Laser recanalization versus endoscopic intubation in the palliation of malignant dysphagia

Advanced Endoscopy for Thoracic Surgeons

The thoracic surgeon, well versed in advanced endoscopy, has an array of therapeutic options for foregut pathologic conditions. Peroral endoscopic myotomy (POEM) offers a less-invasive means to treat achalasia, and the authors' preferred approach is described in this article. They also describe variations of POEM, such as G-POEM, Z-POEM, and D-POEM. In addition, endoscopic stenting, endoluminal vacuum therapy, endoscopic internal drainage, and endoscopic suturing/clipping are discussed and can be valuable tools for esophageal leaks and perforations. Endoscopic procedures are advancing rapidly, and thoracic surgeons must maintain at the forefront of these technologies.

Esophageal stenting for benign and malignant disease: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2021

MALIGNANT DISEASE

1: ESGE recommends placement of partially or fully covered self-expandable metal stents (SEMSs) for palliation of malignant dysphagia over laser therapy, photodynamic therapy, and esophageal bypass.Strong recommendation, high quality evidence. 2 : ESGE recommends brachytherapy as a valid alternative, alone or in addition to stenting, in esophageal cancer patients with malignant dysphagia and expected longer life expectancy.Strong recommendation, high quality evidence. 3: ESGE recommends esophageal SEMS placement for sealing malignant tracheoesophageal or bronchoesophageal fistulas. Strong recommendation, low quality evidence. 4 : ESGE does not recommend SEMS placement as a bridge to surgery or before preoperative chemoradiotherapy because it is associated with a high incidence of adverse events. Other options such as feeding tube placement are preferable. Strong recommendation, low quality evidence.

BENIGN DISEASE

5: ESGE recommends against the use of SEMSs as first-line therapy for the management of benign esophageal strictures because of the potential for adverse events, the availability of alternative therapies, and their cost. Strong recommendation, low quality evidence. 6: ESGE suggests consideration of temporary placement of self-expandable stents for refractory benign esophageal strictures. Weak recommendation, moderate quality evidence. 7: ESGE suggests that fully covered SEMSs be preferred over partially covered SEMSs for the treatment of refractory benign esophageal strictures because of their very low risk of embedment and ease of removability. Weak recommendation, low quality evidence. 8: ESGE recommends the stent-in-stent technique to remove partially covered SEMSs that are embedded in the esophageal wall. Strong recommendation, low quality evidence. 9: ESGE recommends that temporary stent placement can be considered for the treatment of leaks, fistulas, and perforations. No specific type of stent can be recommended, and the duration of stenting should be individualized. Strong recommendation, low quality of evidence. 10 : ESGE recommends considering placement of a fully covered large-diameter SEMS for the treatment of esophageal variceal bleeding refractory to medical, endoscopic, and/or radiological therapy, or as initial therapy for patients with massive bleeding. Strong recommendation, moderate quality evidence.

Self-Expandable Metallic Stent Placement for the Palliation of Esophageal Cancer

Esophageal stents have been used to palliate patients with dysphagia caused by esophageal cancer. Early rigid plastic prostheses have been associated with a high risk of complications. However, with the development of self-expanding stents, it has developed into a widely accepted method for treating malignant esophageal strictures and esophagorespiratory fistulas (ERFs). The present review covers various aspects of self-expanding metallic stent placement for palliating esophageal cancer, including its types, placement procedures, indications, contraindications, complications, and some of innovations that will become available in the future.

Interventions for dysphagia in oesophageal cancer

BACKGROUND

Most patients with oesophageal and gastro-oesophageal carcinoma are diagnosed at an advanced stage and require palliative intervention. Although there are many kinds of interventions, the optimal one for the palliation of dysphagia remains unclear. This review updates the previous version published in 2009.

OBJECTIVES

The aim of this review was to systematically analyse and summarise the efficacy of different interventions used in the palliation of dysphagia in primary oesophageal and gastro-oesophageal carcinoma.

SEARCH METHODS

To find new studies for this updated review, in January 2014 we searched, according to the Cochrane Upper Gastrointestinal and Pancreatic Diseases model, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE, EMBASE and CINAHL; and major conference proceedings (up to January 2014).

SELECTION CRITERIA

Only randomised controlled trials (RCTs) were included in which patients with inoperable or unresectable primary oesophageal cancer underwent palliative treatment. Different interventions like rigid plastic intubation, self-expanding metallic stent (SEMS) insertion, brachytherapy, external beam radiotherapy, chemotherapy, oesophageal bypass surgery, chemical and thermal ablation therapy, either head-to-head or in combination, were included. The primary outcome was dysphagia improvement. Secondary outcomes included recurrent dysphagia, technical success, procedure related mortality, 30-day mortality, adverse effects and quality of life.

DATA COLLECTION AND ANALYSIS

Data collection and analysis were performed in accordance with the methods of the Cochrane Upper Gastrointestinal and Pancreatic Diseases Review Group.

MAIN RESULTS

We included 3684 patients from 53 studies. SEMS insertion was safer and more effective than plastic tube insertion. Thermal and chemical ablative therapy provided comparable dysphagia palliation but had an increased requirement for re-interventions and for adverse effects. Anti-reflux stents provided comparable dysphagia palliation to conventional metal stents. Some anti-reflux stents might have reduced gastro-oesophageal reflux and complications. Newly-designed double-layered nitinol (Niti-S) stents were preferable due to longer survival time and fewer complications compared to simple Niti-S stents. Brachytherapy might be a suitable alternative to SEMS in providing a survival advantage and possibly a better quality of life, and might provide better results when combined with argon plasma coagulation or external beam radiation therapy.

AUTHORS' CONCLUSIONS

Self-expanding metal stent insertion is safe, effective and quicker in palliating dysphagia compared to other modalities. However, high-dose intraluminal brachytherapy is a suitable alternative and might provide additional survival benefit with a better quality of life. Some anti-reflux stents and newly-designed stents lead to longer survival and fewer complications compared to conventional stents. Combinations of brachytherapy with self-expanding metal stent insertion or radiotherapy are preferable due to the reduced requirement for re-interventions. Rigid plastic tube insertion, dilatation alone or in combination with other modalities, and chemotherapy alone are not recommended for palliation of dysphagia due to a high incidence of delayed complications and recurrent dysphagia.

How are palliative care cancer populations characterized in randomized controlled trials? A literature review

CONTEXT

The difficulties in defining a palliative care patient accentuate the need to provide stringent descriptions of the patient population in palliative care research.

OBJECTIVES

To conduct a systematic literature review with the aim of identifying which key variables have been used to describe adult palliative care cancer populations in randomized controlled trials (RCTs).

METHODS

The data sources used were MEDLINE (1950 to January 25, 2010) and Embase (1980 to January 25, 2010), limited to RCTs in adult cancer patients with incurable disease. Forty-three variables were systematically extracted from the eligible articles.

RESULTS

The review includes 336 articles reporting RCTs in palliative care cancer patients. Age (98%), gender (90%), cancer diagnosis (89%), performance status (45%), and survival (45%) were the most frequently reported variables. A large number of other variables were much less frequently reported.

CONCLUSION

A substantial variation exists in how palliative care cancer populations are described in RCTs. Few variables are consistently registered and reported. There is a clear need to standardize the reporting. The results from this work will serve as the basis for an international Delphi process with the aim of reaching consensus on a minimum set of descriptors to characterize a palliative care cancer population.

Experience with stent implantation in malignant esophageal strictures: analysis of 1185 consecutive cases

PURPOSE

The aim of this retrospective study was to analyze the experience in endoprosthesis implantation in cases of malignant esophageal strictures.

METHODS

A total of 1185 consecutive patients underwent endoprosthesis implantation: through open surgery in 42 cases and by endoscopy in 1143 cases.

RESULTS

Stent implantation was performed successfully in 61.2% of cases. Dysphagia was resolved temporarily in 6.2% and permanently in 93.5% of cases. The score of dysphagia decreased from 1.93 to 0.38. Complications were detected in 23.7% of patients, and 69.2% of cases were treated by endoscopy. Wound complications were seen in 21.9% of patients intubated through surgery. The mean survival time of patients with esophageal intubation was 5.4 months and that of patients not eligible for stent implantation was 3.3 months.

CONCLUSIONS

Stent implantation improves the quality of life and gives an opportunity for adjuvant oncological therapy. Evaluation of morphologic anomalies is of considerable importance for achieving success in treatment through implantation.

[Palliative management of malignant oesophageal strictures with endoprosthesis implantation -- 25 years experience]

OBJECTIVES

The aim of this study was to analyse the feasibility of the use of oesophageal endoprosthesis based on a large series of cases.

METHODS

2952 malignant oesophageal strictures managed between 1984 and 2009 were analysed. While surgical intubation was carried out in 42 patients, endoscopic implantation was feasible in 1143 cases. Patients not eligible for oesophageal stenting were treated with gastrostomy in 125, percutaneous endoscopic gastrostomy in 19, catheter jejunostomy in 9 and supportive therapy in 965 cases, respectively.

RESULTS

Endoprosthesis could have been inserted in 61.2% of the patients. Dysphagia was terminated temporarily in 6.2% and permanently in 93.5%. Complications were detected in 23.7% of the cases, which included stent migration, perforation, bleeding, airway obstruction, early unexpected death, aspiration, stent obstruction, tumor overgrowth, oesophago-respiratory fistula formation and neoformation, and reflux. Complications were treated endoscopically primarily (69.2%). Lethal complication rate was 2.1% (27 cases). Furthermore, complication rate of patients who underwent surgical stent insertion was 21.9%. Mean survival of patients with oesophageal intubation was 5.4 months, with nutritional support via gastrostomy, percutaneous endoscopic gastrostomy or jejunostomy 3.6 months and with supportive therapy alone 3.2 months.

CONCLUSIONS

Oesophageal endoprosthesis insertion is an effective method for the palliative management of malignant oesophageal strictures. Stent implantation improves survival as well as quality of life. Methods used for nutritional support decreases hungriness but do not influence survival.

WITHDRAWN: Interventions for dysphagia in oesophageal cancer

BACKGROUND

The majority of oesophageal and gastro-oesophageal cancers are diagnosed at an advanced stage and palliative treatment is the realistic management option for most patients. The optimal intervention for the palliation of dysphagia in these patients has not been established.

OBJECTIVES

To systematically analyse and summarise the efficacy of different interventions used in the palliation of dysphagia in primary oesophageal carcinoma.

SEARCH STRATEGY

We undertook a search according to the Cochrane Upper Gastrointestinal and Pancreatic Diseases model using the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE, EMBASE and CINAHL and major conference proceedings up to August 2005. The literature search was re-run in August 2006 and March 2007.

SELECTION CRITERIA

Randomised controlled trials (RCTs) in patients with inoperable or unresectable primary oesophageal cancer who underwent palliative treatment. We included rigid plastic intubation, self-expanding metallic stent (SEMS) insertion, brachytherapy, external beam radiotherapy, chemotherapy, oesophageal bypass surgery, chemical and thermal ablation therapy, either head-to-head or in combination. The primary outcome was dysphagia improvement. Secondary outcomes included recurrent dysphagia, technical success, procedure related mortality, 30-day mortality, adverse effects and quality of life.

DATA COLLECTION AND ANALYSIS

One author assessed the eligibility criteria of each study and extracted data regarding outcomes and factors affecting risk of bias.

MAIN RESULTS

We included 2542 patients from 40 studies. SEMS insertion is safer and more effective than plastic tube insertion. Thermal and chemical ablative therapy provide comparable dysphagia palliation but have an increased requirement for re-interventions and adverse effects. Anti-reflux stents provide comparable dysphagia palliation to conventional metal stents. Some anti-reflux stents might reduce gastro-oesophageal reflux compared to conventional metal stents. Brachytherapy might be a suitable alternative to SEMS in providing a survival advantage and possibly a better quality of life.

AUTHORS' CONCLUSIONS

Self-expanding metal stent insertion is safe, effective and quicker in palliating dysphagia compared to other modalities. However, high-dose intraluminal brachytherapy is a suitable alternative and might provide additional survival benefit with a better quality of life. Self-expanding metal stent insertion and brachytherapy provide comparable palliation to endoscopic ablative therapy but are preferable due to the reduced requirement for re-interventions. Rigid plastic tube insertion, dilatation alone or in combination with other modalities, chemotherapy alone, combination chemoradiotherapy and bypass surgery are not recommended for palliation of dysphagia due to a high incidence of delayed complications and recurrent dysphagia.

Interventions for dysphagia in oesophageal cancer

BACKGROUND

The majority of oesophageal and gastro-oesophageal cancers are diagnosed at an advanced stage and palliative treatment is the realistic management option for most patients. The optimal intervention for the palliation of dysphagia in these patients has not been established.

OBJECTIVES

To systematically analyse and summarise the efficacy of different interventions used in the palliation of dysphagia in primary oesophageal carcinoma.

SEARCH STRATEGY

We undertook a search according to the Cochrane Upper Gastrointestinal and Pancreatic Diseases model using the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE, EMBASE and CINAHL and major conference proceedings up to August 2005. The literature search was re-run in August 2006 and March 2007.

SELECTION CRITERIA

Randomised controlled trials (RCTs) in patients with inoperable or unresectable primary oesophageal cancer who underwent palliative treatment. We included rigid plastic intubation, self-expanding metallic stent (SEMS) insertion, brachytherapy, external beam radiotherapy, chemotherapy, oesophageal bypass surgery, chemical and thermal ablation therapy, either head-to-head or in combination. The primary outcome was dysphagia improvement. Secondary outcomes included recurrent dysphagia, technical success, procedure related mortality, 30-day mortality, adverse effects and quality of life.

DATA COLLECTION AND ANALYSIS

One author assessed the eligibility criteria of each study and extracted data regarding outcomes and factors affecting risk of bias.

MAIN RESULTS

We included 2542 patients from 40 studies. SEMS insertion is safer and more effective than plastic tube insertion. Thermal and chemical ablative therapy provide comparable dysphagia palliation but have an increased requirement for re-interventions and adverse effects. Anti-reflux stents provide comparable dysphagia palliation to conventional metal stents. Some anti-reflux stents might reduce gastro-oesophageal reflux compared to conventional metal stents. Brachytherapy might be a suitable alternative to SEMS in providing a survival advantage and possibly a better quality of life.

AUTHORS' CONCLUSIONS

Self-expanding metal stent insertion is safe, effective and quicker in palliating dysphagia compared to other modalities. However, high-dose intraluminal brachytherapy is a suitable alternative and might provide additional survival benefit with a better quality of life. Self-expanding metal stent insertion and brachytherapy provide comparable palliation to endoscopic ablative therapy but are preferable due to the reduced requirement for re-interventions. Rigid plastic tube insertion, dilatation alone or in combination with other modalities, chemotherapy alone, combination chemoradiotherapy and bypass surgery are not recommended for palliation of dysphagia due to a high incidence of delayed complications and recurrent dysphagia.

A randomized controlled clinical trial of palliative therapies for patients with inoperable esophageal cancer

OBJECTIVES

A dramatic rise in incidence, an aging population, and expensive palliative treatments have led to an escalating burden on clinicians managing inoperable esophageal cancer with only limited evidence of effectiveness. This study compares the clinical effectiveness and cost-effectiveness of self-expanding metal stents (SEMSs) with other palliative therapies to aid clinicians in making an evidence-based treatment choice.

METHODS

We conducted a prospective, multicenter, randomized, controlled, clinical trial with 215 patients followed until death or study closure. The primary outcome measures were dysphagia, quality of life (QL) 6 weeks following treatment, and total cost of treatment. Secondary outcome measures included treatment-associated morbidity, mortality, survival, and cost-effectiveness. An intention-to-treat analysis was carried out.

RESULTS

There was a significant difference in mean dysphagia grade between treatment arms 6 weeks following treatment (P=0.046), with worse swallowing reported by rigid stent-treated patients (mean dysphagia score difference=-0.49; 95% confidence interval (CI) -0.10 to -0.89, P=0.014). Global QL scores were lower at both 1 and 6 weeks following treatment for patients treated by SEMSs (mean difference QL index week 1=-0.66; 95% CI: -0.02 to -1.30, P=0.04; mean difference QL index week 6=-1.01; 95% CI -0.30 to -1.72, P=0.006). These findings were associated with higher post-procedure pain scores in the SEMS patient group (mean difference of the European Organisation for Research and Treatment of Cancer QLQ C-30 pain symptom score at week 1=11.13; 95% CI: 2.89-19.4; P=0.01). Although mean EQ-5D QL values differed between the treatments (P<0.001), this difference dissipated following generation of quality-adjusted life year values. Total costs varied between treatment arms but these findings canceled out when SEMSs were compared with non-SEMS therapies (95% CI -845.15-1,332.62). These results were robust to sensitivity analysis. There were no differences in the in-hospital mortality or early complication rates, but late complications were more frequent after rigid stenting (risk ratio=2.47; 95% CI 1.88-3.04). There was a survival advantage for non-stent-treated patients (log-rank statistic=4.21, P=0.04).

CONCLUSIONS

The treatment choice for patients with inoperable esophageal cancer should be between a SEMS or a non-stent treatment after consideration has been given to both patient and tumor characteristics and clinician and patient preferences.

Comparative retrospective study on the use of plastic prostheses and self-expanding metal stents in the palliative treatment of malignant strictures of the esophagus and cardia

Palliative treatment of malignant strictures of the esophagus and cardia is usually carried out by the endoscopic placement of a prosthesis. The aim of this retrospective study was to evaluate short- and long-term outcomes of the use of expandable stents, compared with conventional plastic prostheses. One hundred and thirteen endoscopic intubations were carried out in 120 patients affected by malignant stenosis of the esophagus and cardia using plastic prosthesis and self-expanding metal stents. Dysphagia was scored according to Atkinson and Ferguson's classification and the preoperative median score (3.6) was comparable in both groups. The technical success rate was 94.4% with plastic prosthesis and 93.7% with self-expanding metal stent while the functional success rate was, respectively, 85.2% and 88.8%. Three deaths occurred with plastic prostheses (4.4%), while no deaths were observed with metal stents. A comparative analysis of the results of this study suggests that the endoscopic placement of self-expanding metal stents is effective and safe and has to be preferred to the conventional plastic prosthesis for easier implantation and lower morbidity.

Inoperable adenocarcinoma of the oesophagogastric junction: a comparative clinical study of laser coagulation versus self-expanding metallic stents with special reference to cost analysis

AIMS

Neither clinical nor financial comparisons yet exist between self-expanding metallic stents (SEMS) and laser therapy, concentrating on the treatment of obstructive adenocarcinomas of the oesophagogastric junction. The aim of our study was to compare the relative lifetime costs and clinical results of the Nd:YAG laser to those of SEMS as alternative forms of primary palliation of dysphagia for adenocarcinoma near the oesophagogastric junction.

METHODS

Fifty-two patients with distal oesophageal or oesophagogastric adenocarcinomas underwent palliative treatment for dysphagia: 32 treated with laser therapy and 20 with SEMS in this retrospective study. The clinical outcome and real cumulative costs as physical units and in financial terms were analysed for these study groups.

RESULTS

Although patients palliated with SEMS underwent fewer procedures (1.9+/-1.6 vs 3.4+/-4.0, P=0.0048) and spent less time in endoscopic theatre (38+/-25min vs 118+/-152min, P=0.0048), they spent as many days in hospital (12.9 vs 15.1, P=0.370) and required as high overall costs for therapy (5360 EUR vs 5450 EUR, P=0.679) as those treated with laser therapy. In addition, they had higher morbidity rates (30 vs 6.3%, P=0.043), hospital mortality (20 vs 3.1%, P=0.066), and 30-day mortality (40 vs 3.1%, P=0.0011) than did patients with laser therapy, with no evidence of SEMS being the more effective treatment modality.

CONCLUSIONS

In patients with adenocarcinoma at the distal oesophagus or at the oesophagogastric junction, laser therapy palliates dysphagia effectively with lower morbidity and mortality rates and without increased costs or hospital stays than does use of self-expanding metallic stents.

Successful endoscopical sealing of malignant esophageotracheal fistulae by using a covered self-expandable stenting system

OBJECTIVE

Any treatment of tracheo-esophageal fistulae in end-stage malignant stenosis of the esophagus must be weighed against associated morbidity and mortality. In a prospective study we investigated benefits and risks of the use of one type of coated, self-expandable stent.

PATIENTS AND METHODS

We treated four male and two female patients, (mean age 68.3 years, range: 38-90 years), with malignant esophago-tracheal fistula non-resectable due to advanced tumour stage and/or functional reasons. All were in a poor general condition suffering from aspiration pneumonia and malnutrition. Four out of the six patients had had one or multiple extra- or endoluminal palliative treatments at a mean interval of 191 days (range: 7 days-15 ms) since the last intervention. The fistulae were sealed by using a covered, self-expandable stent (ULTRAFLEX esophageal stent system, Microinvasive, Boston Scientific Corporation, Boston, MA).

RESULTS

Stenting did not cause any technical problems and all fistulae were successfully sealed in a one-step procedure. The median hospital stay was 4.6 days (range: 3-9 days). Except for one late stent induced recurrent fistula treated by re-stenting and tracheostomy, we did not observe any stent associated complications. Five patients died of tumour generalization. The median survival of the patients who died was 78 days (range: 35-129 days). One patient is alive and well at 120 days after stenting.

CONCLUSION

In spite of the small number of patients the results suggest that this type of stent represents a safe and efficient approach for palliative endoscopic treatment of this high risk group. Local pretreatment does not preclude the successful use of the self-expandable coated stent.

Chromophore-enhanced 805 nm laser therapy for gastrointestinal neoplasia

BACKGROUND

A new technique of 805 nm semiconductor diode laser-tissue interaction potentiation using indocyanine green (ICG) as an exogenous chromophore has been assessed for use in the palliation of advanced gastrointestinal malignancy.

MATERIALS AND METHODS

The tissue effects of ICG potentiated 805 nm laser were assessed both in-vivo using rat stomach and colon, and in vitro using normal and neoplastic human gastric and colonic mucosa.

RESULTS

Intravenous ICG did not potentiate the laser-tissue effects of the 805 nm laser in in-vivo studies. Local techniques of ICG application (submucosal injection +/- surface painting of 0.1% ICG solution) enhanced the total depth and diameter of laser induced thermal injury in all in-vitro tissues. Without ICG enhancement thermal tissue injury was minimal in normal gastric and colonic mucosa.

CONCLUSION

Local techniques of ICG application enhance laser induced thermal injury in normal and neoplastic gastric and colonic mucosa. This may permit targeting of 805 nm laser-tissue effects with minimal collateral damage during endoscopic laser palliation of advanced gastrointestinal malignancy.

Palliative treatment of malignant esophageal stenosis: the role of self-expanding stent endoscopic implantation

Endoscopic tube implantations were carried out in 40 patients with malignant stenosis of the esophagus and gastric cardia using self-expanding metallic stents. The indications for endoscopic intubation were the advanced stage of the tumor in 27 cases and risk factors that made resection inadvisable in 13 cases. In three patients, it proved impossible to implant a stent endoscopically because we were not able to pass the guide wire through the stenosis, whereas correct stent placement was achieved in 37 cases. Functional results were good in 33 patients, but four patients did not show any improvement of symptoms. Complications occurred in nine patients (24.3%): two bleedings, three neoplastic obstructions, one food obstruction, and three distal dislodgements of the prosthesis were observed, but could be readily corrected. No deaths occurred. The median survival time was 151 days (range 25-545 days). This study suggests that endoscopic placement of metallic self-expanding stents is safe and is to be preferred to plastic stents for easier implantation and lower morbidity.

An update in the palliative management of malignant dysphagia

BACKGROUND

Oesophageal cancer is generally associated with late presentation and poor prognosis. Therefore palliative surgery has been largely superseded by less invasive non-surgical techniques. Once palliation is indicated, the aims of the management should be: the maintenance of oral intake, minimizing hospital stay, relief of pain, elimination of reflux and regurgitation and the prevention of aspiration.

METHODS

This study was a review of all published English language data on the palliation of malignant dysphagia between 1994-1999. The Medline and Bids databases were searched and other references were derived from the material perused.

RESULTS AND CONCLUSIONS

Palliative treatment for oesophageal cancer should be individualized and relate to tumour stage, size and location, the patient's medical condition and his/her personal wishes. The palliative treatment largely includes self-expanding metal stents (SEMS), laser (including photodynamic therapy (PDT)) or a combination of the two to relieve symptoms, this may be employed with or without other treatments such as radiotherapy/chemotherapy (RT/CT) with the aim of reducing tumour bulk and possibly prolonging survival. A multi-disciplinary approach is vital in patients with advanced oesophageal cancer.

Palliation of malignant dysphagia with expanding metallic stents

PURPOSE

The authors describe their experience with expanding metallic stents for the palliation of malignant dysphagia.

MATERIALS AND METHODS

During a 52-month period, 138 stents were inserted in 121 patients with malignant esophageal obstruction. The average age was 74 years; there were 78 men and 43 women. Data regarding the degree of initial dysphagia, presence of an esophago-respiratory fistula, effect of stent placement on swallowing ability, complications at the time of stent placement, and long-term survival were obtained.

RESULTS

An improvement in dysphagia symptoms was recorded in more than 95% of patients. The average survival after stent placement was 24 weeks. Complications necessitating further intervention occurred in 26 patients.

CONCLUSION

Insertion of self-expanding metallic endoprostheses for the palliation of malignant esophageal obstruction is an effective therapy that can be carried out with relative ease. Successful palliation of symptoms can be expected in more than 95% of cases.

A comparison of laser therapy, plastic stents, and expandable metal stents for palliation of malignant dysphagia in patients without a fistula

BACKGROUND

Many options are available for palliation of inoperable malignant stenoses of the esophagus. We report our experience with different modalities of endoscopic therapy.

METHODS

From 1986 to 1996, we treated 125 patients with dysphagia caused by unresectable malignant tumors with endoscopic therapy. Seventy patients were treated with laser therapy, 34 with a plastic endoprosthesis, and 21 with an expandable prosthesis. Therapeutic outcome and complication rates were analyzed for the three groups.

RESULTS

Mean dysphagia score decreased in the same manner in all three groups. Major and minor complications were significantly more common in the plastic endoprosthesis group and in the metallic stent group compared with the laser therapy group. Therapy and patient survival were not significantly different among the three groups.

CONCLUSIONS

Plastic and metal stents carry a high complication rate for a short period of palliation. Endoscopic laser therapy, in contrast, has a low complication rate. Laser therapy should be the first choice for palliation in malignant dysphagia in patients with a short life expectancy. Stents might be used when laser therapy fails, in the presence of fistulas, or in patients with a reasonable life expectancy.

Palliation of malignant dysphagia from oesophageal cancer. Rotterdam Oesophageal Tumor Study Group

Palliative therapies for advanced oesophageal cancer include surgery, radiation therapy, chemotherapy, endoscopic procedures and combinations of these. Of the non-endoscopic modalities is external beam radiation therapy (EBRT) effective and non-invasive. A disadvantage is that relief of dysphagia only occurs over a period of 4-6 weeks. Brachytherapy is more rapid in locally controlling tumour growth and in relieving dysphagia. One of the more commonly used endoscopic procedures is laser therapy, which provides symptomatic relief with low complication rates. Recurrent dysphagia is a problem necessitating repeated treatment sessions. Self-expanding metal stents offer a high degree of palliation and are associated with fewer complications compared with prosthetic tubes. Longer palliation and perhaps even longer survival might be achieved by the combination of different therapies. Most promising are the combination of EBRT plus brachytherapy or chemoradiation. Now is the time to determine which treatment (combination) is best for individual patients.

The role of surgery and laser ablation in oesophageal carcinoma

Between January 1990 and December 1994 oesophagectomy was carried out in 42 patients and comparison made with 38 who had palliative laser therapy. Apart from six patients referred after being unresectable at surgical exploration there were no agreed selection criteria, although the laser patients were in general older (mean 64 V 73 year) with a higher proportion of cardiorespiratory co-morbidity (14 per cent V 18 per cent). Lateral margins were involved in 14 per cent of known palliative resections with 50 per cent having positive nodes. The mean operating time was three hours and two chest drains inserted electively were removed after 3.6 days with mean drainage of 817 ml. The mean ICU stay was 5.4 days and 3 had radiological leaks; all but one settled conservatively. The 90 day mortality was 11.9 per cent for surgery and 34 per cent for laser patients. Twenty-three patients (61 per cent) required further courses of laser-therapy for benign anastomotic stenosis. Including the initial treatment of both groups 6.0 procedures per patient year were required in the laser groups compared with 1.1 for surgery. The 1, 2 and 3 year survival was 60 per cent, 31 per cent, 39 per cent for surgery compared with 24 per cent, 8 per cent, 3 per cent for laser--12 surgical patients are still alive and well at mean of 29 months (range 16-68). Surgery where possible with acceptable morbidity and mortality offers good palliation and long-term survival is possible; selection criteria for palliation only need to be defined.

Esophageal cancer surgery: the value of controlled clinical trials

Prospective randomized controlled trials (RCT) in esophageal cancer were reviewed. Their value and significance in the areas of multimodality therapy, lymphadenectomy, surgical techniques, palliative treatments, and perioperative management were evaluated. Much has been gained through RCT in the management of esophageal cancer, and RCT is the most reliable scientific method in clinical investigations. Problems in the conduct of such trials include lack of expertise by surgeons, lack of patients, lack of funding, and methodologic and ethical problems. These obstacles could be overcome and more well-conducted RCTs encouraged.

The management of patients with advanced cancer (II)

In this second article in the series, obstruction of hollow viscera in patients with advanced malignant disease is discussed. The obstruction of such structures can be associated with the development of painful and incapacitating symptoms, often in patients who have a limited life expectancy. This obstruction may be caused by the primary tumour, compression from adjacent tumour-draining lymph nodes, the presence of metastases distant from the site of the primary tumour or to adhesions within the abdominal compartment (usually as a result of previous surgery). The organs most often affected are the oesophagus, the intestine (small and large), the biliary tree and the genito-urinary tract. Obstruction of each of these organs and its management is discussed in more detail below.

Use of covered expandable metal stents in the treatment of oesophageal carcinoma and tracheo-oesophageal fistula

Palliation for malignant dysphagia has relied on oesophageal dilatation, insertion of rigid prostheses and laser treatment. All three methods have substantial risk of perforation. Displacement of the tube is also well described. Seventeen expandable polyethylene-covered metal stents were inserted in 15 patients with oesophageal carcinoma; there were 11 men and four women, of median age 70 years. Thirteen stents were inserted for dysphagia and four for tracheo-oesophageal fistula (TOF). Stents were inserted endoscopically under fluorosopic control. Seven patients died from their disease a median of 5 (range 1-11) months after stent insertion. Median follow-up in the remainder is 6 (range 1-11) months. Median dysphagia scores before and after insertion were 3 (range 2-4) and 1 (range 1-2) respectively. Stent insertion provided cure of symptoms in patients with TOF. Median hospital stay following insertion was 2 (range 1-20) nights. There were no deaths and no perforations associated with the procedure. Two patients complained of retrosternal chest pain for 2 days after stent insertion. One patient presented with dysphagia related to later stent migration. There has been no deterioration in symptoms of dysphagia in the remainder. Expandable oesophageal stents offer a safe alternative to traditional methods of palliative treatment for oesophageal carcinoma. In the long term they may provide a cost-effective alternative to standard treatments.

Expandable versus conventional esophageal prostheses: easier insertion may not preclude subsequent stent-related problems

BACKGROUND

Although expandable esophageal endoprostheses may be easier to insert and are associated with fewer procedure-related perforations, data comparing clinical results with these stents to those obtained with conventional prostheses are sparse.

METHODS

We reviewed the records of all patients undergoing esophageal stent placement at our institution between October 1983 and July 1995 to define relative risks, clinical results, and need for reintervention prior to death, contrasting conventional to a variety of expandable esophageal endoprostheses.

RESULTS

Over the period of review, 47 patients had conventional prostheses (CP) and 38 had expandable prostheses (EP) placed. Fifteen of 44 patients with CP and 14 of 38 with EP for malignancy also had esophago-airway fistulas. Insertion complications, prestent and poststent dysphagia scores, and complete fistula occlusion rates were comparable. Subacute complications were higher in the patients receiving EP (80%) than in those receiving CP (60%), possibly related to the prospective accumulation of data in patients receiving EP. Survival data were virtually identical and approximated 3 months for either group.

CONCLUSIONS

Although both CP and EP improve dysphagia and occlude tracheoesophageal fistulae, patients ill enough to require a prosthesis do poorly regardless of prosthesis design. Moreover, although EP may be easier to insert than CP, stent- and patient-related problems persist and may require additional intervention.

Comparison of different treatments for unresectable esophageal cancer

Many patient with esophageal cancer have advanced disease that in not amenable to curative treatment. For these individuals the relief of dysphagia is of utmost importance to the quality of their remaining survival time. This article reviews and compares the methods of palliation with focus on indications and contraindications, advantages as well as disadvantages of each technique, success rates, and complications. Tumor characteristics, the physician's experience, the institution's capabilities, cost, and patient preference will influence choice of palliation. Methods are often complementary rather than competitive.

A cost analysis of Nd:YAG laser ablation versus endoscopic intubation for the palliation of malignant dysphagia

Although endoscopic intubation is the mainstay of non-surgical palliation of malignant dysphagia, Nd:YAG laser ablation has been shown to provide good palliation with few complications. The study reported here incorporates data from published and unpublished sources into a cost model which estimates the lifetime cost of palliation with the two therapies. It is estimated that, depending on the assumptions used, laser palliation costs between 153 pounds and 710 pounds more per patient than endoscopic intubation. Sensitivity analysis is used to assess whether variation in clinical practice and in the unit costs of resources will change the conclusions of the study. This indicates that, under most alternative sets of assumptions, intubation retains its cost advantage. However, factors that might reduce, or even eliminate, this cost differential include undertaking more laser procedures as day-cases, using more expensive expanding metal stents for intubation and reducing the need for follow-up laser procedures with palliative radiotherapy.

Stents in the oesophagus

The use of self-expanding metal stents can markedly improve the care of patients with inoperable oesophageal malignancy. The stents can be easily introduced without the need for general anaesthesia. They have fewer complications during insertion than rigid stents and fewer complications than laser therapy. With these stents lumens of up to 2.5 cm are easily obtainable. The article considers the type of patient who may be suitable for stenting, the technique of insertion, benefits and complications of their use.

Changing patterns in the treatment of carcinoma of the esophagus

BACKGROUND

Decision-making in esophageal carcinoma. Treatment of carcinoma of the esophagus knows a great variety of modalities, ranging from simple palliative endoscopic pertubation to extensive curative operations.

METHODS

Retrospective review.

RESULTS

The three main groups of tumors are squamous cell carcinoma related to alcohol and tobacco abuse; adenocarcinoma in Barrett's esophagus related to long-standing gastroesophageal reflux; and adenocarcinoma of the cardia the origin of which is still unknown. Dysphagia and retrosternal pain are not only the most important symptoms but also the most important factors regarding survival. Diagnosis is made by endoscopy and biopsy. In the pretreatment staging a careful selection of the great variety of available diagnostic tools should be made. The ever-increasing diversity of local palliative procedures: tubing, photoablation, brachytherapy all have their place, but should not be allowed to distract us from the fact that surgery is the only hope for cure in these patients. Surgery should only be performed with curative intent and even then the long-term results are modest, with a 5-year survival of about 40% in node-negative and 18% in node-positive patients.

CONCLUSION

In patients with carcinoma of the esophagus a polydisciplinary treatment approach is mandatory.

Esophageal cancer

Esophageal cancer is an important problem in the United States. It results in more deaths (over 10,000 annually) than rectal cancer. Furthermore, the incidence of esophageal adenocarcinoma is increasing at a rate faster than that of nearly any other cancer and the reasons for the increase are not well understood. A variety of tumor-suppressor genes (including p53, APC, DCC and Rb) and proto-oncogenes (including prad1, EGFR, c-erb-2 and TGF alpha) may be involved in the development and progression of esophageal cancer. Clinical prognostic factors include stage, Karnofsky performance status, sex, age, anatomic location of the tumor, and degree of weight loss. A new staging system based on depth of wall penetration and lymph node involvement correlates well with prognosis for patients undergoing esophagectomy. Newer staging procedures including endoscopic ultrasound as well as the use of minimally invasive surgery, such as thoracoscopy and laparoscopy, may allow accurate staging without esophagectomy. Surgical resection provides excellent palliation; however, the chance for cure with esophagectomy alone is only 10% to 20%. Adjuvant treatment with pre- or postesophagectomy radiation may improve local-regional control but does not improve survival. Nor has preoperative chemotherapy been shown to improve survival; however, it remains an active area of investigation. Multimodality therapy, namely, chemotherapy and radiation (chemoradiation), given concurrently prior to surgical resection shows promise, with one study indicating a 5-year survival of 34%. A complete pathologic response to chemoradiation correlates with improved survival. Chemoradiation has been shown to be superior to radiation as primary management of esophageal cancer. There has been no successfully completed randomized trial of surgery versus definitive radiation or chemoradiation. However, chemoradiation represents a reasonable alternative to esophagectomy in the primary management of squamous cell carcinoma of the esophagus and chemoradiation also appears to be effective in the treatment of patients with adenocarcinoma of the esophagus, offering significant palliation and a chance for long-term survival as well. Randomized studies of preoperative chemoradiation versus surgery or versus chemoradiation alone are needed. The treatment of advanced esophageal cancer must be directed toward palliation of symptoms. Newer endoscopic techniques, including the use of expansile metal stents, laser ablation, intraluminal high-dose rate brachytherapy, BICAP tumor probe, or photodynamic therapy, offer selected patients short-term palliation.(ABSTRACT TRUNCATED AT 400 WORDS)

Quality of life with carcinoma of the esophagus

Management of squamous carcinoma of the esophagus remains a dilemma for the clinician. Current treatments produce significant morbidity and mortality, yet most patients still die of their disease. Given the limitations, survival alone is insufficient to assess the various options; quality of life (QOL) must also be addressed. This paper reviews the topic of QOL, the various instruments available to measure it, and methods to evaluate such instruments. A 16-year review of the literature was performed to assess the extent to which QOL has been addressed in patients with esophageal carcinoma. Only 51 of 7569 references on esophageal neoplasms considered QOL. Only 3 used documented QOL instruments with appropriate statistical testing. Currently there is no well validated instrument for measurement of QOL in patients with esophageal carcinoma.

Clinical experience with Montgomery salivary bypass stents in the esophagus

Thirty-seven patients with locally advanced malignancy (18, esophageal obstruction; 19, esophageal fistula formation) underwent attempted placement of a Montgomery salivary stent in the esophagus. This was unsuccessful in 3; in 2, because of inability to dilate, and, in 1, because of perforation. After dilation of the esophagus, there was no detectable underlying stricture in 11 patients; none of these patients experienced stent migration. Overall, there was 100% success in obliterating the fistulous tract, an 8.1% incidence of retrograde migration, no incidence of prograde migration, and no incidence of stent obstruction after discharge. Of the 34 patients with successfully placed stents, 27 were discharged from hospital, and were able to eat and drink without the need for intravenous supplementation or gastrostomy tube feedings. The survival in patients presenting with obstruction ranged from 1 to 13 months (mean, 8.0 months); the survival in patients presenting with a fistula ranged from 2 to 7 months (mean, 5.3 months).

Palliation of malignant dysphagia using the Nd:YAG laser

A group of 141 patients with biopsy-proved malignant dysphagia, treated with neodymium YAG laser between April 1985 and November 1988, have been prospectively evaluated. Patients treated since November 1988 have not been included to allow minimum follow-up of 18 months. The success of treatment has been assessed in terms of survival, relief of dysphagia, complications, and length of inpatient stay. One- and two-year survival rates were 12.6% and 3.5%, respectively (mean survival 24.7 weeks). Ninety-two percent of patients were returned to a semisolid diet or better. In 4% recanalization was impossible, and 4% swallowed only liquids despite an adequate channel. Tumor histology, site of tumor, and length of previous treatment had no significant influence on outcome. The presence of metastases significantly influenced survival (p = 0.007). The principal complications were perforation (6.4%) and tracheoesophageal fistula (2.8%). Laser recanalization provides effective palliation for malignant dysphagia.

Laser recanalization versus endoscopic intubation in the palliation of malignant dysphagia: a randomized prospective study

Forty patients with histologically confirmed malignant dysphagia were randomized to either endoscopic intubation or laser recanalization. Age, sex, tumour histology and site were evenly distributed between the groups. Results were analysed on an 'intention to treat' basis. All patients treated by laser achieved patency; there was one failed intubation. The best swallowing grade achieved was significantly better with laser recanalization (median 4 (range 3-4)) than with intubation (median 3 (range 2-4)) (P < 0.001). The median survival was 21.5 (range 4-62) weeks in the group receiving laser treatment, compared with 14.5 (range 7-102) weeks in the intubated group (P = 0.09). The median inpatient stay as a proportion of survival time was 14 per cent in the group receiving laser treatment compared with 15 per cent in the intubated group (P > 0.05). The median weight loss was less in the laser-treated patients (2.0 (range 2-8) versus 3.0 (range 0-10) kg, P = 0.04). These results indicate that laser recanalization provides better palliation of dysphagia than does intubation, but this is not reflected in an improvement in survival time.

Push-through intubation: effective palliation in 409 patients with cancer of the esophagus and cardia

Between 1980 and 1989, 355 patients with cancer of the esophagus and 54 with cancer of the cardia underwent push-through intubation because of advanced tumor stage or medical contraindications to tumor resection. In 36 other patients (8.1%), the attempt at transtumoral intubation failed. The hospital mortality rate after intubation was 3.4%. The following complications were observed: hemorrhage in 2.0% of the patients, esophageal perforation in 4.9%, tube dislodgment in 12.7%, and tube obstruction in 4.4%. Early resumption of semisolid oral feeding was possible in 80% of the discharged patients. The actuarial 1-year survival rate was 7.7% and the median survival, 3.9 months. In conclusion, push-through intubation represents a valid therapeutic choice, which is indicated mainly for patients with a long, infiltrating, and circumferential stricture of the thoracic esophagus or cardia that is inoperable and for patients with an esophagorespiratory or esophagomediastinal fistula.

Palliation of malignant dysphagia with laser therapy: predictability of results

This study reports the results of 189 patients treated by laser therapy for malignant dysphagia. Ninety-one per cent of patients derived benefit from treatment, but the long-term survival rate was poor, with only 12 per cent of patients surviving for 6 months. Survival was not influenced by either tumour length, site or histological type. Patients with adenocarcinomas initially showed improved swallowing after laser treatment compared with those with squamous tumours, but this difference had disappeared by 2 months. The results of laser treatment were not influenced by either tumour length or site.