Palliation With Endoluminal Palliation With Endoluminal StentsStents

Todd H. Baron, M.D., F.A.C.P.Todd H. Baron, M.D., F.A.C.P.

Professor of MedicineProfessor of Medicine

Gastroenterology & HepatologyGastroenterology & Hepatology

Mayo Clinic College of MedicineMayo Clinic College of Medicine

Enteral StentsEnteral Stents

Malignant Gastric Outlet Malignant Gastric Outlet ObstructionObstruction

Clinical SituationsClinical Situations• Unresectable CAUnresectable CA

pancreatic, GB, Cholangiopancreatic, GB, Cholangio• Metastatic diseaseMetastatic disease• Local invasion - colonLocal invasion - colon• Gastric CAGastric CA• primaryprimary•RecurrentRecurrent

SEMS: OverviewSEMS: Overview

• May be placed endoscopically or May be placed endoscopically or radiologicallyradiologically

• Non-TTS difficult but possibleNon-TTS difficult but possible

• TTS placement - can be placed TTS placement - can be placed beyond ligament of Treitz - beyond ligament of Treitz - uncovereduncovered

WallstentWallstent

• Delivery diameter: Delivery diameter: 10F10F

• Deployed diameter: Deployed diameter:

20mm20mm

22mm22mm

• TTSTTS

ENDO ENDO GASTRO-JGASTRO-J p p

Number of patients Number of patients 1212 15 15

Median survival (days) Median survival (days) 9494 9292 NS NS

Median charges incurred Median charges incurred $9921 $9921 $28,173 $28,173 < 0.005 < 0.005

Median hospitalizationMedian hospitalization stay required (days) stay required (days) 4 4 14 14 < 0.005< 0.005

Number requiring repeat procedures Number requiring repeat procedures and hospitalization and hospitalization 7 (58.3%) 7 (58.3%) 15 (100%) 15 (100%)

Yim, et al., GIE, 2001Yim, et al., GIE, 2001

Cost of Palliation: Pancreatic CACost of Palliation: Pancreatic CA

Malignant Colorectal Malignant Colorectal ObstructionObstruction

Metal Colonic StentsMetal Colonic Stents• Wilson-Cook Z stentWilson-Cook Z stent

• Microvasive WallstentMicrovasive Wallstent

• Precision Ultraflex ColonicPrecision Ultraflex Colonic

OTHEROTHER• Ultraflex Esophageal StentUltraflex Esophageal Stent

Colonic Z-StentColonic Z-Stent

• Delivery diameter:Delivery diameter:

10mm (30F)10mm (30F)

• Deployed diameter: Deployed diameter: 35/25mm35/25mm

Indications for Colorectal StentsIndications for Colorectal Stents

• Pre-operativePre-operative

• PalliativePalliative

• IndeterminateIndeterminate

Potential Benefits ofPotential Benefits ofPre-operative Colon StentsPre-operative Colon Stents

• One-stage operationOne-stage operation

• Reduced costsReduced costs

• Improved QOLImproved QOL

• Elective operationElective operation

• Pre-operative assessmentPre-operative assessment

tumor resectabilitytumor resectability

patient operabilitypatient operability

Complications of Enteral Stents Complications of Enteral Stents • Tumor ingrowth/overgrowthTumor ingrowth/overgrowth

• MigrationMigration

• PerforationPerforation

immediateimmediate

delayeddelayed

• Impaction Impaction

• BleedingBleeding

• Pain/TenesmusPain/Tenesmus

ConclusionsConclusions• SEMS are effective for closing TEF and SEMS are effective for closing TEF and

treating all forms of malignant treating all forms of malignant esophageal obstructionesophageal obstruction

• SEMS are cost-effective for palliation of SEMS are cost-effective for palliation of malignant GOO for pancreatic CAmalignant GOO for pancreatic CA

• SEMS can be used for both pre-SEMS can be used for both pre-operative and palliative treatment of operative and palliative treatment of malignant colonic obstruction malignant colonic obstruction