Should oesophageal stents be used before neo-adjuvant therapy to treat dysphagia in patients awaiting oesophagectomy? Best evidence topic (BET)

Effects of PEG in patients with esophageal squamous cell carcinoma during concurrent chemoradiotherapy: a prospective study

BACKGROUND AND AIMS

This prospective study aimed to compare the changes in nutritional status and adverse events among patients with esophageal squamous cell carcinoma who received enteral nutrition through oral intake, PEG, and an enteral nasogastric tube (NGT) during concurrent chemoradiotherapy (CCRT).

METHODS

Of 141 included patients, 38, 74, and 29 patients were fed through oral intake, PEG, and NGTs, respectively. The clinical characteristics and baseline nutritional status of the 3 groups were recorded and analyzed. The Patient-Generated Subjective Global Assessment score, skeletal muscle index, and quality of life were evaluated before and after CCRT; the incidence of adverse events during feeding using PEG and NGTs was also recorded. The correlations among the different nutritional pathways and the CCRT-related adverse events (eg, radiation esophagitis and myelosuppression) were assessed.

RESULTS

At baseline, the oral intake group had a significantly better nutritional status and lower disease stage than those in the PEG and NGT groups. However, during CCRT, the oral intake group exhibited the most significant decreases in weight and skeletal muscle index. The synchronous chemotherapy completion rate was the highest in the PEG group. Multivariate analysis showed that the planning tumor volume and oral intake and NGT feeding pathways were associated with radiation esophagitis of at least grade 2.

CONCLUSIONS

We found that PEG effectively maintained the body weight and skeletal muscle index of patients with esophageal cancer during CCRT. PEG also improved the synchronous chemotherapy completion rate and reduced the occurrence of at least grade 2 radiation esophagitis. (Clinical trial registration number: NCT04199832.).

Effect of percutaneous endoscopic gastrostomy prior to oesophageal cancer surgery on postoperative wound complications in patients: A meta-analysis

It is still a matter of controversy whether percutaneous endoscopic gastrostomy(PEG) should be used prior to the operation for the purpose of feeding the patient with resectable oesophageal carcinoma (EC). Comparison was made between EC and preoperatively treated PEG and non-preoperative PEG. An extensive literature review has been conducted to determine the results about PEG and No-PEG trials. In this paper, we chose 4 papers out of 407 of them through a strict selection process. In this trial, there were 1027 surgical cases of oesophagus carcinoma, 152 with PEG pre-surgery and 875 without PEG. The total sample size ranged from 14 to 657. Two studies showed that there was no statistically significant difference in the occurrence of postoperative wound infection among PEG and No-PEG(OR, 1.03; 95% CI, 0.38, 2.80 p = 0.96), there was no statistical significance in the likelihood of anastomotic leak among PEG after surgery compared to No-PEG in 4 trials (OR, 1.13; 95% CI, 0.62-2.07 p = 0.69), and there were no statistical differences between PEG and No-PEG before operation on anastomotic stricture for esophagectomy(OR, 0.70; 95% CI, 0.31-1.56 p = 0.38). No wound or anastomosis complications were observed in the PEG group. Thus, PEG preoperatively is an effective and safe procedure without any harmful influence on gastrointestinal structure or anastomosing. It can be applied to patients with oesophagus carcinoma who have a high risk of undernutrition. Nevertheless, because of the limited number of randomized controlled trials in this meta-analysis, caution should be exercised in their treatment. More high-quality research involving a large sample is required to confirm the findings.

Nutritional Status and the Outcomes of Endoscopic Stenting in Benign and Malignant Diseases of Esophagus

BACKGROUND

Endoscopic stenting (ES) is a widely known method for palliative dysphagia treatment in esophageal strictures. Esophageal cancer is often associated with advanced malnutrition, which may increase the risk of complications of the procedure. The aim of this study was to evaluate complication rates and the impact of nutritional status on the outcomes of ES.

PATIENTS AND METHODS

A single-center retrospective study was conducted at Copernicus Hospital in Gdańsk, Poland. Adult patients who underwent endoscopic stenting between February 2014 and December 2018 were included. The influence of patient characteristics (age, sex, indications for esophageal stenting, and location of stenosis) and nutritional status (BMI, NRS 2002, GLIM, and dysphagia score) on complication rates and survival were analyzed.

RESULTS

Eighty-one patients (69% men) were enrolled in the study. In 69%, the indication for ES was malignancy (mainly esophageal cancer). The median dysphagia score significantly decreased from 2.8 to 0.6 after the procedure (p < 0.001). Complications were observed in 27% (n = 22) of the patients. Early complications were bleeding (2.5%), stent unexpansion (2.5%), and stent migration during the procedure (3.7%). There were no early fatal complications of the procedure. Late complications included: stent migration (6.2%), tissue overgrowth (6.2%), food impaction (2.2%), fistula formation (3.7%), bleeding (3.7%), and stent malposition (1.2%). A total of 76% of the participants scored ≥ 3 points in nutritional screening (NRS2002) and 70% were diagnosed with severe malnutrition (GLIM -stage 2). A stent diameter of < 2.2 cm compared with ≥ 2.2 was associated with a higher rate of migrations (15.5% vs. 2.5%). The median survival time in the malignant group was 90 days. Histopathological diagnosis and patients' nutritional status (BMI, NRS 2002, GLIM, and dysphagia score) had no significant effect on complication rates and survival after esophageal stent insertion.

CONCLUSIONS

Endoscopic stenting is a relatively safe procedure for the palliative treatment of esophageal strictures. Severe malnutrition, although common, does not affect the outcomes of the procedure.

Preoperative Esophageal Stenting and 5-Year Survival in Patients Undergoing Esophagectomy for Esophageal Cancer: a Population-Based Nationwide Study from Finland

BACKGROUND

Preoperative esophageal stenting is proposed to have a negative effect on outcomes. The aim was to compare a 5-year survival in patients undergoing esophagectomy for esophageal cancer with and without preoperative esophageal stent in a population-based nationwide cohort from Finland. The secondary outcome was 90-day mortality.

METHODS

This study included curatively intended esophagectomies for esophageal cancer in Finland between 1999 and 2016, with follow-up until December 31, 2019. Cox proportional hazards models provided hazard ratios (HRs) with 95% confidence intervals (CIs) of overall 5-year and 90-day mortality. Model 1 was adjusted for age, sex, year of the surgery, comorbidities, histology, pathological stage, and neoadjuvant therapy. Model 2 included also albumin level and BMI.

RESULT

Of 1064 patients, a total of 134 patients underwent preoperative stenting and 930 did not. In both adjusted models 1 and 2, higher 5-year mortality was seen in patients with preoperative stent with HRs of 1.29 (95% CI 1.00-1.65) and 1.25 (95% CI 0.97-1.62), respectively, compared to no stenting. The adjusted HR of 90-day mortality was 2.49 (95% CI 1.27-4.87) in model 1 and 2.49 (95% CI 1.25-4.99) in model 2. When including only neoadjuvant-treated patients, those with preoperative stent had a 5-year survival of 39.2% compared to 46.4% without stent (adjusted HR 1.34, 95% CI 1.00-1.80), and a 90-day mortality rate of 8.5% and 2.5% (adjusted HR 3.99, 95% CI 1.51-10.50).

DISCUSSION

This nationwide study reports worse 5-year and 90-day outcomes in patients with preoperative esophageal stent. Since residual confounding remains possible, observed difference could be only an association rather than the cause.

Percutaneous endoscopic gastrostomy prior to esophagectomy for esophageal cancer - a systematic review and meta-analysis

BACKGROUND

For resectable esophageal cancer (EC), it remains controversial whether to place percutaneous endoscopic gastrostomy (PEG) before the curative surgery to provide nutritional support during the neoadjuvant therapy.

OBJECTIVE

To compare surgical outcomes for patients who received preoperative PEG and those without PEG placement (No-PEG) insertion prior to surgery in a potentially operable EC.

METHODS

A comprehensive literature search was conducted to identify randomized and non-randomized studies comparing PEG and No-PEG groups.

RESULTS

Four retrospective studies with a total number of 1,027 patients were identified and included in this meta-analysis. The differences in anastomotic leakage, anastomotic stricture, morbidity, pulmonary complications, wound infection, and hospital stay were not statistically significant between the two groups. Operation time was significantly shorter in the PEG group. There was no PEG-related gastric conduit failure and no leak from the PEG site in the PEG group.

CONCLUSION

We conclude preoperative PEG for resectable EC is a safe procedure with no adverse effect on the gastric tube construction and anastomosis, it can be selectively inserted for EC patients with marked weight loss and malnutrition or those at risk of developing malnutrition during neoadjuvant therapy.

Nutritional Support of Cancer Patients without Oral Feeding: How to Select the Most Effective Technique?

BACKGROUND

Digestive tumours are among the leading causes of morbidity and mortality. Many cancer patients cannot maintain oral feeding and develop malnutrition. The authors aim to: review the endoscopic, radiologic and surgical techniques for nutritional support in cancer patients; address the strategies for nutritional intervention according to the selected technique; and establish a decision-making algorithm to define the best approach in a specific tumour setting.

SUMMARY

This is a narrative non-systematic review based on an electronic search through the medical literature using PubMed and UpToDate. The impossibility of maintaining oral feeding is a major cause of malnutrition in head and neck (H&N) cancer, oesophageal tumours and malignant gastric outlet obstruction. Tube feeding, endoscopic stents and gastrojejunostomy are the three main nutritional options. Nasal tubes are indicated for short-term enteral feeding. Percutaneous endoscopic gastrostomy (PEG) is the gold standard when enteral nutrition is expected for more than 3-4 weeks, especially in H&N tumour and oesophageal cancer patients undergoing definite chemoradiotherapy. A gastropexy push system may be considered to avoid cancer seeding. Radiologic and surgical gastrostomy are alternatives when an endoscopic approach is not feasible. Postpyloric nutrition is indicated for patients intolerant to gastric feeding and may be achieved through nasoenteric tubes, PEG with jejunal extension, percutaneous endoscopic jejunostomy and surgical jejunostomy. Oesophageal and enteric stents are palliative techniques that allow oral feeding and improve quality of life. Surgical or EUS-guided gastrojejunostomy is recommended when enteric stents fail or prolonged survival is expected. Nutritional intervention is dependent on the technique chosen. Institutional protocols and decision algorithms should be developed on a multidisciplinary basis to optimize nutritional care.

CONCLUSIONS

Gastroenterologists play a central role in the nutritional support of cancer patients performing endoscopic techniques that maintain oral or enteral feeding. The selection of the most effective technique must consider the cancer type, the oncologic therapeutic program, nutritional aims and expected patient survival.

Use of esophageal stents to relieve dysphagia during neoadjuvant therapy prior to esophageal resection: a systematic review

Esophageal cancer stenting offers symptomatic relief for patients suffering from dysphagia. There are limited data to support their use to relieve dysphagia and improve nutrition during neoadjuvant therapy with some concern that they may negatively impact oncological outcomes. The aim of this systematic review was to quantify the impact of esophageal stents on outcomes prior to resection with curative intent. A literature search was performed using Embase, Medline, PubMed, PubMed Central, the Cochrane library for articles pertaining to esophageal stent use prior to or during neoadjuvant chemotherapy or chemoradiotherapy in patients planned for curative esophagectomy. Data extracted included basic demographics, clinical, nutritional and oncologic outcomes. A total of 9 studies involving 465 patients were included. Esophageal stent use resulted in a significant improvement in mean dysphagia scores in the immediate post stent period but failed to demonstrate any positive changes in weight, body mass index (BMI) or albumin. Only 33% of stented patients ultimately progressed to potential curative surgical resection and stents were associated with reduced R0 resection rates and lower overall survival. This systematic review shows that, although esophageal stenting is associated with improvements in dysphagia during neoadjuvant therapy, their effect on improving patient nutritional status is less clear and they may be associated with poorer long-term oncological outcomes. Stents should be used with caution in patients who are being considered for potentially curative resection of esophageal malignancies and other strategies of nutritional supplementation should be considered.

Preoperative esophageal stenting and short-term outcomes of surgery for esophageal cancer in a population-based study from Finland and Sweden

Population-based studies examining whether preoperative esophageal stenting influences the short-term outcomes after esophagectomy for esophageal cancer are lacking. This nationwide cohort combining data from Finland and Sweden was conducted to cover this gap. Patients with locally advanced esophageal cancer (T ≥ 3 and/or N ≥ 1, M0) who underwent esophagectomy between 2007 and 2014 were identified from nationwide registries in Finland and Sweden. The study exposure was preoperative stenting. The primary outcomes were 30- and 90-day mortality. Secondary outcomes were length of hospital stay and 30- and 90-day readmission rates. Multivariable Cox and linear regression analyses provided hazard ratios (HRs) with 95% confidence intervals (CIs) adjusted for age, sex, comorbidity, tumor histology, year of surgery, and country. Of all 1029 participating patients who underwent surgery for locally advanced esophageal cancer, 127 (12.3%) had an esophageal stent inserted preoperatively. The absolute 30-day mortality rates were higher in stented patients (3.9%) than in those without a stent (1.6%), but the HR was not statistically significantly increased (HR 2.42; 95% CI 0.85-6.92). Similarly, the absolute 90-day mortality rates were increased after preoperative stenting (11.8%) compared to no stenting (7.0%), but again the HR was not statistically significantly increased (HR 1.68; 95% CI 0.95-2.98). Preoperative stenting did not influence length of hospital stay or readmission rates. The possibly increased short-term mortality after preoperative stenting in patients who undergo esophagectomy for esophageal cancer indicated in this study suggests a cautious approach to preoperative stenting until future research or meta-analyses provide a more definite answer.

Nutritional benefit of laparoscopic jejunostomy during neoadjuvant chemotherapy for obstructing esophageal cancer

Neoadjuvant chemotherapy (NAC) confers a survival benefit in esophageal carcinoma, but it is difficult to perform in patients who cannot receive enteral feeding due to an esophageal obstruction. In the current study, the nutritional benefit of laparoscopic jejunostomy (Lap-J) was evaluated in patients with NAC for obstructing esophageal cancer. A total of 91 patients with esophageal cancer who received NAC between 2009 and 2017 were included in the present study. Lap-J was performed prior to NAC in 15 patients (16.5%) with an obstructing tumor. Patients with NAC without Lap-J were used as the control group (n=76). Nutritional parameters and surgical outcomes of the two groups were compared retrospectively. In the patients with Lap-J, 14 of the 15 patients (93.3%) did not experience any procedure-associated complications. No mortalities were associated with Lap-J. Significant decreases in total serum protein, albumin, hemoglobin concentrations and prognostic nutritional index (PNI) occurred following NAC in the control but not in the Lap-J group. Serum albumin and the improved modified Glasgow prognostic score increased significantly after NAC in the Lap-J group but not in the control group. In conclusion, perioperative nutritional support with Lap-J was safe and effective in patients with NAC for obstructing esophageal cancer.

Enteral nutrition in esophageal cancer patients treated with radiotherapy: a Chinese expert consensus 2018

Esophageal cancer (EC) patients receiving radiotherapy are at a high risk of malnutrition, which can increase the side effects of radiotherapy, reduce the accuracy and sensitivity of radiotherapy and decrease treatment effect. Therefore, timely and correct nutritional treatment is crucial. To date, however, neither consensus nor guidelines on enteral nutrition (EN) specifically for EC patients receiving radiotherapy exist. Accordingly, an expert consensus conference was held to establish consensus on the use of EN in EC patients receiving radiotherapy. It reflected the opinions of a multidisciplinary group of experts and a review of the current literature, and established common guidelines for nutritional screening and assessment, nutrition counseling, indication for EN, access and formulas of EN, effect evaluation, nutrition plan adjustment, and home enteral nutrition.

Nutrition therapy in esophageal cancer-Consensus statement of the Gastroenterological Society of Taiwan

A number of clinical guidelines on nutrition therapy in cancer patients have been published by national and international societies; however, most of the reviewed data focused on gastrointestinal cancer or non-cancerous abdominal surgery. To collate the corresponding data for esophageal cancer (EC), a consensus panel was convened to aid specialists from different disciplines, who are involved in the clinical nutrition care of EC patients. The literature was searched using MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, and the ISI Web of Knowledge. We searched for the best evidence pertaining to nutrition therapy in the case of EC. The panel summarized the findings in 3 sections of this consensus statement, based on which, after the diagnosis of EC, an initial distinction is made between the patients, as follows: (1) Assessment; (2) Therapy in patients with resectable disease; patients receiving chemotherapy or chemoradiotherapy prior to resection, and patients with unresectable disease, requiring chemoradiotherapy or palliative therapy; and (3) Formula. The resulting consensus statement reflects the opinions of a multidisciplinary group of experts, and a review of the current literature, and outlines the essential aspects of nutrition therapy in the case of EC. The statements are: Patients with EC are among one of the highest risk to have malnutrition. Patient generated suggestive global assessment is correlated with performance status and prognosis. Nutrition assessment for patients with EC at the diagnosis, prior to definitive therapy and change of treatment strategy are suggested and the timing interval can be two weeks during the treatment period, and one month while the patient is stable. Patients identified as high risk of malnutrition should be considered for preoperative nutritional support (tube feeding) for at least 7-10 days. Various routes for tube feedings are available after esophagectomy with similar nutrition support benefits. Limited intrathoracic anastomotic leakage postesophagectomy can be managed with intravenous antibiotics and self-expanding metal stent (SEMS) or jejunal tube. Enteral nutrition in patients receiving preoperative chemotherapy or chemoradiation provides benefits of maintaining weight, decreasing toxicity, and preventing treatment interruption. Tube feeding or SEMS can offer nutrition support in patients with unresectable esophageal cancer, but SEMS is not recommended for those with neoadjuvant chemoradiation before surgery. Enteral immunonutrition may preserve lean body mass and attenuates stress response after esophagectomy. Administration of glutamine may decrease the severity of chemotherapy induced mucositis. Enteral immunonutrition achieves greater nutrition status or maintains immune functions during concurrent chemoradiation.

Enteral nutrition and quality of life in patients undergoing chemoradiotherapy for esophageal carcinoma: a comparison of nasogastric tube, esophageal stent, and ostomy tube feeding

BACKGROUND AND AIMS

This study prospectively recruited esophageal squamous cell carcinoma patients who received esophageal stent, nasogastric tube (NGT), or jejunostomy/gastrostomy feeding to compare the changes in nutritional status and quality of life during chemoradiation therapy (CRT).

METHODS

In total, 81 patients were analyzed (stent, 7; surgical ostomy, 26; NGT, 19; oral intake, 29). An NGT was inserted when, despite medication, dysphagia or pain worsened with oral feeding during CRT. Serial body weight and daily narcotic demand were recorded. Changes in serum albumin level and quality of life were also assessed. In subgroup analysis comparing NGT and prophylactic surgical ostomy feeding, 5 patients with total occlusion in the ostomy group were excluded.

RESULTS

Patients in all groups had similar decreases in mean body weight with an overall change of -6.41% ± 5.21% at the end of CRT. The stent group had significantly worse pain, decreased albumin (-1.03 ± .9 mg/dL), and decreased quality of life across CRT compared with the other groups. In subgroup analysis the stent group had significantly higher weight loss, whereas the NGT group had higher narcotic demand and slightly worse quality of life. Two patients (7.7%) had ileus days after jejunostomy creation. Five patients (23.8%) among those received prophylactic ostomy creation and scarcely used it.

CONCLUSIONS

These preliminary results raise concerns that use of esophageal stents may be less suitable in patients undergoing CRT. Tube feeding by means of transnasal or percutaneous routes appear to be comparably effective during CRT, but both have advantages and disadvantages. We suggest a careful endoscopic evaluation to select the population more appropriate for NGT feeding on an as-needed basis during CRT.

Esophageal Metal Stents with Concurrent Chemoradiation Therapy for Locally Advanced Esophageal Cancer: Safe or Not?

BACKGROUND

The purpose of this study was to review the risks and benefits of concurrent chemoradiation therapy (CCRT) with esophageal self-expandable metal stents (SEMS) for the treatment of locally advanced esophageal cancer.

MATERIALS AND METHODS

Between January 2014 and December 2016, the data from 46 locally advanced esophageal cancer patients who received CCRT at our institution were retrospectively reviewed. Eight patients who received CCRT concomitant with SEMS placement (SEMS plus CCRT group) and thirty-eight patients who received CCRT without SEMS placement (CCRT group) were identified. The risk of developing esophageal fistula and the overall survival of the two groups were analyzed.

RESULTS

The rate of esophageal fistula formation during or after CCRT was 87.5% in the SEMS plus CCRT group and 2.6% in the CCRT group. The median doses of radiotherapy in the SEMS plus CCRT group and the CCRT group were 47.5 Gy and 50 Gy, respectively. SEMS combined with CCRT was associated with a greater risk of esophageal fistula formation than CCRT alone (hazard ratio [HR], 72.30; 95% confidence interval [CI], 8.62-606.12; p < .001). The median overall survival times in the SEMS plus CCRT and CCRT groups were 6 months and 16 months, respectively. Overall survival was significantly worse in the SEMS plus CCRT group than in the CCRT group (HR, 5.72; 95% CI, 2.15-15.21; p < .001).

CONCLUSION

CCRT concomitant with SEMS for locally advanced esophageal cancer results in earlier life-threatening morbidity and a higher mortality rate than treatment with CCRT alone. Further prospective and randomized studies are warranted to confirm these observations.

IMPLICATIONS FOR PRACTICE

Patients treated with SEMS placement followed by CCRT had higher risk of esophageal fistula formation and inferior overall survival rate compared with patients treated with CCRT alone. SEMS placement should be performed cautiously in patients who are scheduled to receive CCRT with curative intent.

Nutritional optimization during neoadjuvant therapy prior to surgical resection of esophageal cancer-a narrative review

This narrative review aims to evaluate the evidence for the different nutritional approaches employed during neoadjuvant therapy in patients with locoregional esophageal cancer. Patients with esophageal cancer are often malnourished and difficult to optimize nutritionally. While evidence suggests that neoadjuvant therapy can offer a survival advantage, associated toxicity can exacerbate poor nutritional status. There is currently no accepted standard of care regarding optimal nutritional approach. A systematic literature search was undertaken. Studies describing the utilization of an additional nutritional intervention in patients with esophageal cancer receiving neoadjuvant therapy prior to esophagectomy were included. Primary outcome measure was 30-day postoperative mortality after esophagectomy. Secondary outcome measures were loss of weight during neoadjuvant therapy, completion rate of intended neoadjuvant therapy, complications from nutritional intervention, 30-day postoperative morbidity after esophagectomy and quality of life during neoadjuvant treatment. Given the heterogeneity of retrieved articles results was presented as a narrative review. Twenty-five studies were included of which 16 evaluated esophageal stenting, four feeding jejunostomy, three gastrostomy, one nasogastric feeding, and one comparative study of esophageal stenting to feeding jejunostomy. 30-day postoperative mortality was only reported in two of the 26 included studies limiting comparison between nutritional strategies. All studies of esophageal stents reported improvements in dysphagia with reported weight change ranging from -5.4 to +6 kg and one study reported 30-day postoperative mortality after esophagectomy (10%). In patients undergoing esophageal stenting for their neoadjuvant treatment overall migration rate was 29.9%. Studies of laparoscopically inserted jejunostomy were all retrospective reviews that demonstrated an increase in weight ranging from 0.4 to 11.8 kg and similarly no study reported 30-day postoperative mortality. Only one comparative study was included that compared esophageal stents to jejunostomy. This study reported no significant difference between the two groups in respect to complication rates (stents 22% vs. jejunostomy 4%, P = 0.11) or increase in weight (stents 4.4 kg vs. jejunostomy 4.2 kg, P = 0.59). Quality of life was also poorly reported. This review demonstrates the uncertainty on the optimal nutritional approach for patients with resectable esophageal cancer undergoing neoadjuvant treatment prior to esophagectomy. A prospective, multicenter, observational cohort study is needed to determine current practice and inform a prospective clinical trial.

Palliative chemoradiotherapy versus radiotherapy alone for dysphagia in advanced oesophageal cancer: a multicentre randomised controlled trial (TROG 03.01)

BACKGROUND

A short course of radiotherapy is commonly prescribed for palliative relief of malignant dysphagia in patients with incurable oesophageal cancer. We compared chemoradiotherapy with radiotherapy alone for dysphagia relief in the palliative setting.

METHODS

This multicentre randomised controlled trial included patients with advanced or metastatic oesophageal cancer who were randomly assigned (1:1) through a computer-generated adaptive biased coin design to either palliative chemoradiotherapy or radiotherapy alone for treatment of malignant dysphagia at 22 hospitals in Australia, Canada, New Zealand, and the UK. Eligible patients had biopsy-proven oesophageal cancer that was unsuitable for curative treatment, symptomatic dysphagia, Eastern Cooperative Oncology Group performance status 0-2, and adequate haematological and renal function. Patients were stratified by hospital, dysphagia score (Mellow scale 1-4), and presence of metastases. The radiotherapy dose was 35 Gy in 15 fractions over 3 weeks for patients in Australia and New Zealand and 30 Gy in ten fractions over 2 weeks for patients in Canada and the UK. Chemotherapy consisted of one cycle of intravenous cisplatin (either 80 mg/m² on day 1 or 20 mg/m² per day on days 1-4 of radiotherapy at clinician's discretion) and intravenous fluorouracil 800 mg/m² per day on days 1-4 of radiotherapy in week 1. Patients were assessed weekly during treatment. The primary endpoint was dysphagia relief (defined as ≥1 point reduction on the Mellow scale at 9 weeks and maintained 4 weeks later), and key secondary endpoints were dysphagia progression-free survival (defined as a worsening of at least 1 point on the Mellow scale from baseline or best response) and overall survival. These endpoints were analysed in the intention-to-treat population. This study is registered at ClinicalTrials.gov, number NCT00193882. This trial is closed.

FINDINGS

Between July 7, 2003, and March 21, 2012, 111 patients were randomly assigned to chemoradiotherapy and 109 patients to radiotherapy. One patient in the chemoradiotherapy group was omitted from analysis because of ineligibility. 50 (45%, 95% CI 36-55) patients in the chemoradiotherapy group and 38 (35%, 26-44) in the radiotherapy group obtained dysphagia relief (difference 10·6%, 95% CI -2 to 23; p=0·13). Median dysphagia progression-free survival was 4·1 months (95% CI 3·5-4·8) versus 3·4 months (3·1-4·3) in the chemoradiotherapy and radiotherapy groups, respectively (p=0·58), and median overall survival was 6·9 months (95% CI 5·1-8·3) versus 6·7 months (4·9-8·0), respectively (p=0·88). Of the 211 patients who commenced radiotherapy, grade 3-4 acute toxicity occurred in 38 (36%) patients in the chemoradiotherapy group and in 17 (16%) patients in the radiotherapy group (p=0·0017). Anaemia, thrombocytopenia, neutropenia, oesophagitis, diarrhoea, nausea and vomiting, and mucositis were significantly worse in patients who had chemoradiotherapy than in patients who had radiotherapy.

INTERPRETATION

Palliative chemoradiotherapy showed a modest, but not statistically significant, increase in dysphagia relief compared with radiotherapy alone, with minimal improvement in dysphagia progression-free survival and overall survival with chemoradiotherapy but at a cost of increased toxicity. A short course of radiotherapy alone should be considered a safe and well tolerated treatment for malignant dysphagia in the palliative setting.

FUNDING

National Health and Medical Research Council, Canadian Cancer Society Research Institute, Canadian Cancer Trials Group, Trans Tasman Radiation Oncology Group, and Cancer Australia.

Savings from reducing low-value general surgical interventions

Background

Finding opportunities for improving efficiency is important, given the pressure on national health budgets. Identifying and reducing low-value interventions that deliver little benefit is key. A systematic literature evaluation was done to identify low-value interventions in general surgery, with further assessment of their cost.

Methods

A multiplatform method of identifying low value interventions was undertaken, including a broad literature search, a targeted database search, and opportunistic sampling. The results were then stratified by impact, assessing both frequency and cost.

Results

Seventy-one low-value general surgical procedures were identified, of which five were of high frequency and high cost (highest impact), 22 were of high cost and low frequency, 23 were of low cost and high frequency, and 21 were of low cost and low frequency (lowest impact). Highest impact interventions included inguinal hernia repair in minimally symptomatic patients, inappropriate gastroscopy, interval cholecystectomy, CT to diagnose appendicitis and routine endoscopy in those who had CT-confirmed diverticulitis. Their estimated cost was €153 383 953.

Conclusion

Low-value services place a burden on health budgets. Stopping only five high-volume, high-cost general surgical procedures could save the National Health Service €153 million per annum.

Outcomes of nutritional interventions to treat dysphagia in esophageal cancer: a population-based study

Esophageal cancer (EC) is increasing in prevalence due to rising incidence and improved treatment strategies. Dysphagia is a significant morbidity in patients with EC requiring nutritional intervention. We sought to evaluate outcomes of nutritional interventions for EC patients hospitalized with dysphagia at a population level. The National Inpatient Sample (2002-2012) was utilized to include all adult inpatients (≥18 years of age) with EC and presence of dysphagia and stricture that underwent nutritional interventions including feeding tube (FT) placement, esophageal stenting, or parenteral nutrition (PN). Temporal trends were examined with multivariate analysis performed for mortality, length of stay (LOS), and cost of hospitalization. A total of 509,593 EC patients had 12,205 hospitalizations related to dysphagia. The hospitalization rates doubled over the study period (1.52% vs. 3.28%, p < 0.001). The most common nutritional intervention was FT (27%), followed by esophageal stenting (13%), and PN (11%). PN was more frequently associated with a diagnosis of sepsis (6.1%, p = 0.023) compared to FT (2.5%) or esophageal stenting (1.8%). Multivariate analysis demonstrated FT and esophageal stenting had comparable mortality (OR 1.06, 95% CI: 0.49, 2.32); however, PN was associated with higher mortality (OR 2.37, 95% CI: 1.22, 4.63), cost of hospitalization ($5,510, 95% CI: 2,262, 8,759), and LOS (2.13 days, 95% CI: 0.72, 3.54). This study shows that hospitalizations for EC with dysphagia and related nutritional interventions are increasing. As a single modality, parenteral nutrition should be avoided. Among our esophageal stent and FT population, further studies are necessary to determine adequate interventions based on disease stage.

Nutritional status, management and clinical outcomes in patients with esophageal and gastro-oesophageal cancers: A descriptive study

AIM

The aims of this study were to investigate the nutritional management practice and nutritional status of patients with oesophageal and gastro-oesophageal cancers, and to propose strategies for improving their nutritional and clinical outcomes.

METHODS

All patients diagnosed with oesophageal and gastro-oesophageal cancers and treated with chemotherapy and/or radiotherapy at the Liverpool Cancer Therapy Centre (between August 2010 and February 2014) were included in this retrospective study. Patient and tumour characteristics, nutritional status and management were compared to clinical outcomes.

RESULTS

A total of 69 patients met the inclusion criteria. The median weight loss prior to treatment commencement was 10.5% (Interquartile Range (IQR) = 6.6-15.4). A decline in nutritional status continued throughout the treatment course. The median percentage of weight loss during treatment was 3.53% (IQR = 0.00-6.84). Seven and 19 patients required nutrition intervention using a feeding tube or stent insertion to manage dysphagia, respectively. In patients treated with a curative intent, radiotherapy was completed in 100% of those with a nasogastric tube insertion as compared to 80% who had a stent insertion. There was a higher percentage of patients from culturally and linguistically diverse (CALD) background, experiencing significant weight loss when compared with their non-CALD counterparts (P = 0.04).

CONCLUSIONS

Patients with oesophageal and gastro-oesophageal cancers commonly present with significant weight loss and this continues during the course of their anti-cancer treatment. A standardised protocol of nutrition management for these cancer patients is recommended, focusing on assisting patients from CALD backgrounds.

Biodegradable esophageal stents in benign and malignant strictures - a single center experience

BACKGROUND AND STUDY AIMS

Biodegradable (BD) esophageal stents were recently developed mainly for refractory benign strictures, but experience and available literature are limited.

PATIENTS AND METHODS

This was a retrospective observational study. All patients who had BD stents inserted due to refractory benign esophageal strictures or malignant strictures, or were awaiting radical radiotherapy/chemotherapy or neo-adjuvant therapy and esophagectomy between March 2011 and July 2015 were included.

RESULTS

Stent placement was successful in all patients. Ten patients with benign strictures (3 male, median age 80.5 years, IQR: 68.75 - 89.5) were followed-up for a median of 171.5 weeks (IQR: 24 - 177.25). The interval between dilatations prior to the first BD stent placement (median: 34.25 days, IQR: 23.06 - 48.29) was significantly shorter than the interval between the first BD stent placement and the first intervention required (median: 149.5 days, IQR: 94.25 - 209.5) and this difference was statistically significant (P = 0.012). Ten patients with esophageal cancer (8 male, median age: 69 years, IQR: 59.25 - 80.75) were included and they were followed up for a median of 36 weeks (IQR: 26 - 58). Only 1 completed radical radiotherapy successfully, but developed refractory post-radiotherapy stricture. No one proceeded to esophagectomy and 50 % required a self-expanding metal stent (SEMS) at a median of 134 days (IQR: 100 - 263) following stent placement.

CONCLUSIONS

BD stents were successfully deployed in both benign and malignant strictures. They offered a prolonged dilatation-free interval in benign strictures, yet in the majority of patients, strictures recurred. In malignant strictures, stent patency was similar to that of benign strictures, which suggests a potential value in ensuring adequate oral intake during oncologic therapy. In our cohort, however, use of stents did not contribute to improved outcome.

Feeding Challenges in Patients with Esophageal and Gastroesophageal Cancers

BACKGROUND

Patients undergoing treatment for esophagogastric or esophageal cancer are exposed to a considerably high risk of malnutrition due to early obstruction of the gastrointestinal passage. Presently most of the patients undergo modern multimodal therapies which require chemoradiation or chemotherapy ahead of surgery. Therefore reconstruction of the obstructed gastrointestinal passage is considerably delayed. Surgery as the only curative option after neoadjuvant treatment is the mainstay of therapy in this setting. However, many patients are at risk for the development of postoperative complications associated with the complexity of the surgical procedure. Therefore enteral feeding as a prerequisite to avoid malnutrition represents a special therapeutic challenge.

SUMMARY

This review describes the recent literature on the incidence and influence of perioperative malnutrition on oncologic outcome, measures to determine patients at risk, possible strategies to reduce or avoid malnutrition by supportive enteral/parenteral nutrition, implementation of the enhanced recovery after surgery programs and feeding routes, but also surgical and adjuvant procedures in the curative and palliative setting for patients undergoing treatment for gastroesophageal cancers.

KEY MESSAGES

Appropriate identification of patients at risk is crucial to avoid malnutrition. Early nutritional interventions during multimodal/neoadjuvant treatment may be beneficial for weight loss reduction although the evidence is not conclusive. Pouch reconstructions during surgery should be applied in order to increase quality of life and eating capacity. Reduction of postoperative complications could provide potential benefits. In palliative patients, insertion of self-expanding metal stents can reduce dysphagia and improve quality of life, but does not prolong overall survival. Further evidence is required to determine the value of the procedures and measures described in this review.

PRACTICAL IMPLICATIONS

Nutritional risk scoring should be performed for every gastroesophageal cancer patient. Sophisticated reconstruction methods and early recovery programs should be enforced to reduce perioperative starvation periods. Self-expanding metal stents should be used for palliative patients.