Highly Flexible Self-Expanding Meshed Metal Stents for Palliation of Malignant Esophagogastric Obstruction

Abstract

Background and Study Aims: Palliative treatment methods for esophageal and cardiac cancer include dilation, laser vaporization and other thermal methods, alcohol injection, and stent insertion. None of these procedures, however, has proved to be a simple, well-tolerated, and lasting method. We present here our results with a new, highly flexible self-expanding metal stent made of nitinol, which is considered to be particularly useful for difficult (long and tortuous) malignant strictures.

Patients and Methods: From November 1991 to December 1994, 114 patients with unresectable esophagogastric malignancies or tumor recurrences (92 men, 22 women, mean age 64 years) were treated using 138 highly flexible meshed self-expanding metal stents. Regular clinical and endoscopic follow-up was performed, and stent obstruction or overgrowth was treated by argon plasma coagulation (APC). Patients were followed up until death (n = 78; average follow-up 17 weeks, range 1-90 weeks). Thirty- six patients were alive in December 1994 and had had an average of 20 weeks of follow-up (range 1-160 weeks).

Results: Stent insertion was technically successful in 97 % of cases, and led to a reduction of dysphagia (graded 0-4) from a mean score of 3.5 to a mean score of 1.5. Preparatory treatment to open tight strictures was necessary in 80 % of cases. Balloon dilation to support stent expansion was carried out in 42 patients (37 %). During follow-up, tumor ingrowth occurred in 66 % of cases after a mean of seven weeks, and was successfully treated by APC. Including preparatory treatment and re-treatment, patients underwent a mean of 3.5 endoscopic procedures (range 1-12 procedures), which led to good clinical success in 73 % of cases. Ninety-six percent of the patients continued to be able to swallow (dysphagia score ≤ 2) during follow-up.

Conclusions: Highly elastic self-expanding metal stents can be successfully implanted in the majority of patients, particularly in those with difficult malignant strictures not easily amenable to other methods. The devices provide good palliation with effective relief of dysphagia, easy handling and implantation, and offer a satisfactory quality of life to the patient. However, tumor ingrowth is a significant problem, even though it can be successfully managed by APC. Adequate covering of the stent that does not affect its mechanical properties or firm anchoring should solve at least some of these problems.