This study evaluated the use of self-expanding metal stents, plastic stents, and hybrid stents to treat 133 patients with malignant and benign esophageal diseases over an 8-year period at a single institution. Stent placement was successful in relieving obstruction in 91% of patients with a median hospital stay of 1 day. Complications included migration in 9.7% of cases, impaction in 13% requiring endoscopic disimpaction, and tumor ingrowth in 5.2% of uncovered metal stents. Stent placement was found to be a generally safe, quick, and reliable procedure for palliating malignant esophageal obstructions.

1. Esophageal Stenting for Malignant and Benign Disease: 133 Cases on a Thoracic Surgical Service A Dubecz, TJ Watson, A Matousek, J Allen, M Polomsky, R Salvador, CE Jones, DP Raymond, JH Peters Society of Thoracic Surgeons 45th Annual Meeting, January 26-28, 2009, San Francisco, CA Division of Thoracic and Foregut Surgery, Department of Surgery University of Rochester School of Medicine and Dentistry Rochester, NY

2. The authors have nothing to disclose

3. Background Stents have been increasingly utilized to treat a variety of malignant and benign esophageal disorders. easy inexpensive low morbidity increased indications with removable stents for benign disease

4. Background Photodynamic therapy Limitations: photosensitizer costs delayed palliation multiple sessions future uncertain Litle VR, Luketich JD et al. Photodynamic therapy as palliation for esophageal cancer: experience in 215 patients. Ann Thor. Surg. 2003 Nov;76(5):1687-92 1.8% mortality, 2% perforation, 2% stricture, 6% sunburn

5. Background Palliation by surgery Blazeby et al. A prospective longitudinal study examining quality of life in patients with esophageal carcinoma. CANCER 2000 Frenken Best palliation in esophageal cancer: surgery, stenting, radiation or what? Diseases of Esophagus 2001.

6. Background Palliation by chemotherapy or radiotherapy effective delayed effect toxicity Homs MY et al. Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia from oesophageal cancer: multicentre randomised trial. Lancet. 2004 Tumor persistence 18%, tumor regrowth 26%

7. Aim To evaluate our recent experience with self-expanding metal, plastic and hybrid stents in the treatment of esophageal disease on a thoracic surgical service.

8. Methods Single Institution 2000-2008 Retrospective chart review Social Security Death Index for mortality 126 Patients (91 men and 35 women)‏ Age(mean) 68.3 years

9. Indications

10. Stent Type 123 Self Expanding Metal Stents (SEMS)‏ 57 uncovered/ 66 covered 7 Self Expanding Plastic Stents (SEPS)‏ 3 Hybrid Stents

11. Technique Endoscopic assessment Progressive Savary dilations Range:33-51F Fluoroscopic control external marking of proximal/distant end of tumor Routine PPIs when stent crosses GEJ Dietary instructions Pain management

12. Malignant obstruction: SEMS GE junction: uncovered Esophageal body: covered Perforation/TE fistula/leak: covered Benign stricture: SEPS/hybrid Choice of Stent

13. Results Median length of stay: 1 day 121/133 (91%) in OR under general anesthesia 12/133 (9%) in endoscopy suite under sedation (all in 2007-08)‏ 10/12 discharged the same day

14. Complications

15. Complications POD #4 uncontrollable bleeding

16. Complications NO PERFORATIONS

17. Complications 70% of patients had no complications

18. 1/57 (1.8%) uncovered SEMS migrated (40 crossed GE junction)‏ median survival of patients with migration: 225 days (mean 427.7d)‏ 13 migrations in 12 patients (13/133; 9.7%)‏ Migration

19. Impaction 17 impactions in 11 patients; 17/133 (13%)‏ Presented with dysphagia Underwent endoscopic disimpaction

20. Tumor Ingrowth 7 / 133 (5.2%)‏ ‏

21. Tumor Ingrowth 7 / 133 (5.2%)‏ ‏ 2/57 (3.5%) of uncovered SEMS

22. SEPS (n=7)‏ Indications Esophagogastric anastomotic stricture - 4 Obstructing esophageal cancer (prior to chemo/XRT/surgery) -2 Iatrogenic perforation -1 Complications Migration: 4/7 (57%)‏ - 3 for anastomotic stricture Food impaction: 2/7 (29%)‏ Removable Stents

23. Hybrid (n=3)‏ Indications Obstructing esophageal CA -1 Extrinsic compression from lung CA -1 Esophageal perforation / foreign body -1 Complications Migration: 2/3 (66.7%)‏ - 1 extrinsic compression (esophageal body), 1 perforation (GE junction)‏ No food impaction‏ Removable Stents

24. Survival

25. Survival 20% survived <1 month

26. Survival

27. Survival

28. Conclusions Safe, quick and reliable Majority require no further interventions Short life-expectancy Patient selection may be difficult

29. Conclusions Most complications are secondary to stent obstruction Tumor ingrowth rare with uncovered stents Stent migration an issue with any covered stent Esophageal surgeons should be adept at stent placement

30. Thank You!