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Ann Thorac Surg 2001;71:1802
© 2001 The Society of Thoracic Surgeons

Invited commentary

^a Division of Cardiothoracic Surgery, Medical University of South Carolina, 171 Ashley Ave, Charleston, SC 29425-2279, USA

e-mail: reedce{at}musc.edu

Use of self-expanding metallic stents (SEMS) has greatly facilitated the palliation of esophageal cancer. The ease of insertion and high technical success rate account for its popularity. However, the authors of this article have appropriately emphasized the high reintervention rate and the need to closely follow these patients if palliation is to continue. They are to be complimented for their accurate reporting of complications. We have noted a reintervention rate of 25% to 35%.

The reintervention rate in this study is very high largely due to stent obstruction from tumor ingrowth (42 cases) and food impaction (possibly related to incomplete tumor ingrowth) in 10. Overall stent obstruction represents 52 of 87 (60%) of all stent complications. This is likely due to the predominant use of uncovered stents (90 of the 127 stents were uncovered). Other large series of covered stents [1] report much lower rates of tumor obstruction (13 of 132) from overgrowth or food impaction. The authors justify the use of uncovered stents by reporting a higher incidence of stent migration in the covered stents (7 of 30) versus uncovered (4 of 97). Other studies [1, 2] report low rates of stent migration for covered stents (3% to 11%) similar to the 8.7% reported in this series. Our experience at the Medical University of South Carolina with over 100 covered stents is similar with a low rate of migration and obstruction. We do agree that migration is an important consideration for gastroesophageal junction tumors although the consequences of distal migration are not clear [1]. Reflux is a problem that needs to be further addressed by stent modification.

We would not favor use of SEMS for control of dysphagia while patients undergo induction therapy. In this series, it resulted in sepsis followed by death or major complication in one-third of patients receiving chemoradiation.

There is a need for uniform definitions of complications. With such guidelines and accurate reporting and follow-up exemplified by this series, the true role of SEMS in the palliation of esophageal cancer can be assessed.

References

1. Song H.-Y., Do Y.-S., Han Y.-M., et al. Covered, expandable esophageal metallic stent tubes: experiences in 119 patients. Radiology 1994;193:689-695.[Abstract/Free Full Text]
2. Raijman I., Siddique I., Ajani J., Lynch P. Palliation of malignant dysphagia and fistulae with coated expandable metal stents: experience with 101 patients. Gastrointest Endosc 1998;48:172-179.[Medline]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Carolyn E. Reed Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Reed, C. E. Search for Related Content PubMed Articles by Reed, C. E. Related Collections Esophagus - cancer Related Article