Palliative bipolar electrocoagulation therapy of obstructing esophageal cancer

[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.

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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.

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.

Endoscopic therapeutic esophageal interventions

Despite numerous advances in the chemotherapeutic, radiotherapeutic, and surgical treatment of esophageal cancer, most patients require some type of endoscopic palliation for dysphagia during the course of their illness. Numerous modalities exist, including thermal ablation with neodymium:yttrium-aluminum-garnet laser, argon plasma coagulation, electrocautery, nonthermal ablation with alcohol injection or photodynamic therapy, or displacement of tumor with endoscopically placed stents. Each therapy carries with it a unique profile of efficacy and complications. Some therapies may be more appropriate for certain tumor locations and morphologies than others. During the past year, new studies have defined these parameters further. However, it remains essential that the endoscopist have both a thorough knowledge of these various modalities and an ability to chose among them when undertaking endoscopic palliation of this difficult and rapidly rising disease.

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.

Palliation of malignant dysphagia from oesophageal cancer. Rotterdam Oesophageal Tumor Study Group

Palliative therapies for advanced oesophageal cancer include surgery, radiation therapy, chemotherapy, endoscopic procedures and combinations of these. Of the non-endoscopic modalities is external beam radiation therapy (EBRT) effective and non-invasive. A disadvantage is that relief of dysphagia only occurs over a period of 4-6 weeks. Brachytherapy is more rapid in locally controlling tumour growth and in relieving dysphagia. One of the more commonly used endoscopic procedures is laser therapy, which provides symptomatic relief with low complication rates. Recurrent dysphagia is a problem necessitating repeated treatment sessions. Self-expanding metal stents offer a high degree of palliation and are associated with fewer complications compared with prosthetic tubes. Longer palliation and perhaps even longer survival might be achieved by the combination of different therapies. Most promising are the combination of EBRT plus brachytherapy or chemoradiation. Now is the time to determine which treatment (combination) is best for individual patients.

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.

Carcinoma of the oesophagus: the time for a multidiciplinary approach?

Oesophageal cancer is one of the most lethal carcinomas, with 5-year survival rates of less than 5%. This is due to a combination of factors including late presentation, associated cardiac and respiratory disease, and the technical difficulties of resectional surgery. The outcome for patients with oesophageal cancer has changed little in recent years, perpetuating a pervading attitude of pessimism in the surgical community. The epidemiology of oesophageal cancer is changing with the increasing incidence of adenocarcinoma. Most of these tumours arise in the setting of Barrett's oesophagus and chronic gastro-oesophageal reflux disease. Survival following surgery for oesophageal cancer is determined by several independent factors, most notably the pathological stage of the disease and the patients physiological status. However, in patients with limited disease, in particular patients with less than five lymph node metastases, the extent of the nodal dissection positively impacts survival. This article reviews the changing epidemiology of oesophageal cancer, focusing on the need for early diagnosis and the selection of patients for surgery. It places emphasis on the importance of integrating surgical therapy in a multidisciplinary team approach to the management of such patients.

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.

Changing patterns in the treatment of carcinoma of the esophagus

BACKGROUND

Decision-making in esophageal carcinoma. Treatment of carcinoma of the esophagus knows a great variety of modalities, ranging from simple palliative endoscopic pertubation to extensive curative operations.

METHODS

Retrospective review.

RESULTS

The three main groups of tumors are squamous cell carcinoma related to alcohol and tobacco abuse; adenocarcinoma in Barrett's esophagus related to long-standing gastroesophageal reflux; and adenocarcinoma of the cardia the origin of which is still unknown. Dysphagia and retrosternal pain are not only the most important symptoms but also the most important factors regarding survival. Diagnosis is made by endoscopy and biopsy. In the pretreatment staging a careful selection of the great variety of available diagnostic tools should be made. The ever-increasing diversity of local palliative procedures: tubing, photoablation, brachytherapy all have their place, but should not be allowed to distract us from the fact that surgery is the only hope for cure in these patients. Surgery should only be performed with curative intent and even then the long-term results are modest, with a 5-year survival of about 40% in node-negative and 18% in node-positive patients.

CONCLUSION

In patients with carcinoma of the esophagus a polydisciplinary treatment approach is mandatory.

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)

Advanced esophageal carcinoma

From 1976 until 1990 a total of 212 patients with squamous cell carcinoma of the thoracic esophagus were referred for surgical treatment. Resectability was 84.1% (161 of 191). Actuarial 5-year survival in patients with negative lymph nodes was 51.2% versus 12.4% in lymph node-positive patients. Therefore advanced carcinoma was defined to compromise all patients with involved regional (N1) or distal lymph nodes (M+Ly) as well as patients with T4 tumors or solid organ metastasis (M+org) irrespective of their lymph node status. Comparing complete (R0) versus incomplete (R1-R2) resections for stage III and IV carcinoma revealed 20% and 0% five-year survivals, respectively. There was no 5-year survival in the stage IV group. When excluding solid organ metastasis, the median survival shifted from 8.5 months after incomplete (R1-R2) to 20 months after complete (R0) resection. In 1991 three-field lymphadenectomy was initiated that included bilateral cervical lymphadenectomy. Thirty-seven patients have been treated so far (23 squamous cell carcinoma, 14 adenocarcinomas). Cervical lymph nodes were positive in 24.3% with an incidence up to 28.5% for distal-third carcinoma. Subsequently, 6 patients (16%) moved from M0 to M+Ly status. Our results confirm the key role of surgery not only in improving survival and locoregional tumor control but in refining the accuracy of staging advanced carcinomas provided complete resection is possible.(ABSTRACT TRUNCATED AT 250 WORDS)

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.

Oesophageal cancer: a population-based study of survival after treatment

The survival of patients with oesophageal cancer diagnosed during the period 1982-1985 in Nottingham has been studied. Of 496 patients identified from endoscopy, histopathology and hospital activity analysis records, 268 (171 men) lived in the catchment area and had primary oesophageal cancer. Compared with previous studies the proportion of adenocarcinoma (35 per cent) was twice that expected, although survival was similar (hazard rate ratio at 2 years 1.0 (95 per cent confidence interval (c.i.) 0.8-1.4)) whether a squamous cell carcinoma or adenocarcinoma was present. Based on the original treatment intention, surgery was attempted in 34 per cent of cases and was associated with a median survival from diagnosis of 293 (95 per cent c.i. 232-367) days, with 41, 19 and 11 per cent surviving 1, 2 and 3 years respectively. Radical radiotherapy was attempted in 13 per cent of patients and was associated with a median survival of 190 (95 per cent c.i. 136-253) days, with 14, 6 and 6 per cent surviving 1, 2 and 3 years. Intubation alone was performed in 40 per cent of patients, of whom 44 per cent were aged over 75 years and 29 per cent had evidence of metastases, compared with 13 and 11 per cent respectively of those undergoing surgery or radical radiotherapy. The median survival for intubation alone was 100 (95 per cent c.i. 81-122) days, with 6, 3 and 0 per cent of patients surviving 1, 2 and 3 years respectively. Although patients treated surgically had the longest survival, these data indicate that overall survival after any active intervention is modest. Intubation alone is a reasonable option in those not suitable for surgery; randomized trials are needed to compare intubation with new methods of palliation.

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.

The future of veterinary endoscopy

The developing areas of video endoscopy, endoscopic ultrasonography, and small-bowel endoscopy are discussed in this article, and new endoscopic approaches to strictures and bleeding lesions of the gastrointestinal tract are presented. The potential applications of these techniques in veterinary medicine are left to the imagination of the reader.

What does radiotherapy add to survival over endoscopic intubation alone in inoperable squamous cell oesophageal cancer?

The place of radiotherapy in the management of squamous cell oesophageal cancer remains uncertain. Survival of oesophageal cancer patients from the Nottingham area in the years 1982-5 was reviewed. Surgical resection was attempted in 44 of 131 patients with squamous cell oesophageal cancer. Among the remainder 32 had endoscopic intubation alone, 27 had radical radiotherapy alone (six) or combined with endoscopic intubation (21), and 28 had other treatment combinations including surgical intubation and palliative radiotherapy. Patients treated by intubation alone had a mean age of 75 years. They were significantly older and metastases were more common (31%) in this group than in patients treated with radiotherapy (mean age 69 years), of whom 11% had metastases. Some 34% (11 of 32) of patients treated by intubation alone died within 30 days of diagnosis and were therefore not eligible for radiotherapy. Beyond 30 days, survival in the radiotherapy group (median survival 188 days; 95% confidence limits 133-253) was not significantly greater than that for the group treated by intubation alone (median survival 98 days (73-154)). The radiotherapy patients had a median hospital stay of 46 days compared with 23 days for the patients treated by intubation alone. In patients with squamous cell oesophageal cancer unsuitable for surgery, the survival advantage associated with radiotherapy and intubation is small and does not compensate for the extra morbidity and prolonged hospital stay. A controlled trial of radiotherapy in these patients is now needed.

Endoscopic palliative intubation of the esophagus invaded by lung cancer

Thirty-two patients with esophageal involvement by lung cancer were managed by endoscopic intubation. In 22 patients with extrinsic esophageal strictures, the success rate of intubation was 91%, and 82% were discharged with their dysphagia relieved and esophageal patency restored. The mean survival rate was 4.4 months. In 10 patients with esophago-bronchial fistulas, 3 had the fistulous tract obliterated and lived a mean of 5 months. This low success rate of closing fistulas is due to failure to seal off the space between the stent and the fistula because of absence of tumor-associated stenosis. The overall morbidity rate was 28.1% (18.8% perforation, 6.3% hemorrhage, and 3.1% tracheal obstruction). The overall mortality rate was 18.8%. Although complications were more frequent than in primary esophageal tumors, endoscopic intubation was the only way to palliate this desperate condition and provided 66.6% of patients with relief of symptoms, nutritional improvement, and a mean survival time of 4.5 months.

Oesophageal cancer in South Africa. A review of 1926 cases

From November 1985 to August 1988, the National Study Group for Oesophageal Cancer collected and centralized data on 1926 new cases of oesophageal cancer in South Africa. A standard data sheet was used to record the age, sex, and condition of the patients, the site, length, and circumferential extent of the tumor, the presence of extraoesophageal and distant spread, associated pulmonary disease, and the therapeutic technique selected for each case. A computerized audit of cases was reviewed to examine the performance status, stage of disease, and methods of treatment. There were 1438 men and 488 women (male to female ratio, 3 to 1) and their ages ranged from 20 to 100 years (mean age, 56 years). Twenty-four percent were admitted to the hospital with total dysphagia. The performance status was excellent or good in 49% of the patients and fair in 29%. Those in poor or desperate condition included 13% of the patients with oesophago-airway fistulae. The most common site of cancer was the mid-thoracic oesophagus (53% of the cases), but 8.3% had tumors longer than 10 cm involving two or more oesophageal segments. Using the American Joint Committee (AJC) system of staging, 2.8% of the patients were assessed as Stage I, 19.8% as Stage II, and 77.4% as Stage III. Thirty-seven percent of the patients were treated by oesophageal intubation, 35% by radiation therapy, and 22% by chemotherapy. Surgery was selected for 17% of the patients. Although the number of young patients appears to have increased, the typical South African patient with oesophageal cancer is a man 56 years of age, in excellent or good condition, with a mid-thoracic tumor 6 cm in length and Stage III disease. This patient is frequently treated by palliative intubation of the oesophagus but may be a candidate for more intensive anti-cancer therapy.

Endoscopic diagnosis and treatment of mucosal lesions of the esophagus

The rapid evolution of fiberoptic endoscopes over the past three decades has greatly enhanced our understanding of esophageal diseases and has stimulated significant improvements in their management. With the early endoscopic diagnosis of infectious and inflammatory lesions, specific medical or surgical treatment can be initiated promptly and the results monitored easily. Although the diagnosis of malignant lesions is still commonly delayed because of the absence of early symptoms, surveillance of Barrett's esophagus offers the hope of more definitive management in these patients. Endoscopy has assumed an increasingly important therapeutic role in patients with inoperable cancer because it provides access for new ablative techniques or the placement of palliative prosthetic devices. Continuing advances in the use of endoscopic ultrasound, the delivery of photodynamic therapy, and the adjunctive application of intraluminal irradiation promise to further broaden the scope of fiberoptic intervention.

Palliative therapy of malignant esophageal stricture with the bipolar tumor probe and prosthetic tube

Patients with malignant esophageal stricture and dysphagia were prospectively randomized to receive palliative therapy with the bipolar tumor probe (17) or prosthetic tube insertion (13). Both treatments gave good relief of dysphagia compared with pretreatment values on a dysphagia score, the results being statistically significant (p less than 0.005). However, there was no difference in the improvement achieved by one method compared with the other. The tumor probe was not difficult to use and complication rates were comparable. In the Atkinson tube group, two patients developed complications related to the position of the prosthesis and in three others food blocked the tube. Treatment with the tumor probe needed repeating at intervals (median, 28 days; range, 2 to 86 days) in all but four individuals to maintain palliation, with each patient needing a median of two treatments (range, 1 to 8). The probe may have advantages in very high esophageal lesions and may facilitate the treatment of tumor overgrowth or undergrowth of a tube. The prosthetic tube may give long-lasting relief of dysphagia and remains the treatment of choice for bronchopulmonary fistulas.

Intrathoracic stapled anastomosis after oesophagectomy for cancer

Fifty consecutive oesophagectomies for cancer are reported which were performed using a two-stage technique with an intrathoracic stapled anastomosis. The oesophagus was resected through a right thoracotomy. Continuity was restored using orthotopic stomach, mobilized through an abdominal incision and anastomosed to the oesophagus at the apex of the thorax. No deaths occurred within 30 days, but two patients died without leaving hospital. Routine contrast study revealed no anastomotic leaks. Major complications were: chylothorax (one), transient bilateral recurrent laryngeal nerve palsy (one), anastomotic bleed (one), respiratory failure (one) and brain abscess (one). Four upper resection margins contained tumour (all in middle third tumours). With this technique, a reliable anastomosis can be made high in the chest. The amount of oesophagus removed is comparable with that obtained with the 'three-stage' or transhiatal procedures. The problem of occult submucosal spread in oesophageal tumours remains.

Palliation of malignant upper-third oesophageal stricture by bipolar diathermy probe

Bipolar thermocoagulation probes have been used to palliate dysphagia in six patients with an inoperable squamous cell carcinoma of the upper third of the oesophagus. Median dysphagia grade was improved following treatment, and the only serious complication was the development of a tracheo-oesophageal fistula in one patient. Bipolar thermocoagulation probes are an alternative treatment for malignant strictures of the upper third of the oesophagus, a group that may be difficult otherwise to palliate.

Palliative management of esophageal cancer

Symptomatic esophageal cancer is usually an advanced disease and only palliation is possible in the majority of the cases. Endoscopic methods of palliation are becoming very popular because of the simplicity and the low incidence of morbidity and mortality. Endoscopic laser therapy, dilatation, placement of endoprosthesis, bipolar electrocoagulation, and injection therapy are the various methods currently in use. The advantages and disadvantages of different methods are discussed and the need for controlled trials highlighted.

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

The purposes of this study were (a) to determine the applicability of endoscopic palliation for patients with esophagogastric cancer strictures in a referral center, and (b) to compare the efficacy and safety of the BICAP tumor probe with the neodymiumyttrium-aluminum-garnet (YAG) laser for such palliation. Forty-two consecutive patients with weight loss and obstructive symptoms from an unresectable, malignant esophageal stricture were referred for endoscopic palliation. Fourteen patients did not meet the criteria for YAG laser or BICAP tumor probe treatment and other therapies were recommended. Twenty-eight patients were treated, the first 14 with low-power YAG laser and the last 14 with BICAP tumor probe. All patients had coagulation of malignant strictures in one session. Treated patients were similar in background variables and stricture lengths but twice as much thermal energy was needed for the YAG laser as the BICAP tumor probe treatment. Treatment results were not statistically different during the median follow-up and survival of 16 wk. As minor complications, either pain or edema requiring dilatation was more common in the YAG laser-treated group than the BICAP tumor probe group. Treatment-related esophageal strictures developed in 21% of patients treated with YAG laser. A fistula developed in 1 patient with noncircumferential cancer in the BICAP tumor probe group. Compared with only the intake of liquids before treatment, 86% of patients could eat a soft or solid diet after initial treatment with BICAP tumor probe or YAG laser. Our conclusions were that for BICAP tumor probe and YAG laser, endoscopic palliation efficacy and safety for circumferential esophageal cancer strictures were similar. The advantages of using the BICAP tumor probe were portability, lower equipment costs, and the ability to treat submucosal, long, or high esophageal cancer strictures in one session. Treatment with YAG laser was safer than BICAP tumor probe for exophytic, noncircumferential cancers because the laser could be directed endoscopically. Use of the BICAP tumor probe is not recommended for noncircumferential esophagogastric cancer strictures.