Esophageal Stenosis Treatment by Interventional Radiology: Indications, Techniques and complications

Transcription

1 Esophageal Stenosis Treatment by Interventional Radiology: Indications, Techniques and complications Poster No.: C-0437 Congress: ECR 2013 Type: Authors: Keywords: DOI: Educational Exhibit M. Leyva Vásquez-Caicedo, C. García Villafañe, J. Gallego Beuter, J. V. Mendez Montero, J. E. Armijo Astrain, A. Hernández Lezana; Madrid/ES Fluoroscopy, Stomach (incl. Esophagus) /ecr2013/C-0437 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 20

2 Learning objectives - To illustrate, discuss and review the treatment of oesophageal depending on the etiology of strictures: benign or malignant. - To describe the technique, results and complications of managing esophageal strictures. Background Esophageal stricture is a serious complication of various pathological processes such as tumors, caustic ingestion, esophageal surgery, gastroesophageal reflux, endoscopic sclerosis of esophageal varices, infections, vasculitis, radiation, skin diseases such as epidermolysis bullosa, pemphigus and syndrome Steven-Johnson, among others. Esophageal stricture is a serious problem that must be addressed in a multidisciplinary way. Currently there are advances in the treatment of esophageal stricture dilation with new techniques that are better tolerated, require little manipulation, are more comfortable and safer, and constitute a therapeutic option that provides a high safety margin with minimal complications and better long term results. Also avoid surgery and invasive procedures such as gastrostomy and the risks they entail, making it an effective treatment, the duration will be determined by the severity and origin of the stenosis. Imaging findings OR Procedure details Esophageal stenosis are relatively common and can be classified according to their etiology in benign and malignant. Nonsurgical treatment of choice for benign esophageal strictures consists in the use of minimally invasive techniques using radiological or endoscopic dilation. Currently both endoscopists and radiologists use dilatation balloons to treat stenotic areas, using compliant balloon (diameter change depending on the pressure) and non- Page 2 of 20

3 compliant with different diameters. The only difference between the endoscopic and radiological is how to visualize the stenosis. Before dilating a stenosis of benign aspect is important to clarify the etiology of the lesion. This requires a radiologic, endoscopic and histological study. Balloon dilation has the advantage of producing lower incidence of perforation because it is performed under angiographic guidance on fluoroscopy. By using the balloon dilation have been successfully treated anastomosis stenosis secondary to surgical stenosis post-ingestion of caustic, peptic stricture acalasias (Fig. 1). The technique is to perform an esophagogram and identify the level of stricture, then orally inserted a guide which is handled with fluoroscopy vision to overcome the stenotic area, the balloon is advanced over the guide wire and inflated. These balloons are available in different sizes depending on the severity of the stenosis. Balloon dilation produces improvement in most relieving dysphagia patients and therefore can be performed prior to surgery, as in the operated patient if restenosis occurs. Indications: Dilation of benign lesions that should not or can not be treated surgically. Postoperative stenosis dilation. Esophageal dilation extrinsic compressions are usually ineffective. Contraindications: Uncorrectable coagulopathy. Quick Test <50% and / or platelets < > correct with fresh plasma or concentrate platelets. Uncooperative patient (Consider the possibility of anesthesia). Esophageal fistula. Esophageal perforation. Technique: Catheterize the esophagus to the stomach and proceeds to perform transcatheter esophagogram to locate the area of stenosis, rolled the distal end of the guide in stomach Page 3 of 20

4 and passed the catheter balloon, then inflate the balloon until the mark of the stenosis disappears, keeping the inflated approx. 3 minutes. The dilatations are progressive increasing the diameter of the balloons in different sessions to minimize the risk of perforation, reaching a size that allows intake. (18-20mm). The restenosis are common, patients identifies for worsening of dysphagia, and treated dilating again as many times as necessary. Complications: Complications of esophageal balloon dilatations are relatively rare. The most important and serious is perforation that occurs in less than 3% of the procedures. The important precaution to avoid it is to perform the procedure with the necessary technical rigor. The suspicion and early diagnosis of perforation is the key to successful treatment, other complications described are: - Central chest pain. - Mucosal ischemia if the balloon stays inflated longer than it should. - Gastric perforation. Not recommended as first intention stenting in benign disease. Malignant stenosis of the esophagus. About new cases of esophageal cancer are diagnosed each year worldwide, 80% of patients with esophageal cancer are in advanced clinical stages and incurable disease. Tumors in advanced stages have a five-year survival of 10-14%, being lower in some series. So low survival is due to at least 50% of cases are advanced or metastatic tumors at diagnosis. In most patients the palliative treatment is often the only option. The goals of palliative treatment are relief of dysphagia, maintenance of nutritional status and electrolyte and occlusion of tracheoesophageal fistula. In these patients quality of life is seriously affected by severe dysphagia. Page 4 of 20

5 Surgical therapy is preferred but unfortunately most of these tumors are unresectable and therefore are managed with palliative procedures such as percutaneous gastrostomy and radiotherapy. An interesting alternative and highly effective in these patients is the placement of esophageal stent to relieve dysphagia. In the last decade have emerged metallic stent that be placed through small introducers and then, when expanded, can reach a large diameter, which allows an adequate palliation of dysphagia. These prostheses are covered by various types of plastics such as silicone and polyurethane, which helps prevent tumor growth and adequately treat tracheobronchial fistulas can complicate this type of carcinoma. The prosthesis resulting in a substantial improvement of the quality of life of the patient. Are placed endoscopically or under fluoroscopic vision without surgery or general anesthesia. The placement of such stents is now the preferred method for the palliation of dysphagia associated with esophageal cancer. In general, we can indicate in first intention, the insertion of self-expanding stent in the following circumstances: Indications: - Patients with stage IV disease with a life expectancy of less than one year. - Patients with a score according to the Karnofsky scale equal to or greater than When survival is probably greater than three and less than six months and, using a method that requires repeated interventions cause discomfort to the patient. - When there is a tracheoesophageal fistula. Although it is generally known that the prosthesis does not have a direct effect on survival of the patient, the only exception is the presence of a tracheoesophageal fistula. (Fig. 2 - Fig 6). In these unusual circumstances, patients who were not given treatment for fistula die in your average time of three months and 85% of them due to aspiration pneumonia rather than metastatic disease. - Extrinsic compression (tumor or lymph node involvement) and anatomical deformity caused esophageal strictures. (Fig. 7 - Fig. 9). - Patients with distant metastases. - Persistence of tumor activity or recurrence after radiotherapy or chemotherapy. Page 5 of 20

6 - Tumor recurrence after surgery. - Contraindication to surgery (surgical risk IV). - Conditions that contraindicate radiotherapy or chemotherapy. - Circumferential, long, tortuous tumours of any part of the esophagus (except when affect cricopharyngeal) (Fig Fig 11). Contraindications: - Life expectancy short (one month or less). - Tumor of the upper third of the esophagus located 2cm or less from cricopharyngeal. In this circumstance the stent causes a permanent foreign body sensation in the pharynx. - Respiratory failure or massive pleural effusion that prevents the patient assume the supine position for placement of the stent and furthermore are premonitions of death in the short term. - Patients with brain metastases. These patients tend to have swallowing disorders and also their life expectancy is very short. Covered versus non-covered esophageal stents: (Fig. 12). Both are equally effective to treat dysphagia. The covered have the disadvantage of migration and non covered not work to treat tracheoesophageal fistulas and are very difficult to remove. The non covered stents can produce tumor growth between the filaments and cause progressive dysphagia. It is not advisable balloon dilating malignant strictures because it increases the risk of esophageal perforation. (except with a 4 or 5mm balloon and very cautiously to allow passage of the body of the stent). Page 6 of 20

7 Currently no longer used non-covered stents, and instead used the partially covered stents in esophageal tumors. Complications: Symptoms post-placement of stent are controlled with symptomatic medication and disappear over the course of the days. Chest pain is often referred by the patients after placement of the esophageal stent is greater when the prosthesis is positioned at the top of the esophagus due to the radial force of the stent. Esophageal carcinoma is frequently the result of gastroesophageal reflux, in such cases the relief of dysphagia with stent placement may be associated with a recurrence of GERD. Esophagitis and aspiration is more likely when the stent is placed across the gastroesophageal sphincter. The esophageal stent migration occurs at 0% -35% of patients and is associated mainly when the stent is positioned across the gastroesophageal junction. It is also due to the contraction of the tumor by chemotherapy or radiotherapy, bad placement of the stent and the overdilatation of injury before stent placement. Esophageal perforation or fistulization followed by placement of a stent can occur in a 0% -8% of cases and is more common in tumors that were previously treated with chemotherapy, radiation therapy or laser therapy. The diagnosis of perforation should be recognized immediately to allow for a proper management of the same as the covered stent placement in the affected area and the introduction of antibiotics as first line treatment, less invasive. The esophageal stent obstruction may be due to tumor progression, reactive hyperplasia or alimentary bolus impaction. The overgrowth often occurs in 4% -18% of cases and infiltrating tumors can be quickly treated with ablative therapies or by placing additional covered stents. Benign reactive hyperplasia, fibrosis or granulation tissue stent can obstruct in approximately 30% of cases. Excessive bleeding can occur in a 0% -6% of the patients and may be due to erosion of the blood vessels caused by the tumor or the placement of the stents Approximately 0.5% -2% of patients die as a direct result of the esophageal prosthesis placement. Page 7 of 20

8 Patients who were previously treated with radiotherapy or chemotherapy have high risk of complications such as perforation, bleeding, tracheoesophageal fistula, etc.. and a high mortality rate after placement of the esophageal stent. Images for this section: Fig. 1: Balloon dilation of oesophageal stenosis. Is performed esophagogram and identifies the level of stenosis, then orally, progress a guide wire which is handled with fluoroscopic vision until passing the area of stenosis, the balloon is advanced over the guide wire and inflated to overcome the stenotic area. Page 8 of 20

9 Fig. 2: Gastroduodenal study in patient with esophageal cancer. Reduction of caliber of the esophageal lumen at the middle-lower third with passage of contrast to stomach. Page 9 of 20

10 Fig. 3: Chest radiography (AP and lateral) of the same patient. There is evidence of esophageal stent located in the affected area. Page 10 of 20

11 Fig. 4: Gastroduodenal control study in the same patient after the esophageal stent placement (WallFlex partially covered), shows a correct expansion of the stent with adequate passage of contrast into the stomach. Page 11 of 20

12 Fig. 5: Gastroduodenal study which shows contrast leakage due to broncho-esophageal fistula located above the proximal end of the esophageal stent. Page 12 of 20

13 Fig. 6: CT shows the esophageal stent initially placed (external stent), identifying a communication between the left main bronchus and the outermost esophageal stent in relation to esophageal-bronchial fistula (red arrow). It also shown the second stent (innermost) centered over the previous stent, occluding the fistula area. Page 13 of 20

14 Fig. 7: Thoracic CT shows a right hilar mass in relation to primary lung tumor. Page 14 of 20

15 Fig. 8: Gastroduodenal study from the same patient. Shows a esophageal stenosis due to extrinsic compression to the middle third of the esophagus. Page 15 of 20

16 Fig. 9: Chest x-ray (PA and lateral). Note the esophageal stent (Wallflex partially covered) centered in the middle third of the esophagus. Note also the enlarged right hilar known regarding neoplasia. Page 16 of 20

17 Fig. 10: Extensive and irregular narrowing of esophageal lumen ranging from middle third of the esophagus to the esophagogastric junction area in relation to esophageal squamous cancer. Page 17 of 20

18 Fig. 11: Chest x-ray showing the two prosthesis (Wallflex partially covered) located in the middle third of the esophagus and esophagogastric junction. Page 18 of 20

19 Fig. 12: Esophageal stent: Wallflex and Ultraflex (Microvasive / Boston Scientific, Natick, Mass.) non-covered and partially covered. Page 19 of 20

20 Conclusion - Balloon dilation and esophageal stent placement are safe procedures, minimally invasive, and effective for the treatment of esophageal stenosis of various etiologies. - The treatment of benign esophageal stenosis is performed by balloon dilation, is not advisable to use stent. - The treatment of malignant stenosis with or without broncho-esophageal fistula is with stent placement, shouldn't dilate prior or subsequent to the placement of the same by the increased risk of esophageal perforation. References 1. Therasse E, Oliva V, Lafontaine E, et al: Balloon dilation and stent placement for esophageal lesions. Indications, methods, and results. Radiographics 2003; 23: Morgan R, Adam A. Use of metallic stents and balloons in the esophagus and gastrointestinal tract. J Vasc Intervent Radiol 2001; 12: Baron TH. Expandable metal stents for the treatment of cancerous obstruction of the gastrointestinal tract. N Engl J Med 2001; 344: Wang MQ, Sze DY, Wang ZP, Wang ZQ, Gao YA, Dake MD. Delayed complications after esophageal stent placement for treatment of malignant esophageal obstructions and esophagorespiratory fistulas. J Vasc. Interv. Radiol 2001;12: Radiología Esencial. Jose Luis del Cura, Salvador Pedraza, Ángel Gayete. Editorial Panamericana Personal Information Page 20 of 20