Reaction Patterns of the Tracheobronchial Wall to Implanted Noncovered Metal Stents
Peter GreweKlaus Michael MüllerMichael LindstaedtAlfried GermingAnette MüllerAndreas MüggeThomas Deneke
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Malignant Transformation
Self-expanding metal stents (SEMS) seem to be the optimal choice for benign esophageal disorders, especially those not associated with a stricture, such as anastomotic leaks, iatrogenic perforations, and fistulas. On the other hand stent embedding can be an important limitation of SEMS placement, because this precludes safe stent removal [1]. In fact, in the literature there are only a few case series reporting the stent-in-stent technique using SEMS to remove embedded stents (14 – 189 days from the placement of the first stent) [2] [3].
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Endoscopic stenting is a widely used method for managing esophageal anastomotic leaks and perforations. Self-expanding metal stents (SEMSs) have proved effective in sealing these defects, with a lower rate of displacement than that of self-expanding plastic stents (SEPSs) as a result of tissue proliferation and granulation tissue ingrowth at the uncovered portion of the stent, which anchor the prosthesis to the esophageal wall. Removal of a fully embedded stent is challenging because of the risk of bleeding and tears.Temporary placement of a new stent within the first stent (stent-in-stent technique) may facilitate the mobilization and safe removal of both stents by inducing pressure ischemia of the granulation tissue. We report our own experience with the stent-in-stent technique in five consecutive patients in whom a partially covered Ultraflex stent had previously been implanted and compare our results with those in the current literature.The first SEMSs remained in place for a median of 40 days (range 18 - 68) without displacement. Placement of the new stent was technically successful in all patients. All stents were left in place for a median of 9 days. The overall stent-in-stent success rate was 100 % for the removal of embedded stents. No serious adverse events related to the procedure occurred.The procedure was safe, well tolerated, and effective. The use of a partially covered Ultraflex stent of the same size as the old stent for a limited time (≤ 6 days) was consistently successful.
Granulation tissue
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Stent implantation through the stent-strut of a previously implanted self-expandable stent in the superficial femoral artery (SFA) is not usually performed because the additional stent cannot dilate sufficiently. The key point to achieve sufficient expansion of an additional stent is to break the stent-strut of the previously implanted stent. However, there is no report of how to break the stent-strut.
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A retrospective analysis of the endoscopic diagnostic data on 151 cases of gastric polyps of various histological structure was carried out. A relationship between the risk of malignant transformation of gastric polyps, on the one hand, and their histology, presence and degree of dysplasia, on the other, was established. Epithelial dysplasia, in pronounced degree included, was observed in 33.7% of patients with hyperplastic polyps and in all cases of gastric adenoma. Epithelial dysplasia of hyperplastic polyps was mild or moderate in most cases while that of adenomatous polyps was moderate or grave. Gastric cancer as a consequence of malignant transformation of polyps was detected in 15 (9.9%) patients (hyperplastic polyps--2; adenomatous polyps--13). No objective endoscopic criteria for establishing the risk of polyp transformation were developed. Grave epithelial dysplasia, i.e. precancerous lesions in the gastric mucosa, may be suggested as such criterion. Moderate or grave dysplasia of the polyp epithelium should be considered in forming the group at risk first and foremost.
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Malignant Transformation
Adenomatous polyps
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