This document discusses the use of enteral stents to palliate malignant obstructions of the esophagus, colon, and stomach/duodenum. It provides details on the types of stents available, factors to consider when choosing a stent, and techniques for non-TTS and TTS placement. Complications are also reviewed. The key goals of enteral stenting are to relieve malignant dysphagia or obstruction and improve quality of life through a minimally invasive procedure when curative options are not possible.

1. Enteral Stenting:
How, Why and When?
Jason Klapman, MD
Director of Endoscopy
Moffitt Cancer Center
Associate Professor of Medicine
University of South Florida
Tampa, FL

2. Enteral Stenting
• Palliation of malignant dysphagia
• Management and palliation colorectal
obstruction
• Palliation of malignant gastroduodenal
obstruction

3. Palliation of Malignant Dysphagia
• To Palliate-From the Latin Palliatus-to cloak or
conceal.
– To palliate a disease is to treat it partially and
insofar as possible, but not cure it completely.
– Easing the severity of a pain or a disease without
removing the cause

4. Esophageal Stenting
• ASGE Guidelines GIE March 2013
– Esophageal Stenting should be the preferred method for
palliation of malignant dysphagia and Fistulae
– Provides immediate and durable relief in the majority of
patients

5. Pre-Procedure
• Knowledge of location and length of malignant
stricture is key to success (previous EGD or
esophagogram)
– If proximal obstruction consider pre-procedure eval by
imaging, Pulmonary or Thoracic surgery to eval for
tracheal compression and airway compromise
• Consider Fluoroscopy
• Choose stent at least 2mm larger than estimated
lumen or last dilation

6. Esophageal Stents
• Types
– Plastic or Metal
– Fully Covered
– Partially covered
– Uncovered
– Biodegradable

7. Choosing a stent
• Majority are metal stents
• Most SEMS are equally effective in relieving
symptoms, have similar complication rates
– No study has been done comparing all types of metal
stents
• Choice usually determined by perceived ease of
placement and personal experience of endoscopist
• Low incidence of migration is the holy grail!!

8. Choosing a stent (con’t)
• Stent characteristics
– Delivery systems
– Deployment patterns
– Expansile force
– Foreshortening characteristics
– Removability

9. Available Esophageal Stents (U.S.)
• Boston Scientific
– Polyflex -strong expansile force,removable 16-21mm 9-12-15cm length
– Ultraflex- distal and proximal release option, most flexible, least expansile force
(partially or uncovered) 18 or 23 mm, 10,12,15cm lengths
– Wallflex-, no foreshortening, smooth delivery vs. Ultraflex, lasso loop (fully/partially) 18
or 23mm 10,12,15cm
• Cook Endoscopy
– Evolution-no shortening, recapturable, lasso loop, distal release only(fully18,20 -
8,10,12cm or partially 20mm, 8,10,12.5,15
– Z stent - no shortening, short bare wire at ends, has anti-reflux valve option (fully,
partially, anti-reflux)18mm, 8,10,12,14
• Merrit Medical EndoTek
– Alimaxx-E-non-foreshortening, fully covered, lasso loop, distal release only multiple
sizes 12-22mm 7,10,12cm lengths
– EndoMaxx-non-forshortening,fully covered,Metal loop, 19,23mm ,7,10,12,15cm
• Endochoice-Bonastent- Fully covered, Hook/Cross technology, Non-foreshortening,
retrieval lasso-18mm 6-16cm length
• TaeWoong-Niti-S TTS, fully covered ,lasso loop 18mm, 6-15cm

10. Non-TTS placement
• A stiff 0.035 guidewire for stability, over which stent is
deployed
• Remove endoscope leaving wire in place
• Back load stent over wire and advance through
stricture
• Can place endoscope alongside stent to observe
deployment if desired (No fluoroscopy needed)
• Choose stent that is 4cm longer than tumor to allow
for 2cm above and below tumor for stability

11. Non-TTS placement

12. TTS placement
• Niti-s esophageal stent
• 10.5 fr diameter deployment system
• Use therapeutic upper scope
• Proximal release

13. Post Procedure
• Starts clears and slowly advance to soft foods
• Give post stent diet instructions-tailor it to the
size of stent
• Analgesics prn for pain

14. Complications
• Chest pain
• Bleeding
• Perforation
• Aspiration
• Severe GERD
• Dysphagia: tumor ingrowth, migration, food
impaction, device malposition
• Tracheal Esophageal (TE) Fistula formation

15. Colonic stenting
• Indications
– Palliation of malignant obstruction
– Acute colonic obstruction
• Allow colon prep
• May obviate the need for a two stage surgical
procedure

16. Palliation of malignant obstruction
• Uncovered through the scope SEMS
– Boston Scientific
• Wallstent and Ultraflex stent
– Cook Endoscopy
• Evolution Stent

17. Procedure Preparation
• R sided lesions- limited colon prep
• Rectosigmoid lesions- fleets enemas
• Therapeutic Colonoscope
• Fluoroscopy

18. TTS deployment video
Courtesy of Sri Komanduri,MD

19. Complications
• Perforation-5% (avoid in bevacizumab
patients)
• Migration
• Abdominal pain
• Bleeding
• Tumor ingrowth

20. Post Procedure
• Diet-low residue
• Laxative to maintain stool softness
• Consider x-ray to confirm position

21. Gastroduodenal Obstruction (GOO)
• Stenting Indication
– Palliation of malignant obstruction
– Do not place in setting of chemoradiation treatment
• Available SEMS
– TTS stents
• BSC and COOK –uncovered metal stents
• Can be placed along side the scope or through the scope
– Taewoong- covered esophageal stent can be placed in
the stomach/duodenum for attempted fistula closure
due to the ability to use TTS

22. GOO
• Pre-procedure
– Pt. decompressed with NG tube or perform under
general anesthesia
– Consider road map with UGI before the procedure to
delineate the length of the stricture
– Fluoroscopy
– Therapeutic Upper Endoscope
• Intra-procedure
– Technique similar to colonic stenting
– Avoid Dilation of the malignant stricture to allow
passage of the endoscope

23. Complications
• Perforation
• Migration
• Bleeding
• Pain

24. Summary
• Enteral stents are effective in relieving malignant
obstruction of the GI tract
• Pre procedure work-up and preparation is paramount
to the success of the procedure
• Avoid dilation of malignant strictures(except in
Esophagus) to try and advance the endoscope through
the obstruction
• Choose stents 4cm longer than the anticipated
stricture length
• Avoid placing stents in the Stomach/Duodenum or
colon in settings other than palliation or as a bridge to
surgery

25. Thank You