USE OF STENTS FOR UPPER GI DISASTERS. Michael Talbot. The St George Hospital, Sydney

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1 USE OF STENTS FOR UPPER GI DISASTERS Michael Talbot. The St George Hospital, Sydney

2 Disclosures Educational grants by Coviden, Applied Medical, Endogastric Solutions and Allergan in the last 3 years

3 Clinical Indications Biliary/Pancreatic Gastric Bypass/Total gastrectomy Boorhaaves Gastric Sleeve/Oesophagectomy Lessons learned

4 Endoscopic Stenting Part of the Diversion and Drainage algorithm These are off label procedures, so we are using devices in a way that may not fit within the constraints of their design There are few stents created specifically for benign work

devices in a way that may not fit within the constraints of

5 Organisation Preparation is key. All the tools need to be assembled beforehand. Two philosophies exist Early stenting Stenting after fistula established My bias is strongly towards immediate action, with stent placement as part of initial definitive management Once fistula established eradication may not be possible without re operation. Operating on chronic fistula unpleasant

towards immediate action, with stent placement as part of initial definitive management Once

6 Biliary 40 patients managed long term with minimal morbidity with multiple plastic stents 44 patients with SEMS removed at 3 months with control of strictures in short term f/u Biliary stent adequate in patients with ductal continuity, intact hepatic bifurcation and minimal tissue loss

control of strictures in short term f/u Biliary stent adequate in

7 Biliary Injuries Previously well man Long biliary injury at Lap Chole 2 laparotomies, ongoing bile leak Initial plastic stent Eventual stricture

8 Biliary Injuries Biliary sticture present after balloon dilation 80 x 10 mm removable biliary stent placed (australian first) Stent removed 4 weeks later, and cholangiogram 3/12 later ok, remains unchanged

placed (australian first) Stent removed 4 weeks

9 Biliary Injuries

10 Biliary Injuries

11 Pancreatic Pancreatic ductal stents can be used in treatment or prevention of PD fistula (0 of 25 patients), or Rx of complex strictures as well as more established role in fistula Rx

14 Oesophago gastric stenting Approach is modified by anatomy Stricture distal to or at level of defect (Boorhaves, RYGBP, Total gastrectomy) Luminal disparity (Sleeve, Oesophagectomy) Presence of distal reservoir with sphincter (Sleeve, Oesophagectomy) Plan always for single stage definitive Rx Stenting is simply a modification of diversion and drainage algorithm

Presence of distal reservoir with sphincter (Sleeve, Oesophagectomy) Plan always for

15 Stents can t be considered in isolation Physiology and anatomy underlying leak may influence choice of stent/treatment Stent function/limitations Adjuvants and alternatives What we are looking for is Definitive Management. Oversew as a repair fails most leaks and perforations. Drainage alone may not be effective and delays enteral nutrition

alternatives What we are looking for is Definitive Management.

16 Stent Design There are multiple commercially available types, all are deployed over a guidewire with image intensification required Many brands, most unsuitable Need to have knowledge of physical characteristics Will describe the nature of those applicable to benign applications (covered/removable)

most unsuitable Need to have knowledge of physical characteristics Will

17 Stent Design Variation in LENGTH, most companies produce stents 9 15 cm, however some out to 21 cm WIDTH. 20mm is default, proximal and distal flares up to 36mm, however 22mm more common. Colonic stents of 30 35mm size available

20mm is default, proximal and distal flares up to 36mm,

18 Stent Design Designed to deliver radial expansion force to help maintain position The greater the radial expansion forces, the greater the LINEAR TENSION in the stent. Linear tension leads to the stent straightening when deployed rather than conforming to the GI tract. This means the stent will straighten at corners, and not shorten with peristalsis

Linear tension leads to the stent straightening when deployed rather than conforming to

19 Stent Design linear tension Weave method Separate cover from stent (Ultraflex)

20 Stent design linear tension Cover incorporated (alimaxx) Segmented (Choo)

21 Stent Design Polyflex (Boston) Biodegradable (endotherapeutics)

22 Stent Design fixation Uncovered segment Flare (endotherapeutics)

23 Clinical Outcomes What are the possible clinical outcomes after placing a stent Complete, durable exclusion of leak from enteric stream therefore complete seal. Incomplete exclusion Temporary exclusion (fixation)

24 Complete exclusion Requires a stent that is large enough to prevent enteric content tracking around stent from antegrade peristalsis, and prevent retrograde reflux Length is important, proximal flare, proximal and distal fixation.

25 Incomplete Exclusion Poor expansion of stent to cover defect and proximal and distal gut Obstruction of stent at a corner distal to defect will lead to preferential flow of enteric content thru fistula Functional pyloric obstruction with pooling of enteric content under pressure distally

26 Temporary Exclusion Fixation failure is commonest reason for methodological failure Length Diameter/Flare Stent incorporation as part of design (Ultraflex) or suturing (others) Fixation failure will lead to migration of stent distally with luminal obstruction and increasing drainage, in the case of sleeves stent may migrate proximally instead

27 Stent Placement failure Occlusion of distal segment will lead to fluid filled and distended oesophagus, fluid will leak around stent Failure to cover defect due to luminal disparity tube vs oesophagus

28 GBP/Total Gastrectomy Usually shorter defects, in GBP aim to exclude entire pouch and have proximal stent above LOS. Boorhaves similar, in that is often a stricture distal to perforation that aids fixation

29 Single stage management, lavage, debride, drainage and transluminal suture to secure stent position

30 Using this method have obtained 100% seal in 11 cases (6 oesophageal perfs, 1 GBP, 4 total gastrectomy)

31 Boorhaaves Access for debridement depends on which cavity is contaminated. If established thoracic contamination then thoracoscopic/thoracotomy debridement/suture. Most early boorhaves or iatrogenic can be managed by transabdominal mediastinal dissection/drainage and suture

33 Sleeve and Oesophagectomy No stricture. Wide distal lumen. Distal reservoir and pyloric sphincter Complicated in Sleeve by high pressure in tube and tendency of the tube to flex during vomiting leading to stent instability and occlusion

34 Plan A Long Segmented stent, (19.5 or 21 cm) going from above COJ thru pylorus. Sutured in place distally (Vicryl/Monocryl) Will still behave as if they have a degree of obstruction, place NG tube for suction and delay drinking until fistula assessed ONLY OPTION FOR ANTRAL LEAK in sleeve

35 Leaking sleeve Stent from COJ to pylorus No laparotomy (lucky) Drains dried up and diet commenced Stent removed after it migrated day 87

36 Plan B Shorter stent Stent across COJ (sleeve), patient will hate you, retching/vomiting very common. Unless you suture the stent in it will migrate in a day or 2 In oesophagectomy can be used if there is a TOF Botox Oral intake appears unlikely, nausea can settle

37 Plan C Ultraflex Stent Suitable if you have missed the boat Migration still quite possible Can remove the stent by placing long 22 mm polyflex stent thru it

38 Adjuvants Sismesh (Cook), can be sutured into soft tissue defect acutely, or can be used in ribbon/plug forms for chronic fistula Clips (only use the expensive Boston ones), are not stand alone but can hold fistula closed/mesh in place Tisseal glue (repeated every few days 2 3 sessions) with/without Sismesh or Dexon mesh

39 Points The stent must completely exclude the hole from the enteric stream The stent must be sutured unless there is a tight stricture to hold its position, or patient supine and ventilated Longer stents are less likely to migrate (16+cm) Wider fully covered wallstent (Boston) available 28mm. Very rigid so hopeless for sleeve Colonic stents, may be difficult to remove

40 Points Valves are a potential impediment to secretions and probably should be trimmed off Stent placement beyond 6 weeks is not needed and leads to migration

Endoscopic therapy for obesity and complications of bariatric surgery

Endoscopic therapy for obesity and complications of bariatric surgery Jacques Devière, MD, PhD Erasme University Hospital Brussels Belgium jacques.deviere@erasme.ulb.ac.be Obesity Affects 300 millions