Prior radiation and chemotherapy increase the risk of life-threatening complications after insertion of metallic stents for esophagogastric malignancy

doi:10.1016/S0016-5107(96)70315-2

Gastrointestinal Endoscopy

Volume 43, Issue 3, March 1996, Pages 196-203

https://doi.org/10.1016/S0016-5107(96)70315-2 Get rights and content

Abstract

Background: Self-expanding metallic stents (SEMS) are effective in relieving the symptoms of obstructing esophagogastric malignancy. While complications with SEMS have been described, factors influencing such occurrence have not been defined. Methods: Self-expanding Gianturco-Rösch Z-stents were placed successfully in 59 patients with obstructing esophagogastric malignancies. Results: Early procedure-related complications occurred in 6 patients (10%) and were usually minor. Twenty-three late complications occurred in 22 patients (37.5%). Life-threatening complications occurred in 9 patients (15%), including gastrointestinal bleeding (7), perforation (1), and tracheoesophageal fistula (1) and contributed to all five deaths. Eight of 22 patients with prior radiation and/or chemotherapy (36.4%) had life-threatening complications compared to 1 of 37 (2.5%) without prior therapy (p = 0.001). Stent-related mortality occurred in 5 of 22 (23%) patients with prior therapy compared to none of the 37 without prior therapy (p = 0.005). Multivariate analysis confirmed the association between prior radiation and/or chemotherapy and life-threatening complications (p = 0.012; odds ratio, 32.63) and also an association with female gender (p = 0.032; odds ratio, 13.9). There was no association with tumor location or length, histologic type, age, prestent dysphagia grade, or previous surgical resection. Conclusion: Patients with prior radiation and/or chemotherapy have an increased risk of severe complications following placement of SEMS. (Gastrointest Endosc 1996;43:196-203.)

Section snippets

Patients

From July 1990 to January 1994, 59 patients with obstructing esophagogastric malignancies were treated(Table 1). All complications were recorded and we retrospectively analyzed the data to determine which clinical factors predisposed patients to severe, life-threatening complications. Forty-four patients were men and 15 were women; the age range was 50 to 92 (mean, 69.7 years). The diagnosis of malignancy was established by endoscopic biopsy. Adenocarcinoma was found in 44 (42 esophageal, 1

RESULTS

Stents were successfully placed in all 59 patients in 60 attempts (Table 2). In one patient the first stent was placed too distally, and a second stent was placed to overlap the first. A single stent was placed in 52 patients, whereas 7 patients required 2 overlapping stents—because of extensive tumor length in six patients and distal placement in one patient. Fifty-three of 59 (90%) saw improvement of dysphagia of at least 2 grades. Mean dysphagia grade decreased from a mean of 3.24 to 0.85

DISCUSSION

The use of rigid endoprostheses for malignant esophageal obstructions has been thoroughly described.5, 6, 7, 8, 18, 19 The complication rates with placement of rigid endoprostheses are high, with an incidence of perforation of 8% to 11%.5, 6 The aggressive dilation required to accommodate the stent and the shearing forces as the stent is placed may account for the high perforation rates. Stent migration, tissue necrosis with bleeding, tumor overgrowth, and obstruction occur later at variable

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In addition to managing malignant obstruction, esophageal stents (ESs) have evolved to address various benign etiologies of dysphagia. We sought to evaluate national trends and changes in practice of ES placement for both benign and malignant etiologies in hospitalized patients with dysphagia.
The National Inpatient Sample (2003-2013) was used to include all adult inpatients (≥18 years of age) with endoscopy-guided ES placement for a symptom of dysphagia. Multivariable analyses for indications that impact temporal trends (3 time periods: 2003-2005, 2006-2009, and 2010-2013) and for hospital outcomes were performed.
A total of 7198 ESs were deployed endoscopically in hospitalized patients with dysphagia. Compared with malignant etiologies, there was a significant increase in ES placement for benign conditions (2013 vs 2003: 32.7% vs 14.5%, respectively; P < .001). Multivariable analysis using 2003 to 2005 as a reference showed that patients with benign etiologies for dysphagia predominantly contributed to the increase of ES placement during the most recent time period (2010-2013: odds ratio, 2.09; 95% confidence interval, 1.40-3.13). Multivariable analysis of hospital outcomes revealed no differences in inpatient mortality, duration of hospital stay, and hospital costs between malignant and benign indications.
In the preceding decade, ES placement for hospitalized patients with dysphagia has increased, driven largely by an over 8-fold rise in stent placement for benign indications. These findings warrant continued efforts to improve stent technology to decrease the risk of migration and review practice guidelines involving ES placement for benign etiologies.
Self-Expandable Metal Stent Use to Palliate Malignant Esophagorespiratory Fistulas in 88 Patients
2018, Journal of Vascular and Interventional Radiology
To identify predictors associated with clinical outcomes (initial clinical failure, stent patency, and survival) after self-expandable metal stent (SEMS) placement for malignant esophagorespiratory fistulas (ERFs).
Using logistic and Cox regression analyses, this study reviewed 88 patients (mean age 59.4 y ± 8.4; 84 men [95.5%] and 4 women [4.5%]) who underwent fluoroscopic SEMS placement for palliating malignant ERF from January 2000 to December 2016.
Technical success was achieved in all patients. Initial clinical success was achieved in 78.4% (69/88; 95% confidence interval [CI], 68.7%–85.7%). Among the 69 patients in whom initial clinical success was achieved, aspiration symptoms recurred in 37.7% (26/69; 95% CI, 27.2%–49.5%). Overall major complication rate was 25.0% (22/88; 95% CI, 17.1%–35.0%). Cumulative stent patency and cumulative survival rates at 1, 3, 6, and 12 months were 72.8%, 38.9%, 32.4%, and 21.6% and 81.4%, 51.9%, 30.5%, and 13.3%, respectively. Stricture of the upper esophagus was an independent predictor of initial clinical failure (odds ratio, 3.760; 95% CI, 1.207–11.811) and shorter stent patency (hazard ratio [HR], 2.036; 95% CI, 1.170–3.544). Initial clinical failure was an independent predictor of shorter survival (HR, 2.902; 95% CI, 1.587–5.305).
SEMS placement offers sufficient short-term relief despite considerable major complications. Stricture of the upper esophagus is an independent predictor of initial clinical failure and shorter stent patency. Initial clinical failure is an independent predictor of shorter survival.
Prospective trial of biodegradable stents for refractory benign esophageal strictures after curative treatment of esophageal cancer
2017, Gastrointestinal Endoscopy
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.
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.
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.
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.)
Endoscopic management of esophageal strictures
2017, Gastrointestinal Endoscopy
Predictor of massive bleeding following stent placement for malignant oesophageal stricture/fistulae: A multicentre study
2016, Clinical Radiology
To evaluate retrospectively the incidence and predictors of massive bleeding after stent placement for malignant oesophageal stricture/fistulae.
This retrospective study comprised 519 patients with malignant oesophageal stricture/fistulae that were successfully treated with stent placement at three hospitals. The patients were divided into two groups based on the occurrence of massive bleeding. Univariate and multivariate analysis was performed to evaluate predictive factors of massive bleeding.
Massive bleeding occurred in 54 of 519 patients 1–37 days following stent placement. All of the patients who developed massive bleeding died within 24 hours of the event. Univariate analysis showed massive bleeding was associated with the presence of a concomitant tracheal stent (p<0.001), the existence of concomitant oesophageal fistulae (p<0.001), and prior radiotherapy (p<0.001). Multivariate analysis exhibited that concomitant tracheal stent insertion (odds ratio [OR], 23.134; 95% confidence interval [CI], 9.523–56.199; p<0.001), the presence of oesophageal fistulae (OR, 3.724; 95% CI, 1.677–8.269; p=0.001), and prior radiotherapy (OR, 13.310; 95% CI, 5.464–32.421; p<0.001) were predictors of massive bleeding following stenting.
The presence of oesophageal fistulae, prior radiotherapy, and concomitant tracheal stent are important factors contributing to bleeding after stenting.
Development of a prediction model of adverse events after stent placement for esophageal cancer
2016, Gastrointestinal Endoscopy
Self-expandable metal stent (SEMS) positioning is the recommended method for palliation of dysphagia from esophageal cancer, although it is not adverse event–free. The present study was aimed at identifying predictors for adverse events and at proposing a statistical model to predict them.
We performed a retrospective analysis of a prospectively collected database. All patients who underwent SEMS placement for stricture due to esophageal cancer between 2002 and 2011 in a tertiary-care center were identified. Multivariable regression analysis in the presence of competing risk events was used to identify factors associated with SEMS-related adverse events and to build a prediction model.
A total of 267 patients were included. According to the competing risk regression analysis, only 2 variables were significantly associated with the risk of SEMS-related adverse events: prior chemoradiotherapy (CRT), yielding a hazard ratio (HR) of 1.687 (95% confidence interval [CI], 1.076-2.644), and the SEMS length (HR 0.884; 95% CI, 0.798-0.980) for every 10-mm length increase. Based on the estimated probability curves, after 4 months from SEMS placement, the probability of an adverse event in patients who did receive prior CRT was 50.9% compared with 34.4% in those who did not receive prior therapy, which was reduced to 9.2% and 15.1%, respectively, if a 180 mm-length stent was used. The ability of the predictive model to differentiate between patients who did and did not experience the adverse event was moderate (c-index: 0.617).
The rate of SEMS-related adverse events was higher in patients with previous CRT and lower in patients receiving longer stents. Both factors were used to build an accurate predictive model.

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^☆: From the Division of Gastroenterology and the Dotter Institute of Interventional Therapy, Oregon Health Sciences University, Portland, Oregon.

^☆☆: Reprint requests: Ronald M. Katon, MD, Gastroenterology, PV310, Oregon Health Sciences University, 3181 S.W. Sam Jackson Park Road, Portland, OR 97210-3098

^★: 0016-5107/96/4303-0196$5.00 + 0

^★★: GASTROINTESTINAL ENDOSCOPY

^♢: 37/1/68943

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Prior radiation and chemotherapy increase the risk of life-threatening complications after insertion of metallic stents for esophagogastric malignancy☆,☆☆,★,★★,♢

Abstract

Section snippets

Patients

RESULTS

DISCUSSION

J Thorac Cardiovasc Surg

Gastroenterology

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Ann Thorac Surg

Gastrointest Endosc

Eur J Cancer

Cancer Treat Rev

Int J Radiat Oncol Biol Phys

Surgery and current management for cancer of the esophagus and cardia: Part II

Curr Probl Surg

Palliation of advanced esophageal cancer

Semin Oncol

Current palliative modalities for esophageal carcinoma

Acta Chir Scand