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Celestin tube palliation of unresectable esophageal carcinoma
Celestin tube palliation of unresectable esophageal carcinoma Celestin tube intubation was performed in 108 patients with unresectable carcinoma of the esophagus and cardia, in 83 per cent as the initial operation and in 17 per cent after exploration. The hospital mortality rate was 16 per cent, including a 7.4 per cent mortality rate from technical causes. The most frequent causes of death were perforations of the esophagus and cardia and aspiration pneumonia. Nonfatal complications occurred in 13 per cent of surviving patients, obstruction and dislodgment of the tube being the most common. All patients were able to swallow at discharge, and 91 per cent of them could take food by mouth until the time of death. In 9 per cent, additional palliation, usually esophagoscopy or gastrostomy, was required. Ninety-one patients survived one to 21 months (average 5.8 months). The 6 month survival rate was 44 per cent and the one-year survival 9 per cent. Matti I. Kairaluoma, M.D., Kalevi Jokinen, M.D., Pentti Karkola, M.D., and Teuvo K. I. Larmi, M.D., Oulu, Finland
An more than half of the patients with esophageal carcinoma, the disease has progressed beyond curative surgical efforts when the patient is seen initially.1, 2 Dysphagia and progressive inanition are the most urgent symptoms requiring palliation, which is usually accomplished by either the push-through or the pullthrough methods of esophageal intubation.3 Since 1964, we have used the Celestin4 tube as the principal palliative method in patients with unresectable carcinoma of the esophagus and cardia. The 110 patients in whom Celestin tube intubation has been attempted form the basis of this report. Patients and methods During the 12 year period from 1964 to 1975, in a total of 110 patients with unresectable carcinoma of the esophagus and cardia, Celestin tube intubation has been attempted for palliation of severe dysphagia at Oulu University Central Hospital. The 2 patients (2 per cent) in whom the procedure failed because of technical difficulties have been excluded from the series. The mean age of the 108 patients operated upon successfully was 67 years, with a range from 47 to 86 years. From the Departments of Surgery and Otolaryngology, University of Oulu, Oulu, Finland. Received for publication Sept. 17, 1976. Accepted for publication Oct. 28, 1976. Address for reprints: T. K. I. Larmi, M.D., Department of Surgery, University of Oulu, SF-90220 Oulu 22, Finland.
There were 71 men and 37 women. All patients had severe dysphagia and 47 per cent had lost weight. Twenty-five per cent complained of pain. The mean duration of symptoms was about 5 months, ranging from xh to 24 months. The diagnosis was established before intubation by examination and biopsy with an esophagoscope in all patients. Sixty-seven patients (62 per cent) had esophageal carcinoma and 41 patients (38 per cent) carcinoma of the cardia. The tumors involved the lower third of the thoracic esophagus in 45 patients (41.6 per cent), the middle third in 18 patients (16.7 per cent), and the upper third in 4 patients (3.7 per cent). Sixty-one patients (56 per cent) had squamous cell carcinoma, 44 patients (41 per cent) adenocarcinoma, and 3 patients (3 per cent) unclassified carcinoma. In 90 patients (83 per cent), intubation was the initial operation since they were not considered to be suitable candidates for resection mostly because of verified or suspected distant metastases (in 44 per cent) and concomitant severe disease (in 37 per cent) or because of their advanced age and poor general condition (in 19 per cent). In 18 patients (17 per cent) who underwent exploration but whose tumors were assessed unresectable, the main causes of nonresectability were paraaortal lymph node metastases (in 67 per cent), local infiltration (in 28 per cent), and liver metastases (in 5 per cent). One patient had undergone a palliative esophageal 783
The Journal of Thoracic and Cardiovascular Surgery
7 8 4 Kairaluoma et al.
Table I. Technical causes of death Cause
No. of patients
Perforation Esophageal Gastric Aspiration Suture leakage
Table II. Causes of hospital deaths Cause
No. of patients
Aspiration pneumonia Perforation Suture leakage Myocardial infarction Pulmonary emboli
Table III. Complications in 91 surviving patients Complication
No. of patients
Tube obstruction By food By tumor Tube dislodgment Carcinoma of upper esophagus Carcinoma of cardia Wound infection Aspiration pneumonia
resection 6 months before intubation. Sixteen patients received radiotherapy and 4 patients chemotherapy postoperatively. Our operative technique, which is the same as that reported by Haiderer and colleagues,5 has been previously described in detail elsewhere, 6-7 as likewise a number of the patients reported here.8 Results Seventeen patients died while still in the hospital, for a hospital mortality rate of 16 per cent which also includes the deaths from technical causes (7.4 per cent). Eight patients died of complications directly related to the procedure (Table I). Table II shows the causes of hospital death, of which the most common were aspiration pneumonia and perforation. Twelve of the 91 surviving patients (13 percent) had nonfatal postoperative complications, as shown in Table III. Wound infection in 2 patients was the only early complication. Almost all late complications consisted of obstruction and dislodgment of the tube. All 9
of these patients (9 per cent) required additional palliation. A piece of meat or meat bone was removed with an esophagoscope in 3 patients. In 2 patients tumor overgrowth occluding the upper orifice of the Celestin tube necessitated tumor excision with an esophagoscope. The migration of the Celestin tube in a patient with carcinoma of the upper third of the esophagus was managed by replacing the tube with a Malecot-type catheter. This patient belonged to our early series. In 3 patients with carcinoma of the cardia, the Celestin tube dislodged into the stomach. In one of them the distal end of the tube was left unsecured. In every case it was necessary to remove the dislodged tube and perform a feeding gastrostomy. All surviving patients were able to swallow at discharge. The patients stayed in hospital for Celestin tube intubation on an average of 10 days. Eighty-two of them (91 per cent) could take food by mouth until the time of death. The mean survival time was 5.8 months. One patient survived 21 months, but all patients were dead within 2 years. As shown in Fig. 1, almost half of the patients were alive 6 months after intubation, but the one-year survival rate was only 9 per cent. The 16 patients who received postoperative radiotherapy did not differ from the main group with regard to survival time and complications. Discussion Of the numerous methods to relieve severe dysphagia in patients with unresectable esophageal carcinoma, intubation with a Celestin tube has been our choice for 12 years. Recent collective reviews have not established the clear-cut advantages of the pull-through tubes over the push-through tubes.1, 3 Both methods have inherent advantages and disadvantages. The other methods of palliation, such as radiation therapy, gastrostomy, and jejunostomy, do not relieve dysphagia or prevent regurgitation of saliva and subsequent aspiration pneumonia. Palliative resection and bypass procedures are major operations which rather rarely are feasible in patients with far-advanced malignant diseases and poor general condition. The hospital mortality rate of 16 per cent in our series is quite high, but it is somewhat lower than the average reported in the collective review by Girardet and colleagues.3 It is noteworthy that the hospital mortality rate has remained constant from the very beginning of our experience with the Celestin tube, 6-8 a fact which reflects upon the poor condition of the patients. Wound infection proved to be the only nonfatal
Volume 73 Number 5 May, 1977
early complication; other complications resulted in the death of the patients. The technical mortality rate of 7.4 per cent, which is of the same magnitude as that reported by others,3 reflects the operative risk and points up the fact that Celestin intubation is not the benign procedure it appears to be. The Celestin tube is mainly used for lesions of the middle and lower thirds of the esophagus and cardia. In 4 patients with carcinoma of the upper part of the esophagus, our results have not been very satisfactory, as previously reported during our early experience.6-7 On the other hand, tumors of the cardia seem to be more prone to tube dislodgment than those of the middle and lower esophagus. Also the only instance of gastric perforation in the present series occurred in a patient with carcinoma of the cardia. We have not used Celestin tube intubation in the treatment of malignant tracheoesophageal fistulas, but Haiderer and colleagues5 reported that it has been effective in occluding tracheoesophageal fistulas. The late complications, none of which was fatal, consisted almost exclusively of obstruction and dislodgment of the Celestin tube. No late perforation leading to bleeding from an esophagoaortic fistula occurred in the present series.3 The tube obstruction, whether caused by food or by tumor overgrowth, was easily relieved with the esophagoscope, and the patient was able to continue swallowing. The dislodgment of the tube into the stomach was a more serious complication. Replacement of the tube was not possible in any case because of far-advanced tumor growth, and it was necessary to perform a feeding gastrostomy, a far poorer alternative. Ninety-one per cent of the patients were able to take food by mouth until the time of death. Though the procedure did not lengthen the survival time of the patients, about 6 months in the present study,3, 5 it certainly greatly improved the quality of life. However, certain restrictions should be taken into consideration to prevent tube obstruction by meat bolus, for many patients are edentulous and chew their food poorly. They should be cautioned that the food must be well masticated and taken in small qualities with liquid. Elevating the head of the bed is also important in order to prevent aspiration, since the Celestin tube renders the cardioesophageal junction incompetent. Earlier in this series some patients with esophageal carcinoma received radiation therapy after Celestin tube intubation. As the analysis of the results did not disclose any difference between this and the main group, we abandoned postoperative irradiation and re-
Celestin tube for esophageal carcinoma
785
SURVIVAL ° / 0
100
m
°
1/2
1
2 Years
Fig. 1. Survival after intubation with Celestin tube. cently changed to postoperative chemotherapy. Only a few patients have been treated with this combination, and it is too early to tell anything from results. However, both epidermoid and adenocarcinoma are at least somewhat sensitive to chemotherapy, whereas radiotherapy affects only epidermoid carcinoma. In addition, the risk of tube dislodgment and mediastinitis is perhaps slightly less after chemotherapy than after irradiation.8 When the inability to swallow is the main indication for palliation and certain necessary limitations are accepted, esophageal intubation seems at present to be the method of choice in unresectable carcinoma of the esophagus and cardia, because it provides the immediate persistent relief of dysphagia. However, the high mortality rate and quite high incidence of complications suggest that this method is far from optimal, especially in patients with a relatively longer survival expectancy.
REFERENCES 1 Ammann, J. F., and Collis, J. L.: Palliative Intubation of the Esophagus: Analysis of 59 Cases, J. THORAC. CARDIOVASC. SURG. 61: 863,
1971.
2 Sanfelippo, P. M., and Bernatz, P. E.: Celestin-Tube Palliation for Malignant Esophageal Obstruction, Surg. Clin. North Am. 53: 921, 1973. 3 Girardet, R. E., Ransdell, H. T., Jr., and Wheat, M. W.: Palliative Intubation in the Management of Esophageal Carcinoma, Ann. Thorac. Surg. 18: 417, 1974. 4 Celestin, L. R.: Permanent Intubation in Inoperable Cancer of the Esophagus and Cardia, Ann. R. Coll. Surg. Engl. 25: 165, 1959.
7 86
Kairaluoma
et al.
5 Haiderer, O., Masri, Z. H., Girardet, R. E., and Ransdell, H. T., Jr.: Palliation of Advanged Esophageal Carcinoma by Permanent Intubation, J. THORAC. CARDIOVASC. SURG.
67:491, 1974. 6 Palva, T., and Scheinin, T. M.: Inoperable Carcinoma of the Esophagus and Cardia, Arch. Otolaryngol. 83: 241, 1966.
The Journal of Thoracic and Cardiovascular Surgery
7 Palva, T., Heikkinen, E., and Larmi, T. K. I.: Palliative Treatment of Inextirpable Esophageal Cancer, Pract. Otorhinolaryngol. (Basel) 30: 35, 1968. 8 Palva, T., Jokinen, K., and Karkola, P.: Palliative Treatment of Oesophageal Cancer, Ann. Clin. Res. 6: 223, 1974.
An more than half of the patients with esophageal carcinoma, the disease has progressed beyond curative surgical efforts when the patient is seen initially.1, 2 Dysphagia and progressive inanition are the most urgent symptoms requiring palliation, which is usually accomplished by either the push-through or the pullthrough methods of esophageal intubation.3 Since 1964, we have used the Celestin4 tube as the principal palliative method in patients with unresectable carcinoma of the esophagus and cardia. The 110 patients in whom Celestin tube intubation has been attempted form the basis of this report. Patients and methods During the 12 year period from 1964 to 1975, in a total of 110 patients with unresectable carcinoma of the esophagus and cardia, Celestin tube intubation has been attempted for palliation of severe dysphagia at Oulu University Central Hospital. The 2 patients (2 per cent) in whom the procedure failed because of technical difficulties have been excluded from the series. The mean age of the 108 patients operated upon successfully was 67 years, with a range from 47 to 86 years. From the Departments of Surgery and Otolaryngology, University of Oulu, Oulu, Finland. Received for publication Sept. 17, 1976. Accepted for publication Oct. 28, 1976. Address for reprints: T. K. I. Larmi, M.D., Department of Surgery, University of Oulu, SF-90220 Oulu 22, Finland.
There were 71 men and 37 women. All patients had severe dysphagia and 47 per cent had lost weight. Twenty-five per cent complained of pain. The mean duration of symptoms was about 5 months, ranging from xh to 24 months. The diagnosis was established before intubation by examination and biopsy with an esophagoscope in all patients. Sixty-seven patients (62 per cent) had esophageal carcinoma and 41 patients (38 per cent) carcinoma of the cardia. The tumors involved the lower third of the thoracic esophagus in 45 patients (41.6 per cent), the middle third in 18 patients (16.7 per cent), and the upper third in 4 patients (3.7 per cent). Sixty-one patients (56 per cent) had squamous cell carcinoma, 44 patients (41 per cent) adenocarcinoma, and 3 patients (3 per cent) unclassified carcinoma. In 90 patients (83 per cent), intubation was the initial operation since they were not considered to be suitable candidates for resection mostly because of verified or suspected distant metastases (in 44 per cent) and concomitant severe disease (in 37 per cent) or because of their advanced age and poor general condition (in 19 per cent). In 18 patients (17 per cent) who underwent exploration but whose tumors were assessed unresectable, the main causes of nonresectability were paraaortal lymph node metastases (in 67 per cent), local infiltration (in 28 per cent), and liver metastases (in 5 per cent). One patient had undergone a palliative esophageal 783
The Journal of Thoracic and Cardiovascular Surgery
7 8 4 Kairaluoma et al.
Table I. Technical causes of death Cause
No. of patients
Perforation Esophageal Gastric Aspiration Suture leakage
Table II. Causes of hospital deaths Cause
No. of patients
Aspiration pneumonia Perforation Suture leakage Myocardial infarction Pulmonary emboli
Table III. Complications in 91 surviving patients Complication
No. of patients
Tube obstruction By food By tumor Tube dislodgment Carcinoma of upper esophagus Carcinoma of cardia Wound infection Aspiration pneumonia
resection 6 months before intubation. Sixteen patients received radiotherapy and 4 patients chemotherapy postoperatively. Our operative technique, which is the same as that reported by Haiderer and colleagues,5 has been previously described in detail elsewhere, 6-7 as likewise a number of the patients reported here.8 Results Seventeen patients died while still in the hospital, for a hospital mortality rate of 16 per cent which also includes the deaths from technical causes (7.4 per cent). Eight patients died of complications directly related to the procedure (Table I). Table II shows the causes of hospital death, of which the most common were aspiration pneumonia and perforation. Twelve of the 91 surviving patients (13 percent) had nonfatal postoperative complications, as shown in Table III. Wound infection in 2 patients was the only early complication. Almost all late complications consisted of obstruction and dislodgment of the tube. All 9
of these patients (9 per cent) required additional palliation. A piece of meat or meat bone was removed with an esophagoscope in 3 patients. In 2 patients tumor overgrowth occluding the upper orifice of the Celestin tube necessitated tumor excision with an esophagoscope. The migration of the Celestin tube in a patient with carcinoma of the upper third of the esophagus was managed by replacing the tube with a Malecot-type catheter. This patient belonged to our early series. In 3 patients with carcinoma of the cardia, the Celestin tube dislodged into the stomach. In one of them the distal end of the tube was left unsecured. In every case it was necessary to remove the dislodged tube and perform a feeding gastrostomy. All surviving patients were able to swallow at discharge. The patients stayed in hospital for Celestin tube intubation on an average of 10 days. Eighty-two of them (91 per cent) could take food by mouth until the time of death. The mean survival time was 5.8 months. One patient survived 21 months, but all patients were dead within 2 years. As shown in Fig. 1, almost half of the patients were alive 6 months after intubation, but the one-year survival rate was only 9 per cent. The 16 patients who received postoperative radiotherapy did not differ from the main group with regard to survival time and complications. Discussion Of the numerous methods to relieve severe dysphagia in patients with unresectable esophageal carcinoma, intubation with a Celestin tube has been our choice for 12 years. Recent collective reviews have not established the clear-cut advantages of the pull-through tubes over the push-through tubes.1, 3 Both methods have inherent advantages and disadvantages. The other methods of palliation, such as radiation therapy, gastrostomy, and jejunostomy, do not relieve dysphagia or prevent regurgitation of saliva and subsequent aspiration pneumonia. Palliative resection and bypass procedures are major operations which rather rarely are feasible in patients with far-advanced malignant diseases and poor general condition. The hospital mortality rate of 16 per cent in our series is quite high, but it is somewhat lower than the average reported in the collective review by Girardet and colleagues.3 It is noteworthy that the hospital mortality rate has remained constant from the very beginning of our experience with the Celestin tube, 6-8 a fact which reflects upon the poor condition of the patients. Wound infection proved to be the only nonfatal
Volume 73 Number 5 May, 1977
early complication; other complications resulted in the death of the patients. The technical mortality rate of 7.4 per cent, which is of the same magnitude as that reported by others,3 reflects the operative risk and points up the fact that Celestin intubation is not the benign procedure it appears to be. The Celestin tube is mainly used for lesions of the middle and lower thirds of the esophagus and cardia. In 4 patients with carcinoma of the upper part of the esophagus, our results have not been very satisfactory, as previously reported during our early experience.6-7 On the other hand, tumors of the cardia seem to be more prone to tube dislodgment than those of the middle and lower esophagus. Also the only instance of gastric perforation in the present series occurred in a patient with carcinoma of the cardia. We have not used Celestin tube intubation in the treatment of malignant tracheoesophageal fistulas, but Haiderer and colleagues5 reported that it has been effective in occluding tracheoesophageal fistulas. The late complications, none of which was fatal, consisted almost exclusively of obstruction and dislodgment of the Celestin tube. No late perforation leading to bleeding from an esophagoaortic fistula occurred in the present series.3 The tube obstruction, whether caused by food or by tumor overgrowth, was easily relieved with the esophagoscope, and the patient was able to continue swallowing. The dislodgment of the tube into the stomach was a more serious complication. Replacement of the tube was not possible in any case because of far-advanced tumor growth, and it was necessary to perform a feeding gastrostomy, a far poorer alternative. Ninety-one per cent of the patients were able to take food by mouth until the time of death. Though the procedure did not lengthen the survival time of the patients, about 6 months in the present study,3, 5 it certainly greatly improved the quality of life. However, certain restrictions should be taken into consideration to prevent tube obstruction by meat bolus, for many patients are edentulous and chew their food poorly. They should be cautioned that the food must be well masticated and taken in small qualities with liquid. Elevating the head of the bed is also important in order to prevent aspiration, since the Celestin tube renders the cardioesophageal junction incompetent. Earlier in this series some patients with esophageal carcinoma received radiation therapy after Celestin tube intubation. As the analysis of the results did not disclose any difference between this and the main group, we abandoned postoperative irradiation and re-
Celestin tube for esophageal carcinoma
785
SURVIVAL ° / 0
100
m
°
1/2
1
2 Years
Fig. 1. Survival after intubation with Celestin tube. cently changed to postoperative chemotherapy. Only a few patients have been treated with this combination, and it is too early to tell anything from results. However, both epidermoid and adenocarcinoma are at least somewhat sensitive to chemotherapy, whereas radiotherapy affects only epidermoid carcinoma. In addition, the risk of tube dislodgment and mediastinitis is perhaps slightly less after chemotherapy than after irradiation.8 When the inability to swallow is the main indication for palliation and certain necessary limitations are accepted, esophageal intubation seems at present to be the method of choice in unresectable carcinoma of the esophagus and cardia, because it provides the immediate persistent relief of dysphagia. However, the high mortality rate and quite high incidence of complications suggest that this method is far from optimal, especially in patients with a relatively longer survival expectancy.
REFERENCES 1 Ammann, J. F., and Collis, J. L.: Palliative Intubation of the Esophagus: Analysis of 59 Cases, J. THORAC. CARDIOVASC. SURG. 61: 863,
1971.
2 Sanfelippo, P. M., and Bernatz, P. E.: Celestin-Tube Palliation for Malignant Esophageal Obstruction, Surg. Clin. North Am. 53: 921, 1973. 3 Girardet, R. E., Ransdell, H. T., Jr., and Wheat, M. W.: Palliative Intubation in the Management of Esophageal Carcinoma, Ann. Thorac. Surg. 18: 417, 1974. 4 Celestin, L. R.: Permanent Intubation in Inoperable Cancer of the Esophagus and Cardia, Ann. R. Coll. Surg. Engl. 25: 165, 1959.
7 86
Kairaluoma
et al.
5 Haiderer, O., Masri, Z. H., Girardet, R. E., and Ransdell, H. T., Jr.: Palliation of Advanged Esophageal Carcinoma by Permanent Intubation, J. THORAC. CARDIOVASC. SURG.
67:491, 1974. 6 Palva, T., and Scheinin, T. M.: Inoperable Carcinoma of the Esophagus and Cardia, Arch. Otolaryngol. 83: 241, 1966.
The Journal of Thoracic and Cardiovascular Surgery
7 Palva, T., Heikkinen, E., and Larmi, T. K. I.: Palliative Treatment of Inextirpable Esophageal Cancer, Pract. Otorhinolaryngol. (Basel) 30: 35, 1968. 8 Palva, T., Jokinen, K., and Karkola, P.: Palliative Treatment of Oesophageal Cancer, Ann. Clin. Res. 6: 223, 1974.