10. SEMS partial acoperite
Prezinta capete de metal proximal si distal care permit ancorarea
la nivelul peretelui esofagian
Nu exista diferente:
Succes terapeutic
Imbunatatirea disfagiei
Status performanta
Supravietuire
Complicatii
Disfagia recurenta
Migrarea stentului a fost asociata cu
diametrul redus/nu cu tipul de stent
Verschuur et al., Am J Gastroenterol 2008
11. SEMS acoperite total
Stent din nitinol acoperit in intregime cu poliuretan si silicon
Dispozitive de extragere atasate la capetele proximal/distal
Dezintegrarea poliuretanului
Fragmentarea stentului in timpul extragerii
Limitari:
Formare de noi stenoze la capete
Procent ridicat de migrare
12. SEPS acoperite total
Proteza Polyflex(Boston Scientific)
retea poliester tapetata intern cu silicon
insertie sub control fluoroscopic (markeri bariu)
Dilatarea stenozei anterior insertiei
sistem de insertie 12-14 mm
1-2 cm deasupra si sub stenoza
extragere si/sau repozitionare/refolosire
Stenoze esofagiene maligne:
procent mai ridicat de complicatii si migrare decat SEMS
Stenoze esofagiene benigne:
migrare
procent crescut de complicatii
rata scazuta de succes pe termen lung
13. Stent antireflux
jonctiunea gastroesofagiana
nu exista beneficii semnificative comparativ cu
protezele clasice partial acoperite (Ultraflex) cand
se adauga terapia cu IPP.
Sabharwal T, et al: J Gastroenterol Hepatol 2008
14. SEMS duble
Niti-S stent (Taewoong Medical)
Design special stent-in-stent:
reduce migrarea si invazia tumorala
Procentul cel mai scazut de migrare in
stenozele maligne: 8%
Verschuur EM, et al. Am J Gastroenterol 2008
15. Stenturi
biodegradabile
Aliaj magneziu, polimeri acid poliglicolic, polidiaxona
markeri radio-opaci la ambele capete
capetele proximal si distal sunt evazate pentru a reduce migrarea
Integritatea si forta radiala se mentin timp de 6-8 saptamani
Dezintegrarea stentului apare dupa 11-12 saptamani
pH scazut (reflux acid) poate produce dezintegrare mai rapida
Dificultati inerente cu preincarcarea stentului si
radioopacitatea diminuata
Ella-BD stent (ELLA-CS)
16. SEMS acoperite total pentru tratamentul
varicelor esofagiene refractare
Nitinol / retea cu ochiuri variabile
permite miscarile de peristaltica esofagiana
capete atraumatice
Markeri radio-opaci la ambele capete si in portiunea
medie/ dispozitiv de extragere la ambele capete
Se recomanda extragerea la 7 zile
Wright G, et al: Gastrointest Endosc 2010
SX-ELLA-Danis stent (ELLA-CS)
19. Stentarea esofagului - tehnica
2 cm deasupra si sub tumora
Marcare:
marcheri externi (agrafa)
marcheri interni (clip/substanta contrast)
viziune directa (eliberarea proximala)
Dilata anterior – sistem de insertie proteza
Marginea tumorala proximala > 2 cm distal de SES
Control fluoroscopic si endoscopic
20. Ingrijire post protezare
Alimentatie semisolida
Scaderea apetitului post protezare
Proteza impiedica peristaltica fiziologica a esofagului
Evaluare endoscopica a capatului proximal al protezei – expasiunea
eficienta
Nu se recomanda pasarea endoscopului prin proteza
deplasare precoce a stentului, mai ales daca acesta nu este expandat
complet
Protezarea jonctiunii GE
regim antireflux, preventia aspiratiei
Esofagograma a 2-a zi post protezare
eficienta inchiderii fistulei eso-traheale / permeabilizare stenoza
verificare pozitie proteza
31. Dilatare esofag
sonde de cauciuc cu mercur Maloney [Medovations, WI]
dilatatoare rigide cu fir ghid Savary-Gilliard [Cook
Medical]
dilatatoare cu balon prin endoscop (TT sau cu fir ghid
[Boston Scientific]
32. Dilatarea esofagiana Acalazie
Depinde de lungime si diametru
Stenoze stranse sau complexe
< 10 mm in diametru
> 2 cm in lungime
Bujii cu fir ghid sau baloane sub control
fluoroscopic si endoscopic
Stenoze simple - bujii Maloney
Dilatare progresiva (saptamani-luni) cu
cresterea graduala a diametrului bujiilor
Remisia disfagiei dupa dilatare la 40 - 54
French
Nu necesita terapie de mentinere
Studiu cu gastrografin post dilatare /Ba
pasaj
Exclude perforatia esofagiana
33. Complicatii
Dilatare esofagiana
perforatie ,
sangerare ,
bacteriemie - 0 )
Stenoze maligne sau post-iradiere – risc crescut
perforatie
Regula de trei:
Maxim 3 dilatari succesive /sesiune
Diametru esofagian > 15 mm
din pacientii dilatati la mm nu prezinta recurenta la
24 luni
36. Stenoze esofagiene benigne
Rezultate dezamagitoare?
Durata si severitatea raspunsului inflamator:
Temporar in stenozele peptice
Cronic in stenoze post-anastomotice, post-iradiere si
caustice
Tip stent:
SEMS partial acoperite se asociaza cu roliferãri de tesut
conjunctiv reactiv
SEPS procent ridicat de migrare
Dua KS, et al. Am J Gastroenterol 2008
37. Concluzii
Acoperit e mai bine (JGE – migrare)
Nitinol (curbe) vs otel (forta radiala mai mare)
Diametrul mai mare este mai eficient
Protezarea JGE – doza dubla IPP, prokinetice
38. Concluzii
UltraflexTM, Wallflex si Niti-S stents – paliatia
disfagiei maligne
Z-stents si Polyflex® - procent ridicat de complicatii
Nu exista diferente in ceea ce priveste eficienta
bujiilor Savary-Gilliard® si dilatatoarelor cu balon in
tratamentul stenozelor esofagiene benigne
Protezele sunt montate la pacientii cu stenoze
benigne complexe refractare la terapia de dilatare
Editor's Notes
Esophageal strictures are a problem commonly encountered in gastroenterological practice and can be caused by malignant or benign lesions.Upper endoscopy is the diagnostic procedure of choice for the detection of an esophageal stricture and its underlying cause. Nevertheless, it is mandatory that biopsy samples are taken to confirm whether the stricture is benign or malignant in nature, particularly if the suspicion of malignancy is high. Most treatment options available for the relief or treatment of dysphagia can be performed endoscopically.but can also be caused by
Various modalities are currently available for the relief of dysphagia caused by malignant esophageal stricturesThe options available can be divided into endoscopic and non-endoscopic procedures, and these are equally effective for strictures resulting from either esophageal squamous cell carcinoma or esophageal adenocarcinoma.Worldwide, the most frequently used method to treat dysphagia caused by esophageal or gastric cardia cancer is stent placement. Brachytherapy with or without external beam radiation therapy is another option, which has so far been mainly used in some European countries
Over the past 15 years, SEMS have emerged as the treatment of choice for the palliation of malignant dysphagia. In general, SEMS and SEPS work by splinting open the lumen by their inherent memory that generates a radial expansile force against the obstructing disease. They differ in stent material (steel, nitinol, plas- tic, biodegradable), design, luminal diameter, radial forceexerted, flexibility, and degree of shortening after deploy- ment (braided stents shorten, whereas nonbraided stents do not). Nitinol has now have replaced stainless steel as the dominant material for SEMS given the advantages of shape memory, elasticity, ability to conform better to angulations, and higher radial resistive forces. In addition, nitinol stents are ferromagnetic and thus permit magnetic resonance imaging studies.
—inoperable, poor surgical candidate, contraindication to chemoradiation(primary or secondary mediastinal and lung tumors balloon dilation and not surgically amenable
Fara a rezolvamaiintairiscul de compresie a cailoraeriene
Radiological studies help provide knowledge of a fistula, the proximity of a tumor to airways, to help chose an appropriate length stent and avoid the devastating complications of airway compres- sion. In the latter situation, an endobronchial stent placed prior to treatment would allow for safer deployment of an esophageal stent.24,25 Also, the knowledge of a very high stricture (ie, within 2 cm of the upper esophageal sphincter) on a prior imaging or endoscopic study should probably prompt consideration of a different modality for palliation, given the intense globus sensation and pain that are associated with stents in this location in a significant majority of patients. Radiological stud- ies help provide knowledge of a fistula, the proximity of a tumor to airways, to help chose an appropriate length stent and avoid the devastating complications of airway compres- sion.23 In the latter situation, an endobronchial stent placed prior to treatment would allow for safer deployment of an esophageal stent. Also, the knowledge of a very high stricture (ie, within 2 cm of the upper esophageal sphincter) on a prior imaging or endoscopic study should probably prompt consideration of a different modality for palliation, given the intense globus sensation and pain that are associated with stents in this location in a significant majority of patients. Radiological stud- ies help provide knowledge of a fistula, the proximity of a tumor to airways, to help chose an appropriate length stent and avoid the devastating complications of airway compression. In the latter situation, an endobronchial stent placed prior to treatment would allow for safer deployment of an esophageal stent. Also, the knowledge of a very high stricture (ie, within 2 cm of the upper esophageal sphincter) on a prior imaging or endoscopic study should probably prompt consideration of a different modality for palliation, given the intense globus sensation and pain that are associated with stents in this location in a significant majority of patients.
The initial esophageal SEMS were uncovered in design, but because of rapid tumor or granulation tissue ingrowth, partially covered SEMS were developed that significantly re- duced this problem.From left to right: Ultraflex (Boston Scientific), Wallflex (Boston Scientific), An- tireflux Z-stent (Dua Stent; Cook Inc), and Evolution (Cook, Inc).Comparison between various partially covered SEMS:
From left to right: Alimaxx-ES (Merit Endotek), Wall- flex (Boston Scientific), Evolution (Cook, Inc), Niti-S (Taewoong Medical), and double-type Niti-S (Taewoong Medical).It had antimigration struts that were designed to reduce its migration and a polyurethane coating on the entire stent to reduce tissue injury and hyperplasia. However, some case reports indicated disintegration of the polyurethane, leading to stent fragmentation during removal, which was sometimes traumatic and other times technically difficult.Designed to serve the same purpose as the partially covered SEMS for malignant strictures and to be removable for benign conditions similar to the SEPS, several significant limitations still exist, of which new stricture formation at the ends of the stents and high rates of stent migration are the biggest
Currently, the only available SEPS is the Polyflex stent (Boston Scientific). It is made from a polyester mesh with an inner lining of silicone that extends from the top to the bottom of the stent and covers the ends and tends to reduce the tissue damage and resultant hyperplasia. The top of the stent is flared in an effort to reduce the migration rate, with the middle and bottom of the stent being the same size. Barium is impregnated into the proximal, distal, and mid- points of the stent to facilitate fluoroscopic placement. The stent must be loaded onto a fairly bulky delivery system measuring 12-14 mm prior to placement. This large diam- eter of the delivery systems means that a dilation of the stricture is often required prior to placement.41 The stent can be placed under direct endoscopic visualization or under fluoroscopic guidance alone.Retrieval and/or repositioning can be done with a foreign body grasp- ing forceps or a standard polypectomy snare. The same stent can be reused by reloading it back onto the delivery device in case of a complete migration
Fully and partially covered SEMS that are used to bridge the esophagogastric junction can lead to significant acid reflux and its associated symptoms and complications.Stents with antireflux valves were designed with the intent to reduce this problem. The valve is usually just an extension of the existing lining of the stent (polyurethane or silicone).
The double-type Niti-S stent (Taewoong Medical)A fully covered inner nitinol stent prevents tumor ingrowth, and an outer uncovered nitinol sleeve in the mid-portion of the stent is meant to prevent migration, thus combining the best properties of both stent types.
The largest case series using a biode- gradable stent is from Japan in 13 patients with benign strictures. Spontaneous stent migra- tion occurred in 10 patients within 10-21 days and remained in position in 3 patients. None of the patients had symptoms of restenosis requiring repeat endoscopic intervention
designed to treat refractory cases of esophageal variceal bleeding where transjugular intrahepatic portosys- temic shunt or balloon tamponade would have been the only available alternatives
The Ultraflex and the newer Wallflex stents (Boston Scientific) are both deployed over a stiff guidewire using fluoroscopic and sometimes endoscopic control.The Wallflex stent can also be reconstrained in case there is a need to reposition it prior to full deployment. The Z-stent (Cook, Inc) is also delivered over a stiff guidewire, but it does need to be preloaded into the delivery sheathGiven its nonbraided design, there is no fore- shortening, thereby potentially allowing more accurate ini- tial placement. The stent may be repositioned only proximally by pulling on a suture through the proximal flange of the stent. Given its nonbraided design, there is no fore- shortening, thereby potentially allowing more accurate ini- tial placement. The stent may be repositioned only proximally by pulling on a suture through the proximal flange of the stent.
Once the stent is deployed, it probably is a good idea to invest a few minutes to endoscopically evaluate the final resting place of the proximal end of the stent and ensure its adequate expansion.However, endoscopists should resist the temptation to pass a conventional endoscope through the stent for fear of causing early stent displacement, particu- larly if the stent has not fully expanded. Water-soluble contrast can be injected through the scope to assess the mid and distal portions of the stent if desired during the proce- dure itself. The day after stent placement, we routinely order an esophogram to evaluate its position and function. The pur- pose of this study is to answer a few questions. Does the stent adequately bridge the stricture or close the esoph- agoairway fistula? Is expansion adequate? Does it abut the contralateral wall or is it so angulated to preclude its use? After being satisfied with stent position and function, a dietary consultation and patient education about eating a soft diet with copious fluids are very important. If the stent crosses the esophagogastric junction, aspiration precautions and an antireflux regimen are advised.
(if reflux post stent placement is defined as a complication)
Prolonged chest pain caused by stent expansion is more common with larger and more flared stents.case reports of erosion of the stents into the airway or adjacent vascular structures, which can occur early or late
Fully covered SEMS and SEPS have a higher incidence migration compared with partially covered SEMSUncovered stents have the best antimi- gration properties, but lead to the quickest occlusion with tumor/tissue ingrowth, which can cause complete obstruc- tion, sometimes within weeks. At this time, the main ad- vantage of plastic stents over fully covered metal stents is the tendency to cause a lesser hyperplastic tissue response than metal. Larger stents do reduce the risk of migration, but come with the price of more discomfort and increased risk of pressure necrosis
Late recurrent dysphagia can be caused by tumor overgrowth or ingrowth, granulation tis- sue, or epithelial hyperplasia, which can be treated with debulking therapy (laser, argon plasma coagulation), bal- loon dilation, or restenting.The need for repeat procedures after esophageal stenting, according to the British Registry of Esophageal stenting, approaches 60% at 6 months, with stent migration and reocclusion being the most common reason for reintervention.
The mainstay of treatment for benign esophageal strictures is dilation. Although dilation usually results in symptomatic relief, recurrent strictures do occur. In order to predict which types of stric- tures are most likely to recur, it is important to differentiate between esophageal strictures that are simple and those that are more complex
Of these, the Savary-Gilliard® and TTS balloon dilators are currently by far the most frequently used. The main difference between these two dilators is their mechanism of action. A Savary-Gilliard® dilator exerts a radial force as it is passed down, but some of its dilating force is transmitted longitudinally because of its shearing effects. By contrast, longitudinal forces are not transmitted with balloon-type dilators.Nonetheless, no clear advantage has been demonstrated for either one of these two dilator typesSavary-Gilliard® dilators are more cost-effective as they can be re- used, whereas TTS balloon dilators are intended for single use only.
Simple stricture- 1–3 dilations are required to relieve symptoms, with an additional 25–35% of patients requiring repeat dilationsComplex stricture- at least three dilation sessions to relieve symptoms recur within a time interval of 2–4 weeks, or require ongoing (more than 7–10) dilation sessions stent placement and incisional therapy
The main complications associated with esophageal dilation include perforation, hemor- rhage and bacteremia. To minimize the risk of perforation, the "rule of threes”:
