Are Segmented Stents a Superior Option Over Standard Mental Stents for Patients With Esophageal Strictures? A Case Series With Literature Review

Introduction: Fully covered self-expandable metal stents (SEMS) have widely been used in both benign and malignant esophageal strictures. Although SEMS has proven to be efficacious for relief of esophageal obstruction, they are associated with complications such as stent migration, restenosis due to malignant ingrowth, and bleeding. In contrast to SEMS, the segmented stent system (SSS) (Micro-Tech, Nanjing China) incorporates a similar self-expanding design with the added advantage of flexible segments which can adapt to angulated strictures. Case Description/Methods: Our study consisted of 5 cases. All patients required stenting due to malignant strictures in the mid to distal esophagus. SSS was used for stenting and no additional stent fasteners were used for the purpose of this study. Two weeks after stent insertion, only one stent had partially migrated requiring stent repositioning. One of the stents placed in the mid to distal esophagus migrated to the distal esophagus in week 8 but no endoscopic repositioning was required. In one case, the stent remained in place for 16 weeks until it was removed due to decreased tumor burden (Figure 1). Regarding patient outcomes, the SSS was well tolerated except for one patient who reported chest discomfort that resulted in stent removal. The rest of the patients were either transitioned to hospice, passed away, or lost to follow-up (Table 1). Discussion: Traditional SEMS are made of nitinol monofilament wire forming a cylindrical mesh, forming a rigid stent often not flexible enough for angulated esophageal stenoses. However, self-expandable “segmented” stents (SSS) are nitinol stents connected with segments of soft nylon wires, allowing the stent to better adhere to the esophageal wall reducing the risk of stent migration. In one multicenter retrospective study, a total of 369 patients with benign and malignant strictures were managed with traditional SEMS stents. The total migration rate and clinically relevant migration rates were 23% and 14% in malignant strictures vs 30% and 17% in benign strictures respectively. In our study, the overall SSS was well tolerated. No secondary fixation measures such as clips or sutures were used for SSS placement. Clinically relevant migration was only noted in 1 out of 5 cases, and repositioning was successful. Segmental stents may be a viable alternative in patients with esophageal strictures; however, more prospective studies are needed to better assess migration rate compared to the current standard of care SEMS.Figure 1.: On the top - endoscopy pictures for Case 3. Left side - time of placement. Right side - at week 16. Arrowhead indicates location of flexible segments. In the bottom - chest x-ray for case 3. Arrows indicate locations of flexible segments. Table 1. - Summarizes patients’ demographics, indication of stenting, and clinical outcome over 26 weeks Variable Case 1 Case 2 Case 3 Case 4 Case 5 Age/Sex 84 M 66 M 66 M 58 M 49 M Indication for stent Malignant stricture Malignant stricture Malignant stricture Malignant stricture Malignant stricture Stent length 80 mm 100 mm 100 mm 100 mm 120 mm Dysphagia score before stenting Dysphagia to solid food Dysphagia to solid food Dysphagia to solid food Dysphagia to solid food Dysphagia to solid food Dysphagia score after stenting Dysphagia improved Dysphagia improved Dysphagia improved Dysphagia improved Dysphagia improved Undergoing radiation? Yes Yes Yes yes Yes Location of stent on initial XR upon insertion Mid to distal esophagus Distal esophagus crossing GE junction Mid to distal esophagus Distal esophagus Mid esophagus Location of stent in week 2 Mid to distal esophagus Migrated by 2cm toward Gastroesophageal Junction. Endoscopy was required to reposition stent Mid to distal esophagus Distal esophagus Mid esophagus Location of stent in week 4 Mid to distal esophagus N/A Mid to distal esophagus N/A N/A Location of stent in week 8 Distal esophagus N/A Mid to distal esophagus N/A N/A Location of stent in week 16 N/A N/A Mid to distal esophagus N/A N/A Location of stent in week 26 N/A N/A N/A N/A N/A Patient outcome Passed away in week 10 Transitioned to hospice in week 4 Stent was removed shortly after week 16 x-ray, intraluminal tumor burden decreased and stent no longer required Patient lost to follow up Stent was removed 2 weeks after due to chest discomfort. The patient was able to tolerate solids after stent removal