title: Esophageal stents for malignant strictures close to the upper esophageal sphincter.
abstract: BACKGROUND
  Self-expanding stents are a well-accepted palliative treatment modality for strictures resulting from esophageal carcinoma. However, the use of stents close to the upper esophageal sphincter (UES) is considered to be limited by patient intolerance caused by pain and globus sensation and an increased risk of complications, particularly tracheoesophageal fistula formation and aspiration pneumonia.
  
  
  OBJECTIVE
  Our purpose was to determine the efficacy and safety of stent placement in patients with a malignant obstruction close to the UES.
  
  
  METHODS
  Evaluation of 104 patients with dysphagia from a malignant stricture close to the UES treated in the period 1996-2006.
  
  
  METHODS
  Single university center.
  
  
  METHODS
  Patients with primary esophageal carcinoma (n = 66) or recurrent cancer after gastric tube interposition (n = 38) within 8 cm distance distal of the UES. Twenty-four (23%) patients also had a tracheoesophageal fistula.
  
  
  METHODS
  Stent placement.
  
  
  METHODS
  Functional and technical outcome, survival, complications, and recurrent dysphagia. Analyses were performed by chi(2) test, Kaplan-Meier curves, and log-rank testing.
  
  
  RESULTS
  Mean distance from the UES to the upper tumor margin was 4.9 +/- 2.6 cm and to the upper stent margin 3.1 +/- 2.3 cm. The procedure was technically successful in 100 of 104 (96%) patients. Fistula sealing was achieved in 19 of 24 (79%) patients. After 4 weeks, dysphagia had improved from a median score of 3 (liquids only) to 1 (some difficulties with solids). Total complications were seen in 34 of 104 (33%) patients. Of these, major complications (aspiration pneumonia [9], hemorrhage [8], fistula [7], and perforation [2]) occurred in 22 (21%) patients, whereas pain after stent placement was observed in 16 (15%) patients. Recurrent dysphagia occurred in 29 (28%) patients and was mainly caused by tissue ingrowth or overgrowth (n = 10), food bolus obstruction (n = 7), stent migration (n = 3), or other reasons (n = 11), such as persistent fistula (n = 5), difficulty with swallowing (n = 4), and dislocation of the stent (n = 2). Eight (8%) patients complained of globus sensation; however, in none of the patients was stent removal indicated.
  
  
  CONCLUSIONS
  Retrospective design.
  
  
  CONCLUSIONS
  Stent placement is safe and effective for the palliation of dysphagia and sealing of fistulas in patients with a malignant stricture close to the UES. On the basis of these results, stent placement may be considered for palliation in this group of patients with an otherwise dismal prognosis.
authors.affiliation: Department of Gastroenterology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands.
authors.forename: Els M L
authors.initials: EM
authors.lastname: Verschuur
authors.forename: Ernst J
authors.initials: EJ
authors.lastname: Kuipers
authors.forename: Peter D
authors.initials: PD
authors.lastname: Siersema
mesh_terms: D000368:Aged; D004938:Esophageal Neoplasms / Q000150:complications / Q000175:diagnosis / Q000000981:diagnostic imaging / Q000628:therapy*; D049630:Esophageal Sphincter, Lower / Q000502:physiology; D004940:Esophageal Stenosis / Q000209:etiology / Q000628:therapy*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011859:Radiography; D012449:Safety; D015607:Stents / Q000009:adverse effects; D014138:Tracheoesophageal Fistula / Q000209:etiology / Q000628:therapy; D016896:Treatment Outcome