Objective: We aimed to present the effectiveness of self-expandable metallic stents (SEMS) in dysphagia score and fistula closure, which are used in palliation for dysphagia and tracheoesophageal fistula (TEF) seen in primary and secondary advanced esophagus tumors.
Material and methods: We reviewed files and records of 34 patients who underwent stent implantation due to esophageal stricture and/or fistula in our clinic between 1997 and 2002. The patients were assessed regarding age, gender, the reason for stent insertion (stricture or fistula), localization of stricture or fistula, pre-procedural and post-procedural dysphagia scores (DS), stent specifications, tumor histopathology, complications and need for re-stenting.
Findings: In our clinic, 36 self-expandable metallic stents were inserted to 34 patients during this period. The mean age was 64 years (range. 44-82 years). There were 24 men and 10 women. Of the patients considered as inoperable, 15 (44%) had primary esophagus carcinoma while 19 (46%) had secondary esophagus carcinoma including 9 gastric carcinomas, 8 lung cancers, 1 larynx cancer and 1 acute myeloid leukemia (AML). The anatomic localizations included cervical esophagus in one patient (3%), thoracic esophagus in 16 patients (47%), and distal esophagus in 17 patients (50%). There was stricture in 25 patients (73.5%), stricture plus fistula in 6 patients (17.6%), and fistula alone in 3 patients (8.8%). Thirty-six self-expandable stent was implanted in 34 patients for stricture and fistula palliation, including 30 (29 covered, 1 non-covered) Ultraflex stent, 3 Wallstent esophageal stents, and 3 Flamingo stent, a modified Wallstent for gastroesophageal junction tumors. The dysphagia score was 4 (unable to swallow anything) in 5; 3 (difficulty to swallow liquids) in 20; and 2 (difficulty to swallow solid foods) in 6 of 31 patients with a stricture. Mean dysphagia score was found as 2.96 before procedure whereas 0.19 after the procedure. There was minimal difficulty to swallow solid foods (DS: 1) in 6 patients and no dysphagia (DS: 0) in 25 patients after the procedure. The fistula tract was closed by self-expandable metallic stents in all 9 cases (3 with fistula and 6 with fistula plus stricture) in which fistula tract palliation was intended. No major complication was detected in 36 stent interventions performed in 34 patients while minor complication rate was 17.6% including stent migration in 2 patients; complete obstruction at the distal tip due to food plug in 2 and granulation tissue in one patient; and less than 50% expansion of the stent in one patient. Re-stenting was performed in 2 patients with minor complications. The re-stenting rate was 5.8% in our study.
Conclusions: Self-expandable metallic stents are among first-line modalities in the palliation of malignancy-related esophagus stricture and fistula. Palliation of esophagus stricture and fistulas due to primary or secondary esophagus malignancies using SEMS is a safe, effective, and readily tolerable method. The accurate positioning of a stent in a safe manner can be achieved using fluoroscopy during procedure. Endoscopy before and after procedure improves the success and effectiveness of the procedure.
Key words: Esophagus, dysphagia, tracheoesophageal fistula, self-expandable metallic stent
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