Robert E. Barton

Silicone-covered self-expanding metallic stents for the palliation of malignant esophageal obstruction and esophagorespiratory fistulas: Experience in 32 patients and a review of the literature ☆ ☆☆ ★ ★★ ♢

Abstract Esophagogastric malignancies often are manifested with progressive dysphagia or esophagorespiratory fistulas. Palliative modalities currently available have significant limitations. A modified Gianturco-Rosch silicone-covered self-expanding metallic Z stent was used in 32 consecutive patients with malignant esophageal obstruction (n =24) or esophagorespiratory fistulas (n = 8). The stent was placed successfully in all patients. Dysphagia improved by at least two grades in 21 of the 24 patients (87.5%); the mean dysphagia grade fell from 3.21 to 1.08. Six of the 8 patients with fistulas were able to resume a normal diet, and the other 2 were able to eat solids without symptoms of aspiration. Complications occurred in 10/32 patients (31%) and included stent migration (4 patients), food impaction (2 patients), membrane disruption with tumor ingrowth (1 patient), tumor overgrowth (1 patient), early pressure necrosis with hemorrhage (1 patient), and late pressure necrosis with sepsis (1 patient). The latter 2 patients died, giving a mortality rate of 6.3%. Many complications were managed with endoscopic or interventional radiologic techniques. Although randomized prospective clinical trials are needed, the silicone-covered Gianturco-Rosch Z stent offers promise for the effective palliation of malignant esophageal obstruction and esophagorespiratory fistulas. (Gastrontest Endosc 1994;40:22-33.)

Gianturco-Rösch expandable Z-stents in the treatment of superior vena cava syndrome.

Gianturco-Rösch expandable Z-stents were used in 22 patients with superior vena cava syndrome (SVCS). Stents were placed in all patients in the SVC and in 17 patients, also into the innominate veins. Stent placement resulted in complete relief of symptoms in all patients. Twenty-one patients had no SVCS recurrence from 1 to 16 months, to their death, or to the present time. SVCS recurred only in 1 patient 9 months after stent placement due to tumor ingrowth and secondary thrombosis. Based on ours and on other reported experiences, expandable metallic stents are effective devices for treatment of the SVCS which is difficult to manage by other means.

Treatment of Malignant Esophageal Obstructions with Covered Metallic Z Stents: Long-term Results in 52 Patients☆

PURPOSE To prospectively evaluate the clinical efficacy of silicone-covered Gianturco-Rösch self-expandable Z (GRZ) stents in the treatment of malignant esophageal obstruction. PATIENTS AND METHODS GRZ stents were placed in 52 patients (39 men, 13 women) with severe dysphagia due to high-grade malignant esophageal obstruction. RESULTS Stent placement was technically successful, and immediate relief of dysphagia was achieved in 50 of 52 patients (96%), with long-term relief in 47 patients (90%). Fifty-one patients (98%) died during follow-up (range, 1 week to 33 months; mean, 4.3 months). Late complications were most prevalent and included stent migration (n = 5), food impaction (n = 2), chest pain (n = 2), membrane disruption with tumor ingrowth (n = 1), granulomatous reaction above the stent (n = 1), esophageal perforation with mediastinitis (n = 1), and upper gastrointestinal hemorrhage (n = 4). Twelve complications were easily managed with medical, endoscopic, or radiologic intervention. Four deaths may have been related to stent placement (early mortality rate, 7.7%). CONCLUSION GRZ stents provide relatively safe and effective long-term palliation in patients with severe, malignant esophageal obstruction.

Treatment of Malignant Esophagorespiratory Fistulas with Silicone-covered Metallic Z Stents

PURPOSE To prospectively evaluate the clinical efficacy of covered metallic Z stents in the treatment of esophagorespiratory fistulas (ERFs). PATIENTS AND METHODS Twelve patients with severe aspiration symptoms from malignant ERFs were treated with silicone-covered, metallic, self-expanding Gianturco-Rösch Z (GRZ) stents. RESULTS Fluoroscopically guided stent placement was successful and well tolerated in all patients. Immediate postprocedural endoscopy and esophagography showed excellent coverage of the fistulas in all cases. Aspiration symptoms were completely relieved in eight of 12 patients (67%). Four of 12 patients (33%) were improved and able to eat a soft diet. There were no stent-related deaths. Nine patients have died and three patients are alive. Mean follow-up for the entire group was 3.9 months (range, 1 week to 10.5 months). Nonfatal complications occurred in three of 12 patients (25%). Complications included one membrane disruption and one granulomatous reaction with a slight upward stent migration. CONCLUSION GRZ stents are an effective and safe means of palliation in patients with malignant esophagorespiratory fistulas.

Inferior epigastric artery pseudoaneurysm: A complication of paracentesis

Two patients had inferior epigastric artery pseudoaneurysms after therapeutic paracentesis for ascites caused by portal hypertension. The first patient, a 62-year-old man, had a two-week history of left lower quadrant pain, tenderness, and nonpulsatile mass after a paracentesis for ascites. A left inferior epigastric artery pseudoaneurysm measuring 10 cm in diameter and 20 cm in length was diagnosed by means of Duplex ultrasound and arteriography. The patient was treated with percutaneous embolization, with successful thrombosis of the pseudoaneurysm. The second patient, a 33-year-old woman, had a six-week history of left lower quadrant pain, tenderness, and nonpulsatile mass after a paracentesis for ascites. Computerized tomography and arteriography showed a left inferior epigastric artery pseudoaneurysm, measuring 7 cm in diameter and 9 cm in length. The patient was treated with percutaneous embolization with successful thrombosis of the pseudoaneurysm. Both patients were discharged in good condition 2 days after embolization. Inferior epigastric artery pseudoaneurysm is a complication of paracentesis, and percutaneous embolization may be preferable to surgical repair in patients with chronic liver failure and portal hypertension.

Gianturco-Rösch Z Stents in Tracheobronchial Stenoses

PURPOSE To evaluate expandable metallic Gianturco-Rösch Z (GRZ) stents for treatment of benign and malignant tracheobronchial stenoses. PATIENTS AND METHODS Six patients, ages 45-73 years, were treated for severe dyspnea with placement of GRZ stents. Three patients had benign tracheal lesions (one tracheomalacia, two postoperative) and received uncovered GRZ stents. Three patients had malignant stenoses at the level of the carina; one received an uncovered stent and the other two received silicone-covered GRZ stents. RESULTS Two patients with benign lesions responded well to stent placement. One was asymptomatic for a year and then was lost to follow-up; the other improved substantially but died of end-stage lung disease 5 months after stent placement. A third patient with a benign high tracheal lesion did poorly; symptoms recurred secondary to inferior migration of a stent, which was removed surgically at 4 months. All patients with malignant lesions improved symptomatically after stent placement and remained without significant dyspnea until death (from 1 to 6 months). CONCLUSION Expandable GRZ stents are promising devices for treatment of benign lesions and offer effective palliation of malignant tracheobronchial stenoses.

Treatment of esophageal obstruction from mediastinal compressive tumors with covered, self-expanding metallic Z-stents

BACKGROUND Mediastinal malignancies may involve the esophagus, leading to esophageal stenosis and dysphagia. Rigid and self-expanding esophageal stents have been used for effective palliation, but their use in extrinsic, compressive lesions is controversial. METHODS A retrospective review of self-expanding Gianturco-Rösch Z-stents that were successfully placed in 13 patients with malignant esophageal obstruction due to extrinsic lesions. RESULTS All patients had an improvement in dysphagia of at least two dysphagia grades. The mean dysphagia grade fell from 3.15 to 0.62. Mean survival was 2.2 months. Early (within 48 hours) procedure-related complications occurred in 4 of 13 patients and consisted of minor, transient chest pain that resolved within 6 hours (3 patients) and endoscopic stent dislodgment into the stomach (1 patient). Late complications (> 48 hours) occurred in 2 patients and consisted of a partial proximal stent migration and the development of a benign stricture proximal to the stent. There was no procedural or stent related mortality. CONCLUSIONS Esophageal obstruction and malignant dysphagia from extrinsic, compressive mediastinal malignancies can be effectively and safely palliated with self-expanding Gianturco- Rösch Z-stents.

Transjugular Intrahepatic Portosystemic Shunt Creation Using Intravascular Ultrasound Guidance

PURPOSE To describe the use of intravascular ultrasound (US) guidance for creation of transjugular intrahepatic portosystemic shunts (TIPSs) in humans. MATERIALS AND METHODS The initial 25 cases of intravascular US-guided TIPS were retrospectively compared versus the last 75 conventional TIPS cases during the same time period at the same institution in terms of the number of needle passes required to establish portal vein (PV) access, fluoroscopy time, and needle pass-related complications. RESULTS Intravascular US-guided TIPS creation was successful in all cases, and there was no statistically significant difference in number of needle passes, fluoroscopy time, or needle pass-related complications between TIPS techniques. Intravascular US-guided TIPS creation was successful in cases in which conventional TIPS creation had failed as a result of PV thrombosis or distorted anatomy. Intravascular US guidance for TIPS creation was additionally useful in a patient with Budd-Chiari syndrome and in a patient with intrahepatic tumors. CONCLUSIONS Intravascular US is a safe and reproducible means of real-time image guidance for TIPS creation, equivalent in efficacy to conventional fluoroscopic guidance. Real-time sonographic guidance with intravascular US may prove advantageous for cases in which there is PV thrombus, distorted anatomy, Budd-Chiari syndrome, or hepatic tumors.

Extraction of Dental Crowns from the Airway: A Multidisciplinary Approach

We describe two cases of airway foreign bodies (FB) consisting of a dental crown. The shape and composition of dental crowns complicate their extraction from the tracheobronchial tree, sometimes necessitating thoracotomy. We describe the use of a multidisciplinary approach involving rigid and flexible bronchoscopy in concert with the use of wire snares under fluoroscopic guidance for extraction of these challenging FB. These cases illustrate that this multidisciplinary approach can allow successful extraction of the difficult FB from much of the tracheobronchial tree and the avoidance of thoracotomy.

ARTERIAL DUODENOVESICAL FISTULA AFTER SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANTATION

Diabetes mellitus is the most frequent cause of end stage renal disease. Simultaneous kidney and pancreas transplantation is an option for patients with end stage renal disease due to diabetes, since it relieves them from insulin dependency. 1 Hematuria and recurrent urinary tract infections are the most common, occasionally life threatening complications of simultaneous kidney and pancreas transplantation. We report a case of severe recurrent hematuria from the duodenal patch successfully managed with transcatheter arterial embolization. CASE REPORT A 38-year-old woman underwent simultaneous kidney and pancreas transplantation, drained into the bladder with the duodenal segment sutured to the cystotomy. A Lich ureteroneocystostomy was performed for urinary drainage. Preoperatively vancomycin, imipenem and fluconazole were given intravenously. Immunosuppression was induced with antithymocyte globulin, methylprednisolone and azathioprine. After a normal cystogram on postoperative day 13, the Foley catheter was removed. Recurrent gross hematuria required many hospital admissions and cystoscopies with fulguration of a bleeding lesion in the duodenal stump. The patient underwent arteriography, which demonstrated active extravasation into the bladder from a small branch of the allograft pancreaticoduodenal artery. The artery was selectively embolized using a 3Fr microcatheter with multiple helical microcoils. Arteriography after embolization demonstrated occlusion of the segment and no further extravasation (see figure). There was no evidence of recurrent bleeding at 6-month followup. DISCUSSION