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The Cardiovascular and Interventional Radiological Society of Europe guidelines for placement of oesophageal stents

The frequencies of complications caused by implantation of self expanding metal stents as reported by these guidelines are summarised in the table below:

|Complication |Frequency |

|Haemorrhage |3-8 % |

|Prolonged chest pain |14 % |

|Migration: uncovered stent |0-6 % |

|Migration: covered stent |25-32 % |

|Overgrowth |60% |

|Tumor ingrowth: uncovered stent |17-36 % |

|Tumor ingrowth: covered stent |Negligible |

|Fistula |Uncommon |

|Perforation |Uncommon |

|Death |0–1.4 % |

The American College of Gastroenterology Practice Guidelines with regards to the Role of Oesophageal Stents in Benign and Malignant Diseases

The guidelines described the complications resulting from placement of self expanding metal stents in the range of 30 to 35 % in most series and Up to 50 % as the intensity and duration of follow-up increases. The frequencies of complications caused by implantation of self expanding metal stents as reported by these guidelines are summarised in the table below:

|Complication |Frequency |

|Total Complications (most series) |35 % |

|Total Complications (as intensity and duration of follow-up |50 % |

|increases) | |

|Tumour Overgrowth |15 % |

|Tumour Ingrowth |22 % |

|Stent Migration |9 % |

|Food Bolus Obstruction |21 % |

|Fistulas |9 % |

Other Published Complications of Oesophageal Self Expanding Metal Stent Insertion

Oesophageal metal stent insertion is an efficient, easy and safe procedure for relieving dysphagia and malnutrition in patients having malignant oesophageal stenosis and improving their quality of life. Moreover, in comparison with plastic tubes, metal has less procedural mortality and morbidity rates 1-3. However, numerous complications have been reported in the literatures following the placement of metal stents, the majority of which are post-procedural 4.

The major complications caused by self expanding metal stent insertion are illustrated in the table below.

|Major Complications |

|Haemorrhage |

|Perforation |

|Fistula formation |

|Prolonged chest pain |

|Tumour overgrowth |

|Tumour ingrowth |

|Stent migration |

|Procedure related death |

There are different ways to classify complications caused by oesophageal metal stent insertion. They can be classified into immediate, early and late complications 5.

Immediate complications take place at the time of stent insertion and they include:

1) Perforation.

2) Airway compromise.

3) Aspiration.

4) Haemorrhage.

5) Stent misplacement.

6) Failure of the procedure due to entrapment of the delivery system or problems with placement or expansion of the stent.

7) Dislodgment of the stent.

Early complications happen up to one week post stent insertion and they are:

1) Foreign body sensation.

2) Chest pain as an early symptom can occur in up to 100% of the cases. However, fewer than 13% of the patients developed prolonged chest pain 6. The pain is more severe when employing stents of large diameter and in patients whose oesophageal stricture is high 7.

3) Bleeding.

4) Nausea.

Late complications occur after one week from placement of the stent, of which the first five can lead to recurrent dysphagia ( being the main drawback of oesophageal stents) and might necessitate further intervention, include the following 4, 8 :

1) In- or overgrowth of tumour.

2) Stent migration which can also lead to bowel obstruction.

3) Tracheo-oesophageal Fistula or pocket formation.

4) Obstruction by an impacted bolus of food.

5) Incomplete stent dilatation.

6) Bleeding.

7) Stent placement beyond the gastro-oesophageal junction causing acid reflux 9.

Furthermore, various case reports have been published in recent times on unusual complications caused by self expanding metal stents:

1) Erosion of the stent into the oesophageal wall or carotid artery resulting in severe and life-threatening haemorrhage 10, 11.

2) Acute and delayed obstruction of the airways by the stents 12, 13.

3) Placement of the stent to treat upper third strictures of the oesophagus can lead to tracheal compression, even though it is uncommon 14.

4) The risk of oesophageal rupture within one week of self expanding metal stent placement can increase considerably in cases of using adjuvant therapy with either dilatation or thermal ablation or Photodynamic therapy with brachytherapy 15.

5) A relatively rare complication is fracture of the oesophageal stent which has a small number of reports in literatures and it could be due to a defect in the stent material or thermal overstrain during laser 16.

6) A rare postoperative complication reported in the literature was a spinal epidural abscess 17.

7) Aorto-oesophageal Fistula 18.

8) Pericardioesophageal fistula 19.

References:

1. De Palma GD, di Matteo E, Romano G, Fimmano A, Rondinone G, Catanzano C. Plastic prosthesis versus expandable metal stents for palliation of inoperable esophageal thoracic carcinoma; a controlled prospective study. Gastrointestinal Endoscopy 1996; 43(5): 478-482.

2. Roseveare CD, Patel P, Simmonds N, Goggin PM, Kimble J, Shepherd HA. Metal stents improve dysphagia, nutrition and survival in malignant oesophageal stenosis: a randomized controlled trial comparing modified Gianturco Z-stents with plastic Atkinson tubes. European Journal of Gastroenterology & Hepatology 1998;10(8):653-657.

3. Siersema PD, Hop WC, Dees J, Tilanus HW, van Blackenstein M. Coated self-expanding metal stents versus latex prosthesis for esophagogastric cancer with special reference to prior radiation and chemotherapy: a controlled prospective study. Gastrointestinal Endoscopy 1998; 47(2):113-120.

4. Kawasaki R, Sano A, Matsumoto S. Long-term Outcomes and Complications of Metallic Stents for Malignant Esophageal Stenoses. Kobe J Med Sci. 2003;49(6):133-142.

5. Sharma P, Kozarek R and the Practice Parameters Committee of the American College of Gastroenterology. Role of Esophageal Stents in Benign and Malignant Diseases. Am J Gastroenterol 2010; 105:258–273.

6. Acunas B, Rozanes I, Akpinar S, et al. (1996) Palliation of malignant esophageal strictures with self-expanding Nitinol stents: Drawbacks and complications. Radiology 199:648–652.

7. Song HY, Do YS, Han YM, et al. (1998) Covered, expandable oesophageal metallicstent tubes: Experience in 119 patients. Radiology 207:513–518.

8. Homann N, Noftz MR, Klingenberg-Noftz RD, et al. Delayed Complications after Placement of Self Expanding Stents in Malignant Esophageal Obstruction: Treatment Strategies and Survival Rate. Dig Dis Sci (2008) 53:334-340.

9. Sreedharan A, Harris K, Crellin A, Forman D, Everett SM. Interventions for dysphagia in oesophageal cancer. Cochrane Database of Systematic Reviews 2009, Issue 4. Art. No.: CD005048. DOI: 10.1002/14651858.CD005048.pub2.

10. Demarquay JF, Conio M, Dumas R, et al. Fatal complication after placement of an esophageal self-expanding metal stent. Am J Gastroenterol. 1996;91:178-179.

11. Kohl O, Rauber K, Doppl W. Perforation of an esophageal stent into the common carotid artery. Gastrointest Endosc. 2001;53:374-378.

12. Dasgupta A, Jain P, Sandur S, et al. Airway complications of esophageal self-expandable metallic stent. Gastrointest Endosc. 1998;47:532-535.

13. Atkinson K, Prokopiw I. Acute airway obstruction from insertion of a cuffed esophageal stent for malignant tracheoesophageal fistula. Gastrointest Endosc. 1998;47:416-417.

14. Libby ED, Fawaz R, Leano AM, Hassoun PM. Airway complication of expandable stents. Gastrointest Endosc 1999;49:136-137.

15. Maier A, Pinter H, Friehs GB, Renner H, Smolle- Juttner FM. Self expandable coated stents after intraluminal treatment of oesophageal cancer; a risky procedure. Ann Thorac Surg 1999;67:781-784.

16. Zelenˇa´k K, Misˇtuna D, Lu´cˇan J, et al. Broken Esophageal Stent Successfully Treated by Interventional Radiology Technique. CardioVascular and Interventional Radiology. Volume 33, Number 3 / June, 2010: 643-645.

17. Li CY, Chen WC, Yang SH, et al. A rare complication of esophageal stent: Spinal Epidural Abscess. Ann Thorac Surg 2009;88:1700-1702.

18. Grundy A, Glees JP. 1997. Aorto-oesophageal Fistula: A complication of Oesophageal Stenting. Br J Radiol 70: 846-849.

19. Dennert B, Ramirez FC, Sanowski RA. 1997. Pericardioesophageal Fistula Associated with Metallic Stent Placement. Gastrointest Endoscop 45: 82-84.

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