Palliation of Dysphagia of Esophageal Cancer by Endoscopic Lumen Restoration with Intraluminal Tumor Debulking

Video Endoscopic Sequence 1 of 18.

Palliation of Dysphagia of Esophageal Cancer by Endoscopic Lumen Restoration with Intraluminal Tumor Debulking.

Obstructed Esophageal Squamous Cell Carcinoma of the
middle third.
Palliative Treatment to enabling passage of normal food

An 84 year-old male, three months before had had a diagnosis of this neoplasia. The patient and his family rejected surgical treatment, radiotherapy or chemotherapy.

The Patient had dysphagia to liquids and solids with intense sialorrea due to the obstruction caused by the tumor.

Patients with esophageal carcinoma generally lose their chance of curable surgical treatment when symptoms become evident.
At this stage chemoradiotherapy and palliative treatment methods are the only options. Cure of patients with esophageal cancer has remained rare over the past four decades.


Download the video clips by clicking on the endoscopic
 images.



 

Esophageal Dilation

Video Endoscopic Sequence 2 of 18.

Esophageal Dilation

In this Patient, as palliative treatment we used several
therapeutic resources like this hydrostatic dilator,
coagulation with argon plasma (APC).


Peroral dilation can restore esophageal lumen patency,
albeit temporarily, to a diameter adequate to permit
adequate swallowing in over 90% of patients
.

Debulking of the tumor

Video Endoscopic Sequence 3 of 18.

Debulking of the tumor.

Palliative treatment with high power setting of argon
plasma coagulator APC.


The image and the video clip shows the APC catheter,
The APC probe produces a plasma arc that destroys tissue
to a depth of approximately 2 to 3 mm.


Palliation is the only realistic therapeutic option for these patients.
Available palliative treatment modalities include chemotherapy, radiation therapy, esophageal dilation, multipolar electrocoagulation, laser treatment, injection of sclerosing agents, photodynamic therapy, and esophageal endoprostheses

A special forceps was used to remove neoplastic tissues.


A special forceps was used to remove neoplastic tissues.

Video Endoscopic Sequence 4 of 18.

A special forceps was used to remove neoplastic tissues.

The normal esophageal lumen measures approximately 25 mm in functional diameter.
When the lumen diameter is decreased to 13 mm, everyone has solid food or regular diet dysphagia.
When the lumen diameter is less than 18 mm, selective alteration of diet content and consistency is necessary, depending on the characteristics of the stricture. Milder degrees of stricture are easier and safer to dilate than severe strictures.

It is illogical to delay therapy until the patient is able to swallow only liquids, even though adequate total caloric intake has been possible by using a full liquid diet plus dietary supplements.

Devitalization of Pathologic Tissue.

Video Endoscopic Sequence 5 of 18.

Devitalization of Pathologic Tissue.

The video clip shows a large segment of tumor that was
removed with this forceps.

Tumor treatment, especially in the case of bulky tumors, requires effective devitalization and precisely defined depth of thermal effect for reducing tumor mass while simultaneously avoiding hemorrhages or perforation.

Palliation of non-resectable carcinoma of the cardia and esophagus by argon beam coagulation

Video Endoscopic Sequence 6 of 18.

Palliation of non-resectable carcinoma of the cardia and esophagus by argon beam coagulation.

More aggressive setting of argon plasma coagulation.



argon plasma coagulation.

Video Endoscopic Sequence 7 of 18.

Methods:

APC as non-contact, high-frequency electrosurgery under inert argon plasma atmosphere allows dissection, hemostasis, and desiccation of tumor tissue in a one-step procedure. In consideration of the limited and heterogeneous group of patients, results are interpreted descriptively.



The tumor that have been debulked partially

Video Endoscopic Sequence 8 of 18.

The tumor that have been debulked partially.

Restoration and preservation of the lumen for subsequent passage of the corresponding endoscope.

.

 


 

 

Recanalization of the Esophagus.

Video Endoscopic Sequence 9 of 18.

Recanalization of the Esophagus.

Final status after the therapeutic endoscopy, with three
different days, we could introduce the endoscope to the
gastric camera
.

Prior to stent placement, a complete endoscopic
examination should be performed to assess the proximal
and distal extent of the stricture.



Prior to stentplacement, a complete endoscopic examination should be performed to assess the proximal and distal extent of the stricture.

In this video clip you can see the entire segment of the tumor that have been debulked partially.

The preparation of Z-stent in the room of fluroscopy is observed.

Video Endoscopic Sequence 10 of 18.

The preparation of Z-stent in the room of fluroscopy is observed.

The Z-stent has good expansile force, and a new desig incorporates an antireflux valve for bridging th gastroesophageal (GE) junction. S-EMS = self-expandable metallic stent.


Download the video clip by clicking on the image.

The stenosis caused by the tumor is observed in this fluroscopy video clip.

Video Endoscopic Sequence 11 of 18.

The stenosis caused by the tumor is observed in this fluroscopy video clip.

Endoscopic insertion of a stent is an important option in the palliative management of esophageal obstruction


The Stent has been placed in the middle of the esophagus

Video Endoscopic Sequence 12 of 18.

The Stent has been placed in the middle of the esophagus

Although esophageal stent therapy is only a palliative measure for patients with inoperable tumors, it remains an important method for maintaining quality of life.

In particular, the usefulness of a covered S-EMS as therapy for a malignant esophageal obstruction has been reported.

Endoscopic-placed stent to provide palliation of dysphagia.

Video Endoscopic Sequence 13 of 18.

Endoscopic-placed stent to provide palliation of dysphagia.

The patient obtained a significant improvement in the
quality of life.

Successfully deployed Self-expanding stent in the esophagus under fluroscopy control. This image and the video clip were taken one week after the procedure.
Esophageal Z-Stent with dua anti-reflux valve is used to maintain patency of malignant esophageal strictures and to decrease esophageal reflux and aspiration.

Effective method of palliating dysphagia related to stricture caused by malignant esophageal lesions.

Esophageal balloon dilation and expandable stent placement are safe, minimally invasive, effective treatments for esophageal malign strictures.
These procedures have brought the management of dysphagia due to esophageal strictures into the field of interventional radiology.

Esophageal dilation is usually indicated for benign stenoses and is technically successful in more than 90% of cases. Most patients with esophageal carcinoma are not candidates for resection; thus, the main focus of treatment is palliation of malignant dysphagia

 

Endoscopic-placed stent to provide palliation of dysphagia.

Video Endoscopic Sequence 14 of 18.

Endoscopic-placed stent to provide palliation of dysphagia.

This antireflux stent is as safe and effective as the standard open stent in relieving malignant dysphagia and was successful in reducing symptomatic gastroesophageal reflux.
Esophageal stent placement improved his oral alimentation
status.

Esophageal stent placement, which is approved only for malignant strictures, is one of the main therapeutic options in affected patients and relieves dysphagia in approximately 90% of cases.
Dedicated commercially available devices continue to evolve, each with its own advantages and limitations.

Stent placement is subject to technical pitfalls, and adverse events occur following esophageal procedures in a minority of cases. Although chest pain is common and self-limited, reflux esophagitis, stent migration, tracheal compression, and esophageal perforation and obstruction require specific interventions.

In many cases, these complications can be recognized and treated by the interventional radiologist with minimally invasive techniques

 

Endoscopic-placed stent to provide palliation of dysphagia.

Video Endoscopic Sequence 15 of 18.

Endoscopic-placed stent to provide palliation of dysphagia.

In this retroflexed image is observed the stent that emerging from the stric fundus, the anti-reflux valves are observed in the tip.

Stent therapy using a self-expandable metallic stent (S-EMS) in patients, with esophageal stenosis has resulted in improvements to the quality of life for patients with inoperable esophageal cancer.

However, stent-related, complications such as hemorrhage, rupture, stent migration, granulation tissue formation, and esophagotracheobronchial fistula have been reported.


Epidermoid Carcinoma

Video Endoscopic Sequence 16 of 18.

Epidermoid Carcinoma

There is an epithelial perl with keratin. There are also
malignant Squamous cells, with keratin. This is an
epidermoid carcinoma, well differentiated
.

Chest radiograph demonstrating stent position

Video Endoscopic Sequence 17 of 18.

Chest radiograph demonstrating stent position.

Re-establishing the esophageal lumen offers palliation of malignant dysphagia, which is the mainstay of therapy in patients with incurable esophageal cancer.

 


 



Performing this debulking method and placement of the

Video Endoscopic Sequence 18 of 18.

Cat Scan. computerized tomography

Performing this debulking method and placement of the
stent p
alliation was achieved in the patient.

Recanalization enabling passage for normal food was
achieved.

Most patients with esophageal cancer will require palliation for the multiple problems that develop during their limited life span. The responsibility of the palliation therapist is to provide the patient with safe and cost-effective treatments that provide the best possible dysphagia relief.


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