Esophageal stent repositioning
Esophageal stent placement has become an important means of relieving benign and malignant esophageal strictures and various types of esophageal fistulas, and is an emerging technique in the treatment of esophageal diseases at home and abroad in recent years [1,2,3]. With the increased application of stents, the increasing number of complications arising from the placed stents and the disease itself, together with the problem of stenting within the stent, stent reinsertion is an important issue for clinicians [4,5]. We performed reinsertion of esophageal stents (RIES) in 32 patients from March 2005 to November 2009. In this paper, we will summarize the causes, technical points, and results of RIES placement in order to improve the technical level and results of RIES and reduce complications.
1. Materials and methods
1.1 General clinical data
From March 2005 to November 2009, esophageal stent placement was performed in 128 patients, including 86 males and 42 females. A total of 160 stents were placed, of which 32 patients underwent RIES, and the reinsertion rate was 25.0%, 22 males and 10 females, with an average age of 58.4 years. 2 patients had 3 stents placed outside the hospital and the 4th stent was placed in our hospital, and 5 patients had 2 stents placed outside the hospital and the 3rd stent was placed in our hospital. The reasons for the patients’ initial esophageal stent placement are shown in Table 1.
1.2 Reasons for RIES
The reasons why the patient needed repositioning after esophageal stent placement are shown in Table 2. The longest time interval between re-stent placement and the last placement was 63 days and the shortest was 1 day, with an average of 22.8 days.
1.3 Stents used and reinsertion method.
1.3.1 The esophageal stent was a domestically made mesh nickel-titanium alloy memory stent (produced by Nanjing Minimally Invasive Company) with a ball or cup head, a body diameter of 16-26 mm, a length of 60-80 mm, a silicone film covering the stent, and an outer diameter of the stent inserter of 8 mm. the stent was selected according to the nature and length of the lesion, and the upper and lower ends of the stent generally exceeded the lesion by 20-40 mm each. in the case of esophageal fistula, the stent was placed in a very demanding position. In order to ensure the accuracy of the stent placement, some of the stents are retrievable and can be adjusted using traction wires once the release position is deviated because the stent placement position is very demanding.
1.3.2 Stent reinsertion method: Fasting for 6 hours before surgery. Stent reinsertion is performed under the fluoroscopy of DSA machine. Preoperatively, dilute barium or pantothenic glucosamine is drunk to determine the nature of the lesion, the position and length of the original stent and its relationship with the surrounding structures, to understand the condition of the esophagus above and below the stent, etc. Important bony landmarks around the lesion are measured and marked as positioning criteria for stent placement. The patient is placed in a semi-recumbent position, a superslip guidewire is swallowed through the mouth, and a delivery catheter is introduced to the distal end of the lesion or to the stomach. The superslip guidewire is then withdrawn, and a superslip rigid guidewire is inserted so that the front end of the soft part exceeds the front end of the catheter. If the esophageal stricture is <5 mm, esophageal balloon dilation is performed first. After stenting, no crumbly food was allowed for 24 hours, and no cold food was allowed in the near future, and violent nausea and vomiting were avoided as much as possible.
2, Results
2.1 Intraoperative reaction.
In one patient, the stent was displaced downward when releasing the stent and failed to completely seal the anastomotic leak, but the rest of the stents were successfully placed in the appropriate position, with a success rate of 96.9%. ), one of which was episodic ventricular premature, and the other two cases were frequent multi-source ventricular premature, which were treated and the surgery was completed. All patients had varying degrees of chest pain and foreign body sensation after stent release, especially in those with high esophageal stent placement, but most of them thought it was significantly less than the first stent placement.
2.2 Postoperative and follow-up situation.
All patients drank dilute barium or pantethine for 2 days after surgery and were reviewed to observe the position of the stent, its expansion and the sealing of the fistula, and all observations were good. All patients had varying degrees of chest pain and foreign body sensation, especially in those with high esophageal stent placement, and five of them had severe symptoms and were treated symptomatically. one patient died of multiple organ failure due to esophagotracheal fistula, and the rest were discharged successfully.
During the six-month follow-up period, four patients had a downward shift of the stent by 5 mm-15 mm, but it did not affect the closure of the fistula or the expansion of the stenosis, and no stent was dislodged; in one patient, an esophageal stent was placed for an esophageal-tracheal fistula six months after radiotherapy for esophageal cancer, and an esophageal fistula developed in the esophagus at the upper edge of the stent and the esophageal stent was placed again, but the choking symptoms were not significantly relieved. Two patients had esophageal fistula on the upper edge of the stent, and one of them underwent another stent placement and was discharged, while the other refused treatment and died; one patient died of massive mediastinal lymph node metastasis compression; five patients died of cancer metastasis to the brain, liver and systemic failure.
3 , Discussion
Esophageal stent placement has become an important means of relieving benign and malignant esophageal strictures and various types of esophageal fistulas. With the increased application of stents, more and more complications arise from the placed stents and the disease itself, and sometimes RIES is needed to solve the related problems, but RIES is more difficult and more demanding both at the technical level and at the patient’s mental level, and it is an important issue facing clinicians. No corresponding literature has been reported.
3.1 Analysis of the causes of RIES.
It has been reported in the literature [6,7] that stent displacement, dislodgement, restenosis, esophageal fistula, bleeding, and malapposition syndrome can occur after esophageal stent placement. Among the various causes of RIES in our group, stent displacement accounted for 43.7%, and its main causes were (1) premature feeding, especially cold and iced foods; (2) esophageal peristalsis and vomiting during feeding; and (3) improper selection of stent. Inaccurate positioning of the stents accounted for 25% of the cases, indicating that there were problems with the operation of the surgeon during the esophageal stent placement, especially the lack of precise understanding of the changes in the position of the stent after expansion during the stent release. It should not be overlooked that 5 patients in the whole group had upper (lower) edge of stent esophageal fistula, accounting for 15.6% of the reasons for stent reinsertion, not including those who refused to undergo stent reinsertion, and the clinical incidence of upper (lower) edge of stent esophageal fistula is much higher than expected, indicating that the metal wire of the stent can cauterize the esophageal wall under the repeated peristaltic action of the esophagus, causing esophageal fistula, or cauterize the aorta and cause This suggests that although the current stents are significantly better than the previous ones, further improvements are still needed. In cases of stenosis, stent malapposition has little effect, but in patients with esophageal fistula, food or oral secretions may still flow into the fistula through the external gap of the stent after eating, causing severe choking and coughing due to stent malapposition. Therefore, stent reinsertion is still needed if necessary.
3.2 Analysis of the results of RIES.
The success rate of stent reinsertion in this group of cases was 96.9%, which effectively solved the problems of esophageal stenosis and esophageal fistula; during the six-month follow-up period, there were 4 cases of stent displacement, accounting for 12.5%; there were 2 cases of esophageal fistula at the upper edge of reinserted stent, with an incidence of 6.3%; no stent dislodgement, hemorrhage, or stenosis were seen in the whole group, indicating that although RIES is difficult, the effect is exact and the complications are few.
3.3 Analysis of technical points of RIES.
According to the summary of clinical lessons learned, we made some technical improvements to stent reinsertion, including stent selection, insertion techniques, and perioperative disposition.
3.3.1 Selection of different types of esophageal stents according to different disease characteristics.
We believe that all reinsertion stents should be selected with fully laminated stents to avoid the esophageal tumor itself from growing into the stent mesh and blocking the stent, or the stent being slightly displaced resulting in the inability of the stent to seal the fistula; to reduce the esophageal fistula caused by the stent, try to select cup-shaped stents and use less flared stents, and try to select the stent with the cup-shaped stent on the head side for patients with esophageal fistula, so that the stent is more ambulatory and has a better effect on sealing the fistula; to To prevent inaccurate position of stent release, sometimes retrievable stents can be used to facilitate the adjustment of stent position or removal.
3.3.2 Technical points of RIES.
(1) One of the main difficulties in repositioning the stent is that most patients have previously placed a stent with a stent inside a stent, making it easier for the stent to shift and slip out. Therefore, the size, placement position and the degree of overlap between the stent and the stent should be carefully chosen for repositioning the stent, and the characteristics and distance of expansion and contraction after stent release should be deeply understood to determine the appropriate position for stent placement. (2) After determining the position of the stent, the action of releasing the stent should be stable, and the pushing action should be gentle and coherent, and at the same time, the position should be adjusted while pushing. (3) Special attention should be paid to the placement of high esophageal stents and the placement of lower segment esophageal stents. High esophagus involves the cricopharyngeal segment at the beginning of the esophagus and the thoracic inlet, so the placement of stents involves considerable risk because of its function and special location [8]. Therefore, the placement of a high esophageal stent requires a high level of stent placement, and the determination of the stent retraction range and the highest point of the stent is particularly important, because once the stent is placed too high it may cause significant discomfort to the patient, and in severe cases it may be fatal. Therefore, the stent placement should be carefully measured and pre-determined before surgery, and obvious bony marks should be selected as the positioning standard and re-determined under X-ray, and the highest point of the stent should preferably be no higher than the level of the 6th cervical vertebra, and the diameter of the stent should be 12-16 mm. The lower esophagus, due to its good elasticity and mobility, the stent is easily displaced or slipped, so a slightly larger stent or a retrievable stent is generally chosen, which can be recovered or adjusted once it is displaced.
Although RIES has effectively solved the related esophageal diseases, these stent materials still cannot well solve the key problems of biohistocompatibility and mechanical compatibility, and still suffer from complications such as postoperative chest pain, stent displacement, esophageal fistula, and stenosis [9,10], and the authors believe that various specific factors of the lesion should be comprehensively considered, different types of stents should be selected according to the specific condition, and the operation technique should be improved, while further strengthening the development of esophageal stents with better compatibility and better adaptation to clinical practice can minimize the occurrence of complications.