Prophylactic Use of Covered Metal Stent to Prevent Stricture Formation after Long Segment Circumferential EMR

Abstract

Purpose: Endoscopic mucosal resection (EMR) and ablation are alternatives to surgery for Barrett's esophagus (BE) with high grade dysplasia (HGD) and intramucosal carcinoma. Endoscopic therapies may have an advantage over esophagectomy given the associated mortality and morbidity. But circumferential EMR of the esophagus for long segment BE with HGD has been shown to be complicated by stricture formation. We describe a case of circumferential EMR with prophylactic covered stent placement. Methods: A 57 y/o with coronary artery disease was diagnosed with long segment Barrett's (8 cm) with HGD. EUS showed no invasion into the muscularis mucosa or lymph adenopathy. The patient declined surgery and elected EMR. He underwent circumferential EMR of the BE from 42 cm to 34 cm. The BE mucosa was suctioned up into a band ligator to create pseudoplyps. These pseudopolyps were resected with a hot snare. A Roth net was then used to retrieve the tissue and bands. 40 cc of saline mixed with 10 cc of epinephrine was flushed into the lumen to decrease oozing. A 22 × 120 mm alveolus stent was placed over a guide wire positioned parallel to the scope, under direct endoscopic visualization. The patient complained of severe heart burn in the post procedural period and hence the stent was pulled proximally to have distal tip lay above the GE junction with the proximal tip at 23 cm. He later complained of chest pain. In spite of narcotic treatment, he continued to experience moderate pain requiring removal of the stent on Day# 5. Results: The patient recovered well after the stent removal and had no further pain. On follow up at 5 weeks, he had no significant strictures despite extensive EMR. Some residual BE mucosa was again resected to achieve what appeared to be a complete removal of BE mucosa. Patient remains asymptomatic after 3 months on a regular diet. Conclusion: Prophylactic stent placement after circumferential EMR has not been reported to our knowledge. Most common complications of EMR include bleeding, perforation and stricture formation. Strictures when they occur are usually treated with bouginage. Complete loss of lumen will be more difficult to treat. A case of complete esophageal stenosis which eventually required esophagectomy is described (ref). Prophylactic temporary stent placement, even short term, may be an effective way to prevent stricture formation. It should be noted that our patient experienced significant pain requiring stent removal after 5 days. Further experience on a larger patient population is needed to prove efficacy of this strategy.