ENDOSCOPIC SELF-EXPANDABLE METAL STENTING FOR ADVANCED CARCINOMA OESOPHAGUS: A BETTER PALLIATIVE PROSPECTIVE

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1 22 Main Article ENDOSCOPIC SELF-EXPANDABLE METAL STENTING FOR ADVANCED CARCINOMA OESOPHAGUS: A BETTER PALLIATIVE PROSPECTIVE Swagata Khanna 1, Subhash Khanna 2 ABSTRACT: Endoscopic placement of metal stent is an established palliative method for advanced inoperable cases of carcinoma oesophagus. Although various types of prosthesis are available, but the recent development of self-expandable metal stents has gained popularity because of less procedure related complications. We present the technique and result of ultraflex self-expandable metal stenting, which was placed by us in a small series of six patients successfully. Key Words: Self expandable metal stent, Carcinoma oesophagus INTRODUCTION Carcinoma oesophagus is endemic in certain parts of the world and the incidence is quite high in the North East India. Dysphagia is the commonest presenting symptom often accompanied by severe weight loss and cachexia. More than 60% of patients have inoperable disease at the time of presentation and of the rest, 10 to 15% are not suitable candidates for surgery. Most of these patients, particularly those from the North-Eastern states do not have access to irradiation or chemotherapy and do not readily accept feeding gastrostomy tube even. Therapy is therefore usually palliative in nature with the major aims being relief of dysphagia, maintenance of nutrition, and at times occlusion of oesophagotracheal fistula if present. There are numerous non-surgical treatment modalities to provide palliation for dysphagia which include Radiation therapy, Chemotherapy, Endoscopic stenting, Endoscopic tumour ablation with bipolar electro-coagulation, Nd: YAG laser therapy, placement of semirigid prosthesis etc. Nd: YAG Laser therapy is considered an expensive palliative therapy, whereas intubation with semirigid prosthesis, though economical, carries a high complication rate. The choice of palliation for a particular patient will depend on size and site of the tumour, the experience of the endoscopist and the availability of a well-equipped set-up. The aims of expandable metal stent placement in advanced oesophageal cancer are to relieve dysphagia and to prevent malnutrition. Although nutrition can be provided by means of intravenous or naso-gastric tube feeding, but then the satisfaction of being able to take food and fluids orally definitely improves a patient s quality of life. In the present study, six patients presenting with advanced inoperable oesophageal cancer were selected for palliative therapy by endoscopic insertion of an expandable metal stent. Relief of dysphagia was assessed, improvement of general health measured and costs estimated. MATERIALS AND METHODS This is a retrospective short study of six patients undergoing palliative treatment for advanced carcinoma of oesophagus at Swagat Endolaparoscopic Surgical Research Institute, Guwahati in the period between Initially eight cases of oesophageal cancer (6 males and 2 females between 59 and 74 years of age) were recruited for endoscopic placement of self-expanding metal stent. Dysphagia was the predominant symptom and all patients were unable to swallow solid and semisolid food. Physical examination showed dehydration, cachexia and severe weight loss in all of them. All patients underwent upper Gastro Intestinal endoscopy with procurement of biopsy specimen from the growth. Ba-swallow radiography showed that the site of the growth ranged from 22 cm to 31 cm with an average length of the stricture being 8 cm. [Figure 1] After initial assessment two male patients were excluded from our study because of the presence of proximal cervical oesophageal cancer, which was considered a contraindication for placement of metal stent. All six patients 1 Associate Professor of E.N.T.,Gauhati Medical College, 2 Chief Medical Director and Surgeon, Swagat Endolaparoscopic Surgical Research Institute, Guwahati, India.

2 Endoscopic self-expandable metal stenting 23 systems. The distal release stents are used for stent placement in mid and upper oesophagus while proximal release stents are used for gastro-esophageal junction lesions. Figure 1: Barium swallow radiograph showing mitotic stricture at the junction of upper and middle third of the oesophagus of one of our patients. were explained in details about the procedure to be conducted and written informed consent obtained from them before deployment of the stents. Equipment which are required for Endoscopic metal stenting procedure are - a forward viewing endoscope, Fluoroscopic facility with II TV or C Arm,.038 inch stiff 260 cm long guide wire, oesophageal balloon dilatation catheter, 60cc inflation device with gauge for dilatation [Figure 2] and oesophageal metal stent system containing a stent of appropriate length and diameter. In our present series, we used ultraflex stent system. The ultraflex stent (Microvasive Boston Scientific Corporation) is constructed of a single strand of Nitilon wire that exerts a constant, gentle radial pressure while minimizing traumatic tissue compression. This stent also comes in a range of lengths (7-15 cm) and diameters (17-22 mm). The system consists of a flexible delivery catheter preloaded with an expandable metallic stent available with or without a cover. The stents are available in either of two different release Procedure Preliminary Endoscopy was done with the patient in the usual left lateral position with proper sedation (usually Midazolam I cc l mg I.V with I ampoule of Buscopan and throat analgesia with xylocaine spray). A guide wire with floppy tip.038 inch / 260 cm long was introduced and coiled in the stomach. Endoscope was taken out leaving guide wire in position and the scope reintroduced next to the guide wire. Now a balloon dilator catheter was passed within the stricture. 50% dilute contrast or water was injected to inflate the balloon to its recommended pressure. It was only necessary to dilate the stricture to 8 or 10 mm, because of the small diameter of stent introducer sheath. Tumour length was measured endoscopically and fluoroscopically so that the appropriate stent size could be determined. Radio-opaque markers were placed externally to locate the length of the growth. After the stricture was measured, 4 to 6 cm was added to the stent length. The additional length prevents tumour occlusion at the proximal and distal ends and promotes uniform expansion. The patient s head was then tilted to form a straight pathway for stent advancement. Endoscope and mouth guard were removed. The selected stent s tip and nylon thread (cord) were lubricated with water soluble lubricant, and the stent was advanced over the guide wire under fluoroscopic guidance. [Figure 3] The stent was positioned with proximal radioopaque marker positioned above the proximal tumour margin and distal radio-opaque marker below the distal tumour margin. Figure 2: Oesophageal Balloon Dilator (CRE Dilator) 60 c.c. inflation device with gauge Figure 3: The stent being positioned with markers under fluoroscopy before deployment

3 24 Endoscopic self-expandable metal stenting Deployment of Stent When the distal end of the stent was clearly visible the assistant gently pulled the ring to start releasing the suture knots and to unravel the suture. The stent release was monitored under fluoroscopy keeping the margin within the marker. Slight adjustment of the stent was carried out as needed. A final assessment of the deployed stent was done endoscopically [Figure 4] and fluoroscopically [Figure 5] and the delivery system and guide wire were removed. After stent insertion AP and lateral view of X-ray chest was done as a record of stent position. Barium Swallow X-ray of the oesophagus demonstrated adequate stent expansion. [Figure 6] RESULTS Stent placement was successful in all six patients. Full stent expansion required about hours of time. Post stenting period was observed for any signs of complications. Two male patients immediately complained of chest pain, which Figure 4: Final assessment of the deployed stent endoscopically Figure 6: Post stent Barium oesophagogram showing adequate stent expansion was relieved within 24 hours after administration of analgesics. We allowed water and liquid diet within a few hours of stent placement. Semisolid and soft diet was allowed only after confirmation by Ba-Swallow X-ray. It was observed that there was immediate relief from dysphagia in all our patients. Patients were instructed to eat only in upright position, to chew food thoroughly and to drink fluid during and after meals. Patients were discharged between 3 rd to 5 th day after stent placement. Follow up was done at 2 weeks, 3 months and 6 months interval. One male patient died after 4 months, four patients died after 6 to 8 months, and one 72 year old female patient survived till 14 months after stent placement. DISCUSSION Endoscopic placement of self-expanding metal stent is an accepted treatment for patients with unresectable primary carcinoma of the mid and distal oesophagus. Although the role of metal stent in the palliation of patients with complicated malignancies like fistulae, growth near cricopharynx and post oesophago jejunostomy cases is still doubtful, but selfexpanding metal stents provide effective and relatively safe palliation for the complicated group of patients with practically instant relief of dysphagia. (Peter D. et al 2001). Palliation of dysphagia due to oesophageal cancer has been attempted using plastic stents for over 100 years, but was not safe and effective until Although Plastic (Latex) stents are very economical and provide rapid palliation, they have a high complication rate. The major complications are perforation about 15%, and bleeding up to the extent of 10% (Tytgat GNJ 1996). Moreover, incidence of recurrent dysphagia has also been quite high 35% (Fuger et al 1990) Figure 5: Expanded stent seen on fluoroscopy The search for safer method of palliation of malignant

4 Endoscopic self-expandable metal stenting 25 obstruction of oesophagus has led to the development of selfexpanding metal stents. A self-expandable metal stent was placed for the first time in Since then various types of metal stents have been designed to overcome certain limitations. Indications for placement of self-expandable metal stents are similar to those where a plastic stent is deployed. It may be a primary inoperable tumour, or recurrent tumours and fistulae. The new varieties of covered expandable metal stents essentially occlude the tracheo-oesophageal fistulae. Oesophageal metal stenting is contraindicated for benign strictures of the oesophagus, as the long-term effects of the stent in the oesophagus are still unknown. Relative contraindications to the use of self-expandable metal stents in palliative treatment of malignant dysphagia include strictures that are too long or too tight or that involve the cricooesophageal sphincter. Patients that are too ill to safely undergo Endoscopy are not suitable candidates for stenting. The self-expandable metal stents are designed such that they can be placed through a narrow stricture, as they are loaded into a small diameter delivery applicator in the collapsed state. When deployed, they exert outward force and continue to expand to a predetermined diameter. As the stent expands progressively, stent related complications are lower than latex prosthesis. Moreover the larger lumen achieved, i.e. 16mm to 20mm and the flexibility of the stent improves quality of swallowing compared with latex prosthesis. Placement of latex prosthesis is painful and mostly requires general anaesthesia whereas expandable metal stents can be inserted under sedation. General anaesthesia and higher frequency of complications explain the longer hospitalization in the latex prosthesis group of patients. Various studies show that although tumour ingrowth is a problem in metal stenting, but then that can be managed by Laser electro-coagulation or at times by insertion of prosthesis within the metal stent (Helen J. Dalal et al, Traceyl et al). The only disadvantage of metal stenting is that the cost of a metal stent is five to ten times greater than that of a plastic stent. From this study conducted on a small number of patients, we experienced that a self-expandable metal stent is safe and well tolerated, can significantly improve quality of life, has low procedure related morbidity and mortality and requires minimal hospital stay. Overall, there is instant relief of dysphagia which gives the patient the satisfaction of drinking and eating for the remaining short span of life. Survival rates following expandable metal stent placement for palliation have not been presented in many studies. The reported survival of patients in stent group varies from 6.8 weeks to 28.6 weeks (De palma G.D. et al). The shorter duration of survival in this series was probably due to inclusion of older, frailer patients with more advanced disease. You - Tao Yu et al (2004) studied a series of ten cases of advanced oesophageal cancer, to evaluate the therapeutic effect of radiotherapy after placement of expandable metal stent. They opined that radiotherapy for oesophageal cancer after stenting is very helpful in the treatment of advanced oesophageal cancer. CONCLUSION Although a variety of treatment options are available to palliate dysphagia in patients with advanced oesophageal cancer, but recent developments in the use of expandable metal stents have brought new hope in the field of management of cancer oesophagus. Self-expandable metal stents are an effective and safe alternative to conventional prosthesis in the management of advanced malignant oesophageal stricture. It definitely relieves dysphagia and improves the quality of life. Furthermore larger perspective randomized studies are required to compare different types of expandable metal stents and evaluate which patients can effectively be benefited with these new devices. ACKNOWLEDGEMENTS The authors are thankful to the staff and management of Swagat Endolaparoscopic Surgical Research Institute, Guwahati for helping us in doing this work. REFERENCES 1. Maydeo AP, Bapaye A, Desai PN, Khanna SS, Deshpande RK, Badve R. Endoscopic placement of indigenous plastic Esophageal Endo prostheses Does it still have a role in the Era of Expandable Metallic Stents? A prospective Indian study in 265 consecutive patients. Endoscopy 1998;30: Fugger R, Niederle B, Jantsch H, Schiessel R, Schulz F. Endoscopic tube implantation for the palliation of malignant esophageal stenosis. Endoscopy 1990;22: Dalal HJ, Smith GD, Griene DC, Ghosh S, Penman ID, Palmer KR. 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