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Introduction

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Esophageal cancer has an incidence that varies between 12,000 and 18,000 new cases. Unfortunately, the overall survival for esophageal cancer is dismal because patients usually present when symptomatic with dysphagia and/or weight loss, by which time the tumor has metastasized. The symptoms from an obstructing esophageal tumor can have a significant impact on quality of life. Fortunately, palliative treatment options of limited risk are available which can improve swallowing, allow for continued oral intake, and help prevent aspiration.

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Options for palliating the patient with dysphagia from advanced, unresectable esophageal cancer include stenting, photodynamic therapy (PDT), cryoablation, laser ablation, and chemoradiation. Of these, the therapies that are most widely used in the United States are esophageal stenting and PDT. Cryoablation is a newer modality that is gaining in popularity. These three therapies are the focus of this discussion. Generally they deliver rapid relief and provide patients with the ability to consume an oral diet with some modifications.

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Technical Principles

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Stents
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Historically, stenting to relieve malignant strictures of the esophagus involved the use of plastic stents. Typically, these stents had a 10-mm internal diameter with proximal and distal flanges and were placed using an open traction or pulsion technique. With the traction technique, the patient underwent a laparotomy and a gastrotomy. A bougie was advanced orally and retrieved through the gastrotomy. The stent was attached to the bougie and pulled into place. With the pulsion technique, which could be performed under sedation, a guidewire was placed, the obstructing stricture was dilated, and the stent was advanced into position using an introducer device. Complications associated with plastic stents included stent displacement, food impaction, and intractable reflux for stents positioned across the gastroesophageal junction. In one report of 409 patients, this approach improved symptoms of dysphagia in 80% of patients but was associated with a 3% mortality rate.1 In another report comparing traction and pulsion techniques, mortality and length of stay were lower for patients treated using the pulsion technique (14% and 8.4 days, respectively) than those treated using the traction technique (23% and 18.6 days, respectively).2

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Fortunately, the advent of self-expanding metal stents (SEMSs) has simplified palliation. The SEMS can be placed under endoscopic and fluoroscopic guidance. This approach does not require general anesthesia (though this may be ­preferable) or aggressive dilation of the malignant stricture. The stent itself is embedded within the tumor. Consequently, the likelihood of migration is small. The benefits of SEMSs over the earlier plastic stents have been demonstrated in a clinical trial, which showed similar improvement in dysphagia scores using both the techniques, but absence of early complications among patients treated with metal stents as compared to 20% early morbidity and 16% mortality among patients treated with plastic stents.3

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In general, over 85% of patients are palliated immediately from their dysphagia symptoms when an SEMS approach is ...

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