Overview
Definition:
Esophageal stent placement is an endoscopic procedure to insert a self-expandable or removable stent into the esophagus to relieve luminal obstruction or create a conduit
It is typically performed using flexible endoscopy and fluoroscopic guidance.
Epidemiology:
Esophageal obstruction, commonly due to malignancy or benign strictures, affects a significant portion of patients with esophageal cancer or severe benign esophageal diseases
The incidence of benign strictures varies based on etiology (e.g., GERD, radiation, caustic ingestion).
Clinical Significance:
This procedure is crucial for managing dysphagia and improving quality of life in patients with esophageal obstruction
It provides a less invasive alternative to surgery in many cases and is a vital skill for interventional endoscopists and surgeons managing esophageal pathologies
It is a frequently tested topic for DNB and NEET SS examinations in surgery.
Indications
Malignant Obstruction:
Palliation of dysphagia in unresectable esophageal cancer
Relief of malignant fistulas
Relief of extrinsic compression on the esophagus
Palliation of symptoms in advanced esophageal cancer.
Benign Obstruction:
Management of benign strictures refractory to dilation (e.g., peptic, anastomotic, radiation-induced)
Treatment of esophageal fistulas (e.g., tracheoesophageal, bronchoesophageal)
Management of esophageal perforations as a bridge to definitive treatment.
Other Indications:
Management of achalasia if other treatments fail or are contraindicated
Temporary stenting for esophageal leaks post-surgery or trauma.
Contraindications
Absolute Contraindications:
Unstable patient requiring immediate surgery
Complete esophageal obstruction precluding passage of guidewire
Active esophageal infection or sepsis
Severe coagulopathy unresponsive to correction.
Relative Contraindications:
Short life expectancy (less than 1-2 months)
Acute esophageal perforation where immediate surgical intervention is preferred
Severe comorbidities that significantly increase procedural risk
Distal esophageal obstruction extending into the gastroesophageal junction with significant reflux risk without anti-reflux stent configuration.
Diagnostic Approach
History Taking:
Detailed history of dysphagia (onset, progression, nature of food causing difficulty)
Weight loss
Odynophagia
History of GERD, radiation therapy, caustic ingestion, prior surgery, or malignancy
Assessment of patient's performance status (ECOG) and life expectancy.
Physical Examination:
General assessment for cachexia
Palpation for cervical lymphadenopathy or palpable masses
Abdominal examination for hepatomegaly or ascites
Assessment of nutritional status.
Investigations:
Upper GI Endoscopy: To visualize the lesion, assess the extent of obstruction, and obtain biopsies for histology
Barium Swallow: To delineate the anatomy of the stricture or tumor and assess the degree of obstruction
CT Scan Thorax and Abdomen: To stage malignancy, assess resectability, and rule out metastatic disease
Esophageal Manometry: To evaluate for motility disorders like achalasia.
Differential Diagnosis:
Peptic strictures
Radiation-induced strictures
Post-surgical anastomotic strictures
Caustic esophageal injury
Esophageal webs and rings
Esophagitis (infectious or eosinophilic)
Extrinsic compression from mediastinal masses or lymph nodes
Esophageal achalasia.
Preoperative Preparation
Patient Assessment:
Thorough medical evaluation including cardiac and pulmonary assessment
Review of coagulation profile (PT/INR, aPTT) and platelet count
Optimization of nutritional status if possible
Review of imaging to plan stent size and type.
Endoscopic Planning:
Selection of appropriate stent type (e.g., braided, silicone, uncovered, partially covered, fully covered) based on etiology (malignancy vs
benign), location, and length of stricture
Determination of stent diameter and length to ensure adequate esophageal lumen coverage and clearance of the obstruction
Use of guidewires, dilators (if necessary), and delivery systems.
Anesthesia And Sedation:
Procedure typically performed under moderate sedation or general anesthesia
Airway management is critical, especially in patients with significant airway compression or risk of aspiration
Prophylactic antibiotics may be considered in specific cases, especially for benign strictures or fistulas.
Procedure Steps
Endoscopic Visualization:
The endoscope is advanced carefully past the obstruction to visualize the lesion and assess the extent of luminal narrowing
A guidewire is then passed across the stricture under direct vision and confirmed with fluoroscopy.
Dilation If Needed:
If the stricture is very tight, balloon or bougie dilation may be performed to facilitate passage of the guidewire and stent delivery system.
Stent Deployment:
The stent delivery system, loaded with the chosen stent, is advanced over the guidewire to the target position
The stent is then deployed gradually under direct endoscopic and fluoroscopic visualization
The position is confirmed by radiopaque markers on the stent.
Post Deployment Assessment:
After deployment, the endoscope is withdrawn
A post-procedure fluoroscopic examination confirms proper stent position and patency
If a covered stent is used, it should extend beyond the obstructing lesion to prevent tumor ingrowth or leakage
For benign strictures, a partially or fully covered stent may be preferred to facilitate future endoscopic removal or dilation.
Postoperative Care
Immediate Monitoring:
Close monitoring for immediate complications such as chest pain, dyspnea, bleeding, or perforation
Vital signs are continuously assessed
Patients are typically kept nil per os (NPO) initially.
Dietary Advancement:
If no immediate complications arise, clear liquids are usually initiated within a few hours
Diet is gradually advanced as tolerated, with emphasis on soft, easily swallowable foods
Patients are advised to chew food thoroughly and drink fluids with meals to help move food past the stent.
Medications:
Proton pump inhibitors (PPIs) are often prescribed to reduce esophageal acid exposure and aid healing, especially if the obstruction is related to GERD or peptic strictures
Pain management is provided as needed
Prophylactic antibiotics are generally not required unless a fistula was sealed or there was significant contamination.
Follow Up:
Regular follow-up appointments are scheduled to assess symptom relief, monitor for complications, and manage the stent
Follow-up imaging may be performed to evaluate stent patency and rule out migration or ingrowth
For malignant obstructions, the focus is on palliative care and symptom management.
Complications
Early Complications:
Esophageal perforation
Bleeding (minor or major)
Stent migration (proximal or distal displacement)
Chest pain or discomfort
Aspiration pneumonia
Sedation-related complications.
Late Complications:
Tumor ingrowth through stent (especially uncovered stents)
Tumor overgrowth at stent ends
Stent migration
Stent fracture or deformation
Fistula formation (e.g., tracheoesophageal)
Esophagitis or ulceration at stent margins
Granulation tissue formation
Obstruction by food impaction
Sensations of fullness or foreign body.
Prevention Strategies:
Careful patient selection and risk assessment
Accurate stent sizing and placement to cover the lesion adequately
Using appropriate stent type (covered vs
uncovered) based on indication
Thorough fluoroscopic confirmation of deployment
Gradual dietary advancement and patient education on chewing and drinking with meals
Prophylactic PPI therapy
Regular endoscopic surveillance for malignancy-related complications.
Prognosis
Factors Affecting Prognosis:
The underlying cause of obstruction is the primary determinant
For malignant obstructions, prognosis is generally poor and stent placement is palliative
For benign strictures, stent placement can significantly improve swallowing and quality of life, with better long-term outcomes if the underlying cause is addressed.
Outcomes:
Successful stent placement leads to significant improvement in dysphagia scores and quality of life in most patients
Palliation of symptoms in malignant disease can provide weeks to months of improved swallowing
For benign strictures, it can be a durable solution or a bridge to definitive therapy.
Follow Up:
Long-term follow-up is essential for both malignant and benign causes
For malignant cases, follow-up focuses on comfort and symptom management
For benign cases, monitoring for stent-related issues like migration, obstruction, or overgrowth is crucial
Endoscopic removal or replacement may be necessary for benign strictures or fistulas
Patients should be educated to report new or worsening dysphagia, odynophagia, or chest pain.
Key Points
Exam Focus:
Indications for malignant vs
benign stenting
Choice of stent material and design (covered vs
uncovered, braided vs
silicone) for different etiologies
Management of common complications like migration and tumor ingrowth
Importance of fluoroscopy and endoscopy in deployment
Role in palliative care.
Clinical Pearls:
Always confirm guidewire passage across the entire stricture before stent deployment
Ensure stent is deployed with adequate coverage of the diseased segment, extending slightly beyond it
Educate patients thoroughly on post-procedure diet and potential symptoms to report
Consider removable stents for benign conditions where definitive treatment may follow.
Common Mistakes:
Undersizing or oversizing the stent
Inadequate coverage of the obstructing lesion
Failure to confirm guidewire position with fluoroscopy
Ignoring patient comorbidities
Insufficient post-procedure dietary education
Delaying investigation or treatment of stent-related complications.