Rendezvous Maneuver with Stent Deployment for a Completely Obstructing Malignant Esophageal Tumor

Abstract

Purpose: Esophageal cancer may present at an advanced stage with nearly complete obstruction of the esophageal lumen. In those severe cases, the patient's ability to swallow salivary secretions may be limited, and it becomes necessary to intervene to restore function, prior to initiating curative therapy. A rendezvous technique to place an esophageal stent has been reported for patients with benign strictures. This report describes a completely obstructing squamous cell carcinoma (SCCA) of the esophagus in which patency was restored with an Evolution® Controlled Release Esophageal Stent (Cook Medical, NC, USA) placement via a rendezvous maneuver. Methods: A 59-year old African-American man with a history of SCCA of the epiglottis (T2N2c) treated with chemoradiotherapy 7 years ago, initially presented with dysphagia for 6 months. EGD revealed an area of narrowing at 27 cm from the gums with mucosal irregularities that were negative for malignancy. At that time, a PEG tube was placed to assist with feeding. After the patient developed an inability to swallow saliva, a repeat EGD showed a completely obstructing mass at 25 cm from entry, which demonstrated SCCA. A PET/CT scan did not show any evidence of distant metastasis. It was decided that esophageal stent placement would help the patient handle secretion and prevent further morbidities. Results: The proximal end of the completely obstructing mass was visualized by EGD at 25 cm from the entry. An ERCP guide wire through a standard biliary catheter could not be cannulated via the mass under fluoroscopy while utilizing occlusion balloon esophagraphy. A pediatric endoscope after removal of the existing PEG tube was passed via the PEG tube site through the stomach. A hydrophilic biliary guide wire was then transversed in a retrograde fashion through the mass with fluoroscopic monitoring. The guide wire was proximately advanced until it was visualized in the esophagus from above. The guide wire was then drawn out of the mouth. Both ends of the wire were pulled in order to create tension that would prevent a misalignment of the stent. Without pre-dilation of the esophageal lumen, the Evolution® Controlled Release Esophageal Stent with dual flanges (12.5 cm with inner caliber of 20 mm and outer diameter of 25 mm) was successfully placed over the guide wire under fluoroscopic guidance. Stent expansion was confirmed after placement. Conclusion: Combined antegrade and retrograde rendezvous maneuver for Evolution® Controlled Release Esophageal Stent placement appears to be a safe and effective technique for restoring the esophageal lumen in a patient with a completely obstructing esophageal cancer even before curative therapies.