Unresectable Esophageal Carcinoma Research Articles

A multicenter randomized phase II (rPII)/III study comparing concurrent chemoradiotherapy (CRT) with low-dose cisplatin plus continuous infusion of 5-fluorouracil (LDPF) and standard-dose PF (SDPF) for locally advanced unresectable squamous cell carcinoma of the thoracic esophagus (JCOG0303).

4053 Background: Cisplatin-based CRT is one of the standard treatments for locally advanced unresectable esophageal carcinomas. Although both cisplatin and 5-FU are known to enhance the efficacy of radiotherapy, the optimal chemotherapy regimen has not been established. Thus, we evaluated CRT with LDPF on effectiveness and adverse events for locally advanced unresectable esophageal carcinomas in a randomized study to determine if it is an acceptable alternative to SDPF. Methods: Eligibility criteria included histologically proven squamous cell, adenosquamous, or basaloid carcinoma; tumor located in thoracic esophagus; and definite T4 and/or unresectable regional lymph node metastasis. In arm A, two courses of standard chemotherapy of cisplatin (70 mg/m2, div day1, 29) plus 5-FU (700 mg/ m2, ci day1-4, 29-32) were given with external beam radiation (EBRT) in 30 daily fractions, 5 d/week to a total dose of 60 Gy. In arm B, low dose daily cisplatin (4 mg/ m2, div) plus 5-FU (200 mg/ m2, ci) was administered on the same days that EBRT was given. The primary endpoint was overall survival (OS). The rPII study was designed to evaluate the efficacy of LDPF to decide whether it warranted a phase III trial. Results: Between Apr. 2004 and Jun. 2009, 135 pts (Arm A/B; 67/68) from 40 institutions were randomized. Tumor depth (T1-3/T4) was 18/49 in arm A and 13/55 in arm B. The median follow-up time for all eligible pts was 9.9 mos. Toxicities were almost equivalent in both arms; however LDPF necessitated long hospitalization. Moreover, the OS of pts of LDPF group was slightly inferior to that of those treated with SDPF (hazard ratio, 1.048, 95%CI, 0.782-1.045; median OS (A/B), 13.0/13.6 mos.; 3-year OS (A/B), 30/26%). Because of the inferior efficacy of LDPF, the Data and Safety Monitoring Committee of the JCOG recommended the termination of the study at the end of rPII. Conclusions: CRT with LDPF is not recommended for pts with locally advanced unresectable esophageal cancer. No significant financial relationships to disclose.

Results of radiotherapy with concurrent docetaxel and cisplatin in unresectable esophageal carcinoma

Objective To evaluate the efficacy and toxicity of radiotherapy with concurrent docetax-el and cisplatin in patients with unreseetable esophageal squamous cell carcinoma. Methods Between March 2004 and June 2007, 59 patients with histologically diagnosed esophageal squamous cell carcinoma in clinical stage Ⅱ to Ⅳ were enrolled in this study. All patients were confirmed as unresectable and treated by conventional radiotherapy of 60 -64 Gy in 30 -34 fractions concurrently with docetaxel 60 mg/m 2 and cispl-atin 80 mg/m 2 on clay 1 and day 22. Results The overall response ( including complete response and par-tial response) rate was 98%. The median follow-up time was 18 months (3-53 months). The median sur-vival time was 22.6 months. The 3-year overall locoregional, progression-free and metastasis-free survival rates were 37%, 60% and 43%, respectively. Hematologic toxicity, especially leukopenia and neutrope-nia, was the major acute toxicity. While severe non-hemotologic toxicity was infrequent. Eleven patients had curable pteural effusion after chemoradiotherapy. Conclusions In unresectable esophageal squamous cell carcinoma, radiotherapy concurrently with docetaxel and cisplatin has high local control and tolerable hema-tological toxicity with G-CSF support. Key words: Esophageal neoplasms/radio-chemotherapy ; Radio-chemotherapy; concurrent; Prognosis

Observation on effect of Shenmai Injection as an adjuvant therapy on un-resectable esophageal carcinoma

Objection To observe the effect of Shenmai Injection as an adjuvavt therapy on un-resectable esophageal carcinoma. Methods 63 patients were randomized to study group and control group. Both groups were performed radiotherapy, and the study group was treated with Shenmai Injection as an adjuvant therapy additionally. Compare the effect, 12-month survival rote and side-effect between two groups. Results The effect of study group was higher than the control group, and the side effect was lower. Conclusion Shenmai Injection is an effective and safe drug as an adjuvant therapy in treating un-resectable esophageal carcinoma. Key words: Un-resectahle esophageal carcinoma; Shenmai Injection; Adjuvant therapy

A prospective phase I/II trial of capecitabine with escalating mitomycin C and oxaliplatin in patients with advanced or metastatic esophageal carcinoma

15555 Background: In preclinical studies, mitomycin C (MMC) was found to upregulate thymidine phophorylase thereby enhancing cytotoxic activity of capecitabine. Moreover, capecitabine shows promising activity in combination with oxaliplatin in patients with esophageal cancer. Therefore, we conducted a prospective phase I/II trial of the combination of capecitabine, MMC, and oxaliplatin in patients with unresectable advanced esophageal carcinoma. Methods: Capecitabine (2,000 mg/m2, bid, d1–14) and oxaliplatin (100 mg/m2, q3 weeks) were kept constant while MMC was escalated: 6–10 mg/m2, q 6 weeks. Results: 25 pts (3 F, 22 M) received 171 cycles (median 7). Median age was 64 years (41–70). Dose-limiting toxicities were grade 4 thrombocytopenia or grade 4 neutropenia. No patients died from adverse events related drug toxicity. The maximal tolerable dose (MTD) for MMC was 6 mg/m2, q6 weeks. Partial response was seen in 10/25 pts (40%), stable disease in 11/25 pts (44%) and progressive disease in 4/25 pts (16%). Median progression-free survival was 8.9 months (95% CI, 6.2–11.6), and median overall survival was 13.3 months (95% CI, 10.8–15.8). Conclusion: The triple regimen of capecitabine, MMC and oxaliplatin is well tolerated and shows substantial clinical activity in unresectable esophageal carcinoma. The high survival rates suggest the need for prospective randomized studies of this treatment strategy. Updated results will be presented. No significant financial relationships to disclose.

A Randomized Prospective Comparison of Self-Expandable Plastic Stents and Partially Covered Self-Expandable Metal Stents in the Palliation of Malignant Esophageal Dysphagia

Self-expanding metal stents (SEMS) provide effective palliation in patients with malignant dysphagia, although severe complications and mortality may result. We performed a prospective controlled trial to compare a new self-expanding polyester mesh stent (Polyflex) with SEMS (Ultraflex). One hundred one patients with unresectable esophageal carcinoma were randomized to placement of a Polyflex (N=47) or a partially covered Ultraflex (N=54) stent. Patients with esophagogastric junction (EGJ) malignancy were excluded. Placement was successful in 46 (98%) patients with the Polyflex and 54 (100%) patients with the Ultraflex stent. In one patient, the Polyflex stent could not be placed. After 1 wk, dysphagia was improved by at least 1 grade in 100% of the Polyflex group and in 94% of the Ultraflex group. Major complications were observed in 48% of the Polyflex group and 33% of the Ultraflex group. Intraprocedural perforation occurred in 1 Polyflex and 1 Ultraflex patient. Two Polyflex patients had postprocedural hemorrhage. Twenty (44%) patients with a Polyflex stent and 18 (33%) with an Ultraflex stent had recurrent dysphagia because of tumor overgrowth, stent migration, hyperplastic granulomatous reaction, or food bolus impaction. Multivariate analysis showed a significantly higher complication rate with Polyflex than with Ultraflex stents (odds ratio 2.3, 95% CI 1.2-4.4). However, median survival was 134 days with Polyflex and 122 days with Ultraflex stents (P=NS). No difference was seen in palliation of dysphagia between the two stents. Significantly more complications, especially late stent migration, were observed in the Polyflex group.

Tumor Volume as Outcome Determinant in Patients Treated With Chemoradiation for Locally Advanced Esophageal Cancer

The currently used tumor-node metastasis (TNM) staging method is generally not applicable to patients with unresectable esophageal carcinomas. There is a need for both an efficient, easy-to-perform clinical classification and for identification of pretherapeutic prognostic factors that would be useful for oncologists, one of which is tumor volume. Records of 148 patients, admitted to hospital during the period January 1993 to December 2001, were evaluated retrospectively. Median age was 65.7 years (range, 35.5-85.5 years). Most patients had SCC (84.5%). Using the computed tomography (CT) scan classification, tumors were recorded as follows: 1 T1, 42 T2, 93 T3, 6 T4, 2 Nx, 72 N0, 74 N1. Tumor volume from the CT scans was determined as the sum of 2 opposed truncated cones. Median tumor volume was 57.5 cm3 (range, 0.6-288 cm3). Median follow-up was 15.1 month (range, 0.3-82.8 months). Survival rates at 1, 2, and 3 years were 42.5%, 21.6%, and 8%, respectively. Prognostic factors identified by univariate analysis were: dysphagia grade > or =2, other histology than squamous cell, tumor location below the carina, age <65 years and tumor volume > or =100 cm3. Prognostic factors identified with multivariate analysis were: dysphagia grade > or =2 (P = 0.013), weight loss > or =10% (P = 0.047), tumor location below the carina (P = 0.002), and tumor volume > or =100 cm3 (P = 0.041). For patients that the TNM staging system is not applicable, tumor volume is a new powerful determinant of survival. Further clinical trials need to be carried out to validate this prospectively.

Advanced Oesophageal Carcinoma in an 84-year-old Treated with Chemoradiotherapy

We present a case of advanced oesophageal cancer with cardiac invasion in an 84-year-old male presenting with dysphagia and general malaise. Histological analysis of an endoscopic biopsy specimen revealed a poorly differentiated squamous cell carcinoma. Computed tomography indicated a thickened oesophageal wall that was compressing the left atrium, suggesting invasion of the heart, and oesophagography revealed a polypoid lesion 9 cm in length. No distant metastases were seen on computed tomography. The patient was given chemotherapy with 10 mg/m2 cisplatin on days 1 and 4 every week for 5 weeks and concurrent radiotherapy at a dose of 2 Gy five times per week (total dose 52 Gy). After 4 weeks, the mass was no longer visible on oesophagography or endoscopic examination. The patient was free of recurrence and metastases for 4.5 years. In conclusion, chemoradiotherapy may be curative in elderly patients with unresectable oesophageal carcinoma.

Problematic esophageal stricture: an emerging indication for self-expandable silicone stents

Self-expandable metal stents (SEMS) are routinely used to palliate patients with dysphagia caused by unresectable esophageal carcinoma, as well as patients with this malignancy who are poor candidatesforsurgery.However,placementofSEMS in proximal esophageal stricture remains problematic because of the potential for tracheal compression and the foreign-body sensation that arises from pressure on the pharyngeal structures. Refractory benign esophageal strictures also are problematic; treatment options include aggressive medical therapy with life-long esophageal dilation. Patients with benign esophageal stricture should have SEMS placed only if the risk of surgery is prohibitive and the life expectancy is short. 1 In addition, esophageal tissue responses to conventional metallic stents include inflammation, necrosis, and ulceration, with eventual fibrosis. 2 The resultant hyperplastic tissue reaction may lead to worsening dysphagia and restenosis at the proximal or/and the distal end of the stent. A recently developed self-expandable, silicone mesh esophageal stent may circumvent these problems associated with the SEMS. For a number of years, silicone prostheses have been used for management of benign tracheal stenoses; these are well tolerated by patients and of proven efficacy. 3 This is the first report of the use of a selfexpandable silicone stent for management of problematic esophageal strictures.

PROBLEMATIC ESOPHAGEAL STRICTURES

Purpose: Self-expandable metal stents (SEMS) are routinely used to palliate dysphagia in the patients with unresectable esophageal carcinoma. However, proximally located malignant strictures and benign strictures refractory to endoscopic dilations remain problematic due to the potential for tracheal compression, foreign body sensation and tissue responses leading to inflammation, necrosis, and ulceration, with eventual fibrosis. The hyperplastic tissue reaction may progress to worsening dysphagia and restenosis. The recently developed self-expandable silicone stents (SESS) have demonstrated some advantages over SEMS because of their better biocompatibility and may circumvent these problems. Case reports: We present two cases with refractory benign stricture and proximally located malignant stricture which were treated with SESS. The first case is an 81-year-old man who underwent an Ivor-Lewis esophagogas-trectomy for distal esophageal adenocarcinoma. Four months after, he developed benign circumferential anastomotic stricture requiring frequent endoscopic dilations every 3–4 weeks. Given its benign nature and long life expectancy, SESS was considered over SEMS to avoid potential complications from long-term implantation. He was followed more than 1 year with complete resolution of dysphagia and no complication. The second case is a 53-year-old man who underwent an Ivor-Lewis esophagogastrectomy for proximally located squamous cell carcinoma (SCC). One year later, dysphagia recurred and progressed to an inability to handle oral secretions. Recurrence of SCC was found at 22 cm from the incisors with liver metastasis. Given the location, SESS was chosen to avoid tracheal compression and foreign body sensation from SEMS. The proximal end was located at 20 cm from the incisors, just below upper esophageal sphincter (UES). He was followed for 3 months without recurrence of symptoms. Discussions: We demonstrate our initial experience in using SESS in the treatment of refractory benign stricture and proximally located malignant stricture near UES. These cases represent some of the more difficult-to-treat esophageal strictures. With the inert property resulting in less tissue reaction, SESS seem to be more appropriate device to use in these situations compared to SEMS. No tissue reaction or recurrent symptoms in our patients with more than 1 year follow-up period confirm the feasibility and safety of long-term SESS implantation.

Tubo gástrico isoperistáltico no tratamento paliativo do carcinoma irressecável do esôfago

A meta do tratamento dos pacientes portadores de carcinoma avançado de esôfago é o alívio da disfagia. OBJETIVO: O objetivo deste trabalho é relatar a experiência dos autores na utilização da derivação esofagogástrica através de um tubo gástrico isoperistáltico seguido de radioterapia, no tratamento de doentes portadores de carcinoma irressecável do esôfago. MÉTODO: No período de 1990 a 1999, 30 pacientes foram submetidos à cirurgia de derivação. Vinte e quatro doentes (80%) eram do sexo masculino e seis (20%) do feminino; a idade variou de 27 a 69 anos, média de 49,3 anos. Em todos os casos o diagnóstico foi confirmado por endoscopia digestiva alta e biópsia. Aqueles com tumores maiores que 6cm ao esofagograma ou com sinais de invasão da árvore respiratória à broncoscopia foram considerados irressecáveis. Após avaliação clínica e preparo pré-operatório foram submetidos à operação de derivação. O ato operatório foi realizado por duas equipes, uma na região cervical e outra na abdominal e a duração da intervenção variou entre três a quatro horas. Após a alta hospitalar os pacientes foram encaminhados para a radioterapia. RESULTADOS: Não houve óbito operatório. A mortalidade pós-operatória foi de 10%, um caso de tromboembolismo pulmonar e dois de broncopneumonia. Treze pacientes (43,3%) desenvolveram fístula cervical e em 11 ocorreu o fechamento espontâneo da fístula; um caso necessitou de reoperação e outro veio a falecer no 14º dia pós-operatório com a fístula aberta. Oito pacientes (26,6%) apresentaram estenose da anastomose esôfago-tubo; todos evoluíram bem com dilatação endoscópica. A deglutição foi restabelecida em todos os pacientes até o momento do óbito, excetuando aqueles que faleceram em virtude de complicações pós-operatórias (três casos). O tempo de internação variou de 12 a 45 dias e a sobrevida média foi de 7,9 meses. CONCLUSÕES: Os autores concluíram que nos pacientes portadores de carcinoma irressecável do esôfago, a derivação da obstrução através de um tubo gástrico isoperistáltico atinge seu objetivo primeiro que é aliviar a disfagia até o momento do óbito. A morbidade é alta, porém a maioria das complicações tem evolução benigna. A mortalidade é aceitável levando-se em conta a gravidade do carcinoma do esôfago.

EsophaCoil for palliation of dysphagia in unresectable oesophageal carcinoma: short- and long-term results.

Few reports have shown that EsophaCoil is an effective and safe prosthesis for palliation of malignant oesophageal dysphagia. A single centre experience using this type of prosthesis is reported. Between January 1995 and September 2000, 42 consecutive patients, 41 with unresectable oesophageal cancer and one with oesophageal stenosis secondary to lung cancer, were treated with 44 EsophaCoils (2 patients received 2 stents). Tumours were located in lower third of oesophagus and/or gastric cardia in 22 cases, in middle third in 18 and in upper third in 2. Mean stricture length was 5.3 cm. Implantation was performed on hospitalized patients. EsophaCoil placement was successful all 44 times and was followed by complete expansion of the prostheses. There were no major procedure-related complications or deaths. Dysphagia score improved from mean of 2.9 to 1.3 within 24 hours of stent implantation. Median hospital stay was 2.7 days. Late complications occurred in 14 patients (34.2%): 3 migrations into stomach, 7 tissue overgrowth, 2 late perforations and 2 food impactions. Mean survival time was 4.2 months (range 1-10). In our experience, full expansion of EsophaCoil was achieved in all cases. This result, was associated with high incidence of retrosternal pain. Relief of dysphagia score was identical to that obtained with other types of Self-Expanding Metal Stent. Coil design prevented tumour ingrowth and allowed retrieval of three migrated stents. Mean survival time was similar to that reported in larger series using different types of Self-Expanding Metal Stent.

A practical guide for choosing an expandable metal stent for GI malignancies: Is a stent by any other name still a stent?

A practical guide for choosing an expandable metal stent for GI malignancies: Is a stent by any other name still a stent?

7043 A new endoscopic strategy for the treatment of completely obstructing unresectable esophageal cancer.

OBJECTIVE:To determine the efficacy of photodynamic therapy as a treatment strategy in patients with unresectable esophageal cancer and completely obstructed esophagus.METHODS:The medical records of all patients treated with photodynamic therapy for unresectalble esophageal cancer at our institution were reviewed. Five patients with newly diagnosed, completely obstructive esophageal cancer were treated. None were candidates for surgical resection because of extensive or metastatic disease. Three patients had adenocarcinoma of the distal esophagus, and 2 had squamous carcinoma of the proximal esophagus. One of the latter patients also had an esophago-cutaneous fistula arising in the esophagus proximal to the tumor and exiting in the neck. In all cases the tumor was completely obstructing the esophagus and could not be transversed utilizing endoscopic or fluoroscopic methods. All patients were treated with two sessions of photodynamic therapy commencing 48 hours after the injecion of 2 mg/Kg of Photofrin. In all cases the photodynamic therapy light probe was pushed into the tumor mass for the treatments. Within several weeks of the treatments, all 5 patients underwent a successful endoscopic placement of an expandable covered metallic esophageal stent (Ultraflex) with no difficulty in order to insure long-term patency. RESULTS:In all 5 patients treated the esophageal tumor responded to the photodynamic therapy and allowed for a safe dilatation of the previously obstructing strictures. There were no treatment related complications and no long-term serious stent related complications. The 2 patients who had proximal stents did have respiratory complications due to the extent of their disease. The esophago-cutaneous fistula healed after treatment, and then the patient tolerated external beam radiation therapy to the site. CONCLUSIONS:We have successfully applied photodynamic therapy to completely obstructive esophageal carcinoma, and then insured future patency with the placement of an expandable covered metallic stent. In all patients the esophagus remained patent after the stent placement. There were no perforations or stent migrations noted.We report this treatment strategy as a safe palliative endoscopic alternative for patients with obstructing, unresectable esophageal carcinoma who cannot be stented because of a complete obstruction. In this group placing a stent within a few weeks of photodynamic therapy appears to be safe.

Endoscopic palliation of esophageal and cardial cancer: neodymium-yttrium aluminum garnet laser therapy.

The aim of this study was to evaluate the impact of laser palliation on symptoms such as dysphagia and bleeding in patients with esophageal and cardial carcinomas. From November 1992 to October 1997, 174 patients with unresectable esophageal and cardial carcinomas were treated with neodymium-yttrium aluminum garnet laser therapy. The indications for palliative treatment were advanced tumor in 96 patients and high surgical risk in 78. The tumor involved the esophagus and cardia in 107 and 67 patients respectively. The mean length of the tumors was 6 cm. Two laser sessions (range 1-4) were necessary for recanalization. During the follow-up, the average interval between the laser sessions was 2 months. Overall, no early and late complications or hospital mortality occurred. The quality of palliation was excellent or good in 82%, of the patients. The mean survival time was 6 months, and mortality was not related to the procedure. Endoscopic laser therapy in patients with vegetant or hemorrhagic carcinomas may represent the best therapy, with acceptable morbidity and mortality rates and satisfactory functional results.

Palliation of malignant dysphagia by laser therapy.

The outcome of 211 patients undergoing laser therapy as palliation for inoperable carcinoma of the esophagus is presented. The median age was 73 (range 44-97). The histology was adenocarcinoma for 127 patients and squamous-cell carcinoma for 84 patients. For 133 patients, laser was the only therapy while 56 patients had a combination of laser therapy and radiotherapy/chemotherapy. One patient underwent laser recanalization prior to resection while four patients had recurrence after resection treated by laser. Eleven patients underwent laser therapy for recurrent dysphagia after placement of an esophageal endoprosthesis. Eighteen patients died of procedure-related complications (i.e. 9% of patients and 2% of procedures). Of 32 procedures which perforated the tumour, 10 ended in death and the remaining patients were successfully treated conservatively. Good palliation was achieved for 170 patients (80%), while 19 patients underwent intubation after failure of laser therapy. Laser therapy failed to relieve dysphagia for 22 patients. The median survival was 20 weeks with the 1-year survival 12% and 2-year survival 4%; there were no significant differences in survival dependent on histology or administration of adjuvant radiotherapy or chemotherapy. Laser therapy provides a practical alternative to intubation in the treatment of malignant dysphagia for patients with unresectable esophageal carcinoma.

Improving results of esophageal stenting: a study on 160 consecutive unselected patients.

Esophageal stenting is a valuable treatment in the management of malignant dysphagia. Recently, self-expanding stents have proved effective in reducing morbidity and mortality. The aim of this study was to evaluate the early and late results of esophageal stenting in a series of 160 consecutive unselected patients with unresectable esophageal and cardial carcinoma treated between November 1992 and December 1996. The procedure was successful in 159 patients (99.4%). A traditional tube was employed in 84 patients (52.5%). Metallic self-expanding stents have been available since June 1993 and were used in 75 selected patients (46.9%). The tumor was located in the cervical, upper, middle and lower thoracic esophagus, and at the gastric cardia in 16, 16, 56, 22 and 34 patients, respectively. In the remaining 15 patients an esophagovisceral anastomosis was involved. Preoperative chemo- and/or radiotherapy were performed in 82 patients (51.3%). Overall hospital morbidity was 11.3% (18/159) and included four dislodgments, four incomplete expansions of a self-expanding stent, two perforations, two incomplete sealings of a malignant respiratory tract fistula, two hemorrhages, two persistent foreign body sensations, one arrhythmia and one aspiration pneumonia. Hospital mortality was 1.3% (2/159) and was recorded in patients who underwent traditional intubation. At discharge, dysphagia was improved at least 2 degrees in 152 patients (96.8%). The overall long-term morbidity was 23.5% (37/157). Mean survival after the procedure was 4.7 months. Intubation is a safe palliative procedure which can be performed with low morbidity and mortality rates. Self-expanding metallic stents have enhanced the indications and the outcomes of the procedure, resulting in the treatment of strictures where the placement of a traditional tube is difficult or technically impossible.

Intracavitary brachytherapy for carcinoma of the esophagus.

Local control of unresectable esophageal carcinomas remains a significant problem in spite of aggressive treatments. External beam radiation therapy, chemotherapy, and combined modality treatment have all been employed with limited success. Here we review the existing literature and our own experience with external beam radiation followed by low-dose-rate or high-dose-rate intracavitary radiation for carcinoma of esophagus. The addition of intracavitary brachytherapy to external beam irradiation is well tolerated, causes no significant toxicity, and improves local control. Low-dose-rate intracavitary boost compared to high-dose-rate intracavitary boost has the advantage of a greater margin of safety, requires a single application, does not require highly sophisticated computerized technology, and is accompanied with fewer high-grade toxicities. Combined modality therapy consisting of concomitant infusional chemotherapy, external beam irradiation, and low-dose-rate intracavitary boost needs to be investigated.

Endoscopic palliation of oesophageal carcinoma with Atkinson prosthesis

To assess the degree of palliation, the associated morbidity and mortality and to compare our results with other published series, we reviewed our use of the Atkinson prosthesis in 100 consecutive patients for the palliation of unresectable oesophageal carcinoma. The group had a mean age of 71.2 +/- 2.3 years. All prostheses were placed by the pulsion method. Intubation was successful in 91%. Improvement in swallowing was seen in 82.1%. Major early procedure-related morbidity was high at 23% with 11 perforations (11%). Procedure-related mortality was 12%. Those aged 70 years or more had a 34.5% risk of morbidity and 15.5% risk of dying from the procedure. Late procedure-related complications requiring further endoscopic procedures occurred in 27%. Our 7 day mortality was 14.7% (14 patients) and 31 patients (32.6%) had died within 30 days, usually from the disease itself. Those surviving the procedure (> 7 days) had a mean survival of 105 (range 9-735) days. We obtained acceptable palliation but with a significant morbidity and mortality. Endoscopic intubation remains a useful palliative treatment for patients with unresectable carcinoma of the oesophagus and cardia.

An active esophageal prosthesis

Resection of carcinoma of the esophagus may be curative or palliative and usually results in either total esophagectomy or esophagogastrectomy. Continuity of the upper gastrointestinal tract is maintained via a gastric pull-up procedure or, when feasible, by primary reanastomosis of the gastric remnant to the proximal esophagus. 1 If a large part of the stomach has been previously resected or is unsuitable for use, colonic or jejunal interposition may be utilized to maintain continuity. However, these operations are associated with substantial surgical morbidity and mortality and a myriad of postoperative complications, including luminal narrowing caused by edema or ischemia, anastomotic leaks, formation of fistulae and strictures, and development of graft ischemia. 2, 3 These procedures may be precluded in the elderly or in patients with complex medical problems who are poor surgical risks. In these patients and in those with unresectable esophageal carcinoma, palliative cervical esophagostomies are sometimes performed to reduce the discomfort of dysphagia and lessen the at tendant risk for aspiration pneumonia. Nutrition is maintained through surgically placed gastrostomies or jejunostomies and, in rare instances when feeding tube place: ment is not possible or the distal gastrointestinal tract is obstructed, total parenteral nutrition. 2 Although these procedures are palliative, patients usually remain uncomfortable, are unable to eat, and have the extra burden of repeatedly emptying the esophagostomy bag, in which saliva accumulates. They also have the problem of administering enteral feedings and fluids to replace the salivary losses. We have developed an active esophageal prosthesis (AESOP) that, via a small pneumatically driven extracorporeal pump, can maintain a functioning conduit between a cervical esophagostomy and the remainder of the gastrointestinal tract in a closed circuit.

A Randomized Prospective Study of Adjuvant Chemotherapy after Radiotherapy in unresectable Esophageal Carcinoma

A Randomized Prospective Study of Adjuvant Chemotherapy after Radiotherapy in unresectable Esophageal Carcinoma