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Perforation of an esophageal stent into the common carotid artery
O Kohl, K Rauber, W Doppl
Perforation of an esophageal stent into the common carotid artery Oliver Kohl, MD, Klaus Rauber, MD, Wilhelm Doppl, MD
Self-expanding metallic stents are used for palliative therapy in patients with malignant esophageal stenoses. These stents, available since the early 1990s,1 have largely replaced the traditional plastic types2-4 because they are easier and safer to insert.5 Complications associated with metallic stents vary depending on the type of stent and location of the stenosis. Esophageal stents may rarely dislocate6 From the Department of Internal Medicine, Division of Cardiology and Angiology, and the Department of Internal Medicine, Division of Gastroenterology, Pulmonology, Nephrology, and Intensive Care, University Hospital Gießen, and the Department of Radiology, Hospital Wetzlar, Germany. Reprint requests: Wilhelm Doppl, MD, Innere Medizin II (Gastroenterology), Medizinische Universitaetsklinik Gießen, PaulMeimberg-Straße 5, D-35392 Gießen, Germany. Copyright © 2001 by the American Society for Gastrointestinal Endoscopy 0016-5107/2001/$35.00 + 0 37/54/110915 doi:10.1067/mge.2001.110915 374
GASTROINTESTINAL ENDOSCOPY
Esophageal stent perforation into common carotid artery
and/or erode neighboring structures such as the main bronchi7 or produce fistulas.8-11 Song et al.12 encountered a migration of the stent in 12 of 119 patients; 13 became blocked.12 In rare cases life-threatening bleeding from tumor vessels or fistulas to the thoracic aorta was seen.10,11 This is a case of a fistula caused by erosion of a metal stent into the common carotid artery, a complication not previously reported. The resulting life-threatening arterial bleeding was controlled by endoscopic intervention. The patient then underwent vascular surgery and received a homograft. CASE REPORT The patient, a 58-year-old woman, had undergone thyroidectomy and radiation-therapy (60 Gy) in 1964 for a carcinoma of the thyroid gland and laryngectomy in 1986 because of a squamous cell carcinoma of the larynx. Since that time she had a tracheostomy and a worsening esophageal stricture. In September 1995 a 4-cm long filiform stenosis was still present in the proximal esophagus despite repeated balloon dilatations (Fig. 1). Because of this resistance to treatment, a self-expanding metallic stent (Wallstent, AV-Shunt, 14-mm diameter [completely expanded], 60 mm length, Schneider, Zürich, Switzerland) VOLUME 53, NO. 3, 2001
Esophageal stent perforation into common carotid artery
O Kohl, K Rauber, W Doppl
Figure 2. Plain x-ray obtained after implantation of a selfexpanding metallic stent. The upper part of the stent has not yet expanded fully.
Figure 1. Barium esophagogram showing filiform stenosis of the proximal esophagus (length 4 cm, diameter approximately 4 mm). was implanted after obtaining informed consent despite the benign nature of the stenosis (Fig. 2). The stent did not expand completely and therefore balloon dilatations were performed in November and December 1995. Thereafter the patient was asymptomatic until June 1996 when she again developed increasing dysphagia. At this time she also developed recurrent hematemesis and required repeated transfusions. In July 1996 she was only able to swallow liquids and had lost 12 kg of weight. Physical examination (168 cm, 72 kg) was remarkable for paleness, scarred indurated skin over the neck, and a tracheostoma. Hemoglobin was 8.1 g/dL (normal, 12-16 g/dL), erythrocyte sedimentation rate was 80/100 mm n.W. (up to 20 mm n.W. in first hour) and C-reactive protein was 19 mg/L (<5 mg/L). The white blood cell count was 4800/µL (430010,000/µL). Platelets, mean corpuscular volume, mean corpuscular hemoglobin, lactate dehydrogenase, and tumor marker carcinoembryonic antigen were within normal limits. VOLUME 53, NO. 3, 2001
A barium esophagogram (Fig. 3) disclosed free passage of the barium through the stent but in contrast to previous studies there were some irregularities within the stent lumen. CT of the neck (Fig. 4) showed the esophageal stent in the hypopharynx. There was induration of neighboring tissue but no tumor narrowing of the stent from the side was seen. At endoscopy, the hypopharynx above the stent was normal. Passage through and examination of the stent with a pediatric endoscope (GIF P 20, 9 mm, Olympus Optical Co., Hamburg, Germany) were impossible because the inner diameter of the stent was too small. Therefore the esophagus was examined with a bronchoscope (CLK 3 E, Olympus Optical Co.). The esophagus distal to the stent was unremarkable. The right side of the stent lumen was partly narrowed by tissue prolapsing through the mesh, an appearance that raised a strong suspicion of tumor ingrowth. While obtaining a biopsy specimen, a brisk arterial bleeding arose, obstructing the view within seconds. The patient lost consciousness within a minute and developed severe hematemesis. A total of 20 units of packed erythrocytes were administered. The bleeding was acutely controlled by local compression with a solid (7 mm) rubber tube. The rubber tube was then removed and a 9 mm Savary-Gilliard Bougie (Wilson-Cook Medical Inc., Winston-Salem, N.C.) that completely occluded the stent was implanted. Thereafter the patient was stable. Carotid angiography GASTROINTESTINAL ENDOSCOPY
375
O Kohl, K Rauber, W Doppl
Esophageal stent perforation into common carotid artery
Figure 4. CT of the lower neck. The right carotid artery of the severly anemic patient is seen as a circular low-density structure in the immediate vicinity of the esophageal stent.
Figure 3. Esophagogram 10 months after stent implantation showing irregular margins of the barium column within the stent lumen. (Fig. 5) showed massive irregularities of the wall of the right carotid artery with atherosclerotic lesions and an aneurysm. There was a 1 × 0.7 cm ulcer of the artery that extended into the upper third of the stent. Endoscopic biopsies revealed no tumor but there was a florid ulcerous lesion and squamous epithelium with inflammatory changes. A vascular homograft (8-mm diameter) from the ascending aorta to the right carotid bifurcation was implanted, bypassing the right common carotid artery. Histology of the resected vessel showed advanced atherosclerosis with fibrinous plaques and calcifications but no tumor. The patient recovered and was soon able to eat a normal diet. Ten days after the emergency operation, Doppler US revealed an occlusion of the graft. Surgical revision was not undertaken because of the lack of significant neurologic symptoms. Two months after discharge the patient died of hemorrhagic shock due to recurrent arterial bleeding. An autopsy was refused. 376
GASTROINTESTINAL ENDOSCOPY
Figure 5. Angiogram of the carotid artery.
DISCUSSION Self-expanding metallic stents are used palliatively in the treatment of patients with malignant stenoses of the esophagus and biliary ducts.13,14 Complications related to these stents, especially perforation,10,11,15 are relatively rare (< 5%).1 Our patient had the unusual history of high-dose radiation (60 Gy) combined with two cancer operations 32 and 10 years before metal stent placement in the proximal esophagus. Due to excessive scarring and atrophy with resulting distortion of cervical anatoVOLUME 53, NO. 3, 2001
Esophageal stent perforation into common carotid artery
my, the right carotid artery was extremely close to the esophagus. The pressure produced by the expanding metallic stent caused necrosis of the esophageal wall and 10 months after implantation the stent perforated into the atherosclerotic right common carotid artery. This resulted in spontaneous minor bleeding; life-threatening arterial bleeding arose only after 1 small biopsy specimen was taken and was controlled by endoluminal compression. Vascular surgical intervention bridged the source of bleeding. Smaller bleeding vessels can also be treated by embolization,16 but in our patient this was not possible because of the likelihood of devastating neurologic consequences. Fistulas to the aorta caused by metal stents have been reported 10,11 but not fistulas to the carotid artery. Previous radiation and chemotherapy was found to increase the risk of complications in some, 17-21 but not all, studies.22-25 These data are only partly applicable to our case because of the long interval between radiation and stent implantation in our patient. There is variation in the physical properties of the different types of metal stents.26 The Wallstent, used in our patient, has a strong expansile force,26 which may have promoted the perforation. The more flexible Ultraflex stent might have been more suitable in a patient such as ours. It is unknown whether the chemical properties of a metallic stent interfere with the esophageal wall. Only one study has analyzed the reaction of the aortic wall with 6 different stent materials.27 Gold reacted minimally with the aortic wall in comparison to steel, polytetrufluoruethylene, silicone, silver, and copper. Copper-coated stents produced the most severe erosions of the aortic wall.27 Atherosclerosis may be an additional risk factor. A metal stent was used in our patient to treat a presumably benign stenosis only after all other treatment failed. After a careful discussion, the patient chose this alternative from several possible treatments including percutaneous gastrostomy. Metal stents have also been used by others in benign diseases.28-31 Early removal after placement has been described as a way of avoiding complications and may facilitate the choice of treatment. 31,32 REFERENCES 1. Segalin A, Bonavina L, Carazzone A, Ceriani C, Peracchia A. Improving results of esophageal stenting: a study on 160 consecutive unselected patients. Endoscopy 1997;29:701-9. 2. Ogilvie AL, Dronfield MW, Ferguson R, Atkinson M. Palliative intubation of oesophagogastric neoplasms at fibreoptic endoscopy. Gut 1982;23:1060-7. 3. Knyrim K, Wagner HG, Bethge N, Keymling M, Vakil N. A controlled trial of an expansile metal stent for palliation of esophageal obstruction due to inoperable cancer. N Engl J Med 1993;329:1302-7. VOLUME 53, NO. 3, 2001
O Kohl, K Rauber, W Doppl
4. Watkinson AF, Mason RC, Adam A. Oesophageal stents. In: Adam A, Dondelinger RF, Mueller PR, editors. Textbook of metallic stents. Oxford: Isis Medical Media; 1997. p. 87-102. 5. Vitale GC, Larson GM, George M, Tatum C. Management of malignant biliary stricture with self-expanding metallic stent. Surg Endosc 1996;10:970-3. 6. Henne TH, Schaeff B, Paolucci V. Small-bowel obstruction and perforation. A rare complication of an esophageal stent. Surg Endosc 1997;11:383-4. 7. Hendra KP, Saukkonen JJ. Erosion of right mainstem bronchus by an esophageal stent. Chest 1996;110:857-8. 8. Tagawa T, Itoh S, Ide S, Tanaka K, Sumida Y, Ohe H. Esophagobronchial fistula which developed after the insertion of an expandable metallic stent for corrosive esophageal stenosis. Nippon Kyobu Geka Gakkai Zasshi 1997;45:1044-8. 9. Dennert B, Ramirez FC, Sanowski RA. Pericardioesophageal fistula associated with metallic stent placement. Gastrointest Endosc 1997;45:82-4. 10. Allgaier HP, Schwacha H, Technau K, Blum HE. Fatal esophagoaortic fistula after placement of a self-expanding metal stent in a patient with esophageal carcinoma (letter). N Engl J Med 1997;337:1778. 11. Siersema PD, Tan TG, Sutorius FFJM, Dees J, van Blankenstein M. Massive hemorrhage caused by a perforating Gianturco-Z stent resulting in an aortoesophageal fistula. Endoscopy 1997;29:416-20. 12. Song HY, Do YS, Han YM, Sung KB, Choi EK, Sohn KH, et al. Covered, expandable esophageal metallic stent tubes: experiences in 119 patients. Radiology 1994;193:689-95 13. De Palma GD, di Matteo E, Romano G, Fimmano A, Rondinone G, Catanzano C. Plastic prothesis versus expandable metal stent for palliation of inoperable esophageal thoracic carcinoma: a controlled prospective study. Gastrointest Endosc 1996;43:478-82. 14. Davids PHP, Green AK, Rauws EAJ, Tytgat GN, Huibregtse K. Randomised trial of self-expanding metal stents versus polyethylene stents for distal malignant biliary obstruction. Lancet 1992;340:1488-92. 15. Farrugia M, Morgan RA, Latham JA, Glynos M, Mason RC, Adam A. Perforation of the esophagus secondary to insertion of covered wallstent endoprotheses. Cardiovasc Intervent Radiol 1997;20:470-2. 16. Kos X, Trotteur G, Dondelinger RF. Delayed esophageal hemorrhage caused by a metal stent: treatment with embolization. Cardiovasc Intervent Radiol 1998;21:428-30. 17. Nemoto K, Takai Y, Ogawa Y, Kakuto Y, Ariga H, Matsushita H, et al. Fatal hemorrhage in irradiated esophageal cancer patients. Acta Oncol 1998;37:259-62. 18. Bethge N, Sommer A, von Kleist D, Vakil N. A prospective trial of self-expanding metal stents in the palliation of malignant esophageal obstruction after failure of primary curative therapy. Gastrointest Endosc 1996;44:283-6. 19. Kinsman KJ, DeGregorio BT, Katon RM, Morrison K, Saxon RR, Keller FS, et al. Prior radiation and chemotherapy increase the risk of life-threatening complications after insertion of metallic stents for esophagogastric malignancy. Gastointest Endosc 1996;43:196-203. 20. Siersema PD, Hop WCJ, van Blankenstein M, Dees J. A new design metal stent (Flamingo stent) for palliation of malignant dysphagia: a prospective study. Gastrointest Endosc 2000;51:139-45. 21. Siersema PD, Hop WCJ, Dees J, Tilanus HW, van Blankenstein M. Coated self-expanding metal stents versus latex prostheses for esophagogastric cancer with special reference to prior radiation and chemotherapy: a controlled prospective study. Gastrointest Endosc 1998;47:113-20. GASTROINTESTINAL ENDOSCOPY
377
22. Raijman I, Siddique I, Lynch P. Does chemoradiation therapy increase the incidence of complications with self-expanding coated stents in the management of malignant esophageal strictures? Am J Gastroenterol 1997;92:2192-6. 23. Ludwig D, Dehne A, Burmester E, Wiedemann GJ, Stange EF. Treatment of unresectable carcinoma of the esophagus or the gastroesophageal junction by mesh stents with or without radiochemotherapy. Int J Oncol 1998;13:583-8. 24. Bartelsman JFW, Bruno MJ, Jensema AJ, Maringsma J, Reeders JWAJ, Tytgat GNJ. Palliation of patients with esophagogastric neoplasms by insertion of a covered expandable modified Gianturco-Z endoprosthesis: experiences in 153 patients. Gastrointest Endosc 2000;51:134-8. 25. Kozarek RA, Ball TJ, Brandabur JJ, Patterson DJ, Low D, Hill L, et al. Expandable versus conventional esophageal prostheses: easier insertion may not preclude subsequent stent-related problems. Gastrointest Endosc 1996;43:204-8. 26. Chan ACW, Shin FG, Lam YH, Ng EKW, Sung JJY, Lau JYW, et al. A comparison study on physical properties of selfexpandable esophageal metal stents. Gastrointest Endosc 1999;49:462-5.
378
GASTROINTESTINAL ENDOSCOPY
27. Tanigawa N, Sawada S, Kobayashi M. Reaction of the aortic wall to six metallic stent materials. Acad Radiol 1995;2:379-84. 28. Eubanks PJ, Hu E, Nguyen D, Procaccino F, Eysselein VE, Klein SR. Case of Boerhaave’s syndrome successfully treated with a self-expandable metallic stent. Gastrointest Endosc 1999;49:780-3. 29. Yuasa R, Hattori T, Kobayashi Y, Miyata K, Hayashi Y, Seko H. Treatment of spontaneous esophageal rupture with a covered self-expanding metal stent. Gastrointest Endosc 1999;49:777-80. 30. Tan BS, Kennedy C, Morgan R, Owen W, Adam A. Using uncovered metallic endoprostheses to treat recurrent benign esophageal strictures. AJR Am J Roentgenol 1997;169:12814. 31. Song HY, Park SI, Jung HY, Kim SB, Kim JH, Huh SJ, et al. Benign and malignant esophageal strictures: treatment with a polyurethane-covered retrievable expandable metallic stent. Radiology 1997;203:747-52. 32. May A, Goßner L, Feeß G, Bauer R, Ell C. Extraction of migrated self-expanding esophageal metal stents. Gastrointest Endosc 1999;49:524-7.
VOLUME 53, NO. 3, 2001
Perforation of an esophageal stent into the common carotid artery Oliver Kohl, MD, Klaus Rauber, MD, Wilhelm Doppl, MD
Self-expanding metallic stents are used for palliative therapy in patients with malignant esophageal stenoses. These stents, available since the early 1990s,1 have largely replaced the traditional plastic types2-4 because they are easier and safer to insert.5 Complications associated with metallic stents vary depending on the type of stent and location of the stenosis. Esophageal stents may rarely dislocate6 From the Department of Internal Medicine, Division of Cardiology and Angiology, and the Department of Internal Medicine, Division of Gastroenterology, Pulmonology, Nephrology, and Intensive Care, University Hospital Gießen, and the Department of Radiology, Hospital Wetzlar, Germany. Reprint requests: Wilhelm Doppl, MD, Innere Medizin II (Gastroenterology), Medizinische Universitaetsklinik Gießen, PaulMeimberg-Straße 5, D-35392 Gießen, Germany. Copyright © 2001 by the American Society for Gastrointestinal Endoscopy 0016-5107/2001/$35.00 + 0 37/54/110915 doi:10.1067/mge.2001.110915 374
GASTROINTESTINAL ENDOSCOPY
Esophageal stent perforation into common carotid artery
and/or erode neighboring structures such as the main bronchi7 or produce fistulas.8-11 Song et al.12 encountered a migration of the stent in 12 of 119 patients; 13 became blocked.12 In rare cases life-threatening bleeding from tumor vessels or fistulas to the thoracic aorta was seen.10,11 This is a case of a fistula caused by erosion of a metal stent into the common carotid artery, a complication not previously reported. The resulting life-threatening arterial bleeding was controlled by endoscopic intervention. The patient then underwent vascular surgery and received a homograft. CASE REPORT The patient, a 58-year-old woman, had undergone thyroidectomy and radiation-therapy (60 Gy) in 1964 for a carcinoma of the thyroid gland and laryngectomy in 1986 because of a squamous cell carcinoma of the larynx. Since that time she had a tracheostomy and a worsening esophageal stricture. In September 1995 a 4-cm long filiform stenosis was still present in the proximal esophagus despite repeated balloon dilatations (Fig. 1). Because of this resistance to treatment, a self-expanding metallic stent (Wallstent, AV-Shunt, 14-mm diameter [completely expanded], 60 mm length, Schneider, Zürich, Switzerland) VOLUME 53, NO. 3, 2001
Esophageal stent perforation into common carotid artery
O Kohl, K Rauber, W Doppl
Figure 2. Plain x-ray obtained after implantation of a selfexpanding metallic stent. The upper part of the stent has not yet expanded fully.
Figure 1. Barium esophagogram showing filiform stenosis of the proximal esophagus (length 4 cm, diameter approximately 4 mm). was implanted after obtaining informed consent despite the benign nature of the stenosis (Fig. 2). The stent did not expand completely and therefore balloon dilatations were performed in November and December 1995. Thereafter the patient was asymptomatic until June 1996 when she again developed increasing dysphagia. At this time she also developed recurrent hematemesis and required repeated transfusions. In July 1996 she was only able to swallow liquids and had lost 12 kg of weight. Physical examination (168 cm, 72 kg) was remarkable for paleness, scarred indurated skin over the neck, and a tracheostoma. Hemoglobin was 8.1 g/dL (normal, 12-16 g/dL), erythrocyte sedimentation rate was 80/100 mm n.W. (up to 20 mm n.W. in first hour) and C-reactive protein was 19 mg/L (<5 mg/L). The white blood cell count was 4800/µL (430010,000/µL). Platelets, mean corpuscular volume, mean corpuscular hemoglobin, lactate dehydrogenase, and tumor marker carcinoembryonic antigen were within normal limits. VOLUME 53, NO. 3, 2001
A barium esophagogram (Fig. 3) disclosed free passage of the barium through the stent but in contrast to previous studies there were some irregularities within the stent lumen. CT of the neck (Fig. 4) showed the esophageal stent in the hypopharynx. There was induration of neighboring tissue but no tumor narrowing of the stent from the side was seen. At endoscopy, the hypopharynx above the stent was normal. Passage through and examination of the stent with a pediatric endoscope (GIF P 20, 9 mm, Olympus Optical Co., Hamburg, Germany) were impossible because the inner diameter of the stent was too small. Therefore the esophagus was examined with a bronchoscope (CLK 3 E, Olympus Optical Co.). The esophagus distal to the stent was unremarkable. The right side of the stent lumen was partly narrowed by tissue prolapsing through the mesh, an appearance that raised a strong suspicion of tumor ingrowth. While obtaining a biopsy specimen, a brisk arterial bleeding arose, obstructing the view within seconds. The patient lost consciousness within a minute and developed severe hematemesis. A total of 20 units of packed erythrocytes were administered. The bleeding was acutely controlled by local compression with a solid (7 mm) rubber tube. The rubber tube was then removed and a 9 mm Savary-Gilliard Bougie (Wilson-Cook Medical Inc., Winston-Salem, N.C.) that completely occluded the stent was implanted. Thereafter the patient was stable. Carotid angiography GASTROINTESTINAL ENDOSCOPY
375
O Kohl, K Rauber, W Doppl
Esophageal stent perforation into common carotid artery
Figure 4. CT of the lower neck. The right carotid artery of the severly anemic patient is seen as a circular low-density structure in the immediate vicinity of the esophageal stent.
Figure 3. Esophagogram 10 months after stent implantation showing irregular margins of the barium column within the stent lumen. (Fig. 5) showed massive irregularities of the wall of the right carotid artery with atherosclerotic lesions and an aneurysm. There was a 1 × 0.7 cm ulcer of the artery that extended into the upper third of the stent. Endoscopic biopsies revealed no tumor but there was a florid ulcerous lesion and squamous epithelium with inflammatory changes. A vascular homograft (8-mm diameter) from the ascending aorta to the right carotid bifurcation was implanted, bypassing the right common carotid artery. Histology of the resected vessel showed advanced atherosclerosis with fibrinous plaques and calcifications but no tumor. The patient recovered and was soon able to eat a normal diet. Ten days after the emergency operation, Doppler US revealed an occlusion of the graft. Surgical revision was not undertaken because of the lack of significant neurologic symptoms. Two months after discharge the patient died of hemorrhagic shock due to recurrent arterial bleeding. An autopsy was refused. 376
GASTROINTESTINAL ENDOSCOPY
Figure 5. Angiogram of the carotid artery.
DISCUSSION Self-expanding metallic stents are used palliatively in the treatment of patients with malignant stenoses of the esophagus and biliary ducts.13,14 Complications related to these stents, especially perforation,10,11,15 are relatively rare (< 5%).1 Our patient had the unusual history of high-dose radiation (60 Gy) combined with two cancer operations 32 and 10 years before metal stent placement in the proximal esophagus. Due to excessive scarring and atrophy with resulting distortion of cervical anatoVOLUME 53, NO. 3, 2001
Esophageal stent perforation into common carotid artery
my, the right carotid artery was extremely close to the esophagus. The pressure produced by the expanding metallic stent caused necrosis of the esophageal wall and 10 months after implantation the stent perforated into the atherosclerotic right common carotid artery. This resulted in spontaneous minor bleeding; life-threatening arterial bleeding arose only after 1 small biopsy specimen was taken and was controlled by endoluminal compression. Vascular surgical intervention bridged the source of bleeding. Smaller bleeding vessels can also be treated by embolization,16 but in our patient this was not possible because of the likelihood of devastating neurologic consequences. Fistulas to the aorta caused by metal stents have been reported 10,11 but not fistulas to the carotid artery. Previous radiation and chemotherapy was found to increase the risk of complications in some, 17-21 but not all, studies.22-25 These data are only partly applicable to our case because of the long interval between radiation and stent implantation in our patient. There is variation in the physical properties of the different types of metal stents.26 The Wallstent, used in our patient, has a strong expansile force,26 which may have promoted the perforation. The more flexible Ultraflex stent might have been more suitable in a patient such as ours. It is unknown whether the chemical properties of a metallic stent interfere with the esophageal wall. Only one study has analyzed the reaction of the aortic wall with 6 different stent materials.27 Gold reacted minimally with the aortic wall in comparison to steel, polytetrufluoruethylene, silicone, silver, and copper. Copper-coated stents produced the most severe erosions of the aortic wall.27 Atherosclerosis may be an additional risk factor. A metal stent was used in our patient to treat a presumably benign stenosis only after all other treatment failed. After a careful discussion, the patient chose this alternative from several possible treatments including percutaneous gastrostomy. Metal stents have also been used by others in benign diseases.28-31 Early removal after placement has been described as a way of avoiding complications and may facilitate the choice of treatment. 31,32 REFERENCES 1. Segalin A, Bonavina L, Carazzone A, Ceriani C, Peracchia A. Improving results of esophageal stenting: a study on 160 consecutive unselected patients. Endoscopy 1997;29:701-9. 2. Ogilvie AL, Dronfield MW, Ferguson R, Atkinson M. Palliative intubation of oesophagogastric neoplasms at fibreoptic endoscopy. Gut 1982;23:1060-7. 3. Knyrim K, Wagner HG, Bethge N, Keymling M, Vakil N. A controlled trial of an expansile metal stent for palliation of esophageal obstruction due to inoperable cancer. N Engl J Med 1993;329:1302-7. VOLUME 53, NO. 3, 2001
O Kohl, K Rauber, W Doppl
4. Watkinson AF, Mason RC, Adam A. Oesophageal stents. In: Adam A, Dondelinger RF, Mueller PR, editors. Textbook of metallic stents. Oxford: Isis Medical Media; 1997. p. 87-102. 5. Vitale GC, Larson GM, George M, Tatum C. Management of malignant biliary stricture with self-expanding metallic stent. Surg Endosc 1996;10:970-3. 6. Henne TH, Schaeff B, Paolucci V. Small-bowel obstruction and perforation. A rare complication of an esophageal stent. Surg Endosc 1997;11:383-4. 7. Hendra KP, Saukkonen JJ. Erosion of right mainstem bronchus by an esophageal stent. Chest 1996;110:857-8. 8. Tagawa T, Itoh S, Ide S, Tanaka K, Sumida Y, Ohe H. Esophagobronchial fistula which developed after the insertion of an expandable metallic stent for corrosive esophageal stenosis. Nippon Kyobu Geka Gakkai Zasshi 1997;45:1044-8. 9. Dennert B, Ramirez FC, Sanowski RA. Pericardioesophageal fistula associated with metallic stent placement. Gastrointest Endosc 1997;45:82-4. 10. Allgaier HP, Schwacha H, Technau K, Blum HE. Fatal esophagoaortic fistula after placement of a self-expanding metal stent in a patient with esophageal carcinoma (letter). N Engl J Med 1997;337:1778. 11. Siersema PD, Tan TG, Sutorius FFJM, Dees J, van Blankenstein M. Massive hemorrhage caused by a perforating Gianturco-Z stent resulting in an aortoesophageal fistula. Endoscopy 1997;29:416-20. 12. Song HY, Do YS, Han YM, Sung KB, Choi EK, Sohn KH, et al. Covered, expandable esophageal metallic stent tubes: experiences in 119 patients. Radiology 1994;193:689-95 13. De Palma GD, di Matteo E, Romano G, Fimmano A, Rondinone G, Catanzano C. Plastic prothesis versus expandable metal stent for palliation of inoperable esophageal thoracic carcinoma: a controlled prospective study. Gastrointest Endosc 1996;43:478-82. 14. Davids PHP, Green AK, Rauws EAJ, Tytgat GN, Huibregtse K. Randomised trial of self-expanding metal stents versus polyethylene stents for distal malignant biliary obstruction. Lancet 1992;340:1488-92. 15. Farrugia M, Morgan RA, Latham JA, Glynos M, Mason RC, Adam A. Perforation of the esophagus secondary to insertion of covered wallstent endoprotheses. Cardiovasc Intervent Radiol 1997;20:470-2. 16. Kos X, Trotteur G, Dondelinger RF. Delayed esophageal hemorrhage caused by a metal stent: treatment with embolization. Cardiovasc Intervent Radiol 1998;21:428-30. 17. Nemoto K, Takai Y, Ogawa Y, Kakuto Y, Ariga H, Matsushita H, et al. Fatal hemorrhage in irradiated esophageal cancer patients. Acta Oncol 1998;37:259-62. 18. Bethge N, Sommer A, von Kleist D, Vakil N. A prospective trial of self-expanding metal stents in the palliation of malignant esophageal obstruction after failure of primary curative therapy. Gastrointest Endosc 1996;44:283-6. 19. Kinsman KJ, DeGregorio BT, Katon RM, Morrison K, Saxon RR, Keller FS, et al. Prior radiation and chemotherapy increase the risk of life-threatening complications after insertion of metallic stents for esophagogastric malignancy. Gastointest Endosc 1996;43:196-203. 20. Siersema PD, Hop WCJ, van Blankenstein M, Dees J. A new design metal stent (Flamingo stent) for palliation of malignant dysphagia: a prospective study. Gastrointest Endosc 2000;51:139-45. 21. Siersema PD, Hop WCJ, Dees J, Tilanus HW, van Blankenstein M. Coated self-expanding metal stents versus latex prostheses for esophagogastric cancer with special reference to prior radiation and chemotherapy: a controlled prospective study. Gastrointest Endosc 1998;47:113-20. GASTROINTESTINAL ENDOSCOPY
377
22. Raijman I, Siddique I, Lynch P. Does chemoradiation therapy increase the incidence of complications with self-expanding coated stents in the management of malignant esophageal strictures? Am J Gastroenterol 1997;92:2192-6. 23. Ludwig D, Dehne A, Burmester E, Wiedemann GJ, Stange EF. Treatment of unresectable carcinoma of the esophagus or the gastroesophageal junction by mesh stents with or without radiochemotherapy. Int J Oncol 1998;13:583-8. 24. Bartelsman JFW, Bruno MJ, Jensema AJ, Maringsma J, Reeders JWAJ, Tytgat GNJ. Palliation of patients with esophagogastric neoplasms by insertion of a covered expandable modified Gianturco-Z endoprosthesis: experiences in 153 patients. Gastrointest Endosc 2000;51:134-8. 25. Kozarek RA, Ball TJ, Brandabur JJ, Patterson DJ, Low D, Hill L, et al. Expandable versus conventional esophageal prostheses: easier insertion may not preclude subsequent stent-related problems. Gastrointest Endosc 1996;43:204-8. 26. Chan ACW, Shin FG, Lam YH, Ng EKW, Sung JJY, Lau JYW, et al. A comparison study on physical properties of selfexpandable esophageal metal stents. Gastrointest Endosc 1999;49:462-5.
378
GASTROINTESTINAL ENDOSCOPY
27. Tanigawa N, Sawada S, Kobayashi M. Reaction of the aortic wall to six metallic stent materials. Acad Radiol 1995;2:379-84. 28. Eubanks PJ, Hu E, Nguyen D, Procaccino F, Eysselein VE, Klein SR. Case of Boerhaave’s syndrome successfully treated with a self-expandable metallic stent. Gastrointest Endosc 1999;49:780-3. 29. Yuasa R, Hattori T, Kobayashi Y, Miyata K, Hayashi Y, Seko H. Treatment of spontaneous esophageal rupture with a covered self-expanding metal stent. Gastrointest Endosc 1999;49:777-80. 30. Tan BS, Kennedy C, Morgan R, Owen W, Adam A. Using uncovered metallic endoprostheses to treat recurrent benign esophageal strictures. AJR Am J Roentgenol 1997;169:12814. 31. Song HY, Park SI, Jung HY, Kim SB, Kim JH, Huh SJ, et al. Benign and malignant esophageal strictures: treatment with a polyurethane-covered retrievable expandable metallic stent. Radiology 1997;203:747-52. 32. May A, Goßner L, Feeß G, Bauer R, Ell C. Extraction of migrated self-expanding esophageal metal stents. Gastrointest Endosc 1999;49:524-7.
VOLUME 53, NO. 3, 2001