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Abstract
Esophageal carcinoma has, over the past decade, undergone a sea of change, not only in its pathological distribution, but also in the diagnosis, staging and subsequent management. Although the advent of better imaging techniques has helped in diagnosing patients at an earlier period, the majority of them have unresectable disease at the time of presentation. Despite aggressive treatment protocols involving either one or a combination of the options of surgery, radiation, and chemotherapy, the five-year survival remains dismal in the order of 10 to 15%. The two most commonly used surgical techniques for resecting the esophagus, the Ivor Lewis and the trans-hiatal esophagectomy, have similar results in terms of morbidity, mortality and, more importantly, five-year survival following resection. There has been an increasing interest in the surgical treatment of carcinoma esophagus by a minimally invasive approach, as meta-analysis of clinical series have shown that a faster recovery time without any statistically significant difference in the in-hospital mortality or morbidity when compared to conventional surgery. Nonrandomized studies suggest that patients receiving neoadjuvant chemo-radiation have a five year survival advantage compared with those treated with surgery alone, especially if they had a complete histological response to the preoperative regimen. Lastly, palliative procedures, form the mainstay of management of patients with non-resectable disease.
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Affiliation(s)
- Adil Sadiq
- General Thoracic Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Kamal A Mansour
- General Thoracic Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
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2
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Adler DG, Siddiqui AA. Endoscopic management of esophageal strictures. Gastrointest Endosc 2017; 86:35-43. [PMID: 28288841 DOI: 10.1016/j.gie.2017.03.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 03/02/2017] [Indexed: 02/07/2023]
Affiliation(s)
- Douglas G Adler
- Department of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Ali A Siddiqui
- Department of Gastroenterology and Hepatology, Jefferson University School of Medicine, Philadelphia, Pennsylvania, USA
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Ramakrishnaiah VPN, Ramkumar J, Pai D. Intratumoural injection of absolute alcohol in carcinoma of gastroesophageal junction for palliation of dysphagia. Ecancermedicalscience 2014; 8:395. [PMID: 24550996 PMCID: PMC3908612 DOI: 10.3332/ecancer.2014.395] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2013] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Ethanol-induced tumour necrosis (ETN) is a simple, readily available palliative treatment for patients with inoperable carcinoma of the oesophagus with poor performance status. In India, capital outlay needed for stenting or laser therapy is out of reach. Hence, we took up this study to calculate the effect of intratumoral injection of absolute alcohol in palliation of dysphagia due to carcinoma of the oesophagogastric junction and to monitor the improvement in quality of life (QOL). METHODS A total of 16 patients with a mean age of 56.2 ± 7.5 years with dysphagia due to unresectable malignant oesophageal strictures involving the oesophagogastric junction were included in the study. Six to ten cubic centimetres of absolute alcohol in 1 cc aliquots was injected circumferentially into the tumour at the point of luminal obstruction using disposable sclerosing needles (23G). During each follow up dysphagia grade, QOL score and complications, if any, were noted. RESULTS The mean alcohol injected per session was 6.9 ± 1.8 cc. The mean dysphagia grade improved from 5.5 ± 0.5 to 2.5 ± 1.1 before and after alcohol injection, respectively (p < 0.001). The time taken for recurrence of dysphagia ranged from 14 to 80 days with a median of 28 days. The mean QOL score assessed by modified EORTC questionnaire improved from a mean of 63.6 ± 6.9 to 92.6 ± 13.9 (p < 0.001). The dysphagia free survival ranged from 23 to 175 days with a mean of 71.2 days. Complications included oesophageal perforation in one patient and death in one patient. CONCLUSION The endoscopic intratumoral injection of absolute alcohol significantly improves dysphagia and QOL. It is inexpensive and easy to perform.
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Affiliation(s)
| | - J Ramkumar
- Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry 605006, India
| | - Dinker Pai
- Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry 605006, India
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Glare P, Miller J, Nikolova T, Tickoo R. Treating nausea and vomiting in palliative care: a review. Clin Interv Aging 2011; 6:243-59. [PMID: 21966219 PMCID: PMC3180521 DOI: 10.2147/cia.s13109] [Citation(s) in RCA: 84] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Nausea and vomiting are portrayed in the specialist palliative care literature as common and distressing symptoms affecting the majority of patients with advanced cancer and other life-limiting illnesses. However, recent surveys indicate that these symptoms may be less common and bothersome than has previously been reported. The standard palliative care approach to the assessment and treatment of nausea and vomiting is based on determining the cause and then relating this back to the "emetic pathway" before prescribing drugs such as dopamine antagonists, antihistamines, and anticholinergic agents which block neurotransmitters at different sites along the pathway. However, the evidence base for the effectiveness of this approach is meager, and may be in part because relevance of the neuropharmacology of the emetic pathway to palliative care patients is limited. Many palliative care patients are over the age of 65 years, making these agents difficult to use. Greater awareness of drug interactions and QT(c) prolongation are emerging concerns for all age groups. The selective serotonin receptor antagonists are the safest antiemetics, but are not used first-line in many countries because there is very little scientific rationale or clinical evidence to support their use outside the licensed indications. Cannabinoids may have an increasing role. Advances in interventional gastroenterology are increasing the options for nonpharmacological management. Despite these emerging issues, the approach to nausea and vomiting developed within palliative medicine over the past 40 years remains relevant. It advocates careful clinical evaluation of the symptom and the person suffering it, and an understanding of the clinical pharmacology of medicines that are available for palliating them.
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Affiliation(s)
- Paul Glare
- Pain and Palliative Care Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY, USA.
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Sood D, Singh T, Singh A, Chaudhary A. Esophageal tuberculosis mimicking submucosal leiomyoma- report of a case. Indian J Surg 2011. [PMID: 23204713 DOI: 10.1007/s12262-011-0266-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
We present a case of primary esophageal tuberculosis presenting as solitary submucosal mass in cervical esophagus with clinical features of dysphagia, thus mimicking a submucosal leiomyoma on imaging in a 39 year old lady. Excision of this mass revealed features suggestive of tuberculosis on histopathology.
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Affiliation(s)
- Disha Sood
- Sir Ganga Ram Hospital, New Delhi, India
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Conio M, Blanchi S, Filiberti R, De Ceglie A. Self-expanding plastic stent to palliate symptomatic tissue in/overgrowth after self-expanding metal stent placement for esophageal cancer. Dis Esophagus 2010; 23:590-6. [PMID: 20545980 DOI: 10.1111/j.1442-2050.2010.01068.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Self-expanding metal stents (SEMS) are used to treat obstructive malignancies of the esophagus or esophagogastric junction; however, a potential complication is recurrent dysphagia because of tissue in/overgrowth. The placement of a second SEMS is one strategy to re-establish patency of the esophageal lumen. We evaluated the safety and efficacy of an alternative and likely less costly approach: placing a self-expanding plastic stent (SEPS) to manage relapsing dysphagia in patients previously treated with a partially covered SEMS. From December 2007 to January 2009, 13 patients previously treated with a SEMS for malignant dysphagia underwent treatment by inserting a SEPS to palliate relapsing dysphagia, as a result of tissue in/overgrowth. Stenosis was located in the upper esophagus in one patient, in the middle in four patients, and in the lower esophagus in eight patients. Clinical evaluation was performed at the time of stent placement, after 1 week, and then, monthly until death. The SEPS was successfully placed in a single treatment session for all patients. No preliminary dilation was required, and no further treatment was necessary for any patient. Before stenting, the median dysphagia score was 4 (range 3-4), and 1 week later the score was 0 for all patients. The resolution of dysphagia persisted until patient death (from tumor progression). The mean survival after the SEPS insertion was 4 months (range 3-8). This case series supports the use of a SEPS to palliate dysphagia from tissue in/overgrowth of a SEMS. Future clinical trials with larger patient samples are warranted.
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Affiliation(s)
- M Conio
- Department of Gastroenterology, General Hospital, Corso Garibaldi 187, Sanremo, Italy.
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Urano Y, Asanuma D, Hama Y, Koyama Y, Barrett T, Kamiya M, Nagano T, Watanabe T, Hasegawa A, Choyke PL, Kobayashi H. Selective molecular imaging of viable cancer cells with pH-activatable fluorescence probes. Nat Med 2008; 15:104-9. [PMID: 19029979 DOI: 10.1038/nm.1854] [Citation(s) in RCA: 667] [Impact Index Per Article: 41.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2008] [Accepted: 07/07/2008] [Indexed: 11/09/2022]
Abstract
A long-term goal of cancer diagnosis is to develop tumor-imaging techniques that have sufficient specificity and sensitivity. To achieve this goal, minimizing the background signal originating from nontarget tissues is crucial. Here we achieve highly specific in vivo cancer visualization by using a newly designed targeted 'activatable' fluorescent imaging probe. This agent is activated after cellular internalization by sensing the pH change in the lysosome. Novel acidic pH-activatable probes based on the boron-dipyrromethene fluorophore were synthesized and then conjugated to a cancer-targeting monoclonal antibody. As proof of concept, ex vivo and in vivo imaging of human epidermal growth factor receptor type 2-positive lung cancer cells in mice was performed. The probe was highly specific for tumors with minimal background signal. Furthermore, because the acidic pH in lysosomes is maintained by the energy-consuming proton pump, only viable cancer cells were successfully visualized. The design concept can be widely adapted to cancer-specific, cell surface-targeting molecules that result in cellular internalization.
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Affiliation(s)
- Yasuteru Urano
- Graduate School of Pharmaceutical Sciences, The University of Tokyo, Bunkyo, Tokyo, Japan
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9
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Wadleigh RG, Abbasi S, Korman L. Septic monoarthritis and osteomyelitis in an elderly man following Klebsiella pneumoniae genitourinary infection: case report. ANNALS ACADEMY OF MEDICINE SINGAPORE 2006; 331:110-2. [PMID: 16479188 DOI: 10.1097/00000441-200602000-00022] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Klebsiella pneumoniae septic arthritis and osteomyelitis, albeit uncommon in adults, are important sites of disseminated infection. Many case reports have shown K. pneumoniae as a cause of nosocomial transmitted septic arthritis in neonates and children. We report a rare case of an elderly patient with K. pneumoniae genitourinary infection spreading to the liver and other extra hepatic sites like the prostate and peripheral joint. CLINICAL PICTURE The patient presented with a short history of general malaise, fever and urinary symptoms, associated with an acute monoarthritis of the ankle. On admission, he was in septic shock. Investigations suggested an infective cause, as evidenced by raised total white cell count and pyuria. K. pneumoniae was cultured from both urine and ankle synovial fluid. Imaging confirmed multiple liver and prostatic abscesses, as well as osteomyelitis of the foot bones adjacent to the ankle. TREATMENT Treatment in this case included surgical drainage of the affected joint and surrounding soft tissue structures, in addition to a 6-week course of systemic antibiotics. OUTCOME The patient had good clinical response following treatment. In addition, we noted a normalisation of his laboratory parameters and resolution of the intraabdominal and pelvic abscesses. CONCLUSION This case emphasises the importance of timely and accurate diagnosis followed by appropriate treatment in disseminated K. pneumoniae infection to prevent significant morbidity and mortality.
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Affiliation(s)
- Robert G Wadleigh
- Oncology Section, Department of Veterans Affairs Medical Center, Washington, DC, USA.
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Adler DG, Merwat SN. Endoscopic approaches for palliation of luminal gastrointestinal obstruction. Gastroenterol Clin North Am 2006; 35:65-82, viii. [PMID: 16530111 DOI: 10.1016/j.gtc.2005.12.004] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
Much of the workload of a typical gastroenterologist is devoted to screening patients for gastrointestinal malignancies. Efforts such as colorectal cancer screening via colonoscopy and endoscopic surveillance of patients with Barrett's esophagus are widespread and widely endorsed. In recent years, the armamentarium of endoscopy has broadened considerably and now affords physicians a variety of nonsurgical means to palliate malignant obstruction of the gastrointestinal tract. This article reviews endoscopic techniques to treat malignant esophageal, biliary, small bowel, and colonic obstruction.
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Affiliation(s)
- Douglas G Adler
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Texas-Houston Medical School, MSB 4.234, 6431 Fannin, 77030, USA.
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11
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Abstract
There are a wide variety of palliative treatments for esophageal cancer. The aim of most treatments is to maintain oral food intake, which should stabilize or even improve quality of life. Stent placement is currently the most widely used treatment modality for palliation of dysphagia from esophageal cancer. Stent placement offers a rapid relief of dysphagia, however, the rate of complications (late hemorrhage) and recurrent dysphagia (stent migration, tumor overgrowth) is relatively high. The scientific evidence to advocate the use of anti-reflux stents for the prevention of gastro-esophageal reflux is currently too low. Photodynamic therapy is mostly used in North America; however, due to the high costs of the treatment, the long-lasting side effects and the necessity of repeated treatments, it is not an ideal treatment for palliation of malignant dysphagia. Nd:YAG laser is a relatively effective and safe treatment modality, although laser treatment is also expensive, technically difficult and requiring repeated treatment sessions at 4-6 weeks intervals. Single dose brachytherapy compares favorably to stent placement in long-term effectiveness and safety. Effective treatment strategies are probably 12 Gy given in one fraction or 16 Gy given in two fractions. Palliative chemotherapy offers response rates in recent trials (including partial and complete responses) ranging from 35% to 50%. Whether palliative chemotherapy also results in a survival benefit is not established yet. For clinical trials on palliation of esophageal cancer, the measurement of quality of life is an important outcome measure. The cancer-specific EORTC QLQ-C30 and the esophageal cancer-specific EORTC-OES-18 are validated measures for establishing quality of life status. For the future, a multimodality approach with stent placement or brachytherapy in combination with chemotherapy may be indicated.
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Affiliation(s)
- Marjolein Y V Homs
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, 3000 CA Rotterdam, The Netherlands
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12
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Sabharwal T, Morales JP, Irani FG, Adam A. Quality improvement guidelines for placement of esophageal stents. Cardiovasc Intervent Radiol 2005; 28:284-8. [PMID: 15886931 DOI: 10.1007/s00270-004-0344-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Esophageal cancer is now the sixth leading cause of death from cancer worldwide. During the past three decades, important changes have occurred in the epidemiologic patterns associated with this disease. Due to the distensible characteristics of the esophagus, patients may not recognize any symptoms until 50% of the luminal diameter is compromised, explaining why cancer of the esophagus is generally associated with late presentation and poor prognosis. Esophageal cancer has a poor outcome, with an overall 5 year survival rate of less than 10%, and fewer than 50% of patients are suitable for resection at presentation. As a result palliation is the best option in this group of patients. The aims of palliation are maintenance of oral intake, minimizing hospital stay, relief of pain, elimination of reflux and regurgitation, and prevention of aspiration. For palliative care, current treatment options include thermal ablation, photodynamic therapy, radiotherapy, chemotherapy, chemical injection therapy, argon beam or bipolar electrocoagulation therapy, enteral feeding (nasogastric tube/percutaneous endoscopic gastrostomy), and intubation (self-expanding metal stents (SEMS) or semi-rigid prosthetic tubes) with different success and complications rates.
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Affiliation(s)
- Tarun Sabharwal
- Department of Interventional Radiology, Guy's and St. Thomas' Hospital Trust, London, UK.
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13
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Wang KK, Wongkeesong M, Buttar NS. American Gastroenterological Association technical review on the role of the gastroenterologist in the management of esophageal carcinoma. Gastroenterology 2005; 128:1471-505. [PMID: 15887129 DOI: 10.1053/j.gastro.2005.03.077] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Kenneth K Wang
- Barrett's Esophagus Unit, St. Mary's Hospital, Mayo Clinic, Rochester, Minnesota, USA
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14
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Allum WH, Griffin SM, Watson A, Colin-Jones D. Guidelines for the management of oesophageal and gastric cancer. Gut 2002; 50 Suppl 5:v1-23. [PMID: 12049068 PMCID: PMC1867706 DOI: 10.1136/gut.50.90005.v1] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- W H Allum
- Department of Surgery, Epsom Hospital, Epsom, Surrey KT1 7EG, United Kingdom
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15
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Lee SH. The role of oesophageal stenting in the non-surgical management of oesophageal strictures. Br J Radiol 2001; 74:891-900. [PMID: 11675304 DOI: 10.1259/bjr.74.886.740891] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
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.
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Affiliation(s)
- S H Lee
- Department of Radiology, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK
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Monga SP, Wadleigh R, Sharma A, Adib H, Strader D, Singh G, Harmon JW, Berlin M, Monga DK, Mishra L. Intratumoral therapy of cisplatin/epinephrine injectable gel for palliation in patients with obstructive esophageal cancer. Am J Clin Oncol 2000; 23:386-92. [PMID: 10955870 DOI: 10.1097/00000421-200008000-00016] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Obstructing esophageal cancer produces severe dysphagia with ensuing death within 90 days. Palliation is possible with modalities like stent placement, laser, and photodynamic therapy. However, these treatments have a high rate of complications, and the overall mortality is not altered. A new alternative treatment evaluated in this study is endoscopic intratumoral injection with cisplatin/epinephrine (CDDP/epi) gel. CDDP/epi gel injections were administered weekly for 3 to 8 weeks in nine patients, median age, 72 years; mean tumor volume (+/-SEM), 41.44 (+/-22.4) cm3. Eight patients had stage IV, and one had stage III esophageal carcinoma. The mean dysphagia score (+/-SEM) was 3.5 (+/-0.17). All patients were followed up until death. Dysphagia resolved in eight patients with reduction in mean dysphagia score (+/-SEM) from 3.5 (+/-0.17) to 0.75 (+/-0.28; p = 0.005). Tumor volume was reduced by 75% in one patient and by 50% in two patients. The median survival was 4 months. The longest follow-up has been 15 months (458 days). In this pilot study, intratumoral injection of CDDP/epi gel restored swallowing in eight of nine patients and was an effective and safe outpatient treatment in patients with obstructive esophageal cancer.
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Affiliation(s)
- S P Monga
- Department of Gastroenterology/Development and Molecular Biology, Department of Veterans Affairs Medical Center, Washington, DC 20422, USA
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Kubba AK, Krasner N. An update in the palliative management of malignant dysphagia. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2000; 26:116-29. [PMID: 10744928 DOI: 10.1053/ejso.1999.0754] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Oesophageal cancer is generally associated with late presentation and poor prognosis. Therefore palliative surgery has been largely superseded by less invasive non-surgical techniques. Once palliation is indicated, the aims of the management should be: the maintenance of oral intake, minimizing hospital stay, relief of pain, elimination of reflux and regurgitation and the prevention of aspiration. METHODS This study was a review of all published English language data on the palliation of malignant dysphagia between 1994-1999. The Medline and Bids databases were searched and other references were derived from the material perused. RESULTS AND CONCLUSIONS Palliative treatment for oesophageal cancer should be individualized and relate to tumour stage, size and location, the patient's medical condition and his/her personal wishes. The palliative treatment largely includes self-expanding metal stents (SEMS), laser (including photodynamic therapy (PDT)) or a combination of the two to relieve symptoms, this may be employed with or without other treatments such as radiotherapy/chemotherapy (RT/CT) with the aim of reducing tumour bulk and possibly prolonging survival. A multi-disciplinary approach is vital in patients with advanced oesophageal cancer.
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Affiliation(s)
- A K Kubba
- Dept of Surgery, University of Nottingham, Liverpool, UK
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Nelson DB, Bosco JJ, Curtis WD, Faigel DO, Kelsey PB, Leung JW, Mills MR, Smith P, Tarnasky PR, VanDam J, Wassef WY. ASGE technology status evaluation report. Injection needles. February 1999. American Society for Gastrointestinal Endoscopy. Gastrointest Endosc 1999; 50:928-31. [PMID: 10644194 DOI: 10.1016/s0016-5107(99)70198-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
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Nicholson DA, Haycox A, Kay CL, Rate A, Attwood S, Bancewicz J. The cost effectiveness of metal oesophageal stenting in malignant disease compared with conventional therapy. Clin Radiol 1999; 54:212-5. [PMID: 10210338 DOI: 10.1016/s0009-9260(99)91153-4] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Expanding metal oesophageal stents are being used more commonly to palliate patients with inoperable oesophageal carcinoma. Many reports have so far documented their clinical effectiveness, however, their high acquisition cost has caused on-going concern when compared with the cost of conventional therapies. We reviewed 64 consecutive patients with inoperable oesophageal carcinoma, half of whom had received our conventional method of palliation using a variety of techniques including, BICAP diathermy, alcohol injection and Atkinson tube insertion. The other half (32 patients) were treated with expandable metal stents -- Gianturco Z stents (Cook UK Ltd) and uncovered Ultraflex stents (Microvasive, Boston Scientific). The physical amount of resources consumed were identified and measured (number of diagnostic and support procedures, days as in patients, number of day cases or outpatient attending) and an average NHS cost was applied to this resource use. All costs were summated over the period of palliation from the date of the first intervention with palliative intent until death. Although the patients in this study were not randomized, the two groups were matched to ensure comparability in clinical manifestation (uncomplicated biopsy proven oesophageal carcinoma) and the average age of patients from each group. A difference was identified between the length of survival in both patient groups and the analysis was corrected for this by estimating a cost per day of palliative support. Patients palliated with metal stents underwent fewer procedures and spent fewer days in hospital during the time period from presentation until death even when corrected for differences in survival. Patient outcome (effectiveness of palliation) was measured by recording mean dysphagia scores which were recorded before and after palliation. Metal stents were found to lead to a significantly higher improvement in dysphagia in comparison to conventional therapy. In addition, the mortality related to metal oesophageal stents was lower than Atkinson tube insertion. The average cost of palliation was much lower in the metal stent group (mean = pound sterling 2817) compared with the cost in those palliated conventionally (mean = pound sterling 4566). However, once this was corrected for survival the difference in the cost of palliation on a per diem basis was reduced (metal stents = pound sterling 60 per day, conventional group = pound sterling 72 per day). The results of our study indicate that the initial high cost of metal stents is more than outweighed by resource savings elsewhere in the hospital by virtue of reduced need for re-intervention and shorter length of hospital in patient stay. Such cost savings taken in combination with the improved clinical effectiveness and low mortality related to metal stents provide significant support for introducing their use into clinical practice.
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Affiliation(s)
- C J Lightdale
- Department of Medicine, Columbia University, College of Physicians and Surgeons, New York, New York, USA
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Monga SP, Wadleigh R, Adib H, Harmon JW, Berlin M, Mishra L. Endoscopic treatment of gastric cancer with intratumoral cisplatin/epinephrine injectable gel: a case report. Gastrointest Endosc 1998; 48:415-7. [PMID: 9786117 DOI: 10.1016/s0016-5107(98)70014-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- S P Monga
- Department of Gastroenterology/Molecular Biology Research, DVAMC, Washington, DC 20422, USA
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Spencer GM, Thorpe SM, Sargeant IR, Blackman GM, Solano J, Tobias JS, Bown SG. Laser and brachytherapy in the palliation of adenocarcinoma of the oesophagus and cardia. Gut 1996; 39:726-31. [PMID: 9014774 PMCID: PMC1383399 DOI: 10.1136/gut.39.5.726] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Palliation of malignant dysphagia is possible by a variety of methods although all have significant drawbacks. Laser therapy is an effective and safe treatment but has to be repeated at four to five weekly intervals to maintain palliation. A means of augmenting the benefits while reducing the need for repeat treatments would be highly beneficial to these patients. AIMS To prospectively explore the safety and efficacy of intraluminal radiotherapy (brachytherapy) when used to augment laser recanalisation for malignant dysphagia. PATIENTS Nineteen patients with dysphagia due to advanced adenocarcinoma of the oesophagus or cardia were recruited. METHODS All patients received laser recanalisation until able to swallow a soft diet or better, before the application of a single dose of brachytherapy (10 Gy at 1 cm from the source). Patients were followed up and treated promptly by further endoscopic means in the event of their dysphagia worsening. RESULTS Six patients (32%) required no further treatment until death at a median of 10 weeks (range 1-20 weeks). Further therapy was required at a median of 11 weeks (range 4-37 weeks) after brachytherapy for those 13 patients with recurrent dysphagia. Subsequent symptom control required endoscopic intervention at an average of once every nine weeks. There was no mortality associated with laser or brachytherapy. Median survival from initial treatment and including the one survivor was 36 weeks (range 5-132 weeks). CONCLUSIONS Laser plus brachytherapy offers a safe and effective means of palliating malignant dysphagia due to adenocarcinoma, with a longer dysphagia free interval than historical controls treated with laser alone.
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Affiliation(s)
- G M Spencer
- National Medical Laser Centre, University College London Medical School, London
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Abstract
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.
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Affiliation(s)
- C E Reed
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston 29425, USA
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Blazeby JM, Alderson D. The Modem Management of Patients with Oesophageal Cancer. PROGRESS IN PALLIATIVE CARE 1995. [DOI: 10.1080/09699260.1995.11746721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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