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Retrievable Endoscopic Stenting for Benign Oesophageal Disorders

Retrievable Endoscopic Stenting for Benign Oesophageal Disorders. Joint Hospital Surgical Grand Round 15 July 2017 CHAN, Yin On Brian Surgery, Queen Elizabeth Hospital. Case Summary. Case Summary. F/23 No known drug allergy Ex-smoker Past medical history H. pylori negative gastritis

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Retrievable Endoscopic Stenting for Benign Oesophageal Disorders

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  1. Retrievable Endoscopic Stenting for Benign Oesophageal Disorders Joint Hospital Surgical Grand Round 15 July 2017 CHAN, Yin On Brian Surgery, Queen Elizabeth Hospital

  2. Case Summary

  3. Case Summary F/23 • No known drug allergy • Ex-smoker • Past medical history • H. pylori negative gastritis • Anaemia defaulted workup • Pelvic inflammatory disease

  4. Chief complaint • Fever, cough, right pleuritic pain • Physical examination • BP 122/64, P132, Temp 40.6oC • SaO2 100% on 2L O2 nasal cannula • Pallor, moderately dehydrated • Chest: Reduced air entry bilaterally (R>L), rhonchi • Abdomen soft, non-tender • Investigations • Hb 8.4 McHc • WCC 9.9 (Neutrophil 90%) • CXR: Right pleural effusion

  5. Computed Tomography (CT) of thorax with contrast Right lower lobe (RLL) necrotizing pneumonitis Large right empyema Multiple left lung centrilobular nodules suspicious of tuberculosis

  6. Initial Management • Close monitoring of vitals • Septic workup • Sputum for culture/sensitivity (C/ST), Acid Fast Bacilli (AFB) smear/culture • Blood C/ST • Urine dipstick, microscopy, C/ST • Prompt intravenous antibiotics • Augmentin 1.2g Q8H iv • Right chest drain insertion

  7. Oesophagogastroduodenoscopy (OGD) for McHc anaemia Linear deep ulceration at ~25cm from incisor, fistulation suspected Mild antral gastritis, D1/2 normal Biopsy taken: antrum, oesophagus

  8. Fibreoptic Bronchoscopy (FOB) Swollen RLL bronchi, mucosal swelling most prominent at RB6 Patent airways, no fistula opening Copious mucoid secretions along trachea and right bronchial tree Bronchoalveolar lavage (BAL) saved

  9. Gastrograffin Swallow Contrast leakage at lower oesophagus Fistulation to right hemithorax

  10. Microbiology workup • Sputum/pleural fluid • AFB smear: negative • AFB culture: Mycobacterium species • Oesophageal ulcer biopsy - Mycobacterial infection • Inflammed mucosa with necrotizing granuloma, Langhan’s giant cells • Ziehl-Neelsen (ZN) stain occasional AFB • No malignancy, no fungal organisms • BAL • AFB smear: positive • AFB culture: Mycobacterium species HRZM (Isoniazid, Rifampicin, Pyrazinamide, Moxifloxacin) Initiated

  11. Tuberculous infectionEsophagopleural FistulaEmpyema Thoracis

  12. Therapeutic OGD with Endoscopic Stenting Linear ulcer at 24-32cm from incisor, with 5mm fistula opening at 24cm Submucosal lipiodal injection under fluoroscopy – margins of the fistulated ulcer & most distal end of linear ulcer

  13. Therapeutic OGD with Endoscopic Stenting 12cm 22Fr retrievable, fully covered, self-expanding metallic stent (FC-SEMS) with over-the-wire distal delivery stent deployment system (Taewoong Medical, South Korea) Guidewire passage

  14. Therapeutic OGD with Endoscopic Stenting Shoulders of the stent placed across fistula opening Stent deployment Proximal stent secured with two endoclips at 12 & 6 o’clock position

  15. Progress • Patient tolerated procedure well • Short term total parenteral nutrition (TPN) for 2 weeks  Enteral feeding via nasoduodenal tube • Sputum AFB smear negative x3 consecutively

  16. Decortication via right posterolateral thoracotomy Large posterior right empyema cavity, thickened parietal & visceral pleurae, grossly consolidated lobes, multiple military lesions Culprit perforation site 3-4cm above pulmonary ligament, lots of surrounding necrotic tissue Middle esophageal stent in-situ, no active repair performed

  17. Follow up OGD at 8 weeks No stent migration Both ends loosened by pulling on pursestring with endoscopic forceps Uneventful removal by pulling on proximal stent under fluoroscopy Check endoscopy: previous ulcer healed by scarring Retrieved FC-SEMS intact, no tissue ingrowth

  18. Follow up CT thorax with contrast – May 2015 Minimal collection in right lower hemithorax No consolidation or lung mass

  19. Discussion

  20. Oesophagorespiratory Fistulae (ORF) Shin JH, Kim JH, Song HY. Interventional management of esophagorespiratory fistula. Korean J Radiol 2010;11(2):133-140.

  21. High morbidity & mortality • Similar to post-surgical leaks & perforations • Pathogenesis • Significant mediastinal/pleural contamination • Polymicrobial sepsis • Local: Abscesses • Systemic: Septic shock, MODS

  22. Principles of Management • Drainage of collection • Exclusion of fistulation • Aggressive antimicrobials • Intensive nutritional & organ support

  23. Oesophageal Stenting • Self-expanding metallic stents (SEMS) • Nitinol (most common), stainless steel, Elgiloy • Uncovered, partially or fully covered (plastic/silicon membrane) • Self-expanding plastic stents (SEPS) • Polyester, silicone • Innovations • Anti-reflux stent • Anti-migration stent

  24. Oesophageal Stenting

  25. Benign OPF – Efficacy • Kang et al • The only case report specifically on SEMS in OPF • OPF of unknown aetiology • Outcome • Technical success • Stent placement • Clinical success • Defect closure Kang GH, Yoon BY, Kim BH, et al. A case of spontaneous esophagopleural fistula successfully treated by endoscopic stent insertion. Clin Endosc 2013;46(1):91-4.

  26. Benign oesophageal leaks, fistulae, perforation • Acute variceal bleeding • Refractory benign strictures

  27. Benign Leaks, Fistulae & Perforation • Temporary stent placement recommended • Strong recommendation, low quality evidence • Technical success 91-100% • Clinical success (Healing) • No specific type of stent recommended • Optimal duration • 6-8 weeks (range 4-10 weeks) • Migration • 16.2-62.1%

  28. Acute Variceal Bleeding

  29. Esophageal variceal bleeding refractory to medical & endoscopic treatment • SEMS (SX-ELLA Danis Stent; ELLA-CS, Hradec Kralove, Czech Republic); n=13) v.s. balloon tamponade (Sengstaken-Blakemore tube; n=15) • Successful therapy (66 v.s. 20%, p=0.025), higher rate for 15-day bleeding control (85 v.s. 47%, p=0.037), lower transfusion requirements (2 v.s. 6 PRBC, p=0.08) • Lower incidence of serious adverse events (15 v.s. 47%, p=0.077) • Aspiration pneumonia (0 v.s. 5) • Oesophageal tear (1 patient in balloon tamponade group) • No difference in 6-week survival (54% v.s. 40%, p=0.46)

  30. Limitations • Results • 6-week absence of bleeding (54 v.s. 47%, p=0.25) • Most studies published place stent for 2 weeks • 15-day survival (69 v.s. 47%, p=0.39) • Retrieval require specially designed system • PEX-Ella or extractor for SX-Ella Stent Danis • Rebleeding while stent in-situ • Inability for further Sengstaken tube deployment • Cost

  31. Refractory benign strictures • Kochman Criteria • Cicatricial luminal compromise/fibrosis • Clinical symptoms of dysphagia • No endoscopic evidence of inflammation • Refractory • Inability to dilate to at least 14mm over 5 sessions at 2-week intervals • Recurrent • Inability to maintain satisfactory luminal diameter for 4 weeks • Exclusion • Inflammatory stricture • Dysphagia due to neuromuscular dysfunction

  32. Recommendations • Against stenting as 1st line therapy • Potential for adverse events, alternative therapy, costs • Can consider temporary placement if RBES • 40.5% (95% CI 31.5-49.5%) pooled clinical success rates • No significant difference between SEMS/SEPS/biodegradable stents • Migration rate 28.6% (95% CI 21.9-37.1%) • Successful removal 99% • Overall adverse event rate 20.6% (95% CI 15.3-28.1%) Fuccio L, Hassan C, Frazzoni L et al. Clinical outcomes following stent placement in refractory benign esophageal stricture: a systematic review and meta-analysis. Endoscopy 2016; 48: 141–148.

  33. Recommendations • FC-SEMS preferred over PC/uncovered SEMS • Hyperplastic tissue reaction to bare metal mesh • Recurrent dysphagia, preclude safe stent removal • Combined approach NOT recommended • Topical corticosteroid/ mitomycin C • Endoscopic incisional therapy • Dilation • Optimal duration • No studies compared strategies in stenting duration • Generally at least 6-8 weeks, no more than 12 weeks Hirdes MM, Siersema PD, van Boeckel PG et al. Single and sequential biodegradable stent placement for refractory benign esophageal strictures: a prospective follow-up study. Endoscopy 2012; 44: 649–654.

  34. Complications Spaander MC, Baron TH, Siersema PD, et al. Esophageal stenting for benign and malignant disease: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy. 2016 Oct;48(10):939-48.

  35. References • Kang HW, Kim SG. Upper Gastrointestinal Stent Insertion in Malignant and Benign Disorders. Clinic Endosc 2015;48:187-93. • van Halsema EE, van Hooft JE. Clinical outcomes of self-expandable stent placement for benign esophageal diseases: A pooled analysis of the literature. World J Gastrointest Endosc 2015;7(2):135-53. • Mangiavillano B, Pagano N, Arena M, et al. Role of stenting in gastrointestinal benign and malignant diseases. World J Gastrointest Endosc 2015;7(5):460-80. • Kang GH, Yoon BY, Kim BH, et al. A case of spontaneous esophagopleural fistula successfully treated by endoscopic stent insertion. Clin Endosc 2013;46(1):91-4. • Shin JH, Kim JH, Song HY. Interventional management of esophagorespiratory fistula. Korean J Radiol 2010;11(2):133-140. • Albuquerque A, Ramalho R, Macedo G. Multiple esophagopleural and esophagobronchial fistulas in a patient with Crohn’s disease. Endoscopy 2012;44(Suppl 2):E114-5. • Andersson R, Nilsson S. Perforated Barrett’s ulcer with esophago-pleural fistula. A case report. Acta Chir Scand 1985;151(5):495-6. • Agarwal V, Singh SK, Siddiqi MS, et al. Esophagopleural fistula following spontaneous rupture of traction diverticulum. Asian Cardiovasc Thorac Ann 2003;11(4):344-5. • Kim KR, Shin JH, Song HY, et al. Palliative treatment of malignant esophagopulmonary fistulas with covered expandable metallic stents. Am J Roentgenol 2009;193:W278-82. • Rajan PS, Bansal S, Balaji NS, et al. Role of endoscopic stents and selective minimal access drainage in oesophageal leaks: feasibility and outcome. Surg Endosc 2014;28(8):2368-73. • Koo JH, Park KB, Choo SW, et al. Embolization of postsurgical esophagopleural fistula with AMPLATZER vascular plug, coils, and Histoacryl gue. J Vasc Interv Radiol 2010;21(12):1905-10.

  36. References • Kim JJ, Park JK, Moon SW, et al. A new surgical technique for spontaneous esophagopleural fistula after pneumonectomy: cervical esophagogastrostomy via presternal and subcutaneous route, using a thoracic esophageal mucosal stripping. Thorac Cardiovasc Surg 2013;61(6):496-8. • David EA, Kim MP, Blackmon SH. Esophageal salvage with removable covered self-expanding metal stents in the setting of intrathoracic esophageal leakage. Am J Surg 2011;202(6):796-801. • Buscaglia JM, Ho S, Sethi A, et al. Fully covered self-expandable metal stents for benign esophageal disease: a multicenter retrospective case series of 31 patients. Gastrointest Endosc 2011;74(1):207-11. • Park SY, Park CH, Cho SB, et al. The usefulness of clip application in preventing migration of self-expandable metal stents in patients with malignant gastrointestinal obstruction. Korean J Gastroenterol 2007;49:4-9. • Spaander MC, Baron TH, Siersema PD, et al. Esophageal stenting for benign and malignant disease: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy. 2016 Oct;48(10):939-48. • Dai Y, Li C, Xie Y, et al. Interventions for dysphagia in oesophageal cancer. Cochrane Database Syst Rev. 2014 Oct 30;(10):CD005048. • Hirdes MM, Siersema PD, Vleggaar FP. A new fully covered metal stent for the treatment of benign and malignant dysphagia: a prospective follow-up study. Gastrointest Endosc 2012;75:712-718. • Escorsell A, Pavel O, Cardenas A et al. Esophageal balloon tamponade versus esophageal stent in controlling acute refractory variceal bleeding: A multicenter randomized controlled trial. Hepatology 2015; 53: 1957–1967. • Fuccio L, Hassan C, Frazzoni L et al. Clinical outcomes following stent placement in refractory benign esophageal stricture: a systematic review and meta-analysis. Endoscopy 2016; 48: 141–148. • Hirdes MM, Siersema PD, van Boeckel PG et al. Single and sequential biodegradable stent placement for refractory benign esophageal strictures: a prospective follow-up study. Endoscopy 2012; 44: 649–654.

  37. Kang HW, Kim SG. Upper Gastrointestinal Stent Insertion in Malignant and Benign Disorders. Clinic Endosc 2015;48:187-93.

  38. Critical Appraisal

  39. Stent Migration • Contribute to clinical failure • Particularly troubling issue for FC-SEMS in fistulae • Prevention • Appropriate stent size & length • Flared proximal ends • Endoscopic clipping of proximal stent end to oesophageal wall • Early stent migration rate: 0% v.s 26.3%, p=0.04 Park SY, Park CH, Cho SB, et al. The usefulness of clip application in preventing migration of self-expandable metal stents in patients with malignant gastrointestinal obstruction. Korean J Gastroenterol 2007;49:4-9.

  40. Anti-migration Stent • Wallflex FC Stent (Boston Scientific, Natick, Mass)  • Benign and malignant oesophageal strictures • Internal covering, dog-bone design with end shoulderings, proximal flare 2mm longer & wider • 31% migration in benign strictures • No difference from other FCSEMS/SEPS • 31% retrosternal pain • 12% deep ulcers/fistulae Hirdes MM, Siersema PD, Vleggaar FP. A new fully covered metal stent for the treatment of benign and malignant dysphagia: a prospective follow-up study. Gastrointest Endosc 2012;75:712-718.

  41. Anti-reflux Stent Dai Y, Li C, Xie Y, et al. Interventions for dysphagia in oesophageal cancer. Cochrane Database Syst Rev. 2014 Oct 30;(10):CD005048.

  42. Anti-reflux Stent • No significant difference in • Reflux score (favour standard 0.36, -0.02 to 0.75) • QoL score (favour antireflux -0.04, -0.42 to 0.35) • Adverse effects (OR 0.86, 0.38 to 1.94) Dai Y, Li C, Xie Y, et al. Interventions for dysphagia in oesophageal cancer. Cochrane Database Syst Rev. 2014 Oct 30;(10):CD005048.

  43. Oesophagopleural fistula (OPF) – Causes • Malignant • Oesophageal, lung, mediastinal tumours • Benign • Trauma • Post-pneumonectomy (0.2-1%) • Endoscopic sclerotherapy • Gunshot, foreign body ingestion • Infection • Tuberculosis, mycoticdisesase • Candidiasis in immunocompromised • Others – Crohn’s disease, perforated Barrett’s ulcer, ruptured oesophageal diverticulum

  44. Pleural Drainage • Established abscesses persist despite spillage control • Options • Tube thoracostomy • Imaging-guided pigtail insertion • Open or thoracoscopic drainage • Superior option if multiloculated collections • Permits septa breakdown under direct vision, thorough irrigation and placement of drain in ideal position Rajan PS, Bansal S, Balaji NS, et al. Role of endoscopic stents and selective minimal access drainage in oesophageal leaks: feasibility and outcome. Surg Endosc 2014;28(8):2368-73.

  45. Fistula Exclusion • Operative • Primary suturing or segmental oesophagectomy • High morbidity (30-50%) & mortality (10%) • Bypass • Fluoroscopic • Embolization with vascular plug & coils • Endoscopic • Fibrin glue • Argon plasma or electrocoagulation • Suturing/clipping devices • Stenting

  46. Oesophageal Stenting • Usage • Malignant dysphagia (80-95% effective palliation) • Anastomotic leak (81.4% defect closure) • Perforation (86% defect closure) • Malignant ORF (80% healing) • Benign stricture, refractory variceal bleeding (variable success)

  47. SEMS in OPF • Timing of placement • Immediate following leakage confirmation • Insertion • Therapeutic OGD under sedation & fluoroscopic guidance • Stent size according to oesophageal diameter & defect size • 4-6cm proximal & distal coverage • Fitness for enteral feeding • Day 2 after stent placement, via feeding tube • NO oral feeding • Removal • No conclusive timing in studies • 4-6 weeks or 6-8 weeks Rajan PS, Bansal S, Balaji NS, et al. Role of endoscopic stents and selective minimal access drainage in oesophageal leaks: feasibility and outcome. Surg Endosc 2014;28(8):2368-73.

  48. Choice of Intervention • Patient • ASA 3-4, poor functional health • Low BMI, low albumin • Dyspnea, tachycardia • Disease • Highest importance = drainage • Smear positive tuberculosis • Likely fistula closure with targeted HRZM • Procedural • Primary suturing/ oesophagectomy: ultra-major OT, virgin plane • Least invasion, maximal occlusion • Salvage surgery

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