Esophageal stents for malignant strictures close to the upper esophageal sphincter

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. Design: Evaluation of 104 patients with dysphagia from a malignant stricture close to the UES treated in the period 1996-2006. Setting: Single university center. Patients: 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. Interventions: Stent placement. Main Outcome Measurements: Functional and technical outcome, survival, complications, and recurrent dysphagia. Analyses were performed by χ2test, 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. Limitations: 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.

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