Saudi Journal of Gastroenterology
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SPECIAL ARTICLE Table of Contents   
Year : 1996  |  Volume : 2  |  Issue : 2  |  Page : 57-62
Palliative treatment of esophageal cancer: New role of endoprosthesis ?


Department of Medicine and the Division of Molecular Virology, Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas, USA

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   Abstract 

Esophageal endoprostheses are very useful in management of patients with esophageal cancer and are the primary therapy for patients with esophagorespiratory fistula. In addition, patients with tumors, poorly responsive to dilatation or other therapies, will have long-lasting symptomatic relief when an endoprosthesis is placed. The available prostheses are discussed, as well as the methods of insertion and the relative merits of each. The self- expanding metal stents may have advantages over plastic stents.

How to cite this article:
Mourani S, Graham DY. Palliative treatment of esophageal cancer: New role of endoprosthesis ?. Saudi J Gastroenterol 1996;2:57-62

How to cite this URL:
Mourani S, Graham DY. Palliative treatment of esophageal cancer: New role of endoprosthesis ?. Saudi J Gastroenterol [serial online] 1996 [cited 2020 Nov 25];2:57-62. Available from: https://www.saudijgastro.com/text.asp?1996/2/2/57/34027


The etiology of esophageal carcinoma remains unknown, but has been associated with use of alcohol, cigarettes, and the presence of chronic esophageal irritation. Squamous cell carcinomas predominate; adenocarcinomas usually represent either spread of carcinoma from the fundus of the stomach or spontaneous tumors that arise from Barrett's epithelium. Carcinoma of the esophagus usually occurs in persons over the age of 50, and is more common in men than women. Dysphagia, usually progressive, is the most common symptom. Other symptoms are associated with spread of the primary tumor and include pain, bronchopulmonary symptoms (e.g., from a tracheo-esophageal fistula), and hoarseness. Many patients delay seeking medical attention which may contribute to the dismal overall outcome.

Therapy for malignant strictures of the esophagus is either to attempt cure with radiation or surgery or palliation. Choice of therapy depends upon the location of the tumor, its size, and extent of its spread. Surgery is advantageous for tumors located either in the distal or middle one-third of the esophagus, whereas radiotherapy is preferred for tumors located in the, proximal one-third of the esophagus. In general, the results as assessed by five year survival after surgery and radiotherapy are similar, with five-year cures of less than 5% [1],[2] . Chemotherapy alone is currently ineffective and in our experience, combined radiotherapy and chemotherapy has not led to an improvement, but instead has resulted in more frequent complications.


   Palliation Top


Most patients present with far advanced and inoperable disease making palliation the preferred approach [3] . Esophageal dilatation, laser or Bicap tumor ablation [4] , photodynamic therapy [5] , alcohol injection [6] , and endoscopic bypass of the obstruction by insertion of a prosthetic device are among the palliative methods available for patients who, either are inoperable or are failures of primary therapy. The principal goals of palliation are to maintain luminal patency, prevent pulmonary aspiration, and improve patient's quality of life.

Immediate palliation of esophageal carcinoma can often be obtained by dilatation with mercury-filled bougies, metal olives, or Savary or balloon dilators. Dilatation can be performed before, during, or after radiotherapy. Unfortunately, most patients with esophageal cancer have poor appetites and the intake of food is poor, even if patency of the lumen is ensured, insufficient calories are often ingested such that many patients are offered a percutaneous feeding gastrostomy.

The use of esophageal prostheses has a long history [7] , and the introduction of newer prostheses has made this a more important and useful method of palliation. A variety of devices are available [Figure - 1],[Figure - 2]. Until recently, the most commonly used were Celestin tubes made of latex rubber, Atkinson prostheses made of silicone rubber, or Procter-Lewinston tubes made of latex rubber [8] . Some units use polyvinyl chloride tubes which were formed, as needed, from laboratory tubing. A prosthesis with a self-inflating cuff, similar to a cuffed endotracheal tube, has become available and was particularly useful to seal tracheoesophageal fistulae in which traditional prostheses failed [9] . The cuffed prosthesis has largely been superseded by newer, self-expanding metal stents [10] .


   Indications Top


In general, esophageal stents are indicated as a first line therapy for malignant esophagorespiratory fistulas. On the other hand, there is still controversy concerning the proper timing to employ an esophageal stent in the management of malignant esophageal strictures. Availability of other palliative methods, the experience of the operator, and the characteristics of the tumor play a major role in selecting a treatment plan. As a general rule, esophageal stents are indicated for the management of malignant strictures when other forms of palliative therapy become ineffective, are too difficult, or when the required frequency of intervention becomes unacceptably high. The ideal tumor for stent placement is a long (> 4 cm) circumferential growth in a relatively straight segment [11] . Patients with inoperable adenocarcinoma should be considered for stent palliation at an earlier stage as compared to patients with squamous cell carcinoma (8). Relative contraindications include lesions less than two cms from the upper esophageal sphincter, total luminal obstruction, and severely- angulated strictures [12] .


   Prosthetic Devices Top


The three major types of esophageal stents commercially available for use are: the non­expandable plastic stents, the cuffed esophageal endoprosthesis, and the self-expanding metal stents. The nonexpandable plastic stents are available in different lengths. They all have the proximal end of the prosthesis widened into a funnel to assist anchoring to the tumor. The KeyMed Atkinson prosthesis is made of silicon rubber with a nylon spiral, incorporated into the wall to prevent kinking. The Wilson-Cook Prosthesis is made of silicon rubber reinforced with a metal spiral. The Medoc Celestin prosthesis is made of latex rubber and contains a nylon spiral. Latex has the major disadvantage of structural deterioration when exposed to acid, bile, and radiation and must be changed at intervals [13] .

The cuffed esophageal prosthesis [9] is made by Wilson-Cook and is based on the low-pressure cuffed endotracheal tube. The prosthesis is constructed of silicon rubber tube with a metal coil, wrapped with a layer of foam surrounded by a thin sheath of silicon, forming a cuff around the tube. This cuff is a self-inflating balloon with a small opening through which air is extracted before placement. When the hole is unplugged, the cuff inflates. The potential advantages of this prosthesis include a custom fit that tailors to the contour of the tumor making migration less likely, and a tight seal against fistulous tracts without causing tissue necrosis. The cuff inflates very slowly and it is therefore important to wait for four to five minutes before removing the inflating tube. Alternatively, one can inflate the cuff before use, measure the amount of air required, deflate the cuff and add the required amount of air after placing it onto position. One other possible problem occurs when there is a large tracheo-esophageal fistula. In that instance, the inflated cuff may cause airway obstruction. If this occurs, the prosthesis must be immediately deflated and withdrawn. Silver coils have then been used to maintain airway patency allowing the cuffed prosthesis to be used, [14] .

Three prototypes of self-expanding esophageal prosthesis now have a considerable literature [10],[15] . The Wallstent (Schneider Stent) was the first to be used in humans for the palliation of malignant dysphagia [16] . The stent is made of braided Elgiloy (a biochemical superalloy monofilament wire) forming a tubular mesh 18 mm in diameter when fully expanded. The central portion of the stent is covered with a membrane [17] to prevent tumor ingrowth and allow better seal of a fistula. Both ends of the stent are flared to 28 mm to prevent migration. It is available in 8, 10, and 13 cm-length. The delivery system has a 38 Fr diameter. The Strecker stent called the Ultraflex esophageal stent (Microvasive) is made of a single strand of Elastalloy wire ( a titanium-based alloy) into a mesh tube 18 mm in diameter that flares to 21 mm at the proximal end to prevent stent migration. It is available in 7, 10, and 15 cm-length. Covered types will be available with a membrane. The diameter of the stent is 18 mm and flares to 21 mm at both ends. It is available in 6, 8, 10, and 12 cm-length.


   Insertion Techniques Top


A variety of techniques are available to insert the prosthesis into the tumor. Each technique possesses the following three characteristics: 1) ability to accurately direct the prosthesis into the channel, 2) use of a device (pusher) to push the prosthesis into place, and 3) some means to remove or reposition the prosthesis. Adequate dilatation of the stricture should proceed insertion of the stent. For the nonexpanding stents, we recommend that esophageal dilatation be performed over several days to reduce the frequency of esophageal perforation [8] . The new self-expanding metal stents have the advantage of smaller-delivery systems (8-13 mm in diameter) and the ability to dilate the stricture while in place, thus requiring little or no dilatation prior to stent placement. In addition, they are technically easier to place both for the physician and the patient. The negative aspect is the high cost but that may be offset by ease of insertion and long-term success.

Nonexpandable stents require dilatation to a diameter equal to or greater than the diameter of the stent. Esophagoscopy is then performed and the distance from the incisions to the distal and proximal margins of the tumor is measured so that a prosthesis of the correct length can be chosen. There are a variety of techniques for inserting a prosthesis, utilizing different introducing devices. The Nottingham introducer is probably used most frequently but is more dangerous than delivery over an endoscope of Savary dilator. The Nottingham introducer is basically a flexible metal rod that is introduced over a spring-tipped guide wire under fluoroscopic control. The distal end contains a segment that expands to grip the prosthesis firmly and thus allows it to be positioned, repositioned, or removed without difficulty. The Nottingham introducer is prone to injure the posterior pharynx and we prefer to reserve it for removal or retrieval of prosthesis. We prefer inserting a prosthesis by using a small-diameter endoscope or a Savary dilator as a guide. After measurements are taken, the prosthesis and the pusher are mounted on a well-lubricated endoscope. The distance from the incisors teeth to the level where the proximal funnel end of the stent will be placed is measured and marked on the pusher tube. The well-lubricated system is then introduced and the prosthesis is advanced into place over the endoscope. Then, with gentle rotation, the pusher is disengaged from the endoprosthesis, and withdrawn. Subsequently, the endoscope is withdrawn through the prosthesis to check the position.

Many similar delivery systems are used to place self-expanding metal stents and adequate instructions by the manufacturers are usually included. In general, the delivery system is composed of an outer catheter (8-13 mm in diameter) that houses the constrained stent at its distal end, and an inner catheter that is advanced into the proximal end of the outer catheter, until the proximal end of the compressed stent is reached. Stricture dilatation to 10 to 15 mm is adequate in most cases prior to insertion [15] . By using markers on the patient's skin, or injecting water soluble contrast medium submucosally [18] , the proximal and distal margins of the tumor are marked. Under endoscopic and fluoroscopic control, a guide wire is passed through the tumor into the stomach. Over the guide wire, the delivery system is then advanced. When correct alignment is achieved, the outer catheter is withdrawn slowly, while the inner catheter is held firmly in place, thereby releasing the stent to expand. One must take into account that the Wallstent and the Ultraflex stent shorten after insertion (about 23% and one third respectively); the Z-stent does not.

Endoscopy is performed immediately after insertion to confirm accurate placement and stent expansion. If the stent does not expand completely, a balloon 12 or 15 mm can be used to facilitate expansion. However, it should be anticipated that gradual expansion to a maximum diameter will occur over two to three days. When the patient is fully awake, a chest X-ray and a barium swallow will help further confirm luminal patency, stent position, and absence of esophagorespiratory fistula or perforation.


   Complications Top


Complications occur with placement of any type of endoprosthesis [Table - 1]. Although the self­ expanding metal stents are associated with lower frequency of immediate procedure-related complications [19] , safe usage of the nonexpandable stents is possible when dilatation is done prudently. However, tumor ingrowth and overgrowth may occur particularly when noncovered metal stents are used. Perforation is the most important life-threatening complication and has been reported in 6% to 8% of cases [10] . However, with gentle dilatation and good patient selection, a perforation rate of zero to 5% should be achievable. Aggressive reinsertion dilatation, prior esophageal surgery, and necrotic angulated tumor may increase the risk of perforation [11] . Self-expanding metal stents are probably associated with lower incidence of perforation in contrast to plastic stents. Pain or crepitus in the neck or chest should be evaluated immediately by chest X-ray followed by a water soluble contrast esophagogram. If perforation is recognized during the procedure, it is reasonable to complete the insertion to seal the perforation. Adequate conservative management (nothing by mouth, aspiration of upper esophagus, and systemic antibiotics) results in a more than 80% survival rate, particularly when diagnosis is established early. Aspiration may occur at the time of the procedure or later as a result of gastroesophageal reflux, particularly when the stent bridges the lower esophageal sphincter. Standard antireflux precautions are recommended. Rarely, severe reflux esophagitis and peptic strictures may occur.

Airway compression is a potentially, life­threatening complication that occurs secondary to compression of major airways by the hard tumor immediately after insertion of the prosthesis. Patient may complain of dyspnea, and a stridor may be evident. Immediate removal of the stent is required. Distal migration of the stent into the stomach may occur and is managed by endoscopic retrieval.

Leaving the stent in-situ is an alternative in asymptomatic patients, when retrieval is not successful. Proximal displacement may cause symptoms of foreign body - sensation or airway compromise and is managed by repositioning or removal of the stent [11] . Stent migration is more likely to occur with covered metal stents compared to noncovered ones.

Gradually-increasing dysphagia is the usual presentation of tumor ingrowth or overgrowth. It could be managed with destruction of the growth with laser [20] when a plastic stent is in place. Ingrowing tumor through the metal mesh is a major limitation of the uncovered self-expanding metal stents, and laser should not to be used to reopen the lumen when a metal stent is in place (10). This problem could be treated by insertion a plastic stent or another metal stent inside the one in place.

Stent blockage by food is generally manifest by sudden onset of dysphagia. Blockage can usually be prevented by advising the patient to chew food carefully and drink large amounts of liquids with meals. Stent blockage can often be managed with carbonated drinks or by endoscopic removal of the food.

Structural deterioration of some plastic stents is a potential problem [13] . If the prosthesis must remains in place for many months, one made of silicone rubber is preferred. Silicone rubber is nearly inert, whereas latex rubber may dissolve and expose the nylon coil used to strengthen the Celestin prosthesis. The plasticizer in the polyvinyl chloride tube prosthesis is slowly leached out and the tube will gradually lose its normal pliability and become quite firm. It is prudent, therefore, to inspect latex rubber or polyvinyl chloride tube prosthesis at least bimonthly and to replace the prosthesis after 4 to 6 months. Considering the natural history of the underlying tumor, this precaution is frequently not necessary.


   Outcome of stent placement Top


Successful placement of esophageal endoprosthesis is possible in more than 90% of cases. Significant improvement of dysphagia is achieved in the majority of patients, using plastic or metal stents, and most patients will be able to eat a normal or semi-solid diet. Esophageal endoprostheses offer the advantage of long- lasting symptomatic relief without the need for frequent procedures, and they are less expensive than laser therapy. For esophagorespiratory fistulas, both plastic stents and the covered metal stents have good rates of success. The cuffed esophageal endoprosthesis may be used as an alternative when a standard plastic stent fails to seal the fistula.

 
   References Top

1.Earlam R, Cunha-Melo JR. Esophageal squamous cell carcinoma: I. A critical review of surgery. Br J Surg 1980;67:381-90.  Back to cited text no. 1    
2.Earlam R, Cunha-Melo JR. Esophageal squamous cell carcinoma: II. A critical review of radiotherapy. Br J Surg 1980;67:457-61.  Back to cited text no. 2    
3.Gatzinsky P, Berglin E, Demevik L, Larsson I, William-Olsson G. Resectional operations and long term results in carcinoma of the esophagus. J Thorac Cardiovasc Surg 1985;89:71-6.  Back to cited text no. 3    
4.Fleischer D. A comparison of endoscopic laser therapy and bicap tumor therapy for esophageal cancer. Am J Gastroenterol 1987;82:608-12.  Back to cited text no. 4  [PUBMED]  
5.McCaughan JS, Nims TA, Guy JT, Hicks WJ, Williams TE, Laufman LR. Photodynamic therapy for esophageal tumors. Arch Surg 1989;124:74-80.  Back to cited text no. 5    
6.Payne-James JJ, Spiller RC, Misiewics JJ, Silk DBA. Use of ethanol-induced tumor necrosis to palliate dysphagia in patients with esophagogastric cancer. Gastrointest Endosc 1990;36:43-6.  Back to cited text no. 6    
7.Palmer ED. Peroral prosthesis for the management of incurable esophageal carcinoma. Am J Gastroenterol 1973;59:487-98.  Back to cited text no. 7  [PUBMED]  
8.Graham DY. Treatment of benign and malignant strictures of the esophagus. In: Therapeutic Gastrointestinal Endoscopy; Stephen E Silvis (Ed); 2nd Ed; 1990:1-30.  Back to cited text no. 8    
9.Smith JL, Michaletz PA, Tabibian N, Schwartz IT, Graham DY. Improved palliation of a respiratory-esophageal fistula with a cuffed esophageal prosthesis. Am J Gastroenterol 1987;82:1175-6.  Back to cited text no. 9    
10.Tytgat GNJ, Tytgat S. Esophageal endoprosthesis in malignant stricture. J Gastroenterol 1994;29(suppl 8):80-4.  Back to cited text no. 10    
11.Tietjen TG, Pascricha PJ, Kalloo AN. Management of malignant esophageal stricture with esophageal dilation and esophageal scents. Gastointest Endosc Chin N Am 1994;4:851-62.  Back to cited text no. 11    
12.Tytgat GNJ, den Hartog Jager FCA, Bartelsman JFWM. Endoscopic prosthesis for advanced esophageal cancer. Endoscopy 1986;18(suppl 3):32-9.  Back to cited text no. 12    
13.Branicki FJ, Ogilvie AL, Willis MR, Atkinson M. Structural deterioration of prosthetic esophageal tubes: an in-vitro comparison of latex rubber and silicon. Br J Surg 1981;68:861- 4.  Back to cited text no. 13  [PUBMED]  
14.Michaletz PA, Trabanino JG. Palliation of respiratory esophageal fistulas with the cuffed esophageal prosthesis: successes and problems. (Abstract) Gastrointest Endosc 1988;34:180.  Back to cited text no. 14    
15.Wu WC, Katon RM, Saxon RR. Self-expanding metallic stents for palliation of malignant esophageal obstruction and esophagorespiratory fistulae. In: Advanced Therapeutic Endoscopy; Jamie Barkin and Cesar A O'Phelan (Eds);2nd Ed 1994:45-55.  Back to cited text no. 15    
16.Domschke W, Foerster EC, Matek W, Rodl W. Self-expanding metal stents for esophageal cancer stenosis. Endoscopy 1990;22:134-6.  Back to cited text no. 16    
17.Fleischer DE, Bull-Henry K. A new coated self-expanding metal stent for malignant esophageal strictures. Gastrointest Endosc 1992;38:494-6.  Back to cited text no. 17  [PUBMED]  
18.Ismael AE, Leong H, Sung JJY, Chung SCS. Submucosal injection of contrast medium as a radiologic marker for insertion prosthesis. Gastrointest Endosc 1993;39:470-1.  Back to cited text no. 18    
19.Knyrim K, Wagner HJ, Bethge N, Keymling M, Vakil N. A controlled trail of an expansile metal stent for palliation of esophageal obstruction due to inoperable cancer. N Eng J Med 1993;329:1302-7.  Back to cited text no. 19    
20.Sargeant IR, Loizou LA, Tulloch M, Thorpe S, Bown SG. Recanalization of tube overgrowth: a useful new indication for laser in palliation of malignant dysphagia. Gastrointest Endosc 1992;38:165-9.  Back to cited text no. 20    

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Correspondence Address:
David Y Graham
V.A. Medical Center (111D) 2002 Holcombe Blvd.Houston, TX 77030
USA
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