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Malignant dysphagia treated with a metallic self-expanding stent
THE RAD
LLEGE
OF
RAPHERS
Radiography
(1999) 5, 173-I 76
CASE REPORT
M a lignant dysphagia self-expanding stent
treated
with a m e tallic
Jayne Burkitt
X-ray Dcpwtment, King’s Mili Centw fur Hcaithcnre Services (NHS) Trust, Stittotl-ln-AslIfieId. .Vottmghamshire, NG17 4U1, U.K. (Receioed 18 August 1998, and acrcepted 1 May 1999)
A case history is described, of a patient with a squamous cell carcinoma of the oesophagus. As the tumour was too advanced for further treatment, a self-expanding stent was inserted into the oesophagus under fluoroscopic control. The aim of the treatment was to restore the diameter of the oesophagus and to improve palliation.
Keywords: dysphagia; squamous cell carcinoma; endoscopy; amplatz; stent; palliation.
Introduction
swallow structure
Many patients who have oesophageal tumours are unsuitable for curative surgery, either because the disease is too far advanced, or because they are too frail for major surgery. The use of oesophageal stents can improve the quality of the patient’s life by restoring the diameter of the oesophageal lumen, enabling food to be swallowed. Endoscopic insertion of plastic tubes, has until recently been the mainstay of treatment in this group of patients, but self-expanding metal stents are now known to be easier to introduce, provide better palliation and are less often associated with complications.
Case history An 85-year-old female patient presented with an B-month history of dysphagia, and a 3 stone weight loss. The patient had previously been very fit. Endoscopy was performed, confirming a tumour at 30 cm (measurement taken from patient’s front teeth), which at biopsy was found to be a poorly differentiated squamous cell carcinoma. Barium 1078-8174/99/030173+04
$18.00/O
at this time showed a short at the level of the carina.
malignant
Procedure The procedure was explained to the patient by the radiologist on the previous day, informed consent was obtained and the patient starved overnight. The patient’s details were checked in the X-ray Department and she was then positioned in the right anterior oblique position on the fluoroscopy unit. She was screened while drinking a mouthful of non-ionic water soluble contrast medium (Ultravist 240 Schering AG, Germany), so that the upper and lower end of the strictures could be localized (Fig. 1). A radiopaque ruler and metallic markers were placed on the patient’s skin to mark the upper and lower limit of the stricture. The patient’s throat was anaesthetized with xylocaine spray (Astra Pharmaceuticals Ltd.) and a soft 6F end hole catheter was swallowed. Through the catheter an Amplatz extra stiff 0.035 inch diameter guidewire was introduced and under careful fluoroscopic guidance the soft tip of the wire 0 1999 The College of Radiographers
Burkitt
Figure 2. A covered Gianturco stent (courtesy of Cook (UK) Ltd, with permission).
Figure 1. Radiopaque ruler and metallic markers placed on the skin to identify stricture.
the upper and lower margins of the
was passed through the stricture. Intravenous access had been established and the patient was sedated with 2 mg of midazolam (Benzodiazepam) intravenously. Oxygen was administered via a nasal cannula and the patient monitored with a pulse oximeter. The radiology nurse stood by the patient’s head with a suction catheter and the head end of the table was raised to reduce the risk of aspiration. (Cook U.K. Ltd, A 10 cm long Gianturco-Riisch Letchworth, Herts.) polyethylene covered oesophageal stent was chosen (Fig. 2). The Gianturco stent is made of a 0.5 mm stainless steel wire that is bent in a zigzag pattern with ends soldered to form a cylinder and is covered in polyethylene to
prevent tumour ingrowth. The expandable tube is compressed into an introducer catheter. The length of stent needs to allow for some proximal and distal spread of tumour to prevent 2-3 cm at either end of the overgrowth-normally stricture. The lubricated introducer sheath and dilator assembly were advanced over the guidewire and into the correct position within the oesophagus under fluoroscopic guidance. The stent introducer catheter with the premounted stent were pushed into the introducer sheath and the stent advanced by means of a pusher catheter. When the stent was confirmed to be in the correct position it was released by keeping it in position with the pusher catheter, as the introducer sheath was withdrawn. When the sheath is withdrawn the stent ‘springs’ open to the required diameter. The patient then had an erect chest radiograph to check that there was no evidence of pneumomediastinum. Following the procedure, the patient took nothing by mouth for 2-3 h to allow for the topical anaesthetic to wear off (so there was no risk of aspiration) after which time fluids were allowed. of a After 24 h on clear fluids an early resumption solid diet was encouraged. A barium swallow examination (Fig. 3) was performed 48 h after insertion of the stent to check its position.
Discussion Oesophageal carcinoma accounts for more than 3500 deaths per year in the U.K., and ranks as the
alignant
dysphagia
Figure
treated
with a metallic
3. Barium swallow
stent
48 h post-stent
insertion. (a) stent in place; (b) free passage of barium through
seventh most common malignancy worldwide [I]. Research by Jantsch et al. [2] has shown that almost two thirds of patients who present with advanced oesophageal carcinomas are not amenable to curative surgical resection and so long-term prognosis is poor. Patients initially present with dysphagia, particularly for solids and later as the tumour progresses for fluids as well. A barium swallow will frequently show the tumour as a stricture with shouldered margins. Squamous cell carcinoma until recently has been the commonest type of oesophageal cancer, but in recent years the prevalence of adenocarcinoma has been increasing, so now 50% of newly diagnosed cases of oesophageal cancer are adenocarcinoma [3]. The reason for this increase is not clearly understood, although these tumours arise from dysplastic Barrett’s epithelium, brought about by long standing gastro-oesophageal reflux disease. Nevertheless, squamous cell carcinoma remains the commoner tumour in the mid- and upper oesophagus. The palliation of oesophageal carcinoma has advanced since the first successful insertion of an oesophageal stent was reported in 1887 by Sir Charles Symonds. In 1959 Celestin developed a new plastic tube that was widely used in the
the stent.
palliative treatment of malignant oesophageal strictures. was still achieved During the 1980s palliation with plastic stents, but the outcome was often poor, with perforation rates of 7-B% [4] and most patients failing to return to a normal diet. There was also the complication of tumour overgrowth and tube migration causing further dysphagia. The use of metal stents improves palliation because complications such as perforation, haemorrhage, aspiration pneumonia and death at time of procedure are reduced [5]. The small calibre of the delivery system used for metal stents facilitates safe introduction and makes the procedure less distressing for the patients [6]. Radiological control of stent placement has the advantage over surgical and endoscopic techniques in that stent placement in the stricture is more precise. The main disadvantage of metal stents is the relatively high cost, especially if more than one stent is required. Plastic tubes such as the Atkinson’s tube are significantly cheaper but their placement is painful and they have a smaller internal diameter (6 mm less for 18 mm stents) so metal stents are better able to restore oesophageal patency. Although metal stents are more expensive their lower complication rate and consequent
Burkitt
176
reduced length of inpatient stay makes them more cost effective [7]. There are several different designs of metal stent available and choice of stent varies from centre to centre. Covered stents prevent ingrowth but are more prone to migration; however, newer designs can overcome this problem. Uncovered stents may occlude by tumour growth through the stent mesh, but the majority of patients do not live long enough for this to happen; most living only a few months after diagnosis [8]. Recent research suggests that, covered stents are preferable for lesions where the lower end of the stent is left above the cardia, and in patients in whom there is associated fistulation or perforation [9]. Uncovered stents, however, are preferable for lesions at the cardia as they are less prone to migration.
Acknowledgements Thanks are given to Dr Phil Panto, Consultant Radiologist, for his considerable guidance and help during the preparation of this paper, also to Vicki Smith-West Harden for her constructive comments, lain Mackintosh (Cook UK) for his help and finally to my husband David and manager Elaine Torr for ther continual support and encouragement.
References 1. Tan B, Mason R, Adam A. Minimally
advanced oesophageal malignancy. 828-36. 2. Jantsch H, Fuegger
R, Karnel F ef ul. Radiologic placement of endoprostheses for palliative treatment of malignant esophageal obstruction. I Interven Rudiol 1993; 8:
91-5. 3. Blot W, Devesa S, Kneller
adenocarcinoma
Conclusion Palliation of patients with oesophageal carcinoma can be effectively and safely achieved using metal stents. As compared to plastic stents they are easier to place, result in fewer complications and a shorter hospital stay. Stents treat the distress of not being able to eat and alleviate the lack of nutrition. This technological advance has therefore made the palliative care for the terminally ill patient with oesophageal carcinoma more tolerable. Metal stents are therefore a preferred method of palliating malignant oesophageal strictures.
invasive therapy for C/in Radial 1996; 51:
R et nl. Rising incidence of of the esophagus and gastric cardia.
]AMA 1991; 265: 1287-9. 4. Ogilvie A, Dionfield M, Percuson R, Atkinson
M. Palliative intubation of oesophago-gastric neoplasms at fiber optic endoscopy. Gut 1982; 23: 1060-7. 5. Sturgess R, Morris A. Metal stents in the oesophagus. G& 1995; 37: 593-4. 6. Neuhaus H. Metal esophageal stents. &ML 1991; 8: 305-10.
Murphy
Intervent R&cl/
G. Stents in the oesophagus. Postgrad Med ] 1995;
71: 453-6.
Cope C. Cllrrenf Techniques in Interventional Radiology. Philadelphia: Current Medicine, 1995. Adam A, Saunders M, Tan B, Watkinson A, Ellul J, Mason R. Triple randomised comparison of laser therapy and two types of metallic stent in inoperable esophageal carcinoma: initial results. Rudiulogy 1995; 197: 347.
LLEGE
OF
RAPHERS
Radiography
(1999) 5, 173-I 76
CASE REPORT
M a lignant dysphagia self-expanding stent
treated
with a m e tallic
Jayne Burkitt
X-ray Dcpwtment, King’s Mili Centw fur Hcaithcnre Services (NHS) Trust, Stittotl-ln-AslIfieId. .Vottmghamshire, NG17 4U1, U.K. (Receioed 18 August 1998, and acrcepted 1 May 1999)
A case history is described, of a patient with a squamous cell carcinoma of the oesophagus. As the tumour was too advanced for further treatment, a self-expanding stent was inserted into the oesophagus under fluoroscopic control. The aim of the treatment was to restore the diameter of the oesophagus and to improve palliation.
Keywords: dysphagia; squamous cell carcinoma; endoscopy; amplatz; stent; palliation.
Introduction
swallow structure
Many patients who have oesophageal tumours are unsuitable for curative surgery, either because the disease is too far advanced, or because they are too frail for major surgery. The use of oesophageal stents can improve the quality of the patient’s life by restoring the diameter of the oesophageal lumen, enabling food to be swallowed. Endoscopic insertion of plastic tubes, has until recently been the mainstay of treatment in this group of patients, but self-expanding metal stents are now known to be easier to introduce, provide better palliation and are less often associated with complications.
Case history An 85-year-old female patient presented with an B-month history of dysphagia, and a 3 stone weight loss. The patient had previously been very fit. Endoscopy was performed, confirming a tumour at 30 cm (measurement taken from patient’s front teeth), which at biopsy was found to be a poorly differentiated squamous cell carcinoma. Barium 1078-8174/99/030173+04
$18.00/O
at this time showed a short at the level of the carina.
malignant
Procedure The procedure was explained to the patient by the radiologist on the previous day, informed consent was obtained and the patient starved overnight. The patient’s details were checked in the X-ray Department and she was then positioned in the right anterior oblique position on the fluoroscopy unit. She was screened while drinking a mouthful of non-ionic water soluble contrast medium (Ultravist 240 Schering AG, Germany), so that the upper and lower end of the strictures could be localized (Fig. 1). A radiopaque ruler and metallic markers were placed on the patient’s skin to mark the upper and lower limit of the stricture. The patient’s throat was anaesthetized with xylocaine spray (Astra Pharmaceuticals Ltd.) and a soft 6F end hole catheter was swallowed. Through the catheter an Amplatz extra stiff 0.035 inch diameter guidewire was introduced and under careful fluoroscopic guidance the soft tip of the wire 0 1999 The College of Radiographers
Burkitt
Figure 2. A covered Gianturco stent (courtesy of Cook (UK) Ltd, with permission).
Figure 1. Radiopaque ruler and metallic markers placed on the skin to identify stricture.
the upper and lower margins of the
was passed through the stricture. Intravenous access had been established and the patient was sedated with 2 mg of midazolam (Benzodiazepam) intravenously. Oxygen was administered via a nasal cannula and the patient monitored with a pulse oximeter. The radiology nurse stood by the patient’s head with a suction catheter and the head end of the table was raised to reduce the risk of aspiration. (Cook U.K. Ltd, A 10 cm long Gianturco-Riisch Letchworth, Herts.) polyethylene covered oesophageal stent was chosen (Fig. 2). The Gianturco stent is made of a 0.5 mm stainless steel wire that is bent in a zigzag pattern with ends soldered to form a cylinder and is covered in polyethylene to
prevent tumour ingrowth. The expandable tube is compressed into an introducer catheter. The length of stent needs to allow for some proximal and distal spread of tumour to prevent 2-3 cm at either end of the overgrowth-normally stricture. The lubricated introducer sheath and dilator assembly were advanced over the guidewire and into the correct position within the oesophagus under fluoroscopic guidance. The stent introducer catheter with the premounted stent were pushed into the introducer sheath and the stent advanced by means of a pusher catheter. When the stent was confirmed to be in the correct position it was released by keeping it in position with the pusher catheter, as the introducer sheath was withdrawn. When the sheath is withdrawn the stent ‘springs’ open to the required diameter. The patient then had an erect chest radiograph to check that there was no evidence of pneumomediastinum. Following the procedure, the patient took nothing by mouth for 2-3 h to allow for the topical anaesthetic to wear off (so there was no risk of aspiration) after which time fluids were allowed. of a After 24 h on clear fluids an early resumption solid diet was encouraged. A barium swallow examination (Fig. 3) was performed 48 h after insertion of the stent to check its position.
Discussion Oesophageal carcinoma accounts for more than 3500 deaths per year in the U.K., and ranks as the
alignant
dysphagia
Figure
treated
with a metallic
3. Barium swallow
stent
48 h post-stent
insertion. (a) stent in place; (b) free passage of barium through
seventh most common malignancy worldwide [I]. Research by Jantsch et al. [2] has shown that almost two thirds of patients who present with advanced oesophageal carcinomas are not amenable to curative surgical resection and so long-term prognosis is poor. Patients initially present with dysphagia, particularly for solids and later as the tumour progresses for fluids as well. A barium swallow will frequently show the tumour as a stricture with shouldered margins. Squamous cell carcinoma until recently has been the commonest type of oesophageal cancer, but in recent years the prevalence of adenocarcinoma has been increasing, so now 50% of newly diagnosed cases of oesophageal cancer are adenocarcinoma [3]. The reason for this increase is not clearly understood, although these tumours arise from dysplastic Barrett’s epithelium, brought about by long standing gastro-oesophageal reflux disease. Nevertheless, squamous cell carcinoma remains the commoner tumour in the mid- and upper oesophagus. The palliation of oesophageal carcinoma has advanced since the first successful insertion of an oesophageal stent was reported in 1887 by Sir Charles Symonds. In 1959 Celestin developed a new plastic tube that was widely used in the
the stent.
palliative treatment of malignant oesophageal strictures. was still achieved During the 1980s palliation with plastic stents, but the outcome was often poor, with perforation rates of 7-B% [4] and most patients failing to return to a normal diet. There was also the complication of tumour overgrowth and tube migration causing further dysphagia. The use of metal stents improves palliation because complications such as perforation, haemorrhage, aspiration pneumonia and death at time of procedure are reduced [5]. The small calibre of the delivery system used for metal stents facilitates safe introduction and makes the procedure less distressing for the patients [6]. Radiological control of stent placement has the advantage over surgical and endoscopic techniques in that stent placement in the stricture is more precise. The main disadvantage of metal stents is the relatively high cost, especially if more than one stent is required. Plastic tubes such as the Atkinson’s tube are significantly cheaper but their placement is painful and they have a smaller internal diameter (6 mm less for 18 mm stents) so metal stents are better able to restore oesophageal patency. Although metal stents are more expensive their lower complication rate and consequent
Burkitt
176
reduced length of inpatient stay makes them more cost effective [7]. There are several different designs of metal stent available and choice of stent varies from centre to centre. Covered stents prevent ingrowth but are more prone to migration; however, newer designs can overcome this problem. Uncovered stents may occlude by tumour growth through the stent mesh, but the majority of patients do not live long enough for this to happen; most living only a few months after diagnosis [8]. Recent research suggests that, covered stents are preferable for lesions where the lower end of the stent is left above the cardia, and in patients in whom there is associated fistulation or perforation [9]. Uncovered stents, however, are preferable for lesions at the cardia as they are less prone to migration.
Acknowledgements Thanks are given to Dr Phil Panto, Consultant Radiologist, for his considerable guidance and help during the preparation of this paper, also to Vicki Smith-West Harden for her constructive comments, lain Mackintosh (Cook UK) for his help and finally to my husband David and manager Elaine Torr for ther continual support and encouragement.
References 1. Tan B, Mason R, Adam A. Minimally
advanced oesophageal malignancy. 828-36. 2. Jantsch H, Fuegger
R, Karnel F ef ul. Radiologic placement of endoprostheses for palliative treatment of malignant esophageal obstruction. I Interven Rudiol 1993; 8:
91-5. 3. Blot W, Devesa S, Kneller
adenocarcinoma
Conclusion Palliation of patients with oesophageal carcinoma can be effectively and safely achieved using metal stents. As compared to plastic stents they are easier to place, result in fewer complications and a shorter hospital stay. Stents treat the distress of not being able to eat and alleviate the lack of nutrition. This technological advance has therefore made the palliative care for the terminally ill patient with oesophageal carcinoma more tolerable. Metal stents are therefore a preferred method of palliating malignant oesophageal strictures.
invasive therapy for C/in Radial 1996; 51:
R et nl. Rising incidence of of the esophagus and gastric cardia.
]AMA 1991; 265: 1287-9. 4. Ogilvie A, Dionfield M, Percuson R, Atkinson
M. Palliative intubation of oesophago-gastric neoplasms at fiber optic endoscopy. Gut 1982; 23: 1060-7. 5. Sturgess R, Morris A. Metal stents in the oesophagus. G& 1995; 37: 593-4. 6. Neuhaus H. Metal esophageal stents. &ML 1991; 8: 305-10.
Murphy
Intervent R&cl/
G. Stents in the oesophagus. Postgrad Med ] 1995;
71: 453-6.
Cope C. Cllrrenf Techniques in Interventional Radiology. Philadelphia: Current Medicine, 1995. Adam A, Saunders M, Tan B, Watkinson A, Ellul J, Mason R. Triple randomised comparison of laser therapy and two types of metallic stent in inoperable esophageal carcinoma: initial results. Rudiulogy 1995; 197: 347.