Our next case is by Rabia Latorre, who's my colleague. She is the Director of Endoscopy at Bellevue at NYU Grossman School of Medicine. Welcome, Rabia. Hi, good morning. Thank you so much to the ASG and for the course directors for having me today. I'm going to be presenting a case today on esophageal strictures. All right, these are my disclosures. Okay, so I'm just gonna jump right into the case. But as you all know, there's a few different causes for esophageal strictures. We often see peptic strictures for people with longstanding, especially untreated acid reflux. You can also see esophageal rings and webs, as well as akalasia. But I'm going to be presenting a case of a malignant stricture today. So we had a 50-year-old female with no past medical history who presented to an outside hospital with a very classic solid and then liquid progressive dysphagia that progressed over only six weeks and a 20-pound weight loss. She was initially imaged and then scoped at outside hospital and they found a malignant stricture in her distal esophagus that extended into the cardia. And it was biopsied and found to be poorly differentiated adenocarcinoma. And this was back in September 2021. She, during that same hospitalization, underwent a fully covered metal stent placement by the outside hospital practitioners. And then she was referred to our hospital at Bellevue for not only oncologic care, but also surgical oncology care for staging. So during her hospitalization, when she was transferred to us, they did diagnostic laparoscopy and she was diagnosed with peritoneal mets or stage four disease. But during that time, they also placed a surgical J-tube. And the reason was because despite imaging revealing a completely patent stent, she was having very poor PO tolerance and she was also experiencing a lot of reflux, which is very common in patients who have a stent that traverses a GE junction. And it can actually be so intractable that it's something you have to actively counsel someone. When you're going to stent across a GE junction, you have to tell them that the GERD and the acid reflux of symptoms may be pretty severe. And so they must be aware of that fact. So she never really had any follow-up plan with the outside hospital gastroenterologist despite the stent placement and despite the fact that it is a temporary stent, it's fully covered. So she, after her initial staging, they basically wanted to eventually, after she was treated with chemotherapy, I think that was on the last slide, sorry, she got chemotherapy after she was diagnosed with stage four disease. She received eight cycles of chemo with FLOT and she was essentially then re-imaged to see what happened to the tumor. It had decreased in size with the chemotherapy, which was great. And the hope was that eventually we could remove the stent, advance her diet, and then eventually remove the J-tube. But the imaging revealed that despite the fact that she had been doing well and the tumor was shrinking, the stent had migrated into the stomach, which on one hand is unfortunate, but on the other hand it tells you the chemotherapy worked, the tumor shrunk and the stent slid into the stomach. So that's also a good sign. So she was referred to us for stent removal. So we did an endoscopy. You can see on the imaging in the top right on the CT scan that the stent is in the stomach. But in the endoscopy, there appeared to be a benign stricture at 33 centimeters from the incisors, which was where the previously placed stent that was a proximal edge of it. And what it appeared to be was that the stent had been in place for so long that she developed some fibrosis or scarring in that area, and she developed a new stricture. And the stricture was so tight, we weren't actually able to pass the adult gastroscope. So she had to downsize to an XP scope, and we found the actual tumor was a few centimeters distal to this new stricture that was quite tight. So when we tried to remove the stent, when you remove any stent, it's basically a foreign body removal, right? But when you're trying to remove a stent that has either a gold bead or a loop at the proximal phalange, it should collapse really nicely. But what happens is with some stents that have been in place for a very long time, they can get a bit brittle, and they become very hard to collapse. And that's actually what we experienced with this stent. So it broke. The gold bead, the loop broke, and further attempts in trying to pull the proximal phalange resulted in the stent just becoming worse and worse. The phalange is sticking out, and those can be quite dangerous if you leave those in place. It can cause a lot of trauma, bleeding, and even perforation. So eventually we had to give up, and the patient had adamantly refused that a new stent be placed at that time. She said, under no circumstances are you placing a stent, because the first one didn't really help me. I had to get a J-tube anyways, and I refused to have another one placed. And that was going to be our potential plan. So after, this is our initial endoscopy. You can see the stent in the stomach is quite covered with debris, and this is a lumen of it, and you can see us trying to grab the loop, and that's when it broke. So we spoke to her a few times in clinic, and she finally agreed that she would be amenable to another stent placement if it was going to be potentially a conduit for us to remove the first one. So we repeated an endoscopy, and again, there was a persistent fibrotic stricture at 33 centimeters from the incisors, and the XP scope again was able to traverse it. So we placed a wire into the stomach lumen. We placed a new stent traversing not only the fibrotic stricture, but also the malignant stricture, creating essentially a conduit pathway for us to try to remove that old stent. So the new stent was again placed, and the stricture was quite tight in the region of the fibrotic stricture, not necessarily the malignant stricture, which had been sufficiently essentially dilated over a long period of time with that new stent. So we had to dilate the new stent to 12 millimeters just to allow for the passage of the adult gastroscope. The old stent was pulled through the lumen of the new stent. It was eventually like telescoped, and they were moved together, but because we had mangled the proximal flange of the old stent so much, we had to use something called an inversion technique, which is when you grab the distal end of it and pull it almost inside out into the new stent. So here are some images. Here you see a fluoro image of the old stent just floating in the stomach. Here's when we pass our wire into the stomach adjacent to the old stent. We then place a wire through the new stent that we placed, and this is a deployment of the new stent. And then we had to dilate it, and you can see that this will allow for the passage of the adult gastroscope. We then can pass the scope through both stents, and that's when we eventually grab the old stent, pull it through the new stent, and remove this all together. So essentially it's like a glorified foreign body removal, but you're all gonna be in situations where you get that call in the middle of the night, what do we do for this case? And I will say that initially, one of the surgeons had recommended that we just leave the stent in place for the rest of her life. But she developed enough symptoms that we couldn't necessarily say, oh, this is from the stent or not from the stent, that it was time to remove it. So take home point, stent migration is a known risk of palliative esophageal stent placement for malignant strictures. The risk is cited to be anywhere from four to 36% in the literature. And larger diameter stents, logically, have a reduced risk of migration. Covered stents may benefit as a result of this from being placed, secured in place, even if they have anti-migration struts. So I think the logic for not securing the first stent was because it had those anti-migration struts in place, but despite that, with shrinkage of the tumor, it still migrated. So ways that you can actually secure it, there is a new device called StentFix. You can suture it in place. You can also try to clip it in place. And my one advice for suturing it in place is that you have to leave enough suture that it can kind of bounce around a little bit. It should never be so taut, because that can actually cause tissue necrosis and actually not be too great for the proximal area and lead to issues. Tumor shrinkage with chemo and RT can definitely contribute to stent migration risk, as we discussed. And most esophageal stents can be removed by pulling on the lasso or loop on the proximal edge. Even in a general GI case, it's totally fine to just remove those. Again, it's just a foreign body, and it should really nicely collapse if the stent isn't too old or too brittle. But if none exists, because some stents don't have that, you can consider a double channel scope and grasping the proximal flange edges with a rat tooth forceps on both sides or a snare and a rat tooth. And that's a nice way to collapse a proximal edge and prevent it from causing trauma as you're dragging it out. You can also loop these stents to try to reduce the size, snare them. Then you can also throw three endo loops around it and really try to compress it along the length of the stent. And an indwelling, fully covered metal stent can result in fibrosis of the proximal edge restriction. That was something I actually hadn't seen before to this degree. You just assume that it's all from the malignancy, but this was from the stent itself, so it was iatrogenic. And if you're unable to remove it, leaving the stent in place has been a reported option. If the patient's not a surgical candidate and you expect that the life expectancy is going to be short. So thank you so much for your time.

malignant stricture

stent migration

fibrotic stricture

chemotherapy

endoscopy