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

Management and outcomes of localized esophageal and gastroesophageal junction cancer in older patients

BACKGROUND

Older patients are commonly excluded from clinical trials in esophageal and gastroesophageal junction (gej) cancer. High-level evidence to guide management in this group is lacking. In the present study, we compared outcomes and described tolerance for curative- and noncurative-intent treatments among patients 70 years of age and older.

METHODS

We retrospectively reviewed all patients 70 years of age and older diagnosed with localized esophageal and gej cancer at our centre between 2005 and 2012.

RESULTS

The 74 patients identified had a median age of 77 years. Of those patients, 62% received curative-intent treatment, consisting mostly of concomitant chemoradiation therapy (n = 43, 93%). Median overall survival for patients receiving curative-intent treatment was 18.6 months [95% confidence interval (ci): 13.0 to 28.0 months], with 23% being long-term survivors (95% ci: 11.3% to 36.7%). In contrast, patients receiving noncurative-intent treatment had a median overall survival of 8.8 months (95% ci: 6.7 to 11.9 months), with none being long-term survivors (p < 0.0001). Improvement of dysphagia was seen after curative (81%) or palliative radiotherapy (78%) in symptomatic patients, and toxicities were manageable. The odds of not receiving curative treatment was higher by a factor of 8.5 among patients 80 years of age or older compared with those 70-79 years of age (95% ci: 2.5 to 28.7).

CONCLUSIONS

In managing older patients with esophageal and gej cancer, curative-intent treatment (compared with noncurative-intent treatment) leads to a significant survival benefit with a reasonable toxicity profile. Informed counselling of patients and their families about a curative treatment approach and efforts to increase awareness among oncology care providers are suggested.

Endoscopic complications--avoidance and management

The frequency of endoscopic complications is likely to rise owing to the increased number of indications for therapeutic procedures and also to the increased complexity of endoscopic techniques. Informed patient consent should be obtained as part of the procedure. Prevention of endoscopic adverse events is based on knowledge of the relevant risk factors and their mechanisms of occurrence. Thus, suitable training of future gastroenterologists and endoscopists is required for these complex procedures. When facing a complication, appropriate management is generally provided by an early diagnosis followed by prompt therapeutic care tailored to the situation. The most common complications of diagnostic and therapeutic upper gastrointestinal endoscopy, retrograde cholangiopancreatography, small bowel endoscopy and colonoscopy are reviewed here. Different modalities of medical, endoscopic or surgical management are also considered.

Enteral stents

The American Society for Gastrointestinal Endoscopy (ASGE) Technology Committee provides reviews of existing, new, or emerging endoscopic technologies that have an impact on the practice of GI endoscopy. Evidence-based methodology is used, with a MEDLINE literature search to identify pertinent clinical studies on the topic and a MAUDE (U.S. Food and Drug Administration Center for Devices and Radiological Health) database search to identify the reported complications of a given technology. Both are supplemented by accessing the "related articles" feature of PubMed and by scrutinizing pertinent references cited by the identified studies. Controlled clinical trials are emphasized, but in many cases, data from randomized, controlled trials are lacking. In such cases, large case series, preliminary clinical studies, and expert opinions are used. Technical data are gathered from traditional and Web-based publications, proprietary publications, and informal communications with pertinent vendors. Technology Status Evaluation Reports are drafted by 1 or 2 members of the ASGE Technology Committee, reviewed and edited by the committee as a whole, and approved by the Governing Board of the ASGE. When financial guidance is indicated, the most recent coding data and list prices at the time of publication are provided. For this review, the MEDLINE database was searched through August 2010 for articles related to enteral, esophageal, duodenal, and colonic stents. Technology Status Evaluation Reports are scientific reviews provided solely for educational and informational purposes. Technology Status Evaluation Reports are not rules and should not be construed as establishing a legal standard of care or as encouraging, advocating, requiring, or discouraging any particular treatment or payment for such treatment.

Esophageal stenting

Malignant obstruction of the esophagus is a debilitating condition, with dysphagia as its main symptom. Many patients present with advanced disease and palliative treatment is the only possibility. Since their widespread introduction 10 years ago, self-expanding metal stents have become accepted as an extremely effective method of palliating malignant dysphagia. Early reports suggesting very low complications have been superseded by results from randomized trials. It is now evident that the complication rate is significant and the need for reintervention can be as high as 50%. Modifications in stent design should reduce this reintervention rate. There are a large number of stent designs now available and it is essential that the interventional radiologist understand the particular strengths and weaknesses of each design, so that the correct choice of stent can be made for a particular patient. The most recent designs include antireflux stents and removable stents. Both represent significant advances and should reduce stent-related complications.

Palliation of malignant esophageal obstruction and fistulas with self expandable metallic stents

AIM: To evaluate the efficacy of self expandable metallic stents (SEMS) in patients with malignant esophageal obstruction and fistulas.

METHODS: SEMS were implanted in the presence of fluoroscopic guidance in patients suffering from advanced and non-resectable esophageal, cardiac and invasive lung cancer between 2002 and 2009. All procedures were performed under conscious sedation. All patients had esophagus obstruction and/or fistula. In all patients who required reintervention, recurrence of dysphagia, hemorrhage, and fistula formation were indications for further endoscopy. Patients’ files were scanned retrospectively and the obtained data were analyzed using SPSS 13.0 for Windows. The χ² test was used for categorical data and was analysis of variance for non-categorical data. Patients’ long-term survival was assessed using the Kaplan-Meier method.

RESULTS: Stents were successfully implanted in 90 patients using fluoroscopic guidance. Reasons for stent implantation in these patients were esophageal stricture (77/90, 85.5%), external pressure (8/90, 8.8%) and tracheo-esophageal fistula (5/90, 5.5%). Dysphagia scores (mean ± SD) were 3.37 ± 0.52 before and 0.90 ± 0.43 after stent implantation (P = 0.002). Intermittent, non-massive hemorrhage due to the erosion caused by the distal end of the stent in the stomach occurred in only one patient who received implementation at cardio-esophageal junction. Mean survival following stenting was 134.14 d (95% confidence interval: 94.06-174.21).

CONCLUSION: SEMS placement is safe and effective in the palliation of dysphagia in selected patients with malignant esophageal strictures.

The use of self-expanding stents in esophageal and gastroesophageal junction cancer palliation: a meta-analysis and meta-regression analysis of outcomes

BACKGROUND

The objective of this study was to examine the impact of self-expanding stents versus locoregional treatment modalities in the setting of esophageal cancer palliation.

METHODS

The present meta-analysis pooled the effects of outcomes of 1,027 patients enrolled in 16 randomized controlled trials.

RESULTS

The meta-analysis revealed an advantage to the use of stents compared to locoregional modality treatments with respect to the number of patients requiring reinterventions, although the latter treatment arm had a higher 1-year survival. No difference was observed between the use of the antireflux stents and conventional stents in relieving reflux. Previous chemoradiotherapy had no impact on complications, procedural deaths, and overall patient survival. Differences in outcomes among stents were minimal.

CONCLUSIONS

Conventional self-expanding stents and anti-reflux stents are equally effective. Although the risk difference for 1-year survival favoured locoregional palliative treatment modalities, the latter were associated with a higher number of patients requiring reintervention.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Economic analysis of esophageal stenting for management of malignant dysphagia

Over half of patients diagnosed with esophageal cancer are unsuitable for curative resection. A significant proportion of these patients will subsequently require palliative stenting to alleviate dysphagia. There is growing consensus in the literature that the deployment of a Self-Expanding Metal Stent is the optimum stenting strategy; however, it remains unclear whether covered or uncovered metal stents are more cost-effective. In order to determine which type of prosthesis is more cost-effective, we compared the different stenting strategies in terms of 1-year stent-related mortality, health-related quality of life, and cost. A decision analytical model was constructed to compare the 1-year stent-related mortality, health-related quality of life, and cost between covered and uncovered stents. Probabilistic sensitivity analysis was performed to quantify the uncertainty associated with our results. Value of Information analysis was performed to assess the value of further research. In order to fully characterize the uncertainty associated with this decision, plastic stents were included in our analysis. Stent-related mortality was slightly lower following covered stent deployment compared with uncovered stent deployment (1.00% vs. 1.26%). Covered stents were more effective by 0.0013 Quality-Adjusted Life Years (Standard Deviation [SD] 0.0013 Quality-Adjusted Life Years). They were also less expensive by $729.58 (SD $390.63). Probabilistic sensitivity analysis suggested that these results were not sensitive to model parameter uncertainty. Plastic stents deployment was $2832.64 (SD $1182.72) more expensive than uncovered metal stent deployment. Value of Information analysis suggests that the maximum value of further research in the UK is $61,124.30. The results of this study represent strong evidence for the cost-effectiveness of covered compared with uncovered self-expanding metal stents for the palliation of patients with malignant dysphagia. The findings support previously published literature asserting the dominance of self-expanding metal stents over plastic stents. Value of Information analysis suggests that further research may not be cost-effective. These findings have significant implication for both current clinical practice and future clinical research.

Self-expandable metallic stents for palliative treatment of digestive cancer

BACKGROUND/GOAL: Self-expandable metallic stents can be used to reestablish luminal continuity in patients with malignancy of the esophagus, gastric outlet, or colon who are at high risk for surgical intervention. Data regarding their complication profiles remain incomplete. Our aim was to evaluate the feasibility and complications of endoscopic stenting in esophageal, gastroduodenal, and colonic malignancies.

STUDY

Between January 2003 and December 2005, 153 patients underwent 182 endoscopic procedures for insertion of 199 metallic stents in a single referral center. Complications were assessed retrospectively.

RESULTS

The mean follow-up was 170 days. The mortality was 73.9% (113 patients), 105 cases between 1 and 60 weeks after the procedure (median survival, 17 wk), but none directly related to the stent placement. One single stent was required in 115 (75%) patients, and 37 (24.2%) cases required an overlapping stent. The procedure was unsuccessful in only 1 case of colonic obstruction. Thirty-eight (26.6%) patients developed 52 complications, of which 16 (9.4%) procedure-related complications (perforation, 5; migration, 5; obstruction, 3; misplacement, 2; and hemorrhage, 1) and 36 (21.3%) late complications (obstruction, 20; migration, 9; fistula, 6; and perforation, 1). Eight (5.6%) patients experienced more than 1 complication. Five (3.5%) cases required surgery (colon: 2 perforations, 1 fistula, and 1 obstruction; esophagus: 1 perforation). No significant difference on the complication rates was found for any site in which a metallic stent was inserted.

CONCLUSIONS

Endoscopic stenting for palliation of digestive cancer, despite a reasonable complication rate, is feasible in most patients. Most dysfunctions are not life-threatening and can be managed endoscopically.

Neoplasia avançada de esôfago: diagnóstico ainda muito tardio

RACIONAL: A neoplasia de esôfago está entre as 10 mais incidentes no Brasil. O diagnóstico é geralmente tardio e a sobrevida média é de 4 a 6 meses, independente da terapêutica. O alívio da disfagia e a melhora da qualidade de vida são os objetivos principais da terapêutica paliativa. OBJETIVO: Avaliar a qualidade de vida e a paliação da disfagia obtida com diferentes tipos de tratamento oferecidos aos pacientes com neoplasia avançada de esôfago. PACIENTES E MÉTODO: Avaliação prospectiva de 38 pacientes com neoplasia avançada de esôfago, com disfagia, sem possibilidade de tratamento curativo, entre setembro de 2001 a junho de 2005. Os pacientes foram alocados aleatoriamente, de acordo com a disponibilidade da terapia ou preferência do paciente ou do médico responsável, sendo 14 tratados com colocação de prótese (9 metálicas auto-expansíveis, 4 plásticas e 1 plástica auto-expansível), 4 com cirurgia paliativa, 8 com gastrostomia (7 cirúrgicas e 1 endoscópica) e 12 com sonda nasoenteral. RESULTADOS: Houve melhora do índice médio de disfagia em 30 dias em todos os grupos, exceto no da gastrostomia. A colocação da prótese de esôfago melhorou a disfagia de forma estatisticamente significante em relação às outras terapias paliativas. A qualidade de vida avaliada pela mediana do índice de Karnofsky não apresentou melhora em nenhum grupo de pacientes. O número de internações necessárias não foi diferente entre os grupos. A duração média das internações foi maior no grupo de tratamento cirúrgico (42 dias), embora sem diferença significativa. Não houve diferença na sobrevida média dos pacientes, independente do tipo de tratamento. CONCLUSÃO: A paliação ideal para todos os casos não existe. O método deve ser individualizado para cada paciente. O tratamento cirúrgico paliativo é o mais oneroso, devido ao prolongado tempo médio de internação desses pacientes. Infelizmente, o diagnóstico de tumor de esôfago em nosso meio ainda é muito tardio, limitando o benefício que poderia advir dos métodos de ponta de paliação endoscópica.

Esophageal palliation--photodynamic therapy/stents/brachytherapy

The optimal treatment for malignant dysphagia should be safe, effective,cost-effective, and have minimal morbidity. Photodynamic therapy,brachytherapy, and esophageal stenting all represent viable options for the palliation of malignant dysphagia. Characterization of the patients and their tumors allows individualization of the treatment and the selection of the optimal treatment for each individual patient. Institutional resources and expertise also are significant factors in treatment. Further comparative studies may help further delineate the relative merits of these treatments and the optimal treatment of patients with malignant obstruction.

Natural course of inoperable esophageal cancer treated with metallic expandable stents: quality of life and cost-effectiveness analysis

BACKGROUND AND AIM

The aim of this study was to evaluate the efficacy and safety of endoscopic therapy with self-expanding metallic endoprostheses in the management of malignant esophageal obstruction or stenosis and the cost-effectiveness of the method in patients suffering from primary esophageal carcinoma. All patients with inoperable esophageal cancers treated with either laser palliation or endoprosthesis insertion were studied retrospectively.

METHOD

Between May 1997 and December 2002 obstruction of the esophagus was diagnosed in 78 patients (52 male, 26 female, age range 53-102 years, mean 72.3 years). The etiology of obstruction was squamous cell carcinoma (n = 42) and adenocarcinoma of the esophagus (n = 36). The site of obstruction was in the upper (n = 1), in the middle (n = 38) and in the lower esophagus (n = 39). In 16 cases the gastroesophageal junction was also involved. Four patients had broncho-esophageal fistulas. In all cases the tumor was considered non-resectable. A total of 89 Ultraflex metal stents were introduced endoscopically. In 46 patients dilation with Savary dilators prior to stent placement was required.

RESULTS

Stents were placed successfully in all patients. After 48 h, all patients were able to tolerate solid or semisolid food. During the follow-up period eight patients developed dysphagia due to food impaction (treated successfully endoscopically). Eleven patients presented with recurrent dysphagia 4-16 weeks after stenting due to tumor overgrowth and were treated with placement of a second stent. The median survival time was 18 weeks. There was no survival difference between squamous cell and esophageal adenocarcinoma. A cost-effective analysis was performed, comparing esophageal stenting with laser therapy. The mean survival and the cost were similar. A small difference of 156 Euro was noted (3.103 Euro and 2.947 Euro for each group of patients, respectively). A significant improvement in quality of life was noted in patients that underwent stenting (96% and 75%vs 71% and 57% for the first 2 months).

CONCLUSION

Placement of self-expanding metal stents is a safe and cost effective treatment modality that improve the quality of life, as compared with other palliative techniques, for patients with inoperable malignant esophageal obstructions. In cases of expansion of the mass a second stent can be used; however, the overall survival of these patients, is poor.

Cost study of metal stent placement vs single-dose brachytherapy in the palliative treatment of oesophageal cancer

Self-expanding metal stent placement and single-dose brachytherapy are commonly used for the palliation of oesophageal obstruction due to inoperable oesophagogastric cancer. We randomised 209 patients to the placement of an Ultraflex stent (n=108) or single-dose brachytherapy (12 Gy, n=101). Cost comparisons included comprehensive data of hospital costs, diagnostic interventions and extramural care. We acquired detailed information on health care consumption from a case record form and from monthly home visits by a specialised nurse. The initial costs of stent placement were higher than the costs of brachytherapy (€1500 vs €570; P<0.001). Total medical costs were, however, similar (stent €11 195 vs brachytherapy €10 078, P>0.20). Total hospital stay during follow-up was 11.5 days after stent placement vs 12.4 days after brachytherapy, which was responsible for the high intramural costs in both treatment groups (stent €6512 vs brachytherapy €7982, P>0.20). Costs for medical procedures during follow-up were higher after stent placement (stent €249 vs brachytherapy €168, P=0.002), while the costs of extramural care were similar (€1278 vs €1046, P>0.20). In conclusion, there are only small differences between the total medical costs of both palliative treatment modalities, despite the fact that the initial costs of stent placement are much higher than those of brachytherapy. Therefore, cost considerations should not play an important role in decision making on the appropriate palliative treatment strategy for patients with malignant dysphagia.

Therapeutic options for esophageal cancer

Options for the treatment of esophageal cancer used to be very limited, with surgical resection and radiotherapy methods aimed at both cure or palliation, and, in those unfortunate patients with severe dysphagia, intubation with a plastic prosthesis to restore esophageal luminal patency. Progress in the management of this cancer in the past two decades includes refinement in surgical techniques and perioperative care, better radiological staging methods, enhanced means of planning and delivering radiotherapy, multimodality treatments, and better designs in esophageal prosthesis. For individual patients, a stage-directed therapeutic plan can be used. Long-term survival, however, remains suboptimal for this deadly disease. The current review presents an overview of the commonly employed therapeutic options for esophageal cancer at the beginning of the 21st century.

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Endoluminal palliation for dysphagia secondary to esophageal carcinoma

There are now a variety of treatment options available to palliate dysphagia in patients with advanced esophageal carcinoma. The decision as to which therapy to recommend for a patient should be based on a though understanding of the therapies and must be individualized for each patient and on the experience of the endoscopist or surgeon. In addition, consideration should be given as to resource availability at a particular institution. External beam radiation currently has little role as primary treatment for dysphagia. Brachytherapy is labor intensive; requires 2 to 3 weekly treatments, highly specialized radiation equipment, and an experienced radiation oncologist; and is therefore limited to tertiary care centers. Endoluminal YAG-laser tumor ablation is feasible at many institutions and provides immediate dysphagia relief but has limited durability (weeks) if not followed by adjuvant therapy, and requires an endoscopist with significant laser experience. PDT is relatively easy to perform and has a lower perforation rate and longer durability than YAG laser therapy but it is relatively costly and less patient friendly due to the morbidity of its attendant 6 weeks of photosensitivity. Advances in stent technology have rendered this a safe, readily available treatment for the palliation of dysphagia. Palliation of dysphagia is an important but difficult goal that may require creative use of a variety of endoscopic interventions, either in combination or serially. Ideally, physicians who palliate dysphagia secondary to esophageal cancer should be facile in both endoscopic ablative and stenting techniques and have a close working relationship with both radiation and medical oncologists.

Endoscopic palliation of unresectable malignant oesophageal strictures with self-expanding metal stents: comparing Ultraflex and Esophacoil stents

BACKGROUND

Two types of self-expanding metal stents to palliate dysphagia in patients with unresectable malignant oesophageal strictures have been compared.

METHODS

From February 1996 to October 2000, 50 metal stents (23 covered Ultraflex and 27 Esophacoil) were placed in 50 patients (40 males, mean age: 67+/-12 years, range: 33-100, mean dysphagia score: 3.18+/-0.66) with unresectable malignant oesophageal strictures. Patients were followed until death. A retrospective review has been made of a prospectively collected database.

RESULTS

The two groups were comparable as far as concerns degree of dysphagia, location and stricture length. Stent placement was successful in all cases. Covered Ultraflex stent was placed in 2 patients with oesophagobronchial fistula. No procedure-related deaths were seen. Early severe complications occurred in 2 patients (perforation in 1 and tumour bleeding in 1, in the Esophacoil group). Nine patients and 1 patient complained of pain following Esophacoil and Ultraflex stent placement, respectively. Late complications were asymptomatic rupture of distal Esophacoil rings in 2 patients, symptomatic Ultraflex stent migration in 2 and tumour overgrowth in 3 (Esophacoil 1, Ultraflex 2). Mean dysphagia score at 4 weeks after stent placement was 1.9+/-0.77. Mean survival was 177+/-109 days (range: 35-603 days). There were no significant differences in technical success, dysphagia palliation, complications (except chest pain) and survival using the two types of stent.

CONCLUSIONS

Self-expanding metal stents are safe with high technical success and achieve satisfactory long-term palliation for dysphagia. The covered Ultraflex and Esophacoil stents are equally effective.

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.

Changing disease burden and management issues for esophageal cancer in the Asia-Pacific region

The changing epidemiology of esophageal cancer in developed countries is from squamous cell type to adenocarcinomas arising from Barrett's epithelium and the gastric cardia. This has implications for management of this disease. Earlier diagnosis of cancer from screening high-risk patients with Barrett's esophagus is potentially possible, and mucosal ablation together with acid-suppressive therapies have been investigated to revert Barrett's epithelium in its premalignant stage. When a cancer has developed, the strategies of staging methodology and surgical approaches also differ from those applicable for squamous cell cancers located in more proximal locations of the esophagus. By contrast, in the Asia-Pacific region (with the exceptions of Australia and New Zealand), squamous cell cancers in the middle portion of the esophagus remain the main cell type seen. An overall increase in life expectancy has led to more elderly patients presenting with carcinoma of the esophagus. This is of particular importance when surgical resection is contemplated. Advances in surgical management, multimodality programs, and endoscopic therapies are most marked in recent years. Treatment for patients with esophageal cancer should be individualized. The choice depends on expertise and facilities available, tumor and patient factors, and local economics.

The role of oesophageal stenting in the non-surgical management of oesophageal strictures

The role of oesophageal stenting continues to evolve, with several new stents currently on the market. These stents possess anti-reflux valves, internal plastic coatings and retrievable threads. In patients with malignant dysphagia, management should ideally take place within multi-disciplinary teams such that accurate tumour staging occurs prior to treatment. Multi-modality therapy can not only improve dysphagia and response rates but may also improve survival. Several non-surgical palliative techniques are available to recanalize malignant obstruction, including oesophageal stenting. Other therapeutic modalities include the use of endoluminal laser therapy, photodynamic therapy, argon beam and bipolar electrocoagulation, ethanol injection and intracavity brachytherapy. Their use often depends on local availability and expertise. Although the initial costs of metal stents are high, the overall costs compare favourably with other forms of palliative therapy that often require multiple procedures with repeated inpatient hospitalization. Treatment of refractory benign strictures with oesophageal stents remains uncommon and several recent reports using retrievable stents appear to improve outcome, although more work is required in this area.

Results of expandable metal stents for malignant esophageal obstruction in 100 patients: short-term and long-term follow-up

BACKGROUND

Expandable metal stents palliate malignant dysphagia in most cases, but early complications and outcomes in long-term survivors have not been well described. This report summarizes our experience with expandable metal stents for malignant dysphagia.

METHODS

Over a 48-month period, 127 stents were placed in 100 patients with dysphagia from esophageal cancer (93%) or lung cancer. Most had undergone prior treatment. Dysphagia scores, duration of palliation, complications, and reintervention were evaluated.

RESULTS

Immediate improvement in dysphagia was observed in 85% of patients with no procedure-related deaths. Dysphagia score decreased from 3.3 before stent to 2.3 (p < 0.005). Average interval to reintervention was 80 days. In 40 patients surviving more than 120 days, 31 (78%) required reintervention. Major complications occurred in 3 patients receiving poststent chemoradiation (tracheoesophageal fistula, T1 vertebral body abscess, mediastinal abscess). Other complications included unsatisfactory deployment requiring immediate removal (3 patients), migration (11 patients), pain requiring removal (2 patients), food impaction (10 patients), and tumor ingrowth (37 patients).

CONCLUSIONS

Expandable metal stents offer excellent short-term palliation of malignant dysphagia. In long-term survivors, recurrent dysphagia requiring reintervention is common. In a small subset of patients receiving chemoradiation after stent placement, major complications were observed.

Delayed complications after esophageal stent placement for treatment of malignant esophageal obstructions and esophagorespiratory fistulas

PURPOSE

To evaluate delayed complications after esophageal expandable metallic stent placement.

MATERIALS AND METHODS

From April 1993 to December 1997, 90 expandable metallic stents were placed in 82 consecutive patients with inoperable malignant esophageal obstruction (n = 49) or malignant esophagorespiratory fistula (n = 33). Stents used included covered Gianturco-Rosch Z stents (n = 20), Wallstents (covered, n = 31; uncovered, n = 13), and Ultraflex stents (covered, n = 8; uncovered, n = 10). Patients were followed prospectively and monitored for delayed complications, defined as major (hemorrhage, tracheal compression, stent migration, perforation or fistula formation, granulomatous obstruction, tumor ingrowth and overgrowth, funnel phenomenon, and stent covering disruption) or minor (reflux, chest pain, and food impaction).

RESULTS

Mean survival was 4.5 months after stent placement (range, 3 weeks to 26 months). The overall incidence of delayed complications was 64.6%, with 17 patients (20.7%) experiencing more than one complication. The rates of delayed complications in patients with Z stents, Wallstents, and Ultraflex stents were 75.0%, 68.1%, and 44.4%, respectively (P <.05). Most complications were life-threatening and occurred more frequently when stents were placed in the proximal third of the esophagus, compared with more distally (P <.05). Thirteen patients (15.9%) died from complications directly related to stent placement.

CONCLUSION

Esophageal stent placement for malignant obstruction or fistula is associated with a substantial incidence of delayed complications.

Chest pain following oesophageal stenting for malignant dysphagia

AIM

The palliative use of self-expanding metallic stents has been widely reported to relieve dysphagia in cases of oesophageal carcinoma. Little has been documented on the severity of chest pain following oesophageal stenting. The aim of this study was to investigate the association of pain with oesophageal stenting for malignant dysphagia.

METHODS

Fifty-two patients with inoperable oesophageal carcinoma underwent stent placement between 1995-1999. Daily opioid analgesic requirements (mg of morphine equivalent doses) were monitored for 3 days before and 7 days after stenting. The degree of palliation was expressed as a dysphagia score (0-3). Hospital stay, readmission days, stent complications and patient survival time were also recorded.

RESULTS

Twenty-six patients (50%) required opioid analgesia for chest pain (median dose: 80 mg morphine/day) within 48 h of the procedure compared to 11 (21.2%) patients before stenting (P = 0.0041). A significant increase was evident in the analgesic consumption following stent deployment (P < 0.001). The dysphagia score improved by a median value of 1 (CI 0.25)P < 0.001, with a re-intervention rate of 11.5%. The median survival time was 40 days post stenting (range 1-120).

CONCLUSION

A significant proportion of patients developed chest pain after oesophageal stenting, requiring high dose opioid analgesia. As the origin of the pain is still unknown, pre-emptive analgesia may a play role in reducing stent-related morbidity and possibly in-hospital stay.

Endoscopic therapeutic esophageal interventions

At the close of the 20th century, therapeutic endoscopy in the esophagus has expanded to encompass a broad array of interventions. As the number of procedures grows, emphasis in the medical literature has begun to shift to analyses of which procedures should be performed. Many studies published in 1999 on topics ranging from endoscopic treatment of benign and malignant strictures, to variceal bleeding, to Barrett esophagus have focused on which of several methods provides the best long-term response with the fewest interventions. This is a review of the major published studies of endoscopic interventions in the esophagus as well as selected abstracts. The conclusions of these studies and reports of new endoscopic therapies draw a clear map of where nonoperative esophageal therapeutics are headed in the next several years.