Management of an esophageal metallic stent obstructed by tumor progression: endoscopic alcohol injection therapy instead of restenting

We report here a patient in whom an esophageal metallic stent was obstructed by tumor progression. The obstruction was treated successfully by endoscopic alcohol injection.

A 74-year-old man was diagnosed as having nonresectable esophageal cancer. An esophageal self-expanding covered metallic stent was implanted, but 5 months later the patient complained of inability to swallow fluids and saliva. Upper gastrointestinal endoscopy revealed a stent opening of 5 – 6 mm ([Fig. 1]), with the proximal end of the esophageal metallic stent obstructed by malignant tumor progression.

Fig. 1 Pretreatment endoscopic view showing severe narrowing of the proximal end of the esophageal metallic stent because of the infiltrating esophageal cancer.

We injected a total of 20 mL of 98 % alcohol across the four quadrants of the esophagus. The postintervention course was uneventful and the patient started oral intake of food on day 2 after the procedure. A follow-up endoscopic examination carried out 10 days after the procedure revealed a fully patent esophagus ([Fig. 2]).

Fig. 2 Posttreatment endoscopic view showing the patent esophagus, which depended on necrosis of the tumor after alcohol injection treatment. The previously placed stent is also seen.

The patency of the esophagus was adequate at further endoscopic follow-up 2 months later.

Covered metallic stents are increasingly used to prevent obstruction of the stent lumen by tumor progression [1] [2] [3]. However, the distal or the proximal end of an esophageal stent may also be obstructed due to tumor infiltration, as found in our patient. The general approach to management in such cases is implantation of a second stent [4]. However, insertion of stent is a costly procedure, requiring an experienced operator, and is associated with increased risk of stent-related complications such as esophageal perforation, aspiration pneumonia, bleeding, and severe retrosternal pain [5]. Obstruction of either end of a stent usually occurs over a short segment of the stent. It is easy to inject alcohol into the tumor tissue without prior dilatation. In our experience no serious complication was observed. In conclusion, endoscopic alcohol injection therapy is a cost-effective, easily carried out alternative to restenting in a patient with obstruction of an esophageal stent by tumor progression.

Endoscopy_UCTN_Code_TTT_1AO_2AZ

References

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