116-5107/90/3601-0043$02.00 ASTROINTESTINAL ENDOSCOPY opyright © 1990 by the American Society for Gastrointestinal Endoscopy
Jse of ethanol-induced tumor necrosis to Jalliate dysphagia in patients with 3sophagogastric cancer J. J. Payne-James, FRCS, FRCSEd, R. C. Spiller, MD, MRCP J. J. Misiewicz, FRCP, D. B. A. Silk, MD, FRCP London, United Kingdom
:Ieven patients with dysphagia caused by inoperable, unresectable, or recurrent cancer were treated by endoscopic injection of ethanol (with or without per-oral dilation) to induce tumor necrosis. Prior to treatment, patients had a mean dysphagia grade of 3. After one treatment, dysphagia grade had improved to a mean of 1.5. An optimum dysphagia grade (mean, 0.9) was achieved after a mean of 1.6 injection treatments. Treatments were repeated as symptoms recurred, with a mean period between repeat treatments of 32 days (median, 26). There were no complications associated with ethanol-induced tumor necrosis (ETN). Mean patient survival was 140 days (median, 109). These results suggest that ETN has considerable potential for palliation of malignant dysphagia in selected patients. (Gastrointest Endosc 1990;36:43-46) ~sophagogastric
Prognosis for patients with carcinomas of the esophagus and stomach is poor, and most patients are beyond cure by the time the diagnosis has been made. Palliation of symptoms, predominantly dysphagia, is therefore often the main aim of treatment. Surgery offers the possibility of complete relief of dysphagia with an acceptably low mortality rate,1 even within the elderly population. 2 There are, however, three groups of patients, those with inoperable tumors, those with unresectable tumors, and those with recurrent tumors, in whom surgery is not possible and for whom an effective method of palliation is needed. It has been stated that the ideal palliative technique should be "quick, safe, painless, needing only a short inpatient stay, and a low complication rate.,,3 To this list could be added, "easily repeatable, but only needing repetition infrequently," as regrowth of tumor and recurrence of symptoms is common. Four main methods of palliation of malignant dysphagia are available, each with differing advantages and disadvantages. Intubation of the maligReceived December 1, 1988. For revision April 3, 1989. Accepted July 19, 1990. From the Department of Gastroenterology and Nutrition, Central Middlesex Hospital, London, United Kingdom. Reprint requests: J. J. Payne-James, FRCS, Department of GaBtroenterology and Nutrition, Central Middlesex Hospital, Acton Lane, London NWlO 7NS, United Kingdom. VOLUME 36, NO.1, 1990
nant obstruction, by either a surgical or an endoscopic technique, has been shown to be effective in improving quality of life, albeit with an associated morbidity and mortality.4,5 Per-oral endoscopic dilation by itself fulfills most of the criteria for an ideal palliative technique, but may require repeating on many occasions, sometimes on a weekly basis. G,7 Radiation therapy is predominantly suitable for squamous cell carcinomas, and despite increasingly sophisticated techniques (some requiring general anesthesia8 ) the degree of palliation may not be markedly different from other methods. 9 Recent studies have demonstrated the usefulness of laser,1O-12 but this equipment is not readily available in a majority of hospitals at present. Despite the variety of palliative techniques, it is apparent that the optimal therapy has not yet been found for this difficult group of patients. Clearly it is desirable to keep hospital attendances and length of inpatient stay to a minimum. Encouraging results using dehydrated alcohol to cause necrosis and destruction of gastric cancer have been reported. 13 Injection of sclerosant solutions into the esophagus for the treatment of esophageal varices has become an established procedure that has been performed on an outpatient baSiS. 14 ,15 The possibility was considered that malignant dysphagia related to esophageal or gastric cardia neoplasms could be palliated by direct injection of tumor with alcohol via an endoscope, thereby inducing tumor 43
necrosis. A summary of the initial results of five patients undergoing this method of treatment has been reported. 16 We present a full analysis of those and six other patients treated with this technique. METHODS Patients
All patients (N = 11) were referred for palliation of dysphagia secondary to malignant obstructing lesions of the esophagus or gastric cardia. Patient and stricture details are listed in Table 1. All patients were considered to be incurable. Dysphagia was graded using a score modified from Bown et al. 1l (Table 2). There were 10 men and 1 woman with a mean age of 72.9 years (range, 58 to 87). Nine patients had adenocarcinomas and two had squamous cell carcinomas. Mean stricture length was 5.27 cm (range, 1 to 10 cm) with six strictures less than 5 cm and five between 5 and 10 cm.
Endoscopic technique
Patients underwent upper gastrointestinal endoscopy. Intravenous diazepam was used as a sedative with either intravenous pethidine or nalbuphine as analgesia. If occlusion of the esophageal lumen was not complete, dilation of the esophagus using 12- or 18-mm Celestin dilators was undertaken as required (N = 6) to permit passage of the endoscope beyond the obstruction. If the endoscope could traverse the stricture with or without dilation, dehydrated ethanol was injected via the endoscope using a variceal injector needle. The needle was inserted into the tumor to its full depth. Injections were directed in 0.5- or I-ml aliquots directly into macroscopic tumor. Satisfactory injection was recognized by blanching of the tumor mass at the injection site. If blanching did not occur, but there was no visible leak back of alcohol, injection was also considered to be satisfactory. Injections were sited away from macroscopically normal esophagus to
minimize the possible complication of stricture fOJ mation. The number and total volume of injection required at each treatment was empirical and depend ent on the size (length and bulk) of the tumor. Thm all visible tumor was injected, with longer and mor exophytic strictures requiring a larger number of in jections. After each treatment, temperature, pulse, ant blood pressure were monitored for 6 hours and thel free fluids were started. The patients had a ligh breakfast the morning following treatment after whicl the patient could be discharged from the hospital Dysphagia grades were recorded at least 3 days afte each treatment. In those patients with total obstruc tion in whom passage of the endoscope and pre-injec tion dilation was impossible (N = 4), circumferentia ethanol injection into visible tumor was undertaken Patients were reendoscoped 1 week later, and dilatior was attempted again. This was successfully achievec in three patients but was not possible in the remainin~ one at the time of the second injection treatment despite improvement in dysphagia. Dilation was eventually achieved at a third endoscopy. Following discharge the patients were advised to contact the Unit when subsequent deterioration in symptoms occurred, so that a direct admission for repeat treatment could be arranged. Dietary advice including the use of dietary supplements was also given. Table 2. Dysphagia grade Grade
Degree of dysphagia
o
Normal swallowing Occasional sticking of solids Swallows semisolid/pureed diet Swallows only liquids Vnable to swallow saliva
1 2 3 4
Table 1. Patients details Patient
Age
Sex
1 2 3 4 5
58 82 73 77 68
M M M M M
6 7 8
68 74 78 87 62 75
M F M M M M
9
10 11
Status
va I V I R
V I I I
V I
Stricture site (cm from incisors)
Length (cm)
28-36" 40-45 30-40 35-40 At anastomosis
8 5 10 5 1
42-50 35-38 36-40 30-35· 35-40 36-40
8 3 4 5 5 4
Comments Fixed tumor COPD Fixed tumor COPD Ivor-Lewis esophagectomy Fixed tumor Liver metastases COPD Lung metastases Fixed tumor Refused operation
V, unresectable; I, inoperable; R, recurrence; COPD, chronic obstructive pulmonary disease. " Squamous cell carcinoma.
a
44
GASTROINTESTINAL ENDOSCOPY
RESULTS
The typical appearance 1 week after injection is een in Figure 1. Similarity will be noticed between 1jection treatment and the appearance after laser herapy. Patients had a mean dysphagia score of 3 ± .6 (grades 2 to 4) before the first treatment. Ten of he 11 patients (91 %) improved by at least one dysIhagia grade after one treatment, and 100% eventually mproved. Dysphagia scores were 1.5 ± 0.8 (grades 0 o 3) after the first treatment recorded 3 to 5 days lfter injection. The best dysphagia scores of 0.9 ± 0.7 grades 0 to 2) were achieved after repeated therapy, 'esulting in a mean improvement of 2.1 dysphagia (rades. Nine patients (82%) were able to manage most ,olid food (dysphagia grade 1). Individual results are :ecorded in Table 3. The patients underwent 36 treatnents in total. Volumes of ethanol injected were 9 ± 1.6 (1.5 to 22) ml. Mean number of dilations per mbject was 1.2 ± 1.5 (0 to 5). Patients underwent 3.3 ± 2.4 (1 to 8) injections. All patients have now died with a mean survival after first treatment of 140 ± 84 days (median, 109). All patients but one were able at least to swallow
Typical endoscopic appearance of esophagus 1 week after ETN.
Figure 1.
pureed food. One patient (no. 10) with a squamous carcinoma had two injection treatments prior to palliative radiotherapy. After radiotherapy, however, the dysphagia worsened, necessitating insertion of an Atkinson tube. No injection or dilation complications were recorded in this series of patients. DISCUSSiON
In this small series the results after ethanol-induced tumor necrosis (ETN) compare favorably with other methods of palliation. ETN fulfills criteria for an ideal palliation agent. It is quick, as it is undertaken with intravenous sedation in an endoscopy unit. It is safe. In this series no complications or deaths were recorded, although the possibility of perforation, hemmorrhage, and other complications associated with tumor destruction is present. Pain is controlled by titration of intravenous opiate analgesia during the procedure, and none of the patients have required more than simple analgesia. Analgesia was not required after 24 hours. Future treatments are planned on a day-stay basis. Most patients will be able to swallow most solid foods, and all in this series had a marked improvement in symptoms compared with symptoms at presentation. A mean overall improvement of 2.1 on the dysphagia scale compares with a figure of 1.7 following laser therapyll (although slight differences in grading were used). It is unlikely that the improvement can be attributed entirely to dilation as this was not done in every patient. The four patients who did not undergo dilation all improved their dysphagia grades. Two patients (nos. 4 and 9) improved by one grade, and two patients (nos. 5 and 8) by two grades, after one injection without dilation. For those in whom dilation was undertaken, the numbers of dilations per patient are substantially less when compared with other series where per-oral dilation is the sole method of treatment. 6 • 7 ETN requires no special skills or training beyond those of an endoscopist fully experienced in both
Table 3. Treatment details Dysphagia grade After one treatment
Best grade
No. of injections
No. of dilations
Survival (days)
2
1
3 3 3 3 3
2 3 2
0 1 0 1 1 1 2 0 2 1 1
5 3 2 7 1 1 2 2 2 8 3
1 1 3 0 0 1 1 0 0 5 1
186 212 109 301 94 94 21 167 92 223 47
Patient Pre-treatment 1 2 3 4
5 6 7 8 9 10 11
VOLUME 36, NO.1, 1990
1 1
4
2
2 3 3
o
4
1
2 2
45
esophageal dilation and injection sclerotherapy. All the equipment is readily available in any therapeutic endoscopy unit. Cost implications in establishing an ETN service are therefore negligible, while other palliative techniques may require a substantial capital outlayY Patient in-hospital stay is short, and repetition of treatment is undertaken less often than dilation alone 6,7 and is comparable to laser. 11, 12 The poor survival of these patients emphasizes the desirability of quick, effective palliation. ETN would seem to have marked potential in the treatment of dysphagia resulting from malignant stricture in selected patients. It must be stressed, however, that these are results from a small series of patients and before definite recommendations for the use of this technique can be made, further prospective evaluation to determine specific details such as optimum injection volumes and length of time between treatments must be undertaken. It would seem that a prospective controlled trial comparing ETN with laser therapy would be of considerable interest.
5.
6. 7. 8. 9. 10. 11. 12. 13.
14.
REFERENCES 1. Hennessy TPJ. Choice of treatment in carcinoma of the oesophagus. Br J Surg 1988;75:193-4. 2. Keeling P, Gillen P, Hennessy TPJ. Oesophageal resection in the elderly. Ann Coli Surg EngI1988;70:34-6. 3. Cox J, Bennett JR. Light at the end of the tunnel? Palliation for oesophageal carcinoma. Gut 1987;28:781-5. 4. Watson A. A study of the quality and duration of survival
46
15. 16. 17.
following resection, endoscopic intubation and surgical intubl tion in oesophageal carcinoma. Br J Surg 1982;69:585-8. Den Hartog Jager FCA, Bartelsman JFWM, Tytgat GNJ. Pa liative treatment of obstructing esophagogastric malignancy b endoscopic positioning of a plastic prosthesis. Gastroenterolo~ 1979;77:1008-14. Heit HA, Johnson LF, Siegel SR, Boyce HW. Palliative dilatio for dysphagia in esophageal carcinoma. Ann Intern Me 1978;89:629-31. Moses FM, Peura DA, Wong, RKH, Johnson LF. Palliativ dilation of esophageal carcinoma. Gastrointest Endos 1985;31:61-3. Rowland CG, Pagliero KM. Intracavitary irradiation in pallia tion of carcinoma of oesophagus and cardia. Lancet 1985;2:98] Earlam R, Cunha-Melo JR. Oesophageal squamous cell carci noma II. A critical review of radiotherapy. Br J Sur 1980;67:457-61. Fleischer D, Sivak MV. Endoscopic Nd:YAG laser therapy a palliation for esophagogastric cancer. Parameters affecting ini tial outcome. Gastroenterology 1985;89:827-31. Bown SG, Hawes R, Matthewson K, Swain CP, Barr H, Boulo, PB, Clark CG. Endoscopic laser palliation for advanced malig nant dysphagia. Gut 1987;28:799-807. Krasner N, Barr H, Skidmore C, Morris AI. Palliative lase: therapy for malignant dysphagia. Gut 1987;28:792-8. Maruyama M, Adachi H, Ito Y, Kurokawa K, Suzuki S. Endo scopic treatment of gastric carcinoma by local injection of pun ethanol. Presented at European Gastrointestinal Endoscop) Congress (Lisbon 1984): abstract 29. Drell E, Prindiville T, Trudeau W. Outpatient endoscopic injection sclerosis of esophageal varices. Gastrointest Endose 1986;32:4-6. Korula J. Outpatient esophageal variceal sclerotherapy. Gastrointest Endosc 1986;32:1-3. Spiller RC, Misiewicz JJ. Ethanol-induced tumor necrosis for palliation of malignant dysphagia. Lancet 1987;2:792. Myszor MF, Rich AJ, Bottrill P, Record CO. The impact of an endoscopic laser service on gastroenterological practice. Q J Med 1989;261:73-9.
GASTROINTESTINAL ENDOSCOPY
Jse of ethanol-induced tumor necrosis to Jalliate dysphagia in patients with 3sophagogastric cancer J. J. Payne-James, FRCS, FRCSEd, R. C. Spiller, MD, MRCP J. J. Misiewicz, FRCP, D. B. A. Silk, MD, FRCP London, United Kingdom
:Ieven patients with dysphagia caused by inoperable, unresectable, or recurrent cancer were treated by endoscopic injection of ethanol (with or without per-oral dilation) to induce tumor necrosis. Prior to treatment, patients had a mean dysphagia grade of 3. After one treatment, dysphagia grade had improved to a mean of 1.5. An optimum dysphagia grade (mean, 0.9) was achieved after a mean of 1.6 injection treatments. Treatments were repeated as symptoms recurred, with a mean period between repeat treatments of 32 days (median, 26). There were no complications associated with ethanol-induced tumor necrosis (ETN). Mean patient survival was 140 days (median, 109). These results suggest that ETN has considerable potential for palliation of malignant dysphagia in selected patients. (Gastrointest Endosc 1990;36:43-46) ~sophagogastric
Prognosis for patients with carcinomas of the esophagus and stomach is poor, and most patients are beyond cure by the time the diagnosis has been made. Palliation of symptoms, predominantly dysphagia, is therefore often the main aim of treatment. Surgery offers the possibility of complete relief of dysphagia with an acceptably low mortality rate,1 even within the elderly population. 2 There are, however, three groups of patients, those with inoperable tumors, those with unresectable tumors, and those with recurrent tumors, in whom surgery is not possible and for whom an effective method of palliation is needed. It has been stated that the ideal palliative technique should be "quick, safe, painless, needing only a short inpatient stay, and a low complication rate.,,3 To this list could be added, "easily repeatable, but only needing repetition infrequently," as regrowth of tumor and recurrence of symptoms is common. Four main methods of palliation of malignant dysphagia are available, each with differing advantages and disadvantages. Intubation of the maligReceived December 1, 1988. For revision April 3, 1989. Accepted July 19, 1990. From the Department of Gastroenterology and Nutrition, Central Middlesex Hospital, London, United Kingdom. Reprint requests: J. J. Payne-James, FRCS, Department of GaBtroenterology and Nutrition, Central Middlesex Hospital, Acton Lane, London NWlO 7NS, United Kingdom. VOLUME 36, NO.1, 1990
nant obstruction, by either a surgical or an endoscopic technique, has been shown to be effective in improving quality of life, albeit with an associated morbidity and mortality.4,5 Per-oral endoscopic dilation by itself fulfills most of the criteria for an ideal palliative technique, but may require repeating on many occasions, sometimes on a weekly basis. G,7 Radiation therapy is predominantly suitable for squamous cell carcinomas, and despite increasingly sophisticated techniques (some requiring general anesthesia8 ) the degree of palliation may not be markedly different from other methods. 9 Recent studies have demonstrated the usefulness of laser,1O-12 but this equipment is not readily available in a majority of hospitals at present. Despite the variety of palliative techniques, it is apparent that the optimal therapy has not yet been found for this difficult group of patients. Clearly it is desirable to keep hospital attendances and length of inpatient stay to a minimum. Encouraging results using dehydrated alcohol to cause necrosis and destruction of gastric cancer have been reported. 13 Injection of sclerosant solutions into the esophagus for the treatment of esophageal varices has become an established procedure that has been performed on an outpatient baSiS. 14 ,15 The possibility was considered that malignant dysphagia related to esophageal or gastric cardia neoplasms could be palliated by direct injection of tumor with alcohol via an endoscope, thereby inducing tumor 43
necrosis. A summary of the initial results of five patients undergoing this method of treatment has been reported. 16 We present a full analysis of those and six other patients treated with this technique. METHODS Patients
All patients (N = 11) were referred for palliation of dysphagia secondary to malignant obstructing lesions of the esophagus or gastric cardia. Patient and stricture details are listed in Table 1. All patients were considered to be incurable. Dysphagia was graded using a score modified from Bown et al. 1l (Table 2). There were 10 men and 1 woman with a mean age of 72.9 years (range, 58 to 87). Nine patients had adenocarcinomas and two had squamous cell carcinomas. Mean stricture length was 5.27 cm (range, 1 to 10 cm) with six strictures less than 5 cm and five between 5 and 10 cm.
Endoscopic technique
Patients underwent upper gastrointestinal endoscopy. Intravenous diazepam was used as a sedative with either intravenous pethidine or nalbuphine as analgesia. If occlusion of the esophageal lumen was not complete, dilation of the esophagus using 12- or 18-mm Celestin dilators was undertaken as required (N = 6) to permit passage of the endoscope beyond the obstruction. If the endoscope could traverse the stricture with or without dilation, dehydrated ethanol was injected via the endoscope using a variceal injector needle. The needle was inserted into the tumor to its full depth. Injections were directed in 0.5- or I-ml aliquots directly into macroscopic tumor. Satisfactory injection was recognized by blanching of the tumor mass at the injection site. If blanching did not occur, but there was no visible leak back of alcohol, injection was also considered to be satisfactory. Injections were sited away from macroscopically normal esophagus to
minimize the possible complication of stricture fOJ mation. The number and total volume of injection required at each treatment was empirical and depend ent on the size (length and bulk) of the tumor. Thm all visible tumor was injected, with longer and mor exophytic strictures requiring a larger number of in jections. After each treatment, temperature, pulse, ant blood pressure were monitored for 6 hours and thel free fluids were started. The patients had a ligh breakfast the morning following treatment after whicl the patient could be discharged from the hospital Dysphagia grades were recorded at least 3 days afte each treatment. In those patients with total obstruc tion in whom passage of the endoscope and pre-injec tion dilation was impossible (N = 4), circumferentia ethanol injection into visible tumor was undertaken Patients were reendoscoped 1 week later, and dilatior was attempted again. This was successfully achievec in three patients but was not possible in the remainin~ one at the time of the second injection treatment despite improvement in dysphagia. Dilation was eventually achieved at a third endoscopy. Following discharge the patients were advised to contact the Unit when subsequent deterioration in symptoms occurred, so that a direct admission for repeat treatment could be arranged. Dietary advice including the use of dietary supplements was also given. Table 2. Dysphagia grade Grade
Degree of dysphagia
o
Normal swallowing Occasional sticking of solids Swallows semisolid/pureed diet Swallows only liquids Vnable to swallow saliva
1 2 3 4
Table 1. Patients details Patient
Age
Sex
1 2 3 4 5
58 82 73 77 68
M M M M M
6 7 8
68 74 78 87 62 75
M F M M M M
9
10 11
Status
va I V I R
V I I I
V I
Stricture site (cm from incisors)
Length (cm)
28-36" 40-45 30-40 35-40 At anastomosis
8 5 10 5 1
42-50 35-38 36-40 30-35· 35-40 36-40
8 3 4 5 5 4
Comments Fixed tumor COPD Fixed tumor COPD Ivor-Lewis esophagectomy Fixed tumor Liver metastases COPD Lung metastases Fixed tumor Refused operation
V, unresectable; I, inoperable; R, recurrence; COPD, chronic obstructive pulmonary disease. " Squamous cell carcinoma.
a
44
GASTROINTESTINAL ENDOSCOPY
RESULTS
The typical appearance 1 week after injection is een in Figure 1. Similarity will be noticed between 1jection treatment and the appearance after laser herapy. Patients had a mean dysphagia score of 3 ± .6 (grades 2 to 4) before the first treatment. Ten of he 11 patients (91 %) improved by at least one dysIhagia grade after one treatment, and 100% eventually mproved. Dysphagia scores were 1.5 ± 0.8 (grades 0 o 3) after the first treatment recorded 3 to 5 days lfter injection. The best dysphagia scores of 0.9 ± 0.7 grades 0 to 2) were achieved after repeated therapy, 'esulting in a mean improvement of 2.1 dysphagia (rades. Nine patients (82%) were able to manage most ,olid food (dysphagia grade 1). Individual results are :ecorded in Table 3. The patients underwent 36 treatnents in total. Volumes of ethanol injected were 9 ± 1.6 (1.5 to 22) ml. Mean number of dilations per mbject was 1.2 ± 1.5 (0 to 5). Patients underwent 3.3 ± 2.4 (1 to 8) injections. All patients have now died with a mean survival after first treatment of 140 ± 84 days (median, 109). All patients but one were able at least to swallow
Typical endoscopic appearance of esophagus 1 week after ETN.
Figure 1.
pureed food. One patient (no. 10) with a squamous carcinoma had two injection treatments prior to palliative radiotherapy. After radiotherapy, however, the dysphagia worsened, necessitating insertion of an Atkinson tube. No injection or dilation complications were recorded in this series of patients. DISCUSSiON
In this small series the results after ethanol-induced tumor necrosis (ETN) compare favorably with other methods of palliation. ETN fulfills criteria for an ideal palliation agent. It is quick, as it is undertaken with intravenous sedation in an endoscopy unit. It is safe. In this series no complications or deaths were recorded, although the possibility of perforation, hemmorrhage, and other complications associated with tumor destruction is present. Pain is controlled by titration of intravenous opiate analgesia during the procedure, and none of the patients have required more than simple analgesia. Analgesia was not required after 24 hours. Future treatments are planned on a day-stay basis. Most patients will be able to swallow most solid foods, and all in this series had a marked improvement in symptoms compared with symptoms at presentation. A mean overall improvement of 2.1 on the dysphagia scale compares with a figure of 1.7 following laser therapyll (although slight differences in grading were used). It is unlikely that the improvement can be attributed entirely to dilation as this was not done in every patient. The four patients who did not undergo dilation all improved their dysphagia grades. Two patients (nos. 4 and 9) improved by one grade, and two patients (nos. 5 and 8) by two grades, after one injection without dilation. For those in whom dilation was undertaken, the numbers of dilations per patient are substantially less when compared with other series where per-oral dilation is the sole method of treatment. 6 • 7 ETN requires no special skills or training beyond those of an endoscopist fully experienced in both
Table 3. Treatment details Dysphagia grade After one treatment
Best grade
No. of injections
No. of dilations
Survival (days)
2
1
3 3 3 3 3
2 3 2
0 1 0 1 1 1 2 0 2 1 1
5 3 2 7 1 1 2 2 2 8 3
1 1 3 0 0 1 1 0 0 5 1
186 212 109 301 94 94 21 167 92 223 47
Patient Pre-treatment 1 2 3 4
5 6 7 8 9 10 11
VOLUME 36, NO.1, 1990
1 1
4
2
2 3 3
o
4
1
2 2
45
esophageal dilation and injection sclerotherapy. All the equipment is readily available in any therapeutic endoscopy unit. Cost implications in establishing an ETN service are therefore negligible, while other palliative techniques may require a substantial capital outlayY Patient in-hospital stay is short, and repetition of treatment is undertaken less often than dilation alone 6,7 and is comparable to laser. 11, 12 The poor survival of these patients emphasizes the desirability of quick, effective palliation. ETN would seem to have marked potential in the treatment of dysphagia resulting from malignant stricture in selected patients. It must be stressed, however, that these are results from a small series of patients and before definite recommendations for the use of this technique can be made, further prospective evaluation to determine specific details such as optimum injection volumes and length of time between treatments must be undertaken. It would seem that a prospective controlled trial comparing ETN with laser therapy would be of considerable interest.
5.
6. 7. 8. 9. 10. 11. 12. 13.
14.
REFERENCES 1. Hennessy TPJ. Choice of treatment in carcinoma of the oesophagus. Br J Surg 1988;75:193-4. 2. Keeling P, Gillen P, Hennessy TPJ. Oesophageal resection in the elderly. Ann Coli Surg EngI1988;70:34-6. 3. Cox J, Bennett JR. Light at the end of the tunnel? Palliation for oesophageal carcinoma. Gut 1987;28:781-5. 4. Watson A. A study of the quality and duration of survival
46
15. 16. 17.
following resection, endoscopic intubation and surgical intubl tion in oesophageal carcinoma. Br J Surg 1982;69:585-8. Den Hartog Jager FCA, Bartelsman JFWM, Tytgat GNJ. Pa liative treatment of obstructing esophagogastric malignancy b endoscopic positioning of a plastic prosthesis. Gastroenterolo~ 1979;77:1008-14. Heit HA, Johnson LF, Siegel SR, Boyce HW. Palliative dilatio for dysphagia in esophageal carcinoma. Ann Intern Me 1978;89:629-31. Moses FM, Peura DA, Wong, RKH, Johnson LF. Palliativ dilation of esophageal carcinoma. Gastrointest Endos 1985;31:61-3. Rowland CG, Pagliero KM. Intracavitary irradiation in pallia tion of carcinoma of oesophagus and cardia. Lancet 1985;2:98] Earlam R, Cunha-Melo JR. Oesophageal squamous cell carci noma II. A critical review of radiotherapy. Br J Sur 1980;67:457-61. Fleischer D, Sivak MV. Endoscopic Nd:YAG laser therapy a palliation for esophagogastric cancer. Parameters affecting ini tial outcome. Gastroenterology 1985;89:827-31. Bown SG, Hawes R, Matthewson K, Swain CP, Barr H, Boulo, PB, Clark CG. Endoscopic laser palliation for advanced malig nant dysphagia. Gut 1987;28:799-807. Krasner N, Barr H, Skidmore C, Morris AI. Palliative lase: therapy for malignant dysphagia. Gut 1987;28:792-8. Maruyama M, Adachi H, Ito Y, Kurokawa K, Suzuki S. Endo scopic treatment of gastric carcinoma by local injection of pun ethanol. Presented at European Gastrointestinal Endoscop) Congress (Lisbon 1984): abstract 29. Drell E, Prindiville T, Trudeau W. Outpatient endoscopic injection sclerosis of esophageal varices. Gastrointest Endose 1986;32:4-6. Korula J. Outpatient esophageal variceal sclerotherapy. Gastrointest Endosc 1986;32:1-3. Spiller RC, Misiewicz JJ. Ethanol-induced tumor necrosis for palliation of malignant dysphagia. Lancet 1987;2:792. Myszor MF, Rich AJ, Bottrill P, Record CO. The impact of an endoscopic laser service on gastroenterological practice. Q J Med 1989;261:73-9.
GASTROINTESTINAL ENDOSCOPY
