Cryorecanalization for In-stent Recanalization in the Esophagus

Abstract

tent placement is commonly used for the manageSment of esophageal strictures and esophageotracheal fistula. However, recurrent dysphagia frequently occurs as a long-term complication and may be caused by hyperplastic or malignant tissue ingrowth despite the use of covered stents. Current treatment options include dilatation; however, this does not reduce redundant tissue. On the other hand, thermic ablation with argon plasma coagulation and snare resection shows good short-term efficacy, but induces hyperplasia itself and may damage the stent covering and mesh. Our 63-year-old patient underwent radiochemotherapy 3 years previously for proximal esophageal squamous cell cancer. Nine months after radiation, complete stenosis of the proximal esophagus had been recanalized by rendezvous retrograde wire cannulation. A 100-mm, fully covered stent (Ultraflex, Boston-Scientific, Ratingen, Germany, 18 mm/ 23 mm inner diameter) was placed from 14 to 24 cm from the incisors. Four months later, a 20-mm tracheoesophageal fistula developed that was already bridged with the esophageal stent. Tracheostomy had to be performed after vocal cord paralysis and maintained to date. In total, 35 gastroscopies and bronchoscopies had to be performed in the past 3 years for recurrent dysphagia and dyspnea, without histologic evidence of tumor recurrence. Now, the patient again presented with inability to swallow fluids. Esophagogastroduodenoscopy showed a short proximal stenosis that was balloon dilated and a longer distal stenosis from tissue ingrowth. Thermal tissue ablation at the distal site was not deemed an adequate option owing to the risk of breaking the integrity of the stent covering the esophagotracheal fistula; neither was placing a second stent across the lower end for risk of recurrent tissue ingrowth. Repeated dilatation had only provided short-term relief. Therefore, the patient was consented to cryoablation of hyperplastic tissue.