Expandable Stents for Malignant Esophageal Disease

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Esophageal cancer

Rapid and persistent palliation of dysphagia is one of the main challenges in treating patients with incurable esophageal cancer to improve their quality of life. Brachytherapy and placement of an expandable stent are the 2 most evidence-based palliative treatment options for these patients. Two randomized controlled studies comparing expandable stent placement with brachytherapy have shown that self-expandable metal stent (SEMS) insertion provides rapid palliation of dysphagia when compared

Esophagorespiratory fistulas

Malignant esophagorespiratory fistulas (EFs) (Fig. 4) are a complication of primary tumor growth or recurrence of esophageal or lung cancer, or may result from chemotherapy and/or radiation therapy, leading to tumor necrosis. EFs result in frequent aspiration (pneumonia) and poor nutritional intake. The mean survival of patients with this complication is from 1 to 6 weeks with supportive care alone.32

Surgical closure, resection, or bypass surgery does not produce good palliative results for

Bridge-to-surgery stenting

An increasing proportion of patients with resectable esophageal cancer are being treated with neoadjuvant chemotherapy and radiotherapy or definite chemoradiation. Some of these patients into, however, have severe dysphagia and weight loss while receiving such treatment. Temporary expandable stent placement, sometimes referred to as bridge-to-surgery stenting, is an option rather than nasoenteric feeding tube or percutaneous endoscopic gastrostomy tube placement and instantly restores

Recurrent local tumor growth after esophagectomy

A substantial proportion of patients present with recurrent dysphagia because of locoregional recurrence or mediastinal metastasis within 2 years after esophagectomy and gastric conduit reconstruction (Fig. 6). Because the prognosis is dismal in these patients and rapid relief of dysphagia is therefore required, expandable stent placement seems the most optimal palliative treatment option. A recent prospective cohort study on 81 patients with recurrent tumor growth after esophagectomy

Extrinsic malignant compression on the esophagus

Malignant dysphagia because of extrinsic compression on the esophagus is another indication for palliative expandable stent placement because the majority of these patients are incurable, with a predicted life expectancy of less than 6 months. Partially as well as fully covered SEMSs have been used in this patient population with good relief of dysphagia. Despite the absence of intraluminal tumor growth, stent migration was observed in only 4% of cases in a recently published series of 50

Very proximal esophageal cancers

Tumors close to (<2 cm) the upper esophageal sphincter (UES) are seen in 7% to 10% of all esophageal cancers and are traditionally considered to be a contraindication to expandable stent placement because of the increased risk of complications such as perforation, airway compression, proximal migration, aspiration pneumonia, and discomfort due to pain and globus sensation. However, this belief has changed because several studies have shown that stent placement in patients with tumors located

Summary

The currently available expandable stents for malignant esophageal disease provide rapid and sufficient palliation of dysphagia. The rate of recurrent dysphagia due to stent migration varies, with SEPSs and fully covered SEMSs having higher migration rates than partially covered SEMSs. In contrast, tissue ingrowth or overgrowth is more frequently observed with partially covered stents. Antireflux stents can be used in patients with refractory reflux esophagitis despite PPI treatment; however,

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