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Patients with esophageal strictures pose significant clinical management issues. To help physicians determine intervention strategies that maximize therapeutic effectiveness and optimize quality-of-life issues for patients with esophageal strictures, new guidelines from the American College of Gastroenterology (ACG) describe the use of stents in malignant and benign esophageal disease. Highlights include the following.
Esophageal stents for malignant disease:
Self-expanding metal stents (SEMS) are superior to rigid plastic stents.
Covered SEMS are superior to uncovered SEMS for palliation of unresectable esophageal cancers and are associated with lower complication rates than self-expanding plastic stents (SEPS).
No particular brand of SEMS is recommended, although minor differences between brands were noted in efficacy and complication rates.
For malignant esophageal fistulas, endoscopic placement of covered SEMS is the treatment of choice.
Esophageal stents for benign disease:
Neither partially covered SEMS nor fully covered SEPS was recommended for routine use.
Uncontrolled trial data suggest that the rate of major complications (including mortality) associated with SEMS could be as high as 80%.
For SEPS, the advantage is easy removal; however, stent migration is more common, particularly in patients with proximal, distal, or short strictures.
In highly selected cases, both SEMS and SEPS can be considered as initial nonsurgical treatment of esophageal perforations and anastomotic leaks.
Sharma P and Kozarek R. Role of esophageal stents in benign and malignant diseases. Am J Gastroenterol 2010 Feb; 105:258.
Comment
These guidelines provide a pragmatic review of the literature. For each recommendation, the quality of the evidence and the strength of the recommendations were graded. Clinicians will need to integrate these recommendations with their own clinical judgment as well as patient specifics and preferences.