Practical Gastrointestinal Endoscopy

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CHAPTER 5
Post-stent management
Patients are usually kept in the hospital overnight under observation,
because of the immediate risk of perforation and bleeding,
and for necessary pain control. Chest and water-soluble
contrast swallow radiographic studies are performed after about
2·hours. Clear fluids can be given after 4·hours if there have been
no adverse developments.
Patients must understand the limitations of the stent, and the
need to maintain a soft diet with plenty of fluids during and
after meals. Written instruction should be provided and relatives
counseled. Overambitious eating or inadequate chewing
may result in obstruction. Iffood impaction occurs, the bolus can
usually be removed or fragmented endoscopically using snares,
biopsy forceps or balloons.
Stent dysfunction due to tumor overgrowth can be managed
by endoscopic ablation or placement of another stent inside the
first. Gastro-esophageal reflux can be a problem with stents
crossing the cardia. Patients may need to sleep propped up, and
to use acid-reducing medications. Occasionally, a good result
from chemotherapy or radiotherapy may make it possible to remove
a stent. For the same reason, stents (especially the covered
variety) may migrate spontaneously. Recovery of stents from the
stomach can be challenging.
Esophageal perforation
The endoscopic treatment of esophageal strictures is relatively
safe in most cases using optimal techniques. However, perforations
do occur, especially with complex and malignant strictures
approached by inexperienced or overconfident endoscopists.
The rate is approximately 0.1% in benign esophageal strictures,
1% in achalasia dilation, and 5–10% in treatment of malignant
lesions. The risk is minimized by taking the process step by
step—gradually anddeliberately. Never try to dilate to the largest
balloon or bougie simply because it is available.
Early suspicion and recognition of perforation is the key to successful
management, and no complaint should be ignored. The
problem is usually obvious clinically; the patient is distressed
and in pain. Signs of subcutaneous emphysema may develop
within a few hours. Radiographic studies should be performed.
Surgical consultation is mandatory when perforation is seriously
suspected or confirmed. Many confined perforations have been
managed conservatively, with nil oral intake, intravenous fluids
and antibiotics—with or without placement of a sump tube
across the perforation. The choice between surgical and conservative
management (and the timing of surgical intervention
if conservative management appears to be failing) is often difficult;
review of the literature shows varied and strong opinions.