A retrospective study of the epidemiology of esophageal cancer and its management in a Central Indian Institute

Background: The aim of the study was to better understand the epidemiology of esophageal cancer and its management in Indian patients.Methods: This was a retrospective study conducted in a Central Indian institute in which 42 patients of esophageal cancer admitted during a 2 year period were evaluated and treated. All underwent upper gastrointestinal (GI) endoscopy and computed tomography (CT) scan to assess site and extent of tumor.Results: There were a total of 42 patients in the study of which the mean age group was 50-65 years with the disease occurring more commonly in males (65%). The male -female ratio was 1.8:1. The most common histological type was squamous cell carcinoma with 32 patients (76.2%) followed by adenocarcinoma with 10 patients (23.8%). The most common site of the esophagus involved was the lower third and gastro-esophageal junction in 23 patients (54.76%) followed by mid esophagus in 14 patients (33.3%). Most patients were inoperable as the most common stage of presentation was IV in 18 patients. Esophagectomy was possible in 8 patients while 26 underwent feeding jejunostomy and 8 underwent esophageal stenting before being sent for chemoradiation. The 1 year survival rate in this study was 16.6%.Conclusions: Cancer esophagus is still a disease that presents late for treatment in India with majority of patients managed with palliative interventions followed by chemoradiation. The survival rate is poor. Squamous cell carcinoma is far more common with adenocarcinoma showing increasing trends, both occurring more commonly in the lower esophagus.

ENDOSCOPIC STENTING IN THE TREATMENT OF RECURRENT EPIPHRENIC DIVERTICULUM AFTER LAPAROSCOPIC DIVERTICULECTOMY. CLINICAL CASE REPORT

Epiphrenic diverticulum, also known as a pulsion diverticulum, is a rare type of esophageal diverticulum occurring in the distal 10 centimeters of the esophagus. They are most commonly 4-10 cm above the gastric cardia representing 10% of all esophageal diverticula. Laparoscopic diverticulectomy has become the treatment of choice. This clinical case study is dedicated to minimally invasive treatment of recurrent epiphrenic diverticulum after laparoscopic diverticulectomy. A 74-year-old male patient was admitted to the hospital with complaints of dysphagia, regurgitation and halitosis. The examination revealed a 5 cm epiphrenic diverticulum with sings of inflammation. Laparoscopic transchiatal diverticulectomy, the Dor (anterior) fundoplication, cruroraphia and mediastinal drainage were performed. The patient was discharged on the 11-th postoperative day. The patient exhibited dysphagia relapse during a 3-month follow-up. Taking into account the previous surgical treatment and the habitus endoscopic esophageal stenting was chosen as the technique of choice for management. Under intravenous anesthesia a partially covered metal self-expandable stent 10 cm x 1.8 cm was inserted into the distal esophagus. Next day control fluoroscopy showed stable stent position and no evidence of leakage. The water-soluble contrast agent reached stomach freely. The patient was discharged on the 2nd post-operative day. Within 4 months after having a stent placed, the patient feels well and oral feeding is satisfactory. In terms of literature search we have not come across any reference to the post-epiphrenic diverticulectomy recurrence treatment, so the management was chosen individually based on the comorbid status of the patient. The installation of a partially covered metal self-expandable stent allowed to promptly eliminate dysphagia and design features enabled to achieve stent stable position. A partially covered metal self-expandable stent can be considered effective in the post-epiphrenic diverticulectomy recurrence treatment.

THERAPEUTIC TACTICS FOR PEPTIC STRICTURES OF THE ESOPHAGUS. LITERATURE REVIEW

The work is based on the analysis of literature data devoted to the choice of treatment for peptic esophageal strictures. The main goal of this review is to identify treatment tactics for patients with stenosing reflux esophagitis. Researchers point out that the main causes of GERD are a decrease in pressure in the lower esophageal sphincter, the action of the damaging properties of the refluctant. Untimely treatment of GERD can lead to complications such as peptic stricture, Barrett's esophagus. The appearance of GERD stricture is most often promoted by: persistent heartburn after bougienage, erosion of the lower third of the esophagus, shortening of the II degree esophagus, and inadequate antisecretory therapy.Various methods of treatment at all stages of the appearance of peptic stricture are presented, depending on the degree of dysphagia and the length of the stricture, the use of adequate conservative therapy regimens for PPIs, bougienage, as well as a description of various methods of antireflux operations. Endoscopic dilation is the first treatment option for all symptomatic benign esophageal strictures. There are treatments for benign refractory esophageal strictures such as endoscopic dilatation with intraluminal steroid injection, endoscopic postoperative therapy or stricturoplasty, esophageal stenting, self-bougienage, as well as surgery - antireflux surgery, esophagectomy with replacement of the esophagus by the stomach or colon [1].The main goal in the treatment of peptic esophageal strictures, according to most authors, is to eliminate the progression of GERD, conduct bougienage or balloon dilatation, and select the optimal antireflux surgery. Treatment for peptic strictures should minimize the risk of re-stricture of the esophagus.

Esophageal metal stent for malignant obstruction after prior radiotherapy

The association between severe adverse events (SAEs) and prior radiotherapy or stent type remains controversial. Patients with esophageal or esophagogastric junctional cancer who underwent stent placement (2005–2019) were enrolled in this retrospective study conducted at a tertiary cancer institute in Japan. The exclusion criteria were follow-up period of < 1 month and insufficient data on stent type or cancer characteristics. We used Mann–Whitney’s U test for quantitative data and Fisher’s exact test for categorical data. Multivariate analysis was performed using a logistic regression model. 107 stents were placed. Low radial-force stents (L group) were used in 51 procedures and high radial-force stents (H group) in 56 procedures. SAEs developed after nine procedures, the median interval from stent placement being 6 days (range, 1–141 days). SAEs occurred more frequently in the H (14%: 8/56) than in the L group (2%: 1/51) (P = 0.03). In patients who had undergone prior radiotherapy, SAEs were more frequent in the H (36%: 4/11) than in the L group (0%: 0/13) (P = 0.03). Re-obstruction and migration occurred after 16 and three procedures, respectively; these rates did not differ significantly between groups (P = 0.59, P = 1, respectively). Low radial-force stents may reduce the risk of SAEs after esophageal stenting.

INNOVATIVE DIAGNOSTIC METHODS FOR THE TREATMENT OF PATIENTS WITH BOERHAAVE SYNDROME AND ITS COMPLICATIONS

Transluminal endoscopic interventions in the treatment of patients with spontaneous rupture of the esophagus can significantly improve treatment results. Esophageal stenting and vacuum therapy for the treatment of esophageal rupture and suture incompetence are alternatives to surgery.

Esophageal stenting for unresectable cancer (review of literature)

To date, the main way to stop dysphagia for patients with unresectable esophageal cancer is stenting. Being widely accepted and effective, this technique, however, allows for oral nutrition only for an average of 3–4 months and is accompanied by the development of a wide range of complications. Recent Russian and foreign publications in the field show that evaluation of the effectiveness of the stenting technique, including analysis of possibility of complications development, is important for practical application. To improve long-term outcomes, the potential trends in the method evolution have already been identified. The stents coated with radioactive isotopes of iodine are among of the actively used novelties. Application of 3D printing for the manufacture of custom-tailored stents, as well as the inclusion of chemotherapeutic agents in the coating of self-expanding metal stents seem promising approach. The search for a «perfect stent» continues under paradigm of personalization.

Endoscopic stenting of refractory benign esophageal strictures (review)

Despite the fact that the overwhelming majority of benign esophageal strictures, although long-term, but effectively stop with the help of endoscopic recanalization, 10% of them recur. Such strictures are a major problem in thoracic surgery. Disabled surgical methods of treatment are associated with a sufficiently high mortality rate and do not guarantee the formation of new anastomotic strictures. Esophageal stenting against the background of a limited endoscopic arsenal of methods for recanalization of benign strictures is the last option. A lot of different models of esophageal stents with their own individual characteristics and features have appeared since the introduction of the first stents in clinical practice. All were investigated in an attempt to identify the optimal stent type and design for the treatment of refractory benign strictures. The review is devoted to the current state of stenting in recurrent benign esophageal stenosis. The review reflects the efficacy and disadvantages of various types of stents and their comparison with a focus on new biodegradable stents used in the treatment of benign esophageal strictures.

Esophago-Pericardial Fistulae as a Sequela of Boerhaave Syndrome and Esophageal Stenting: A Case Report and Review of Literature

Esophago-pericardial fistulae is a rare and dreaded entity. Most reported cases in the literature were described in association with advanced upper gastrointestinal malignancies, prior surgical procedures, and radiofrequency atrial fibrillation ablation. It has been rarely reported in association with benign esophageal conditions. Surgery had been the mainstay of treatment, but there are increasingly reported cases treated successfully with esophageal stenting and pericardial drainage. In this article, we report a novel case of an esophago-pericardial fistulae occurring as a sequela of esophageal stent placed for the management of Boerhaave syndrome.