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Endoscopic stenting for palliation of malignant esophageal obstruction

Endoscopic stenting for palliation of malignant esophageal obstruction
Literature review current through: Jan 2024.
This topic last updated: Oct 25, 2022.

INTRODUCTION — Endoscopic stent placement is a nonsurgical alternative for palliation of malignant esophageal obstruction. Tumor-related dysphagia results in limited oral intake and weight loss. Esophageal cancer is a common cause of malignant obstruction and is often diagnosed at an advanced stage. Esophageal stents also provide palliation of dysphagia for patients with malignancy that results in extrinsic compression.

This topic will review endoscopy-guided stent placement for malignant esophageal obstruction. Other methods of endoscopic palliation for esophageal cancer (eg, brachytherapy) are discussed separately. (See "Endoscopic palliation of esophageal cancer".)

Common causes of malignant esophageal obstruction include squamous cell carcinoma and adenocarcinoma of the esophagus. The tumor may involve the proximal (cervical), middle, and/or distal esophagus. Management of esophageal cancer is discussed separately:

(See "Management of locally advanced, unresectable and inoperable esophageal cancer".)

(See "Surgical management of resectable esophageal and esophagogastric junction cancers".)

(See "Radiation therapy, chemoradiotherapy, neoadjuvant approaches, and postoperative adjuvant therapy for localized cancers of the esophagus".)

The evaluation for patients with a mediastinal tumor causing esophageal obstruction is discussed separately. (See "Approach to the adult patient with a mediastinal mass".)

Endoscopy-guided esophageal stent placement for nonmalignant disease is discussed separately:

Nonmalignant esophageal stricture (see "Endoscopic interventions for nonmalignant esophageal strictures in adults")

Esophageal varices (see "Methods to achieve hemostasis in patients with acute variceal hemorrhage", section on 'Esophageal stents')

Anastomotic leak following esophageal resection (see "Complications of esophageal resection")

INDICATIONS — Esophageal stent placement for palliating dysphagia related to malignant obstruction is indicated for the following [1-3] (see "Management of locally advanced, unresectable and inoperable esophageal cancer"):

Patients with surgically incurable cancer resulting in intrinsic esophageal obstruction or extrinsic esophageal compression

Patients with limited functional status who cannot tolerate surgery or chemoradiotherapy

Patients with locally recurrent disease after primary therapy

Goals of esophageal stent placement include:

Improve dysphagia such that oral intake is maintained

Alleviate other symptoms such as cough

Esophageal stents are not routinely placed for patients with locally advanced, potentially resectable disease prior to neoadjuvant chemoradiotherapy. While self-expandable metallic stent (SEMS) placement has been studied to allow oral feeding in such patients, studies have raised concerns about the increased risk of toxicity during chemoradiation therapy, the possible negative impact on oncologic outcomes, and the uncertain benefit for nutritional status [4-7]. (See "Radiation therapy, chemoradiotherapy, neoadjuvant approaches, and postoperative adjuvant therapy for localized cancers of the esophagus".)

CONTRAINDICATIONS — Contraindications to endoscopic stenting for malignant esophageal obstruction include:

Patients who cannot tolerate moderate sedation, monitored anesthesia care, or general anesthesia (see "Anesthesia for gastrointestinal endoscopy in adults")

Patients who are hemodynamically unstable

Patients with untreated disorders of hemostasis (eg, platelet count <50,000/microL) (see "Gastrointestinal endoscopy in patients with disorders of hemostasis")

PREPROCEDURE EVALUATION — For patients undergoing esophageal stent placement for malignant obstruction, preprocedure evaluation includes reviewing imaging studies and direct endoscopic visualization. Most patients will have had imaging (eg, computed tomography [CT] scan) as part of the diagnostic evaluation, thereby mitigating the need for additional imaging.

Radiographic imaging (eg, CT scan of the chest and upper abdomen) can provide the following information:

Estimated length of the esophageal narrowing and severity of obstruction.

Evaluation for risk of tracheal compression. Patients with bulky proximal or midesophageal tumors or mediastinal tumors (eg, lung cancer) may be at risk for airway compromise from tracheal compression (image 1 and table 1), whereas tumors that are below the level of the carina do not typically lead to symptomatic airway compromise [8]. Cross-sectional imaging prior to the procedure can identify patients who are at risk for airway compromise. For such patients, preprocedure evaluation includes consultation with an interventional pulmonary specialist to evaluate for airway stent placement. Indications for and placement of an airway stent are discussed separately. (See "Airway stents".)

Clinical features (tachypnea, stridor) and management of airway compromise are discussed separately. (See "Clinical presentation, diagnostic evaluation, and management of malignant central airway obstruction in adults" and "Radiology of the trachea", section on 'Short segment narrowing'.)

The goals of direct endoscopic visualization of the site of obstruction are:

To assess the site for potential stent placement (eg, severity of obstruction, degree of angulation)

To identify origin of the tumor (intrinsic versus extrinsic)

To obtain tissue biopsy for histologic diagnosis of an intrinsic esophageal tumor (if biopsy was not performed previously)

STENT PLACEMENT

Patient preparation — The preprocedure preparation for patients undergoing endoscopic stent placement is similar to that described for patients undergoing upper endoscopy (see "Overview of upper gastrointestinal endoscopy (esophagogastroduodenoscopy)", section on 'Patient preparation'):

Adjusting medications – Most patients do not need to discontinue aspirin or nonsteroidal anti-inflammatories when undergoing upper endoscopy. The management of antiplatelet and anticoagulant therapy is typically individualized, managed in conjunction with the prescribing subspecialist, and discussed separately. (See "Management of antiplatelet agents in patients undergoing endoscopic procedures" and "Management of anticoagulants in patients undergoing endoscopic procedures" and "Gastrointestinal endoscopy in patients with disorders of hemostasis".)

Antibiotic prophylaxis – Patients do not routinely need prophylactic antibiotics prior to esophageal stent placement. (See "Antibiotic prophylaxis for gastrointestinal endoscopic procedures".)

Anesthesia – The procedure is typically performed using monitored anesthesia care or general anesthesia. Anesthetic management for endoscopic procedures including preprocedure fasting is discussed separately. (See "Anesthesia for gastrointestinal endoscopy in adults".)

Types of stents — Esophageal stents are available in varying lengths, diameters, and delivery systems. Newer-generation stents are often brought to market [9]. Thus, this section describes commonly used stents and is not a comprehensive list of all available stents.

Self-expandable metallic stents — Specific features of self-expandable metallic stents (SEMS) for palliation of malignant esophageal obstruction include [10] (see 'Selecting a stent' below):

Material – Most SEMS are composed of nitinol, an alloy of nickel and titanium.

Covering – SEMS may be uncovered (meshwork is bare wire) or covered (meshwork is partially or fully covered to decrease tissue growth into the stent) (picture 1). Some fully covered SEMS have fenestrations in their covering without any exposed bare metal struts. The advantage of covered SEMS is that they resist tumor ingrowth and are removable, but they have higher migration rates, especially when fully covered [11]. Covered SEMS can also be used in the closure of fistulas. (See 'Patients with tracheoesophageal fistula' below.)

Partially covered stents are uncovered at their ends, which allows the stent to embed in the tissue and helps to prevent migration. Uncovered stents may be less likely to migrate but are subject to higher rates of tumor ingrowth and recurrent esophageal obstruction.

Delivery system – Most stent delivery systems are too large in diameter to pass through the accessory channel of a standard endoscope in their predeployed forms. However, some delivery systems can be advanced through a larger accessory channel (ie, channel diameter ≥3.7 mm) of a therapeutic endoscope (eg, Niti-S through-the-scope esophageal stent). The advantage of such delivery systems is that direct endoscopic visualization during stent deployment is possible, but the downside is that use of an endoscope with a large outer diameter (ie, outer diameter 10 mm) is required. This can limit endoscopic assessment of the stricture without first performing esophageal dilation, which is not typically needed when using an endoscope with a small outer diameter (outer diameter range 4.9 to 5.4 mm).

Stent length – Stent length ranges from 6 to 19.5 cm, although the maximum length available in the United States is 15 cm.

Stent diameter – Stent (or shaft) diameter ranges from 10 to 23 mm. Studies have reported use of smaller diameter SEMS (eg, biliary stents) for patients with malignant proximal (cervical) esophageal strictures [12-15]. (See "Endoscopic stenting for malignant biliary obstruction", section on 'Metal stents'.)

Other features – Some SEMS have an antireflux valve with a goal of preventing gastroesophageal reflux in patients with stents that have been placed across the esophagogastric junction (EGJ). All devices available in the United States do not have an antireflux valve.

Devices available in the United States include:

Wallflex – Partially covered and fully covered nitinol stents.

Evolution – Partially covered and fully covered nitinol stents.

Ultraflex stent – Partially covered and uncovered nitinol stents.

Agile – Partially covered and fully covered nitinol stent housed on a through-the-scope delivery system.

Hanarostent – Partially covered and fully covered nitinol stent housed on a through-the-scope delivery system.

Alimaxx-ES, Endomaxx, and Endomaxx EVT stents – Fully covered nitinol stents without or with a valve (Endomaxx EVT only).

Niti-S – Fully covered nitinol stent available in two versions: the covered Niti-S and the double-layered Niti-S that has an additional layer of nitinol [16]. A through-the-scope delivery system is available.

Other stents — A self-expandable plastic stent made from polyester and covered with silicone is available, but such stents are approved only for benign esophageal disease (eg, refractory esophageal stricture) (picture 1). (See "Endoscopic interventions for nonmalignant esophageal strictures in adults", section on 'Refractory strictures'.)

Selecting a stent — For most patients with malignant esophageal obstruction from unresectable tumor, partially or fully covered SEMS are placed for palliation of dysphagia because such stents are effective for improving dysphagia and facilitating oral intake and the rates of occlusion from tumor ingrowth are lower than other stent types [17-22]. In a trial including 101 patients with unresectable esophageal cancer, patients with covered SEMS had lower rates of recurrent dysphagia compared with self-expandable plastic stents (SEPS) (33 versus 48 percent). In an analysis adjusted for age, comorbidities, previous therapy, and stenosis severity, the stent-related complication risk was higher for patients with SEPS (odds ratio 2.3, 95% CI 1.2-4.4) [17]. In a trial including 62 patients with unresectable esophageal cancer, improvement in dysphagia was not significantly different for patients with covered or uncovered SEMS [18]. However, rates of tumor ingrowth were lower in the covered stent group (3 versus 30 percent), while there was no significant difference in rates of stent migration for patients with covered compared with uncovered SEMS (12 versus 7 percent). (See 'Stent migration' below.)

Data have suggested that rates of recurrent obstruction or other adverse events were not significantly different for patients with fully or partially covered SEMS [23,24]. As an example, in a trial including 98 patients with incurable malignant obstruction of the esophagus or cardia, rates of recurrent obstruction were not significantly different for patients with fully covered SEMS compared with partially covered SEMS (19 versus 22 percent) [23]. In addition, the rate of stent migration was not significantly different for patients with fully covered SEMS compared with partially covered SEMS (8 versus 6 percent).

Endoscopy with stent deployment — For patients with malignant esophageal obstruction, endoscopic stent placement is initiated in a similar fashion to upper endoscopy (esophagogastroduodenoscopy), and the general technique is summarized as follows (see "Overview of upper gastrointestinal endoscopy (esophagogastroduodenoscopy)"):

Position the patient in the left lateral decubitus position.

Introduce the gastroscope into the patient's mouth and advance it under direct visualization through the upper esophageal sphincter and into the proximal esophagus.

Use carbon dioxide insufflation instead of air during endoscopy to minimize luminal distension [25].

Continue advancing the gastroscope until the tip of the instrument reaches the obstructing lesion.

Inspect the lesion and gently traverse it, if technically feasible.

Assess the appearance and length of the malignant stricture. Some advanced endoscopists place internal radio-opaque markers (eg, metal clips used for hemostasis) to mark the proximal and distal margins of the tumor prior to stent deployment under fluoroscopic guidance. (See "Endoscopic clip therapy in the gastrointestinal tract: Bleeding lesions and beyond".)

Most malignant strictures do not require dilation prior to stent placement. However, gentle dilation of some strictures may be required to allow passage of the predeployed stent.

Select a stent with a length that equals the length of the stricture plus a minimum of 2 cm at the proximal and distal margins of the stricture (ie, stent length equals the stricture length plus a minimum of 4 cm). (See 'Selecting a stent' above.)

With the tip of the endoscope positioned distal to the obstructing lesion, advance the tip of the guidewire through the accessory channel of the endoscope and into the stomach.

Withdraw the endoscope, while maintaining the position of the guidewire. The wire should serve as an immobile monorail over which the predeployed stent and delivery system are passed.

Proceed with stent deployment. Esophageal stents can be deployed using fluoroscopic guidance, endoscopic guidance, or both. Visualization technique for stent deployment is typically determined by the delivery system, location of obstruction site, and clinician preference.

Remove the guidewire. If endoscopic visualization was used, remove the endoscope.

After the stent is deployed, it expands against the stricture and against the mucosa at the stricture margins. This process anchors the stent in place and helps prevent stent migration. The process of complete stent expansion may require 48 to 72 hours.

Modifications to the general technique for stent deployment are generally based on the location and characteristics of the obstruction:

Patients with proximal esophageal obstruction – SEMS placement in the proximal esophagus can be technically challenging in patients with cervical esophageal obstruction [11,26,27]. Placement can be accomplished endoscopically by visualizing and documenting the distance from the incisors to the proximal margin of the tumor, followed by stent placement under endoscopic visualization. For patients with malignant esophageal strictures near the upper esophageal sphincter, the position of the stent during deployment is adjusted so that the proximal margin of the stent is below the upper esophageal sphincter [27].

Patients with obstruction of the EGJ – For stent placement in the distal esophagus, it is important to avoid an excessive length of stent within the stomach because such stent positioning may result in contact with the mucosa of the gastric cardia or on the contralateral gastric wall, leading to ulceration.

Postprocedure care — After the procedure, patients are recovered from sedation or anesthesia. (See "Anesthesia for gastrointestinal endoscopy in adults", section on 'Post-anesthesia care'.)

Patients may drink water after recovering from sedation. Patients are discharged with written diet instructions based on results of stent placement and the expected gradual expansion of the stent. Patients are typically advised to consume liquids only for 24 to 48 hours and then to advance to a soft solid diet as tolerated (table 2). Patients are also advised to adhere to long-term avoidance of fibrous foods such as raw vegetables and large pieces of meat [28].

For patients with stent placement across the gastroesophageal junction, measures to prevent acid reflux and aspiration of gastric contents are advised, and they include maintaining an upright (or semiupright) position at all times and daily proton pump inhibitor (table 3).

Efficacy — For most patients with malignant esophageal obstruction treated with stenting, SEMS placement is technically successful and effective for relieving dysphagia. In a cohort study including 997 patients who had SEMS for malignant esophageal obstruction, rates of technical success were >95 percent, and dysphagia scores improved from a median of grade 3 (tolerating liquids only) to grade 0 (tolerating normal diet) at four weeks [29,30].

Despite initial success with SEMS placement, dysphagia recurrence is common. In a cohort study including 997 patients with SEMS, recurrent dysphagia occurred in 309 patients (31 percent) after a median duration of 56 days. Recurrent dysphagia was most often related to stent occlusion from tumor or hyperplastic tissue ingrowth/overgrowth (44 percent), stent migration (36 percent) (image 2), or stent occlusion from food bolus (23 percent). (See 'Stent-related' below.)

Data have suggested that dysphagia from tumor-related extrinsic compression improved with SEMS placement. In a study including 105 patients with malignant esophageal obstruction, improvement in dysphagia scores was not significantly different for patients treated for extrinsic compression of the esophagus compared with intrinsic obstruction [2]. In addition, complication rates were not significantly different between the groups.

ADVERSE EVENTS — Adverse events associated with endoscopic stenting for malignant esophageal obstruction may be related to the endoscopic procedure or to stent placement.

Endoscopy related — Complications associated with upper endoscopy alone are uncommon, but they may be due to the endoscopy or due to anesthesia (eg, hypotension). Endoscopy-and anesthesia-related complications are discussed separately. (See "Anesthesia for gastrointestinal endoscopy in adults", section on 'Complications' and "Overview of upper gastrointestinal endoscopy (esophagogastroduodenoscopy)", section on 'Complications'.)

Stent-related — Data have suggested that self-expandable metallic stent (SEMS) placement was associated with an overall complication rate ranging from 45 to 60 percent [23,29,31]. In an observational cohort including 997 patients with palliative SEMS placement for malignant esophageal obstruction, the most commonly reported adverse events included retrosternal pain (30 percent), tissue ingrowth/overgrowth (14 percent), and stent migration (11 percent) [29]. Major adverse events that were less commonly reported included bleeding (8 percent), pneumonia (5 percent), fever (5 percent), esophageal fistula formation (3 percent), and perforation (2 percent).

Reported mortality rates related to esophageal stent insertion have been low and ranged from 0 to 2 percent [29,32].

Timing and risk factors — The timing of adverse events can be classified as immediate or delayed [33-35]:

Immediate complications include retrosternal pain, bleeding, perforation, tracheal compression, and acute respiratory failure.

Delayed complications include gastroesophageal reflux, tumor ingrowth/overgrowth (resulting in stent occlusion and recurrent dysphagia), stent migration, delayed bleeding, tracheo- or broncho-esophageal fistula formation, and perforation.

Data on chemotherapy and/or radiation therapy as a risk factor for complications after stent placement have been mixed. Some studies have demonstrated that chemoradiotherapy was associated with increased risk of complications such as esophago-respiratory fistula [29,36-38], while other studies have not [31]. The approach to and complications of chemoradiation for inoperable esophageal cancer are discussed separately. (See "Management of locally advanced, unresectable and inoperable esophageal cancer", section on 'Patients who are fit for combined modality therapy'.)

Limited data suggest that patients with tumors invading the aorta may be at increased risk for delayed bleeding. As an example, in a cohort study including 22 patients with SEMS for progressive or recurrent cancer after chemoradiotherapy, eight patients (36 percent) had tumor invasion into the aorta. Six of these patients (75 percent) died suddenly from massive hemorrhage after a median of 31 days [39].

Stent migration — Migration of the esophageal stent (typically into the stomach) is a common indication for reintervention after stent placement. Reported rates of stent migration have ranged from 5 to 25 percent [23,29,40].

Endoscopic methods that have been utilized to lower the risk of stent migration have included endoscopic suturing systems [41] and over-the-scope clip devices [42-44]. (See "Endoscopic clip therapy in the gastrointestinal tract: Bleeding lesions and beyond".)

However, retrospective case series utilizing esophageal stent anchoring methods have reported stent migration rates of approximately 15 percent [41-43]. Thus, additional studies are needed before antimigration measures are used routinely for patients with malignant esophageal obstruction.

Stent occlusion — Stent occlusion may be related to tumor ingrowth/overgrowth or food bolus, but it can often be managed endoscopically [29]. As an example, for patients with tumor growth, palliation of dysphagia can be achieved by placing a second esophageal stent through the occluded stent or by using other endoscopic methods (eg, laser ablation) [45]. (See "Endoscopic palliation of esophageal cancer".)

Other complications — Other stent-related complications include:

Retrosternal pain – Retrosternal pain is commonly reported following esophageal stent placement. Based on limited published data and clinical experience, retrosternal pain is often self-limited and improves with oral nonopioid analgesics [29].

Esophageal fistula – Esophago-respiratory fistula is a serious delayed adverse event of esophageal stent placement. In a retrospective study of 397 patients who had received esophageal stents for both malignant and benign causes, stent-related esophago-respiratory fistulas developed in 16 patients (4 percent) after a median of five months (range <1 to 53 months) [38]. In another observational study including 208 patients with stent placement (with or without radiation therapy) for inoperable, locally advanced esophageal cancer, 18 patients (9 percent) developed an esophageal fistula, 17 of whom had received radiation therapy (94 percent) [37]. The risk of esophageal fistula was higher among patients who received radiation therapy after stent placement compared with radiation prior to stent placement. (See "Radiation therapy, chemoradiotherapy, neoadjuvant approaches, and postoperative adjuvant therapy for localized cancers of the esophagus".)

Gastroesophageal reflux – For patients with malignant obstruction involving the distal esophagus and esophagogastric junction, SEMS placement across the lower esophageal sphincter produces an open conduit for reflux of gastric contents. Gastroesophageal reflux may be complicated by regurgitation and aspiration. Measures to prevent reflux symptoms and reflux esophagitis include daily proton pump inhibitor therapy and reflux precautions (ie, maintaining an upright or semi-upright position at all times) (table 3). Medical management of gastroesophageal reflux disease is discussed in more detail separately. (See "Medical management of gastroesophageal reflux disease in adults".)

SEMS with antireflux barriers by means of a one-way valve on the gastric side (ie, distal end) of the stent have been developed, but none are available in the United States. A meta-analysis of six trials including 276 patients with inoperable cancer of the esophagogastric junction (EGJ) suggested that antireflux stents were effective for improving dysphagia [46]. However, there were no significant differences in rates of adverse events or in reflux symptom severity for SEMS with an antireflux valve compared with open SEMS with or without proton pump inhibitor use.

SAFETY OF MRI — Most self-expandable metallic stents appear safe for performing magnetic resonance imaging (MRI). However, factors such as stent shape, magnetic field orientation, and alloy composition may influence signal intensity in vitro; thus, stent characteristics and its orientation to the magnetic field should be reviewed before MRI is performed [33]. (See "Patient evaluation for metallic or electrical implants, devices, or foreign bodies before magnetic resonance imaging".)

SPECIAL POPULATIONS

Patients with tracheoesophageal fistula — Some patients with dysphagia related to malignant esophageal obstruction also have tracheoesophageal fistula (TEF), a pathologic connection between the esophagus and trachea. Symptoms of TEF include coughing with oral intake, aspiration, and pulmonary infections. Treatment for most malignant TEF involves stenting the esophagus, the airway, or both. For patients with malignant TEF, data have suggested that covered SEMS in the esophagus were associated with rates of fistula closure ranging from 80 to 100 percent (picture 2) [26,47]. Palliative interventions for patients with malignant TEF are discussed separately. (See "Tracheo- and broncho-esophageal fistulas in adults", section on 'Malignant lesions (palliative therapy)'.)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Esophageal cancer" and "Society guideline links: Esophageal strictures, foreign bodies, and caustic injury".)

SUMMARY AND RECOMMENDATIONS

Upper endoscopy with esophageal stent placement is indicated for palliation of malignant dysphagia for patients with any of the following (see 'Indications' above):

Surgically incurable cancer resulting in intrinsic esophageal obstruction or extrinsic esophageal compression

Poor functional status that limits use of other therapies (surgery, chemoradiotherapy)

Locally recurrent disease after primary treatment

For patients undergoing esophageal stent placement for malignant obstruction, preprocedure evaluation includes reviewing imaging studies and direct endoscopic visualization. Most patients will have had imaging (eg, computed tomography [CT] scan), thereby mitigating the need for additional imaging. (See 'Preprocedure evaluation' above.)

Patients with bulky proximal or midesophageal tumors or mediastinal tumors may be risk for airway compromise from tracheal compression (table 1). Preprocedure cross-sectional imaging can identify patients who are at risk for airway compromise. For such patients, preprocedure evaluation includes consultation with an interventional pulmonary specialist for evaluation of airway stent placement. (See "Airway stents".)

Esophageal self-expandable metallic stents (SEMS) are available in varying lengths, diameters, and delivery systems. Most SEMS are composed of nitinol, an alloy of nickel and titanium. (See 'Types of stents' above.)

For patients with malignant esophageal obstruction who undergo esophageal stent placement, we suggest partially or fully covered SEMS for palliation of dysphagia rather than self-expandable plastic stents (SEPS) or uncovered SEMS (Grade 2C). Covered SEMS are effective for improving dysphagia and facilitating oral intake and have lower rates of stent occlusion from tumor ingrowth. (See 'Selecting a stent' above.)

Following esophageal stent placement and recovery from sedation, patients are discharged with written diet instructions. Patients are typically advised to consume only liquids for 24 to 48 hours and then to advance to a soft solid diet as tolerated (table 2). Patients are also advised to adhere to long-term avoidance of fibrous foods such as raw vegetables and large pieces of meat. (See 'Postprocedure care' above.)

SEMS placement for malignant esophageal obstruction has been associated with an overall complication rate ranging from 45 to 60 percent. Commonly reported adverse events included retrosternal pain, tissue ingrowth/overgrowth, and stent migration. (See 'Stent-related' above.)

Common causes of malignant esophageal obstruction include squamous cell carcinoma and adenocarcinoma of the esophagus. The tumor may involve the proximal (cervical), middle, and/or distal esophagus. Management of esophageal cancer is discussed separately:

(See "Management of locally advanced, unresectable and inoperable esophageal cancer".)

(See "Surgical management of resectable esophageal and esophagogastric junction cancers".)

(See "Radiation therapy, chemoradiotherapy, neoadjuvant approaches, and postoperative adjuvant therapy for localized cancers of the esophagus".)

  1. Van Heel NC, Haringsma J, Spaander MC, et al. Esophageal stents for the palliation of malignant dysphagia and fistula recurrence after esophagectomy. Gastrointest Endosc 2010; 72:249.
  2. Rhee K, Kim JH, Jung DH, et al. Self-expandable metal stents for malignant esophageal obstruction: a comparative study between extrinsic and intrinsic compression. Dis Esophagus 2016; 29:224.
  3. Spaander MCW, van der Bogt RD, Baron TH, et al. Esophageal stenting for benign and malignant disease: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2021. Endoscopy 2021; 53:751.
  4. Mariette C, Gronnier C, Duhamel A, et al. Self-expanding covered metallic stent as a bridge to surgery in esophageal cancer: impact on oncologic outcomes. J Am Coll Surg 2015; 220:287.
  5. Mão-de-Ferro S, Serrano M, Ferreira S, et al. Stents in patients with esophageal cancer before chemoradiotherapy: high risk of complications and no impact on the nutritional status. Eur J Clin Nutr 2016; 70:409.
  6. Francis SR, Orton A, Thorpe C, et al. Toxicity and Outcomes in Patients With and Without Esophageal Stents in Locally Advanced Esophageal Cancer. Int J Radiat Oncol Biol Phys 2017; 99:884.
  7. Jones CM, Griffiths EA. Should oesophageal stents be used before neo-adjuvant therapy to treat dysphagia in patients awaiting oesophagectomy? Best evidence topic (BET). Int J Surg 2014; 12:1172.
  8. Paleti S, Rustagi T. Stridor From Tracheal Compression Caused by Esophageal Stent. Am J Gastroenterol 2021; 116:450.
  9. van Rossum PSN, Mohammad NH, Vleggaar FP, van Hillegersberg R. Treatment for unresectable or metastatic oesophageal cancer: current evidence and trends. Nat Rev Gastroenterol Hepatol 2018; 15:235.
  10. Vermeulen BD, Siersema PD. Esophageal Stenting in Clinical Practice: an Overview. Curr Treat Options Gastroenterol 2018; 16:260.
  11. Sharma P, Kozarek R, Practice Parameters Committee of American College of Gastroenterology. Role of esophageal stents in benign and malignant diseases. Am J Gastroenterol 2010; 105:258.
  12. Bethge N, Sommer A, Vakil N. A prospective trial of self-expanding metal stents in the palliation of malignant esophageal strictures near the upper esophageal sphincter. Gastrointest Endosc 1997; 45:300.
  13. Battaglia G, Antonello A, Realdon S, et al. Feasibility, efficacy and safety of stent insertion as a palliative treatment for malignant strictures in the cervical segment of the esophagus and the hypopharynx. Surg Endosc 2016; 30:159.
  14. Speer E, Dunst CM, Shada A, et al. Covered stents in cervical anastomoses following esophagectomy. Surg Endosc 2016; 30:3297.
  15. Bechtler M, Wagner F, Fuchs ES, Jakobs R. Biliary metal stents for proximal esophageal or hypopharyngeal strictures. Surg Endosc 2015; 29:3205.
  16. Hussain Z, Diamantopoulos A, Krokidis M, Katsanos K. Double-layered covered stent for the treatment of malignant oesophageal obstructions: Systematic review and meta-analysis. World J Gastroenterol 2016; 22:7841.
  17. Conio M, Repici A, Battaglia G, et al. A randomized prospective comparison of self-expandable plastic stents and partially covered self-expandable metal stents in the palliation of malignant esophageal dysphagia. Am J Gastroenterol 2007; 102:2667.
  18. Vakil N, Morris AI, Marcon N, et al. A prospective, randomized, controlled trial of covered expandable metal stents in the palliation of malignant esophageal obstruction at the gastroesophageal junction. Am J Gastroenterol 2001; 96:1791.
  19. Rozanes I, Poyanli A, Acunaş B. Palliative treatment of inoperable malignant esophageal strictures with metal stents: one center's experience with four different stents. Eur J Radiol 2002; 43:196.
  20. Siersema PD, Hop WC, van Blankenstein M, et al. A comparison of 3 types of covered metal stents for the palliation of patients with dysphagia caused by esophagogastric carcinoma: a prospective, randomized study. Gastrointest Endosc 2001; 54:145.
  21. Im JP, Kang JM, Kim SG, et al. Clinical outcomes and patency of self-expanding metal stents in patients with malignant upper gastrointestinal obstruction. Dig Dis Sci 2008; 53:938.
  22. Ahmed O, Lee JH, Thompson CC, Faulx A. AGA Clinical Practice Update on the Optimal Management of the Malignant Alimentary Tract Obstruction: Expert Review. Clin Gastroenterol Hepatol 2021; 19:1780.
  23. Didden P, Reijm AN, Erler NS, et al. Fully vs. partially covered selfexpandable metal stent for palliation of malignant esophageal strictures: a randomized trial (the COPAC study). Endoscopy 2018; 50:961.
  24. Persson J, Smedh U, Johnsson Å, et al. Fully covered stents are similar to semi-covered stents with regard to migration in palliative treatment of malignant strictures of the esophagus and gastric cardia: results of a randomized controlled trial. Surg Endosc 2017; 31:4025.
  25. Dellon ES, Hawk JS, Grimm IS, Shaheen NJ. The use of carbon dioxide for insufflation during GI endoscopy: a systematic review. Gastrointest Endosc 2009; 69:843.
  26. Verschuur EM, Kuipers EJ, Siersema PD. Esophageal stents for malignant strictures close to the upper esophageal sphincter. Gastrointest Endosc 2007; 66:1082.
  27. Eleftheriadis E, Kotzampassi K. Endoprosthesis implantation at the pharyngo-esophageal level: problems, limitations and challenges. World J Gastroenterol 2006; 12:2103.
  28. Jacobson BC, Hirota W, Baron TH, et al. The role of endoscopy in the assessment and treatment of esophageal cancer. Gastrointest Endosc 2003; 57:817.
  29. Reijm AN, Didden P, Schelling SJ, et al. Self-expandable metal stent placement for malignant esophageal strictures - changes in clinical outcomes over time. Endoscopy 2019; 51:18.
  30. Tian D, Wen H, Fu M. Comparative study of self-expanding metal stent and intraluminal radioactive stent for inoperable esophageal squamous cell carcinoma. World J Surg Oncol 2016; 14:18.
  31. Medeiros VS, Martins BC, Lenz L, et al. Adverse events of self-expandable esophageal metallic stents in patients with long-term survival from advanced malignant disease. Gastrointest Endosc 2017; 86:299.
  32. Parthipun A, Diamantopoulos A, Shaw A, et al. Self-expanding metal stents in palliative malignant oesophageal dysplasia. Ann Palliat Med 2014; 3:92.
  33. Baron TH. Expandable metal stents for the treatment of cancerous obstruction of the gastrointestinal tract. N Engl J Med 2001; 344:1681.
  34. Burstow M, Kelly T, Panchani S, et al. Outcome of palliative esophageal stenting for malignant dysphagia: a retrospective analysis. Dis Esophagus 2009; 22:519.
  35. Adler DG. Esophageal Stents: Placement, Complications, Tips, and Tricks. Video Journal and Encyclopedia of GI Endoscopy 2013; 1:66.
  36. Fuccio L, Scagliarini M, Frazzoni L, Battaglia G. Development of a prediction model of adverse events after stent placement for esophageal cancer. Gastrointest Endosc 2016; 83:746.
  37. Park JY, Shin JH, Song HY, et al. Airway complications after covered stent placement for malignant esophageal stricture: special reference to radiation therapy. AJR Am J Roentgenol 2012; 198:453.
  38. Bick BL, Song LM, Buttar NS, et al. Stent-associated esophagorespiratory fistulas: incidence and risk factors. Gastrointest Endosc 2013; 77:181.
  39. Sumiyoshi T, Gotoda T, Muro K, et al. Morbidity and mortality after self-expandable metallic stent placement in patients with progressive or recurrent esophageal cancer after chemoradiotherapy. Gastrointest Endosc 2003; 57:882.
  40. Fuccio L, Hassan C, Frazzoni L, et al. Clinical outcomes following stent placement in refractory benign esophageal stricture: a systematic review and meta-analysis. Endoscopy 2016; 48:141.
  41. Law R, Prabhu A, Fujii-Lau L, et al. Stent migration following endoscopic suture fixation of esophageal self-expandable metal stents: a systematic review and meta-analysis. Surg Endosc 2018; 32:675.
  42. Irani S, Baron TH, Gluck M, et al. Preventing migration of fully covered esophageal stents with an over-the-scope clip device (with videos). Gastrointest Endosc 2014; 79:844.
  43. Mudumbi S, Velazquez-Aviña J, Neumann H, et al. Anchoring of self-expanding metal stents using the over-the-scope clip, and a technique for subsequent removal. Endoscopy 2014; 46:1106.
  44. Park KH, Lew D, Samaan J, et al. Comparison of no stent fixation, endoscopic suturing, and a novel over-the-scope clip for stent fixation in preventing migration of fully covered self-expanding metal stents: a retrospective comparative study (with video). Gastrointest Endosc 2022; 96:771.
  45. Lagattolla NR, Rowe PH, Anderson H, Dunk AA. Restenting malignant oesophageal strictures. Br J Surg 1998; 85:261.
  46. Dai Y, Li C, Xie Y, et al. Interventions for dysphagia in oesophageal cancer. Cochrane Database Syst Rev 2014; :CD005048.
  47. Raijman I, Siddique I, Ajani J, Lynch P. Palliation of malignant dysphagia and fistulae with coated expandable metal stents: experience with 101 patients. Gastrointest Endosc 1998; 48:172.
Topic 2677 Version 30.0

References

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