Transcript Related Guidelines

Management of Esophageal Obstruction, Pain, and Bleeding and Palliative Therapy of Dysphagia During Definitive Therapy

Walid Chalhoub, MD · Georgetown University

Disclosures

February 24, 2021

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Medscape &

Key Takeaways:

  • Palliative therapy is commonly used to address dysphagia in patients with esophageal cancer who are unwilling or unable to undergo surgery, chemotherapy, or radiation

  • Endoscopic options for palliation include dilation, stenting, chemical or ablative debulking, and enteral feeding to address nutritional deficiency and weight loss

  • Although every type of treatment has potential complications, stents are the current mainstay for restoring lumen patency, and opioids are typically used for pain management

This transcript has been edited for clarity.

The definition of malignant dysphagia, which is the most common symptom in esophageal obstruction, is difficulty swallowing, resulting from esophageal obstruction due to cancer. And this usually progresses from solids to liquids.

Endoscopic therapy for esophageal cancer can be categorized broadly as therapy with curative intent or therapy to palliate symptoms. So, just very briefly touching on endoscopic curative therapy, it's used usually more for mucosal cancers, where endoscopic mucosal resection (EMR) and ESD (which is endoscopic submucosal dissection) are the mainstay techniques of therapy. And with palliation, it's used for patients unwilling or unable to undergo surgery, chemotherapy, or radiation. My talk today is pretty much just focusing on palliative therapy, which is the main topic. 

The goal of palliative treatment is to reduce dysphagia and improve oral dietary intake. So, with palliation, nutritional deficiency and weight loss are significant concerns in patients with esophageal cancer. And obstruction and fistulas—specifically, tracheoesophageal fistula formation—are frequent complications of this.

The endoscopic options for palliation include dilation, stenting, chemical or ablative debulking, and enteral feeding. Endoscopic options for dilation usually include the balloons; dilation of obstructing masses, though, rarely provides sustained relief of symptoms and is usually complicated by a high perforation rate in itself. And, not to mention, always when we're attempting any form of palliation, just including the patient and the caregiver and the plan of action is very, very important to bring everybody to the same table of discussion. 

Stenting, which is really the mainstay of therapy in esophageal cancers, is the more durable symptom relief technique that we usually use. Self-expandable metal stents are the current treatment of choice, given that they enable the immediate restoration of oral intake. Other than that, these stents have been used since the 1990s, so we have a lot of data and studies about these specific stents. 

Just one thing I'd like to touch on as well. Stents usually have a decreased risk of perforation than dilation alone. And specifically, self-expanding metal stents, though, don't provide any associated improvements in nutrition. That's something very important to always let our patients know. It's more of an overall improvement on the quality of life than anything else. Every procedure has complications, and with stents specifically, complications could include intolerable chest pain, perforation in itself, migration, tumor ingrowth, bleeding, and fistula formation as well. Some studies have touched on self-expandable plastic stents versus self-expandable metal stents, and we saw that there's a higher complication rate with self-expandable plastic stents. 

The third thing that we had talked about in trying to treat these cancers palliatively is debulking. And debulking is usually [done] either chemically or via laser ablation or photodynamic therapy. Debulking usually is, you inject the actual mass with absolute alcohol. There are other concoctions that are also used, such as epinephrine and cisplatin as well, but those are just case reports that have just showed very limited benefit. More of the studies have been done on absolute alcohol in itself. 

Successful restoration of the lumen patency by laser has been reported in about 97%,[1] but the downfall to that versus stents is that you have to bring the patients back for multiple sessions; even if they're patent, you have to still bring them back. And some reports do show that symptom improvements were disappointing with this continuous bringing back of patients for APC (argon plasma coagulation). So, stents really remain the mainstay in keeping patency the highest. 

Photodynamic therapy, just to touch very quickly on it, is usually used to facilitate stenting or as a salvage therapy in obstructing malignancies. They do have a higher complication rate, though, when used after standard chemotherapy or radiation.

For pain management in these patients, we usually always start with a short-acting opioid. And then [for] people who can't swallow those pills or have severe dysphagia, we use liquid formulations or short-acting opioids, which are the more preferable type. Sublingual preparations are always an excellent option as well. And then, [for] people who do require more than just three doses of a short-acting opioid within 24 hours, we always want to add a long-acting sustained-release opioid that can improve their pain. 

The last thing I want to talk about is feeding in these patients. The stent itself opens up the patency, and people can start eating much [more] easily after the stent's put in. But also, things like endoscopic placement of an enteral tube feed—specifically, a gastrostomy bypass for obstructing lesions—is used for delivery of nutrition. Let's say somebody needs to be beefed up nutritionally prior to getting his chemoradiation and can't swallow too much even through the stent—initially placing a PEG (percutaneous endoscopic gastrostomy) tube via interventional radiology, obviously, is imperative to give them that kind of enteral feeding before[hand]. We just need to make sure [patients are aware] that, specifically, there's some complication to PEG tube placements, and we must be aware that gastrostomy tube placements can complicate esophagectomies, if they're in the prospect of happening, and gastric pullup procedures as well.

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