Stenting Esophageal Disease

In 1885, Charles Symonds placed the first rigid endoprosthesis across a malignant esophageal stricture. With the introduction of the fiberoptic endoscope and the development of the rigid Celestin tube nearly one century later, the revolution was initiated. Over the past 2 decades, esophageal stents have drastically improved. Prior to 1990, stents were made from rigid polyvinyl plastic or rubber. These prostheses were able to restore luminal patency, however placement was difficult and bleeding, pain, and perforations frequently occurred. In the early nineties, rigid endoprostheses were replaced by uncovered self-expandable metal stents (SEMS). SEMS placement appeared to be less invasive, provided wider lumen, and was associated with fewer complications. However, new problems soon appeared. Through the uncovered mesh tumor ingrowth frequently occurred, leading to recurrent dysphagia shortly after placement. To impede tissue ingrowth, SEMS were modified with a plastic or silicone layer in the middle of the endoprosthesis. These partially-covered SEMS (PCSEMS) were not only able to re-open a blocked esophagus, but also sealed malignant esophagorespiratory fistulae. In 2001, removable fully covered metal stents (FCSEMS) and plastic stents (SEPS) were introduced. The ability to remove these stents after deployment has opened up new applications, such as the insertion of a stents as a temporary device in patients with benign esophageal fistulae or stenosis and to bridge chemo- and radiotherapy in patients with malignant esophageal disease. Initial results were suboptimal as well. Fully-covered expandable stents were associated with a higher migration rate. SEMS are generally preloaded in a thin delivery catheter, yet FCSEPS require being loaded onto the significantly larger and stiffer delivery device.