Safety implications of oesophageal stents used for the palliation of dysphagia in patients undergoing neoadjuvant therapy for oesophageal malignancy—authors’ reply

Sirs,

We thank Drs. Jones and Griffiths for their interest in our article (1). They have raised some valid points against the use of oesophageal stents used for the palliation of dysphagia in patients undergoing neoadjuvant therapy for oesophageal cancer. There was significant improvement in dysphagia scores observed in our analysis. Their concerns are based on reports of life threatening complications like oesophago-tracheobronchial fistulae, acute oesophageal perforation and migration with small bowel obstruction or perforation (2-4). In our paper we examined patients with operable disease which is a different cohort of patients that had the life threatening complications. The latter group had locally advanced disease or extensive metastatic disease and were having palliative therapy (3).

After our study was published, two more studies have been published demonstrating significant improvement in quality of life related to dysphagia and increase in oral alimentation in patients having neoadjuvant therapy prior to planned oesophageal resection (5,6). The incidence of oesophageal erosion, fistula or perforation was zero.

Our study does not address the use of stents for palliation, hence, the observations from Shenfine et al. (7) are not be applicable. Recently, Zhu et al. (8) performed a multicentre, single-blind and randomized phase 3 trial with 160 unresectable oesophageal cancers from 16 hospitals in China that compared conventional stents versus stents loaded with ¹²⁵Iodine seeds. There was a survival benefit of 30 days reported with stents loaded with ¹²⁵Iodine seeds. The stents loaded with ¹²⁵Iodine seeds holds an interesting future in unresectable oesophageal cancer therapy, but again is examining the use of stents for palliation.

The potential limitation of this meta-analysis could be the small number of studies and sample size included for the analysis. The other main limitation of this meta-analysis is the lack of patient level data, particularly survival data which precluded us from performing a robust analysis. The considerable variations in reported outcomes of patients besides poor outcomes have not been reported sufficiently in the literature and could be a cofounding factor. Obviously, all retrospective studies have the drawback that can be overcome only by a large well designed prospective, randomized controlled trial and the present meta-analysis provides an insight into the evidence available today. We agree that a robust randomized controlled trial is vital for evaluating the role of oesophageal stents compared to the use of nasogastric feeding in patients undergoing neoadjuvant therapy for oesophageal cancer. Until that time either removable stents or the insertion of a nasogastric tube would be an appropriate choice for patients requiring nutritional support.

Acknowledgements

Disclosure: The authors declare no conflict of interest.

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