Original Article
Clinical Endoscopy
Effect of stent size on complications and recurrent dysphagia in patients with esophageal or gastric cardia cancer

https://doi.org/10.1016/j.gie.2006.12.018Get rights and content

Background

Stents are commonly used for the palliation of dysphagia from esophageal or gastric cardia cancer. A major drawback of stents is the occurrence of recurrent dysphagia. Large-diameter stents were introduced for the prevention of migration but may be associated with more complications.

Objective

To compare small- and large-diameter stents for improvement of dysphagia, complications, and recurrent dysphagia.

Design

Evaluation of 338 prospectively followed patients with dysphagia from obstructing esophageal or gastric cardia cancer who were treated with an Ultraflex stent (n = 153), a Gianturco Z-stent (n = 89), or a Flamingo Wallstent (n = 96) of either a small diameter (n = 265) or a large diameter (n = 73) during the period 1996 to 2004.

Setting

Single academic center.

Patients

Patients with an inoperable malignant obstruction of the esophagus or the gastric cardia, or recurrent dysphagia after prior radiation, with curative or palliative intent for esophageal cancer.

Interventions

Stent placement.

Main Outcome Measurements

Dysphagia score (on a scale from 0 [no dysphagia] to 4 [complete dysphagia]), complications, and recurrent dysphagia. Analysis was by χ2 test, log-rank test, and Cox regression analysis.

Results

Improvement in dysphagia was similar between patients with a small- or a large-diameter stent (P = .35). The occurrence of major complications, such as hemorrhage, perforation, fistula, and fever, was increased in patients with a large-diameter Gianturco Z-stent compared with those treated with a small-diameter stent (4 [40%] vs 16 [20%]; adjusted hazard ratio [HR] 5.03, 95% confidence interval [CI] 1.33-19.11) but not in patients with a large-diameter Ultraflex stent or a Flamingo Wallstent. Moreover, minor complications, particularly pain, were associated with prior radiation and/or chemotherapy in patients with a large- or a small-diameter Gianturco Z-stent (HR 4.27, 95% CI 1.44-12.71) but not in those with an Ultraflex stent or a Flamingo Wallstent. Dysphagia from stent migration, tissue overgrowth, and food bolus obstruction reoccurred more frequently in patients with a small-diameter stent than in those with a large-diameter stent (Ultraflex stent: 54 [42%] vs 3 [13%], adjusted HR 0.16, 95% CI 0.04-0.74; Gianturco Z-stent: 21 [27%] vs 1 [10%], adjusted HR 0.97, 95% CI 0.11-8.67; and Flamingo Wallstent: 21 [37%] vs 6 [15%], adjusted HR 0.40, 95% CI 0.03-4.79).

Limitations

Nonrandomized study design.

Conclusions

Large-diameter stents reduce the risk of recurrent dysphagia from stent migration, tissue overgrowth, or food obstruction. Increasing the diameter in some stent types may, however, increase the risk of stent-related complications to the esophagus.

Section snippets

Patients

At the Erasmus MC University Medical Center Rotterdam, from January 1996 to December 2004, 556 patients were treated with a metal stent in the esophagus or the gastric cardia. Data from these patients were collected in a prospective database. Informed consent of patients to analyze this information is not needed in The Netherlands. Patients were included if they had an inoperable malignant obstruction of the esophagus or the gastric cardia, or recurrent dysphagia after prior radiation with

Clinical characteristics

Clinical characteristics of the 338 patients treated with a small-diameter (n = 265) or a large-diameter (n = 73) stent and fulfilling the inclusion criteria are shown in Table 1. In approximately 20% of patients, the tumor was located in the gastric cardia, whereas, in the remainder, it was located in the esophagus. Large-diameter stents were more frequently placed in patients with a tumor located in the gastric cardia (P < .0001). If the Flamingo Wallstent was used, then a large-diameter

Discussion

This nonrandomized comparison between small- and large-diameter stents demonstrated that endoscopic placement of large-diameter stents was associated with a lower frequency of recurrent dysphagia from stent migration, tissue overgrowth, and food-bolus obstruction. Nonetheless, for some stent types, particularly the Gianturco Z-stent, increasing the stent size will likely result in more stent-related complications to the esophagus.

Migration is suggested to occur more frequently with stents

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See CME section; p. 672.

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