G a s t r o i n t e s t i n a l Ima g i ng C l i n i c a l O b s e r v a t i o n s

D
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Esophageal Stents:
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Findings on
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Patients
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e. Gregory S.
OBJECTIVE. The purpose of this report is to assess the findings on esophagography in
or Anderson1 Marc S.
g pa- tients with esophageal stents for palliation of malignant tumors involving the esophagus.
by Levine1 Stephen CONCLUSION. Radiologists should be familiar with findings of little importance
11 E. Rubesin1 Igor (stent narrowing, flow of contrast medium around stent, stent kinks, and apparent esophageal
5. Laufer1 narrow- ing below stent because of incompletely distended hiatal hernias) versus more
17
8.
Gregory G. important find- ings (polypoid defects above or below stent, narrowing within or below
23 Ginsberg2 Michael stent, delayed stent emptying, esophageal-airway fistulas, stent migration, and abutting of
5. L. Kochman2 distal stent against greater curvature of stomach) on esophagography after stent placement
50 to guide endoscopists regarding the need for stent revision.
on
11
elf-expanding metallic stents have

S
/0 evaluate positioning of the stent and to exclude per-
3/ increasingly been used as the foration. Two patients had their initial esophagrams
16 treatment of choice for and eight patients had a total of 13 follow-up
fr inoperable
o esoph-
m University of Pennsylvania, esophageal cancer because of low
Philadelphia, PA.
IP complication rates and their effectiveness in palliating
ad dysphagia in patients with malig- nant strictures [14].
AJR 2006;
dr
187:1274
Patients with esoph- ageal stents may undergo
es
s esophagography immediately after stent placement to
1279
11 evaluate positioning of the stent and rule out perfora- tion,
0361
5. or they may undergo esophagography weeks to months
17 803X/06/18 after stent placement to eval- uate dysphagia and rule out
8. 751274 esophageal-air- way fistulas. The purpose of our
23
5. American Roentgen Ray Society investigation was to assess the various findings on esopha-
50 gography in a series of patients with esoph- ageal stents
. placed for palliation of inopera- ble esophageal cancer or
C other malignant tumors involving the esophagus.
op
yri
gh Keywords: dysphagia, esophageal cancer, Materials and Methods
t esophageal disease, esophageal stent, A review of our computerized radiology database revealed 116
A esophagography, esophagram esophagrams after stent placement for inoperable esophageal cancer
R or other malignant tu- mors involving the esophagus from 1996 to
R DOI:10.2214/AJR.05.0465
2003. Fifty-seven studies were excluded because of lack of
S.
Received March 16, 2005; accepted after availability of radiographic images or inadequate follow-up. The
Fo
revision June 7, 2005. remaining 59 studies were performed in 46 patients, including 38
1 who had one esoph- agram, five who had two esophagrams, two
Department of Radiology, Hospital of the
University of Pennsylvania, 3400 Spruce St., who had three esophagrams, and one who had five esoph-
Philadelphia, PA 19104. Address correspondence agrams. These 46 patients comprised our study group. Forty-four
to M. S. Levine patients had esophagrams within 3 days of stent placement (mean
(marc.levine@uphs.upenn.edu).
interval, 1 day) to
2
Department of Medicine, Hospital of the
AJR:187, November 1
2006
agrams 113 months after stent placement
(mean in- terval, 2 months). These 15
esophagrams were ob- tained because of
dysphagia (n = 13) or suspected esophageal-
airway fistulas (n = 2).
When esophagrams were obtained
immedi- ately after stent placement, the
patients initially were given a water-soluble
contrast agent (diatri- zoate meglumine and
diatrizoate sodium [Gastro- view,
Mallinckrodt]). If spot images showed a
leak into the mediastinum, the study was
terminated. If spot images did not show a
2 AJR:187, November
leak, however, the pa- tient was
given a 250% weight/volume
barium suspension (E-Z-HD, E-
Z-EM, Inc.), and addi- tional
images were obtained. The
studies were performed by
residents, fellows, or attending
gas- trointestinal radiologists,
and all were interpreted by the
attending radiologists.
All stents were covered, self-
expanding metal- lic stents,
including Ultraflex stents in 24 patients,
Wallstent II stents in 11, Wallstent I stents in
seven, Z-stents in three, and a Flamingo stent in
one (Z-stent, Wilson-Cook Medical; all other
stents, Boston Scientific). All of these stents have
a short uncovered segment at their ends to allow
the stent struts to anchor to the esophageal wall.
The stents were located in the upper and mid
esophagus in 10 patients; the mid and distal
esophagus in nine; the upper, mid, and distal
esophagus in 10; and extended into the gastric
fun- dus in 17. The stents had a mean length of
11 cm (range, 415 cm).
2006
 Anderson et
al.

A Fig. 270-year-old man with stent placed

for palliation of dysphagia caused by
advanced malignant tumor of uncertain
B origin involving upper thoracic esophagus.
Left posterior oblique spot image from single-
Fig. 180-year-old woman with stent placed for palliation of dysphagia caused by squamous contrast esophagram shows barium (arrows)
D cell carcinoma of esophagus. fowing around left anterolateral wall of
o A, Left posterior oblique scout image shows tapered narrowing (arrows) of midportion of stent. proximal end of stent.
w B, Left posterior oblique spot image from single-contrast esophagram shows tapered
nl narrowing of barium column (arrows) where lumen and stent are compressed by surrounding
oa esophageal tumor.
de
d
fr The radiographic images were interpreted by
Results Radiographic
o con- sensus retrospectively by two gastrointestinal Clinical Aspects Findings of Little
m radiol- ogists who were blinded to the clinical
w Thirty patients (65%) were men, and 16 Clinical
and endo- scopic findings. They reviewed the Importance
w (35%) were women. The mean age was 67
w. images to assess the flow of contrast material Narrowing of stent caliberSeventeen
years (range, 4598 years). Twenty-six
ajr through or around the stents, kinking or fracture of (29%) of the 59 esophagrams revealed
patients (57%) had esophageal carcinoma,
on the stents, filling defects or contour defects above tapered nar- rowing (less than 50% of the
lin three (6%) had gastric carcinoma, four (9%)
or below the stents, the cal- iber and contour of the diameter of the stent) in the midportion of
e. had lung can- cer invading the esophagus,
lumen within and below the stents, emptying of the stent (Fig. 1). All but two patients had
or one (2%) had met- astatic endometrial
g contrast material from the stents, stent migration, relief from dys- phagia, so this waist
sarcoma, and 12 (26%) had malignant
by the presence or absence of perfora- tion or characteristic was not thought to be
strictures of uncertain origin. The stents
11 esophageal-airway fistulas, and any other important.
5. were placed for palliation of dysphagia in 35
findings. Medical records were also reviewed to de- Flow of contrast material around the sides
17 patients (76%) and palliation of esophageal-
termine the indications for stent placement and the
8. airway fistulas in 11 (24%). of the stentSixteen esophagrams (27%) re-
clinical findings and course. Seventeen patients
23 Twenty-nine (83%) of the 35 patients in vealed flow of contrast material around one
5. (37%) had follow-up endoscopy after esophagogra-
whom stents were placed for palliation of (n = 11) or both (n = 5) sides of the stent (Fig.
50 phy; the endoscopic and pathology reports were re-
dysphagia had substantial relief or resolution 2). In 15 of these patients, this finding was
on viewed and correlated with the radiographic
11 of dysphagia. Eight (28%) of these 29 patients not thought to be important because their
findings in these patients.
/0 developed recur- rent dysphagia within 13 dysphagia resolved without further
Our institutional review board approved all as-
3/ months (mean duration, 5 months) after stent intervention. In the other patient, contrast
16 pects of this retrospective study and did not re-
placement. Seven (15%) of the 46 patients material passed around the stent into a
fr quire informed consent from any patients included
had additional stents placed be- cause of tracheoesophageal fistula.
o in our study.
m intractable dysphagia (n = 5) or contin- ued Stent kinksThree esophagrams (5%) re-
IP esophageal-airway fistulas (n = 2). vealed kinking or angulation of the stent
ad (Fig. 3). This finding was not thought to be
dr important because these patients all had
es
s
11
5.
17
8.
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 Fig. 375-year-old man with stent placed
for palliation of dysphagia caused by
adenocarcinoma of distal esophagus
invading gastric cardia and fundus. Steep
right posterior oblique spot image from
single-contrast esophagram shows
narrowing and kinking of stent (black arrow)
by surrounding tumor in distal esophagus.
D Note how stent traverses gastroesophageal
o junction with distal end (white arrow) in
w gastric fundus.
nl
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by
11
5.
17
8.
23
5.
50
on
11
/0
3/
16
fr
o
m
IP
ad
dr
es Fig. 460-year-old
man with stent
s placed for palliation
11 of dysphagia caused
5. by squamous cell
17 carcinoma of
esophagus. A, Steep
8. right posterior
23 oblique spot image
5. from single-contrast
50 esophagram shows
apparent narrowing
. of distal esophagus
C (arrows) from distal
op end of stent to
yri gastroesophageal
gh junction.
B, Frontal spot
t image from same
A examination as A
R shows barium
R trapped between
gastric folds of
S. incompletely filled
Fo hiatal hernia
(arrows). Subsequent
endoscopy
confirmed presence
of hiatal hernia in
this patient.
A B
 Narrowing of lumen abutting distal end of
stentFourteen esophagrams (24%) revealed
Fig. 653-year-old man with stent placed
Fig. 555-year-old man with stent placed for for palliation of dysphagia caused by esophageal narrowing abutting the distal end
palliation of dysphagia caused by squamous malignant tumor of uncertain origin of the stent because of tumor overgrowth (n =
cell carcinoma of esophagus. Left posterior encasing mid esophagus. Right posterior
oblique spot image from single-contrast oblique spot image from single-contrast 3), tumor ingrowth (n = 2), debris or blood
esophagram shows asymmetric mass effect esophagram shows focal segment of marked clot (n = 3), epithelial hyperplasia (n = 2),
D (arrows) on right posterolateral wall of distal luminal narrowing (black arrows) in distal
o esophagus abutting stent. This finding was end of stent. Note irregular contour and and un- known causes (n = 4). The
w caused by tumor overgrowth into distal end abrupt, shelflike distal margins (white narrowed segment had an irregular contour
of stent. arrows) of narrowed segment. At endoscopy,
nl this finding was caused by tumor ingrowth with abrupt margins in both patients with
oa through uncovered distal end of stent.
de
tumor ingrowth and a smooth contour with
d symptomatic improvement without further tapered margins in both patients with
fr intervention. Defects below stentTwo esophagrams epithelial hyperplasia.
o Incomplete distention of hiatal hernia (3%) revealed polypoid defects (2 and 3 cm) Delayed emptying of stentThree esoph-
m mimicking narrowed distal esophagusTwo in the esophagus abutting the distal end of agrams (5%) revealed delayed emptying of
w
w
esophagrams (3%) revealed apparent narrow- the stents. One patient had overgrowth of tu- contrast material from the stent because of
w. ing of the distal esophagus just below the mor into the distal end of the stent (Fig. 5), recurrent tumor in two patients and blood
ajr stent because of a partially collapsed hiatal and the other had exuberant reactive fibrosis clot in one.
on hernia with barium trapped in the folds of the at endoscopy. Esophageal-airway fistulasFour esoph-
lin hernia (Fig. 4). In both of these patients, en- Narrowing of lumen within stentFourteen agrams (7%) revealed contrast material
e.
doscopy confirmed a hiatal hernia. esophagrams (24%) revealed esophageal enter- ing fistulas (two tracheoesophageal
or
g narrowing within the distal end of the stent and two esophagobronchial fistulas). The
by Radiographic because of tumor (n = 3), debris or blood stents had all been placed for palliation of
11 Findings of Greater clot (n = 3), epithelial hyperplasia (n = 3), known fistu- las. In two patients, the stents
5. Clinical Importance and unknown causes (n = 5). The narrowed failed to protect the fistulas because their
17
Defects above stentTwo (3%) of the 59 segment had an irregular contour and abrupt distal ends were im- properly positioned
8.
23 esophagrams revealed polypoid defects (1 distal margins in patients with tumor in- above the fistulas. In the remaining two
5. cm and 0.7 cm) in the esophagus abutting growth (Fig. 6) and a smooth contour and patients, the stents were prop- erly
50 the proximal end of the stents. Both patients more gradual margins in the patients with positioned, but barium passed around the
on had overgrowth of tumor into the proximal epithelial hyperplasia (Fig. 7). stent into the fistula in one and through the
11
end of the stent at endoscopy, so uncovered distal end of the stent into a new
/0
3/ additional stents were placed. fistula in the other (Fig. 8). In two patients,
16 additional stents were placed.
fr Stent migrationOne esophagram (2%)
o revealed that a stent placed across the gastro-
m
IP
esophageal junction for palliation of a carci-
ad noma of the cardia had migrated into the
dr stomach (Fig. 9A). A new stent was
es therefore placed (Fig. 9B).
s Distal end of stent abutting gastric wall
11
5.
Five esophagrams (8%) revealed stents tra-
17 versing malignant strictures at the cardia,
8. with the distal end of the stent abutting the
23 greater curvature of the proximal stomach
5. (Fig. 9B). This finding raised concern about
50
. the possibil- ity of impending obstruction,
C but none of these patients had problems with
op stent function.
yri
gh Stent Fractures
t
A None of the 59 esophagrams revealed
R stent fractures after stent placement.
R
S. Perforation
Fo None of the 59 esophagrams revealed
esophageal perforations after stent placement.

Discussion
Expandable metallic stents have been used
with increasing frequency for palliation of
dys- phagia or esophageal-airway fistulas in
patients with inoperable esophageal carcinoma or other
 Fig. 771-year-old
woman with stent
placed for palliation
of carcinoma of lung
invading upper
thoracic esophagus.
Right posterior
oblique spot image
D from single- contrast
o esophagram shows
w narrowing of lumen
(arrows) in distal
nl end of stent. Note
oa relatively smooth
de contour and tapered
d margins of narrowed
segment.
fr
Endoscopic biopsy
o specimens from this
m region revealed
w epithelial
w hyperplasia. (Note
pneumomediastinum
w. and subcutaneous
ajr emphysema in soft
on tissues of neck from
lin esophageal
e. perforation that
occurred during
or endoscopic
g dilatation procedure
by before placement of
11 stent.)
5.
17
8.
23
5.
50
on
11
/0
3/
16
fr malignant tumors involving the esophagus. tended hiatal hernia (Fig. 4B). The most feared complication of stent place- ment is
o These stents are often evaluated by esophageal perforation. Such perfora- tions are usually
m esophagog- raphy, so it is important for caused by erosion of the stent through a friable tumor or an
IP radiologists to be fa- miliar with the findings
ad esophageal wall already damaged by mediastinal irradiation
after stent placement. or laser therapy [2]. When perforation is sus- pected,
dr
es In our study, we made a number of observa- radiographic studies with water-soluble contrast agents may
s tions about esophageal stents on esophagogra- show extravasation of con- trast material into the
11 phy that are of little clinical importance mediastinum or pleural space. Esophageal perforation rates
5. because these patients rarely had dysphagia.
17 have ranged from 0% to 14% after stent placement [1, 5, 6].
Tapered nar- rowing in the midportion of the However, we did not encounter any pa- tients with this
8.
23 stent was often seen in patients in whom complication, indicating that stent placement is a safe
5. dysphagia was palli- ated after stent procedure associated with a low perforation rate when the
50 placement (Fig. 1). This phenom- enon is stents are deployed by endoscopists experienced in per-
. probably secondary to impingement on the
C forming this procedure.
expanding stent by surrounding tumor. Flow An esophageal stent may fail to palliate dys- phagia if the
op
yri of contrast material around one or both sides stent is not properly positioned or if it migrates distally
gh of the stent was another frequent finding of because of inadequate anchor- ing to the esophageal wall
t little importance (Fig. 2), presumably resulting (Fig. 9A). Recurrent dysphagia may also be caused by tumor
A from incomplete apposition of the stent
R over- growth or ingrowth, epithelial hyperplasia, or ad- herent
against the esophageal wall. In one patient, debris or blood clot. Therapeutic options for palliating the
R
S. however, con- trast material flowed around patients dysphagia include bal- loon dilatation, laser therapy,
Fo the stent into an esophagobronchial fistula, stent revision, and endoscopic removal of any debris or blood
necessitating place- ment of a new stent. clots.
Finally, two esophagrams revealed apparent
narrowing of the distal esoph- agus below the
stent (Fig. 4A), raising concern about tumor
overgrowth. In both patients, how- ever, this
finding was caused by trapping of bar- ium in
gastric folds within an incompletely dis-

Fig. 879-year-old man with
stent placed for palliation of
tracheoesophageal fistula
caused by squamous cell
carcinoma of esophagus. Left
posterior oblique spot image
from single-contrast
esophagram shows irregular
luminal narrowing (white
arrows) in distal end of stent.
Also note barium in left
mainstem bronchus (black
arrows) from
esophagobronchial fistula that
presumably developed as a
result of tumor ingrowth
through adjacent uncovered
distal portion of stent.
is defined as extension of a tumor directly
Tumor overgrowth is
defined as extension of a
tumor into one end of the stent
with varying degrees of
obstruction [2]. In our series,
tumor overgrowth was
characterized by a polypoid
defect above or below the
stent or by asymmet- ric mass
effect and narrowing below
the stent (Fig. 5). In contrast, tumor ingrowth
into the lumen through uncovered metallic
stents or through the uncovered proximal or
distal ends of cov- ered metallic stents [2].
Tumor ingrowth through the uncovered
distal end of the stent was characterized on
esophagography by ir- regular luminal
narrowing with abrupt distal margins (Fig.
6). Finally, epithelial hyperplasia is defined
as exuberant tissue overgrowth as a reaction
to metallic esophageal stents [7, 8]. In
 A B
Fig. 962-year-old man with stent placed for palliation of dysphagia caused by carcinoma of gastric cardia invading distal esophagus.
A, Left posterior oblique spot image from single-contrast esophagram shows distal migration of stent (white arrows) into gastric fundus. Note
barium in distal esophagus (black arrows). B, Malpositioned stent was removed, and a new stent was placed across gastroesophageal junction.
Repeat examination 1 day after first study shows proper positioning of new stent (black arrows) with proximal half in distal esophagus and
D distal half in proximal stomach. Note how distal end of stent (large white arrow) directly abuts greater curvature of proximal stomach.
o Despite this finding, patients dysphagia was adequately palliated by stent. Polypoid carcinoma (small white arrows) is seen at gastroesophageal
w junction.
nl previous studies, the frequency of epithelial ment for esophageal lesions: indications, methods,
oa longer after stent placement because of dysph-
hyperplasia has ranged from 2% to 28% after and results. RadioGraphics 2003; 23:89105
de agia, and these individuals were more likely to
d esophageal stent placement [810]. Epithelial 5. Song HY, Do YS, Han YM, et al. Covered,
fr hyperplasia was characterized by esophageal have abnormalities. Because of the retrospec-
tive nature of our investigation, these follow- expand- able esophageal metallic stent tubes:
o narrowing with a smooth contour and more
m up esophagrams were not obtained at experiences in 119 patients. Radiology 1994;
ta- pered margins than tumor ingrowth (Fig. 193:689695
w uniform time intervals after stent placement.
w 7).
w. Covered metallic stents are also placed for The presence of different types of stents in 6. Knyrim K, Wagner HJ, Bethge N, Keymling M,
ajr palliation of esophageal-airway fistulas. Stent our study patients represented another Vakil N. A controlled trial of an expansile metal
on failure can result from an improperly confounding variable. Fi- nally, it was not stent for palliation of esophageal obstruction due
lin positioned stent or from stent migration possible to have a pathologic diagnosis in to inoperable cancer. N Engl J Med 1993;
e. approximately 25% of patients with luminal 329:13021307
or below the fistula. In our study, however, one
narrowing or masses because bi- opsy or
g patient with a prop- erly positioned stent
surgical specimens were not obtained in
7. Mayoral W, Fleischer D, Salcedo J, Roy P, Al-
by developed a new esophago- bronchial fistula Kawas F, Benjamin S. Nonmalignant obstruction
11 because of tumor ingrowth through the these individuals.
is a common problem with metal stents in the
5. uncovered distal end of the stent (Fig. 8). treatment of esophageal cancer. Gastrointest En-
17
8. Another had a properly positioned stent that dosc 2000; 51:556559
23 failed to palliate a fistula because of flow of
5. contrast material around the stent. References 8. Vakil N, Gross U, Bethge N. Human tissue re-
50 sponses to metal stents. Gastrointest Endosc
on
Radiologists, therefore, should be aware that 1. Schaer J, Katon RM, Ivancev K, Uchida B, Rosch 1999; 9:359367
a covered stent may not palliate all J, Binmoeller K. Treatment of malignant
11
/0 esophageal-airway fistulas despite proper esophageal obstruction with silicone-coated 9. Wang MQ, Sze DY, Wang ZP, Wang ZQ, Gao
3/ positioning of the stent. metallic self-ex- panding stents. Gastrointest YA, Dake MD. Delayed complications after
16 Our investigation has the inherent Endosc 1992; 38:711 esoph- ageal stent placement for treatment of
fr limitations of a retrospective study, such as malignant esophageal obstructions and
o
selection bias. The frequency of various 2. Gollub MJ, Gerdes H, Bains MS. Radiographic esophagorespira- tory fistulas. J Vasc Interv
m ap- pearances of esophageal stents.
IP complications related to stent placement may Radiol 2001; 12:465474
therefore be skewed by our study population, RadioGraphics 1997; 17:11691182
ad 10. Siersema PD, Hop WC, Blankenstein M, et
dr which did not represent a random sample but 3. Cwikiel W, Tranberg KG, Cwikiel M, Lillo-Gil R. al. A comparison of 3 types of covered metal
es rather a selected group of patients, most of Malignant dysphagia: palliation with esophageal
s stents for the palliation of patients with
whom had esophagrams within 3 days of stentslong-term results in 100 patients. Radiol-
11 dysphagia caused by esophagogastric carcinoma:
5. stent placement. A subset of patients had ogy 1998; 207:513518
a prospective, random- ized study. Gastrointest
17 follow-up esophagrams 1 month or
8.
4. Therasse E, Oliva VL, Lafontaine E, Perreault P, Endosc 2001; 54:145153
23 Gi- roux MF, Soulez G. Balloon dilation and stent
5. place-
50
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