Self-expanding oesophageal stents: Strategies for re-intervention

Background and Study Aims: Self-expanding metal stents have become accepted palliation for inoperable malignant oesophageal obstruction, the cost of t he devices being offset against the ease of insertion and the reduced compl ication rate. However, re-intervention is often required for obstruction, m alposition, migration and tumour progression. The marginal cost of re-stent ing is generally higher than other modalities. This study aims to determine the rate of re-intervention and the effectiveness of the various intervent ion modalities. Patients and Methods: A population of 165 patients, treated in a tertiary r eferral oesophageal centre, (132 with oesophageal cancer, 31 with mediastin al metastases from other tumours, two with benign conditions) whose initial stent placement was performed between January 1994 and December 1998 was f ollowed-up through July 1999 or till death. Results: A total of 75 re-interventions were required in 44 patients and we re successful in 51 (68%). Rigid oesophagoscopy and removal of food bolus w as successful in three out of three, dilation in one of 11, rigid oesophago scopy and physical debridement in 12 of 17 and laser debridement in 12 of 2 0. Re-stenting was the primary re-intervention in 10 cases and was ultimate ly necessary in 14 patients with 11 self-expanding metal stents, three Cele stin) who had previously undergone other forms of re-intervention. It was n ot successful in one case. The median survival following first re-intervent ion was 9.8 weeks (compared with 14.3 weeks for initial stenting) and was l onger in those receiving radiotherapy (23.6 weeks) or chemotherapy (14.4 we eks). Conclusions: While repeated stenting is usually successful, debridement and laser vaporization are viable alternatives for proximal tumour overgrowth or ingrowth in the upper or middle third of the oesophagus. Distal tumour g rowth or ingrowth at the oesophagogastric junction are best treated with a second stent. Repeated treatment is justified, as survival following first re-intervention is comparable to that after initial stenting, particularly in those patients who are able to undergo chemotherapy or radiotherapy.