DOI: 10.1148/rg.231025051
Balloon Dilation and Stent Placement for Esophageal Lesions: Indications, Methods, and Results1
Eric Therasse, MD,
Vincent L. Oliva, MD,
Edwin Lafontaine, MD,
Pierre Perreault, MD,
Marie-France Giroux, MD and
Gilles Soulez, MD
1 From the Departments of Radiology (E.T., V.L.O., P.P., M.F.G., G.S.) and Surgery (E.L.), Centre Hospitalier de l’Université de Montréal (CHUM), 3840 St Urbain St, Montreal, Quebec, Canada H2W 1T8. Recipient of a Certificate of Merit award for an education exhibit at the 2001 RSNA scientific assembly. Received March 8, 2002; revision requested April 25 and received May 24; accepted May 28. Address correspondence to E.T. (e-mail: eric.therasse.chum@ssss.gouv.qc.ca).
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Figure 1a. Photographs show FDA-approved covered esophageal stents: the Ultraflex stent (a), the Wallstent II (b), and the Z-stent without anchors (shown with an antireflux valve [arrows]) (c).
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Figure 1b. Photographs show FDA-approved covered esophageal stents: the Ultraflex stent (a), the Wallstent II (b), and the Z-stent without anchors (shown with an antireflux valve [arrows]) (c).
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Figure 1c. Photographs show FDA-approved covered esophageal stents: the Ultraflex stent (a), the Wallstent II (b), and the Z-stent without anchors (shown with an antireflux valve [arrows]) (c).
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Figure 2a. Drawings illustrate the delivery system of the Ultraflex stent. (a) The distal release system allows elimination of proximal foreshortening during deployment and is best suited for stent placement in the middle and upper esophagus. (b) The proximal release system allows elimination of distal foreshortening during deployment and is best suited for stent placement in the gastroesophageal junction. Arrows indicate how to release the stent by pulling out the string. (Courtesy of Microvasive/Boston Scientific, Natick, Mass.)
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Figure 2b. Drawings illustrate the delivery system of the Ultraflex stent. (a) The distal release system allows elimination of proximal foreshortening during deployment and is best suited for stent placement in the middle and upper esophagus. (b) The proximal release system allows elimination of distal foreshortening during deployment and is best suited for stent placement in the gastroesophageal junction. Arrows indicate how to release the stent by pulling out the string. (Courtesy of Microvasive/Boston Scientific, Natick, Mass.)
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Figure 3a. Photographs illustrate the delivery system of the Wallstent. (a) Wallstent before deployment. (b, c) To deploy the stent, the inner catheter (arrow in b) is held stationary while the outer sheath (arrowhead in b) is withdrawn, allowing distal to proximal stent release (c).
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Figure 3b. Photographs illustrate the delivery system of the Wallstent. (a) Wallstent before deployment. (b, c) To deploy the stent, the inner catheter (arrow in b) is held stationary while the outer sheath (arrowhead in b) is withdrawn, allowing distal to proximal stent release (c).
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Figure 3c. Photographs illustrate the delivery system of the Wallstent. (a) Wallstent before deployment. (b, c) To deploy the stent, the inner catheter (arrow in b) is held stationary while the outer sheath (arrowhead in b) is withdrawn, allowing distal to proximal stent release (c).
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Figure 4a. Photographs illustrate the delivery system of the Z-stent. (a) The stent is lubricated and is loaded through a funnel in the tip of the outer tube by pulling on threads (arrow). (b) The guiding tip (arrowhead) is adapted to the sheath by pulling on the other end of its shaft (arrow). (c) To deploy the stent, the locking device is pulled out and the inner catheter (arrow) is held stationary while the outer sheath (arrowhead) is withdrawn. The thread is cut and removed before retrieving the delivery system.
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Figure 4b. Photographs illustrate the delivery system of the Z-stent. (a) The stent is lubricated and is loaded through a funnel in the tip of the outer tube by pulling on threads (arrow). (b) The guiding tip (arrowhead) is adapted to the sheath by pulling on the other end of its shaft (arrow). (c) To deploy the stent, the locking device is pulled out and the inner catheter (arrow) is held stationary while the outer sheath (arrowhead) is withdrawn. The thread is cut and removed before retrieving the delivery system.
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Figure 4c. Photographs illustrate the delivery system of the Z-stent. (a) The stent is lubricated and is loaded through a funnel in the tip of the outer tube by pulling on threads (arrow). (b) The guiding tip (arrowhead) is adapted to the sheath by pulling on the other end of its shaft (arrow). (c) To deploy the stent, the locking device is pulled out and the inner catheter (arrow) is held stationary while the outer sheath (arrowhead) is withdrawn. The thread is cut and removed before retrieving the delivery system.
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Figure 5a. Better delineation of tumor extension with endoscopy in a patient with esophageal carcinoma. (a) Esophagogram demonstrates adequate stent placement with a residual waist located in the midportion of the stent (arrow) due to the stricture. No obstruction is seen at the lower end of the stent (arrowhead). (b) Endoscopic image obtained 2 weeks later demonstrates malignant disease (arrows) beyond the stent.
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Figure 5b. Better delineation of tumor extension with endoscopy in a patient with esophageal carcinoma. (a) Esophagogram demonstrates adequate stent placement with a residual waist located in the midportion of the stent (arrow) due to the stricture. No obstruction is seen at the lower end of the stent (arrowhead). (b) Endoscopic image obtained 2 weeks later demonstrates malignant disease (arrows) beyond the stent.
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Figure 6a. Esophageal tear after balloon dilation. (a) Esophagogram shows an esophageal peptic stricture with a lumen 6 mm in diameter (arrow). (b) Esophagogram shows a waist (arrow) in the balloon at the beginning of inflation. (c) Esophagogram demonstrates complete dilation of the balloon to 12 mm, which is achieved over a 2-minute period. (d) Postdilation esophagogram demonstrates a small, contained esophageal laceration (arrows).
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Figure 6b. Esophageal tear after balloon dilation. (a) Esophagogram shows an esophageal peptic stricture with a lumen 6 mm in diameter (arrow). (b) Esophagogram shows a waist (arrow) in the balloon at the beginning of inflation. (c) Esophagogram demonstrates complete dilation of the balloon to 12 mm, which is achieved over a 2-minute period. (d) Postdilation esophagogram demonstrates a small, contained esophageal laceration (arrows).
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Figure 6c. Esophageal tear after balloon dilation. (a) Esophagogram shows an esophageal peptic stricture with a lumen 6 mm in diameter (arrow). (b) Esophagogram shows a waist (arrow) in the balloon at the beginning of inflation. (c) Esophagogram demonstrates complete dilation of the balloon to 12 mm, which is achieved over a 2-minute period. (d) Postdilation esophagogram demonstrates a small, contained esophageal laceration (arrows).
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Figure 6d. Esophageal tear after balloon dilation. (a) Esophagogram shows an esophageal peptic stricture with a lumen 6 mm in diameter (arrow). (b) Esophagogram shows a waist (arrow) in the balloon at the beginning of inflation. (c) Esophagogram demonstrates complete dilation of the balloon to 12 mm, which is achieved over a 2-minute period. (d) Postdilation esophagogram demonstrates a small, contained esophageal laceration (arrows).
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Figure 7a. Esophageal stent placement technique. (a) Esophagogram demonstrates a malignant stricture (arrowheads) 4 cm below the superior esophageal sphincter (arrow). (b) Esophagogram shows dilation of the stricture. (c) Esophagogram shows the expected postdeployment position of the covered portion of an Ultraflex stent (arrows). (d) Esophagogram demonstrates a stricture-induced waist in the middle of the stent (arrowheads), a finding that indicates good stent location.
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Figure 7b. Esophageal stent placement technique. (a) Esophagogram demonstrates a malignant stricture (arrowheads) 4 cm below the superior esophageal sphincter (arrow). (b) Esophagogram shows dilation of the stricture. (c) Esophagogram shows the expected postdeployment position of the covered portion of an Ultraflex stent (arrows). (d) Esophagogram demonstrates a stricture-induced waist in the middle of the stent (arrowheads), a finding that indicates good stent location.
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Figure 7c. Esophageal stent placement technique. (a) Esophagogram demonstrates a malignant stricture (arrowheads) 4 cm below the superior esophageal sphincter (arrow). (b) Esophagogram shows dilation of the stricture. (c) Esophagogram shows the expected postdeployment position of the covered portion of an Ultraflex stent (arrows). (d) Esophagogram demonstrates a stricture-induced waist in the middle of the stent (arrowheads), a finding that indicates good stent location.
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Figure 7d. Esophageal stent placement technique. (a) Esophagogram demonstrates a malignant stricture (arrowheads) 4 cm below the superior esophageal sphincter (arrow). (b) Esophagogram shows dilation of the stricture. (c) Esophagogram shows the expected postdeployment position of the covered portion of an Ultraflex stent (arrows). (d) Esophagogram demonstrates a stricture-induced waist in the middle of the stent (arrowheads), a finding that indicates good stent location.
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Figure 8a. Stent placement through the superior esophageal sphincter. (a) Esophagogram shows a Wallstent whose upper end (arrow) was inadvertently positioned across the superior esophageal sphincter (C5-C6 level). Stent placement was intended as treatment for a proximal esophageal stricture. The patient experienced discomfort and swallowing difficulties, with reflux of contrast medium into the maxillary sinuses (arrowheads). (b) Esophagogram demonstrates aspiration into the lungs (arrow).
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Figure 8b. Stent placement through the superior esophageal sphincter. (a) Esophagogram shows a Wallstent whose upper end (arrow) was inadvertently positioned across the superior esophageal sphincter (C5-C6 level). Stent placement was intended as treatment for a proximal esophageal stricture. The patient experienced discomfort and swallowing difficulties, with reflux of contrast medium into the maxillary sinuses (arrowheads). (b) Esophagogram demonstrates aspiration into the lungs (arrow).
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Figure 9a. Compression of the esophagus and trachea. (a) Computed tomographic (CT) scan shows compression of the trachea (arrow) by a mesothelioma (arrowheads). (b) Esophagogram shows extrinsic compression of the esophagus. Stents (arrows) were positioned in the trachea and right main bronchus. (c) Esophagogram obtained after esophageal stent placement demonstrates relief of esophageal obstruction.
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Figure 9b. Compression of the esophagus and trachea. (a) Computed tomographic (CT) scan shows compression of the trachea (arrow) by a mesothelioma (arrowheads). (b) Esophagogram shows extrinsic compression of the esophagus. Stents (arrows) were positioned in the trachea and right main bronchus. (c) Esophagogram obtained after esophageal stent placement demonstrates relief of esophageal obstruction.
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Figure 9c. Compression of the esophagus and trachea. (a) Computed tomographic (CT) scan shows compression of the trachea (arrow) by a mesothelioma (arrowheads). (b) Esophagogram shows extrinsic compression of the esophagus. Stents (arrows) were positioned in the trachea and right main bronchus. (c) Esophagogram obtained after esophageal stent placement demonstrates relief of esophageal obstruction.
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Figure 10a. Malignant left esophagobronchial fistula and stricture at the tracheal bifurcation. (a) Chest radiograph shows a stent that was dilated into the left main bronchus. (b) Esophagogram reveals that an esophageal stricture and a left bronchoesophageal fistula are still present after bronchial stent placement. (c) Esophagogram shows an esophageal Wallstent that was placed for treatment of the esophageal stricture and fistula. However, the Wallstent is constricted by the tumor (arrows).
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Figure 10b. Malignant left esophagobronchial fistula and stricture at the tracheal bifurcation. (a) Chest radiograph shows a stent that was dilated into the left main bronchus. (b) Esophagogram reveals that an esophageal stricture and a left bronchoesophageal fistula are still present after bronchial stent placement. (c) Esophagogram shows an esophageal Wallstent that was placed for treatment of the esophageal stricture and fistula. However, the Wallstent is constricted by the tumor (arrows).
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Figure 10c. Malignant left esophagobronchial fistula and stricture at the tracheal bifurcation. (a) Chest radiograph shows a stent that was dilated into the left main bronchus. (b) Esophagogram reveals that an esophageal stricture and a left bronchoesophageal fistula are still present after bronchial stent placement. (c) Esophagogram shows an esophageal Wallstent that was placed for treatment of the esophageal stricture and fistula. However, the Wallstent is constricted by the tumor (arrows).
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Figure 11a. Treatment of malignant gastric and esophageal stenoses. (a) Esophagogram shows gastric carcinoma with antral (arrowheads) and distal esophageal strictures. (b) Esophagogram shows a 15-cm-long Wallstent that has been positioned across the gastroesophageal junction. The stent extends to the gastric antrum but ends before reaching the duodenal bulb (arrows).
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Figure 11b. Treatment of malignant gastric and esophageal stenoses. (a) Esophagogram shows gastric carcinoma with antral (arrowheads) and distal esophageal strictures. (b) Esophagogram shows a 15-cm-long Wallstent that has been positioned across the gastroesophageal junction. The stent extends to the gastric antrum but ends before reaching the duodenal bulb (arrows).
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Figure 12a. Postoperative esophageal fistulas. (a) Esophagogram obtained following left pneumonectomy for lung cancer shows an irregular cavity (arrow) that arises from the left side of the esophagus. (b) Esophagogram demonstrates a covered Wallstent that has been positioned across the fistula. Residual contrast medium (arrows) from esophagography performed prior to stent placement remains trapped in the cavity.
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Figure 12b. Postoperative esophageal fistulas. (a) Esophagogram obtained following left pneumonectomy for lung cancer shows an irregular cavity (arrow) that arises from the left side of the esophagus. (b) Esophagogram demonstrates a covered Wallstent that has been positioned across the fistula. Residual contrast medium (arrows) from esophagography performed prior to stent placement remains trapped in the cavity.
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Figure 13a. Malignant postoperative anastomotic stricture. (a) Esophagogram obtained 1 year after gastrectomy shows a malignant stricture at the esophagojejunal anastomosis (arrow). (b) Esophagogram shows a Wallstent that successfully relieved the stricture, even though the stent is almost perpendicular to the jejunum.
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Figure 13b. Malignant postoperative anastomotic stricture. (a) Esophagogram obtained 1 year after gastrectomy shows a malignant stricture at the esophagojejunal anastomosis (arrow). (b) Esophagogram shows a Wallstent that successfully relieved the stricture, even though the stent is almost perpendicular to the jejunum.
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Figure 14a. Reflux esophagitis. (a) Endoscopic image obtained after placement of a stent across the gastroesophageal junction shows normal-colored mucosa above the stent. (b) Endoscopic image obtained 3 months later demonstrates severe esophagitis (note the redness of the mucosa) that resulted from gastroesophageal reflux. Tumor overgrowth is also apparent (arrowheads).
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Figure 14b. Reflux esophagitis. (a) Endoscopic image obtained after placement of a stent across the gastroesophageal junction shows normal-colored mucosa above the stent. (b) Endoscopic image obtained 3 months later demonstrates severe esophagitis (note the redness of the mucosa) that resulted from gastroesophageal reflux. Tumor overgrowth is also apparent (arrowheads).
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Figure 15a. Stent migration. (a) Esophagogram shows that an Ultraflex stent (arrows) positioned through a gastroesophageal lesion has migrated upward in the esophagus. (b) Esophagogram shows the extent of the lesion (arrows) near the distal end of the stent (arrowhead). (c) Esophagogram demonstrates a Wallstent that has been positioned through the lesion and overlaps the distal end of the Ultraflex stent.
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Figure 15b. Stent migration. (a) Esophagogram shows that an Ultraflex stent (arrows) positioned through a gastroesophageal lesion has migrated upward in the esophagus. (b) Esophagogram shows the extent of the lesion (arrows) near the distal end of the stent (arrowhead). (c) Esophagogram demonstrates a Wallstent that has been positioned through the lesion and overlaps the distal end of the Ultraflex stent.
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Figure 15c. Stent migration. (a) Esophagogram shows that an Ultraflex stent (arrows) positioned through a gastroesophageal lesion has migrated upward in the esophagus. (b) Esophagogram shows the extent of the lesion (arrows) near the distal end of the stent (arrowhead). (c) Esophagogram demonstrates a Wallstent that has been positioned through the lesion and overlaps the distal end of the Ultraflex stent.
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Figure 16a. Esophageal perforation. (a) Esophagogram obtained following radiation therapy and chemotherapy shows a necrotic esophageal carcinoma with ulceration (arrow). (b) Esophagogram shows a catheter that has perforated the esophagus during an attempt to position the catheter across the lesion. Contrast medium is seen around the spleen (arrows). The catheter was subsequently repositioned in the true lumen of the esophagus. (c) Esophagogram shows a Wallstent that was positioned across the gastroesophageal lesion. Antibiotics were administered, and despite the presence of pneumoperitoneum (arrow), the patient underwent no further intervention and was discharged free of dysphagia 4 days later.
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Figure 16b. Esophageal perforation. (a) Esophagogram obtained following radiation therapy and chemotherapy shows a necrotic esophageal carcinoma with ulceration (arrow). (b) Esophagogram shows a catheter that has perforated the esophagus during an attempt to position the catheter across the lesion. Contrast medium is seen around the spleen (arrows). The catheter was subsequently repositioned in the true lumen of the esophagus. (c) Esophagogram shows a Wallstent that was positioned across the gastroesophageal lesion. Antibiotics were administered, and despite the presence of pneumoperitoneum (arrow), the patient underwent no further intervention and was discharged free of dysphagia 4 days later.
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Figure 16c. Esophageal perforation. (a) Esophagogram obtained following radiation therapy and chemotherapy shows a necrotic esophageal carcinoma with ulceration (arrow). (b) Esophagogram shows a catheter that has perforated the esophagus during an attempt to position the catheter across the lesion. Contrast medium is seen around the spleen (arrows). The catheter was subsequently repositioned in the true lumen of the esophagus. (c) Esophagogram shows a Wallstent that was positioned across the gastroesophageal lesion. Antibiotics were administered, and despite the presence of pneumoperitoneum (arrow), the patient underwent no further intervention and was discharged free of dysphagia 4 days later.
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Figure 17a. Tumor overgrowth. (a) Esophagogram shows a Wallstent that was placed for treatment of a malignant stricture at the esophagojejunal anastomosis. The covered portion of the stent (arrowhead) was positioned only 2 cm above the lesion, which induces a waist in the stent (arrow). (b) Esophagogram obtained 6 months later shows stent shortening associated with limited stent coverage of the lesion, which led to tumor overgrowth through the bare stent extremity (arrow). (c) Spot radiograph demonstrates balloon dilation. (d) Esophagogram shows a second Wallstent that was positioned through the stricture.
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Figure 17b. Tumor overgrowth. (a) Esophagogram shows a Wallstent that was placed for treatment of a malignant stricture at the esophagojejunal anastomosis. The covered portion of the stent (arrowhead) was positioned only 2 cm above the lesion, which induces a waist in the stent (arrow). (b) Esophagogram obtained 6 months later shows stent shortening associated with limited stent coverage of the lesion, which led to tumor overgrowth through the bare stent extremity (arrow). (c) Spot radiograph demonstrates balloon dilation. (d) Esophagogram shows a second Wallstent that was positioned through the stricture.
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Figure 17c. Tumor overgrowth. (a) Esophagogram shows a Wallstent that was placed for treatment of a malignant stricture at the esophagojejunal anastomosis. The covered portion of the stent (arrowhead) was positioned only 2 cm above the lesion, which induces a waist in the stent (arrow). (b) Esophagogram obtained 6 months later shows stent shortening associated with limited stent coverage of the lesion, which led to tumor overgrowth through the bare stent extremity (arrow). (c) Spot radiograph demonstrates balloon dilation. (d) Esophagogram shows a second Wallstent that was positioned through the stricture.
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Figure 17d. Tumor overgrowth. (a) Esophagogram shows a Wallstent that was placed for treatment of a malignant stricture at the esophagojejunal anastomosis. The covered portion of the stent (arrowhead) was positioned only 2 cm above the lesion, which induces a waist in the stent (arrow). (b) Esophagogram obtained 6 months later shows stent shortening associated with limited stent coverage of the lesion, which led to tumor overgrowth through the bare stent extremity (arrow). (c) Spot radiograph demonstrates balloon dilation. (d) Esophagogram shows a second Wallstent that was positioned through the stricture.
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Figure 18a. Tracheal compression. (a) CT scan obtained before stent placement demonstrates a proximal esophageal cancer but no tracheal compression. (b) CT scan obtained following esophageal stent placement demonstrates moderate tracheal compression.
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Figure 18b. Tracheal compression. (a) CT scan obtained before stent placement demonstrates a proximal esophageal cancer but no tracheal compression. (b) CT scan obtained following esophageal stent placement demonstrates moderate tracheal compression.
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Copyright © 2003 by the Radiological Society of North America.
