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Ann Thorac Surg 1999;67:781-784
© 1999 The Society of Thoracic Surgeons

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Original Articles

Self-expandable coated stent after intraluminal treatment of esophageal cancer: a risky procedure?

^a Department of Thoracic and Hyperbaric Surgery, University Medical School, Graz, Austria

Accepted for publication July 20, 1998.

Address reprint requests to Dr Maier, Dept Thorax und Hyperbare Chirurgie, Univ. Klinik für Chirurgie, Auenbruggerplatz 29, A-8036 Graz, Austria

	Abstract

Top Abstract Introduction Patients and methods Results Comment References

 
Background. Stenting is a well established palliative treatment for stenotic malignant disease of the esophagus. Because of its merely mechanical potential other tumoricidal techniques are often done before stenting.

Methods. We did esophageal stenting in 11 patients (9 men and 2 women) using a self-expanding coated stent system. Three tumors were localized in the proximal, four in the middle, and four in the distal third of the esophagus. In 9 patients tumors were locally or functional nonresectable, 1 patient refused an operation, and 1 had a recurrence after esophagojejunostomy. One patient had had pretreatment by repetitive dilatation and local hyperthermia, 9 had had photodynamic therapy followed by endoluminal iridium 192 high-dose rate brachyradiotherapy, and 1 patient was admitted with esophagotracheal fistula. The interval between the last endoluminal treatment and stent insertion was between 3 and 29 days (mean, 11 days).

Results. In 7 patients (63.7%) no complications were observed. Four patients (36.3%) died of major complications within 1 week. Postmortem examination confirmed that the pressure of the fully expanding stent to the esophageal wall caused the rupture.

Conclusion. The use of self-expanding coated stents in pretreated esophageal tumors is associated with a high risk of perforation due to pressure of the indwelling tube in a less resistant esophageal wall.

	Introduction

Top Abstract Introduction Patients and methods Results Comment References

 
Esophageal stenting is a well established palliative method. Its efficacy, however, is limited by the fact that it acts merely mechanically by pushing aside the tumor mass, thereby reinstituting an at least limited oral diet, obviating the need for hospitalization. Because a variety of tumoricidal palliative measures are now available, stenting is often used as a secondary modality of palliative treatment.

Laser disobliteration [1], local hyperthermia [2], endoluminal high-dose rate afterloading [3], and photodynamic therapy [4] are effective, commonly used methods for palliation of nonresectable esophageal malignancies. They could, however, result in scarring or weakening the esophageal wall at the site of the tumor-bearing area. Thus, if stenting becomes necessary because of therapeutic failure of those techniques or development of esophagotracheal fistula [5, 6, 7], the esophagus is highly susceptible to rupture.

The old semirigid push-through tubes [8] carried a high risk of perforation, as their positioning required a dilatation of the esophageal lumen to about 18 mm. Furthermore, the configuration of the tube with buttresses at the outside caused a rough passage through the stenosis. Theoretically, the newly developed, coated, self-expandable stent systems [9, 10] would be less dangerous, as a lumen of only 12 mm is required to enable the insertion of the folded stent. After release, the wire mesh, which on palpation is less rigid than the wall of the formerly used plastic stents, gradually expands to its final outer diameter of 16 mm. We report our experience with the use of coated self-expandable stents in 11 patients, 10 of whom had extensive endoluminal pretreatment.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment References

 
During the past 6 months, 9 men and 2 women (mean age, 62 years; range, 44 to 77 years) underwent esophageal stenting (Covered Ultraflex Esophageal Stent System, Microvasive, Boston Scientific Corporation, Boston, MA). Histologically, six squamous-cell carcinomas and five adenocarcinomas were documented. Nine tumors were nonresectable for anatomic or functional reasons. One patient refused an operation, and 1 had an anastomotic recurrence after esophagogastrectomy and esophagojejunostomy. In all cases the tumor showed a circumferential involvement of the esophageal wall (mean length of stenosis, 8 cm; range, 4 to 11 cm). Three tumors were localized in the proximal, four in the middle, and four in the lower third of the esophagus.

One patient had had pretreatment by repetitive dilatation and local hyperthermia [2], 9 had photodynamic therapy [4], 2 mg/kg of body mass (Photosan-3, Seehof Laboratorium GmbH, Wesselburenerkoog, Germany), 48 hours before 100 J/cm² 630-nm monochrome dye-laser beam application, followed by endoluminal iridium 192 (¹⁹²Ir) high-dose rate brachyradiotherapy (total dose, 10 Gy at 1-cm distance from the surface of the source). One patient had an esophagotracheal fistula at the time of admittance.

The indications for stenting were insufficient patency of the lumen with dysphagia for liquids and saliva and signs of a developing esophagotracheal fistula [5, 6, 7] in 9 cases and persistent esophagotracheal fistula in 2 cases. The interval between the last endoluminal treatment and stent insertion was between 3 and 29 days (mean, 11 days).

Dilatation to a lumen of 12 mm before placement was necessary in 6 cases with postirradiation scarring. In 3 patients the esophageal passage for the 11-mm endoscope was free, but the wall collapsed, causing functional stenosis. Gross tumor necrosis was visible in 4 patients. Under endoscopic and fluoroscopic control, the proximal and distal tumor margins were marked with hypodermic needles on the surface of the thorax, at the same time a guide was inserted through the endoscope. After removing the endoscope the covered Ultraflex stent system delivery catheter was passed over the guide wire, placing the stent in a way to ensure that the external marker needles were centered between the two radiopaque markers of the stent (Fig 1). Once in position, the stent was deployed, beginning at its distal end (Fig 2). After removal of the applicator and the guide wire, correct positioning and the absence of a perforation was confirmed by endoscopy (Fig 3) and by swallow of contrast medium (Fig 4).

View larger version (105K): [in this window] [in a new window]   Fig 1. Distal and proximal tumor margins, marked with hypodermic needles (arrows) on the surface of the thorax.

View larger version (133K): [in this window] [in a new window]   Fig 2. Stent deployment. Large arrow indicates stent that is not fully deployed.

View larger version (134K): [in this window] [in a new window]   Fig 3. Fully deployed stent. Large arrows indicate proximal and distal stent margins.

View larger version (119K): [in this window] [in a new window]   Fig 4. Postinterventional fluoroscopy. Large arrow indicates punctum maximum of tumor stenosis.

	Results

Top Abstract Introduction Patients and methods Results Comment References

Relief from dysphagia was immediate in all patients. Within 1 week, however, major complications evolved in 4 patients. One patient with carcinoma in the proximal third of the esophagus developed a stent protruding into the tracheal lumen with no signs of esophagotracheal fistula but severe dyspnea. The patient had refused prior operation, and he was treated by repetitive dilatation and local hyperthermia. The indication for stenting was severe dysphagia and signs of a developing esophagotracheal fistula. Several days after stent insertion the patient showed a stent protruding into the tracheal lumen from the fourth tracheal ring to the carina with a stenosis of more than 60%. Stenting of the trachea was impossible because of a destroyed paries membranaceus of the trachea. The patient was treated symptomatically with steroids, nonsteroidal antirheumatics, antiobstructive drugs, and analgesics; he was able to take a liquid diet. Four weeks after stent implantation he died of respiratory insufficiency as a consequence of the stent protruding into the trachea.

Three patients with carcinoma in the distal third of the esophagus had penetration of the stent into the mediastinum with consecutive mediastinitis and empyema. Surprisingly, the site of perforation was not at the margin of the stents but alongside the tubular parts. It had been caused by self-dilation of the mesh into a necroctic esophageal wall. All 3 patients had prior photodynamic therapy, ¹⁹²Ir brachyradiotherapy, and laser disobliteration. The patients had shown gross tumor necrosis and collapse of the esophageal wall after the tumoricidal pretreatment. Stenting had been done within 2 weeks after the last endoluminal treatment. In these patients complications evolved within 1 week. Because of poor prognosis and bad general condition, all complications were treated with intercostal suction drainage, antibiotics, parenteral feeding, and analgesics. The patients died within 2 weeks after having developed their complication. Postmortem examination confirmed that the pressure of the fully expanded stent to the pretreated and weak esophageal wall caused its rupture.

In 7 patients (63.7%) no complications were observed. The overall palliative result of stenting was satisfactory, enabling the intake of well-chewed solids. Lethal complications were observed in 3 (33%) of 9 patients pretreated with photodynamic therapy, ¹⁹²Ir brachyradiotherapy, and laser disobliteration. All of these patients showed gross tumor necrosis, and stenting was done within 2 weeks after the last tumoricidal endoluminal pretreatment.

	Comment

Top Abstract Introduction Patients and methods Results Comment References

 
Stenting is one of the oldest techniques for palliation of esophageal carcinoma. The open pull-through techniques have been replaced by push-through techniques, which do not require a laparotomy. In both techniques, however, gross dilatation of the tumor stenosis was necessary to enable the passage of the semirigid plastic or rubber tubes [8, 11]. Consequently, the rate of gross esophageal rupture at the tumor site, as well as aspiration, reflux, pneumonia, and sepsis with lethal complications was high, with a mortality rate of up to 42% [12]. As the effect of the stent is merely mechanical, by simply pushing aside the tumor mass, its duration is also limited. Problems such as penetration into the mediastinum or secondary perforation into neighboring organs, tumor regrowth at the borders of the stent, and dislocation are common [13]. Furthermore, the inappropriate diet as well as the lack of peristalsis causes stent obliteration if the patient does not chew his food well enough.

With the development of tumoricidal intraluminal palliation techniques the use of stents has become less frequent, as good and long-term palliative results can be achieved with a low rate of complications [3]. Laser disobliteration techniques, endoluminal high- dose rate brachyradiotherapy, or photodynamic therapy are successfully used in nonresectable esophageal cancer [1, 3, 4].

In some cases, however, the need for a stent might evolve because of tumor regrowth, extrinsic stenosis, esophagotracheal fistula, or scarring refractory to dilatation. In these pretreated patients, however, the esophagus is prone to rupturing when gross dilatation must be applied before stenting. We hoped that the new self-expandable system [9, 10] would overcome this basic problem.

The custom made self-expandable coated stent system [9] requires dilatation to 12 mm only. The wire-guided and fluoroscopically controlled passage of the stent folded around the applicator into the stenosis was smooth and without additional trauma to the esophageal wall. Once deployed, the metal mesh of the stent gradually expanded to its final diameter of 23 mm. By palpation, the outer circumference seemed far less rigid than the rubber or silicone elastomer stents. Postintervention endoscopy and fluoroscopy and the clinical course throughout the first few postoperative days documented the absence of perforation. Nevertheless, serious complications developed later.

In all patients in this series their esophageal carcinoma had been pretreated. Stenting [14] was the ultima ratio in these patients because of poor prognosis, bad general condition, and persistent severe dysphagia and esophagotracheal fistula with no other optional palliative treatment.

Postmortem examination confirmed the changes in the esophageal wall. Tumor necrosis and subsequent fibrotic scarring caused thinning, and tumor regrowth further decreased the mechanical resistance of the esophageal wall. With the increasing pressure of the stent expanding to a full diameter of 17 to 23 mm within a few days, disruption of the esophagus alongside the stent developed, especially in a pretreated weak esophageal wall.

In conclusion, the problem of recurrent intrinsic or extrinsic stenosis after having applied various tumoricidal intraluminal palliative treatments for esophageal carcinoma remains. Especially in cases of visible tumor necrosis in a pretreated esophagus, stent implantation should be considered very risky. The subgroup of patients pretreated with photodynamic therapy, ¹⁹²Ir brachyradiotherapy, and laser disobliteration had the greatest risk of a developing lethal complication. We recommend waiting more than 4 weeks between last tumoricidal endoluminal pretreatment and stent insertion. The interval of 4 weeks after the last endoluminal tumoricidal therapy has been estimated on the basis of our experience: no complications evolved in patients who underwent stenting after this interval. Nevertheless, 4 weeks is an intuitive estimation. However, regarding the discomfort associated with gastrostomy and cervical esophagostomy or with long-term feeding through a nasogastric tube or with parenteral nutrition, a patient unable to swallow his saliva has only few options left.

	References

Top Abstract Introduction Patients and methods Results Comment References

 

1. Moraldi A., Iascone C., Zerilli M., et al. A prospective randomized study of Nd:YAG laser therapy versus intubation for cancer of the esophagus and cardia. In: Ferguson M.K., Little A.G., Skinner D.B., eds. . Diseases of the esophagus. Mt Kisco, NY: Futura Publishing Company, Inc, 1990:345-349.
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