Patient Tolerance of Cervical Esophageal Metallic Stents

doi:10.1016/S1051-0443(07)61807-7

Journal of Vascular and Interventional Radiology

Volume 11, Issue 7, July–August 2000, Pages 891-898

https://doi.org/10.1016/S1051-0443(07)61807-7 Get rights and content

PURPOSE

To demonstrate that proximal esophageal stenoses and tracheoesophageal fistulas can be adequately palliated with use of metallic stents without significant foreign-body sensation.

MATERIALS AND METHODS

Between June 1994 and March 1999, 22 patients with lesions within 3 cm of the cricopharyngeus were treated by placement of metallic stents. The series was reviewed retrospectively. Twenty patients had surgically unresectable malignant lesions, two patients had benign disease. Ten patients had associated tracheoesophageal fistulas. In all, the upper limit of the stent was between C5 vertebral body inferior endplate and the T2 vertebral body superior endplate. The case-notes were reviewed until patient death (range, 6–198 days), or to date in the two surviving patients with benign disease.

RESULTS

Immediate technical success was 93% (27 of 29). Dysphagia scores improved from a median of 3 to 2 after stent placement. Eighteen of 22 (82%) patients reported no foreign-body sensation. There have been no cases of proximal migration, periprocedural perforation, or deaths. The two patients with benign disease experienced significant complications.

CONCLUSION

Lesions in proximity to the cricopharyngeus can be successfully palliated without significant foreign-body sensation in the majority of patients with use of metallic stents. The authors urge caution in placing stents in patients with benign disease.

Section snippets

MATERIALS AND METHODS

All esophageal stents were placed solely under fluoroscopic guidance using bony landmarks, contrast material injection, and visualization of the laryngeal airway. Endoscopic confirmation of proximity to the cricopharyngeus was provided in two patients, one female and one male. Both stents were placed at the superior endplate of the vertebral body of T1 and were subsequently identified approximately 1.5 cm from the cricopharyngeus during endoscopy. All lesions requiring the proximal extent of a

RESULTS

The study group consisted of nine women and 13 men, who ranged in age from 28 years to 79 years (median age, 63 years). Thirteen patients had intrinsic esophageal malignancy (biopsy-proved squamous carcinoma in 11, adenocarcinoma in two), seven patients had extrinsic esophageal compression (due to bronchogenic carcinoma in four and malignant nodal compression in three). These lesions were surgically irresectible based on the demonstration of local invasion or distant spread on contrast-enhanced

CASE REPORT

A 60-year-old woman was diagnosed with inoperable squamous carcinoma of the cervical esophagus in 1994. She was treated with radiation therapy and chemotherapy but, by December 1995, had a dysphagia score of 3. She was managed by placement of an 18-mm uncovered Ultraflex stent, with its proximal extent at the inferior endplate of C5 (Figure). She was unaware of foreign-body sensation and her dysphagia score increased to 1. She required no further intervention and died of widespread metastatic

DISCUSSION

There are two randomized controlled trials comparing metallic and plastic prostheses in patients with malignant dysphagia (18, 19). In addition, several series report the deployment of various types of metallic stents. The evidence available to date suggests that metallic stents have an established role in the palliation of malignant esophageal strictures and in tracheoesophageal fistulas (13, 16, 20, 24).

Several series report a high technical success for placement of metallic stents, with

LIMITATIONS

This was a retrospective observational study; clearly, a prospective study would have been more robust. The sample size is small and different stents were used according to operator preference. In addition, we have no information about exclusions from the study (ie, those patients who were not referred to the interventional radiological service).

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Cited by (53)

Management of a cervical tracheoesophageal fistula with a modified self-expanding metal stent: Report of a case
2011, Formosan Journal of Surgery
Treatment of tracheoesophageal (TE) fistula is always a challenge, in particular TE fistula caused by malignancy. In the past decade, the development of a self-expanding metal stent (SEMS) has made management of esophageal stenosis or perforation much easier. Nevertheless, management of a cervical esophageal lesion is still debatable. A cervical esophageal stent may compromise the upper esophageal sphincter (UES) function and is usually listed as a contraindication. Here, a 53-year-old male had cervical esophageal cancer complicated with a TE fistula. After initial management with a SEMS, the patient had temporary improvement, but later suffered a recurrent TE fistula. The TE fistula was successfully managed by the placement of a second modified SEMS just below the UES without removal of the previous SEMS. The patient tolerated the procedure well and regained proper swallowing function.
Stents for proximal esophageal cancer: A case-control study
2011, Gastrointestinal Endoscopy
Self-expandable metal stents (SEMSs) are an established palliative therapy for esophageal cancer. SEMS placement for cancers near the upper esophageal sphincter (UES) is controversial because of a perceived increased risk of complications.
To compare outcomes after patients stented for proximal esophageal cancer (PC) and distal esophageal cancer (DC).
Matched case-control study from a prospective database.
Tertiary referral center, Tenwek Hospital, Bomet, Kenya.
All patients with PC located within 6 cm of the UES were matched with randomly selected controls with DC.
Outcomes of PC cases were compared with those of DC controls.
Dysphagia score, complications, median survival.
A total of 151 patients with PC were identified and were randomly matched with DC controls. Ninety-three case-control pairs had adequate follow-up information available. Mean dysphagia scores (scale 0-4) improved from 3.4 and 3.3 before stenting for PC and DC, respectively, to 1.5 after stenting for both groups (P = .93). Early complications occurred in 6.5% of PC cases and 9.7% of DC controls (P = .44). Late complications occurred in 20.4% of PC cases and 15.1% of DC controls (P = .25). Median survival was 210 days for PC cases and 272 days for DC controls (P = .25). Outcomes were similar for the subgroup of PC cases whose cancer extended to within 2 cm of the UES.
An important limitation is the absence of adequate follow-up data for 58 of the 151 case-control pairs.
SEMSs effectively palliate dysphagia in PC cases, whereas complication and survival rates are not statistically different from those of DC controls.
Endoscopic Palliation of Malignant Dysphagia and Esophageal Fistulas
2011, Clinical Gastrointestinal Endoscopy, Second Edition
Esophageal stents for malignant strictures close to the upper esophageal sphincter
2007, Gastrointestinal Endoscopy
Self-expanding stents are a well-accepted palliative treatment modality for strictures resulting from esophageal carcinoma. However, the use of stents close to the upper esophageal sphincter (UES) is considered to be limited by patient intolerance caused by pain and globus sensation and an increased risk of complications, particularly tracheoesophageal fistula formation and aspiration pneumonia.
Our purpose was to determine the efficacy and safety of stent placement in patients with a malignant obstruction close to the UES.
Evaluation of 104 patients with dysphagia from a malignant stricture close to the UES treated in the period 1996-2006.
Single university center.
Patients with primary esophageal carcinoma (n = 66) or recurrent cancer after gastric tube interposition (n = 38) within 8 cm distance distal of the UES. Twenty-four (23%) patients also had a tracheoesophageal fistula.
Stent placement.
Functional and technical outcome, survival, complications, and recurrent dysphagia. Analyses were performed by χ² test, Kaplan-Meier curves, and log-rank testing.
Mean distance from the UES to the upper tumor margin was 4.9 ± 2.6 cm and to the upper stent margin 3.1 ± 2.3 cm. The procedure was technically successful in 100 of 104 (96%) patients. Fistula sealing was achieved in 19 of 24 (79%) patients. After 4 weeks, dysphagia had improved from a median score of 3 (liquids only) to 1 (some difficulties with solids). Total complications were seen in 34 of 104 (33%) patients. Of these, major complications (aspiration pneumonia [9], hemorrhage [8], fistula [7], and perforation [2]) occurred in 22 (21%) patients, whereas pain after stent placement was observed in 16 (15%) patients. Recurrent dysphagia occurred in 29 (28%) patients and was mainly caused by tissue ingrowth or overgrowth (n = 10), food bolus obstruction (n = 7), stent migration (n = 3), or other reasons (n = 11), such as persistent fistula (n = 5), difficulty with swallowing (n = 4), and dislocation of the stent (n = 2). Eight (8%) patients complained of globus sensation; however, in none of the patients was stent removal indicated.
Retrospective design.
Stent placement is safe and effective for the palliation of dysphagia and sealing of fistulas in patients with a malignant stricture close to the UES. On the basis of these results, stent placement may be considered for palliation in this group of patients with an otherwise dismal prognosis.
Covered Metallic Stent Placement in the Management of Cervical Esophageal Strictures
2007, Journal of Vascular and Interventional Radiology
Citation Excerpt :
Given the tortuous nature of the cervical esophagus, stent flexibility and concomitant ability to conform to the demands of head/neck movement are crucial for patient comfort. Moreover, the complex sensory innervation of the pharyngeal mucosa makes high stent placement particularly sensitive to excessive stent pressure (16). Therefore, low radial force is important for minimizing the foreign body sensation or pain that results from undue mucosa pressure stemming from the expansile force of the stent.
To describe the authors’ experience with self-expandable covered metallic stents in 16 patients with malignant and benign cervical esophageal strictures.
Sixteen expandable covered metallic stents were placed with fluoroscopic guidance in 16 patients (14 men, two women; mean age, 60 years; age range, 26–75 years) with malignant and benign strictures of the cervical esophagus. The causes of strictures were ingestion of corrosive agents (n = 3), biopsy-proved squamous cell carcinoma (n = 12), and postsurgical scarring (n = 1). The mean dysphagia scores at presentation were compared with those after stent placement by using the Wilcoxon signed rank test.
Stent placement was technically successful in all patients. The reduction in the mean dysphagia score after stent placement was statistically significant (P = .0327). All patients complained of mild to severe foreign body sensation, with four reporting severe pain necessitating immediate stent removal. With the exception of one patient with limited follow-up, complications requiring intervention occurred in all patients, including migration in nine patients and tissue hyperproliferation in two. Of the 12 patients with a malignant stricture of the esophagus, four patients eventually underwent gastrostomy for the placement of a feeding tube and one patient underwent surgery. All four patients with a benign cervical stricture failed to achieve long-lasting improvement with temporary stent placement.
Although the placement of covered metallic stents in the cervical esophagus provides adequate initial palliation, it is associated with poor patient tolerance and a high complication rate.
Endoscopic Management of the Difficult Benign Esophageal Stricture
2007, Techniques in Gastrointestinal Endoscopy
Citation Excerpt :
Studies of stents in this area have consisted mostly of malignant strictures, and stents have alleviated effectively symptoms in this group of patients.50,51 Even when the proximal end of the stent was at the cervical esophagus or hypopharynx, these stents were surprisingly well tolerated.51 In Evrard’s25 study of the Polyflex stent in benign conditions, eight patients had strictures in the proximal esophagus.
The incidence of benign esophageal strictures is decreasing, likely due to the widespread use of proton pump inhibitors. Although most strictures respond well to dilation, a minority of them, mostly those of nonpeptic origin, may be difficult to manage. Challenges include the need for repeat dilations, not being able to reach a minimum diameter, and inability to provide significant symptomatic relief. The mainstay of management of benign esophageal strictures is esophageal dilation. Several techniques for dilation exist. The use of a specific dilation technique is dictated by the character of the stricture. Adjuncts to the management of difficult benign esophageal strictures include steroid injection, use of cautery, and more recently, the use of removable stents. As a result of these improvements on endoscopic techniques, the indications for surgical intervention in difficult esophageal strictures are changing and likely will decrease in the future.

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Patient Tolerance of Cervical Esophageal Metallic Stents

PURPOSE

MATERIALS AND METHODS

RESULTS

CONCLUSION

Section snippets

MATERIALS AND METHODS

RESULTS

CASE REPORT

DISCUSSION

LIMITATIONS

Am J Med

Gastrointest Endosc

Gastrointest Endosc

Ann Thorac Surg

Gastrointest Endosc

Clin Rad

Gastrointest Endosc

Gastrointest Endosc

Am J Gastroenterol

Surg Clin North Am

Clin Radiol

Surgical therapy of oesophageal carcinoma

Br J Surg

Oesophageal squamous cell carcinoma: a critical review of surgery

Br J Surg

Treatment and survival in cancer of the cervical esophagus

Am J Surg

Sphincteric action of crico-pharyngeus: radiographic demonstration

Br J Radiol

Osteology

Treatment of pharyngoesophageal stenosis by polyvinyl prosthesis

Am J Gastroenterol

Experiences with the Montgomery salivary bypass tube

Dysphagia