title: Natural course of inoperable esophageal cancer treated with metallic expandable stents: quality of life and cost-effectiveness analysis.
abstract: OBJECTIVE
  The aim of this study was to evaluate the efficacy and safety of endoscopic therapy with self-expanding metallic endoprostheses in the management of malignant esophageal obstruction or stenosis and the cost-effectiveness of the method in patients suffering from primary esophageal carcinoma. All patients with inoperable esophageal cancers treated with either laser palliation or endoprosthesis insertion were studied retrospectively.
  
  
  METHODS
  Between May 1997 and December 2002 obstruction of the esophagus was diagnosed in 78 patients (52 male, 26 female, age range 53-102 years, mean 72.3 years). The etiology of obstruction was squamous cell carcinoma (n = 42) and adenocarcinoma of the esophagus (n = 36). The site of obstruction was in the upper (n = 1), in the middle (n = 38) and in the lower esophagus (n = 39). In 16 cases the gastroesophageal junction was also involved. Four patients had broncho-esophageal fistulas. In all cases the tumor was considered non-resectable. A total of 89 Ultraflex metal stents were introduced endoscopically. In 46 patients dilation with Savary dilators prior to stent placement was required.
  
  
  RESULTS
  Stents were placed successfully in all patients. After 48 h, all patients were able to tolerate solid or semisolid food. During the follow-up period eight patients developed dysphagia due to food impaction (treated successfully endoscopically). Eleven patients presented with recurrent dysphagia 4-16 weeks after stenting due to tumor overgrowth and were treated with placement of a second stent. The median survival time was 18 weeks. There was no survival difference between squamous cell and esophageal adenocarcinoma. A cost-effective analysis was performed, comparing esophageal stenting with laser therapy. The mean survival and the cost were similar. A small difference of 156 Euro was noted (3.103 Euro and 2.947 Euro for each group of patients, respectively). A significant improvement in quality of life was noted in patients that underwent stenting (96% and 75%vs 71% and 57% for the first 2 months).
  
  
  CONCLUSIONS
  Placement of self-expanding metal stents is a safe and cost effective treatment modality that improve the quality of life, as compared with other palliative techniques, for patients with inoperable malignant esophageal obstructions. In cases of expansion of the mass a second stent can be used; however, the overall survival of these patients, is poor.
authors.affiliation: Gastroenterology Unit, Saint Savvas Cancer Hospital, Athens, Greece. dimdim@otenet.gr
authors.forename: Dimitrios
authors.initials: D
authors.lastname: Xinopoulos
authors.forename: Dimitrios
authors.initials: D
authors.lastname: Dimitroulopoulos
authors.forename: Ioanna
authors.initials: I
authors.lastname: Moschandrea
authors.forename: Panagiotis
authors.initials: P
authors.lastname: Skordilis
authors.forename: Athanassios
authors.initials: A
authors.lastname: Bazinis
authors.forename: Marios
authors.initials: M
authors.lastname: Kontis
authors.forename: Ioannis
authors.initials: I
authors.lastname: Paraskevas
authors.forename: Elias
authors.initials: E
authors.lastname: Kouroumalis
authors.forename: Emmanuel
authors.initials: E
authors.lastname: Paraskevas
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D003362:Cost-Benefit Analysis; D004867:Equipment Design; D004938:Esophageal Neoplasms / Q000191:economics* / Q000601:surgery*; D005260:Female; D006801:Humans; D053685:Laser Therapy; D008297:Male; D008875:Middle Aged; D011788:Quality of Life; D012189:Retrospective Studies; D015607:Stents / Q000191:economics*