Gastroenterologie
a hepatologie

Expandable stents in the treatment of benign and malignant tumors of the esophagus

Tibor Hlavatý ^{Orcid.org  1}, Martin Huorka ^{Orcid.org  2}, Tomáš Koller ^{Orcid.org  2}, Jozef Tóth ^{Orcid.org  2,3}

+ Affiliation
¹ 5th Department of Internal Medicine, Faculty of Medicine, Comenius University and University Hospital Bratislava, Slovak Republic
² Gastroenterologické a hepatologické oddelenie, V. interná klinika LF UK a UN Bratislava
³ IBD Center, Subdepartment of Gastroenterology and Hepatology, 5th Department of Internal Medicine, Faculty of Medicine, Comenius University and University Hospital Bratislava, Slovak Republic

Summary

Enteral stents have been subject of significant development in the recent years. Construction design and insertion techniques have improved and the indications are expanding. Stenting as a palliative treatment of esophageal malignant stenoses is nowadays a routine part of therapeutic strategies. Besides malignant indications for stenting, there is a growing spectrum of benign conditions, such as the therapy of refractory benign esophageal stenoses, esophagorespiratory fistulas, anastomotic leaks, perforations and bleeding esophageal varices. As there is a lack of comparative trials, the selection of an optimal stent and treat­ment protocol is a matter of clinical experience and availability of particular stents. There are several promising innovations in the field of enteral stents such as biodegradable stents or double layer stents. Further intensive development of new stents, techniques and clinical indications can be expected in the near future. 

Keywords

esophageal varices, esophago­respiratory fistula, esophageal carcinoma, palliative therapy, esophageal perforation, enteral stent, stenosis

To read this article in full, please register for free on this website.

Benefits for subscribers

Benefits for logged users

Literature

1. Kochar R, Shah N. Enteral stents: from esophagus to colon. Gastrointest Endosc 2013; 78(6): 913–918. doi: 10.1016/j. gie.2013.07.015.
2. Sharma P, Kozarek R. Role of esophageal stents in benign and malignant diseases. Am J Gastroenterol 2010; 105(2): 258–273. doi: 10.1038/ajg.2009.684.
3. Rejchrt S, Bures J, Brozík J et al. Use of biodegradable stents for the treatment of refractory benign gastrointestinal stenoses. Acta Medica (Hradec Kralove) 2011; 54(4): 137–143.
4. Irani S, Kozarek R. Esophageal stents: past, present, and future. Tech Gastrointest Endosc 2010; 12(4): 178–190.
5. Palmer ED. Experiences with management of malignant esophagorespiratory fistula by peroral esophageal prosthesis. Gastrointest Endosc 1970; 17(1): 12–16.
6. Knyrim K, Wagner HJ, Bethge N et al. A controlled trial of an expansile metal stent for palliation of esophageal obstruction due to inoperable cancer. N Engl J Med 1993; 329(18): 1302–1307.
7. Žitňan Ľ, Májek J, Pekárek B et al. Stenty v liečbe zhubných nádorov kolorekta – prehľad a vlastné skúsenosti. Gastroent Hepatol 2013; 67(1): 49–53.
8. Hirdes MM, Vleggaar FP, de Beule M et al. In vitro evaluation of the radial and axial force of selfexpanding esophageal stents. Endoscopy 2013; 45(12): 997–1005. doi: 10.1055/s­0033­1344985.
9. Tanaka T, Takahashi M, Nitta N et al. Newly developed biodegradable stents for benign gastrointestinal tract stenoses: a preliminary clinical trial. Digestion 2006; 74(3–4): 199–205.
10. Stivaros SM, Williams LR, Senger C et al. Woven polydioxanone biodegradable stents: a new treatment option for benign and malignant oesophageal strictures. Eur Radiol 2010; 20(5): 1069–1072. doi: 10.1007/s00330­009­1662­5.
11. Laasch HU, Marriott A, Wilbraham L et al. Effectiveness of open versus antireflux stents for palliation of distal esophageal carcinoma and prevention of symptomatic gastroesophageal reflux. Radiology 2002; 225(2): 359–365.
12. Conio M, Repici A, Battaglia G et al. A randomized prospective comparison of self­expandable plastic stents and partially covered self­expandable metal stents in the palliation of malignant esophageal dysphagia. Am J Gastroenterol 2007; 102(12): 2667–2677.
13. Verschuur EM, Repici A, Kuipers EJ et al. New design esophageal stents for the palliation of dysphagia from esophageal or gastric cardia cancer: a randomized trial. Am J Gastroenterol 2008; 103(2): 304–312.
14. ShimCS, Jung IS, Cheon YK et al. Management of malignant stricture of the esophagogastric junction with a newly designed self­expanding metal stent with an antireflux mechanism. Endoscopy 2005; 37(4): 335–339.
15. Langer FB, Schoppmann SF, Prager G et al. Temporary placement of self­expanding oesophageal stents as bridging for neo-adjuvant therapy. Ann Surg Oncol 2010; 17(2): 470–475. doi: 10.1245/ s10434­009­0760­6.
16. Yakami M, Mitsumori M, Sai H et al. Development of severe complications caused by stent placement followed by definitive radiation therapy for T4 esophageal cancer. Int J Clin Oncol 2003; 8(6): 395–398.
17. Sabharwal T, Morales JP, Irani FG et al. Quality improvement guidelines for placement of esophageal stents. Cardiovasc Intervent Radiol 2005; 28(3): 284–288.
18. Hirdes MM, van Hooft JE, Wijrde­man HK et al. Combination of biodegradable stent placement and single­dose brachytherapy is associated with an unacceptably high complication rate in the treatment of dysphagia from esophageal cancer. Gastrointest Endosc 2012; 76(2): 267–274. doi: 10.1016/j.gie.2012.04.442.
19. De Palma GD, Iovino P, Catanzano C. Distally migrated esophageal self­expanding metal stents: wait and see or remove? Gastrointest Endosc 2001; 53(1): 96–98.
20. Mayoral W, Fleischer D, Salcedo J et al. Nonmalignant obstruction is a common problem with metal stents in the treatment of esophageal cancer. Gastrointest Endosc 2000; 51(5): 556–559.
21. 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(12): 1292–1301. doi: 10.1111/j.1365­2036.2011.04663.x.
22. Hirdes MM, Siersema PD, Houben MH et al. Stent­in-stent technique for removal of embedded esophageal self­expanding metal stents. Am J Gastroenterol 2011; 106(2): 286–293. doi: 10.1038/ ajg.2010.394.
23. Conio M, De Ceglie A, Blanchi S et al. Esophageal strictures, tumors, and fistulae: stents for primary esophageal cancer. Tech Gastrointest Endosc 2010; 12: 191–202.
24. Homs MY, Steyerberg EW, Eijkenboom WM et al. Single­dose brachytherapy versus metal stent placement for the palliation of dysphagia from oesophageal cancer: multicentre randomised trial. Lan­cet 2004; 364(9444): 1497–1504.
25. 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(3): 131–139.
26. Schmassmann A, Meyenberger C, Knuchel J et al. Self­expanding metal stents in malignant esophageal obstruction: a comparison between two stent types. Am J Gastroenterol 1997; 92(3): 400–406.
27. Siersema PD, Hop WC, van Blankenstein M et al. A comparison of 3 types of covered metal stents for the palliation of patients with dysphagia caused by esophagogastric carcinoma: a prospective, randomized study. Gastrointest Endosc 2001; 54(2): 145–153.
28. Sabharwal T, Hamady MS, Chui S et al. A randomised prospective comparison of the Flamingo Wallstent and Ultraflex stent for palliation of dysphagia associated with lower third oesophageal carcinoma. Gut 2003; 52(7): 922–926.
29. Kozarek RA, Raltz S, Marcon N et al. Use of the 25 mm flanged esophageal Z stent for malignant dysphagia: a prospective multicenter trial. Gastrointest Endosc 1997; 46(2): 156–160.
30. Vakil N, Morris AI, Marcon N et al. A prospective, randomized, controlled trial of covered expandable metal stents in the palliation of malignant esophageal obstruction at the gastroesophageal junction. Am J Gastroenterol 2001; 96(6): 1791–1796.
31. Yakoub D, Fahmy R, Athanasiou T et al. Evidence­based choice of esophageal stent for the palliative management of malignant dysphagia. World J Surg 2008; 32(9): 1996–2009. doi: 10.1007/s00268­008­9654­1.
32. Varadarajulu S, Banerjee S, Barth B et al. Enteral stents. Gastrointest Endosc 2011; 74(3): 455–464. doi: 10.1016/j.gie. 2011.04.011.
33. Siddiqui AA, Sarkar A, Beltz S et al. Placement of fully covered self­expandable metal stents in patients with locally advanced esophageal cancer before neoadjuvant therapy. Gastrointest Endosc 2012; 76(1): 44–51. doi: 10.1016/j. gie.2012.02.036.
34. Van Heel NC, Haringsma J, Boot H et al. Comparison of 2 expandable stents for malignant esophageal disease: a randomized controlled trial. Gastrointest Endosc 2012; 76(1): 52–58. doi: 10.1016/j. gie.2012.02.050.
35. Kim ES, Jeon SW, Park SY et al. Com­parison of double­layered and covered
Niti-S stents for palliation of malignant dysphagia. J Gastroenterol Hepatol 2009; 24(1): 114–119. doi: 10.1111/j.1440­1746. 2008.05674.x.
36. Verschuur EM, Homs MY, Steyer­berg EW et al. A new esophageal stent design (Niti­S stent) for the prevention of migration: a prospective study in 42 patients. Gastrointest Endosc 2006; 63(1): 134–140.
37. Uitdehaag MJ, Siersema PD, Spaander MC et al. A new fully covered stent with antimigration properties for the palliation of malignant dysphagia: a prospective cohort study. Gastrointest Endosc 2010; 71(3): 600–605. doi: 10.1016/j. gie.2009.09.023.
38. White RE, Parker RK, Fitzwater JW et al. Stents as sole therapy for oesophageal cancer: a prospective analysis of outcomes after placement. Lancet Oncol 2009; 10(3): 240–246. doi: 10.1016/S1470­2045(09)70004­X.
39. Park JJ, Lee YC, Kim BK et al. Long­term clinical outcomes of self­expanding metal stents for treatment of malignant gastroesophageal junction obstructions and prognostic factors for stent patency: effects of anticancer treatments. Dig Liver Dis 2010; 42(6): 436–440. doi: 10.1016/j. dld.2009.07.020.
40. Choi EK, Song HY, Kim JW et al. Covered metallic stent placement in the management of cervical esophageal strictures. J Vasc Interv Radiol 2007; 18(7): 888–895.
41. Wong Kee Song LM, Baron TH. Stents for uncommon malignant and benign esophageal indications (extrinsic compression, esophagorespiratory fistulas, and proximal esophageal obstruction). Tech Gastrointest Endosc 2010; 12(4): 210–215.
42. Eleftheriadis E, Kotzampassi K. Endo­prosthesis implantation at the haryngo­esophageal level: problems, limitations and challenges. World J Gastroenterol 2006; 12(13): 2103–2108.
43. Adler DG, Fang J, Wong R et al. Placement of Polyflex stents in patients with locally advanced esophageal cancer is safe and improves dysphagia during neoadjuvant therapy. Gastrointest Endosc 2009; 70(4): 614–619. doi: 10.1016/j.gie. 2009.01.026.
44. Siddiqui AA, Glynn C, Loren D et al. Self­expanding plastic esophageal stents versus jejunostomy tubes for the maintenance of nutrition during neoadjuvant chemoradiation therapy in patients with esophageal cancer: a retrospective study. Dis Esophagus 2009; 22(3): 216–222. doi: 10.1111/j.1442­2050.2008.00905.x.
45. Van Heel NC, Haringsma J, Spaander MC et al. Esophageal stents for the relief of malignant dysphagia due to extrinsic compression. Endoscopy 2010; 42(7): 536–540. doi: 10.1055/s­0029­1244123.
46. Tojo T, Iioka S, Kitamura S et al. Management of malignant tracheobronchial stenosis with metal stents and Dumon stents. Ann Thorac Surg 1996; 61(4): 1074–1078.
47. Thies J, Elfeldt RJ. Indications, technical implementation and results of endobronchial stent implantation. Langenbecks Arch Chir Suppl Kongressbd 1996; 113: 547–549.
48. Bethge N, Sommer A, Vakil N. Palliation of malignant esophageal obstruction due to intrinsic and extrinsic lesions with expandable metal stents. Am J Gastroenterol 1998; 93(10): 1829–1832.
49. Evrard S, Le Moine O, Lazaraki G et al. Self­expanding plastic stents for benign esophageal lesions. Gastrointest Endosc 2004; 60(6): 894–900.
50. García­Cano J. Dilation of benign strictures in the esophagus and colon with the polyflex stent: a case series study. Dig Dis Sci 2008; 53(2): 341–346.
51. Holm AN, de la Mora Levy JG, Gostout CJ et al. Self­expanding plastic stents in treatment of benign esophageal conditions. Gastrointest Endosc 2008; 67(1): 20–25.
52. Triester SL, Fleischer DE, Sharma VK. Failure of self­expanding plastic stents in treatment of refractory benign esophageal strictures. Endoscopy 2006; 38(5): 533–537.
53. Canena JM, Liberato MJ, Rio­Tinto RA et al. A comparison of the temporary placement of 3 different self­expanding stents for the treatment of refractory benign esophageal strictures: a prospective multicentre study. BMC Gastroenterol 2012; 12: 70.
54. Van Boeckel PG, Vleggaar FP, Siersema PD. A comparison of temporary self­expanding plastic and biodegradable stents for refractory benign esophageal strictures. Clin Gastroenterol Hepatol 2011; 9(8): 653–659. doi: 10.1016/j.cgh. 2011.04.006.
55. Van Halsema EE, Wong Kee Song LM, Baron TH et al. Safety of endoscopic removal of self­expandable stents after treatment of benign esophageal diseases. Gastrointest Endosc 2013; 77(1): 18–28. doi: 10.1016/j.gie.2012.09.001.
56. Veseliny E, Jarčuška P, Zakuciová M et al. Liečba achalázie – súčasný prístup a vlastné skúsenosti. Gastroent Hepatol 2012; 66(2): 116–124.
57. Zhao JG, Li YD, Cheng YS et al. Long­term safety and outcome of a temporary self­expanding metallic stent for achalasia: a prospective study with a 13­year single­center experience. Eur Radiol 2009; 19(8): 1973–1980. doi: 10.1007/s00330­009­1373­y.
58. Li YD, Tang GY, Cheng YS et al. 13­year follow­up of a prospective comparison of the long­term clinical efficacy of temporary self­expanding metallic stents and pneumatic dilatation for the treatment of achalasia in 120 patients. Am J Roentgenol 2010; 195(6): 1429–1437. doi: 10.2214/ AJR.10.4407.
59. Van den Bongard HJ, Boot H, Baas P et al. The role of parallel stent insertion in patients with esophagorespiratory fistulas. Gastrointest Endosc 2002; 55(1): 110–115.
60. Cellier C, Landi B, Faye A et al. Upper gastrointestinal tract fistulae: endoscopic obliteration with fibrin sealant. Gastrointest Endosc 1996; 44(6): 731–733.
61. El Hajj II, Imperiale TF, Rex DK et al. Treatment of esophageal leaks, fistulae, and perforations with temporary stents: evaluation of efficacy, adverse events, and factors associated with successful outcomes. Gastrointest Endosc 2014; 79(4): 589–598. doi: 10.1016/j.gie.2013.08.039.
62. Krajc T, Janík M, Lučeni M et al. Možnosti a výsledky chirurgického riešenia benígnej tracheoezofageálnej fistuly. Rozhl Chir 2010; 89(8): 478–489.
63. Von Renteln D, Denzer UW, Schach­schal G et al. Endoscopic closure of GI fistulae by using an over­the­scope clip (with
videos). Gastrointest Endosc 2010; 72(6): 1289–1296. doi: 10.1016/j.gie.2010.07.033.
64. Siersema PD. Treatment of esophageal perforations and anastomotic leaks: the endoscopist is stepping into the arena. Gastrointest Endosc 2005; 61(7): 897–900.
65. Janík M, Haruštiak S, Krajč T et al. Syndroma Boerhaave. Slov Chirurg 2004; 8: 16–20.
66. Tilanus HW, Bossuyt P, Schattenkerk ME et al. Treatment of oesophageal perforation: a multivariate analysis. Br J Surg 1991; 78(5): 582–585.
67. Janík M, Haruštiak S, Benej R et al. Výsledky liečby akútnej mediastinitídy v našom súbore pacientov. Studia Pneumol Phtiseol 2002; 62: 41–45.
68. Janík M, Krajč T, Benej R et al. Aktuálne trendy v liečbe akútnej mediastinitídy. Slov Chirurg 2008; 5: 4–8.
69. Almadi MA, Aljebreen AM, Bamihriz F. Resolution of an esophageal leak and posterior gastric wall necrosis with esophageal self­expandable metal stents. World J Gastroenterol 2013; 19(40): 6931–6933. doi: 10.3748/wjg.v19.i40.6931.
70. Schubert D, Scheidbach H, Kuhn R et al. Endoscopic treatment of thoracic esophageal anastomotic leaks by using silicone­covered, self­expanding polyester stents. Gastrointest Endosc 2005; 61(7): 891–896.
71. Kumar N, Thompson CC. Endoscopic management of complications after gastrointestinal weight loss surgery. Clin Gastroenterol Hepatol 2013; 11(4): 343–353. doi: 10.1016/j.cgh.2012.10.043.
72. Aurora AR, Khaitan L, Saber AA. Sleeve gastrectomy and the risk of leak: a systematic analysis of 4,888 patients. Surg Endosc 2012; 26(6): 1509–1515. doi: 10.1007/ s00464­011­2085­3.
73. Zehetner J, Shamiyeh A, Wayand W et al. Results of a new method to stop acute bleeding from esophageal varices: implantation of a self­expanding stent. Surg Endosc 2008; 22(10): 2149–2152. doi: 10.1007/s00464­008­0009­7.
74. Wright G, Lewis H, Hogan B et al. A self­expanding metal stent for complicated variceal hemorrhage: experience at a single center. Gastrointest Endosc 2010; 71(1): 71–78. doi: 10.1016/j.gie.2009.07.028.
75. Hubmann R, Bodlaj G, Czompo M et al. The use of self­expanding metal stents to treat acute esophageal variceal bleeding. Endoscopy 2006; 38(9): 896–901.
76. Bruha R, Drastich P, Fejfar T et al. Guidelines on the diagnosis and treatment of bleeding into the digestive tract caused by portal hypertension. Gastroent Hepatol 2011; 65(3): 141–142.
77. Fejfar T, Šafka V, Jirkovský V et al. Danišův jícnový stent v terapii varikózního krvácení. Gastroent Hepatol 2013; 67(2): 98–103.