7049 Endoscopic placement of esophageal expandable metal stents without fluoroscopic guidance.

Abstract

The insertion of expandable metal stents (EMS) is a fundamental palliative treatment for esophageal malignant neoplasia. Endoscopic placement of stents is usually performed under fluoroscopic guidance. Aims: Evaluation of feasability, efficacy and safety of the endoscopic insertion of EMS in esophageal malignant neoplasia without fluoroscopic guidance. Patients and Methods: Retrospective study of 60 patients (pts) with nonresectable esophageal cancer in whom 72 EMS were placed. The EMS used were distal release Ultraflex™ (Microvasive®, Boston Scientific Corporation), 7-15 cm long and 18 mm in diameter (22 covered stents). 91% of the patients were previously submitted to dilation and/or Nd:YAG laser. The procedures were done under sedation with midazolam and EMS were placed under endoscopic control with no fluoroscopic guidance. Severity of dysphagia was graded in a 0 to 4 score according to the consistency of food causing symptoms: 0 no dysphagia; 1 solid food; 2 semi-solid food; 3 liquid food; 4 total dysphagia. Results: 49 men and 11 women. Mean age 65±11 years. The indications for EMS insertion were dysphagia (78%) and esophagorespiratory fistulas (22%). Mean stricture length: 7.0±1.9 cm.The neoplasia were located in the upper esophagus in 23%, in the middle in 47% and in the lower in 30%. A significant improvement in dysphagia after stent placement was observed (mean pre-treatment score: 3.1±0.7; mean score after stenting: 1.5±0.5 - p<0.0001). Successful fistula closure was achieved in all cases. The indications for the insertion of more than one stent were: esophagorespiratory fistulas - 7; tumor ingrowth or overgrowth - 4; partial migration - 1. Early complications: incomplete stent expansion - 6; acute tracheal obstruction - 2; pneumonia - 1; mediastinal abcess - 1. Late complications: tumor ingrowth or overgrowth - 14; fistulas - 5; partial migration - 1. Procedure related mortality: none. Mean survival after stenting: 5.5+4.9 months. Conclusions: Endoscopic EMS placement in esophageal malignant neoplasia performed without flouroscopic control presented high efficacy with low complication rates. This approach has the advantage of lowering cost and duration of the procedure and avoids exposing pts and staff to radiation