Correspondence

Endoscopic Palliation of Malignant Dysphagia

N Engl J Med 1997; 336:294-295January 23, 1997

Article

To the Editor:

In the Images in Clinical Medicine series (Aug. 15 issue),1 Wong and Van Dam described a case in which an expandable metallic esophageal prosthesis spared their patient considerable discomfort and expense. Expandable metal stents, especially the latest “coated” ones that retard the ingrowth of tumors, are an important advance in the treatment of inoperable esophageal cancer. However, the placement of these stents is not without risk. My colleagues and I have encountered a high complication rate in our initial experience in 11 patients with the five types of expandable metallic stents currently available. Two patients had intractable substernal pain, and one had food impaction with aspiration. In one, the stent migrated, with subsequent uncontrollable gastric hemorrhage. In another, the stent eroded into the aorta, and the patient bled to death within 24 hours after placement of the stent. Six patients had no complications.

We believe that these stents should not be placed routinely after initial bougienage in patients with esophageal cancer but should be reserved for patients who have evidence of an esophageal perforation or tracheoesophageal fistula or those who require frequent bougienage and laser ablation.

Richard S. McCray, M.D.
St. Luke's–Roosevelt Hospital Center, New York, NY 10025

1 References

1. 1

   Wong RCK, Van Dam J. Endoscopic palliation of malignant dysphagia. N Engl J Med 1996;335:475-475
   Full Text | Web of Science | Medline

Author/Editor Response

The authors reply:

To the Editor: We thank Dr. McCray for his comments and agree that the use of expandable metallic endoprostheses (stents) for palliation of dysphagia in patients with malignant esophageal obstruction is not without risk. Dr. McCray's overall complication rate of 45 percent and procedure-related mortality rate of 18 percent are high and appear out of proportion to those reported in the original prospective, randomized trial by Knyrim et al.1 In that study, palliation of malignant dysphagia using conventional plastic stents was compared with that achieved by the use of expandable metallic esophageal stents, and complications were significantly less frequent with the metallic stents than with the plastic stents (0 vs. 43 percent). However, more recent studies using metallic stents have revealed widely divergent complication and mortality rates. For example, Kozarek et al.2 and Vermeijden et al.3 reported stent-related mortality rates of 3 percent and 25 percent, respectively.

Kinsman et al.4 identified the use of radiation, chemotherapy, or both before stent placement as a potential cause of increased morbidity and mortality. In their evaluation of 59 patients, Kinsman et al.4 reported a stent-related mortality rate of 23 percent (5 of 22 patients) among those who had previously received radiotherapy, chemotherapy, or both, as compared with a rate of 0 percent (0 of 37) among those who had received no such prior therapy. Radiation and chemotherapy might induce tumor necrosis and vascular changes that could weaken the esophageal wall.4,5

It is unclear whether the patients described by Dr. McCray had received radiation or chemotherapy before stent placement. If so, this could have resulted in higher-than-expected rates of complications and mortality. Also, the use of five different types of stents in 11 patients suggests a limited experience with any one stent design. We have limited the placement of these stents to patients who have not previously received radiation or chemotherapy. In addition, our post-stenting care entails advancing the patient's diet no further than to a soft solid diet (as tolerated), giving all patients acid-suppressive therapy, and instituting antireflux precautions. We believe that endoscopically deployed expandable metallic endoprostheses are an effective form of palliation for malignant dysphagia with an acceptable complication rate in experienced hands and when placed in selected patients.

Richard C.K. Wong, M.B., B.S.
University Hospitals of Cleveland, Cleveland, OH 44106

Jacques Van Dam, M.D., Ph.D.
Brigham and Women's Hospital, Boston, MA 02115

5 References

1. 1

   Knyrim K, Wagner H-J, Bethge N, Keymling M, Vakil N. A controlled trial of an expansile metal stent for palliation of esophageal obstruction due to inoperable cancer. N Engl J Med 1993;329:1302-1307
   Full Text | Web of Science | Medline

2. 2

   Kozarek RA, Ball TJ, Brandabur JJ, et al. Expandable versus conventional esophageal prostheses: easier insertion may not preclude subsequent stent-related problems. Gastrointest Endosc 1996;43:204-208
   CrossRef | Web of Science | Medline

3. 3

   Vermeijden JR, Bartelsman JF, Fockens P, Meijer RC, Tytgat GN. Self-expanding metal stents for palliation of esophagocardial malignancies. Gastrointest Endosc 1995;41:58-63
   CrossRef | Web of Science | Medline

4. 4

   Kinsman KJ, DeGregorio BT, Katon RM, et al. Prior radiation and chemotherapy increase the risk of life-threatening complications after insertion of metallic stents for esophagogastric malignancy. Gastrointest Endosc 1996;43:196-203
   CrossRef | Web of Science | Medline

5. 5

   Bethge N, Sommer A, von Kleist D, Vakil N. A prospective trial of self-expanding metal stents in the palliation of malignant esophageal obstruction after failure of primary curative therapy. Gastrointest Endosc 1996;44:283-286
   CrossRef | Web of Science | Medline

Citing Articles (1)

Citing Articles

1. 1

   M WANG, D SZE, Z WANG, Z WANG, Y GAO, M DAKE. (2001) Delayed Complications after Esophageal Stent Placement for Treatment of Malignant Esophageal Obstructions and Esophagorespiratory Fistulas. Journal of Vascular and Interventional Radiology 12:4, 465-474
   CrossRef