Editing Gastroscopy procedures (section)

== '''Oesophageal stenting''' ==

* Stents
** SEMS
** Can be covered or uncovered
** Covered - resist tumour ingrowth. May be removable. Higher incidence of migration. Offer better long-term palliation than uncovered stents for malignant disease.
** Uncovered - embed into surrounding tissue. Tumour ingrowth occurs frequently.
** Can be effective with extrinsic compression, but not as effective as for primary oesophageal lesions.
* Outcomes
** Provides rapid relief of dysphagia
* Contraindications
** Haemodynamically unstable, clotting disorder, or cannot tolerate moderate sedation
** Plan for future radiotherapy (high risk trache-oesophageal fistula)
* Technique principles
** Can be performed under either endoscopic or fluoroscopic guidance
** Stricture needs to be dilated to between 9 and 14mm
** Aim for 2cm margin proximally and distally
** Avoid traversing the stent after deployment due to risk of migration before it is fully expanded (takes about 48 hours)
** If two stents are required to traverse a long stricture, overlap them by 1-2cm
** Avoid leaving excessive stent length in stomach due to risk of ulceration
** Can be done in cervical oesophagus, although with lower efficacy. At least 1-2mm between upper oesophageal sphincter and proximal margin of stent (reported feeling of choking if stent is within 5cm of upper oesophageal sphincter - try to avoid).
* Wallstent (I think WallFlex is same - perhaps the old version - made of nitinol instead of steel)
** Information
*** Partially coated with bare proximal and distal ends (2cm each end)
*** 18.5Fr delivery system
*** 18 or 23mm diameter (some surgeons use 18 for women, 23 for men)
*** 18mm stent comes in 103mm, 123mm or 153mm lengths; 23mm stent comes in 105mm, 125mm or 155mm lengths
*** Can be partially covered or fully covered - all same sizes available
*** Can be recaptured and repositioned as long as <50% of the stent has been deployed
*** Can foreshorten after deployment
*** High radial force compared to other stents - good dysphagia relief, but increased post-procedural pain
*** Ideal for patients with advanced lesions
** Technique
*** Need - 2x straightened paperclips with tape, II from start, 260cm straight tip jagwire for guidewire (none in package), and appropriate stent sizes in room
*** Dilate the stricture adequately
*** Pass scope to stomach/duodenum and get a nice screening II that has all the relevant points of interest in field, so the II doesn't have to be moved again
*** Use markers/paperclips taped to skin to measure distance from top to bottom, with 2cm overlap at top and bottom edge of tumour. Open appropriate stent.
*** Insert the guidewire across the stricture, into the stomach/duodenum
*** Remove the scope, keeping wire in place
*** After flushing inner channel with saline, insert the stent delivery mechanism over the guidewire - three markers on the delivery system

***# Distal extent (be aware it's a little bit back from tip)
***# Point of no return
***# Proximal extent

*** Open the stent by pulling the distal handle towards the proximal handle (open slowly under fluoro)
*** Remove stent delivery mechanism and guidewire
* Post-stenting advice
** Liquids for first 24 hours
** Eat slowly, small bites, chew food well
** Sit upright while eating
** Take sips of coca-cola if food feels stuck