Patient: Male, 74 years
Clinical Summary: Patient presenting with grade 3 dysphagia and weight loss
Clinical History and Imaging Procedures
The patient presented with a three month history of progressive dysphagia and weight loss associated with upper abdominal discomfort. A barium swallow showed a malignant looking stricture in the lower oesophagus (Fig. 1) above a sliding hiatus hernia. Upper GI endoscopy was performed and biopsies were taken from an obstructing tumour found at 30cm from the mouth (Fig. 2). It was too tight to be passed with the scope, histology was of an adenocarcinoma. Staging CT scan of thorax and abdomen demonstrated a 6cm diameter distal oesophageal mass indenting the trachea and left atrium with associated pre-tracheal lymphadenopathy indicating inoperability (Fig. 3). He was referred for palliative oesophageal stenting. At that time he had grade 3 dysphagia, managing only liquids.
After informed consent the patient was enrolled into a trial comparing three anti-reflux stents and randomised towards insertion of a FerX-ELLA anti-reflux stent.
The procedure was performed under conscious sedation and fluoroscopic guidance. A 15cm covered Fer-X Ella anti-reflux stent (Radiologic UK/Ella-CS, Czech Republic) was deployed with the distal end in a small axial hiatus hernia. Free fluids were allowed after two hours and a soft diet the same evening. The patient was very reluctant to eat although a check-swallow with water-soluble contrast showed the stent to be fully expanded in a good position. It took several weeks to build up the patient´s confidence sufficiently to return to a normal diet, although this was tolerated without problems.
The incidence of oesophageal carcinoma is rising due to rapidly increasing number of adenocarcinoma arising in the lower oesophagus. Onset of symptoms is often late and many tumours are inoperable at presentation. Progressive dysphagia and weight loss of short duration are the presenting complaint in the vast majority of patients. Malignant dysphagia is a highly debilitating condition, which aggravates tumour cachexia as well as excluding patients from social functions. As a result, quality of life is badly impaired and malnutrition reduces poor life expectancy even further. A number of options are available for palliation.
Endoscopic ablation using laser and stenting techniques are commonly used. Placement of self-expanding oesophageal endoprostheses is initially more expensive but has substantially faster and more maintained palliation of dysphagia than endoscopic laser therapy. Palliative radiotherapy has the drawback of slow onset of improvement and dysphagia is often made worse initially due to the mucosal oedema. Advances in stent technology have rendered this a safe, readily available treatment for the palliation of dysphagia. One of the more recent improvements in stent design is the introduction of antireflux valves for stents crossing the gastro-oesophageal junction. Antireflux stents are as safe and effective as standard open stents in relieving malignant dysphagia and dramatically reduce the incidence of symptomatic gastroesophageal reflux as well as the risk of aspirating gastric content. They do not interfere clinically with oesophageal emptying and significantly improve the quality of life of these patients.