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A novel method for esophageal stent placement: retroflexed endoscopic guidance from the stomach
CASE STUDY
A novel method for esophageal stent placement: retroflexed endoscopic guidance from the stomach Ashish R. Shah, MD, Imad Elkhatib, MD, Mary L. Krinsky, DO San Diego, California, USA
The incidence of esophageal adenocarcinoma has been increasing over the past 2 decades, with associated high mortality rates.1,2 Curative treatment options are limited, and therefore palliative treatments are a mainstay to improve quality of life and nutritional intake.3 Endoscopically placed self-expandable metal stents (SEMSs) are used increasingly as a nonsurgical alternative for the palliation of malignant esophageal strictures. There are a wide variety of SEMSs available, but almost all are placed under endoscopic guidance with or without the use of fluoroscopy.4-7 Precise stent placement to bridge the tumor is required to provide palliation of dysphagia and prevent adverse events (eg, airway obstruction, gastric ulceration, and early stent occlusion). Historically, fluoroscopic guidance has permitted the accurate positioning of stents by the use of several radiopaque methods to mark the tumor’s margins (eg, ethiodized oil injection, mucosal clip placement, and externally taped paperclips on the patient’s chest). Previous studies have shown that SEMSs can be placed under direct proximal antegrade endoscopic visualization without the use of fluoroscopy while accurate placement is achievable.8-11 In patients with distal esophageal cancer, we describe successful guidance of stent deployment from a retroflexed endoscope positioned in the stomach in the absence of fluoroscopy.
for retroflexed esophageal stent placement from November 2013 through March 2014. All patients were diagnosed with distal esophageal adenocarcinoma involving the gastroesophageal (GE) junction after they presented with gradual-onset dysphagia initially to solids and then liquids. One patient had metastatic disease to the bone, and the other 4 patients were either stage IIIA or IIIB at the time of initial endoscopy. In 3 of the 5 cases, the tumor could be seen clearly on retroflexion of the endoscope in the stomach. All patients had 1-month follow-up radiographs to confirm stent position after stent placement.
METHODS AND/OR ENDOSCOPIC TECHNIQUE With patients under moderate sedation, an ultrathin pediatric endoscope (GIF-XP 160, 5.9 mm diameter, Olympus Medical, Center Valley, Pa, USA) was used to intubate the esophagus. A distal esophageal mass was encountered in all 5 patients. The endoscope was advanced into the stomach and into the second portion of the duodenum. A stiff,
PATIENTS A total of 5 patients in a tertiary-care referral Veterans Affairs medical center were found to be good candidates Abbreviations: GE, gastroesophageal; SEMS, self-expandable metal stent. DISCLOSURE: All authors disclosed no financial relationships relevant to this article. Copyright ª 2014 by the American Society for Gastrointestinal Endoscopy 0016-5107/$36.00 http://dx.doi.org/10.1016/j.gie.2014.09.042 Received June 16, 2014. Accepted September 12, 2014. Current affiliations: Department of Gastroenterology, University of California at San Diego, San Diego, CA; VA Medical Center, San Diego, CA, USA. Reprint requests: Ashish R. Shah, MD, University of California at San Diego, Hospital of Veterans Affairs, La Jolla, CA 92093-0956.
www.giejournal.org
Figure 1. Retroflexed view of gastroesophageal junction mass.
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: 2014 GASTROINTESTINAL ENDOSCOPY 1
Esophageal stent placement
Shah et al
Figure 4. Retroflexed view of the stent deployment in perfect position. Figure 2. Retroflexed view of guidewire traversing the gastroesophageal junction mass.
Figure 5. Radiograph confirming correct position of the esophageal stent.
Figure 3. Retroflexed view of the esophageal stent with the distal tip in the stomach.
0.035-inch diameter guidewire (Dreamwire Stiff Shaft 0.035 inch 260 cm; Boston Scientific, Natick, Mass) was advanced through the endoscope channel into the second portion of the duodenum and the endoscope was then withdrawn. Next, the endoscope was reintroduced and advanced, alongside the guidewire, into the stomach and 2 GASTROINTESTINAL ENDOSCOPY Volume
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No.
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: 2014
was retroflexed in the stomach to expose the GE junction (Figs. 1-4). An esophageal stent (Wallflex fully or partially covered stent; Boston Scientific, Natick, Mass, USA) was advanced over the guidewire and deployed under direct retrograde endoscopic visualization from within the stomach (Figs. 1-4). Once deployed, the stent was noted to be in excellent position, with the distal aspect about 2 cm past the GE junction or tumor. The endoscope was withdrawn to the proximal aspect of the stent without inducing stent migration in all cases. This was confirmed with www.giejournal.org
Shah et al
Esophageal stent placement
TABLE 1. Demographic data including comorbidities in each patient (all male) along with initial stage of the cancer Age, y
Comorbidities
Cancer
Metastatic at time of diagnosis
1
Patient
61
GERD
Adenocarcinoma with focal signet-ring cell features
No, stage IIIB, potentially resectable
2
66
Hypertension, hyperlipidemia, CAD
Adenocarcinoma
Yes
3
70
Hypertension, CAD status post aortic valve replacement
Adenocarcinoma with signet-ring cell features
No, stage IIIB, potentially resectable
4
66
Alcoholic cirrhosis, CAD, CHF, hyperlipidemia, hypertension
Adenocarcinoma
No, stage IIIA, potentially resectable
5
65
Hypertension, chronic obstructive pulmonary disease
Adenocarcinoma
No, stage IIIB
CAD, Coronary artery disease; CHF, congestive heart failure.
TABLE 2. Cancer appearance and type of stent placed
Patient 1
2
*
Cancer description Fungating mass, fully circumferential, causing near-complete obstruction
Length of cancer 40-45 cm
Stent placed*
Follow-up imaging
Wallflex Radiograph and 18 123 mm, CT abdomen/pelvis fully covered
Large, malignant appearing, 35-42 cm Wallflex friable mass with contact 23 123 mm, bleeding. Partially obstructing partially covered and partially circumferential (involving 2/3 of the lumen circumference)
Adverse events
Outcomes
None, no migration on imaging 4 weeks after stent placement
Died from tumor bleeding within 1-month follow-up period
Yes, radiograph
None, yhad no follow-up Underwent imaging because initial chemoradiationd dysphagia radiograph was performed improved worsening reflux the day after stent placement
None, no migration on Underwent imaging 4 weeks later after chemoradiationd dysphagia placement improved worsening reflux
3
Mass necrotic, ulcerated and exophytic distally, hemicircumferential distally
35-40 cm
Wallflex 18 103 mm, fully covered
Yes, radiograph
4
Large, submucosal mass in the middle to distal third of the esophagus. Partially obstructing and fully circumferential
30-37 cm
Wallflex 18 103 mm, fully covered
Yes, radiograph
None, no migration on imaging 4 weeks after placement
Dysphagia improvedd declined chemotherapy/radiation therapy, chose hospice
5
Exophytic mass. Partially obstructing involving 1/2 of the lumen circumferentially
41-44 cm
Wallflex 23 105 mm, partially covered
Yes, radiograph
None, no migration on imaging 4 weeks after placement
Underwent chemoradiationd dysphagia improved
Wallflex, Boston Scientific, Natick, Mass.
advancement of the endoscope through the newly placed esophageal stent, and the stent position was visually confirmed. Stent placement took !10 minutes to complete in the first 3 cases; however, we did not track the procedure time in the last 2 patients. A radiograph obtained the same or following day confirmed the correct position of the esophageal stent (Fig. 5).
RESULTS The mean age of the patients was 65.6 years. Table 1 shows demographic data including comorbidities in each www.giejournal.org
patient along with initial stage of the cancer. Table 2 provides information on cancer appearance and type of stent placed. In 3 patients, a fully covered stent was selected because of the treatment goal of possible tumor resectability following chemoradiation therapy. In the other 2 patients, a partially covered stent was selected. In all 5 patients, follow-up radiographs 24 hours later confirmed the stent to be in proper position. During the follow-up period of 1 month, 3 of 5 patients had further imaging (CT scan or positron emission tomography-CT scan) (Fig. 6) performed as part of the cancer work-up. Volume
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No.
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: 2014 GASTROINTESTINAL ENDOSCOPY 3
Esophageal stent placement
Shah et al
Figure 6. CT scan confirming correct position of the esophageal stent.
This imaging confirmed the proper stent position without any issues of migration. There were no adverse events related to stent placement. All 5 patients had improvement in dysphagia; however, they did experience worsening of heartburn. Four of 5 patients remain alive, and 2 are undergoing therapy. One patient died because of tumor bleeding that was not thought to be stent related.
DISCUSSION Esophageal adenocarcinoma incidence has been increasing, and at the time of diagnosis most patients present with locally advanced or unresectable metastatic disease.1,12,13 The majority of patients are not surgical candidates at the time of presentation and require a palliative procedure to alleviate symptoms of dysphagia. The preferred method for near immediate palliation of dysphagia has been the endoscopic placement of an enteral stent or a feeding tube. The American Society for Gastrointestinal Endoscopy 2013 guidelines recommend esophageal stenting as the preferred method for endoscopic palliation of dysphagia.14 This case series is the first to illustrate that retroflexed endoscopic guidance from the stomach is successful for esophageal stent placement of distal esophageal strictures at the GE junction. This retroflexed view from the stomach 4 GASTROINTESTINAL ENDOSCOPY Volume
-,
No.
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: 2014
allows for an accurate confirmation of stent position at the GE junction. Furthermore, in our experience we provide additional evidence that a fully covered and partially covered (Wallflex) SEMS can be placed safely and efficiently under direct endoscopic visualization without the use of fluoroscopy. Placement of esophageal stents may become problematic in centers with limited fluoroscopic services. In some instances, during a preoperative staging EUS, it is noted that the patient will require a palliative esophageal stent. However, fluoroscopy may not be available at that time. The direct endoscopic visualization technique may save time for the patient and endoscopist and may avoid a repeat endoscopic procedure. Furthermore, stent placement in the distal esophagus and GE junction has challenges, which include the risk of leaving too much stent protruding into the stomach. This commonly leads to gastric wall ulceration and stent obstruction. In addition, migration may occur more frequently when a few centimeters of stent is placed proximal to the tumor mass. We speculate from our experience that leaving a greater length of stent proximal to the tumor may take advantage of the GE junction angulation, providing secure anchoring of the stent. In addition, we have performed this technique in 2 additional patients without esophageal adenocarcinoma. One patient had refractory achalasia, and a stent was placed across the GE junction for palliation of dysphagia. At 4 weeks, the stent migrated into the stomach, and at 2 months after retrieval the patient remained symptom free. We also used this technique to place a rectosigmoid stent in a patient with metastatic colon cancer. His previously placed stent had obstructed only at its proximal aspect. This technique enabled us to monitor the stent deployment to assure proper placement bridging the proximal tumor ingrowth. A large variety of self-expandable metal esophageal stents exist, most of them having a delivery system of 5 to 8 mm that is too large to pass through the endoscopic channel, requiring fluoroscopic guidance. Previous studies have shown the feasibility of placing esophageal stents under direct endoscopic visualization without the aid of fluoroscopy.9,11-13 However, a newer esophageal stent by TaeWoong Medical (Goyang-Si, Gyeonggi-do, South Korea) has been developed that can be placed through the endoscopic working channel and can eliminate the need for fluoroscopy. Wilkes et al11 published a case series of successful placement of an esophageal stent in 90 of 98 patients under endoscopic guidance without the use of fluoroscopy. Fifty-nine patients (60.2%) did not require any further endoscopic intervention (due to food boluses, re-stenting because of tumor ingrowth or migration, etc). In their published case series, esophageal stents were placed under endoscopic visualization, with the endoscope in the antegrade (forward) view. In 2011, Ferreira et al14 showed that there were no differences in the incidence of adverse www.giejournal.org
Shah et al
events or in survival between patients who underwent SEMS placement under fluoroscopic control versus endoscopic guidance. In our case series, we provide further evidence that SEMSs can be placed safely under direct endoscopic visualization without the use of fluoroscopy. We demonstrate successful and accurate placement of an esophageal stent via retroflexed endoscope guidance from the stomach. This approach to stent placement is technically efficient and easily can take!10 minutes to complete. This method may be considered when precise deployment at the furthest location from the lumen entry point is required to assure proper stent positioning.
REFERENCES 1. Faivre J, Forman D, Esteve J, et al. Survival of patients with oesophageal and gastric cancers in Europe. EUROCARE working group. Eur J Cancer 1998;34(14 spec no):2167-75. 2. Ferlay J, Shin HR, Bray F, et al. Estimates of worldwide burden of cancer in 2008: GLOBOCAN 2008. Int J Cancer 2010;127:2893-917. 3. Sreedharan A, Harris K, Crellin A, et al. Interventions for dysphagia in oesophageal cancer. Cochrane Database Syst Rev 2011;(2):CD005048. 4. Jacobson BC, Hirota W, Baron TH, et al. Standards of Practice Committee. American Society for Gastrointestinal Endoscopy. The role of endoscopy in the assessment and treatment of esophageal cancer. Gastrointest Endosc 2003;57:817-22.
www.giejournal.org
Esophageal stent placement 5. Sharma P, Kozarek R; Practice Parameters Committee of the American College of Gastroenterology. Role of esophageal stents in benign and malignant diseases. Am J Gastroenterol 2010;105:258, 73; quiz 274. 6. Siddiqui AA, Sarkar A, Beltz S, et al. Placement of fully covered selfexpandable metal stents in patients with locally advanced esophageal cancer before neoadjuvant therapy. Gastrointest Endosc 2012;76: 44-51. 7. Siersema PD, Hop WC, van Blankenstein M, et al. A comparison of 3 types of covered metal stents for the palliation of patients with dysphagia caused by esophagogastric carcinoma: a prospective, randomized study. Gastrointest Endosc 2001;54:145-53. 8. Austin AS, Khan Z, Cole AT, et al. Placement of esophageal selfexpanding metallic stents without fluoroscopy. Gastrointest Endosc 2001;54:357-9. 9. Rathore OI, Coss A, Patchett SE, et al. Direct-vision stenting: the way forward for malignant oesophageal obstruction. Endoscopy 2006;38: 382-4. 10. White RE, Mungatana C, Topazian M. Esophageal stent placement without fluoroscopy. Gastrointest Endosc 2001;53:348-51. 11. Wilkes EA, Jackson LM, Cole AT, et al. Insertion of expandable metallic stents in esophageal cancer without fluoroscopy is safe and effective: a 5-year experience. Gastrointest Endosc 2007;65:923-9. 12. Blot WJ, Devesa SS, Kneller RW, et al. Rising incidence of adenocarcinoma of the esophagus and gastric cardia. JAMA 1991;265:1287-9. 13. Bollschweiler E, Wolfgarten E, Gutschow C, et al. Demographic variations in the rising incidence of esophageal adenocarcinoma in white males. Cancer 2001;92:549-55. 14. Ferreira F, Bastos P, Ribeiro A, et al. A comparative study between fluoroscopic and endoscopic guidance in palliative esophageal stent placement. Dis Esophagus 2012;25:608-13.
Volume
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No.
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: 2014 GASTROINTESTINAL ENDOSCOPY 5
A novel method for esophageal stent placement: retroflexed endoscopic guidance from the stomach Ashish R. Shah, MD, Imad Elkhatib, MD, Mary L. Krinsky, DO San Diego, California, USA
The incidence of esophageal adenocarcinoma has been increasing over the past 2 decades, with associated high mortality rates.1,2 Curative treatment options are limited, and therefore palliative treatments are a mainstay to improve quality of life and nutritional intake.3 Endoscopically placed self-expandable metal stents (SEMSs) are used increasingly as a nonsurgical alternative for the palliation of malignant esophageal strictures. There are a wide variety of SEMSs available, but almost all are placed under endoscopic guidance with or without the use of fluoroscopy.4-7 Precise stent placement to bridge the tumor is required to provide palliation of dysphagia and prevent adverse events (eg, airway obstruction, gastric ulceration, and early stent occlusion). Historically, fluoroscopic guidance has permitted the accurate positioning of stents by the use of several radiopaque methods to mark the tumor’s margins (eg, ethiodized oil injection, mucosal clip placement, and externally taped paperclips on the patient’s chest). Previous studies have shown that SEMSs can be placed under direct proximal antegrade endoscopic visualization without the use of fluoroscopy while accurate placement is achievable.8-11 In patients with distal esophageal cancer, we describe successful guidance of stent deployment from a retroflexed endoscope positioned in the stomach in the absence of fluoroscopy.
for retroflexed esophageal stent placement from November 2013 through March 2014. All patients were diagnosed with distal esophageal adenocarcinoma involving the gastroesophageal (GE) junction after they presented with gradual-onset dysphagia initially to solids and then liquids. One patient had metastatic disease to the bone, and the other 4 patients were either stage IIIA or IIIB at the time of initial endoscopy. In 3 of the 5 cases, the tumor could be seen clearly on retroflexion of the endoscope in the stomach. All patients had 1-month follow-up radiographs to confirm stent position after stent placement.
METHODS AND/OR ENDOSCOPIC TECHNIQUE With patients under moderate sedation, an ultrathin pediatric endoscope (GIF-XP 160, 5.9 mm diameter, Olympus Medical, Center Valley, Pa, USA) was used to intubate the esophagus. A distal esophageal mass was encountered in all 5 patients. The endoscope was advanced into the stomach and into the second portion of the duodenum. A stiff,
PATIENTS A total of 5 patients in a tertiary-care referral Veterans Affairs medical center were found to be good candidates Abbreviations: GE, gastroesophageal; SEMS, self-expandable metal stent. DISCLOSURE: All authors disclosed no financial relationships relevant to this article. Copyright ª 2014 by the American Society for Gastrointestinal Endoscopy 0016-5107/$36.00 http://dx.doi.org/10.1016/j.gie.2014.09.042 Received June 16, 2014. Accepted September 12, 2014. Current affiliations: Department of Gastroenterology, University of California at San Diego, San Diego, CA; VA Medical Center, San Diego, CA, USA. Reprint requests: Ashish R. Shah, MD, University of California at San Diego, Hospital of Veterans Affairs, La Jolla, CA 92093-0956.
www.giejournal.org
Figure 1. Retroflexed view of gastroesophageal junction mass.
Volume
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No.
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: 2014 GASTROINTESTINAL ENDOSCOPY 1
Esophageal stent placement
Shah et al
Figure 4. Retroflexed view of the stent deployment in perfect position. Figure 2. Retroflexed view of guidewire traversing the gastroesophageal junction mass.
Figure 5. Radiograph confirming correct position of the esophageal stent.
Figure 3. Retroflexed view of the esophageal stent with the distal tip in the stomach.
0.035-inch diameter guidewire (Dreamwire Stiff Shaft 0.035 inch 260 cm; Boston Scientific, Natick, Mass) was advanced through the endoscope channel into the second portion of the duodenum and the endoscope was then withdrawn. Next, the endoscope was reintroduced and advanced, alongside the guidewire, into the stomach and 2 GASTROINTESTINAL ENDOSCOPY Volume
-,
No.
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: 2014
was retroflexed in the stomach to expose the GE junction (Figs. 1-4). An esophageal stent (Wallflex fully or partially covered stent; Boston Scientific, Natick, Mass, USA) was advanced over the guidewire and deployed under direct retrograde endoscopic visualization from within the stomach (Figs. 1-4). Once deployed, the stent was noted to be in excellent position, with the distal aspect about 2 cm past the GE junction or tumor. The endoscope was withdrawn to the proximal aspect of the stent without inducing stent migration in all cases. This was confirmed with www.giejournal.org
Shah et al
Esophageal stent placement
TABLE 1. Demographic data including comorbidities in each patient (all male) along with initial stage of the cancer Age, y
Comorbidities
Cancer
Metastatic at time of diagnosis
1
Patient
61
GERD
Adenocarcinoma with focal signet-ring cell features
No, stage IIIB, potentially resectable
2
66
Hypertension, hyperlipidemia, CAD
Adenocarcinoma
Yes
3
70
Hypertension, CAD status post aortic valve replacement
Adenocarcinoma with signet-ring cell features
No, stage IIIB, potentially resectable
4
66
Alcoholic cirrhosis, CAD, CHF, hyperlipidemia, hypertension
Adenocarcinoma
No, stage IIIA, potentially resectable
5
65
Hypertension, chronic obstructive pulmonary disease
Adenocarcinoma
No, stage IIIB
CAD, Coronary artery disease; CHF, congestive heart failure.
TABLE 2. Cancer appearance and type of stent placed
Patient 1
2
*
Cancer description Fungating mass, fully circumferential, causing near-complete obstruction
Length of cancer 40-45 cm
Stent placed*
Follow-up imaging
Wallflex Radiograph and 18 123 mm, CT abdomen/pelvis fully covered
Large, malignant appearing, 35-42 cm Wallflex friable mass with contact 23 123 mm, bleeding. Partially obstructing partially covered and partially circumferential (involving 2/3 of the lumen circumference)
Adverse events
Outcomes
None, no migration on imaging 4 weeks after stent placement
Died from tumor bleeding within 1-month follow-up period
Yes, radiograph
None, yhad no follow-up Underwent imaging because initial chemoradiationd dysphagia radiograph was performed improved worsening reflux the day after stent placement
None, no migration on Underwent imaging 4 weeks later after chemoradiationd dysphagia placement improved worsening reflux
3
Mass necrotic, ulcerated and exophytic distally, hemicircumferential distally
35-40 cm
Wallflex 18 103 mm, fully covered
Yes, radiograph
4
Large, submucosal mass in the middle to distal third of the esophagus. Partially obstructing and fully circumferential
30-37 cm
Wallflex 18 103 mm, fully covered
Yes, radiograph
None, no migration on imaging 4 weeks after placement
Dysphagia improvedd declined chemotherapy/radiation therapy, chose hospice
5
Exophytic mass. Partially obstructing involving 1/2 of the lumen circumferentially
41-44 cm
Wallflex 23 105 mm, partially covered
Yes, radiograph
None, no migration on imaging 4 weeks after placement
Underwent chemoradiationd dysphagia improved
Wallflex, Boston Scientific, Natick, Mass.
advancement of the endoscope through the newly placed esophageal stent, and the stent position was visually confirmed. Stent placement took !10 minutes to complete in the first 3 cases; however, we did not track the procedure time in the last 2 patients. A radiograph obtained the same or following day confirmed the correct position of the esophageal stent (Fig. 5).
RESULTS The mean age of the patients was 65.6 years. Table 1 shows demographic data including comorbidities in each www.giejournal.org
patient along with initial stage of the cancer. Table 2 provides information on cancer appearance and type of stent placed. In 3 patients, a fully covered stent was selected because of the treatment goal of possible tumor resectability following chemoradiation therapy. In the other 2 patients, a partially covered stent was selected. In all 5 patients, follow-up radiographs 24 hours later confirmed the stent to be in proper position. During the follow-up period of 1 month, 3 of 5 patients had further imaging (CT scan or positron emission tomography-CT scan) (Fig. 6) performed as part of the cancer work-up. Volume
-,
No.
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: 2014 GASTROINTESTINAL ENDOSCOPY 3
Esophageal stent placement
Shah et al
Figure 6. CT scan confirming correct position of the esophageal stent.
This imaging confirmed the proper stent position without any issues of migration. There were no adverse events related to stent placement. All 5 patients had improvement in dysphagia; however, they did experience worsening of heartburn. Four of 5 patients remain alive, and 2 are undergoing therapy. One patient died because of tumor bleeding that was not thought to be stent related.
DISCUSSION Esophageal adenocarcinoma incidence has been increasing, and at the time of diagnosis most patients present with locally advanced or unresectable metastatic disease.1,12,13 The majority of patients are not surgical candidates at the time of presentation and require a palliative procedure to alleviate symptoms of dysphagia. The preferred method for near immediate palliation of dysphagia has been the endoscopic placement of an enteral stent or a feeding tube. The American Society for Gastrointestinal Endoscopy 2013 guidelines recommend esophageal stenting as the preferred method for endoscopic palliation of dysphagia.14 This case series is the first to illustrate that retroflexed endoscopic guidance from the stomach is successful for esophageal stent placement of distal esophageal strictures at the GE junction. This retroflexed view from the stomach 4 GASTROINTESTINAL ENDOSCOPY Volume
-,
No.
-
: 2014
allows for an accurate confirmation of stent position at the GE junction. Furthermore, in our experience we provide additional evidence that a fully covered and partially covered (Wallflex) SEMS can be placed safely and efficiently under direct endoscopic visualization without the use of fluoroscopy. Placement of esophageal stents may become problematic in centers with limited fluoroscopic services. In some instances, during a preoperative staging EUS, it is noted that the patient will require a palliative esophageal stent. However, fluoroscopy may not be available at that time. The direct endoscopic visualization technique may save time for the patient and endoscopist and may avoid a repeat endoscopic procedure. Furthermore, stent placement in the distal esophagus and GE junction has challenges, which include the risk of leaving too much stent protruding into the stomach. This commonly leads to gastric wall ulceration and stent obstruction. In addition, migration may occur more frequently when a few centimeters of stent is placed proximal to the tumor mass. We speculate from our experience that leaving a greater length of stent proximal to the tumor may take advantage of the GE junction angulation, providing secure anchoring of the stent. In addition, we have performed this technique in 2 additional patients without esophageal adenocarcinoma. One patient had refractory achalasia, and a stent was placed across the GE junction for palliation of dysphagia. At 4 weeks, the stent migrated into the stomach, and at 2 months after retrieval the patient remained symptom free. We also used this technique to place a rectosigmoid stent in a patient with metastatic colon cancer. His previously placed stent had obstructed only at its proximal aspect. This technique enabled us to monitor the stent deployment to assure proper placement bridging the proximal tumor ingrowth. A large variety of self-expandable metal esophageal stents exist, most of them having a delivery system of 5 to 8 mm that is too large to pass through the endoscopic channel, requiring fluoroscopic guidance. Previous studies have shown the feasibility of placing esophageal stents under direct endoscopic visualization without the aid of fluoroscopy.9,11-13 However, a newer esophageal stent by TaeWoong Medical (Goyang-Si, Gyeonggi-do, South Korea) has been developed that can be placed through the endoscopic working channel and can eliminate the need for fluoroscopy. Wilkes et al11 published a case series of successful placement of an esophageal stent in 90 of 98 patients under endoscopic guidance without the use of fluoroscopy. Fifty-nine patients (60.2%) did not require any further endoscopic intervention (due to food boluses, re-stenting because of tumor ingrowth or migration, etc). In their published case series, esophageal stents were placed under endoscopic visualization, with the endoscope in the antegrade (forward) view. In 2011, Ferreira et al14 showed that there were no differences in the incidence of adverse www.giejournal.org
Shah et al
events or in survival between patients who underwent SEMS placement under fluoroscopic control versus endoscopic guidance. In our case series, we provide further evidence that SEMSs can be placed safely under direct endoscopic visualization without the use of fluoroscopy. We demonstrate successful and accurate placement of an esophageal stent via retroflexed endoscope guidance from the stomach. This approach to stent placement is technically efficient and easily can take!10 minutes to complete. This method may be considered when precise deployment at the furthest location from the lumen entry point is required to assure proper stent positioning.
REFERENCES 1. Faivre J, Forman D, Esteve J, et al. Survival of patients with oesophageal and gastric cancers in Europe. EUROCARE working group. Eur J Cancer 1998;34(14 spec no):2167-75. 2. Ferlay J, Shin HR, Bray F, et al. Estimates of worldwide burden of cancer in 2008: GLOBOCAN 2008. Int J Cancer 2010;127:2893-917. 3. Sreedharan A, Harris K, Crellin A, et al. Interventions for dysphagia in oesophageal cancer. Cochrane Database Syst Rev 2011;(2):CD005048. 4. Jacobson BC, Hirota W, Baron TH, et al. Standards of Practice Committee. American Society for Gastrointestinal Endoscopy. The role of endoscopy in the assessment and treatment of esophageal cancer. Gastrointest Endosc 2003;57:817-22.
www.giejournal.org
Esophageal stent placement 5. Sharma P, Kozarek R; Practice Parameters Committee of the American College of Gastroenterology. Role of esophageal stents in benign and malignant diseases. Am J Gastroenterol 2010;105:258, 73; quiz 274. 6. Siddiqui AA, Sarkar A, Beltz S, et al. Placement of fully covered selfexpandable metal stents in patients with locally advanced esophageal cancer before neoadjuvant therapy. Gastrointest Endosc 2012;76: 44-51. 7. Siersema PD, Hop WC, van Blankenstein M, et al. A comparison of 3 types of covered metal stents for the palliation of patients with dysphagia caused by esophagogastric carcinoma: a prospective, randomized study. Gastrointest Endosc 2001;54:145-53. 8. Austin AS, Khan Z, Cole AT, et al. Placement of esophageal selfexpanding metallic stents without fluoroscopy. Gastrointest Endosc 2001;54:357-9. 9. Rathore OI, Coss A, Patchett SE, et al. Direct-vision stenting: the way forward for malignant oesophageal obstruction. Endoscopy 2006;38: 382-4. 10. White RE, Mungatana C, Topazian M. Esophageal stent placement without fluoroscopy. Gastrointest Endosc 2001;53:348-51. 11. Wilkes EA, Jackson LM, Cole AT, et al. Insertion of expandable metallic stents in esophageal cancer without fluoroscopy is safe and effective: a 5-year experience. Gastrointest Endosc 2007;65:923-9. 12. Blot WJ, Devesa SS, Kneller RW, et al. Rising incidence of adenocarcinoma of the esophagus and gastric cardia. JAMA 1991;265:1287-9. 13. Bollschweiler E, Wolfgarten E, Gutschow C, et al. Demographic variations in the rising incidence of esophageal adenocarcinoma in white males. Cancer 2001;92:549-55. 14. Ferreira F, Bastos P, Ribeiro A, et al. A comparative study between fluoroscopic and endoscopic guidance in palliative esophageal stent placement. Dis Esophagus 2012;25:608-13.
Volume
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No.
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: 2014 GASTROINTESTINAL ENDOSCOPY 5