Key Points

• Self-expanding metal stents provide rapid relief from dysphagia.
• Lasers control bleeding and relieve proximal esophageal obstruction.
• Thermal Nd:YAG laser provides rapid palliation
• Cryospray ablation is a promising new tool
• PDT laser provides the best hemostasis.
• All endoscopic therapies are complementary.

The American Cancer Society estimates that 18,440 new esophageal cancers will be diagnosed in 2020 and 16,170 patients with esophageal cancer will die from the disease.[1] Esophageal cancer is the sixth leading cause of cancer related mortality worldwide and more than 80% cases occur in developing countries.^[2][3] Although the overall survival from esophageal cancer has improved over the last decade, the long-term prognosis remains dismal with a 5-year survival of 20% for all stages combined.^[4] Survival rates are better with early stage disease but less than half of the patients will be eligible for potentially curative resection at time of presentation.^[5] Most often patients present with dysphagia and weight loss; thus, the majority of patients may be candidates for palliative interventions to improve their swallowing, allow adequate oral intake, and reduce the risk of aspiration pneumonia. The goals of palliation are a return to oral intake, ease of treatment, and short hospital stay.

Palliation of dysphagia is usually reserved for advanced stage, patients not candidate for curative treatment, or recurrence of disease. Patients with dysphagia at diagnosis but with minimal nutritional deficits, who are candidates for chemotherapy or chemoradiation therapy, usually respond to therapy and will not need initial interventions for dysphagia. However, a significant number of patients - with a very tight stricture (Figure 1) - may need endoscopic interventions to improve oral intake and nutritional status as the first step in their treatment algorithm. Most endoscopic therapies vary considerably in their durability but share in common a fairly brisk initial improvement in dysphagia. After improvement in oral nutrition, performance may improve and other therapies may be tolerated.

Figure 1A

Radiologic (a) and endoscopic (b) appearance of a tight malignant stricture involving the distal esophagus.

Figure 1B

Radiologic (a) and endoscopic (b) appearance of a tight malignant stricture involving the distal esophagus.

In this chapter we review all the commonly employed methods for endoscopic palliation of malignant dysphagia. In general, these methods deliver rapid relief and allow intake of a soft to regular diet with some modifications depending on the individual. Some limitations in oral diet are still required, but most patients will be able to avoid the need for percutaneous feeding tubes. The durability of the relief of dysphagia is variable, depending on the method used and the progression of the disease at the locoregional level. Many patients who live longer than a few months will need some form of reintervention to maintain relief. On a rare occasion, in a patient with very good performance status with incurable disease, esophagectomy may be indicated for palliation when other interventions fail. Choosing a palliative option has become a complex and dynamic decision-making process given the number of variables to consider. The extent of disease, the cost-effectiveness, the durability of the approach, and the predicted life expectancy of the patient should be considered when deciding upon an appropriate palliative option.