Management of unresectable malignant esophageal obstruction

Malignant esophageal obstruction (MEO), especially with esophago-respiratory fistula (ERF), requires efforts to achieve a meaningful degree of palliation. Laser vaporization (LV) of the esophageal tumor and placement of an endoesophageal prosthesis (EEP) represents a new combination for palliation of MEO. The purpose of the present study was to evaluate the neodymium-yttrium-aluminum-garnet (Nd:Yag) laser in reopening the esophageal channel to permit both swallowing and insertion of an EEP. Twenty-three consecutive patients with MEO were evaluated, and ERF was documented by preoperative contrast study in eight patients. All 23 patients underwent laser vaporization, dilation, and surgical placement of EEP. Adequate swallowing was attained in 21 patients; one patient with an ERF experienced recurrent aspiration from failure of the EEP to occlude the fistulous tract. Operative morbidity was 17% (4/23), which included: wound infection, 2; persistence of ERF, 1; esophageal perforation, 1; and food impaction, 1. Thirty-day operative mortality was 9% (2/23). Palliation was excellent in 87% (20/23), with discharge from the hospital by the seventh postoperative day. Mean survival was 3.3 months. We conclude that laser vaporization followed by placement of an EEP represents a major advance in the palliation of MEO.