1. No category

8
Gastrointestinal tract stent related
complication: Incidence, how to
prevent, and management
‘√‘°“≠®πå ¬“¡“¥–
∫∑π”
°“√‡°‘¥¿“«–·∑√°´âÕπ„π°“√„ à∑àÕ∂à“ߢ¬“¬ (Stent) ”À√—∫∑“߇¥‘π
Õ“À“√æ∫‰¥â„π√Ÿª·∫∫μà“ßÊ ºŸâªÉ«¬ à«π„À≠à¡—°‡ªìπºŸâªÉ«¬¡–‡√Áß√–∫∫∑“߇¥‘π
Õ“À“√√–¬– ÿ¥∑⓬ (Advance stage esophageal malignancy) ¡“°°«à“ 90%1
´÷Ëß«—μ∂ÿª√– ߧ塗°‡æ◊Ëՙ૬§ÿ≥¿“æ™’«‘μÀ√◊ՙ૬≈¥‚Õ°“ ‡ ’ˬ߄π°“√ºà“μ—¥
∑—π∑’‚¥¬°“√„ à∑àÕ∂à“ߢ¬“¬‰«â™—Ë«§√“« ¥—ßπ—Èπ°“√æ‘®“√≥“°“√∑”À—μ∂°“√®–
μâÕߧ”π÷ß∂÷ߪ√–‚¬™πå„π°“√√—°…“¿“«–·∑√°´âÕπ®“°‚√§¡–‡√Á߇ªìπÀ≈—°·≈–
μâÕߧ”π÷ß∂÷ߧ«“¡ ÿ¢ ∫“¬¢ÕߺŸâªÉ«¬À≈—ß°“√„ à∑àÕ∂à“ߢ¬“¬ ∂â“°“√∑”À—μ∂°“√
‡æ‘Ë¡§«“¡‰¡à ÿ¢ ∫“¬ ‰¡à™à«¬§ÿ≥¿“æ™’«‘μ À√◊Õ∑”„Àâ¡’ªí≠À“„π°“√ºà“μ—¥‡æ‘Ë¡¢÷Èπ
∫“ߧ√—Èß°“√„ à∑àÕ∂à“ߢ¬“¬∑’˺‘¥¢âÕ∫àß™’È°ÁÕ“®´È”‡μ‘¡ºŸâªÉ«¬‰¥â„π°≈ÿà¡∑’Ë¡’¿“«–
·∑√°´âÕπ®“°°“√∑”À—μ∂°“√‚¥¬‰¡à®”‡ªìπ „πºŸâªÉ«¬∫“ß°≈ÿà¡°“√„ à∑àÕ∂à“ß
¢¬“¬‡ªìπ°“√™à«¬·°â‰¢¿“«–·∑√°´âÕπ¢Õß‚√§∑’ˉ¡à„™à¡–‡√Áß (Benign disease)
ª√–¡“≥ 3-6%1 „π¢≥–∑’˺ŸâªÉ«¬∑’ˉ¡à “¡“√∂∑π°“√ºà“μ—¥„À≠à‰¥â¡—°‡ªìπ°“√
™à«¬°“√√—°…“°àÕπ°“√ºà“μ—¥À√◊Õ∑”„Àâ°“√ºà“μ—¥∑”‰¥âß“à ¬¢÷πÈ (Bridge to Surgery)
‚¥¬‡©æ“–ºŸâªÉ«¬∑’Ë¡’°“√Õÿ¥μ—π≈”‰ â„À≠à¥â“π´â“¬
86
Gastrointestinal tract stent related complication: Incidence, how to prevent, and management 87
Incidence of Stent related complication
°“√æ‘®“√≥“°“√„ à∑Õà ∂à“ߢ¬“¬´÷ßË μàÕ‰ªπ’®È –¢Õ∑—∫»—æ∑å§Õ◊ çStenté ¡’¢Õâ
∫àß™’È∑’Ë®”‡ªìπ„π°“√∑”À—μ∂°“√¬—߉¡à°«â“ߢ«“ß·≈–¡—°‰¡à„™à Modality ·√°„π
°“√„Àâ°“√√—°…“‚√§¡–‡√Áß ‚¥¬√«¡·≈â«°“√∑”°“√∂à“ߢ¬“¬¡’‚Õ°“ ‡°‘¥¿“«–
·∑√°´âÕπ‰¥â‚¥¬·μà≈–°“√»÷°…“„π™à«ß‡«≈“∑’ºË “à π¡“¡’Õμ— √“·∑√°´âÕπ√ÿπ·√ß≈¥
≈ß1-3 „πªí®®ÿ∫—πÕ—μ√“°“√‡°‘¥¿“«–·∑√°´âÕπ√ÿπ·√ß≈¥≈߉ªÕ¬à“ß¡“° ◊∫
‡π◊ËÕß®“° ¡’»—≈¬·æ∑¬å Õ“¬ÿ√·æ∑¬å ∑’˺Ÿâ™”π“≠°“√ àÕß°≈âÕß ¡’™π‘¥¢Õß stent
„Àâ‡≈◊Õ°¡“°¢÷Èπ°«à“„πÕ¥’μ ¢π“¥·≈–√Ÿª√à“ß∑’Ëæ—≤π“„Àâ‡À¡“– ¡°—∫ à«πμà“ßÊ
¢Õß∑“߇¥‘πÕ“À“√ «— ¥ÿ∑’Ë¡’§«“¡∑π∑“π·≈–∑”Õ—πμ√“¬μàÕº‘«‡¬◊ËÕ∫ÿ≈¥≈ß ¡’¢âÕ
∫àß™’È∑’ˇÀ¡“– ¡„π°“√æ‘®“√≥“‡≈◊Õ°ºŸâªÉ«¬ √«¡‰ª∂÷ß technique ªí®®ÿ∫—π ¡’°“√
æ—≤𓉪¡“° ‚¥¬ Self-expandable metallic stent (SEMS) ‡¡◊ËÕ‡∑’¬∫°—∫¬ÿ§
·√°‡¡◊ËÕª√–¡“≥°«à“ 10 ªï°àÕπ ¡’§«“¡®”‡ªìπμâÕß°“√∂à“ߢ¬“¬®ÿ¥Õÿ¥μ—π°àÕπ
retain stent π—Èπ¡’§«“¡®”‡ªìπ≈¥≈ß
‡π◊ËÕß®“°°“√∑”À—μ∂°“√™π‘¥π’È¡—°¡’ªí®®—¬À≈“¬Õ¬à“ß∑’Ë∫“ߧ√—ÈßÀ≈’°
‡≈’ˬ߿“«–·∑√°´âÕ𬓰·≈–Õ“®μâÕß°√–∑”„πºŸâªÉ«¬∑’Ë¡’§«“¡‡ ’Ë¬ß ŸßμàÕ°“√
ºà“μ—¥Õ¬Ÿà·≈â«¥—ßπ—Èπ°“√‡°‘¥¿“«–·∑√°´âÕπ∑’ˉ¡à√ÿπ·√ß®÷ß¡—°‡ªìπ∑’ˬա√—∫‰¥â
√“¬ß“π°“√»÷°…“¡—°√“¬ß“π®“°∑“ß Õ‡¡√‘°“ ¬ÿ‚√ª ‡°“À≈’·≈– ®’π ´÷Ë߇ªìπ
ª√–‡∑»∑’Ë¡’°“√º≈‘μ stent Õ¬à“ß·æ√àÀ≈“¬ °“√‡°‘¥¿“«–·∑√°´âÕπ®“° Esophageal stent æ∫∫àÕ¬·μà‰¡à√ÿπ·√ß√“¬ß“π°“√‡°‘¥¿“«–·∑√°´âÕπ√ÿπ·√߉¥â
ª√–¡“≥μ—Èß·μà 2-5% ¿“«–·∑√°´âÕπ‰¡à√ÿπ·√ßæ∫‰¥âª√–¡“≥μ—Èß·μà 4-42%
2,3 (μ“√“ß∑’Ë 1) à«π colonic ·≈– rectal stent æ∫¿“«–·∑√°´âÕπ√ÿπ·√ßπâÕ¬
°«à“ 4% „π°√≥’ palliative non-emergency setting ·μàæ∫¿“«–·∑√°´âÕπ
√ÿπ·√ß„π°√≥’ emergency setting ‰¥â∂÷ß 11.6% Õ¬à“߉√°Á¥’Õ—μ√“°“√‡®Á∫
ªÉ«¬À√◊Õ¿“«–·∑√°´âÕπ¡’Õ—μ√“πâÕ¬°«à“‡¡◊ËÕ‡∑’¬∫°—∫°“√‡ªî¥™àÕß∑âÕߺà“μ—¥
©ÿ°‡©‘π´÷Ëßæ∫¿“«–·∑√°´âÕπ‰¥âª√–¡“≥ 41% ·≈–„π°√≥’¿“«–·∑√°´âÕπ‰¡à
√ÿπ·√ß®“°°“√ retain colonic ·≈– rectal stent æ∫‰¥âª√–¡“≥μ—ßÈ ·μà 7-30%1,4,5
88
‘√‘°“≠®πå ¬“¡“¥–
μ“√“ß∑’Ë 1 Over all early and late complication of self-expandable metal stents for cancer24
Over all
Perforation
Stent Migration
Tumor overgrowth
Stool impaction
Other
Early complication: no. (%)
Late complication: no. (%)
11(15.5)
4(5.6)
2(2.8)
1(1.4)
2(2.8)
2(28)*
24(33.8)
5(7.0)
7(9.9)
15(21.1)
0
2(2.8)
Type of Gastrointestinal tract Stent by location
: Indication and contraindication for stent placement6-11
°“√∑√“∫∂÷ ß ¢â Õ ∫à ß ™’È · ≈–¢â Õ Àâ “ ¡‡ªì π °“√™à « ¬ªÑ Õ ß°— π °“√‡°‘ ¥ ¿“«–
·∑√°´âÕπÕ¬à“ßÀπ÷Ë߇™àπ°—π ´÷Ëß®–∑”„Àâ¡’°“√‡≈◊Õ°ºŸâªÉ«¬∑’ˇÀ¡“– ¡·≈–¡’°“√
‡≈◊Õ°«‘∏’∑’ˇÀ¡“– ¡°—∫ºŸâªÉ«¬·μà≈–√“¬Õ¬à“ß¡’À≈—°°“√ (Tailor methods or individualization match)
1) For Upper GI tract disease: Esophageal Stent
Absolute indication
Absolute Contraindication
- Advance stage esophageal malignancy
- Aorto enteric fistula connected to TE fistula
- Tracheo or broncheo-Esophageal fistula
- Severe inflammation or fungal infection in
- Recurrent laryngeal nerve palsy
the esophageal lumen
- Scope and /or guide wire cannot be
properly passed the lumen.
Relative indication
Relative Contraindication
- Other advance malignancy compression or - No specialist, or no experience surgeons
invasion to esophagus
- Stent Material and size do not match for
lesion
Gastrointestinal tract stent related complication: Incidence, how to prevent, and management 89
- Iatrogenic intra thoracic esophageal
- Non-functioning or hypo motility
12
esophagus
perforation
- Very short life expectancy
- Severe acute radiation esophagitis
- Late thoracic esophageal perforation
- Disease is at UES or EG junction
- Post operative esophageal anastomosis
leakage13
- Dilation resistance on failure reconstruction of anastomotic stricture
- Extreme age and severe cachexia
- Failure of control primary or systemic diseases
- Poor physical fitness or pulmonary function test
- relapse of serious infection and intolerable to major operation
2) For Lower GI tract disease: Colonic and Rectal Stent14-21
Absolute indication
Absolute Contraindication
- Bridge to Urgency or Elective Surgery to help - Suspicious of perforation/ peritonitis
Bowel preparation
- Localized intra-abdominal abscess
- Bridge to multimodality therapy: CCRT
- Patients do not well tolerate to
and /or Surgery
intervention with difficulty of orientation
- Paliative therapy in recurrent or advance
- Fail to pass the wire or systemic
stage with metastasis
scope without clearing of luminal view
Relative indication
Relative Contraindication
- Severe uncontrolled systemic disease
- Anatomical orientation difficulty
- Advance other pelvic malignancy involve
- Less personal experience of endoscopies
rectum
- High type rectovaginal fistula
- Co-committent of acute severe colitis
(covered stent)
- Benign severe stenosis
- Post chemotherapy or vascular endothelial
growth factor(VEGF) Rx
90
‘√‘°“≠®πå ¬“¡“¥–
Type of complications: pitfalls, how to prevent, and management
A) Esophageal Stent
Self-expandable metals stents (SEMSs) ¡’°“√„™âÕ¬à“ß·æ√àÀ≈“¬¡“°
¢÷Èπ ”À√—∫°“√„ à‰«â™—Ë«§√“«„π°“√√Õ°“√√—°…“ modality Õ◊ËπÊ ‡™àπ°àÕπ°“√„Àâ
‡§¡’∫”∫—¥√à«¡°—∫°“√©“¬· ß (Bridge to surgery before concurrent chemoradiation therapy) „πºŸªâ «É ¬¡–‡√ÁßÀ≈Õ¥Õ“À“√√–¬–∑’Ë 3 À√◊Õ„πºŸªâ «É ¬∑’¡Ë ’ esophageal defects or stenosis À≈—ß®“°°“√©“¬· ßÀ√◊Õ∑”°“√∂à“ߢ¬“¬ „π°√≥’¢Õß
benign stricture ¬—ß ‰¡à¡’ evidence base ∑’™Ë ¥— ‡®π·≈–¬—ß¡’°“√√—°…“Õ◊πË ∑’‰Ë ¥âº≈¡“°
ÿ ¿“æÀ√◊Õ °≈‰°
°«à“22,23 ∂÷ß·¡â«“à °“√„™â stent ®–™à«¬∑”„À⺪Ÿâ «É ¬∑“π‰¥â ·μà§≥
°“√∑”ß“π¢ÕßÀ≈Õ¥Õ“À“√°Á‰¡à‰¥â‡ªìπ‰ªμ“¡ª°μ‘ °“√ retain SEMSs À√◊Õ °“√
remove ·¡â«à“®–¡’°“√º≈‘μ™π‘¥∑’Ë∑”„Àâ –¥«°¢÷Èπ·μà°“√ remove °Á‰¡à‰¥âßà“¬¡“°
√«¡∑—ÈßÕ“®∑”„À⇰‘¥°“√∫“¥‡®Á∫ Õ—°‡ ∫ ´÷Ë߇ªìπªí®®—¬¢Õß °“√‡°‘¥ restricture
‡™àπ‡¥’¬«°—π ¥—ßπ—Èπ¬—߉¡à„™à¢âÕ∫àß™’È™—¥„π°“√√—°…“ severe benign stricture
Õ¬à“߉√°Á¥’ ºŸπâ æ‘ π∏姥‘ «à“ ªí®®—¬¥—ß°≈à“«Õ“®·°â‰¥â∂“â «— ¥ÿ∑„’Ë ™â∑”„À⇰‘¥ radial force
¡“°æÕ·≈–«— ¥ÿ∑’Ë„™â∑”¡’§«“¡‡√’¬∫§≈⓬ silicone tube ‰¡à§«√‡ªìπ plastic ∑’Ë
®–‡°‘¥§«“¡·¢Áߢ÷Èπ·≈–¡’·√ßΩó¥°—∫ºπ—ßÀ≈Õ¥Õ“À“√‚¥¬‡©æ“–‡¡◊ËÕ∂÷߇«≈“„π
™à«ß∑’Ë®–∑”°“√ remove °“√∑”°“√ retain stent „π benign stricture ®÷ߧ«√¡’
μ—«π”ºà“π nasal cavity ‡æ◊ËÕ –¥«°·≈–¡’·√ߥ÷߇æ‘Ë¡¢÷Èπ·≈–‡≈’ˬ߂հ“ ≈⡇À≈«
‡¡◊ËÕμâÕß°“√ remove plastic stent Õ¬à“߉√°Á¥’¢âÕ∫àß™’Ȭ—߉¡à™—¥‡®π‡¡◊ËÕ‡∑’¬∫º≈
°“√»÷°…“„π√–¬–¬“«·≈–À≈—°°“√√—°…“·μ°μà“ß®“°°“√Õÿ¥μ—π®“°¡–‡√Áß ‡π◊ËÕß
®“°‡ªìπ°≈‰°°“√‡°‘¥°“√Õ—°‡ ∫·≈–·º≈‡ªìπ (scar) ´÷Ëß™π‘¥¢Õß stent ∑’Ë
æ—≤π“„π°“√√—°…“ benign stricture §«√¡’≈°— …≥–«— ¥ÿ∑≈’Ë ¥°“√Õ—°‡ ∫‡ ’¬¥ ’·≈–
reflux ‚¥¬‰¡à‡°‘¥ reaction μàÕ°“√Õ—°‡ ∫¢Õ߇π◊ÈÕ‡¬◊ËÕÀ√◊Õ¡’ double full covered
‚¥¬«— ¥ÿ∑’Ë∑”®“° silicone
1) Early post stenting complication
Major local complication: Immediate and delayed complication in
30 days
Gastrointestinal tract stent related complication: Incidence, how to prevent, and management 91
- Perforation
- Bleeding
- Stent Malposition: Õ“®∑”„À⇰‘¥ stent migration μàÕ‰ª
- Intestinal obstruction
Major systemic complication
- Airway obstruction and severe coughing reflex
- Aspiration and respiratory tract infection complication
- Myocardial ischemia and/ or arrhythmia
Minor complication: ¡—°‰¡à®”‡ªìπμâÕß„Àâ°“√√—°…“·≈–¡—°¥’¢÷Èπ‡¡◊ËÕ
‡«≈“ºà“π‰ª
- Sore throat
- Hypopharyngel pain
- Chest discomfort
- Coughing reflex
- Feeling of food stagnation and /or reflux
2) Late complication
Major complication
- Bleeding (since early to late): ¡—°‡°‘¥°—∫°≈ÿà¡ partial covered stent ·≈– ‡°‘¥ stent induced ulcer ´÷ËßÕ“®æ∫À≈—ß®“° retain stent ‰¥â
π“π∂÷ß 10 ‡¥◊Õπ24
- Stent Migration: æ∫‰¥â∫àÕ¬‡π◊ËÕß®“° ‡¡◊ËÕ¡–‡√Áß¡’°“√μÕ∫
πÕßμàÕ°“√√—°…“¥â«¬‡§¡’∫”∫—¥À√◊Õ©“¬· ß ·≈–≈¥¢π“¥®–∑”„Àâ stent ¡’
°“√‡ª≈’ˬπ∑’ËÀ√◊Õ¬â“¬μ”·Àπàß
- Lose of luminal patency ¡’√“¬ß“π„πºŸªâ «É ¬ 81 √“¬∑’¡Ë §’ “à median Õ¬Ÿà∑’Ë 119 «—π ´÷Ëß‚¥¬¡“°‡°‘¥®“°¡’ Tumor over growth and implantation
Wall stent abscess with minor perforation
- Failure to remove the stent: „π°“√»÷°…“Àπ÷Ëßæ∫«à“¡’Õ—μ√“
92
‘√‘°“≠®πå ¬“¡“¥–
Uncomplicated primary removal (retrieval) rate Ÿß„π fully covered stent
¡“°°«à“°≈ÿ¡à partially covered stents (p =.035)11,22 ·≈–ßà“¬°«à“„π°≈ÿ¡à single
stent ‡¡◊ËÕ‡∑’¬∫°—∫ overlap stent (P =.033) °√≥’„πºÿâªÉ«¬∑’Ë∑”°“√ remove
¬“°¡—°‡°‘¥®“°°“√ retain stent π“π‡°‘π‰ª‡¡◊ÕË ‡∑’¬∫°—∫°≈ÿ¡à ∑’‰Ë ¡à‡°‘¥ªí≠À“ (126
days vs 28 days; P =.01) ·≈–æ∫«à“μâÕ߇ª≈’ˬπ‡ªìπ surgical removal „πºÿâªÉ«¬
3 §π (2.4%) ·≈–¡’ºÿâªÉ«¬ 6 §π (5%) ∑’Ë¡’¿“«–·∑√°´âÕπ √ÿπ·√ß·≈–
—¡æ—π∏å°—∫À—μ∂°“√ endoscopic extraction
Minor complication
- Swallowing function: Semi solid and liquid23
- Persistent of malnutrition
Factors related complication and how to prevent
1) Level of disease and stage or disease severity related complication
: °√≥’∑√’Ë Õ¬‚√§Õ¬Ÿ„à π à«π√Õ¬μàÕ‡™àπ Upper esophageal sphincter
(UES) À√◊Õ EG junction °“√retain stent “¡“√∂∑”‰¥â ·μà®–‡æ‘Ë¡ªí≠À“¢Õß
reflux ·≈– Õ“°“√∑’Ë —¡æ—π∏åÕ◊ËπÊ
2) Type of stent material related complication
: °√≥’¢Õß TE À√◊Õ Broncheo esophageal fistula §«√‡≈◊Õ°™π‘¥
stent ‡ªìπ·∫∫ full covered stent ‡æ◊ËÕªî¥√Õ¬μ‘¥μàÕ¢Õß∑“߇¥‘πÕ“À“√·≈–
∑“߇¥‘πÀ“¬„®Õ¬à“ß ¡∫Ÿ√≥å „πªí®®ÿ∫—π ‚Õ°“ ∑’Ë®–‡°‘¥°“√≈ÿ°≈“¡‰¡à¡“°
3) Size and length selection related complication
: °“√‡≈◊Õ°¢π“¥‡ âπºà“π»Ÿπ¬å°≈“ß·≈–§«“¡¬“«∑’ˇÀ¡“– ¡®–
∑”„Àâ°“√√—°…“‰¡à‡°‘¥¿“«–·∑√°´âÕ𠧫√«—¥√–¬–‚¥¬ª√–¡“≥®“°¿“æ∂à“¬√—ß ’
(∂â“¡’) °àÕπ∑’Ë®–∑”°“√μ—¥ ‘π„® ‡æ◊ËÕÀ≈’°‡≈’ˬ߿“«–·∑√°´âÕπ ·≈– ®”‡ªìπ∑’Ë®–
μâÕߪ√–‡¡‘π √à“ß°“¬, nutritional status °àÕπ·≈–À≈—ß°“√∑”À—μ∂°“√„π°≈ÿ¡à ·√°
§«√¡’¢Õß∑’√Ë ∫— ª√–∑“π‰¥âß“à ¬À≈—ß°“√∑”À—μ∂°“√¡—°‡ªìπ liquid ·≈– semi-solid
‡™àπ π¡, ¢â“«μâ¡, ‡μâ“ÀŸâ °“√‡≈◊Õ° ¢π“¥‡ âπºà“π»Ÿπ¬å°≈“ß∑’ˇ≈Á°‰ª ¡—°‡°‘¥ stent
Gastrointestinal tract stent related complication: Incidence, how to prevent, and management 93
migration „π¢≥–∑’Ë„À≠à‡°‘π‰ª Õ“°“√∑’Ëæ∫∫àÕ¬§◊Õ chest pain
4) Inadequate nutritional assessment related complication on
substantial malnutrition Õ“®®”‡ªìπμâÕߙ૬°“√„ÀâÕ“À“√∑“ß “¬¬“ß√à«¡‡¡◊ÕË luminal patency ≈¥≈ß‚¥¬ Jejunostomy
B) Colonic and rectal Stent
1) Early post stenting complication: ·∫à߇ªìπ 2 ™à«ß§◊Õ immediate
(72 ™—Ë«‚¡ß) and delayed complication (>72 ™—Ë«‚¡ß)
Major complication: ¡—°μâÕß°“√°“√ºà“μ—¥√—°…“‚¥¬«‘∏’ conventional
method ·≈–¡—°∑”„À⇰‘¥ morbidity ·μà‰¡àæ∫ —¡æ—π∏åÕ—μ√“°“√‡ ’¬™’«‘μ ·μà
Õ¬à“߉√°Á¥’μâÕßæ‘®“√≥“μ“¡¢âÕ∫àß™’È·≈–§«“¡‡À¡“– ¡¢ÕߺŸâªÉ«¬·μà≈–√“¬‡æ◊ËÕ
∑”„À⇰‘¥ªí≠À“·∑√°´âÕπ ®“°°“√欓¬“¡‰¡àºà“μ—¥≈¥≈ß
- Perforation: ¡—°‡°‘¥®“°¿“«–Õÿ¥μ—π ¡∫Ÿ√≥åÀ√◊Õ∂Ÿ°°√–μÿâπ¥â«¬
¬“°≈ÿà¡ Narcotic À√◊Õ°“√ «π (Enema)
- Bleeding: §«√∫Õ°ºŸâªÉ«¬„Àâ™—¥‡®π‡√◊ËÕß°“√„ à stent ·≈–™π‘¥¢Õß
stent ‡æ√“–„π√–¬–¬“«‚Õ°“ ¢Õß tumor replacement of stent Õ“®æ∫¡“°¢÷Èπ
¥—ßπ—Èπ§«√„Àâ°“√Õ∏‘∫“¬‚Õ°“ ‡°‘¥ªí≠À“·∑√°´âÕπ®“°°“√ retain stent „π
√–¬–¬“«‰«â¥â«¬
- Malposition of stent: °√≥’°“√∑”À—μ∂°“√¡’§«“¡¬“° ‡√“§«√
‡μ√’¬¡‡§√◊ËÕߥŸ¥∑’Ë·√ßæÕ„π™à«ß∑’Ë¡’°“√ decompress ®–™à«¬∑”„Àâ‡ÀÁπ tract ¥’¢÷Èπ
(√Ÿª∑’Ë 1)
Minor Complication
- Overflow incontinent: °“√ retain rectal stent ∑’ËμË”‡°‘π‰ª (< 5cm
from anal verge) ¡—°‰¥âº≈‰¡à‡ªìπ∑’Ëπà“æÕ„® ·≈–∫“ߧ√—Èß„À⺟âªÉ«¬∂à“¬·≈⫬—ß
√Ÿâ ÷°√”§“≠Õ¬Ÿàμ≈Õ¥‡«≈“
2) Late complication: ‡°‘¥¿“¬À≈—ßπ“π°«à“ 30 «—πÀ≈—ß°“√∑”À—μ∂°“√
Major complication:
- Bleeding ¬—ߧßæ∫‰¥â∂÷ß 3 ‡¥◊Õπ
94
‘√‘°“≠®πå ¬“¡“¥–
- Stent Migration
- Lose of luminal patency
- Severe anal pain
- Fistula and tumor implantation
Minor complication: Anal pain or tenesmus À√◊Õ ¡’ over flow incontinent æ∫‰¥â∫àÕ¬¡—°‰¡à¡’§«“¡®”‡ªìπ„π°“√·°â‰¢‡π◊ËÕß®“°Õ“°“√‰¡à¡“°
Factors related complication and how to prevent
1) Level of disease and stage or disease severity related complication
2) Colonic obstruction ∑”‰¥â¬“°°«à“ ‡π◊ÕË ß®“°¡—°Õ¬Ÿ„à π¿“«–©ÿ°‡©‘π
·≈– ¡’ à«π∑’Ë‚§âßÀ√◊Õ ∫‘¥ßÕμ“¡≈—°…≥–¢Õß≈”‰ â„À≠à ¥—ßπ—È𠧫√‡≈◊Õ° stent ∑’Ë
¡’ flexibility ·≈– soften ‰¡à§«√‡ªìπ covered stent ·μà¢Õâ ‡ ’¬§◊Õ tumor over growth
on stent ∂â“ retain ‰«âπ“π Õ“®∑”„À⇰‘¥ bleeding À√◊Õ perforation ‰¥â °√≥’‡ªìπ
palliative stent ∫“ß°“√»÷°…“·π–π”„Àâ„™â secondary stent placement ‚¥¬‰¡à
remove stent ‡¥‘¡ ‚¥¬«‘∏’°“√Õ“®‰¥âº≈¥’ ·μà‰¡à‰¥â‡æ‘Ë¡ quality of life „π√–¬–
À≈—ߢÕߺŸâªÉ«¬
3) Type of stent material related complication : ¡’°“√»÷°…“æ∫«à“
Covered and non- covered stent ¡’Õ—μ√“°“√‡°‘¥ stent migration μà“ß°—π
‚¥¬°“√‡°‘¥„π°≈ÿà¡ covered stent æ∫‰¥â¡“°°«à“
4) Size selection related complication: º≈·∑√°´âÕπ√ÿπ·√ßæ∫
‰¡à∫àÕ¬·≈–∫“ß°“√»÷°…“‰¡àæ∫«à“¡’§«“¡ —¡æ—π∏å‚¥¬μ√ß°—∫¿“«–·∑√°´âÕπ
·μà‚¥¬À≈—°°“√¡—°∑”„Àâ¡’‚Õ°“ ‡°‘¥ stent migration À√◊Õ discomfort ¡“°¢÷Èπ
5) Inadequate preoperative assessment cause of troublesome
for definite treatment
°“√¥Ÿ·≈ “√πÈ” §«√„Àâ°“√§«∫§ÿ¡„ÀâÕ¬Ÿ„à π ¡¥ÿ≈ §«√æ‘®“√≥“„Àâ
Antibiotic„πºŸªâ «É ¬ colonic obstruction ∑ÿ°√“¬°àÕπ°“√∑”À—μ∂°“√ ·≈–§«√ decompress „Àâ¡“°∑’Ë ÿ¥‚¥¬ colonoscopy À≈—ß®“° retain stent
Gastrointestinal tract stent related complication: Incidence, how to prevent, and management 95
A: nearly complete obstruction with
severe angulation of sigmoid
colon axis
A
B: Guide wire was difficult to pass
into the lumen but finally without forceful insertion
B
C: The yellow marker was not seen
due to a large amount of feces
went down during launching and
malposition of distal end of
stent occurred by slip above the
lower margin of tumor edge
C
96
‘√‘°“≠®πå ¬“¡“¥–
D: Stent was malposition but working on the purpose of Bridging
to surgery and decompression
was well done. Position was
checked by fluoroscopy that the
stent is well expand in the lumen and covered the length of
tumor.
D
E: Pull back of distal end temporary patent all lumen without migration under fluoroscopy
E
Case Comment: Colonic non-covered stent was slip during launching proximally to above
the lower edge of tumor due to mark content overflow after guide wire and introducer
passing into the lumen. Bridge to surgery was planed to do in 7-10 days after successfully stenting for emergency complete left side colonic obstruction and decompression by
colonoscopy under light sedation without intubation. However, patient was monitored closely
by anesthesiologist. Patientû discomfort and pain relieve was absolutely statisfactory after
intervention. There is no aspiration complication or other immediate serious complication.
Fever was declined and fluid was well balanced by the next 48 hours after the procedure.
Patient and cousin were signed of consent on risk of complication, conversion, and disadvantage of instrumental cost or failure those may occur. The setting was double set up
in endoscopic intervention suit and prompt to surgery if operative conversion was needed.
√Ÿª∑’Ë 1 (A,B,C,D,E): Emergency colonic stenting for complete large intestinal obstruction at sigmoid colon. (Niti-stent, Taewong- placement on minimal malposition
above the lower edge of tumor)
Gastrointestinal tract stent related complication: Incidence, how to prevent, and management 97
ºŸπâ æ‘ π∏å¡°— „™â water soluble contrast „π°“√™à«¬≈¥ bowel swelling „π™à«ß¢≥– intervention ·≈– ™à«ß early post stenting period ·≈–∑”„Àâ°“√
clear bowel ‚¥¬‰¡à‡°‘¥ discomfort ∑”‰¥âßà“¬¢÷Èπ°«à“°“√ clear bowel «‘∏’Õ◊ËπÊ
6) Personal experience and instrumental/ endoscopy suit with
fluoroscopy
‡Õ° “√Õâ“ßÕ‘ß
1. Simmon DT, Baron TH. Technology Insight: Enteral Stenting and New Technology.
1. Nat Clin Pract Gastroenterol Hepatol 2005;2(8):365-74.
2. Sharma P, Kozarek R. Practice parameters committee of the American college of
gastroenterology. Role of esophageal stent in benign and malignant diseases.
Am J Gastroenterol 2010;105:258-73.
3. Jiménez-Pérez J, Pérez-Miranda M, Simón MA, Cabriada J, Aparicio JR, Sánchez
E, et al. Minor complications after self-expandable metal stent placement in
patients with esophageal malignancies. UEGW 2007. P-0340.
4. Garrett MN. Advanced Colon and Rectal Cancer. ASCRS (American Society of
colon and trecteal surgeon) 2011 www.fascrs.org
5. Ptok H, Meyer F, Marusch F, Steinert R, Lippert H, Gastinger I. Incurable stenosing colorectal carcinoma: endoscopic stent implantation or palliative surgery.
World J Surg 2006;30(8):1481-7.
6. Tytgat GN, Tytgat S. Esophageal endoprostheis in malignant stricture. J
Gastroenterol 1994;29:80-4.
7. Grundy A, Glees JP. Aorto-oesophageal fistula: a complication of oesophageal
stenting. Br J Radiol 1997;70:846-9.
8. Radecke K, gerken G, Treichel U. Impact of a self -expanding, plastic esophageal stent on various esophageal stenosis, fistulas, and leakages: a singlecenter experience in 39 patients. Gastrointest Endosc 2005;61(7):812-8.
9. Kawasaki R, Sano A, Matsumoto S. Long term outcomes and complications of
metallic stents for malignant esophageal stenosis. Kobe J Med Sci
2003;49(6):133-42.
98
‘√‘°“≠®πå ¬“¡“¥–
10. Dumonceau J, Cremer M, Lalmand. Esophageal fistula sealing: choice of stent
practical management and cost. Gastrointest Endosc 1999;49(10):70-9.
11. Bakken JC, Wong Kee Song LM, de Groen PC, Baron TH. Use of a fully covered
self-expandable metal stent for the treatment of benign esophageal diseases.
Gastrointest Endosc 2010;72(4):712-20.
12. Freeman R, VaWoerkom J. Esophageal stent placement for the treatment of
iatrogenic intrathoracic esophageal perforation. Ann Thorac Surg 2007;83:20038.
13. Lee K, Shin S, Hwang J, et al. Proximal-releasing stent insertion under transnasal
endoscopic guidance in patients with post- operative esophageal leakage.
Gasrtointest Endosc 2010;72(1):180-6.
14. Wong Kee Song LM, Baron TH. Stenting for acute malignant colonic obstruction:
A bridge to nowhere? Lancet Oncol 2011;12(4):314-5.
15. Repici A, Vandervoort J, Fox B, Mesiner S, Fockens P, Park P, et al. Results
demonstrated in a European retrospective multicentre study çThe new nitinol
WallFlex(tm) colonic stent: results from a multicenter European study UEGW
2005.
16. Baron TH. A practical guide for choosing an expandable metal stent for GI malignancies: a stent by any other name is still a stent. Gastrointest Endosc
2001;54(2):145-53.
17. Repici A. Metal Stents for decompression of acute colorectal obstruction, UEGW
2001.
18. Rapici A. Self-expandable covered esophageal Ultraflex stent for palliation of
malignant colorectal anastomotic complicated by multiple fistulas. Gastrointest
Endosc 2000;51:2365-71.
19. Law WL, Chu KW, Ho JW. Self-expandable metallic stent in the treatment of
colonic obstruction caused by advance malignancy. Dis Colon Rectum
2000;43:1522-7.
20. Caceres A, Zhou Q, Lasonos A, Gerdes H, Chi DS, Barakat RR. Colorectal stents
for palliation of large-bowel obstructions in recurrent gynecologic cancer: an
updated series. Gynecol Oncol 2008;108:482-5.
21. Repici A, De Caro G, Luigino C. WallFlex colonic stent placement for management
Gastrointestinal tract stent related complication: Incidence, how to prevent, and management 99
22.
23.
24.
25.
26.
of malignant colonic obstruction: a prospective study at two centers. Gastrointest
Endosc 2008;67:77-84.
Nicoline CM, Heel V, Haringsma J, Wijnhoven Bas PL, Kuipers EJ. Endoscopic
removal of self-expandable metal stents from the esophagus. Gastrointest Endosc
2011;74(1):44-50.
Homs M, essink-Bat, Borsboom G. Quality of life after palliative treatment for
oesophageal carcinoma- a prospective comparison between stent placement
and single dose brachytherapy. Eur J Cancer 2004;40:1862-71.
Nicoline CM, Heel V, Haringsma J, Spander CWM, Didden P, Bruno MJ, et al.
Esophageal stent for the palliation of malignant dysphagia and fistula recurrence
after esophagectomy 2010;72(2):249-53.
Lee HJ, Hong SP, Cheon JH, Kim TI, Min BS, Kim NK, et al. Long term outcome
of palliative therapy for malignant colorectal obstruction in patients with
unresectable metastatic colorectal cancers: endoscopic stenting versus surgery.
Gastrointest Endosc 2011;73(3):535-42.
Shan Cheung HY, Chung CC, Chieng Tsang WW, Hoo Wong JC, Kay Yau KK, Wah
Li MK. Endolaparoscopic approach vs conventional open surgery in the treatment
of obstructing left-sided colon cancer. Arch Surg 2009;144(2):1127-32.