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Esophageal Cancer-Palliation

Esophageal Cancer Palliation

Of patients amenable to resection, 72% have LN mets, 25% are resectable for cure

1. Palliative resection or bypass

A. Bypass
1) Mortality=20-40%
2) Morbidity 25%
3) Orringer noted increased incidence of anastomotic leak with bypass
4) Retrosternal route offers best conduit to neck
a) Portals for palliative RT can avoid neoesophagus
b) Reduces possibilty for malignant dysphagia
c) Remove upper manubrium and clavicular heads to enlarge thoracic inlet & decrease anastomotoic leak and stricture 5. Substernal if retrosternal unavailable
6) Gastric-emptying procedure recommended
7) Kirschner - Roux-en-Y drainage of esophageal remnant - others say it is unnecessary
B. Indications
1) Esophagorespiratory fistula in young, fit pts
a) Avoids constant aspiration
b) Other option is esophageal intubation 2. Disease unresectable for cure (discovered at operation) when bypass or resection will add little to morbidity

2. Esophageal dilatation

A. Multiple dilatations and return trips to the hospital are usually required
B. Mercury-filled, red rubber (Maloney or Hurst) are most common
1) Short strictures with visible lumen
2) Fluouroscopy increases safety
C. Guide-wire systems
1) For long, angulated, or eccentric strictures
2) Puestow - supplanted by hollow-core polyvinyl (American, Savary-Gillard)
3) Require endoscopic or fluouroscopic placement of guide-wire into stomach
D. Balloons
1) Potentially decreased risk of perforation (radial vs. Vector force!)
E. Dilate to max 45 French

3. Esophageal intubation (intentional)

A. Tubes have a proximal funnel and a lumen >= 10mm
B. Traction method (Celestin tube)
1) Surgical procedure
2) Pilot bougie is passed through gastrotomy and tube is sutured to lesser curve over a teflon pledget
C. Pulsion method
1) Shorter hospital stay (8.4 vs. 18.6 days) and lower mortality (14% vs. 23%) c/w traction
2) Tube is inserted endoscopically over a guidewire w/fluouroscopic control
3) Celestin tube, Atkinson, Wilson-Cook
4) Savary-wire reinforced polyvinyl - resistant to compression
D. Expandable wire stents
1) For Ca and esophagorespiratory fistula
2) Dilating tumor not nedcessary prior to insertion
3) Problems: expense, inability to move after placement, tumor ingrowth
E. Complications
1) Perforation 4-12%, 4-9% of patients die.
a) Surgery usually ontraindicated
b) Tx w/NPO, IV Abx, nutrition
2) Reflux esophagitis
a) Elevate HOB
b) Omeprazole
3) Tube displacement 10-20%
4) Tumor overgrowth
a) Nd:YAG ablation
b) Replacement w/longer tube

4. Chemotherapy

A. Single agents: 5-FU, cisplatin 15-20% response rate
B. Multi-drug regimens (+/- RT) 33-50% and up to 77% respectively
C. 44% life-threatening side effects

5. Brachytherapy

A. Radioactive sources afterloaded into fluouroscopically placed PVC catheters
B. 3500 cGy at surface of catheter, 1500cGy 1cm from center
C. Benefits
1) Cesium-137 and iridium 192 - more exact dosing
2) Proximity to tumor minimizes radiation to normal tissues
D. Patients with dysphagia due to extrinsic malignant compression more likely to fail
E. 75% have improvement in dysphagia score
F. 1-yr survival: 10% for SCC, 20% for adeno
G. Complications = sore throat, esophagitis, epigastric pain
H. Combined w/external beam (Flores) complete restoration of swallowing in 62%
1) Radiation esophagitis common

6. Compared to laser tx: shorter hospital stay and less likely to require re-treatment

7. Laser photoablation

A. Nd:YAG is most common
B. Works by tissue vaporization and thermal necrosis
C. Authors recommend:
1) Snare cautery debridement of exophytic tumor first
2) Routine re-treatment 2-4 days post-procedure
D. All tumor types, any location - exophytic more successful, extrinsic compression less successful
E. Relatively safe, effective (80%), improves quality of life
F. Complications (1-2.7% mortality)
1) Related to experience
2) Minor - 10-50%
3) Perforation - 5% (experienced operator), bleeding 4% (tx w/laser)

8. Photodynamic therapy

A. IV photosensitizing agents (hematoporphyrin derivatives & phthallocyanines)
B. Dye lasers tuned to appropraite wavelength 2-3 days later - photochemical prrocess
C. Mean survival 6.8 mo
D. Complications
1) Photosensitivity
2) Failure of tx

9. Summary

A. Palliation reserved for:
1) Medically unfit for resection
2) Incurable disease on pre-op evaluation
3) Unresectable at operation
4) Refusal of surgical tx