Comparison of low-power YAG laser and BICAP tumor probe for palliation of esophageal cancer strictures

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.

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.

[Palliative endoscopic treatments for esophageal cancers]

Esophageal cancer five-year survival has slightly increased during past 20 years (from 5 to 9%), but remains low. At time of diagnosis, 60% of the patients are only relevant for palliative therapy. Recent advances in therapeutic endoscopy have allowed improving dysphagia and quality of life. Endoscopic techniques are chosen according to tumor characteristics. According to French societies guidelines (FFCD, "Standards-Options-Recommandations" from FNCLCC, SNFGE) endoscopic treatment is a "gold standard" for metastatic patients with poor performance status, as well as oesophago-tracheal fistula. Expandable metal stent are efficient for malignant stenosis with lower morbidity and mortality than plastic prosthesis. Endoscopic placement of a covered self-expanding metal stent is the treatment of choice of an esophago-respiratory fistula. Dilatation is often the first step before other endoscopic therapies or medical treatment such as radiochemotherapy. Single dose brachytherapy could provide better long-term relief of dysphagia and fewer complications than stent placement, but is less widespread. Other techniques like bipolar electrocoagulation have restricted indications especially for circonferential stenosis of cervical esophagus. However, the main problem remains the dysphagia relapse after treatment.

New approach to malignant strictures of the esophagus

Primary esophageal cancer is the most common cause of malignant esophageal stricture. Prognosis and treatment outcomes vary with the stage of the disease. Endoscopic ultrasound has a high accuracy rate for local and regional staging. Surgery is curative for early cancer. Endoscopic mucosal resection, photodynamic therapy, or brachytherapy can be used with curative intent for early cancer, especially in patients with comorbid conditions precluding surgery. Unfortunately, the majority of patients with esophageal cancer present with advanced disease. The primary aim in these patients is to alleviate symptoms with a minimum of side effects and reinterventions. Palliative surgery or chemoradiotherapy can be associated with high morbidity and mortality rates. Several endoscopic techniques for palliation are available, and all have the potential of significantly improving swallowing. The choice of a particular endoscopic approach is usually determined by local expertise and characteristics of the stricture.

Complications of upper GI endoscopy

This is one of a series of statements discussing the utilization of gastrointestinal endoscopy in common clinical situations. The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy prepared this text. In preparing this guideline, a MEDLINE literature search was performed, and additional references were obtained from the bibliographies of the identified articles and from recommendations of expert consultants. When little or no data exist from well-designed prospective trials, emphasis is given to results from large series and reports from recognized experts. Guidelines for appropriate utilization of endoscopy are based on a critical review of the available data and expert consensus. Further controlled clinical studies are needed to clarify aspects of this statement, and revision may be necessary as new data appear. Clinical consideration may justify a course of action at variance to these recommendations.

Methods of palliation of esophageal and gastric cancer

Esophageal and gastric malignancies are common worldwide. Less than half are amenable to curative treatment at the time of diagnosis because of advanced or metastatic disease. Palliation is often required for symptoms, such as dysphagia, gastrointestinal bleeding, aspiration caused by tracheoesophageal fistula, nausea and emesis secondary to gastric outlet obstruction, and malnutrition. This article reviews the gastric outlet obstruction, and malnutrition. This article reviews the medical, endoscopic, and surgical options for palliative treatment.

Esophageal cancer: a systematic review

Carcinoma of the esophagus has one of the lowest possibilities of cure, with 5-year survival rates estimated to be approximately 10% overall; these rates are second only to hepatobiliary and pancreatic cancers. This fact and the rapid increase in the incidence of adenocarcinomas of the esophagus in recent years challenges us to identify areas of improvement for all aspects of this disease. We discuss potential reasons for the increase in the incidence of adenocarcinomas, evidence that defines the similarity between tumors of the gastroesophageal junction and the tubular esophagus, and other prognostic factors that may influence future modifications of our staging classification of this disease. Surgical advances have translated into improvements in surgical morbidity and mortality rates. Current therapeutic options and the relative merits of the options are discussed. Improvements in patient outcome most likely hinge on earlier diagnosis, more accurate staging, and the optimal use of combined modalities, coupled with technical advances in the modalities. A systematic review approach was undertaken to evaluate the performance characteristics of newer staging tools and the value of different combined modality approaches with particular focus on the use of those approaches for patients with potentially curable disease. A similar methodologic approach was used to address the utility of the many strategies currently used in practice for the palliation of esophageal tumors, with particular focus on the relief of malignant dysphagia. Finally, a summary of published guidelines and population-based patterns of care are presented. This serves as an overview of how all of this evidence actually translates into the care we are providing. A coordinated international effort in population-based research and randomized controlled trials would be the cornerstone to future advances in this relatively uncommon but devastating disease.

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.

The spectrum of spontaneous and iatrogenic esophageal injury: perforations, Mallory-Weiss tears, and hematomas

Esophageal perforations, Mallory-Weiss tears, and esophageal hematoma involve traumatic injury to the esophagus. These can be iatrogenic, in particular due to esophageal instrumentation, but can also occur spontaneously. The remarkable increase in diagnostic and therapeutic endoscopy as well as esophageal surgery has made instrumentation the most common cause of esophageal perforation. In many instances, spontaneous perforations are associated with retching and vomiting, which causes a sudden increase in intraesophageal pressure. A high index of suspicion leading to rapid diagnosis and appropriate therapy are needed to optimize clinical outcomes. This article focuses on esophageal perforations, Mallory-Weiss tears, and esophageal hematomas, with emphasis on etiology, pathogenesis, clinical presentation, diagnosis, management, and prevention.

The cost effectiveness of metal oesophageal stenting in malignant disease compared with conventional therapy

Expanding metal oesophageal stents are being used more commonly to palliate patients with inoperable oesophageal carcinoma. Many reports have so far documented their clinical effectiveness, however, their high acquisition cost has caused on-going concern when compared with the cost of conventional therapies. We reviewed 64 consecutive patients with inoperable oesophageal carcinoma, half of whom had received our conventional method of palliation using a variety of techniques including, BICAP diathermy, alcohol injection and Atkinson tube insertion. The other half (32 patients) were treated with expandable metal stents -- Gianturco Z stents (Cook UK Ltd) and uncovered Ultraflex stents (Microvasive, Boston Scientific). The physical amount of resources consumed were identified and measured (number of diagnostic and support procedures, days as in patients, number of day cases or outpatient attending) and an average NHS cost was applied to this resource use. All costs were summated over the period of palliation from the date of the first intervention with palliative intent until death. Although the patients in this study were not randomized, the two groups were matched to ensure comparability in clinical manifestation (uncomplicated biopsy proven oesophageal carcinoma) and the average age of patients from each group. A difference was identified between the length of survival in both patient groups and the analysis was corrected for this by estimating a cost per day of palliative support. Patients palliated with metal stents underwent fewer procedures and spent fewer days in hospital during the time period from presentation until death even when corrected for differences in survival. Patient outcome (effectiveness of palliation) was measured by recording mean dysphagia scores which were recorded before and after palliation. Metal stents were found to lead to a significantly higher improvement in dysphagia in comparison to conventional therapy. In addition, the mortality related to metal oesophageal stents was lower than Atkinson tube insertion. The average cost of palliation was much lower in the metal stent group (mean = pound sterling 2817) compared with the cost in those palliated conventionally (mean = pound sterling 4566). However, once this was corrected for survival the difference in the cost of palliation on a per diem basis was reduced (metal stents = pound sterling 60 per day, conventional group = pound sterling 72 per day). The results of our study indicate that the initial high cost of metal stents is more than outweighed by resource savings elsewhere in the hospital by virtue of reduced need for re-intervention and shorter length of hospital in patient stay. Such cost savings taken in combination with the improved clinical effectiveness and low mortality related to metal stents provide significant support for introducing their use into clinical practice.

Endoscopic therapy of esophageal cancer

In the management of esophageal cancer, endoscopy has evolved from a tool used to provide biopsy confirmation of suspected tumor to an integral part of the staging and ongoing treatment of patients. Endoscopic ultrasound is currently the most accurate means for T and N staging. Improved endoscopic techniques like dye staining and aggressive biopsy protocols can identify very early stage tumors in high-risk groups and allow curative surgery. Patients with early-stage tumors who are not surgical candidates can also be treated with endoscopic mucosectomy, photodynamic therapy, or Nd:YAG laser and still have a chance of long-term cure. Palliation of advanced tumors remains the major role of endoscopy in patients with esophageal cancer. A variety of techniques have proven effective over the years, including dilatation, laser, and rigid prostheses. Newer developments like bipolar probes, injection therapy, photodynamic therapy, and brachytherapy offer potential applications. The development and continuing improvements in both coated and uncoated expandable metal stents have been perhaps the greatest recent advance in endoscopic palliation of malignant dysphagia and esophagorespiratory fistulas. With the increasing array of endoscopic treatments and palliative techniques, emphasis must be placed on considering functional status; tumor characteristics like stage, location, and shape; patient wishes; and local expertise in tailoring treatment plans for each situation.

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.

Palliation of oesophageal carcinoma using the argon beam coagulator

Oesophageal intubation occasionally fails to palliate inoperable carcinoma: some tumours are unsuitable for this procedure and others overgrow the tube. This study reports a series of nine patients (median age 79 (range 55-87) years) in whom the argon beam monopolar coagulator via a flexible endoscopic probe was used to ablate such tumours. Fourteen ablation procedures were performed. The endoscope was passed to the stomach at the end of each procedure. There were no complications; the median hospital stay was 2 (range 1-13) days. Thirteen procedures rendered the patients completely asymptomatic for a median of 6 (range 4-12) weeks. Six patients died a median of 14 (range 4-38) weeks after the first ablation, reflecting their limited life expectancy. The argon beam coagulator provides an effective alternative to laser ablation, being considerably cheaper and safer, while maintaining the minimally invasive nature of the palliation.

Photodynamic therapy with porfimer sodium versus thermal ablation therapy with Nd:YAG laser for palliation of esophageal cancer: a multicenter randomized trial

BACKGROUND

Photodynamic therapy (PDT) is a different type of laser treatment from Nd:YAG thermal ablation for palliation of dysphagia from esophageal cancer.

METHODS

In this prospective, multicenter study, patients with advanced esophageal cancer were randomized to receive PDT with porfimer sodium and argon-pumped dye laser or Nd:YAG laser therapy.

RESULTS

Two hundred thirty-six patients were randomized and 218 treated (PDT 110, Nd:YAG 108) at 24 centers. Improvement in dysphagia was equivalent between the two treatment groups. Objective tumor response was also equivalent at week 1, but at month 1 was 32% after PDT and 20% after Nd:YAG (p < 0.05). Nine complete tumor responses occurred after PDT and two after Nd:YAG. Trends for improved responses for PDT were seen in tumors located in the upper and lower third of the esophagus, in long tumors, and in patients who had prior therapy. More mild to moderate complications followed PDT, including sunburn in 19% of patients. Perforations from laser treatments or associated dilations occurred after PDT in 1%, Nd:YAG 7% (p < 0.05). Termination of laser sessions due to adverse events occurred in 3% with PDT and in 19% with Nd:YAG (p < 0.05).

CONCLUSIONS

Photodynamic therapy with porfimer sodium has overall equal efficacy to Nd:YAG laser thermal ablation for palliation of dysphagia in esophageal cancer, and equal or better objective tumor response rate. Temporary photosensitivity is a limitation, but PDT is carried out with greater ease and is associated with fewer acute perforations than Nd:YAG laser therapy.

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.

Changes in the surgical management of esophageal cancer from 1970 to 1993

PURPOSE

To evaluate the changes since 1970 in the management and outcome of esophageal resection for cancer.

METHODS

The records of all 316 patients who underwent esophageal resection for cancer at University of California Los Angeles Medical Center during the years 1970 to 1993 were reviewed.

RESULTS

When records from 1984 to 1993 were compared to those from 1970 to 1983, significant decreases were seen in operative mortality (10% to 3%, P < 0.01), morbidity (72% to 60%, P < 0.05), anastomotic leaks (12% to 5%, P < 0.03), and reoperations (20% to 8%, P < 0.003). Time spent in hospital and in intensive care decreased 40%. These improvements in short-term outcome were most evident in patients with disease in later stages. The 5-year survival rate increased (12% to 21%, P < 0.01). A greater percentage of tumors presented in early stages (21% versus 37%).

CONCLUSIONS

Short-term outcome of surgical resection for esophageal carcinoma improved between 1970 and 1993, in part because of changes in perioperative and surgical management. Long-term survival improved, probably due to earlier detection of tumors.

Applications of lasers in gastroenterology

In this article the clinical uses of lasers in gastroenterology are reviewed. The endoscopic delivery of light for therapeutic as well as diagnostic purposes is discussed. Current research directions in the field are also indicated where appropriate.

Laser therapy for esophageal cancer. Results and additional endoscopic treatments

Between 1/1/1988 and 5/31/1991, we treated 96 patients with laser therapy to the esophagus. In 61 inoperable patients, laser therapy has been performed initially. In 64% of these 61 patients, laser therapy alone gave sufficient relief of symptoms until death. However, in 36% of the patients, additional endoscopical interventions had to be performed. In 14 patients (23%), a prosthesis became necessary; 13 patients (21%) needed a percutaneous endoscopical gastrostomy. We conclude that laser therapy has an important role in the treatment of esophageal cancer, but in a significant number of patients, it might not be sufficient alone.

Ablation of neoplasia by direct current

The application of low-voltage direct electrical current (DEC) has been studied in animals and humans for the ablation of anal condylomata, oesophageal cancer and Kaposi's sarcoma. Twenty milliamps of DEC passed through multiple 6 cm x 1 cm, flat-plate longitudinal electrodes into the squamous mucosa of the oesophagus of healthy dogs for periods ranging from 10 min to 2 h resulted in denudation and necrosis of the oesophageal mucosa at the site of application of the current. In humans, the application of DEC to two patients with benign anal condyloma acuminata, three patients with inoperable obstructing oesophageal cancer and one patient with disseminated Kaposi sarcoma resulted in striking necrosis of tumour tissue that was confirmed by macroscopic and microscopic studies. These initial findings imply promising therapeutic potential for the use of DEC as a simple, effective, safe, low-cost alternative for ablation of neoplasia.

Endoscopic treatment of major bleeding from advanced gastroduodenal malignant lesions

OBJECTIVE

To summarize the results of endoscopic therapy for acute hemorrhage from gastroduodenal malignant lesions.

DESIGN

The 3-year experience (1989 through 1991) of a specialized gastrointestinal (GI) bleeding team in the endoscopic treatment of acute upper GI bleeding from gastroduodenal malignant tumors was retrospectively reviewed.

MATERIAL AND METHODS

Of 1,083 consecutive patients with acute major upper GI hemorrhage, 21 (1.9%) were found to have advanced tumors of the stomach and duodenum, 15 of whom received endoscopic therapy. In this study group of 15 patients, the tumors were gastric in 11 and duodenal in 4. Endoscopic treatment consisted of injection of epinephrine, heater probe coagulation, neodymium:yttrium-aluminum-garnet laser coagulation, or injection of sodium tetradecyl sulfate.

RESULTS

Initial endoscopic hemostasis was achieved in 10 of the 15 patients (67%); however, bleeding recurred in 8 of 10 (80%), and all 5 in whom endoscopic hemostasis was not achieved continued to bleed. Mean transfusion requirements for the 30 days before and the 30 days after the first endoscopic treatment were 7.6 and 6.4 units of packed erythrocytes, respectively (P > 0.10). Five major procedure-related complications occurred, two of which were fatal. The median duration of survival after the first endoscopic treatment was 39 days (range, 1 to 1,414).

CONCLUSION

In patients with major bleeding from advanced gastroduodenal malignant lesions, endoscopic therapy seems to provide limited benefit.

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)

Does performance status influence the outcome of Nd:YAG laser therapy of proximal esophageal tumors?

The value of endoscopic palliative therapy for malignant obstruction in the proximal esophagus has been questioned. To assess the importance of pre-treatment performance status on treatment outcome, we reviewed the records of patients with tumors of the proximal esophagus undergoing endoscopic laser therapy between January 1986 and December 1988. As compared with 10 patients having a good performance status, eight patients with a poor performance status had a lower frequency of obtaining complete functional relief of dysphagia (14% versus 71%), an increased rate of complications (50% versus 0%), and a shorter median survival time (24 days versus 161 days). We conclude that performance status should be considered in determining the appropriateness of laser therapy in patients with proximal esophageal cancer.

Palliation of malignant dysphagia by ethanol induced tumour necrosis

Thirty two patients (74 (43-93) years; median, (range)) with dysphagia because of inoperable, unresectable or recurrent oesophagogastric carcinoma were treated by ethanol induced tumour necrosis (ETN). Endoscopic injection of absolute alcohol was performed using a variceal injector needle, with 0.5-1 ml aliquots injected retrogradely from distal to proximal tumour margin. Dilatation to 12 mm was used only if the endoscope would not traverse the stricture. In patients with total occlusion, injection into the proximal tumour was followed by a repeat endoscopy 3-7 days later. Dysphagia was graded from 0 = no dysphagia to 4 = total dysphagia. The significance of changes in the dysphagia grade after ETN were assessed using the Wilcoxon rank sum test. Results (median (range)) were as follows: stricture length = 5.0 cm (1-15). Dysphagia grade before treatment was 3 (2-4) improving after first treatment to 1 (0-3), p < 0.003. Best dysphagia grade achieved was 1 (0-3) and interval between treatments was 28.5 days (4-170). The volume of ethanol injected = 10 ml (1.5-29) and survival after first treatment was 93 days (6-660). The number of treatment sessions required to achieve best grade = 1 (1-3). There were no treatment complications. ETN significantly improves dysphagia. Results of palliation are similar to those of laser therapy, but can be achieved quickly and safely on a day case basis in most patients and at a small proportion of the cost.

Silicone-covered self-expanding metallic stents for the palliation of malignant esophageal obstruction and esophagorespiratory fistulas: experience in 32 patients and a review of the literature

Esophagogastric malignancies often are manifested with progressive dysphagia or esophagorespiratory fistulas. Palliative modalities currently available have significant limitations. A modified Gianturco-Rösch silicone-covered self-expanding metallic Z stent was used in 32 consecutive patients with malignant esophageal obstruction (n = 24) or esophagorespiratory fistulas (n = 8). The stent was placed successfully in all patients. Dysphagia improved by at least two grades in 21 of the 24 patients (87.5%); the mean dysphagia grade fell from 3.21 to 1.08. Six of the 8 patients with fistulas were able to resume a normal diet, and the other 2 were able to eat solids without symptoms of aspiration. Complications occurred in 10/32 patients (31%) and included stent migration (4 patients), food impaction (2 patients), membrane disruption with tumor ingrowth (1 patient), tumor overgrowth (1 patient), early pressure necrosis with hemorrhage (1 patient), and late pressure necrosis with sepsis (1 patient). The latter 2 patients died, giving a mortality rate of 6.3%. Many complications were managed with endoscopic or interventional radiologic techniques. Although randomized prospective clinical trials are needed, the silicone-covered Gianturco-Rösch Z stent offers promise for the effective palliation of malignant esophageal obstruction and esophagorespiratory fistulas.

Radiation enhancement of laser palliation for malignant dysphagia: a pilot study

Laser therapy offers rapid relief of dysphagia for patients with cancers of the oesophagus and gastric cardia but repeat treatments are required approximately every five weeks to maintain good swallowing. To try to prolong the treatment interval, 22 elderly patients were given additional external beam radiotherapy. Nine had squamous cell carcinoma and 13 adenocarcinoma: five had documented metastases. Six received 40 Gy and 16,30 Gy in 10-20 fractions. A 'check' endoscopy was performed three weeks after external beam radiotherapy. Dysphagia was graded from 0-4 (0 = normal; 4 = dysphagia for liquids). The median dysphagia grade improved from 3 to 1 after laser treatment. This improvement was maintained in the 30 Gy group but there was a noticeable deterioration in three of those who had received the higher radiation dose. A lifelong dysphagia grade of 2 or better was enjoyed by 14 of 16 patients in the 30 Gy group but only two of six in the 40 Gy group. The dysphagia controlled interval was 9 weeks (median) after check endoscopy and subsequent endoscopic procedures were required every 13 weeks to maintain good swallowing. There were no endoscopy related complications. Combined treatment is a promising approach for reducing the frequency of endoscopic treatments. The 30 Gy dose seems more appropriate and may prolong survival. A randomised study to test these conclusions is in progress.

Endoscopic palliation for inoperable malignant dysphagia: long term follow up

This prospective non-randomised trial of 128 selected patients with unresectable oesophageal or gastrooesophageal junction cancers aims to evaluate the initial relief of malignant obstruction by means of bipolar electrocoagulation for both circumferential and submucosal strictures of Nd:YAG laser for the other patients. A limited dilatation was performed initially if a small calibre endoscope was unable to pass through the stricture. Prompt and significant relief of dysphagia without complications was achieved in 83% of patients. Improved patients were retreated monthly during the follow up period. Radiotherapy was recommended when possible. Symptomatic relief of obstruction lasted 4.2 months on average and 76% of patients remained palliated until death. Monthly retreatment using the most appropriate endoscopic procedure for the tumour configuration and radiotherapy after endoscopic relief of obstruction seems to give the best palliation for patients with unresectable cancers of the oesophagus or gastrooesophageal junction.

The rat esophagus: ultrastructure and radiological aspects of tissue response after 1320 nm Nd:YAG laser irradiation

Morphological tissue response towards laser treatment was investigated in the esophagi of adult Wistar rats by light- and transmission electron microscopy. The specimens were fixed by perfusion immediately, 2 days and 14 days after laser treatment in order to assess different stages of the healing process. The epithelium of the lasercentre was completely destroyed in the immediate group. The connective tissue showed damaged cells, fused collagenous fibres and occluded blood vessels. Smooth muscle cells presented a vacuolated sarcoplasm and pycnotic nuclei. The cross striation of skeletal muscle cells had disappeared and their nuclei were karyolytic. In a distance of 4 mm from the lasercentre all wall tissues had an almost normal appearance. After 2 days the morphological feature of the lasercentre was the same as in the immediate group. In a distance of 2 mm some layers of flat and intact epithelial cells were observed below the necrotic epithelium. The adjacent connective tissue was infiltrated by inflammatory cells. After 14 days the formation of granulation tissue had caused an occlusion of the lumen in the lasercentre. In a distance of 2 mm the lumen was patent and the wall tissues had been partly restored. As the rat esophagus serves as a model for esophagotracheal fistulae in newborn children we assume the 1320 nm Nd:YAG laser to be a possible application in occlusion of these fistulae.

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.

Laser treatment of esophageal and gastric lesions

Lasers have contributed in a significant way to the evolution of therapeutic endoscopy. Their ability to coagulate and ablate tissue precisely has been applied to a wide variety of lesions in the upper gastrointestinal tract. Meanwhile, the number of nonlaser devices has also continued to expand, making it necessary to frequently reassess their respective roles. Available evidence suggests that current laser equipment is best suited for the palliative ablation of tumors, especially in the esophagus. On the other hand, the hemostatic properties of the laser are still indicated in the control of vascular malformations but have been largely displaced in the management of peptic ulcer disease by other, more convenient and less expensive methods. With a new generation of laser equipment likely to be introduced soon, these comparisons will undoubtedly need to continue for some time.

Recanalization of tube overgrowth: a useful new indication for laser in palliation of malignant dysphagia

Overgrowth of an esophageal prosthesis by cancer is a late complication of insertion which presents a difficult management problem. We have treated 14 such patients; 9 had Celestin tubes and 5 Atkinson tubes in situ for a median of 7 months. The median patient age was 75 years; 3 had squamous cell carcinomas and 11 adenocarcinomas; 12 were at the lowest thoracic esophagus or cardia, and 2 were anastomotic. Eleven tubes were overgrown at the top, two at the bottom only, and one at both ends. Dysphagia was graded from 0 to 4 (0 = normal; 4 = dysphagia for liquids). All patients but one improved with treatment. The median pre-treatment grade was 4 (range, 2 to 4) and post-treatment was 2 (0 to 3). This improvement was significant (p less than 0.01) Wilcoxon-signal rank). Most patients required only one or two endoscopies. The median survival was 9 weeks from first laser session (range, 3 to 36 weeks). We feel these results justify laser treatment in most patients in whom cancer overgrowth causes blockage of an esophageal prosthesis.

Palliation of malignant esophageal obstruction

Progressive dysphagia is common in patients with advanced esophageal carcinoma. Multiple nonsurgical techniques are available to provide palliation and improved nutrition. Simple dilatation is the oldest technique and newer methods may offer greater efficacy. Laser therapy now provides an excellent opportunity to treat obstructing tumors. Placement of an esophageal prosthesis may become particularly useful when dilatation must be performed too frequently or has become ineffective or in the patient with an esophageal-pulmonary fistula. Newer techniques including BICAP tumor probe, intracavitary radiotherapy, or absolute alcohol injection offer promise. This review discusses the advantages and disadvantages of these different palliative techniques for patients with the extremely poor prognosis associated with esophageal cancer.

Palliative bipolar electrocoagulation treatment of malignant gastroesophageal strictures

Seventeen patients with non-resectable circumferential malignant strictures of the esophagus (n = 13) or the gastroesophageal junction (n = 4) were treated with a bipolar electrocoagulation tumor probe (BICAP). None had received prior radiotherapy or chemotherapy. The mean tumor length was 7.2 cm. After treatment swallowing was improved in 86.7% of the patients. The mean duration of response to the first treatment was 18 days. Three major complications (1 fatal hemorrhage, 2 tracheoesophageal fistulae) and two minor complications (chest pain) were observed. The overall actuarial survival rate after 13 months of follow-up was 20%. The BICAP tumor probe can be considered an efficacious and safe device in selected patients with long, circumferential esophageal cancers.