Palliation in Malignant Esophageal Stricture and Fistulas with Self-expandable Metallic Stents

Abstract

Objective:We aimed to present the effectiveness of self-expandable metallic stents (SEMS) in dysphagia score and fistula closure, which are used in palliation for dysphagia and tracheoesophageal fistula seen in primary and secondary advanced esophagus tumors.Method:We reviewed the files and records of 34 patients who underwent stent implantation due to esophageal stricture and/or fistula in our clinic between 1997 and 2002. The patients were assessed regarding age, gender, the reason for stent insertion (stricture or fistula), localization of stricture or fistula, pre-procedural and post-procedural dysphagia scores (DS), stent specifications, tumor histopathology, complications and need for re-stenting.Results:In our clinic, 36 SEMS were inserted to 34 patients during this period. The median age was 64 years (range: 44-82 years). There were 24 men and 10 women. Of the patients considered as inoperable, 15 (44%) had primary esophagus carcinoma while 19 (46%) had secondary esophagus carcinoma including 9 gastric carcinomas, 8 lung cancers, 1 larynx cancer and 1 acute myeloid leukemia. The anatomic localizations included cervical esophagus in one patient (3%), thoracic esophagus in 16 patients (47%), and distal esophagus in 17 patients (50%). There was stricture in 25 patients (73.5%), stricture plus fistula in 6 patients (17.6%), and fistula alone in 3 patients (8.8%). Thirty-six self-expandable stents were implanted in 34 patients for stricture and fistula palliation, including 30 (29 covered, 1 non-covered) Ultraflex stent, 3 Wallstent esophageal stents, and 3 Flamingo stent, a modified Wallstent for gastroesophageal junction tumors. The dysphagia score was 4 (unable to swallow anything) in 5, 3 (difficulty to swallow liquids) in 20, and 2 (difficulty to swallow solid foods) in 6 of 31 patients with a stricture. The mean dysphagia score was found as 2.96 before the procedure whereas 0.19 after the procedure. There was minimal difficulty to swallow solid foods (DS:1) in 6 patients and no dysphagia (DS:0) in 25 patients after the procedure. The fistula tract was closed by SEMS in all 9 cases (3 with fistula and 6 with fistula plus stricture) in which fistula tract palliation was intended. No major complication was detected in 36 stent interventions performed in 34 patients while minor complication rate was 17.6% including stent migration in 2 patients, complete obstruction at the distal tip due to food plug in 2 and granulation tissue in one patient, and less than 50% expansion of the stent in one patient. Re-stenting was performed in 2 patients with minor complications. The re-stenting rate was 5.8% in our study.Conclusion:SEMS are among first-line modalities in the palliation of malignancy-related esophagus stricture and fistula. Palliation of esophagus stricture and fistulas due to primary or secondary esophagus malignancies using SEMS is a safe, effective, and readily tolerable method. The accurate positioning of a stent in a safe manner can be achieved using fluoroscopy during procedure. Endoscopy before and after procedure improves the success and effectiveness of the procedure.

Keywords

• dysphagia
• esophagus
• self-expandable metallic stent
• tracheoesophageal fistula