British Journal of Radiology (2004) 77, 245-247
© 2004 British Institute of Radiology
doi: 10.1259/bjr/32883350
Benign complications of expandable metal stents used in the palliation of oesophageal carcinoma: two case reports
M J Metcalfe, MRCS1,
A C Steger, MS, FRCS2 and
A Leslie, MSc, MRCP, FRCR3
1 Department of Surgery, 9th Floor, Royal Free Hospital, London NW3 2QG, 2 Department of Surgery, University Hospital Lewisham, London SE13 6LH and 3 Department of Clinical Radiology, University Hospital Lewisham, London SE13 6LH, UK
Correspondence: Dr A Leslie
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Abstract
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We describe two patients who were treated with self-expanding metal stent (SEMS) insertion as palliation of malignant oesophageal strictures. Both patients re-presented with dysphagia several months after SEMS insertion due to benign strictures. Initial treatment with balloon dilation and medical management had limited success so both patients had further SEMS inserted across the secondary benign strictures. This provided very good symptomatic relief. Chemotherapy and chemo-radiation in patients with inoperable oesophageal carcinoma are prolonging patient survival. As patients survival lengthens benign complications of SEMS may become an increasing clinical problem.
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Introduction
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Self-expandable metal stents (SEMS) have become the treatment of choice in the palliation of inoperable oesophageal carcinoma [1–6]. Stent obstruction due to malignant overgrowth is a well recognised complication [1–6]. Stent obstruction due to benign strictures has not been widely reported. We report two cases of patients who developed benign strictures following insertion of SEMS.
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Case 1
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A 64-year-old female presented with dysphagia and weight loss. Investigations revealed a poorly differentiated adenocarcinoma at the gastro-oesophageal junction and multiple liver metastases. The patient was managed by insertion of a 12 cm covered SEMS (Flamingo Wallstent; Boston Scientific, Watertown, MA) and palliative chemotherapy. As the stent crossed the gastro-oesophageal junction proton-pump inhibitors were started to prevent reflux.
5 months after diagnosis, the patient re-presented with dysphagia. This was shortly after her proton-pump inhibitors had been stopped due to a drug rash. Barium swallow showed complete obstruction approximately 2 cm above the proximal end of the oesophageal stent (Figure 1a
). The stricture was biopsied and histology showed stratified squamous epithelium and granulation tissue with no evidence of malignancy. The patient underwent several balloon dilations of the stricture (Figure 1b) and the proton-pump inhibitors were re-started. After each dilatation symptoms improved for a matter of days, then dysphagia recurred. 7 months post diagnosis a 7 cm uncovered SEMS (Ultraflex; Boston Scientific, Watertown, MA) was inserted across the benign stricture (Figure 1c). The patient had immediate control of her symptoms. Maximal anti-reflux treatment was continued. 9 months after the second stent the patient is alive and well palliated.
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Figure 1. (a) Barium swallow shows complete obstruction of the oesophagus 2 cm above the stent. (b) Waisting of the balloon at the level of the benign stricture prior to dilatation. (c) Insertion of the second, overlapping stent at the level of the benign stricture.
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Case 2
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A 52-year-old man presented with dysphagia and weight loss. Endoscopy revealed a moderately differentiated squamous cell carcinoma of the mid-oesophagus. This was staged at T4, N1 by endoscopic ultrasound. Local symptoms were controlled by insertion of a 10 cm covered SEMS (Ultraflex) and he was given a course of chemoradiation.
He was initially well palliated by the SEMS but 8 months after diagnosis he re-presented with dysphagia. He was found to have a narrowing at the distal end of the stent (Figure 2a). Biopsies from the narrowing showed inflamed hyperplastic squamous mucosa and granulation tissue with no evidence of malignancy. He was treated with balloon dilatation of the stricture. This was successful initially but symptoms of dysphagia soon returned. A 7 cm uncovered SEMS (Ultraflex Wallstent) was inserted across the benign stricture (Figure 2b). The patient is alive and well 10 months after the second SEMS insertion and has had no further problems with dysphagia.
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Figure 2. (a) Barium swallow showing stricture at the distal end of the stent. (b) Insertion of the second, overlapping stent at the level of the benign stricture.
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Discussion
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Malignant overgrowth following SEMS insertion for oesophageal carcinoma is well recognised, occurring in up to 50% of patients [1–6]. Benign strictures are infrequently reported. We could only find one series that reported benign strictures occurring after SEMS insertion for malignant obstruction [7]. In this series Mayoral et al followed 116 patients who had had SEMS insertion for malignant oesophageal strictures. 60% developed recurrent dysphagia. Of these 23 (47%) had non-malignant strictures.
Benign strictures arising in patients who have had SEMS inserted for benign disease are well documented [8–10]. Ackroyd et al [8], report three cases of SEMS inserted for benign oesophageal conditions. All three developed further benign strictures above the level of the SEMS. Song et al [9], reported a high rate of delayed complications in a series of 12 patients treated with SEMS for benign oesophageal conditions, with 5 patients developing strictures above the original stents. Cwikiel et al [10], described their findings in experimental work with pigs and with clinical cases. In animal studies, 8 weeks after stent insertion, they found necrosis of parts of the oesophagus and replacement of the oesophageal wall with fibrotic and granulation tissue along the length of the oesophagus that had been in contact with the stent. This process was particularly marked at the ends of the stents. They found a similar pattern of disease in their clinical group.
The fact that benign complications are well recognised in SEMS for use in benign disease but not in those use for malignant disease may, in part reflect the delay before these complications arise. It may also represent an assumption that recurrent strictures in patients with malignant disease are due to malignant overgrowth.
Patients who have SEMS inserted for malignant oesophageal strictures are at risk of developing benign strictures for several reasons. First, the stent produces an inflammatory reaction where it is in direct contact with the oesophageal wall. This results in the formation of granulation tissue, necrosis and fibrosis. Second, patients in whom the gastro-oesophageal junction has been stented have no sphincter mechanism to prevent gastric contents refluxing up the stent to the proximal oesophagus. They are therefore at risk of developing peptic strictures. For this reason proton pump inhibitors should be given to all patients who have had SEMS inserted in this region. Third, patients who have had local radiation treatment are at risk of developing medial hyperplasia.
We used short uncovered SEMS to treat the secondary benign strictures. They are less likely to slip and malignant overgrowth was not an issue. Metal stents are not recommended for use in benign conditions. We felt we were justified in using them in these cases as both patients had limited life expectancy and had symptoms that had been resistant to other treatments.
Palliative treatments for oesophageal carcinoma are becoming increasingly effective. Following chemotherapy the median survival for patients with squamous cell carcinoma is 13 months and for adenocarcinoma is 19 months [11]. As patient survival lengthens due to more effective forms of palliative treatment benign complications of SEMS may become an increasing clinical problem.
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Acknowledgments
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Mrs Susan Watson, Mrs Margaret Thomas and Mrs Anne Afeku.
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Footnotes
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The work discussed in this paper was carried out at University Hospital Lewisham. 
Received for publication January 15, 2003.
Revision received April 30, 2003.
Accepted for publication June 11, 2003.
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References
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Abstract
Introduction
