How much luminal dilation (if any) is necessary prior to placement of an esophageal Wallstent?

The use of various metallic stents is a popular therapeutic modality in the palliative treatment of malignant esophageal stricture. Despite an enlarging experience, there is no consent as to how much esophageal dilation is required prior to placement of such stents. We report our experience with 99 coated Wallstents (Schneider, Minnesota) placed between 11/94 and 10/96 for the palliation of malignant esophageal stricture. In all pts, graduated Savary dilators were used and desired dilation and stent (maximal outer diameter of 38 Fr) placement were performed during the index session. In our first 22 pts, we dilated the esophageal lumen to 42 Fr with the idea of facilitating stent expansion, especially for tight angulated strictures. During that period, 2 stent migrations (10%) occurred. In the next 22 pts, we decreased the dilation to 38-39 Fr, same diameter as the stent apparatus. During that period, we encountered 1 stent migration (5%). We then reduced the dilation to 27 Fr (same as standard Olylmpus GIF 100 endoscope), or to no dilation if the endoscope passed beyond the stricture. Of 55 stents placed during that period, no stent migration occurred. No perforations have occurred during any period. During the second period, (38-39 Fr), I esophageal tear occurred during passage of the guide wire. We have not found a relationship between stent migration and the use of ChemoXRT, previous laser therapy, histological type, primary vs metastatic, or the mucosal pattern of the tumor. However, mid-to-junctional esophageal lesions may be associated with the risk of migration. In conclusion, placement of the Wallstent should be carried out with no dilation or only enough to allow advancement of the endoscope beyond the stricture. Such recommendation is independent of the location or type of stricture. Caution should always be exercised to avoid potential mucosal tears and/or perforation.