Use of a Fully Covered Metal Stent for the Treatment of Dysphagia due to Fixed Tortuous Esophagus скачать в хорошем качестве

Use of a Fully Covered Metal Stent for the Treatment of Dysphagia due to Fixed Tortuous Esophagus

Use of a Fully Covered Self-Expanding Metal Stent (SEMS) for the Treatment of Dysphagia due to Severe Torturous Presbyesophagus. Andrew Mazulis, MD, Sarosh Bukhari, DO, Kenneth D. Chi, MD We describe a minimally invasive treatment option for progressive chronic refractory dysphagia due to presbyesophagus associated acute angulation of the distal esophagus. Our patient is an 80 year old man with multiple medical comorbidities, who had been suffering from chronic post-prandial vomiting and dysphagia for over 10 years. He had previously seen several gastroenterologists and had undergone upper endoscopy with biopsies, manometry, motility and imaging studies with a negative workup other than non-specific findings. He had also been previously treated with acid suppression therapy, as well as empiric esophageal Savary dilatation and Botox therapy with only minimal improvement. Although he has been able to maintain his weight with diet modification (liquids and pureed foods), he would frequently have difficulty swallowing solid foods. He would often need to excuse himself from social events just to regurgitate the food out. Our repeat esophagram revealed a torturous esophagus with a near 90-degree angulation of the distal esophagus causing a "zig-zag" appearance [0:59]. Barium pill was shown to become obstructed at this level on imaging, along with slow transit. This angulation was further verified by upper endoscopy [1:51]. The patient refused any surgical interventions but was willing to try an esophageal stent. A 22x120mm fully-covered SEMS (Wallflex, Boston Scientific) was placed under endoscopic and fluoroscopic guidance across the angulated portion of the esophagus. Distal stent migration was prevented by the acute angulation causing a stricture-effect below the proximal flare. Proximal migration was prevented by having the distal flare below the gastroesophageal junction. Within 2 days, the patient was able to introduce solid foods into his diet for the first time in years, without subsequent regurgitation. He did experience some transient chest discomfort and heartburn during the first week which was controlled with acid suppression medications. A repeat esophagram at three months confirmed adequate stent positioning and improved angulation [5:22] without migration. At six months, the patient was doing well and extremely pleased with the significant improvement in his quality of life. (Three month EGD was performed for followup which is shown here 5:45) This video case report demonstrates a novel use of a fully covered SEMS as a treatment of benign dysphagia due to severe torturous presbyesophagus. It is a reversible, less invasive option in patients who are not surgical candidates. Care should be taken to stress the importance of potential complications of stent placement (and removal) as well as the likelihood of trading one symptom (dysphagia) with another (heartburn). To our knowledge, there have been no previous reports in the literature for the use of fully covered removable SEMS in this clinical setting, and may pose to be an alternative treatment option when all other treatments have failed.