QJM Advance Access published online on April 27, 2008
QJM, doi:10.1093/qjmed/hcn045
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Oesophageal stent insertion for palliation of dysphagia in a District General Hospital: experience from a case series of 137 patients
From the Penine Acute NHS Trust, Greater Manchester, England
Address correspondence to C.P. Selinger, 55 Miry Lane, Westhoughton, BL5 2HW, UK. email: Christian.selinger{at}web.de
Received 30 November 2007 and in revised form 10 March 2008
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Summary |
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Background: Endoscopic oesophageal stent insertion is a widely used procedure to alleviate dysphagia caused by malignant strictures of the oesophagus and gastric cardia. It can, however, be associated with significant complications, mortality and morbidity.
Aim and method: This retrospective case note study was undertaken to assess success rates, complications and mortality of oesophageal stenting when undertaken in a UK District General Hospital (DGH) setting. Patients who underwent oesophageal stenting for malignant disease from January 2000 to January 2006 were included.
Results: Of the 137 patients studied, oesophageal adenocarcinoma was present in 57% of patients, squamous cell oesophageal carcinoma in 37% and gastric adenocarcinoma in 6%. Indications for stent insertion were: presence of non-resectable tumours (65%), co-morbidities that contraindicated surgery (25%), refusal by patients for surgery for potentially resectable disease (6%) and a need for enhanced oral nutrition prior to surgery (4%). Prior to stenting 86.4% of patients suffered from advanced dysphagia. A significant improvement in symptoms was seen in 94% of patients. Discharge from hospital was within 48 h in 45% of cases. Chest pain was experienced by 13.9% of patients and serious acute stent-related complications (perforation or bleeding) occurred in 5.8% of patients. Overall 41.6% of patients had at least one complication. Mortality was 4.4% at 7 days and 24.8% at 30 days.
Conclusions: Oesophageal stent insertion proved to be an effective palliation of dysphagia in group studied. It is a relatively safe procedure with a low rate of serious acute complications (5.8%) and can be done as a short stay in many patients.
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Background |
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Patients suffering from oesophageal or gastric cardia cancer are often not amenable to curative surgery as their disease may be in an advanced stage. Furthermore, their co-morbidities may prevent surgery and patients might decline curative surgery. Dysphagia is the most devastating symptom in those patients.1 In advanced dysphagia patients are also at high risk of aspiration and subsequent pneumonia.
Several methods for alleviating dysphagia are available for these patients who have an expected median survival of <6 months. Palliative surgery is rarely practiced nowadays as it is considered more invasive and dangerous than the alternative treatments.1 Radiotherapy (either externally applied, as brachytherapy or as a combination) can provide relief from dysphagia and restoration of quality of life.1 In the UK it is however only available in tertiary care cancer centres. Other methods like intraluminal laser treatment or argon beam therapy are currently not widely used in the UK.
Endoscopic placement of self expanding metal stents has become a widely used method to palliate dysphagia. While improvements in dysphagia scores (Box 1) have clearly been shown,2,3 there remains a question mark over the improvement in overall quality of life.4–7 Furthermore, oesophageal stent placement is associated with a number of acute severe complications (bleeding and perforation) and significant morbidity and mortality (14–29% at 30 days).1 Overall complication rates vary between 27% and 55%.8,9
| Box 1 Mellow–Pinkas-Score for dysphagia2 0 = able to eat normal diet/no dysphagia 1 = able to swallow some solid foods 2 = able to swallow only semi solid foods 3 = able to swallow liquids only 4 = unable to swallow anything/total dysphagia
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Most of the larger series reporting on oesophageal stent insertion have been reported from tertiary care centres.9,10
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Aim and method |
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The aim of this retrospective study was to assess success rates, complications and mortality of oesophageal stenting when applied to an unselected group of patients in a UK DGH setting. All patients undergoing oesophageal stenting for malignant disease from January 2000 to January 2006 at three Pennine Acute NHS Trust hospitals (North Manchester General Hospital, The Royal Oldham Hospital and Rochdale Infirmary) were identified by interrogation of hospital radiology and endoscopy department databases. Case notes for all identified patients were obtained and analysed to collect data on histological type, stenting procedure itself, early and late complications, morbidity and mortality. Success rates were measured by assessments of the Mellow–Pinkas-Score prior to procedure and post-procedure prior to discharge from hospital. Follow up was ceased in May 2006.
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Results |
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Case notes for 137 patients were analysed. Sixty-three percent of those were male, with an average age of 70 years (range 37–95 years), whereas females were on average 77 years old (range 51–96 years). The underlying malignancies were oesophageal adenocarcinomas in 57% of patients, squamous cell oesophageal carcinomas in 37% and gastric adenocarcinomas in 6%. While 90% of these patients were not eligible for curative surgery because of advanced disease (65%) or co-morbidities preventing surgery (25%), 6% of patients had a potentially respectable lesion but declined surgery. A further 4% of patients had a stent inserted to allow oral nutrition prior to curative surgery.
All patients were either electively admitted or were already inpatients prior to stent insertion. After an endoscopic examination of the oesophagus the following stents were placed using fluoroscopic guidance: 34 HANAROSTENT (MI Tech), 25 CHOOSTENT or DOSTENT (MI Tech), 15 microvasive (Boston scientific), 25 ultraflex (Boston scientific), 4 Niti-S (Taewoong Medical Co.), 5 Flamingo (Boston scientific), 31 others or not specified. In two cases patients received a combination of stents (microvasive and Flamingo; HANARO and CHOO). Oesophageal dilatation was carried out immediately prior to stent insertion in 10.9% of cases.
Most patients received sedation during the procedure (130, 94.9%). This was administered as an opiate only (4, 2.9%), a benzodiazepine only (41, 29.9%) or a combination of the two (85, 62%). Two patients were given a general anaesthetic, four patients received no sedation and data were missing in one case.
Mellow–Pinkas-Scores (Box 1) were used to quantify dysphagia. Prior to stenting 86.4% of patients suffered from advanced dysphagia (Mellow–Pinkas-Score of 2 or greater). Adequate information of swallowing status post-procedure was found in 129 case notes. An improvement in swallowing was noted in 122 of these 129 (94.6%) cases. The median Mellow–Pinkas-Score fell from 3 prior to stenting to 1, whereas the average improved from 2.48 to 1.36.
Serious acute complications occurred in eight (5.8%) patients, three of those suffered a perforation (2.2%). In two cases the perforation occurred on dilatation prior to stenting. Subsequent placement of the stent sealed the perforation and both patients survived for another 11 weeks. The third patient suffered a perforation during the stent placement and died during the same hospital admission. Significant bleeding occurred in four (2.9%) patients within 48 h of procedure. One died on the same day of admission whereas, the other three survived for at least another 3 months. One death occurred in a patient (0.7%) with a major haemorrhage 38 days after stent placement. The most common acute complication was chest pain, which was experienced by 19 (13.9%) patients within 48 h of the procedure.
Late complications included stent migration in 14 (10.2%), tumour in-growth in 14 (10.2%), aspiration pneumonia in 8 (5.8%) and food bolus obstruction in 5 (3.6%) of cases. None of our patients developed a fistula due to stent deployment. Overall 41.6% of patients had at least one complication. An overview of complications rates for individual type of stents is given in Table 1.
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Twenty-six patients were still alive at the end of our study period in May 2006. Median survival for those who died was 63 days and all-cause mortality was 4.4% at 7 days and 24.8% at 30 days (Figure 1). No deaths occurred within 48 h of procedure. Thirteen patients died during their index admissions; four of them had suffered a serious complication (two aspiration pneumonias, one perforation and one haemorrhage). One hundred and twenty-four patients were discharged from hospital alive, of which 56 (45%) could leave hospital within 48 h of procedure.
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Discussion |
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The number of patients being newly diagnosed with oesophageal malignancies in England has increased to over 6000 in 2004.11 This has lead to an increased need for palliation of associated symptoms mainly in the form of dysphagia. Oesophageal stent insertion is widely available and enables the patient to be treated locally. Most papers reporting on success and complication rates however have been published by large tertiary centres.9,10 A national study from Sweden has shown that hospital volume has no influence on outcome of oesophageal stenting.8
Our experience of patients being treated in three DGHs shows a success rate in improving dysphagia of 94.6%. This lies within the 86–100% range reported by other authors.9,10 Complications occur frequently after stent insertion and our figure of 41.6% lies again with the range reported in the literature (27–53%).8,9 Serious acute complications were only seen in 5.8% of our cohort. This shows that oesophageal stent insertion is a safe procedure when carried out in a UK DGH setting. Significant bleeding was treated successfully in three cases and was partially attributing to one patient's death. Perforation was seen in 2 of 15 (13%) cases being dilated prior to stent insertion. In our opinion this technique should therefore be avoided if possible. A short elective admission is a feasible way of facilitating stent insertion as most patients required sedation only and nearly half were discharged within 48 h.
Looking at the short-term outcome of stent insertion the benefits outweigh the risks by far. However a third of patients treated with stents unfortunately experienced serious late complications. Given a median survival of 63 days a quick solution is required for patients suffering from advanced dysphagia. For most patients stent insertion will be the quickest way of palliation as it avoids the need for referral and travel to tertiary centres.
In our group of patients we observed considerable differences in complications rates for different stents (Table 1). The highest rate of late complications was seen in patients treated with Ultraflex stents. These figures have to be taken with caution however. First in a number of cases the type of stent used was not documented in the case notes leading to a classification of ‘others’. Secondly our observational study has not been designed to look at differences in outcome between different types of stents. Prospective, randomized studies addressing differences between stents have mainly compared Ultraflex with Flamingo, Niti-S or Polyflex stents and are therefore not useful to evaluate our data.12–15 Most of them have however not reported significantly different outcomes between these stents.
The 30-day mortality rate for our patients compares well to other studies.10 When comparing median survival (63 days vs. 77 days) however it has to be taken into account that the 26 patients still alive at the end of our study period were not included in this figure. Of those who died, 
10% survived longer than 200 days. This may be a reflection of an early stage of disease in our patient population.
We conclude that oesophageal stent insertion in a UK DGH setting provides patients with a reasonably safe, quick, effective and locally available treatment for dysphagia. Patients should however be made aware of the significant morbidity and mortality of this intervention.
Conflict of interest: None declared.
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References |
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