Upper GI Stenting GI cancer... · 2016. 11. 17. · Owen Dickinson Consultant in Endoscopy &...
Transcript of Upper GI Stenting GI cancer... · 2016. 11. 17. · Owen Dickinson Consultant in Endoscopy &...
Owen Dickinson Consultant in Endoscopy & Interventional Radiology
Rotherham Foundation Trust
Upper GI Stenting
Owen Dickinson Consultant in Endoscopy & Interventional Radiology
Rotherham Foundation Trust
Declaration
• No source of financial or commercial sponsorship
Why do we stent the upper GI
tract?
• Inability to eat solids
• Inability to drink fluids
• Inability to swallow saliva
• Occasional vomiting
• Persistent vomiting
Oesophageal stenting – when?
• Malignancy – intrinsic / extrinsic
• Refractory benign strictures
• Oesophageal perforations
1 Asymptomatic
2 Eats solids with some dysphagia
3 Eats soft or pureed food only
4 Drinks liquids only
5 Unable to swallow saliva
Indications
Oesophageal cancer
Other indications
• Extrinsic compression eg LNs, lung cancer
• Fistula / perforation
• Benign strictures eg peptic strictures
Who stents?
Gastroenterologist or Upper GI Surgeon
Endoscopic insertion without xray
• Problems occasionally encountered
– Unable to pass the endoscope through – too tight
– May require pre-dilation ( risk of perforation )
– Unable to assess length of stricture – therefore what length stent?
– Unable to confidently manipulate guidewire through stricture
Who else stents? Interventional Radiology
Xray insertion only • No need for an endoscope
• Catheterisation of stricture is atraumatic and virtually always successful
• Position & length of stricture accurately demonstrated
• Position of guidewire tip is seen at all times
• No pre-dilatation
• Accurate stent placement
Equipment in IR
• 4Fr Headhunter catheter
• Angled Terumo wire
• Amplatz superstiff wire
Which stent?
1 2
3
4
5
6
7
8 1 Flamingo
2 Ultraflex
3 Dua
4 Ella
5 Polyflex
6 Choo
7 Do
8 Niti-S “Double”
8
Ultraflex
Niti-S “Double” Stent
Removable stents
Process to Oesophageal
Stenting
How I do it
• Catheterise oesophagus
with angled catheter and
hydrophilic guidewire
Manipulate hydrophilic guidewire through stricture
Delineate with contrast +/- air
• Mark
• Exchange hydrophilic for stiff
guidewire
• Remove catheter
Introduce stent Deploy
Result
• Technical success rates
approach 100%
• Improved dysphagia score 4
(liquids only) to 2 (able to eat
most solids)
1 Asymptomatic
2 Eats solids with some dysphagia
3 Eats soft or pureed food only
4 Drinks liquids only
5 Unable to swallow saliva
Oesophageal complications
Complications
• Reflux
• Aspiration
• Chest pain 10%
• Food impaction 10%
• Stent migration 10%
• Ingrowth 30%
• Overgrowth 10%
• Perforation 5%
Proximal overgrowth
Stent migration
Stent migration
Stent migration 3 days later
Tracheo-oesophageal fistula
Jan 11
CASE
TOF
• 51 M SCC oesophagus
• EUS & PET T3N1M1
• Chemoradiotherapy
Jan 11
Endoscopic stent insertion
June 11 (5m)
Sep 11 (7m) – presents with cough on swallowing
Jan 12 (12m) – presents with dysphagia
6 dilatations May 12 – Apr 13 (28m)
What next?
May 12 (12m) – presents with high dysphagia
• Same evening develops marked SOB
• CTPA requested
CASE
GSW
• 42 M
• Gunshot through neck
• Pneumocephalus; comminuted # T1 & T2 with fragments
in canal; neck haematoma; surgical emphysema &
pneumomediastinum; comminuted # left thumb
• Cardiothoracic and ENT emergency surgery for
disruption to trachea & oesophagus
• Chest drain insertion; tracheostomy; repair of trachea &
oesophagus
Day 6
Day 7
Day 26
3 months later
Gastric Outlet (GOO) Stenting
For your consideration
• Stainless steel or Nitinol
• Length
• Uncovered or covered
• Biliary stent required?
A Boston Scientific Enteral Wallstent
B Diagmed Hanaro Enteral Stent
C Taewoong Niti-S Duodenal Covered Stent
D Taewoong Niti-S Duodenal Stent
E EnterElla Stent
• Malignant “GOO”
considered a
preterminal event
• Average survival 4/12
• Persistent vomiting
• Malnutrition
• Dehydration
• Electrolyte imbalance
Gastric Outlet Score
0 No oral intake
1 Liquids only
2 Soft solids
3 Full diet
Treatment options
• Antiemetics
• Nasogastric tube
• Venting gastrostomy
• Surgical gastrojejunostomy
• Laparoscopic gastrojejunostomy
• Stenting
Surgical gastroenterostomy
Traditional palliative treatment for malignant gastric outlet obstruction
Mortality 2-36%
• Complications 13-55%
• Delayed gastric emptying
• Longer hospital stay mean 15 days (5-80 days) Gastroduodenal Stent Placement: Current Status
Radiographics 2004
Open gastrojejunostomy vs laparoscopic
gastrojejunostomy vs endoscopic stenting in malignant
gastroduodenal obstruction
• Significant reduction in time to starting free oral fluids and light diet
Average hospital stay mean 6.3 days (2-15 days)
• Reduction in length of stay after the procedure
Average hospital Stay 24-48 hours
• Significantly more complications in patients who underwent surgical palliation
Lee,F. Abdul-Halim,R. Dickinson,O. (2016). Malignant gastroduodenal obstruction: An endoscopic approach. Gastrointestinal Intervention. (5): 105-110
Cholangiocarcinoma
Introduce catheter
Get through stricture
Stiff wire in
Antral Carcinoma
Cannulate stricture
Get the wire as distal as possible
Get ready to stent
Stent in situ
Stent lumen expanded
Stent blockage
Ingrowth
Ingrowth
Stent Fracture
Stent Collapse
Summary
• Overview of indications for stenting the
upper GI tract
• Overview of the various methods and
stents used
• Overview of the problems and
complications encountered