Esophageal Stenting

ABSTRACT

Malignant obstruction of the esophagus is a debilitating condition, with dysphagia as its main symptom. Many patients present with advanced disease and palliative treatment is the only possibility. Since their widespread introduction 10 years ago, self-expanding metal stents have become accepted as an extremely effective method of palliating malignant dysphagia. Early reports suggesting very low complications have been superseded by results from randomized trials. It is now evident that the complication rate is significant and the need for reintervention can be as high as 50%. Modifications in stent design should reduce this reintervention rate. There are a large number of stent designs now available and it is essential that the interventional radiologist understand the particular strengths and weaknesses of each design, so that the correct choice of stent can be made for a particular patient. The most recent designs include antireflux stents and removable stents. Both represent significant advances and should reduce stent-related complications.

KEYWORDS

Esophageal stents - metallic stents - esophageal cancer

REFERENCES

• 1 Parkin D M, Laara E, Muir C S. Estimates of the worldwide frequency of sixteen major cancers in 1980.  Int J Cancer. 1988;  41 184-197
• 2 CRC (Cancer Research Campaign) .Factsheet 1.1 Incidence-UK. London; Cancer Research Campaign 1998
• 3 CRC (Cancer Research Campaign) .Cancer Stats Mortality-UK. London; Cancer Research Campaign 1999
• 4 Sihvo E I, Salminen J T, Ramo O J, Salo J A. The epidemiology of oesophageal adenocarcinoma: has cancer of the gastric cardia an influence on the rising incidence of oesophageal adenocarcinoma?.  Scand J Gastroenterol. 2000;  35 1082-1086
• 5 Stein H J, Feith M, Siewert J R. Cancer of the esophago-gastric junction.  Surg Oncol. 2000;  9 35-41
• 6 Bancewicz J. Palliation in oesophageal neoplasia.  Ann R Coll Surg Engl. 1999;  81 382-386
• 7 Tytgat G NJ. Endoscopic therapy of oesophageal cancer: possibilities and limitations.  Endoscopy. 1990;  22 263-267
• 8 Tan D S, Mason R C, Adam A. Minimally invasive therapy for advanced oesophageal malignancy.  Clin Radiol  1996;  51 828-836
• 9 Kok T C. Chemotherapy in oesophageal cancer.  Cancer Treat Rev. 1997;  23 65-85
• 10 Spencer G M, Thorpe S M, Sargeant I R et al.. Laser and brachytherapy in the palliation of adenocarcinoma of the oesophagus and cardia.  Gut. 1996;  39 726-731
• 11 Cwikiel W, Stridbeck H, Tranberg K G et al.. Malignant esophageal strictures: treatment with a self-expanding Nitinol stent.  Radiology. 1993;  187 661-665
• 12 Nicholson A A, Royston C MS, Wedgewood K, Milkins R, Taylor A D. Palliation of malignant oesophageal perforation and proximal oesophageal malignant dysphagia with covered metal stents.  Clin Radiol. 1995;  50 11-14
• 13 Watkinson A, Ellul J, Entwistle K, Farrugia M, Mason R, Adam A. Plastic-covered metallic endoprostheses in the management of oesophageal perforation in patients with oesophageal carcinoma.  Clin Radiol. 1995;  50 304-309
• 14 Watkinson A, Ellul J, Entwistle K, Mason R, Adam A. Esophageal carcinoma: initial results of palliative treatment with covered self-expanding endoprostheses.  Radiology. 1995;  195 821-827
• 15 Acunas B, Rozanes I, Akpinar S, Tunaci A, Tunaci M, Acunas G. Palliation of malignant esophageal strictures with self-expanding Nitinol stents: drawbacks and complications.  Radiology. 1996;  199 648-652
• 16 Laasch H- U, Nicholson D A, Kay C L, Attwood S, Bancewicz J. The clinical effectiveness of the Gianturco oesophageal stent in malignant oesophageal obstruction.  Clin Radiol. 1998;  53 666-672
• 17 Raijman I, Siddique I, Ajani J, Lynch P. Palliation of malignant dysphagia and fistulae with coated expandable metal stents: experience with 101 patients.  Gastrointest Endosc. 1998;  48 172-179
• 18 Song H Y, Do Y S, Han Y M et al.. Covered expandable esophageal metallic stent tubes: experiences in 119 patients.  Radiology. 1994;  193 689-695
• 19 Bartelsman J F, Bruno M J, Jensema A J, Haringsma J, Reeders J W, Tytgat G N. Palliation of patients with esophagogastric neoplasms by insertion of a covered expandable modified Gianturco-Z endoprosthesis: experiences in 153 patients.  Gastrointest Endosc. 2000;  51 134-138
• 20 Adam A, Ellul J, Watkinson A F et al.. Palliation of inoperable oesophageal carcinoma: a prospective randomized trial of laser therapy and stent placement.  Radiology. 1997;  202 344-348
• 21 De Palma G D, Matteo E, Romano G et al.. Plastic prostheses versus expandable metal stents for palliation of inoperable esophageal thoracic carcinoma: a controlled prospective study.  Gastrointest Endosc. 1996;  43 478-482
• 22 Nicholson D A. Tracheal and oesophageal stenting for carcinoma of the upper oesophagus invading the tracheo-bronchial tree.  Clin Radiol. 1998;  53 760-763
• 23 May A, Selmaier M, Hochberger J et al.. Memory metal stents for palliation of malignant obstruction of the oesophagus and cardia.  Gut. 1995;  37 309-313
• 24 Siersema P D, Hop W C, Dees J, Tilanus H W, Blankenstein M. Coated self-expanding metal stents versus latex prostheses for esophageal cancer with special reference to prior radiation and chemotherapy: a controlled prospective study.  Gastrointest Endosc. 1998;  47 113-120
• 25 Sabharwal T, Hamady M S, Chui S, Atkinson S, Mason R, Adam A. A randomised prospective comparison of the Flamingo Wallstent and Utraflex stent for the palliation of dysphagia associated with lower third oesophageal carcinoma.  Gut. 2003;  52 922-926
• 26 Kinsman K J, DeGregorio B T, Katon R M et al.. Prior radiation and chemotherapy increase the risk of life-threatening complications after insertion of metallic stents for esophagogastric malignancy.  Gastrointest Endosc. 1996;  43 196-203
• 27 Kozarek R, Raltz S, Brugge W R et al.. Prospective multicenter trial of esophageal Z-stent placement for malignant dysphagia and tracheoesophageal fistula.  Gastrointest Endosc. 1996;  44 562-567
• 28 Siersema P D, Tan T G, Sutorius F F, Dees J, van Blankenstein M. Massive hemorrhage caused by a perforating Gianturco-Z stent resulting in an aortoesophageal fistula.  Endoscopy. 1997;  29 416-442
• 29 Kennedy C, Steger A. Fatal haemorrhage in esophageal carcinoma: tumour necrosis of the aorta.  Cardiovasc Intervent Radiol. 2001;  24 443-444
• 30 Köcher M, Dlouhy M, Neoral C et al.. Esophageal stent with antireflux valve for tumours involving the cardia: work in progress.  J Vasc Interv Radiol. 1998;  9 1007-1010
• 31 Dua K S, Kozarek R, Kim J et al.. Self-expanding metal esophageal stent with anti-reflux mechanism.  Gastrointest Endosc. 2001;  53 603-613
• 32 Laasch H U, Marriott A, Wilbraham L, Tunnah S, England R, Martin D. Effectiveness of open versus anti-reflux stents for palliation of distal esophageal carcinoma and prevention of symptomatic gastroesophageal reflux.  Radiology. 2002;  225 359-365
• 33 Ogilvie A L, Dronfield M W, Percuson R, Atkinson M. Palliative intubation of oesophagogastric neoplasms at fibreoptic endoscopy.  Gut. 1982;  23 1060-1067
• 34 Den Hartog Jager F CA, Bartelsman J FWM, Tytgat G N. Palliative treatment of obstructing esophagogastric malignancy by endoscopic positioning of a plastic prosthesis.  Gastroenterology. 1979;  77 1008-1014
• 35 Függer R, Niederle B, Jantsch H, Schiessel R, Schulz F. Endoscopic tube implantation for the palliation of malignant esophageal stenosis.  Endoscopy. 1990;  22 101-104
• 36 Barr H, Krasner N, Raouf A, Walker R J. Prospective randomised trial of laser therapy only and laser therapy followed by endoscopic intubation for the palliation of malignant dysphagia.  Gut. 1990;  31 252-258
• 37 Knyrim K, Wagner H J, Bethge N, Keymling M, Vakil N. A controlled trial of an expansile metal stent for palliation of esophageal obstruction due to inoperable cancer.  N Engl J Med. 1993;  329 1302-1307
• 38 Roseveare C D, Patel P, Simmonds N, Goggin P M, Kimble J, Shepherd H A. Metal stents improve dysphagia, nutrition and survival in malignant oesophageal stenosis: a randomised control comparing modified Gianturco-Z stents with plastic Atkinson tubes.  Eur J Gastroenterol Hepatol. 1998;  10 653-657
• 39 O'Donnell C A, Fullarton G M, Watt E, Lennon K, Murray G D, Moss J G. Randomised clinical trial comparing self-expanding metallic stents with plastic endoprostheses in the palliation of oesophageal cancer.  Br J Surg. 2002;  89 985-992
• 40 Nicholson D A, Haycox A, Kay C L, Rate A, Attwood S, Bancewicz J. The cost effectiveness of oesophageal stenting in malignant disease compared with conventional therapy.  Clin Radiol. 1999;  54 212-215
• 41 Birch J F, White S A, Berry D P, Veitch P S. A cost-benefit comparison of self-expanding metal stents and Atkinson tubes for the palliation of obstructing esophageal tumours.  Dis Esophagus. 1998;  11 172-176
• 42 Costamagna G, Shah S K, Tringali A, Mutignani M, Perri V, Riccioni M E. Prospective evaluation of a new self-expanding plastic stent for inoperable esophageal strictures.  Surg Endosc. 2003;  17 891-895
• 43 Dormann A J, Eisendrath P, Wigginhaus B, Huchzermeyer H, Deviere J. Palliation of oesophageal carcinoma with a new self-expanding plastic stent.  Endoscopy. 2003;  35 207-211
• 44 Dallal H, Smith G D, Grieve D C, Ghosh S, Penman I D, Palmer K R. 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
• 45 Fleischer D E. Stents, cloggology and esophageal cancer.  Gastrointest Endosc. 1996;  43 258-260
• 46 Sheilds S J. Esophageal self-expanding metallic stents.  Gastrointest Endosc. 1997;  45 439-442
• 47 Law S, Tung P, Chu M-K, Wong J. Self-expanding metallic stents for palliation of recurrent malignant esophageal obstruction after subtotal esophagectomy for cancer.  Gastrointest Endosc. 1999;  50 427-436
• 48 Bethge N, Sommer A, Vakil N. A prospective trial of self-expanding stents in the palliation of malignant esophageal sphincters near the upper esophageal sphincter.  Gastrointest Endosc. 1997;  45 300-303
• 49 Siersema P D, Schrauwen S L, van Blankenstein M et al.. Self-expanding metal stents for complicated and recurrent esophagogastric cancer.  Gastrointest Endosc. 2001;  54 579-586
• 50 Morgan R A, Ellul J PM, Denton E RE, Glynos M, Mason R C, Adam A. Malignant esophageal fistulas and perforations: management with plastic-covered metallic endoprostheses.  Radiology. 1997;  204 527-532
• 51 Saxon R R, Morrison K E, Lakin P C et al.. Malignant oesophageal obstruction and esophagorespiratory fistula: palliation with a polyethylene-covered Z stent.  Radiology. 1997;  202 349-354
• 52 Ackroyd R, Watson D I, Devitt P G, Jamieson G G. Expandable metallic stents should not be used in the treatment of benign esophageal strictures.  J Gastroenterol Hepatol. 2001;  16 484-487
• 53 Song H Y, Jung H Y, Park S I et al.. Covered retrievable expandable Nitinol stents in patients with benign esophageal strictures: initial experience.  Radiology. 2000;  217 551-557
• 54 Song H Y, Lee D H, Seo T S et al.. Retrievable covered Nitinol stents: experiences in 108 patients with malignant esophageal strictures.  J Vasc Interv Radiol. 2002;  13 285-292
• 55 Mayoral W, Fleischer D, Salcedo J, Roy P, Al-Kawas F, Benjamin S. Nonmalignant obstruction is a common problem in metal stents in the treatment of esophageal cancer.  Gastrointest Endosc. 2000;  51 556-559
• 56 Won J H, Lee J D, Wang H J et al.. Self-expandable covered metallic esophageal stent impregnated with a beta-emitting radionuclide: an experimental study in canine esophagus.  Int J Radiat Oncol Biol Phys. 2002;  53 1005-1013