Preoperative Placement of Polyflex Esophageal Stents in Patients with Locally Advanced Esophageal Cancer Undergoing Neoadjuvant Therapy

Abstract

Purpose: Most patients with esophageal cancer have dysphagia and/or weight loss. Polyflex stents may serve to relieve dysphagia and improve oral intake in patients undergoing neoadjuvant therapy. The aims of the study were 1) to determine if Polyflex esophageal stents improve dysphagia and weight loss in patients with locally advanced esophageal cancer undergoing neoadjuvant therapy 2) and to evaluate complications. Methods: Subjects with esophageal cancer with EUS staging from April 2006 to Nov 2007 were enrolled. Subjects were >18 y with dysphagia, locally advanced esophageal cancer, and had Polyflex stent placement. Subjects with distant metastatic disease or with a malignant stricture within 2 cm of the upper esophageal sphincter were excluded. Subjects were followed until removal of stent or death. All patients received neoadjuvant therapy following stent placement. Dysphagia was assessed by a 5-point scale prior to stent placement and at one week intervals. Weight change was assessed. The dysphagia score was analyzed using Wilcoxon signed rank. Results: 13 subjects met entry criteria and were enrolled. All subjects were male, the mean age was 63.3 ± 12.3 (45–82). One subject was not included in the analysis due to unrecognized metastatic disease. Stents remained in place for a mean of 65.9 ± 56.2 days (2–180). Dysphagia scores were significantly improved at weeks 1, 2, 3, and 4 when compared to the mean baseline score of 3.1 (1.1, 0.8 0.9, 1) (P= 0.005, P= 0.01, P= 0.02, P= 0.008). All subjects reported weight loss prior to stent placement (mean, 9.9 ± 5.6 kg). Weight loss slowed with a mean weight change of −2.6 ± 7.8 kg over a mean of 2.4 ± 1.6 weeks. There were no immediate complications. All but one patient experienced chest or abdominal pain following stent placement. Stents migrated in 6/13 (46%) patients in a mean of 42.7 days (2–90). 3/6 patients with migrated stents went on to esophagectomy at an average of 8.5 weeks later. 5/6 migrated stents were safely removed during endoscopy, 1 was removed at time of esophagectomy. One stent was removed due to severe pain 2 days after placement. 1 stent remained in place 180 days and showed tumor overgrowth. Conclusion: Polyflex stents provided safe and rapid relief from dysphagia in patients undergoing neoadjuvant therapy. Complications were mild. Weight loss largely stabilized. The stents served either as a bridge to surgery, migrated when they were no longer needed, or remained in place in patients not felt to be operative candidates. Chest pain is common following stent placement. Although stent migration is common following chemoradiation, the stents were easily removed endoscopically or at the time of surgery.