Esophageal Stenting: Expert Techniques

Esophageal stents are useful for palliation of dysphagia in patients who are not candidates for other therapy modalities either because of their comorbidities or because of tumor characteristics that classify the lesion as unresectable. Stenting is also indicated in patients with recurrent disease after completion of primary treatment. Stents are also used in the treatment of malignant tracheoesophageal fistulas as well as for nutritional support during neoadjuvant therapy. Benign indications for use include patients with esophageal perforations that are otherwise surgically unfit, patients with anastomotic leak after esophagectomy, and in patients with refractory esophageal strictures. Absolute contraindications include proximity of the lesion to the upper esophageal sphincter, presence of tracheal stent, and perforation measurement greater than 50 percent circumference of the esophagus or greater than 5cm in length. Relative contraindications include hemodynamically unstable patients as well as those with unresolved coagulopathy. Proximity of the lesion to the gastroesophageal junction (GEJ) is also a relative contraindication due to the risk of stent migration or stent placement in the stomach. 

Self-expanding metal stents come in two different types. Uncovered stents facilitate better embedding but can be difficult to remove and have a high risk of dysphagia symptoms. The fully covered stents allow for easy removal but have a higher risk of migration. The other most commonly used products are self-expanding plastic stents. The advantages to these stents are that they are easily retrieved endoscopically, but they have a higher migration rate and are technically more difficult to place. 

A thorough history and physical examination of the patient should be obtained. We recommend counseling patients about the possibility of post procedure chest discomfort, which is due to the expansion of the stent for up to seventy-two hours post deployment. 

We recommend a fluoroscopy compatible bed as well as C-arm capabilities. A standard EGD scope is needed, as well as an easily accessible pediatric scope. We recommend carbon dioxide insufflation as this is more readily absorbed by the GI tract mucosa and is associated with less postprocedure pain. The instructions for use card provided with the stent should be carefully examined to ensure proper usage. We recommend general anesthesia for this procedure as this facilitates easier placement, protects the airway from possible aspiration, and allows for concurrent bronchoscopy if needed. The patient should be positioned supine with the arms tucked to allow for C-arm movement. The procedure should begin with a diagnostic EGD. Radio-opaque markers are then used to note the GEJ, site of the lesion, and 2cm distal to the lesion. A spring tip guidewire is then placed endoscopically and positioned distal to the lesion. 

Choice of stent is guided by the internal diameter and should be slightly larger than the lesion to provide adequate radial force. The stent should overlap the lesion by 2cm proximally and distally. The EGD scope is withdrawn, and the stent deployment apparatus is placed over the guidewire. Proper placement is confirmed with fluoroscopy, and the stent is deployed directly under fluoroscopy. We recommend avoidance of reinstrumentation after deployment, which may dislodge the stent and lead to migration. 

References

1. Fackche, N.T., Garner, M., Ito, T., Brock, M. (2020) Use of Esophageal Stents, In Cameron, J.L., Cameron, A.M. (Eds), Current Surgical Therapy 13th ed. (pp. 70-78) 2020. Philadelphia: Elsevier Inc.
2. Wtodarczyk, J., Kuzdzal, J. Stenting in Palliation of Unresectable Esophageal Cancer. World J Surg 2018; 42 (12): 3988-3996.
3. Rhee K., Kim J.H., Jung D.H., Han, J.W., Lee, Y.C., Shin S.K., et al. Self-expandable metal stents for malignant esophageal obstruction: a comparative study between extrinsic and intrinsic compression Dis Esophagus 2016; 29 (3): 224.
4. van Heel, N.C.M., Haringsma, J., Spaander, M.C.W., Bruno, M.J., Kuipers, E.J., Short-Term Esophageal Stenting in the Management of Benign Perforations Am J Gastroenterology 2010; 105 (7): 1515-1520.
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 (2) 258.
6. Fuccio, L., Hassan, C., Frazzoni, L., Miglio R., Repici, A. Clinical outcomes following stent placement in refractory benign esophageal stricture: a systematic review and meta-analysis. Endoscopy 2016; 48 (2): 141-148.
7. van Heel, N.C.M., Haringsma, J., Spaander, M.C.W., Didden, P.,  Bruno, M.J., Kuipers, E.J., Esophageal stents for palliation of malignant dysphagia and fistula recurrence after esophagectomy. Gastrointest Endosc 2010; 72(2): 249.
8. Zhou, C., Hu, Y., Xiao, Y., Yin, W. Current treatment of tracheoesophageal fistula. Ther Adv Respir Dis 2017; 11(4): 173

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