Endoscopic palliation of esophageal cancer
- John R Saltzman, MD, FACP, FACG, FASGE, AGAF
John R Saltzman, MD, FACP, FACG, FASGE, AGAF
- Section Editor — Therapeutic and Diagnostic Endoscopy
- Professor of Medicine
- Harvard Medical School
Esophageal cancer is often diagnosed at an advanced incurable stage. (See "Epidemiology, pathobiology, and clinical manifestations of esophageal cancer".) Although surgical palliation may be considered in patients without metastatic disease who are good operative risk, locally unresectable or medically poor risk patients may achieve excellent palliation of swallowing from nonoperative means. Palliation of dysphagia can often be achieved by radiation, with or without chemotherapy. (See "Management of locally advanced unresectable and inoperable esophageal cancer".)
However, improvement in swallowing may not occur for several weeks, and not all patients can tolerate these treatments. These individuals are plagued by symptoms of esophageal obstruction or fistulae, dysphagia, aspiration, poor nutrition, and weight loss.
Symptomatic patients who are not candidates for chemoradiotherapy, or who have recurrent dysphagia following definitive chemoradiotherapy may benefit from palliative endoscopic maneuvers. While a variety of endoscopic methods have been described, esophageal stenting is probably most commonly used . In a 2013 guideline, the American Society for Gastrointestinal Endoscopy recommended esophageal stenting as the preferred method for palliation of dysphagia and fistulas in patients with esophageal cancer . The degree of palliation with any of these methods is typically incomplete, underscoring that better approaches are still needed. As a general rule, palliative approaches for inoperable esophageal cancer should be based upon patient and tumor characteristics, goals of care, and patient and clinician preferences [2,3].
This topic will provide an overview of the endoscopic options available for the palliation of esophageal cancer. The use of expandable stents in treating esophageal obstruction is discussed in detail elsewhere. (See "Use of expandable stents in the esophagus".)
Esophageal dilatation with either through-the-scope balloon or wire-guided polyvinyl bougies can provide temporary relief of dysphagia until more definitive treatment can be accomplished. Most malignant strictures can be safely dilated to 16 or 17 mm in several sessions . However, repeat dilatation is usually required every three to four weeks. Esophageal dilation is also associated with a small risk of perforation, especially if performed by blind Maloney dilation during radiotherapy [5-8].
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- ESOPHAGEAL DILATION
- LASER THERAPY
- ABSOLUTE ALCOHOL INJECTION
- INTRATUMORAL INJECTION OF CISPLATIN/EPINEPHRINE GEL
- ENDOSCOPIC MUCOSAL RESECTION
- Inoperable patients with early stage disease
- PHOTODYNAMIC THERAPY
- Palliation of dysphagia in advanced disease
- Inoperable patients with early stage disease
- ARGON PLASMA COAGULATION
- CRYOSPRAY ABLATION
- ENDOSCOPIC STENTING
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS