Continuous Access Technique for Dilation, Evaluation, and Stent Palliation of Malignant Luminal Digestive Tract Strictures

Abstract

Introduction: Endoluminal stent placement is an effective means of palliating malignant stenoses. Malignant stenoses in which there is complete obstruction, fistula, and/or inability to pass the endoscope present challenges to endoluminal stent therapy. It is advantageous to advance the endoscope through these malignant stenoses to precisely appreciate their localization, length, and configuration. These factors impact on stent selection and deployment. We define, and describe our experience with, a technique to establish and maintain continuous access to facilitate evaluation and stent placement in challenging malignant stenoses. Methods: The continuous access technique employs advancement of an 0.035″ Teflon coated coiled steel or hydrophilic coated nitinol guidewire under endoscopic and fluoroscopic guidance through the stenosis. A guidewire-compatible graded radial diameter through-the-scope balloon dilator is then advanced into the stenosis. Incremental balloon dilation is performed to 1-mm above the outside diameter of the endoscope. Then, with the inflated dilator snug to the tip of the endoscope, using the balloon dilator as an obturator tip, this assembly is advanced over the guidewire through the stenosis. The dilation catheter is then removed; the distal margin of the tumor marked; and stent placement performed. This Continuous Access (CA) technique was defined and detailed in the records of stent placement beginning in February 1999. We reviewed the records for techniques of all stent placements by two clinicians from Feb 1999 through Aug 2004. Results: There were 126 attempted stent placements for malignant strictures (96 Esophageal/EG junction, 22 Gastroduodenal, 8 Colorectal). In 75 (60%) the endoscope traversed the stricture with no dilation. In 13 (10%) the scope traversed after standard dilation was performed. In 8 (6%) stents were placed after only a guidewire was advanced across the stricture under fluoroscopic guidance. In 30 (24%), inability to advance the scope with or without standard dilation prompted use of the CA technique. CA technique was successful in traversing the stricture in 29 (1 failure,esophageal). A stent was successfully placed in all but one patient. There were no procedure related complications. Conclusion: The continuous access technique safely and effectively facilitates scope passage through strictures thereby enhancing precision in stent selection and deployment for palliation of challenging malignant stenoses. Introduction: Endoluminal stent placement is an effective means of palliating malignant stenoses. Malignant stenoses in which there is complete obstruction, fistula, and/or inability to pass the endoscope present challenges to endoluminal stent therapy. It is advantageous to advance the endoscope through these malignant stenoses to precisely appreciate their localization, length, and configuration. These factors impact on stent selection and deployment. We define, and describe our experience with, a technique to establish and maintain continuous access to facilitate evaluation and stent placement in challenging malignant stenoses. Methods: The continuous access technique employs advancement of an 0.035″ Teflon coated coiled steel or hydrophilic coated nitinol guidewire under endoscopic and fluoroscopic guidance through the stenosis. A guidewire-compatible graded radial diameter through-the-scope balloon dilator is then advanced into the stenosis. Incremental balloon dilation is performed to 1-mm above the outside diameter of the endoscope. Then, with the inflated dilator snug to the tip of the endoscope, using the balloon dilator as an obturator tip, this assembly is advanced over the guidewire through the stenosis. The dilation catheter is then removed; the distal margin of the tumor marked; and stent placement performed. This Continuous Access (CA) technique was defined and detailed in the records of stent placement beginning in February 1999. We reviewed the records for techniques of all stent placements by two clinicians from Feb 1999 through Aug 2004. Results: There were 126 attempted stent placements for malignant strictures (96 Esophageal/EG junction, 22 Gastroduodenal, 8 Colorectal). In 75 (60%) the endoscope traversed the stricture with no dilation. In 13 (10%) the scope traversed after standard dilation was performed. In 8 (6%) stents were placed after only a guidewire was advanced across the stricture under fluoroscopic guidance. In 30 (24%), inability to advance the scope with or without standard dilation prompted use of the CA technique. CA technique was successful in traversing the stricture in 29 (1 failure,esophageal). A stent was successfully placed in all but one patient. There were no procedure related complications. Conclusion: The continuous access technique safely and effectively facilitates scope passage through strictures thereby enhancing precision in stent selection and deployment for palliation of challenging malignant stenoses.