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A1-G Surg Note Esophagus > Esophageal Stent > Flashcards

Esophageal Stent Flashcards

1
Q

What condition is esophageal stenting (ES) commonly used to relieve?

A

-Severe dysphagia caused by benign or malignant esophageal strictures
-prevent luminal contamination of the mediastinum

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2
Q

What properties of Nitinol make it ideal for use in SEMS?

A

Superelasticity and shape memory, which allow it to expand at body temperature to fit the lesion’s morphology.

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3
Q

What is a drawback of uncovered SEMS (uc-SEMS)?

A

They can foster stent stenosis due to fibrotic tissue ingrowth through the mesh openings

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4
Q

Why were fully covered and partially covered stents developed?

A

To reduce fibrotic tissue ingrowth and stent stenosis while providing additional luminal anchorage

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5
Q

What is the potential downside of using covered stents?

A

more susceptible to migration, particularly in high-risk areas like the distal esophagus.

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6
Q

What are self-expandable plastic stents (SEPS) made of?

A

double-layered, with polyester mesh on the outside and a smooth silicon layer on the inside.

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7
Q

What is the primary use of biodegradable stents (BDS)?

A

They are mainly used for benign strictures and do not require retrieval.

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8
Q

What material are biodegradable stents (BDS) made from, and how long do they maintain mechanical strength?

A

plaited polydioxanone, maintaining mechanical strength for 4 to 6 weeks and degrade over 8 to 12 weeks

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9
Q

What has the FDA approved esophageal stenting (ES) for?

A

Preservation of luminal patency in malignant strictures and occlusion of concurrent esophageal fistula

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10
Q

What conditions has the use of ES increased for in the past decade?

A

Refractory benign esophageal strictures (RBES),
esophageal perforations
variceal bleeding
postsurgical anastomotic leaks
and achalasia

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11
Q

What causes malignant esophageal dysphagia?

A

-intramural growth of primary esophageal tumors
-extrinsic compression from mediastinal and airway tract neoplasms

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12
Q

What is the primary goal of treatment in patients with advanced malignant esophageal dysphagia?

A

Relief of dysphagia
resumption of oral intake to improve quality of life (QOL) and sometimes survival.

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13
Q

What is considered the first-line therapy for palliation of malignant dysphagia?

A

Esophageal stenting (ES), specifically using self-expandable metal stents (SEMS).

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14
Q

What are the benefits of SEMS for malignant dysphagia?

A

SEMS provide prompt relief of dysphagia and help optimize the patient’s nutritional status

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15
Q

How does single-dose brachytherapy compare to SEMS in treating malignant dysphagia?

A

Brachytherapy provides longer-lasting dysphagia relief, higher QOL scores, and less morbidity, but stenting offers earlier relief.

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16
Q

Why has enthusiasm for brachytherapy diminished in treating malignant dysphagia?

A

Due to the frequent need to insert rescue stents after brachytherapy.

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17
Q

When might brachytherapy still be considered for malignant dysphagia?

A

For carefully selected patients with mild to moderate dysphagia and a longer life expectancy.

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18
Q

What is the first line of intervention for patients with moderate to severe dysphagia or recurrent dysphagia after brachytherapy?

A

Esophageal stenting (ES), particularly with fully covered SEMS (fc-SEMS)

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19
Q

Why are fully covered SEMS (fc-SEMS) preferred over uncovered SEMS (uc-SEMS) or self-expandable plastic stents (SEPS)?

A

fc-SEMS have a lower rate of tumor ingrowth compared to partially covered

and less risk of stent migration compared to SEPS

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20
Q

What causes malignant esophageal fistulas?

A

Primarily from esophageal tumor infiltration into surrounding structures like the trachea, mediastinum, pleura, and proximal abdominal cavity

or from extrinsic infiltration or chemoradiation-induced tumor necrosis.

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21
Q

What initial management steps are recommended for malignant esophageal fistulas?

A

Temporary suspension of oral intake
drainage of involved spaces
and endoscopic insertion of a fully covered self-expandable metal stent (fc-SEMS)

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22
Q

Why is the palliation of gastroesophageal junction (GEJ) strictures by endoscopic means technically challenging?

A

Due to the acute angle and varying luminal diameters at the GEJ, which can interfere with satisfactory stent fixation

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23
Q

What are the common complications of esophageal stenting (ES) at the GEJ?

A

Increased risk of acid reflux
distal stent migration
and ineffective palliation.

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24
Q

What type of stent is considered the stent of choice for GEJ strictures?

A

Partially covered self-expandable metal stents (pc-SEMS)

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25
Q

How might preoperative esophageal stenting (ES) benefit patients with locally advanced esophageal cancer (EC) undergoing neoadjuvant therapy?

A

nutritional optimization
improved oral intake
weight stabilization, and enhanced quality of life (QOL) before surgical resection

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26
Q

Why might SEMS negatively affect oncologic outcomes in preoperative esophageal cancer patients

A

SEMS may induce mural inflammation, potentially distorting tissue planes and interfering with the completeness of surgical resection.

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27
Q

What might upward stent migration rates of up to 50% indicate during neoadjuvant therapy in esophageal cancer patients?

A

Stent migration may represent a favorable response to neoadjuvant therapy

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28
Q

What is the mainstay treatment for benign esophageal strictures?

A

Periodic endoscopic balloon dilation

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29
Q

What are common causes of refractory benign esophageal strictures (RBES)?

A

Caustic injuries
chest or mediastinal radiation
postsurgical esophagodigestive anastomoses
POEM and endoscopic mucosal resection

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30
Q

What are key characteristics of an ideal stent for RBES?

A

The stent should be easily retrievable and resistant to migration.

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31
Q

Which stent type is most commonly used for RBES

A

Fully covered self-expanding metal stents (fc-SEMS).

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32
Q

What is an advantage of biodegradable stents (BDS) over fc-SEMS in RBES management?

A

BDS does not require retrieval

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33
Q

What complications are more common with biodegradable stents (BDS)?

A

Retrosternal pain and bleeding.

34
Q

How can benign esophageal perforations (BEP) be classified?

A

as spontaneous (e.g., Boerhaave’s syndrome), iatrogenic, or traumatic.

35
Q

What serious complications can arise from fistulas in the esophagus?

A

contamination of mediastinal or pleural spaces, causing lethal inflammation and infection.

36
Q

What is the role of endoscopic stenting (ES) in patients with noncontained esophageal leaks?

A

ES can reduce morbidity and is increasingly used to avoid surgical intervention in patients with noncontained leaks.

37
Q

What are the goals of therapy in using stents for esophageal perforations?

A

drain contaminated spaces, seal the leak, divert oral secretions, and prevent widespread infection.

38
Q

Which type of stents are recommended for hemodynamically stable patients with BEP?

A

Covered stents, including fully covered self-expanding metal stents (fc-SEMS) or partially covered SEMS (pc-SEMS).

39
Q

What are the mainstays of definitive therapy for achalasia?

A

Surgical and endoscopic interventions, including Heller myotomy and per-oral endoscopic myotomy (POEM).

40
Q

When might temporary retrievable stenting with SEMS be considered in the treatment of achalasia?

A

may be an option for patients with achalasia who are not surgical candidates.

41
Q

What diameter of SEMS was found to be more effective than pneumatic dilation in the long-term follow-up study?

A

30-mm SEMS were found to be more effective.

42
Q

What type of stent may be used for refractory esophageal variceal bleeding?

A

Fully covered self-expanding metal stents (SEMS)

43
Q

What is a key design feature of SEMS used for esophageal variceal bleeding?

A

They have a wide diameter, typically at least 25 mm, designed for this specific indication.

44
Q

In what clinical situation are fully covered SEMS indicated for use?

A

indicated for refractory esophageal variceal bleeding when other interventions have failed.

45
Q

Why should the internal diameter of a stent be slightly larger than the lesion?

A

To ensure adequate radial force is applied, securing the stent in place

46
Q

What are the risks of using an inadequately small stent diameter?

A

It may increase the risk of stent migration

47
Q

What are the potential complications of using an oversized stent?

A

lead to perforation and excessive pressure necrosis.

48
Q

How long should a stent be relative to the lesion?

A

The stent should be at least 4 cm longer than the lesion, overlapping it by at least 2 cm both proximally and distally.

49
Q

What challenges are associated with stent placement in the proximal esophagus?

A

Placement near the upper esophageal sphincter (UES) is challenging; the proximal stent margin may need to be less than 2 cm below the UES

50
Q

What must be considered when placing a stent in the distal esophagus or across the gastroesophageal junction (GEJ)?

A

Avoiding an excessively long stent to prevent distal contact with the gastric wall, which could cause ulceration or perforation

51
Q

Why is repeat endoscopy or an upper gastrointestinal series performed 24 to 36 hours after stent deployment?

A

To confirm proper stent placement and assess for complications before resuming oral intake

52
Q

How long does it typically take for a deployed stent to fully expand?

A

The stent usually fully expands within 48 to 72 hours post-deployment

53
Q

What dietary recommendations are given to patients after stent placement?

A

Patients start with liquids for 24 to 48 hours, then gradually progress to a soft solid diet as tolerated.

54
Q

What long-term dietary restrictions are generally advised for patients with an esophageal stent?

A

Patients are advised to avoid fibrous foods, such as raw vegetables and large pieces of meat, to reduce the risk of blockage

55
Q

What are common mild to moderate complications after esophageal stent placement?

A

Retrosternal pain and reflux symptoms, which often resolve within 1 to 2 weeks.

56
Q

What might persistent retrosternal pain beyond 2 weeks indicate?

A

It may indicate the need for endoscopic removal of the stent.

57
Q

How can reflux symptoms be managed in patients with gastroesophageal junction (GEJ) lesions?

A

Using stents with a distal reflux valve has shown to improve reflux symptoms

58
Q

What additional measures can help prevent acid reflux and aspiration of gastric contents post-stent placement?

A

Maintaining an upright or semi-upright position and using a daily proton pump inhibitor (PPI).

59
Q

What are common early complications of esophageal stent placement?

A

Retrosternal pain
minor hemorrhage
aspiration
gastroesophageal reflux disease (GERD)
and stent migration

60
Q

What are common late complications of esophageal stent placement?

A

Stent migration
occlusion
stent fracture
obstruction or tumor ingrowth erosion
airway erosion/compression, and vascular erosion

61
Q

Which complications can affect both early and late periods after stent placement?

A

Migration
airway erosion/compression
and vascular erosion.

62
Q

What type of stents are most commonly associated with stent occlusion due to tumor ingrowth?

A

Uncovered or partially covered stents.

63
Q

How can stent occlusion due to tumor ingrowth be managed?

A

with a stent-in-stent technique.

64
Q

What contributes to tissue necrosis leading to stent erosion?

A

High radial pressure on the esophageal wall
poor tissue perfusion
and impaired wound healing
often due to malnutrition or prior radiation exposure.

65
Q

How does prior radiation to the chest or mediastinum impact the risk of stent erosion?

A

Prior radiation increases the risk of tissue erosion from esophageal stents

66
Q

What is the risk associated with dual stenting of the esophagus and trachea?

A

Dual stenting is associated with an increased risk of tissue erosion.

67
Q

What is the most common type of vascular erosion associated with esophageal stent placement?

A

Aortoesophageal fistula.

68
Q

Which arteries, besides the aorta, have been reported in cases of vascular erosion from esophageal stents?

A

The retroesophageal subclavian and common carotid arteries

69
Q

What symptoms should raise suspicion for vascular erosion in a patient with a history of esophageal stent placement?

A

Abrupt sentinel hematemesis and retrosternal chest pain.

70
Q

What is the primary goal in the emergent management of an aortoesophageal fistula?

A

Prompt control of hemorrhage
‘‘Endoscopic balloons, Sengstaken-Blakemore tubes, temporary intravascular occlusion, and emergent surgery’’

followed by vascular repair.

71
Q

What steps are taken for the esophageal defect once the patient is stabilized from a vascular erosion?

A

Small defects may be repaired with muscle interposition,

larger defects may require esophagectomy.

In moribund patients, a conservative approach or palliative care may be more appropriate > Diversion

72
Q

How do the symptoms of tracheoesophageal erosion typically present compared to vascular erosion?

A

often presents with nonspecific symptoms like dyspnea and frequent pulmonary infections.

73
Q

What imaging and diagnostic tools are used to assess tracheoesophageal erosion?

A

A chest CT scan may help identify the lesion, but bronchoscopic and endoscopic evaluations are often necessary to characterize the defect

74
Q

What should be the priority in managing a tracheoesophageal fistula in a patient presenting in extremis?

A

Securing the airway should be the priority, maintaining spontaneous ventilation if possible.

75
Q

What intubation options are available if ventilation is difficult in a patient with a tracheoesophageal fistula?

A

contralateral mainstem intubation
use of a double lumen tube
a bronchial blocker
or sedation to facilitate ventilation

76
Q

What are potential treatment options for stable patients with tracheoesophageal erosion and good esophageal tissue integrity?

A

Stable patients may undergo primary repair with muscle interposition

or an esophagectomy

77
Q

What management options are considered for patients with poor functional status or compromised tissue integrity?

A

Tracheal stenting, esophageal diversion, and palliative care are considered for these patients

78
Q

What is the most common complication of esophageal stenting in esophageal stricture, and how often does it occur?

A

Stent migration, occurring in 11% to 33% of cases

79
Q

What methods have been developed to reduce stent migration?

A

-anchoring the stent to the esophageal wall with endoclips
-endoscopic suturing devices like Apollo OverStitch
-over-the-scope clips (OTSC)
-lumen-apposing metal stents (LAMS) with a dumbbell-shaped design

80
Q

How does stent indwelling time impact migration rates, according to Freeman et al.’s study?

A

Shorter indwelling times significantly reduce stent migration rates and other stent-related complications.

81
Q

reduction in stent migration rate in anastamotic leak was seen with a stent indwelling time of fewer than

A

14 days

82
Q

In patients with acute perforation

A

duration of fewer than 28 days

A1-G Surg Note Esophagus (15 decks)

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