Owen Dickinson Consultant in Endoscopy & Interventional Radiology Upper GI Stenting Rotherham Foundation Trust
Owen Dickinson Consultant in Endoscopy & Interventional Radiology Rotherham Foundation Trust
Declaration No source of financial or commercial sponsorship
Why do we stent the upper GI tract? Inability to eat solids Inability to drink fluids Inability to swallow saliva Occasional vomiting Persistent vomiting
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
Oesophageal cancer Indications
Other indications Extrinsic compression eg LNs, lung cancer Fistula / perforation Benign strictures eg peptic strictures
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
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
Equipment in IR 4Fr Headhunter catheter Angled Terumo wire Amplatz superstiff wire
Which stent? 6 8 8 1 Flamingo 2 Ultraflex 3 Dua 1 2 3 4 5 7 4 Ella 5 Polyflex 6 Choo 7 Do 8 Niti-S Double
Ultraflex
Niti-S Double Stent
Removable stents
Process to Oesophageal Stenting
Catheterise oesophagus with angled catheter and hydrophilic guidewire How I do it
Manipulate hydrophilic guidewire through stricture
Delineate with contrast +/- air
Mark Exchange hydrophilic for stiff guidewire Remove catheter
Introduce stent Deploy
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
Oesophageal complications
Complications Reflux Aspiration Chest pain 10% Food impaction 10% Stent migration 10% Ingrowth 30% Overgrowth 10% Perforation 5%
Proximal overgrowth
Stent migration
Stent migration
Stent migration 3 days later
Tracheo-oesophageal fistula
CASE TOF Jan 11
51 M SCC oesophagus EUS & PET T3N1M1 Chemoradiotherapy Jan 11
Endoscopic stent insertion June 11 (5m)
Sep 11 (7m) presents with cough on swallowing
Jan 12 (12m) presents with dysphagia
May 12 (12m) presents with high dysphagia 6 dilatations May 12 Apr 13 (28m) What next?
Same evening develops marked SOB CTPA requested
CASE GSW
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
Day 6
Day 7
Day 26
3 months later
Gastric Outlet (GOO) Stenting
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
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
Treatment options Antiemetics Nasogastric tube Venting gastrostomy Surgical gastrojejunostomy Laparoscopic gastrojejunostomy Stenting
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
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
Cholangiocarcinoma
Introduce catheter
Get through stricture
Stiff wire in
Antral Carcinoma
Cannulate stricture
Get the wire as distal as possible
Get ready to stent
Stent in situ
Stent lumen expanded
Stent blockage
Ingrowth
Ingrowth
Stent Fracture
Stent Collapse
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