This 65 year old gentleman had been referred for palliative therapy for a stage IV esophageal cancer with a bronchoesophageal fistula communicating with the right main bronchus (CT chest. A1: white arrow shows the extensive local invasion and white arrow in A2 shows the fistulous communication between esophagus and right bronchus). His barium studies didn't show any holdup of contrast but the irregular outline of the mucosa was evident (B1 & B2). On endoscopy, the lesion started at 23cm from incisors (C). The fistula opening was seen clearly (D: black arrow). The lesion continued till the 35cm mark (E) after which the lumen seemed disease free (F). Keep in in mid the 12cm long affected area, we decided to place a 14 cm long partially covered stent of 20mm diameter. This stent has a 1 cm uncovered segment at each end (G: Stent assembly partially deployed for demonstration - white arrow shows the sheath, black arrow shows the coated/covered segment of the stent and blue arrow shows the uncovered distal segment). After passing a guidewire, markers were stuck to the patient's body under fluoroscopic guidance to mark the extent of lesion (H: white arrows show the markers stuck on the patient's skin). The stent assembly was then placed in the correct position (I: white arrows) and deployed (J: white arrows show the lower end of stent being deployed and expanding. K: white arrows mark the fully deployed stent and black arrows indicate the skin markers). Repeat endoscopy after stent deployment showed that the upper end of the stent was barely above the upper margin of the tumor (L: white arrows). We decided to use a forceps to grasp the thread at the upper end to pull the stent slightly upward for a better clearer margin (M: white arrow). The stent was now in a better position to our satisfaction with a larger clear zone above the tumor (N: black arrows show the clear zone).
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