Stent insertion for malignant esophageal strictures: endoscopy with fluoroscopy or endoscopy alone

Dysphagia is a debilitating consequence for patients with esophageal cancer. Recanalization of the obstruction with esophageal stents is one of the palliative measures that can most improve the quality of life in these patients. Among patients with dysphagia due to obstructing esophageal cancer, stent insertion has a high technical and clinical success with rapid relief of dysphagia. Interventional radiologists typically insert esophageal stents under fluoroscopic guidance only, whereas endoscopists insert them exclusively under endoscopic monitoring or by endoscopy and fluoroscopy. In this editorial we discuss the study by Relvas, which compares endoscopic-only insertion with fluoroscopy-guided insertion in obstructive esophageal tumors. The difficulties encountered by endoscopists in using proper radiological facilities is probably the main reason for not employing fluoroscopy in esophageal stenting. Proper placement of a guidewire beyond the esophageal stricture is often the first and most critical step in esophageal stenting. The undeployed stent is then slid over the guidewire. Fluoroscopy offers a high degree of certainty that the guidewire has successfully passed through the stenosis, but it is generally assumed that it is not necessary for esophageal stent placement if the stenosis can be passed through with an endoscope. When fluoroscopy is not available, several endoscopic methods can be used for the insertion of esophageal stents. The study by Relvas confirms that the results of endoscopic and fluoroscopic guided insertion are similar. However, ideally, endoscopists should have their own high-quality radiological facilities, such as those available to interventional cardiologists.