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Ventricular fibrillation after insertion of a self-expanding metallic stent for malignant dysphagia
AJG – March, 2000
Ventricular Fibrillation After Insertion of a Self-Expanding Metallic Stent for Malignant Dysphagia TO THE EDITOR: Since the first successful insertion of a metallic prosthesis in 1990 (1), self-expanding metallic stents (SEMS) are increasingly being used for palliation of dysphagia caused by upper gastrointestinal malignancy. Ease of insertion, low procedure-related mortality, and rapid improvement in dysphagia make metal stents a logical choice over plastic ones. Compared to the semirigid plastic prostheses, their safety profile is excellent (2). Tumor ingrowth/overgrowth and stent migration are common, but perforation and procedure related-mortality are exceedingly rare (2, 3). We report a case of refractory ventricular fibrillation after placement of a SEMS. Investigation of dysphagia and weight loss in a 73-yr-old man revealed a stricturing 5-cm tumor at the gastroesophageal junction. Bougie dilation with Savary-Guilliard dilators was performed and biopsies were taken at the time of the initial endoscopy. Histology revealed the tumor to be an adenocarcinoma. The patient had a past history of ischemic heart disease and had been on treatment with amiodarone for episodes of ventricular tachycardia, which had to be discontinued 3 months earlier because of development of side effects. He had not been prescribed any alternative antiarrhythmic since stopping the amiodarone. Computed tomography (CT) of the chest showed local infiltration from the tumor and spread to the regional lymph nodes. In view of his past medical history and CT scan result, surgical treatment was considered inappropriate and he was referred for palliation with a SEMS. Endoscopy was performed under conscious sedation with a combination of midazolam 5 mg and pethidine 25 mg. During the procedure he received supplemental oxygen, and his oxygen saturation was monitored by pulse oximetry. After dilation to 12.8 mm, a size 18-10, Esophacoil stent (Medtronic Instent; Medtronic, Eden Prairie) with a variable release handle, was placed in the lower esophagus and cardia, under fluoroscopy. The prosthesis is constructed from nitinol (nickel-titanium alloy), which is in the form of a tightly wound, coiled spring that shortens and widens on release. Satisfactory position was confirmed at re-endoscopy after placement of the stent. While the endoscope was being withdrawn, the patient’s oxygen saturation dropped, and he became cyanosed and started fitting. As no pulse was palpable, cardiopulmonary resuscitation was commenced. The patient was found to be in ventricular fibrillation (VF). Attempts at resuscitation, including repeated DC shocks, were unsuccessful, and the VF could not be terminated. We believe that, although our patient had underlying risk factors in the form of ischemic heart disease and previous episodes of ventricular tachycardia, the sudden, forceful expansion of the Instent Esophacoil contributed to the development of the VF. Cardiopulmonary complications of
Letters to the Editor
827
sedation, including respiratory depression and arrythmias, are the most common causes of death associated with upper gastrointestinal endoscopies (4, 5). The satisfactory oxygen saturation during the procedure in our patient makes respiratory complication of sedation an unlikely factor. The timing of the VF, on the other hand, suggests that the expansion of the coil prosthesis initiated the fatal arrhythmia by jolting the diseased myocardium. Experience with nitinol coil prostheses is limited, and there have been very few reports in the literature about its complications. Previously it has been reported that the expansion of the Esophacoil may lead to severe pain, necessitating its removal (6), but our report suggests that, very rarely, it may have more serious and unfortunate consequences. Hamid Awad Khan Ishfaq Ahmad Waqar Ahmed Department of Gastroenterology Gwynedd Hospital Bangor, United Kingdom
REFERENCES 1. Domschke W, Foerster Ech, Matek W, et al. Self-expanding mesh stent for esophageal cancer stenosis. Endoscopy 1990;22: 134 – 6. 2. Knyrim K, Wagner HJ, Bethge N, et al. A controlled trial of an expansile metal stent for palliation of esophageal obstruction due to inoperable cancer. N Engl J Med 1993;329:1302–7. 3. Cowling MG, Hale H, Grundy A. Management of malignant oesophageal obstruction with self-expanding metallic stents. Br J Surg 1998;85:264 – 6. 4. Bell GD. Premedication and intravenous sedation for upper gastrointestinal endoscopies. Aliment Pharmacol Ther 1990;4: 103–23. 5. Daneshmand TK, Bell GD, Logan RF. Sedation for upper gastrointestinal endoscopy: Result of a nationwide survey. Gut 1991;32:12–5. 6. Axelrad AM, Fleischer DE, Gomes M. Nitinol coil esophageal prosthesis: Advantages of removable self-expanding metallic stents. Gastrointest Endosc 1996;43:155– 60. Reprint requests and correspondence: Dr. Hamid Awad Khan, Department of Gastroenterology, Gwynedd Hospital, Bangor LL57 2PW, United Kingdom. Received Sep. 28, 1999; accepted Sep. 30, 1999.
Complete Regression of Hepatocellular Carcinoma Under Tamoxifen TO THE EDITOR: Hepatocellular carcinoma (HCC) is a common malignancy with a poor prognosis, particularly when the tumor is unresectable. The results of tamoxifen treatment on survival and tumor progression in patients with unresectable HCC have been disappointing (1, 2). We report the case of a 78-yr-old-man with genetic hemochromatosisrelated cirrhosis and multifocal, biopsy-proven hepatocellu-
Ventricular Fibrillation After Insertion of a Self-Expanding Metallic Stent for Malignant Dysphagia TO THE EDITOR: Since the first successful insertion of a metallic prosthesis in 1990 (1), self-expanding metallic stents (SEMS) are increasingly being used for palliation of dysphagia caused by upper gastrointestinal malignancy. Ease of insertion, low procedure-related mortality, and rapid improvement in dysphagia make metal stents a logical choice over plastic ones. Compared to the semirigid plastic prostheses, their safety profile is excellent (2). Tumor ingrowth/overgrowth and stent migration are common, but perforation and procedure related-mortality are exceedingly rare (2, 3). We report a case of refractory ventricular fibrillation after placement of a SEMS. Investigation of dysphagia and weight loss in a 73-yr-old man revealed a stricturing 5-cm tumor at the gastroesophageal junction. Bougie dilation with Savary-Guilliard dilators was performed and biopsies were taken at the time of the initial endoscopy. Histology revealed the tumor to be an adenocarcinoma. The patient had a past history of ischemic heart disease and had been on treatment with amiodarone for episodes of ventricular tachycardia, which had to be discontinued 3 months earlier because of development of side effects. He had not been prescribed any alternative antiarrhythmic since stopping the amiodarone. Computed tomography (CT) of the chest showed local infiltration from the tumor and spread to the regional lymph nodes. In view of his past medical history and CT scan result, surgical treatment was considered inappropriate and he was referred for palliation with a SEMS. Endoscopy was performed under conscious sedation with a combination of midazolam 5 mg and pethidine 25 mg. During the procedure he received supplemental oxygen, and his oxygen saturation was monitored by pulse oximetry. After dilation to 12.8 mm, a size 18-10, Esophacoil stent (Medtronic Instent; Medtronic, Eden Prairie) with a variable release handle, was placed in the lower esophagus and cardia, under fluoroscopy. The prosthesis is constructed from nitinol (nickel-titanium alloy), which is in the form of a tightly wound, coiled spring that shortens and widens on release. Satisfactory position was confirmed at re-endoscopy after placement of the stent. While the endoscope was being withdrawn, the patient’s oxygen saturation dropped, and he became cyanosed and started fitting. As no pulse was palpable, cardiopulmonary resuscitation was commenced. The patient was found to be in ventricular fibrillation (VF). Attempts at resuscitation, including repeated DC shocks, were unsuccessful, and the VF could not be terminated. We believe that, although our patient had underlying risk factors in the form of ischemic heart disease and previous episodes of ventricular tachycardia, the sudden, forceful expansion of the Instent Esophacoil contributed to the development of the VF. Cardiopulmonary complications of
Letters to the Editor
827
sedation, including respiratory depression and arrythmias, are the most common causes of death associated with upper gastrointestinal endoscopies (4, 5). The satisfactory oxygen saturation during the procedure in our patient makes respiratory complication of sedation an unlikely factor. The timing of the VF, on the other hand, suggests that the expansion of the coil prosthesis initiated the fatal arrhythmia by jolting the diseased myocardium. Experience with nitinol coil prostheses is limited, and there have been very few reports in the literature about its complications. Previously it has been reported that the expansion of the Esophacoil may lead to severe pain, necessitating its removal (6), but our report suggests that, very rarely, it may have more serious and unfortunate consequences. Hamid Awad Khan Ishfaq Ahmad Waqar Ahmed Department of Gastroenterology Gwynedd Hospital Bangor, United Kingdom
REFERENCES 1. Domschke W, Foerster Ech, Matek W, et al. Self-expanding mesh stent for esophageal cancer stenosis. Endoscopy 1990;22: 134 – 6. 2. Knyrim K, Wagner HJ, Bethge N, et al. A controlled trial of an expansile metal stent for palliation of esophageal obstruction due to inoperable cancer. N Engl J Med 1993;329:1302–7. 3. Cowling MG, Hale H, Grundy A. Management of malignant oesophageal obstruction with self-expanding metallic stents. Br J Surg 1998;85:264 – 6. 4. Bell GD. Premedication and intravenous sedation for upper gastrointestinal endoscopies. Aliment Pharmacol Ther 1990;4: 103–23. 5. Daneshmand TK, Bell GD, Logan RF. Sedation for upper gastrointestinal endoscopy: Result of a nationwide survey. Gut 1991;32:12–5. 6. Axelrad AM, Fleischer DE, Gomes M. Nitinol coil esophageal prosthesis: Advantages of removable self-expanding metallic stents. Gastrointest Endosc 1996;43:155– 60. Reprint requests and correspondence: Dr. Hamid Awad Khan, Department of Gastroenterology, Gwynedd Hospital, Bangor LL57 2PW, United Kingdom. Received Sep. 28, 1999; accepted Sep. 30, 1999.
Complete Regression of Hepatocellular Carcinoma Under Tamoxifen TO THE EDITOR: Hepatocellular carcinoma (HCC) is a common malignancy with a poor prognosis, particularly when the tumor is unresectable. The results of tamoxifen treatment on survival and tumor progression in patients with unresectable HCC have been disappointing (1, 2). We report the case of a 78-yr-old-man with genetic hemochromatosisrelated cirrhosis and multifocal, biopsy-proven hepatocellu-