Endoscopic intubation with conventional plastic stents: a safe and cost-effective palliation for inoperable esophageal cancer

Effects of Different Anesthetic and Analgesic Methods on Cellular Immune Function and Stress Hormone Levels in Patients Undergoing Esophageal Cancer Surgery

The change of perioperative immune function in patients with esophageal cancer is mainly caused by the joint action of surgical trauma and anesthesia. In our study, we aimed to investigate the effects of different anesthetic methods on the changes of T lymphocyte subsets and cytokines in peripheral blood of patients with esophageal cancer surgery. 50 patients with esophageal cancer were divided into the study group and the control group. Among them, the patients in the control group chose intravenous anesthesia and received self-controlled intravenous analgesia after surgery. Patients in the study group chose thoracic epidural anesthesia combined with general anesthesia, undergoing self-controlled epidural analgesia after surgery; serum interleukin-2 (IL-2) and soluble interleukin-2 receptor (sIL-2R) were measured by ELISA. Serum stress hormones GH and sIL-8 were measured by radioimmunoassay. Both groups of patients achieved significant postoperative analgesia, but the VAS score in the study group at the T2-T4 time point was lower than that in the control group. The serum GH concentration in the study group increased at T1 and reached its highest peak at T2, then decreased. The serum IL-8 concentration of the two groups showed a downward trend from T1 to T4. Thoracic epidural anesthesia combined with general anesthesia for postoperative epidural analgesia can relieve the degree of cellular immunosuppression during and after surgery. Moreover, the thoracic epidural block combined with general anesthesia for esophageal cancer surgery and epidural analgesia after surgery for patients are anesthetic and analgesic methods with clinically significant effects. Our research results have a positive effect on the promotion of postoperative rehabilitation in patients with malignant cell tumors.

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.

Outcome of palliative esophageal stenting for malignant dysphagia: a retrospective analysis

Greater than 50% of patients with esophageal carcinoma are found to be incurable at the time of diagnosis, leaving only palliative options. Self-expanding metal stents (SEMs) are effective for relieving symptoms and complications associated with esophageal carcinoma and improving quality of life. We undertook a retrospective analysis to evaluate the experience of palliative esophageal stenting for symptomatic malignant dysphagia in our institution over a period of 7 years. Between January 1999 and January 2006, 126 patients who received SEMs for malignant dysphagia were identified using an upper gastrointestinal specialist nurse clinician database. Data were obtained from patient case notes, endoscopy, histopathology, radiology, and external agency databases. Of the 126 identified, 36 patients were excluded from the analysis. A number of variables including age, sex, presenting complaints, type of stent, indications of stenting, success or failure of stent insertion, survival rate, and complication rate were analyzed. Of the 90 patients, 55 (61%) were male and 35 (39%) were female. The mean age of patients was 70.79 (range 40-97) years. The predominant presenting complaints were dysphagia (n = 81) and weight loss (n = 48). The indication for stenting was worsening dysphagia in all patients. Tumors were confined to the distal esophagus and esophagogastric junction in 73 patients (81%), and the mid-esophagus in 17 (19%). Adenocarcinoma was identified in 61 patients (67.8%) and squamous cell carcinoma in 29 (32.2%). Stenting numbers were comparable in endoscopic and radiologic groups (47 vs. 43), with successful stent deployment in 89 patients. The 7- and 30-day mortality was 9% (n = 8) and 28% (n = 25), respectively. Comparable numbers of early deaths were seen in both radiologic (n = 13) and endoscopic (n = 12) groups. Causes of early inpatient death included hemorrhage (n = 5), pneumonia (n = 7), exhaustion (n = 2), cardiac causes (n = 3), perforation (n = 1), and sepsis (n = 1). The number of patients with complications was 41 (45.6%), 25 in the surgical group and 15 in the radiologic group; the difference was not significant (P = 0.13). The mean survival time was 92.5 (0-638) days and median survival time was 61 days. A subgroup of patients with complete dysphagia (score 4) gained a mean survival of 59 days. Those patients receiving adjuvant chemotherapy or radiotherapy survived significantly longer than those receiving stenting alone (152.8 days vs. 71.8 days). There is no significant difference in complications or survival when using endoscopic or radiologic methods to deploy SEMs in patients with inoperable esophageal cancer. Mortality is low; however, the morbidity rate is significant. Patients receiving adjuvant chemotherapy or radiotherapy, in addition to stenting, survived significantly longer than those with a stent only.

Evidence-based choice of esophageal stent for the palliative management of malignant dysphagia

BACKGROUND

The type of stent used for the management of patients with malignant dysphagia is chosen according to subjective physician's preference. There is no recent study available to provide updated evidence on early outcomes related to the use of different types of stents.

METHODS

A literature search was performed using Embase, MEDLINE, Cochrane Library, and Google Scholar databases for comparative studies assessing different types of stents. The primary end point was stent-related mortality; secondary end points included: stent-related morbidity, successful palliation of dysphagia, and 30-day mortality. A random-effects model was used and heterogeneity was assessed.

RESULTS

Twelve studies that included 911 patients compared metallic (46.54%) and plastic stents (53.45%), and eight studies that included 564 patients compared covered (43.26%) and uncovered metal stents (56.73%). Meta-analysis of randomized, controlled trials showed that metallic stents were associated with significantly reduced stent-related mortality (1.7% vs. 11.1% for the plastic group, odds ratio (OR), 0.2; 95% confidence interval (CI), 0.06-0.74; P = 0.02), morbidity in the form of reduced esophageal perforation (1.4% vs. 9.4% for plastic stent, OR, 0.27; 95% CI, 0.08-0.89; P = 0.03), and stent migration, yet increased rate of tumor in-growth (13% vs. 1.6% for plastic stents, OR, 4.84; 95% CI, 0.99-23.76; P = 0.05). Covered metallic stents had significantly less tumor in-growth than the uncovered and an increased migration rate. There was no significant difference between metallic and plastic stents in terms of any other stent-related morbidity and 30-day mortality.

CONCLUSION

Self-expanding metallic stents are superior to plastic stents in terms of stent insertion-related mortality, morbidity, and quality of palliation. The uncovered variety is disadvantaged by high rate of tumor in-growth; adequately designed randomized, controlled trials need to examine outcomes and cost-effectiveness of covered versus uncovered metallic stents.

Self-expanding plastic stents in treatment of benign esophageal conditions

BACKGROUND

Recently, self-expanding plastic stents (SEPSs) have been proposed for the treatment of benign esophageal disease.

OBJECTIVES

Our purpose was to review our experience with SEPSs in patients with benign esophageal conditions.

DESIGN

This was a retrospective case review of patients who underwent SEPS placement for benign esophageal disease, including (1) benign stricture, including reflux disease, ischemia, and idiopathic, (2) radiation-induced strictures, (3) anastomotic strictures, and (4) esophageal leak/fistulae.

PATIENTS

Nineteen male and 11 female patients (average age 52.1 years, range 11-87 years) underwent SEPS placement.

INTERVENTIONS

SEPS placement.

MAIN OUTCOME MEASUREMENTS

Initial complications, stent migration, long-term complications, and treatment success according to clinical symptoms, follow-up endoscopy, or imaging.

RESULTS

Eighty-three of 84 SEPS placements were successful. The most common complications were chest pain, dysphagia, nausea, and vomiting. No deaths were reported from stent placement. Stent migration was more frequent in proximal (30/44 stents, 68.1%) and distal (19/27 stents, 70.4%) compared with mid esophageal (3/10 stents, 30%). Migration was more frequent in stents placed for benign strictures (18/22 stents, 81.8%), anastomotic strictures (18/24 stents, 75%), and fistulae/leak (13/22 stents, 59.1%) compared with radiation-induced strictures (4/14 stents, 28.6%). Only 5 of 83 interventions (6%) resulted in long-term improvement after stent removal.

LIMITATIONS

This was a retrospective review, and patients were selected from a tertiary medical center.

CONCLUSION

Use of SEPSs for benign esophageal conditions resulted in frequent stent migration and few cases of long-term improvement. Further investigation is warranted to identify optimal patient populations and to guide future recommendations for the use of SEPSs.

Self-expanding Polyflex plastic stents in esophageal disease: various indications, complications, and outcomes

BACKGROUND

Esophageal stenting has become an important technique in the treatment of different clinical problems such as malignant or benign stenosis, anastomotic leaks after surgery, or fistulas. In this study we present our experience with the self-expanding Polyflex plastic stent in various indications, arising complications, and patient's outcomes.

METHODS

Over a three-year period, 35 patients underwent self-expanding Polyflex plastic stent placement for esophageal stenosis (n = 23) with 22 malignant, and for perforations, fistulas, or anastomotic leaks after surgery (n = 12). The short-term efficacy and long-term outcomes were analyzed.

RESULTS

In patients with stenosis, implantation was performed without any complications in 91% (21/23). In one patient perforation occurred while passing the stenosis; in another patient the stent dislocated during the insertion procedure. Dysphagia score improved from 3.0 to 1.0 after stenting. In all patients with perforations, fistulas, or anastomotic leaks (n = 12), stents were placed successfully without any complication. Complete sealing of the mucosal defect was proven by radiography in 92% (n = 11) and healing was seen in 42% (n = 5). If indicated, stent removal was performed without any complications. Stent migration (n = 13; 37%) was the most common long-term complication.

CONCLUSIONS

The placement of self-expanding Polyflex plastic stents is a highly sufficient and cost-effective treatment for malignant and benign esophageal disorders. Because the long-term results were highly favorable, self-expanding plastic stent placement could be used as the initial treatment for various conditions.

Incurable Esophageal Cancer: Patterns of Tumor Spread and Therapeutic Consequences

BACKGROUND

The aim of the study was to determine if the two histologic tumor types in esophageal cancer exhibit different behavior at advanced tumour stages and require a differentiated therapy.

PATIENTS AND METHODS

From November 1997 to December 2003, 268 patients presented with esophageal carcinoma. Esophagectomy was contraindicated in 88 (32.8%) patients (75 men, 13 women) with a median age of 64.7 (42-83) years. Fifty-six (63.6%) had squamous cell carcinoma; adenocarcinoma was identified in 31 (35.2%).

RESULTS

The causes of incurable disease were non-resectable distant metastases in 32 (36.4%) patients, local tumor spread in 25 (28.4%), and general operative risk in 19 (21.5%). Surgical intervention was contraindicated in 7 patients because of a combination of general inoperability and local tumor spread, or the presence of distant metastases at the time of diagnosis (4 patients declined to undergo surgery and in one patient esophageal resection and reconstruction was technically not possible). The incurability rate for squamous cell carcinoma was 44.6% because of the presence of local tumor spread, compared to a rate of 12.4% for adenocarcinoma. Adenocarcinomas with proven hematogenic metastases were characterized by a higher incurability rate (64.5% vs. 21.4%) (P=0.0014). The prevalence of technical causes of inoperability or of poor general condition was similar in both patient groups (P>0.05). The median 1-year survival rates estimated (Kaplan-Meier) were 36.5% for patients with squamous cell carcinoma and 23.7% for patients with adenocarcinoma (P=0.051). Therapeutic measures had a significant influence on the prognosis: patients without tumor-specific therapy survived 3.4 (0-24) months; those with radiochemotherapy 10.6 (0-25) months; those with radiotherapy 11.0 (0-65) months; and those with chemotherapy 16.5 [0-16.5] months (log-rank test: P=0.0229). In the multivariate analysis, the therapeutic measures (P=0.0126) and tumor localization (P=0.0474) proved significant for prognosis, but were not the cause of incurability (P=0.0948).

CONCLUSIONS

The histologic tumor type does not represent an independent prognostic factor in patients with incurable disease. Rather, the prognosis is dependent on the suitability of the induction of tumor-specific therapeutic measures. These are also recommended in patients with incurable disease after consideration of the extent of tumor spread, provided the performance of the selected measures is justified by the general condition of the patient and the expected prognosis.

Endoluminal palliation

Endoluminal palliation involves the application of endoscopic techniques or devices to relieve the symptoms of malignant gastrointestinal obstruction. This is most often achieved with the use of self-expandable metal stents (SEMS). SEMS can be deployed as far distally or proximally in the gastrointestinal tract as the reach of an adult colonoscope. This article outlines the use of endoscopic techniques to provide endoluminal palliation.

Impact of a self-expanding, plastic esophageal stent on various esophageal stenoses, fistulas, and leakages: a single-center experience in 39 patients

BACKGROUND

In this study, we describe our experience with the use of a self-expanding, covered, plastic esophageal stent (SEPS). The majority of placements were difficult to treat situations, i.e., proximal or extremely proximal stent release or emergency cases in the intensive care unit.

METHODS

Thirty-nine patients were treated by insertion of a SEPS by endoscopic or radiologic guidance for the following: malignant stenosis (n = 22), malignant fistula (n = 8), benign stenosis after treatment for malignant disease (n = 6), benign fistula (n = 2), and perforation or leakage after surgery of the esophagus (n = 5).

RESULTS

Stent placement was technically feasible in all patients. In patients with a stenosis, esophageal passage was achieved in 92.8%. Fistulas, perforations, and leakages were sealed in 73.3%. In 6 patients (15.4%), the stent was electively removed because of the completion of the therapy. Complications included respiratory insufficiency, mediastinal emphysema, and tracheal impression in one patient each; a new fistula in two patients; bleeding in 3 patients; stent-induced ulcers in two patients; and stent migration in 8 patients.

CONCLUSIONS

The therapeutical success and the complication rate after SEPS placement are similar to that reported for self-expanding metal stents. In addition, the SEPS can be readily removed, and the costs are significantly lower.

Use of stents in head and neck surgery

PURPOSE OF REVIEW

This paper provides a review of the most recent literature regarding the use of endoluminal stents in the upper aerodigestive tract.

RECENT FINDINGS

New technologies and materials as well as modifications of traditional stents allows the palliation of patients with esophageal and tracheobronchial obstruction due to carcinoma, to obturate tracheoesophageal fistulas in patients who are poor surgical candidates and to provide temporary relief of aspiration while awaiting for definitive surgery. The use of stents for airway obstruction is limited by their tendency to migrate (silicone stents) or to produce abundant and airway threatening granulation tissue (self expandable metal stents).

SUMMARY

Stents are best used for the palliation of obstruction caused by tracheobronchial or esophageal malignancies and for those patients affected by benign conditions but who are considered poor surgical candidates.