Self-Expandable Stents in the Gastrointestinal Tract by Richard Kozarek Todd Baron & Ho-Young Song

Author:Richard Kozarek, Todd Baron & Ho-Young Song
Language: eng
Format: epub
Publisher: Springer New York, New York, NY

Choice of Endoscope

The choice of endoscope for gastroduodenal stent placement depends on the site of the lesion (stomach versus duodenum), type of stent, and whether an ERCP will be done at the same setting. Small-caliber endoscopes (5.4-mm outer diameter or less) can be used for gastric lesions and those with a disease process at or near a gastrojejunal anastomosis. These endoscopes allow easy traversal of tight strictures for endoscopic inspection and may obviate fluoroscopy to determine stricture length. However, the working channel is small, suction capability is suboptimal, and the scopes do not permit passage of accessories (catheters), and essentially, only guidewires can be passed. However, once a guidewire is passed, the endoscope can be removed, and a therapeutic channel endoscope can be backloaded over the wire for TTS delivery [28].

Standard adult endoscopes are intermediate in terms of flexibility and use of accessories, but the working channel does not allow TTS stent placement. Therapeutic channel endoscopes (working channel ≥3.8 mm) are most often used when TTS stents with predeployment delivery systems of 10 Fr are placed.

Duodenoscopes also allow passage of TTS stents and are advantageous when ERCP with biliary stent placement and gastroduodenal stents are placed in the same session, precluding the need to change endoscopes. The side-viewing duodenoscope may be helpful in those patients in whom the stricture cannot be traversed with a forward endoscope and may allow an en face view of the stricture.

Upper endoscopes and duodenoscopes are usually limited to lesions proximal to the second duodenum in patients with GOO since the often dilated stomach creates looping that consumes the length of the endoscope. Thus, even for proximal duodenal lesions, it may be useful to use adult caliber colonoscopes for TTS placement. These scopes are essential for lesions beyond the second to third duodenum, to include the proximal jejunum in patients with intact anatomy. Moreover, they are often used for patients with afferent limb obstructions far from the origin of the anastomoses.

Finally, balloon enteroscopes may be useful in selected cases, not only because of the ability to pass deep into the bowel but also because of their flexibility. Following wire passage beyond the stenosis, the endoscope can either be removed and a therapeutic endoscope backloaded over the wire, or the stent can be passed through the overtube [29]. Similar placement techniques have been used with spiral overtubes [30].

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