The modern approach to esophageal palliative and emergency surgery

Abstract

Thoracic surgeons currently have multiple options and strategies to guide treatment in esophageal palliative and emergency conditions. To guide the selection of an individualized palliative approach, physicians, including thoracic surgeons, must take into consideration many factors including prognosis, performance status and comorbidities of patients. For dysphagia more specifically, esophageal stent placement is the most widely used intervention for rapidly relieving dysphagia in inoperable esophageal cancer patients. The combination of esophageal stent placement with other therapies has an impact on palliative care. Innovations including radioactive stents, drug-eluding stents and biodegradable stents will require further evaluation and validation studies. Currently, patients with inoperable esophageal cancer have access to oncological and biological therapies that are improving their prognosis. A shift toward restaging and potential curative intent is occurring in current clinical practice. In acute intrathoracic esophageal perforation cases, high index of suspicion, multidisciplinary team expertise, antibiotics and hybrid treatment strategies, have significantly improved outcomes of patients in recent years. Hybrid treatment strategies denote the combination of minimally invasive interventions for source control and endoluminal procedures to seal the esophageal perforation. Endoluminal procedures as treatment of acute intrathoracic esophageal perforation include stent placement, over-the-scope clip and endoluminal vacuum therapy. Future perspective in the management of esophageal perforation seems to be the combination of endoluminal therapies tailored to the specific clinical scenario. Thoracic surgeons benefit from mastering endoluminal therapies and advanced endoscopic techniques. An understanding of these rapidly evolving therapies, i.e., outcomes, limitations and innovations, is required to optimally manage esophageal palliative and emergency conditions.

Keywords: Esophageal cancer; dysphagia; emergency; palliation; perforation.

Figure 1

Esophageal stent placement as palliative approach to dysphagia. Endoscopic view of an esophageal stent placement in a patient with dysphagia secondary to esophageal cancer.

Figure 2

Tracheoesophageal fistula at the left mainstem bronchus caused by invading esophageal cancer following EBRT. Bronchoscopic view of the membranous part of the left mainstem bronchus of a patient with tracheoesophageal fistula after EBRT. EBRT, external beam radiotherapy.

Figure 3

Double stenting approach of a tracheoesophageal fistula. Patient with tracheoesophageal fistula with esophageal and tracheal stents: (A) lateral images chest X-ray; (B) lateral images CT-scan thorax.

Figure 4

Over-the-scope clips in an acute intrathoracic esophageal perforation. Patient with iatrogenic esophageal perforation and a prior chest surgery: (A) endoscopic images of over-the-scope clip placement; the same patient after endoluminal procedure; (B) antero-posterior images chest X-ray.