Description:

The patient is a 66 year old male referred for evaluation of dysphagia. His medical history is notable for obesity and longstanding gastroesophageal reflux disease. He had undergone laparoscopic Roux en Y gastric bypass and Nissen fundoplication 5 years prior.
Endoscopy demonstrated an adenocarcinoma at the gastroesophageal junction, staged as a T3 lesion by radial echoendosonography. The hypoechoic tumor can be seen extending through the muscularis propria layer of the esophagus.
Despite treatment with chemotherapy and radiation, the patient experienced progressive disease, and several months later an esophageal stent placement was requested for palliation of dysphagia.
Repeat endoscopy demonstrates an obstructing tumor in the distal esophagus. An ultraslim endoscope was selected for this examination, and this was used to gently dissect alongside the tumor through the narrow, residual esophageal lumen. Distal to the obstruction, the patient's anatomy was consistent with prior gastric bypass. The gastrojejunal anastomosis is visualized, and is measured at 5 cm beyond the distal extent of tumor.
A Savary guidewire is advanced through the working channel of the scope and positioned distal to the obstruction. The scope is then slowly withdrawn, leaving the wire in place. Here, the region of tumor is visualized during withdrawal.
A partially covered metal stent, 10 cm in length, was selected in this case. The stent delivery system is advanced over the wire and across the region of tumor under fluoroscopic visualization. Paper clips have been taped to the patient's skin to externally mark the proximal and distal stent margins.
The esophagus is reintubated with the ultraslim endoscope, which is positioned alongside the stent delivery catheter for direct visualization of stent deployment. During slow deployment, fluoroscopic monitoring confirms appropriate continued position of the semi-deployed stent.
Following stent deployment and removal of the delivery catheter and guidewire, the stent is gently traversed with the ultraslim endoscope. This demonstrates luminal patency, as well as appropriate position across the region of obstruction and proximal to the gastrojejunal anastomosis. Final fluoroscopy demonstrates a waist in the midportion of the stent.
This case demonstrates placement of a palliative permanent esophageal stent following Roux en Y gastric bypass. The post-operative anatomy was clearly defined in order to guide stent position, and to select a stent length which minimized distal overlap. There has been speculation that diversion of gastric acid contents will over the long term decrease the incidence of esophageal adenocarcinoma in patients with GERD who undergo gastric bypass. As this case demonstrates, patients with long-standing pre-operative GERD may not be immune to long-term complications of acid reflux, even following successful bypass surgery.

Contributed By:

Patrick Yachimski, MD, Vanderbilt University Medical Center

Final result with esophageal stent in place with a waist noted at the area of maximal stenosis.