This document discusses methods for palliating malignant dysphagia, including endoscopic dilation, ablation, radiation, and stenting. It focuses on endoscopic stenting, describing it as the preferred initial treatment for palliating dysphagia and treating tracheoesophageal fistulas. Several types of esophageal stents are outlined and factors for choosing a stent include its delivery system, expansile force, and removability. Placement techniques for both through-the-scope and non-through-the-scope stents are covered. Managing complications and the endoscopic treatment of tracheoesophageal fistulas, often with fully covered self-expanding metal stents, are also summarized.

1. Palliation of Malignant
Dysphagia
Jason Klapman, MD FASGE
Director of Endoscopy
Moffitt Cancer Center
Tampa, FL

2. Definition
 To Palliate-From the Latin Palliatus-to cloak
or conceal.
 To palliate a disease is to treat it partially and
insofar as possible, but not cure it completely.
 Easing the severity of a pain or a disease without
removing the cause

3. OUTLINE
 Methods of Palliation
 Endoscopic Management of TE Fistulas

4. Methods of Palliation
 Dilation
 Ablation
 Radiation
 Stenting

5. Endoscopic dilation
 Temporary relief of dysphagia
 Balloon or polyvinyl Bougies
 Goal to 15-16mm will allow most foods
 Need for repeat sessions
 Associated procedure risks
 Aspiration
 Perforation

6. Ablation Methods
 Nd:YAG laser
 APC
 PDT
 CRYO

7. Nd:YAG
 Neodymium-yttrium-aluminum-garnet
 Fleisher et al. Am J Surg. 1982
 A new palliative approach for esophageal cancer
 Fulgurating the esophageal cancer to make a
larger lumen.
 Generally requires multiple sessions
 Can be challenging at the cervical esophagus or
GE junction
 Risk of perforation is up to 7%*
 Lightdale et al. GIE Dec1995

8. APC
 Argon Plasma Coagulation
 Monopolar, non-contact method causes tissue
coagulation
 Main complication is bleeding
 Most useful in combination therapy
 CONSORT 1a trial Rupinski et al. Am J of Gastro Sept 2011
 93 pt’s randomized to APC with HDR,PDT or APC alone
 Time to first dysphagia recurrence was 88,59 and 35days
respectively
 APC with HDR fewest complications and highest QoL

9. PDT
 Photodynamic Therapy
 Uses a photosensitizing agent in combination with laser
exposure to ablate malignant tissue
 Porfiner sodium (Photofrin) is the only photosensitizing agent
available in US
 More effective than other ablative techniques
 Lightdale et al. GIE Dec 1995 Multicenter randomized trial of PDT
vs. Nd:Yag laser for palliation of esophageal cancer
 PDT equally efficacious and better tumor response
 Easier to perform
 Less complications than Nd:Yag (1% vs 7%)
 Use is limited by photosensitivity and high cost

10. Cryotherapy
 Used for early or superficial recurrent
esophageal cancer
 Not routinely used for palliation

11. Radiation
 High-dose Brachytherapy (HDR)
 Localized treatment with high-dose radiation with sparing of the
surrounding structures
 Depth of 1cm and length adjustable to tumor length
 Timing of Brachytherapy
 As Monotherapy? Before or after Stenting? In combination with
esophageal stenting or other modalities?
 HDR as Monotherapy
 Homs et al. Lancet 2004
 Brachytherapy better for long term palliation for patients with life
expectancy >3months but less than 6 months
 Stenting better for patients with <3months life expectancy

12. HDR combination therapy
 CONSORT 1a showed benefit in combination with APC
 Berquist et al. Dis Esophagus Jul 2012
 Combined stent insertion and HDR pilot study
 12 patients received stent insertion and then single dose of 12Gy
 Relief of dysphagia in 10/11
 Median survival was 6.6months
 Hirdes et al. GIE Aug 2012
 Combination of Biodegradable stent and single-dose
brachytherapy
 Brachy 12Gy first then stent placement
 19 patients
 28 complications in 17patients (mainly pain and vomiting) causing
premature ending of study

13. Esophageal Stenting
 ASGE Guidelines GIE March 2013
 Esophageal Stenting should be the preferred method
for palliation of malignant dysphagia and Fistulae
 Provides immediate and durable relief in the majority
of patients

14. Esophageal Stents
 Types
 Plastic or Metal
 Fully Covered
 Partially covered
 Uncovered
 Biodegradable

15. Choosing a stent
 Majority are Metal stents
 Most SEMS are equally effective in relieving
symptoms, have similar complication rates
 No study has been done comparing all types of metal
stents
 Choice usually determined by perceived ease of
placement and personal experience of
endoscopist
 Low incidence of migration is the holy grail!!

16. Choosing a stent (con’t)
 Stent characteristics
 Delivery systems
 Deployment patterns
 Expansile force
 Foreshortening characteristics
 Removability

17. Available Esophageal Stents (U.S.)
 Boston Scientific
 Polyflex -strong expansile force,removable 16-21mm 9-12-15cm length
 Ultraflex- distal and proximal release option, most flexible, least expansile force
(partially or uncovered) 18 or 23 mm, 10,12,15cm lengths
 Wallflex-, no foreshortening, smooth delivery vs. Ultraflex, lasso loop
(fully/partially) 18 or 23mm 10,12,15cm
 Cook Endoscopy
 Evolution-no shortening, recapturable, lasso loop, distal release only(fully18,20
-8,10,12cm or partially 20mm, 8,10,12.5,15
 Z stent - no shortening, short bare wire at ends, has anti-reflux valve option
(fully, partially, anti-reflux)18mm, 8,10,12,14
 Merrit Medical EndoTek
 Alimaxx-E-non-foreshortening, fully covered, lasso loop, distal release only
multiple sizes 12-22mm 7,10,12cm lengths
 EndoMaxx-non-forshortening,fully covered,Metal loop, 19,23mm ,7,10,12,15cm
 Endochoice-Bonastent- Fully covered, Hook/Cross technology, Non-
foreshortening, retrieval lasso-18mm 6-16cm length
 TaeWoong- Niti-S TTS, fully covered ,lasso loop 18mm, 6-15cm ,(

18. Non-TTS placement
 A stiff 0.035 guidewire for stability, over which
stent is deployed
 Remove endoscope leaving wire in place
 Back load stent over wire and advance through
stricture
 Can place endoscope alongside stent to observe
deployment if desired (No fluoroscopy needed)
 Choose stent that is 4cm longer than tumor to
allow for 2cm above and below tumor for stability

19. Non-TTS placement

20. TTS placement
 Niti-s esophageal stent
 10.5 fr diameter deployment system
 Use therapeutic upper scope
 Proximal release

21. After stent placement
 Starts clears and slowly advance to soft
foods
 Give post stent diet instructions-tailor it to
the size of stent
 Analgesics prn for pain

22. Complications
 Chest pain
 Bleeding
 Perforation
 Aspiration
 Severe GERD
 Dysphagia: tumor ingrowth, migration, food
impaction, device malposition
 Tracheal Esophageal (TE) Fistula formation

23. OUTLINE
 Methods of Palliation
 Endoscopic Management of TE Fistulas

24. Case History
 65 y.o definitive chemo XRT for proximal
squamous cell esophageal cancer
 Developed non-malignant XRT stricture 6mos
post treatment
 Underwent serial dilations ( 3 over 6 weeks
w/limited improvement)
 Feedings mainly through G-tube
 Presented with worsening dysphagia and cough
and CXR c/w pneumonia

25. Case History
 Endoscopy performed

26. Management of TE Fistula
 Etiology
 Malignant vs. Benign
 Pre-treatment vs. during treatment
 Risk factors
 Previous radiation
 Location (never distal)
 In situ esophageal Stent

27. Endoscopic options
 Placement of a fully covered esophageal
stent is the preferred treatment

28. TTS stent insertion for TE-Fistula

29. Stenting for TE-Fistula
 Success rate is 70%-85% (consider double
stenting)
 Leave stent in for 4-6 weeks and re-evaluate
 Unsuccessful
 Consider re-stenting
 Clipping (OTSC) +/- stenting
 Fibrin Glue application +/- Clipping +/-stenting
 Surgery bypass or mucus fistula

30. Summary
 Palliation in esophageal cancer has one primary
goal
 To allow patients to maintain oral intake and improve quality of
life
 Multiple palliative options are available which
may be used as monotherapy, in combination,
or sequentially.
 Endoscopic stenting is now the preferred initial treatment
modality for both palliation of dysphagia and treatment of TE-
fistula
 Choosing the right stent involves many factors including
physician preference, esophageal stricture characteristics and
location, and patients clinical scenario

31. Thank You!!