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Palliative dilation of esophageal carcinoma
0016-5107/85/3102-0061$02.00 GASTROINTESTINAL ENDOSCOPY Copyright © 1985 by the American Society for Gastrointestinal Endoscopy
Palliative dilation of esophageal carcinoma Frank M. Moses, MD, David A. Peura, MD Roy K. H. Wong, MD, Lawrence F. Johnson, MD Washington, DC
The authors' experience with palliative dilation of 46 consecutive patients evaluated for squamous cell carcinoma of the esophagus was retrospectively reviewed. Thirty-nine of 46 patients (85%) underwent dilation in order to palliate symptoms, enable endoscopy and biopsy, or prepare for placement of an esophageal prosthesis. Thirty-two of the 46 patients (70%) were treated with radiation therapy and seven (15%) underwent placement of an esophageal prosthesis. Thirty-five of the 39 patients dilated (90%) noted improvement in swallowing, allowing resumption of a soft or regular diet. Complications were noted in three of the 39 patients dilated (8%). The authors conclude that peroral dilation is a safe, effective, and probably underutilized method of palliation in patients with squamous cell esophageal carcinoma.
Squamous cell carcinoma of the esophagus (SCCE) accounts for 2% of all cancers annually in the United States. l Despite current treatment modalities, it has a poor prognosis with a I-year and 5-year survival of 18% and 5%.2 Since cure of this disease is rare, palliation of symptoms (primarily dysphagia) is of paramount importance. Surgical resection is not possible in most patients (61 %),2-4 and thus dysphagia becomes a significant and progressive problem quite early in the disease. Chronic peroral dilation of malignant esophageal strictures to maintain a patent lumen has been shown in a previous report from this institution to be a safe and effective method of achieving palliation of dysphagia. 5 The purpose of this series is to report our continued experience during the subsequent 5-year period utilizing peroral dilation for palliation of dysphagia due to SCCE. MATERIALS AND METHODS
The records of 46 patients with SCCE seen at Walter Reed Army Medical Center (WRAMC) over a 5-year period from January 1977 to December 1981 were retrospectively reviewed. The following information was obtained from inpatient records, clinic dilation records, and tumor registry: From the Gastroenterology Service, Department of Medicine, Walter Reed Army Medical Center, and Uniformed Services University of the Health Sciences, Washington, DC. Reprint requests: David A. Peura, MD, Director, Clinical Services, Gastroenterology Service, Walter Reed Army Medical Center, Washington, DC 20307. The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense.
VOLUME 31, NO.2, 1985
age, sex, dates of admission, diagnosis, disposition and/or death, symptoms at presentation, tumor location, treatment modality and date, dilator size and type, duration of bougienage, patient response, concomitant therapy, usage of prosthesis, complications, and cause of death. Esophageal dilations were performed using two types of esophageal dilators, alone and in combination: mercuryfilled rubber bougies, either the blunt-tipped Hurst (Pilling Co., Fort Washington, Pa.) or the tapered-tipped Maloney (Pilling Co.); or metal olives passed over a guide wire that had been fluoroscopically placed in the stomach (EderPuestow dilators: Pilling Co.). The latter was used only when the stricture was too narrow to permit effective dilation with mercury-filled dilators. The diameter of all dilators was expressed in French units (1 mm = 3 French units), and each passage of a dilator was counted as one dilation. During radiotherapy dilations were performed prior to, during, and after therapy, at a frequency dependent on the patient's complaints of dysphagia. Indications for esophageal dilation were to palliate dysphagia, to facilitate diagnosis, and to prepare the esophagus for prosthesis placement. Only patient refusal was an absolute contraindication to dilation. The techniques of dilation have been previously described. 6 Typically, only three sequential dilators were passed at a single session, but this was modified for patient tolerance or if excessive resistance was noted. Fluoroscopy was used initially in all cases, whenever the Eder-Puestow dilator was used, and during difficult dilations. RESULTS
Forty-six patients were admitted to WRAMC with the diagnosis of SCCE between January 1977 and December 1981. There were 37 men and nine women. 61
The average age was 53 years with a range of 41 to 77 years. Dysphagia was a presenting symptom in 40 of 46 (87%). Significant weight loss (>10% of body weight) was noted in 24 (52%), chest pain in 12 (26%), odynophagia in five (11 %); gastrointestinal bleeding, gastroesophageal reflux symptoms, and pulmonary symptoms occurred in four patients. One patient presented moribund and one with only regurgitation and hiccups. Information regarding the location of the tumor was available in 42 of 46 patients. Three patients had proximal esophageal tumors, 15 had midesophageal tumors, and 21 had distal location. Three patients had carcinoma throughout the length of the esophagus. The treatment of the tumor included resection (13 patients), radiotherapy (32 patients), protocol chemotherapy (four patients), and esophageal prosthesis (seven patients). Thirty-nine (85%) patients were dilated an average of 27 times (range, 2 to 115). A Maloney dilator was used in 100%, an Eder-Puestow dilator in 29%, and a Hurst dilator in 15% of patients dilated. Lumen size was maintained at a minimum of 13 mm (range, 13 to 17 mm). Thirty-five of the 39 patients dilated (90%) noted improvement in swallowing following dilation, allowing resumption of soft or regular diet. Failure of dilation occurred in four patients: three patients who refused further dilation and were treated with an indwelling feeding tube, and one patient who died during dilation. Those 35 patients who responded to dilation continued oral intake until shortly before death or the advent of a complication that required the placement of the prosthesis. Thirty-two of 46 patients (70%) underwent radiation therapy for SCCE. Eighteen of these 32 patients (56%) underwent peroral dilation during this period of radiotherapy with no complications noted. Seven patients (15%) underwent dilation in preparation for esophageal prosthetic tube placement used to palliate either dysphagia refractory to dilation or a malignant tracheoesophageal fistula. No complications were noted during dilation in this group. Complications of dilation were noted in three of 39 patients (8%). The only major complication encountered during dilation that resulted in death was a perforated duodenal ulcer. Minor complications occurred in two patients who developed fever and chest pain that resolved within 24 hours without sequelae. Dilations were subsequently resumed in these two individuals without further complications or difficulties. One patient died after perforation of the esophagus during insertion of a prosthetic device. This patient, however, had tolerated routine dilations without incident for 4 months prior to prosthetic intubation and 62
therefore was not considered a complication of dilation. The mean survival in 32 patients for whom followup data were available was lOA months (median, 9; range, 1 to 48 months). Known causes of death included six cases of cardiopulmonary complications, three of hemorrhage (either gastrointestinal or major vessel erosion), four of sepsis, and one of complications of carcinomatosis. Survival was independent of cancer location. DISCUSSION
Despite advances in surgical and radiation techniques, the diagnosis of SCCE carries with it a dismal prognosis. In a recent extensive review, it was stated that only 39% of patients have resectable disease on presentation and 1- and 5-year survival averages are 18 and 5%.2 Operative mortality for esophageal resection for SCCE ranged from 104 to 40%.3,4,7,8 Indeed, esophageal resection for carcinoma has the highest operative mortality of any routinely performed surgical procedure. 2 Radiotherapy, although generally used for patients with extensive disease, has 1- and 5year survival rates of 18% and 6%.9 Chemotherapy has not been shown to be of benefit in this disease. 1o Because of the lack of an effective curative regimen, palliation of the symptoms of esophageal cancer becomes of paramount importance. There are several different modalities currently used to palliate the dysphagia in the esophageal cancer patient. Diversion procedures to assure nutrition such as a feeding gastrostomy are relatively simple but carry a significant mortality (10 to 40%) in the debilitated patient. In addition, such palliation does not allow the patient to enjoy oral intake or guarantee disposal of salivary secretion. Bypass procedures in the unresectable patient also are associated with significant morbidity and mortality.2,l1 Alternatively, a malignant stricture may be intubated operatively or perorally with a prosthetic device. Several large reviews of prosthesis intubation show a complication rate of 25% with a mortality rate ranging from 3.6 to 23.5%.12-15 Peroral dilation of benign strictures is well accepted for palliation of symptoms.16 Few series report the use of esophageal dilation alone or in conjunction with other therapeutic modalities to palliate malignant disease. Other series have mentioned the use of peroral dilation during the treatment of malignant disease and have found it to be useful but have not critically evaluated its role. 17,18 Most workers find it necessary to dilate malignant strictures in preparation for placement of an esophageal prosthesis, although this is often done in one session under general anesthesia. A perforation rate of 2.5 to 9% has been reported for this procedure in several series. 12-14 We agree with GASTROINTESTINAL ENDOSCOPY
Boyce19 who stated that gradual dilation is better tolerated and, because it appears to be associated with a lower rate of perforation, is also safer. An unusual complication seen in one of our patients was duodenal ulcer perforation. The occurrence of peptic ulcer perforation and esophageal stricture manipulation has been previously reported by Chung et a1. 20 who thought that the pressure of gastric air trapped by the esophageal stricture blew out an established peptic ulcer. Esophageal dilation can be safely and effectively performed during radiation therapy. Eighteen of 39 patients underwent dilation while receiving radiation therapy without complication. Dysphagia may worsen during radiation therapy and, indeed, necessitate a temporary reduction in dilator size. We believe that continued dilation during radiation therapy is essential and not contraindicated. This is in agreement with both Heit et a1. 5 and Palmer17 who also documented the safety of dilation during radiation therapy. Peroral dilation effectively palliates dysphagia due to SCCE. In our series 90% of patients who were treated were able to eat and maintain their weight. This is similar to that reported by Heit et a1. 5 Dysphagia occurs at a lumen diameter of 12 mm or less. Peroral dilation will generally maintain esophageal diameter above 12 mm, and in our series the range was 13 to 17 mm. Palliation can be achieved with surgical modalities equally effectively; however, even after surgery, dilation may be required. It has been reported that 30% of postsurgical patients and 50% of postradiation patients will require esophageal dilation for palliation of dysphagia. 2, 10, 12,21 Peroral dilation does not preclude the use of an esophageal prosthesis if subsequently required for dilation failure or esophagopulmonary fistula. In fact, it may be easier to intubate the stricture in the patient who has been adequately dilated. A review of 2459 patients undergoing prosthesis placement showed an overall complication rate of 25.4% with the most frequent complications being tube dislodgement (9.9%) and obstruction (8.6%).14 Since complications related to prosthesis are common, we reserve their use for patients late in the course of their disease when either continued peroral dilation is unsuccessful at relieving dysphagia or an esophagopulmonary fistula develops. Only seven patients (15%) in our series required prosthesis placement at some time during their course. The remainder (85%) were effectively palliated without the need to resort to more invasive modalities.
VOLUME 31, NO.2, 1985
In addition to being safe and effective, peroral dilation is well tolerated, can be performed in most patients, and requires only topical pharyngeal anesthesia. The technique is known to most gastroenterologists and many surgeons and thus is readily available outside of specialized centers. Dilations can be done as an outpatient procedure, allowing the patient to continue a normal lifestyle.
REFERENCES 1. Cancer statistics, 1981. Cancer 1981;31:13. 2. Earlam R, Cunha-Melo JR. Oesophageal squamous cell carcinoma. I. A critical review of surgery. Br J Surg 1980;67:381-90. 3. Mannell A. Carcinoma of the esophagus. Curr Prob Surg 1982;19:553-647. 4. Akiyama H, Tsurumaru M, Kawamura T, et al. Principles of surgical treatment for carcinoma of the esophagus. Ann Surg 1981;194:438-46. 5. Heit HA, Johnson LF, Siegel SR, Boyce HW. Palliative dilation for dysphagia in esophageal carcinoma. Ann Intern Med 1978;89:629-31. 6. Boyce HW, Palmer ED. Techniques ofclinical gastroenterology. Springfield, Ill.: Charles C Thomas, 1975:237-51. 7. Parker EF, Gregorie HB, Prioleau WH, et al. Carcinoma of the esophagus: observations of 40 years. Ann Surg 1982;195:61823. 8. Giugli R, Gignoux M. Treatment of esophageal carcinoma: retrospective review of 2400 patients. Ann Surg 1980;192:4452. 9. Earlam R, Cunha-Melo JR. Oesophageal squamous cell carcinoma. II. A critical review of radiotherapy. Br J Surg 1980;67:457-61. 10. Kelsen D. Treatment of advanced esophageal cancer. Cancer 1982;50:2576-81. 11. Wong J, Lam KH, Wei WI, et al. Results of the Kirschner operation. World J Surg 1981;5:547-52. 12. Bennett Jr. Intubation of gastro-oesophageal malignancies: a survey of current practice in Britain, 1980. Gut 1981;22:236338. 13. Angorn IB, Hegarty MM. Palliative pulsion intubation in oesophageal carcinoma. Ann Roy Col Surg 1979;61:212-4. 14. Girardet RE, Randsdell HT, Wheat MW. Palliative intubation in the management of esophageal carcinoma. Ann Thorac Surg 1974;18:417-30. 15. Watson A. A study of the quality and duration of survival following resection, endoscopic intubation and surgical intubation in oesophageal carcinoma. Br J Surg 1982;69:585-8. 16. Johnson LF, Peura DA. Dysphagia and esophageal obstruction. In: Conn HF, ed. Current therapy, 1981. Philadelphia: WB Saunders, 1981:374-8. 17. Palmer ED. Peroral prosthesis for the management of incurable esophageal carcinoma. Am J GastroenteroI1973;59:487-98. 18. Den Hartog Jager FCA, Bartelsoman JFWM, Tytgat GNJ. Palliative treatment of obstructing esophagogastric malignancy by endoscopic positioning of a plastic prosthesis. Gastroenterology 1979;77:1008-14. 19. Boyce HW. Peroral prostheses for palliating malignant esophageal and gastric obstruction. Gastroenterology 1979;77:11413. 20. Chung RKS, Gurll NJ, Shirazi SS. Perforation of peptic ulcers related to fiberoptic endoscopy. Dig Dis Sci 1979;24:926-8. 21. Pearson JG. Radiotherapy for esophageal carcinoma. World J Surg 1981;5:489-97.
63
Palliative dilation of esophageal carcinoma Frank M. Moses, MD, David A. Peura, MD Roy K. H. Wong, MD, Lawrence F. Johnson, MD Washington, DC
The authors' experience with palliative dilation of 46 consecutive patients evaluated for squamous cell carcinoma of the esophagus was retrospectively reviewed. Thirty-nine of 46 patients (85%) underwent dilation in order to palliate symptoms, enable endoscopy and biopsy, or prepare for placement of an esophageal prosthesis. Thirty-two of the 46 patients (70%) were treated with radiation therapy and seven (15%) underwent placement of an esophageal prosthesis. Thirty-five of the 39 patients dilated (90%) noted improvement in swallowing, allowing resumption of a soft or regular diet. Complications were noted in three of the 39 patients dilated (8%). The authors conclude that peroral dilation is a safe, effective, and probably underutilized method of palliation in patients with squamous cell esophageal carcinoma.
Squamous cell carcinoma of the esophagus (SCCE) accounts for 2% of all cancers annually in the United States. l Despite current treatment modalities, it has a poor prognosis with a I-year and 5-year survival of 18% and 5%.2 Since cure of this disease is rare, palliation of symptoms (primarily dysphagia) is of paramount importance. Surgical resection is not possible in most patients (61 %),2-4 and thus dysphagia becomes a significant and progressive problem quite early in the disease. Chronic peroral dilation of malignant esophageal strictures to maintain a patent lumen has been shown in a previous report from this institution to be a safe and effective method of achieving palliation of dysphagia. 5 The purpose of this series is to report our continued experience during the subsequent 5-year period utilizing peroral dilation for palliation of dysphagia due to SCCE. MATERIALS AND METHODS
The records of 46 patients with SCCE seen at Walter Reed Army Medical Center (WRAMC) over a 5-year period from January 1977 to December 1981 were retrospectively reviewed. The following information was obtained from inpatient records, clinic dilation records, and tumor registry: From the Gastroenterology Service, Department of Medicine, Walter Reed Army Medical Center, and Uniformed Services University of the Health Sciences, Washington, DC. Reprint requests: David A. Peura, MD, Director, Clinical Services, Gastroenterology Service, Walter Reed Army Medical Center, Washington, DC 20307. The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense.
VOLUME 31, NO.2, 1985
age, sex, dates of admission, diagnosis, disposition and/or death, symptoms at presentation, tumor location, treatment modality and date, dilator size and type, duration of bougienage, patient response, concomitant therapy, usage of prosthesis, complications, and cause of death. Esophageal dilations were performed using two types of esophageal dilators, alone and in combination: mercuryfilled rubber bougies, either the blunt-tipped Hurst (Pilling Co., Fort Washington, Pa.) or the tapered-tipped Maloney (Pilling Co.); or metal olives passed over a guide wire that had been fluoroscopically placed in the stomach (EderPuestow dilators: Pilling Co.). The latter was used only when the stricture was too narrow to permit effective dilation with mercury-filled dilators. The diameter of all dilators was expressed in French units (1 mm = 3 French units), and each passage of a dilator was counted as one dilation. During radiotherapy dilations were performed prior to, during, and after therapy, at a frequency dependent on the patient's complaints of dysphagia. Indications for esophageal dilation were to palliate dysphagia, to facilitate diagnosis, and to prepare the esophagus for prosthesis placement. Only patient refusal was an absolute contraindication to dilation. The techniques of dilation have been previously described. 6 Typically, only three sequential dilators were passed at a single session, but this was modified for patient tolerance or if excessive resistance was noted. Fluoroscopy was used initially in all cases, whenever the Eder-Puestow dilator was used, and during difficult dilations. RESULTS
Forty-six patients were admitted to WRAMC with the diagnosis of SCCE between January 1977 and December 1981. There were 37 men and nine women. 61
The average age was 53 years with a range of 41 to 77 years. Dysphagia was a presenting symptom in 40 of 46 (87%). Significant weight loss (>10% of body weight) was noted in 24 (52%), chest pain in 12 (26%), odynophagia in five (11 %); gastrointestinal bleeding, gastroesophageal reflux symptoms, and pulmonary symptoms occurred in four patients. One patient presented moribund and one with only regurgitation and hiccups. Information regarding the location of the tumor was available in 42 of 46 patients. Three patients had proximal esophageal tumors, 15 had midesophageal tumors, and 21 had distal location. Three patients had carcinoma throughout the length of the esophagus. The treatment of the tumor included resection (13 patients), radiotherapy (32 patients), protocol chemotherapy (four patients), and esophageal prosthesis (seven patients). Thirty-nine (85%) patients were dilated an average of 27 times (range, 2 to 115). A Maloney dilator was used in 100%, an Eder-Puestow dilator in 29%, and a Hurst dilator in 15% of patients dilated. Lumen size was maintained at a minimum of 13 mm (range, 13 to 17 mm). Thirty-five of the 39 patients dilated (90%) noted improvement in swallowing following dilation, allowing resumption of soft or regular diet. Failure of dilation occurred in four patients: three patients who refused further dilation and were treated with an indwelling feeding tube, and one patient who died during dilation. Those 35 patients who responded to dilation continued oral intake until shortly before death or the advent of a complication that required the placement of the prosthesis. Thirty-two of 46 patients (70%) underwent radiation therapy for SCCE. Eighteen of these 32 patients (56%) underwent peroral dilation during this period of radiotherapy with no complications noted. Seven patients (15%) underwent dilation in preparation for esophageal prosthetic tube placement used to palliate either dysphagia refractory to dilation or a malignant tracheoesophageal fistula. No complications were noted during dilation in this group. Complications of dilation were noted in three of 39 patients (8%). The only major complication encountered during dilation that resulted in death was a perforated duodenal ulcer. Minor complications occurred in two patients who developed fever and chest pain that resolved within 24 hours without sequelae. Dilations were subsequently resumed in these two individuals without further complications or difficulties. One patient died after perforation of the esophagus during insertion of a prosthetic device. This patient, however, had tolerated routine dilations without incident for 4 months prior to prosthetic intubation and 62
therefore was not considered a complication of dilation. The mean survival in 32 patients for whom followup data were available was lOA months (median, 9; range, 1 to 48 months). Known causes of death included six cases of cardiopulmonary complications, three of hemorrhage (either gastrointestinal or major vessel erosion), four of sepsis, and one of complications of carcinomatosis. Survival was independent of cancer location. DISCUSSION
Despite advances in surgical and radiation techniques, the diagnosis of SCCE carries with it a dismal prognosis. In a recent extensive review, it was stated that only 39% of patients have resectable disease on presentation and 1- and 5-year survival averages are 18 and 5%.2 Operative mortality for esophageal resection for SCCE ranged from 104 to 40%.3,4,7,8 Indeed, esophageal resection for carcinoma has the highest operative mortality of any routinely performed surgical procedure. 2 Radiotherapy, although generally used for patients with extensive disease, has 1- and 5year survival rates of 18% and 6%.9 Chemotherapy has not been shown to be of benefit in this disease. 1o Because of the lack of an effective curative regimen, palliation of the symptoms of esophageal cancer becomes of paramount importance. There are several different modalities currently used to palliate the dysphagia in the esophageal cancer patient. Diversion procedures to assure nutrition such as a feeding gastrostomy are relatively simple but carry a significant mortality (10 to 40%) in the debilitated patient. In addition, such palliation does not allow the patient to enjoy oral intake or guarantee disposal of salivary secretion. Bypass procedures in the unresectable patient also are associated with significant morbidity and mortality.2,l1 Alternatively, a malignant stricture may be intubated operatively or perorally with a prosthetic device. Several large reviews of prosthesis intubation show a complication rate of 25% with a mortality rate ranging from 3.6 to 23.5%.12-15 Peroral dilation of benign strictures is well accepted for palliation of symptoms.16 Few series report the use of esophageal dilation alone or in conjunction with other therapeutic modalities to palliate malignant disease. Other series have mentioned the use of peroral dilation during the treatment of malignant disease and have found it to be useful but have not critically evaluated its role. 17,18 Most workers find it necessary to dilate malignant strictures in preparation for placement of an esophageal prosthesis, although this is often done in one session under general anesthesia. A perforation rate of 2.5 to 9% has been reported for this procedure in several series. 12-14 We agree with GASTROINTESTINAL ENDOSCOPY
Boyce19 who stated that gradual dilation is better tolerated and, because it appears to be associated with a lower rate of perforation, is also safer. An unusual complication seen in one of our patients was duodenal ulcer perforation. The occurrence of peptic ulcer perforation and esophageal stricture manipulation has been previously reported by Chung et a1. 20 who thought that the pressure of gastric air trapped by the esophageal stricture blew out an established peptic ulcer. Esophageal dilation can be safely and effectively performed during radiation therapy. Eighteen of 39 patients underwent dilation while receiving radiation therapy without complication. Dysphagia may worsen during radiation therapy and, indeed, necessitate a temporary reduction in dilator size. We believe that continued dilation during radiation therapy is essential and not contraindicated. This is in agreement with both Heit et a1. 5 and Palmer17 who also documented the safety of dilation during radiation therapy. Peroral dilation effectively palliates dysphagia due to SCCE. In our series 90% of patients who were treated were able to eat and maintain their weight. This is similar to that reported by Heit et a1. 5 Dysphagia occurs at a lumen diameter of 12 mm or less. Peroral dilation will generally maintain esophageal diameter above 12 mm, and in our series the range was 13 to 17 mm. Palliation can be achieved with surgical modalities equally effectively; however, even after surgery, dilation may be required. It has been reported that 30% of postsurgical patients and 50% of postradiation patients will require esophageal dilation for palliation of dysphagia. 2, 10, 12,21 Peroral dilation does not preclude the use of an esophageal prosthesis if subsequently required for dilation failure or esophagopulmonary fistula. In fact, it may be easier to intubate the stricture in the patient who has been adequately dilated. A review of 2459 patients undergoing prosthesis placement showed an overall complication rate of 25.4% with the most frequent complications being tube dislodgement (9.9%) and obstruction (8.6%).14 Since complications related to prosthesis are common, we reserve their use for patients late in the course of their disease when either continued peroral dilation is unsuccessful at relieving dysphagia or an esophagopulmonary fistula develops. Only seven patients (15%) in our series required prosthesis placement at some time during their course. The remainder (85%) were effectively palliated without the need to resort to more invasive modalities.
VOLUME 31, NO.2, 1985
In addition to being safe and effective, peroral dilation is well tolerated, can be performed in most patients, and requires only topical pharyngeal anesthesia. The technique is known to most gastroenterologists and many surgeons and thus is readily available outside of specialized centers. Dilations can be done as an outpatient procedure, allowing the patient to continue a normal lifestyle.
REFERENCES 1. Cancer statistics, 1981. Cancer 1981;31:13. 2. Earlam R, Cunha-Melo JR. Oesophageal squamous cell carcinoma. I. A critical review of surgery. Br J Surg 1980;67:381-90. 3. Mannell A. Carcinoma of the esophagus. Curr Prob Surg 1982;19:553-647. 4. Akiyama H, Tsurumaru M, Kawamura T, et al. Principles of surgical treatment for carcinoma of the esophagus. Ann Surg 1981;194:438-46. 5. Heit HA, Johnson LF, Siegel SR, Boyce HW. Palliative dilation for dysphagia in esophageal carcinoma. Ann Intern Med 1978;89:629-31. 6. Boyce HW, Palmer ED. Techniques ofclinical gastroenterology. Springfield, Ill.: Charles C Thomas, 1975:237-51. 7. Parker EF, Gregorie HB, Prioleau WH, et al. Carcinoma of the esophagus: observations of 40 years. Ann Surg 1982;195:61823. 8. Giugli R, Gignoux M. Treatment of esophageal carcinoma: retrospective review of 2400 patients. Ann Surg 1980;192:4452. 9. Earlam R, Cunha-Melo JR. Oesophageal squamous cell carcinoma. II. A critical review of radiotherapy. Br J Surg 1980;67:457-61. 10. Kelsen D. Treatment of advanced esophageal cancer. Cancer 1982;50:2576-81. 11. Wong J, Lam KH, Wei WI, et al. Results of the Kirschner operation. World J Surg 1981;5:547-52. 12. Bennett Jr. Intubation of gastro-oesophageal malignancies: a survey of current practice in Britain, 1980. Gut 1981;22:236338. 13. Angorn IB, Hegarty MM. Palliative pulsion intubation in oesophageal carcinoma. Ann Roy Col Surg 1979;61:212-4. 14. Girardet RE, Randsdell HT, Wheat MW. Palliative intubation in the management of esophageal carcinoma. Ann Thorac Surg 1974;18:417-30. 15. Watson A. A study of the quality and duration of survival following resection, endoscopic intubation and surgical intubation in oesophageal carcinoma. Br J Surg 1982;69:585-8. 16. Johnson LF, Peura DA. Dysphagia and esophageal obstruction. In: Conn HF, ed. Current therapy, 1981. Philadelphia: WB Saunders, 1981:374-8. 17. Palmer ED. Peroral prosthesis for the management of incurable esophageal carcinoma. Am J GastroenteroI1973;59:487-98. 18. Den Hartog Jager FCA, Bartelsoman JFWM, Tytgat GNJ. Palliative treatment of obstructing esophagogastric malignancy by endoscopic positioning of a plastic prosthesis. Gastroenterology 1979;77:1008-14. 19. Boyce HW. Peroral prostheses for palliating malignant esophageal and gastric obstruction. Gastroenterology 1979;77:11413. 20. Chung RKS, Gurll NJ, Shirazi SS. Perforation of peptic ulcers related to fiberoptic endoscopy. Dig Dis Sci 1979;24:926-8. 21. Pearson JG. Radiotherapy for esophageal carcinoma. World J Surg 1981;5:489-97.
63