Improving results of stent placement in the esophagus and biliary tract: clinical studies

Abstract

Main conclusions from this thesis Part I Esophagus Benign esophageal ruptures or leaks - Covered stents placed for a period of 6 weeks are effective and safe. Stent choice should to a large extent depend on expected risks of stent migration, particularly when SEPS and FSEMS are used, and tissue in- or overgrowth, particularly with PSEMS, since efficacy rates between PSEMS, FSEMS and SEPS was not found to be very much different. Refractory benign esophageal strictures - Both temporary SEPS (for a period of 6 weeks) and BD stent placement achieve long-term relief without a further need for dilation in 30% and 33% of patients, respectively. Placement of BD stents has the advantage that fewer endoscopic reinterventions are required, the latter mainly being performed for stent removal. Malignant esophageal strictures - The partially covered Evolution stent (Cook Medical, Limerick, Ireland) is safe and effective for palliation of dysphagia from esophageal and gastric cardia cancer. -The partially covered Wallflex stent (Boston Scientific, Natick, MA., USA) is also a safe and effective stent for palliation of malignant dysphagia. However, retrosternal pain seemed to occur more often with this stent design as compared to other designs. Based on this, we recommend not to place this stent in patients who previously have undergone radiation and/or chemotherapy for esophageal cancer as these patients are known to be at an increased risk of post-procedural retrosternal pain. Part II Biliary tract Benign distal biliary strictures -Based on clinical success (re-establishment of biliary patency) and risk of complications (e.g. cholangitis, pancreatitis and stent migration) placement of multiple plastic stents is currently the best choice for the endoscopic treatment of a benign distal biliary stricture. Malignant inoperable distal biliary strictures -Both uSEMS and cSEMS have a longer patency than plastic stents, but the number of reinterventions is lowest after placement of uSEMS. -Based on a model, we propose that the subgroup of patients with a tight malignant biliary stricture requiring preceding dilation and/or a high initial bilirubin level, with an expected survival longer than 14 weeks should be treated with an uSEMS to reduce the risk of stent occlusion. In the remaining patients, placement of a plastic stent should be considered, again depending on the patients’ expected survival