed by two independent experts. After adjustment and final approval by the guideline team, the manuscript was submitted for publication by Endoscopy.

This Guideline was issued in 2021 and will again be considered for updating in 2025.

3 Malignant disorders

3.1 Efficacy

Several randomized controlled trials (RCTs) have compared the outcomes of esophageal stent placement with other treatment strategies for the palliation of malignant dysphagia due to esophageal cancer (Table  2s). Laser therapy, photodynamic therapy, and esophageal bypass surgery have shown comparable outcomes to esophageal stent placement [8] [9] [10] [11] [12] [13].

Based on two RCTs comparing the outcomes of self-expandable metal stent (SEMS) placement versus brachytherapy, brachytherapy may be considered over SEMS placement in patients with expected long-term survival [14] [15]. Even though SEMS placement leads to a more rapid relief of dysphagia, brachytherapy is preferable in these patients for its durable relief of symptoms [15] [16]. Furthermore, the use of brachytherapy is associated with a lower risk of serious adverse events and favorable quality of life outcomes [14] [15]. Despite these benefits, the availability of brachytherapy in daily practice is restricted by the need for local expertise and dedicated logistics [17]. A short course of EBRT may be a valid alternative to brachytherapy [18]. In patients with a good performance status, chemoradiotherapy can be considered to prolong dysphagia-free survival, but is associated with an increased toxicity compared with radiotherapy alone [19].

Esophageal stent placement is indicated in patients with an expected short-term survival (i. e. less than 3 months) for its rapid relief of symptoms, usually within 1–2 days after stent placement [6]. Several prognostic tools may aid the selection of esophageal stent candidates, but these lack external validation [20] [21] [22]. The presence of metastases and poor performance status have repeatedly been shown to be associated with poor survival [21] [22] [23] [24]. When esophageal stent placement is considered, SEMSs are recommended over self-expandable plastic stents (SEPSs) owing to a lower rate of symptom recurrence and serious adverse events [6]. To date, there have been no differences shown in the outcomes of FCSEMS and PCSEMS placement, or the placement of SEMSs with or without an antireflux mechanism [25] [26] [27] [28].

3.2 Safety

In the previous ESGE guideline, a meta-analysis of the available evidence was performed for the occurrence of stent-related adverse events [7]. The major adverse event rate was reported to be 21 % for FCSEMSs and 18 % for PCSEMSs. The most frequent early adverse events were reflux (9.3 %), severe pain (8.7 %), and bleeding (7.6 %). The most frequent late adverse events were reflux (15 %), severe pain (15 %), and ingrowth/overgrowth (14 %).

In recent years, an increase in stent-related adverse events has been reported, which has been attributed to the increased use of chemotherapy and/or radiotherapy before SEMS placement [29]. Other patient characteristics that appear to be associated with an increased risk of adverse events include female sex and dilation before SEMS placement [28] [29].

3.3 Fistula

The incidence of esophageal fistulas has increased markedly as a result of advances in palliative therapies for esophageal cancer [30] [31]. Esophageal fistulas usually occur in the context of advanced esophageal cancer, but may also result from other malignancies or prior (palliative) therapy [30] [31] [32] [33] [34]. The symptoms of an esophageal fistula include cough, fever, and pneumonia [35]. Because the development of an esophageal fistula is considered to be an indicator of poor survival (weeks to months), treatment strategies should aim to rapidly relieve symptoms and improve the patient’s remaining quality of life.

The clinical success rate of SEMS placement for malignant fistulas ranges between 56 % and 100 % [35] [36] [37] [38] [39] [40] [41] [42] [43] [44]. Factors associated with treatment failure include proximal fistula location, fistula orifice size > 1 cm, and Eastern Cooperative Oncology Group (ECOG) performance status of 3–4 [42] [43]. After the fistula has been successfully sealed, reopening occurs in 0–39 % of patients [39] [40] [41] [42]. In most cases, reopening can be managed endoscopically by repositioning the SEMS or by placement of an additional SEMS [41] [42]. Airway stenting may be considered in addition to esophageal SEMS placement to improve the success rate and prevent airway obstruction [44] [45] [46] [47].

The outcomes of SEMS placement have been compared with other treatment strategies in two retrospective studies [37] [38]. Chen et al. reported on the outcomes of SEMS placement (n = 30) versus feeding gastrostomy/jejunostomy (n = 35) and found SEMS placement to be associated with an improved overall survival [37]. In a study by Hu et al., the outcomes of SEMS placement (n = 17) were compared with gastrostomy (n = 9) and best supportive care (n = 9) [38]. The median survival was comparable among the treatment arms. Patients who underwent SEMS placement had favorable quality of life outcomes on several subscales, including eating and respiratory problems.

3.4 Bridge to surgery

Neoadjuvant therapy followed by surgery is the current clinical standard for treatment with curative intent for esophageal cancer [48] [49]. Malnutrition and cachexia – common in esophageal cancer patients – are known risk factors for treatment-related adverse events and poor survival [50] [51] [52]. From this perspective, the European Society of Parenteral and Enteral Nutrition (ESPEN) recommends regular assessment of a patient’s nutritional status [53]. Initial screening can be performed by assessment of nutritional intake, weight change, and body mass index. Nutritional support is strongly recommended for patients at severe nutritional risk, defined as more than 10 %–15 % weight loss in the previous 6 months [54] [55].

Esophageal stents have been used to improve nutritional status before neoadjuvant therapy and surgery. In a meta-analysis of nine studies (5 SEPS, 3 SEMS, 1 SEPS + SEMS), the outcomes of 180 patients undergoing stent placement prior to or during neoadjuvant therapy were pooled [56]. Stent placement was technically successful in 95 % of patients, with a statistically significant improvement in dysphagia symptoms, but without improvement in weight or serum albumin levels. Stent migration and chest discomfort occurred in 32 % and 51 % of patients, respectively. The relatively high rate of stent migration in this setting has been attributed to neoadjuvant therapy-induced tumor shrinkage, as most of these patients do not require repeated intervention [56] [57]. To overcome the substantial risk of adverse events, van den Berg et al. investigated the outcomes of BDS placement in 10 patients scheduled to undergo neoadjuvant chemoradiotherapy [58]. A statistically significant decrease in dysphagia symptoms occurred without any major adverse events. Nevertheless, 7 of 10 patients required additional nutritional support and median weight loss before surgery was 5.4 kg.

In the past, SEMS placement before surgery has been reported to be associated with a worse oncologic outcome with a lower rate of R0 resections, a higher rate of major adverse events, and decreased overall survival [59] [60]. Contrarily, recent studies have reported no difference in R0 resection rate, overall survival, and postoperative complications [61] [62] [63].

Alternatives to esophageal stent placement include oral nutritional supplements, nasogastric tube placement, percutaneous feeding tube placement, and parenteral nutrition. In general, the use of percutaneous feeding tube placement (i. e. percutaneous endoscopic gastrostomy or endoscopic jejunostomy) is recommended when enteral feeding is expected to be continued for at least 4 weeks [64] [65] [66]. In surgical candidates, percutaneous endoscopic gastrostomy is considered by some surgical teams to be a contraindication as it may compromise the construction of a gastric conduit created during distal esophageal/proximal stomach reconstruction.

3.5 Combined approach

To improve the outcome of stent placement, the use of radiotherapy in addition to SEMS placement has been investigated. This combined approach may potentially lead to prolonged dysphagia relief and improved overall survival [67] [68] [69] [70]. Nevertheless, a high risk of major adverse events has been reported for the combination of EBRT and stent placement, suggesting stent placement is better reserved for patients who have failed prior radiotherapy [71].

In contrast to EBRT, the combination of single-dose brachytherapy and SEMS placement is safe and effective [67]. The use of irradiated SEMSs has been a topic of interest that potentially provides an advantage of combining the benefits of SEMS placement and brachytherapy. Based on a meta-analysis of six RCTs, the use of irradiated SEMSs led to an increased dysphagia-free time compared with traditional SEMSs, without affecting the rate of adverse events [72]. To date, however, all of these studies have been performed in Chinese populations, thereby warranting (prospective) evaluation in Western populations.

Only one study has investigated the outcomes of single-dose brachytherapy in addition to BDS placement [68]. Although satisfactory relief of symptoms was achieved, an unacceptably high rate of major adverse events was observed, which necessitated premature study termination.

3.6 Prior palliative therapy

In patients with recurrent dysphagia after first-line palliative radiotherapy, SEMS placement is considered the main treatment [73]. However, the association between prior palliative therapy and stent-related adverse events remains controversial. Several studies have reported that prior chemotherapy and/or radiotherapy increase the risk of life-threatening adverse events after SEMS placement, whereas other studies have shown the risk of adverse events to be unaffected [29] [34] [74] [75] [76] [77] [78] [79] [80] [81] [82]. Pneumonia, fistula formation, and stent-related pain may be increased in patients with prior therapy who receive stents [29] [34] [80] [81] [82].

The increased risk of adverse events has been explained by pulmonary toxicity and radiation-induced changes, which increase the susceptibility to pressure necrosis [29] [79] [81] [82] [83] [84] [85]. The potential role of radiotherapy-induced changes is supported by the increase in the rate of adverse events with a corresponding increase in radiation dosage [82] [83]. Regardless, the increased adverse event rate may also be partially explained by advanced disease stage, which is known to be related to an increased risk of life-threatening bleeding and fistula formation [34] [79].

4 Benign disease

4.1 Refractory benign esophageal strictures

The use of esophageal stents for the treatment of benign esophageal strictures has mainly been investigated in the context of refractory or recurrent benign esophageal strictures (RBESs; Table 3s). As defined by Kochman et al., these patients either fail to reach a target diameter of 14 mm after biweekly dilations over 5 weeks or fail to maintain the target diameter up to 4 weeks after the last dilation [86]. Esophageal stent placement has a potential benefit because of its continuous expansion force, which may lead to stricture remodeling. Although stent placement has not been compared with dilation in treatment-naïve patients, it is generally accepted that esophageal stent placement should only be considered as a second-line approach owing to its relatively high rate of adverse events and its cost.

In a recent meta-analysis, the outcomes of 18 studies with a total of 444 patients were pooled [87]. The clinical success rate after stent placement was 40.5 % (95 % confidence interval [CI] 31.5 %–49.5 %). Stent migration was the most common stent-related adverse event, occurring in 28.6 % (95 %CI 21.9 %–37.1 %). Other adverse events occurred in 20.6 % (95 %CI 15.3 %–28.1 %). Treatment outcomes did not differ among the SEMS, SEPS, and BDS groups.

To reduce the risk of SEMS migration, endoscopic stent fixation by endoscopic suturing or over-the-stent clips has been investigated (Table 4s). In general, endoscopic stent fixation is highly successful (96.7 %; 95 %CI 92.3 %–98.6 %) and safe (procedure-related adverse events, 3.7 %; 95 %CI 1.6 %–8.2 %) [88]. In the largest study of RBES patients, endoscopic suturing of the FCSEMS led to a reduction in stent migration rate compared with no suturing (9.4 % vs. 39.5 %; P = 0.01) [89]. It remains unclear if there is a benefit of routine stent fixation, and it may be considered in patients with prior stent migration.

Another method to reduce the risk of stent migration is the use of lumen-apposing metal stents (LAMSs). It is believed that the typical wide flanges and short lengths of LAMSs may prevent stent migration. To date, LAMSs have only been investigated in mixed study populations restricted by small sample sizes [90] [91] [92] [93] [94]. More studies are needed to evaluate their potential benefit in RBES patients.

4.1.1 Factors predicting successful treatment

The current literature provides some evidence that patient characteristics affect outcomes following stent placement in RBES patients. The previously mentioned meta-analysis showed a tendency toward a higher clinical success rate in studies that included a larger proportion of patients with radiotherapy-induced strictures and anastomotic strictures [87]. A similar trend was observed for the risk of stent-related adverse events, with the risk seeming to be lower in anastomotic strictures compared with other etiologies. In addition to stricture etiology, cervical stricture location and increasing stricture length have been reported to be associated with lower clinical success rates [95] [96] [97]. Because most studies do not take into account patient characteristics when reporting study outcomes, their specific impact remains unclear.

The optimal stent duration for the management of RBES patients has not been formally tested. It is recommended that stents remain in place for at least 6–8 weeks, but not longer than 10–12 weeks after stent placement. It is believed that this stent duration provides sufficient time to induce stricture remodeling and at the same time prevents stent embedment. One retrospective study investigated the influence of stent duration on the safety of stent removal but found no such association [98]. Stent design was the only independent predictor of complicated stent removal. Adverse events were more common with PCSEMSs (odds ratio [OR] 8.83; 95 %CI 3.29–23.70) and SEPSs (OR 4.71; 95 %CI 1.39–15.97) when compared with FCSEMSs. The use of BDSs has been suggested to obviate stent removal, but compelling evidence for BDSs over other stent types is lacking [96] [99].

Different methods for endoscopic removal of an embedded PCSEMS have been described [100] [101] [102] [103] [104] [105] [106]. Most studies have reported on the use of the stent-in-stent technique, which relies on the placement of an additional FCSEMS fully overlapping the location of the embedded PCSEMS. To induce pressure necrosis, the stent diameter of the additional FCSEMS should be at least that of the embedded PCSEMS. In > 90 % of patients, both SEMSs can be safely removed 10–14 days after placement of the additional FCSEMS [100] [101]. If removal of the embedded PCSEMS is unsuccessful, the stent-in-stent technique can be reattempted.

4.1.2 Combined approach

Concurrent endoscopic incisional therapy, corticosteroid injection, and mitomycin-C application are reported to enhance treatment outcomes of endoscopic dilation therapy. Data on the use of these endoscopic interventions in combination with esophageal stent placement are scarce. Only one study has reported on the outcomes of corticosteroid injection in combination with FCSEMS placement but no clear benefit was found [107].

4.1.3 Options after stent failure

In patients with recurrent dysphagia after stent placement, repeated esophageal stent placement may be considered, but has not been shown to have significant incremental benefit [108] [109]. When repeat esophageal stent placement does not lead to satisfactory results, alternative treatment strategies should be considered. Surgical treatment represents a valid option in selected patients, depending on the stricture location and patient performance status. Furthermore, self-dilation is safe and effective in the majority of patients [110] [111] [112]. Treatment success with self-dilation relies on patient compliance, restricting its use to self-motivated patients and poor surgical candidates.

4.2 Leaks, fistulas, and perforations

Esophageal stents are increasingly used in the management of esophageal perforations [113]. Based on three systematic reviews on the use of PCSEMSs, FCSEMSs, and SEPSs in anastomotic leaks and perforations, the clinical success rate of esophageal stent placement is 81 %–87 %, with no difference among the stent types [114] [115] [116]. Even though the clinical success rates are comparable, SEMSs are reported to perform better than SEPSs in leaks and perforations, with higher technical success (95 % vs. 91 %; P  = 0.03), and reduced risk of migration (16 % vs. 24 %; P = 0.001) and stent repositioning (3 % vs. 11 %; P < 0.001), as well as a reduced risk of perforation when considering anastomotic leaks only (0 % vs. 2 %; P = 0.01) [116]. Data on the use of BDSs in these patients are restricted to a few small retrospective studies (Table  5s) [117] [118] [119].

To identify patients who may benefit from esophageal stent placement, van Halsema et al. developed a clinical prediction rule based on four clinical parameters: etiology (leak, fistula, perforation), location, orifice size, and C-reactive protein (CRP) level [120]. In the validation cohort, the sensitivity and specificity for a 70 % predicted probability of clinical success were 33 % and 89 %, respectively. Multivariable logistic regression showed fistulas and orifice size of > 2 cm to be associated with a lower rate of clinical success. The observed difference between anastomotic leaks and fistulas emphasizes that leaks, fistulas, and perforations are different entities and may require an individual approach. For instance, in fistula patients, SEMS placement is usually performed in combination with other therapies and a longer stent duration may be needed in anastomotic leaks compared with perforations [121] [122]. Nevertheless, the current literature provides insufficient data to formulate separate recommendations.

No study has investigated the optimal stent duration. Stents are usually removed 6–8 weeks after insertion and repeated stent placement is needed in 11 % of patients [114] [115] [116]. In patients who are endoscopically treated for benign esophageal perforations, early diagnosis (< 24 hours) has been shown to be associated with a lower need for re-intervention and intensive care admission, and a shorter hospital stay [123].

Recently, the outcomes of SEMS placement have been compared with endoscopic vacuum therapy for the treatment of post-surgical leaks [124]. The use of endoscopic vacuum therapy was associated with a higher leak closure rate, more endoscopic device changes, shorter duration of treatment, and lower in-hospital mortality. Because the management of these patients may be challenging and often requires a multimodality approach, esophageal stent placement may still be considered in addition to other endoscopic techniques to optimize treatment outcomes [119].

4.2.1 Safety

Stent migration is the most common stent-related adverse event and tends to be higher when FCSEMSs (26 %) and SEPSs are used (31 %) compared with PCSEMSs (12 %) [114]. The use of large-diameter SEMSs has been suggested to reduce the risk of stent migration in anastomotic leaks [119]. Furthermore, suturing of FCSEMSs may render migration rates similar to those of PCSEMSs, without the difficulties associated with the removal of PCSEMSs and with a lower risk of adverse events [125]. Other stent-related adverse events include the development of a stricture, stent erosion, perforation, and bleeding [114] [115] [116]. Repeated endoscopic intervention is needed in 17 %–25 % of patients and 7 %–13 % require surgical intervention [114] [115] [116].

4.3 Acute variceal bleeding

Esophageal stent placement for acute variceal bleeding has mainly been investigated in small retrospective studies using a dedicated stent design (SX-ELLA stent DANIS) for the treatment of refractory bleeding (Table 6s). Stent duration is reported to range from 1–30 days [126]. Pooled data analysis shows that SEMS placement leads to control of bleeding in > 80 % of patients, without severe stent-related adverse events [126] [127]. In 21 % of patients, bleeding reoccurs within 6 weeks after SEMS placement [128]. Only one RCT has performed a direct comparison of SEMSs and balloon tamponade [129]. In this study of 28 patients, SEMS placement led to a higher rate of control of bleeding during the first 15 days (85 % vs. 47 %; P = 0.04) and a lower rate of adverse events (31 % vs. 73 %; P = 0.02).

Despite its effectiveness, the 30-day mortality rate after SEMS placement may be as high as 36 %, also reflecting the severity of the underlying condition [127]. Accordingly, SEMSs have been proposed as a bridge to transjugular intrahepatic portosystemic shunting (TIPS) or liver transplantation.

Disclaimer

The legal disclaimer for ESGE guidelines [130] applies to this Guideline.

Competing interests

T.H. Baron has been a speaker and consultant for Boston Scientific and Cook Endoscopy (2014 to present). A. Repici has been on the advisory board and provided consultancy to Boston Scientific and Medtronic, and provided consultancy to ERBE (all 2017 to present). P.D. Siersema receives research support from Pentax, The eNose company, Norgine, Motus GI, and MicroTech; he is Editor-in-Chief of Endoscopy. M.C.W. Spaander has received research support from Boston Scientific (2013 to present). J.E. van Hooft has provided consultancy to Boston Scientific (2014 to 2017) and Olympus (2021), has received lecture fees from Medtronics (2014, 2015, and 2019) and Cook Medical (2019); her department has received research grants from Cook Medical (2014 to 2019) and Abbott (2014 to 2017). D. Albers, D. Blero, M. Conio, L. Czakó, A. de Ceglie, S. Everett, L. Fuccio, J.-C. Garcia-Pagán, A. Ginès, M. Jovani, E. Rodrigues-Pinto, R.D. van der Bogt declare that they have no conflict of interest.

Acknowledgments

The authors are grateful to Dr. Cesare Hassan, Nuovo Regina Margherita Hospital, Rome, Italy, and Professor Konstantinos Triantafyllou, National and Kapodistrian University of Athens, Athens, Greece, for their review of this manuscript; and for comments received from Dr. David Karsenti on behalf of the French Society of Digestive Endoscopy (SFED), Dr. Tony C. K. Tham on behalf of the Irish Society of Gastroenterology (ISG), and Dr. Endrit Shahini, University of Bari Aldo Moro, Bari, Italy.

• References

• 1 Bray F, Ferlay J, Soerjomataram I. et al. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin 2018; 68: 394-424
• 2 Arnold M, Ferlay J, van Berge Henegouwen MI. et al. Global burden of oesophageal and gastric cancer by histology and subsite in 2018. Gut 2020; 69: 1564-1571
• 3 International Agency for Research on Cancer. Global Cancer Observatory: Cancer Today; 2020. https://gco.iarc.fr/today/online-analysis-table (accessed: 25 March 2021)
• 4 Daly JM, Fry WA, Little AG. et al. Esophageal cancer: results of an American College of Surgeons patient care evaluation study. J Am Coll Surg 2000; 190: 562-572 discussion 572-563
• 5 Enzinger PC, Mayer RJ. Esophageal cancer. NEJM 2003; 349: 2241-2252
• 6 Dai Y, Li C, Xie Y. et al. Interventions for dysphagia in oesophageal cancer. Cochrane Database Syst Rev 2014; CD005048
• 7 Spaander MC, Baron TH, Siersema PD. et al. Esophageal stenting for benign and malignant disease: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy 2016; 48: 939-948
• 8 Alderson D, Wright PD. Laser recanalization versus endoscopic intubation in the palliation of malignant dysphagia. Br J Surg 1990; 77: 1151-1153
• 9 Carter R, Smith JS, Anderson JR. Laser recanalization versus endoscopic intubation in the palliation of malignant dysphagia: a randomized prospective study. Br J Surg 1992; 79: 1167-1170
• 10 Fuchs KH, Freys SM, Schaube H. et al. Randomized comparison of endoscopic palliation of malignant esophageal stenoses. Surg Endosc 1991; 5: 63-67
• 11 Adam A, Ellul J, Watkinson AF. et al. Palliation of inoperable esophageal carcinoma: a prospective randomized trial of laser therapy and stent placement. Radiology 1997; 202: 344-348
• 12 Aoki T, Osaka Y, Takagi Y. et al. Comparative study of self-expandable metallic stent and bypass surgery for inoperable esophageal cancer. Dis Esophagus 2001; 14: 208-211
• 13 Dallal HJ, Smith GD, Grieve DC. et al. A randomized trial of thermal ablative therapy versus expandable metal stents in the palliative treatment of patients with esophageal carcinoma. Gastrointest Endosc 2001; 54: 549-557
• 14 Bergquist H, Wenger U, Johnsson E. et al. Stent insertion or endoluminal brachytherapy as palliation of patients with advanced cancer of the esophagus and gastroesophageal junction. Results of a randomized, controlled clinical trial. Dis Esophagus 2005; 18: 131-139
• 15 Homs MY, Steyerberg EW, Eijkenboom WM. et al. Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia from oesophageal cancer: multicentre randomised trial. Lancet 2004; 364: 1497-1504
• 16 Fuccio L, Mandolesi D, Farioli A. et al. Brachytherapy for the palliation of dysphagia owing to esophageal cancer: A systematic review and meta-analysis of prospective studies. Radiother Oncol 2017; 122: 332-339
• 17 Fuccio L, Guido A, Hassan C. et al. Underuse of brachytherapy for the treatment of dysphagia owing to esophageal cancer. An Italian survey. Dig Liver Dis 2016; 48: 1233-1236
• 18 Jeene PM, Vermeulen BD, Rozema T. et al. Short-course external beam radiotherapy versus brachytherapy for palliation of dysphagia in esophageal cancer: a matched comparison of two prospective trials. J Thorac Oncol 2020; 15: 1361-1368
• 19 Penniment MG, De Ieso PB, Harvey JA. et al. Palliative chemoradiotherapy versus radiotherapy alone for dysphagia in advanced oesophageal cancer: a multicentre randomised controlled trial (TROG 03.01). Lancet Gastroenterol Hepatol 2018; 3: 114-124
• 20 Driver RJ, Handforth C, Radhakrishna G. et al. The Glasgow prognostic score at the time of palliative esophageal stent insertion is a predictive factor of 30-day mortality and overall survival. J Clin Gastroenterol 2018; 52: 223-228
• 21 Steyerberg EW, Homs MY, Stokvis A. et al. Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer: a prognostic model to guide treatment selection. Gastrointest Endosc 2005; 62: 333-340
• 22 Park JH, Woodley N, McMillan DC. et al. Palliative stenting for oesophagogastric cancer: tumour and host factors and prognosis. BMJ Support Palliat Care 2019; 9: 332-339
• 23 Bergquist H, Johnsson A, Hammerlid E. et al. Factors predicting survival in patients with advanced oesophageal cancer: a prospective multicentre evaluation. Aliment Pharmacol Ther 2008; 27: 385-395
• 24 Rosenblatt E, Jones G, Sur RK. et al. Adding external beam to intra-luminal brachytherapy improves palliation in obstructive squamous cell oesophageal cancer: a prospective multi-centre randomized trial of the International Atomic Energy Agency. Radiother Oncol 2010; 97: 488-494
• 25 Wang C, Wei H, Li Y. Comparison of fully-covered vs partially covered self-expanding metallic stents for palliative treatment of inoperable esophageal malignancy: a systematic review and meta-analysis. BMC Cancer 2020; 20: 73
• 26 Persson J, Smedh U, Johnsson A. et al. Fully covered stents are similar to semi-covered stents with regard to migration in palliative treatment of malignant strictures of the esophagus and gastric cardia: results of a randomized controlled trial. Surg Endosc 2017; 31: 4025-4033
• 27 Pandit S, Samant H, Morris J. et al. Efficacy and safety of standard and anti-reflux self-expanding metal stent: A systematic review and meta-analysis of randomized controlled trials. World J Gastrointest Endosc 2019; 11: 271-280
• 28 Didden P, Reijm AN, Erler NS. et al. Fully vs. partially covered selfexpandable metal stent for palliation of malignant esophageal strictures: a randomized trial (the COPAC study). Endoscopy 2018; 50: 961-971
• 29 Reijm AN, Didden P, Schelling SJC. et al. Self-expandable metal stent placement for malignant esophageal strictures - changes in clinical outcomes over time. Endoscopy 2019; 51: 18-29
• 30 Hurtgen M, Herber SCA. Treatment of malignant tracheoesophageal fistula. Thorac Surg Clin 2014; 24: 117-127
• 31 Rodriguez AN, Diaz-Jimenez JP. Malignant respiratory-digestive fistulas. Curr Opin Pulm Med 2010; 16: 329-333
• 32 Spigel DR, Hainsworth JD, Yardley DA. et al. Tracheoesophageal fistula formation in patients with lung cancer treated with chemoradiation and bevacizumab. J Clin Oncol 2010; 28: 43-48
• 33 Gore E, Currey A, Choong N. Tracheoesophageal fistula associated with bevacizumab 21 months after completion of radiation therapy. J Thorac Oncol 2009; 4: 1590-1591
• 34 Didden P, Spaander MC, Kuipers EJ. et al. Safety of stent placement in recurrent or persistent esophageal cancer after definitive chemoradiotherapy: a case series. Gastrointest Endosc 2012; 76: 426-430
• 35 Balazs A, Kupcsulik PK, Galambos Z. Esophagorespiratory fistulas of tumorous origin. Non-operative management of 264 cases in a 20-year period. Eur J Cardiothorac Surg 2008; 34: 1103-1107
• 36 Sarper A, Oz N, Cihangir C. et al. The efficacy of self-expanding metal stents for palliation of malignant esophageal strictures and fistulas. Eur J Cardiothorac Surg 2003; 23: 794-798
• 37 Chen YH, Li SH, Chiu YC. et al. Comparative study of esophageal stent and feeding gastrostomy/jejunostomy for tracheoesophageal fistula caused by esophageal squamous cell carcinoma. PLoS One 2012; 7: e42766
• 38 Hu Y, Zhao YF, Chen LQ. et al. Comparative study of different treatments for malignant tracheoesophageal/bronchoesophageal fistulae. Dis Esophagus 2009; 22: 526-531
• 39 May A, Ell C. Palliative treatment of malignant esophagorespiratory fistulas with Gianturco-Z stents. A prospective clinical trial and review of the literature on covered metal stents. Am J Gastroenterol 1998; 93: 532-535
• 40 Dumonceau JM, Cremer M, Lalmand B. et al. Esophageal fistula sealing: choice of stent, practical management, and cost. Gastrointest Endosc 1999; 49: 70-78
• 41 Shin JH, Song HY, Ko GY. et al. Esophagorespiratory fistula: long-term results of palliative treatment with covered expandable metallic stents in 61 patients. Radiology 2004; 232: 252-259
• 42 Kim PH, Kim KY, Song HY. et al. Self-expandable metal stent use to palliate malignant esophagorespiratory fistulas in 88 patients. J Vasc Interv Radiol 2018; 29: 320-327
• 43 Ribeiro MSI, da Costa Martins B, Simas de Lima M. et al. Self-expandable metal stent for malignant esophagorespiratory fistula: predictive factors associated with clinical failure. Gastrointest Endosc 2018; 87: 390-396
• 44 Wlodarczyk JR, Kuzdzal J. Safety and efficacy of airway stenting in patients with malignant oesophago-airway fistula. J Thorac Dis 2018; 10: 2731-2739
• 45 Freitag L, Tekolf E, Steveling H. et al. Management of malignant esophagotracheal fistulas with airway stenting and double stenting. Chest 1996; 110: 1155-1160
• 46 Colt HG, Meric B, Dumon JF. Double stents for carcinoma of the esophagus invading the tracheo-bronchial tree. Gastrointest Endosc 1992; 38: 485-489
• 47 Huang PM, Lee JM. Are single or dual luminal covered expandable metallic stents suitable for esophageal squamous cell carcinoma with esophago-airway fistula?. Surg Endosc 2017; 31: 1148-1155
• 48 Sjoquist KM, Burmeister BH, Smithers BM. et al. Survival after neoadjuvant chemotherapy or chemoradiotherapy for resectable oesophageal carcinoma: an updated meta-analysis. Lancet Oncol 2011; 12: 681-692
• 49 Walsh TN. Oesophageal cancer: who needs neoadjuvant therapy?. Lancet Oncol 2011; 12: 615-616
• 50 Anandavadivelan P, Lagergren P. Cachexia in patients with oesophageal cancer. Nat Rev Clin Oncol 2016; 13: 185-198
• 51 Kazemi-Bajestani SM, Mazurak VC, Baracos V. Computed tomography-defined muscle and fat wasting are associated with cancer clinical outcomes. Semin Cell Dev Biol 2016; 54: 2-10
• 52 Hebuterne X, Lemarie E, Michallet M. et al. Prevalence of malnutrition and current use of nutrition support in patients with cancer. JPEN J Parenter Enteral Nutr 2014; 38: 196-204
• 53 Arends J, Bachmann P, Baracos V. et al. ESPEN guidelines on nutrition in cancer patients. Clin Nutr 2017; 36: 11-48
• 54 Weimann A, Braga M, Harsanyi L. et al. ESPEN Guidelines on Enteral Nutrition: Surgery including organ transplantation. Clin Nutr 2006; 25: 224-244
• 55 Senesse P, Assenat E, Schneider S. et al. Nutritional support during oncologic treatment of patients with gastrointestinal cancer: who could benefit?. Cancer Treat Rev 2008; 34: 568-575
• 56 Nagaraja V, Cox MR, Eslick GD. Safety and efficacy of esophageal stents preceding or during neoadjuvant chemotherapy for esophageal cancer: a systematic review and meta-analysis. J Gastrointest Oncol 2014; 5: 119-126
• 57 Siddiqui AA, Sarkar A, Beltz S. et al. Placement of fully covered self-expandable metal stents in patients with locally advanced esophageal cancer before neoadjuvant therapy. Gastrointest Endosc 2012; 76: 44-51
• 58 van den Berg MW, Walter D, de Vries EM. et al. Biodegradable stent placement before neoadjuvant chemoradiotherapy as a bridge to surgery in patients with locally advanced esophageal cancer. Gastrointest Endosc 2014; 80: 908-913
• 59 Mariette C, Gronnier C, Duhamel A. et al. Self-expanding covered metallic stent as a bridge to surgery in esophageal cancer: impact on oncologic outcomes. J Am Coll Surg 2015; 220: 287-296
• 60 Ahmed O, Bolger JC, O'Neill B. et al. Use of esophageal stents to relieve dysphagia during neoadjuvant therapy prior to esophageal resection: a systematic review. Dis Esophagus 2020; 33: doz090 DOI: 10.1093/dote/doz090.
• 61 Helminen O, Kauppila JH, Kyto V. et al. Preoperative esophageal stenting and short-term outcomes of surgery for esophageal cancer in a population-based study from Finland and Sweden. Dis Esophagus 2019; 32: doz005 DOI: 10.1093/dote/doz005.
• 62 Rodrigues-Pinto E, Ferreira-Silva J, Sousa-Pinto B. et al. Self-expandable metal stents in esophageal cancer before preoperative neoadjuvant therapy: efficacy, safety, and long-term outcomes. Surg Endosc 2020; DOI: 10.1007/s00464-020-08002-8.
• 63 Jarvinen T, Ilonen I, Ylikoski E. et al. Preoperative stenting in oesophageal cancer has no effect on survival: a propensity-matched case-control study. Eur J Cardiothorac Surg 2017; 52: 385-391
• 64 Loser C, Aschl G, Hebuterne X. et al. ESPEN guidelines on artificial enteral nutrition--percutaneous endoscopic gastrostomy (PEG). Clin Nutr 2005; 24: 848-861
• 65 Toussaint E, van Gossum A, Ballarin A. et al. Enteral access in adults. Clin Nutr 2015; 34: 350-358
• 66 Arvanitakis M, Gkolfakis P, Despott EJ. et al. Endoscopic management of enteral tubes in adult patients – Part 1: Definitions and indications. European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2021; 53: 81-92
• 67 Bergquist H, Johnsson E, Nyman J. et al. Combined stent insertion and single high-dose brachytherapy in patients with advanced esophageal cancer -- results of a prospective safety study. Dis Esophagus 2012; 25: 410-415
• 68 Hirdes MM, van Hooft JE, Wijrdeman HK. et al. Combination of biodegradable stent placement and single-dose brachytherapy is associated with an unacceptably high complication rate in the treatment of dysphagia from esophageal cancer. Gastrointest Endosc 2012; 76: 267-274
• 69 Song HY, Lee DH, Seo TS. et al. Retrievable covered nitinol stents: experiences in 108 patients with malignant esophageal strictures. J Vasc Interv Radiol 2002; 13: 285-293
• 70 Tinusz B, Soos A, Hegyi P. et al. Efficacy and safety of stenting and additional oncological treatment versus stenting alone in unresectable esophageal cancer: A meta-analysis and systematic review. Radiother Oncol 2020; 147: 169-177
• 71 Nishimura Y, Nagata K, Katano S. et al. Severe complications in advanced esophageal cancer treated with radiotherapy after intubation of esophageal stents: a questionnaire survey of the Japanese Society for Esophageal Diseases. Int J Radiat Oncol Biol Phys 2003; 56: 1327-1332
• 72 Yang ZM, Geng HT, Wu H. Radioactive stent for malignant esophageal obstruction: a meta-analysis of randomized controlled trials. J Laparoendosc Adv Surg Tech A 2020; DOI: 10.1089/lap.2020.0666.
• 73 van der Bogt RD, Vermeulen BD, Reijm AN. et al. Palliation of dysphagia. Best Pract Res Clin Gastroenterol 2018; 36–37: 97-103
• 74 Iwasaki H, Mizushima T, Suzuki Y. et al. Factors that affect stent-related complications in patients with malignant obstruction of the esophagus or gastric cardia. Gut Liver 2017; 11: 47-54
• 75 Siersema PD, Hop WC, Dees J. et al. Coated self-expanding metal stents versus latex prostheses for esophagogastric cancer with special reference to prior radiation and chemotherapy: a controlled, prospective study. Gastrointest Endosc 1998; 47: 113-120
• 76 Medeiros VS, Martins BC, Lenz L. et al. Adverse events of self-expandable esophageal metallic stents in patients with long-term survival from advanced malignant disease. Gastrointest Endosc 2017; 86: 299-306
• 77 Sgourakis G, Gockel I, Radtke A. et al. The use of self-expanding stents in esophageal and gastroesophageal junction cancer palliation: a meta-analysis and meta-regression analysis of outcomes. Dig Dis Sci 2010; 55: 3018-3030
• 78 Homs MY, Hansen BE, van Blankenstein M. et al. Prior radiation and/or chemotherapy has no effect on the outcome of metal stent placement for oesophagogastric carcinoma. Eur J Gastroenterol Hepatol 2004; 16: 163-170
• 79 Sumiyoshi T, Gotoda T, Muro K. et al. Morbidity and mortality after self-expandable metallic stent placement in patients with progressive or recurrent esophageal cancer after chemoradiotherapy. Gastrointest Endosc 2003; 57: 882-885
• 80 Fuccio L, Scagliarini M, Frazzoni L. et al. Development of a prediction model of adverse events after stent placement for esophageal cancer. Gastrointest Endosc 2016; 83: 746-752
• 81 Iraha Y, Murayama S, Toita T. et al. Self-expandable metallic stent placement for patients with inoperable esophageal carcinoma: investigation of the influence of prior radiotherapy and chemotherapy. Radiat Med 2006; 24: 247-252
• 82 Lecleire S, Di Fiore F, Ben-Soussan E. et al. Prior chemoradiotherapy is associated with a higher life-threatening complication rate after palliative insertion of metal stents in patients with oesophageal cancer. Aliment Pharmacol Ther 2006; 23: 1693-1702
• 83 Qiu G, Tao Y, Du X. et al. The impact of prior radiotherapy on fatal complications after self-expandable metallic stents (SEMS) for malignant dysphagia due to esophageal carcinoma. Dis Esophagus 2013; 26: 175-181
• 84 Muto M, Ohtsu A, Miyata Y. et al. Self-expandable metallic stents for patients with recurrent esophageal carcinoma after failure of primary chemoradiotherapy. Jpn J Clin Oncol 2001; 31: 270-274
• 85 Park JY, Shin JH, Song HY. et al. Airway complications after covered stent placement for malignant esophageal stricture: special reference to radiation therapy. AJR Am J Roentgenol 2012; 198: 453-459
• 86 Kochman ML, McClave SA, Boyce HW. The refractory and the recurrent esophageal stricture: a definition. Gastrointest Endosc 2005; 62: 474-475
• 87 Fuccio L, Hassan C, Frazzoni L. et al. Clinical outcomes following stent placement in refractory benign esophageal stricture: a systematic review and meta-analysis. Endoscopy 2016; 48: 141-148
• 88 Law R, Prabhu A, Fujii-Lau L. et al. Stent migration following endoscopic suture fixation of esophageal self-expandable metal stents: a systematic review and meta-analysis. Surg Endosc 2018; 32: 675-681
• 89 Bick BL, Imperiale TF, Johnson CS. et al. Endoscopic suturing of esophageal fully covered self-expanding metal stents reduces rates of stent migration. Gastrointest Endosc 2017; 86: 1015-1021
• 90 Bazerbachi F, Heffley JD, Abu Dayyeh BK. et al. Safety and efficacy of coaxial lumen-apposing metal stents in the management of refractory gastrointestinal luminal strictures: a multicenter study. Endosc Int Open 2017; 5: E861-E867
• 91 Irani S, Jalaj S, Ross A. et al. Use of a lumen-apposing metal stent to treat GI strictures (with videos). Gastrointest Endosc 2017; 85: 1285-1289
• 92 Nogales O, Clemente A, Caballero-Marcos A. et al. Endoscopically placed stents: a useful alternative for the management of refractory benign cervical esophageal stenosis. Rev Esp Enferm Dig 2017; 109: 510-515
• 93 Yang D, Nieto JM, Siddiqui A. et al. Lumen-apposing covered self-expandable metal stents for short benign gastrointestinal strictures: a multicenter study. Endoscopy 2017; 49: 327-333
• 94 Larson B, Adler DG. Lumen-apposing metal stents for gastrointestinal luminal strictures: current use and future directions. Ann Gastroenterol 2019; 32: 141-146
• 95 Repici A, Hassan C, Sharma P. et al. Systematic review: the role of self-expanding plastic stents for benign oesophageal strictures. Aliment Pharmacol Ther 2010; 31: 1268-1275
• 96 Canena JM, Liberato MJ, Rio-Tinto RA. et al. A comparison of the temporary placement of 3 different self-expanding stents for the treatment of refractory benign esophageal strictures: a prospective multicentre study. BMC Gastroenterol 2012; 12: 70
• 97 Kappelle WF, van Hooft JE, Spaander MCW. et al. Treatment of refractory post-esophagectomy anastomotic esophageal strictures using temporary fully covered esophageal metal stenting compared to repeated bougie dilation: results of a randomized controlled trial. Endosc Int Open 2019; 7: E178-E185
• 98 van Halsema EE, Wong Kee Song LM, Baron TH. et al. Safety of endoscopic removal of self-expandable stents after treatment of benign esophageal diseases. Gastrointest Endosc 2013; 77: 18-28
• 99 van Boeckel PG, Vleggaar FP, Siersema PD. A comparison of temporary self-expanding plastic and biodegradable stents for refractory benign esophageal strictures. Clin Gastroenterol Hepatol 2011; 9: 653-659
• 100 Hirdes MM, Siersema PD, Houben MH. et al. Stent-in-stent technique for removal of embedded esophageal self-expanding metal stents. Am J Gastroenterol 2011; 106: 286-293
• 101 DaVee T, Irani S, Leggett CL. et al. Stent-in-stent technique for removal of embedded partially covered self-expanding metal stents. Surg Endosc 2016; 30: 2332-2341
• 102 Peng GY, Kang XF, Lu X. et al. Plastic tube-assisted gastroscopic removal of embedded esophageal metal stents: a case report. World J Gastroenterol 2013; 19: 6505-6508
• 103 Liu XQ, Zhou M, Shi WX. et al. Successful endoscopic removal of three embedded esophageal self-expanding metal stents. World J Gastrointest Endosc 2017; 9: 494-498
• 104 Chandnani M, Cohen J, Berzin TM. Combined approach of cryoablation and stent-in-stent technique for removal of an embedded esophageal stent. Case Rep Gastrointest Med 2018; 2018: 8619252
• 105 Hill C, Khalil BK, Barola S. et al. Inversion technique for the removal of partially covered self-expandable metallic stents. Obes Surg 2018; 28: 161-168
• 106 Dumonceau JM, Deviere J. Treatment of Boerhaave's syndrome using the ultraflex self-expandable stent. Gastrointest Endosc 2000; 51: 773-774
• 107 Wilson JL, Louie BE, Farivar AS. et al. Fully covered self-expanding metal stents are effective for benign esophagogastric disruptions and strictures. J Gastrointest Surg 2013; 17: 2045-2050
• 108 Hirdes MM, Siersema PD, van Boeckel PG. et al. Single and sequential biodegradable stent placement for refractory benign esophageal strictures: a prospective follow-up study. Endoscopy 2012; 44: 649-654
• 109 Repici A, Small AJ, Mendelson A. et al. Natural history and management of refractory benign esophageal strictures. Gastrointest Endosc 2016; 84: 222-228
• 110 Qin Y, Sunjaya DB, Myburgh S. et al. Outcomes of oesophageal self-dilation for patients with refractory benign oesophageal strictures. Aliment Pharmacol Ther 2018; 48: 87-94
• 111 Dzeletovic I, Fleischer DE. Self-dilation for resistant, benign esophageal strictures. Am J Gastroenterol 2010; 105: 2142-2143
• 112 Dzeletovic I, Fleischer DE, Crowell MD. et al. Self-dilation as a treatment for resistant, benign esophageal strictures. Dig Dis Sci 2013; 58: 3218-3223
• 113 Thornblade LW, Cheng AM, Wood DE. et al. A nationwide rise in the use of stents for benign esophageal perforation. Ann Thorac Surg 2017; 104: 227-233
• 114 van Boeckel PG, Sijbring A, Vleggaar FP. et al. Systematic review: temporary stent placement for benign rupture or anastomotic leak of the oesophagus. Aliment Pharmacol Ther 2011; 33: 1292-1301
• 115 Dasari BV, Neely D, Kennedy A. et al. The role of esophageal stents in the management of esophageal anastomotic leaks and benign esophageal perforations. Ann Surg 2014; 259: 852-860
• 116 Kamarajah SK, Bundred J, Spence G. et al. Critical appraisal of the impact of oesophageal stents in the management of oesophageal anastomotic leaks and benign oesophageal perforations: an updated systematic review. World J Surg 2020; 44: 1173-1189
• 117 Kones O, Oran E. Self-expanding biodegradable stents for postoperative upper gastrointestinal issues. JSLS 2018; 22: e2018.00011
• 118 Cerna M, Kocher M, Valek V. et al. Covered biodegradable stent: new therapeutic option for the management of esophageal perforation or anastomotic leak. Cardiovasc Intervent Radiol 2011; 34: 1267-1271
• 119 Rodrigues-Pinto E, Pereira P, Sousa-Pinto B. et al. Retrospective multicenter study on endoscopic treatment of upper GI postsurgical leaks. Gastrointest Endosc 2020; DOI: 10.1016/j.gie.2020.10.015.
• 120 van Halsema EE, Kappelle WFW, Weusten B. et al. Stent placement for benign esophageal leaks, perforations, and fistulae: a clinical prediction rule for successful leakage control. Endoscopy 2018; 50: 98-108
• 121 Debourdeau A, Gonzalez JM, Dutau H. et al. Endoscopic treatment of nonmalignant tracheoesophageal and bronchoesophageal fistula: results and prognostic factors for its success. Surg Endosc 2019; 33: 549-556
• 122 Huh CW, Kim JS, Choi HH. et al. Treatment of benign perforations and leaks of the esophagus: factors associated with success after stent placement. Surg Endosc 2018; 32: 3646-3651
• 123 Vermeulen BD, van der Leeden B, Ali JT. et al. Early diagnosis is associated with improved clinical outcomes in benign esophageal perforation: an individual patient data meta-analysis. Surg Endosc 2020; DOI: 10.1007/s00464-020-07806-y.
• 124 Scognamiglio P, Reeh M, Karstens K. et al. Endoscopic vacuum therapy versus stenting for postoperative esophago-enteric anastomotic leakage: systematic review and meta-analysis. Endoscopy 2020; 52: 632-642
• 125 Ngamruengphong S, Sharaiha R, Sethi A. et al. Fully-covered metal stents with endoscopic suturing vs. partially-covered metal stents for benign upper gastrointestinal diseases: a comparative study. . Endosc Int Open 2018; 6: E217-E223
• 126 Mohan BP, Chandan S, Khan SR. et al. Self-expanding metal stents versus TIPS in treatment of refractory bleeding esophageal varices: a systematic review and meta-analysis. Endosc Int Open 2020; 8: E291-E300
• 127 Marot A, Trepo E, Doerig C. et al. Systematic review with meta-analysis: self-expanding metal stents in patients with cirrhosis and severe or refractory oesophageal variceal bleeding. Aliment Pharmacol Ther 2015; 42: 1250-1260
• 128 Rodrigues SG, Cardenas A, Escorsell A. et al. Balloon tamponade and esophageal stenting for esophageal variceal bleeding in cirrhosis: a systematic review and meta-analysis. Semin Liver Dis 2019; 39: 178-194
• 129 Escorsell A, Pavel O, Cardenas A. et al. Esophageal balloon tamponade versus esophageal stent in controlling acute refractory variceal bleeding: A multicenter randomized, controlled trial. Hepatology 2016; 63: 1957-1967
• 130 Hassan C, Ponchon T, Bisschops R. et al. European Society of Gastrointestinal Endoscopy (ESGE) Publications Policy – Update 2020. Endoscopy 2020; 52: 123-126

Publication History

Article published online:
30 April 2021