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Thrower A, Nasrullah A, Lowe A, Stephenson S, Kay C. The use of self-expanding metal stents in the cervical esophagus. GASTROINTESTINAL INTERVENTION 2016. [DOI: 10.18528/gii160002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Andrew Thrower
- Department of Radiology, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
- Department of Radiology, Hampshire NHS Hospital Trust, Winchester, UK
| | - Ayesha Nasrullah
- Department of Radiology, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Andy Lowe
- Department of Radiology, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Sophie Stephenson
- Department of Radiology, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Clive Kay
- Department of Radiology, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
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Abstract
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 Early reports suggesting very low complications have been superseded by results from randomized trials.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.
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Affiliation(s)
- Andrew S Lowe
- St James's University Hospital, The Leeds Teaching Hospitals Trust, Leeds, United Kingdom
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Parker RK, White RE, Topazian M, Chepkwony R, Dawsey S, Enders F. Stents for proximal esophageal cancer: a case-control study. Gastrointest Endosc 2011; 73:1098-105. [PMID: 21295300 DOI: 10.1016/j.gie.2010.11.036] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2010] [Accepted: 11/18/2010] [Indexed: 01/12/2023]
Abstract
BACKGROUND Self-expandable metal stents (SEMSs) are an established palliative therapy for esophageal cancer. SEMS placement for cancers near the upper esophageal sphincter (UES) is controversial because of a perceived increased risk of complications. OBJECTIVE To compare outcomes after patients stented for proximal esophageal cancer (PC) and distal esophageal cancer (DC). DESIGN Matched case-control study from a prospective database. SETTING Tertiary referral center, Tenwek Hospital, Bomet, Kenya. PATIENTS All patients with PC located within 6 cm of the UES were matched with randomly selected controls with DC. INTERVENTIONS Outcomes of PC cases were compared with those of DC controls. MAIN OUTCOME MEASUREMENTS Dysphagia score, complications, median survival. RESULTS A total of 151 patients with PC were identified and were randomly matched with DC controls. Ninety-three case-control pairs had adequate follow-up information available. Mean dysphagia scores (scale 0-4) improved from 3.4 and 3.3 before stenting for PC and DC, respectively, to 1.5 after stenting for both groups (P = .93). Early complications occurred in 6.5% of PC cases and 9.7% of DC controls (P = .44). Late complications occurred in 20.4% of PC cases and 15.1% of DC controls (P = .25). Median survival was 210 days for PC cases and 272 days for DC controls (P = .25). Outcomes were similar for the subgroup of PC cases whose cancer extended to within 2 cm of the UES. LIMITATION An important limitation is the absence of adequate follow-up data for 58 of the 151 case-control pairs. CONCLUSIONS SEMSs effectively palliate dysphagia in PC cases, whereas complication and survival rates are not statistically different from those of DC controls.
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Tong DKH, Law S, Wong KH. The use of self-expanding metallic stents (SEMS) is effective in symptom palliation from recurrent tumor after esophagogastrectomy for cancer. Dis Esophagus 2010; 23:660-5. [PMID: 20545971 DOI: 10.1111/j.1442-2050.2010.01077.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The efficacy of using self-expanding metallic stent (SEMS) for palliation of symptoms because of tumor recurrence after prior esophagogastrectomy has not been properly assessed despite the well recognized use of SEMS in patients without prior surgery. The aim of this study is to evaluate the efficacy and safety of using SEMS in patients who had prior esophagogastrectomy. The study group included 35 patients with carcinoma of esophagus or cardia documented to have loco-regional recurrence after esophagogastrectomy and in whom SEMS were placed for palliation. The median age was 67 (ranged 41-85). The indications for stenting were dysphagia caused by recurrence at the esophageal anastomosis (n= 4) and in the esophageal remnant (n= 5), or extrinsic compression from mediastinal nodal disease (n= 7); gastric outlet obstruction produced by extrinsic tumor compression (n= 13); and tracheo-esophageal fistulae (n= 6). Forty-three stenting procedures were performed, and the technical success rate was 97.6%. The dysphagia score improved from 4.66 to 2.54 (P < 0.001). All patients with tracheo-esophageal fistula had their symptoms successfully palliated. The immediate complication rate was 14% (n= 5); two patients had stent malpositioning, two had inadequate opening of their stents, and one had a failed stenting procedure. On follow-up, 15 (42.8%) patients required a total of 22 re-intervention procedures for various reasons: endoscopic dilatation (five dilatations in three patients), removal of foreign bodies (nine procedures in four patients), and insertion of a second SEMS related to tumor growth (eight stents in eight patients). There was no procedure-related mortality. The median survival was short at 42 days (range 5-290 days), mostly related to advanced disease stage. SEMS in patients with recurrent tumor after esophagogastrectomy is safe and effective.
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Affiliation(s)
- D K-H Tong
- Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China
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Lazaraki G, Katsinelos P, Nakos A, Chatzimavroudis G, Pilpilidis I, Paikos D, Tzilves D, Katsos I. Malignant esophageal dysphagia palliation using insertion of a covered Ultraflex stent without fluoroscopy: a prospective observational study. Surg Endosc 2010; 25:628-35. [PMID: 20644961 DOI: 10.1007/s00464-010-1236-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2009] [Accepted: 01/23/2010] [Indexed: 01/20/2023]
Abstract
BACKGROUND This study aimed to investigate the efficacy and safety of placing self-expandable metal stents (SEMSs) without fluoroscopy for palliation of malignant esophageal or esophagogastric strictures. METHODS From January 2003 to June 2008, a prospective observational study investigated the placement of covered proximal-release Ultraflex stents without fluoroscopy in nonoperable malignant esophageal and esophagogastric strictures. The technical success as well as the early and late complications (perforation, migration, severe gastroesophageal reflux, hematemesis, and reobstruction due to tissue ingrowth or overgrowth) were recorded. Dysphagia before and after stent placement was scored on a 5-point scale. All the patients were observed monthly in the outpatient clinic or by telephone contact until death. RESULTS The study enrolled 89 patients (16 women; mean age, 69.54±7.1 years) with dysphagia due to inoperable esophageal or esophagogastric malignant strictures (29 squamous cell cancers, 52 adenocarcinomas, and 8 obstructive malignant extrinsic compressions). The mean stricture length was 6.2±2.8 cm. Endoscopic deployment was achieved for 83 patients (93.2%), with accurate stent positioning in all the patients except one. An adequate relief of symptoms was noted for 82 of the patients (92.1%). During the follow-up period, 36 patients (43.4%) had recurrent dysphagia, caused by tumor overgrowth in 32 cases and stent migration in 4 cases, after an average time of 82 days (range 67-216 days). A stent-in-stent procedure was performed in 27 cases. For two patients, a third stent-in-stent needed to be placed after 85 and 216 days, respectively. CONCLUSION In most cases, SEMSs can be accurately and safely positioned without fluoroscopy for palliative treatment of malignant esophageal dysphagia.
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Affiliation(s)
- Georgia Lazaraki
- Department of Gastrointestinal Oncology, Theagenion Cancer Hospital, Al. Simeonidi 2 str, 54007, Thessaloniki, Greece.
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Abstract
The application of stents in the GI tract has expanded tremendously. Stent placement is the most frequently used treatment modality for palliating dysphagia from esophageal or gastric cardia cancer. Newly designed esophageal stents, including the Polyflex stent and the Niti-S double stent, have been introduced to reduce recurrent dysphagia owing to migration or nontumoral or tumor overgrowth. Stents are also the treatment of choice for esophagorespiratory fistulas, for proximal malignant lesions near the upper esophageal sphincter, for recurrent carcinoma after esophagectomy or gastrectomy and for sealing traumatic or iatrogenic nonmalignant ruptures, such as Boerhaave's syndrome and leakages following surgery. Stents in the latter patient group should be removed within 4-8 weeks after placement to prevent the formation of granulation tissue or hyperplasia at the stent ends. For gastric outlet obstruction, many case series have been published. Only two, small, randomized controlled trials have compared stent placement with gastrojejunostomy to date, and a large, randomized trial is currently being conducted in The Netherlands. Obstructive jaundice caused by a malignancy in the common bile duct can be treated effectively with plastic or metal stent placement. However, a prognostic score needs to be developed that guides a treatment decision towards using either of these stents. Finally, colonic stents are applied successfully for acute malignant obstruction as a 'bridge to surgery' in patients with tumors that are deemed to be resectable, or as a palliative treatment for patients with locally advanced or metastatic disease.
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Affiliation(s)
- Marjolein Y V Homs
- University Medical Center Utrecht, Dept of Internal Medicine, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
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Abstract
The divergence in epidemiology between the East and West has made interpretation of data in the literature more difficult and has affected the choice of the most appropriate surgical technique and treatment strategies. The management of esophageal cancer certainly has evolved, and many more options are available. Stage-directed strategies and individualization of treatment are important considerations. Surgeons play a central role in directing management of this disease by advising how best to integrate surgical therapy with nonoperative programs. Surgeons should aim at improving their results further, so that the best results of surgery are compared with seemingly "safer" nonsurgical therapies. Low death rates have been achieved in specialized centers, but there still is much room for improvement in morbidity rates. Even with the best surgical resection and chemoradiation therapy, distant failure remains a barrier to improved survival rates. Therapeutic improvements will require more effective systemic drugs and a better ability to predict responders with precision. Management strategies will evolve further, with improvements in molecular techniques, imaging methods, and introduction of more novel tumoricidal agents. The challenge for the future is to test strategies critically in a scientific, unbiased manner and to explore other innovative treatments.
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Affiliation(s)
- Simon Law
- Department of Surgery, University of Hong Kong Medical Centre, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong, China.
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Verschuur EML, Kuipers EJ, Siersema PD. Esophageal stents for malignant strictures close to the upper esophageal sphincter. Gastrointest Endosc 2007; 66:1082-90. [PMID: 17826774 DOI: 10.1016/j.gie.2007.03.1087] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2007] [Accepted: 03/29/2007] [Indexed: 02/08/2023]
Abstract
BACKGROUND Self-expanding stents are a well-accepted palliative treatment modality for strictures resulting from esophageal carcinoma. However, the use of stents close to the upper esophageal sphincter (UES) is considered to be limited by patient intolerance caused by pain and globus sensation and an increased risk of complications, particularly tracheoesophageal fistula formation and aspiration pneumonia. OBJECTIVE Our purpose was to determine the efficacy and safety of stent placement in patients with a malignant obstruction close to the UES. DESIGN Evaluation of 104 patients with dysphagia from a malignant stricture close to the UES treated in the period 1996-2006. SETTING Single university center. PATIENTS Patients with primary esophageal carcinoma (n = 66) or recurrent cancer after gastric tube interposition (n = 38) within 8 cm distance distal of the UES. Twenty-four (23%) patients also had a tracheoesophageal fistula. INTERVENTIONS Stent placement. MAIN OUTCOME MEASUREMENTS Functional and technical outcome, survival, complications, and recurrent dysphagia. Analyses were performed by chi(2) test, Kaplan-Meier curves, and log-rank testing. RESULTS Mean distance from the UES to the upper tumor margin was 4.9 +/- 2.6 cm and to the upper stent margin 3.1 +/- 2.3 cm. The procedure was technically successful in 100 of 104 (96%) patients. Fistula sealing was achieved in 19 of 24 (79%) patients. After 4 weeks, dysphagia had improved from a median score of 3 (liquids only) to 1 (some difficulties with solids). Total complications were seen in 34 of 104 (33%) patients. Of these, major complications (aspiration pneumonia [9], hemorrhage [8], fistula [7], and perforation [2]) occurred in 22 (21%) patients, whereas pain after stent placement was observed in 16 (15%) patients. Recurrent dysphagia occurred in 29 (28%) patients and was mainly caused by tissue ingrowth or overgrowth (n = 10), food bolus obstruction (n = 7), stent migration (n = 3), or other reasons (n = 11), such as persistent fistula (n = 5), difficulty with swallowing (n = 4), and dislocation of the stent (n = 2). Eight (8%) patients complained of globus sensation; however, in none of the patients was stent removal indicated. LIMITATIONS Retrospective design. CONCLUSIONS Stent placement is safe and effective for the palliation of dysphagia and sealing of fistulas in patients with a malignant stricture close to the UES. On the basis of these results, stent placement may be considered for palliation in this group of patients with an otherwise dismal prognosis.
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Affiliation(s)
- Els M L Verschuur
- Department of Gastroenterology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
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Choi EK, Song HY, Kim JW, Shin JH, Kim KR, Kim JH, Kim SB, Jung HY, Park SI. Covered Metallic Stent Placement in the Management of Cervical Esophageal Strictures. J Vasc Interv Radiol 2007; 18:888-95. [PMID: 17609449 DOI: 10.1016/j.jvir.2007.04.017] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
PURPOSE To describe the authors' experience with self-expandable covered metallic stents in 16 patients with malignant and benign cervical esophageal strictures. MATERIALS AND METHODS Sixteen expandable covered metallic stents were placed with fluoroscopic guidance in 16 patients (14 men, two women; mean age, 60 years; age range, 26-75 years) with malignant and benign strictures of the cervical esophagus. The causes of strictures were ingestion of corrosive agents (n = 3), biopsy-proved squamous cell carcinoma (n = 12), and postsurgical scarring (n = 1). The mean dysphagia scores at presentation were compared with those after stent placement by using the Wilcoxon signed rank test. RESULTS Stent placement was technically successful in all patients. The reduction in the mean dysphagia score after stent placement was statistically significant (P = .0327). All patients complained of mild to severe foreign body sensation, with four reporting severe pain necessitating immediate stent removal. With the exception of one patient with limited follow-up, complications requiring intervention occurred in all patients, including migration in nine patients and tissue hyperproliferation in two. Of the 12 patients with a malignant stricture of the esophagus, four patients eventually underwent gastrostomy for the placement of a feeding tube and one patient underwent surgery. All four patients with a benign cervical stricture failed to achieve long-lasting improvement with temporary stent placement. CONCLUSIONS Although the placement of covered metallic stents in the cervical esophagus provides adequate initial palliation, it is associated with poor patient tolerance and a high complication rate.
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Affiliation(s)
- Eugene K Choi
- Department of Radiology, Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Songpa-Gu, Seoul, Korea
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Eleftheriadis E, Kotzampassi K. Endoprosthesis implantation at the pharyngo-esophageal level: Problems, limitations and challenges. World J Gastroenterol 2006; 12:2103-8. [PMID: 16610065 PMCID: PMC4087693 DOI: 10.3748/wjg.v12.i13.2103] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To present our experience with endoscopic placement of an esophageal endoprosthesis in 19 patients.
METHODS: A retrospective evaluation was made for the use of 19 stents positioned at the level of the cervical esophagus: 11 for malignant tumours (7 causing obstruction, 4 complicated by an esophago -tracheal or -cutaneous fistula), and 8 for an acquired benign tracheo-esophageal fistula due to prolonged intubation. The covered Ultraflex stent was used in all cases except two. These two patients had an esophagocutaneous fistula following laryngectomy and a Flamingo Wall stent was used.
RESULTS: Stent implantation was technically successful in all patients. Dysphagia score was improved from 3 to 2 in stenosis patients, while sealing of the fistula was achieved in all cases. The median hospital stay was 3 d for malignant tumour patients and 13.5 d for esophagocutaneous fistula patients. One Ultraflex stent and two Flamingo Wall stents were easily removed 33 d and 3 months respectively after implantation when the fistulas had totally occluded.
CONCLUSION: Endoprosthesis implantation for malignancy and/or fistula of malignant or benign origin at the level of the cervical esophagus is an easy, well tolerated, safe and effective procedure with no complications or mortality.
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Affiliation(s)
- David Mitton
- Department of Surgery, Royal Hallamshire Hospital, Sheffield, United Kingdom
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12
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Abstract
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.
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Affiliation(s)
- Simon Law
- Division of Esophageal Surgery, Department of Surgery, University of Hong Kong Medical Center, Queen Mary Hospital, Hong Kong
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Law S, Wong J. Changing disease burden and management issues for esophageal cancer in the Asia-Pacific region. J Gastroenterol Hepatol 2002; 17:374-81. [PMID: 11982715 DOI: 10.1046/j.1440-1746.2002.02728.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
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.
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Affiliation(s)
- Simon Law
- Division of Esophageal Surgery, Department of Surgery, University of Hong Kong Medical Center, Queen Mary Hospital, Hong Kong
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Abstract
OBJECTIVE The use of endoscopic ultrasound (EUS) with guided fine needle aspiration (FNA) of suspicious lymph nodes has become an important aid in the staging of esophageal carcinoma. The economic impact of this staging strategy has not yet been described. We applied a decision analysis model to compare the costs of EUS FNA, CT-guided FNA, and surgery in the management of esophageal tumors. A cost-minimization approach was employed, as viewed from the perspective of the payer. METHODS A decision analysis model with three management arms was designed using DATA 3.5 software, taking the entry criteria as esophageal carcinoma without evidence of distant metastases as determined by CT. Detection of tumor on celiac lymph node (CLN) FNA signified unresectability and prompted palliative treatment: chemoradiotherapy with endoscopic esophageal stenting rather than surgery. Baseline probabilities were varied through plausible ranges using sensitivity analysis. Cost inputs were based on Medicare professional fees plus Medicare facility fees. The endpoint was the cost of management per patient. RESULTS EUS FNA was the least costly strategy ($13,811), compared to CT FNA ($14,350) and surgery ($13,992). The model outcome was sensitive to changes in both EUS FNA sensitivity and prevalence of CLN metastases. EUS FNA remained the least costly option provided the prevalence of CLN involvement was >16%; below this value, surgery became the most economical strategy. CONCLUSION By minimizing unnecessary surgery, primarily by detecting CLN involvement, EUS FNA is the least costly staging strategy in the workup of patients with nonmetastatic esophageal cancer. Under certain circumstances, surgery is the preferred strategy.
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Affiliation(s)
- Gavin C Harewood
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota 55905, USA
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Siersema PD, Schrauwen SL, van Blankenstein M, Steyerberg EW, van der Gaast A, Tilanus HW, Dees J. Self-expanding metal stents for complicated and recurrent esophagogastric cancer. Gastrointest Endosc 2001; 54:579-86. [PMID: 11677473 DOI: 10.1067/mge.2001.118716] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND Fewer complications are encountered with the use of self-expanding metal stents compared with semirigid prostheses in the palliation of patients with malignant esophagogastric obstructions. Metal stents can also be used to treat patients with complicated and/or recurrent esophagogastric carcinoma. METHODS Covered metal stents were placed in 57 patients for the following reasons: esophagorespiratory fistula (n = 16), recurrent carcinoma in a gastric tube interposition (n = 21), recurrent carcinoma after partial (n = 4) or total (n = 6) gastrectomy, or a carcinoma near the upper esophageal sphincter (n = 10). RESULTS The procedure was technically successful in 55 of 57 (96%) patients. Dysphagia score improved from a mean of 3.6 to 1.6 (p < 0.001). Major complications occurred in 13 (23%) patients. In all cases, esophagorespiratory fistulas were occluded. Tumor recurred in 5 of 16 patients with a fistula, 8 of 21 patients after gastric tube interposition, 3 of 10 patients after gastrectomy, and 2 of 10 patients with a tumor immediately distal to the upper esophageal sphincter. Median survival was 61 days. Prior radiation, chemotherapy, or both increased the risk of specific stent-related complications in relation to the (neo)esophagus (6 of 16 [38%] versus 4 of 41 [10%]: odds ratio, 5.5: 95% CI [1.3, 24], p = 0.018). CONCLUSIONS Self-expanding metal stents are effective and relatively safe for palliation of patients with malignancy and dysphagia caused by fistula formation, postoperative recurrence, and tumors near the upper esophageal sphincter. Placement should be considered at an early stage in these conditions.
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Affiliation(s)
- P D Siersema
- Department of Gastroenterology and Hepatology, University Hospital Rotterdam-Dijkzigt, Rotterdam, The Netherlands
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Austin AS, Khan Z, Cole AT, Freeman JG. Placement of esophageal self-expanding metallic stents without fluoroscopy. Gastrointest Endosc 2001; 54:357-9. [PMID: 11522978 DOI: 10.1067/mge.2001.117153] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND Fluoroscopy is routinely used to guide the placement of self-expanding metallic stents for the palliative treatment of patients with esophageal malignancy. This is a description of a novel method of stent placement without fluoroscopy. METHODS This technique relies on a clear endoscopic view of the proximal radiopaque marker on the stent. This was achieved by the application of an external white marker at this level. A gastroscope was passed, allowing guidewire deployment and measurement of stricture length. The endoscope was reinserted and placed alongside the guidewire giving direct visualization of the proximal margin of the stricture. The stent delivery device was positioned, keeping the white mark visible proximal to the stricture, and the stent was deployed. RESULTS Thirty consecutive patients with inoperable esophageal malignancy underwent endoscopic placement of self-expanding metal stents. Deployment in satisfactory position without fluoroscopy was successful in 23 of 30 (77%); there were no complications. CONCLUSIONS The majority of esophageal stents can be accurately positioned without fluoroscopy.
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Affiliation(s)
- A S Austin
- Department of Medicine, Derby City General Hospital NHS Trust, United Kingdom
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17
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Abstract
Accurate pretherapy staging for esophageal cancer is important for stage-directed therapy. Precise staging is also essential for quality control and ensuring the validity of clinical trials. Endoscopic ultrasound is currently the best technique in local regional staging. Various investigators have attempted to overcome the problems of nontraversable lesions and restaging after neoadjuvant therapy. Positron emission tomography scan was shown to be especially useful in identifying distant metastases. Its more widespread use is likely to impact on treatment strategies. Surgical resection remains the mainstay of treatment of esophageal cancer. Improvement in immediate postoperative morbidity, mortality, and long-term survival was shown by various reports to relate to experience and volume. The concept of three-field dissection was further defined by illustrating the importance of lymphadenectomy around the recurrent laryngeal nerves. Multimodality treatments continue to receive attention. Several studies have established the patterns of practice in the United States in treating esophageal cancer. Chemoradiation programs are gaining a more important role and are widely used, although their exact roles are uncertain. Closely related to this area of research is the search of molecular markers of favorable response to such therapies. Concerning palliative treatment for esophageal cancer, self-expanding metallic stents have a definite role in patients with malignant dysphagia. Their results and complications are reviewed. Lastly, quality-of-life issues have assumed more importance in studies in oncology. Prospective quality-of-life data should be evaluated in future studies on different treatment methods for this deadly disease.
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Affiliation(s)
- S Law
- Department of Surgery, University of Hong Kong Medical Center, Queen Mary Hospital, Hong Kong
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Abstract
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.
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Affiliation(s)
- D B Schembre
- Virginia Mason Medical Center, Seattle, Washington 98111, USA
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