Palliation of Dysphagia of Esophageal Cancer by Endoscopic Lumen Restoration
Techniques
H. Worth Boyce, Jr, MD, FACP, MACG
Proper management of dysphagia due to esophageal carcinoma
should include palliative methods.
Background: Cure of patients with esophageal cancer has
remained rare over the past four decades. The overall five-year survival
rate for squamous cell and adenocarcinoma of the esophagus currently is
reported as 12% in whites and 8% in blacks. The five-year survival
rate for localized disease at initial staging is only 26% for whites and
13% for blacks. With regional involvement, these rates are 11% and
7%, respectively.
Methods: The author reviews the literature on optimal
endoscopic lumen restoration techniques, including dilation, thermal laser
and chemical ablation, photodynamic therapy, and stents. Procedures
for pain relief and nutritional support are also presented.
Results: Lumen restoration to relieve dysphagia and
provide the opportunity for sustaining reasonable peroral nutrition is
an essential element in the overall management. Nonsurgical lumen
restoration procedures have much to offer for dysphagia palliation and
are briefly reviewed in this presentation. The major options include
ablation of intraluminal tumor mass by thermal laser, photodynamic laser,
chemical ablation, peroral dilation, and placement of esophageal stents.
Most patients require more than one palliative method to sustain lumen
patency during the course of their disease.
Conclusions: Most patients with esophageal cancer will
require palliation for the multiple problems that develop during their
limited life span. The responsibility of the palliation therapist
is to provide the patient with safe and cost-effective treatments that
provide the best possible dysphagia relief.
Introduction
At the present time, approximately 10% of patients with
esophageal cancer survive five years. Thus, approximately 90% are incurable
and will need some effort at palliation. Modern radiation and chemotherapy
regimens offer some patients a reasonable chance for short-term palliation
with tolerable morbidity and essentially no mortality. The morbidity of
radiation and chemotherapy can be managed well by alterations of dosage
and frequency. In selected patients with distal lesions, surgical therapy
may offer good palliation of dysphagia at the price of operative risk and
postresection sequelae.
The optimum palliative care for the majority of patients
with esophageal cancer should include the safest, most effective, and least
expensive therapies that can be performed promptly as the need arises.
All too often, quality of life is neither protected nor supported adequately
between the stage of recognized incurability and death. All-out 11th-hour,
relatively heroic efforts should not occur or, at most, should be the exception.
Proven palliative measures are safer, less expensive, and more cost effective
when applied at the first indication of need. This is especially true for
those techniques designed to relieve the dysphagia of malignant esophageal
obstruction.
Physicians who assume responsibility for medical
care of patients with esophageal cancer must accept the fact that, except
in highly selected patients, the overall five-year "cure" rates for these
neoplasms have not changed significantly during the past 40 years, despite
the excellent progress made in supportive care, surgical technique, radiation,
and chemotherapy. The reason for the persistently poor results is that
esophageal cancer is rarely diagnosed early enough to permit surgery, radiation,
or chemotherapy to be curative.
General supportive care, relief of pain, restoration
of adequate nutritional status, and treatment of specific sequelae of the
carcinoma are all essential to proper therapy. No single method is adequate
for palliating esophageal carcinoma, especially dysphagia.
Dysphagia literally means difficulty with eating,
but the term is used clinically to indicate difficulty in passage of solid
and liquid boluses through the esophagus to the stomach. The presence of
dysphagia as a presenting symptom of esophageal cancer usually is indicative
of incurability. The average patient has had significant, easily recognizable
dysphagia for at least three to six months before seeking medical care.
Obstructive dysphagia correlates with more than 50% occlusion of the esophageal
lumen and usually indicates extensive intramural spread of the cancer.
Most patients also have 5 cm or more of longitudinal intramural esophageal
involvement at diagnosis. Sialorrhea or excessive saliva production is
regularly associated with esophageal obstruction. The rapid accumulation
and regurgitation of this "foamy mucus" is a common complaint that contributes
to daytime misery with frequent spitting, as well as insomnia and the increased
risk of aspiration pneumonia. The presence of chest pain at initial presentation
is also a poor prognostic sign.
Dysphagia in patients with residual esophageal cancer
after therapy by either esophagectomy and/or radiation and chemotherapy
will be the primary focus of this presentation. Neglected or delayed palliative
care for patients with esophageal cancer and dysphagia needs emphasis and
wider publicity. Lumen restoration techniques performed with the aid of
endoscopy are reviewed in this article. The nonsurgical treatment methods
discussed are applicable to those who have had prior attempts at curative
and palliative therapy, as well as to those rare patients who elect to
have no formal initial therapy for the obstructing lesion.
Esophageal Dilation
In many cases, patients present with obviously incurable
and obstructing lesions but are not referred for early dilation either
before chemotherapy and radiation therapy are begun or after those treatments
have failed to provide dysphagia relief. This hesitation causes the patient
needless suffering for many weeks. Although the improved lumen patency
provided by timely dilation is limited, even temporary relief with improved
swallowing is beneficial.
The first order of therapeutic business should be
to care for the patient’s nutrition, pain, and psychological needs. Also,
the stenotic esophageal lumen needs to be restored to a diameter sufficient
to allow ingestion of liquids and some solid food as well to improve clearing
the significant volume of saliva produced every day. Peroral dilation should
begin as soon as possible in patients with dysphagia. When proper instruments
and techniques are used, risk in dilating a malignant stricture either
before, during or after radiation therapy is minimal.1-3
Within three to six weeks after palliative chemoradiation
therapy, the optimum lumen restoring response can be expected. If lumen
patency is improved and adequate, both by complete history and barium swallow,
including a pill bolus challenge, the patient simply should be followed
with periodic, thorough historical and physical evaluations to evaluate
nutritional status and to detect recurrent lumen occlusion. Dysphagia may
be due to recurrent tumor, radiation-induced stricture, or both. In any
of these instances, additional dysphagia palliation should be promptly
recommended.
The normal esophageal lumen measures approximately
25 mm in functional diameter. When the lumen diameter is decreased to 13
mm, everyone has solid food or regular diet dysphagia. When the lumen diameter
is less than 18 mm, selective alteration of diet content and consistency
is necessary, depending on the characteristics of the stricture. Milder
degrees of stricture are easier and safer to dilate than severe strictures.
It is illogical to delay therapy until the patient is able to swallow only
liquids, even though adequate total caloric intake has been possible by
using a full liquid diet plus dietary supplements.
Peroral dilation can restore esophageal lumen patency,
albeit temporarily, to a diameter adequate to permit adequate swallowing
in over 90% of patients.2 Either flexible, tapered dilators
(Savary) passed over a guide wire or rubber dilators (Maloney) are used
in progressive sizes under fluoroscopic control. Most malignant strictures
can be safely dilated in several sessions to a size 48F to 51F (16 to 17
mm). Lumen diameter must be greater than 39F (13 mm) if solid-food dysphagia
is to be at least partially relieved. A maintenance program for frequency
of dilation is an individual matter based on each stricture’s response.
Although adequate lumen diameter can be restored by dilation, recurrent
lumen stenosis occurs within days to a few weeks so any relief obtained
usually is of short duration. When a short-term response is observed, the
therapist needs to start planning and educating the patient about the next
options for more prolonged palliation.
There is no evidence that properly performed esophageal
dilation of obstructing carcinoma carries an unacceptable risk. Failure
to dilate a malignant esophageal stricture is due more to a lack of proper
training of the physician or surgeon in dilation therapy than to inherent
dangers of the methods. Heit et al1 reported a 92% success rate
for dilation and demonstrated the safety of peroral dilation for obstructing
esophageal cancer in their report of 26 consecutive patients in whom 616
dilations were performed under fluoroscopic control before, during, and
after radiation therapy with no major complications. Properly performed
dilation is safe considering the type of severe strictures and the debilitated
patients who require this therapy. In the largest series reported, Cassidy
et al2 noted only three deaths in 154 patients in whom a total
of 3,160 dilators were passed before, during, and after radiation therapy.
Two perforations (1.3%) with death were due to perforations by the Eder-Puestow
wire-guide spring tip (Eder Instrument Co, Chicago, Ill), which is no longer
used. Peroral dilation was possible in 98% of their patients.
Thermal Laser Ablation
Transendoscopic ablation of obstructing intraluminal
cancer by laser thermal coagulation offers another relatively safe but
often temporary palliation for dysphagia. The value of this method relative
to other palliative treatments has been extensively evaluated.
4-10
Laser ablation is most helpful for treating lesions that are polypoid or
that occlude by intraluminal growth. Laser therapy carries a higher risk
and is less effective for cancer of the proximal esophagus or esophagogastric
junction and for long lesions.
Transendoscopic laser ablation of obstructing esophageal
cancers was first described in 1982 using high-power neodymium yttrium-aluminum-garnet
(Nd:YAG) laser.4 The degree of dysphagia relief is less predictable
after laser therapy than after stent placement. Successful ablation usually
provides a wider lumen diameter than a stent and allows intake of a more
solid consistency diet temporarily. Approximately one third of patients
can take a modified regular diet initially, and another 50% are able to
take some solids or semi-solids (Table 1).11 The maximum benefit
is observed a few days after treatment, but dysphagia gradually recurs
and requires repeat therapy sessions, usually every four to six weeks for
life.
One helpful application of laser ablation is for
pre-stent ablation of a polypoid, eccentric intraluminal mass that typically
would either cause acute angulation and partial occlusion or prevent suitable
anchoring of a stent (Figs 1A-B). Other special cases in which laser or
other thermal ablation may help include hemostasis for necrotic chronic
bleeding lesions and for ablation of tumors obstructing a stent by overgrowth
at either end or by ingrowth through an uncoated metal expandable stent.
Contraindications for laser therapy include subepithelial
metastasis in a diffuse pattern, excessively angulated lesions, and presence
of an esophagopulmonary fistula. Also contraindicated are (1) lesions often
associated with unsafe aiming conditions such as cancer in the cervical
esophagus adjacent to the cricopharyngeus muscle and (2) long or angulated
lesions at the esophagogastric junction. Ideally, the laser ablation should
begin at the distal margin of a circumferential lesion after the lumen
has been adequately dilated to allow safe aiming of the laser beam. The
ablation is then continued as the endoscope is slowly retracted. The interval
between ablation sessions usually is two to four weeks but can be shortened
as indicated. Initial morbidity and mortality are low, but with repeated
laser sessions (usually three to five) required in the presence of advancing
disease, cachexia, and other organ malfunction, the risks steadily increase
(Table 2).12
Ell and colleagues5 reported results of
laser therapy in 816 patients with esophageal cancer with a success rate
of 83%, a perforation rate of 2.1%, and procedure-related mortality of
1%. A more recent multicenter trial of laser therapy reported a 7% perforation
rate.13 This same prospective study revealed only approximately
50% of patients improving at least one dysphagia grade and another 25%
with no change. Although the technical success (ability to relieve the
esophageal obstruction) is approximately 90%, the functional success (the
ability to maintain adequate nutrition by peroral intake) is only approximately
70%. Luminal patency in this disease does not equate with free passage
of food following any lumen restoration procedure, be it laser ablation,
stent, or brachytherapy. Adequate nutrition is hindered to varying degrees
because of past radiation- or laser-induced neuromuscular injury or fibrosis,
and especially by the ever-present anorexia related to metastatic cancer.
Mean survival time following thermal laser ablation is similar to other
ablation methods.14
Chemical Ablation
Intraluminal tumor mass can be reduced by direct transendoscopic
injection of absolute alcohol and other sclerosing or chemotherapeutic
agents. These methods offer inexpensive and safe alternatives to therapy
by other ablative methods; however, clinical experience is limited, and
long-term follow-up is lacking.
Transendoscopic injection of absolute alcohol, using
a standard sclerotherapy needle, has been reported as safe, simple, and
effective. Initial results are similar to laser therapy.15 The
injected tumor necroses and sloughs within several days after absolute
alcohol injection. Repeat sessions are needed as with laser ablation. In
the small number of cases reported thus far, complications have been rare,
and costs above the basic endoscopy charge are minimal. Obviously, direct
visual access to the injection sites around a bulky tumor is imperative
since the therapist must assure that the injection site is at least 1 cm
away from the underlying esophageal wall. Alcohol injection is contraindicated
in patients with infiltrating or minimally protruding tumors due to the
risk for perforation.
Photodynamic Therapy
Photodynamic therapy (PDT) begins with administration
of a chemical photosensitizer that accumulates in higher concentrations
in neoplastic tissue than in normal tissue.
13,16-19 This chemical,
porfimer sodium (Photofrin II, Quadra Logic Technologies, Vancouver, British
Columbia), is given intravenously in a dose of 2 mg/kg of body weight.
After approximately 48 hours, the area of cancer is exposed to a red light
with a wavelength of 630 nm provided by a continuous-wave argon-pumped
dye laser via a quartz fiber passed through a standard videoendoscope.
This light exposure initiates a chemical reaction of the porphyrin compound
within the cells that leads to production of oxygen radicals that destroy
the cells. After another 48 hours with repeat endoscopy and debridement,
residual tumor can be similarly treated since an adequate concentration
of the photosensitizer remains. Patients remain photosensitive to sunlight
for one to two months and must avoid such exposure. Transient side effects
include odynophagia, chest pain, low-grade fever and, uncommonly, minor
pleural effusion. There is a 1% perforation rate reported in the largest
series to date.
13
The overall efficacy of PDT compared to Nd:YAG thermal
ablation is comparable. PDT is considered to be technically easier, less
operator dependent, and less painful than laser in patients under conscious
sedation. The time to palliation failure of one month was comparable for
PDT and thermal laser therapy. The cost of PDT is high due to the cost
of porfimer sodium (approximately $2,000 per treatment) plus two endoscopies
and hospital observation to manage the possible short-term side effects.
As with Nd:YAG laser therapy, repeat treatment is required approximately
every month, a not-so-satisfactory frequency for an expensive palliative
therapy in a patient with advanced carcinoma and short survival. PDT has
also been used recently to treat tumor ingrowth in expandable esophageal
stents, but this problem can be managed at less cost by thermal coagulation
with a multipolar electrocoagulation probe or argon plasma coagulator.20
Esophageal Stents
Palliation of dysphagia due to esophageal cancer by
placement of peroral stents has been performed for over 100 years but was
not safe and effective until the 1950s.
21 Stents or prostheses
have been made from animal tusks, coiled silver wire, raw gum latex, rubber,
polyethylene, polyvinyl chloride, and silicone (Fig 2); more recently,
either stainless steel wire and space age alloys or memory metals have
been used to construct metal stents that areexpandable.
22-25
Four metal expandable stents are currently available. Three metal stents
are shown in Figs 3A-C. Suitable coatings have been developed for these
three devices. Each manufacturer has several lengths of stents available.
The models most often used will have a shaft length of between 7 and 12
cm. Although "piggy-backing" of shorter stents is possible, this practice
will double the already considerable cost.
26 Improvements in
stent materials, design, and construction plus gradually improving physician
education and training have initiated a trend toward earlier and more appropriate
therapeutic application of these devices.
23,27,28
There is a developing consensus that esophageal obstruction
due to either fibrosis from radiation or residual recurrent neoplasm is
best managed by dilation followed by peroral stent placement.2,3,29
Thermal ablation by Nd:YAG laser, multipolar electrocoagulation probe or
heater probe, chemical ablation by injection of absolute alcohol or chemotherapeutic
agents, and photochemical ablation by photodynamic laser therapy are effective
transiently for lumen restoration; however, they are best used for pre-stent
lumen preparation where there is a need to reduce the bulk of masses that
protrude into the lumen. The use of the argon plasma coagulator for debulking
intraluminal carcinoma is being evaluated, but information to date is insufficient
to establish its efficacy. This technique is effective for ablating small
lesions and ingrowth/overgrowth of tumor or granulation tissue associated
with stents. These thermal ablative measures offer no real benefit for
intramural infiltrating malignancy.
If dilation therapy has failed, a peroral stent may
be inserted through the adequately dilated stricture using only mild sedative
analgesic medication and an anesthetic gargle. When malignant strictures
have been neglected and severe lumen stenosis has developed, it is necessary
to plan adequate dilation over several sessions before stent placement.
The literature has clearly demonstrated that those who dilate severe strictures
and place stents in a single session have unacceptably high perforation
rates.30 The technique for proper placement of any type of esophageal
stent must include adequate pre-stent dilation.3,29 The larger
the diameter of dilation, the easier and safer stent placement will be.
This assumes, of course, that correct dilation procedure is used.
The diameter of stent-related lumen restoration varies
between 9 and 18 mm. Plastic and silicone stents have lumen sizes of 9
to 12 mm. Metal expandable stents are advertised to have potential lumen
diameters up to 25 mm; however, the maximum advertised diameter is not
predictably achieved because stricture resistance often exceeds stent radial
force.31 Metal stents with high radial expansile force can achieve
larger diameters but at a higher risk of perforation and greater difficulty
with rapid extraction when emergent removal is indicated.
The concept for proper stent location requires that
the stent extend at least 2.5 cm above and below the obstructing lesion.
For metal stents that are uncoated at each end, the 2.5-cm overlap measurement
should be calculated to allow 2.5 cm of coated stent above and below the
lesion if possible. Positioning the stent in this fashion helps to compensate
for the possibility of the carcinoma to overgrow either end or to grow
through the uncoated wire mesh at either end and obstruct the lumen (Figs
4A-B). This degree of extension beyond the lesion usually is adequate to
prevent overgrowth of the cancer.
Placement requires between one and five minutes depending
on the type of stent used. In 90% of patients, the stent remains in position
for life and usually permits adequate swallowing of liquids and a modified
soft diet (Figs 5A-C). This peroral method for stent placement under conscious
sedation is recognized as having far less risk than peroral placement under
general anesthesia as practiced by some.32
When proper technique is used, the perforation risk
for peroral esophageal stents will be less than 5% and the mortality near
zero. In our recent series of 212 plastic stents, the perforation rate
was 2.8% and stent-related mortality was 1.8%. In 23 consecutive patients
having metal expandable stents, there were no perforations but one death
(4.7%) related to tracheal occlusion by a Wallstent (Microvasive, Boston
Scientific, Boston, Mass) in a patient without bronchoscopic evidence of
tracheal involvement. A recent literature review compared the risks of
various types of stents (Table 3).25 The high mortality and
perforation rates for plastic stents is believed to be due to the lack
of programmed pre-stent dilation and to the type of stent and introduction
apparatus used. Raijman et al33 recently reported that chemotherapy
does not increase the risk of complications with metal stents. Usually,
only one or two days of hospital observation is necessary unless the patient
is suffering from other problems associated with advanced disease. Some
reports indicate stent placement can be done on an outpatient basis; however,
at least one overnight period of observation is prudent, considering the
physical status of these patients.34
Rarely, stent placement can precipitate airway obstruction.
This will more likely occur if airway compromise by tumor involvement already
exists. Because of this unlikely but real possibility, all patients having
a stent placed for an esophageal cancer cephalad to the level of the left
main bronchus should have pre-stent bronchoscopy to exclude existing airway
compromise by the carcinoma.
As with other palliative therapies, increased risk
and technical difficulty are concerns for lesions in the cervical esophagus
and at the gastroesophageal junction.35,36 Cancer in the cervical
esophagus also presents problems for stents and other therapies, but stents
are safe and effective at this location in approximately two thirds of
patients.36-38 Lesions of the lower esophageal and gastric cardia
can be effectively stented but do present potential technical problems.35
Another caveat is worthy of emphasis to all physicians
who plan to offer dysphagia therapy by various endoscopic procedures: Never
initiate therapy for dysphagia by any method in a patient with esophageal
cancer without a current barium esophagram. Late-stage esophageal cancer
has a tendency to necrose and produce intramural or extramural cavitation.
If the unsuspecting therapist disregards this possibility and proceeds
to perform invasive procedures without up-to-date radiography, a post-procedure
barium esophagram may reveal extraluminal barium. In such an instance,
no one knows whether the leak is due solely to tumor necrosis or is the
result of the esophageal manipulation -- so who gets credit for this "complication"?
Major considerations in the United States are the
cost of medical care and the efficacy and safety of the procedure. The
cost of a metal stent is five to 10 times greater than a plastic stent.
If the patient is properly prepared before stent placement and good technique
is used, the cost of hospitalization for different stents should be similar.
Once some metal stents are placed, they cannot be
easily repositioned and are either very difficult or impossible to remove.23
In some cases, malposition can be compensated for by placing a second stent
overlapping (piggybacking) the first. Piggybacking metal stents can cost
up to $3,000 for stents alone. Plastic and metal stents become dislocated
in 5% to 10% of cases but usually can be properly repositioned.
Food impaction is not a complication of a plastic
or fully deployed metallic stent per se. It is usually due to a lack of
patient education or noncompliance with instructions for proper food selection,
chewing, and swallowing. Stent diet instructions, verbal and written, should
be given to patients and family members or caregivers prior to patients’
discharge from the hospital.3
Current models of stents are safe. The major risks
result from an untrained operator, the pre-stent dilation, the placement
apparatus and technique used, the premedication or general anesthesia,
and the post-placement dietary management.29 One danger of making
devices easy to use is that those who are ill-prepared to use them will
assume that simplicity of placement equates with safety. Anyone who assumes
responsibility for application of a technique, regardless of its publicized
simplicity and efficacy, is responsible for having a thorough understanding
of the disorder being treated, its indications, its contraindications and
the principles of long-term management before attempting use of the method.
The timing for placement of either plastic or metal
expandable stents is important for procedure safety, quality of life, and
duration of survival. This short survival is in some measure due to the
habit of late referral. Unfortunately, physicians in past years have neglected
to refer patients for stents until very late in their illness. Nearly all
series report the average survival after stent placement to range between
three and five months.6,11,38-40
Overall survival has not been improved by metal stents
compared to plastic stents.11,28,41 Palliation of dysphagia
is similar in both groups, and the quality of life after uncomplicated
stent placement is similar as well. However, if metal stents were regularly
able to expand to a lumen diameter of 18 mm or larger, which they are not,
they would provide better dysphagia relief. Any potential reduction in
morbidity and mortality related to metal stents may be offset by technical
and judgment errors made by the many physicians with no prior stent experience
who will be inserting them because placement is technically easier.
Esophageal stents provide palliation and survival
time similar to laser and other techniques designed to reduce dysphagia.
In a prospective, nonrandomized, multicenter trial, Loizou et al39
reported that long-term improvement (until death) in swallowing was noted
in only 50% of 34 adenocarcinomas treated by laser but occurred in 92%
of 20 patients treated with a stent. Those who treat malignant esophageal
obstruction are well aware that improvement of dysphagia does not equate
with relief of anorexia, nutritional restoration, or prolonged survival.
However, stents do allow the patient to enjoy the pleasures of oral alimentation
and less time in the physician’s office or hospital during the relatively
short interval before death. At present, too few patients are informed
of a peroral esophageal stent or given the option to have one placed early
enough to provide optimum benefit.
The increase in enthusiasm for esophageal stents
is impressive and long overdue. Needless to say, the development of metal
expandable stents and insertion devices of small diameter have much to
do with this trend. The unacceptable complication and mortality rates associated
with plastic and silicone esophageal stents occurred after development
of commercial insertion devices that were larger and more rigid than necessary.30
The other major negative factor in plastic stent safety was the practice
by some of rapid dilation of a malignant stricture at the same sitting
the stent was placed. An apparatus that was too large and rigid, combined
with overly vigorous dilation of malignant strictures, proved to be a dynamic
duo with unfair mechanical advantage over a very diseased and weakened
esophagus and patient.
The wider use of metal stents for palliation of malignant
esophageal obstruction by operators with little or no stent placement training
carries with it an expanding role of responsibility that applies to physician
and manufacturer alike. Since these devices will be used by many physicians
who are not adequately trained in the techniques of esophageal stenting,
manufacturers must perfect their stent products by thorough testing in
large numbers of patients before marketing.31 On the other hand,
these devices should be used only by physicians with a solid background
of training in esophageal dilation and supervised training with some type
of esophageal stent placement.
The potential benefits of the ideal esophageal stent
will be easy, rapid, and safe placement, restoration of a predictable and
adequate lumen size, optimal palliation of dysphagia and sialorrhea, and
provision of the best possible quality of life for the known small quantity
of life remaining for the patient with esophageal cancer.
Esophagopulmonary Fistulas
A major complication of esophageal carcinoma is the
development of an esophagopulmonary fistula that, if untreated, typically
leads to pulmonary infection and earlier death (Fig 6A). A fistula develops
in approximately 15% of cases and usually should be attributed to the natural
history of this disease. Fistulas are the consequence of tissue destruction
by carcinoma invading normal tissue (Fig 6B). They may first become manifest
before any therapy or after irradiation or chemotherapy has produced the
desired destruction of the invading cancer. The fistula, however, should
not be considered a complication of irradiation, dilation, or other therapy
for this malignancy; it is simply a natural event to be expected when necrotic,
neoplastic tissue necroses or is removed or displaced. When the necrotic
tissue between esophagus and major airway is displaced, an esophageal-pulmonary
fistula then becomes clinically obvious.
The most reasonable palliation of the problems of
malignant esophagopulmonary fistulas is an esophageal stent -- plastic,
silicone, or coated metal expandable.3,23,24,42,43 Effective
occlusion of a fistula within minutes by proper stent placement is one
of the most dramatic and satisfying therapeutic ventures in medicine (Fig
6C). The elimination of cough, the reduction of sialorrhea and tracheobronchial
leakage, the restoration of ability to rest and sleep without the constant
cough, and the improvement in quality of life and psychological status
of the patient and family provide a positive experience for all concerned.
Concomitant Palliation
This review of lumen restoration procedures for malignant
esophageal obstruction would be incomplete without emphasizing concomitant
measures so essential to care of the "whole patient." Pain relief and nutrition
support must be continued throughout the palliative treatment program.
Pain Therapy
Pain due to the primary carcinoma and/or regional
metastases is a major problem in these diseases. Pain typically becomes
serious enough to require regular drug therapy relatively late in the course
but may occur in 10% as the first symptom preceding dysphagia. It is ordinarily
a constant, deep, aching, or boring pain noted in the retrosternal area,
back, or epigastrium and may be referred to neck, jaws, or shoulders. This
pain responds incompletely to medications containing combinations of aspirin
or acetaminophen plus codeine analogues. In the later stages, Dilaudid
(Knoll Pharmaceuticals, Whippany, NJ), morphine sulfate, methadone, or
other potent narcotics usually are required and should be prescribed at
a dose and frequency adequate to provide relief. Liquid morphine or other
liquid analgesic preparations are most useful in patients with dysphagia.
A sedative at bedtime may help by enhancing the analgesic effect of a narcotic
drug. These debilitated patients should be encouraged to use analgesics
as needed to be kept comfortable, but they should be observed closely for
narcotic side effects manifested primarily by pulmonary and gastrointestinal
sequelae. The risk of addiction is low and should not influence the need
for adequate pain relief. The extreme fatigue suffered by these patients
due to pain and insomnia can be relieved only by an effective pain management
regimen.
Nutritional Support
The patient’s nutritional status should be assessed
periodically. Treatment of the protein and calorie malnutrition so common
in these patients should be initiated early. Depending on overall status
and prognosis, it may be appropriate to begin this restoration by a percutaneous
endoscopic gastrostomy/jejunostomy, by a nasoenteric feeding tube or, rarely,
by central venous alimentation. Oral feeding is encouraged as tolerated
at the same time, although the tumor-related anorexia and pain often create
major obstacles to achieving adequate nutrition. Early deaths may result
as much from the consequences of malnutrition and infection, especially
pneumonia, as from spread of the carcinoma.
Other important aspects of supportive care include
maintenance of good oral hygiene, adequate dentition, and pulmonary toilet.
The care, compassion, and ready availability of a knowledgeable physician
who can provide psychological support for the patient and concerned family
members are important to the quality of the patient’s remaining life.
Conclusions
It is clear from reports over the past two decades that
proper management of dysphagia due to incurable esophageal carcinoma should
include the option for several palliative methods in case the initial efforts
fail. A determination of a single best dysphagia palliation is not possible
in the absence of properly conducted prospective therapeutic trials. These
trials must include a careful objective assessment of the stage of disease
and the patient’s physical status, precise documentation of the consistency
of the diet and total caloric intake, the frequency and indications for
all invasive procedures, a recording of all procedure-related complications,
a standardized quality-of-life assessment and length of survival. At present,
there is no proof that any one of the available palliative therapies is
superior for dysphagia relief in patients with advanced cancer who have
failed the usual surgical, radiation, and chemotherapy regimens. However,
the pendulum is rapidly swinging in favor of stents.
In the absence of a clearly superior method, the
determinants for palliative efforts will continue to be local expertise
and procedural bias. However, it is imperative that the palliation therapist
consider the individual patient and the clinical situation. It is especially
important to be willing to make a decision that a patient’s status may
be too far advanced to justify any invasive procedures. A proper decision
not to "invade" is usually more difficult -- but often more compassionate
-- than proceeding with palliative attempts when survival prognosis is
likely only a few days to several weeks.
A peroral stent to restore and maintain lumen patency
usually is well tolerated, can significantly improve quality of life, has
a low procedure-related morbidity and mortality, requires a minimal hospital
stay, and does not require regular repeat treatment sessions. A stent is
the least expensive, fastest, and most desirable method to maintain lumen
patency sufficient for adequate caloric intake and the related pleasures
of drinking and eating.
Appreciation is expressed to Ms Joanne Penders
for editorial assistance.
No significant relationship exists between the author
and the companies/organizations whose products or services may be referenced
in this article.
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