According to GLOBOCAN 2022 data, esophageal cancer is a major issue in world health, ranking as the seventh most deadly type of cancer and the eleventh most common cancer worldwide. Epidemiological data reveals a male-to-female ratio of approximately 2.5:1 in incidence and mortality [¹]. In the United States, there are around 22,000 annual diagnoses that lead to approximately 16,000 deaths [²]. This highlights how serious an issue esophageal cancer is, how it affects public health, and how quickly we need interventions that work.

This malignancy has two histological subtypes, squamous cell carcinoma (SCC) and adenocarcinoma, with significant geographical variations in incidence patterns. SCC predominates in Eastern, Southeast Asia, and Sub-Saharan Africa, whereas adenocarcinoma is more common in North America and Northern and Western Europe [³].

SCC is highly associated with smoking, drinking hot beverages, nitrosamine exposure, and poor diets with limited fruit and vegetable intake. Adenocarcinoma is linked to obesity, smoking, and Barrett’s esophagus [⁴].

A range of symptoms characterizes the progression of esophageal cancer, which covers from subtle difficulty in swallowing and weight loss in the initial phases to severe complications such as tracheoesophageal fistula and anemia in the later stages of the disease.

Diagnostic assessment of the condition involves a comprehensive methodology that includes upper endoscopy with biopsy, endoscopic ultrasound, CT scans, PET imaging, bronchoscopy, and laparoscopy [⁵,⁶]. Unfortunately, at the time of diagnosis, a high percentage of patients have advanced-stage, inoperable disease, leaving only palliative treatment as an option to manage symptoms, primarily dysphagia.

Available treatment options are still restricted, with esophagectomy being the primary method of treatment. Nevertheless, the intrusive characteristics of this treatment and the resulting morbidity and mortality rates highlight the urgent need for alternate therapeutic approaches.

Chemoradiotherapy, intraluminal tumor ablation, electrocoagulation, or chemical necrolysis are some traditional interventions previously employed to address esophageal narrowing, but evidence regarding these interventions remains conflicting. For example, a recent Cochrane review did not find benefits in chemotherapy over supportive care in patients with metastatic carcinoma of the esophagus. Hence, current guidelines cannot recommend using esophageal stents in conjunction with chemo-radiation therapy [⁷,⁸,⁹,¹⁰].

Furthermore, a recent re-analysis of the SIREC (stent versus intraluminal radiotherapy for inoperable esophageal carcinoma) study, a multicenter randomized control trial that used SEMS vs. brachytherapy1, had the aim to create a scoring system to identify patient’s prognosis to assess the benefit of stenting and its equivalence to brachytherapy. In this developed score, prognostic factors for decreased survival were tumor length >10 cm, World Health Organization performance score, presence of metastasis, male gender, and age >70 years old. This analysis identified that in patients with poor prognosis, esophageal stenting has an equivalent benefit as brachytherapy, which is a preferable but not widely available therapy for inoperable cancer of the esophagus or GE junction [¹¹].

That being said, the advent of minimally invasive endoscopic procedures has introduced esophageal stents as a viable alternative. These stents aim to maintain lumen patency, improving symptoms, nutritional status, and overall quality of life. Esophageal stenting has the advantage over other treatments because of its minimally invasive nature, rapid relief of dysphagia, and reversible nature, as stents can be removed after the resolution of some benign disease [¹²,¹³]. Nevertheless, the implantation of stents is not without its difficulties, as demonstrated by possible complications, including retrosternal discomfort, perforation, stent migration, recurrent obstruction by tumor ingrowth, bleeding, perforation, food impaction, and fistula formation [¹³,¹⁴].

However, through careful patient selection and diligent post-procedural care, esophageal stenting can be considered a valuable palliative aid for patients with esophageal cancer. It can provide concrete relief amidst the intricate challenges associated with this condition [¹⁵,¹⁶].

A range of stent designs, each possessing distinct characteristics, are accessible for clinical application. These characteristics encompass mechanical properties, such as material composition (metal, plastic, or biodegradable), radial and axial forces exerted on the esophageal lumen, and the nature and design of the stent mesh cover. The advantages and drawbacks of various stent types are detailed in .

Between January 2022 and December 2022, 183 patients with advanced esophageal cancer underwent palliative esophageal stent placement across three tertiary healthcare centers. The cohort was stratified into three groups based on the type of stent received: self-expanding metallic stents (SEMS; n = 84), self-expanding plastic stents (SEPS; n = 61), and fully covered self-expanding metallic stents (FCSEMS; n = 38). Baseline demographics, tumor location, and disease stage were comparable across the three groups.

Esophageal cancer remains a malignancy with a poor prognosis, typically diagnosed at an advanced stage. Dysphagia, odynophagia, and weight loss are the most common presenting symptoms. Endoscopic stent placement has emerged as a widely accepted palliative modality to alleviate dysphagia and improve the quality of life in patients with limited survival.

The application of an esophageal endoprosthesis, employing an ivory tube, was initially documented in 1845 for managing malignant dysphagia. Since this milestone, the endoscopic introduction of stents into the esophagus has undergone significant advancements. Frimberger reported the successful use of metal stents for treating esophageal stenosis in 1983, introducing a novel approach to managing esophageal stenosis. These early stents often faced challenges with migration, discomfort, and tissue irritation, leading to limited success.

Esophageal stent placement is employed across a broad spectrum of esophageal pathologies. Some stent types include Self-expanding metal stents (SEMS), SEMS with an anti-reflux valve, Drug-eluting, and radioactive SEMS, Self-expanding plastic stents (SEPS), and biodegradable stents that dissolve over time and do not need to be removed [⁷].

In patients with poor prognosis or limited life expectancy, esophageal stents are preferable due to their rapid symptom relief—often within 48 hours. Importantly, while stents do not improve overall survival, they significantly improve nutritional status and quality of life. Innovations such as drug-eluting and anti-reflux stents aim to prolong stent patency and offer therapeutic benefits beyond palliation.

Currently, drug-eluting stents for non-surgical candidates can be an adjunctive therapy, not just a palliative measure but with the therapeutic goal of improving dysphagia by inhibiting tumor growth, ultimately prolonging patients’ lives [¹⁹,²³]. So far, there have been trials with docetaxel [²⁴], paclitaxel – animal mode [¹¹], and 5-fluoracil [²⁵,²⁶,²⁷] with different factors influencing how the drug is released from the stent, such as the environmental ph [¹⁹]. Other adjunctive therapies, like the use of corticosteroid injections in combination with fully covered SEMS (FCSEMS), have shown no clear benefit [²¹,²⁰].

Multiple studies have scrutinized various stent types’ attributes, outcomes, and complexities. These investigations have delineated several factors that influence the selection of stent types for specific patient cohorts. For instance, it has been documented that self-expandable plastic stents (SEPS) exhibit a heightened propensity for migration but induce less tissue trauma compared to self-expandable metal stents (SEMS), rendering them preferable for benign strictures [⁷,¹⁹]. Conversely, fully covered SEMS have shown a higher migration rate than partially covered SEMS, with transversality of malignant esophageal strictures emerging as a primary risk factor for this complication [²²]. Additionally, the use of uncovered stents is favored for extrinsic compressions or in cases of significantly dilated esophagus or gastric pull-up procedures to mitigate food entrapment, thereby diminishing the risk of migration and reducing the likelihood of mucosal hyperplasia and tumor ingrowth [¹⁷]

Further exploration into complications reveals that dilation preceding stent placement heightens the risk of adverse events associated with esophageal stenting [²¹,²⁸,²⁹]. Complications such as perforation, pneumonia, fistula formation, and chest pain have been observed in patients who underwent dilation of malignant strictures prior to stent insertion [²⁸,²⁹,³⁰,³¹]. Moreover, prior dilation, chemotherapy, and radiation therapy have been linked to elevated rates of complications such as perforation, bleeding, and tracheoesophageal fistulas1.

There is also conflicting evidence regarding pre-dilation as an option to avoid the use of fluoroscopy to help facilitate the introduction and delivery of the system, providing a more accurate placement [¹⁷]. A retrospective study of 3823 patients in a limited resource setting concluded that dilation is effective in facilitating stent placement without fluoroscopy as long as it doesn’t exceed 36F, significantly increasing the perforation risk [³²]. A next day esophagogram is recommended to confirm adequate expansion and satisfactory position18 since revision endoscopy can increase the risk of stent migration [³⁰].

Current ESGE guidelines recommend placement of partially or fully covered Self-expandable metal stents (SEMSs) for palliation of malignant dysphagia over other modalities since SEMS is associated with fewer complications. Partially covered SEMS have less migration risk since the uncovered portion allows for embedding and anchoring. However, this can be associated with tumor ingrowth and mucosal hyperplasia, causing restenosis and worsening dysphagia compared to uncovered SEMS. Several RCTs have been performed comparing different brands of partially covered stents. Still, no significant differences have been found in efficacy and complication rates, so currently, there is no recommended brand over others [⁷,³³,³⁴,²⁹].

In addition, despite the higher cost of SEMS, it has proven to be a cost-effective therapy since it is associated with lower hospitalization rates as well as a lower risk of fatal complications [⁷,²⁷]. The goal of the palliative treatment is to relieve dysphagia and improve caloric intake20

Our study fully covered self-expanding metallic stents (FCSEMS), which exhibited notable advantages, demonstrating prolonged stent patency compared to other types. However, due to a higher incidence of stent migration, careful consideration is warranted for patients in the self-expanding plastic stents (SEPS) group. The high technical success rates and immediate dysphagia relief affirm this procedure’s proficiency and immediate positive impact.

Further research should aim to develop standardized protocols for stent placement and address long-term safety and efficacy concerns, given the essential role of esophageal stents in palliative care for cancer patients. The ongoing evolution in stent technology, improved materials, and a better understanding of patient selection criteria continue to enhance the efficacy and safety of stent placement, contributing to improved patient outcomes and quality of life.

Although esophageal cancer remains a leading cause of cancer-related mortality worldwide, palliative stenting plays a pivotal role in enhancing quality of life. This prospective study highlights the clinical advantage of fully covered SEMS, which demonstrated superior stent patency and lower migration rates. Future innovations should aim to address cost and long-term complication profiles to broaden access and impact for high-risk patients.

The study has potential limitations. The effects of this study were based on a study conducted over one year during the COVID-19 pandemic and follow-up six months after stent placement. Given the study’s nature of duration and period, the sample size and population were constrained, which may not be representative of the entire population. In addition, the lack of blinding can introduce potential biases in the study.

Another limitation is the short period of longitudinal follow-up, which may have led to an underestimation of the benefits of intervention and failure to detect hazards and long-term outcomes. Additionally, the study may not have completely accounted for potential confounding variables, such as patient, disease, and procedure-based variables, that may have affected the outcome. Finally, the study has a limited scope as only 3 types of stents were investigated.

This prospective study reinforces the role of esophageal stent placement as a valuable palliative option for patients with advanced esophageal cancer, offering high technical success and immediate dysphagia relief. Among the three stent types studied, fully covered self-expanding metallic stents (FCSEMS) demonstrated superior median stent patency and the lowest migration rates, suggesting their advantage in selected cases. Although all stents improved patient comfort and quality of life, careful stent selection is essential to minimize complications. These findings support a tailored approach to stent selection and underscore the importance of further research to optimize patient outcomes.