Palliation Of Malignant Dysphagia Research Articles

Palliation of Malignant Dysphagia: Dilation, Stents, Cryoablation or Photodynamic Therapy—A Surgical Perspective

Esophageal cancer remains a major cause of morbidity and mortality worldwide, with a low survival rate. Patients with advanced disease most commonly present with dysphagia and weight loss. Treatment is geared toward palliation of symptoms and improved quality of life in these patients. Various treatment modalities are available for these patients, although there is no data demonstrating the superiority of any particular technique. The aim of this chapter is to review these palliative interventions while focusing on endoscopic dilation, stents, cryoablation, and photodynamic therapy.

Palliation of malignant dysphagia with a segmented self-expanding metal stent: A STROBE-compliant article.

Self-expanding metal stents (SEMSs) in different geometric shapes are an established palliative treatment for malignant tumors of the esophagus. Mechanical properties and stent design have an impact on patient comfort, migration rate, and removability. SEMS with a segmented design (segSEMS) have recently become available on the market, promising new biomechanical properties for stent placement in benign and malignant esophageal diseases. In this study, we evaluated recurrent dysphagia, quality of life as well as technical success and complications for segmented SEMS-implantation in a retrospective study in palliative patients with dysphagia caused by malignant tumors of the esophagus.Between May 2017 and December 2018, patients presented to the interdisciplinary department of endoscopy of the University Hospital Cologne underwent segmented SEMS placement for malignant dysphagia. Patient follow-up was evaluated, and complications were monitored. Quality of life and functional improvement were monitored using the EORTC QLQ-C30 and QLQ-OE18.A total of 20 consecutive patients (16 men, 4 women; mean age: 65.5, range: 46-82) participated in the study and were treated with 20 segSEMS in total. The success rate of stent placement was 100%. Stent migration occurred in 3 patients (15.0%). Insertion of segSEMS immediately lead to a 48.0% reduction of dysphagia in the first 2 months (P < .001). Pain while eating (odynophagia) could also be significantly reduced by 39.6% over the first 2 months (P < .001).Implantation of segSEMS is a feasible and effective treatment for dysphagia in palliative patients with malignant tumors of the esophagus, offering immediate relief of symptoms and gain of physical functions.

Efficacy and Safety of Fully Covered Self-Expanding Metal Stents for Malignant Esophageal Obstruction.

Malignant dysphagia can result in poor nutritional status with severe weight loss. Rapid relief from dysphagia can be achieved with esophageal self-expanding metal stents (SEMSs), a minimally invasive method. In this study, we evaluated the usefulness of SEMSs for malignant dysphagia. Between 2012 and 2015, 119 patients with malignant dysphagia underwent esophageal SEMS insertion with endoscopic assistance. Their demographics and clinical outcomes were collected. Factors associated with stent-related complications and patient survival were evaluated. All data were retrospectively analyzed. The mean age of the 119 patients was 64.9±11.6years, and 25 (21%) were female. Seventy-five patients (63.0%) had squamous carcinoma, majority of which were located in the lower thoracic esophagus (n=42), followed by middle thoracic esophagus (n=19) and upper esophagus (n=10). Eighty patients (67.2%) underwent SEMS insertion at diagnosis. Technical and clinical success rates were 99.2 and 89.9%, respectively. Complications occurred in 47 patients (39.5%); the most common complication was migration (36.3%), followed by pain and obstruction. The median stent patency time was 145days (95% confidence interval 55.19-234.81days). Gastric cancer (odds ratio 3.51, 95% confidence interval 1.21-10.15; p=0.021) and a 20-mm-wide stent (odds ratio 2.922, 95% confidence interval 1.237-6.904; p=0.015) were risk factors for complications. SEMSs are effective in palliation of malignant dysphagia. However, stent-related complications should be borne in mind, particularly in patients with gastric cancer with esophageal invasion and with larger width stents.

Self-expandable metal stent for palliation of malignant dysphagia & quality of life improvement in advanced cancer esophagus: Upper Egypt experience

BackgroundIn advanced cancer esophagus patients, self-expandable metallic stents (SEMS) are utilized to relieve malignant difficulty in swallowing and improve their quality of the life. Retrospectively, we evaluated the efficacy, feasibility, and outcomes of SEMS in palliation of malignant dysphagia in advanced cancer esophagus and its' complications. MethodsWe retrospectively reviewed data of 350 patients with malignant dysphagia due to advanced cancer esophagus from December 2012 to April 2017. They were subjected to esophageal stenting with SEMS in our GIT endoscopy unit, General and Cardiothoracic Surgery departments at Qena and Sohag University Hospitals, Egypt. ResultsThe mean age was 56.34 + 12.44 years ranging from 30 to 85 years, and 264 of them were males. Mean duration of dysphagia was 2.90 months. SEMSs were placed successfully in all cases without major complications; however minor bleeding and retrosternal discomfort were seen. The improvement in the dysphagia score was significant. ConclusionsSEMSs were safe and effective in palliation of malignant dysphagia and improvement of the quality of life in advanced esophageal cancer patients without major complications.

A prospective trial comparing two types of self-expanding stents in the palliation of malignant dysphagia: SEMS (Wallflex stent) versus SEPS (Polyflex stent)

A prospective trial comparing two types of self-expanding stents in the palliation of malignant dysphagia: SEMS (Wallflex stent) versus SEPS (Polyflex stent)

Self-expandable metallic stents for the palliation of malignant dysphagia: a single center experience

Self-expandable metallic stents for the palliation of malignant dysphagia: a single center experience

PTH-018 Predicting survival in palliative oesophageal stent insertion

<h3>Introduction</h3> Self-expanding metal stents (SEMS) are an important treatment modality in palliation of malignant dysphagia, either alone or in addition to chemotherapy or radiotherapy. However, the optimal timing of stent insertion remains uncertain when considering prognosis in advanced malignancy. We present a large single centre experience of patients undergoing SEMS insertion for malignant dysphagia. The aim was to identify risk factors associated with overall and 30 day mortality post-oesophageal stenting. <h3>Method</h3> All patients receiving an oesophageal stent for palliation of dysphagia in primary oesophageal malignancy between January 2009 and December 2013 in Leeds Teaching Hospitals NHS Trust were included. All devices used were Niti S double covered stents inserted by four experienced practitioners using a combined endoscopic and fluoroscopic procedure. Demographics, tumour site and stage, performance status, Charlson co-morbidity index, dysphagia score, previous oncological therapies and serum albumin and CRP in the week prior to stent insertion were retrieved from electronic patient records. Kaplan-Meier survival estimates and Cox proportional hazards regression were performed to identify risk factors predictive of mortality. <h3>Results</h3> Among 259 patients (mean age 70.3 (range 32 to 99)), the median post-stent survival was 100 days (95% CI, 87 to 116). 51 patients (20%) died within 30 days of the stenting procedure and 10 patients (4%) died within 7 days. 35 patients (14%) required repeat stenting for tumour overgrowth, stricture or stent migration; the median time to re-stent was 137 days (95% CI, 99 to 175). Serum CRP &gt; 50 was an independent predictor of 30 day mortality (hazard ratio [HR], 3.7; 95% CI, 1.7 to 8.0). Overall post-stent mortality was associated with CRP &gt; 50 (HR, 2.3; 95% CI, 1.6 to 3.2) and albumin &lt; 30 (HR, 1.9; 95% CI, 1.1 to 3.1). <h3>Conclusion</h3> Our 30 day mortality of 20% is consistent with data published elsewhere (13¹–25%²), but this study identifies the association of elevated CRP with short-term mortality. This may reflect advanced disease or concurrent infection (such as aspiration pneumonia) and may be a useful guide to optimising timing of stent insertion. <h3>Disclosure of interest</h3> None Declared. <h3>References</h3> Homs MY, Steyerberg EW, Eijkenboom WM, <i>et al</i>. Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia from oesophageal cancer: multicentre randomised trial. Lancet 2004;364(9444):1497–504 van Heel NC, Haringsma J, Boot H, <i>et al</i>. Comparison of 2 expandable stents for malignant esophageal disease: a randomized controlled trial. Gastrointestinal Endoscopy;76(1):52–8

PWE-176 Palliative stenting in oesophageal cancer

Introduction Palliative stenting is now established as a major treatment for dysphagia resulting from inoperable oesophageal cancer. There are many possible complications after oesophageal stent insertion; most of these present with increasing dysphagia; however pain, bleeding, and reflux are also common. Although data on rates of various complications are available, there are no agreed standards to audit performance against, nor any requirement to do so. As this is a palliative procedure, success in symptom control is paramount; if this is not being achieved, then the appropriateness of the procedure must be questioned. As with any invasive procedure, complication rates are affected by multiple variables: technique, type of stent, length and site of stricture, operator experience, and patient co-morbidities. As a result of these variables, stated complication rates also vary: Only one study reported a rate of dysphagia (29%); migration occurred in 5–15% of cases, tumour overgrowth 5–20%, and food bolus obstruction in 5–15%. Quoted median survival ranged from 61–104 days, with a 30-day mortality of 20–28%. Method A retrospective study of all patients undergoing oesophageal stent insertion at a single endoscopy unit during 2012–13 was undertaken, looking for evidence of complications, repeat interventions, and for survival statistics after stent insertion. Patients who had undergone stent insertion for reasons other than oesophageal malignancy were excluded. Results During the two-year period, 74 stents were inserted in 62 patients for palliation of malignant dysphagia. Of these stent insertions 24 (32.4%) were documented to have recurrent dysphagia, of which the causes were: tumour over- or ingrowth in 7 (9.5%); stent migration in 5 (6.8%); obstruction due to gastric folds, hiatus hernia, or anti-reflux valve in 3.(4.1%); and food bolus obstruction in 2 cases (2.7%). In total there were documented complications post stent in 32 (43.2%) of all stent insertions, with pain in 8 (10.8%), bleeding in 6 (8.1%), and nausea or refluxing 3 cases (4.1%) accounting for the complications which did not cause dysphagia. Median survival of the 74 patients after stent insertion was 95 days and 30-day mortality was 9.7% (6 patients). It is important to note that with retrospective data analysis, some data are not available, due to variations in recording at the time and a reliance on the patient to report symptoms to a clinician. Conclusion Palliative stenting at this centre continues to be an effective treatment for patients with malignant dysphagia. Outcomes compare favourably with published data in terms of recurrent dysphagia, other complications, and mortality. Steps to improve post-procedure monitoring in the form of a “stent registry” with prospective collection of data by telephone or face-to-face follow up could be useful in future service development. Disclosure of interest None Declared.

Palliation of malignant dysphagia with self expandable esophageal stents

Palliation of malignant dysphagia with self expandable esophageal stents

A case of an iatrogenic esophageal perforation salvaged by anterograde–retrograde rendezvous approach and stenting

Esophageal self-expandable metal stent placement is an effective treatment for palliation of malignant dysphagia, which has a low insertion-related complication rate. However, stent-related perforation can be a life-threatening event. We experienced a patient with advanced esophageal cancer who developed an iatrogenic esophageal perforation resulting from incorrect stent insertion. After removal of the original stent, we attempted to perform antegrade insertion of a second covered stent, but failed because we were not able to find the true lumen to the stomach. Due to his poor general condition and the high risk of surgical esophageal repair, we attempted esophageal stent placement using the combined antegrade–retrograde rendezvous technique using the gastrostomy route. By the performance of esophageal stenting using the rendezvous technique, we were able to avoid risky surgical esophageal repair. We expect that the rendezvous technique may be feasible therapy for patients with iatrogenic esophageal perforation when conventional antegrade endoscopic treatment fails.

Su1503 Dysphagia Relief and Adverse Events Associated With Fully Covered Evolution® Esophageal Stents in Malignant Esophageal Strictures: Does Size Matter?

covered 20-mm SEMS which combines bilateral flared ends and three rows of anchoring flaps on the stent body for the prevention of migration. Aim: To evaluate the clinical efficacy and safety of the HANARO-Utrecht stent for the palliation of malignant dysphagia. Methods: Consecutive patients who underwent HANARO-Utrecht stent placement for palliation of malignant dysphagia in four centers from June 2011 until October 2012 were included. Patients were contacted after 2 weeks and monthly thereafter until death. Technical success, recurrent dysphagia, migration, survival and complications were evaluated. Results: Forty patients (29 men (72.5%), mean age 68 11 years) were included. Malignant dysphagia was caused by esophageal cancer (n 32), malignant extrinsic compression (n 5), tumor recurrence after esophagectomy (n 2) and gastric cancer (n 1). Four patients (10%) had an esophageal-respiratory fistula and 26 patients (65%) had undergone previous radiation and/or chemotherapy. Stent placement was technically successful in 38 patients (95%), in 1 patient the stent collapsed during repositioning and a second stent was placed through the stent and in 1 patient the stent was placed more distally than intended despite repositioning. Thirty-four patients (85%) remained dysphagia free during followup (median 59 days, range 2-397), while 6 patients (17%) had recurrent dysphagia after a median of 39 days (range 9-48), due to stent migration (n 5) and tissue overgrowth (n 1). In 4 of these patients, the stent had partially migrated and could be repositioned endoscopically, while in 2 patients a new stent was placed. One patient presented with recurrent partial migration after 59 days, for which repeat repositioning was performed. Fourteen patients are still alive after a median of 59 days (range 15-397) and 26 patients died after a median of 58 days (range 2-210), due to disease progression (n 20), complicated pneumonia (n 3), cardiac disease (n 1), euthanasia (n 1) and acute hypoxemia due to tumor ingrowth in the trachea (n 1). In total, 24 major complications occurred in 18 patients (47%), including severe pain (n 7), severe nausea and/or vomiting (n 6), bleeding (n 4), aspiration pneumonia (n 4), fistula formation (n 2) and tracheal compression (n 1). Conclusion: Despite the specific anti-migration features of the HANARO-Utrecht stent, migration was the main cause of recurrent dysphagia. We also observed a relatively high complication rate, especially severe pain, nausea and vomiting after placement, further improvements in stent design are needed.

Ten-year experience of esophageal self-expanding metal stent insertion at a single institution

Palliation of malignant dysphagia can be achieved using self-expanding metal stents (SEMS). This study was conceived to confirm that the insertion of SEMS improved patient symptoms without serious complications and to allow comparison with recent national data. Retrospective case note review of all patients receiving SEMS over a 10-year period between March 1999 and February 2009 was used in this study. There were 138 consecutive patients (50 female), median age of 75 (range 46-90) years, 122 (88.5%) had primary malignant disease of the esophagus or gastroesophageal junction. In total, 250 endoscopic examinations were carried out, with 200 interventional procedures, including the insertion of 156 SEMS. Before stenting, 74.2% of patients had a dysphagia score of 2-3. Following stent insertion, dysphagia scores improved to 0-1 in 90.3% of patients (P < 0.0001, Wilcoxon signed ranks). No complications were encountered in 61 (44%) patients. Chest pain was the most frequent difficulty, encountered in 50 (36%) patients. Tumor overgrowth occurred in 17 (12.3%) patients and food bolus obstruction was seen in 7% of patients. There were no esophageal perforations attributable to SEMS insertion. Overall 30-day mortality for those with esophago-gastric malignancy was 11.6% (16 patients), although the SEMS-related mortality was 2.2% (3 patients). Median survival from SEMS insertion was 3 (IQR 1.5-7) months. Patients requiring re-intervention for tumor overgrowth had a significantly longer median survival of 9.2 months (P= 0.001, log rank). SEMS were well tolerated with overall mortality and complication rates comparable to national data. For the longer survivors, re-intervention for recurrent dysphagia was not unusual.

Fully covered, retrievable self-expanding metal stents (Niti-S) in palliation of malignant dysphagia: Long-term results of a prospective study

Background. In the palliative treatment of malignant dysphagia, fully covered, retrievable metal stents are not commonly used, mainly due to the high risk of migration. Therefore, we performed a prospective study to evaluate the clinical efficacy of a fully covered, retrievable self-expanding metal stent (Niti-S). Method. Between October 1998 and February 2009, 100 consecutive patients with malignant esophageal obstruction treated with the fully covered Niti-S stent (Niti-S, Taewoong Medical, Seoul, South Korea) were included. Data collected contained functional outcome, feasibility of endoscopic stent retrieval, recurrent dysphagia, complications, and survival. Result. At 4 weeks after stent placement, dysphagia significantly improved in all patients (p = 0.000). Recurrent dysphagia occurred in 19 of 100 patients treated with Niti-S stents (19%) mainly due to tumor overgrowth (7/100, 7%), stent migration (6/100, 6%), and food impaction (6/100, 6%). Endoscopic stent retrieval was successful in all the attempted 17 patients (17/100, 17%) – 7 overgrowth, 6 stent migration, 2 stent degradation, and 2 severe pain. Major complications were 2 hemorrhage, 2 severe pain, and 1 tracheal compression (5/100, 5%), and minor complications were 10 retrosternal pain and 7 symptomatic gastroesophageal reflux (17/100, 17%). After a median follow-up of 142 days, 97 patients had expired. There was no stent-related mortality or 30-day mortality. Conclusion. The fully covered, retrievable Niti-S stent has proved its effectiveness for palliation of malignant dysphagia and feasibility of endoscopic retrieval. We estimate its dog-bone shaped flanges at both ends and it being completely covered provide good resistance to migration and overgrowth.

Clinical Outcomes of Using a Conservative Approach of Late Esophageal Stent Placement in Palliation of Malignant Dysphagia

Esophageal stents have been used as first-line treatment for palliation of malignant dysphagia, but this is associated with significant complications. The present study evaluated clinical outcomes and survival in patients with malignant dysphagia with esophageal stent placement who did not respond to prior chemoradiation or endoscopic modalities. Patients with esophageal cancer, who had esophageal stents, were retrospectively reviewed from the electronic medical records. The patient demographics, type of stent placed, dysphagia scores, stent-related complications, and survival were recorded. Thirty-five patients with esophageal cancer received a total of 41 stents. There were 25 males and 10 females with mean age of 69.8 years. Twenty-two patients had esophageal adenocarcinoma, ten patients had squamous cell carcinoma, and three had poorly differentiated tumor. Esophageal malignancy was early stage (I, II) in 10 patients and advanced (III, IV) in 24 patients. Three patients had upper esophageal involvement, eight patients had mid-esophageal involvement; distal esophageal malignancy was present in 24 patients with 10 patients having gastroesophageal junction involvement. Six patients presented with tracheoesophageal fistula. Nine patients had prior esophagectomy. Thirty-three patients had chemoradiation, and 32 patients had other endoscopic therapies previously. Twelve of the 35 (33%) patients developed stent-related complications; nine patients had dysphagia due to various causes; one patient each developed aspiration, intractable hiccups, and intractable vomiting after stent placement, respectively. Nine patients underwent a repeat esophagogastroduodenoscopy. Development of stent-related complications was not significantly associated with poor survival. The clinical outcomes for patients with esophageal stent placement for malignant dysphagia after chemoradiation and other endoscopic treatments is not worse than that reported in patients where esophageal stent placement was used as first-line treatment.

M1957 A Prospective Randomised Controlled Trial of Ethanol-Induced Tumour Necrosis (Etn) with or Without Adjuvant External Beam Radiotherapy in the Palliation of Malignant Dysphagia

M1957 A Prospective Randomised Controlled Trial of Ethanol-Induced Tumour Necrosis (Etn) with or Without Adjuvant External Beam Radiotherapy in the Palliation of Malignant Dysphagia

A New Metal Stent with Controlled Release System (Evolution) for the Palliation of Malignant Dysphagia: A Prospective Follow-Up Study

A New Metal Stent with Controlled Release System (Evolution) for the Palliation of Malignant Dysphagia: A Prospective Follow-Up Study

A multicenter, prospective randomized trial comparing two types of self-expanding stents in the palliation of malignant dysphagia: SEMS (Ultraflex Stent) versus SEPS (Polyflex Stent)

A multicenter, prospective randomized trial comparing two types of self-expanding stents in the palliation of malignant dysphagia: SEMS (Ultraflex Stent) versus SEPS (Polyflex Stent)

A Multicenter, Prospective Randomized Trial Comparing Two Types of Self-Expanding Stents in the Palliation of Malignant Dysphagia: SEMS (Ultraflex Stent) Versus SEPS (Polyflex Stent)

A Multicenter, Prospective Randomized Trial Comparing Two Types of Self-Expanding Stents in the Palliation of Malignant Dysphagia: SEMS (Ultraflex Stent) Versus SEPS (Polyflex Stent)

A multicenter, prospective randomized trial comparing two types of self-expanding stents in the palliation of malignant dysphagia: SEMS (Ultraflex stent) versus SEPS (Polyflex stent)

A multicenter, prospective randomized trial comparing two types of self-expanding stents in the palliation of malignant dysphagia: SEMS (Ultraflex stent) versus SEPS (Polyflex stent)

The Niti-S Oesophageal Stent Reduces Migration Rates in the Palliation of Malignant Dysphagia

Background: Self-expanding metal mesh stents (SEMS) are frequently used in the palliation of malignant dysphagia. Our Unit has significant experience of both the Ultraflex stent (Boston Scientific, Natick, Mass) and the Niti-S stent (Taewong Medical, Seoul, Korea). A comparative study was conducted to determine the frequency of stent-related complications with the use of Ultraflex and Niti-S stents in one institution. Methods: Between April 2003 and June 2006 135 patients required SEMS insertion for the palliation of malignant oesophageal obstruction. Individuals received either an Ultraflex (n = 72) or a Niti-S (n = 63) stent. The incidence of complications including retrosternal pain, bleeding, perforation, tumour in-growth or over-growth, migration and 30-day mortality was compared. Results: The age, gender distribution, tumour length, stent length and number of days in hospital after stent insertion were similar between the two groups (median (interquartile range)). The number of patients with retrosternal pain, haematemesis, perforation, bolus obstruction, tumour in-growth or over-growth, and 30-day mortality were also similar. However, the incidence of stent migration was significantly less in the Niti-S stent group. Distal oesophageal and oesophago-gastric junction (OGJ) tumours accounted for 82% of patients receiving an Ultraflex stent and 81% of patients receiving a Niti-S stent. Ultraflex stent migration only occurred in distal oesophageal or junctional cases. Conclusion: The Niti-S stent has design features aimed at reducing stent migration and tumour in-growth. This study has demonstrated a significantly reduced migration rate when compared with the Ultraflex stent with no increase in morbidity or mortality. This finding was sustained even in the distal third and OGJ cancers where the risk of migration is greatest. There was a trend towards reduced tumour in-/over-growth. This study supports the development of a prospective randomised trial. Tabled 1 Ultrafex (n = 72) Niti-S (n = 63) p value Age (years) 74 (62-84) 76 (64-83) n/s Male:female 45:27 44:19 n/s Tumour length (cm) 6 (5-8) 6 (5-9) n/s Distal oesophageal tumour 35 26 n/s OGJ tumour 24 25 n/s Stent length (cm) 9 (7-12) 8 (8-12) n/s Post-stent stay (days) 3 (2-4) 3 (2-5) n/s Tumour in-/over-growth 14 9 n/s Stent migration (all tumours) 8 0 0.02 Stent migration (distal oesophageal tumour) 3 0 n/a Stent migration (OGJ tumour) 5 0 n/a 30-day mortality 2 0 n/a n/s - not significant. n/a - not applicable (numbers too small) Open table in a new tab n/s - not significant. n/a - not applicable (numbers too small)