1. 1. Enteral Stenting: How, Why and When? Jason Klapman, MD Director of Endoscopy Moffitt Cancer Center Associate Professor of Medicine University of South Florida Tampa, FL
2. 2. Enteral Stenting Palliation of malignant dysphagia Management and palliation colorectal obstruction Palliation of malignant gastroduodenal obstruction
3. 3. Palliation of Malignant Dysphagia To Palliate-From the Latin Palliatus-to cloak or conceal. To palliate a disease is to treat it partially and insofar as possible, but not cure it completely. Easing the severity of a pain or a disease without removing the cause
4. 4. Esophageal Stenting ASGE Guidelines GIE March 2013 Esophageal Stenting should be the preferred method for palliation of malignant dysphagia and Fistulae Provides immediate and durable relief in the majority of patients
5. 5. Pre-Procedure Knowledge of location and length of malignant stricture is key to success (previous EGD or esophagogram) If proximal obstruction consider pre-procedure eval by imaging, Pulmonary or Thoracic surgery to eval for tracheal compression and airway compromise Consider Fluoroscopy Choose stent at least 2mm larger than estimated lumen or last dilation
6. 6. Esophageal Stents Types Plastic or Metal Fully Covered Partially covered Uncovered Biodegradable
7. 7. Choosing a stent Majority are metal stents Most SEMS are equally effective in relieving symptoms, have similar complication rates No study has been done comparing all types of metal stents Choice usually determined by perceived ease of placement and personal experience of endoscopist Low incidence of migration is the holy grail!!
8. 8. Choosing a stent (cont) Stent characteristics Delivery systems Deployment patterns Expansile force Foreshortening characteristics Removability
9. 9. Available Esophageal Stents (U.S.) Boston Scientific Polyflex -strong expansile force,removable 16-21mm 9-12-15cm length Ultraflex- distal and proximal release option, most flexible, least expansile force (partially or uncovered) 18 or 23 mm, 10,12,15cm lengths Wallflex-, no foreshortening, smooth delivery vs. Ultraflex, lasso loop (fully/partially) 18 or 23mm 10,12,15cm Cook Endoscopy Evolution-no shortening, recapturable, lasso loop, distal release only(fully18,20 - 8,10,12cm or partially 20mm, 8,10,12.5,15 Z stent - no shortening, short bare wire at ends, has anti-reflux valve option (fully, partially, anti-reflux)18mm, 8,10,12,14 Merrit Medical EndoTek Alimaxx-E-non-foreshortening, fully covered, lasso loop, distal release only multiple sizes 12-22mm 7,10,12cm lengths EndoMaxx-non-forshortening,fully covered,Metal loop, 19,23mm ,7,10,12,15cm Endochoice-Bonastent- Fully covered, Hook/Cross technology, Non-foreshortening, retrieval lasso-18mm 6-16cm length TaeWoong-Niti-S TTS, fully covered ,lasso loop 18mm, 6-15cm
10. 10. Non-TTS placement A stiff 0.035 guidewire for stability, over which stent is deployed Remove endoscope leaving wire in place Back load stent over wire and advance through stricture Can place endoscope alongside stent to observe deployment if desired (No fluoroscopy needed) Choose stent that is 4cm longer than tumor to allow for 2cm above and below tumor for stability
11. 11. Non-TTS placement
12. 12. TTS placement Niti-s esophageal stent 10.5 fr diameter deployment system Use therapeutic upper scope Proximal release
13. 13. Post Procedure Starts clears and slowly advance to soft foods Give post stent diet instructions-tailor it to the size of stent Analgesics prn for pain
14. 14. Complications Chest pain Bleeding Perforation Aspiration Severe GERD Dysphagia: tumor ingrowth, migration, food impaction, device malposition Tracheal Esophageal (TE) Fistula formation
15. 15. Colonic stenting Indications Palliation of malignant obstruction Acute colonic obstruction Allow colon prep May obviate the need for a two stage surgical procedure
16. 16. Palliation of malignant obstruction Uncovered through the scope SEMS Boston Scientific Wallstent and Ultraflex stent Cook Endoscopy Evolution Stent
17. 17. Procedure Preparation R sided lesions- limited colon prep Rectosigmoid lesions- fleets enemas Therapeutic Colonoscope Fluoroscopy
18. 18. TTS deployment video Courtesy of Sri Komanduri,MD
19. 19. Complications Perforation-5% (avoid in bevacizumab patients) Migration Abdominal pain Bleeding Tumor ingrowth
20. 20. Post Procedure Diet-low residue Laxative to maintain stool softness Consider x-ray to confirm position
21. 21. Gastroduodenal Obstruction (GOO) Stenting Indication Palliation of malignant obstruction Do not place in setting of chemoradiation treatment Available SEMS TTS stents BSC and COOK uncovered metal stents Can be placed along side the scope or through the scope Taewoong- covered esophageal stent can be placed in the stomach/duodenum for attempted fistula closure due to the ability to use TTS
22. 22. GOO Pre-procedure Pt. decompressed with NG tube or perform under general anesthesia Consider road map with UGI before the procedure to delineate the length of the stricture Fluoroscopy Therapeutic Upper Endoscope Intra-procedure Technique similar to colonic stenting Avoid Dilation of the malignant stricture to allow passage of the endoscope
23. 23. Complications Perforation Migration Bleeding Pain
24. 24. Summary Enteral stents are effective in relieving malignant obstruction of the GI tract Pre procedure work-up and preparation is paramount to the success of the procedure Avoid dilation of malignant strictures(except in Esophagus) to try and advance the endoscope through the obstruction Choose stents 4cm longer than the anticipated stricture length Avoid placing stents in the Stomach/Duodenum or colon in settings other than palliation or as a bridge to surgery
25. 25. Thank You