The consequences and effectiveness of intubation in the palliation of dysphagia due to benign and malignant strictures affecting the oesophagus

Endoscopic Insertion of Celestin Tubes in Carcinoma of the Oesophagus

‘Carcinoma of the oesophagus is by no means uncommon, and few conditions are more distressing. If left to himself the patient has nothing to look forward to but death by slow starvation … The problem of his relief is the purely mechanical one of relieving his obstruction.’

Sir Henry S Souttar 1924

Outcome, survival, and costs in patients undergoing intubation for carcinoma of the esophagus

BACKGROUND

In this prospective study a consecutive series of 70 patients undergoing insertion of a Wilson-Cook endoprosthesis for palliation of esophageal carcinoma was examined.

METHODS

The tube was inserted endoscopically using intravenous sedation and a pulsion technique.

RESULTS

The patients had a mean (SEM) age of 70.7 (1.5) years and 44 (63%) were men. Two patients died in hospital and 2 died after discharge, giving a procedure-related mortality of 2.8% and a 30-day mortality of 5.7%. Nine patients experienced complications, giving a morbidity rate of 12.8% following the initial procedure. Twenty patients required a second or further procedure. The indications were tube migration in 22 cases, obstruction in 10, and fistula formation in 2 patients. Thirty-day mortality in this group was significantly greater than after a first procedure (7 patients, 20.1%; P <0.05). The median survival following insertion of a Wilson-Cook endoprosthesis was 16 weeks.

CONCLUSIONS

This study describes a safe, effective method for insertion of an endoprosthesis, with a low morbidity and mortality. The average cost for endoscopic insertion of a Wilson-Cook endoprosthesis in this unit is $1,600, and in view of the short median survival in this group of patients, the introduction of costly self-expanding stents is not warranted without demonstrable benefits in a controlled, prospective, randomized clinical trial.

Endoscopic patch closure of malignant esophagotracheal fistula using Histoacryl glue

Esophagotracheal fistula is one sequel of advanced carcinoma of the esophagus. Although the pneumatic cuffed tracheoesophageal fistula stent provides satisfactory palliation for fistulas, high fistulas remain a major problem. We report a case of a 64-year-old gentleman with a high fistula that was treated successfully with endoscopic patch closure using Histoacryl glue.

Limitations of laser treatment for malignant dysphagia

Of 86 patients with inoperable malignant dysphagia, 68 (79 per cent) underwent successful palliation by endoscopic laser therapy, of whom 24 remained well palliated until the time of death. In 18 patients laser treatment was unsuccessful and nine of these underwent intubation, eight successfully. After successful laser therapy, dysphagia recurred in 44 patients a mean of 7.8 weeks later. Of these, 31 received palliation until death by dilatation with or without laser therapy, and 13 required intubation. The overall laser-related complication rate was 12 per cent with a mortality rate of 4 per cent. The intubation-related mortality rate was 9 per cent.

Lasers in surgery

In January 1991 the winter meeting of the Surgical Research Society was held at St. Bartholomew's Hospital and the Institute of Education, London. During the meeting a symposium was held entitled 'Shedding light on lasers'. Speakers addressed the general principles of lasers, laser-tissue interactions and the applications of lasers in gastro-enterology and in vascular disease. This was followed by an open discussion of the current indications, complications and outcome, together with future possible applications for lasers in medicine.

Endoscopic placement of a prosthesis for benign anastomotic stenosis after oesophagectomy and colonic interposition

After oesophagectomy for oesophageal carcinoma and retrosternal colonic interposition, a benign stenosis developed at the collar anastomosis. Bouginage was unsuccessful. Therefore, a prothesis was placed endoscopically, which enabled the patient to swallow without problems until his death as a result of diffuse metastasis 9 months later.

Endoscopic Nd-YAG laser therapy for palliation of upper gastrointestinal malignancy

Endoscopic laser therapy with the neodymium-yttrium-aluminium-garnet (Nd-YAG) laser has been shown to provide good palliation of upper gastrointestinal obstruction caused by malignancy, and to be associated with a low morbidity and a low mortality rate. Fifty patients with inoperable upper gastrointestinal malignancy have been treated with this method: 22 had oesophageal carcinoma, 16 adenocarcinoma at the cardio-oesophageal junction, two carcinoma of the antrum and 10 recurrent tumours at the site of previous anastomoses. The main symptoms were dysphagia in 40 and vomiting in seven; three others had recurrent bleeding. An Nd-YAG laser was used to photocoagulate the tumours using power levels of 50-100 W and an average energy output per treatment of 10,000 J. Thirty patients (75%) with dysphagia improved with treatment but vomiting was relieved in only three of the seven patients with this symptom. Complications were infrequent--two patients (4%) developed a perforation and one had a respiratory arrest which was reversible. The 30-day mortality rate was 14% with 2% being related to the procedure. Endoscopic Nd-YAG laser therapy is an acceptable alternative to the more established methods of palliation such as surgical or endoscopic intubation.

Prospective randomised trial of laser therapy only and laser therapy followed by endoscopic intubation for the palliation of malignant dysphagia

Forty six consecutive patients admitted for the relief of malignant dysphagia were prospectively randomised to receive laser therapy only or initial laser therapy followed by endoscopic intubation. Twenty patients were treated in each group with six exclusions. The patients' swallowing ability was assessed before and during the remainder of their life on a 0-4 scale with 0 being normal swallowing and 4 total dysphagia. The patient's quality of life was measured at the same times, using a physician's assessment (QL index) and the patient's own assessment using a linear analogue self assessment (LASA). There was a significant correlation between all the QL index and the LASA scores collected (n = 126; rs = 0.594, p less than 0.001). The mean monthly dysphagia grade correlated with the QL index (rs = 0.433, p less than 0.001) and the LASA (rs = 0.272, p less than 0.002). There was no significant difference in the dysphagia grade before or after treatment in either group. Dysphagia fluctuated more in those treated with the laser only, however, than in those with a tube inserted. There was also no significant difference in the quality of life measured between the two groups of patients. The complication rate (laser only 10%, laser/intubation 40%, p less than 0.05) was significantly higher in intubated patients. The recurrent dysphagia rate (laser only 25%, laser/intubation 45%, NS) was higher in patients treated with intubation, but they required fewer endoscopic procedures. Overall both procedures were effective in relieving dysphagia and in maintaining quality of life. There was no procedure related mortality in either group.

Photodynamic therapy of skin and esophageal cancers

We report on 27 patients with cutaneous and subcutaneous malignancies and 40 patients with esophageal tumors treated with photodynamic therapy (PDT). Of those patients treated for skin tumors, seven had basal cell, three squamous cell, three malignant melanoma, one liposarcoma, and twelve had breast cancers. One patient had Bowen's disease. Treatment was given either by surface radiation or interstitially. One month after treatment, 48 (67%) of the treatment sessions resulted in a complete response (no clinical evidence of tumor) and 19 (26%) resulted in a partial response (more than a 50% reduction in the number or size of tumors). Of the 15 patients evaluable 12 months after treatment, 31 treatment sessions were evaluated as complete response 1 month after therapy, 15 (48%) of which retained this status at 1 year posttreatment. Esophageal tumors were as follows: 19 adenocarcinomas, 19 squamous carcinomas, and 2 melanomas. Most patients were reendoscoped 2 to 3 days after PDT and repeat endoscopies were performed 1 month after PDT and as needed when symptoms recurred. The goal of therapy was to improve the patient's ability to swallow. At 1 month, the average length of all tumors decreased from 7.0 to 6.1 cm, and the average minimal diameter opening increased from 6 to 9 mm. Of the 35 patients who were evaluable 1 month after PDT, the average diet grade improved from 16 to 32 (i.e., improvement in food intake from a liquid to a soft diet).

Method of endoscopic esophageal intubation using a rigid esophagoscope

Endoscopic intubation of malignant esophageal strictures carries a substantial risk of esophageal perforation. We have developed a method of endoscopic intubation that reduces to a minimum the elements of the procedure that have to be performed "blind." The use of this method has been associated with a reduction in perforation rates when compared with other series.

Efficacy of rehabilitative management of dysphagia

Efficacy of treatment for dysphagia in medically stable patients was defined as a reduction in the occurrence of aspiration pneumonia. Aspiration pneumonia was diagnosed by radiographic and/or laboratory analysis and was identified by retrospective chart review. Two groups of treated patients (48 without and 13 with a history of aspiration pneumonia) were compared to a group of untreated patients. There were no statistically significant differences in the occurrence of aspiration pneumonia in the treated groups, but both treated groups were subject to significantly less aspiration pneumonia than the untreated group. Measures of severity indicated that even mildly dysphagic patients were at risk for the development of aspiration pneumonia, and even severely dysphagic patients responded to rehabilitative management of their swallowing problems. Efficacy of treating swallowing was demonstrated, and a general outcome criterion for treatment was proposed.

Clinical and pathological study of dysphagia conservatively managed in patients with advanced malignant disease

A series of patients with dysphagia associated with terminal malignant disease is presented. 33 patients had clinical evidence of organic dysphagia associated with tumours of the upper aerodigestive tract. Over 80% of this group who underwent necropsy had locally obstructive lesions. Conservative treatment alone led to amelioration of dysphagia in approximately 60% of patients.

Management of oesophageal cancer at Westmead Hospital from 1979-1985

The aim of this study was to evaluate the various treatment options, including radiotherapy, surgery and chemotherapy, when all patients with carcinoma of the oesophagus were assessed and managed by the same team. From December 1, 1979 to December 31, 1985, 144 patients with carcinoma of the oesophagus were referred to Westmead Hospital. Eighty-five patients were men, 59 patients were women and the median age was 63 years. Twenty-five patients were at stage I, 75 patients were at stage II, 24 patients were at stage III and 20 patients were at stage IV of oesophageal cancer. Forty-two patients underwent surgical resection. Fifty patients underwent radical radiotherapy, 30 patients underwent palliative radiotherapy and 22 patients underwent palliative intubation. The operative mortality of those patients who underwent surgery was zero. The treatment mortality of those who underwent radical radiotherapy was 6%, and for those who underwent palliative radiotherapy, was 16.7%. The mortality after intubation was 12.5%. The prevalence of benign strictures was 7.5% after surgery, 33% after radical radiotherapy and 8% after palliative radiotherapy. The prevalence of malignant strictures (recurrent disease) was 2.5% after surgery, 21% after radical radiotherapy and 20% after palliative radiotherapy. The median survival after surgery was 12 months; that after radical radiotherapy, 12 months; that after palliative radiotherapy, six months; and that after intubation, 3.5 months. Where all patients with carcinoma of the oesophagus were managed by a team approach the treatment mortality was low but the long-term survival remained poor.

Bypass surgery for unresectable oesophageal cancer: early and late results in 124 cases

The early and late results of bypass surgery in 124 patients with unresectable oesophageal cancer are reported. Patients were grouped according to the extent of disease: group A, tumour localized to the oesophagus where severe pulmonary disease contra-indicated oesophagectomy (n = 9); group B, tumour less than or equal to 10 cm in length with mediastinal invasion (n = 81); group C, tumour greater than 10 cm in length with mediastinal invasion and/or fixed malignant lymph nodes (n = 33). Extent of disease was not recorded in one patient. The operative mortality was 4 per cent but 9 other patients died in hospital (hospital mortality, 11 per cent). Mortality was increased in patients undergoing colon bypass and in those with a large tumour load but these differences failed to reach statistical significance. The most frequent complication was neck sepsis, secondary to leakage from the proximal end of the excluded oesophagus. Eighty-nine per cent of the survivors could eat a normal, unrestricted diet on discharge and eighty-two per cent of survivors had complete and lasting relief from dysphagia. Median survival after bypass was 5 months but survival was significantly improved by radiotherapy to the tumour (P less than 0.001). Gastric bypass with radiotherapy is indicated in patients with extra-oesophageal spread of malignancy and in patients with tumours localized to the oesophagus who are unfit for resection. Bypass surgery may be contra-indicated in patients with a primary tumour greater than 10 cm in length and/or fixed lymph node metastases because mortality is increased and survival after operation is short.

Preliminary experience with a combined-modality approach to the management of oesophageal cancer

A synchronous chemoradiotherapy schedule of modest dosage has been used in 36 patients with oesophageal cancer since July 1984 at the Royal Adelaide Hospital. The schedule, which comprises two five-day continuous infusions of 5-fluorouracil, each of which is followed by a short cisplatin infusion, together with 30-35 Gy of megavoltage irradiation over three weeks, has been used alone, or before surgical resection or further chemo-irradiation. It has been extremely well tolerated and has caused complete endoscopic resolution of disease before surgery or further chemo-irradiation in 69% of patients. At the end of the full course of treatment, complete relief of dysphagia has been achieved in 27 (84%) of the 32 patients in whom this symptom was present at the start of treatment. The median duration of relief has not yet been reached with a median follow-up of over one year. This degree of palliation is significantly better than that which was achieved in a series of patients who were treated radically either by surgery or radiation alone between the years 1978 and 1983 at the Royal Adelaide Hospital. The 12- and 18-month actuarial survival figures of 72% and 55%, respectively, for the 30 patients in this series whose disease remained apparently localized to the thorax at presentation, compare very favourably with the corresponding figures for the much more highly-selected group of patients who were treated surgically between 1978 and 1983.

Palliative laser therapy for malignant dysphagia

Seventy six patients with dysphagia caused by malignant tumours of the oesophagus or gastric cardia have been treated using the Neodymium Yttrium Aluminium Garnet (NdYag) laser. The laser was set to deliver 80-100 watts of power for 0.5-1 second pulses. To obtain improvement, patients on average needed four treatment sessions with a mean energy per treatment of 3586 joules. Follow up endoscopy and laser treatment was at four week intervals, unless the clinical or endoscopic results indicated otherwise. The immediate result was to allow 32% of patients to swallow anything they liked, a further 54% were able to take most solids and 9% were improved, or maintained on liquids only. The mortality of laser recanalisation and associated treatment was 5%. The improvement in swallowing was maintained until death in all but 15% of these patients, some of the 15% needed intubation to allow adequate swallowing. Endoscopic, or surgical intubation was required immediately in five patients after an initial laser course failed to provide improvement. The mean survival of the whole group was 19 weeks (range one to 112 weeks).

The diagnosis and management of perforations of esophagus and pharynx sustained during intubation of neoplastic esophageal strictures

Twenty-six esophageal and eight pharyngeal perforations sustained during palliative intubation of esophagogastric neoplasms have been reviewed. The majority of the tears were recognized either endoscopically or by the immediate development of subcutaneous emphysema. However, 15 perforations were first identified by radiology, and 10 of these 15 patients were initially asymptomatic. In the years 1976-1979 with conservative management, three patients of eight died from the perforation and none had a pneumothorax. From 1980 a more aggressive nonsurgical approach was used, and of 26 patients who sustained a perforation, there were six deaths before leaving hospital but only four deaths were directly related to the perforation and each of these had sustained a pneumothorax. Pharyngeal tears invariably did well with conservative management. Our experience favors conservative management for instrumental esophageal perforation.

Palliation of esophageal malignancy with photodynamic therapy

Sixteen patients with esophageal malignancies received photodynamic therapy after 3 mg of hematoporphyrin derivative (Photofrin I) or 2 mg of Photofrin II per kilogram of body weight was injected intravenously two to six days prior to treatment. A tunable dye argon laser system delivered 630 nm light through quartz fibers passed through the biopsy channel of a gastroscope. All patients obtained improvement in swallowing, usually from total obstruction or clear liquids only to a regular diet within three weeks and with new techniques, at least liquids within three days of treatment. Karnofsky Performance Status (KPS) and esophageal grades were measured before treatment, 1 month following treatment, and periodically until death. Ten patients died an average of 3.7 months after initial treatment (range, 0.6 to 19 months). Six patients are alive at 11, 10, 5, 2.5, 2 months, and 1 month after treatment. The median survival of 12 patients treated more than 6 months ago was 6.5 months and of 9 patients with an initial KPS higher than 30, 8.1 months.

Surgical treatment of squamous cell carcinoma of the oesophagus

During the period 1976-1983, a total of 72 patients with squamous cell carcinoma of the oesophagus were seen. Exploration was undertaken in 62 patients and all those explored had their tumours resected. The overall operative mortality rate was 12.9 per cent. Overall survival rates were 49 per cent at 1 year, 31 per cent at 2 years and 11.5 per cent at 5 years.