Effect of stent size on complications and recurrent dysphagia in patients with esophageal or gastric cardia cancer.
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.


METHODS
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.


METHODS
Single academic center.


METHODS
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.


METHODS
Stent placement.


METHODS
Dysphagia score (on a scale from 0 [no dysphagia] to 4 [complete dysphagia]), complications, and recurrent dysphagia. Analysis was by chi2 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).


CONCLUSIONS
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.
Verschuur
Els M L
EM
Department of Gastroenterology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands.
Steyerberg
Ewout W
EW
Kuipers
Ernst J
EJ
Siersema
Peter D
PD
D000368:Aged; D002299:Cardia; D003680:Deglutition Disorders / Q000209:etiology* / Q000517:prevention & control / Q000601:surgery*; D016099:Endoscopy, Gastrointestinal / Q000379:methods; D004867:Equipment Design; D004938:Esophageal Neoplasms / Q000150:complications*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications; D011446:Prospective Studies; D055502:Secondary Prevention; D015607:Stents / Q000009:adverse effects; D013274:Stomach Neoplasms / Q000150:complications*; D016896:Treatment Outcome