- Email: [email protected]
Palliation of malignant dysphagia and fistulae with the wallstent: Experience with 101 patients
ESOPHAGUS 213 HOW MUCH LUMINAL DILATION (IF ANY) IS NECESSARY PRIOR TO PLACEMENT OF AN ESOPHAGEAL WALLSTENT? I Raijman. I Siddique, J Ajani, P Lynch. MD Anderson Cancer Center. and University of Texas. Houston. The use of various metallic stents is a popular therapeutic modality in the palliative treatment of malignant esophageal stricture. Despite an enlarging experience, there is no consem as to how much esophageal dilation is required prior to placement of such stems. We report our experience with 99 coated Wallstents (Schneider. Minnesota) placed between 11/94 and 10/96 for the palliation of malignant esophageal stricture. In all pts, graduated Savary dilators were used and desired dilation and stem tmaximal outer diameter of 38 Fr) placement were performed during the index session. In our first 22 pts, we dilated the esophageal lumen to 42 Fr with the idea of facilitating stem expansion, especially for tight angulated strictures. During that period, 2 stem migrations (10%) occurred. In the next 22 pts, we decreased the dilation to 38-39 Fr. same diameter as the stem apparatus. During that period. we encountered 1 stem migration (5%). We then reduced the dilation to 27 Fr ~same as standard Olylmpus GIF 100 endoscope), or to no dilation if the endoscope passed beyond the stricture. Of 55 stems placed during that period, no stem rmgration occurred. No perforations have occurred during any period. During the second period, (38-39 Fr), 1 esophageal tear occurred during passage of the guide wire. We have not found a relationship between stent migration and the use of ChemoXRT. previous laser therapy, histological type, primary vs metastatic, or the mucosal pattern of the tumor. However. mid-to-junctional esophageal lesions may be associated with the risk of migration. In conclusion, placemem of the Wallstent should be carried out with no dilation or only enough to allow advancement of the endoscope beyond the stricture. Such recommendation is independent of the location or type of stricture. Caution should always be exercised to avoid potential mucosal tears and/or perforation.
+215 PALLIATION OF MALIGNANT DYSPHAGtA AND FISTULAE WITH THE WALLSTENT: EXPERIENCE WITH 101 PATIENTS. I Raijman, I Siddique, J Ajani, P Lynch. MD Anderson Cancer Center, and University of Texas, Houston. Treatment of malignant dyspha~ia and fistulae with coated metallic stents is the preferred palliative modality. We report our experience with 101 pts treated with the coated Wallstent (Schneider, Minnesota) (cEES). There were 63 men, 38 women, mean age 70.3 y (range 25-90). The dysphagia grading was: 0, normal; 1, solids; 2, semisolids; 3, liquids; 4, saliva. Eighty three had esophageal cancer (46 squamous) and 18 metastatic disease. The location was proximal (11), mid (29), dista] 137), and GE junction (24~. Thirteen pts had a digestive-respiratory fistula (DRF). The mean stricture length wes 6.9 cms (99 pts). Previous Rx included ChXRT in 80 (11 ongoing ChXRT at the time of stent placement), surgery in 27, laser in 22, end noncoated EES in 5. Esophageal bougeniage was performed in 80. Correct cEES placement was achieved in 100. In 1, the cEES was placed too distal, requiring a second cEES. Tumor margins were injected with radiographic contrast and the head of the fluoroscopy bed was kept at 30 degree elevation. Stent placement was difficult in 4 pts due to cervical osteopathy and in I due to fluoroscopy failure. Early complications (< 1 week) included bleeding (5), esophageal tear (1), chest pare (13), foreign body sensation (3), and stent misplacement (1). Delayed complications (>1 week) included tumor bleeding (2), gastric ulcer (2), tumor overgrowth ("understented" pts)(6), esophageal ulcer (2), foreign body sensation (1), and stent nugration (3). There were no perforations or aspiration and the procedure related mortality was 0. Eighty two of the procedures were performed as an outpatient. During a mean follow-up of 201 days (16-400), dysphagla unproved from 3.6 to 1.4. All DRF healed. The overall well-being sensation and quality of life improved in 82% of the pts. Gastrostomy was required for persistent dys-phagia despite stent patency in 4, I with DRF and respiratory insufficiency. Ninety five pts died of tumor progression and 6 are alive. In conclusion, the coated Wallstent offers excellent palliation of malignant dysphagia and DRF and improves the patienfs quality of life. Stent coating prevents tumor ingrowth, overgrowth is prevented by "over-stenting/', and migration is prevented by nunmuzmg luminal dilation. A randomized trial of laser vs coated Wallstent is ongoing.
+214
+216
THE OVERALL COMPLICATION RATE AFTER ESOPHAGEAL WALLSTENT IS RELATED TO ~ ESOPHAGEAL ~ T I O N OF THE LESION. I Rai|man, I Siddique, J Ajani, P Lynch. MD Anderson Cancer Center, and University of Texas, Houston. The most c o m m o n complications after expandable esophageal stents are migration, perforation, and bleeding. Although an increased rate of stent migration has been reported in GE junction lesions, there is little information regarding the overall complication rate and the location of the esophageal lesion. Between 11/94 and 10/96, we have treated 101 patients with the coated Wallstent (Schneider, Minnesota) for malignant dysphagia a n d / o r digestive-respiratory fistulae. The overall complication rate was: major, 17/101 (16%) and minor, 23/101 (22.7%). The relationship between the anatomic location of the esophageal lesion and s p ~ ~lications is: Prox Mid Distal GE Jct Total n = 1 1 % I n=29 % n=37 % n=24 % n=101% aieedin~ 0 o 0 0 3 8 4 1 7 7 6.9 Perforation 0 0 0 0 0 0 10 0 0 0 Migration 0 0 0 0 1 3 2 8 3 2.9 Overgrowth 1 10 i2 7 3 8 10 0 6 5.9 Ingrowth 0 0 0 0 0 0 0 0 0 0 010 0 4 3.9 Foreign 3 27 1 ' ' 3
PALLIATION OF MALIGNANT DYSPHAGIA WUTI CHEMORADIATION THERAPY (CHXRT) DOES NOT INCREASE THE RATE OF SERIOUS CDMPLICATIONS WITH COATED WAU, SH/NT. I Raiiman, ISiddique, JAjani, PLynch. MD Anderson Cancer Canter, and University of Texas, Houston. An increased incidence of complications after expandable esophageal stents has been reported after ChXRT. We have previously reported on 51 pts w h o received coated Wallstent (Schneider, Minnesota) that ChXRT does not increase the complication rate. We now report our extended experience with 101 patients treated with the coated Walistent (cEES). There were 63 M, 38 W, mean age 70.3 y (range 25-90). Eighty three had e s o p h a g e a l cancer (46 squamous) and 18 metastatic disease. The If-cation was proximal (11), mid (29), distal (37), and GE junction (24). Thirl~m pts h a d a digestive-respiratory fistula (DRF). The m e a n stricture length was 6.9 cms (99 pts). Previous Rx included ChXRT in 80 (11 ongoing CbXRT at the time of stent placement), surgery in 27, laser in 22, and noncoated EES in 5. Esophageal bougeniage was performed in 80 and correct cEES placement was achieved in 100. In 1, the cEES was placed too distal, requiring a second cEES. Of the 21 pts without ChXRT, 3 de-veloped bleeding, 3 tumor overgrowth, I gastric ulceration, 3 chest pa/n, and I stent migration, Of the 80 pts with ChXRT, 4 developed bleeding, 3 tumor overgrowth, I esophageal tear, 2 esophageal ulcers, I gastric ulceration, 10 chest pain, and 2 stent migration. There were no perforations or mortality in either group. All bleeding episodes except one were self limited but required blood transfusion and I required external XRT for hemostasis (ChXRT group). All tumor overgrowths were treated with second cEES. The overall complication rate wa s 11/21pts (52.3%) without ChXRT and 23/81 pts (28.4%) (pNS) with ChXRT. The incidence of serious complications w a s 3/21 (14%) and 5/80 (6%) (pNS), respectively. In conclusion, ChXRT m a y decrease the overall complication rate. It does not increase the rate of potentially fatal complications in patients treated with the coaled WallstenL A prospective evaluation is under study.
body,
:~
Chest pain 3 27 14 1 3 5' 21 1 3 12.9 Other. 0 0 13 10 0 0 2 8 5 4.9 Total 7 63 10 34 8 22 13 54 9Esophageal tear 1, esophageal ulcer 2, gastric ulcer 2 fin conclusion, the location of the esophageal lesion, either.stricture, fistula, or both, m a y influence the overall complication rate after coated WallstenL Particularly, a proximal lesion increases the rate of minor complications such as foreign body sensation and chest pain, while a mid-to-junctional lesion i n c e n s e s the risk of major complications, such as bleeding, migration, and !overgrowth.
AB78
GASTROINTESTINAL ENDOSCOPY
VOLUME 45, NO. 4, 1997
+215 PALLIATION OF MALIGNANT DYSPHAGtA AND FISTULAE WITH THE WALLSTENT: EXPERIENCE WITH 101 PATIENTS. I Raijman, I Siddique, J Ajani, P Lynch. MD Anderson Cancer Center, and University of Texas, Houston. Treatment of malignant dyspha~ia and fistulae with coated metallic stents is the preferred palliative modality. We report our experience with 101 pts treated with the coated Wallstent (Schneider, Minnesota) (cEES). There were 63 men, 38 women, mean age 70.3 y (range 25-90). The dysphagia grading was: 0, normal; 1, solids; 2, semisolids; 3, liquids; 4, saliva. Eighty three had esophageal cancer (46 squamous) and 18 metastatic disease. The location was proximal (11), mid (29), dista] 137), and GE junction (24~. Thirteen pts had a digestive-respiratory fistula (DRF). The mean stricture length wes 6.9 cms (99 pts). Previous Rx included ChXRT in 80 (11 ongoing ChXRT at the time of stent placement), surgery in 27, laser in 22, end noncoated EES in 5. Esophageal bougeniage was performed in 80. Correct cEES placement was achieved in 100. In 1, the cEES was placed too distal, requiring a second cEES. Tumor margins were injected with radiographic contrast and the head of the fluoroscopy bed was kept at 30 degree elevation. Stent placement was difficult in 4 pts due to cervical osteopathy and in I due to fluoroscopy failure. Early complications (< 1 week) included bleeding (5), esophageal tear (1), chest pare (13), foreign body sensation (3), and stent misplacement (1). Delayed complications (>1 week) included tumor bleeding (2), gastric ulcer (2), tumor overgrowth ("understented" pts)(6), esophageal ulcer (2), foreign body sensation (1), and stent nugration (3). There were no perforations or aspiration and the procedure related mortality was 0. Eighty two of the procedures were performed as an outpatient. During a mean follow-up of 201 days (16-400), dysphagla unproved from 3.6 to 1.4. All DRF healed. The overall well-being sensation and quality of life improved in 82% of the pts. Gastrostomy was required for persistent dys-phagia despite stent patency in 4, I with DRF and respiratory insufficiency. Ninety five pts died of tumor progression and 6 are alive. In conclusion, the coated Wallstent offers excellent palliation of malignant dysphagia and DRF and improves the patienfs quality of life. Stent coating prevents tumor ingrowth, overgrowth is prevented by "over-stenting/', and migration is prevented by nunmuzmg luminal dilation. A randomized trial of laser vs coated Wallstent is ongoing.
+214
+216
THE OVERALL COMPLICATION RATE AFTER ESOPHAGEAL WALLSTENT IS RELATED TO ~ ESOPHAGEAL ~ T I O N OF THE LESION. I Rai|man, I Siddique, J Ajani, P Lynch. MD Anderson Cancer Center, and University of Texas, Houston. The most c o m m o n complications after expandable esophageal stents are migration, perforation, and bleeding. Although an increased rate of stent migration has been reported in GE junction lesions, there is little information regarding the overall complication rate and the location of the esophageal lesion. Between 11/94 and 10/96, we have treated 101 patients with the coated Wallstent (Schneider, Minnesota) for malignant dysphagia a n d / o r digestive-respiratory fistulae. The overall complication rate was: major, 17/101 (16%) and minor, 23/101 (22.7%). The relationship between the anatomic location of the esophageal lesion and s p ~ ~lications is: Prox Mid Distal GE Jct Total n = 1 1 % I n=29 % n=37 % n=24 % n=101% aieedin~ 0 o 0 0 3 8 4 1 7 7 6.9 Perforation 0 0 0 0 0 0 10 0 0 0 Migration 0 0 0 0 1 3 2 8 3 2.9 Overgrowth 1 10 i2 7 3 8 10 0 6 5.9 Ingrowth 0 0 0 0 0 0 0 0 0 0 010 0 4 3.9 Foreign 3 27 1 ' ' 3
PALLIATION OF MALIGNANT DYSPHAGIA WUTI CHEMORADIATION THERAPY (CHXRT) DOES NOT INCREASE THE RATE OF SERIOUS CDMPLICATIONS WITH COATED WAU, SH/NT. I Raiiman, ISiddique, JAjani, PLynch. MD Anderson Cancer Canter, and University of Texas, Houston. An increased incidence of complications after expandable esophageal stents has been reported after ChXRT. We have previously reported on 51 pts w h o received coated Wallstent (Schneider, Minnesota) that ChXRT does not increase the complication rate. We now report our extended experience with 101 patients treated with the coated Walistent (cEES). There were 63 M, 38 W, mean age 70.3 y (range 25-90). Eighty three had e s o p h a g e a l cancer (46 squamous) and 18 metastatic disease. The If-cation was proximal (11), mid (29), distal (37), and GE junction (24). Thirl~m pts h a d a digestive-respiratory fistula (DRF). The m e a n stricture length was 6.9 cms (99 pts). Previous Rx included ChXRT in 80 (11 ongoing CbXRT at the time of stent placement), surgery in 27, laser in 22, and noncoated EES in 5. Esophageal bougeniage was performed in 80 and correct cEES placement was achieved in 100. In 1, the cEES was placed too distal, requiring a second cEES. Of the 21 pts without ChXRT, 3 de-veloped bleeding, 3 tumor overgrowth, I gastric ulceration, 3 chest pa/n, and I stent migration, Of the 80 pts with ChXRT, 4 developed bleeding, 3 tumor overgrowth, I esophageal tear, 2 esophageal ulcers, I gastric ulceration, 10 chest pain, and 2 stent migration. There were no perforations or mortality in either group. All bleeding episodes except one were self limited but required blood transfusion and I required external XRT for hemostasis (ChXRT group). All tumor overgrowths were treated with second cEES. The overall complication rate wa s 11/21pts (52.3%) without ChXRT and 23/81 pts (28.4%) (pNS) with ChXRT. The incidence of serious complications w a s 3/21 (14%) and 5/80 (6%) (pNS), respectively. In conclusion, ChXRT m a y decrease the overall complication rate. It does not increase the rate of potentially fatal complications in patients treated with the coaled WallstenL A prospective evaluation is under study.
body,
:~
Chest pain 3 27 14 1 3 5' 21 1 3 12.9 Other. 0 0 13 10 0 0 2 8 5 4.9 Total 7 63 10 34 8 22 13 54 9Esophageal tear 1, esophageal ulcer 2, gastric ulcer 2 fin conclusion, the location of the esophageal lesion, either.stricture, fistula, or both, m a y influence the overall complication rate after coated WallstenL Particularly, a proximal lesion increases the rate of minor complications such as foreign body sensation and chest pain, while a mid-to-junctional lesion i n c e n s e s the risk of major complications, such as bleeding, migration, and !overgrowth.
AB78
GASTROINTESTINAL ENDOSCOPY
VOLUME 45, NO. 4, 1997