S2225 Novel Hemostatic Stenting in the Esophageal Cancer Patient

Abstract

INTRODUCTION: This is a case of unconventional stent placement to achieve hemostasis of upper GI bleeding due to esophageal adenocarcinoma. CASE DESCRIPTION/METHODS: An 81-year-old woman with a history of metastatic esophageal adenocarcinoma, coronary artery disease status post CABG and non-insulin-dependent diabetes mellitus presented to the emergency department with a 24-hour history of intermittent lightheadedness and auditory and visual hallucinations. Patient also reported dyspnea, nausea, hemoptysis and melena. She was receiving chemotherapy with capecitabine and monthly esophageal dilations to maintain patency and relieve dysphagia. Her vital signs were within normal limits. Pertinent findings on physical exam included acute distress and pallor of the conjunctivae and mucosa. She had maroon-colored coffee ground output from her PEG tube. Labs showed an elevated BUN and creatinine, mildly elevated troponin, and trace ketones in her urine. She was profoundly anemic with an H&H of 5.2/18.5 and an MCV of 95.9. On endoscopic evaluation, a hemorrhagic exophytic mass measuring 4 cm was seen in the distal esophagus. Following gastric lavage, a fully covered self-expanding metal stent (SEMS) was successfully placed over the length of the mass achieving complete hemostasis. She was volume resuscitated over several days and discharged home with an H&H of 10.5/32. DISCUSSION: Over half of esophageal cancers are unresectable at the time of diagnosis due to distant metastasis and involvement of local structures. Consequently, diagnosis currently confers a 5-year survival rate of less than 20% and treatment is often palliative rather than curative. The use of SEMS in the treatment of dysphagia, maintenance of patency, and management of esophageal variceal bleeding is well-documented. It was this last application that inspired off-label use of SEMS for hemostasis in this case. Other available hemostatic techniques provide effective short-term hemostasis, but have higher rates of rebleeding. A future rebleed would be potentially catastrophic to this patient with stage IV esophageal adenocarcinoma which highlighted the importance of a more long-term solution in order to avoid future need for intervention. A search of the medical literature revealed another case report from 2016 which achieved similar satisfactory results indicating a promising venue for further research in this area. The compassionate use of SEMS in this case may represent a favorable alternative to the present technologies which have many limitations.Figure 1.: Retroflexed view of tumor with active bleed extending beyond GE junction.Figure 2.: Successful stent placement.Figure 3.: Patient's hemoglobin levels before and after stent placement. Orange arrow indicates time of stent placement.