A CONTROLLED TRIAL OF AN EXPANSILE METAL STENT FOR PALLIATION OF ESOPHAGEAL OBSTRUCTION DUE TO INOPERABLE CANCER

Background. Esophageal obstruction due to cancer can produce debilitat ing dysphagia. Rapid palliation is usually possible with endoscopic pl acement of a plastic esophageal prosthesis, but this device has a high rate of complications. A new alternative is a metal-mesh stent that c ollapses to 3 mm in diameter at placement but can then expand up to 16 mm. Methods. Patients with esophageal carcinoma (39 patients) or mali gnant extrinsic obstruction (3 patients) were randomly assigned to tre atment with either a plastic prosthesis (16 mm in diameter) or an expa nsile metal-mesh stent. The patients were evaluated every six weeks un til death. The degree of palliation was expressed as a dysphagia score and a Karnofsky performance score. Results. Complications were signif icantly less frequent with the metal stents than with the plastic pros theses (no complications vs. nine; P<0.001). The dysphagia and Karnofs ky scores improved significantly and to a similar degree in both treat ment groups. The most common causes of recurrent dysphagia were migrat ion of the plastic prostheses (five patients) and ingrowth or overgrow th of the metal stents by tumor (five patients). The rates of reinterv ention were similar in both treatment groups, as were the 30-day morta lity rates. The period of hospitalization after placement of a prosthe sis was significantly longer in the group given plastic prostheses tha n in the group given metal stents (mean +/-SE, 12.5+/-2.1 vs. 5.4+/-1. 0 days; P = 0.005). Despite their higher initial cost, the metal stent s were cost effective because of the absence of fatal complications an d the decrease in the hospital stay. Conclusions. Expansile metal sten ts are a safe and cost-effective alternative to conventional plastic e ndoprostheses in the treatment of esophageal obstruction due to inoper able cancer.