The Role of Stenting in Palliative Medicine

1
The Role of Stenting in Palliative Medicine

• Joel Marquess, MSIV
• 2/19/2008

2
Goals

• To describe four stenting procedures applicable
  to palliative medicine
• Procedure
• Indications
• Potential complications

3
Biliary Stent Placement

• Indication
• Unresectable bile duct stricture
• Symptoms
• Jaundice
• Itching
• Pain
• Nausea/Vomiting
• gt 75 clinical success in relieving obstruction1

4
Biliary Stent Placement

• Procedure1
• Endoscopic (ERCP)
• Less invasive
• Similar results
• Preferred method
• Percutaneous
• Biliary tree accessed transhepatically
• More invasive, significant pain
• Used when ERCP unsuccessful

5
Biliary Stent Placement

• Stents used1

• Plastic
• Inexpensive
• Easy to replace
• Short patency
• 1.8 5.5 mo
• Poor prognosis patients
• lt 6 mo

• Metal
• Covered vs. Mesh
• Difficult to replace
• Longer Patency
• 3.6 9.1 mo
• Lower re-intervation rate lower long-term cost

6
Biliary Stent Placement

• Risks2
• Bleeding
• Infection
• Cholangitis/Pancreatitis
• Bowel injury
• Stent obstruction/migration

7
Colorectal Stenting

• Indication3
• Alternative or bridge to surgery in malignant
  colonic obstruction
• Symptoms
• Nausea
• Vomiting
• Pain
• 88.6 clinical success3
• (72 when used as bridge to surgery)
• 50 reduction in cost to treat
• (12 reduction if bridge to surgery)

8
Colorectal Stenting

• Procedure3
• Placement of self-expanding metal stent across
  lesion using endoscopic and/or radiologic
  guidance.
• Most effective in left-sided lesions
• Prevents need for colostomy

9
Colorectal Stenting

• Risks3
• Perforation
• 3.76
• Reobstruction
• 7.34
• Median 24 wk (1-52 wk range)
• Lower rate with covered stents
• Migration
• 11.8
• Easily corrected
• Mortality rate
• Emergent surgery
• 0.9-6
• Stenting
• 0.58

10
Ureteral Stenting

• Indications4
• Ureteral stenosis (among others)
• Ex. Compression by retroperitoneal mass
• Leads to pain and loss of renal function
• 79.7 clinical success4
• Prevents need for external nephrostomy tube
• Lower risk of infection4

11
Ureteral Stenting

• Procedure4
• Double pigtail stent (DPS) placed in ureter with
  coiled ends in renal pelvis and bladder
• Placed via cystoscopy, ureteroscopy, percutaneous
  nephrostomy, or open surgery

12
Ureteral Stenting

• Risks4
• 20 will have at least one complication
• Hematuria
• 16
• Pain
• 4.2
• Fever
• 0.2
• Migration
• 1.7
• Restenosis
• 2.1
• Most are mild and tolerable4

13
TIPSS

• Transjugular Intrahepatic Portosystemic Shunt
• Indications5
• Prevent recurrent GI bleeding in severely
  portal-hypertensive patients
• Alleviate refractory ascites in portal
  hypertensives
• High success in GI rebleeders (70-95) with lt 20
  rebleed rate after TIPSS5

14
TIPSS

• Procedure5
• Access to the (right) hepatic vein obtained via
  jugular approach
• Portogram obtained via catheter wedged in
  terminal hepatic vein branch
• Portal system accessed via hepatic vein through
  liver parenchyma
• Expanding metal stent placed across new tract to
  maintain patency
• Shunt created from portal to systemic
  circulation, bypassing liver sinusoids
• Lowers portal pressure
• Increases cardiac output and promotes natriuresis

15
TIPSS

• Risks5
• Hepatic
• Shunts blood away from sinusoids
• Hepatic artery must provide blood supply to the
  liver
• May cause liver failure if HA is unable to
  compensate
• Cardiopulmonary
• Shunt increases blood return to heart
• May unmask or worsen heart failure or pulmonary
  hypertension
• Heart failure and pulmonary hypertension are
  contraindications
• Shunt dysfunction
• Up to 70 experience stenosis w/in 1 year
• Requires frequent doppler exams
• TIPS should be considered on-going therapy, as
  opposed to a single definitive intervention
• Portosystemic encephalopathy (PSE)
• 35-55 in first year, usually w/in first 3 mo
• May require narrowing of shunt or complete
  occlusion
• Usually responds to medical management
• Patients must be selected carefully
• Elective cases associated with fewer
  complications than emergent cases

16
References

• Tsutuguchi, T et al., Stenting and
  interventional radiology for obstructive jaundice
  in patients with unresectable biliary tract
  carcinomas, J Hepatobiliary Pancreat Surg (2008)
  1569-73.
• Van Delden, O et al., Percutaneous drainage and
  stenting for palliation of malignant bile duct
  obstruction, Eur Radiol (2008) 18 448-456.
• Sebastian, S et al., Pooled analysis of the
  efficacy and safety of self-expanding metal
  stenting in malignant colorectal obstruction, Am
  J Gastroenterol 2004992051-2057.
• Ping, H et al., Clinical evaluation of
  double-pigtail stent in patients with upper
  urinary tract diseases report of 2685 cases,
  Journal of Endourology, January 1, 2008, 22(1)
  65-70.
• Colombato, Luis, The role of transjugular
  intrahepatic portosystemic shunt (TIPS) in the
  management of portal hypertension, J Clin
  Gastroenterol 200741S344-S351.