British Journal of Radiology (2004) 77, 787-789
© 2004 British Institute of Radiology
doi: 10.1259/bjr/93367963
Cervical oesophageal stent placement via a retrograde transgastric route
Y Inaba, MD
1
M Kamata, MD
2
Y Arai, MD
1
K Matsueda, MD
1
T Aramaki, MD
1 and
H Takaki, MD
1
Departments of 1 Diagnostic and Interventional Radiology and 2 Radiation Oncology, Aichi Cancer Center, 1-1 Kanokoden Chikusa-ku, Nagoya 464-8681, Japan
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Abstract
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During attempted oesophageal stent placement in a patient with cervical oesophageal cancer in whom swallowing of even saliva was impossible, transoral access to the cervical oesophagus was unsuccessful. Under ultrasound and fluoroscopy guidance, percutaneous gastric puncture was performed, and using an angiographic catheter and guidewire, access to the oesophagus by a retrograde transgastric route was successfully achieved. The obstructed segment of the oesophagus was traversed. It was then possible to pull the guidewire through the mouth and place an oesophageal stent via an antegrade approach.
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Introduction
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The usefulness of metallic stents for the palliation of malignant oesophageal stenoses is well established [1–3]. In general, stent placement in the oesophagus begins with the transoral passage of a guidewire through the oesophageal stenosis under endoscopic or fluoroscopic guidance. Cases are occasionally encountered in which passage of the guidewire is made difficult by the severity of the stenosis. By utilizing angiographic techniques with catheters and guidewires, impassable oesophageal stenoses have become rare.
We recently encountered a patient in whom even swallowing saliva was impossible. Transoral access to the distal cervical oesophagus was not possible due to the severity of the stenosis. As such, we performed a percutaneous gastric puncture, and gained access to the oesophagus by a retrograde transgastric route. It was then possible to pass the guidewire through the stricture into the mouth and place an oesophageal stent via a transoral route antegradely.
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Case report
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A 55-year-old man with cervical oesophageal cancer associated with tracheal invasion, was treated with external beam radiotherapy (72 Gy) combined with chemotherapy (5-FU and nedaplatin). From the start of these treatments, swallowing of liquids became impaired, and intravenous hyperalimentation was administered. After this treatment the invaded tracheal portion showed improvement, but the patient's dysphagia worsened, and even the swallowing of saliva became impossible. Unfortunately a nasogastric tube for feeding could not be inserted, and under ultrasound guidance the gastric wall was percutaneously punctured with a 23 G needle, the stomach inflated by injecting air into the gastric lumen, and percutaneous gastric puncture performed once again under fluoroscopic guidance using a Cope gastrointestinal suture anchor set (Cook, Bloomington, IN) to create a gastrostomy. However, 1 month later the gastrostomy tube was removed because of a subcutaneous infection around the gastrostomy site.
It was decided to insert an oesophageal self-expanding metallic endoprosthesis, and the cervical oesophagus was approached transorally. Using an angiographic catheter and guidewire, passage through the obstructed portion of the oesophagus was attempted, but the guidewire only entered the associated oesophagotracheal fistula (Figure 1
) and did not reach the proximal side of the oesophagus. Endoscopic attempts to traverse the obstruction were also unsuccessful. After treatment of the subcutaneous infection at the earlier gastrostomy site, a repeat percutaneous gastric puncture under ultrasound and fluoroscopy guidance was performed, and a 5 F angiographic sheath (Terumo, Tokyo, Japan) placed in the stomach. An angiographic catheter (5 F Headhunter; Clinical Supply, Gifu, Japan) and guidewire (0.035'' Radifocus; Terumo, Tokyo, Japan) were used to retrogradely cannulate the oesophageal stricture (Figure 1). The guidewire and catheter were then pulled through the mouth. The guidewire was then exchanged for a stiff wire 0.035'' Zebra exchange guidewire (Microvasive/Boston Scientific, Natick, MA). A 24 F Teflon sheath (Cook) was inserted in a transoral, antegrade fashion distal to the oesophageal obstruction, and a covered oesophageal stent (10 cm long covered Ultraflex; Microvasive/Boston Scientific) released proximally, and positioned under fluoroscopy such that its proximal edge did not extend as far as the oral side of the orifice of the oesophagus (Figure 2). The upper edge of the stent after placement was located at the level of the centre of the C6 vertebral body. A nasogastric tube was inserted, and the sheath placed in the stomach was removed. After stent placement the patient felt neither cervical pain nor foreign-body sensation, but experienced pain when attempting to swallow saliva. A follow up contrast study performed on the 4th day after stent placement, showed the stent to be almost completely expanded, and the associated shortening of its long axis resulted in a slightly lower position of the upper edge of the stent. Although only a small volume of contrast material could be swallowed at a time, passage through the stented area was good, and no oesophagotracheal fistula was depicted.
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Figure 1. Contrast oesophogogram performed retrogradely via the catheter inserted from the stomach and positioned at the distal edge of the obstructed portion of the oesophagus (arrows). The oesophagus proximal to the stricture and an oesophagotracheal fistula (arrowheads) are visualized.
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Figure 2. The oesophageal stent inserted via a transoral, antegrade fashion is seen at the level of the oesophageal stricture.
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7 days after stent placement the patient was able to swallow smoothly, and oral ingestion of semi-solids became feasible, allowing removal of the nasogastric tube. He died of progressive cancer 5 months after the stent placement, with oral intake continuing to be possible up to the week prior to his death.
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Discussion
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The use of expandable metallic stents for oesophageal stenoses due to unresectable malignant tumours is now established as valuable palliation, with the rapid amelioration of symptoms in a high proportion of cases. It is minimal invasive and low risk [1–3]. Stent placement is usually possible from the cervical oesophagus to oesophagogastric junction. In the cervical oesophagus there is concern that the more proximally the stent is placed the more marked will be the foreign-body sensation felt by the patient [1]. For this reason, initially stent placement near the oesophageal orifice (within 2 cm of the cricopharyngeus) was considered to be contraindicated [1]. Recently there have been some reports noting an absence of foreign-body sensation problems with stent placement up to the cricopharyngeus [4–7].
Stent placement in the oesophagus is usually via the transoral passage of a guidewire under endoscopic or fluoroscopic guidance through the stenotic portion of the oesophagus. Even in cases in which the severity of the stenosis precludes easy passage, this can usually be achieved by using angiographic technique with angiographic catheters and hydrophilic guidewires. Hitherto we had never experienced a case in which we had to abandon such a procedure because of the unsuccessful passage of a guidewire through the stenosis.
However, in the patient with cervical oesophageal cancer we describe, it was not possible to pass a guidewire transorally through the obstructed portion of the oesophagus. The distance from the cricopharyngeus to the obstructed portion was approximately 3 cm. Since the radiochemotherapy treatment had successfully reduced the size of the infiltrated portion of the trachea, it is possible that rather than progression of the cancer itself, marked fibrosis associated with the radiotherapy developed.
In cases of vascular obstruction it is not unusual if passage of a guidewire from one direction is difficult, to be able to pass the guidewire from the opposite direction with relative ease [8]. A transgastric retrograde approach was attempted making use of percutaneous gastrostomy technique, and as the stomach was collapsed ultrasound guidance was used. The oesophageal obstruction was traversed retrogradely, enabling a stent to be placed at the stricture. Before the present case, Novak et al reported percutaneous transgastric placement of oesophageal stents [9]. They inserted the 18–24 F delivery system through a gastrostomy, while we placed a 5 F angiographic sheath only in the stomach and pulled a guidewire retrogradely through the mouth, and then inserted the delivery system via an oral route antegradely. After stent placement the 5 F sheath via a transgastric route was removed, but no complications occurred.
Although it is unclear how effective a retrograde approach can be for luminal obstruction when passage from one direction is difficult, in cases in which access can be achieved an approach from both sides should be considered.
Received for publication September 9, 2003.
Revision received December 8, 2003.
Accepted for publication February 3, 2004.
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References
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Abstract
Introduction
