Recalcitrant Upper Esophageal Stricture Treated with Lumen-Apposing Metal Stent (LAMS)

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#LAMS #Stricture #Esophagus #advanced_endoscopy

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#LAMS #Stricture #Esophagus #advanced_endoscopy 

A 63 year-old gentleman was referred to our advanced endoscopy practice for severe dysphagia to both solids and liquids of more than 1 year duration. He had a history of laryngeal cancer, now in remission after chemotherapy, radiation and laryngectomy with placement of a Blom-Singer voice prosthesis. He also had a pacemaker with implantable cardioverter-defibrillator (ICD) for prior episode of cardiac arrest, third degree AV block and sustained ventricular tachycardia.

Water-soluble contrast esophagram revealed minimal trace passage of contrast into the lower neck, consistent with a high-grade/near complete stenosis in the upper cervical esophagus (Panel A). On initial endoscopy, he was noted to have a severe stricture in the proximal upper esophagus, approximately 13cm from incisors (Panel B). The luminal diameter was approximately 2mm, and was characterized by dense fibrotic tissue, which precluded the passage of the standard or neonatal gastroscopes. On fluoroscopy, the stricture measured approximately 1cm in length.

Cautious weekly serial hydrostatic balloon dilations with discretional needle knife stricturotomy using an IT Nano knife (Olympus Corp., Tokyo, Japan) to strategically direct the scar tissue tearing during dilation were performed over 7 sessions (Panel C) until a balloon diameter of 19mm was successfully achieved. Triamcinolone injections at the sites of the radial cuts of the stricturotomies were also performed during one of the sessions. The esophagus distal to the stricture, with the voice prosthesis (Panel D), as well as the stomach and first portion of the duodenum were eventually able to be endoscopically interrogated and did not display any abnormalities.

Unfortunately, since the patient was feeling so well, he declined further follow-up procedures and was lost to follow-up for 6 months, time at which he was admitted to the hospital for chest pain. On admission, his magnesium levels were undetectable by serum testing. It was then revealed that the patient had been consuming approximately 1 bottle of vodka on a daily basis since his successful dilations. Upon interrogation of the pacemaker, the ICD had delivered 43 shocks to the patient in the last 48 hours preceding admission. After stabilization and correcting his electrolyte abnormalities, a repeat endoscopy was performed, showing complete re-stenosis of the lumen (Panel E).

Serial weekly hydrostatic balloon dilations were once again pursued with the patient’s consent. Since progress with the achieved diameters after each dilation was slower than the initial round of dilation, the decision to consider placement of a lumen-apposing metal stent (LAMS; [off-label use] 15mm inner diameter Axios stent, Boston Scientific, USA) was made. While these stents are typically deployed with the use of an electrosurgically-enhanced tip, this particular stent was deployed in the “cold” fashion, with the distal flange being positioned distal to the stricture and the proximal flange being located proximal to the stricture (Panel F; notice the visible voice prosthesis distal to the stent). The patient did very well for the next 8 weeks, time at which a repeat upper endoscopy was performed, revealing a fully-expanded LAMS with healthy surrounding tissue (Panel G). The decision was made to remove the stent, having achieved the desired effect. On 1-year follow-up, the patient has no dysphagia and upper endoscopy reveals widely-patent upper esophagus.

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