Esophageal Cancer. Part 4
This is just showing the stent now in position. The guide-wire and delivery system is very carefully being removed, but you can see the annulated portion of the tumor in this region here with plenty of stent on each side. This device can actually be removed, or you can adjust this position after its placement. Keep in mind, be very careful when you remove the delivery system. It’s possible to snag on any of the stents and pull it out. This is just showing an endoscopic view of the lumen. This is an 18 mm diameter and the patient is now swallowing contrast material and you can see that pass through quite nicely off the distal end. So again, a successful placement.
A second video clip just showing the placement of Wilson-Cook Z stent. Again it comes in different sizes. It’s coded and it has flared ends on both sides. That’s hopefully to anchor the stent once it is positioned. The delivery system here is a bit different. More of the typical sheath retraction delivery system. But just watch. The tumor is located here and the upper margin is about there, but just watch as this stent is deployed there will be very minimal retraction. So fairly precise measurements can be made and hopefully you can maintain that precision when the stent is deployed. Here you can see the stent being slowly released as the sheath is being withdrawn, and you’ll see the delivery system and guide-wire have been carefully removed through the stent. This kind of device doesn’t quite have the radial force, as mentioned, of the EsophaCoil so you have to be very careful. It may not be fully opened for a minute or two. Always allow plenty of time for full deployment of the stent. In some situations you may actually want to go back down with the scope afterwards and carefully pass a TTS balloon to kind of aid in the full expansion of the stent. So here we are removing the guide-wire, you can look inside and if you think you need to, suggested by the radiographs, you may want to pass a TTS balloon and help the stent deploy a little bit further.
Those are two examples where things went pretty well. Does it always go that way? Of course not. This is called a “birds nest sign”. This is an EsophaCoil where the distal and proximal portions of the stent were beautifully released, and in the mid-portion unfortunately the whole thing just coiled up. Just kind of happened that way. Fortunately this can be taken care of. You can remove the EsophaCoil by grabbing the proximal end and just carefully removing the stent, and then a second was placed allowing for adequate lumen stenting.
How accepted are the stents right now? Well things really changed in 1993. This was the first randomized controlled trial comparing the plastic rigid-type stents to the … this was actually the Wallstent that was used, a randomized trial and following this the stents really gained a lot of acceptance and began to be used much more frequently. This study, as you will recall, isn’t a perfect study in that patients were kept in the hospital for a long time for the plastic stents, for dilation and general anesthesia and such, but the important take-home message is that the expandable metal stents were just as effective technically and functionally, but the complication was much less significant for the expandable metal stents. Perforations, pneumonias, migrations, didn’t occur in this limited study. And that’s really held true over the last six or seven years. Self-expanding stents require minimal pre-stent dilation. As I mentioned, the smaller caliber stents can be placed typically without any dilation whatsoever. The technical success across the board, looking at different series, between 90-100% – and most importantly – the functional success. The patient actually gets relief of dysphagia again at a very significant rate.