2019 SCIENCELINE

Journal of Life Science and Biomedicine

J Life Sci Biomed, 9 (4): 82-88, 2019

License: CC BY 4.0

ISSN 2251-9939

Role and place of the endoscopic therapy

in advanced stages of cardioesophageal

cancer

Leonard Petrovich STRUSSKIY, Zayniddin Makhamatovich NIZAMKHODJAEV, Ruslan Efimovich LIGAY,

Anvar Mirzaakbarovh KHUSANOV and Rasul Rakhmatovich OMONOV^

Republican Specialized Centre of Surgery named after acad. V.Vakhidov, JSC, Tashkent, Uzbekistan

Corresponding author’s Email: firebat2004@inbox.ru

ABSTRACT

Original Article

PII: S225199391900013-9

Aim. The aim of study was to investigate efficacy of palliative treatment of proximal

gastric tumors. Methods. The article describes experience of treating 232 patients with

unresectable cardioesophageal cancer (UCC). Of these, minimally invasive endoscopic

procedures: endoscopic diatermotunnelization (ED), endoscopic bougienage (EB) and

endoscopic stenting (ES) was performed in 101 patients. Currently, the method of

endoscopic stenting is preferred, which was performed in 84 patients, and own-developed

model of a silicone tube stent was used in all patients. Main early and late complications

of using this method were described. Results. Minimally invasive techniques described,

the absence of a cosmetic defect, there is no need of specific care set endoprothesis and

relatively easily tolerated by patients of the technique endoprosthetic stent installation

suggest a viable alternative to the imposition of gastrostomy and jejunostomy.

Rec.

Rev.

Pub.

13 March 2019

18 June 2019

25 July 2019

Keywords

Tumours of the proximal part of

the stomach,

Surgical treatment,

Unresectability,

Invasive technologies,

Diathermotunnelization,

Endoscopic bougienage,

Endoscopic stenting.

INTRODUCTION

In spite of the steady decline in the incidence and mortality of gastric cancer remains extremely relevant

problem [1-4 ]. For a long time this terrible disease was the leading cause of death from cancer pathology

worldwide. Over the past 20 years, against a background of reducing the overall incidence of cancer of the

stomach, marked by a sharp increase in the incidence of cancer cardio-esophageal region [4-8 ].

Among all sites of tumor lesions of the stomach cardioesophageal zones occupy from 10 to 37% [9, 10 ]. The

main reason for the treatment of patients for medical treatment when cancer is cardioesophageal dysphagia,

which progression occurs much faster than in benign narrowing [11-14 ]. Carried out before: gastrostomias &

Yeyunostomia and ensure minimal invasiveness and adequacy of enteral nutrition.

The introduction into clinical practice of minimally invasive technologies have greatly reconsider the

tactics of treatment of patients with unresectable stage cardioesophageal tumors, which are aimed at

improving the quality of the remaining life of patients and meet two basic requirements: minimum trauma and

preserving the natural oral feeding. Objective of study was to examine the results of minimally invasive

endoscopic treatment of patients with inoperable and unresectable stage cardioesophageal tumors.

MATERIAL AND METHODS

In the period from 2001 to 2014, in the department of surgery of the esophagus and the stomach of "RSCS them.

Acad. V.Vahidova" were hospitalized 444 patients with tumors of the proximal stomach. Men was 333 (75%),

women - 111 (25%). Patients underwent a comprehensive study, which included endoscopy, radiopaque

polypositional study of the esophagus and stomach, ultrasound of the abdomen, Multi-slice computed

tomography (MSCT) and morphological study of biopsy specimens and macropreparations. In accordance with

the classification of tumors cardioesophageal patients were distributed as follows:

Citation: Strusskiy LP, Nizamkhodjaev ZM, Ligay RE, Khusanov AM and Omonov RR. 2019. Role and place of the endoscopic therapy in advanced stages of

cardioesophageal cancer. J. Life Sci. Biomed. 9(4): 82-88; www.jlsb.science-line.com

Type I - adenocarcinoma of the distal esophagus with the ability to spread in the direction of the stomach -

115 (25.9%) patients; Type II - a true adenocarcinoma of the gastroesophageal transition zone (true cancer of the

cardia) - 75 (16.9%) patients; Type III - a cancer of the localization of the main array subcardial tumors of the

stomach and the possible involvement of the distal esophagus - 254 (57.2%) patients. Distribution of patients

according to the extent of the cardioesophageal junction (CEJ) and the distal esophagus is presented in figure 1.

One of the first reasons for the treatment of patients with dysphagia was, in connection with which it

analyzed the degree of tumor spread to the esophagus and the cortical evoked responses (CEP), which is

presented in table 1. Only 93 (20.9%), dysphagia clinic was not, and in the majority of cases - 351 (79.1%) had

dysphagia varying degrees of severity.

A: With the spread of the

esophagus and the CET

N=82 (18.5%)

C: With the transition to the

abdominal esophagus

N=167 (37.6%)

D: With the transition to the

lower third of the thoracic

N=71 (15.9%)

B: Spread on the CEJ

N=124 (27.9%)

Figure 1. Distribution of patients according to the extent of the cortical evoked responses (CEP) and the distal

esophagus. CEJ=cardioesophageal junction, CET= complete esophageal transit

Table 1. Degree of tumor spread

Prevalence in the CET and the esophagus

The degree of

dysphagia

Total

CET

abdominal esophagus

l/3 thoracic esophagus

Absolute

No dysphagia

I degree

11(8.9%)

18(10.8%)

46(27.5%)

2(2.8%)

62(75.6%)

93(20.9%)

116(26.1%)

42(33.9%)

17(23.9%)

11(13.7%)

II degree

III degree

64(51.6%)

6(4.8%)

89(53.3%)

12(7.2%)

33(46.5%)

13(18.3%)

9(10.9%)

195(43.9%)

31(6.9%)

IV degree

Total

1(0.8%)

124

2(1.2%)

167

6(8.5)

9(2%)

444(100%)

CET= complete esophageal transit

Ethical approval

The review board and ethics committee of RSCS named after acad. V.Vakhidov approved the study

protocol and informed consents were taken from all the participants.

RESULTS AND DISCUSSION

Of 444 patients, resection procedures were performed in 212 (47.7%) patients. The remaining 232 (52.3%)

due to various reasons the process is recognized as inoperable or unresectable. This category of patients is

devoted to the study. In 122 of 232 patients, which accounted for 52.6% of inoperable established on the basis of

a comprehensive survey, while 110 (47.4%) only after laparotomy or laparoscopy. Summary of therapeutic

measures is shown in table 2.

Citation: Strusskiy LP, Nizamkhodjaev ZM, Ligay RE, Khusanov AM and Omonov RR. 2019. Role and place of the endoscopic therapy in advanced stages of

cardioesophageal cancer. J. Life Sci. Biomed. 9(4): 82-88; www.jlsb.science-line.com

Symptomatic treatment was performed in 128 patients, which accounted for 55.2%. All patients were

discharged to conduct a specific treatment in oncological institutions. Gastrostomy used only in 3 (1.3%) cases.

Minimally invasive procedures were performed in 101 (43.5%) patients. Patients with dysphagia 3-4 degree and

pronounced alimentary cachexia, as a preliminary preparation for the restriction zone was conducted

nasogastric feeding controlled by endoscopy.

Scheme of the probe is shown in figure 2 A. Summary of minimally invasive interventions was as follows:

Endoscopic diathermy tunneling (EDT) tumors in 17 (16.8%) and endoscopic stenting (ES) in 84 (83.2%).

Endoscopic diatermotunelisation tumor performed in 17 (16.8%). Scheme of endoscopic diatermotunelisation is

shown in figure 2 B. The reasons for rejection of stent placement was: in 14 cases, the absence of a circular

growth suprastenotic expansion of the lumen of the distal esophagus, which can lead to migration of the

implant, and in 3 patients, which was planned stenting, in step diatermotunelisation stepped perforation of the

tumor, therefore the 2 patients operated on an emergency basis, and 1 patient was successfully conducted

conservative treatment.

Table 2. Summary of therapeutic measures

Items

After exploratory surgery

Not operated patients

Total

3 (1.3%)

Gastrostomy

Symptomatic treatment

Minimally invasive methods

Total

128 (55.2%)

101 (43.5%)

232

110 (47.4%)

122 (52.6%)

A. Scheme of nasogastric tube feeding under the

control of the endoscope

B. Scheme of endoscopic diathermy tunneling

Figure 2. Scheme of the probe

Endoscopic stenting

The basic meaning of the use of stenting (prolonged esophageal intubation) is the possibility of oral

nutrition because tunneling and probing can not provide a long-term restoration of patency of the esophagus

due to the constant growth of the tumor, occlusive lumen again. Thus, stent stenosis restricts tumor clearance,

acting as a skeleton. However, stenting can not be used in all patients, as requires two conditions: the presence

suprastenotic expansion and circular lesion to prevent stent migration. We used a stent made of silicone tube of

his own design, developed in the endoscopy department of JSC "RSCS named after Acad. V.Vahidova". The stent

is made individually from the silicone tube with a funnel-shaped initial part for preventing its migration. The

required length and diameter were determined on the basis of endoscopic and radiologic data. Silicone stents: a

straight and S-shaped, are presented in picture 1. We used 4 methods of endoscopic stenting:

1. "Direct" when there is no need for pre-extension-rhenium luminal tumors performed in 11 (13.1%) cases;

2. Pre endoscopic diathermic tunalization tumor, described above, formed in 31 (36.9%) patients;

3. preliminary dilatation was performed in 15 (17.8%) patients;

4. preliminary endoscopic boujing (EB) performed in 27 (32.1%) patients.

Citation: Strusskiy LP, Nizamkhodjaev ZM, Ligay RE, Khusanov AM and Omonov RR. 2019. Role and place of the endoscopic therapy in advanced stages of

cardioesophageal cancer. J. Life Sci. Biomed. 9(4): 82-88; www.jlsb.science-line.com

It should be noted that the choice of method is individually endoscopic stenting and depends on the

severity of the patient's condition, the nature of the tumor growth and the extent of its spread to the esophagus

and stomach. If there is evidence to pre-expand the lumen of the tumor is currently prefer the combination of

EDB and EB, which allow the most optimized and safely perform this manipulation. For the EB used a set of

standard and interchangeable olive-proprietary. Scheme of endoscopic bougienage bougies and sets are shown

in picture 2. Endoscopic stenting carried out under the supervision of endoscopy according to its own

developed methods: the instrument on the endoscope and Bouje with the pusher tube. Scheme of endoscopic

stenting is shown in figure 3.

All patients fulfilled the radiological control of the correct establishment of the endoprosthesis, which was

carried out the next day after stenting. Of the 84 patients, 4 cases, which was 4.7%, the offset is set down

endoprothesis, whereby the distal end of the prosthesis rested against the stomach wall. In this connection, the

removal of the stent was performed followed by restenting. X-ray picture and scheme productions silicone stent

is shown in picture 3.

Straight stent

Picture 1. Type of stents

S-shaped silicone stent

Scheme of endoscopic bougienage

A set of traditional and removable bougies olive

Picture 2. Scheme of endoscopic bougienage

Citation: Strusskiy LP, Nizamkhodjaev ZM, Ligay RE, Khusanov AM and Omonov RR. 2019. Role and place of the endoscopic therapy in advanced stages of

cardioesophageal cancer. J. Life Sci. Biomed. 9(4): 82-88; www.jlsb.science-line.com

Stent in the device for endoscope

Stent in the bouje

Figure 3. Installation of stent and bouje

Scheme of installed S-shaped stent

X-Ray after installing endoprothesis

Picture 3. S-shaped stent

Despite its minimally invasive ES possible development of specific complications, which are divided into

early and late complications:

A) Early complications. During the ES, observed track-guides complications: bleeding from the tumor area

- 12 (11.8%); Funchtion of the cardia of the stomach - 1 (0.99%); perforation of the abdominal department pi

schevoda - 1 (0.99%); perforation of the lower third of the thoracic esophagus - 1 (0.99%). tumor perforation

diagnosis was based on clinical data of objective examination and X-ray studies with water-soluble contrast. In

this case, 1 case of laparotomy performed, suturing tumor defect, sanitation, drenaging and plugging with a

satisfactory result. The remaining patients were discharged in a serious condition due to the ongoing

Citation: Strusskiy LP, Nizamkhodjaev ZM, Ligay RE, Khusanov AM and Omonov RR. 2019. Role and place of the endoscopic therapy in advanced stages of

cardioesophageal cancer. J. Life Sci. Biomed. 9(4): 82-88; www.jlsb.science-line.com

peritonitis and mediastinitis due to the categorical rejection of the proposed emergency operations. Bleeding in

the form of vomiting fresh blood in all cases stopped by conservative measures.

B) Late complications. Among the specific complications inherent ES technique, the following were

observed late complications: occlusion of the stent food - 18 (21.4%); obstruction of proximal part of the stent

tumor - 9 (10.7%), occlusion of the distal stent tumor - 6 (7.1%); migration of the stent into the stomach - 3 (3.6%);

migration of the stent in the esophagus - 1 (1.2%); pain, analgesics are not docked - 6 (7.1%). In cases of stent

obstruction was conducted fragmentation food bolus under control endoscopy and push food at the distal end

of the stent. When tumor obstruction of the proximal end of the stent held EDT followed by further

restentirovaniem. In cases the tumor obstruction of the distal end of the stent was performed by only EDT. In

cases of stent migration into the stomach was carried out under the supervision of the extraction of the stent

endoscopy followed restenting. When the left-Bo syndrome, not cropped analgesics stent removed.

CONCLUSION

The introduction of endoscopic techniques has solved the most important issue - the elimination of dysphagia,

which in these patients leads to nutritional depletion of non-resectable patients. Minimally invasive techniques

described, the absence of a cosmetic defect, there is no need of specific care set endoprothesis and relatively

easily tolerated by patients of the technique endoprothesis stent installation suggest a viable alternative to the

imposition of gastrostomy and jejunostomy.

DECLARATIONS

Acknowledgements

This work was supported by “Republican Specialized Scientific and Practical Medical Center of Surgery

named after Academician V.Vakhidov”, Uzbekistan.

Authors’ Contributions

All authors contributed equally to this work.

Competing interests

The authors declare that they have no competing interests.

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