Changing epidemiology of esophageal stent placement for dysphagia: a decade of trends and the impact of benign indications

Published:February 24, 2020DOI:

      Background and Aims

      In addition to managing malignant obstruction, esophageal stents (ESs) have evolved to address various benign etiologies of dysphagia. We sought to evaluate national trends and changes in practice of ES placement for both benign and malignant etiologies in hospitalized patients with dysphagia.


      The National Inpatient Sample (2003-2013) was used to include all adult inpatients (≥18 years of age) with endoscopy-guided ES placement for a symptom of dysphagia. Multivariable analyses for indications that impact temporal trends (3 time periods: 2003-2005, 2006-2009, and 2010-2013) and for hospital outcomes were performed.


      A total of 7198 ESs were deployed endoscopically in hospitalized patients with dysphagia. Compared with malignant etiologies, there was a significant increase in ES placement for benign conditions (2013 vs 2003: 32.7% vs 14.5%, respectively; P < .001). Multivariable analysis using 2003 to 2005 as a reference showed that patients with benign etiologies for dysphagia predominantly contributed to the increase of ES placement during the most recent time period (2010-2013: odds ratio, 2.09; 95% confidence interval, 1.40-3.13). Multivariable analysis of hospital outcomes revealed no differences in inpatient mortality, duration of hospital stay, and hospital costs between malignant and benign indications.


      In the preceding decade, ES placement for hospitalized patients with dysphagia has increased, driven largely by an over 8-fold rise in stent placement for benign indications. These findings warrant continued efforts to improve stent technology to decrease the risk of migration and review practice guidelines involving ES placement for benign etiologies.


      CI (confidence interval), ES (esophageal stent), ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification), NIS (National Inpatient Sample), OR (odds ratio), SEMS (self-expandable metal stent)
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        • Sharma P.
        • Kozarek R.
        Role of esophageal stents in benign and malignant diseases.
        Am J Gastroenterol. 2010; 105: 258-273
        • Didden P.
        • Reijm A.N.
        • Erler N.S.
        • et al.
        Fully vs. partially covered self expandable metal stent for palliation of malignant esophageal strictures: a randomized trial (the COPAC study).
        Endoscopy. 2018; 50: 961-971
        • So H.
        • Ahn J.Y.
        • Han S.
        • et al.
        Efficacy and safety of fully covered self-expanding metal stents for malignant esophageal obstruction.
        Dig Dis Sci. 2018; 63: 234-241
        • Varadarajulu S.
        • Banerjee S.
        • et al.
        • ASGE Technology Committee
        Enteral stents.
        Gastrointest Endosc. 2011; 74: 455-464
        • Raijman I.
        • Siddique I.
        • Lynch P.
        Does chemoradiation therapy increase the incidence of complications with self-expanding coated stents in the management of malignant esophageal strictures?.
        Am J Gastroenterol. 1997; 92: 2192-2196
        • Kinsman K.J.
        • DeGregorio B.T.
        • Katon R.M.
        • et al.
        Prior radiation and chemotherapy increase the risk of life-threatening complications after insertion of metallic stents for esophagogastric malignancy.
        Gastrointest Endosc. 1996; 43: 196-203
        • Lee S.
        • Osugi H.
        • Tokuhara T.
        • et al.
        Self-expandable metallic stent for unresectable malignant strictures in the esophagus and cardia.
        Jpn J Thorac Cardiovasc Surg. 2005; 53: 470-476
        • Knyrim K.
        • Wagner H.J.
        • Bethge N.
        • et al.
        A controlled trial of an expansile metal stent for palliation of esophageal obstruction due to inoperable cancer.
        N Engl J Med. 1993; 329: 1302-1307
        • Roseveare C.D.
        • Patel P.
        • Simmonds N.
        • et al.
        Metal stents improve dysphagia, nutrition and survival in malignant oesophageal stenosis: a randomized controlled trial comparing modified Gianturco Z-stents with plastic Atkinson tubes.
        Eur J Gastroenterol Hepatol. 1998; 10: 653-657
        • Eickhoff A.
        • Knoll M.
        • Jakobs R.
        • et al.
        Self-expanding metal stents versus plastic prostheses in the palliation of malignant dysphagia: long-term outcome of 153 consecutive patients.
        J Clin Gastroenterol. 2005; 39: 877-885
        • Siersema P.D.
        Stenting for benign esophageal strictures.
        Endoscopy. 2009; 41: 363-373
        • Vermeulen B.D.
        • Siersema P.D.
        Esophageal stenting in clinical practice: an overview.
        Curr Treat Options Gastroenterol. 2018; 16: 260-273
        • Ravich W.J.
        Endoscopic management of benign esophageal strictures.
        Curr Gastroenterol Rep. 2017; 19: 50
        • Kahalekar V.
        • Gupta D.T.
        • Bhatt P.
        • et al.
        Fully covered self-expanding metallic stent placement for benign refractory esophageal strictures.
        Indian J Gastroenterol. 2017; 36: 197-201
        • Anikhindi S.A.
        • Ranjan P.
        • Sachdeva M.
        • et al.
        Self-expanding plastic stent for esophageal leaks and fistulae.
        Indian J Gastroenterol. 2016; 35: 287-293
        • El Hajj II,
        • Imperiale T.F.
        • Rex D.K.
        • et al.
        Treatment of esophageal leaks, fistulae, and perforations with temporary stents: evaluation of efficacy, adverse events, and factors associated with successful outcomes.
        Gastrointest Endosc. 2014; 79: 589-598
        • van Boeckel P.G.A.
        • Siersema P.D.
        Refractory esophageal strictures: what to do when dilation fails.
        Curr Treat Options Gastroenterol. 2015; 13: 47-58
        • Spaander M.
        • Baron T.
        • Siersema P.
        • et al.
        Esophageal stenting for benign and malignant disease: European Society of Gastrointestinal Endoscopy (ESGE) clinical guideline.
        Endoscopy. 2016; 48: 939-948
      1. Healthcare Cost and Utilization Project (HCUP). HCUP databases. Agency for Healthcare Research and Quality, Rockville, MD2016
        • Kotwall C.A.
        • Maxwell J.G.
        • Brinker C.C.
        • et al.
        National estimates of mortality rates for radical pancreaticoduodenectomy in 25,000 patients.
        Ann Surg Oncol. 2002; 9: 847-854
        • Dimick J.B.
        • Welch H.G.
        • Birkmeyer J.D.
        Surgical mortality as an indicator of hospital quality: the problem with small sample size.
        JAMA. 2004; 292: 847-851
        • inamdar s.
        • slattery e.
        • bhalla r.
        • et al.
        comparison of adverse events for endoscopic vs percutaneous biliary drainage in the treatment of malignant biliary tract obstruction in an inpatient national cohort.
        JAMA Oncol. 2016; 2: 112-117
        • Elixhauser A.
        • Steiner C.
        • Harris D.R.
        • et al.
        Comorbidity measures for use with administrative data.
        Med Care. 1998; 36: 8-27
        • Segalin A.
        • Bonavina L.
        • Lazzerini M.
        • et al.
        Endoscopic management of inveterate esophageal perforations and leaks.
        Surg Endosc. 1996; 10: 928-932
        • Nelson D.B.
        • Silvis S.E.
        • Ansel H.J.
        Management of a tracheoesophageal fistula with a silicone-covered self-expanding metal stent.
        Gastrointest Endosc. 1994; 40: 497-499
        • Hramiec J.E.
        • O’Shea M.A.
        • Quinlan R.M.
        Expandable metallic esophageal stents in benign disease: a cause for concern.
        Surg Laparosc Endosc. 1998; 8: 40-43
        • Song H.Y.
        • Park S.I.
        • Do Y.S.
        • et al.
        Expandable metallic stent placement in patients with benign esophageal strictures: results of long-term follow-up.
        Radiology. 1997; 203: 131-136
        • Suzuki T.
        • Siddiqui A.
        • Taylor L.J.
        • et al.
        Clinical outcomes, efficacy, and adverse events in patients undergoing esophageal stent placement for benign indications: a large multicenter study.
        J Clin Gastroenterol. 2016; 50: 373-378
        • Xie S.-H.
        • Lagergren J.
        The male predominance in esophageal adenocarcinoma.
        Clin Gastroenterol Hepatol. 2016; 14: 338-347
        • Domper Arnal M.J.
        • Ferrández Arenas Á.
        • Lanas Arbeloa Á.
        Esophageal cancer: risk factors, screening and endoscopic treatment in Western and Eastern countries.
        World J Gastroenterol. 2015; 21: 7933-7943
        • van Rossum P.S.N.
        • Mohammad N.H.
        • Vleggaar F.P.
        • et al.
        Treatment for unresectable or metastatic oesophageal cancer: current evidence and trends.
        Nat Rev Gastroenterol Hepatol. 2018; 15: 235-249
        • Dai Y.
        • Li C.
        • Xie Y.
        • et al.
        Interventions for dysphagia in oesophageal cancer.
        Cochrane Database Syst Rev. 2014; CD005048
        • Penniment M.G.
        • De Ieso P.B.
        • Harvey J.A.
        • et al.
        Palliative chemoradiotherapy versus radiotherapy alone for dysphagia in advanced oesophageal cancer: a multicentre randomised controlled trial (TROG 03.01).
        Lancet Gastroenterol Hepatol. 2018; 3: 114-124
        • Vakil N.
        • Morris A.I.
        • Marcon N.
        • et al.
        A prospective, randomized, controlled trial of covered expandable metal stents in the palliation of malignant esophageal obstruction at the gastroesophageal junction.
        Am J Gastroenterol. 2001; 96: 1791-1796
        • Conio M.
        • Repici A.
        • Battaglia G.
        • et al.
        A randomized prospective comparison of self-expandable plastic stents and partially covered self-expandable metal stents in the palliation of malignant esophageal dysphagia.
        Am J Gastroenterol. 2007; 102: 2667-2677
        • Diamantis G.
        • Scarpa M.
        • Bocus P.
        • et al.
        Quality of life in patients with esophageal stenting for the palliation of malignant dysphagia.
        World J Gastroenterol. 2011; 17: 144-150
        • Baron T.H.
        Minimizing endoscopic complications: endoluminal stents.
        Gastrointest Endosc Clin North Am. 2007; 17: 83-104
        • Reijm A.N.
        • Didden P.
        • Schelling S.J.C.
        • et al.
        Self-expandable metal stent placement for malignant esophageal strictures—changes in clinical outcomes over time.
        Endoscopy. 2019; 51: 18-29
        • Hirdes M.M.C.
        • Siersema P.D.
        • Vleggaar F.P.
        A new fully covered metal stent for the treatment of benign and malignant dysphagia: a prospective follow-up study.
        Gastrointest Endosc. 2012; 75: 712-718
        • Fuccio L.
        • Hassan C.
        • Frazzoni L.
        • et al.
        Clinical outcomes following stent placement in refractory benign esophageal stricture: a systematic review and meta-analysis.
        Endoscopy. 2016; 48: 141-148
        • van Halsema E.E.
        • van Hooft J.E.
        Clinical outcomes of self-expandable stent placement for benign esophageal diseases: a pooled analysis of the literature.
        World J Gastrointest Endosc. 2015; 7: 135-153
        • Sharaiha R.Z.
        • Kim K.J.
        • Singh V.K.
        • et al.
        Endoscopic stenting for benign upper gastrointestinal strictures and leaks.
        Surg Endosc. 2014; 28: 178-184
        • Holm A.N.
        • de la Mora Levy J.G.
        • Gostout C.J.
        • et al.
        Self-expanding plastic stents in treatment of benign esophageal conditions.
        Gastrointest Endosc. 2008; 67: 20-25
        • Bick B.L.
        • Imperiale T.F.
        • Johnson C.S.
        • et al.
        Endoscopic suturing of esophageal fully covered self-expanding metal stents reduces rates of stent migration.
        Gastrointest Endosc. 2017; 86: 1015-1021
        • Sharaiha R.Z.
        • Kumta N.A.
        • DeFilippis E.M.
        • et al.
        A large multicenter experience with endoscopic suturing for management of gastrointestinal defects and stent anchorage in 122 patients: a retrospective review.
        J Clin Gastroenterol. 2016; 50: 388-392
        • Evans J.A.
        • Early D.S.
        • et al.
        • ASGE Standards of Practice Committee
        The role of endoscopy in the assessment and treatment of esophageal cancer.
        Gastrointest Endosc. 2013; 77: 328-334
        • van Halsema E.E.
        • Kappelle W.F.W.
        • Weusten B.L.A.M.
        • et al.
        Stent placement for benign esophageal leaks, perforations, and fistulae: a clinical prediction rule for successful leakage control.
        Endoscopy. 2018; 50: 98-108
        • Steyerberg E.W.
        • Homs M.Y.V.
        • Stokvis A.
        • et al.
        Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer: a prognostic model to guide treatment selection.
        Gastrointest Endosc. 2005; 62: 333-340
        • Lu Q.
        • Lei T.-T.
        • Wang Y.-L.
        • et al.
        Development and validation of a model to determine risk of refractory benign esophageal strictures.
        World J Clin Cases. 2019; 7: 1623-1633