Esophageal Stent Flashcards
What condition is esophageal stenting (ES) commonly used to relieve?
-Severe dysphagia caused by benign or malignant esophageal strictures
-prevent luminal contamination of the mediastinum
What properties of Nitinol make it ideal for use in SEMS?
Superelasticity and shape memory, which allow it to expand at body temperature to fit the lesion’s morphology.
What is a drawback of uncovered SEMS (uc-SEMS)?
They can foster stent stenosis due to fibrotic tissue ingrowth through the mesh openings
Why were fully covered and partially covered stents developed?
To reduce fibrotic tissue ingrowth and stent stenosis while providing additional luminal anchorage
What is the potential downside of using covered stents?
more susceptible to migration, particularly in high-risk areas like the distal esophagus.
What are self-expandable plastic stents (SEPS) made of?
double-layered, with polyester mesh on the outside and a smooth silicon layer on the inside.
What is the primary use of biodegradable stents (BDS)?
They are mainly used for benign strictures and do not require retrieval.
What material are biodegradable stents (BDS) made from, and how long do they maintain mechanical strength?
plaited polydioxanone, maintaining mechanical strength for 4 to 6 weeks and degrade over 8 to 12 weeks
What has the FDA approved esophageal stenting (ES) for?
Preservation of luminal patency in malignant strictures and occlusion of concurrent esophageal fistula
What conditions has the use of ES increased for in the past decade?
Refractory benign esophageal strictures (RBES),
esophageal perforations
variceal bleeding
postsurgical anastomotic leaks
and achalasia
What causes malignant esophageal dysphagia?
-intramural growth of primary esophageal tumors
-extrinsic compression from mediastinal and airway tract neoplasms
What is the primary goal of treatment in patients with advanced malignant esophageal dysphagia?
Relief of dysphagia
resumption of oral intake to improve quality of life (QOL) and sometimes survival.
What is considered the first-line therapy for palliation of malignant dysphagia?
Esophageal stenting (ES), specifically using self-expandable metal stents (SEMS).
What are the benefits of SEMS for malignant dysphagia?
SEMS provide prompt relief of dysphagia and help optimize the patient’s nutritional status
How does single-dose brachytherapy compare to SEMS in treating malignant dysphagia?
Brachytherapy provides longer-lasting dysphagia relief, higher QOL scores, and less morbidity, but stenting offers earlier relief.
Why has enthusiasm for brachytherapy diminished in treating malignant dysphagia?
Due to the frequent need to insert rescue stents after brachytherapy.
When might brachytherapy still be considered for malignant dysphagia?
For carefully selected patients with mild to moderate dysphagia and a longer life expectancy.
What is the first line of intervention for patients with moderate to severe dysphagia or recurrent dysphagia after brachytherapy?
Esophageal stenting (ES), particularly with fully covered SEMS (fc-SEMS)
Why are fully covered SEMS (fc-SEMS) preferred over uncovered SEMS (uc-SEMS) or self-expandable plastic stents (SEPS)?
fc-SEMS have a lower rate of tumor ingrowth compared to partially covered
and less risk of stent migration compared to SEPS
What causes malignant esophageal fistulas?
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.
What initial management steps are recommended for malignant esophageal fistulas?
Temporary suspension of oral intake
drainage of involved spaces
and endoscopic insertion of a fully covered self-expandable metal stent (fc-SEMS)
Why is the palliation of gastroesophageal junction (GEJ) strictures by endoscopic means technically challenging?
Due to the acute angle and varying luminal diameters at the GEJ, which can interfere with satisfactory stent fixation
What are the common complications of esophageal stenting (ES) at the GEJ?
Increased risk of acid reflux
distal stent migration
and ineffective palliation.
What type of stent is considered the stent of choice for GEJ strictures?
Partially covered self-expandable metal stents (pc-SEMS)
How might preoperative esophageal stenting (ES) benefit patients with locally advanced esophageal cancer (EC) undergoing neoadjuvant therapy?
nutritional optimization
improved oral intake
weight stabilization, and enhanced quality of life (QOL) before surgical resection
Why might SEMS negatively affect oncologic outcomes in preoperative esophageal cancer patients
SEMS may induce mural inflammation, potentially distorting tissue planes and interfering with the completeness of surgical resection.
What might upward stent migration rates of up to 50% indicate during neoadjuvant therapy in esophageal cancer patients?
Stent migration may represent a favorable response to neoadjuvant therapy
What is the mainstay treatment for benign esophageal strictures?
Periodic endoscopic balloon dilation
What are common causes of refractory benign esophageal strictures (RBES)?
Caustic injuries
chest or mediastinal radiation
postsurgical esophagodigestive anastomoses
POEM and endoscopic mucosal resection
What are key characteristics of an ideal stent for RBES?
The stent should be easily retrievable and resistant to migration.
Which stent type is most commonly used for RBES
Fully covered self-expanding metal stents (fc-SEMS).
What is an advantage of biodegradable stents (BDS) over fc-SEMS in RBES management?
BDS does not require retrieval
What complications are more common with biodegradable stents (BDS)?
Retrosternal pain and bleeding.
How can benign esophageal perforations (BEP) be classified?
as spontaneous (e.g., Boerhaave’s syndrome), iatrogenic, or traumatic.
What serious complications can arise from fistulas in the esophagus?
contamination of mediastinal or pleural spaces, causing lethal inflammation and infection.
What is the role of endoscopic stenting (ES) in patients with noncontained esophageal leaks?
ES can reduce morbidity and is increasingly used to avoid surgical intervention in patients with noncontained leaks.
What are the goals of therapy in using stents for esophageal perforations?
drain contaminated spaces, seal the leak, divert oral secretions, and prevent widespread infection.
Which type of stents are recommended for hemodynamically stable patients with BEP?
Covered stents, including fully covered self-expanding metal stents (fc-SEMS) or partially covered SEMS (pc-SEMS).
What are the mainstays of definitive therapy for achalasia?
Surgical and endoscopic interventions, including Heller myotomy and per-oral endoscopic myotomy (POEM).
When might temporary retrievable stenting with SEMS be considered in the treatment of achalasia?
may be an option for patients with achalasia who are not surgical candidates.
What diameter of SEMS was found to be more effective than pneumatic dilation in the long-term follow-up study?
30-mm SEMS were found to be more effective.
What type of stent may be used for refractory esophageal variceal bleeding?
Fully covered self-expanding metal stents (SEMS)
What is a key design feature of SEMS used for esophageal variceal bleeding?
They have a wide diameter, typically at least 25 mm, designed for this specific indication.
In what clinical situation are fully covered SEMS indicated for use?
indicated for refractory esophageal variceal bleeding when other interventions have failed.
Why should the internal diameter of a stent be slightly larger than the lesion?
To ensure adequate radial force is applied, securing the stent in place
What are the risks of using an inadequately small stent diameter?
It may increase the risk of stent migration
What are the potential complications of using an oversized stent?
lead to perforation and excessive pressure necrosis.
How long should a stent be relative to the lesion?
The stent should be at least 4 cm longer than the lesion, overlapping it by at least 2 cm both proximally and distally.
What challenges are associated with stent placement in the proximal esophagus?
Placement near the upper esophageal sphincter (UES) is challenging; the proximal stent margin may need to be less than 2 cm below the UES
What must be considered when placing a stent in the distal esophagus or across the gastroesophageal junction (GEJ)?
Avoiding an excessively long stent to prevent distal contact with the gastric wall, which could cause ulceration or perforation
Why is repeat endoscopy or an upper gastrointestinal series performed 24 to 36 hours after stent deployment?
To confirm proper stent placement and assess for complications before resuming oral intake
How long does it typically take for a deployed stent to fully expand?
The stent usually fully expands within 48 to 72 hours post-deployment
What dietary recommendations are given to patients after stent placement?
Patients start with liquids for 24 to 48 hours, then gradually progress to a soft solid diet as tolerated.
What long-term dietary restrictions are generally advised for patients with an esophageal stent?
Patients are advised to avoid fibrous foods, such as raw vegetables and large pieces of meat, to reduce the risk of blockage
What are common mild to moderate complications after esophageal stent placement?
Retrosternal pain and reflux symptoms, which often resolve within 1 to 2 weeks.
What might persistent retrosternal pain beyond 2 weeks indicate?
It may indicate the need for endoscopic removal of the stent.
How can reflux symptoms be managed in patients with gastroesophageal junction (GEJ) lesions?
Using stents with a distal reflux valve has shown to improve reflux symptoms
What additional measures can help prevent acid reflux and aspiration of gastric contents post-stent placement?
Maintaining an upright or semi-upright position and using a daily proton pump inhibitor (PPI).
What are common early complications of esophageal stent placement?
Retrosternal pain
minor hemorrhage
aspiration
gastroesophageal reflux disease (GERD)
and stent migration
What are common late complications of esophageal stent placement?
Stent migration
occlusion
stent fracture
obstruction or tumor ingrowth erosion
airway erosion/compression, and vascular erosion
Which complications can affect both early and late periods after stent placement?
Migration
airway erosion/compression
and vascular erosion.
What type of stents are most commonly associated with stent occlusion due to tumor ingrowth?
Uncovered or partially covered stents.
How can stent occlusion due to tumor ingrowth be managed?
with a stent-in-stent technique.
What contributes to tissue necrosis leading to stent erosion?
High radial pressure on the esophageal wall
poor tissue perfusion
and impaired wound healing
often due to malnutrition or prior radiation exposure.
How does prior radiation to the chest or mediastinum impact the risk of stent erosion?
Prior radiation increases the risk of tissue erosion from esophageal stents
What is the risk associated with dual stenting of the esophagus and trachea?
Dual stenting is associated with an increased risk of tissue erosion.
What is the most common type of vascular erosion associated with esophageal stent placement?
Aortoesophageal fistula.
Which arteries, besides the aorta, have been reported in cases of vascular erosion from esophageal stents?
The retroesophageal subclavian and common carotid arteries
What symptoms should raise suspicion for vascular erosion in a patient with a history of esophageal stent placement?
Abrupt sentinel hematemesis and retrosternal chest pain.
What is the primary goal in the emergent management of an aortoesophageal fistula?
Prompt control of hemorrhage
‘‘Endoscopic balloons, Sengstaken-Blakemore tubes, temporary intravascular occlusion, and emergent surgery’’
followed by vascular repair.
What steps are taken for the esophageal defect once the patient is stabilized from a vascular erosion?
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
How do the symptoms of tracheoesophageal erosion typically present compared to vascular erosion?
often presents with nonspecific symptoms like dyspnea and frequent pulmonary infections.
What imaging and diagnostic tools are used to assess tracheoesophageal erosion?
A chest CT scan may help identify the lesion, but bronchoscopic and endoscopic evaluations are often necessary to characterize the defect
What should be the priority in managing a tracheoesophageal fistula in a patient presenting in extremis?
Securing the airway should be the priority, maintaining spontaneous ventilation if possible.
What intubation options are available if ventilation is difficult in a patient with a tracheoesophageal fistula?
contralateral mainstem intubation
use of a double lumen tube
a bronchial blocker
or sedation to facilitate ventilation
What are potential treatment options for stable patients with tracheoesophageal erosion and good esophageal tissue integrity?
Stable patients may undergo primary repair with muscle interposition
or an esophagectomy
What management options are considered for patients with poor functional status or compromised tissue integrity?
Tracheal stenting, esophageal diversion, and palliative care are considered for these patients
What is the most common complication of esophageal stenting in esophageal stricture, and how often does it occur?
Stent migration, occurring in 11% to 33% of cases
What methods have been developed to reduce stent migration?
-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
How does stent indwelling time impact migration rates, according to Freeman et al.’s study?
Shorter indwelling times significantly reduce stent migration rates and other stent-related complications.
reduction in stent migration rate in anastamotic leak was seen with a stent indwelling time of fewer than
14 days
In patients with acute perforation
duration of fewer than 28 days
