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Ann Thorac Surg 1996;62:963-967
© 1996 The Society of Thoracic Surgeons

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Original Articles: General Thoracic

Treatment of Esophageal Obstruction With Covered, Self-Expanding Esophageal Wallstents

Division of Cardiothoracic Surgery, Albany Medical Center; and Department of Thoracic Surgery, St. Peter's Hospital, Albany, New York

	Abstract

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Background. Conventional endoluminal plastic prostheses used for relieving esophageal obstruction allow variable palliation. Covered, expandable metal stents provide an 18-mm lumen to allow improved deglutition.

Methods. From December 1994 to December 1995, 20 patients underwent placement of self-expanding, silicone-covered Wallstents (Schneider, Plymouth, MN) for esophageal obstruction. Fifteen patients had obstruction secondary to carcinoma and 5 patients had benign esophageal stricture. There were 13 men and 7 women, ranging in age from 54 to 94 years. All patients underwent esophageal dilation using a flexible gastroscope and Savary bougies. After dilation to 42F or 45F, placement of the stent was performed under fluoroscopic control.

Results. Follow-up was complete in all patients, ranging from 4 weeks to 12 months. Technical success was achieved in all patients. There was one postoperative death (bronchoesophageal fistula) and one migration of the stent requiring removal (peptic stricture). The remaining stents were well tolerated, even in the cervical region (4 patients). All patients successfully intubated were able to eat well, including solid foods.

Conclusions. Covered, self-expanding esophageal Wallstents are technically simple and safe to insert and appear to provide durable, excellent palliation of esophageal obstruction due to either benign or malignant conditions. A larger patient population is required to make firm conclusions.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Esophageal obstruction from any cause is debilitating. Most cases of nonmalignant esophageal obstruction are due to peptic stricture or lye ingestion. Peptic stricture almost always can be dilated and treated with antireflux measures, with or without the need for an antireflux operation. There is a small subset of patients with benign esophageal obstruction who cannot be managed adequately with medical therapy and who are not suitable for operative intervention.

Malignant esophageal obstruction is usually caused by primary esophageal carcinoma or, less commonly, by metastatic tumor within the mediastinum that invades or compresses the esophagus. For patients with unresectable or inoperable tumors, palliation to relieve dysphagia, discomfort, and pain is the primary goal. Such treatments should be effective, safe, and well tolerated. Adequate palliation may be effected by operation, radiation, laser, repeat dilation, endoprostheses, or a combination of these measures [1]. Endoscopic implantation of an endoesophageal prosthesis is a relatively simple procedure that usually provides effective palliation of esophageal obstruction from benign and malignant causes.For editorial comment, see page 961.

Recently, a new class of endoesophageal prosthesis has become available [2–5]. Initial experience with uncovered, expandable metal stents for esophageal obstruction had the disadvantage of regrowth of tissue through the metal interstices, producing recurrence of obstruction [6, 7]. Recent improvement of these stents by covering with silicone offers the potential advantage of preventing recurrent obstruction due to tumor ingrowth and thereby providing longer palliation than from the earlier self-expanding devices. They are also suitable for tracheoesophageal fistulas [8, 9].

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
From December 1994 to December 1995, 20 patients underwent placement of self-expanding, silicone-covered Wallstents (Schneider, Plymouth, MN) for esophageal obstruction (Figs 1–3). There were 13 men and 7 women, ranging in age from 54 to 94 years. Twelve patients had obstruction from esophageal carcinoma (unresectable disease in 6, recurrent anastomotic disease in 4, and bronchoesophageal fistula in 2), 3 had other obstructive carcinoma (gastric in 1, lung in 1, and mesothelioma in 1), and 5 had benign disease (peptic stricture in 3 and anastomotic stricture in 2). All patients underwent esophageal dilation using a flexible gastroscope and Savary bougies. After dilation to 42F or 45F, the length of the obstruction was marked, and placement of the esophageal Wallstent was performed under fluoroscopic control (Fig 4). Wallstents self expand and do not require additional internal dilation after placement. All patients underwent barium esophagography after placement of the stent to ensure adequate placement and luminal patency (Fig 5).

View larger version (44K): [in this window] [in a new window]   Fig 1. . Wallstent within introducer.

View larger version (44K): [in this window] [in a new window]   Fig 2. . Partially deployed Wallstent.

View larger version (126K): [in this window] [in a new window]   Fig 3. . Wallstents measuring 4, 6, and 9 cm long.

View larger version (100K): [in this window] [in a new window]   Fig 4. . Fluoroscopic picture of Wallstent between radiopaque markers.

View larger version (128K): [in this window] [in a new window]   Fig 5. . (A) A 94-year-old woman with primary esophageal carcinoma before use of the Wallstent. (B) After Wallstent placement, she survived for 4 months without further dysphagia.

	Results

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Follow-up was complete in all patients and ranged from 4 weeks to 12 months. Technical success was achieved in all patients. There was one postoperative death in a 78-year-old woman with bronchoesophageal fistula. Two hours after stent placement, tension pneumothorax and subcutaneous emphysema developed; she suffered cardiac arrest and died in the recovery room. It was believed that dilation of the stricture and stent placement most likely converted the bronchoesophageal fistula into a bronchoesophagomediastinal fistula, thereby causing the tension pneumothorax. No autopsy was performed. The other patient with bronchoesophageal fistula survived 7 weeks and had no further episode of aspiration after stent placement.

Stent migration occurred in a 79-year-old man with hiatal hernia, longstanding tight peptic stricture, and severe inoperable coronary artery disease. Migration most likely occurred because a 4-cm Wallstent had been placed too low in the peptic stricture. The stent, which migrated into the stomach, required limited laparotomy with gastrotomy for removal. A 6-cm covered Wallstent then was placed through the stricture, with no further problems. All other stents were well tolerated, and patients were able to eat normally, including solid foods.

	Comment

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
For patients who have inoperable carcinoma of the esophagus, a means of palliation is necessary to provide comfort and to restore gastrointestinal continuity. Tumors may be unresectable and incurable because of local invasion, regional lymph node metastasis, distant metastasis, or irreversible cardiopulmonary conditions that may preclude an attempt at operative resection. When esophageal carcinoma cannot be resected completely, palliative esophagectomy or bypass procedures may be possible, but produce high morbidity rates and poor results [10]. For this group of patients, the options for palliation are repeated esophageal dilation, laser therapy or photodynamic therapy, radiation therapy, combination chemotherapy, and endoesophageal prostheses. Laser therapy or photodynamic therapy may be successful in relieving dysphagia and provides good palliation with reasonably low morbidity, but usually requires multiple tedious, time-consuming sessions [11–13]. Radiation therapy can relieve esophageal obstruction with a response rate of approximately 80%. An adequate response from radiotherapy, however, may take several weeks, and the relief is often short lived [14, 15]. Combination chemotherapy consisting of cisplatin, vindesine, and bleomycin has been shown to provide a marked clinical response in 65% of patients with carcinoma of the esophagus [16]. Although this chemotherapy regimen can achieve good results and relieve dysphagia, the treatment is toxic, expensive, and time consuming. In one recent study, severe side effects occurred in 44% of patients receiving combination chemotherapy and radiotherapy. Life-threatening side effects occurred in 20%, and only 58% had improvement in their ability to swallow [17].

Endoluminal esophageal prostheses for esophageal obstruction have been in use for more than 100 years [18]. Over this time, many tubes of the pulsion and traction variety have been described. The original tubes were made of decalcified ivory or metal. They were of small diameter, were dangerous to insert because of esophageal perforation, and led to high complication rates and poor palliation. In 1956, Mousseau and associates [19] developed a method of inserting an esophageal tube prosthesis by traction, requiring laparotomy. This technique was modified by Celestin in 1959 [20]. The Celestin tube was again a traction tube placed at laparotomy and became very widely used for palliation of esophageal obstruction. Atkinson and Ferguson in 1977 [21] introduced a pulsion tube similar to the Celestin tube, which was placed at fiberoptic endoscopy. The major advantage of the Atkinson tube, and of subsequent modifications developed by others, was that the tube could be placed safely without the need for laparotomy.

In 1974, Girardet and colleagues [22] published a collective review of 2,459 patients who were treated with esophageal tubes. The overall hospital mortality rate was 13.9%. Patients who underwent placement of traction tubes had a mortality rate of 23.5%; patients who underwent placement of pulsion tubes had a rate of 11%. The overall complication rate was 25.4%, with the most common complication being tube dislodgment and obstruction. The average survival after placement of an esophageal stent was 4.2 months. In a study by Gasparri and co-workers [23], only slightly over 50% of patients with placement of endoscopic tubes had satisfactory improvement in their ability to swallow.

Self-expanding metal endoprostheses, previously used for vascular, urethral, and biliary strictures, have been developed recently for esophageal stenting. Two different self-expanding metal endoprostheses are currently available commercially: the Wallstent and a modified Gianturco stent (Cook, Bloomington, IN). These self-expanding metal prostheses are easily placed endoscopically using either local or general anesthesia. The original self-expanding metal stents for esophageal obstruction were uncovered and allowed tumor ingrowth through the metal interstices, with reobstruction of the esophagus. Covering the metal stents with silicone has the advantage of preventing tumor ingrowth, and therefore allows longer periods of durable palliation. Fragmentation of the silicone, reported with the prototypes of the covered stent, has been eliminated with improvements in design. The current commercially available Wallstent incorporates the silicone between two layers of wire mesh. Since this modification, there have been no reports of fragmentation of Wallstents.

In our series, we treated patients with both benign and malignant esophageal obstruction. The malignant group included patients with unresectable and inoperable primary esophageal tumors, recurrent malignant anastomotic stricture, and metastatic disease in the mediastinum causing invasion or obstruction of the esophagus. The benign group included elderly patients with peptic strictures that could not be managed adequately by dilation and patients with benign anastomotic strictures after transhiatal esophagectomy. Two patients in our series had a malignant esophagorespiratory fistula. We placed stents at all levels in the esophagus, including the cervical esophagus and the gastroesophageal junction, with excellent palliation. Caution must be exercised when stents are placed through the gastroesophageal junction, as stents in this location may cause free gastroesophageal reflux. After stent placement through the gastroesophageal junction, patients should be managed with elevation of the head of the bed and long-term omeprazole and cisapride therapy. Using this regimen in patients with stents through the gastroesophageal junction, we have had no episode of significant aspiration or further esophageal stricture formation proximal to the Wallstents.

Obstruction in the cervical esophagus is believed to be a contraindication to the placement of conventional plastic esophageal stents [18]. Patients in our series who underwent placement of the Wallstent in the cervical esophagus tolerated the prosthesis well, and there was no evidence of erosion into the trachea or migration of the stent proximally across the cricopharyngeus. If the Wallstent must be placed high in the cervical esophagus, the stent may be removed completely from the introducer before the procedure and the proximal exposed wires cut off to allow placement just below the cricopharyngeus (Fig 6).

View larger version (71K): [in this window] [in a new window]   Fig 6. . Computed tomographic scan showing cross-section of a Wallstent in the upper esophagus. The esophageal lumen is widely patent with no tracheal compression.

Extreme care must be exercised to place the stent precisely through the stricture. When partially deployed, the stents may be recaptured within the introducer; once fully deployed, however, the stents are virtually impossible to remove.

Placement of a self-expanding metal esophageal prosthesis does not prevent or preclude the patient from undergoing subsequent radiotherapy or chemotherapy. It has been reported that in patients with conventional stents, postinsertion radiotherapy creates sufficient tumor necrosis that tube dislodgment may occur [24]. This complication theoretically also can occur in patients with indwelling conventional prostheses who undergo chemotherapy. The advantage of the covered esophageal Wallstent is its facility to expand, thereby remaining in place despite the changes from the response to chemotherapy. One of the patients in our series who had placement of the Wallstent subsequently underwent extensive chemotherapy. Despite a substantial response to the chemotherapy and a reduction of tumor size, the Wallstent remained in place and did not migrate.

In conclusion, the covered, expandable Wallstent is safe and easy to place. It provides excellent and durable palliation of benign and malignant esophageal obstruction at all levels. The delivery system has a low profile of only 13 mm. Once fully expanded, the stent has an internal diameter of 18 mm. Use of the Wallstent is compatible with antineoplastic therapy. The stent is available in 4-, 6-, and 9-cm lengths. For patients with obstructing lesions longer than 9 cm, Wallstents may be stacked on end. The Wallstent is suitable for use in patients with esophagorespiratory fistula.

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Presented at the Poster Session of the Thirty-second Annual Meeting of The Society of Thoracic Surgeons, Orlando, FL, Jan 29–31, 1996.

Address reprint requests to Dr Moores, Albany Cardiothoracic Surgeons, PC, 319 S Manning Blvd, Suite 301, Albany, NY 12208.

	References

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 

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