Esophageal Stents May Interfere with the Swallowing Reflex: An Illustrative Case History

Transcription

1 254 Journal of Pain and Symptom Management Vol. 16 No. 4 October 1998 Original Article Esophageal Stents May Interfere with the Swallowing Reflex: An Illustrative Case History Angel Lee, MRCP (UK), and Karen Forbes, MRCP (UK) Department of Palliative Medicine, Bristol Oncology Centre, Horfield Road, Bristol, United Kingdom Abstract Dysphagia is an important and distressing symptom which has a significant impact on the quality of life of patients with carcinoma of the esophagus. Although endoscopic palliation of dysphagia due to unresectable or recurrent esophageal carcinoma can be provided by esophageal dilatation and intubation, laser ablation, injection of alcohol or sclerosants, or brachytherapy, these techniques are often unsuitable for the palliation of high esophageal tumors. We present a patient with recurrent carcinoma of the proximal esophagus who developed an inability to swallow as a complication of intubation with an esophageal stent. The dysphagia improved dramatically after the stent was removed. J Pain Symptom Manage 1998;16: U.S. Cancer Pain Relief Committee, Key Words Deglutition disorder, esophageal neoplasm, stents, palliative care Introduction Surgical resection offers the best chance of long-term survival and palliation of symptoms in patients with carcinoma of the esophagus. However, up to two-thirds of patients are not amenable to surgery at the time of presentation, either because of the extent of disease or other coexisting medical conditions. 1 In these patients, the goal of management is the effective palliation of dysphagia and odynophagia, usually by reestablishing the patency of the esophageal lumen. Esophageal stents are often used as palliative therapy in patients who have failed or are not suitable for other forms of palliative treatment, Address reprint requests to: Angel Lee, MRCP, Palliative Care Service, Tan Tock Seng Hospital, Moulmein Road, Singapore , Singapore. Accepted for publication: January 26, such as surgery, radiotherapy, or laser therapy. Stents can be successfully placed in more than 90% of cases 2 and the procedure is relatively simple and safe. Recognized complications include esophageal perforation (5 19%), tube migration (10 15%), and tube obstruction (6%). 3-5 Dysphagia is not well recognized as a complication of placement of esophageal stents. We present a patient who developed inability to swallow after stent insertion. Case Report The patient was a 77-year-old man who had an esophagectomy for a poorly differentiated adenocarcinoma of the esophagus. He was well for 2 months, but over the following 8 months, he required 19 endoscopic dilatations for an anastomotic stricture at 21 cm from the incisors. Biopsy at the stricture was suspicious of re- U.S. Cancer Pain Relief Committee, /98/$19.00 Published by Elsevier, New York, New York PII S (98)

2 Vol. 16 No. 4 October 1998 Esophageal Stents and Swallowing Reflex current disease. In view of the frequency of dilatations, he was admitted for elective insertion of a Celestin tube. Following this procedure he developed dysphagia even to fluids. His prognosis was judged to be short and he was referred to our hospital palliative care team for symptom control. On examination, he was frail and cachectic. He had no cervical lymphadenopathy and no other physical signs of metastatic disease. He had a hoarse voice and a weak cough, which had developed after stent insertion, and was continually spitting out saliva. All attempts at swallowing induced distressing laryngospasm with stridor. Hyoscine butylbromide (60 mg) was given subcutaneously in a syringe driver over 24 hours to dry secretions. Hyoscine butylbromide was chosen over hydrobromide because of its lesser sedative effect. Despite this, the dose had to be subsequently decreased to 40 mg over 24 hours because the patient became sleepy. 255 Endoscopy showed that the top of the stent was at 18 cm from the incisors. This was thought to be just below the cricopharyngeus muscle, with the distal end of the stent at 30 cm. There was no evidence of any obstruction of the Celestin tube. Both vocal cords were noted to be paralyzed in the adducted position. Chest radiography (Fig. 1) and lateral neck radiography (Fig. 2) showed the top of the stent just below the level of the sixth cervical vertebra, generally taken to be the level of the upper esophageal sphincter.6 Swallowing assessment by a speech therapist revealed a normal oral phase but poor laryngeal lift. Swallowing resulted in violent choking with stridor. Videofluoroscopy was unsuccessful since the patient was too fearful of choking to swallow during the procedure. It was feared that removal of the stent might lead to esophageal rupture. Nonetheless, because the patient s dysphagia did not improve after 2 weeks the stent was removed. This was followed by gradual improvement of both the Fig 1. Chest radiograph showing position of Celestin tube.

3 256 Lee and Forbes Vol. 16 No. 4 October 1998 Fig 2. Lateral radiograph of the neck showing the upper end of the Celestin tube just below the level of the sixth cervical vertebra. patient s swallowing and his voice. He tolerated a liquid diet by the third day and progressed to a soft diet a few days later. Hysoscine was discontinued as his swallowing improved. The patient was discharged home and required another esophageal dilatation for recurrent dysphagia 4 weeks later. His general condition continued to deteriorate and he died at home 2 weeks following this. Discussion Patients often need increasingly frequent dilatations for recurrent dysphagia when this is used as the primary therapy. 7 The usual indications for placement of esophageal stents are a requirement for frequent and/or difficult dilatations to minimize dysphagia, and the persistence of dysphagia despite dilatation. Esophageal stenting is also considered to be the definitive treatment for tracheoesophageal fistulae. Alternative methods for palliating dysphagia in patients with carcinoma of the esophagus are laser therapy and injection of ethanol. Unfortunately, neither of these methods would have been suitable in this patient. Ethanol injection is best for exophytic tumors and laser therapy is generally only suitable for relatively short tumors (less than 6 cm), which are exophytic, noncircumferential and in the mid or distal esophagus. 8 The upper esophageal sphincter has variously been considered a pharyngeal or an esophageal structure. The position of the pharyngoesophageal sphincter is usually taken to be at about 20 cm when measured from the incisors endoscopically. The muscular elements of this sphincter are made up of the cricopharyngeous muscle, the inferior pharyngeal constrictor, and adjacent portions of the cervical esophagus. High esophageal strictures, i.e., within 2 cm of the pharyngoesophageal sphincter, are considered unsuitable for intubation. A stent at this site is not usually tolerated because of the sensation of foreign body; stridor from laryngeal obstruction and proximal migration of the prosthesis may also occur. Swallowing is a complex sequence of events allowing propulsion of food into the stomach and prevention of food passing down the trachea or up into the nasopharynx. It is divided into oral, pharyngeal, and esophageal phases. During the oral phase, the food bolus is moved backwards by the tongue. Stimulation of the

4 Vol. 16 No. 4 October 1998 Esophageal Stents and Swallowing Reflex 257 pharyngeal wall by the food bolus or apposition of the soft palate against the pharynx results in reflex pharyngeal peristalsis. Muscular contractions then traverse the oropharynx and hypopharynx, and reach the upper esophageal sphincter in less than 1 second. The pharyngeal and parapharyngeal muscles then contract in a coordinated sequence, pushing the food bolus ahead. At the same time, to prevent food from going up the nose or down the trachea, the palatopharyngeal folds come together as the vocal cords adduct, the larynx moves upward and the epiglottis covers the larynx. As the wave of contraction reaches the upper esophageal sphincter, it relaxes and a series of peristaltic waves helps to bring the food to the stomach. This primary wave of peristalsis is assisted by secondary contractions stimulated by esophageal distention. 9,10 Laryngeal movement is crucial to a successful swallowing mechanism because the laryngeal inlet must be closed and physically removed from the path of the food bolus during the swallow. Because sphincteric musculature has a single insertion anterior to the cartilage of the larynx, the sphincter and the larynx are obliged to move together during the act of swallowing. The presence of a prosthesis splinting the movement of the larynx can lead to a picture similar to oropharyngeal dysphagia with a primary neurological cause. Our patient developed inability to swallow, discomfort in the upper chest, audible stridor (especially after attempts at swallowing), and hoarseness of the voice following stent insertion. Both vocal cords were observed to be adducted at endoscopy. It is not known whether the patient s cords were moving normally before or after the esophagus was stented, however the patient s hoarse voice, stridor, and dysphagia all improved after stent removal. It is possible that trauma during stent insertion caused edema and recurrent laryngeal nerve palsies due to compression, which resolved following stent removal. Clinically, it seems that although the stent was observed endoscopically to be distal to the cricopharyngeous muscle, it was proximal enough to lead to laryngeal compression with splinting of movement. Successful stenting in patients with high esophageal strictures close to the cricopharyngeus has been reported, 11,12 for example, with modified Celestin tubes with a soft funnel designed to sit above the cricopharyngeus. 13 Expanding metal stents may provide a less traumatic and better tolerated method of stenting with fewer complications for the majority of patients with carcinoma of the esophagus. 2,14 The role of the latter devices in patients with such proximal lesions is uncertain. Conclusion This case provides an insight into the complex mechanism of swallowing and how it can be disturbed. Stent removal provided a simple solution to the acute dysphagia in this patient. Patients with dysphagia due to recurrent disease with high, circumferential esophageal strictures remain difficult to palliate despite recent advances in endoscopic palliation and prostheses. Acknowledgment With thanks to Professor D. Alderson for permission to report on his patient. References 1. Earlam R, Cunha-Melo JR. Oesophageal squamous carcinoma. I. A critical review of surgery. Br J Surg 1980;67: De Palma GD, di Matteo E, Giovanni R, Fimmano A, Rondinone G, Catanzano C. Plastic prosthesis versus expandable metal stents for palliation of inoperable esophageal thoracic carcinoma a controlled prospective study. Gastrointest Endosc 1996;43: Wilton A, Smith PM. Endoscopic intubation of oesophagogastric malignancy. Eur J Gastroenterol Hepatol 1995;7: Függer R, Niederle B, Jantsch H, Schiessel R, Schulz F. Endoscopic tube implantation for the palliation of malignant oesophageal stenosis. Endoscopy 1990;22: Tytgat GNJ. Endoscopic therapy of oesophageal cancer: possibilities and limitations. Endoscopy 1990; 22: Plavsic BM, Robinson AE, Jeffrey RB. Gastrointestinal radiology: a concise text. New York: McGraw-Hill, Sturgess R, Krasner N. Oesophageal carcinoma treatment: palliative modalities. Eur J Gastroenterol Hepatol 1994;6: Reed CE. Comparison of different treatments for unresectable oesophageal cancer. World J Surg 1995;19:

5 258 Lee and Forbes Vol. 16 No. 4 October Buchan AMJ. Gastrointestinal motility. In: Patten HD, Fuchs AF, Hille B, Scher AM, Steiner R, eds. Textbook of physiology: circulation, respiration, body fluids, metabolism and endocrinology. Philadelphia: Saunders, 1989: Christensen J. Motor functions of the pharynx and esophagus. In: Johnson LR, ed. Physiology of the gastrointestinal tract. New York: Raven Press, 1987: Sturgess RP, Morris AI. Metal stents in the oesophagus. Gut 1995;37: Loizou LA, Rampton D, Brown SG. Treatment of malignant strictures of the cervical oesophagus by endoscopic intubation using modified endoprostheses. Gastrointest Endosc 1992;38: Goldschmid S, Boyce HW Jr, Nord J, Brady PG. Treatment of pharyngoesophageal stenosis by polyvinyl prosthesis. Am J Gastroenterol 1988;83: Winkelbauer FW, Schofl R, Wildling R, Thurnher S, Lammer J. Palliative treatment of obstructing cancer with nitinol stents: value, safety and longterm results. Am J Radiol 1996;166:79 84.