Improvement In Dysphagia Score Research Articles

A novel self-inflatable balloon for treating refractory benign esophageal strictures: a prospective, single-arm, multicenter study.

Current treatments for refractory benign esophageal strictures (BESs) often take several years and have poor effects. The authors propose a novel method of self-help inflatable balloon (SHIB) and evaluate its efficacy and safety. A prospective, multicenter study was conducted from January 2019 to March 2022. All enrolled patients were diagnosed with refractory BESs and received SHIB. The primary endpoint was the clinical success rate at 12 months after removing SHIB. The secondary endpoints were the number of days of placing SHIB, and changes from baseline in BMI and health-related quality of life at 1, 3, 6, and 12 months. The clinical success rate was 51.2% (21/41) with the median days of placing SHIB being 104.0 days (range: 62.0-134.5 days), which was higher in the endoscopic group compared to the caustic and surgery groups (63.3 vs. 28.6% vs. 0, P=0.025). All patients (100%) showed significant improvement in dysphagia scores during placing SHIB. Although 20 patients (48.8%) experienced recurrent stricture, the median stricture length was decreased (P<0.001) and the median intervention-free interval was prolonged (P<0.001). In all patients, the mean BMI at and health-related quality of life at 1, 3, 6, and 12 months were significantly increased compared with baseline (P<0.05). On multivariate analysis, stricture etiology and wearing time were independent predictors of recurrent stricture. The SHIB has high efficacy and safety in treating refractory BESs of different origins, especially for endoscopic resection. Stricture etiology and wearing time were independent predictors of recurrent stricture.

OGBN P02 Longer term symptom control following revision anti-reflux surgery: a cohort of 379 patients

Abstract Background Symptom recurrence after primary hiatus hernia surgery is an established problem and revision anti-reflux surgery may be indicated in select cases of recurrence after primary surgery. Previous studies on this subject are of small number and often lack objective measures. Our aim is to review the long term post operative outcomes and assess the impact of revisional anti reflux surgery on symptom improvement and quality of life measures. Methods A prospectively maintained single-surgeon database of revisional hiatus hernia surgery from 1992 to 2022 was retrospectively evaluated. The results of the pre operative assessments were collated to identify the symptomatic, anatomical and physiological indications. Validated scoring systems including GIQLI, Visick, Dakkak and Reflux Symptom Index scores were compared pre-operatively and post-operatively. Post-operative GIQLI scores were measured in the first 12 months (short term), 12 to 36 months (medium term) and after 36 months (long term) in order to obtain a trend in patient reported outcomes. Questions assessing heartburn, dysphagia, and regurgitation were analysed to determine progress of these specific symptoms. Results The dataset consisted of 379 patients, of whom 59% were female. The average age at the time of first revisional surgery was 59 years (range 19-91). Laparoscopic surgery was performed in 90% of primary operations compared to 68% of revision operations. There was overall improvement in outcomes as demonstrated in this table. Additionally, evaluation of symptoms specific questions of the GIQLI showed a statistically significant improvement in dysphagia scores in the long term category (p = 0.0210). Conclusions There is a global improvement in long term control of reflux and dysphagia symptoms following revision hiatus hernia surgery showed. However, volume regurgitation symptoms were not shown to be consistently improved post operatively. This may be due to an underlying motility disorder in these patients or the potential of dysmotility caused by revision surgery from injury to the vagus nerve. Caution should be exercised when considering revision anti reflux surgery in this patient cohort.

Endoscopic Treatment of Postoperative Esophageal Anastomotic Strictures: A Single Center Experience

Background&#x0D; To evaluate the analysis, treatment methods and results of endoscopic treatments of esophagojejunostomy (EJ) and esophagogastric (EG) anastomotic strictures. &#x0D; Methods:&#x0D; Data from patients treated between 2009 and 2019 was collected and analyzed. The primary endpoint was defined as the absence of dysphagia for at least 6 months after the final endoscopic treatment session. The improvement in dysphagia scores at 1 and 6 months was accepted as the secondary endpoint.&#x0D; Results&#x0D; Of 18 patients (10 male), there were 11 patients with EG anastomotic stricture and 7 patients with EJ anastomotic stricture. Only balloon or bougie dilatation was applied to 13 patients, while 5 patients received a full-covered metal stent (FCMS) in addition to balloon or bougie dilatation due to persistent dysphagia symptoms. The primary endpoint was reached in 10 of the 13 patients (76.9%) who received only balloon or bougie dilatation. The secondary endpoint was reached in 3 patients. The primary endpoint was reached in 4 of the 5 patients (80%) who received a FCMS in addition to balloon or bougie dilatation. 6 patients (33.3%) had a recurrence. Major complications occurred in 4 (22.2%) patients, including perforation in 2 and stent migration in 2 patients.&#x0D; Conclusion&#x0D; The study demonstrated that endoscopic treatment of esophageal anastomotic strictures is a reliable and effective treatment option with a high success rate. The use of FCMS, either as a primary treatment option or in the treatment of perforation as a complication of endoscopic treatment, showed good effectiveness in our study.

Long-term outcomes of Zenker's peroral endoscopic myotomy (Z-POEM) for treatment of Zenker's diverticulum.

Background and study aims Z-POEM is now an established therapy for symptomatic Zenker's diverticulum (ZD). Short-term follow-up of up to 1-year post Z-POEM suggests excellent efficacy and safety; however, long-term outcomes are not known. Thus, we sought to report on longer-term outcomes (≥ 2 years) following Z-POEM for treatment of ZD. Patients and methods This was an International multicenter retrospective study at eight institutions across North America, Europe, and Asia over a 5-year period (from December 3, 2015 to March 13, 2020) of patients who underwent Z-POEM for management of ZD with a minimum 2-year follow-up. The primary outcome was clinical success, defined as improvement in dysphagia score to ≤ 1 without need for further procedures during the first 6 months. Secondary outcomes included rate of recurrence in patients initially meeting clinical success, rate of reintervention, and adverse events (AEs). Results A total of 89 patients (male 57.3 %, mean age 71 ± 12 years) underwent Z-POEM for treatment of ZD (mean diverticulum size was 3.4 ± 1.3 cm). Technical success was achieved in 97.8 % of patients (n = 87) with a mean procedure time of 43.8 ± 19.2 minutes. The median post-procedure hospital stay was 1 day. There were eight AEs (9 %) (3 mild, 5 moderate). Overall, clinical success was achieved in 84 patients (94 %). Mean dysphagia, regurgitation, and respiratory scores all improved dramatically from 2.1 ± 0.8, 2.8 ± 1.3, and 1.8 ± 1.6 pre-procedure to 0.13 ± 0.5, 0.11 ± 0.5, and 0.05 ± 0.4, respectively, post-procedure at most recent follow-up (all P < 0.0001). Recurrence occurred in six patients (6.7 %) during a mean length of follow-up of 37 months (range 24 to 63 months). Conclusions Z-POEM is a highly safe and effective treatment for Zenker's diverticulum with durable treatment effect to at least 2 years.

Clinical and financial outcomes of per-oral endoscopic myotomy compared to laparoscopic heller myotomy for treatment of achalasia.

Previous studies analyzing short-term outcomes for per-oral endoscopic myotomy (POEM) have shown excellent clinical response rates and shorter operative times compared to laparoscopic Heller myotomy (LHM). Despite this, many payors have been slow to recognize POEM as a valid treatment option. Furthermore, comparative studies analyzing long-term outcomes are limited. This study compares perioperative and long-term outcomes, cost-effectiveness, and reimbursement for POEM and LHM at a single institution. Adult patients who underwent POEM or LHM between 2014 and 2021 and had complete preoperative data with at least one complete follow up, were retrospectively analyzed. Demographic data, success rate, operative time, myotomy length, length of stay, pre- and postoperative symptom scores, anti-reflux medication use, cost and reimbursement were compared. 58 patients met inclusion with 25 undergoing LHM and 33 undergoing POEM. There were no significant differences in preoperative characteristics. Treatment success (Eckardt ≤ 3) for POEM and LHM was achieved by 88% and 76% of patients, respectively (p = 0.302). POEM patients had a shorter median operative time (106min. vs. 145min., p = 0.003) and longer median myotomy length (11cm vs. 8cm, p < 0.001). All LHM patients had a length of stay (LOS) ≥ 1day vs. 51.5% for POEM patients (p < 0.001). Both groups showed improvements in dysphagia, heartburn, regurgitation, Eckardt score, GERD HRQL, RSI, and anti-reflux medication use. The improvement in dysphagia score was greater in patients undergoing POEM (2.30 vs 1.12, p = 0.003). Median hospital reimbursement was dramatically less for POEM ($3,658 vs. $14,152, p = 0.002), despite median hospital costs being significantly lower compared to LHM ($2,420 vs. $3,132, p = 0.029). POEM is associated with a shorter operative time and LOS, longer myotomy length, and greater resolution of dysphagia compared to LHM. POEM costs are significantly less than LHM but is poorly reimbursed.

Flexible endoscopic incisional therapy for Zenker's diverticulum (FEIT-Z) is an effective treatment for surgical failures or non-operative patients.

Symptomatic Zenker's diverticulum (ZD) occurs mostly in the elderly, who often have significant comorbidities, and poor neck hyperextension, putting them at high risk for surgical management while also increasing the potential of technical failure. Flexible endoscopic incisional therapy for Zenker's diverticulum (FEIT-Z) offers a safe approach to this problem with high technical and clinical success rates. There are limited data on its use following a failed surgical approach or in patients unfit for a surgical approach. The aim of this study was to assess clinical and technical outcomes of FEIT-Z in patients who were non-operative candidates or refused or failed surgical management. Patients who underwent FEIT-Z from January 2015 to February 2019 at a tertiary referral center were included. Patient demographics, prior ZD surgical history, procedural data, dysphagia scores, clinical success, and adverse events (AE) were collected. Univariable analysis was performed to assess differences between pre- and post-FEIT-Z dysphagia scores. 30 patients undergoing FEIT-Z were included. Seven had a prior failed ZD surgical approach, 6 refused surgical management, and 17 were deemed to be non-operative candidates based on medical comorbidities. Mean age was 78.4 (± 12.1) and 36.7% were male. Technical success of FEIT-Z was 96.7%. There was a significant improvement in dysphagia scores after FEIT-Z: 2.3 (± 0.64) vs. before, 0.4 (± 0.76) (p < 0.001). Long-term clinical success was achieved in 73.3% of patients. Adverse events were seen in 23.3% of patients; however, these were graded as mild in 85.7% of patients. One microperforation was managed with antibiotics. FEIT-Z is a safe procedure with low adverse events and a high rate of technical and clinical success. FEIT-Z can be done in patients who fail previous surgical treatment, refuse a surgical approach, or are not surgical candidates due to medical comorbidity or other factors.

645 THE OUTCOMES OF PALLIATIVE SELF-EXPANDING METALLIC SEM) STENTS IN THE MANAGEMENT OF INOPERABLE ESOPHAGEAL CARCINOMA.

Abstract The incidence of esophageal carcinoma (EC) in Singapore is declining since 1970s. However, the age-incidence curve in 2010s shows a steep rise after age 40-50s. The majority of EC patients presented late with locally advanced or metastatic disease. The outcomes of inoperable esophageal carcinoma treated with palliative self-expanding metallic (SEM) stents were reviewed. Methods Consecutive cases of EC including Siewert Type I adenocarcinoma of esophago-gastric junction (AEG) were identified from electronic medical records from August 2015 to February 2021. There were 78 cases of EC and of which 14 were stented. The outcomes of inoperable or metastatic EC cases treated with palliative SEM stents were analyzed. Other palliative treatment included best supportive care and palliative chemotherapy with or without radiotherapy. Results The demographics showed the mean age of 73 ± 11 years with ECOG score 0-1 in 86% and mean BMI 19.1 ± 3.8. All were males with the risks from smoking in 85% and alcohol in 50%. The mean length of EC was 6.2 ± 2.6 cm. There were 10 Wallflex and 4 Ultraflex partially covered stents deployed successfully. The pre-stent dysphagia score was 3 in 72% and 4 in 29% whilst all had post-stent score of 1. The mean duration of survival was 4.4 ± 4.1 months. Post-stent complications included stent migration without obstruction and food bolus obstruction. Conclusion About 18% of patients diagnosed with advanced symptomatic EC were treated with palliative SEM stent insertion in a safe and effective manner. Those at risk were elderly males with smoking history. All stented cases had immediate improvement of dysphagia score and were able to tolerate soft diet. The overall duration of survival was variable up to 1 year likely due to different tumour biology and concurrent palliative systemic therapy.

Transillumination Assisted Cricopharyngeal Myotomy.

Cricopharyngeal muscle myotomy (CPM) is a common intervention for relief of dysphagia in patients with Oculo-pharyngeal muscular dystrophy (OPMD). Because of difficulties in approaching and dissecting cricopharyngeal muscle in these patients, we used transillumination for the myotomy (TA-CPM). Transillumination is a simple technique to improve the guidance and navigation of the surgeon in determining the location and depth of myotomy. The purpose of this study is to evaluate the efficacy and safety of transillumination in CPM in OPMD patients. An observational cohort of patients with OPMD who underwent CPM due to dysphagia at one medical center between 2010 and 2019. Two groups of patients are included, according to whether transillumination was used during their surgery. Patients were evaluated before and after surgery (1week and 1month) for their dysphagia score with a standardized questionnaire. The surgical team preferences, experience and complexity with and without transillumination were evaluated. Ten OPMD patients (8 heterozygotes, 2 homozygotes for the commonmutation) underwent CPM for relieving dysphagia symptoms at medium size medical center in Israel between 2010 and 2019. Five patients had TA-CPM and the 5 patients had CPM without transillumination. All patients showed an improvement at follow-up examinations, 1week and 1month postoperative, including a decrease in dysphagia score and in choking and aspiration events, compared to their preoperative state. TA-CPM improved the surgical approach, reduced the difficulty of CPM and was preferred by the surgical team. From the patients' point of view, TA-CPM was as good as a non-transillumination approach in improving dysphagia. TA-CPM is a cheap, fast and simple technique to improve the surgical outcomes in CPM for patients with OPMD. TA-CPM navigates the surgeon, helps with anatomical orientation, improve the surgeon's comfortable, may shorten the duration of surgery and reduces potential errors. Improvement in dysphagia score was similar in both groups. This technique may improve myotomy procedures for dysphagia of other etiologies. IV. Case series (with or without comparison). Endoscopic transillumination assisted myotomy.

Outcomes of concurrent chemoradiotherapy versus chemotherapy alone for esophageal squamous cell cancer patients presenting with oligometastases.

The potential survival benefits of adding radiotherapy to systemic therapy for esophageal cancer patients with oligometastases are unknown. In this retrospective analysis, patients with stage IV esophageal cancer (according to the American Joint Committee on Cancer Seventh edition staging system) with ≤3 metastases who underwent chemotherapy with cisplatin/paclitaxel between 2012 and 2015 were identified. Patients received chemotherapy (CT) alone vs. concurrent chemoradiotherapy (CCRT) to all metastases. Of 461 patients, 97% had squamous cell cancer. One hundred and ninety-six patients (42.5%) received CCRT and 265 (57.5%) underwent CT alone. At week 8, there were 3 (1.5%) complete responses (CR) and 95 (48.5%) partial responses (PR) in the CCRT group, compared to 3 (1.1%) CR and 102 (38.5%) PR in the CT alone group. The overall rate of improvement in dysphagia score was noted in 78.5% of patients in the CCRT group versus 61.5% in the CT alone group (P=0.014). A statistically significant difference was demonstrated in disease control rate between the two groups (81.6% vs. 64.5%, P<0.001). Patients who underwent CCRT had superior median PFS and a trend toward longer median OS compared to those receiving CT alone (8.7 vs. 7.3 months, P=0.002 and 16.8 vs. 14.8 months, P=0.056, respectively). The median OS was 19.3 months in patients who achieved CR/PR, compared to 14.9 months and 9.6 months for patients who had stable disease and progressive disease, respectively (P<0.001). Compared to chemotherapy alone, chemoradiation to all sites in patients with esophageal cancer with ≤3 metastases may lead to a modest increase in PFS and a trend toward longer OS. Further investigation of optimal integration of radiotherapy and chemotherapy in these patients is warranted.

Efficacy and Safety of Endoscopic Self-Expanding Metallic Stent for Esophageal Malignancy: A Two-Institute Experience

Abstract Background: Self-expandable metallic stents (SEMS) placement is the procedure of choice for palliation of dysphagia in inoperable esophageal malignancies. Aim To evaluate the safety of placement of SEMS in esophageal cancer at two institutes using only endoscopic control without fluoroscopy and to determine efficacy of SEMS in palliation of dysphagia after deployment. Methods: Participants who underwent endoscopy and esophageal SEMS placement at two centers for inoperable esophageal malignancy between 2014 and 2017 were included retrospectively. The indication for the procedure and clinical outcome measures like adverse events and improvement in dysphagia score were recorded on uniform structured data forms. Results: Eighty-three esophageal SEMS placement was performed in 78 patients (mean age 64 ± 10.1 years; 59 men). The indication of SEMS placement was stricture in 72 (92.3%) and in 6 cases SEMS was placed for closure of trachea–esophageal fistula. All the patients in dysphagia score of 3 have improved to lower dysphagia scores post stent deployment. Postprocedure retrosternal pain, respiratory distress, and aspiration pneumonia in 58, 9, and 2 patients, respectively. Five patients required repeat stenting due to tumor ingrowth/granulation tissue during follow-up. The median survival of patients who received SEMS was significantly different from controls who did not receive SEMS (141 [41–360] days versus 98 [30–165 days]; p = 0.01). In 2 cases stent repositioning was done due to distal migration at the time of placement. There was no SEMS migration or stent related complications at follow-up. Conclusions: SEMS can be placed effectively under endoscopic control without fluoroscopic control in palliation of esophageal malignancy. Early SEMS deployment for palliating dysphagia may lead to survival advantage.

Palliative radiotherapy and chemoradiotherapy in stage IVA/B esophageal cancer patients with dysphagia.

Palliative therapeutic strategies in esophageal squamous cell carcinoma (ESCC) patients with dysphagia remain controversial. Only few studies have assessed therapeutic effect factors related to improvement in dysphagia score and nutrition-support-free survival (NSFS). The present study assessed the efficacy and therapeutic effect factors related to the use of palliative radiotherapy (RT) and chemoradiotherapy (CRT) in ESCC patients with dysphagia. We retrospectively evaluated 70 patients with stage IVA/B ESCC. Patients received RT of 30Gy in 10 fractions or concurrent CRT using 5-fluorouracil plus cisplatin of 40Gy in 20 fractions. The change in the dysphagia score from before to after treatment was assessed, and NSFS was evaluated. The median follow-up duration was 6 months (range 1-41 months). The overall rate of improvement in the dysphagia score was 60%. The median NSFS was 7.5 months. Craniocaudal tumor length < 6cm, tumor circumference < 3/4, and CRT of 40Gy in 20 fractions were associated with a significant improvement in the dysphagia score (p = 0.0036, p = 0.0069, and p = 0.03, respectively). NSFS was significantly longer with CRT than with RT (p = 0.048). Palliative RT and CRT are effective treatment options for ESCC patients with dysphagia. Craniocaudal tumor length < 6cm, tumor circumference < 3/4, and CRT of 40Gy in 20 fractions may improve dysphagia. CRT of 40Gy in 20 fractions may improve NSFS.

Palliative Therapy of Esophageal Stent Installation with Shim Modified Fixation Techniques on An Esophageal Adenocarsinoma Patients

Esophageal carcinoma is a progeny disease that often results in significant disruption to the ability to ingest solid foods and liquid foods at an advanced stage. Reported case of a 27-year-old man with a diagnosis of an intestinal type of adenocarcinoma gastroesophageal junction stage III with a dysphagia score 4. Diagnosis based on anamnesis, endoscopy and anatomical pathology. Patients have undergone chemotherapy and palliative therapy with esophageal dilatation. Patients experienced improvement in dysphagia score from initial score 3 (unable to swallow solid or liquid food), to 2 (able to swallow semisolid food) after the installation of esophageal stent. The patient planned to continue therapy his chemotherapy.

Role of Esophageal Metal Stents Placement and Combination Therapy in Inoperable Esophageal Carcinoma: A Systematic Review and Meta-analysis.

More than 50% of patients with esophageal cancer already have inoperable disease at the time of diagnosis. Controversy surrounds the outcomes of patients with advanced esophageal cancer who receive palliative care by either stent alone or stent plus an additional modality. We set out to perform a systematic review and meta-analysis of studies assessing the use of metal stents as treatment options for symptomatic improvement, survival, and adverse events. We searched Embase, MEDLINE, and the Cochrane Central Register of Controlled Trials (CENTRAL) from inception until January 14, 2016, as well as other databases for randomized controlled trials (RCTs) comparing esophageal stent versus either esophageal stent plus brachytherapy, radiotherapy, or chemotherapy. For quality assurance purposes throughout the systematic review, multiple independent extractions were performed, and the process was executed as per the standards of the Cochrane collaboration. Primary outcomes were mean change in dysphagia score, overall survival, and quality of life. Secondary outcomes were adverse events including fever, severe pain, aspiration, fistula, stent migration, perforation, and restenosis. Eight RCTs enrolling 732 patients were included with three distinct comparisons: stents combination therapy vs stents alone (5 studies, n=417), stents alone versus brachytherapy alone (2 studies, n=274), and stents+brachytherapy vs brachytherapy alone (1 study, n=41). Stents combination therapy was defined as stents plus radiotherapy, chemotherapy, or both. Mean change in dysphagia scores favored stents combination therapy versus stents alone, and the effect was seen in patients surviving longer than 3months. Stents combination therapy was also associated with a more favorable overall survival. The risks of stent migration, aspiration pneumonia, and restenosis were lower in the stents combination group compared to stents alone, while the risks of severe pain, hemorrhage, and fistula formation were higher. Changes in dysphagia scores and overall survival did not differ significantly in the brachytherapy-alone vs stents-alone comparison. The risk of fistula formation and hemorrhage were higher in the stents-alone group, while the risk of perforation was lower, compared to brachytherapy alone. Quality of life improvements were seen in all treatment groups, but were not pooled in analysis due to differing methods of measurement. While there appears to be no immediate short-term differences, those who live longer than 3months experience a significant improvement in dysphagia score using a stents combination therapy approach vs stents alone. The combination therapy significantly improves the overall survival as well as showed improvements in quality of life scores. Larger randomized controlled trials are needed to assess improvements in dysphagia score, overall survival, quality of life, and adverse events.

Abstract 2766: Esophageal stenting in resource-limited settings

Abstract Background: Esophageal cancer is the 6th leading cause of cancer death globally, with geographical high-risk areas in Asia, the Middle East, and eastern and southern Africa. Esophageal squamous cell carcinoma (ESCC) is the more common variant in Africa. In Kenya, its incidence is 2nd in men after prostate cancer and 3rd in women after breast and cervix-uteri cancers. Late presentation is a common occurrence in developing countries and is multifactorial due to challenges in access to health care, low socioeconomic status and delayed or missed diagnosis. A large percentage of these tumors are thus unresectable and are only eligible for palliative care via stenting. Our hospital is a 300-bed referral center in southwestern Kenya, which is a hotspot for ESCC, and we see over 400 cases of ESCC annually. Methods: We have developed a technique for placement of esophageal self-expanding metallic stents (SEMS) without fluoroscopy that is safe and easily reproducible. This is an outpatient procedure, with the majority done under conscious sedation, and routine followup is not necessary. The tumor margins are noted at time of video endoscopy, a guidewire is placed, and dilation done with Savary dilators as required. The SEMS are then loaded on the stent delivery device and deployed into the proper position based on measurements, and placement is subsequently confirmed via endoscopic visualization. Results: A total of 3000 SEMS have been placed to date at our hospital, without using fluoroscopy. The male: female ratio has been 1.5:1, and the average age has been 60.4 years. The distribution of tumor locations was 67% in the middle and distal third. The most common complications were tumor overgrowth with obstruction and stent migration. Procedure related mortality was 0.3%. Post-procedure improvement in dysphagia score was seen in over 80% , and patient satisfaction was high. Initial data puts our post stent survival time around 8 months/ 250 days Conclusions: Placement of SEMS for ESCC, without fluoroscopy, is a safe and reproducible procedure which has a low rate of adverse events. This procedure results in effective palliation of a difficult disease and can easily be done in resource-limited settings which have endoscopy capabilities. Current efforts are ongoing to increase opportunities for training endoscopists in this procedure and for provision of affordable stents in Africa. Citation Format: Michael M. Mwachiro, Robert K. Parker, Stephen Burgert, Justus Lando, Sinkeet Rankeeti, Robert Chepkwony, Emmanuel Kiniga, Sanford Dawsey, Mark Topazian, Russell E. White. Esophageal stenting in resource-limited settings [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 2766. doi:10.1158/1538-7445.AM2017-2766

Palliative Radiotherapy in the Local Management of Stage IVB Esophageal Cancer: Factors Affecting Swallowing and Survival.

To clarify the role of external-beam radiotherapy in the local management of state IVB esophageal cancer. We reviewed records of 31 patients with histopathologically-proven squamous cell carcinoma who underwent radiotherapy for their primary lesion. The change in dysphagia score from before to after treatment was assessed. Nutritional support-free survival (NSFS) was also evaluated. The median overall survival was 6 months. The overall rate of improvement in dysphagia score was 73% (23/31). The median NSFS was 5 months. Age at presentation <67 years, tumor location in the middle thoracic esophagus, and tumor length <7 cm were associated with significant improvement in swallowing scores. Responders to radiotherapy had significantly longer NSFS than non-responders (p=0.04). Palliative radiotherapy in the local management of stage IVB esophageal cancer is an effective treatment option for dysphagia. Factors highly associated with improvement of swallowing are age, tumor location, and tumor length. Response to radiotherapy is the most important factor in improving NSFS.

Usefulness of the Hook knife in flexible endoscopic myotomy for Zenker's diverticulum.

AIMTo investigate the outcome of flexible endoscopic myotomy performed with the Hook knife in patients with symptomatic Zenker’s diverticulum (ZD).METHODSAll consecutive patients treated for ZD at our institution between 7/2012 and 12/2016 were included. The flexible endoscopic soft diverticuloscope-assisted technique with endoclips placement and Hook knife myotomy were performed in all patients. Here we report a retrospective review of prospectively collected data. Demographics, dysphagia score (Dakkak and Bennett), associated symptoms and adverse events were collected pre-procedure, at 2 and 6 mo post-procedure, and at the end of the follow-up period. Clinical success was defined as at least 1-point improvement in dysphagia score and a residual dysphagia score ≤ 1, with no need for reintervention. Dysphagia scores were compared before treatment and at end-of-follow-up using the Wilcoxon test.RESULTSTwenty-four patients were included. Mean size of ZD was 3.0 cm (range 2-8 cm). Mean number of sessions was 1.17/patient (range 1-3 sessions). Overall clinical success was 91.7%. Two adverse events (8.3%) occurred, and both were managed conservatively. No bleeding or perforation was reported. Mild pain was reported by 9 patients (37.5%). Median hospital stay was 1 d (range 1-6). Median follow-up was 19.5 mo (range 6-53). Mean ± SD dysphagia score was 2.25 ± 0.89 before treatment and decreased to 0.41 ± 0.92 at end-of-follow-up (P < 0.001). Regurgitation and cough dropped from 91.7% and 50% to 12.5% and 0% at the end of follow-up, respectively. Recurrence was observed in 3 patients, and all 3 were symptom-free after one more session.CONCLUSIONThe Hook knife, used in the soft diverticuloscope-assisted technique setting, is efficient and safe for treatment of ZD.

The Outcome of Ultra-long Benign Esophageal Strictures

Introduction: Long (≥2-5cm) and ultra-long (≥5cm) esophageal strictures have been reported after endoscopic mucosal resection, ablation and radiation. In contrast to short strictures, their outcome is unclear and treatment relies on expert opinion from small case series. Aim: To investigate the outcome of ultra-long benign, intrinsic esophageal strictures. Methods: All patients who underwent endoscopic treatment of benign, intrinsic esophageal strictures of ≥2cm length at a single tertiary between 7/2010 and 5/2014. Data was abstracted by retrospective chart review, including stricture etiology, duration of presence of stricture, endoscopic procedures and long-term outcome. The main endpoints were to calculate the treatment success defined as improved dysphagia score, resolution of dysphagia, and the rate of gastrostomy-dependent patients and patients requiring esophagectomy.Figure 1Results: 83 patients (mean age 63years, SD 16.9; 54% female) were followed over 16months (median) at our facility for esophageal strictures. Stricture etiology included peptic 23%, radiation 26%, anastomotic 11%, post-ablation 11%, post-EMR 10%, dermatologic conditions 10% and others 9% strictures, with a mean length of 43mm and mean diameter of 8.4mm. Median dysphagia score at presentation to our facility was 2 (able to swallow semi-solid only). Patients underwent a median of 7 dilations, which correspondents with 0.3 dilations per months. Only a minority of patients underwent in addition to dilation argon plasma tissue vaporization, stent placement, steroid and Mitomycin-C application. Median dysphagia score remained unchanged at 2, with 14% of patients having resolution of dysphagia, whereas 61% patients experienced unchanged or worsened dysphagia. 25% were eventually gastrostomydependent and 4% required esophagectomy. Stricture length and diameter remained not significantly changed at end of follow up. Kaplan-Meier analysis delineated resolution of dysphagia according to stricture length: 50% in strictures 2.0-4.9cm, 12.5% in 5.0-9.9cm and 0% in ≥10.0cm. Limitations: Single center, retrospective study, heterogeneous cohort. Conclusion: Endoscopic treatment is effective in only 50% for long (≥2-5cm) esophageal strictures as reflected by improvement of dysphagia score. However, dysphagia remained unchanged in most ultralong strictures (≥5cm). Gastrostomy or esophagectomy were long-term required in 29% of strictures ≥2cm.

Retropharyngeal Steroids and Dysphagia Following Multilevel Anterior Cervical Surgery.

A retrospective case-control study. The aim of this study was to determine the effect of retropharyngeal steroids on postoperative dysphagia scores and clinical outcomes following multilevel anterior cervical discectomy and fusion (ACDF). Dysphagia is a well-known complication following ACDF surgery and increased rates of dysphagia are seen with increased levels of surgery. Retropharyngeal steroids have been shown to decrease painful swallowing and prevertebral soft tissue (PSTS) swelling in 1- and 2-level anterior cervical surgery. A retrospective review of 44 patients undergoing multilevel (2-, 3-, 4-level) ACDF. Twenty-two patients who received retropharyngeal steroids (methylprednisone) placed on a collagen sponge at the time of surgery were compared with a matched cohort of controls who did not receive local steroids. Postoperative day 1 and 6-week radiographs were analyzed for differences in PSTS. Clinical outcomes were measured pre-operatively, 6 weeks, and 3 months postoperatively utilizing the Neck Disability Index (NDI), the Bazaz-Yoo Dysphagia Scoring System, and Eat Assessment Tool (EAT-10). Significant improvement in dysphagia scores were seen utilizing both outcome measures. Bazaz-Yoo scores were significantly better at both 6 weeks and 3 months in patients receiving local steroids compared with controls (P = 0.008 and P = 0.022, respectively). EAT-10 showed similar improvement of the steroid group versus control at 6 weeks and 3 months (P = 0.067 and P = 0.012, respectively). A trend toward decreased PSTS was found with locally delivered steroids on initial postoperative radiographs (P = 0.07), but was no longer evident at 6 weeks. NDI, although improved from pre-operative scores, failed to demonstrate significant differences between groups. No differences in length of stay or complications were observed between the groups. The use of retropharyngeal steroids resulted in decreased rates of dysphagia following multilevel ACDF. Locally delivered methylprednisone did not result in increased rates of short-term postoperative complications. 4.

Long Term Outcome in Patients with Esophageal Stenting for Cancer Esophagus - Our Experience at a Rural Hospital of Punjab, India.

Cancer of the esophagus is among the leading cause of cancer deaths in Punjab, India. Patients generally present with dysphagia as their first symptom and more often they have advanced disease at the time of presentation to a tertiary care centre. Palliative procedures have important roles in this setting. Stenting is the best option to palliate the symptoms of dysphagia, from which patient is suffering the most. To know the success rate, early and long term complications and mortality in esophageal stenting, when it was done in malignant esophageal stricture patients. One hundred patients, who had undergone esophageal stenting from January 2012 to January 2015, were included in the study. We retrospectively analysed the data for patient characteristics, causes of non-operability, early and long term complications, re-interventions, efficacy and mortality. Out of 100 patients, indications for stenting were locally advanced disease not amenable to surgery (52%), metastatic disease (35%), CVA (1%), cardiac and respiratory problem (8%), un-willing for surgery in 5% of patients. Majority of patients (94%) had squamous cell carcinoma, while only 6% had adenocarcinoma. 84% of patients presented with dysphagia with or without chest pain and recurrent cough while 16% had recurrent vomiting. 58% had dysphagia to liquids and solids and 17% had complete dysphagia. After stenting 93% had significant improvement in dysphagia score from median of 3 to 1. Post procedure stay was 3.61±1.0 days. One patient had procedure related major complication in the form of post procedural bleed (after 16 days of stenting) leading to death of that patient. Minor complications were present in 52 patients treated conservatively not affecting the efficacy of procedure. These include pain after stenting (38%), stent obstruction (23%) and stent migration (6%). All the minor complications were treated conservatively except in six patients in whom re-stenting was done. Esophageal stenting is relatively safe procedure with short stay of the patient in the hospital. Although, it helps in alleviating patients' morbidity very effectively and reliably, there are many technical glitches, which needs to be kept into account and patient should be properly counseled before the procedure to prevent and manage post procedure complications and medico legal aspects.

Randomized controlled trial comparing esophageal dilation to no dilation among adults with esophageal eosinophilia and dysphagia.

The role of esophageal dilation in patients with esophageal eosinophilia with dysphagia remains unknown. The practice of dilation is currently based on center preferences and expert opinion. The aim of this study is to determine if, and to what extent, dysphagia improves in response to initial esophageal dilation followed by standard medical therapies. We conducted a randomized, blinded, controlled trial evaluating adult patients with dysphagia and newly diagnosed esophageal eosinophilia from 2008 to 2013. Patients were randomized to dilation or no dilation at time of endoscopy and blinded to dilation status. Endoscopic features were graded as major and minor. Subsequent to randomization and endoscopy, all patients received fluticasone and dexlansoprazole for 2 months. The primary study outcome was reduction in overall dysphagia score, assessed at 30 and 60 days post-intervention. Patients with severe strictures (less than 7-mm esophageal diameter) were excluded from the study. Thirty-one patients were randomized and completed the protocol: 17 randomized to dilation and 14 to no dilation. Both groups were similar with regard to gender, age, eosinophil density, endoscopic score, and baseline dysphagia score. The population exhibited moderate to severe dysphagia and moderate esophageal stricturing at baseline. Overall, there was a significant (P < 0.001) but similar reduction in mean dysphagia score at 30 and 60 days post-randomization compared with baseline in both groups. No significant difference in dysphagia scores between treatment groups after 30 (P = 0.93) or 60 (P = 0.21) days post-intervention was observed. Esophageal dilation did not result in additional improvement in dysphagia score compared with treatment with proton pump inhibitor and fluticasone alone. In patients with symptomatic esophageal eosinophilia without severe stricture, dilation does not appear to be a necessary initial treatment strategy.