Self-expanding metal stent with anti-reflux valve for palliation of distal oesophageal carcinoma

Clinical History

Patient presenting with grade 3 dysphagia and weight loss.

Imaging Findings

The patient presented with a three month history of progressive dysphagia and weight loss associated with upper abdominal discomfort. A barium swallow showed a malignant looking stricture in the lower oesophagus (Fig. 1) above a sliding hiatus hernia. Upper GI endoscopy was performed and biopsies were taken from an obstructing tumour found at 30cm from the mouth (Fig. 2). It was too tight to be passed with the scope, histology was of an adenocarcinoma.
Staging CT scan of thorax and abdomen demonstrated a 6cm diameter distal oesophageal mass indenting the trachea and left atrium with associated pre-tracheal lymphadenopathy indicating inoperability (Fig. 3). He was referred for palliative oesophageal stenting. At that time he had grade 3 dysphagia, managing only liquids.
After informed consent the patient was enrolled into a trial comparing three anti-reflux stents and randomised towards insertion of a FerX–ELLA anti-reflux stent (Fig. 4). The procedure was performed under conscious sedation and fluoroscopic guidance. After application of 4% xylocaine spray to the throat, the patient was placed in a prone position and given nasal oxygen and monitored by a dedicated interventional nurse, including pulse-oxymetry and non-invasive blood pressure measurement. Sedation was achieved by titration of a total of 25mg pethidine and 4 mg midazolam.
Under fluoroscopy a 6 Fr. general purpose catheter (Cordis/Johnson & Johnson) was introduced into the oesophagus and the stricture negotiated with an 0.035” hydrophilic wire (Radiofocus, Terumo UK). The stricture was outlined with non-ionic contrast (Omnipaque 350, Nycomed Amersham) and metal markers attached to the patient’s skin indicating the level of the stricture. After exchange for a 0.035” stiff wire (Amplatz superstiff, Cordis/Johnson & Johnson) a 15cm covered Fer-X Ella anti-reflux stent (Radiologic UK/Ella-CS, Czech Republic) was deployed with the distal end in a small axial hiatus hernia. The procedure is illustrated in figure 5. Stent release was uncomplicated, but on withdrawal the introducer tip would initially not pass through the narrowest point of the stent (Fig. 6). A 15mm dilatation balloon was passed alongside and the waist of the stent dilated, after which the introducer system could be removed without further problem (Fig. 7). Free fluids were allowed after two hours and a soft diet the same evening. The patient was very reluctant to eat although a check-swallow with water-soluble contrast showed the stent to be fully expanded in a good position (Fig. 8) It took several weeks to build up the patient’s confidence sufficiently to return to a normal diet, although this was tolerated without problems.

Discussion

The incidence of oesophageal carcinoma is rising due to rapidly increasing number of adenocarcinoma arising in the lower oesophagus. Onset of symptoms is often late and many tumours are inoperable at presentation. Progressive dysphagia and weight loss of short duration are the presenting complaint in the vast majority of patients. Malignant dysphagia is a highly debilitating condition, which aggravates tumour cachexia as well as excluding patients from social functions. As a result, quality of life is badly impaired and malnutrition reduces poor life expectancy even further.
A number of options are available for palliation. Endoscopic ablation using laser and stenting techniques are commonly used [1]. Placement of self-expanding oesophageal endoprostheses is initially more expensive but has substantially faster and more maintained palliation of dysphagia than endoscopic laser therapy [2]. Palliative radiotherapy has the drawback of slow onset of improvement and dysphagia is often made worse initially due to the mucosal oedema.
Advances in stent technology have rendered this a safe, readily available treatment for the palliation of dysphagia [1], which has superseded rigid rubber tubes, bi-cap diathermy and ethanol injection.
One of the more recent improvements in stent design is the introduction of antireflux valves for stents crossing the gastro-oesophageal junction. Antireflux stents are as safe and effective as standard open stents in relieving malignant dysphagia and dramatically reduce the incidence of symptomatic gastroesophageal reflux as well as the risk of aspirating gastric content [3]. They do not interfere clinically with oesophageal emptying and significantly improve the quality of life of these patients [4]. Successful palliation dysphagia with oesophageal stents can be expected in more than 95% of cases [5]. Stent placement under fluoroscopic rather than endoscopic guidance is less expensive and quicker and allows more accurate positioning. Check swallow examinations are not routinely required.

Differential Diagnosis List

Final Diagnosis

Oesophageal carcinoma, stenting

URL:	https://www.eurorad.org/case/2167
DOI:	10.1594/EURORAD/CASE.2167
ISSN:	1563-4086