Self Expending Metallic Stents (SEMS) with Antireflux Valve for Distal Esophageal Carcinoma: Results of a Randomized Trial

Progressive esophageal carcinoma can infiltrate the surrounding tissues with subsequent development of a fistula, most commonly between the esophagus and the respiratory tract. The endoscopic placement of covered self-expanding metallic stents (SEMS) is the treatment of choice for malignant esophageal fistulas and should be performed immediately, as a fistula formation represents a potential life-threatening complication. We report the case of a 64-year-old male diagnosed with esophageal carcinoma, who had a 20Fr surgical gastrostomy tube inserted before chemo- and radiotherapy and was referred to our department for complete dysphagia, cough after swallowing and fever. The attempt to insert a SEMS using the classic endoscopic procedure failed. Then, a fully covered stent was inserted, as the 0.035” guide wire was passed through stenosis retrogradely by using an Olympus Exera II GIF-N180 (4.9 mm in diameter endoscope) via surgical gastrostomy, with a good outcome for the patient. The retrograde approach via gastrostomy under endoscopic/fluoroscopic guidance with the placement of a fully covered SEMS proved to be the technique of choice, in a patient with malignant esophageal fistula in whom other methods of treatment were not feasible. Abbreviations: ERCP: endoscopic retrograde cholangio-pancreatography; GI: gastrointestinal; SEMS: self-expandable metallic stents.

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Randomized Trial of Preoperative Chemoradiation Versus Surgery Alone in Patients With Locoregional Esophageal Carcinoma

Journal of Clinical Oncology ◽

10.1200/jco.2001.19.2.305 ◽

2001 ◽

Vol 19 (2) ◽

pp. 305-313 ◽

Cited By ~ 944

Author(s):

Susan G. Urba ◽

Mark B. Orringer ◽

Andrew Turrisi ◽

Mark Iannettoni ◽

Arlene Forastiere ◽

...

Keyword(s):

Esophageal Carcinoma ◽

Randomized Trial ◽

Median Survival ◽

Transhiatal Esophagectomy ◽

Preoperative Chemoradiation ◽

Survival Difference ◽

Significant Survival ◽

Significant Difference ◽

Resectable Esophageal ◽

Cervical Esophagogastric Anastomosis

PURPOSE: A pilot study of 43 patients with potentially resectable esophageal carcinoma treated with an intensive regimen of preoperative chemoradiation with cisplatin, fluorouracil, and vinblastine before surgery showed a median survival of 29 months in comparison with the 12-month median survival of 100 historical controls treated with surgery alone at the same institution. We designed a randomized trial to compare survival for patients treated with this preoperative chemoradiation regimen versus surgery alone.MATERIALS AND METHODS: One hundred patients with esophageal carcinoma were randomized to receive either surgery alone (arm I) or preoperative chemoradiation (arm II) with cisplatin 20 mg/m2/d on days 1 through 5 and 17 through 21, fluorouracil 300 mg/m2/d on days 1 through 21, and vinblastine 1 mg/m2/d on days 1 through 4 and 17 through 20. Radiotherapy consisted of 1.5-Gy fractions twice daily, Monday through Friday over 21 days, to a total dose of 45 Gy. Transhiatal esophagectomy with a cervical esophagogastric anastomosis was performed on approximately day 42.RESULTS: At median follow-up of 8.2 years, there is no significant difference in survival between the treatment arms. Median survival is 17.6 months in arm I and 16.9 months in arm II. Survival at 3 years was 16% in arm I and 30% in arm II (P = .15). This study was statistically powered to detect a relatively large increase in median survival from 1 year to 2.2 years, with at least 80% power.CONCLUSION: This randomized trial of preoperative chemoradiation versus surgery alone for patients with potentially resectable esophageal carcinoma did not demonstrate a statistically significant survival difference.

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