Enteral Stenting: How, Why and When? Jason Klapman, MD Director of Endoscopy Moffitt Cancer Center Associate Professor of Medicine University of South Florida Tampa, FL
1. Enteral Stenting: How, Why and When? Jason Klapman, MD
Director of Endoscopy Moffitt Cancer Center Associate Professor of
Medicine University of South Florida Tampa, FL
2. Enteral Stenting Palliation of malignant dysphagia
Management and palliation colorectal obstruction Palliation of
malignant gastroduodenal obstruction
3. Palliation of Malignant Dysphagia To Palliate-From the Latin
Palliatus-to cloak or conceal. To palliate a disease is to treat it
partially and insofar as possible, but not cure it completely.
Easing the severity of a pain or a disease without removing the
cause
4. Esophageal Stenting ASGE Guidelines GIE March 2013
Esophageal Stenting should be the preferred method for palliation
of malignant dysphagia and Fistulae Provides immediate and durable
relief in the majority of patients
5. Pre-Procedure Knowledge of location and length of malignant
stricture is key to success (previous EGD or esophagogram) If
proximal obstruction consider pre-procedure eval by imaging,
Pulmonary or Thoracic surgery to eval for tracheal compression and
airway compromise Consider Fluoroscopy Choose stent at least 2mm
larger than estimated lumen or last dilation
6. Esophageal Stents Types Plastic or Metal Fully Covered
Partially covered Uncovered Biodegradable
7. Choosing a stent Majority are metal stents Most SEMS are
equally effective in relieving symptoms, have similar complication
rates No study has been done comparing all types of metal stents
Choice usually determined by perceived ease of placement and
personal experience of endoscopist Low incidence of migration is
the holy grail!!
8. Choosing a stent (cont) Stent characteristics Delivery
systems Deployment patterns Expansile force Foreshortening
characteristics Removability
9. Available Esophageal Stents (U.S.) Boston Scientific
Polyflex -strong expansile force,removable 16-21mm 9-12-15cm length
Ultraflex- distal and proximal release option, most flexible, least
expansile force (partially or uncovered) 18 or 23 mm, 10,12,15cm
lengths Wallflex-, no foreshortening, smooth delivery vs.
Ultraflex, lasso loop (fully/partially) 18 or 23mm 10,12,15cm Cook
Endoscopy Evolution-no shortening, recapturable, lasso loop, distal
release only(fully18,20 - 8,10,12cm or partially 20mm, 8,10,12.5,15
Z stent - no shortening, short bare wire at ends, has anti-reflux
valve option (fully, partially, anti-reflux)18mm, 8,10,12,14 Merrit
Medical EndoTek Alimaxx-E-non-foreshortening, fully covered, lasso
loop, distal release only multiple sizes 12-22mm 7,10,12cm lengths
EndoMaxx-non-forshortening,fully covered,Metal loop, 19,23mm
,7,10,12,15cm Endochoice-Bonastent- Fully covered, Hook/Cross
technology, Non-foreshortening, retrieval lasso-18mm 6-16cm length
TaeWoong-Niti-S TTS, fully covered ,lasso loop 18mm, 6-15cm
10. Non-TTS placement A stiff 0.035 guidewire for stability,
over which stent is deployed Remove endoscope leaving wire in place
Back load stent over wire and advance through stricture Can place
endoscope alongside stent to observe deployment if desired (No
fluoroscopy needed) Choose stent that is 4cm longer than tumor to
allow for 2cm above and below tumor for stability
11. Non-TTS placement
12. TTS placement Niti-s esophageal stent 10.5 fr diameter
deployment system Use therapeutic upper scope Proximal release
13. Post Procedure Starts clears and slowly advance to soft
foods Give post stent diet instructions-tailor it to the size of
stent Analgesics prn for pain
15. Colonic stenting Indications Palliation of malignant
obstruction Acute colonic obstruction Allow colon prep May obviate
the need for a two stage surgical procedure
16. Palliation of malignant obstruction Uncovered through the
scope SEMS Boston Scientific Wallstent and Ultraflex stent Cook
Endoscopy Evolution Stent
20. Post Procedure Diet-low residue Laxative to maintain stool
softness Consider x-ray to confirm position
21. Gastroduodenal Obstruction (GOO) Stenting Indication
Palliation of malignant obstruction Do not place in setting of
chemoradiation treatment Available SEMS TTS stents BSC and COOK
uncovered metal stents Can be placed along side the scope or
through the scope Taewoong- covered esophageal stent can be placed
in the stomach/duodenum for attempted fistula closure due to the
ability to use TTS
22. GOO Pre-procedure Pt. decompressed with NG tube or perform
under general anesthesia Consider road map with UGI before the
procedure to delineate the length of the stricture Fluoroscopy
Therapeutic Upper Endoscope Intra-procedure Technique similar to
colonic stenting Avoid Dilation of the malignant stricture to allow
passage of the endoscope
24. Summary Enteral stents are effective in relieving malignant
obstruction of the GI tract Pre procedure work-up and preparation
is paramount to the success of the procedure Avoid dilation of
malignant strictures(except in Esophagus) to try and advance the
endoscope through the obstruction Choose stents 4cm longer than the
anticipated stricture length Avoid placing stents in the
Stomach/Duodenum or colon in settings other than palliation or as a
bridge to surgery