- Email: [email protected]
Esophagojejunal stenting for recurrent gastric carcinoma
P Sherwood, A Duggan, F Shek, et al. 20. May GR, Cotton PB, Edmunds SEJ, Chong W. Removal of stones from the bile duct at ERCP without sphincterotomy. Gastrointest Endosc 1993;39:749-54. 21. MacMathuna P, White P, Clarke E, Merriman R, Lennon J, R., Crowe J. Endoscopic balloon sphincteroplasty (papillary dilation) for bile duct stones: efficacy, safety, and follow-up in 100 patients. Gastrointest Endosc 1995;42:468-74. 22. Kawabe T, Komatsu Y, Tada M, Toda N, Ohashi M, Shiratori Y, et al. Endoscopic papillary balloon dilation in cirrhotic patients: removal of common bile duct stones without sphincterotomy. Endoscopy 1996;28:694-8. 23. DiSario JA, Freeman ML, Bjorkman DJ, MacMathuna P, Petersen B, Sherman S, et al. Endoscopic balloon dilation compared to sphincterotomy for extraction of bile duct stones: preliminary results [abstract]. Gastrointest Endosc 1997;45: AB129. 24. Tarnasky PR, Cunningham JT, Hawes RH, Hoffman BJ, Cotton PB. Pitfalls of bile duct stone removal after balloon sphincter dilation. Am J Gastroenterol 1996;91:822. 25. Cotton PB, Chung SC, Davis WZ, Gibson RM, Ransohoff DF, Strasberg SM. Issues in cholecystectomy and management of duct stones. Am J Gastroenterol 1994;89:S169-76. 26. Kozarek RA. Laparoscopic cholecystectomy: what to do with the common duct. Gastrointest Endosc 1993;39:99-101. 27. Binmoeller KF, Soehendra N, Liguory C. The common bile
Esophagojejunal stenting for recurrent gastric carcinoma Paul Sherwood, MB, ChB, MRCP Anne Duggan, BMed, MHP, FRACP Fanny Shek, BM, BS, BMedSci, MRCP Dominic Clarke, MRCP, FRCR Jan Freeman, MD, FRCP
Self-expanding metal stents are increasingly being used to palliate patients with obstructing gastrointestinal cancers in less than conventional circumstances. We report the unusual application of stenting in the case of a woman with dysphagia caused by recurrent gastric carcinoma after a total gastrectomy. Despite initial difficulties, the insertion of a self-expanding metal stent across the esophago-jejunal anastomosis provided excellent palliation and avoided further surgery. This case illustrates the benefits of persisting with combined palliative treatments in difficult situations. CASE REPORT An 82-year-old woman presented with dysphagia to semi-solids, a few kilograms of weight loss, and vomiting From Derby City General Hospital, Derby, United Kingdom. Reprint requests: J. Freeman, MD, FRCP, Department of Gastroenterology, Derby City General Hospital, Uttoxeter Rd., Derby DE22 3NE, United Kingdom. Copyright © 1998 by the American Society for Gastrointestinal Endoscopy 0016-5107/98/$5.00 1 0 37/4/86738 192 GASTROINTESTINAL ENDOSCOPY
Esophagojejunal stenting for recurrent gastric carcinoma
28. 29. 30.
31. 32. 33. 34.
duct stone: time to leave it to the laparoscopic surgeon? Endoscopy 1994;26:315-9. DePaula AL, Hashiba K, Bafutto M. Laparoscopic management of choledocholithiasis. Surg Endosc 1994;8:1399403. Rhodes M, Nathanson L, O’Rourke N, Fielding G. Laparoscopic exploration of the common bile duct: lessons learned from 129 consecutive cases. Br J Surg 1995;82:666-8. Deslandres E, Gagner M, Pomp A, Rheault M, Leduc R, Clermont R, et al. Intraoperative endoscopic sphincterotomy for common bile duct stones during laparoscopic cholecystectomy. Gastrointest Endosc 1993;39:54-8. Siddiqui MN, Hamid S, Khan H, Ahmed M. Peroperative endoscopic retrograde cholangiopancreatography for common bile duct stones. Gastrointest Endosc 1994;40:348-50. Cox MR, Wilson TG, Toouli J. Peroperative endoscopic sphincterotomy during laparoscopic cholecystectomy for choledocholithiasis. Br J Surg 1995;82:257-9. Adams D, Tarnasky PR. Peroperative endoscopic sphincterotomy during laparoscopic cholecystectomy for choledocholithiasis. Gastrointest Endosc 1996;43:178-80. Tagge EP, Tarnasky PR, Chandler JC, Tagge DU, Cunningham JT, Hoffman BJ, et al. Multidisciplinary approach to the treatment of pediatric pancreaticobiliary disorders. J Pediatr Surg 1997;32:158-65.
of undigested food in August 1996. She had undergone a total gastrectomy in October 1995 for gastric adenocarcinoma. Gastroscopy performed urgently revealed a high-grade malignant stricture 33 cm from the incisors extending distally for 6 cm. The tumor was dilated gently with the endoscope and partially debulked by photoablation with the Nd/YAG laser. Despite a second session of laser therapy, the patient’s symptoms continued. At repeat endoscopy the endoscope could be easily passed into what appeared to be an afferent loop but could not be negotiated into the efferent loop of jejunum, the entrance of which had not been recognized at previous endoscopic examination because of obstructing tumor. A barium swallow revealed a tight malignant anastomotic stricture at the junction of the esophagus and efferent jejunal loop of Roux-en-Y (Fig. 1). Because of the anatomy and angulation of the stricture, further endoscopic laser therapy was judged to be relatively hazardous. The patient refused further surgery. After one failed attempt with a standard endoscopy we managed to intubate the entrance to the efferent jejunal loop with a smaller diameter endoscope (Pentax EG2901; Pentax (UK) Ltd., Langley, U.K.) and pass a guidewire well beyond the stricture into the jejunum, allowing the scope to follow safely. A 10 cm long, 18 mm expanded diameter Microvasive Ultraflex uncovered esophageal prosthesis (Boston Scientific Inc., Boston, Mass.) was then deployed across the stricture. Initial expansion was incomplete despite attempted dilatation of the stent with a 12 mm balloon. In view of reports and our experience of delayed stent expansion, we waited to see whether this stenting attempt was sufficient. Unfortunately the patient continued to complain of VOLUME 47, NO. 2, 1998
Esophagojejunal stenting for recurrent gastric carcinoma
Figure 1. Water-soluble contrast swallow. Tight stricture of the distal esophagus involving the esophago-jejunal anastomosis (thin arrow). The efferent loop entrance is narrowed with hold-up of contrast and formation of a contrast-air fluid level (thick arrow).
P Sherwood, A Duggan, F Shek, et al.
Figure 2. Water-soluble contrast swallow. The Ultraflex stent is straddling the tumor but is kinked and compressed.
DISCUSSION dysphagia and vomiting. Repeat radiographs, a contrast swallow and a gastroscopy confirmed that the stent had failed to open fully because of tumor compression (Fig. 2). Attempts to pass the endoscope through the stent caused the mesh to fracture. In view of the failure of the primary stent a second stent with a higher radial force was placed across the Ultraflex stent. Under fluoroscopic guidance it was possible to intubate this with the small diameter endoscope with difficulty and place a guidewire deep into the jejunum. An Esophacoil prosthesis (Instent, Eden Prairie, Minn.), 15 cm long, 18 mm diameter was deployed straddling the original stent (Fig. 3). Although this stent did not expand immediately, a gastroscopy 4 days later revealed the stent was correctly placed and well open; some of the coils in the middle of the stent were splayed apart with some tumor protruding through. This was treated with Nd/YAG laser photoablation to good effect. The patient was discharged home able to swallow semi-solid food and otherwise asymptomatic. She survived a further 24 weeks with good swallowing but 1 week before her death developed jaundice for which she refused any further intervention. VOLUME 47, NO. 2, 1998
Self-expanding metal stents are conventionally used for palliation of malignant esophageal and biliary obstruction.1,2 New uses are still being found, for example, in the rectum and sigmoid,3,4 for gastric outlet obstruction5,6 and for duodenal compression caused by pancreatic carcinoma or metastases.7 This case illustrates several points relevant in luminal gastrointestinal tumor palliation. Our patient did not have a usual indication for a metal stent but still did well after some persistence and avoided surgery. There have been several reports of unconventional but successful uses of stents, and they should now be considered for palliation of patients with endoscopically accessible, obstructing, incurable tumors. Developments in stent technology are likely to increase the choice of prostheses and the range of indications. At present each of the four stent types generally available (the Ultraflex prosthesis, the Esophacoil, the Wallstent, and the Gianturco-Rosch Z stent) have achieved favorable results in medium-sized GASTROINTESTINAL ENDOSCOPY 193
P Sherwood, A Duggan, F Shek, et al.
Esophagojejunal stenting for recurrent gastric carcinoma
locations helps when deciding if stenting a particular tumor is likely to be successful. Patients appreciate the rapid symptomatic improvement a stent can bring. In this patient, although the series of endoscopies, laser treatment and stenting attempts did take considerably longer than is usual, much of her treatment was performed on an outpatient basis. She was grateful to avoid surgery and pleased with the eventual symptom relief. REFERENCES
Figure 3. The Esophacoil is seen to bridge the tumor and previous stent and has completely expanded.
series.8-11 All have important differences that can be exploited in various clinical situations; in most cases, use of any of the stents will be successful. Our case shows that when treatment with the first chosen stent is unsuccessful, it is worth trying an alternative prosthesis. Our case also illustrates the importance of appreciating the deranged anatomy of a malignant stricture when attempting to stent it. For all cases where stenting is less than straightforward we perform contrast studies; in this patient’s case we would have benefited from requesting the radiologic examination earlier. We often find that initial laser therapy helps in managing malignant obstruction, to reduce bulky exophytic parts of the tumor even if it is decided that stent placement is required. The use of laser therapy after stenting can be difficult as the stent metal can melt or, as in one report, ignite.12 However with low power and careful aiming we have found laser therapy useful to treat tumor ingrowth, overgrowth, or residual unstented tumor. Stents are likely to remain fairly expensive but probably save money if surgery is the alternative. Experience with different stent types in various
194 GASTROINTESTINAL ENDOSCOPY
1. De Palma GD, diMatteo E, Romano G, Fimmano A, Rondinone G, Catanzano C. Plastic prosthesis versus expandable metal stent for palliation of inoperable esophageal thoracic carcinoma: a controlled prospective study. Gastrointest Endosc 1996;43:478-82. 2. Davids PHP, Green AK, Rauws EAJ, Tytgat GN, Huibregtse K. Randomised trial of self-expanding metal stents versus polyethylene stents for distal malignant biliary obstruction. Lancet 1992;340:1488-92. 3. Rey JF, Romancyzk T, Greff M. Metal stents for palliation of rectal carcinoma; a preliminary report on 12 patients. Endoscopy 1995;27:501-4. 4. Saida Y, Sumiyama Y, Nagao J, Takase M. Stent endoprosthesis for obstructing colorectal cancers. Dis Colon Rectum 1996;39:552-5. 5. Solt J, Papp Z. Strecker stent implantation in malignant gastric outlet stenosis. Gastrointest Endosc 1993;39:442-4. 6. Kozarek RA, Bradabur J, Raltz S. Expandable stents (ES)/ unusual locations [abstract]. Gastrointest Endosc 1996;43: 298. 7. Baron T, Morgan D. Expandable metal stents for treatment of non-oesophageal/non-colonic enteral obstruction [abstract]. Gastrointest Endosc 1996;43:348. 8. Raijman I, Walden D, Kortan P, Haber GB, Fuchs E, Siemans M, et al. Expandable esophageal stents: initial experience with a new nitinol stent. Gastrointest Endosc 1994;40:614-21. 9. Goldin E, Fiorini A, Ratan J, Novis B, Libson E, Beyer M, et al. Results of new self expandable oesophageal prosthesis (Esophacoil) in 33 patients [abstract]. Gastrointest Endosc 1994;40(Pt 2):P75. 10. Vermeijden J, Bartelsman J, Fockens P, Meijer RCA, Tytgat GNJ. Self-expanding metal stents for palliation of esophagocardial malignancies. Gastrointest Endosc 1995;41:58-63. 11. Song H-Y, Do Y-S, Han Y-M, Sung K-B, Choi E-K, Sohn K-H, et al. Covered, expandable esophageal metallic stent tubes: experience in 119 patients. Radiology 1994;193:689-95. 12. Swain CP, Gong F, Murfitt J. Difficulties with placement of esophageal metal stents and development and testing of new delivery method and covered stents [abstract]. Gastrointest Endosc 1995;41:358.
VOLUME 47, NO. 2, 1998
Esophagojejunal stenting for recurrent gastric carcinoma Paul Sherwood, MB, ChB, MRCP Anne Duggan, BMed, MHP, FRACP Fanny Shek, BM, BS, BMedSci, MRCP Dominic Clarke, MRCP, FRCR Jan Freeman, MD, FRCP
Self-expanding metal stents are increasingly being used to palliate patients with obstructing gastrointestinal cancers in less than conventional circumstances. We report the unusual application of stenting in the case of a woman with dysphagia caused by recurrent gastric carcinoma after a total gastrectomy. Despite initial difficulties, the insertion of a self-expanding metal stent across the esophago-jejunal anastomosis provided excellent palliation and avoided further surgery. This case illustrates the benefits of persisting with combined palliative treatments in difficult situations. CASE REPORT An 82-year-old woman presented with dysphagia to semi-solids, a few kilograms of weight loss, and vomiting From Derby City General Hospital, Derby, United Kingdom. Reprint requests: J. Freeman, MD, FRCP, Department of Gastroenterology, Derby City General Hospital, Uttoxeter Rd., Derby DE22 3NE, United Kingdom. Copyright © 1998 by the American Society for Gastrointestinal Endoscopy 0016-5107/98/$5.00 1 0 37/4/86738 192 GASTROINTESTINAL ENDOSCOPY
Esophagojejunal stenting for recurrent gastric carcinoma
28. 29. 30.
31. 32. 33. 34.
duct stone: time to leave it to the laparoscopic surgeon? Endoscopy 1994;26:315-9. DePaula AL, Hashiba K, Bafutto M. Laparoscopic management of choledocholithiasis. Surg Endosc 1994;8:1399403. Rhodes M, Nathanson L, O’Rourke N, Fielding G. Laparoscopic exploration of the common bile duct: lessons learned from 129 consecutive cases. Br J Surg 1995;82:666-8. Deslandres E, Gagner M, Pomp A, Rheault M, Leduc R, Clermont R, et al. Intraoperative endoscopic sphincterotomy for common bile duct stones during laparoscopic cholecystectomy. Gastrointest Endosc 1993;39:54-8. Siddiqui MN, Hamid S, Khan H, Ahmed M. Peroperative endoscopic retrograde cholangiopancreatography for common bile duct stones. Gastrointest Endosc 1994;40:348-50. Cox MR, Wilson TG, Toouli J. Peroperative endoscopic sphincterotomy during laparoscopic cholecystectomy for choledocholithiasis. Br J Surg 1995;82:257-9. Adams D, Tarnasky PR. Peroperative endoscopic sphincterotomy during laparoscopic cholecystectomy for choledocholithiasis. Gastrointest Endosc 1996;43:178-80. Tagge EP, Tarnasky PR, Chandler JC, Tagge DU, Cunningham JT, Hoffman BJ, et al. Multidisciplinary approach to the treatment of pediatric pancreaticobiliary disorders. J Pediatr Surg 1997;32:158-65.
of undigested food in August 1996. She had undergone a total gastrectomy in October 1995 for gastric adenocarcinoma. Gastroscopy performed urgently revealed a high-grade malignant stricture 33 cm from the incisors extending distally for 6 cm. The tumor was dilated gently with the endoscope and partially debulked by photoablation with the Nd/YAG laser. Despite a second session of laser therapy, the patient’s symptoms continued. At repeat endoscopy the endoscope could be easily passed into what appeared to be an afferent loop but could not be negotiated into the efferent loop of jejunum, the entrance of which had not been recognized at previous endoscopic examination because of obstructing tumor. A barium swallow revealed a tight malignant anastomotic stricture at the junction of the esophagus and efferent jejunal loop of Roux-en-Y (Fig. 1). Because of the anatomy and angulation of the stricture, further endoscopic laser therapy was judged to be relatively hazardous. The patient refused further surgery. After one failed attempt with a standard endoscopy we managed to intubate the entrance to the efferent jejunal loop with a smaller diameter endoscope (Pentax EG2901; Pentax (UK) Ltd., Langley, U.K.) and pass a guidewire well beyond the stricture into the jejunum, allowing the scope to follow safely. A 10 cm long, 18 mm expanded diameter Microvasive Ultraflex uncovered esophageal prosthesis (Boston Scientific Inc., Boston, Mass.) was then deployed across the stricture. Initial expansion was incomplete despite attempted dilatation of the stent with a 12 mm balloon. In view of reports and our experience of delayed stent expansion, we waited to see whether this stenting attempt was sufficient. Unfortunately the patient continued to complain of VOLUME 47, NO. 2, 1998
Esophagojejunal stenting for recurrent gastric carcinoma
Figure 1. Water-soluble contrast swallow. Tight stricture of the distal esophagus involving the esophago-jejunal anastomosis (thin arrow). The efferent loop entrance is narrowed with hold-up of contrast and formation of a contrast-air fluid level (thick arrow).
P Sherwood, A Duggan, F Shek, et al.
Figure 2. Water-soluble contrast swallow. The Ultraflex stent is straddling the tumor but is kinked and compressed.
DISCUSSION dysphagia and vomiting. Repeat radiographs, a contrast swallow and a gastroscopy confirmed that the stent had failed to open fully because of tumor compression (Fig. 2). Attempts to pass the endoscope through the stent caused the mesh to fracture. In view of the failure of the primary stent a second stent with a higher radial force was placed across the Ultraflex stent. Under fluoroscopic guidance it was possible to intubate this with the small diameter endoscope with difficulty and place a guidewire deep into the jejunum. An Esophacoil prosthesis (Instent, Eden Prairie, Minn.), 15 cm long, 18 mm diameter was deployed straddling the original stent (Fig. 3). Although this stent did not expand immediately, a gastroscopy 4 days later revealed the stent was correctly placed and well open; some of the coils in the middle of the stent were splayed apart with some tumor protruding through. This was treated with Nd/YAG laser photoablation to good effect. The patient was discharged home able to swallow semi-solid food and otherwise asymptomatic. She survived a further 24 weeks with good swallowing but 1 week before her death developed jaundice for which she refused any further intervention. VOLUME 47, NO. 2, 1998
Self-expanding metal stents are conventionally used for palliation of malignant esophageal and biliary obstruction.1,2 New uses are still being found, for example, in the rectum and sigmoid,3,4 for gastric outlet obstruction5,6 and for duodenal compression caused by pancreatic carcinoma or metastases.7 This case illustrates several points relevant in luminal gastrointestinal tumor palliation. Our patient did not have a usual indication for a metal stent but still did well after some persistence and avoided surgery. There have been several reports of unconventional but successful uses of stents, and they should now be considered for palliation of patients with endoscopically accessible, obstructing, incurable tumors. Developments in stent technology are likely to increase the choice of prostheses and the range of indications. At present each of the four stent types generally available (the Ultraflex prosthesis, the Esophacoil, the Wallstent, and the Gianturco-Rosch Z stent) have achieved favorable results in medium-sized GASTROINTESTINAL ENDOSCOPY 193
P Sherwood, A Duggan, F Shek, et al.
Esophagojejunal stenting for recurrent gastric carcinoma
locations helps when deciding if stenting a particular tumor is likely to be successful. Patients appreciate the rapid symptomatic improvement a stent can bring. In this patient, although the series of endoscopies, laser treatment and stenting attempts did take considerably longer than is usual, much of her treatment was performed on an outpatient basis. She was grateful to avoid surgery and pleased with the eventual symptom relief. REFERENCES
Figure 3. The Esophacoil is seen to bridge the tumor and previous stent and has completely expanded.
series.8-11 All have important differences that can be exploited in various clinical situations; in most cases, use of any of the stents will be successful. Our case shows that when treatment with the first chosen stent is unsuccessful, it is worth trying an alternative prosthesis. Our case also illustrates the importance of appreciating the deranged anatomy of a malignant stricture when attempting to stent it. For all cases where stenting is less than straightforward we perform contrast studies; in this patient’s case we would have benefited from requesting the radiologic examination earlier. We often find that initial laser therapy helps in managing malignant obstruction, to reduce bulky exophytic parts of the tumor even if it is decided that stent placement is required. The use of laser therapy after stenting can be difficult as the stent metal can melt or, as in one report, ignite.12 However with low power and careful aiming we have found laser therapy useful to treat tumor ingrowth, overgrowth, or residual unstented tumor. Stents are likely to remain fairly expensive but probably save money if surgery is the alternative. Experience with different stent types in various
194 GASTROINTESTINAL ENDOSCOPY
1. De Palma GD, diMatteo E, Romano G, Fimmano A, Rondinone G, Catanzano C. Plastic prosthesis versus expandable metal stent for palliation of inoperable esophageal thoracic carcinoma: a controlled prospective study. Gastrointest Endosc 1996;43:478-82. 2. Davids PHP, Green AK, Rauws EAJ, Tytgat GN, Huibregtse K. Randomised trial of self-expanding metal stents versus polyethylene stents for distal malignant biliary obstruction. Lancet 1992;340:1488-92. 3. Rey JF, Romancyzk T, Greff M. Metal stents for palliation of rectal carcinoma; a preliminary report on 12 patients. Endoscopy 1995;27:501-4. 4. Saida Y, Sumiyama Y, Nagao J, Takase M. Stent endoprosthesis for obstructing colorectal cancers. Dis Colon Rectum 1996;39:552-5. 5. Solt J, Papp Z. Strecker stent implantation in malignant gastric outlet stenosis. Gastrointest Endosc 1993;39:442-4. 6. Kozarek RA, Bradabur J, Raltz S. Expandable stents (ES)/ unusual locations [abstract]. Gastrointest Endosc 1996;43: 298. 7. Baron T, Morgan D. Expandable metal stents for treatment of non-oesophageal/non-colonic enteral obstruction [abstract]. Gastrointest Endosc 1996;43:348. 8. Raijman I, Walden D, Kortan P, Haber GB, Fuchs E, Siemans M, et al. Expandable esophageal stents: initial experience with a new nitinol stent. Gastrointest Endosc 1994;40:614-21. 9. Goldin E, Fiorini A, Ratan J, Novis B, Libson E, Beyer M, et al. Results of new self expandable oesophageal prosthesis (Esophacoil) in 33 patients [abstract]. Gastrointest Endosc 1994;40(Pt 2):P75. 10. Vermeijden J, Bartelsman J, Fockens P, Meijer RCA, Tytgat GNJ. Self-expanding metal stents for palliation of esophagocardial malignancies. Gastrointest Endosc 1995;41:58-63. 11. Song H-Y, Do Y-S, Han Y-M, Sung K-B, Choi E-K, Sohn K-H, et al. Covered, expandable esophageal metallic stent tubes: experience in 119 patients. Radiology 1994;193:689-95. 12. Swain CP, Gong F, Murfitt J. Difficulties with placement of esophageal metal stents and development and testing of new delivery method and covered stents [abstract]. Gastrointest Endosc 1995;41:358.
VOLUME 47, NO. 2, 1998