Palliation of malignant dysphagia3

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  • Palliation of Malignant DysphagiaJason Klapman, MD FASGEDirector of EndoscopyMoffitt Cancer CenterTampa, FL

  • DefinitionTo Palliate-From the Latin Palliatus-to cloak or conceal. To palliate a disease is to treat it partially and insofar as possible, but not cure it completely. Easing the severity of a pain or a disease without removing the cause

  • OUTLINEMethods of PalliationEndoscopic Management of TE Fistulas

  • Methods of Palliation DilationAblationRadiationStenting

  • Endoscopic dilationTemporary relief of dysphagiaBalloon or polyvinyl BougiesGoal to 15-16mm will allow most foodsNeed for repeat sessionsAssociated procedure risksAspirationPerforation

  • Ablation MethodsNd:YAG laserAPCPDTCRYO

  • Nd:YAGNeodymium-yttrium-aluminum-garnetFleisher et al. Am J Surg. 1982 A new palliative approach for esophageal cancerFulgurating the esophageal cancer to make a larger lumen.Generally requires multiple sessionsCan be challenging at the cervical esophagus or GE junctionRisk of perforation is up to 7%* Lightdale et al. GIE Dec1995

  • APCArgon Plasma Coagulation Monopolar, non-contact method causes tissue coagulationMain complication is bleedingMost useful in combination therapy CONSORT 1a trial Rupinski et al. Am J of Gastro Sept 201193 pts randomized to APC with HDR,PDT or APC aloneTime to first dysphagia recurrence was 88,59 and 35days respectivelyAPC with HDR fewest complications and highest QoL

  • PDTPhotodynamic TherapyUses a photosensitizing agent in combination with laser exposure to ablate malignant tissuePorfiner sodium (Photofrin) is the only photosensitizing agent available in USMore effective than other ablative techniques Lightdale et al. GIE Dec 1995 Multicenter randomized trial of PDT vs. Nd:Yag laser for palliation of esophageal cancerPDT equally efficacious and better tumor responseEasier to performLess complications than Nd:Yag (1% vs 7%)Use is limited by photosensitivity and high cost

  • CryotherapyUsed for early or superficial recurrent esophageal cancerNot routinely used for palliation

  • RadiationHigh-dose Brachytherapy (HDR)Localized treatment with high-dose radiation with sparing of the surrounding structuresDepth of 1cm and length adjustable to tumor lengthTiming of BrachytherapyAs Monotherapy? Before or after Stenting? In combination with esophageal stenting or other modalities?HDR as MonotherapyHoms et al. Lancet 2004 Brachytherapy better for long term palliation for patients with life expectancy >3months but less than 6 months Stenting better for patients with
  • HDR combination therapy CONSORT 1a showed benefit in combination with APCBerquist et al. Dis Esophagus Jul 2012Combined stent insertion and HDR pilot study12 patients received stent insertion and then single dose of 12Gy Relief of dysphagia in 10/11Median survival was 6.6monthsHirdes et al. GIE Aug 2012Combination of Biodegradable stent and single-dose brachytherapyBrachy 12Gy first then stent placement19 patients28 complications in 17patients (mainly pain and vomiting) causing premature ending of study

  • Esophageal StentingASGE Guidelines GIE March 2013Esophageal Stenting should be the preferred method for palliation of malignant dysphagia and FistulaeProvides immediate and durable relief in the majority of patients

  • Esophageal StentsTypesPlastic or MetalFully CoveredPartially coveredUncoveredBiodegradable

  • Choosing a stentMajority are Metal stents Most SEMS are equally effective in relieving symptoms, have similar complication ratesNo study has been done comparing all types of metal stentsChoice usually determined by perceived ease of placement and personal experience of endoscopistLow incidence of migration is the holy grail!!

  • Choosing a stent (cont)Stent characteristics Delivery systemsDeployment patternsExpansile forceForeshortening characteristicsRemovability

  • Available Esophageal Stents (U.S.)Boston ScientificPolyflex -strong expansile force,removable 16-21mm 9-12-15cm lengthUltraflex- distal and proximal release option, most flexible, least expansile force (partially or uncovered) 18 or 23 mm, 10,12,15cm lengthsWallflex-, no foreshortening, smooth delivery vs. Ultraflex, lasso loop (fully/partially) 18 or 23mm 10,12,15cmCook EndoscopyEvolution-no shortening, recapturable, lasso loop, distal release only(fully18,20 -8,10,12cm or partially 20mm, 8,10,12.5,15Z stent - no shortening, short bare wire at ends, has anti-reflux valve option (fully, partially, anti-reflux)18mm, 8,10,12,14Merrit Medical EndoTek Alimaxx-E-non-foreshortening, fully covered, lasso loop, distal release only multiple sizes 12-22mm 7,10,12cm lengthsEndoMaxx-non-forshortening,fully covered,Metal loop, 19,23mm ,7,10,12,15cmEndochoice-Bonastent- Fully covered, Hook/Cross technology, Non-foreshortening, retrieval lasso-18mm 6-16cm lengthTaeWoong- Niti-S TTS, fully covered ,lasso loop 18mm, 6-15cm ,(

  • Non-TTS placementA stiff 0.035 guidewire for stability, over which stent is deployedRemove endoscope leaving wire in placeBack load stent over wire and advance through stricture Can place endoscope alongside stent to observe deployment if desired (No fluoroscopy needed)Choose stent that is 4cm longer than tumor to allow for 2cm above and below tumor for stability

  • Non-TTS placement

  • TTS placementNiti-s esophageal stent10.5 fr diameter deployment systemUse therapeutic upper scopeProximal release

  • After stent placementStarts clears and slowly advance to soft foodsGive post stent diet instructions-tailor it to the size of stentAnalgesics prn for pain

  • ComplicationsChest painBleedingPerforationAspirationSevere GERDDysphagia: tumor ingrowth, migration, food impaction, device malpositionTracheal Esophageal (TE) Fistula formation

  • OUTLINEMethods of PalliationEndoscopic Management of TE Fistulas

  • Case History65 y.o definitive chemo XRT for proximal squamous cell esophageal cancerDeveloped non-malignant XRT stricture 6mos post treatmentUnderwent serial dilations ( 3 over 6 weeks w/limited improvement) Feedings mainly through G-tubePresented with worsening dysphagia and cough and CXR c/w pneumonia

  • Case HistoryEndoscopy performed

  • Management of TE FistulaEtiologyMalignant vs. BenignPre-treatment vs. during treatmentRisk factorsPrevious radiationLocation (never distal)In situ esophageal Stent

  • Endoscopic optionsPlacement of a fully covered esophageal stent is the preferred treatment

  • TTS stent insertion for TE-Fistula

  • Stenting for TE-FistulaSuccess rate is 70%-85% (consider double stenting)Leave stent in for 4-6 weeks and re-evaluateUnsuccessfulConsider re-stentingClipping (OTSC) +/- stentingFibrin Glue application +/- Clipping +/-stentingSurgery bypass or mucus fistula

  • SummaryPalliation in esophageal cancer has one primary goalTo allow patients to maintain oral intake and improve quality of lifeMultiple palliative options are available which may be used as monotherapy, in combination, or sequentially.Endoscopic stenting is now the preferred initial treatment modality for both palliation of dysphagia and treatment of TE-fistulaChoosing the right stent involves many factors including physician preference, esophageal stricture characteristics and location, and patients clinical scenario

  • Thank You!!

    ****Dilation performed to aid in EUS staging and in initial diagnostic procedure ****218 patients were treated 110 PDT and 108 ND Yag*Describe the endscopists role for brachy catheter placementStenting gives more immediate relief and bracy more sustrained reliefHolms-multicenter 108stent 101 brachy 12 Gy

    Berquist Covered Ultraflex stent and brachy within 14daysComplications may be due to the biodegradable stentNeed multicenter trial**Going to limit my talk to SEWMS even though the plastic BSC are still avilable but due to the need to put together and high migration rate have fallen out of favorBoston- plastic, partial, fully or uncovered stentsCook-Anti-reflux option no foreshortening Alimax-small diameter and larger fully coveredEndochoice-18mm*Discuss fluoro vs non-fluoro use

    *****Pre treatment use to be relative contraindication to RT or chemo /XRTStent placement during chemo/xrt reported to be as high as 7-8%******