Large-Diameter Metal Stents are Associated with Stent-Related Esophageal Complications

 

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We read with interest the recent article by Hasan et al. [1] which described three patients who developed an esophagorespiratory fistula at the proximal edge of the upper flange of a large-diameter Flamingo Wallstent. This stent has a proximal diameter of 30 mm. In all three cases, the fistula developed some time after stent placement and the authors speculated that the fistulas had formed as a result of pressure necrosis caused by the proximal flange of the Flamingo Wallstent. The authors found only one other report of an esophagorespiratory fistula occurring at this site [2]. In that study, however, a Wallstent with a proximal diameter of 20 mm had been used.

Some years ago, we reported the results of a prospective study of 40 patients in whom we placed either a small-diameter Flamingo Wallstent (proximal diameter 24 mm, n = 21) or a large-diameter Flamingo Wallstent (n = 19) [3]. Major complications occurred in seven out of the 40 patients (18 %): bleeding (n = 4), perforation (n = 1), fever (n = 1), and fistula (n = 1). In this study, the large-diameter stents appeared to be associated with an increased risk of esophageal complications: five of the seven major complications (one perforation and four bleeds) were observed in patients who had had a large-diameter Flamingo Wallstent placed (P = 0.07). Because large-diameter Flamingo Wallstents were only used in patients with prestenotic dilatation of the esophagus, we supposed that these patients may have had tighter strictures than the patients who did not have prestenotic dilatation and therefore that they would be more likely to have required balloon dilation before stenting. However, two patients from each stent group required balloon dilation before stent placement. We speculated, therefore, that the explanation for the greater incidence of major complications that occurred with the large-diameter Flamingo stents was simply the effect of the larger diameter. This was supported by the results of another study in which patients were treated using either a Wallstent or an Ultraflex stent. In that study it was suggested that the higher expansile force exerted by the Wallstents had contributed to the 23 % incidence of severe chest pain and to the esophageal perforation and bleeding which occurred in the patients who had these stents placed; these complications did not occur in the patients in whom Ultraflex stents had been placed [4].

Hasan et al. [1] recommended that large-diameter stents should only be used in patients with a life expectancy of less than 6 months, because the esophagorespiratory fistulas were only seen in patients who had survived for a relatively long time. However, based on their findings as well as our own, we would suggest that large-diameter stents (stents with an upper-flange diameter of 28 mm or more) should not be used until comparative studies have provided more data on the effect of stent diameter on efficacy and, specifically, on the risk of complications in patients with malignant dysphagia.

References

• 1 Hasan S, Beckly D, Rahamim J. Oesophagorespiratory fistulas as a complication of self-expanding metal oesophageal stents.  Endoscopy. 2004;  36 731-734
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• 2 Knyrim K, Wagner H J, 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 1302-1307
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• 3 Siersema P D, Hop W C, van Blankenstein M, Dees J. A new design metal stent (Flamingo stent) for palliation of malignant dysphagia: a prospective study.  Gastrointest Endosc. 2000;  51 139-145
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P. D. Siersema, M. D.

Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam

PO Box 20403000 CA RotterdamThe Netherlands

Fax: +31-10-4634-682

Email: p.siersema@erasmusmc.nl