Background and Aims
Self-expanding metal stents (SEMSs) when deployed across the gastroesophageal junction
(GEJ) can lead to reflux with risks of aspiration. A SEMS with a tricuspid antireflux
valve (SEMS-V) was designed to address this issue. The aim of this study was to evaluate
the efficacy and safety of this stent.
Methods
A phase III, multicenter, prospective, noninferiority, randomized controlled trial
was conducted on patients with malignant dysphagia requiring SEMSs to be placed across
the GEJ. Patients were randomized to receive SEMSs with no valve (SEMS-NV) or SEMS-V.
Postdeployment dysphagia score at 2 weeks and Gastroesophageal Reflux Disease-Health
Related Quality of Life (GERD-HRQL) questionnaire score at 4 weeks were measured.
Patients were followed for 24 weeks.
Results
Sixty patients were randomized (SEMS-NV: 30 patients, mean age 67 ± 13 years; SEMS-V:
30 patients, mean age 65 ± 12 years). Baseline dysphagia scores (SEMS-NV, 2.5 ± .8;
SEMS-V, 2.5 ± .8) and GERD-HRQL scores (SEMS-NV, 11.1 ± 8.2; SEMS-V, 12.8 ± 8.3) were
similar. All SEMSs were successfully deployed. A similar proportion of patients in
both arms improved from advanced dysphagia to moderate to no dysphagia (SEMS-NV, 71%;
SEMS-V, 74%; 95% confidence interval, 1.93 [–17.8 to 21.7]). The dysphagia scores
were also similar across all follow-up time points. Mean GERD-HRQL scores improved
by 7.4 ± 10.2 points in the SEMS-V arm and by 5.2 ± 8.3 in the SEMS-NV group (P = .96). The GERD-HRQL scores were similar across all follow-up time points. Aspiration
pneumonia occurred in 3.3% in the SEMS-NV arm and 6.9% in the SEMS-V arm (P = .61). Migration rates were similar (SEMS-NV, 33%; SEMS-V, 48%; P = .29). Two SEMS-V spontaneously fractured. There was no perforation, food impaction,
or stent-related death in either group.
Conclusions
The SEMS-V was equally effective in relieving dysphagia as compared with the SEMS-NV.
Presence of the valve did not increase the risks of adverse events. GERD symptom scores
were similar between the 2 stents, implying either that the valve was not effective
or that all patients on proton pump inhibitors could have masked the symptoms of GERD.
Studies with objective evaluations such as fluoroscopy and/or pH/impedance are recommended.
(Clinical trial registration number: NCT02159898.)
Graphical abstract
Graphical Abstract
Abbreviations:
AE (adverse event), FDA (U.S. Food and Drug Administration), GEJ (gastroesophageal junction), GER (gastroesophageal reflux), GERD-HRQL (Gastroesophageal Reflux Disease-Health Related Quality of Life), ITT (intention-to-treat), LOCF (last-observation-carried-forward), PPI (proton pump inhibitor), SEMS (self-expanding metal stent), SEMS-NV (self-expanding metal stent with no valve), SEMS-V (self-expanding metal stent with an antireflux valve)To read this article in full you will need to make a payment
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Article info
Publication history
Published online: January 23, 2019
Accepted:
January 9,
2019
Received:
October 18,
2018
Footnotes
DISCLOSURE: The following authors disclosed financial relationships relevant to this publication: K. S. Dua: Grant recipient from Boston Scientific, Cook Medical, and Merit Medical; speaker for Boston Scientific. J. M. DeWitt: Consultant for Olympus America, Boston Scientific, and Pinnacle Biologics. W. R. Kessler, P. V. Draganov: Grant recipient from Merit Medical, consultant for Cook, BSC, Olympus, Microteck, and MicroTech; Merit and paid speaker for Cook, BSC, and Olympus. D. L. Diehl: Consultant for Merit Medical. M. S. Wagh: Consultant for Boston Scientific and Medtronic. M. Kahaleh: Grant recipient from Merit Medical, Olympus America, Boston Scientific, Cook Medical, Aspire Bariatrics, GI Dynamics, Apollo, Fuji, Pentax, Emcision, Concordia, MI Tech, Maunakea Tech, Ninepoint Medical, and W.L. Gore. S. A. Edmundowicz: Medical advisory board member for Endostim, Check-Cap, Motus GI, Elira, and Olympus; stock options from Endostim, Check-Cap, Motus GI, and Freehold Surgical; stockholder for Elira (also spouse), Aspero Medical Inc, UV Concepts Incorporated (spouse), and Motus GI (spouse); consultant for Motus GI, Olympus, Medtronic, and Allurion; co-founder of Aspero Medical Inc; paid associate editor for Elsevier; Data Safety Monitoring Board Chair for Allurion. B. C. Brauer: Consultant for Boston Scientific and Medtronic; grant recipient from Erbe. D. G. Adler: Consultant for Boston Scientific and Merit Medical. L.M. Wong Kee Song: grant from Merit Medical. All other authors disclosed no financial relationships relevant to this publication. Research support for this study was provided by Merit Medical.
See CME section; p. 150.
If you would like to chat with an author of this article, you may contact Dr Dua at [email protected]
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