ESPEN Congress Brussels Stenting of the esophagus and small bowel. Jean-Marc Dumonceau

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1 ESPEN Congress Brussels 2005 Stenting of the esophagus and small bowel Jean-Marc Dumonceau

2 Stenting of the esophagus and small bowel Jean-Marc Dumonceau, Div. of Gastroenterology Geneva, Switzerland

3 Indication: malignant stricture Esophagus: > 50% patients: disease not curable at presentation Dysphagia: most frequent symptom Duodenum: Pre-terminal event Small bowel Exceptional

4 Survival after esophageal SEMS insertion Wenger U et al, Endoscopy 2005:

5 Esophageal SEMS: : instant lumen patency

6 Dysphagia Go covered improves (even in for 90% the of cardia; patients RCT, (RCT, n=62) n=62) Liquids Semi-solids Some solids = Uncovered; = Covered SEMS Vakil N et al, Am J Gastroenterol 2001:1791-6

7 Nutritional status with esophageal SEMS (n=116) Dysphagia improved 1 grade 89.6% Median survival (mo) 2.5 Lecleire S et al, SNFGE 2005 (abstract 71)

8 Nutritional status with esophageal SEMS (n=116) Dysphagia improved 1 grade 89.6% Median survival (mo) 2.5 Baseline 1 month later BMI (kg/m 2 ) * Serum albumin (g/l) ** Performance status * *p<0.05; **p<0.01 No change in patients alive at 3, 6, 9, 12 months Lecleire S et al, SNFGE 2005 (abstract 71)

9 Complications remain frequent with covered SEMS (RCT, n=100) Major complications 7 days* 12% > 7 days** 14% Minor complications 34% Recurrent dysphagia 28% *Perforation (6%), bleeding (2%), fever (2%), pressure necrosis (1%), severe pain (1%) **Bleeding (14%) Siersema P et al, GI Endoscopy 2001:

10 Mucosal hyperplasia

11 Mucosal hyperplasia

12 Combine radiotherapy with SEMS (temporary / permanent) Perm. stent Temp. stent RXT Shin JH et al, J Vasc Interv Radiol 2005:

13 Combine radiotherapy with SEMS (temporary / permanent) P=0.005 P=0.001 Shin JH et al, J Vasc Interv Radiol 2005:

14 Other situations: 1. Esophageal fistula Malignant fistula post RX-chemo T: fistula sealing

15 Fistulas are sealed by covered SEMS Stainless steel (Wallstent-Z stent) N = 5 Complete sealing 20% Nitinol (Ultraflex) N = %* Absence of stricture 20% 33% F-up (days( days) 98 ± ± 41 Cost/day (EUR)** * P < **Total costs per day free from fistula symptoms in patients with a malignant fistula Dumonceau et al, GI Endoscopy 1999:70-8

$Refractory$ Anastomotic

16 Other indications: 2. Refractory stricures Anastomotic stricture post eso-gastrectomy

17 Anastomotic stricture post eso-gastrectomy

18 Removable Covered Self Expandable Plastic Stents (SEPS) Rüsch Polyflex stent

19 Evard S et al, GI Endosc 2004: Temporary SEPS for benign esophageal lesions (n=21) Lesion Stricture* Anastomotic leak 81% 19% *Hyperpastic (29%), anastomotic (24%), post-rxt (18%), caustic (18%), peptic (12%)

20 Evard S et al, GI Endosc 2004: Temporary SEPS for benign esophageal lesions (n=21) Lesion Stricture* Anastomotic leak Follow-up post removal (mo) No dysphagia without other treatment Complication (tracheal( compression) Living at the end of f-upf 81% 19% 21 81% 5% 95% *Hyperpastic (29%), anastomotic (24%), post-rxt (18%), caustic (18%), peptic (12%)

26 Sytematic review of the clinical effectiveness of enteral SEMS 32 publications (10 prospective); 606 patients Stricture caused by: Pancreas 34% Stomach 32% Metastases 14% Cholangiocarcinoma 7% Other 13% Dormann AJ et al, Endoscopy 2004:

27 Results (32 studies,, n=606) Technical success 97% Clinical success* 87% Mean survival (wks) 12.1 *Relief of symptoms and/or improved food intake Dormann AJ et al, Endoscopy 2004:

28 Oral intake status Oral intake* Before After None 61% 0% Liquids only 34% 13% Soft solids 5% 39% Full diet 0% 48% *Information available for 401 patients with clinically successful treatment; Dormann AJ et al, Endoscopy 2004:

29 Body weight with duodenal SEMS (n=50) 0 0 Body weight change (%) M1 M2 M6 M8 M M1 M2 M4 M6 M8 Graber et al, Digestive Disease Week 2005

30 16% 31% Telford J et al, GI Endosc :916-20

31 Telford J et al, GI Endosc :916-20

32 Longer oral intake with adjuvant therapy (n=176) Hazard ratio 95% CI Age Male gender Pancreatic cancer Duodenal obstruction Chemotherapy Radiotherapy Telford J et al, GI Endosc :916-20

33 SEMS vs. Surgical by-pass: RCT SEMS (n=9) Surgery (n=9) Complication 11% 11% Gatric emtying - 1 wk - 3 mo 89% 100% 67% 100% Time to oral intake (d) 2.1* 6.3 Hospital stay 3.1* 10 *P< Fiori E et al, Anticancer Res 2004:269-71

34 SEMS vs. Surgical by-pass: non randomized comparison SEMS (n=20) Surgery (n=19) Complication 40% 32% 0.74 Median survival (d) P 0.98 Parenteral-free 55% 47% 0.75 Time to oral diet (d) 1 (1-2) 9 (7.3-12) in performance status (before-after) Hospital stay (d) < Maetani I et al, Endoscopy 2004:73-8

35 Conclusion Instant relief of obstruction Covered models Yes for the esophagus (incl. cardia) No for the duodenum Complications: frequent-managed by endoscopy Nutrition: few data (no improvement)

36 SEMS after palliative gastrojejunostomy

38 Why may symptoms recur? - Days Timing weeks - Weeks-months - Variable Etiology - Multiple obstructions - GI motility - Continued stent shortening - Tumor in/overgrowth overgrowth* - CNS metastasis Adapted from Soetkino,, 1999

39 Food impaction < inadequate patient education or compliance Dietary instructions (oral + written): Food selection Food preparation (skin of veg/meat meat, bread toasted ) Chewing (denture) Swallowing (pace, with liquids) Medication (crushed)

40 Complications (n=606) Procedural mortality 0 All severe complications 1.2% - Perforation - Bleeding All nonsevere complications - Stent obstruction - Stent migration - Pain - Biliary problems - Other 0.7% 0.5% 27% 17% 5% 3% 1% Dormann AJ et al, Endoscopy 2004:

41 Retrospective comparison of surgery and SEMS for GOO (matched( patients, n=46) Mittal J et al, Br J Surg 2004:205-9

42 Survival after esophageal SEMS insertion Siersema P et al, GI Endoscopy 2001:

43 Mucosal hyperplasia

44 Stent flexibility is crucial For adherence to the wall Dumonceau et al, GI Endoscopy 1999:70-8

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

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