In many patients, it is helpful to use an endoclip
or other radio-opaque marker to identify the proximal and distal margins of the stricture. Stent insertion in the upper esophagus can be technically difficult. Accurate positioning of the stent will usually require both endoscopy (with direct visualization of the proximal margin) and fluoroscopy. For stents in the distal esophagus, the distal portion of the stent should not be redundant as this can cause ulceration on the opposite gastric wall. After stent insertion, most patients are restricted to a soft diet to minimize the risk of food impaction. Both endoscopy and fluoroscopy are usually used for stent insertion Palbociclib clinical trial in the gastrointestinal tract.44–46 CHIR-99021 chemical structure However, stents may need to be inserted using fluoroscopy alone when strictures are tight or angulated as can occur in the sigmoid colon. In many patients, it is helpful to pass the endoscope through
the stricture prior to deployment of the stent but excessive pressure should be avoided as there is a small risk of perforation. When using a non-through-the-scope stent in the colon, the guide-wire should be passed at least 20 cm beyond the stricture prior to removal of the endoscope. The stent introducer is then passed over the guide-wire using fluoroscopy. An endoscope can also be inserted to clarify the position of the introducer. In non-through-the-scope stents in the upper gastrointestinal tract, one problem is the formation
of loops in the stomach. These can sometimes be prevented by changing the position of the patient, applying pressure to the abdomen or using a snare or grasping forceps through the endoscope to support the introducer as it passes through the stricture.47,48 Percutaneous insertion of a stent through selleck compound a gastrostomy has also been described.49 The choice of stent is determined by a number of factors including age, location of disease, stage of disease, comorbidities and likelihood that the stent will result in significant palliation. Stents also vary in price but, overall, appear to be cost-effective in at least some clinical settings. There are now several studies that have compared different stents for palliation of malignant disease. Results from several of the larger studies are summarized below. In a non-randomized study in 1997, 82 patients were treated with either an uncovered Wallstent or an Ultraflex nitinol stent. Both stents resulted in a substantial improvement in dysphagia. However, Wallstents were associated with a higher frequency of early complications whereas nitinol stents were associated with a higher frequency of stent dysfunction and reintervention rates.50 In a study in 1996, Wallstents, Ultraflex stents and Gianturco-Z stents were inserted in 87 patients with cancer of the esophagus.