Chapter 22

Esophageal cancer has an annual incidence of approximately 14,000 in the United States. Unfortunately, most patients are not candidates for curative treatment with esophagectomy because symptoms of dysphagia usually do not present until at least 50% of the circumference of the esophagus is involved with tumor. By this time, the disease usually has spread to distant sites. The symptoms of dysphagia and weight loss that are commonly experienced have a significant impact on quality of life for these unfortunate patients. A number of palliative therapies are available to the surgeon that are not as invasive or as high risk as esophagectomy but nevertheless may provide significant symptomatic relief for the patient.

The options for treating dysphagia that is caused by advanced, unresectable esophageal cancer include stenting, photodynamic therapy (PDT), thermal laser ablation, and brachytherapy. Of these options, the most widely used therapies in the United States are esophageal stenting and PDT. These therapies are the focus of this discussion.

### Stents

Endoscopic stent placement plays an important role in the palliation of dysphagia secondary to esophageal cancer. Over the past decade, advances in expandable stent technology have led to smaller, more flexible delivery systems that are easier to manipulate than the original plastic stents. These attributes permit successful deployment without exposing patients to the risks of aggressive mechanical dilation.

Most plastic stents have an internal diameter of 10 mm and include a proximal funnel to collect food and liquids and a flange at the distal end to prevent migration. The two methods of insertion are traction and pulsion. Traction stenting requires a general anesthetic and a laparotomy incision. For traction stenting, a pilot bougie is inserted orally and retrieved through a gastrostomy. The stent is sutured to the bougie and pulled into place at the site of obstruction. Then the tube is trimmed to length and the gastroscopy closed. Pulsion stenting can be performed with sedation; however, general anesthesia is also often used. A guidewire is placed, followed by dilation at the obstruction site.

All plastic stents necessitate aggressive dilation to a diameter of 45F before placement. The need for aggressive dilation imposes a significant risk of perforation. Additional problems include tube displacement, food impaction, and intractable reflux for stents placed across the gastroesophageal junction. In a study of these older methods of stenting, significantly lower mortality was seen in the pulsion group (14%) than in the traction group (23%).1 Length of hospital stay was 8.4 days, compared with 18.6 days in the pulsion and traction groups, respectively. Clearly, these results are not acceptable by current standards of care, particularly when the intent is palliation rather than cure.

A new generation of stents has evolved. Chief among them is the expandable metal stent (EMS). The EMS eliminates the need for aggressive dilation before insertion and can be placed with sedation alone. Because the stent itself is embedded in ...

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