title: Self-expanding metal stent placement for oesophageal cancer without fluoroscopy is safe and effective.
abstract: BACKGROUND
  Self-expanding metal stents (SEMS) are widely used to palliate patients with oesophageal cancer. Placement is usually done under endoscopic and fluoroscopic guidance. We have developed an exclusively endoscopic technique to deploy these stents. This article documents the technique and periprocedural experience.
  
  
  METHODS
  All patients who had SEMS placement for oesophageal cancer at Grey's Hospital, Pietermaritzburg, South Africa, over a 5-year period (2007-2011) were reviewed. Stenting was performed without radiological guidance using the technique documented in this article. At endoscopy, the oesophageal lesion was identified, dilated over a guidewire if necessary, and a partially covered stent was passed over the wire and positioned and deployed under direct vision. Data were captured from completed procedure forms and included demographics, tumour length, the presence of fistulas, stent size and immediate complications.
  
  
  RESULTS
  A total of 480 SEMS were inserted, involving 453 patients, of whom 43 required repeat stenting. There were 185 female patients (40.8%) and 268 male patients (59.2%). The mean age was 60 years (range 38 - 101). There were 432 black patients (95.4%), 15 white patients (3.3%) and 6 Indian patients (1.3%). The reasons for palliative stenting were distributed as follows: age>70 years n=95 patients, tumour>8 cm n=142, tracheo-oesophageal fistula (TOF) n=29, and unspecified n=170. One patient refused surgery, and one stent was placed for a post-oesophagectomy leak. Repeat stenting was for stent migration (n=15), tumour overgrowth (n=26) and a blocked stent and a stricture (n=1 each). Complications were recorded in six cases (1.3%): iatrogenic TOF (n=2), false tracts (n=3) and perforation (n=1). All six were nevertheless successfully stented. There was no periprocedural mortality.
  
  
  CONCLUSIONS
  The endoscopic placement technique described is a viable and safe option with a low periprocedural complication rate. It is of particular use in situations of restricted access to fluoroscopic guidance.
authors.affiliation: Department of Surgery, Pietermaritzburg Metropolitan Complex and College of Health Sciences, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa. morg@iafrica.com.
authors.forename: Morgie
authors.initials: M
authors.lastname: Govender
authors.forename: Colleen
authors.initials: C
authors.lastname: Aldous
authors.forename: Lucien
authors.initials: L
authors.lastname: Ferndale
authors.forename: Sandie R
authors.initials: SR
authors.lastname: Thomson
authors.forename: Damian Luiz
authors.initials: DL
authors.lastname: Clarke