Can a stent be placed in the esophagus?

Esophageal Stent Placement: Indications and Clinical Application

Yes, stents can be placed in the esophagus and are a well-established endoscopic intervention for both malignant and benign esophageal conditions, with self-expanding metal stents (SEMS) being the preferred option in most clinical scenarios. 1, 2

Primary Indications for Esophageal Stenting

Malignant Esophageal Obstruction

For patients with non-resectable esophageal cancer causing dysphagia, SEMS placement is a first-line palliative treatment that provides rapid symptom relief and can be used alone or in combination with chemotherapy or radiation. 1

• SEMS placement is superior to laser therapy, photodynamic therapy (PDT), and rigid plastic stents for malignant dysphagia, with lower adverse event rates and better efficacy 1, 2
• Combination therapy (stent plus chemotherapy or radiation) provides significantly improved long-term dysphagia relief (>5 months) and overall survival compared to stent alone 1
• Brachytherapy is an equally valid alternative to SEMS placement, with no significant differences in dysphagia improvement or overall survival 1, 2

Critical caveat: For patients who are potential surgical candidates or undergoing neoadjuvant chemoradiation, do not routinely place SEMS without multidisciplinary review due to high stent migration rates (up to 30%), increased morbidity and mortality, and potentially lower R0 resection rates 1. Instead, consider enteral feeding tubes (nasogastric or percutaneous) for nutritional support 1

Malignant Tracheoesophageal or Bronchoesophageal Fistulas

• SEMS placement is recommended for sealing malignant fistulas 2
• Covered stents are essential to prevent continued contamination through the fistula tract 3, 4

Benign Esophageal Conditions

Refractory Benign Strictures:

• SEMS are not recommended as first-line therapy for benign strictures due to potential adverse events, availability of alternative therapies (dilation, incisional therapy, steroid injection), and cost 2
• Consider temporary stent placement only after other endoscopic methods have failed to maintain adequate esophageal patency 1, 2
• Optimal stent duration is typically 4-8 weeks, though up to 3 months may be required; longer placement risks stent embedding 1
• Complete dysphagia relief occurs in approximately 40% of patients, but recurrence rates remain high (up to 69%), particularly with long strictures (>7 cm) 1

Esophageal Perforations, Leaks, and Anastomotic Dehiscence:

• Covered SEMS can seal perforations and leaks, preventing further contamination of surrounding tissue 1, 2, 5
• Technical success rates are 91% with clinical success (complete healing) of 81% 5
• This approach is most effective when performed early with limited mediastinal or pleural contamination and in conjunction with adequate drainage 5
• For fresh esophagectomy leaks within days of operation, primary closure with clips or endosuturing plus fully covered stent placement is recommended 1

Refractory Esophageal Variceal Bleeding:

• Fully covered large-diameter SEMS can be considered for variceal bleeding refractory to medical, endoscopic, and radiological therapy, or as initial therapy for massive bleeding 2

Stent Selection: Critical Technical Considerations

Stent Type

For malignant obstruction, use fully covered SEMS (FCSEMS) or partially covered SEMS (PCSEMS) rather than uncovered SEMS (UCSEMS). 1

• UCSEMS have increased rates of tumor ingrowth and need for re-intervention 1
• FCSEMS are preferred for benign strictures due to very low risk of embedding and ease of removal 2
• PCSEMS provide better seal but create tissue ingrowth, making removal more challenging 6

Stent Dimensions

• Allow at least 2 cm margin both proximally and distally from the stricture 1
• Use larger diameter stents (20-23 mm) when crossing the gastroesophageal junction to prevent migration 1
• Small-diameter stents (16-18 mm) have increased recurrent dysphagia, tissue overgrowth, and food bolus obstruction 1
• Large-diameter stents have higher hemorrhage and perforation rates 1

Migration Prevention

Consider stent-anchoring methods to reduce migration risk, which occurs in approximately 30% of cases: 1

• Endoscopic suturing has demonstrated effectiveness in reducing stent migration 1
• Over-the-scope clips can anchor the stent and decrease migration rates 1
• These techniques are particularly important when no stricture exists to hold the stent in place (e.g., fistulas) 1

Common Adverse Events and Management

Stent placement is associated with adverse events in approximately 20% of patients: 1

• Chest pain (very common, occurring in large proportion of patients) 1
• Stent migration (approximately 30% with both metal and plastic stents) 1
• Gastroesophageal reflux (70-100% of cases when stent crosses GE junction) 1
• Bleeding and perforation (higher with large-diameter stents) 1
• Recurrent obstruction from tumor ingrowth/overgrowth or tissue overgrowth 1
• Aspiration pneumonia 1
• Serious adverse events occur in <5% with procedure-related mortality <2% 3

For embedded partially covered SEMS, use the stent-in-stent technique for removal 2

Key Clinical Pitfalls to Avoid

• Never place SEMS as bridge to surgery or before preoperative chemoradiotherapy due to high adverse event rates; use feeding tubes instead 2
• Avoid partially or uncovered metal stents in benign strictures due to risk of embedding that may preclude safe removal 1
• Do not leave temporary stents in place longer than 3 months due to embedding risk 1
• Recognize that FCSEMS do not provide a "watertight" seal—oral contents can pass alongside the stent, potentially perpetuating leaks 6
• Address downstream stenosis or stricture before stent placement, as elevated intraluminal pressures can propagate leak formation 6
• Be aware of PEG tube risks in surgical candidates: potential abdominal wall tumor seeding and difficulty with subsequent gastric conduit formation 1