Endoscopic placement of self-expanding metallic stent without fluoroscopy in palliative treatment of esophageal cancer - is it safe and feasible? A multicenter experience

Background Self-expanding metallic stent (SEMS) is considered nowadays as the gold standard in the palliative management of malignant dysphagia. Esophageal stenting is usually performed under both endoscopic and fluoroscopic guidance. However, placement of SEMS without fluoroscopy is still a common practice in our country owing to limited resources and long waiting list. Aim To evaluate the safety and feasibility of SEMS placement under endoscopic guidance only without fluoroscopy. Patients and methods A prospective interventional study was conducted on patients with inoperable esophageal cancer who presented to five tertiary hospitals for palliative esophageal stenting during the period from June 2019 to June 2022. Demographic, pathological, periprocedural, and the outcome data were collected, tabulated, and analyzed. Results A total of 195 patients were included in the current study. SEMS placement under endoscopic guidance only was done in all patients. No technical problem was encountered during placement of the SEMS. Before SEMS placement, dilatation of stricture was needed in 168 (95.38%) patients. Statistically and clinically significant improvement was seen in the dysphagia score after stenting in all patients (4.15 +/- 1 before stenting vs. 1.15 +/- 0.5 after stenting, P<0.001). No major complications were encountered during or immediately after the procedure. Minor complications like retrosternal pain (that relieved by opioid analgesia) occurred in 30 (15.38%) patients. Hiccup occurred in nine (4.61%) patients, and it was stopped within 48 h with adequate treatment. Six (3.076%) stent migrations were encountered 1 week after SEMS placement during follow-up upper endoscopy and managed by restenting. Conclusion Placement of SEMS under endoscopic guidance only without fluoroscopy for palliating patients with inoperable malignant dysphagia is safe and feasible in selected patients. It could be adopted when fluoroscopy is not available, in centers with low resources, in low-income to middle-income countries, or in institutions that have restricted access to fluoroscopic guidance.