Do we need to fixate a fully covered esophageal metal stent?

 

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Self-expanding metal stents (SEMSs) have been used successfully in both malignant and benign esophageal disease. Esophageal stent placement for malignant disease aims to maintain oral intake and improve the quality of life for patients with malignant obstruction, malignant fistula, or extrinsic compression; while esophageal stent placement for benign upper gastrointestinal (UGI) diseases mainly includes the treatment of refractory benign esophageal strictures and the sealing of benign perforations, fistulas, or leaks [1] [2] [3].

Different types and brands of self-expanding stent are available. The currently available expandable stents, with the exception of biodegradable stents, are made of metal alloy compounds and durable polymers. There are mainly two types of stent: fully covered, and partially covered SEMSs (PCSEMSs). In fully covered metal stents (FCSEMSs) and fully covered plastic stents (SEPSs), the entire length of the stent is covered, while in PCSEMSs the proximal and distal ends of the stent are devoid of a covering, which allows them to embed into the esophageal wall.

In patients where a stent is placed for a benign esophageal condition, the stent should be removed, usually within 3 months after insertion. FCSEMSs and plastic stents have been developed to reduce tissue ingrowth making stent retrieval easier [3] [4] [5]. Consequently, they are often used for benign conditions such as esophageal strictures, fistulas, perforations, and anastomotic leaks. However, the low tissue ingrowth with FCSEMSs and SEPSs is associated with a higher migration risk of 58 % for FCSEMSs and up to 75 % for SEPSs [6] [7]. In a systematic review and meta-analysis of 444 patients, a clinical success rate for stent placement for refractory benign esophageal stenosis of 40.5 % was found, with an overall migration rate of 28.6 % [8].

Because stent migration often results in repeated stent placements, different methods to fixate the stent to the esophageal wall have been invented and evaluated, such as endoscopic mucosal clipping using both through-the-scope and over-the-scope clips to fix the upper flared end of the stent to the esophageal mucosal layer; stent fixation with an endoscopic snare; placement of a PCSEMS; or endoscopic suturing of the stent. In addition, the use of large-bore stents or stents designed with anti-migration features e. g. stents with increased resistance on the outside, stents with distinct shouldering of the upper end of the stent, and stents with a flip-flop collar have been described to prevent migration [9].

An advantage of placement of a PCSEMS, especially in patients with esophageal perforations, leaks, or fistulas, is that the ingrowth into the uncovered proximal flare prevents both migration and leakage of saliva and fluids that can slide through the outside of the stent into the leak or fistula. A disadvantage of PCSEMSs is the difficulty of stent retrieval after a few weeks, because of tissue ingrowth into the uncovered parts of the stent. With the use of the stent-in-stent technique, PCSEMSs are now easier to extract, making placement of a PCSEMSs a good option, especially for patients with fistulas, perforations, or leaks in whom a covered stent has migrated [10].

Most stent fixation techniques have mainly been studied in small studies. In the current issue of Endoscopy, Ngamruengphong et al. [11] describe the effect of endoscopic suturing on stent migration in 125 patients treated with an FCSEMS for benign UGI diseases. Of note, these patients were selected from seven tertiary centers and 26 patients who underwent endoscopic suturing for stent anchorage were also included in an earlier study. In more than half of the patients an FCSEMS was indicated for the treatment of a leak/fistula or a perforation.

A total of 44 patients were treated with endoscopic suturing of the FCSEMS versus 81 patients who received an FCSEMS without any fixation method. A total of 22 different types and brands of FCSEMS were placed. A significantly lower migration rate was found in patients with an FCSEMS that was endoscopically sutured compared with those in whom the stent was placed without suturing the FCSEMS to the esophageal wall (16 % vs. 33 %). In addition, the time to stent migration was longer in the group with endoscopic suturing of the stent. In the subgroup analysis, Ngamruengphong et al. evaluated the effect of suturing the stent to the esophageal wall on stent migration across various subgroups. They found that endoscopic suturing was associated with a significant reduction of stent migration in patients with a prior history of stent migration. In addition, the clinical success rate was significantly higher in patients treated with an endoscopically sutured FCSEMSs than in those treated with an unfixed FCSEMS (60 % vs. 38 %), while no difference in adverse events were found. All anchoring sutures were placed and removed with ease and without complications.

Bias may have been introduced in this study because the data were retrospective and non-randomized, and the suturing method and decision to perform suturing were not standardized, but at the discretion of the endoscopist. In more than half of the patients in the endoscopic suturing group, the stent was placed for treatment of leaks, fistulas, or perforations. Because migration appeared to be more common in stents placed for strictures the lower number of patients with benign strictures included in the endoscopic suturing group may have contributed to the lower migration rate found in this group. In addition, many different types and brands of stents were used.

Although the data were retrospective and non-randomized, a large number of patients who underwent endoscopic suturing were included and compared to those who did not have any fixation method used for their stents. The study of Ngamruengphong et al. shows that fixation of an FCSEMS helps to prevent stent migration and provides an improvement in clinical outcome. Therefore fixation techniques should be considered in patients who are at risk for stent migration, such as those with a prior history of stent placement.

No clinical studies have compared the different fixation techniques. Most clinical studies however have shown a reduction in migration rate in favor of the fixation method described. Therefore the choice still has to be made based on the preference of the endoscopist how to fixate an esophageal stent and the usability of the technique, including whether the stent can be easily removed when required.

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