1. Esophageal Stents for Malignant
and Benign Indications
Peter D. Siersema, MD, PhD
Dept. of Gastroenterology and Hepatology

2. Stents in the esophagus
• Malignant obstruction
• Esophagorespiratory fistula
• Benign stricture
• Benign rupture or anastomotic leak

3. Esophageal stents - issues
• Complications/recurrent dysphagia

4. Stents - Complications and
recurrent dysphagia
Procedure-related complications (5%)
• Perforation, (aspiration) pneumonia, (severe) pain
Late complications (10-15%)
• Hemorrhage, fistula formation
Minor complications (10-20%)
• (Minor) pain, gastro-esophageal reflux

5. Treatment of reflux
Antireflux valve (Retrofit)

6. Treatment of reflux
Antireflux valve (Retrofit)

7. Stents - Complications and
recurrent dysphagia
Procedure-related complications (5%)
• Perforation, (aspiration) pneumonia, (severe) pain
Late complications (10-15%)
• Hemorrhage, fistula formation
Minor complications (10-20%)
• (Minor) pain, gastro-esophageal reflux
Recurrent dysphagia (20-35%)
• Stent migration, tissue in- and overgrowth, food obstruction

8. Recurrent dysphagia
Tissue in- and Food obstruction Stent migration
overgrowth

9. Esophageal stents - issues
• Complications/recurrent dysphagia
• Stents for malignant indications

10. Esophageal stents
Niti-S SX-Ella Alimaxx-E Polyflex Wallflex PC Evolution Ultraflex
(Taewoong) (Ella CS) (Merit) (Boston Scientific) (Cook) (BS)

11. Esophageal stents - issues
• Complications/recurrent dysphagia
• Stents for malignant indications
• Stents for benign strictures

12. Benign obstruction
Stent choice
Fully covered stents
• Plastic (SEPS):
− Polyflex
• Nitinol (SEMS):
−Niti-S
−SX-Ella
−Alimaxx-E
−Wallflex FC
−Evolution FC
Siersema et al. Gastrointest Endosc 2009

13. Benign obstruction
Stent choice
Fully covered stents
Efficacy:
• Plastic (SEPS): −Long-term: 40-45%
− Polyflex
Pro:
−Removable
• Nitinol (SEMS):
−Niti-S Contra:
−SX-Ella −Recurrent dysphagia
• Stent migration
−Alimaxx-E
• Tissue overgrowth
−Wallflex FC −Stent removal is indicated
−Evolution FC
Dua et al. Am J Gastroenterol 2008
Siersema et al. Gastrointest Endosc 2009

14. Benign obstruction
Stent choice
Fully covered stents
• Plastic (SEPS)
Polyflex (FDA approved)
•Nitinol stents (SEMS)
Wallflex FC
Biodegradable stents
• Ella BD stent
Siersema et al. Gastrointest Endosc 2009
Repici et al. Gastrointest Endosc 2010 (in press)

15. Mr. S, 68 yrs
4 weeks after ELLA BD stent placement; dysphagia score: 0

16. Mr. S, 68 yrs
8 weeks after ELLA BD stent placement; dysphagia score: 0

17. Mr. S, 68 yrs
16 weeks after ELLA BD stent placement; dysphagia score: 0
Recurrent dysphagia at 20 weeks 2nd ELLA BD stent

18. Benign obstruction
Stent choice
Fully covered stents
• Plastic (SEPS) Efficacy:
Polyflex − Long-term: 40-45%
Pro:
•Nitinol stents (SEMS) − Stent removal not necessary
Wallflex FC − Migration low
Biodegradable stents Contra:
− Tissue ingrowth (uncovered mesh)
− Repeat stent placement
• Ella BD stent
Siersema et al. Gastrointest Endosc 2009
Repici et al. Gastrointest Endosc 2010 (in press)

19. Esophageal stents - issues
• Complications/recurrent dysphagia
• Stents for malignant indications
• Stents for benign strictures
• Stents for benign ruptures and anastomotic leaks

20. Benign rupture/leak
Treatment algorithm
Small (<2 cm) Intermediate (>2 cm) Large
(<25% of circumference) (>25% and <50-70%) (>50-70%)
Stricture (-) Stricture (+)
<1 cm <1 cm
??
SEALANT ENDOCLIP STENT SURGERY
Siersema. Chapter 19: Esophageal perforation In: Tham T, Collins J and Soetikno R, eds.
Gastrointestinal Emergencies Oxford: Blackwell Publishing Ltd 2008

21. Benign rupture/leak
Treatment algorithm
Small (<2 cm) Intermediate (>2 cm) Large
(<25% of circumference) (>25% and <50-70%) (>50-70%)
??
STENT
Siersema. Chapter 19: Esophageal perforation In: Tham T, Collins J and Soetikno R, eds.
Gastrointestinal Emergencies Oxford: Blackwell Publishing Ltd 2008

22. Benign rupture/leak
Stent choice
Fully covered stents
• Polyflex
• Niti-S
• SX-Ella
• Alimaxx-E
• Evolution FC
• Wallflex FC
Siersema et al. Gastrointest Endosc 2009

23. Benign rupture/leak
Stent choice
Fully covered stents
• Polyflex
• Niti-S
• SX-Ella Pro:
- Incomplete sealing (?)
• Alimaxx-E
• Evolution FC
• Wallflex FC
Siersema et al. Gastrointest Endosc 2009

24. Benign rupture/leak
Stent choice
Fully covered stents
Partially covered stents
• Ultraflex
• Evolution PC
• Wallflex PC
Siersema et al. Gastrointest Endosc 2009

25. Benign rupture/leak
Stent choice
Fully covered stents
Partially covered stents
• Ultraflex Pro:
- More complete sealing (?)
• Evolution PC
- Success rate (n=52): 76% (i.t.t. 65%)
• Wallflex PC
Contra:
- Repeat stenting (83 stents (52 pats.)) (q 3-4 wks.)
- Complications (migration, tissue in-/overgrowth)
Tissue overgrowth: stent-in-stent technique
Siersema et al. Gastrointest Endosc 2009
van Boeckel et al. Surg Endosc (submitted)
Hirdes et al. Am J Gastroenterol 2010 (in press)

26. Stent-in-stent technique
• Embedded stent visualized during
endoscopy
• Insert second, fully covered stent
inside embedded stent
– with similar length + diameter HV-ELLA stent
– at level of tissue hyperplasia
• Stent-in-stent for 10-14 days in situ
• Radial force induces pressure
necrosis of hyperplastic tissue
Polyflex stent

32. Esophageal stents - issues
• Complications/recurrent dysphagia
• Stents for malignant indications
• Stents for benign strictures
• Stents for benign ruptures and anastomotic leaks
→Future developments

33. Esophageal stents - Future
Malignant esophageal strictures:
– (New design) covered biodegradable stents
– Stents plus radiation therapy (brachytherapy)
– Bridge-to-Surgery

34. Esophageal stents - Future
Malignant esophageal strictures:
– (New design) covered biodegradable stents
– Stents plus radiation therapy (brachytherapy)
– Bridge-to-Surgery
Benign esophageal strictures or ruptures:
– (New design) covered biodegradable stents
– Non-traumatic, more flexible (nitinol) stents
– Stents with antifibrotic agents incorporated