| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Ann Thorac Surg 1996;62:961-962
© 1996 The Society of Thoracic Surgeons
Virginia Mason Medical Center, Seattle, Washington
Successful management of patients with malignant, incurable esophageal obstruction should be safe and effective treatment that is both time and cost efficient. Radiation, both external beam and brachytherapy, and chemotherapy are options that may be applicable after the relief of the acute obstructive process. However, the prerequisite delay in the resumption of oral nutrition and the ability to manage salivary secretions requires techniques that produce immediate results.
Repeated bouginage can provide immediate improvement in swallowing but usually requires frequent repeat treatments. Laser therapy has a proven track record with respect to acute palliation of malignant obstruction but requires expensive equipment and multiple treatments with both complication rates and outcomes highly dependent on the skill and experience of the laser endoscopist. As a result, the vast majority of people with malignant esophageal obstruction are currently managed with a variety of endoscopic and fluoroscopically inserted esophageal prostheses.
The history of esophageal stenting originates with the surgically placed stents such as the Celestin tube. These stents now see limited application due to the development of nonoperatively placed stents and unacceptably high in-hospital mortality rates [1]. Conventional pulsion stents such as the Atkinson tube (Key Med, Inc, New Hyde Park, NY) and the coiled polyvinyl prosthesis (Wilson-Cook, Inc, Winston-Salem, NC) have seen wide application, and successful palliation has been achieved in more than 90% of cases in some series [2]. However, complications including bleeding, tracheal compression, prosthesis occlusion, and migration in up to 50% of cases [3], and perforation and procedure-related mortality rates as high as 10% [2, 3] have resulted in ongoing efforts to "build a better mousetrap."
The article that appears in this issue authored by Drs Moores and Ilves [4] is an excellent example of the potential impact of the "new breed" of coated self-expanding wire mesh esophageal stents. This series, as reported by an experienced thoracic surgical unit, appropriately highlights the fact that these coated prostheses are easier to insert, require less initial esophageal dilation, can be used in patients with tracheoesophageal fistulas, and when successful produce a larger neolumen than their predecessors.
Our institution has significant experience in testing a wide variety of expandable esophageal prostheses including the Wallstent, Z-stent, Esophacoil, and Ultraflex models. This experience demonstrates that there continues to be a role for a variety of stents depending on the clinical presentation. Our initial review demonstrated that subacute complications including tumor overgrowth, delamination, chest pain, migration, aspiration pneumonitis, and erosion were slightly higher with the expandable stents than with the conventional pulsion prostheses [5]. A proportion of these complications are undoubtedly related to the use of several varieties of expandable stent prototypes; eg, initial versions of the Wallstent tended to delaminate. However, as pointed out by Moores and Ilves, many of the technical problems in these early stents have been improved upon, although this has not led to the complete elimination of insertion-related complications and mortality.
We have recently taken part in a national multicenter prospective trial using urethane-covered Z-stents in patients with malignant dysphagia and esophagorespiratory fistula [6]. More than 95% of these patients had successful stent placement and improvement in dysphagia; however, multiple stents were required in more than 30% of patients and 11% had acute complications such as severe chest pain and bleeding. The mortality rate in this series was 4%, virtually identical to that experienced by Drs Moores and Ilves. The clinicians involved in this multicenter study were all selected because of their experience with endoscopic and fluoroscopic procedures, indicating that the advertised advantages of "safe and easier to insert" must be kept in perspective.
We have found that patients with significant extraluminal esophageal obstruction are more successfully managed with conventional stents. This is because extraluminal compression secondary to primary cancer or malignant nodes often does not respond to dilation and can impede full deployment of the metallic stents.
As demonstrated by Drs Moores and Ilves' experience, there is an increased risk of stent migration in patients with very distal esophageal tumors. Metallic stents should be placed with the majority of the stent above the malignant stricture and the gastroesophageal junction. When these prostheses migrate they will virtually always require a surgical procedure to retrieve them. Doctors Moores and Ilves appropriately highlight the importance of meticulous technique when inserting expandable stents. We have seen several patients who have been sent for "additional management" after inappropriate deployment of expandable stents.
Doctors Moores and Ilves' article reports a 50% success rate with respect to occluding malignant tracheoesophageal fistulas. We have used these devices to successfully restore functional swallowing and obstruct fistulas in 11 of 12 patients in the past 2 years. The majority of these patients are very debilitated, and a minimalist approach with respect to medical intervention is appropriate. However, it is our belief that there remains a small subset of younger, physiologically fit patients with tracheoesophageal fistula who may benefit from surgical treatment [7]. In the past 5 years we have had 4 physiologically fit patients in whom fistula occlusion with an esophageal prosthesis was either impossible or unsuccessful. These patients underwent extraanatomic surgical bypass with esophageal exclusion without major complication, with a mean postprocedural survival of 6 months (range, 2 to 11 months). The individual choice of treatment approach in these difficult patients will be contingent upon personal experience and the availability of expertise in the various treatment options. Identification of patients who may benefit from surgical intervention requires communication and cooperation between thoracic surgical and gastroenterology units to identify appropriate patients.
Doctors Moores and Ilves' article reports 5 patients who had insertion of expandable metallic prostheses for benign reflux-induced strictures or refractory anastomotic stenoses. As they stated in their article, these stents are virtually impossible to remove once fully deployed short of major operative intervention (a situation that the stent is intended to avoid). Long-term ramifications of expandable metallic stent technology are unknown. As a result, obtaining full informed consent from these patients will be impossible, and it will be the responsibility of selected clinical units inserting these prototype stents in patients with benign stenoses to fully report long-term results. It would be unethical and inappropriate at this point for these stents to see a wide application in patients without terminal malignant disease. We have found that the vast majority of these refractory benign strictures can be managed with either repeated bouginage, patient self dilation, or the temporary insertion of a conventional prosthesis for a period of 3 to 4 months, which can subsequently be removed.
The best treatment approach to patients with malignant esophageal obstruction and fistula will be achieved by multispecialty units with the availability and experience to apply a multiplicity of treatment options. The new coated, expandable, metallic wire mesh stents are an excellent addition to the treatment armamentarium, but they are not foolproof and do have an attendant morbidity and mortality, which can be significant unless they are inserted by experienced practitioners. In addition, these devices have a per unit cost of between $1,000 and $1,900 compared with $80 to $100 for most conventional prostheses. Cost effectiveness would indicate continued use of standard pulsion stents in situations where either type of device will provide adequate palliation.
Too many clinicians have "one hammer" that they attempt to apply to all situations. Judgment, experience, and the ability to bring to bear a selection or combination of treatment modalities including esophageal dilation, laser, stent placement, radiotherapy, medical oncology, and surgery will help ensure the best and most successful treatment in each individual patient.
Footnotes
Address reprint requests to Dr Low, Department of Surgery, Virginia Mason Clinic, 1100 Ninth Ave, PO Box 900 C6-N, Seattle, WA 98111-0900.
References
Related Article
This article has been cited by other articles:
|
|
 |
|
  M. De Groot, D. W. O. Moores, and R. Ilves Expandable Stents in Esophageal Malignancy Ann. Thorac. Surg., July 1, 1997; 64(1): 287 - 288. [Full Text]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| ANN THORAC SURG | ASIAN CARDIOVASC THORAC ANN | EUR J CARDIOTHORAC SURG |
| J THORAC CARDIOVASC SURG | ICVTS | ALL CTSNet JOURNALS |
