upper gi stenting gi cancer... · 2016. 11. 17. · owen dickinson consultant in endoscopy &...
TRANSCRIPT
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Owen Dickinson Consultant in Endoscopy & Interventional Radiology
Rotherham Foundation Trust
Upper GI Stenting
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Owen Dickinson Consultant in Endoscopy & Interventional Radiology
Rotherham Foundation Trust
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Declaration
• No source of financial or commercial sponsorship
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Why do we stent the upper GI
tract?
• Inability to eat solids
• Inability to drink fluids
• Inability to swallow saliva
• Occasional vomiting
• Persistent vomiting
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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
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Indications
Oesophageal cancer
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Other indications
• Extrinsic compression eg LNs, lung cancer
• Fistula / perforation
• Benign strictures eg peptic strictures
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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
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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
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Equipment in IR
• 4Fr Headhunter catheter
• Angled Terumo wire
• Amplatz superstiff wire
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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
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Ultraflex
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Niti-S “Double” Stent
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Removable stents
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Process to Oesophageal
Stenting
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How I do it
• Catheterise oesophagus
with angled catheter and
hydrophilic guidewire
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Manipulate hydrophilic guidewire through stricture
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Delineate with contrast +/- air
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• Mark
• Exchange hydrophilic for stiff
guidewire
• Remove catheter
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Introduce stent Deploy
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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
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Oesophageal complications
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Complications
• Reflux
• Aspiration
• Chest pain 10%
• Food impaction 10%
• Stent migration 10%
• Ingrowth 30%
• Overgrowth 10%
• Perforation 5%
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Proximal overgrowth
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Stent migration
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Stent migration
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Stent migration 3 days later
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Tracheo-oesophageal fistula
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Jan 11
CASE
TOF
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• 51 M SCC oesophagus
• EUS & PET T3N1M1
• Chemoradiotherapy
Jan 11
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Endoscopic stent insertion
June 11 (5m)
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Sep 11 (7m) – presents with cough on swallowing
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Jan 12 (12m) – presents with dysphagia
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6 dilatations May 12 – Apr 13 (28m)
What next?
May 12 (12m) – presents with high dysphagia
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• Same evening develops marked SOB
• CTPA requested
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CASE
GSW
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• 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
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Day 6
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Day 7
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Day 26
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3 months later
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Gastric Outlet (GOO) Stenting
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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
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• 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
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Treatment options
• Antiemetics
• Nasogastric tube
• Venting gastrostomy
• Surgical gastrojejunostomy
• Laparoscopic gastrojejunostomy
• Stenting
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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
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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
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Cholangiocarcinoma
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Introduce catheter
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Get through stricture
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Stiff wire in
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Antral Carcinoma
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Cannulate stricture
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Get the wire as distal as possible
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Get ready to stent
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Stent in situ
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Stent lumen expanded
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Stent blockage
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Ingrowth
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Ingrowth
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Stent Fracture
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Stent Collapse
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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
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