2151 Size Matters: A Case of Recurrent Proximal Esophageal Stenosis Treated With a Biliary Self Expanding Metal Stent (SEMS)

Abstract

INTRODUCTION: Esophageal stenosis after radiotherapy occurs in up to 15% of patients within 3 months of treatment. Endoscopic dilation remains the standard of care for cervical esophageal stenosis with refractory cases requiring stenting. Proximal stenosis pose a challenge as standard esophageal stents can cause cervicalgia and globus sensation due to their size and expansive force making the a biliary SEMS a better solution. CASE DESCRIPTION/METHODS: Patient is a 72 year-old Vietnamese male with pertinent past medical history of stage IV laryngeal cancer status post total laryngectomy, radiotherapy, and tracheostomy presenting with recurrent dysphagia. Patient had previously undergone four endoscopic dilations within the previous month for the same complaint. Upper endoscopy at time of admission revealed a recurrent benign stricture at the level of the upper esophageal sphincter. Given previous failed dilations, severity of stricture, and patient’s refusal for surgical correction or a gastrostomy tube, a biliary SEMS was placed with palliative intent. A fully covered biliary SEMS measuring 10 mm × 60 mm was deployed at the level of the stricture resulting in symptom resolution for 5 months. On recurrence of dysphagia, evaluation revealed distal migration of the SEMS. Retrieval was unsuccessful and the existing SEMS was overlapped with another 10 mm × 60 mm biliary SEMS which resulted in a symptom-free interval of 11 months. Both SEMS were retrieved and exchanged for a fully covered esophageal SEMS (18 mm). Patient had persistent symptoms and endoscopy revealed proximal migration of the esophageal SEMS. The esophageal SEMS was retrieved and a biliary SEMS (10 mm) was again deployed at the level of the stricture which resulted in resolution of symptoms. Patient has since had the stent exchanged every 3-4 months due to stent migration. DISCUSSION: Recurrent proximal esophageal stenosis pose a challenge for endoscopists due to their challenging anatomy. Standard esophageal stents currently available in the market start at a diameter of 12 mm making it less ideal for proximal esophageal strictures that cannot tolerate the expansive force of the larger stents. We have demonstrated the success of using a smaller-diameter biliary stent for the relief of dysphagia along with longer symptom-free intervals when compared to dilation and standard esophageal stents. This case demonstrates the need for further research and development of specialized esophageal stents for the treatment of recurrent proximal esophageal stenosis.