A comparison of the temporary placement of 3 different self-expanding stents for the treatment of refractory benign esophageal strictures: a prospective multicentre study

Abstract

Background: Refractory benign esophageal strictures (RBESs) have been treated with the temporary placement of different self-expanding stents with conflicting results. We compared the clinical effectiveness of 3 types of stents: self-expanding plastic stents (SEPSs), biodegradable stents, and fully covered self-expanding metal stents (FCSEMSs), for the treatment of RBES.

Methods: This study prospectively evaluated 3 groups of 30 consecutive patients with RBESs who underwent temporary placement of either SEPSs (12 weeks, n = 10), biodegradable stents (n = 10) or FCSEMSs (12 weeks, n = 10). Data were collected to analyze the technical success and clinical outcome of the stents as evaluated by recurrent dysphagia, complications and reinterventions.

Results: Stent implantation was technically successful in all patients. Migration occurred in 11 patients: 6 (60%) in the SEPS group, 2 (20%) in the biodegradable group and 3 (30%) in the FCSEMS group (P = 0.16). A total of 8/30 patients (26.6%) were dysphagia-free after the end of follow-up: 1 (10%) in the SEPS group, 3 (30%) in the biodegradable group and 4 (40%) in the FCSEMS group (P = 0.27). More reinterventions were required in the SEPS group (n = 24) than in the biodegradable group (n = 13) or the FCSEMS group (n = 13) (P = 0.24). Multivariate analysis showed that stricture length was significantly associated with higher recurrence rates after temporary stent placement (HR = 1.37; 95% CI = 1.08-1.75; P = 0.011).

Conclusions: Temporary placement of a biodegradable stent or of a FCSEMS in patients with RBES may lead to long-term relief of dysphagia in 30 and 40% of patients, respectively. The use of SEPSs seems least preferable, as they are associated with frequent stent migration, more reinterventions and few cases of long-term improvement. Additionally, longer strictures were associated with a higher risk of recurrence.

Figure 1

(a) Endoscopic view of a biodegradable stent immediately after placement. (b) Endoscopic appearance of the process of biodegradation at 2 months. (c) Endoscopic appearance of tissue hyperplasia 3 months after stent degradation.

Figure 2

(a) Endoscopic view of an anastomotic stricture before stent placement. (b) Endoscopic view of a fully cover SEMS 3 months after stent deployment. (c) Endoscopic appearance of the initial stricture 3 months after stent removal.

Figure 3

Cumulative period free of dysphagia (esophageal patency) curves by Kaplan-Meier analysis in patients treated using self-expandable plastic stent (SEPS), biodegradable (BD) stent and fully cover self-expandable metal stent (SEMS). Although not statistically significant there is an advantage using fully cover SEMS and BD stent vs. SEPS. The benefits of stenting decreased rapidly with time and esophageal patency appeared to plateau between 8–9 weeks for all stents.

Figure 4

Clustered multiple variables graph with mean dysphagia scores over time after temporary placement of self-expandable plastic stent (SEPS), biodegradable (BD) stent and fully cover self-expandable metal stent (SEMS). Bars represent 95% CI for mean. Dysphagia score improved significantly from baseline level to 4 weeks after stent placement (p < 0.001) in the 3 groups. Dysphagia score improved significantly from baseline level to post treatment for BD stent and fully cover SEMS but not for SEPS. (final post-treatment after stent removal and dysphagia recurrence for all patients).