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Generally, cancer of the esophagus and gastroesophageal junction carries with it a poor prognosis. The expected 5-year survival with esophageal cancer is 40%, 21%, and 4%, for localized, regional, and distant disease, respectively.1 Approximately 50% of patients presenting with esophageal cancer are not candidates for surgical resection at the time of diagnosis.2 Unfortunately, these patients frequently have symptoms, particularly dysphagia, that require palliation. Therefore, the first objective of treatment is to adequately assess their symptoms. Establishing the extent of dysphagia (Table 91-1), and assessing accompanying pain, bleeding, aspiration, and other symptoms will assist in determining the best therapies required for effective palliation.
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There are many different treatment modalities available for the palliation of esophageal cancer. Endoscopic intervention is the most common means and includes dilation, ablative techniques, local injection, and endoluminal stents. Similarly radiation, chemoradiation, and chemotherapy are used for symptomatic relief in unresectable patients. Surgery is used palliatively as a means for obtaining enteric access. Due to the poor prognosis and significant morbidity, radical palliative resection is rarely, if ever, indicated and mentioned only for completeness.
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ENDOSCOPIC PROCEDURES
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Endoscopic procedures are becoming increasingly common in the management of advanced malignancy. The primary indication is dysphagia without complete obstruction. The goal of therapy is restoration of the esophageal lumen with return or improvement of enteral intake.
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Endoscopic dilation offers a temporary relief of symptoms. Generally, the therapeutic effects of dilation last a couple of days to 2 weeks.2 This method of palliation is used primarily to allow access for other modalities or in patients with short-term life expectancies. The benefits of esophageal dilation are its low cost and immediate effectiveness. There are several modes of esophageal dilation including mercury-weighted rubber bougies (Maloney dilators), hydrostatic and pneumatic endoscopic balloon dilators, and wire-guided poly-vinyl bougies (Savary dilators). To date, there are no large trials comparing the types of esophageal dilation. Hernandez and colleagues published a report comparing the types of dilation used and their associated complications. In their series of 142 patients, four patients experienced a perforation during dilation. All four patients were dilated blindly with a Mahoney dilator and had complex strictures defined by having one or more of the following: asymmetry, diameter of less than or equal to 12 mm, malignancy, caustic esophagitis, sclerotherapy for esophageal varices, surgically altered anatomy, or associated esophageal diverticulae.3 However, while there is a reported perforation risk of approximately 5%, dilation remains an acceptable short-term palliative therapy for malignant esophageal strictures.4
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