SAGES Magazine

THE SOUTH AFRICAN GASTROENTEROLOGY REVIEW 2021 | VOLUME 19 | ISSUE 2 | 14 Tracheoesophageal/ bronchoesophageal fistulae Oesophageal fistulas tend to occur in advanced oesophageal cancer, with other malignancies, and in the context of prior palliative or radical radiotherapy. At present partially of fully covered SEMS are recommended for the oesophagus, or, when insufficient, in combination with airway stenting. 22 Bridge to chemotherapy / surgery In patients with potentially curative oesophageal cancer, much research has arisen with regards to whether optimising Table 1. Indications and recommendations for oesophageal stenting Indication Recommendation Malignant disease Short-term survival Partially or fully covered SEMS Long-term survival Brachytherapy or External Beam radiotherapy + SEMS Tracheoesophageal/ bronchoesophageal fistulae Fully covered SEMS OGJ tumour SEMS in combination with proton-pump inhibitor* or anti-reflux valves in the context of clinical trial Bridge to chemotherapy/ surgery Stents currently not recommended Benign disease Peptic strictures Fully covered SEMS (for refractory strictures/ dilation failure) +-stent fixation (suturing/ OTS clips) Caustic strictures Fully covered SEMS (for refractory strictures/ dilation failure)* Anastomotic leaks/ perforations Case-by-case decision on stent type and duration (partially covered SEMS/ fully covered SEMS/SEPS) Variceal bleeding Fully covered large- diameter SEMS (upon failure of initial management principles) Stent-in-stent Fully covered SEMS Paediatric disease* Refractory peptic strictures Case-by-case decision on stenting Anastomotic leaks/ perforations Stenting may have a potential role in treatment Tracheoesophageal fistula Bridge to definitive surgery SEMS: self-expandable metal stents, OGJ: oesophago- gastric junction, OTS: over-the-scope, SEPS: self- expandable plastic stents *not included in ESGE guideline nutritional state (pre-chemotherapy or pre-surgery) by temporarily stenting a patient is preferable to curbed oral intake, feeding tubes (nasogastric, nasojejunal, percutaneous gastrostomy (PEG) and jejunostomy (PEG-J) tubes), or parenteral nutrition via central catheter. Partially and fully covered SEMS as well as plastic and biodegradable stents have been studied as a potential “bridge” to definitive management. Although there is an improvement in dysphagia, studies show discrepant results regarding improvements in nutritional state. Complications of stenting remain high, with as many as 32% of stents migrating and 51.4% of patients experiencing chest discomfort. 27,28 Another major concern is that of stents complicating surgical and oncological outcomes. Mariette et al. found that stenting resulted in a significant reduction in resection rates (71% vs 85.5%) and 3-year overall survival (25 vs 44%) when compared to controls. 29 Due to complications and worsened outcomes, stents are currently not recommended as a “bridge” to curative therapy. Benign disease Refractory peptic strictures The first-line treatment of a symptomatic peptic stricture is endoscopic dilation using either bougie or balloon dilator. 30 A stricture is considered to be refractory when there is failure to reach a diameter of 14mm after biweekly dilations for 5 weeks or failure to maintain a target diameter for up to 4 weeks after the last dilation. 31 ESGE recommends the temporary placement (less than 3 months) of fully covered SEMS over partially covered SEMS. Although the benefit is unclear, stent fixation using sutures or OTS clips can be used to prevent stent migration. Adjuncts that have been used with dilatation, such as corticosteroid injection, endoscopic incisional therapy and mitomycin-C, should not be used in combination with stenting as the outcomes are unclear. 22 Caustic Although caustic-induced strictures are benign, they tend to be more difficult to treat and require more sessions of dilations due to recurrence. 32 Kochhar et al. explored the use of BD stents as an option to treat refractory caustic-induced strictures. Unfortunately, the efficacy of BD stents was limited, and the short-term radial force applied was inadequate to provide long term relief in such patients. 33 As SEPS and fully covered SEMS have high migration rates, and partially covered SEMS cause tissue hyperplasia in a significant number of patients, the ideal solution therefore remains unsolved. Anastomotic leaks/ perforations Oesophageal anastomotic leaks and other causes of oesophageal perforation result in major morbidity and mortality, hence early recognition and management will help improve outcomes. Despite a recent systematic review demonstrating that temporary stenting is a safe option, with covered SEMS performing better then SEPS, there are currently no recommendations regarding stent type (SEMS, SEPS, BD) and duration. 34 This is mostly due to limited studies as well as the need for individualised treatment for each diverse pathology (anastomotic leaks, fistulas, iatrogenic perforations, Boerhaave syndrome, and perforations due to foreign body or trauma). 22 An alternative option to stenting that has recently emerged for management of leaks and perforations, is endoscopic vacuum- assisted closure therapy (EndoVac). Its use has a 90% clinical success rate and has been shown to have a higher leak closure rate, shorter duration of treatment and lower in-hospital mortality. 35,36 There is currently no head-to-head comparison of stenting versus vacuum assisted closure in this category and availability and local expertise will dictate which the option is be used. REVIEW