Airway stenting for unresectable esophageal cancer

Because of the close anatomical relationship between the upper esophagus and the tracheobronchial tree, many patients with advanced esophageal cancer will suffer from airway complications. These include airway stenosis or esophago-respiratory fistulation. Airway stenting is proven to offer effective palliation for patients with both these complications. When managing such patients, the thoracic surgeon faces different options in terms of pre-stenting investigation, choice of stents and stenting strategy. Although airway stenting is a safe and effective procedure in experienced hands, there are nonetheless complications which await the unwary. This review discusses the currently available options for airway stenting in these patients, and offers practical advice on avoiding the pitfalls.     

Temporary stenting for malignant tracheal stenosis due to esophageal cancer: a case report

We present a case of a 56-year-old male with esophageal cancer who underwent successful temporary tracheal stenting followed by a surgical procedure. The trachea was obstructed owing to endotracheal metastasis and the patient had severe dyspnea. A silicone Y-stent was initially inserted into the tracheal stenosis to secure the airway, and then tumor-specific chemo-radiotherapy was applied. The tumor was reduced, the stent was removed and a pathological study indicated that the tracheal metastasis had disappeared. The patient then underwent esophagectomy and tumor-specific chemo-radiotherapy was continued after the surgery. The patient has remained alive and free of esophageal cancer for 18 months after the airway stent emplacement. These findings suggested that the silicone stent was suitable as a temporary measure and that temporary stenting combined with tumor-specific therapy was effective as part of the aggressive therapeutic strategy with which to treat the malignant airway stenosis due to esophageal cancer.     

食管支架置入术治疗晚期食管癌的疗效及预后分析

目的探讨食管支架置入术治疗晚期食管癌的疗效及预后的影响因素。方法收集98例行食管支架置入术的晚期食管癌患者的临床资料和随访资料,比较支架置入前后患者的吞咽困难程度,采用Kaplan-Meier法绘制生存曲线,采用Cox回归模型分析影响患者生存时间的危险因素。结果食管癌患者支架置入前以3级吞咽困难(77.55%)为主,支架置入后以1级吞咽困难(89.80%)为主。支架置入前后患者的吞咽困难分级比较,差异有统计学意义(P﹤0.01)。随访时间为1～29个月,失访4例。患者的中位生存时间为5.75个月(95%CI:4.287～6.713),6个月、1年和2年总生存率分别为45.92%、20.41%和6.12%。合并食管瘘、肿瘤分化程度低及肿瘤浸润深度深均是影响晚期食管癌支架置入患者生存时间的危险因素(P﹤0.05)。结论食管支架置入术对晚期食管癌吞咽困难的疗效较好,合并食管瘘、肿瘤分化程度低及肿瘤浸润深度深是影响晚期食管癌支架置入患者生存时间的危险因素。     

Analysis of postoperative pulmonary complications after esophagectomy for esophageal cancer

We examined factors contributing to an onset of postoperative pulmonary complications following esophagectomy for esophagus cancer. One hundred thirty-two cases of the resected esophageal cancer were studied. We considered the relationship between preoperative patient factors, operative factors, clinical stage factors and postoperative pulmonary complications. Postoperative pulmonary complication was observed in 27 cases (20%). The incidence of postoperative pulmonary complications was significantly higher in patients aged 70 and above and those with a preoperative serum albumin value of less than 4 .0 g/dL. Additionally, these two factors were correlated with an onset of postoperative pulmonary complications in multivariate analyses. A decrease of preoperative serum albumin value was reflecting the chronic poor nutritional condition. Moreover, it was possible that poor nutritional condition served as a prognostic factor of postoperative complications in relation to reduction of cellular immunity. The results indicated that there was a possibility of decreasing an onset of postoperative pulmonary complications using various nutrition managements before operations.     

胃经食管床颈部吻合食管癌根治术对术后呼吸功能的影响

 目的　探讨胃经食管床颈部吻合食管癌根治术对患者术后呼吸功能的影响。方法　60例食管胸中段癌患者，30例行食管癌切除胃经食管床颈部食管胃吻合术，30例行胸内食管胃弓上吻合术，测量比较术前、术后3周、3个月肺功能主要指标变化。结果　患者均手术成功。颈部吻合组与胸内吻合组术前的肺活量（VC）、第1秒时间肺活量（FEV1）和最大通气量（MVV）差异均无统计学意义（P＞0.05）。术后3周、3个月两组相比VC、FEV1和MVV差异均有统计学意义（P＜0.05）。结论　经食管床行食管胃颈部吻合对患者呼吸功能影响小。     

内镜下覆膜支架置入对晚期食管癌患者生活质量的影响

目的了解内镜下覆膜支架置入对晚期食管癌患者生活质量的影响。方法采用欧洲癌症研究与治疗组织生存质量问卷第3版（EORTCQLQ-C30V3.0）和食管癌专用量表（QLO-OES18）对2004年9月至2008年10月在我院进行覆膜支架置入治疗的伴有吞咽困难的38例无法手术治疗的晚期食管癌患者在治疗前、治疗后1周、4周和12周进行生存质量评估。结果覆膜支架置入后患者整体生活质量（37.8±14.9对74.3±10.8;P〈0.01）和所有功能领域生活评分显著提高并持续到治疗后12周。患者吞咽困难症状明显改善（18.9±24.5对90.8±7.9;P〈0.01）,并持续到治疗后12周。梗阻（48.1±27.5对18.3±30.5;P〈0.01）和进食（25.2±15.7对5.1±18.7;P〈0.01）等症状方面均有显著改善。结论覆膜支架置入能够显著提高患者的整体生存质量和全部功能领域评分,并能改善患者的吞咽困难和梗阻等症状。     

食管及贲门癌术后并发症再手术治疗（附17例分析）

目的：分析对食管及贲门癌术后几种常见并发症施再手术治疗的临床意义。方法：对１７例食管及贲让癌术后发生吻合口瘘、乳糜胸、胃穿孔等并发症的患者进行再次开胸分别施行吻合口重建,胸导管结扎及胃穿也修补术,并对再手术治疗的治愈率,死亡率进行统计分析。结果：经再手术治疗的１７例中因乳糜胸行胸导管结扎术７例,治愈４例,死亡３例。因吻合口瘘行吻理建术５例。治愈３例,死亡１例,１例自动出院;因胸内胃穿孔行胃穿孔修补     

Pulmonary complications after bleomycin, irradiation and surgery for esophageal cancer.

Eight patients with epidermoid carcinoma of the esophagus were given radiotherapy of 3000 rads and 120 mg of bleomycin. Esophageal resection was performed five to six weeks later. Four of these patients died within six weeks, three from respiratory failure, and one from complications secondary to an anastomotic fistula. Of the remaining four patients, three showed varying degrees of pulmonary infiltration for several weeks. Interstitial pneumonitis was demonstrated in all the fatal cases. Four patients given the same irradiation and bleomycin doses were only subjected to exploratory surgery. They had no postoperative pulmonary complications. Ten patients given the same irradiation and bleomycin treatment without surgery also showed no pulmonary complications. Sixteen patients received higher doses of radiotherapy and bleomycin. Seven of these developed lung infiltrations terminating fatally in four. The likely mechanism of the observed postoperative pulmonary complications is that the preoperative treatment sensitized the lungs, while the subsequent surgical trauma triggered a reaction in the lungs leading to respiratory failure.     

带膜食管支架置入术32例临床疗效观察

目的:探讨带膜食管支架置入术治疗食管癌性狭窄和食管-气管瘘的临床效果。方法:32例晚期食管癌性狭窄和食管-支气管瘘患者,均无手术指征,术前已行内镜和X线钡剂造影检查明确病变部位和性质。术中应用利多卡因胶浆行咽喉部麻醉,置开口器,透视下将超滑导丝与5F导管送入食管内,撤出导丝,经导管注入造影剂确定病变上下端,体表用铅条标记定位病变狭窄区;导丝及导管进入胃腔内,置换不折钢丝,沿钢丝将支架送至病变部位,X线透视下缓慢释放,观察临床疗效。结果:所有患者吞咽困难均显著改善,食管-气管瘘患者呛咳显著缓解。但患者均有不同程度的胸痛、胸部异物感,平均缓解时间2周,支架术后平均存活13个月,并发症有疼痛、再狭窄、支架移位、胃内容物反流、出血、支架嵌顿填塞等。结论:带膜食管支架能显著缓解食管癌患者的进食困难及食管-支气管瘘呛咳、肺内感染、严重营养不良症状,提高患者的生活质量,延长生存时间。对于重度吞咽困难而又失去手术机会或拒绝接受手术治疗的食管癌患者,经口腔在X线透视下放置带膜食管支架是一种操作安全可靠、微创、简单易行、见效快、费用相对低廉的治疗方法。     

食管及贲门癌手术少见并发症临床分析

  目的  总结食管及贲门癌手术少见并发症的诊断及治疗体会,吸取其诊断失误、治疗失败的教训。  方法  回顾性分析少见并发症的发病原因、临床诊断、处理方法、预防措施及其中治疗失败的相关因素。  结果  治愈及死亡分别为10例及8例（除外已报道的8例）。  结论  1）该文所述的并发症虽然少见,但临床上时有发生,若处理不当,常造成严重后果;2）对主动脉食管固有支撕脱性损伤的喷射状出血,术者要沉着、冷静,只要处理方法正确,损伤口均可以修补成功;3）右胸径路是预防奇静脉损伤的关键措施;4）吻合口腹内瘘的患者,若早期漏出感染物包裹于膈下,容易延误诊断;5）吻合口主动脉瘘,关键在于预防;6）警惕术后肺动脉栓塞的发生,提高其防治意识;7）胸胃纵隔疝若不及时处理,预后较差。      

Esophageal stenting for the palliation of malignant dysphagia

Self-expanding metal stents (SEMS) are currently the standard for palliation of malignant dysphagia. Innovations in stent technology, including the advent of retrievable stents and the development of self-expanding plastic stents (SEPS), show promise to increase the possible applications for esophageal stents. This article reviews the indications and usage of both SEMS and SEPS in patients with malignant dysphagia as well as the potential complications of their use.     

Palliation of malignant dysphagia in esophageal cancer: a literature-based review

Esophageal cancer is a lethal malignancy and adenocarcinoma of the esophagus is increasing in incidence. Most patients present with locally advanced, unresectable or metastatic disease.The 5-year survival rate of patients with esophageal cancer is < 20%. Dysphagia is the most common presenting symptom of this disease and leads to nutritional compromise, pain, and deterioration of quality of life. Palliation is an important goal of esophageal cancer therapy. Severity is commonly measured using a dysphagia grade, and dysphagia is an integral component of quality-of-life instruments, such as FACT-E and EORTC-OES 24. Investigation of dysphagia includes radiographic studies such as barium or Gastrografin swallow, esophagogastroduodenoscopy, endoscopic ultrasonography, and other staging studies for esophageal cancer. Current management options for the palliation of dysphagia include esophageal dilatation, intraluminal stents, Nd:YAG laser therapy, photodynamic therapy, argon laser, systemic chemotherapy, external beam radiation therapy, brachytherapy, and combined chemoradiation therapy. The clinical situation, local expertise, and cost effectiveness play an important role in choosing the appropriate treatment modality.The benefits and disadvantages of these approaches along with a concise review of the literature are presented.     

Airway stent for airway obstruction caused by esophageal carcinoma

The result of airway stent and adjuvant therapy for airway obstruction caused by advanced esophageal carcinoma was evaluated. In Tokyo Metropolitan Ohkubo Hospital, four cases of esophageal carcinoma with airway obstruction were treated by tracheo-bronchial stent. Two were primary cases and the others were recurrent cases. Three of the patients demonstrated progressive dyspnea due to airway obstruction, and the other complained of bloody discharge. An ultraflex non-covered stent was used cases. After insertion of the airway stent. The patients' dyspnea improved immediately. One patient was discharged without adjuvant treatment, and died of the cancer one month later. Adjuvant treatment was adopted in the other three cases. The size of the tumor decreased, but fistula formation was observed in two cases. An airway stent is an effective treatment with immediate results for dyspnea caused by airway obstruction. Adjuvant treatment after stent placement is often associated with fistula formation. It should be considered carefully.     

Radiotherapy versus stenting in treating malignant dysphagia

The most commonly used treatments for maliganat dysphagia are stenting and radiotherapy (RT). A prospective data of 91 patients with locally advanced or metastatic esophageal cancer who has been treated with either palliative RT, stent or both. Group I had RT only, Group II had stent only and group III had both RT and stent. The median overall survival was 169, 119 and 237 in the three groups respectively. The difference between GI & III was statistically significant (P=0.01). Combinations of stent and RT may provide survival benefit in patients with malignant dysphagia. A randomized clinical trial is recommended.Key Words: Malignant dysphagia, esophageal cancer, radiotherapy, stent     

Preoperative risk assessment and prevention of complications in patients with esophageal cancer

In this review the preoperative risk assessment and prevention of complications in patients undergoing esophagectomy for cancer is discussed. Age, pulmonary and cardiovascular condition, nutritional status, and neoadjuvant chemo(radio)therapy are known predictive factors. None of these factors is a valid exclusion criterion for esophagectomy, but may help in careful patient selection. Both anesthetists and surgeons play an important role in intraoperative risk reduction by means of appropriate fluid management and application of optimal surgical techniques. J. Surg. Oncol. 2010; 101:270–278. © 2010 Wiley‐Liss, Inc.     

精细化饮食指导对食管癌术后患者饮食相关并发症的影响

目的探讨精细化饮食指导对食管癌术后患者饮食相关并发症的影响。方法选取2017年10月至2018年5月间复旦大学附属中山医院收治的61例行食管癌根治术的患者,采用随机数字表法分为观察组(31例)和对照组(30例)。观察组患者采用精细化饮食指导,对照组患者采用常规饮食指导,比较两组患者进食后饮食相关并发症发生率及每日进食总量。结果两组患者进食引起的呛咳、饱胀不适、恶心呕吐和反酸烧心等例数比较,差异无统计学意义(P> 0. 05),但饮食相关并发症总发生率比较,差异有统计学意义(P <0. 05)。观察组患者每日进食总量为(729±47) ml,高于对照组患者的(598±124) ml,差异有统计学意义(P <0. 05)。结论对食管癌术后患者采用精细化饮食指导,可增加患者的每日进食总量,提高舒适度,利于康复。