A 95-year-old man with locally advanced gastroesophageal junction cancer diagnosed
2 months previously was referred for consideration of stent revision due to recurrent
dysphagia. The patient had undergone stent treatment before, complicated by failure
to advance a conventional applicator system through the short but tight and sharply
angulated malignant stricture. Therefore, on that occasion, a 60- × 10-mm uncovered
gastroduodenal through-the-scope (TTS) stent was placed.
Recent endoscopy excluded stent migration, but the proximal stent end barely bridged
the stricture and appeared partially tilted, giving rise to an almost 90° angle to
the esophageal axis, consistent with the clinical impression of poor stent function
([Fig. 1 a]). A decision was therefore made to perform stent-in-stent revision to extend the
stent, placing another stent into the more proximal part of the esophagus. To this
end, a 35-inch stiff guidewire (Jagwire; Boston Scientific) was preinserted into the
stomach after endoscopic passage through the stent, which thus excluded threading
through the stent meshes. However, during advancement of the applicator system of
the 100- × 20-mm partially covered self-expanding metal stent (SEMS; Taewong Medical),
resistance was noted, with stent and guidewire deformation apparent on endoscopy and
fluoroscopy ([Fig. 1 b, ]
[Fig. 2 a]). As a novel endoscopic bailout for this rare situation, we utilized endoscopic
countertraction after parallel reinsertion of the gastroscope by grasping the proximal
stent ([Fig. 1 c, ]
[Fig. 2 b]). The scope with the grasped stent was kept under tension to straighten the stent
and allow axial alignment. At the same time, the applicator system was cautiously
advanced with initial judicious to-and-fro movements until resistance was no longer
encountered ([Fig. 1 d, ]
[Fig. 2 c]; [Video 1]). Finally, the procedure was successfully finished with adequate stent-in-stent
extension achieved.
Fig. 1 Endoscopic images. a Initial position with a partially tilted proximal stent end due to sharp angulation
of the gastroesophageal junction cancer with poor clinical stent function. b Increasing stent deformation during attempts to advance the applicator system through
the stent under wire guidance (the guidewire was placed endoscopically after passage
into the stomach, thus excluding threading through stent meshes). c Endoscopy-guided grasping of proximal stent meshes with a forceps. d Successful advancement of the applicator system, followed by stent-in-stent deployment
as per standard procedure after removal of the forceps.
Fig. 2 Fluoroscopic images. a Deformation of the in-situ stent and guidewire during conventional wire-guided advancement
of the applicator system due to hooking into the stent meshes. b Endoscopic countertraction exerted by grasping the proximal end of the stent in order
to straighten the stent and enable proper axial alignment. c Successful introduction and partial deployment of the stent-in-stent revision/extension.
Video 1 Clinical utility of endoscopic countertraction to enable a tricky revision procedure
for stent extension in a sharply angulated gastroesophageal junction cancer.
Esophageal and/or gastroesophageal stenting is usually straightforward, with high
reported technical success rates at primary and/or secondary deployment [1]
[2]. Notwithstanding, however, isolated tricky clinical situations may arise, and this
novel approach utilizing endoscopic countertraction might be instrumental in overcoming
such occasional challenges [3].
Endoscopy_UCTN_Code_TTT_1AO_2AZ
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