esophageal cancer accounts for 1% of all cancers and it is the seventh - most frequent cause of cancer - related deaths . the prognosis in this cancer is poor because in 50% of affected patients the diagnosis is made at an inoperable stage of the disease .
local symptoms of esophageal cancer include dysphagia , odynophagia , cough , nausea , vomiting , regurgitation and retrosternal pain .
dysphagia is a main , but not pathognomonic , symptom , as it may occur in several non - neoplastic diseases ( eg , in achalasia ) . in esophageal cancer , surgery is a treatment of choice if the neoplasm is in operable stage . in inoperable stage
irresectability of esophageal cancer is related to local progression , presence of distant metastases and concurrent severe conditions .
the aim of palliative treatment is to maintain digestive tract patency and to relieve pain .
the latter goal is achieved by pharmacotherapy . in palliative treatment to reduce dysphagia in patients with neoplastic esophageal obstruction , the endoscopic and non - endoscopic methods are applied .
surgery is not useful for symptomatic treatment due to high perioperative mortality and frequent complications . in patients in quite good general condition
however , in most patients with inoperable esophageal tumor , this method is not applicable due to complications and low efficacy .
these 3 aforementioned methods are rarely applied in palliative treatment of esophageal cancer because of severe complications such as post - irradiation esophagitis , esophageal obstruction or tracheoesophageal fistula .
endoscopic methods are : ( 1 ) tumor mass reduction with electrocoagulation , laser therapy , argon plasma coagulation , photodynamic therapy and injection therapy ; and ( 2 ) preservation of a proper diameter of esophagus lumen with the aid of dilation , implantation of esophageal endoprostheses , and use of a gastric feeding tube . within the endoscopic methods , only the use of endoprostheses yields long - term effects ; however , the other methods have high recurrence rates . a patient with primary esophageal cancer and life expectancy over 3 months should be qualified to palliative brachytherapy . in patients with life expectancy below 3 months , as well as with recurrence of dysphagia after brachytherapy ,
the main differences between them concern the material they are made from , their shape , type of net braid , flexibility , diameter , length , manner of drug releasing , degree of torsion after application and the presence of an anti - reflux valve . currently , self - expanding drug - coated stents are used most often because of better long - term effect of palliation in neoplastic dysphagia .
no particular type of drug - coated self - expanding stents has been proven to be superior to others in the treatment of neoplastic dysphagia .
the choice of therapeutic method should be based on technical capabilities of the medical centre , and experience and skills of the operator .
patients with neoplastic dysphagia fulfilling criteria of inoperability were included into the study . in patients with dysphagia
, the palliative treatment was introduced due to local progression of the lesion , presence of metastases or poor general condition .
all patients had total esophageal obstruction . within years 20092010 , a total of 46 patients ( 41 males and 5 females ) were qualified to palliative implantation of coated self - expandable stent ( cook evolution , cook ireland ltd . ) in the gastrointestinal endoscopy laboratory of the wam medical university hospital in d .
the mean age of the patients was 67 years ( from 51 to 78 ) .
neoplastic tumor resulting in obstruction was localized in the following parts of esophagus : distal ( within the distal 10 cm ) in 24 patients , medial in 13 patients and proximal ( up to 10 cm from the upper esophageal sphincter ) in 9 patients .
tracheoesophageal fistulas in tumor mass were detected in 3 patients by means of contrast radiological examination . in all patients evolution type coated ,
the evolution stent is an elastic self - expandable stent woven from a single nitinol wire .
the procedures were conducted with sedation , in supine position , under fluoroscopic control . prior
to stent implantation , the endoscopic examination evaluating the size and the extent of the esophageal lesion , anatomical localization in esophagus , as well as the distance from the upper and lower esophageal sphincter , was performed in every patient .
the following types of endoscopes were used : gif q165  8.9 mm , gif xp180n  5.9 mm and gif hi80j  9 mm . in the cases of difficulty in passing the endoscope through an obstruction ,
balloon dilation ( up to 20 mm , in accordance with the prosthesis dilatability ) was carried out . during stent
the length of the stent was adjusted so that it was 46 cm longer than the neoplastic lesion , protruding 2 cm both above and under the lesion margins .
in the cases of tumor localization in the proximal esophagus , the patient was qualified for stent implantation provided there was a 2 centimeter margin from the upper esophageal sphincter free from the neoplastic infiltration .
this condition is crucial for safe stent implantation without subsequent symptoms of pain , tracheal compression or feeling of a foreign body in the esophagus . in all cases , 24 hours after the implantation , radiological examination was performed to assess the stent location .
all patients included in the study were discharged from hospital up to 48 hours from stent implantation .
after the procedure , proton pump inhibitor ( ppi ) was chronically administered in all patients in order to reduce the symptoms and not irritate the inflamed mucous membrane of the esophagus .
other drugs used by some of the patients included analgesics , received also before the implantation due to the basic disease .
the results of esophageal cancer treatment with coated stent implantation are shown in table 2 .
pictures of lesion prior to and following stent implantation are presented in figures 13 ( endoscopic images ) and in figure 4 ( x - ray images ) . in 4 patients of the study group ,
tracheoesophageal fistulas were found before stent implantation . in 3 cases they were consequences of the neoplasm , while 1 was iatrogenic due to prior esophageal dilation .
endoscopic esophageal dilation prior to stent implantation was required in 21 patients . in all 4 cases ,
application of the coated stent provided entire sealing of fistulas , and in the subsequent follow - up no complications related to fistulas were observed . among the aforementioned complications , summarized in table 6
they accounted for 28% ( 5/18 ) of complications and occurred in less than 9% of patients ( 4/46 ) .
the second group comprises non - life threatening complications , which only required application of an additional procedure .
those complications include stent malposition , chest pain , nausea , gastroesophageal reflux and stent occlusion by food material .
this group accounted for 72% ( 13/18 ) of all complications , and they occurred in 17% ( 8/46 ) of patients .
the stage of neoplastic disease , general patient condition and ( in consequence ) life expectancy , should be taken into account in choosing a method for palliative treatment of dysphagia caused by esophageal cancer .
our study confirmed the usefulness of this method in palliative treatment of neoplastic dysphagia . in 44
of 46 patients the degree of dysphagia improved from stage 5/6 ( inability to swallow any food or saliva ) to stage 1 ( ability to swallow solid food ) .
satisfactory remission of dysphagia was not reached in 2 cases in which the tumor was localized in the area of the gastric cardia . in these cases ,
average time of survival in all the patients was 102 days . in our research ,
the percentage of patients in which any complications occurred as a result of esophageal stenting with coated nitinol prosthesis was 39% .
severe complications such as perforation , respiratory tract compression , bleeding and death occurred in 11% of the patients under therapy .
non - severe complications such as stent malposition , chest pain , nausea , gastroesophageal reflux and stent occlusion by food material occurred in 17% of the analyzed patients . in comparison with results from the literature ,
immediate complications occurring during stent implantation include perforation , aspiration pneumonia , fever , bleeding , stent malposition , respiratory failure and death*. in our research these complications occurred in 11% ( 5/46 ) of the patients . in 2 cases ,
a perforation caused by balloon dilation of the esophagus occurred and in 1 case stent malposition , was verified in the next endoscopic investigation and the reposition was made with the aid of pincers .
the 2 most severe complications occurred in 1 patient in poor general condition  respiratory failure led to the patient s death .
this patient had a left lung cavity tumor , infiltrating the bronchi and the esophagus , with metastases to the liver . due to the bronchus infiltration it was impossible to secure it with simultaneous bronchus stenting according to recommendations found in the literature . due to early complications ( occurring in the first 7 days after the stent implantation ) we observed 1 bleeding , 2 stent migrations and 4 patients complained of chest pain .
the bleeding that occurred in patient with a gastric cardia tumor was caused by mechanical damage to the tumor mass and was controlled pharmacologically ; endoscopic intervention was unnecessary in this case .
reported the occurrence of chest pain after esophageal self - expanding stent implantation in 30% of the patients .
in other papers the frequency of this complication was estimated at from 5% to 50% . in our study
all of these cases were successfully controlled with non - steroidal anti - inflammatory drugs within 48 hours after the stent implantation .
late complications ( occurring more than 1 week after the procedure ) included : recurrent dysphagia , stent migration , fistulas , bleeding , symptoms of gastroesophageal reflux and neoplasm overgrowth . according to the literature
, prosthesis migration occurs in approximately 515% of the cases , as an early , immediate or late complication .
the most frequent re - intervention methods after stent migration are second stent implantation or stent reposition with the aid of a loop or pincers . in our research
this complication occurred in 5% of the cases and concerned stent implantation in patients with tumor of the distal part of the esophagus . in 1 of those cases , for the correct placement of the prosthesis , it was enough to perform reposition with the aid of pincers . in the second case it was necessary to apply a second stent to obtain patency of the esophagus ; in our research this was an early complication .
gastroesophageal reflux is a common complaint of patients with neoplasms located in the distal part of the esophagus , when the distal end of the prosthesis goes through the lower esophageal sphincter . as a preventive method
, a prosthesis with an anti - reflux valve or pharmacological treatment may be applied .
other studies , due to the lack of clear proof of efficacy of stents with an anti - reflux valve , do not recommend their application in patients with dysphagia caused by neoplastic stenosis of the distal part of the esophagus and cardia .
bleeding most often occurs as a late complication ; the etiology of this complication is not fully agreed upon .
the procedures in case of severe hemorrhage include blood transfusion and pharmacological treatment . in our study , bleeding as a late complication did not occur . in 1 case
this lesion appeared in the fourth week of observation as a consequence of esophageal wall weakening by a pathological neoplastic mass that did not withstand the centrifugal force exerted by the stent .
the fistula occurred in the area where the coated and uncoated parts of the stent are joined .
the most common late complication , occurring 24 months after the stent implantation , is neoplasm infiltration at the ends of the prosthesis .
both ends are affected with comparable frequency in this complication , which has been observed in 1020% of patients .
in such a case , the method of choice is implantation of a second stent . in our observation , adhering to the rule that both ends of the prosthesis protrude by 23 cm of the neoplastic stenosis allowed avoidance of the infiltration of the prosthesis by the neoplastic mass . in our observation , in 2 cases the reoccurrence of dysphagia appeared as a result of stent occlusion with food material .
it was a late complication in both cases , it resulted from violating the rules of proper food consumption , and it was easily treated by endoscopic stent cleaning .
in patients with neoplastic esophageal stenosis , stenting with coated , self - expandable nitinol prostheses is a safe , effective and quick method of palliative dysphagia treatment .
severe , possibly life - threatening , complications constituted 28% of all the complications and occurred in 9% of the patients .
other complications , which were less severe , occurred in 17% of the observed patients and were not life - threatening . future research to enhance the quality of the available stents , as well as the introduction of new stent types ( biodegradable , with radioactive coating , delivering drugs ) will help to decrease of the number of complications and enhance the quality of life of patients in the terminal phase of the disease .
 summarybackgroundesophageal cancer is the seventh - most frequent cause of cancer - related deaths and it is usually diagnosed at an inoperable stage . in palliative treatment , endoscopic and non - endoscopic methods are applied to reduce dysphagia in patients with neoplastic esophageal obstruction . because of severe complications , non - endoscopic treatment ( surgery , radiotherapy , brachytherapy and chemotherapy ) is applied rarely . within the endoscopic methods , only the use of endoprostheses yields long - term effects . 
 the aim of this study was to evaluate the safety and efficacy of implantation of self - expandable esophageal stents in palliative treatment of dysphagia related to esophageal cancer.material/methodsa total number of 46 patients ( 41 males and 5 females ) were qualified to palliative implantation of coated self - expandable stent . 
 the mean age of the patients was 67 years ( from 51 to 78 years ) . in all patients , evolution - type coated self - expandable stents 
 were used . in all cases , 24 hours after the implantation , radiological examination was performed to assess the stent location.resultssevere , possibly life - threatening , complications constituted 28% of all the complications and occurred in 9% of the patients . 
 less severe complications occurred in 17% of the observed patients and were not life-threatening.conclusionsin patients with neoplastic esophageal stenosis , stenting with coated , self - expandable nitinol prostheses is a safe , effective and fast method of palliative dysphagia treatment . 
Background
Material and Methods
Results
Discussion
Conclusions