P-0009 Palliative Esophageal Metal Stenting Under Endoscopic Guidance Without the Use of Fluoroscopy: Initial Experience at an Indian Centre

Abstract

ABSTRACT Introduction Esophageal carcinoma is a common cancer, many patients require palliative metal stenting. Fluoroscopy is not available in every endoscopy unit, this situation leads to delay in treatment or to transfer to other centres for metal stent insertion. Few reports of stent insertion under endoscopic guidance. We assessed safety and efficacy of expandable Esophageal metal stent placement under the endoscopic guidance. Methods From March 2010 to January 2012, 8 patients with Carcinoma Esophagus and 5 with carcinoma Gastroesophageal junction were included in the study for esophageal metal stent placement under endoscopic guidance with use of Olympus EVIS 130 Gastroscope. A proximal release covered Ultraflex, Boston scientific, Microvasive or distal release covered Choo stent was used. Dilatation of stricture was done up to 8 mm with American dilator in selected patients. Study was conducted at our centre by single endoscopist. Patients had been worked up for resectability by Compound tomography chest and abdomen, Initial Gastroscopy had been done for extent, circumference of tumor and histopathology confirmation done by biopsy of tumor. All the tumors were unresectable. All the GE junction tumors were adenocarcinoma and seven out of eight esophageal carcinomas were squamous cell in origin. Metal stenting was done under the scope guidance after placement of guidewire with gastroscope, removal of scope, pushing stent over the guidewire till desired extent as per marking, lastly scope was again placed in just above the stricture, the stent was gradually opened. After full opening of stent, confirmation of correct position was done with passage of scope through the stent. After the stenting patients were followed 2 weekly as OPD visit for Clinical assessment, x ray chest and Upper GI endoscopy. Results Stent placement under the Gastroscope guidance was successful in 12 out of 13 patients. Early complication (with in 1 week) were stent migration in one patient with air leak at Gastroesophageal junction most likely during dilatation before stent placement, patient recovered well with conservative treatment. In one patient stent could not open fully, then it was opened with the help of through the scope balloon dilatation, in one patient stent could not fully cover the malignancy at lower end, one more metal stent placed to cover up the malignancy fully. Seven patients complained of retrosternal pain lasting 1 to 2 days. There was late complication like persistent chest pain in one patient and reflux symptom in 2 patient with GE junction carcinoma, which was managed with propped up position, prokinetics and Proton pump inhibitors. Immediate relief of dysphagia observed in all patients within 48 hours, dysphagia score improved from 3.6 to 1.2 in all. Later on 2 month follow up X Ray Chest and Upper Gastrointestinal endoscopy confirmed proper placement of stent in twelve out of thirteen patients as described above. Conclusion Expandable esophageal metal stent can be safely and accurately placed under gastroscope guidance. This method obviates the fluoroscopy requirement lacking at many endoscopy units and also avoids exposure to radiation.