Dr. Cartwright earns runner-up finish in 2017 ICS research competition

Esophageal Stents: a Single-Center Retrospective Review of Surgical Experience
Tessa Cartwright, MD, MPH, FICS; Holly Stillz, PA-C; Sibu Saha, MD, MBA

ABSTRACT
Background: Esophageal stenting methods have been the mainstay of treatment of palliative therapy of esophageal cancer. Through advancement in stent technology, indications of stent placement have expanded to include treatment of non-malignant esophageal disorders such as refractory stricture, tracheoesophageal fistula, iatrogenic esophageal perforation, or leak. Known complications of esophageal stents are aspiration, malposition, dislodgement, perforation, bleeding, fistula formation, and migration. The purpose of our study was to review our experience at University of Kentucky utilizing esophageal stents in both malignant and benign esophageal disease, indications, patient characteristics, morbidity and mortality, and need for re-intervention.

Methods: We undertook a retrospective analysis of the electronic medical records from our University Cardiothoracic Surgery Division to evaluate the experience of esophageal stent placements using codes 43219 and 43212 between January 2000 to December 2014. A review of the literature was also performed. Data was analyzed using SPSS statistical software v. 23 (IBM Corp., Armonk, NY).

Results: One hundred procedures were identified for 56 patients, including two pediatric patients receiving 11 stent procedures for TEF. Twenty-five patients had two or more consecutive procedures. The median age at time of procedure was 57.5 years (range 2.6-85) and almost two-thirds of procedures were performed in males (36/56, Table 1). Sixty-four percent of patients had a history of esophageal or lung cancer. Indications for the 100 surgeries included fistula (30%), dysphagia (25%), perforation (23%), stricture (15%) and leak (7%). Stents included 20 proximal, 24 middle and 56 distal esophagus placements.

Morbidities included 24 stent migrations, 2 displacements, 2 obstructions, 8 esophageal leaks, 4 fistulas, and one each of pneumonia, airway compression, dysphagia, and hemoptysis (Table 2). A statistically significantly greater stent migration complication was noted for stents placed proximally (55%) as compared with distal (19.6%) and middle (8.3%) (p<0.01). The morbidity rate for benign indication was 48% versus 41% for malignant indication (p = .548). Among procedures performed on adults only (N=89), the morbidity rate for benign indication was 64.5% versus 41.4% for malignant indication (p = .047).

Of the 56 patients, 12 were lost to follow-up such that their mortality status is unknown. In the remaining 44 patients 30 (68%) died at a median 107 days (range 2-2383) after their first or only stent placement. Known mortality was 90% (26/29) in malignant indications vs. 27% (4/13) for benign indications (p < .001). 30-day death only occurred in the malignant group (7/29, 24%). Of the 54 patients, 12 were lost to follow-up such that their mortality status is unknown. In the remaining 42 patients 30 (71%) died at a median 107 days (range 2-2383) after their first or only stent placement. Mortality was 72% (26/29) in malignant indications vs. 22% (4/13) for benign indications (p = .001). 30-day death only occurred in the malignant group (7/29, 24%).

Conclusions: Esophageal Stents are commonly used for palliation and for contained leaks. Perioperative mortality is low for benign indications; however, the morbidity rate was significantly higher for those with benign indications as compared to malignant. The overall mortality was significantly higher for malignant indications as compared to benign. The most common indication for stent placement was fistula followed by dysphagia, perforation, stricture and leak. A statistically significantly greater stent migration complication was noted for stents placed proximally (55%) as compared with distal (19.6%) and middle (8.3%). Lastly, we did not find a statistically significant difference in complication stent placed for benign as compared with a malignant etiology.