- Email: [email protected]
Esophageal Stents
Tuesday, March 5, 1996
II
puncture, followed by balloon dilatation of the stricture and stone extraction or electrohydraulie lithotripsy (4).
14.
References 1. Citron SJ, Martin LG. Benign biliary strictures: treatment with percutaneous cholangioplasty. Radiology 1991; 178:339341. 2. Northover JMA, Terblanche J. A new look at the arterial supply of the bile duct in man and its surgical implications. Br J Surg 1979; 66:379-384. 3. Terblanche J, Allison HF, Northover ]MA. An ischemic basis for biliary strictures. Surgery 1983; 94:52-57. 4. Mueller PR, vanSonnenberg E, Ferrucci JT, et al. Biliary stricture dilatation: multi-center review of clinical management in 73 patients. Radiology 1986; 160:17-22. 5. Rossi P, Bezzi M, Salvatori FM, et al. Recurrent benign biliary strictures: management with self-expanding metallic stents. Radiology 1990; 175:661-665. 6. Gallacher D], Kadir S, Kaufman SL, et al. Nonoperative management of benign postoperative biliary strictures. Radiology 1985; 156:625-629. 7. Moore AV, Illescas FF, Mill SR, et al. Percutaneous dilation of benign biliary strictures. Radiology 1987; 163:625-628. 8. Bezzi M, Salvatori F, Maccioni F, et al. Biliary metallic stents in benign strictures. Sernin Intervent Radiol 1991; 8:321-330. 9. Maccioni F, Rossi M, Salvatory FM, et al. Metallic stents in benign biliary strictures: three-year follow-up. Cardiovasc Intervent Radiol 1992; 15:360-366. 10. Martin EC, Laffey KJ, Bixon R. Percutaneous transjejunal approaches to the biliary system. Radiology 1989; 172:10311034. 11. Russel E, Irizarry JM, Huber JS, et al. Percutaneous transjejunal biliary dilatation: Alternate management for benign strictures. Radiology 1986; 159:209-214. 12. Lee Y, Lee BH, Park JH, Suh CH. Balloon dilatation of intrahepatic biliary strictures for percutaneous extraction of residual intrahepatic stones. Cardiovasc Intervent Radiol 1991; 14:102-105. 13. vanSonnenberg E, FerrucciJT, Neff CC, et al. Biliary pressure: manometric and perfusion studies at percutaneous transhepatic cholangiography and
228
15.
16.
17.
18.
19.
20.
21.
percutaneous biliary drainage. Radiology 1983; 148:41-50. Adam A. Metallic biliary endoprostheses. Cardiovasc Intervent Radio11994; 17:127132. Coons H. Metallic stents for the treatment of biliary obstruction: report of 100 cases. Cardiovasc Intervent Radiol 1992; 15:367374. Adams DB. The importance of extrahepatic biliary anatomy in preventing complications at laparoscopic cholecystectomy. Surg Clin N Am 1993; 73:861-871. Adams DB, Borowicz MR, Wootton FT, Cunninghan]T. Bile duct complications after laparoscopic cholecystectomy. Surg Endosc 1993; 7:79-83. Lee VS, Chari RS, Cucchiaro G, Meyer We. Complications of laparoscopic cholecystectomy. Am] Surg 1993; 165:527532. Kozarek RA, Ball TJ, Patterson DJ, Brandabur JJ, Raltz S, Traverso W. Endoscopic treatment of biliary injury in the era of laparoscopic cholecystectomy. Gastrointest Endosc 1994; 40:10-16. Bonnel DH, Liguory CE, Cornud FE, Lefebvre ]F. Common bile duct and intrahepatic stones: results of transhepatic electrohydraulic lithotripsy in 50 patients. Radiology 1991; 180:345-348. Venbrux AC, Robbins KY, Savader SJ. Endoscopy as an adjuvant to biliary radiologic intervention. Radiology 1991; 180:355-361.
9:00 am
Esophageal Stents Frederick S. Keller, MD Learning objective: To discuss the use of covered expandable metallic stents for malignant dysphagia.
Approximately 10,000 cases of carcinoma of the esophagus are diagnosed annually. Unfortunately, at the time of diagnosis, 60% of patients with this disease are nonoperable. Furthermore, the prognosis for esophageal carcinoma is dismal, with a survival rate of 18% at 1 year and 5% at 5 years. The earliest symptom of this disease is progressive, unrelenting dysphagia. Dysphagia can also result from compression of the esophagus by adjacent primary lung tumors or mediastinal metastases. In ap-
Tuesday, March 5, 1996 proximately 15% of primary esophageal carcinomas and 5% of other malignancies that involve the esophagus, erosion into the trachea or a bronchus will occur with creation of an esophagorespiratory fistula. This devastating complication results in chronic, constant coughing from aspiration of all food and saliva and causes death from pulmonary infections usually within 6 months. Dysphagia can be graded on a scale developed by Mellow where grade 0 is no dysphagia, grade 1 is dysphagia to normal solids, grade 2 is dysphagia to soft solids, grade 3 is dysphagia to all solids and liqUids, and grade 4 is the inability to swallow. Available palliative therapy for esophageal carcinoma includes radiation, chemotherapy, recurrent dilation, Nd:Yag laser photocoagulation, bicap tumor probe, and various endoprostheses. For difficult cases of severe dysphagia, therapy has been limited to the Nd:Yag laser and rigid endoprostheses. Both have significant drawbacks. Nd:Yag lasers are expensive instruments, costing between $80,000 and $100,000, and are not readily available. Usually, multiple treatment sessions are required. Frequent recurrences require additional treatments. Another disadvantage of the Nd:Yag laser is that it is ineffective in treating submucosal tumors and other primary or metastatic tumors that compress the esophagus. Rigid stents require a large-bore insertion device that results in traumatic placement and a high perforation rate. Furthermore, stent migration, obstruction with food, and late pressure necrosis are common occurrences. Rigid stent insertion is associated with a 4%-7% mortality. The ideal palliation for malignant dysphagia has been described as a treatment with low morbidity, low mortality, and low cost that involves a short hospital stay and is effective. Expandable metallic stents fit that description. At the Dotter Interventional Institute, we began experimenting with placement of expandable metallic esophageal stents in swine approximately 7 years ago. A stent with a suitable covering was developed and has been used clinically since May 1990 for 88 patients with malignant obstructions of the esophagus causing either dysphagia or esophagorespiratory fistula. The first 62 patients were treated with a stent manufactured in our research lab. It consisted of a Gianturco-Rasch stent with a silicone cover and barbs to prevent migration. The stent used in the last 26 patients was simi-
lar in design; however, the covering was polyethylene.
II
Seventy-three of the 88 patients had malignant obstructions and 15 had esophagorespiratory fistulas. Stent insertion was an outpatient procedure. Topical anesthesia and intravenous sedation were used. The only imaging study required before stent placement was barium esophagography. Nevertheless, because of our close collaboration with our gastroenterologists on this project, most of our patients underwent preprocedure endoscopy. The lesion was crossed under fluoroscopic monitoring by using a soft, floppy guide wire that was exchanged in the stomach for a super-stiff wire. The stent was then advanced over this wire to the proper position and deployed. Following deployment, an esophagogram was obtained, and the patient was discharged. The patient was on a regular diet over 3-4 days. Of the 73 patients with malignant dysphagia, 71 (97%) experienced immediate relief. In this group, the mean dysphagia grade of 3.2 before stent placement dropped to 0.75 after the procedure. Sustained relief of dysphagia was achieved in 58 (82%) patients for a mean time until death of 3.2 months. Thirteen patients had recurrent dysphagia, which was related to tumor overgrowth or stent migration. The latter complication was primarily seen with an early version of the silicone-covered stent. Eight of these were successfully treated with placement of an additional stent. Complete relief of aspiration was achieved in 11 (73%) of the 15 patients with esophagorespiratory fistula for a mean time until death of 3.9 months. Partial relief with tolerance of a soft solid diet but continued aspiration of liquids was observed in the remaining 4 (27%) patients. We have found that covered expandable metallic stents are an effective method of palliating both malignant dysphagia and the complications of esophagorespiratory fistulas. Placement of an expandable metallic esophageal stent is a safe, inexpensive outpatient procedure that results in a significant improvement in the quality of life.
Selected Bibliography Boyce HW]r. Palliation of advanced esophageal cancer. Semin Oncol 1984; 11: 186-195. Knyrim K, Wagner HJ, Bethge N, Keymling M, Vakil N. Controlled trial of an expansile
229
Tuesday, March 5, 1996 metal stent for palliation of esophageal obstruction due to inoperable cancer. N Engl J Med 1993; 329:1302-1307. Saxon RR, Barton'RE, Katon RM, et al. Treatment of malignant esophageal obstructions using covered metallic Zstents: long-term results in 52 patients. ]VIR (in press). Saxon RR, Barton RE, Katon RM, et al. Treatment of malignant esophagorespiratory fistulas with silicone covered metallic Z stents. ]VIR 1995; 6: 237-242. Song HY, Choi KC, Kwon HC, Yang DH, Cho BH, Lee ST. Esophageal stricture treatment with a new design of modified Gianturco stent. Radiology 1992; 184:729-734. Wu WC, Katon RM, Saxon RR, et al. Siliconecovered self-expanding metallic stents for the palliation of malignant esophageal obstruction and esophagorespiratory fistulas: experience in 32 patients and a review of the literature. Gastrointest Endosc 1994; 40:22-33.
9:20 am Gastrointestinal Interventions: Current Concepts and Future Directions Albert A. Nemcek, jr, MD Learning objectives: (1) To identify basic anatomic considerations as they apply to percutaneous access to the alimentary tract and gallbladder. (2) To analyze current patterns of practice concerning percutaneous gastrointestinal tract access with respect to available information on its relative advantages and disadvantages compared with surgical, laparoscopic, and endoscopic alternatives. (3) To assess current methods of percutaneous gastrointestinal tract access and current equipment used for these procedures with respect to success rates, complications, ease of use, and patient satisfaction. (4) To analyze, in the setting of acute cholecystitis, selection criteria for performance of percutaneous cholecystostomy (PC) as they relate to clinical response and complication rates. (5) To identify less common or potential future indications for percutaneous enterostomy and Pc.
Percutaneous access to the gastrointestinal tract is most often performed for enteric alimentation. Yet, interventional radiologists may use ~nteric or transenteric access for several other
230
purposes, including diagnostic soft tissue or fluid sampling, bowel decompression, drainage of fluid collections shielded by bowel, access for therapy of gastrointestinal strictures, and diagnostic or therapeutic access to the biliary tree in patients with choledochoenteric anastomoses. Despite concern that infectious complications in particular would be unacceptably high following such procedures, these techniques have proved both safe and effective. Radiologic placement of gastrostomy, gastrojejunostomy, and jejunostomy tubes is currently a reasonable alternative among several reasonable options. Indications for these procedures as methods of providing enteral therapy are generally those of longer-term nutritional requirements in patients who, because of mechanical, functional, or psychologic disorders, are unable to meet their nutritional needs without assistance but who are still able to assimilate enterically administered nutrients. While information on benefits and risks of each of these approaches is available, direct comparison with surgical, endoscopic, radiologic, and the more recently reported laparoscopic techniques is minimal. Consequently, local referral patterns and politics, as well as local expertise, may result in widely variable use of these differing methods from institution to institution. High 30day mortality rates reported in several series dealing with enteral access raise questions about how patients should be selected as candidates for enteral access and whether more conservative methods, such as nasogastric tube feeding, should receive renewed attention. Now that many enteral access techniques have matured, the importance of studies that compare efficacy, costs, and complication rates cannot be overemphasized. Potential advantages of percutaneous gastrostomy include lower overall morbidity, mortality, and cost (compared with surgical gastrostomy), and improved success rates in patients with pathologic narrowing of the esophagus, decreased incidence of skin infection, and better ability to advance the catheter past the pylorus and into the jejunum immediately (compared with endoscopic gastrostomy). Techniques for performing percutaneous gastrostomy and gastrojejunostomy successfully and safely have been elaborated. Among the areas of controversy regarding technique is the advisability of using fixation devices to appose the anterior gastric wall to the anterior abdomi-
II
puncture, followed by balloon dilatation of the stricture and stone extraction or electrohydraulie lithotripsy (4).
14.
References 1. Citron SJ, Martin LG. Benign biliary strictures: treatment with percutaneous cholangioplasty. Radiology 1991; 178:339341. 2. Northover JMA, Terblanche J. A new look at the arterial supply of the bile duct in man and its surgical implications. Br J Surg 1979; 66:379-384. 3. Terblanche J, Allison HF, Northover ]MA. An ischemic basis for biliary strictures. Surgery 1983; 94:52-57. 4. Mueller PR, vanSonnenberg E, Ferrucci JT, et al. Biliary stricture dilatation: multi-center review of clinical management in 73 patients. Radiology 1986; 160:17-22. 5. Rossi P, Bezzi M, Salvatori FM, et al. Recurrent benign biliary strictures: management with self-expanding metallic stents. Radiology 1990; 175:661-665. 6. Gallacher D], Kadir S, Kaufman SL, et al. Nonoperative management of benign postoperative biliary strictures. Radiology 1985; 156:625-629. 7. Moore AV, Illescas FF, Mill SR, et al. Percutaneous dilation of benign biliary strictures. Radiology 1987; 163:625-628. 8. Bezzi M, Salvatori F, Maccioni F, et al. Biliary metallic stents in benign strictures. Sernin Intervent Radiol 1991; 8:321-330. 9. Maccioni F, Rossi M, Salvatory FM, et al. Metallic stents in benign biliary strictures: three-year follow-up. Cardiovasc Intervent Radiol 1992; 15:360-366. 10. Martin EC, Laffey KJ, Bixon R. Percutaneous transjejunal approaches to the biliary system. Radiology 1989; 172:10311034. 11. Russel E, Irizarry JM, Huber JS, et al. Percutaneous transjejunal biliary dilatation: Alternate management for benign strictures. Radiology 1986; 159:209-214. 12. Lee Y, Lee BH, Park JH, Suh CH. Balloon dilatation of intrahepatic biliary strictures for percutaneous extraction of residual intrahepatic stones. Cardiovasc Intervent Radiol 1991; 14:102-105. 13. vanSonnenberg E, FerrucciJT, Neff CC, et al. Biliary pressure: manometric and perfusion studies at percutaneous transhepatic cholangiography and
228
15.
16.
17.
18.
19.
20.
21.
percutaneous biliary drainage. Radiology 1983; 148:41-50. Adam A. Metallic biliary endoprostheses. Cardiovasc Intervent Radio11994; 17:127132. Coons H. Metallic stents for the treatment of biliary obstruction: report of 100 cases. Cardiovasc Intervent Radiol 1992; 15:367374. Adams DB. The importance of extrahepatic biliary anatomy in preventing complications at laparoscopic cholecystectomy. Surg Clin N Am 1993; 73:861-871. Adams DB, Borowicz MR, Wootton FT, Cunninghan]T. Bile duct complications after laparoscopic cholecystectomy. Surg Endosc 1993; 7:79-83. Lee VS, Chari RS, Cucchiaro G, Meyer We. Complications of laparoscopic cholecystectomy. Am] Surg 1993; 165:527532. Kozarek RA, Ball TJ, Patterson DJ, Brandabur JJ, Raltz S, Traverso W. Endoscopic treatment of biliary injury in the era of laparoscopic cholecystectomy. Gastrointest Endosc 1994; 40:10-16. Bonnel DH, Liguory CE, Cornud FE, Lefebvre ]F. Common bile duct and intrahepatic stones: results of transhepatic electrohydraulic lithotripsy in 50 patients. Radiology 1991; 180:345-348. Venbrux AC, Robbins KY, Savader SJ. Endoscopy as an adjuvant to biliary radiologic intervention. Radiology 1991; 180:355-361.
9:00 am
Esophageal Stents Frederick S. Keller, MD Learning objective: To discuss the use of covered expandable metallic stents for malignant dysphagia.
Approximately 10,000 cases of carcinoma of the esophagus are diagnosed annually. Unfortunately, at the time of diagnosis, 60% of patients with this disease are nonoperable. Furthermore, the prognosis for esophageal carcinoma is dismal, with a survival rate of 18% at 1 year and 5% at 5 years. The earliest symptom of this disease is progressive, unrelenting dysphagia. Dysphagia can also result from compression of the esophagus by adjacent primary lung tumors or mediastinal metastases. In ap-
Tuesday, March 5, 1996 proximately 15% of primary esophageal carcinomas and 5% of other malignancies that involve the esophagus, erosion into the trachea or a bronchus will occur with creation of an esophagorespiratory fistula. This devastating complication results in chronic, constant coughing from aspiration of all food and saliva and causes death from pulmonary infections usually within 6 months. Dysphagia can be graded on a scale developed by Mellow where grade 0 is no dysphagia, grade 1 is dysphagia to normal solids, grade 2 is dysphagia to soft solids, grade 3 is dysphagia to all solids and liqUids, and grade 4 is the inability to swallow. Available palliative therapy for esophageal carcinoma includes radiation, chemotherapy, recurrent dilation, Nd:Yag laser photocoagulation, bicap tumor probe, and various endoprostheses. For difficult cases of severe dysphagia, therapy has been limited to the Nd:Yag laser and rigid endoprostheses. Both have significant drawbacks. Nd:Yag lasers are expensive instruments, costing between $80,000 and $100,000, and are not readily available. Usually, multiple treatment sessions are required. Frequent recurrences require additional treatments. Another disadvantage of the Nd:Yag laser is that it is ineffective in treating submucosal tumors and other primary or metastatic tumors that compress the esophagus. Rigid stents require a large-bore insertion device that results in traumatic placement and a high perforation rate. Furthermore, stent migration, obstruction with food, and late pressure necrosis are common occurrences. Rigid stent insertion is associated with a 4%-7% mortality. The ideal palliation for malignant dysphagia has been described as a treatment with low morbidity, low mortality, and low cost that involves a short hospital stay and is effective. Expandable metallic stents fit that description. At the Dotter Interventional Institute, we began experimenting with placement of expandable metallic esophageal stents in swine approximately 7 years ago. A stent with a suitable covering was developed and has been used clinically since May 1990 for 88 patients with malignant obstructions of the esophagus causing either dysphagia or esophagorespiratory fistula. The first 62 patients were treated with a stent manufactured in our research lab. It consisted of a Gianturco-Rasch stent with a silicone cover and barbs to prevent migration. The stent used in the last 26 patients was simi-
lar in design; however, the covering was polyethylene.
II
Seventy-three of the 88 patients had malignant obstructions and 15 had esophagorespiratory fistulas. Stent insertion was an outpatient procedure. Topical anesthesia and intravenous sedation were used. The only imaging study required before stent placement was barium esophagography. Nevertheless, because of our close collaboration with our gastroenterologists on this project, most of our patients underwent preprocedure endoscopy. The lesion was crossed under fluoroscopic monitoring by using a soft, floppy guide wire that was exchanged in the stomach for a super-stiff wire. The stent was then advanced over this wire to the proper position and deployed. Following deployment, an esophagogram was obtained, and the patient was discharged. The patient was on a regular diet over 3-4 days. Of the 73 patients with malignant dysphagia, 71 (97%) experienced immediate relief. In this group, the mean dysphagia grade of 3.2 before stent placement dropped to 0.75 after the procedure. Sustained relief of dysphagia was achieved in 58 (82%) patients for a mean time until death of 3.2 months. Thirteen patients had recurrent dysphagia, which was related to tumor overgrowth or stent migration. The latter complication was primarily seen with an early version of the silicone-covered stent. Eight of these were successfully treated with placement of an additional stent. Complete relief of aspiration was achieved in 11 (73%) of the 15 patients with esophagorespiratory fistula for a mean time until death of 3.9 months. Partial relief with tolerance of a soft solid diet but continued aspiration of liquids was observed in the remaining 4 (27%) patients. We have found that covered expandable metallic stents are an effective method of palliating both malignant dysphagia and the complications of esophagorespiratory fistulas. Placement of an expandable metallic esophageal stent is a safe, inexpensive outpatient procedure that results in a significant improvement in the quality of life.
Selected Bibliography Boyce HW]r. Palliation of advanced esophageal cancer. Semin Oncol 1984; 11: 186-195. Knyrim K, Wagner HJ, Bethge N, Keymling M, Vakil N. Controlled trial of an expansile
229
Tuesday, March 5, 1996 metal stent for palliation of esophageal obstruction due to inoperable cancer. N Engl J Med 1993; 329:1302-1307. Saxon RR, Barton'RE, Katon RM, et al. Treatment of malignant esophageal obstructions using covered metallic Zstents: long-term results in 52 patients. ]VIR (in press). Saxon RR, Barton RE, Katon RM, et al. Treatment of malignant esophagorespiratory fistulas with silicone covered metallic Z stents. ]VIR 1995; 6: 237-242. Song HY, Choi KC, Kwon HC, Yang DH, Cho BH, Lee ST. Esophageal stricture treatment with a new design of modified Gianturco stent. Radiology 1992; 184:729-734. Wu WC, Katon RM, Saxon RR, et al. Siliconecovered self-expanding metallic stents for the palliation of malignant esophageal obstruction and esophagorespiratory fistulas: experience in 32 patients and a review of the literature. Gastrointest Endosc 1994; 40:22-33.
9:20 am Gastrointestinal Interventions: Current Concepts and Future Directions Albert A. Nemcek, jr, MD Learning objectives: (1) To identify basic anatomic considerations as they apply to percutaneous access to the alimentary tract and gallbladder. (2) To analyze current patterns of practice concerning percutaneous gastrointestinal tract access with respect to available information on its relative advantages and disadvantages compared with surgical, laparoscopic, and endoscopic alternatives. (3) To assess current methods of percutaneous gastrointestinal tract access and current equipment used for these procedures with respect to success rates, complications, ease of use, and patient satisfaction. (4) To analyze, in the setting of acute cholecystitis, selection criteria for performance of percutaneous cholecystostomy (PC) as they relate to clinical response and complication rates. (5) To identify less common or potential future indications for percutaneous enterostomy and Pc.
Percutaneous access to the gastrointestinal tract is most often performed for enteric alimentation. Yet, interventional radiologists may use ~nteric or transenteric access for several other
230
purposes, including diagnostic soft tissue or fluid sampling, bowel decompression, drainage of fluid collections shielded by bowel, access for therapy of gastrointestinal strictures, and diagnostic or therapeutic access to the biliary tree in patients with choledochoenteric anastomoses. Despite concern that infectious complications in particular would be unacceptably high following such procedures, these techniques have proved both safe and effective. Radiologic placement of gastrostomy, gastrojejunostomy, and jejunostomy tubes is currently a reasonable alternative among several reasonable options. Indications for these procedures as methods of providing enteral therapy are generally those of longer-term nutritional requirements in patients who, because of mechanical, functional, or psychologic disorders, are unable to meet their nutritional needs without assistance but who are still able to assimilate enterically administered nutrients. While information on benefits and risks of each of these approaches is available, direct comparison with surgical, endoscopic, radiologic, and the more recently reported laparoscopic techniques is minimal. Consequently, local referral patterns and politics, as well as local expertise, may result in widely variable use of these differing methods from institution to institution. High 30day mortality rates reported in several series dealing with enteral access raise questions about how patients should be selected as candidates for enteral access and whether more conservative methods, such as nasogastric tube feeding, should receive renewed attention. Now that many enteral access techniques have matured, the importance of studies that compare efficacy, costs, and complication rates cannot be overemphasized. Potential advantages of percutaneous gastrostomy include lower overall morbidity, mortality, and cost (compared with surgical gastrostomy), and improved success rates in patients with pathologic narrowing of the esophagus, decreased incidence of skin infection, and better ability to advance the catheter past the pylorus and into the jejunum immediately (compared with endoscopic gastrostomy). Techniques for performing percutaneous gastrostomy and gastrojejunostomy successfully and safely have been elaborated. Among the areas of controversy regarding technique is the advisability of using fixation devices to appose the anterior gastric wall to the anterior abdomi-