Endoscopy 2004; 36(10): 880-886
DOI: 10.1055/s-2004-825855
Original Article
© Georg Thieme Verlag Stuttgart · New York

Causes and Treatment of Recurrent Dysphagia after Self-Expanding Metal Stent Placement for Palliation of Esophageal Carcinoma

M.  Y.  V.  Homs1 , E.  W.  Steyerberg2 , E.  J.  Kuipers1 , A.  van der Gaast3 , J.  Haringsma1 , M.  van Blankenstein1 , P.  D.  Siersema1
  • 1Dept. of Gastroenterology and Hepatology, Erasmus MC University, Medical Center Rotterdam, Netherlands
  • 2Dept. of Public Health, Erasmus MC University, Medical Center Rotterdam, Netherlands
  • 3Dept. of Oncology, Erasmus Medical Center, Erasmus University, Rotterdam, Netherlands
Weitere Informationen

Publikationsverlauf

Submitted 17 December 2003

Accepted after Revision 15 June 2004

Publikationsdatum:
28. September 2004 (online)

Background and Study Aims: Recurrent dysphagia frequently complicates the palliative treatment of esophageal cancer with self-expanding metal stents. Strategies for repeat interventions and subsequent outcomes have not been adequately reported to date.
Patients and Methods: A total of 216 patients underwent placement of a self-expanding metal stent (Ultraflex, n = 75; Flamingo Wallstent, n = 71; Z-stent, n = 70) for malignant dysphagia, and were followed up prospectively. The causes of stent-related recurrent dysphagia, the intervals after first stent placement, and the procedures used for repeat intervention and their outcomes were evaluated.
Results: Seventy-four episodes of stent-related recurrent dysphagia occurred in 63 patients (29 %), mainly due to tumor overgrowth (n = 30; median 129 days), stent migration (n = 26; median 92 days) and food bolus obstruction (n = 16; median 80 days). Stent migration occurred more frequently (P = 0.05), whereas tumor overgrowth occurred less frequently (P = 0.05) with Ultraflex stents in comparison with Flamingo Wallstents and Z-stents. Tumor overgrowth was treated in 25 patients mainly by a second stent (n = 19) and was effective in 23 of the 25 patients (92 %). Five patients received no further treatment. Stent migration was treated by placing a second stent (n = 14), repositioning the migrated stent (n = 7), other treatments (n = 3), or no further treatment (n = 2), and treatment was effective in 20 of 24 (83 %) patients. Food bolus obstruction was treated by endoscopic stent clearance in all patients. Repeat intervention for stent-related recurrent dysphagia improved the dysphagia score from a median of 3 to 1 (P < 0.001). The median survival period after repeat treatment was 68 days.
Conclusions: Recurrent dysphagia occurs in almost one-third of patients after stent placement. Repeat interventions for stent-related recurrent dysphagia are effective in over 90 % of patients. New innovations in stent design are needed to reduce the risk of stent-related recurrent dysphagia.

References

  • 1 Bollschweiler E, Wolfgarten E, Gutschow C, Holscher A H. Demographic variations in the rising incidence of esophageal adenocarcinoma in white males.  Cancer. 2001;  92 549-555
  • 2 Botterweck A A, Schouten L J, Volovics A. et al . Trends in incidence of adenocarcinoma of the oesophagus and gastric cardia in ten European countries.  Int J Epidemiol. 2000;  29 645-654
  • 3 Devesa S S, Blot W J, Fraumeni J F Jr. Changing patterns in the incidence of esophageal and gastric carcinoma in the United States.  Cancer. 1998;  83 2049-2053
  • 4 Bartelsman J F, Bruno M J, Jensema A J. et al . Palliation of patients with esophagogastric neoplasms by insertion of a covered expandable modified Gianturco-Z endoprosthesis: experiences in 153 patients.  Gastrointest Endosc. 2000;  51 134-138
  • 5 Christie N A, Buenaventura P O, Fernando H C. et al . Results of expandable metal stents for malignant esophageal obstruction in 100 patients: short-term and long-term follow-up.  Ann Thorac Surg. 2001;  71 1797-1801; discussion 1801-1802
  • 6 De Palma G D, di Matteo E, Romano G. et al . Plastic prosthesis versus expandable metal stents for palliation of inoperable esophageal thoracic carcinoma: a controlled prospective study.  Gastrointest Endosc. 1996;  43 478-482
  • 7 Kozarek R A, Raltz S, Brugge W R. et al . Prospective multicenter trial of esophageal Z-stent placement for malignant dysphagia and tracheoesophageal fistula.  Gastrointest Endosc. 1996;  44 562-567
  • 8 Siersema P D, Hop W C, Dees J. et al . Coated self-expanding metal stents versus latex prostheses for esophagogastric cancer with special reference to prior radiation and chemotherapy: a controlled, prospective study.  Gastrointest Endosc. 1998;  47 113-120
  • 9 Siersema P D, Hop W C, van Blankenstein M. et al . A comparison of 3 types of covered metal stents for the palliation of patients with dysphagia caused by esophagogastric carcinoma: a prospective, randomized study.  Gastrointest Endosc. 2001;  54 145-153
  • 10 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
  • 11 De Palma G D, Iovino P, Catanzano C. Distally migrated esophageal self-expanding metal stents: wait and see or remove?.  Gastrointest Endosc. 2001;  53 96-98
  • 12 McManus K, Khan I, McGuigan J. Self-expanding oesophageal stents: strategies for re-intervention.  Endoscopy. 2001;  33 601-604
  • 13 Wang M Q, Sze D Y, Wang Z P. et al . Delayed complications after esophageal stent placement for treatment of malignant esophageal obstructions and esophagorespiratory fistulas.  J Vasc Interv Radiol. 2001;  12 465-474
  • 14 Ogilvie A L, Dronfield M W, Ferguson R, Atkinson M. Palliative intubation of oesophagogastric neoplasms at fibre-optic endoscopy.  Gut. 1982;  23 1060-1067
  • 15 Mayoral W, Fleischer D, Salcedo J. et al . Nonmalignant obstruction is a common problem with metal stents in the treatment of esophageal cancer.  Gastrointest Endosc. 2000;  51 556-559
  • 16 Harbord M, Dawes R F, Barr H. et al . Palliation of patients with dysphagia due to advanced esophageal cancer by endoscopic injection of cisplatin/epinephrine injectable gel.  Gastrointest Endosc. 2002;  56 644-651
  • 17 Won J H, Lee J D, Wang H J. et al . Self-expandable covered metallic esophageal stent impregnated with beta-emitting radionuclide: an experimental study in canine esophagus.  Int J Radiat Oncol Biol Phys. 2002;  53 1005-1013
  • 18 Di Fiore F, Lecleire S, Antonietti M. et al . Spontaneous passage of a dislocated esophageal metal stent: report of two cases.  Endoscopy. 2003;  35 223-225
  • 19 Rosen C, Goldberg R I. Repositioning of a migrated esophageal stent using a retroflexed endoscope.  Gastrointest Endosc. 1995;  42 278-279
  • 20 Berkelhammer C, Roberts J, Steinecker G. Repositioning a migrated esophageal stent using a retroflexed endoscope: a note of caution.  Gastrointest Endosc. 1996;  44 632-634
  • 21 Fry S W, Fleischer D E. Management of a refractory benign esophageal stricture with a new biodegradable stent.  Gastrointest Endosc. 1997;  45 179-182
  • 22 Ell C, May A. Self-expanding metal stents for palliation of stenosing tumors of the esophagus and cardia: a critical review.  Endoscopy. 1997;  29 392-398
  • 23 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. The Rotterdam Esophageal Tumor Study Group.  Gastrointest Endosc. 2000;  51 139-145

P. D. Siersema, M. D.

Dept. of Gastroenterology and Hepatology, Erasmus MC University, Medical Center Rotterdam

P.O. Box 2040 · 3000 CA Rotterdam · The Netherlands

Fax: + 31-10 463 4682 ·

eMail: p.siersema@erasmusmc.nl