Post written by Michael M. Mwachiro, MBChB, from Tenwek Hospital, Bomet, Kenya.
In this video, we describe the technique for placement of self-expanding metal stents (SEMS) for palliation of dysphagia due to esophageal malignancy without the use of optical or fluoroscopic visualization. The patient undergoes a video-endoscopic procedure to assess tumor length and proximal tumor margin. A 0.035 250-cm guidewire is placed across the tumor and endoscopic dilation is done with Savary dilators. The endoscope is then passed through, tumor length verified, and a complete exam performed to the duodenum. Biopsies are also done at the same time. A 12-cm, 20-mm SEMS (Advanced Technology and Materials Company, Beijing, China) stent is then loaded into its delivery system and passed over the guidewire into the esophagus. The stent is deployed using markings to place it at 4 cm proximal to the tumor margin and have a 3-cm distal margin. The delivery system is then withdrawn and the endoscope passed down to confirm placement and positioning.
Esophageal squamous cell carcinoma (ESCC) is one of the leading cancer causes of death in our region. Due to multiple factors, patients often present late and as such can only be offered palliation. Provision of palliation is also affected by low socio-economic status and loss to follow-up. In addition, there is a lack of enough centers that can place the stents, a lack of fluoroscopy units, and reduced access to SEMS stents due to the costs of importing them into the country. This technique for SEMS placement is reproducible and has been shown to be safe with appropriate training and attention to detail. In addition, it allows for placement of these stents in a resource-limited setting where there is no access to fluoroscopy. We have refined this technique at our institution for almost a decade now and would like to have endoscopists be aware that this is an alternative option that is feasible in the appropriate setting.
We report our revised method of safe, non-fluoroscopic, non-optical SEMS placement with measurements alone, which is a feasible alternative with acceptable outcomes. This low-cost, efficient intervention allows for effective palliation of dysphagia and improved quality of life. SEMS placement with measurements alone is reproducible in similar settings and will help to provide care in low-resource settings, where it will be of greatest utility.
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