Endoscopic treatment of extreme esophageal stenosis complicated with esophagotracheal fistula: A case report

BACKGROUND At present,there is no unified and effective treatment for extreme corrosive esophageal stenosis(CES)with esophagotracheal fistula(ETF).This case had extreme and severe esophageal stenosis(ES)and ETF after ingesting an enzyme-based chemical detergent,resulting in a serious pulmonary infection and severe malnutrition.Upper gastrointestinal imaging showed that he had an ETF,and endoscopy showed that he had extreme and severe esophageal stricture.This case was complex and difficult to treat.According to the domestic and foreign lite-rature,there is no universal treatment that is low-risk.CASE SUMMARY A patient came to our hospital with extreme ES,an ETF,and severe malnutrition complicated with pulmonary tuberculosis 1 mo after the consumption of an enzy-me-based detergent.The ES was serious,and the endoscope was unable to pass through the esophagus.We treated him by endoscopic incision method(EIM),esophageal stent placement(ESP),and endoscopic balloon dilation(EBD)by using the bronchoscope and gastroscope.This treatment not only closed the ETF,but also expanded the esophagus,with minimal trauma,greatly reducing the pain of the patient.According to the literature,there are no similar reported cases.CONCLUSION We report,for the first time,a patient with extreme CES complicated with ETF,where the endoscope could not be passed through his esophagus but he could be examined by bronchoscopy and treated by EIM,ESP,and EBD.

Silicone-covered biodegradable magnesium stent for treating benign esophageal stricture in a rabbit model

BACKGROUND Stent insertion can effective alleviate the symptoms of benign esophageal strictures(BES).Magnesium alloy stents are a good candidate because of biological safety,but show a poor corrosion resistance and a quick loss of mechanical support in vivo.AIM To test the therapeutic and adverse effects of a silicone-covered magnesium alloy biodegradable esophageal stent.METHODS Fifteen rabbits underwent silicone-covered biodegradable magnesium stent insertion into the benign esophageal stricture under fluoroscopic guidance(stent group).The wall reconstruction and tissue reaction of stenotic esophagus in the stent group were compared with those of six esophageal stricture models(control group).Esophagography was performed at 1,2,and 3 weeks.Four,six,and five rabbits in the stent group and two rabbits in the control groups were euthanized,respectively,at each time point for histological examination.RESULTS All stent insertions were well tolerated.The esophageal diameters at immediately,1,2 and 3 wk were 9.8±0.3 mm,9.7±0.7 mm,9.4±0.8 mm,and 9.2±0.5 mm,respectively(vs 4.9±0.3 mm before stent insertion;P<0.05).Magnesium stents migrated in eight rabbits[one at 1 wk(1/15),three at 2 wk(3/11),and four at 3 wk(4/5)].Esophageal wall remodeling(thinner epithelial and smooth muscle layers)was found significantly thinner in the stent group than in the control group(P<0.05).Esophageal injury and collagen deposition following stent insertion were similar and did not differ compared to rabbits with esophageal stricture and normal rabbits(P>0.05).CONCLUSION Esophageal silicone-covered biodegradable magnesium stent insertion is feasible for BES without causing severe injury or tissue reaction.Our study suggests that insertion of silicone-covered magnesium esophageal stent is a promising approach for treating BES.

Covered nitinol stents for the treatment of esophageal strictures and leaks

AIM:To compare 2 different types of covered esophageal nitinol stents(Ultraflex and Choostent) in terms of efficacy,complications,and long-term outcome.METHODS:A retrospective review of a consecutive series of 65 patients who underwent endoscopic placement of an Ultraflex stent(n = 33) or a Choostent(n = 32) from June 2001 to October 2009 was conducted.RESULTS:Stent placement was successful in all patients without hospital mortality.No significant differences in patient discomfort and complications were observed between the Ultraflex stent and Choostent groups.The median follow-up time was 6 mo(interquartile range 3-16 mo).Endoscopic reintervention was required in 9 patients(14%) because of stent migration or food obstruction.No significant difference in the rate of reintervention between the 2 groups was observed(P = 0.8).The mean dysphagia score 1 mo after stent placement was 1.9 ± 0.3 for the Ultraflex stent and 2.1 ± 0.4 for the Choostent(P = 0.6).At 1-mo follow-up endoscopy,the cover membrane of the stent appeared to be damaged more frequently in the Choostent group(P = 0.34).Removal of the Choostent was possible up to 8 wk without difficulty.CONCLUSION:Ultraflex and Choostent proved to be equally reliable for palliation of dysphagia and leaks.Removal of the Choostent was easy and safe under mild sedation.

Combined treatment of refractory benign stricture after esophageal endoscopic mucosal dissection:A case report

BACKGROUND Endoscopic submucosal dissection(ESD)post-procedure stricture is a relatively common long-term complication following ESD treatment.A range of approaches has been implemented for the treatment of post-procedural stricture using endoscopic techniques such as endoscopic dilation,self-expandable metallic stent insertion,local steroid injection in the esophagus,oral steroid administration,radial incision and cutting(RIC).The actual efficacy of these different therapeutic options is highly variable,and uniform international standards for the prevention or treatment of stricture.CASE SUMMARY In this report,we describe the case of a 51-year-old male diagnosed with early esophageal cancer.To protect against esophageal stricture,the patient was administered oral steroids and underwent self-expandable metallic stent insertion for 45 d.Despite these interventions,stricture was detected at the lower edge of the stent following its removal.The patient remained refractory to multiple rounds of endoscopic bougie dilation treatment,and thus suffered from complex refractory benign esophageal stricture.As such,RIC combined with bougie dilation and steroid injection was employed to treat this patient more effectively,ultimately achieving satisfactory therapeutic efficacy.CONCLUSION Combination of RIC,dilation,and steroid injection can be safely and effectively implemented to treat cases of post-ESD refractory esophageal stricture.

Effect of polyglycolic acid sheet plus esophageal stent placement in preventing esophageal stricture after endoscopic submucosal dissection in patients with earlystage esophageal cancer: A randomized, controlled trial

AIM To assess the effect of polyglycolic acid(PGA) plus stent placement compared with stent placement alone in the prevention of post-endoscopic submucosal dissection(ESD) esophageal stricture in early-stage esophageal cancer(EC) patients. METHODS Seventy EC patients undergoing ESD were enrolled in this randomized, controlled study. Patients were allocated randomly at a 1:1 ratio into two groups as follows:(1) PGA plus stent group(PGA sheet-coated stent placement was performed); and(2) Stent group(only stent placement was performed). This study was registered on http://www.chictr.org.cn(No. chictrinr-16008709). RESULTS The occurrence rate of esophageal stricture in the PGA plus stent group was 20.5%(n = 7), which was lower than that in the stent group(46.9%, n = 15)(P = 0.024). The mean value of esophageal stricture time was 59.6 ± 16.1 d and 70.7 ± 28.6 d in the PGA plus stent group and stent group(P = 0.174), respectively. Times of balloon dilatation in the PGA plus stent group were less than those in the stent group [4(2-5) vs 6(1-14), P = 0.007]. The length(P = 0.080) and diameter(P = 0.061) of esophageal strictures were numerically decreased in the PGA plus stent group, whereas no difference in location(P = 0.232) between the two groups was found. Multivariate logistic analysis suggested that PGA plus stent placement(P = 0.026) was an independent predictive factor for a lower risk of esophageal stricture, while location in the middle third(P = 0.034) and circumferential range = 1/1(P = 0.028) could independently predict a higher risk of esophageal stricture in EC patients after ESD. CONCLUSION PGA plus stent placement is more effective in preventing post-ESD esophageal stricture compared with stent placement alone in EC patients with earlystage disease.

Prophylactic stenting for esophageal stricture prevention after endoscopic submucosal dissection

Endoscopic submucosal dissection (ESD) of superficial esophageal cancer has been increasingly used as an alternative to surgery because it is minimally invasiveand has a high rate of en bloc resection. However, a high rate of esophageal stricture is observed after ESD for large lesions, which can dramatically decrease the patient's quality of life. Stricture prevention is necessary to allow for endoscopic therapy to expand. We, herein, review the most recent evidence and discuss the role of the metallic self-expandable stent and the biodegradable stent in esophageal stricture prevention. Limited studies suggested that prophylactic stenting could reduce the stricture rate without increasing the number of complications. In addition, the number of bougie dilation procedures was significantly lower with stent placement. Esophageal stenting is a promising option for post-ESD stricture prevention. However, current evidence is too preliminary to formulate practice standards. Future studies are needed to further validate the efficacy and safety of prophylactic stenting and determine the best strategy for stricture prevention. Stent migration is the most common complication. A new stent that has advantages of a low migration rate and minimal tissue reaction will need to be developed. Therefore, randomized controlled trials with long-term follow-up periods are required before prophylactic stenting could be considered a valid option to prevent post-ESD stricture.

Metal stenting to resolve post-photodynamic therapy stricture in early esophageal cancer

Photodynamic therapy (PDT) is an established endoscopic technique for ablating Barrett's esophagus with high-grade dysplasia or early-stage intraepithelial neoplasia. The most common clinically significant adverse effect of PDT is esophageal stricture formation. The strictures are usually superficial and might be dilated effectively with standard endoscopic accessories, such as endoscope balloon or Savary dilators. However, multiple dilations might be required to achieve stricture resolution in some cases. We report the case of stricture that recurred after dilation with a bougie, which was completely relieved by a self-expandable metal stent.

Newly designed “pieced” stent in a rabbit model of benign esophageal stricture

AIM:To investigate a newly designed stent and its dilatation effect in a rabbit model of benign esophageal stricture.METHODS:Thirty-four New Zealand white rabbits underwent a corrosive injury in the middle esophagus for esophageal stricture formation.Thirty rabbits with a successful formation of esophageal strictures were randomly allocated into two groups.The control group(n = 15) was implanted with a conventional stent,and the study group(n= 15) was implanted with a detachable "pieced" stent.The study stent(30 mm in length,10 mm in diameter) was composed of three covered metallic pieces connected by surgical suture lines.The stent was collapsed by pulling the suture lines out of the mesh.Two weeks after stricture formation,endoscopic placement of a conventional stent or the new stent was performed.Endoscopic extraction was carried out four weeks later.The extraction rate,ease of extraction,migration,complications,and survival were evaluated.RESULTS:Stent migration occurred in 3/15(20%)animals in the control group and 2/15(13%) animals in the study group;the difference between the two groups was not statistically significant.At the end of four weeks,the remaining stents were successfully extracted with the endoscope in 100%(11/11) of the animals in the study group,and 60%(6/10)of the animals in the control group;this difference was statistically significant(P < 0.05).There was no difference in the mean number of follow-up days between the control and study groups(25.33 vs25.85).Minor bleeding was reported in five cases in the study group and four in the control group.There were no severe complications directly associated with stent implantation or extraction in either of the two groups.CONCLUSION:In this experimental protocol of benign esophageal strictures,the novel "pieced" stent demonstrated a superior removal rate with a similar migration rate compared to a conventional stent.

Repair of an aberrant subclavian arterioesophageal fistula following esophageal stent placement

A fistula formation between the esophagus and an aberrant right subclavian artery is a rare but fatal com-plication that has been mostly described in the setting of prolonged nasogastric intubation and foreign body erosion. We report a case of a young morbidly obese patient who underwent sleeve gastrectomy that was complicated by a postoperative leak at the level of the gastroesophageal junction. A covered esophageal stent was placed endoscopically to treat the leak. The pa-tient developed massive upper gastrointestinal bleeding secondary to the erosion of the stent into an aberrant retroesophageal right subclavian artery twelve days after stent placement. She was ultimately treated by endovascular stenting of the aberrant right subclavian artery followed by thoracotomy and esophageal repair over a T-tube. This case report highlights the multidis-ciplinary approach needed to diagnose and managesuch a devastating complication. It also emphasizes the need for imaging studies prior to stent deployment to delineate the vascular anatomy and rule out the possi-bility of such an anomaly in view of the growing popu-larity of esophageal stents, especially in the setting of a leak.

Clinical outcomes of self-expandable stent placement for benign esophageal diseases: A pooled analysis of the literature

AIM: To analyze the outcomes of self-expandable stent placement for benign esophageal strictures and benign esophageal leaks in the literature.METHODS: The Pub Med, Embase and Cochrane databases were searched for relevant articles published between January 2000 and July 2014. Eight prospective studies were identified that analyzed the outcomes of stent placement for refractory benign esophageal strictures. The outcomes of stent placement for benign esophageal leaks, perforations and fistulae were extracted from 20 retrospective studies that were published after the inclusion period of a recent systematic review. Data were pooled and analyzed using descriptive statistics.RESULTS: Fully covered self-expandable metal stents(FC SEMS)(n = 85), biodegradable(BD) stents(n = 77) and self-expandable plastic stents(SEPS)(n = 70) were inserted in 232 patients with refractory benign esophageal strictures. The overall clinical success rate was 24.2% and according to stent type 14.1% for FC SEMS, 32.9% for BD stents and 27.1% for SEPS. Stent migration occurred in 24.6% of cases. The overall complication rate was 31.0%, including major(17.7%) and minor(13.4%) complications. A total of 643 patients were treated with self-expandable stents mainly for postsurgical leaks(64.5%), iatrogenic perforations(19.6%), Boerhaave's syndrome(7.8%) and fistulae(3.7%). FC SEMS and partially covered SEMS were used in the majority of patients. Successful closure of the defect was achieved in 76.8% of patients and according to etiology in 81.4% for postsurgical leaks, 86.0% for perforations and 64.7% for fistulae. The pooled stent migration rate was 16.5%. Stent-related complications occurred in 13.4% of patients, including major(7.8%) and minor(5.5%) complications.CONCLUSION: The outcomes of stent placement for refractory benign esophageal strictures were poor. However, randomized trials are needed to put this into perspective. The evidence on successful stent placement for benign esophageal leaks, perforationsand fistulae is promising.

Endoscopic management and prevention of migrated esophageal stents

The use of self-expandable metallic stents has increased recently to palliate inoperable esophageal neoplasia and also in the management of benign strictures. Migration is one of the most common complications after stent placement and the endoscopist should be able to recognize and manage this situation. Several techniques for managing migrated stents have been described, as well as new techniques for preventing stent migration. Most stents have a "lasso" at the upper flange which facilitates stent repositioning or removal. An overtube, endoloop and large polypectomy snare may be useful for the retrieval of stents migrated into the stomach. External fixation of the stent with Shim's technique is efficient in preventing stent migration. Suturing the stent to the esophageal wall, new stent designs with larger flanges and double-layered stents are promising techniques to prevent stent migration but they warrant validation in a larger cohort of patients.

Development and validation of a model to determine risk of refractory benign esophageal strictures

BACKGROUND Current research has identified several risk factors for refractory benign esophageal strictures (RBES), but research is scarce on the prediction of RBES in benign esophageal strictures patients. Meanwhile, the long-term outcomes of RBES remain unclear. The aim of this study was to develop and validate a model to determine the progression of RBES in patients with benign esophageal strictures. And we also explored the long-term outcomes and safety in patients with RBES. AIM To develop and validate a model to determine the progression of RBES in patients with benign esophageal strictures, based on the demographic data and endoscopic findings. METHODS A total of 507 benign esophageal stricture patients treated by dilation alone or in combination with stenting were retrospectively enrolled between January 2009 and February 2018. The primary outcome was to establish a risk-scoring model predicting RBES in benign esophageal strictures. The secondary outcome was to explore the clinical effectiveness and adverse events in patients with RBES. RESULTS In the study, age, etiology, and number and length of strictures were the independent risk factors for the refractory performance of benign esophageal strictures. According to risk factors of benign esophageal strictures, a risk-scoring model for predicting RBES in benign esophageal strictures was established: The risk score ranged from 0 to 8 points, and the risk scores were divided into low risk (0-2 points), intermediate risk (3-5 points), and high risk (6-8 points). The proportions of RBES in the corresponding risk categories were 1.0%, 12.2%, and 76.0%, respectively. Among 507 patients, 57 had RBES (39 males;median age, 60 years). The success rate of dilation treatment (51.2%, 21/41) was higher than that of stent placement (37.5%, 6/16). CONCLUSION In this study, 11.3%(57/507) patients had RBES at our hospital. The risk-scoring model predicting RBES in benign esophageal strictures could predict the longterm outcome of patients with strictures ahead.

Acute upper gastrointestinal bleeding caused by esophageal right bronchial artery fistula:A case report

BACKGROUND Fistula between the esophagus and bronchial artery is an extremely rare and potentially life-threatening cause of acute upper gastrointestinal bleeding.Here,we report a case of fistula formation between the esophagus and a nonaneurysmal right bronchial artery(RBA).CASE SUMMARY An 80-year-old woman with previous left pneumonectomy and recent placement of an uncovered self-expandable metallic stent for esophageal adenocarcinoma was admitted due to hematemesis.Emergent computed tomography showed indirect signs of fistulization between the esophagus and a nonaneurysmal RBA,in the absence of active bleeding.Endoscopy revealed the esophageal stent correctly placed and a moderate amount of red blood within the stomach,in the absence of active bleeding or tumor ingrowth/overgrowth.After prompt multidisciplinary evaluation,a step-up approach was planned.The bleeding was successfully controlled by esophageal restenting followed by RBA embolization.No signs of rebleeding were observed and the patient was discharged home with stable hemoglobin level on postoperative day 7.CONCLUSION This was a previously unreported case of an esophageal RBA fistula successfully managed by esophageal restenting followed by RBA embolization.

Exfoliative esophageal bleeding caused by blind placement of a nasogastric tube:Two cases and a literature review

Transnasal intubation is a clinical operation usually performed blindly at the bedside.Mild adverse events,such as epistaxis and tube misplacement,are relatively common.Esophageal bleeding or perforation and other serious adverse events are rare.In the present study,two cases of severe diffuse esophageal bleeding caused by the blind placement of a nasogastric tube are described.These cases were successfully treated using a covered metal stent or Sengstaken-Blakemore tube.A review of the literature regarding the possible causes of such adverse events and the potential endoscopic treatments for severe hemorrhage are discussed.

Successful endoscopic removal of three embedded esophageal self-expanding metal stents

In the report,we describe a case of refractory benign esophageal strictures from esophageal cancer after an operation for the placement of three partially covered self-expanding metal stents (SEMSs),which were all embedded in the esophageal wall.Using the stentin-stent technique,the three embedded SEMSs were successfully removed without significant complications.To the best of our knowledge,few cases of the successful removal of multiple embedded esophageal SEMSs have been reported in the literature.This case also highlights that the stent-in-stent technique is effective for removing multiple embedded esophageal SEMSs.

Review of(acquired) incidental, rare and difficult tracheoesophageal fistula management

Acquired benign tracheoesophageal fistula is a rare condition and a difficult problem. The rarity and unpredictable presentation of this condition makes the design and setting of randomized prospective trials impossible. Guidelines on this matter are also difficult to establish. Based on a comprehensive evaluation of published literature and their experience, the authors review the etiology and best options for treatment, either surgical and non surgical, according to present knowledge.

The Placement of Esophageal Stents in Different Esophageal Disease Related Conditions—A Review

In the past, the esophagus diseases causing the patient to unable to intake oral diet such as esophageal strictures, leaks, tracheoesophageal fistulas, etc. were managed by surgical interventions and parenteral nutrition to meet the demand of the body. After the development of technique of stent placement in esopahgus, there was revolutionary change in the management of such conditions promoting patients to take diet orally and improve their nutritional status as well as quality of life. Different types of commercial stents are available in the market with their own pros and cons. Our aim of this study was to review the different stents being used currently in the clinical practice, comparing the stents on their therapeutic outcome and complications, optimal timing of removal of stents for benign conditions and the methods studied by different clinicians to lower the rate of complications and reinterventions.

Self-expanding metal stent for relieving the stricture after endoscopic injection for esophageal varices

BACKGROUND Esophageal stricture is one of the complications after esophageal varices sclero-therapy injection(ESI),and the incidence rate is between 2%-10%.AIM To explore the efficacy of self-expanding metal stent(SEMS)for the stricture after endoscopic injection with cyanoacrylate(CYA)and sclerotherapy for esophageal varices.METHODS We retrospectively analyzed the efficacy of SEMS to improve the stricture after endoscopic injection with CYA and sclerotherapy for esophageal varices in 4 patients from February 2023 to June 2023.RESULTS The strictures were improved in four patients after stenting.The stent was removed after two weeks because of chest pain with embedding into esophageal mucosa in one patient.The stent was removed after one month,however,the stent was reinserted because of the strictures happening again in two patients.The stent was removed after three months,however,the stent was reinserted because of the strictures happening again in one patient.The stent embedded into esophageal mucosa in three patients.There were 3 patients suffered reflux esophagitis,and the acid reflux was relieved by taking hydrotalcite.There was no other complication of esophageal perforation,bleeding from varices or infection.CONCLUSION SEMS may relieve the stricture which happened after endoscopic injection with CYA and sclerotherapy for esophageal varices.However,when we should remove the stent still needs to be explored.

Endoscopic management of esophageal stenosis in children:New and traditional treatments

Post-esophageal atresia anastomotic strictures and postcorrosive esophagitis are the most frequent types of cicatricial esophageal stricture. Congenital esophageal stenosis has been reported to be a rare but typical disease in children; other pediatric conditions are peptic, eosinophilic esophagitis and dystrophic recessive epidermolysis bullosa strictures. The conservative treatment of esophageal stenosis and strictures(ES) rather than surgery is a well-known strategy for children. Before planning esophageal dilation, the esophageal morphology should be assessed in detail for its length, aspect, number and level, and different conservative strategies should be chosen accordingly. Endoscopic dilators and techniques that involve different adjuvant treatment strategies have been reported and depend on the stricture's etiology, the availability of different tools and the operator's experience and preferences. Balloon and semirigid dilators are the most frequently used tools. No high-quality studies have reported on the differences in the efficacies and rates of complications associated with these two types of dilators. There is no consensus in the literature regarding the frequency of dilations or the diameter that should be achieved. The use of adjuvant treatments has been reported in cases of recalcitrant stenosis or strictures with evidence of dysphagic symptoms. Corticosteroids(either systemically or locally injected), the local application of mitomycin C, diathermy and laser ES sectioning have been reported. Some authors have suggested that stenting can reduce both the number of dilations and the treatment length. In many cases, this strategy is effective when either metallic or plastic stents are utilized. Treatment complications, such esophageal perforations, can be conservatively managed, considering surgery only in cases with severe pleural cavity involvement. In cases of stricture relapse,even if such relapses occur following the execution of well-conducted conservative strategies, surgical stricture resection and anastomosis or esophageal substitution are the only remaining options.

Economical effect of lumen apposing metal stents for treating benign foregut strictures

AIM To evaluate the clinical and economical efficacy of lumen apposing metal stent(LAMS) in the treatment of benign foregut strictures.METHODS A single center retrospective database of patients who underwent endoscopic treatment of benign foregut strictures between January 2014 and May 2017 was analyzed. A control group of non-stented patients who underwent three endoscopic dilations was compared to patients who underwent LAMS placement. Statistical tests performed included independent t-tests and fiveparameter regression analysis RESULTS Nine hundred and ninety-eight foregut endoscopic dilations were performed between January 2014 and May 2017. 15 patients underwent endoscopic LAMS placement for treatment of benign foregut stricture. Thirty-six patients with recurrent benign foregut strictures underwent three or more endoscopic dilations without stent placement. The cost ratio of endoscopic dilation to LAMS(stent, placement and retrieval) is 5.77. Cost effective analysis demonstrated LAMS to be economical after three endoscopic dilation overall.LAMS was cost effective after two dilations in the Postsurgical stricture subgroup. CONCLUSION Endoscopists should consider LAMS for the treatment of benign foregut strictures if symptoms persist past three endoscopic dilations. Post-surgical strictures may benefit from LAMS if symptoms persist after two dilations in a post-surgical. Early intervention with LAMS appears to be a clinically and economically viable option for durable symptomatic relief in patients with these strictures.