Esophageal stenting in the palliation of malignant strictures

Abstract

Background: The prognosis among patients with esophageal or cardia cancer is worse than that in most cancer diseases. Moreover, more than half of the patients with carcinoma of the esophageal or gastric cardia diagnosed in Sweden present with an advanced disease where the only available treatment is palliation. A major challenge in this palliative treatment is to relieve the dysphagia, the dominating symptom in most of these patients. Currently, the most recognized treatment alternatives for palliation are 1) insertion of an esophageal stent by means of endoscopic application of a tube-formed self-expanding metal stent over the area of the tumor or 2) local endoluminal radiation therapy, i.e., brachytherapy.

Results and conclusion: In paper I, a nationwide retrospective population-based study in Sweden, we investigated the safety of stent insertion in relation to age, sex, and hospital volume. All patients treated with esophageal stenting for malignant disease recorded in Swedish national registers during the period 1997-2000 were included. The study showed that self - expanding metal stent insertion in patients with malignant dysphagia is commonly performed and entails a low risk of procedure-related mortality without differences between sexes or age groups. The risk of complications was considerable, but of similar frequency in high volume and low volume hospitals. In paper II we compared the palliative effect of self-expanding metal stent placement with that of endoluminal brachytherapy regarding quality of life and specific symptoms in a randomized clinical trial. Among 65 randomized patients, the outcomes in the two treatment groups were similar in most respects. Stenting offered more instant relief of dysphagia compared to brachytherapy, while health-related quality of life was more stable with time after the treatment in the brachytherapy group. In paper III we conducted a prospective randomized study to compare stent placement and brachytherapy regarding health economic outcomes. Esophageal stenting was health economically more favorable than fractionated endoluminal brachytherapy in Sweden. In paper paper IV we addressed the problem that placement of metal stents across the esophagogastric junction for treatment of malignant strictures often leads to severe gastroesophageal reflux, with the possibility of pulmonary aspiration. A Dua antireflux stent was compared with a standard open stent and the study showed that antireflux stents might be used without increased risks of complications, mortality, esophageal symptoms or reduced quality of life. Dyspnea seems to be less frequent after antireflux stent therapy.