Placement of Esophageal Self-Expandable Metal Stents

Anna Tavakkoli, MD, MSc

Ryan Law, DO

Esophageal self-expandable metal stent (SEMS) use continues to evolve. Over the last several years increasing applications have arisen for use in patients with benign disease, and technical improvements in stent design and materials have streamlined use. Several FDA-approved SEMS are currently available; however, the only FDA-approved indication for use is palliation of malignant dysphagia. All other indications are considered off-label use. Each currently available stent has unique features, such as antimigration properties, improved fluoroscopic visualization, through-the-scope placement, and non-foreshortening during deployment.¹ SEMS are typically divided into fully covered (FCSEMS), partially covered (PCSEMS), and uncovered.² Partially covered stents have the proximal and distal flange uncovered with the midbody of the stent covered. The type of SEMS needs to be carefully considered for each clinical scenario though stent placement and functionality are largely similar.

CONTRAINDICATIONS

1. Those associated with upper endoscopy (see Chapter 5).
2. Compression of the trachea by esophageal cancer. This is a relative contraindication as bronchoscopy may be required to assess the airway prior to stent placement.
3. The use of concurrent external radiotherapy, as a bridge to surgery, or prior to chemoradiotherapy.² These treatments have reasonable success in decreasing tumor bulk and allowing palliation of dysphagia, thus a stent may not be necessary.
4. Lesions that require stent placement within 2 cm of the upper esophageal sphincter.
5. Severe cardiac and/or respiratory disorder.
6. Bleeding diathesis or anticipated need for chronic anticoagulation.
7. Limited life expectancy.

PREPARATION

1. Fast the patient for at least 8 hours prior to the procedure.
2. Obtain informed consent from the patient or patient representative, outlining the possible procedural adverse events as well as alternative methods of treatment.
3. Assess the patient’s airway by bronchoscopy in situations where an esophageal mass involves the airway, or the patient is exhibiting signs of pulmonary compromise.
4. Administer a topical anesthetic for pharyngeal anesthesia.
5. Start an intravenous line for administration of systemic sedation.
6. Obtain oral suction in the case of retained fluid or inability to clear secretions during the procedure.