Indications
– Esophageal Stricture
– Esophageal Perforation
Contraindications
– Esophageal Stricture that wire cannot pass
– Esophageal perforation with sepsis (needs open surgery)
1) Using Endoscopy and Fluoroscopy mark the proximal and distal end of pathology. Use the paper clip technique (on the patient’s chest wall just place a standard paper clip held in place with tape. Under fluro, mark where the scope is at the most distal site of the perforation and place a paper clip on the patient’s chest wall, and then do the same for the proximal site of the perforation) please see video
2) Place a guide wire through the endoscope, and remove scope leaving guide wire. This is done via the Seldinger technique. The guide wires to choose from include: Standard J-Wires are in sized 0.018, 0.021, 0.025, and 0.035 diameter. These are very flexible, at times too flexible, thus I always use the larger size. 0.035. What I prefer is the metal Savary wire which is 5 French or 0.035 mm.
3) Place stent over a guide wire: There are multiple stents to choose from. You will need to look at the sized for the diameter of the stent you choose to use. I prefer the largest diameter possible for the esophagus. This is usually the 28 mm at the flare, with a 25 mm diameter for the shaft. There is also the option of fuller covered, partially covered, and uncovered. The less covering, the more tissue ingrowth will occur. Thus, if you want to remove the stent, then choose a fuller covered stent. If you are going to place a stent permanently, ie for metastatic obstructive cancer, then use an uncovered stent.
4) Using Fluoroscopy deploy the sent covering the pathology. Ensure the area where the paper clips are located is covered. You will want to cover more proximal then distal, as stents are very prone to migrating distally.
5) Fix the proximal end of the stent in place. The can be done with endoscopic suturing (which requires an advanced skill set), or with a metal clip(s). With no fixation, esophageal stents have a 20% chance of distal migration.
6) Using endoscopy to confirm stent is in the right location,and save this image to the patient’s chart.
Pre Operative Diagnosis – Esophageal perforation
Post Operative Diagnosis – Esophageal perforation
Procedure Performed – Endoscopic Stent placement
Surgeon: Christopher Ducoin, MD
First Assistant: None
Anesthesia: GETA
Findings – Long segment esophageal stricture
Specimen: None
Complications: None
Condition: Awake, Alert and Orientated, will be evaluated in PACU and admitted to the hospital bed.
Indications: Pt is a 48 yo male with a long-standing history of dysphagia and was found to have a long segment esophageal stricture. He has been getting serial esophageal dilations, however now the diameter is too small to fit a balloon. Risks and benefits explained and the patient is willing to undergo Endoscopic Surgery.
Procedure: The patient was seen in the Pre-Operative holding area where history and physical were examined along with consent forms. The patient was then moved to the operating room and secured on the OR table with a lap belt. A timeout was called acknowledging patient, procedure, and anatomical surgical sites. GETA was provided by the anesthesia team. A bite block was placed and a flexible front viewing endoscope was placed transorally, through the mouth and esophagus and a stricture is noted at 32 cm from the incisors. The scope is not able to pass. Using fluoroscopy and contrast through the scope we can see that the stricture goes to the level of the GE junction. This has been biopsied before in the past and is a benign stricture. Using Fluoroscopy we mark the proximal and distal segment of the stricture. A wire is placed through the scope, into the esophagus, and under fluoroscopy, we see that it goes into the stomach. The scope is then removed leaving only the wire in place. We then place the stent over the wire and deploy the stent using fluoroscopy. The wire and stent deployment system is then removed. We then repeat endoscopy to confirm the stent is in the appropriate location, which it is. The scope is removed along with the bite block. The patient was seen gently waking from anesthesia, transferred from the OR bed to the stretcher, will be evaluated in PACU and admitted to a hospital bed. The family has been updated.