Comparison of Endoscopic Stenting Versus Surgical Jejunostomy Tube for Maintainance of Nutrition and Dysphagia in Patients with a Malignant Esophageal Stricture Receiving Neoadjuvant Chemoradiation

Abstract

Background: In patients undergoing chemoradiotherapy for esophageal cancer, the inability to eat may severely impair nutritional status and quality of life. The use of a jejunostomy tube (JT) can improve nutritional status, but deprives the patient of the pleasure of eating. The aim of this study was to compare the efficacy of the Polyflex self-expanding silicone stent (PS) vs. a surgically-placed JT for maintaining nutrition during neoadjuvant chemoradiation therapy in patients scheduled to have resectional surgery for obstructing esophageal cancers. Methods: 36 patients with esophageal cancers that were deemed respectable were treated either with PS placement (12 patients) or JT placement (24 patients) immediately prior to receiving an 8 week course of neoadjuvant chemoradiation therapy. Patients were interviewed weekly until cessation of their chemoradiotherapy. For all patients, data were collected on procedural success and complication rates, nutritional status (serum albumin and weight) and dysphagia scores. A 2 × 2 mixed factorial analysis of variance was computed for the dysphagia score, albumin levels, and weight using treatment group (PS or JT) as the between factor and time (pre-procedure and at the completion of chemoradiation) as the within factor. Results: Baseline characteristics of the two groups did not differ significantly. PS placement was successful in 11 of 12 patients (92%), and those 11 patients were able to resume oral nutrition. Migration of the stent into the stomach occurred in 3 (25%) patients, who experienced no further complications. Dysphagia scores improved from a mean of 3 (ability to ingest liquids only) to 1 (ability to eat some solid food) in the PS group [p < 0.005], but did not change significantly in the JT group. PS were removed endoscopically without complications prior to the esophagectomies. Albumin levels and weight increased significantly in both the PS and JT groups [F(1, 33) = 126.25, p < .001 and F(1, 33) = 89.86, p < .001, respectively]. There were no significant differences between the groups in the procedural success rates (PS 92% v JT 100%, p = 0.33), complication rates (PS 22% v JT 4%, p = 0.11), mean increase in weight (PS 4.4 kg v JT 4.2 kg, p = 0.59) and mean increase in serum albumin (PS 0.62 g/dL v JT 0.44 g/dL, p = 0.05). Conclusions: Polyflex stent is a safe and effective alternative to a surgical jejunostomy tube for maintaining nutrition during neoadjuvant chemoradiation therapy in patients with obstructing esophageal neoplasms. Although both procedures result in similar improvements in nutritional status with similar rates of complications, only the PS improves dysphagia scores significantly.