Esophageal Stenting in Unusual Situations

Introduction

Esophageal cancer is frequently unresectable at the time of diagnosis because of local invasion or metastatic disease. Therapy is therefore usually palliative in nature, with the major aims being relief of dysphagia, maintenance of nutrition and occlusion of tracheoesophageal fistula. Palliative surgery eventually offers the best palliation for esophageal obstruction symptoms and signs such as dysphagia and vomiting. However because of the very poor prognosis, the short median survival time and the considerable morbidity and mortality rate of surgery, this approach cannot be justified in preference to less invasive nonsurgical techniques.

There are numerous nonsurgical palliative treatments, including radiation therapy (external or intracavitary), endoscopic stenting, chemotherapy, endoscopic tumor ablation with BICAP electrocoagulation and argon plasma coagulation (APC), injection of necrolytic agents, Nd:YAG laser photocoagulation and photodynamic therapy. Recently various self-expandable metal stents (SEMS) have been developed for palliation of malignant obstruction of the esophagus.

The major impact of these stents is associated with the ease of insertion and the potential for fewer complications compared with plastic stents. Because SEMS offer many advantages, endoscopists have in recent times preferred to use SEMS for the treatment of esophageal obstruction. In spite of the many advantages of SEMS, limitations and difficulty are sometimes encountered in esophageal stenting because of complete luminal obstruction; sharp angulation of the esophagus due to tortuous tumor growth; previous surgery; previous radiotheraphy and severe kyphoscoliosis; the tumor’s being unusually soft and necrotic or excessively hard and scirrhous; the presence of fistula in the absence of appreciable luminal constriction starting at the upper or lower end of the malignancy; and extension of the tumor to the upper esophageal sphincter.

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