- Email: [email protected]
Esophageal stent placement without fluoroscopy
R White, C Mungatana, M Topazian
Esophageal stent placement without fluoroscopy Russell E. White, MD, Caesar Mungatana, MBChB, Mark Topazian, MD Background: Access to fluoroscopic equipment is limited in some regions where esophageal cancer is common. This report describes a simple method for placement of expandable esophageal stents without fluoroscopy. Methods: Patients with dysphagia due to unresectable esophageal cancer underwent esophageal stent placement under endoscopic control alone. A colored mark on the stent delivery catheter was used to properly position the undeployed stent with respect to the proximal end of the tumor. Results: Stent placement was attempted in 70 patients and was successful in every case. There were no immeReceived May 8, 2000. For revision July 20, 2000. Accepted November 9, 2000. From Tenwek Hospital, Bomet, Kenya, and Yale University School of Medicine, New Haven, Connecticut. Reprint requests: Russell E. White, MD, MPH, Chief of Surgery, Tenwek Hospital, PO Box 39, Bomet, Kenya. Copyright © 2001 by the American Society for Gastrointestinal Endoscopy 0016-5107/2001/$35.00 + 0 37/69/112844 doi:10.1067/mge.2001.112844 348
GASTROINTESTINAL ENDOSCOPY
Esophageal stent placement without fluoroscopy
diate complications of stent placement. Mean dysphagia score decreased from 3.3 before stent placement to 0.5 at follow-up. There was a trend toward lower dysphagia scores in patients who received coated stents. Conclusion: Expandable esophageal stents can be accurately and safely placed under direct endoscopic control, without fluoroscopy.
Esophageal cancer is common in certain parts of the world. Palliative treatment options are often limited for patients with advanced disease, many of whom are unable to swallow liquids and have dramatic weight loss. Limited availability of fluoroscopy equipment may prevent widespread use of esophageal stents in some areas where esophageal cancer is endemic. This report describes a simple and reliable method for esophageal stent placement without fluoroscopy. PATIENTS AND METHODS Patients with dysphagia due to unresectable esophageal cancer were offered stent placement. All patients were cared for at Tenwek Hospital in Bomet, Kenya. Tumors were deemed unresectable in the presence of advanced age, severe wasting, comorbid medical conditions, tracheoesophageal fistula, vocal cord or diaphragmatic paralysis, or VOLUME 53, NO. 3, 2001
Esophageal stent placement without fluoroscopy
A
B
R White, C Mungatana, M Topazian
C
Figure 1. Endoscopic views of placement of an expandable stainless steel stent. A, Guidewire left in place across an esophageal cancer. B, Colored mark (arrow) on the stent delivery catheter (corresponding to the base of the stent’s proximal flange) positioned at proximal end of tumor. C, View of deployed stent. metastases detected by physical examination, chest radiograph, or abdominal US. All patients underwent dilation of their esophageal tumor by passage of polyvinyl dilators over a guidewire at the time of initial endoscopic diagnosis. Early in our experience expandable stents were placed during a second endoscopic procedure, but subsequently stents were often placed during the initial endoscopy. Stents were either made of woven stainless steel wire and a silicone membrane (Wallstent II, Boston Scientific Corporation/Microvasive Endoscopy, Natick, Mass.) or knit from nitinol (Ultraflex, Boston Scientific Corporation/Microvasive Endoscopy). Stainless steel stents were 10 cm in length and nitinol stents were 5, 7, 10, 12, or 15 cm in length. Nitinol stents had either a distal or proximal release mechanism. Dilations and stent placements were performed without fluoroscopy, which was unavailable. Informed consent was obtained from patients and their available family members before endoscopy, dilation, and stent placement. Stents were prepared for placement by marking the stent delivery catheter with a circumferential colored mark at the base of the constrained stent’s proximal flange (Figs. 1 and 2). In the case of the stainless steel stents, which shorten by 30% to 35% during deployment and have a tapering 2 cm proximal flange, the mark was placed approximately 3 cm from the proximal end of the constrained stent. In the case of the nitinol stents, which shorten by 43% during deployment and have a 1.5 cm proximal flange, the mark was placed approximately 2.5 cm distal to the black ring on the delivery catheter that marks the expected final location of the proximal end of the deployed stent. An indelible colored marker or reflective nail polish was used to mark the stent delivery catheters. Before stent placement an endoscope was passed through the tumor to the stomach and a stiff 0.035-inch guidewire with a soft tip was placed in the antrum. When the endoscope would not pass through the tumor, a guidewire was gently passed into the stomach and dilation with polyvinyl dilators to at least 36F was performed. The tumor’s position and length were noted during endoscope withdrawal, and a stent of appropriate length was chosen for placement. The VOLUME 53, NO. 3, 2001
constrained stent was passed over the guidewire and through the tumor, and the endoscope was then reintroduced into the proximal esophagus alongside the stent delivery catheter. The catheter was repositioned under direct endoscopic guidance so that the colored mark was visible at the proximal edge of the tumor (Figs. 1 and 2). Stent deployment was monitored endoscopically with the endoscope tip positioned proximal to the constrained stent. For proximal tumors, care was taken to ensure that the undeployed stent was distal to the upper esophageal sphincter. After stent deployment the endoscope was gently passed into or through the stent to assess stent patency and position. When stainless steel stents were used, the colored mark on the delivery catheter moved once stent deployment had begun, but the stent was maintained in stable position by direct endoscopic observation of the proximal end of the stent through the clear outer membrane of the stent delivery system. When nitinol stents were placed the colored mark remained in stable position until the proximal end of the stent was almost completely deployed. Most stents were placed on an outpatient basis. Patients were asked to return if symptoms persisted or recurred, and for a follow-up clinic visit in one month. Dysphagia scores were recorded before stent placement and at follow-up clinic visits with the following scale: 0 = normal, no dysphagia; 1 = can swallow most foods; 2 = can swallow a soft diet; 3 = can swallow fluids only; 4 = unable to swallow saliva. Between August 1999 and August 2000 stent placement was attempted in 70 patients, 43 of whom were men. Mean age was 63 years (range 39 to 85) and 5 patients had a tracheo-esophageal fistula. In 10 cases the proximal end of the tumor was less than 25 cm from the incisors. Stainless steel stents were placed in 30 patients, and nitinol stents were placed in 40 patients.
RESULTS Stents were successfully deployed in all cases. The proximal end of the deployed stent was in the intended location in every patient. An endoscope GASTROINTESTINAL ENDOSCOPY
349
R White, C Mungatana, M Topazian
Esophageal stent placement without fluoroscopy
B
A
C
Figure 2. Endoscopic views of placement of an expandable nitinol stent. A, Guidewire left in place across an esophageal cancer. B, Colored mark (arrow) on the black threads of stent delivery catheter (corresponding to the base of the stent’s proximal flange) positioned at proximal end of tumor. C, View of deployed stent.
could be immediately passed through the stent to the stomach in 54 patients, and in another 4 patients endoscopic views from the mid-shaft of the stent showed that the stent bridged the entire tumor. In 6 patients the endoscope was not passed far enough into the stent to visualize its distal end, due to fear of causing stent migration. In the remaining 6 patients the endoscope was not passed through the stent because only a 12.8-mm diameter therapeutic gastroscope was available. All patients were able to swallow liquids without difficulty immediately after stent placement. Mean dysphagia score before stent placement was 3.3 for the entire cohort and 3.4 for the 32 patients for whom 1 month follow-up data were available. Some patients had traveled long distances for treatment and did not return for follow-up visits. For the 32 patients seen in follow-up, mean dysphagia score after stent placement was 0.5. There was a trend toward lower dysphagia scores in patients who received coated stents (0.12) versus those who received uncoated stents (0.77) (p > 0.05). Five of the 32 patients had a dysphagia score of 2 or higher during the follow-up period, and all had received uncoated stents. Four of these 5 patients had dysphagia scores of 0 or 1 after stent insertion but developed worsening dysphagia 15 to 21 weeks later. Three underwent endoscopy, which demonstrated tumor ingrowth through the interstices of the stent in 2 cases (treated with alcohol injection) and tumor growth over the proximal end of the stent in 1 case (treated with placement of a second stent). The fifth patient had persistent dysphagia immediately after stent placement. She had a malignancy of the cervical esophagus with vocal cord paralysis, and her dysphagia was felt to be neuromuscular in origin after a follow-up endoscopy showed a widely patent stent. 350
GASTROINTESTINAL ENDOSCOPY
Most patients noted mild chest pain after dilation and stent insertion that resolved within 24 hours. In 29 cases stents were deployed across the gastroesophageal junction, and all of these patients received prophylactic oral antacid treatment after stent placement. One of these patients complained of persistent reflux symptoms that were controlled by treatment with an H2 receptor antagonist. The cohort included 2 patients who had esophageal perforation during dilation procedures performed at the time of initial diagnosis. In both cases the perforation was seen endoscopically, and subcutaneous emphysema was palpable in the neck. The first patient underwent a water soluble radiographic contrast study that showed an 8-cm collection in the mediastinum without communication to the pleura. She was treated with intravenous antibiotics, jejunostomy and gastrostomy tubes were placed surgically, and a naso-mediastinal tube was passed through the perforation under endoscopic guidance and placed to low intermittent suction. Follow-up radiographic contrast studies showed substantial resolution of the collection, the nasomediastinal tube was removed, and an uncoated stent was placed across the tumor on the tenth hospital day. One month after discharge the patient was eating a regular diet with no dysphagia, chest pain, or fever. The second patient underwent immediate placement of a coated stent when the perforation was discovered endoscopically, minutes after dilation. He was also treated with intravenous antibiotics and did well without dysphagia, pain, or fever. DISCUSSION Squamous cell esophageal cancer is endemic in certain parts of the world and is the most common malignancy seen at Tenwek hospital in southwestern Kenya. Dysphagia is the commonest presenting VOLUME 53, NO. 3, 2001
Esophageal stent placement without fluoroscopy
symptom, often accompanied by severe weight loss and cachexia. The majority of patients are not candidates for surgical resection, do not have access to radiation or chemotherapy, and will not readily accept gastrostomy tube placement. In this setting, endoscopic treatment may be the only means of providing palliative care. The best form of endoscopic palliation for such patients is placement of an expandable esophageal stent.1-5 Esophageal stents are usually placed under fluoroscopic guidance. Radiographic determination of proper stent position requires a fluoroscopy unit with an image intensifier, which is unavailable in some hospital endoscopy units. In addition, fluoroscopic techniques for stent placement rely on radioopaque markers to identify the position of the tumor. External radio-opaque markers can slip out of place, and adjacent anatomic landmarks can rotate with patient movement. Endoscopically placed markers such as submucosal radiographic contrast injections or clips6 overcome these limitations, but stents may still be malpositioned when deployed under fluoroscopic control, due to inaccurate positioning of the undeployed stent or failure to compensate for stent shortening during deployment.7 Proper positioning of the stent with regard to the upper esophageal sphincter can be especially difficult to judge fluoroscopically. As a result, some endoscopists combine fluoroscopic and endoscopic monitoring of stent deployment to improve the accuracy of stent placement.8 Stents were placed under direct endoscopic control alone by using an indelible mark on the stent delivery catheter to position the stent’s proximal flange at the proximal end of the tumor. This method was found to be an easy and accurate means of determining the proper location for stent deployment. Stent position after deployment appeared satisfactory in every case. Stent placement generally proceeded more rapidly than if submucosal contrast injections and fluoroscopic guidance had been used. No difficulty was encountered in passing an endoscope through the upper esophageal sphincter next to a stent delivery catheter to monitor stent deployment. Our technique allows accurate placement of
VOLUME 53, NO. 3, 2001
R White, C Mungatana, M Topazian
the stent with regard to the upper esophageal sphincter, an important issue when tumors are proximal in location.9 Esophageal stents relieve dysphagia dramatically in patients with advanced esophageal cancer. Expandable stents can be safely and accurately deployed under direct endoscopic control, without fluoroscopy. This technique enables stent placement when fluoroscopy is not available, and could be combined with fluoroscopy to enhance the accurate positioning of esophageal stents. ACKNOWLEDGEMENT We thank Boston Scientific Corporation/Microvasive Endoscopy for their kind donation of the stents used in this study. REFERENCES 1. Sanyika C, Corr P, Haffejee A. Palliative treatment of oesophageal carcinoma—efficacy of plastic versus selfexpandable stents. South African Med J 1999;89:640-3. 2. Coyle WJ, Lawson JM. Malignant dysphagia: palliation with esophageal stents—long-term results with 100 patients. Gastrointest Endosc 1999;50:134-5. 3. Adam A, Ellul J, Watkinson AF, Tan BS, Morgan RA, Saunders MP, et al. Palliation of inoperable esophageal carcinoma: a prospective randomized trial of laser therapy and stent placement. Radiology 1997;202:344-8. 4. De Palma GD, di Matteo E, Romano G, Fimmano A, Rondinone G, Catanzano C. Plastic prosthesis versus expandable metal stents for palliation of inoperable esophageal thoracic carcinoma: a controlled prospective study. Gastrointest Endosc 1996;43:478-82. 5. 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. New Engl J Med 1993;329:1302-7. 6. de Boer WA, van Haren F, Driessen WM. Marking clips for the accurate positioning of self-expandable esophageal stents. Gastrointest Endosc 1995;42:73-6. 7. Lam YH, Chan A, Lau J, Lee D, Ng E, Wong S, et al. Selfexpandable metal stents for malignant dysphagia. Australian New Zealand J Surg 1999;69:668-71. 8. Conio M, Caroli-Bosc F, Demarquay JF, Sorbi D, Maes B, Delmont J, et al. Self-expanding metal stents in the palliation of neoplasms of the cervical esophagus. HepatoGastroenterology 1999;46:272-7. 9. Bethge N, Sommer A, Vakil N. A prospective trial of selfexpanding metal stents in the palliation of malignant esophageal strictures near the upper esophageal sphincter. Gastrointest Endosc 1997;45:300-3.
GASTROINTESTINAL ENDOSCOPY
351
Esophageal stent placement without fluoroscopy Russell E. White, MD, Caesar Mungatana, MBChB, Mark Topazian, MD Background: Access to fluoroscopic equipment is limited in some regions where esophageal cancer is common. This report describes a simple method for placement of expandable esophageal stents without fluoroscopy. Methods: Patients with dysphagia due to unresectable esophageal cancer underwent esophageal stent placement under endoscopic control alone. A colored mark on the stent delivery catheter was used to properly position the undeployed stent with respect to the proximal end of the tumor. Results: Stent placement was attempted in 70 patients and was successful in every case. There were no immeReceived May 8, 2000. For revision July 20, 2000. Accepted November 9, 2000. From Tenwek Hospital, Bomet, Kenya, and Yale University School of Medicine, New Haven, Connecticut. Reprint requests: Russell E. White, MD, MPH, Chief of Surgery, Tenwek Hospital, PO Box 39, Bomet, Kenya. Copyright © 2001 by the American Society for Gastrointestinal Endoscopy 0016-5107/2001/$35.00 + 0 37/69/112844 doi:10.1067/mge.2001.112844 348
GASTROINTESTINAL ENDOSCOPY
Esophageal stent placement without fluoroscopy
diate complications of stent placement. Mean dysphagia score decreased from 3.3 before stent placement to 0.5 at follow-up. There was a trend toward lower dysphagia scores in patients who received coated stents. Conclusion: Expandable esophageal stents can be accurately and safely placed under direct endoscopic control, without fluoroscopy.
Esophageal cancer is common in certain parts of the world. Palliative treatment options are often limited for patients with advanced disease, many of whom are unable to swallow liquids and have dramatic weight loss. Limited availability of fluoroscopy equipment may prevent widespread use of esophageal stents in some areas where esophageal cancer is endemic. This report describes a simple and reliable method for esophageal stent placement without fluoroscopy. PATIENTS AND METHODS Patients with dysphagia due to unresectable esophageal cancer were offered stent placement. All patients were cared for at Tenwek Hospital in Bomet, Kenya. Tumors were deemed unresectable in the presence of advanced age, severe wasting, comorbid medical conditions, tracheoesophageal fistula, vocal cord or diaphragmatic paralysis, or VOLUME 53, NO. 3, 2001
Esophageal stent placement without fluoroscopy
A
B
R White, C Mungatana, M Topazian
C
Figure 1. Endoscopic views of placement of an expandable stainless steel stent. A, Guidewire left in place across an esophageal cancer. B, Colored mark (arrow) on the stent delivery catheter (corresponding to the base of the stent’s proximal flange) positioned at proximal end of tumor. C, View of deployed stent. metastases detected by physical examination, chest radiograph, or abdominal US. All patients underwent dilation of their esophageal tumor by passage of polyvinyl dilators over a guidewire at the time of initial endoscopic diagnosis. Early in our experience expandable stents were placed during a second endoscopic procedure, but subsequently stents were often placed during the initial endoscopy. Stents were either made of woven stainless steel wire and a silicone membrane (Wallstent II, Boston Scientific Corporation/Microvasive Endoscopy, Natick, Mass.) or knit from nitinol (Ultraflex, Boston Scientific Corporation/Microvasive Endoscopy). Stainless steel stents were 10 cm in length and nitinol stents were 5, 7, 10, 12, or 15 cm in length. Nitinol stents had either a distal or proximal release mechanism. Dilations and stent placements were performed without fluoroscopy, which was unavailable. Informed consent was obtained from patients and their available family members before endoscopy, dilation, and stent placement. Stents were prepared for placement by marking the stent delivery catheter with a circumferential colored mark at the base of the constrained stent’s proximal flange (Figs. 1 and 2). In the case of the stainless steel stents, which shorten by 30% to 35% during deployment and have a tapering 2 cm proximal flange, the mark was placed approximately 3 cm from the proximal end of the constrained stent. In the case of the nitinol stents, which shorten by 43% during deployment and have a 1.5 cm proximal flange, the mark was placed approximately 2.5 cm distal to the black ring on the delivery catheter that marks the expected final location of the proximal end of the deployed stent. An indelible colored marker or reflective nail polish was used to mark the stent delivery catheters. Before stent placement an endoscope was passed through the tumor to the stomach and a stiff 0.035-inch guidewire with a soft tip was placed in the antrum. When the endoscope would not pass through the tumor, a guidewire was gently passed into the stomach and dilation with polyvinyl dilators to at least 36F was performed. The tumor’s position and length were noted during endoscope withdrawal, and a stent of appropriate length was chosen for placement. The VOLUME 53, NO. 3, 2001
constrained stent was passed over the guidewire and through the tumor, and the endoscope was then reintroduced into the proximal esophagus alongside the stent delivery catheter. The catheter was repositioned under direct endoscopic guidance so that the colored mark was visible at the proximal edge of the tumor (Figs. 1 and 2). Stent deployment was monitored endoscopically with the endoscope tip positioned proximal to the constrained stent. For proximal tumors, care was taken to ensure that the undeployed stent was distal to the upper esophageal sphincter. After stent deployment the endoscope was gently passed into or through the stent to assess stent patency and position. When stainless steel stents were used, the colored mark on the delivery catheter moved once stent deployment had begun, but the stent was maintained in stable position by direct endoscopic observation of the proximal end of the stent through the clear outer membrane of the stent delivery system. When nitinol stents were placed the colored mark remained in stable position until the proximal end of the stent was almost completely deployed. Most stents were placed on an outpatient basis. Patients were asked to return if symptoms persisted or recurred, and for a follow-up clinic visit in one month. Dysphagia scores were recorded before stent placement and at follow-up clinic visits with the following scale: 0 = normal, no dysphagia; 1 = can swallow most foods; 2 = can swallow a soft diet; 3 = can swallow fluids only; 4 = unable to swallow saliva. Between August 1999 and August 2000 stent placement was attempted in 70 patients, 43 of whom were men. Mean age was 63 years (range 39 to 85) and 5 patients had a tracheo-esophageal fistula. In 10 cases the proximal end of the tumor was less than 25 cm from the incisors. Stainless steel stents were placed in 30 patients, and nitinol stents were placed in 40 patients.
RESULTS Stents were successfully deployed in all cases. The proximal end of the deployed stent was in the intended location in every patient. An endoscope GASTROINTESTINAL ENDOSCOPY
349
R White, C Mungatana, M Topazian
Esophageal stent placement without fluoroscopy
B
A
C
Figure 2. Endoscopic views of placement of an expandable nitinol stent. A, Guidewire left in place across an esophageal cancer. B, Colored mark (arrow) on the black threads of stent delivery catheter (corresponding to the base of the stent’s proximal flange) positioned at proximal end of tumor. C, View of deployed stent.
could be immediately passed through the stent to the stomach in 54 patients, and in another 4 patients endoscopic views from the mid-shaft of the stent showed that the stent bridged the entire tumor. In 6 patients the endoscope was not passed far enough into the stent to visualize its distal end, due to fear of causing stent migration. In the remaining 6 patients the endoscope was not passed through the stent because only a 12.8-mm diameter therapeutic gastroscope was available. All patients were able to swallow liquids without difficulty immediately after stent placement. Mean dysphagia score before stent placement was 3.3 for the entire cohort and 3.4 for the 32 patients for whom 1 month follow-up data were available. Some patients had traveled long distances for treatment and did not return for follow-up visits. For the 32 patients seen in follow-up, mean dysphagia score after stent placement was 0.5. There was a trend toward lower dysphagia scores in patients who received coated stents (0.12) versus those who received uncoated stents (0.77) (p > 0.05). Five of the 32 patients had a dysphagia score of 2 or higher during the follow-up period, and all had received uncoated stents. Four of these 5 patients had dysphagia scores of 0 or 1 after stent insertion but developed worsening dysphagia 15 to 21 weeks later. Three underwent endoscopy, which demonstrated tumor ingrowth through the interstices of the stent in 2 cases (treated with alcohol injection) and tumor growth over the proximal end of the stent in 1 case (treated with placement of a second stent). The fifth patient had persistent dysphagia immediately after stent placement. She had a malignancy of the cervical esophagus with vocal cord paralysis, and her dysphagia was felt to be neuromuscular in origin after a follow-up endoscopy showed a widely patent stent. 350
GASTROINTESTINAL ENDOSCOPY
Most patients noted mild chest pain after dilation and stent insertion that resolved within 24 hours. In 29 cases stents were deployed across the gastroesophageal junction, and all of these patients received prophylactic oral antacid treatment after stent placement. One of these patients complained of persistent reflux symptoms that were controlled by treatment with an H2 receptor antagonist. The cohort included 2 patients who had esophageal perforation during dilation procedures performed at the time of initial diagnosis. In both cases the perforation was seen endoscopically, and subcutaneous emphysema was palpable in the neck. The first patient underwent a water soluble radiographic contrast study that showed an 8-cm collection in the mediastinum without communication to the pleura. She was treated with intravenous antibiotics, jejunostomy and gastrostomy tubes were placed surgically, and a naso-mediastinal tube was passed through the perforation under endoscopic guidance and placed to low intermittent suction. Follow-up radiographic contrast studies showed substantial resolution of the collection, the nasomediastinal tube was removed, and an uncoated stent was placed across the tumor on the tenth hospital day. One month after discharge the patient was eating a regular diet with no dysphagia, chest pain, or fever. The second patient underwent immediate placement of a coated stent when the perforation was discovered endoscopically, minutes after dilation. He was also treated with intravenous antibiotics and did well without dysphagia, pain, or fever. DISCUSSION Squamous cell esophageal cancer is endemic in certain parts of the world and is the most common malignancy seen at Tenwek hospital in southwestern Kenya. Dysphagia is the commonest presenting VOLUME 53, NO. 3, 2001
Esophageal stent placement without fluoroscopy
symptom, often accompanied by severe weight loss and cachexia. The majority of patients are not candidates for surgical resection, do not have access to radiation or chemotherapy, and will not readily accept gastrostomy tube placement. In this setting, endoscopic treatment may be the only means of providing palliative care. The best form of endoscopic palliation for such patients is placement of an expandable esophageal stent.1-5 Esophageal stents are usually placed under fluoroscopic guidance. Radiographic determination of proper stent position requires a fluoroscopy unit with an image intensifier, which is unavailable in some hospital endoscopy units. In addition, fluoroscopic techniques for stent placement rely on radioopaque markers to identify the position of the tumor. External radio-opaque markers can slip out of place, and adjacent anatomic landmarks can rotate with patient movement. Endoscopically placed markers such as submucosal radiographic contrast injections or clips6 overcome these limitations, but stents may still be malpositioned when deployed under fluoroscopic control, due to inaccurate positioning of the undeployed stent or failure to compensate for stent shortening during deployment.7 Proper positioning of the stent with regard to the upper esophageal sphincter can be especially difficult to judge fluoroscopically. As a result, some endoscopists combine fluoroscopic and endoscopic monitoring of stent deployment to improve the accuracy of stent placement.8 Stents were placed under direct endoscopic control alone by using an indelible mark on the stent delivery catheter to position the stent’s proximal flange at the proximal end of the tumor. This method was found to be an easy and accurate means of determining the proper location for stent deployment. Stent position after deployment appeared satisfactory in every case. Stent placement generally proceeded more rapidly than if submucosal contrast injections and fluoroscopic guidance had been used. No difficulty was encountered in passing an endoscope through the upper esophageal sphincter next to a stent delivery catheter to monitor stent deployment. Our technique allows accurate placement of
VOLUME 53, NO. 3, 2001
R White, C Mungatana, M Topazian
the stent with regard to the upper esophageal sphincter, an important issue when tumors are proximal in location.9 Esophageal stents relieve dysphagia dramatically in patients with advanced esophageal cancer. Expandable stents can be safely and accurately deployed under direct endoscopic control, without fluoroscopy. This technique enables stent placement when fluoroscopy is not available, and could be combined with fluoroscopy to enhance the accurate positioning of esophageal stents. ACKNOWLEDGEMENT We thank Boston Scientific Corporation/Microvasive Endoscopy for their kind donation of the stents used in this study. REFERENCES 1. Sanyika C, Corr P, Haffejee A. Palliative treatment of oesophageal carcinoma—efficacy of plastic versus selfexpandable stents. South African Med J 1999;89:640-3. 2. Coyle WJ, Lawson JM. Malignant dysphagia: palliation with esophageal stents—long-term results with 100 patients. Gastrointest Endosc 1999;50:134-5. 3. Adam A, Ellul J, Watkinson AF, Tan BS, Morgan RA, Saunders MP, et al. Palliation of inoperable esophageal carcinoma: a prospective randomized trial of laser therapy and stent placement. Radiology 1997;202:344-8. 4. De Palma GD, di Matteo E, Romano G, Fimmano A, Rondinone G, Catanzano C. Plastic prosthesis versus expandable metal stents for palliation of inoperable esophageal thoracic carcinoma: a controlled prospective study. Gastrointest Endosc 1996;43:478-82. 5. 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. New Engl J Med 1993;329:1302-7. 6. de Boer WA, van Haren F, Driessen WM. Marking clips for the accurate positioning of self-expandable esophageal stents. Gastrointest Endosc 1995;42:73-6. 7. Lam YH, Chan A, Lau J, Lee D, Ng E, Wong S, et al. Selfexpandable metal stents for malignant dysphagia. Australian New Zealand J Surg 1999;69:668-71. 8. Conio M, Caroli-Bosc F, Demarquay JF, Sorbi D, Maes B, Delmont J, et al. Self-expanding metal stents in the palliation of neoplasms of the cervical esophagus. HepatoGastroenterology 1999;46:272-7. 9. Bethge N, Sommer A, Vakil N. A prospective trial of selfexpanding metal stents in the palliation of malignant esophageal strictures near the upper esophageal sphincter. Gastrointest Endosc 1997;45:300-3.
GASTROINTESTINAL ENDOSCOPY
351