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Stenting and Curative Resection
LETTERS
Stenting in the Neoadjuvant Setting
3. Mariette C, Gronnier C, Duhamel A, et al. Self-expanding covered metallic stent as a bridge to surgery in esophageal cancer: impact on oncologic outcomes. J Am Coll Surg 2015;220:287e296.
Gregory L Falk, MBBS Lindfield, Australia
Disclosure Information: Nothing to disclose.
I read with a little concern the excellent study by Philips and colleagues1 on the efficacy of gastro-esophageal stenting. Although quality of life and swallowing were enhanced in this group, there was a high rate of stent migration (63%), and this therapy is recognized only for palliative cases. So these data are quite applicable to the palliative group and are reassuring. There are no data available for the use of stenting as a bridge to curative resection with neoadjuvant therapy. Our concerns were first raised when an early and unusual pattern of recurrence of esophageal carcinoma was found in a number of patients, and cure on the basis of histopathology would have been expected. In several other patients, stents were seen in the mediastinum, indicating cancer perforation and incurability. With this experience, we reviewed the very scant literature. One can only theorize that stenting a tumor in the esophagus or cardio-esophageal junction leads to micro-cracking of the exterior of the tumor and potential for dissemination. Jones and Griffiths2 indicated that stenting in the neoadjuvant setting can lead to significant complications and can compromise the opportunity for surgical cure. In a collected series, Mariette and colleagues3 demonstrated a negative effect of stenting on oncologic outcomes in the neoadjuvant situation. On the basis of such concerns, a moratorium needs to be called on stenting in the neoadjuvant situation until adequate randomized data show it to be effective and able to produce equivalent oncologic outcomes to those of current techniques. REFERENCES 1. Philips P, North DA, Scoggins C, et al. Gastric-esophageal stenting for malignant dysphagia: results of prospective clinical trial evaluation of long-term gastroesophageal reflux and quality of life-related symptoms. J Am Coll Surg 2015;221: 165e173. 2. Jones CM, Griffiths EA. Should oesophageal stents be used before neo-adjuvant therapy to treat dysphagia in patients awaiting oesophagectomy? Best evidence topic (BET). Int J Surg 2014;12:1172e1180.
ª 2015 by the American College of Surgeons. Published by Elsevier Inc. All rights reserved.
Stenting and Curative Resection In Reply to Falk Robert CG Martin II, Louisville, KY
MD, PhD, FACS
Thank you very much for your kind comments regarding our study on the use of gastroesophageal stenting in patients with gastroesophageal (GE)-junction adenocarcinoma. Respectfully, we would like to inform you that there actually is a wealth of data on the use of stenting as a bridge to curative resection while patients are on neoadjuvant therapy that has been published in the literature. One of the larger studies was published by our division, by Brown and colleagues,1 which demonstrated the surgical safety and more importantly, the lack of increased operative time and operative complexity in patients who had undergone neoadjuvant chemotherapy and/or radiation therapy while having an esophageal stent in place. This study was further expanded, and a much larger study, which is currently the largest series outlining the use of neoadjuvant stenting, was again carried out by our Division of Surgical Oncology. These demonstrated the significant improvement in quality of life and efficacy with the use of neoadjuvant stenting in patients with potentially resectable GE-junction adenocarcinoma.2 A third review, again performed by our Division of Surgical Oncology by Bower and coauthors,3 demonstrated the significant improvement in overall nutritional parameters in patients who underwent neoadjuvant stenting in comparison with patients who had enteral feeding tubes in place or who attempted to maintain their nutrition with simple oral intake. These are just the studies that have been published from our division; multiple other manuscripts have been published on the use of stenting as a bridge to curative resection with neoadjuvant therapy.4-7 More importantly, with the studies mentioned above as well as the other studies, there has not been any type of report of “micro-cracking,” and therefore, a worsening
1093
http://dx.doi.org/10.1016/j.jamcollsurg.2015.08.426 ISSN 1072-7515/15
1094
J Am Coll Surg
Letters
overall outcome in this patient subset. I find it hard to believe that placement of a stent would affect overall survival, when this is the same technique that is used for pancreatic adenocarcinoma-induced jaundice before resection, hilar cholangiocarcinoma, and colon cancerdall examples of pre-resection stenting not demonstrating adverse overall survival. More importantly, it is imperative that safe GE-junction esophageal stenting use appropriate diameter stents, and it should not proceed with any type of balloon dilatation or forceful dilatation before esophageal stent placement. Professor Falk mentioned only 2 publications, which do not provide any specific information regarding esophageal stent use. For example, the study by Mariette and coworkers8 stated, “As a consequence of both the time period (10 years) and multicenter nature of the study, a variety of SEMS brands were used.” So I find it hard to believe that because the authors of this study cannot present the exact length, diameter, and type of stents used, they can then claim that ALL stents are bad. The article by Jones and colleagues9 is a simple review of previous studies, which do not demonstrate the critical finding that esophageal stenting is harmful. Esophageal stenting requires attention to detail and precision in order to achieve success, as in many facets of oncology care. It has been our experience that with precise education and with strong use of surgical endoscopy, dilation can be avoided, and appropriate stenting and more importantly, optimal oncologic management, can be achieved with the use of neoadjuvant stenting. Therefore, there are no data to support placing a moratorium on esophageal stenting in the neoadjuvant setting. More importantly, there should be precise oversight in the type of stents that are placed, appropriate endoscopic mapping of the tumor in regard to its length and diameter, and most importantly, the appropriate diameter, length, and radial force stent must be used precisely for each patient, given the heterogeneity with which these patients with mid and distal esophageal cancers can present. REFERENCES 1. Brown RE, Abbas AE, Ellis S, et al. A prospective phase II evaluation of esophageal stenting for neoadjuvant therapy for esophageal cancer: optimal performance and surgical safety. J Am Coll Surg 2011;212:582e588. 2. Martin RC 2nd, Cannon RM, Brown RE, et al. Evaluation of quality of life following placement of self-expanding plastic stents as a bridge to surgery in patients receiving neoadjuvant therapy for esophageal cancer. Oncologist 2014;19: 259e265. 3. Bower M, Jones W, Vessels B, et al. Nutritional support with endoluminal stenting during neoadjuvant therapy for esophageal malignancy. Ann Surg Oncol 2009;16: 3161e3168.
4. Langer FB, Schoppmann SF, Prager G, et al. Temporary placement of self-expanding oesophageal stents as bridging for neo-adjuvant therapy. Ann Surg Oncol 2010;17: 470e475. 5. Siddiqui AA, Glynn C, Loren D, Kowalski T. Self-expanding plastic esophageal stents versus jejunostomy tubes for the maintenance of nutrition during neoadjuvant chemoradiation therapy in patients with esophageal cancer: a retrospective study. Dis Esophagus 2009;22:216e222. 6. Siddiqui AA, Ansari S, Ghouri MA, Memon MS. Self expandable metallic stent endoscopic insertion in esophageal cancer. J Coll Physicians SurgePakistan 2010;20:502e505. 7. Siddiqui AA, Sarkar A, Beltz S, et al. Placement of fully covered self-expandable metal stents in patients with locally advanced esophageal cancer before neoadjuvant therapy. Gastrointest Endosc 2012;76:44e51. 8. Mariette C, Gronnier C, Duhamel A, et al. Self-expanding covered metallic stent as a bridge to surgery in esophageal cancer: impact on oncologic outcomes. J Am Coll Surg 2015;220:287e296. 9. Jones CM, Griffiths EA. Should oesophageal stents be used before neo-adjuvant therapy to treat dysphagia in patients awaiting oesophagectomy? Best evidence topic (BET). Int J Surg 2014;12:1172e1180.
Disclosure Information: Nothing to disclose.
Feasibility of Angiotensin Inhibition for Obese Trauma Patients Tetsuji Fujita, Tokyo, Japan
MD
In the August 2015 issue of the Journal of the American College of Surgeons, Dr Winfield and colleagues1 published an interesting study that analyzed multiple organ failure (MOF) scores and leukocyte surface markers of 271 trauma patients divided into 4 groups after adjustment for age, sex, and Injury Severity Score. Obese patients receiving angiotensin receptor blocker (ARB) and/or angiotensin converting enzyme inhibitor (ACE) exhibited lower MOF scores compared with those not receiving ARB/ACE. These potential benefits of angiotensin inhibitors were not found among nonobese trauma patients. Dr Winfield and colleagues1 assumed that T-cell preservation and monocyte activation might contribute to a reduction in MOF scores, because obese patients on ARB/ACE showed lower expression of CD328 in CD2þ T-cells and higher expression of CD47 in CD36þ monocytes. On the basis of these findings, Dr Winfield and colleagues1 concluded that clinical trials are warranted to determine the potential use of ARB/ ACE in obese trauma patients.
Stenting in the Neoadjuvant Setting
3. Mariette C, Gronnier C, Duhamel A, et al. Self-expanding covered metallic stent as a bridge to surgery in esophageal cancer: impact on oncologic outcomes. J Am Coll Surg 2015;220:287e296.
Gregory L Falk, MBBS Lindfield, Australia
Disclosure Information: Nothing to disclose.
I read with a little concern the excellent study by Philips and colleagues1 on the efficacy of gastro-esophageal stenting. Although quality of life and swallowing were enhanced in this group, there was a high rate of stent migration (63%), and this therapy is recognized only for palliative cases. So these data are quite applicable to the palliative group and are reassuring. There are no data available for the use of stenting as a bridge to curative resection with neoadjuvant therapy. Our concerns were first raised when an early and unusual pattern of recurrence of esophageal carcinoma was found in a number of patients, and cure on the basis of histopathology would have been expected. In several other patients, stents were seen in the mediastinum, indicating cancer perforation and incurability. With this experience, we reviewed the very scant literature. One can only theorize that stenting a tumor in the esophagus or cardio-esophageal junction leads to micro-cracking of the exterior of the tumor and potential for dissemination. Jones and Griffiths2 indicated that stenting in the neoadjuvant setting can lead to significant complications and can compromise the opportunity for surgical cure. In a collected series, Mariette and colleagues3 demonstrated a negative effect of stenting on oncologic outcomes in the neoadjuvant situation. On the basis of such concerns, a moratorium needs to be called on stenting in the neoadjuvant situation until adequate randomized data show it to be effective and able to produce equivalent oncologic outcomes to those of current techniques. REFERENCES 1. Philips P, North DA, Scoggins C, et al. Gastric-esophageal stenting for malignant dysphagia: results of prospective clinical trial evaluation of long-term gastroesophageal reflux and quality of life-related symptoms. J Am Coll Surg 2015;221: 165e173. 2. Jones CM, Griffiths EA. Should oesophageal stents be used before neo-adjuvant therapy to treat dysphagia in patients awaiting oesophagectomy? Best evidence topic (BET). Int J Surg 2014;12:1172e1180.
ª 2015 by the American College of Surgeons. Published by Elsevier Inc. All rights reserved.
Stenting and Curative Resection In Reply to Falk Robert CG Martin II, Louisville, KY
MD, PhD, FACS
Thank you very much for your kind comments regarding our study on the use of gastroesophageal stenting in patients with gastroesophageal (GE)-junction adenocarcinoma. Respectfully, we would like to inform you that there actually is a wealth of data on the use of stenting as a bridge to curative resection while patients are on neoadjuvant therapy that has been published in the literature. One of the larger studies was published by our division, by Brown and colleagues,1 which demonstrated the surgical safety and more importantly, the lack of increased operative time and operative complexity in patients who had undergone neoadjuvant chemotherapy and/or radiation therapy while having an esophageal stent in place. This study was further expanded, and a much larger study, which is currently the largest series outlining the use of neoadjuvant stenting, was again carried out by our Division of Surgical Oncology. These demonstrated the significant improvement in quality of life and efficacy with the use of neoadjuvant stenting in patients with potentially resectable GE-junction adenocarcinoma.2 A third review, again performed by our Division of Surgical Oncology by Bower and coauthors,3 demonstrated the significant improvement in overall nutritional parameters in patients who underwent neoadjuvant stenting in comparison with patients who had enteral feeding tubes in place or who attempted to maintain their nutrition with simple oral intake. These are just the studies that have been published from our division; multiple other manuscripts have been published on the use of stenting as a bridge to curative resection with neoadjuvant therapy.4-7 More importantly, with the studies mentioned above as well as the other studies, there has not been any type of report of “micro-cracking,” and therefore, a worsening
1093
http://dx.doi.org/10.1016/j.jamcollsurg.2015.08.426 ISSN 1072-7515/15
1094
J Am Coll Surg
Letters
overall outcome in this patient subset. I find it hard to believe that placement of a stent would affect overall survival, when this is the same technique that is used for pancreatic adenocarcinoma-induced jaundice before resection, hilar cholangiocarcinoma, and colon cancerdall examples of pre-resection stenting not demonstrating adverse overall survival. More importantly, it is imperative that safe GE-junction esophageal stenting use appropriate diameter stents, and it should not proceed with any type of balloon dilatation or forceful dilatation before esophageal stent placement. Professor Falk mentioned only 2 publications, which do not provide any specific information regarding esophageal stent use. For example, the study by Mariette and coworkers8 stated, “As a consequence of both the time period (10 years) and multicenter nature of the study, a variety of SEMS brands were used.” So I find it hard to believe that because the authors of this study cannot present the exact length, diameter, and type of stents used, they can then claim that ALL stents are bad. The article by Jones and colleagues9 is a simple review of previous studies, which do not demonstrate the critical finding that esophageal stenting is harmful. Esophageal stenting requires attention to detail and precision in order to achieve success, as in many facets of oncology care. It has been our experience that with precise education and with strong use of surgical endoscopy, dilation can be avoided, and appropriate stenting and more importantly, optimal oncologic management, can be achieved with the use of neoadjuvant stenting. Therefore, there are no data to support placing a moratorium on esophageal stenting in the neoadjuvant setting. More importantly, there should be precise oversight in the type of stents that are placed, appropriate endoscopic mapping of the tumor in regard to its length and diameter, and most importantly, the appropriate diameter, length, and radial force stent must be used precisely for each patient, given the heterogeneity with which these patients with mid and distal esophageal cancers can present. REFERENCES 1. Brown RE, Abbas AE, Ellis S, et al. A prospective phase II evaluation of esophageal stenting for neoadjuvant therapy for esophageal cancer: optimal performance and surgical safety. J Am Coll Surg 2011;212:582e588. 2. Martin RC 2nd, Cannon RM, Brown RE, et al. Evaluation of quality of life following placement of self-expanding plastic stents as a bridge to surgery in patients receiving neoadjuvant therapy for esophageal cancer. Oncologist 2014;19: 259e265. 3. Bower M, Jones W, Vessels B, et al. Nutritional support with endoluminal stenting during neoadjuvant therapy for esophageal malignancy. Ann Surg Oncol 2009;16: 3161e3168.
4. Langer FB, Schoppmann SF, Prager G, et al. Temporary placement of self-expanding oesophageal stents as bridging for neo-adjuvant therapy. Ann Surg Oncol 2010;17: 470e475. 5. Siddiqui AA, Glynn C, Loren D, Kowalski T. Self-expanding plastic esophageal stents versus jejunostomy tubes for the maintenance of nutrition during neoadjuvant chemoradiation therapy in patients with esophageal cancer: a retrospective study. Dis Esophagus 2009;22:216e222. 6. Siddiqui AA, Ansari S, Ghouri MA, Memon MS. Self expandable metallic stent endoscopic insertion in esophageal cancer. J Coll Physicians SurgePakistan 2010;20:502e505. 7. Siddiqui AA, Sarkar A, Beltz S, et al. Placement of fully covered self-expandable metal stents in patients with locally advanced esophageal cancer before neoadjuvant therapy. Gastrointest Endosc 2012;76:44e51. 8. Mariette C, Gronnier C, Duhamel A, et al. Self-expanding covered metallic stent as a bridge to surgery in esophageal cancer: impact on oncologic outcomes. J Am Coll Surg 2015;220:287e296. 9. Jones CM, Griffiths EA. Should oesophageal stents be used before neo-adjuvant therapy to treat dysphagia in patients awaiting oesophagectomy? Best evidence topic (BET). Int J Surg 2014;12:1172e1180.
Disclosure Information: Nothing to disclose.
Feasibility of Angiotensin Inhibition for Obese Trauma Patients Tetsuji Fujita, Tokyo, Japan
MD
In the August 2015 issue of the Journal of the American College of Surgeons, Dr Winfield and colleagues1 published an interesting study that analyzed multiple organ failure (MOF) scores and leukocyte surface markers of 271 trauma patients divided into 4 groups after adjustment for age, sex, and Injury Severity Score. Obese patients receiving angiotensin receptor blocker (ARB) and/or angiotensin converting enzyme inhibitor (ACE) exhibited lower MOF scores compared with those not receiving ARB/ACE. These potential benefits of angiotensin inhibitors were not found among nonobese trauma patients. Dr Winfield and colleagues1 assumed that T-cell preservation and monocyte activation might contribute to a reduction in MOF scores, because obese patients on ARB/ACE showed lower expression of CD328 in CD2þ T-cells and higher expression of CD47 in CD36þ monocytes. On the basis of these findings, Dr Winfield and colleagues1 concluded that clinical trials are warranted to determine the potential use of ARB/ ACE in obese trauma patients.