Management of Esophageal and Tracheal obstruction by stenting

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Presentation transcript:

Management of Esophageal and Tracheal obstruction by stenting Prof Khaled KARARA Prof of Cardiothoracic Surgery Alexandria Faculty of Medicine

> 50% of Oesophageal tumours are inoperable at time of diagnosis.

Esophagogram showing lower third cancer esophagus

Esophagogram showing middle third cancer esophagus

Esophagogram showing upper third cancer esophagus

Esophagogram showing malignant tracheo-esophageal fistula.

Esophagogram showing malignant tracheo-esophageal fistula.

Endoscopic view of annular cancer esophagus

Endoscopic view of fungating cancer esophagus

Endoscopic view of ulcerative cancer esophagus

Indications for stenting airways or esophagus Stents are used for benign and malignant conditions. 1- Endoluminal obstruction: Benign conditions include strictures (such as those induced by peptic ulcers, anastomoses, and radiation), Malignant conditions include inoperable esophageal cancer, gastroesophageal junction cancer, and gastric cardia cancer. 2- Extraluminal compression 3- Tracheo-oesophageal fistulae, iatrogenic perforations, and leaks; 4- Malacic airways 5- Anastomotic strictures & recurrences

Type of stents Old types : ( Pulsion & traction ) Present types: * Self-expanding metal stents (SEMS) * Self-expanding plastic stents (SEPS) - Silicone

Rigid plastic prostheses: Mousseau- Barben (Traction tube) (left) or Celisten tube. Rigid metallic prostheses: Souttar tube (right).

Soutar tube (Pulsion tube) inserted in a patient with terminal tracheostomy and gastric pull up.

Obstructed Mousseau- Barben tube.

Perforating Mousseau- Barben tube.

SEMS Material: Biologically inert, resistant to corrosion Cobalt alloys Stainless steel Nickel – Titanium alloy (nitinol)

Constitution Woven Knitted Zigzag Coil

Covering Uncovered Partially covered with polyurethane or silicone Fully covered. For covered: Adv: Tumor in growth Disadv : Stent migration

Companies Boston Scientific, available in Egypt. Cook Medical, available in Egypt. EndoChoice, Merit Medical Endotek, Taewoong Medical Co., ELLA-CS are available in Egypt.

From left to right, 1- Boston Scientific's Polyflex Esophageal Stent, 2- Ultraflex Esophageal NG Stent System, 3- WallFlex Fully Covered Esophageal Stent, and 4- WallFlex Partially Covered Esophageal Stent.

Sample of covered and partially covered SEMP

Silicone Stents (SEPS) Made of silastic rubber Flanged or Studded - Cylindrical, T, Y or T-Y shaped

SEPS

Adv over EMS - Removable Dis adv: - Not for permanent use. - More expensive. - More difficult to apply. - Easier to be obstructed.

Definitive Metal Bridge to surgery Silicone (Removable) Esopheal malignancy Metal Air ways Silicone

Introducer system

Measure the length of the tumor

Dilate the tumor

Pass the guidewire into the stomach

Pass the introducer set to the desired level marked fluoroscopically.

Deployment of the stent

Withdrawal of the introducer

Stent in place, endoscopic view

Stent in place, radiologic view

Stenting lower esophagus

Stent for long segment tumor

Complications Early Chest pain, fever, bleeding, gastroesophageal reflux disease, globus (FB) sensation, perforation (0.8%), and stent migration (up or down). Failure to insert (5%). Delayed Stent migration, stent occlusion (FB, tumor growth above or below stent or ingrowths with uncovered stent.), development of esophageal fistulae, and recurrence of strictures.

Stricture above the level of the stent

Obstructed Stent

Stent slipped to the stomach.

- Improvement of dysphagia 90-100% Results: Procedure related mortality 0-2.5% - Improvement of dysphagia 90-100%

Advances: Stent in stent & Extension stents. Anti reflex stents. Upper esophageal stents. Retrivalbe stents. Biodegradable Stents

Tracheal Stenosis Post prolonged intubation.

Measure the length of the tracheal narrowing and put radio opaque marker

Stent was introduced with the marks on it visualized.

Pulling the thread of the introducer will release the stent.

Stent being released

Double Stenting Stenting both the trachea and esophagus. When mediastinal tumor compresses both. For esophageal tumors invading the trachea. When a tracheal tumor invades the esophagus. For some cases of tracheo-esophgeal fistulae.

Double stenting (tracheal & oesophageal)

Multidsciplinary approach Rigid bronchoscopy & esophagoscopy with debridement. Dilatation (Balloon). Photodynamic therapy. Cryotherapy. Laser (Nd.Yag). Brachy therapy. Chemotherapy.

Conclusion Stents are relatively safe and effective method of palliation for obstructed air way and for esophageal cancer patients.