Owen Dickinson. Consultant in Endoscopy & Interventional Radiology. Upper GI Stenting. Rotherham Foundation Trust

Transcription

1 Owen Dickinson Consultant in Endoscopy & Interventional Radiology Upper GI Stenting Rotherham Foundation Trust

2 Owen Dickinson Consultant in Endoscopy & Interventional Radiology Rotherham Foundation Trust

3 Declaration No source of financial or commercial sponsorship

4 Why do we stent the upper GI tract? Inability to eat solids Inability to drink fluids Inability to swallow saliva Occasional vomiting Persistent vomiting

5 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

6 Oesophageal cancer Indications

7 Other indications Extrinsic compression eg LNs, lung cancer Fistula / perforation Benign strictures eg peptic strictures

8 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

9 Interventional Radiology Who else stents? 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

10 Equipment in IR 4Fr Headhunter catheter Angled Terumo wire Amplatz superstiff wire

11 Which stent? Flamingo 2 Ultraflex 3 Dua Ella 5 Polyflex 6 Choo 7 Do 8 Niti-S Double

12 Ultraflex

13 Niti-S Double Stent

14 Removable stents

15 Process to Oesophageal Stenting

16 Catheterise oesophagus with angled catheter and hydrophilic guidewire How I do it

17 Manipulate hydrophilic guidewire through stricture

18 Delineate with contrast +/- air

19 Mark Exchange hydrophilic for stiff guidewire Remove catheter

20 Introduce stent Deploy

21 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

22 Oesophageal complications

23 Complications Reflux Aspiration Chest pain 10% Food impaction 10% Stent migration 10% Ingrowth 30% Overgrowth 10% Perforation 5%

24 Proximal overgrowth

25 Stent migration

26 Stent migration

27 Stent migration 3 days later

28 Tracheo-oesophageal fistula

29 CASE TOF Jan 11

30 51 M SCC oesophagus EUS & PET T3N1M1 Chemoradiotherapy Jan 11

31 Endoscopic stent insertion June 11 (5m)

32 Sep 11 (7m) presents with cough on swallowing

33 Jan 12 (12m) presents with dysphagia

34 May 12 (12m) presents with high dysphagia 6 dilatations May 12 Apr 13 (28m) What next?

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36 Same evening develops marked SOB CTPA requested

37 CASE GSW

38 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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40 Day 6

41 Day 7

42 Day 26

43 3 months later

44 Gastric Outlet (GOO) Stenting

45 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

46 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

47 Treatment options Antiemetics Nasogastric tube Venting gastrostomy Surgical gastrojejunostomy Laparoscopic gastrojejunostomy Stenting

48 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

49 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 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):

50 Cholangiocarcinoma

51 Introduce catheter

52 Get through stricture

53 Stiff wire in

54 Antral Carcinoma

55 Cannulate stricture

56 Get the wire as distal as possible

57 Get ready to stent

58 Stent in situ

59 Stent lumen expanded

60 Stent blockage

61 Ingrowth

62 Ingrowth

63 Stent Fracture

64 Stent Collapse

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70 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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