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Abstract
Esophageal carcinoma is the seventh most common malignancy worldwide. Unfortunately most patients are no longer curable at the time of presentation with dysphagia as the esophageal lumen has often reduced by at least 50–75% of its normal caliber. Approximately 90% are incurable and will need some effort at palliation. Modern radiation and chemotherapy regimens offer some patients a reasonable chance for short-term palliation with tolerable morbidity and essentially no mortality. The morbidity of radiation and chemotherapy can be managed well by alterations of dosage and frequency.
In selected patients with distal lesions, surgical therapy may offer good palliation of dysphasia at the price of operative risk and post-resection squeal. Esophageal cancer remains a lethal killer, with mortality exceeding 95%. Early detection could improve prognosis. Endoscopy plays a pivotal role in both diagnosis and staging. Recent advances in endoscopic ultrasound result in extremely accurate staging, which can be used to determine whether patients are candidates for curative resection, neoadjuvant therapy, or palliation.
Endoscopically placed stents provide good palliation in advanced disease. The role of esophageal stenting continues to evolve, with several new stents currently on the market. These stents possess anti-reflux valves, internal plastic coatings and retrievable threads.
In patients with malignant dysphagia, management should ideally take place within multi-disciplinary teams such that accurate tumor staging occurs prior to treatment. Multi-modality therapy can not only improve dysphagia and response rates but may also improve survival. Several non-surgical palliative techniques are available to recanalize malignant obstruction, including esophageal stenting. Other therapeutic modalities include the use of endoluminal laser therapy, photodynamic therapy, argon beam and bipolar electrocoagulation, ethanol injection and intracavity brachytherapy. Their use often depends on local availability and expertise. Although the initial costs of metal stents are high, the overall costs compare favorably with other forms of palliative therapy that often require multiple procedures with repeated inpatient hospitalization.
A new alternative is a SEMS which insure rapid and dramatic improvement without change of normal pathway of food , this procedure can withstand long time and can be changed if needed.
Stenting in advanced cancer esophagus is an easy, reliable and effective method for palliation of dysphagia as it is a minor invasive simple technique with low risk on the patient which markedly improves dysphagia.
So patients can generally improve and withstands other adjuvant modalities which may improve the prognosis and survival. However to judge the study needs longer follow-up and cooperation with radiotherapy and chemotherapy teams.
Conclusions
It is clear from reports over the past two decades that proper management of dysphagia due to incurable esophageal carcinoma should include the option for several palliative methods in case the initial efforts fail. A determination of a single best dysphagia palliation is not possible in the absence of properly conducted prospective therapeutic trials.
These trials must include a careful objective assessment of the stage of disease and the patient’s physical status, precise documentation of the consistency of the diet and total caloric intake, the frequency and indications for all invasive procedures, a recording of all procedure-related complications, a standardized quality-of-life assessment and length of survival.
At present, there is no proof that any one of the available palliative therapies is superior for dysphagia relief in patients with advanced cancer who have failed the usual surgical, radiation, and chemotherapy regimens. However, the pendulum is rapidly swinging in favor of stents.
It can be concluded from this thesis that:
1- SEMS is an easy, reliable and effective method for palliation of dysphagia as it is a minor invasive simple technique with low risk on the patient .
2- Patient’s general and nutritional condition improve and can withstand other adjuvant modalities which may improve the prognosis and survival rate..
3- SEMS can withstand long time and can be changed if needed.