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

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Gregory S.
Anderson1 Marc S.
Levine1 Stephen
E. Rubesin1 Igor
Laufer1
Gregory G.
Ginsberg2 Michael
L. Kochman2

Esophageal Stents:
Findings on
Esophagography in 46
Patients
OBJECTIVE. The purpose of this report is to assess the findings on esophagography in
pa- tients with esophageal stents for palliation of malignant tumors involving the esophagus.
CONCLUSION. Radiologists should be familiar with findings of little importance
(stent narrowing, flow of contrast medium around stent, stent kinks, and apparent esophageal
narrow- ing below stent because of incompletely distended hiatal hernias) versus more
important find- ings (polypoid defects above or below stent, narrowing within or below
stent, delayed stent emptying, esophageal-airway fistulas, stent migration, and abutting of
distal stent against greater curvature of stomach) on esophagography after stent placement
to guide endoscopists regarding the need for stent revision.

elf-expanding metallic stents have

increasingly been used as the
treatment
of
choice
for
inoperable
University of Pennsylvania,
Philadelphia, PA.
AJR 2006;
187:1274
1279
0361
803X/06/18
751274
American Roentgen Ray Society

Keywords: dysphagia, esophageal cancer,

esophageal disease, esophageal stent,
esophagography, esophagram
DOI:10.2214/AJR.05.0465
Received March 16, 2005; accepted after
revision June 7, 2005.
1

Department of Radiology, Hospital of the

University of Pennsylvania, 3400 Spruce St.,
Philadelphia, PA 19104. Address correspondence
to M. S. Levine
(marc.levine@uphs.upenn.edu).
2

Department of Medicine, Hospital of the

AJR:187, November
2006

evaluate positioning of the stent and to exclude perforation. Two patients had their initial esophagrams
and eight patients had a total of 13 follow-up
esoph-

esophageal cancer because of low

complication rates and their effectiveness in palliating
dysphagia in patients with malig- nant strictures [14].
Patients with esoph- ageal stents may undergo
esophagography immediately after stent placement to
evaluate positioning of the stent and rule out perfora- tion,
or they may undergo esophagography weeks to months
after stent placement to eval- uate dysphagia and rule out
esophageal-air- way fistulas. The purpose of our
investigation was to assess the various findings on esophagography in a series of patients with esoph- ageal stents
placed for palliation of inopera- ble esophageal cancer or
other malignant tumors involving the esophagus.
Materials and Methods
A review of our computerized radiology database revealed 116
esophagrams after stent placement for inoperable esophageal cancer
or other malignant tu- mors involving the esophagus from 1996 to
2003. Fifty-seven studies were excluded because of lack of
availability of radiographic images or inadequate follow-up. The
remaining 59 studies were performed in 46 patients, including 38
who had one esoph- agram, five who had two esophagrams, two
who had three esophagrams, and one who had five esophagrams. These 46 patients comprised our study group. Forty-four
patients had esophagrams within 3 days of stent placement (mean
interval, 1 day) to

agrams 113 months after stent placement

(mean in- terval, 2 months). These 15
esophagrams were ob- tained because of
dysphagia (n = 13) or suspected esophagealairway 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
[Gastroview,
Mallinckrodt]). If spot images showed a
leak into the mediastinum, the study was
terminated. If spot images did not show a

leak, however, the pa- tient was

given a 250% weight/volume
barium suspension (E-Z-HD, EZ-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, selfexpanding 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).

AJR:187, November
2006

Anderson et
al.
A
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Fig. 180-year-old woman with stent placed for palliation of dysphagia caused by squamous
cell carcinoma of esophagus.
A, Left posterior oblique scout image shows tapered narrowing (arrows) of midportion of stent.
B, Left posterior oblique spot image from single-contrast esophagram shows tapered
narrowing of barium column (arrows) where lumen and stent are compressed by surrounding
esophageal tumor.

The radiographic images were interpreted by

con- sensus retrospectively by two gastrointestinal
radiol- ogists who were blinded to the clinical
and endo- scopic findings. They reviewed the
images to assess the flow of contrast material
through or around the stents, kinking or fracture of
the stents, filling defects or contour defects above
or below the stents, the cal- iber and contour of the
lumen within and below the stents, emptying of
contrast material from the stents, stent migration,
the presence or absence of perfora- tion or
esophageal-airway fistulas, and any other
findings. Medical records were also reviewed to determine the indications for stent placement and the
clinical findings and course. Seventeen patients
(37%) had follow-up endoscopy after esophagography; the endoscopic and pathology reports were reviewed and correlated with the radiographic
findings in these patients.
Our institutional review board approved all aspects of this retrospective study and did not require informed consent from any patients included
in our study.

Results
Clinical Aspects
Thirty patients (65%) were men, and 16
(35%) were women. The mean age was 67
years (range, 4598 years). Twenty-six
patients (57%) had esophageal carcinoma,
three (6%) had gastric carcinoma, four (9%)
had lung can- cer invading the esophagus,
one (2%) had met- astatic endometrial
sarcoma, and 12 (26%) had malignant
strictures of uncertain origin. The stents
were placed for palliation of dysphagia in 35
patients (76%) and palliation of esophagealairway fistulas in 11 (24%).
Twenty-nine (83%) of the 35 patients in
whom stents were placed for palliation of
dysphagia had substantial relief or resolution
of dysphagia. Eight (28%) of these 29 patients
developed recur- rent dysphagia within 13
months (mean duration, 5 months) after stent
placement. Seven (15%) of the 46 patients
had additional stents placed be- cause of
intractable dysphagia (n = 5) or contin- ued
esophageal-airway fistulas (n = 2).

Fig. 270-year-old man with stent placed

for palliation of dysphagia caused by
advanced malignant tumor of uncertain
origin involving upper thoracic esophagus.
Left posterior oblique spot image from singlecontrast esophagram shows barium (arrows)
fowing around left anterolateral wall of
proximal end of stent.

Radiographic
Findings of Little
Clinical
Importance
Narrowing of stent caliberSeventeen
(29%) of the 59 esophagrams revealed
tapered nar- rowing (less than 50% of the
diameter of the stent) in the midportion of
the stent (Fig. 1). All but two patients had
relief from dys- phagia, so this waist
characteristic was not thought to be
important.
Flow of contrast material around the sides
of the stentSixteen esophagrams (27%) revealed flow of contrast material around one
(n = 11) or both (n = 5) sides of the stent (Fig.
2). In 15 of these patients, this finding was
not thought to be important because their
dysphagia
resolved
without
further
intervention. In the other patient, contrast
material passed around the stent into a
tracheoesophageal fistula.
Stent kinksThree esophagrams (5%) revealed kinking or angulation of the stent
(Fig. 3). This finding was not thought to be
important because these patients all had

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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.
Note how stent traverses gastroesophageal
junction with distal end (white arrow) in
gastric fundus.

Fig. 460-year-old
man with stent
placed for palliation
of dysphagia caused
by squamous cell
carcinoma of
esophagus. A, Steep
right posterior
oblique spot image
from single-contrast
esophagram shows
apparent narrowing
of distal esophagus
(arrows) from distal
end of stent to
gastroesophageal
junction.
B, Frontal spot
image from same
examination as A
shows barium
trapped between
gastric folds of
incompletely filled
hiatal hernia
(arrows). Subsequent
endoscopy
confirmed presence
of hiatal hernia in
this patient.

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Fig. 555-year-old man with stent placed for

palliation of dysphagia caused by squamous
cell carcinoma of esophagus. Left posterior
oblique spot image from single-contrast
esophagram shows asymmetric mass effect
(arrows) on right posterolateral wall of distal
esophagus abutting stent. This finding was
caused by tumor overgrowth into distal end
of stent.

symptomatic improvement without further

intervention.
Incomplete distention of hiatal hernia
mimicking narrowed distal esophagusTwo
esophagrams (3%) revealed apparent narrowing of the distal esophagus just below the
stent because of a partially collapsed hiatal
hernia with barium trapped in the folds of the
hernia (Fig. 4). In both of these patients, endoscopy confirmed a hiatal hernia.
Radiographic
Findings of Greater
Clinical Importance
Defects above stentTwo (3%) of the 59
esophagrams revealed polypoid defects (1
cm and 0.7 cm) in the esophagus abutting
the proximal end of the stents. Both patients
had overgrowth of tumor into the proximal
end of the stent at endoscopy, so
additional stents were placed.

Fig. 653-year-old man with stent placed

for palliation of dysphagia caused by
malignant tumor of uncertain origin
encasing mid esophagus. Right posterior
oblique spot image from single-contrast
esophagram shows focal segment of marked
luminal narrowing (black arrows) in distal
end of stent. Note irregular contour and
abrupt, shelflike distal margins (white
arrows) of narrowed segment. At endoscopy,
this finding was caused by tumor ingrowth
through uncovered distal end of stent.

Defects below stentTwo esophagrams

(3%) revealed polypoid defects (2 and 3 cm)
in the esophagus abutting the distal end of
the stents. One patient had overgrowth of tumor into the distal end of the stent (Fig. 5),
and the other had exuberant reactive fibrosis
at endoscopy.
Narrowing of lumen within stentFourteen
esophagrams (24%) revealed esophageal
narrowing within the distal end of the stent
because of tumor (n = 3), debris or blood
clot (n = 3), epithelial hyperplasia (n = 3),
and unknown causes (n = 5). The narrowed
segment had an irregular contour and abrupt
distal margins in patients with tumor ingrowth (Fig. 6) and a smooth contour and
more gradual margins in the patients with
epithelial hyperplasia (Fig. 7).

Narrowing of lumen abutting distal end of

stentFourteen esophagrams (24%) revealed
esophageal narrowing abutting the distal end
of the stent because of tumor overgrowth (n =
3), tumor ingrowth (n = 2), debris or blood
clot (n = 3), epithelial hyperplasia (n = 2),
and un- known causes (n = 4). The
narrowed segment had an irregular contour
with abrupt margins in both patients with
tumor ingrowth and a smooth contour with
tapered margins in both patients with
epithelial hyperplasia.
Delayed emptying of stentThree esophagrams (5%) revealed delayed emptying of
contrast material from the stent because of
recurrent tumor in two patients and blood
clot in one.
Esophageal-airway fistulasFour esophagrams (7%) revealed contrast material
enter- ing fistulas (two tracheoesophageal
and two esophagobronchial fistulas). The
stents had all been placed for palliation of
known fistu- las. In two patients, the stents
failed to protect the fistulas because their
distal ends were im- properly positioned
above the fistulas. In the remaining two
patients, the stents were prop- erly
positioned, but barium passed around the
stent into the fistula in one and through the
uncovered distal end of the stent into a new
fistula in the other (Fig. 8). In two patients,
additional stents were placed.
Stent migrationOne esophagram (2%)
revealed that a stent placed across the gastroesophageal junction for palliation of a carcinoma of the cardia had migrated into the
stomach (Fig. 9A). A new stent was
therefore placed (Fig. 9B).
Distal end of stent abutting gastric wall
Five esophagrams (8%) revealed stents traversing malignant strictures at the cardia,
with the distal end of the stent abutting the
greater curvature of the proximal stomach
(Fig. 9B). This finding raised concern about
the possibil- ity of impending obstruction,
but none of these patients had problems with
stent function.
Stent Fractures
None of the 59 esophagrams revealed
stent fractures after stent placement.
Perforation
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

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Fig. 771-year-old
woman with stent
placed for palliation
of carcinoma of lung
invading upper
thoracic esophagus.
Right posterior
oblique spot image
from single- contrast
esophagram shows
narrowing of lumen
(arrows) in distal
end of stent. Note
relatively smooth
contour and tapered
margins of narrowed
segment.
Endoscopic biopsy
specimens from this
region revealed
epithelial
hyperplasia. (Note
pneumomediastinum
and subcutaneous
emphysema in soft
tissues of neck from
esophageal
perforation that
occurred during
endoscopic
dilatation procedure
before placement of
stent.)

malignant tumors involving the esophagus.

These stents are often evaluated by
esophagog- raphy, so it is important for
radiologists to be fa- miliar with the findings
after stent placement.
In our study, we made a number of observations about esophageal stents on esophagography that are of little clinical importance
because these patients rarely had dysphagia.
Tapered nar- rowing in the midportion of the
stent was often seen in patients in whom
dysphagia was palli- ated after stent
placement (Fig. 1). This phenom- enon is
probably secondary to impingement on the
expanding stent by surrounding tumor. Flow
of contrast material around one or both sides
of the stent was another frequent finding of
little importance (Fig. 2), presumably resulting
from incomplete apposition of the stent
against the esophageal wall. In one patient,
however, con- trast material flowed around
the stent into an esophagobronchial fistula,
necessitating place- ment of a new stent.
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-

tended hiatal hernia (Fig. 4B).

The most feared complication of stent place- ment is

esophageal perforation. Such perfora- tions are usually
caused by erosion of the stent through a friable tumor or an
esophageal wall already damaged by mediastinal irradiation
or laser therapy [2]. When perforation is sus- pected,
radiographic studies with water-soluble contrast agents may
show extravasation of con- trast material into the
mediastinum or pleural space. Esophageal perforation rates
have ranged from 0% to 14% after stent placement [1, 5, 6].
However, we did not encounter any pa- tients with this
complication, indicating that stent placement is a safe
procedure associated with a low perforation rate when the
stents are deployed by endoscopists experienced in performing this procedure.
An esophageal stent may fail to palliate dys- phagia if the
stent is not properly positioned or if it migrates distally
because of inadequate anchor- ing to the esophageal wall
(Fig. 9A). Recurrent dysphagia may also be caused by tumor
over- growth or ingrowth, epithelial hyperplasia, or ad- herent
debris or blood clot. Therapeutic options for palliating the
patients dysphagia include bal- loon dilatation, laser therapy,
stent revision, and endoscopic removal of any debris or blood
clots.

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.

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

is defined as extension of a tumor directly
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

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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
distal half in proximal stomach. Note how distal end of stent (large white arrow) directly abuts greater curvature of proximal stomach.
Despite this finding, patients dysphagia was adequately palliated by stent. Polypoid carcinoma (small white arrows) is seen at gastroesophageal
junction.

previous studies, the frequency of epithelial

hyperplasia has ranged from 2% to 28% after
esophageal stent placement [810]. Epithelial
hyperplasia was characterized by esophageal
narrowing with a smooth contour and more
ta- pered margins than tumor ingrowth (Fig.
7).
Covered metallic stents are also placed for
palliation of esophageal-airway fistulas. Stent
failure can result from an improperly
positioned stent or from stent migration
below the fistula. In our study, however, one
patient with a prop- erly positioned stent
developed a new esophago- bronchial fistula
because of tumor ingrowth through the
uncovered distal end of the stent (Fig. 8).
Another had a properly positioned stent that
failed to palliate a fistula because of flow of
contrast
material
around the
stent.
Radiologists, therefore, should be aware that
a covered stent may not palliate all
esophageal-airway fistulas despite proper
positioning of the stent.
Our investigation has the inherent
limitations of a retrospective study, such as
selection bias. The frequency of various
complications related to stent placement may
therefore be skewed by our study population,
which did not represent a random sample but
rather a selected group of patients, most of
whom had esophagrams within 3 days of
stent placement. A subset of patients had
follow-up esophagrams 1 month or

longer after stent placement because of dysphagia, and these individuals were more likely to
have abnormalities. Because of the retrospective nature of our investigation, these followup esophagrams were not obtained at
uniform time intervals after stent placement.
The presence of different types of stents in
our study patients represented another
confounding variable. Fi- nally, it was not
possible to have a pathologic diagnosis in
approximately 25% of patients with luminal
narrowing or masses because bi- opsy or
surgical specimens were not obtained in
these individuals.

5. Song

HY, Do YS, Han YM, et al. Covered,

expand- able esophageal metallic stent tubes:

experiences in 119 patients. Radiology 1994;
193:689695

6. Knyrim K, Wagner HJ, Bethge N, Keymling M,

Vakil N. A controlled trial of an expansile metal
stent for palliation of esophageal obstruction due
to inoperable cancer. N Engl J Med 1993;
329:13021307

7. Mayoral W, Fleischer D, Salcedo J, Roy P, AlKawas F, Benjamin S. Nonmalignant obstruction

is a common problem with metal stents in the
treatment of esophageal cancer. Gastrointest Endosc 2000; 51:556559

8. Vakil N, Gross U, Bethge N. Human tissue re-

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