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Gastro-intestinal intervention 

Gastro-intestinal intervention
Chapter:
Gastro-intestinal intervention
DOI:
10.1093/med/9780199547722.003.0014
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  • Oesophageal stenting [link]

  • Benign strictures [link]

  • Gastric/gastroduodenal stents [link]

  • Jejunal stents [link]

  • Radiologically placed gastrostomy (RIG) or percutaneouslyplaced gastrostomy (PIG) [link]

  • PIG [link]

  • Percutaenous jejunostomy [link]

  • Colonic stenting [link]

Oesophageal stenting

Indications

  • Malignant oesophageal stricture – either for palliation or to improve nutrition prior to treatment.

  • Extrinsic compression from mediastinal tumour.

  • Fistula between oesophagus and tracheal/bronchus.

  • Oesophageal perforation.

  • Malignant anastomotic leak/recurrent tumour.

  • Benign strictures – refractory to balloon dilatation (consider retrievable stent).

Contraindications

  • No absolute contraindications.

  • Relative contraindications:

    • Coagulopathy.

    • Patient unfit for conscious sedation.

    • Recent high dose chemotherapy/radiotherapy.

    • Obstructed stomach/small bowel.

    • Severe tracheal compression.

    • High strictures close to vocal cords.

Types of stents available

  • All self expanding.

  • Generally metal with plastic covering.

  • 16–18F delivery system.

  • Typically 16–24 mm expanded diameter.

  • Anti reflux valve option.

  • Retrievable option.

Uncovered stents

  • Reduced risk of migration.

  • Increased risk of blockage due to tumour in-growth.

  • May be useful in extrinsic compression, hugely dilated oesophagus, gastric pull-through.

Covered stents

  • Improved designs with proximal ± distal flowing, partial covering and covering on inside of stent have reduced the risk of migration.

  • Now first choice in most situations.

Anti-reflux valve stents

Reduce acid reflux post stent insertion across gastro-oesophageal junction.

Retrievable stents

Can be removed endoscopically for a limited period (see manufacturer's recommendations for individual stents), or left in permanently. They are useful in the following circumstances:

  • Benign strictures – for a limited time, e.g. 6–8 weeks, to give a prolonged dilatation.

  • Where tolerance of stent is questionable – e.g. in high strictures.

  • As a bridge to surgery, allowing improved nutrition in the pre-operative period.

  • To allow a fistula/perforation to seal.

Technique

  • Perform a preliminary contrast swallow to define site and length of stricture.

  • Patient usually in lateral position.

  • Anaesthetic (xylocaine) throat spray and conscious sedation with P, BP and O2 monitoring.

  • Per oral catheter – e.g. biliary manipulation catheter (BMC), or multi-purpose catheter, into oesophagus.

  • Contrast injected to delineate stricture.

  • Stiff guidewire (Amplatz) passed across stricture and into gastric antrum/D1 (use hydrophilic wire to cross stricture initially if necessary and then exchange).

  • Stent delivery device passed over guidewire and across stricture.

  • Markers on the stent/delivery system are visible with fluoroscopy allowing accurate placement of device across stricture.

  • Stent deployed, generally by pulling back the outer sheath, under fluoroscopic guidance, and with slightly more stent above than below stricture.

  • A follow-up swallow, e.g. at 24 hours will confirm stent position and function (Figure 14.1).

Figure 14.1 (a) Pre-stent swallow shows tight stricture at the junction of the middle and lower third of the oesophagus. (b) Post-stent swallow shows good flow of barium.

Figure 14.1
(a) Pre-stent swallow shows tight stricture at the junction of the middle and lower third of the oesophagus. (b) Post-stent swallow shows good flow of barium.

TIPS/CAUTION:

  • Approximately 60% of the stent should be above the stricture to reduce risk of migration.

  • Anti-reflux valves useful for lesions requiring stents to cross the GOJ (redcue need for proton pump inhibitors) but may obstruct more easily.

  • Beware proximal lesions near cricopharangeus (C6/7). Stents which don't shorten or are retrievable may be better for these lesions.

  • Don't use large Flamingo stents for mid or proimal oesophageal lesions (risk of aortic fistula).

Aftercare

  • Start with oral fluids.

  • Progress to low residue diet.

  • Provide patients with dietary advice sheet, i.e.:

    • Avoid lumps of food and chew well.

    • Take plenty of fluid with meals.

    • Fizzy drinks can be helpful.

    • Treat any reflux symptoms with a protein pump inhibitor.

    • Stay upright for 1 hour after meals (particularly for GOJ stents).

Benign strictures

Caution required – there will be initial clinical relief of symptoms but a recurrent dysphagia rate of almost 100%, due to tissue hyperplasia blocking the stent, if left in situ long term.

If stenting is required, consider a retrievable option.

Complications

  • Haemorrhage 3–8%.

  • Prolonged chest pain 14%.

  • Migration 0–10%.

  • Tumour in-growth:

    • uncovered 17–36%.

    • covered 0–1%.

  • Perforation 2–3%.

  • Death 0–1.4%.

Gastric/gastroduodenal stents

Indications

  • Linitus plastica – stents are not very helpful in the author's experience.

  • Gastric outflow/proximal duodenal obstruction, e.g. due to carcinoma of pancreas – can provide useful palliation.

Technique

  • Can be fluoroscopic, endoscopic or a combination of the two.

  • Pass a stiff (e.g. Amplatz) wire through to DJ flexure if possible, with insertion technique otherwise similar to that of oesophageal stenting.

Jejunal stents

Indications

Stricture due to inoperable tumour.

Technique

  • May be possible with oral technique but difficult.

  • Create gastrostomy (see Gastro-intestinal intervention pg. [link]).

  • Dilate tract and place 10F sheath.

  • Cross pylorus into duodenum and across stricture using a combination of curved catheters (Cobra/BMC, etc.) and soft wires (Bentson). Hydrophilic wires are useful but gastric acid rapidly damages the coating and wires become sticky, so have to be quick.

  • Exchange for stiff wire (Amplatz) and place stent (wall stent or Nitis).

  • Fix sheath for temporary venting and access. A temporary catheter can also be left across the lesion.

  • Alternatively, a direct puncture into the Jejunum just proximal tothe obstruction can be peformed (see section on Gastrostomy) and this used to place a stent as above (Figure 14.2).

Figure 14.2 Two jejunal self expanding wallstents have been placed directly through direct jejunal access with good expansion and drainage.

Figure 14.2
Two jejunal self expanding wallstents have been placed directly through direct jejunal access with good expansion and drainage.

References/Further reading

Sabharwal, T., Morales, J.P., Irani, A.A. (2005) C.V.I.R. 28(3): 284–8.Find this resource:

Kessel, D., Robertson, I. (2005) Interventional Radiology – A Survival Guide, Elsevier (Churchill Livingstone)Find this resource:

    Adam, A. Dondelinger, R.F., Mueller, P.R. (eds) (2004) Interventional Radiology in Cancer, Springer-Verlag.Find this resource:

    Radiologically placed gastrostomy (RIG) or percutaneously placed gastrostomy (PIG)

    The former is quicker and easier to perform. The latter has much better indwell times.

    Indications

    Enteral feeding but inability to swallow, i.e tumour, neurological damage.

    Preparation

    • Clotting:

    • IV Access.

    • Ideally NG tube in place.

    • Barium down NG tube 24 hours before if possible.

    • Single dose of antibiotic, i.e. ciprofloxacin.

    Equipment

    • 10 ml 1% lidocaine.

    • 18 gauge needle.

    • T fastners (Appendix).

    • Stiff wire, i.e. Amplatz stiff.

    • Dilaters 6–12F.

    • >12F Peel away sheath.

    • Replacement Balloon PEG or self retaining catheter.

    Technique

    • Check position of liver with US.

    • Insufflate stomach through NG tube to distend stomach and bring below rib cage, liver, and colon.

    • Puncture site over stomach should be mid way between lesser and greater curve to avoid vessels.

    • Infiltrate 10 mls Lidocaine over 2 cm area over intended site.

    • For gastrostomy angle towards fundus for gastrojejunostomy towards duodenum (Figure 14.3).

    • Introduce T fastener needle and check position either by aspiration of air or instill tiny amount of contrast (tricky with the thread in the way)

    • Place at least one T fastener as shown (Figure 14.4) some place 2–4.

    • Pull stomach forward and anchor by either stiching or with the attached needle to the skin (Figure 14.5), using the clip on the suture (Harpon T fastner – Figure 14.6) or simply pull on suture.

    • Introduce 18 gauge seldinger into the stomach and check position as above.

    • Introduce stiff wire and dilate to appropriate size (Figure 14.7).

    • Over the wire peel away sheath.

    • Introduce PEG/Tube through the peelway (Figure 14.8). More secure if done over the wire.

    • Inflate balloon on PEG and pull snugly to anchor in place.

    Figure 14.3 Puncture site A for gastro-jejunostomy and B for standard gastrostomy.

    Figure 14.3
    Puncture site A for gastro-jejunostomy and B for standard gastrostomy.

    Figure 14.4 Introduction of T fasteners.

    Figure 14.4
    Introduction of T fasteners.

    Figure 14.5 Lateral view showing anchoring of the stomach with single T fasteners.

    Figure 14.5
    Lateral view showing anchoring of the stomach with single T fasteners.

    Figure 14.6 Fixing the clip on the suture using the Harpon T fasteners.

    Figure 14.6
    Fixing the clip on the suture using the Harpon T fasteners.

    Figure 14.7 Insertion of a a guidewire through the same needle as a T fasteners.

    Figure 14.7
    Insertion of a a guidewire through the same needle as a T fasteners.

    Figure 14.8 Peel away sheath being peeled off following inflation of replacement PEG balloon. © Pyramed.

    Figure 14.8
    Peel away sheath being peeled off following inflation of replacement PEG balloon. © Pyramed.

    TIPS:

    • Introduce the guide wire through the second or third T fastener needle to reduce punctures before anchoring T fastener.

    • Many need buscopan if the stomach is peristalsing and pushing air into small bowel.

    PIG

    This is to place a standard endoscopic type gastrostomy with a phlanage, which has much better indwell time. It needs additional equipment:

    • Curved catheter, i.e. BMC, Cobra, headhunter, etc.

    • 7F bright tip sheath.

    • Terumo Wire and long 260 cm standard wire.

    • Push type Gastrostomy and adapter.

    Technique

    Initial technique for access identical to RIG:

    • Over the stiff wire place 7F sheath.

    • Use curved catheter to access GOJ.

    • Pass long wire up to the mouth. Assistant grasps the end and a long catheter passed out of the mouth.

    • The threads which come with the gastrostomy can sometimes be passed through the catheter and tied to the loop on the gastromy and pulled through. Sometimes a snare is required if threads won't pass. Some gastrostomy catheters will pass over the wire.

    • The gastrostomy end is retrieved from the abdominal wall and pulled out until the phalange is snug, the end cut, and the adapter fixed to the end and anchored to the wall.

    TIPS:

    • When puncturing the stomach may need to go a little lower and laterally to get a good angle to go for the GOJ.

    • Angling the tube is helpful in seeing where the NG tube enters the stomach.

    • If great difficulty in accessing GOJ, snare the NG tube or wire from the NG tube and gently pull back the NG to get the catheters up the oesophagus.

    Aftercare

    • Erect CXR next day to exclude large pneumoperitoneum.

    • Then commence water at approximately 50 ml/hr. If ok commence feeding.

    • Remove T fasteners after approximately 1 week.

    Technical success >95%

    Complications <5% (Peritonitis, visceral puncture, bleeding)

    If the tube falls out after a week and/or the T fastners are still in, it is usually possible just to push it back. If <1 week, no T fastners and no tract then may need to start from the beginning.

    Percutaenous jejunostomy

    Technique very similar to the above with jejunostomy tube placement.

    TIPS:

    • Jejunum can be punctured under fluoroscopic guidance, however the bowel is mobile and may be difficult to puncture. This is much easier under CT guidance.

    • Identify anterior loop near abdominal wall.

    • Instill local anesthetic. Buscopan may be useful to reduce peristalsis.

    • Puncture the jejunum and instill a small amount of air to confirm luminal position.

    • Place T fasteners and use same needle to insert guidewire as above and dilate to appropriate size and exchange for feeding tube.

    • Connect adapter and anchor to abdominal wall.

    Further reading

    Davies R.P, Kew J., West G.P. (2001) Percutaneous jejunostomy using CT fluoroscopy.A.J.R. 176: 808–10.Find this resource:

    Evans AL and Uberoi R, CT-Guided Jejunostomy Tube Insertion AJR 2005; 185: 1369Find this resource:

    Colonic stenting

    The evidence base for this is weak.

    Indications

    Malignancy

    • Acute obstruction as prelude to delayed surgery.

    • Prophylactive if tight stricture on enema.

    • Palliation in inoperable cancer (high risk/metastases).

    • Fistula (consider removable stents) only with stricture.

    Benign

    • Should be avoided as stents will certainly migrate. But have been used to treat benign stricture temporarily where repeated balloon dilatation fails.

    Contraindications

    • Perforation.

    • Uncooperative patient.

    • Right colon lesions.

    Preparation

    • Bowel prep/rectal suppository/washouts rarely necessary.

    • IV access.

    • Single dose of broad spectrum antibiotic, i.e ciprofloxacin + metronidazole.

    Equipment

    • Colonoscope/stack with large channel for stent. Colonoscopic assistance speeds up the procedure. Length depends on site of lesion, the shorter the better.

    • 10F Arrowflex sheath.

    • Curved catheter, i.e. 5F Cobra, BMC, 5F headhunter.

    • Bentson wire, standard and stiff treumo wire and long 260 cm Amplatz superstiff. Occasionally long ERCP type wires, i.e 400 cm JAG wire.

    • Colonic stent are large bare stents >20 mm with different designs to prevent migration. Some are flared, i.e. Wallflex (Boston) or may be double barrelled stents, i.e. Nitis (Pyramed) or have irregular jagged surface, i.e. Memotherm (Bard), etc.

    • Lubricant gel.

    Imaging

    • Idealy all patients should have colonsopic and contrast enema confirmation of tumour site/length and tightness of stricture or obstruction.

    • CT is acceptable in planning cases.

    Technique

    Usually in the fluoroscopy room or mobile C arm.

    Without colonoscope

    • Patient left lateral semi-prone on fluoroscopy table.

    • Lubricate BMC catheter combined with Bentson wire, negotiate fold in rectum into sigmoid.

    • Air or standard diluted iodinated contrast can be used to distend and show lumen/stricture.

    • Standard terumo wire/stiff wires are useful for direction control round bends and avoiding diverticula. Cobra catheter may have better shape in the rectosigmoid tumours and head hunter better for more proximal lesions, i.e descending colon.

    • Standard terumo better for tortuous segments and stiff terumo often better for pushing through strictures.

    • Oblique C arm to show stricture/occlusion tangentially and probe with terumo wire while rotating BMC catheter until stricture is crossed.

    • Place catheter 5–6 cm beyond stricture, confirm position, exchange for stiff guidewire.

    • Place arrow flex sheath, opacify length of stricture to assess stent size/length.

    • Place stent of appropriate length with slightly more stent above the stricture than below to reduce migration risk. Ideally, there should be 3–4 cm of stent above the stricture and 2–3 cm below (Figure 14.9).

    • Opacify stent length for peforation and opening.

    • Do not routinely balloon dilate pre-or post stent to reduce risk of perforation. Rarely may need dilatation to insert stent. Use small balloon to allow stent delivery passage, i.e 10 mm.

    Figure 14.9 Colonic stent insertion using catheter and guidewire technique.

    Figure 14.9
    Colonic stent insertion using catheter and guidewire technique.

    With colosnoscopy

    • The scope is negotiated to stricture. Not usually possible to pass across (if you can, usually don't need stent).

    • Opacify the distal end of the stricture.

    • Pass long guidewire up to 400 cm through the stricture. The 400 cm length is used if the working channel of the scope will not allow stent delivery passage (10F) and the scope needs to be exchanged for a long sheath.

    • Opacify the proximal end of the stricture.

    • Pass stent delivery through scope across lesion and deploy under fluoroscopy.

    • If working channel unsuitable for direct stent, exchange scope for Arrowflex sheath over long wire and complete procedure as above (Figure 14.10).

    Figure 14.10 Colonic stent insertion with colonoscopic assistance.

    Figure 14.10
    Colonic stent insertion with colonoscopic assistance.

    Post procedure

    • Monitoring of pulse, BP, respiration and assessment for possible perforation hourly for 4 hours and then 6 hourly for 24 hours.

    • AP plain film at 12–24 hours to assess stent opening/migration/perforation.

    • Stool softeners are advisable.

    TIPS:

    • Don't over distend the bowel as this makes finding the lumen more difficult. Sometimes aspiration or air/contrast aids in directing the guidewire.

    • If difficult to get stiff wire to go up. Use small balloon above stricture to anchor position, i.e 5–6 mm.

    • If catheter will not follow wire try using a 4F glide Cobra.

    • If a lesion cannot be crossed while using a scope. Insert a long 6F MPA catheter (125 cm) through the scope to give direction and stiff terumo wire. Use plenty of saline to lubricate.

    • If lesion still not crossed, try exchanging for a sheath and try with a 5F headhunter.

    Technical success: >94%

    Clinical success >91%

    Complications: 23%

    • Predominantly:

    • Perforation <4%

    • Migration <12%

    • Re-obsbruction <8%