Hello, welcome. My name is Aarti Bedi, I'm one of the Advanced Endoscopist here at the University of Michigan in the Division of Gastroenterology. Today, we're going to be discussing what are the palliative endoscopic management options for patients that present with dysphagia. Let's get started. The objectives for this lecture are going to be for you to walk way and know what's the role of endoscopy and not only management but diagnosis of dysphagia. What are the therapeutic options that we have at our disposal. What are the indications, and what are the complications of said options. As we start going through the topic, and through the slides, I'd like you to keep these questions in mind. So you can keep an eye out for the right answer is and why that is the correct answer. So number one, patients begin to complain of dysphagia when esophageal luminal diameter narrows to what? Less than 23 millimeters, less than 20 mm, less than 17 millimeters, or less than 13 millimeters. Question number two, optimal stent type in malignant obstruction is, a, fully covered metal stent, b, a partially covered metal stent, or c, an uncovered metal stent. Question number three, a patient with metastatic esophageal cancer presents for a PEG, a percutaneous endoscopic gastrostomy tube. Which is a contraindication? A, an INR greater than 1, b, platelets of 185, c, colonic obstruction, or d, a history of MRSA or Methicillin-resistant Staphylococcus aureus. So let's start talking about dysphagia. Before we can discuss what we do about it, you should probably understand what it is and how we define it. So simply put, dysphagia is difficulty in swallowing. There are many causes, and oftentimes we break them down to get a better understanding of them, and to group them in our minds, as well as for the patient, into structural and neuromuscular etiologies. Now there are things on exam and there are things within the history that can tip you off by what the patient is telling you and to whether or not you're going to group this patient into the structural group or the neuromuscular group. Initially, at least, patients will complain to, about dysphagia to solid foods alone whenever you're talking about a structural phenomenon. They usually say liquid or things that are pureed or softer go down without a problem. Inflammatory and malignant processes fall within this group. Neuromuscular, patients will describe dysphagia to solid and liquid from the get go, and sometimes they can be intermittent. So you have patients that present with motility disorders or patients who have presented with dysphagia post a stroke, for example. They will have problems with solids and liquids straightaway. What is the role of endoscopy? Well number one, we could directly visualize what's going on, so we can figure out what is the underlying etiology when somebody comes complaining of dysphagia. It's important for us to do this to exclude malignant or pre-malignant conditions. We could assess the need for therapy while they're there we can even perform therapeutic intervention as needed. Endoscopic evaluation is by EGD or, EsophagoGastroDuodenoscopy. It is also called an upper endoscopy in layman's terms. It is reliable. It is cost effective. And it allows us to directly visualize what's going on. The diameter of our standard gastro-scope tip is about 9 millimeters. And this is important for us to keep in mind because we can use that in real time to assess the severity of narrowing that we are encountering. If for example, our scope tip cannot go through an area, we become concerned that the area of opening or luminal orifice is less than 9 millimeters. Via an EGD, we can also biopsy, take a brushing or sample an area that's in question or concern. Before we start talking about the structures in more details, we should also go through what some basic stricture terminology is, often times in our endoscopic reports you'll see us describe a stricture as either mild, moderate, or severe. Bottom line is if we can't traverse the stricture, we cannot get through the area, we're going to call it severe. Mild allows for us to put our scope down without really any problem. And if we encounter some resistance, we're going to describe it as moderate. Further going down that path of terminology we can break it down into simple or complex. Functionally, a complex stricture is a stricture that's longer than 2 centimeters in length, and as you would expect, it's complicated. It's angulated, it's irregular, the diameter is less than 12 millimeters. Keep in mind our scope tip is 9, and so sometimes we can use that as an indirect measurement of the area of opening. Whenever we talk about a simple stricture, it's simple. It's short, it's concentric, and the diameter is much greater or equal to 12 millimeters. Intrinsic strictures as oppose to an external compressive phenomenon include peptic which would be related to reflux, caustic which would be related to ingestion such as lye. Pill-induced, the bisphosphonates are often implicated in producing or causing intrinsic structuring, radiation injury, anastomotic, iatrogenic, malignant rings or webs. Esophageal luminal diameter less than 13 millimeters results in dysphagia. Whenever a patient gets to about 15 millimeters they're starting to have a little bit of trouble and they're able to modify their diet and oftentimes avoid coming in or be brought to medical attention. That as soon as they start complaining of not being able to get things down, you're usually dealing with the diameter of less than or equal to 13 millimeters when you're talking about a structural ideology. So when these patients come to us, oftentimes it's for palliated reasons. Obstruction and tracheoesophageal fistula formation as well as inability to get nutrition in, failure to thrive in infection are common in patients that develop these problems. Our aim, is at improving delivery of nutrition, and palliation of their symptoms. So what do we have to offer these people endoscopically? There's dilation, we can place stents, either metal or plastic and, within the metal, partially or fully covered or uncovered metal stents. We can go in and endoscopically debulk an area. That can be done chemically, laser, or with photo endemic therapy. The one then to keep in mind here is that this is not durable. And the last thing we often times are called upon to do is to provide nutrition for patients via enteral feeding. Let's talk about dilation, the goal here is to provide immediate relief and hopefully, durable symptomatic relief. It is noteworthy that, depending on which patient population you're dealing with, a malignant patient versus a patient with eosinophilic esophagitis. The perforation rates are going to vary. But as we have talked about in a previous lecture, perforation rates in the malignant population are quite high in the 27% range, so that's important to keep in mind. Usually, it's not a durable response that we would like to see. One thing to keep in mind is that intrinsic etiologies such as webs, rings, searchers, will respond much better than extrinsic phenomenon, obviously because we're not directly addressing what the problem is if it's an extrinsic problem. Motility disorders may not respond compared to structural etiologies. The one exception to this is in achalasia and patient will respond even to motility disorder to dilation. We have a few types of dilators, one is weighted push type which is called the Maloney dilator. That exerts radial and axial forces to cause the dilation. It should not be used with complex short strictures due to perforation risk upstream. So a weighted push-type dilator is just going to literally use blunt force to push forward. And if you have a complicated, complex angled stricture, that you shouldn't just be blindly doing that. You have wire guided dilator, which is also call the savary dilator. It also exerts radial and axial forces. And you have balloon dilators, we oftentime will use either TTS or OTW, TTS meaning through the scope and OTW meaning over the wire to further describe those balloons. Balloon dilators use radial forces and not axial forces. Balloon dilators are what we oftentime will employ as advanced endoscopists because we can directly visualize what's going on. And the stricters that we are dealing with tend to be the more complicated ones. We directly visualize what we're dilating. We can immediately visualize after dilation to confirm that we haven't created a perforation or encountered bleeding that we need to control. And so that's one of the benefits of the balloons. When we talk about stents, we have metal or plastic. And within metal, we talk about covered, partially covered, or uncovered stents. Partially covered stents are superior to uncovered stents in malignant dysphagia. Simply because it doesn't allow the neoplastic tumor tissue to grow into the stent, and further cause obstruction down the road. SEMS stands for self expanding metal stent. And here, you see a picture of all three stent types. So at the very top, you see a stent that is completely covered with this white material. Oftentimes, we have a stent that is covered in a silicone covering, and this is a fully covered metal stent. Here we call this partially covered, and this is likely the silicone covering over this nitinol stent, where the ends are uncovered. And this allows the stent to anchor where it needs to anchor without slipping or sliding. As you can see here, the tissue is not going to grow into the stent, and it's not going to adhere or anchor it. And so if you have a fully covered stent, this thing can slip up and down in the esophagus and cause obstruction further downstream, which we will get to whenever we talk about the complications of stent placement. The partially covered stent, the purpose is to anchor against tissue proximally and distally in hopes of keeping that stent in place. Here you see a completely uncovered or a bare metal stent. There is no covering in this type of stent is good and that will anchor and it usually will stay where it needs to stay because the tissue will grow into the lattices of the stent. Like I said, metal and plastic stents are available to us whenever we're stenting patients. People get present with malignant dysphagia, self expanding metal stents are effective and are associated with fewer complications than plastic stents. It can be used for obstruction as well as tracheoesophageal fistulas. Functionally, you will cover the fistula so that there is a diversion of food and oral secretions beyond the area or past the area of fistulization down into the gastric cavity. The durable dysphagia relief, but the interesting thing is there is no real improvement in nutritional status just by stenting. It is very important before you send a patient for stenting and before you place a stent to discuss that there are dietary restrictions after we place stents. Whenever we stent somebody they are not going to go home and have steak and potatoes that night. It's gotta be a pureed diet and a soft diet and it's critical because if they develop a food bolus or a food impaction that you've stuck within the stent we're in a world of hurt. Because not only do we have a problem with the impacted item of food as well, but we also run the risk of damaging or displacing the stent in addition to causing trouble to whatever the underlying comorbidity was. Whether it is tumor, whether it's stricture, or whether it's a fistula. So here you can see what the endoscopic image would be in a person with an esophageal tumor. Pre-stenting and you can see here that it's possible that there's esophageal lumen right here, and that's probably about it. You have this very nasty, fungi eating mass. And this is post-stenting, where basically, we'd just place the stent, and we slam all of that tissue out and around so that you create a nice new open patency. You can see the stent placed against the mucosal tissue right here. This is uncovered from the way it looks and this tissue will anchor itself by growing in slightly through these lattices and the stent to anchor it in place. But you can see what a difference that is and how the patient will immediately feel better when it comes to their dysphagia. Immediate complications of placement of self expanding metal stents include aspiration, airway compromise, malposition, delivery system entrapment meaning essentially that whenever we are deploying the stent, the stent get stuck within the delivery system. And sometimes, the delivery system can get stuck within the scope, then the scope can be stuck within the patient. Very rare but it has been reported. The stent can dislodge and migrate either upstream or downstream and called obstructive problems later on. And there's always a risk of perforation. Again, particularly in our patients with malignancy, malignant tissues, not normal tissue. It doesn't have the normal pliability and elasticity that help the tissue does. And so anytime you're stretching or doing anything to it, but you don't often have that warning as you would with normal tissue and you can create perforation. We break the complications into, usually early and delayed. Early is defined as up to 1 week post placement and those usually include bleeding, chest pain and nausea. Late complications of self expanding metal stents are defined as greater than one week out and they can include recurrent dysphagia and often times because there's reobstruction usually from tumor. But like we talked about if somebody doesn't adhere to the dietary recommendations that we make post stint placement, they can present with food impactions as well. Migration of the stent tracheoesophageal fistula can form. Just from stent placement we can get problems with bleeding and you can have reflux disease and aspiration because now where there was an obstruction. All those gastric content are now coming up into the esophagus and theoretically into the lung via aspiration. So now that we've talked about stent placement as well as dilation. We will wrap this section up and then revisit the issues of debulking as well as enteral feeding, which are also endoscopic therapies we can offer for palliation of dysphagia in patients in addition to what we already discussed.
