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

2. > 50% of Oesophageal tumours are inoperable at time of diagnosis.

3. Esophagogram showing lower third cancer esophagus

4. Esophagogram showing middle third cancer esophagus

5. Esophagogram showing upper third cancer esophagus

6. Esophagogram showing malignant tracheo-esophageal fistula.

7. Esophagogram showing malignant tracheo-esophageal fistula.

8. Endoscopic view of annular cancer esophagus

9. Endoscopic view of fungating cancer esophagus

10. Endoscopic view of ulcerative cancer esophagus

11. 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

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

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

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

15. Obstructed Mousseau- Barben tube.

16. Perforating Mousseau- Barben tube.

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

18. Constitution
Woven
Knitted
Zigzag
Coil

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

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

21. 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.

22. Sample of covered and partially covered SEMP

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

24. SEPS

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

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

27. Introducer system

28. Measure the length of the tumor

29. Dilate the tumor

30. Pass the guidewire into the stomach

31. Pass the introducer set to the desired level marked fluoroscopically.

32. Deployment of the stent

33. Withdrawal of the introducer

34. Stent in place, endoscopic view

35. Stent in place, radiologic view

36. Stenting lower esophagus

37. Stent for long segment tumor

38. 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.

39. Stricture above the level of the stent

40. Obstructed Stent

41. Stent slipped to the stomach.

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

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

45. Tracheal Stenosis Post prolonged intubation.

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

47. Stent was introduced with the marks on it visualized.

48. Pulling the thread of the introducer will release the stent.

49. Stent being released

50. 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.

51. Double stenting (tracheal & oesophageal)

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

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