Carcinoma of the oesophagus in Transkei: treatment by intubation.

Abstract

The management of carcinoma of the oesophagus poses formidable logistic problems in countries such as Transkei where the condition is common and resources are limited. Most patients present late, often with complications, and are reluctant to undergo major surgery. Two hundred and fifty consecutive patients who presented over nine months in Transkei were studied. The incidence increased with age until 70 years and the disease occurred equally in men and women. The neoplasm was predominantly squamous cell (243 patients, 97%) and was found most often in the middle third ofthe oesophagus (1 18, 47%). On admission only eight ofthe 250 patients could take a semi-solid diet and only 21 a fluid diet. The policy where feasible was to introduce a Proctor Livingstone tube endoscopically through the dilated oesophageal stricture by a pulsion technique under light general anaesthesia. When abdominal perforation ofthe oesophagus seemed likely, retrograde intubation via a gastrotomy was performed. Sixty patients were not intubated, because the stricture was too proximal (47) or could not be dilated adequately (6), the lesion was suitable for resection (6), or the patient refused (1). Fifty one (27%) patients died in hospital, 29 deaths being due to oesophageal perforation (including six of the 10 who were intubated retrogradely). The mean hospital stay was 4 7 days. On discharge 64% ofthe intubated patients were able to take semi-solid food and a further 6% a fluid diet. Palliation by intubation was performed rapidly and the tube was well tolerated by patients. The overall mortality was high, but this can be reduced by experience. Intubation is an acceptable, cost effective solution where large numbers ofpatients present with advanced oesophageal carcinoma in circumstances where resources are severely limited.

Optimal management of esophageal cancer in Africa: A systemic review of treatment strategies

“…Two case series 30,32 and five RCTs 53,54,56,57,60 reported outcomes of intubation with plastic stents. Operative mortality rates ranged from 0% to 27% 30,53,54,60 with median OS ranging from 12 to 19 weeks 32,54,56,57 .…”

“…20 Of the 37 nonrandomized studies, 17 reported on palliative luminal and surgical interventions ( Table 1). Ten of these studies reported on self-expandable metallic stents (SEMS) 6,[20][21][22][23][24][25][26][27][28] ; five on rigid plastic stents, laser treatment or dilation [29][30][31][32][33] ; and two on retrosternal gastric bypass. 34,35 Four studies reported on palliative radiotherapy, 18,20,32,36 six studies on chemotherapy 32,37-41 and three studies on concurrent chemoradiotherapy 32,42,43 (Table 2).…”

“…RCT evaluated retrosternal gastric bypass as compared to intubation with plastic stents and found that plastic stents caused fewer complications with comparable palliation and operative mortality. 53 Two case series 30,32 and five RCTs 53,54,56,57,60 reported outcomes of intubation with plastic stents. Operative mortality rates ranged from 0% to 27% 30,53,54,60 with median OS ranging from 12 to 19 weeks.…”

“…53 Two case series 30,32 and five RCTs 53,54,56,57,60 reported outcomes of intubation with plastic stents. Operative mortality rates ranged from 0% to 27% 30,53,54,60 with median OS ranging from 12 to 19 weeks. 32,54,56,57 Among the RCTs, early studies examined rigid plastic stents as compared to plastics stents with chemotherapy, 57 with radiotherapy 57 and with concurrent chemoradiation.…”

Oesophageal cancer in South Africa: A scoping review

“…These stents provided relief to dysphagia and symptoms of trachea-oesophageal fistula as well as improvement of nutritional status of patients but with high procedure-related mortality rate of between 15% and 40% and no long-term follow-up data. 58,59,60,61,62,63,64,65 The first study to use metal stents compared them to plastic stents and found metal stents to have superior efficacy but with greater cost. 66 Five studies investigating the palliation of malignant dysphagia using self-expanding metal stents (SEMS) were published after the year 2000.…”