Stenting

Definition

Stenting is a procedure in which a cylindrical structure (stent) is placed into a hollow tubular organ to provide artificial support and maintain the patency of the opening. Although it is most often used for cardiovascular functioning, it is also utilized to manage obstructions in cancer patients.

Purpose

Stents are used in cancer patients to relieve obstructions due to:

• direct blockages within the tube (or lumen) due to cancer growth
• narrowing of the lumen from tumor growth outside pressing on the tube and narrowing the lumen
• occasionally from the build up of scar tissue (fibrosis) from radiation therapy

Tumors most likely to cause obstruction requiring stent placement include esophageal cancer, bronchogenic carcinoma, pancreatic cancer, cancers of the bile duct, and occasionally colorectal carcinomas.

Precautions

Every patient should be viewed individually with special consideration given to the patient's present status. Generally, surgical procedures are for the correction of a problem; but in many cancer cases, relief of symptoms is the only therapeutic option. Since it is extremely difficult to remove or reposition these stents after they are placed, the degree of relief to be offered by its insertion should be significant. The physician and the patient should discuss all alternatives and come to a mutual decision.

Description

Endoscopic retrograde cholangiopancreatography (ERCP) is the name of the procedure utilized to place most stents for pancreatic and biliary tumors. The ERCP is a flexible endoscope, which can be directed and moved around the many bends in the upper gastrointestinal tract. The newer video endoscopes have a tiny, optically sensitive computer chip at the end which transmits electronic signals up the scope to a computer that displays an image on a large video screen. The scope has an open channel that permits other instruments to be passed through it to perform biopsies, inject solutions, or place stents. Since ERCP uses x-ray films, the procedure takes place in an x-ray area. Initially the throat is anesthetized with a spray solution and the patient is also usually mildly sedated. The endoscope is inserted into the upper esophagus and a thin tube is inserted through it to the main bile duct entering the intestinal area. Dye is injected into the bile duct and/or the pancreatic duct and x-ray films are taken. The patient usually lies on the left side and then turns onto the stomach to allow complete visualization of the ducts. The patient is able to breathe easily throughout the exam and rarely gags. Any gallstones found may be removed or if the duct has become narrowed, an incision can be made using electrocautery (electrical heat) to relieve the blockage. It is also possible to widen narrowed ducts by placing stents in these areas to keep them open. The patient is taken to recovery following the procedure, which takes 20-40 minutes.

Other endoscopes are used to place stents elsewhere in the body. For example, an esophagoscope is used to place stents in cases of esophageal cancer, a broncho-scope is used for procedures involving endobronchial obstructions, and a colonoscope is used in cases of colorectal obstructions.

Preparation

The patient is instructed not to eat or drink anything for eight hours prior to the procedure. Some physicians may request that no asprin be taken for a certain time period prior to the procedure to prevent excessive bleeding.

Aftercare

The patient may go home after the procedure or may spend one or two nights in the hospital. Antibiotics may be given especially if there has been long-standing biliary obstruction. Dietary restrictions are common after esophageal and colorectal stenting.

Risks

The most serious risk associated with the placement of a stent is the risk of perforation. If a tear is made, leakage with life-threatening infection may occur. Migration or recurrent obstruction may necessitate repeat stenting if possible. Occasionally bleeding may occur.

Normal results

Relief of the obstruction with resumption of the ability to eat, breathe, normally clear fluids from the liver or pancreas, or allow normal passage of stool is the desired result of this procedure.

Abnormal results

A sudden change in the degree of pain and/or fever that persists as well as any unusual changes should be communicated immediately to a physician.

Resources

BOOKS

Dolmath, Bart L., and Ulrich Blum, (eds). Stent-Grafts: Cur rent Clinical Practice New York: Thieme, 2000.

OTHER

American Society of Clinical Oncology, 1900 Duke Street, Suite 200, Alexandria, VA 22314. Phone: 703-299-0150. <http://www.asco.org>.

American Cancer Society, P.O. Box 102454, Atlanta, GA 30368-2454. <http://www.ca.cancer.org>.

Jackson Gastroenterology. <http://www.gicare.com>.

National Digestive Diseases Information Clearinghouse. ERCP (Endoscopic Retrograde Cholangiopancreatography). <http://www.niddk.nih.gov/health/digest/pubs/diagtest/ercp.htm>.

Linda K. Bennington, C.N.S., M.S.N.

Endoscope

—An instrument used for direct visual inspection of hollow organs or body cavities.

Esophagus

—The muscular, membranous structure that extends from the throat to the stomach.

Lumen

—The cavity or channel within a tube or tubular organ, such as a blood vessel or the intestine.

QUESTIONS TO ASK THE DOCTOR

• Am I a good candidate for this procedure?
• Do I have any contraindications that should be considered before having the procedure?
• Will I experience any improvement in my quality of life?
• What are the advantages and disadvantages of the procedure?
• Does the physician performing the procedure do this often or only occasionally?