Douglas G. Adler MD. ACG Regional Postgraduate Course - Nashville, TN Copyright 2013 American College of Gastroenterology

Transcription

1 Enteral Stents 2013: State of the Art Douglas G. Adler MD Associate Professor of Medicine Director of Therapeutic Endoscopy University of Utah School of Medicine Huntsman Cancer Center Esophageal Stents Overview Gastroduodenal Stents Colonic Stents 1

2 Esophageal Stents Malignant Dysphagia Inability to swallow as a consequence of cancer Intrinsic tumor Esophageal adenocarcinoma Esophageal squamous cell carcinoma Junctional tumors Extrinsic tumor Lung Cancer TEF Closure Goals of Esophageal Stenting Minimize dysphagia symptoms Use the DSS Allow oral nutrition Allow oral hydration Allow oral medication delivery 2

3 Face of the enemy 3

4 Complications: Up to 20% Bleeding Perforation Chemotherapy Radiation therapy Pain Worsening or no improvement in dysphagia Migration Tumor overgrowth/ingrowth Airway compression Mougey and Adler Supp Onc

5 Tumor Overgrowth 5

6 13 Patients with locally advanced esophageal cancer Simultaneous EUS and stent placement No perforations No bleeding Migration in 6/13 patients Adler DG et al. GIE Siddiqui and Adler GIE patients with LAEC 45 pts with distal lesions, 10 with midesoph lesions DSS mean (p<0.001) Patients maintained their weights Migration 17/55 patients Only 8/55 ultimately underwent surgery 6

7 You re gonna need this!!! If you see this. Fully Covered Stents Malignant dysphagia Consider in patients undergoing neoadjuvant therapy Benign stenoses/rbes Benign TEF Iatrogenic perforations Bariatric complications Boerhaave s syndrome Adler GIE 2005, Adler GIE 2009, Bege GIE

8 FCSEMS migration in LAEC Maybe not a bad thing Migration is usually associated with tumor response Loss of tumor bulk less severe esophageal stricture dislodgement of stent If patient has intact pylorus stent very unlikely to migrate If patient has had gastrectomy adios!!! Towards Less Migration 8

9 FCSEMS for Benign Fistulae Data scant Case reports Bakken JC GIE 2010 reported 38% success in treating esophageal leaks via endoscopic stents in a small series Senousy DDS 2010 reported 85% success in treating esophageal leaks via endoscopic stents in a small series Many case reports of Boerhaave s syndrome 9

10 Malignant Gastric Outlet Obstruction (GOO) The inability of the stomach to empty Gastric obstruction Proximal small bowel obstruction A severe consequence of upper GI malignancy Pancreatic cancer (Most Common) Cholangiocarcinoma Ampullary cancer Gastric cancer Metastatic cancers Symptoms Onset: slow and insidious Symptoms: can be mistaken for side effects of chemotherapy, XRT, etc. Nausea Vomiting Dehydration Weight loss 10

11 Goals of Treatment Relieve symptoms of obstruction Allow adequate nutrition and hydration Allow oral feeding Improve quality of life Prolong survival (?) Other Treatment Options XRT Can be effective, but takes time PEG-J Allows nutrition, but no peroral feeding PEJ Allows nutrition, but no peroral feedings TPN Not a great option for patients with advanced malignancy; no peroral feedings 11

12 Gastric Outlet Obstruction Scoring System (GOOSS) Level of Oral Intake Score No oral intake 0 Liquids only 1 Soft solids 2 Low residue or full diet 3 GOOSS Score Change Median (mean) GOOSS pre-procedure: procedure: 0 (0.25) Median (mean) GOOSS post-procedure: procedure: 2.0 (1.83) Change in GOOSS (P < ) [Wilcoxon Signed Rank Test] 12

13 Don t Forget the Bile Duct! 13

14 Colonic Stents All uncovered metal stents None removable Indications Malignant large bowel obstruction Malignant or presumed malignant in etiology Indeterminate strictures with clinical obstruction Adler and Baron Curr Gastro 2000 Colonic Stents Ok to place in cancer patients at time of presentation Allows decompression, colonic preparation Surgical candidates en bloc resection Nonsurgical candidates palliative device 14

15 Proximal Colonic Stenting Old CW: Cannot place SEMS above sigmoid id colon New CW: Stents effective anywhere in colon Technical success comparable Clinical success comparable Complications comparable Repici, Adler, Baron GIE 2008 Repici, Adler, Baron GIE centers: UT Houston, Mayo, Milan 21 patients (15M, 6F) Obstruction Complete 8/21 Partial 13/21 Technical success 20/21 (95%) Clinical success 17/20 (85%) 15

16 Repici, Adler, Baron GIE 2007 Complications No bleeding No perforation 1 patient did develop repeat obstruction from tumor ingrowth Proximal colonic obstruction stenting Safe Comparable to distal colonic obstruction 16

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18 Bleeding Complications Relatively uncommon Perforation: 1-4% Beware the sensation of impending doom Beware AVASTIN! Migration: 11% Uncommon in malignant obstruction Tumor overgrowth/ingrowth : 7% Frech EJ, Adler DG. Supp Onc 2008, Baron GIE

19 SEMS Here to stay Conclusions Esophageal, Gastroduodenal, Colonic Now part of mainstream practice If you can do ERCP, you can do SEMS! Safe and effective Surgery still an option for treatment failures 19