The use of self-expandable metallic stents for palliative treatment of inoperable esophageal cancer

Efficacy and Safety of Self-Expandable Metallic Stent Placement for Malignant Esophageal Fistula

Patients with malignant esophageal fistulas often experience dysphagia and infection, resulting in poor prognoses. Self-expandable metallic stent (SEMS) placement is a palliative treatment option; however, its efficacy and safety are unclear. We aimed to determine the efficacy and safety of SEMS placement for malignant esophageal fistulas. We retrospectively investigated patients who underwent SEMS placement for malignant esophageal fistulas between 2013 and 2022 at the Cancer Institute Hospital. Dysphagia scores (DSs) before and after SEMS placement, adverse events, and overall survival from SEMS placement until death were evaluated. A total of 17 patients underwent SEMS placement, including 12 and 5 patients with esophageal and lung cancers, respectively. Prior treatments included chemoradiotherapy (n = 11), radiotherapy (n = 4), and chemotherapy (n = 4); two patients underwent palliative radiotherapy after chemotherapy. All procedures were technically successful. After SEMS placement, 14 (82.4%) patients were able to consume semisolid or solid food (DS ≤ 2). Major adverse events were encountered in only one case. The median survival time after SEMS placement was 71 days (range 17-247 days). SEMS placement allowed most patients to resume oral intake with a low rate of major adverse events. SEMS placement is a reasonable palliative treatment option for patients with malignant fistulas who have poor prognoses.

Clinical efficacy and safety of palliative esophageal stenting without fluoroscopy: a systematic review and meta-analysis

Background and study aims  Despite advances in curative treatments for esophageal cancer, many patients often present with advanced disease. Dysphagia resulting in significant weight loss and malnutrition leads to poor quality of life. Palliative esophageal stenting with self-expanding metal stents (SEMS) helps alleviate symptoms and prolongs survival. However, access to fluoroscopy may be limited at certain centers causing delay in patient care. Methods  We searched multiple databases from inception to November 2019 to identify studies evaluating the efficacy and safety of endoscopic palliative esophageal stenting and selected only those studies where fluoroscopic guidance was not used. Our primary aim was to calculate the overall technical as well as clinical success. Using meta-regression analysis, we also evaluated the effect of tumor location and obstruction length on overall technical and clinical success. Results  A total of 1778 patients from 17 studies were analyzed. A total of 2036 stents were placed without the aid of fluoroscopy. The pooled rate of technical success was 94.7 % (CI 89.9-97.3, PI 55-99; I ²  = 85) and clinical success was 82.1 % (CI 67.1-91.2, PI 24-99; I ²  = 87). Based on meta-regression analysis both the length of obstruction and tumor location did not have any statistically significant effect on technical and clinical success. The pooled rate of adverse events was 4.1 % (CI 2.4-7.2; I ²  = 72) for stent migration, 8.1 % (CI 4.1-15.4; I ²  = 89) for tumor overgrowth and 1.2 % (CI 0.7-2; I ²  = 0) for perforation. The most frequent clinical adverse event was retro-sternal chest pain. Conclusion  Palliative esophageal stenting without fluoroscopy using SEMS is both safe and effective in patients with advanced esophageal cancer.

Bypass Operation for Unresectable Esophageal Cancer: Postoperative Complications After Thoracotomy Versus No Thoracotomy

Patients with unresectable esophageal cancer suffer from dysphagia, causing severe malnutrition and reduced quality of life (QOL). We elect to perform bypass because patients can have greater long-term survival with chemoradiation following this operation. We sought to compare complications in cases of bypass without thoracotomy versus those with thoracotomy. Thirty-four locally advanced esophageal cancer patients between 2007 and 2014 were studied. Eighteen patients underwent thoracotomy, and 16 patients did not have a thoracotomy. CT was obtained to check the anastomosis and the oral stump of the esophagus and to measure the diameter of the intrathoracic esophagus. In the thoracotomy group, the rate of postoperative pulmonary complications was high. On the other hand, in the non-thoracotomy group, the rates of anastomotic leak and recurrent nerve paralysis were high. The stump of the esophagus was 2 cm lower in the T group than in the nT group. As the esophagus shortens after division, the final difference in esophageal height between the groups was only around 1 cm. We concluded that a viable gastric tube with a good blood supply as well as a careful cervical operation are the most important aspects of the esophageal bypass operation.

Palliation of Dysphagia in Carcinoma Esophagus

Esophageal carcinoma has a special place in gastrointestinal carcinomas because it contains two main types, namely, squamous cell carcinoma and adenocarcinoma. Carcinoma esophagus patients require some form of palliation because of locally advanced stage or distant metastasis, where it cannot be subjected to curable treatment with surgery and chemoradiation. Many modalities of palliation of dysphagia are available, but the procedure with least morbidity, mortality, and long-term palliation of dysphagia needs to be chosen for the patient. This study aims to discuss the recent trends in palliation of dysphagia with promising results and the most suitable therapy for palliation of dysphagia in a given patient. A total of 64 articles that were published between years 2005 and 2015 on various modes of palliation of dysphagia in carcinoma esophagus were studied, which were mainly randomized and prospective studies. Through this study, we conclude that stents are the first choice of therapy for palliation, which is safe and cost-effective, and they can be combined with either radiotherapy or chemotherapy for long-term palliation of dysphagia with good quality of life. Radiotherapy can be used as a second-line treatment modality.

Combined brachytherapy and external beam radiation: an effective approach for palliation in esophageal cancer

PURPOSE

Palliation of dysphagia is a challenge in advanced esophageal cancer. The addition of external beam radiotherapy (EBRT) to intraluminal brachytherapy (ILBT) has shown significant improvement in dysphagia relief and symptom scores. The aim of the present study was to evaluate the efficacy of combined use of ILBT and EBRT.

MATERIAL AND METHODS

The medical records of 148 patients with advanced/metastatic esophageal cancer were screened from January 2008 to April 2014, and 74 patients were found eligible for the analysis. All patients received two fractions of 8 Gy each of ILBT, followed by EBRT. Patients were assessed for the symptom scores of dysphagia, odynophagia, regurgitation, and chest pain and weight was recorded periodically.

RESULTS

For a median follow-up of 6 months, the median OS was 9.5 months (95% CI: 7.5-10.5). The median dysphagia free survival was 6 months (95% CI: 4.8-7.1). The scores for dysphagia significantly improved after completion of 1(st) ILBT (p = 0.000), 2(nd) ILBT (p = 0.000), and at 3 months after EBRT compared to ILBT (p = 0.02). Overall 47% had improvement in dysphagia scores and 35% maintained the improvement of scores till last follow up. There was significant improvement in weight after completion of ILBT (p = 0.001) and at 3 months after completion of EBRT (p = 0.00). Twenty nine (39%) patients required nasogastric (NGT) insertions and 12 (16%) needed hospitalization for supportive care. 36.4% had complications in the form of stricture (27%), fistula (5.4%), and bleeding (4%).

CONCLUSIONS

Palliative radiotherapy is an effective alternative for palliation of dysphagia with improvement in symptom scores being evident and sustained. The results of this clinical audit were comparable with those from the trial setting.

Advanced esophageal cancer with tracheobronchial fistula successfully treated by esophageal bypass surgery

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Twelve patients who underwent esophageal bypass between 2006 and 2011 in our hospital were studied.

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Ten patients were able to enjoy oral intake up until the last few days of life. Three patients survived for more than 10 months.

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The only complication was postoperative delirium in 1 patient.

Introduction

When esophageal cancer infiltrates the respiratory tract and forms a fistula, a patient’s quality of life falls remarkably. Abstinence from oral feeding is necessary to prevent respiratory complications including pneumonia. Surgery is sometimes necessary to maintain quality of life. The aim of this study was to examine clinical outcomes of esophageal cancer complicated by tracheobronchial fistula.

Presentation of case

Twelve patients who underwent esophageal bypass between 2006 and 2011 in our hospital were studied. Patient characteristics, therapeutic course, outcome, and operation type were compared. Six patients among 8 who could not tolerate oral feeding could do so after bypass surgery. Ten patients were able to enjoy oral intake up until the last few days of life. Three patients survived for more than 10 months. In spite of undergoing an operation, 1 patient survived for only 2 months and another for 4 months. The only complication was postoperative delirium in 1 patient.

Discussion

While surgical bypass is more invasive than procedures such as endoscopic stenting, we had few complications after operative intervention and were able to maintain quality of life in our patients.

Conclusion

This bypass procedure is a treatment option for patients with tracheobronchial fistula from advanced esophageal cancer.

Experience with stent implantation in malignant esophageal strictures: analysis of 1185 consecutive cases

PURPOSE

The aim of this retrospective study was to analyze the experience in endoprosthesis implantation in cases of malignant esophageal strictures.

METHODS

A total of 1185 consecutive patients underwent endoprosthesis implantation: through open surgery in 42 cases and by endoscopy in 1143 cases.

RESULTS

Stent implantation was performed successfully in 61.2% of cases. Dysphagia was resolved temporarily in 6.2% and permanently in 93.5% of cases. The score of dysphagia decreased from 1.93 to 0.38. Complications were detected in 23.7% of patients, and 69.2% of cases were treated by endoscopy. Wound complications were seen in 21.9% of patients intubated through surgery. The mean survival time of patients with esophageal intubation was 5.4 months and that of patients not eligible for stent implantation was 3.3 months.

CONCLUSIONS

Stent implantation improves the quality of life and gives an opportunity for adjuvant oncological therapy. Evaluation of morphologic anomalies is of considerable importance for achieving success in treatment through implantation.

Temporary stent placement with concurrent chemoradiation therapy in patients with unresectable oesophageal carcinoma: is there an optimal time for stent removal?

OBJECTIVE

To investigate the influence of the timing of stent removal on the outcome of temporary stent placement with concurrent chemoradiation therapy in patients with unresectable oesophageal carcinoma.

METHODS

Retrospective analysis was performed on 52 patients undergoing temporary stent placement. Stents were electively removed within 4 weeks in 15 patients (group A), 4-6 weeks in 17 patients (group B) and after 6 weeks in 20 patients (group C). Recurrent symptoms after stent removal, dysphagia score and overall survival periods were compared among the groups.

RESULTS

Stent placement and removal were technically successful in all patients. The dysphagia score was significantly improved in all groups (P < 0.001). In 19 patients (36 %), recurrent symptoms occurred 15-441 days after stent removal. In group A, recurrent obstruction was significantly higher than in groups B (P = 0.049) and C (P = 0.019). Incidence of oesophago-respiratory fistulas in group C was significantly higher than in group A (P = 0.027). There was no significant difference in survival periods.

CONCLUSION

The ideal time for stent removal likely falls between 4 and 6 weeks following the start of palliative CCRT allowing the temporary stents to relieve dysphagia effectively in patients with unresectable oesophageal carcinoma.

KEY POINTS

• Stents are usually required for unresectable oesophageal carcinoma • Optimal timing of stent removal is 4-6 weeks after starting palliative CCRT. • Early stent removal (<4 weeks) is associated with higher recurrence rates. • Delayed stent removal (>6 weeks) is associated with greater oesophago-respiratory fistula development.

[Palliative management of malignant oesophageal strictures with endoprosthesis implantation -- 25 years experience]

OBJECTIVES

The aim of this study was to analyse the feasibility of the use of oesophageal endoprosthesis based on a large series of cases.

METHODS

2952 malignant oesophageal strictures managed between 1984 and 2009 were analysed. While surgical intubation was carried out in 42 patients, endoscopic implantation was feasible in 1143 cases. Patients not eligible for oesophageal stenting were treated with gastrostomy in 125, percutaneous endoscopic gastrostomy in 19, catheter jejunostomy in 9 and supportive therapy in 965 cases, respectively.

RESULTS

Endoprosthesis could have been inserted in 61.2% of the patients. Dysphagia was terminated temporarily in 6.2% and permanently in 93.5%. Complications were detected in 23.7% of the cases, which included stent migration, perforation, bleeding, airway obstruction, early unexpected death, aspiration, stent obstruction, tumor overgrowth, oesophago-respiratory fistula formation and neoformation, and reflux. Complications were treated endoscopically primarily (69.2%). Lethal complication rate was 2.1% (27 cases). Furthermore, complication rate of patients who underwent surgical stent insertion was 21.9%. Mean survival of patients with oesophageal intubation was 5.4 months, with nutritional support via gastrostomy, percutaneous endoscopic gastrostomy or jejunostomy 3.6 months and with supportive therapy alone 3.2 months.

CONCLUSIONS

Oesophageal endoprosthesis insertion is an effective method for the palliative management of malignant oesophageal strictures. Stent implantation improves survival as well as quality of life. Methods used for nutritional support decreases hungriness but do not influence survival.

A comparative study between fluoroscopic and endoscopic guidance in palliative esophageal stent placement

Self-expanding metallic stents (SEMS) are the treatment of choice for incurable obstructive malignant esophageal strictures. Although the placement of SEMS is usually performed with fluoroscopic control (FC), recently several authors have shown the feasibility of placing SEMS under endoscopic control alone (EC). However, studies comparing the two techniques are lacking. The objective of this study was to compare the feasibility and safety of SEMS insertion under fluoroscopic control and endoscopic control. The study was performed through the retrospective analysis of patients who underwent SEMS insertion for malignant dysphagia between January 2005 and January 2010. Data concerning early and late complications and survival were retrieved. Early complications were defined as pain, vomiting, bleeding, malposition/migration, perforation, and/or dysphagia occurring until 30 days of SEMS insertion; and late complications as tumor ingrowth and overgrowth, migration, hemorrhage, fistulae, food impaction, and/or esophagitis occurring after 30 days. We placed 126 SEMS of which 87% for esophageal stricture, 8% for esophagus-respiratory fistula, and 5% for extrinsic compression. The mean age of the patients was 62 years, and 93 were male. SEMS insertion was performed with FC in 66 patients and EC in 60. Early complications occurred in 34 patients (52%) in the FC group and 28 (47%) in the EC group (P=0.71), including: pain in 22 patients of the FC group and 15 of the EC group (P=0.31); vomiting in 15 of the FC group and nine of the EC group (P=0.27); malposition/migration in three of the FC group and four of the EC group (P=0.60); hemorrhage in one of the FC group and two of the EC group (P=0.27); and dysphagia in two of the FC group and three of the EC group (P=0.57). Late complications occurred in 20 patients (30%) in the FC group and 22 (37%) in the EC group (P=0.44), including: tumor in/overgrowth in 13 patients of the FC group and 10 of the EC group (P=0.66); prostheses migration in five of the FC group and eight of the EC group (P=0.28); hemorrhage in two of the FC group and two of the EC group (P=0.54); appearance of esophageal fistulae in seven of the FC group and four of the EC group (P=0.43); food impaction in nine of the FC group and eight of the EC group (P=0.96); esophagitis in 12 of the FC group and 15 of the EC group (P=0.35). Median survival was 107 days (95% confidence interval [CI]=6-369 days) with no difference between the two groups. There were no statistical significant differences in the incidence of complications and in survival between patients undergoing SEMS placement under fluoroscopic control or endoscopic control.

[Tracheoesophageal fistula]

Congenital deformities, various forms of trauma, foreign bodies, granulomatous infection and tumors are the most common causes of tracheoesophageal fistulas. This is a rare but life-threatening complication with mortality rates up to 60% due to chronic aspiration and innominate artery arrosion and bleeding. Bronchoscopy should be done promptly if a fistula is suspected, followed by esophagoscopy. Radiologic examinations are only helpful for operational planning. Surgical treatment is mandatory for benign fistulas with excellent short-term and long-term results. However, for malignant fistulas the survival time is often only weeks to months and are best treated by palliative stenting, which offers a short-term improvement in the quality of life.