Ventricular FibrillationAfter Insertion of a Self-ExpandingMetallic Stent for Malignant DysphagiaTO THE EDITOR: Since the first successful insertion of ametallic prosthesis in 1990 (1), self-expanding metallicstents (SEMS) are increasingly being used for palliation ofdysphagia caused by upper gastrointestinal malignancy.Ease of insertion, low procedure-related mortality, and rapidimprovement in dysphagia make metal stents a logicalchoice over plastic ones. Compared to the semirigid plasticprostheses, their safety profile is excellent (2). Tumor in-growth/overgrowth and stent migration are common, butperforation and procedure related-mortality are exceedinglyrare (2, 3). We report a case of refractory ventricular fibril-lation after placement of a SEMS.

Investigation of dysphagia and weight loss in a 73-yr-oldman revealed a stricturing 5-cm tumor at the gastroesoph-ageal junction. Bougie dilation with Savary-Guilliard dila-tors was performed and biopsies were taken at the time ofthe initial endoscopy. Histology revealed the tumor to be anadenocarcinoma. The patient had a past history of ischemicheart disease and had been on treatment with amiodarone forepisodes of ventricular tachycardia, which had to be discon-tinued 3 months earlier because of development of sideeffects. He had not been prescribed any alternative antiar-rhythmic since stopping the amiodarone. Computed tomog-raphy (CT) of the chest showed local infiltration from thetumor and spread to the regional lymph nodes. In view of hispast medical history and CT scan result, surgical treatmentwas considered inappropriate and he was referred for palli-ation with a SEMS.

Endoscopy was performed under conscious sedation witha combination of midazolam 5 mg and pethidine 25 mg.During the procedure he received supplemental oxygen, andhis oxygen saturation was monitored by pulse oximetry.After dilation to 12.8 mm, a size 18-10, Esophacoil stent(Medtronic Instent; Medtronic, Eden Prairie) with a variablerelease handle, was placed in the lower esophagus andcardia, under fluoroscopy. The prosthesis is constructedfrom nitinol (nickel-titanium alloy), which is in the form ofa tightly wound, coiled spring that shortens and widens onrelease. Satisfactory position was confirmed at re-endoscopyafter placement of the stent. While the endoscope was beingwithdrawn, the patient’s oxygen saturation dropped, and hebecame cyanosed and started fitting. As no pulse was pal-pable, cardiopulmonary resuscitation was commenced. Thepatient was found to be in ventricular fibrillation (VF).Attempts at resuscitation, including repeated DC shocks,were unsuccessful, and the VF could not be terminated.

We believe that, although our patient had underlying riskfactors in the form of ischemic heart disease and previousepisodes of ventricular tachycardia, the sudden, forcefulexpansion of the Instent Esophacoil contributed to the de-velopment of the VF. Cardiopulmonary complications of

sedation, including respiratory depression and arrythmias,are the most common causes of death associated with uppergastrointestinal endoscopies (4, 5). The satisfactory oxygensaturation during the procedure in our patient makes respi-ratory complication of sedation an unlikely factor. Thetiming of the VF, on the other hand, suggests that theexpansion of the coil prosthesis initiated the fatal arrhythmiaby jolting the diseased myocardium. Experience with nitinolcoil prostheses is limited, and there have been very fewreports in the literature about its complications. Previouslyit has been reported that the expansion of the Esophacoilmay lead to severe pain, necessitating its removal (6), butour report suggests that, very rarely, it may have moreserious and unfortunate consequences.

Hamid Awad KhanIshfaq AhmadWaqar Ahmed

Department of GastroenterologyGwynedd Hospital

Bangor, United Kingdom

REFERENCES

1. Domschke W, Foerster Ech, Matek W, et al. Self-expandingmesh stent for esophageal cancer stenosis. Endoscopy 1990;22:134–6.

2. Knyrim K, Wagner HJ, Bethge N, et al. A controlled trial of anexpansile metal stent for palliation of esophageal obstructiondue to inoperable cancer. N Engl J Med 1993;329:1302–7.

3. Cowling MG, Hale H, Grundy A. Management of malignantoesophageal obstruction with self-expanding metallic stents.Br J Surg 1998;85:264–6.

4. Bell GD. Premedication and intravenous sedation for uppergastrointestinal endoscopies. Aliment Pharmacol Ther 1990;4:103–23.

5. Daneshmand TK, Bell GD, Logan RF. Sedation for uppergastrointestinal endoscopy: Result of a nationwide survey. Gut1991;32:12–5.

6. Axelrad AM, Fleischer DE, Gomes M. Nitinol coil esophagealprosthesis: Advantages of removable self-expanding metallicstents. Gastrointest Endosc 1996;43:155–60.

Reprint requests and correspondence:Dr. Hamid Awad Khan,Department of Gastroenterology, Gwynedd Hospital, BangorLL57 2PW, United Kingdom.

Received Sep. 28, 1999; accepted Sep. 30, 1999.

Complete Regression of HepatocellularCarcinoma Under TamoxifenTO THE EDITOR: Hepatocellular carcinoma (HCC) is acommon malignancy with a poor prognosis, particularlywhen the tumor is unresectable. The results of tamoxifentreatment on survival and tumor progression in patients withunresectable HCC have been disappointing (1, 2). We reportthe case of a 78-yr-old-man with genetic hemochromatosis-related cirrhosis and multifocal, biopsy-proven hepatocellu-

827AJG – March, 2000 Letters to the Editor

lar carcinoma that has undergone complete regression undertamoxifen treatment.

The patient was screened for HCC by ultrasonographyanda-fetoprotein determination twice a year since 1991. InJanuary 1997, abdominal ultrasound disclosed a multifocaltumor without portal vein thrombosis at Doppler examina-tion. Several nodular lesions were detected on CT scan inthe right liver lobe (with a nodule of 8 cm of largestdiameter in segment VIII), as well as a nodule of 1.5 cm insegment IV in the left lobe (Fig. 1A). At that time the patientwas asymptomatic, with normal physical examination andseruma-fetoprotein levels reaching 1276 ng/ml (normal,,7). Histological examination showed poorly differentiatedhepatocellular carcinoma with focal necrosis. The patientwas considered for palliative treatment. After written in-formed consent, he was enrolled in February 1997 in arandomized therapeutical trial comparing the effect of ta-moxifen (30 mgper os daily) versusthe combination offlutamide (750 mgper osdaily), plus leuprorelin (3.75 mgs.c. monthly) and tamoxifen on survival. He received ta-moxifen. The follow-up consisted of clinical examinationand liver test determination every month, and abdominal CTscan examination anda-fetoprotein determination every 3months. A dramatic reduction in tumor size on CT scan,associated with normalization ofa-fetoprotein level, wasobserved 4 months after initiation of tamoxifen (Fig. 1B).During the next 18 months of follow-up, the patient re-mained in excellent physical condition with normal livertests and persistently normala-fetoprotein levels. Tumorcould not be any more detected radiologically on repeatCT-scan examinations (Fig. 1C). At present,i.e., 24 monthsafter diagnosis and 23 months after initiation of tamoxifen,the patient is still in excellent clinical condition with noevidence of recurrence.

In the case that we report, the diagnosis of HCC, sus-pected on ultrasonography and CT scan findings and asignificant increase ina-fetoprotein level, was confirmedhistologically. Regression was likely because of the con-comitant normalization of seruma-fetoprotein level anddisappearance of radiological lesions on serial abdominalCT scans. Concomitant regression of multiple nodulesmakes the hypothesis of a vascularly induced necrosis un-likely. None of the factors previously associated with spon-taneous regression, including symptoms suggesting tumornecrosis (3), hemorrhagic shock (4), treatment with herbalmedicine (5), immunological mechanisms (6), and alcoholwithdrawal (7), were observed in our patient, despite regularfollow-up. Although we cannot strictly eliminate the hy-pothesis of a spontaneous regression, the chronological re-lationship between HCC regression and initiation of tamox-ifen bears a rather convincing evidence for its role. Partialreduction in tumor size anda-fetoprotein levels have beenobserved in some cases of unresectable HCC treated withtamoxifen at the same dosage (i.e., 30 mg daily), sug-gesting an effect on tumor growth (1). However, no caseof complete regression of HCC during treatment with

Figure 1. (A) CT-scan of our patient at the time of diagnosis ofhepatocellular carcinoma. Several nodular lesions are seen in theright liver lobe. (B) CT-scan made 4 months after initiation oftamoxifen, showing a dramatic reduction in tumor size. (C) CT-scan made 19 months after initiation of tamoxifen. Tumor can nolonger be visualized.

828 Letters to the Editor AJG – Vol. 95, No. 3, 2000

tamoxifen has been reported so far. The mechanisms bywhich tamoxifen could induce tumor regression remainunclear. It has been suggested that tamoxifen may inhibittumoral cell growth through estrogen receptor-mediatedmechanisms (8) but also calmodulin inhibition, interac-tion with growth factors, induction of apoptosis, andprobably other operating mechanisms that remain to beelucidated.

This case suggests that, although in clinical trials ofpatients with unresectable HCC tamoxifen has not provedto be effective in prolonging survival, complete regres-sion of HCC may occur under tamoxifen in individualpatient cases.

Laurent Caste´raValerie Boige

Laurence RocherJean-Charles Duclos-Valle´e

Monique FabreCatherine Buffet

Department of Liver DiseasesDepartment of PathologyDepartment of Radiology

Hopital BicetreUniversiteParis-Sud

Le Kremlin-Bicetre, France

REFERENCES

1. Trinchet JC, Beaugrand M. Treatment of hepatocellular carci-noma in patients with cirrhosis. J Hepatol 1997;27:756–65.

2. Gallo C, CLIP group. Tamoxifen in treatment of hepatocellularcarcinoma: A randomised controlled trial. Lancet 1998;352:17–20.

3. Ozeki Y, Matsubara N, Tateyama K, et al. Spontaneous com-plete necrosis of hepatocellular carcinoma. Am J Gastroenterol1996;91:391–2.

4. Tocci G, Conte A, Guarascio P, et al. Spontaneous remission ofhepatocellular carcinoma after massive gastrointestinal haem-orrhage. Br Med J 1990;300:641–2.

5. Chien R, Chen T, Liaw Y. Spontaneous regression of hepato-cellular carcinoma. Am J Gastroenterol 1992;87:903–5.

6. Markovic S, Ferlan-Marolt V, Hlebanja Z. Spontaneous regres-sion of hepatocellular carcinoma. Am J Gastroenterol 1996;91:392–3.

7. Gottfried EB, Steller R, Paronetto F, et al. Spontaneous regres-sion of hepatocellular carcinoma. Gastroenterology 1982;82:770–4.

8. Francavilla A, Polimeno L, DiLeo A, et al. The effect ofestrogen and tamoxifen on hepatocyte proliferation in vivo andin vitro. Hepatology 1989;9:614–20.

Reprint requests and correspondence:Laurent Caste´ra, M.D.,Service des Maladies du F´oie et de l’Appareil Digestif, CentreHospitalier Universitaire de Biceˆtre, 78, rue du ge´neral-Leclerc,94275 Le Kremlin-Biceˆtre, France.

Received Mar. 1, 1999; accepted May 21, 1999.

Topical PharyngealAnesthesia for UpperGastrointestinal EndoscopyTO THE EDITOR: The article on topical pharyngeal anes-thesia by Daviset al. was interesting (1). The amnesic effectof benzodiazepines can confound the results as the authorsthemselves have mentioned. They have quoted a study byHedenbroet al., in which less discomfort was experiencedby patients given topical anesthesia (2). We had also pub-lished a randomized, double-blind, placebo-controlled studyon the use of pharyngeal anesthesia in unsedated patients(3). In this study, we evaluated 153 consecutive patientsusing visual analog scores. We did not find any significantdifference in the patient discomfort scores in the two studyarms.

Thus, it appears that topical pharyngeal anesthesia doesnot benefit patients undergoing upper endoscopy, regardlessof sedation. Topical anesthesia is supposed to inhibit sen-sations arising from contact with the endoscope. There areno studies evaluating the efficacy of topical spray in com-pletely anesthetizing the mucosa. Probably the anesthesia isnot complete, owing to the anatomic complexity of thepharynx and hypopharynx. Moreover, the expertise of en-doscopists for reassuring anxious patients, and the techniqueof passage, are important. Beginners find it difficult to reachthe cricopharynx smoothly, and the endoscope touches orpushes sensitive pharyngeal mucosa. With the current thinmodels of endoscopes, an experienced endoscopist can in-troduce the endoscope smoothly and quickly, and thus ob-viate the need for topical anesthesia. None of the studieshave addressed this issue.

Cultural influences are often used to explain the differ-ences in pre-endoscopic medication requirements amongpatients in the eastern and western hemispheres (4). Thestudy by Daviset al. shows that East and West have similarpharyngeal sensibilities. Probably the patients from bothparts of the globe may prefer to eat equally soon after theirendoscopic experience.

Vinay Dhir, M.D., D.N.B.K. M. Mohandas, M.D., D.N.B.

Division of Digestive Diseases and Clinical NutritionTata Memorial Hospital

Parel, Mumbai, India

REFERENCES

1. Davis DE, Jones MP, Kubik CM. Topical pharyngeal anesthe-sia does not improve upper gastrointestinal endoscopy in con-scious sedated patients. Am J Gastroenterol 1999;94:1853–6.

2. Hedenbro JL, Ekelund M, Jansson O, et al. A randomizeddouble blind placebo controlled study to evaluate topical anes-thesia of the pharynx in upper gastrointestinal endoscopy. En-doscopy 1992;24:585–7.

3. Dhir V, Santhi Swaroop V, Vazifdar KF, et al. Topical pha-ryngeal anesthesia without intravenous sedation during upper

829AJG – March, 2000 Letters to the Editor