2152 A Novel Technique Using Hemostatic Spray and Endoscopic Stent-in-stent for Palliation of Hemorrhaging Esophageal Cancer

Abstract

INTRODUCTION: Most esophageal cancers present at an advanced unresectable stage; thus, the main focus is on palliative treatment and symptom management to improve quality of life. Esophageal stents in combination with radiation therapy are commonly used to palliate dysphagia and bleeding in these patients. We describe a novel case of an advanced metastatic esophageal cancer presenting with a massive GI bleed, treated successfully with hemostatic spray and stent in stent technique. CASE DESCRIPTION/METHODS: A 61-year-old male with recent diagnosis of stage IV esophageal adenocarcinoma was transferred to our hospital with a massive GI bleed. He had undergone an emergent EGD at that facility with unsuccessful endoscopic hemostasis of the profusely bleeding esophagus mass. We performed a repeat EGD, that showed a 20 cm long, diffusely bleeding partially obstructing malignant esophageal tumor. We achieved successful endoscopic hemostasis with the use of the hemostatic spray, followed by EUS-guided fiducial marker placement at the proximal and distal ends of the tumor in preparation for stereotactic radiation therapy. The entire length of the tumor was then stented using the 20 mm × 15 cm and a 20 mm × 8 cm through-the-scope fully covered esophageal metal stents with a stent-in-stent technique for tamponade of bleeding and palliation of dysphagia. He did not have any further rebleed episodes and was able to successfully receive palliative radiation as outpatient with improved quality of life at 6 months follow up. DISCUSSION: Treatment of advanced esophageal cancers is mainly based on palliative management. Chemo or radiation therapy can provide palliation in patients with unresectable disease. Our case highlights the use of a novel approach with combined use of hemostatic spray and stent-in-stent technique as a bridge to radiation therapy after adequate control of tumor bleeding, facilitating palliative radiation therapy and improved quality of life and survival.