One-Stage Retrograde Approach to Nd: YAG Laser Palliation of Esophageal Carcinoma

Abstract

Background and Study Aims: The aim of the present study was to determine the safety, efficacy, and feasibility of a one-stage retrograde approach to Nd:YAG laser palliation of esophageal carcinoma carried out under general anesthesia.

Patients and Methods: Endoscopic Nd:YAG laser therapy was used on 150 occasions in 62 consecutive patients with advanced malignant obstruction of the esophagus. All procedures were carried out under general anesthesia. The lesion was first dilated using a Savary-Gilliard dilator or balloon technique, and the endoscope was then passed beyond the lesion. Laser energy was applied to the lesion in a circumferential manner as the scope was withdrawn along the length of the lesion, until an adequate lumen was established.

Results: Ninety-three percent of the patients had symptomatic improvement, defined as reduction in the subjective dysphagia grade, and only 14 % of the patients required repeat procedures within 30 days. Fifty percent of the patients experienced effective palliation with only one procedure over the entire course of their illness. In patients with recurrent dysphagia, the mean time between procedures was 100 days. Seventy-six percent of the patients were discharged on the day following the procedure. Complications included the development of pneumomediastinum or subcutaneous emphysema in five cases, and esophageal perforation in two cases. All cases of pneumomediastinum or subcutaneous emphysema or perforation were managed by conservative therapy. Hemorrhage requiring transfusion occurred in two cases. There were three apparently procedure-related deaths occurring within 30 days of the initial procedure.

Conclusions: Effective palliation of obstructing esophageal carcinoma can be achieved in one session using a one-stage retrograde approach with the Nd:YAG laser under general anesthesia. When compared to other palliative modalities, this method produces a longer dysphagia-free interval, and patients with a terminal illness are therefore able to spend more time out of hospital.