How to deal with the complications after esophageal stents implantation

In 1983, metal stent was used for the treatment of esophageal stricture and acquired great success. With the advancement of the technology and renewal of the material, stents implantation technique has developed into a world widely used operation to solve the dysphagia and food taking difficulty for patients with esophageal carcinoma in late stage, anastomotic stricture after esophagectomy, and esophageal and bronchial fistula. Stent implantation could reduce remarkably the inflammation of lung, and win time for the patients to do radiotherapy or chemical therapy which could extend patient’s life.

Esophageal stents are used well with its easy operation, minimal trauma which could take effect on various kinds of esophageal stenosis, benign or malignant. However, the complications of esophageal stents implantation should be addressed carefully during clinical applications.

We have listed some major complications with corresponding preventive measures for clinical reference.

Chest pain and foreign body feeling

The expanded esophagus, stent compression and reflux of gastric acid shall lead to swelling pain of different degrees for patients. When the lesion is at the higher position of the esophagus, the pain feeling is stronger. The larger diameter of the stent, the pain feeling is stronger.  But the patients could endure the pain in normal circumstance.

In order to reduce and alleviate this complication, the stent cannot be placed higher than spinal C7. Choose the stent with proper diameter and material with good flexibility.

Reflux esophagitis

When the stent is placed at cardia, the anti-reflux function of cardia will be weakened. Gastric acid shall reflux which lead to reflux esophagitis, even the proliferation of granulation tissue and re-stenosis.

For the stenosis at lower esophagus or near the cardia, the patients should be placed with anti-reflux esophageal stents. Use acid and gastrointestinal motivating drugs for 1 month after stent implantation, which can reduce the patient's symptoms.

Bleeding on upper gastrointestinal tract

This complication has low incidence and the bleeding is normally in small volume.

The main reasons of the bleedings include local mucosa injury, ulcer or ischemia by stent compression, local inflammation.

If little bleeding is caused by the radiotherapy after stent implantation, it shall not be treated with special methods. If bleeding happens in large amount with vomit or black stool, the patients should not take any food to prevent the risk of suffocation. Keep the air way unblocked. Take norepinephrine diluent and acid inhibition drugs. If necessary, blood transfusion will be adopted and observe the patients with high attention.

Stent migration

Stent is made of shape memory material nitinol wire. When the stent is implanted into the human body, it takes some time for the stent to expand. The patient should not take frozen food or vomit violently after the operation. When stent migrate, it should be adjusted or placed again. 

Customized stent should be a good option to avoid stent migration based on the tumor position and size.

Esophageal perforation

Esophageal perforation is the most serious complication of stent implantation with occurrence rate 1%~10%.

The stent implantation is easy to perform, but if the physicians perform with strong force or insert the guide wire into the obstructed cavity, then it will lead to the perforation.

In case of sudden severe pain, shortness of breath, choking on drinking water, subcutaneous emphysema and liquid pneumothorax during or after operation, perforation should be taken with enough attention. Therefore, the operator should be gentle in the operation, and should not feel forced to place stent when encountering resistance or obstruction. When perforation happen, the lantern-shaped stent or covered stent should be selected as far as possible. In serious cases, surgical consultation should be conducted.

Esophageal restenosis

There were a total of 7 cases of esophageal restenosis in our observation group between 1 month and six months after the operation, which may caused by tumor growth or granulation tissue proliferation which leading to the restenosis of the upper or lower stent or esophageal and bronchus fistula. The stent should be placed again.

The principle of stent implantation is the same, but the second stent placement should overlap the first stent by 2cm, the other end of the stent should exceed the tumor by 2cm. The diameter of the stent after implantation must be equal to or slightly larger than the previous stent diameter.

After multiple stents implantation, the patients may feel that food taking is not that unobstructed, as the stent does not have biological movement of the esophagus. The patients are instructed to eat less and more frequently, take liquid or semi-liquid food. Drink water during and after meals, avoid food incarceration. Do not take food in the lying or half lying positions.