Reply to García-Cano et al.

I read with interest Dr. García-Cano’s remarks concerning our recently published paper on the use of self-expandable plastic stents (SEPS) in malignant strictures [1]. The main advantage of using SEPS in esophageal carcinoma is the absence of metal meshes and the complete coverage of the stent by a silicone membrane, which reduces benign tissue hyperplasia and allows safe removal of the device even after extended periods.

The concept of step-by-step slow, continuous dilation of benign esophageal strictures using temporary stent insertion was introduced by Didcott in 1956 and has been accepted over the years [2]. We now have effective tools for treating various difficult benign conditions, including strictures, perforations, caustic stenoses, and fistulas [3] [4]. Trials are still in progress to assess the initial results with SEPS in clinical experience, but it is clear that plastic stents are superior to self-expanding metallic stents for these indications [5]. There is still debate regarding how long the stents should be left in place to dilate stenoses, but on the basis of our own experience, we would suggest that 3 weeks up to a maximum of 4 months of continuous placement are sufficient to keep benign strictures dilated. After this period, an increased rate of stent migration and also tissue overgrowth are seen with SEPS.

Dilation of the stricture is sometimes necessary before stent insertion, as the diameter of the Polyflex applicators is 12 or 14 mm. To reduce the stent migration rate, we would recommend dilation up to a maximum of 12 mm in strictures that cannot be passed with the application device [1].

The method described by García-Cano for placing the Polyflex stent without fluoroscopic guidance is helpful and easy to use. We also use this approach in proximal strictures and additionally monitor the stent release with endoscopic visualization. If the stent position is not adequate, the device can then be removed easily and reinserted afterwards. At present, we consider that this approach is only needed if there is no access to fluoroscopy available in the endoscopy unit.

References

• 1 Dormann A J, Eisendrath P, Wigginghaus B. et al . Palliation of esophageal carcinoma with a new self-expanding plastic stent.  Endoscopy. 2003;  35 207-211
• 2 Didcott C C. Oesophageal strictures: treatment by slow continuous dilatation.  Ann R Coll Surg Engl. 1973;  53 112-126
• 3 Repicii A, Conio M, de Angelis C. et al . Temporary placement of an expandable polyester silicone-covered stent for treatment of refractory benign esophageal strictures.  Gastrointest Endosc. 2004;  60 513-519
• 4 Dormann A J, Wigginghaus B, Deppe H, Huchzermeyer H. Successful treatment of esophageal perforation with a removable self-expanding plastic stent.  Am J Gastroenterol. 2001;  96 923-924
• 5 Song H Y, Park S I, Do Y S. et al . Expandable metallic stent placement in patients with benign esophageal strictures: results of long-term follow-up.  Radiology. 1997;  203 131-136