Polyflex Stent Placement Immediately Following Endoscopic Ultrasound Staging of Advanced Esophageal Malignancy: A Feasible and Effective Alternative to Surgical Jejunostomy

Abstract

Purpose: Endoscopic Ultrasound is evolving as an integral tool in T and N staging for esophageal malignancies. Preoperative neoadjuvant chemotherapy and radiation is the standard of care for locally advanced tumors (T2B and T3). Adequate nutrition during neoadjuvant therapy significantly improves patient outcome. In addition, the ability to eat during therapy is desirable and vastly improves patient satisfaction. The standard of care to date for providing nutrition during neoadjuvant therapy has been enteral feeding through a surgical jejunostomy. We describe our experience with the placement of a removable, expandable esophageal stent at the time of endoscopic ultrasound staging for locally advanced esophageal malignancies. Methods: Six consecutive patients staged by endoscopic ultrasound as T2b or T3 underwent simultaneous placement of a Polyflex (Boston Scientific) stent. After EUS staging, the stent was deployed under fluoroscopic guidance as per routine. The length and diameter of the stent was determined based on the lumenal diameter and fluoroscopic length of obstruction. All patients were consented preprocedurally for both EUS and stent placement. All patients considered for stent placement had a dysphagia score of 3-4 (0-4 scale). All patients were given the option of feeding jejunostomy as an alternative to stent placement. Results: All six patients underwent Polyflex stent placement successfully without complication. Follow up these patients currently ranges from 6-9 weeks. All patients have successfully begun neoadjuvant therapy and report dysphagia scores of 0 to 1. To date there have been no stent migration or complications. All patients are maintaining adequate nutrition during neoadjuvant therapy and have normal to near normal dysphagia scores. All patients report increase in overall physical and mental well being after stent placement. Conclusion: Polyflex stent placement immediately following staging of locally advanced esophageal malignancies is both feasible and effective. Placement of the stent at the time of EUS did not add significant procedural time. It provides tremendous patient satisfaction in comparison to a feeding jejunostomy and significantly reduces dysphagia scores. Polyflex stent placement should be considered as an alternative to feeding jejunostomy in patients undergoing preoperative neoadjuvant chemotherapy and radiation for locally advanced esophageal malignancies.