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