Russell E. White.
Tenwek Hospital, Bomet, Kenya.
OBJECTIVE:
Esophageal carcinoma (EC) has a worldwide 5-year survival of less than 10%. It has a marked worldwide geographic variation in distribution and is the most common cancer in Kenya. Presentation is usually late due to esophageal lumen obstruction, resulting in dysphagia and weight loss. At a single, referral center in western Kenya, EC accounts for 35% of all tumors and over 90% of patients with EC present with advanced, predominately inoperable disease. In a country of 35 million people, surgical resection has been the only means of treatment. However, many patients are not surgical candidates, and many are found to have unresectable disease. Therefore, palliation is most often the goal and must be affordable through the use of locally available technology. Placement of SEMS without fluoroscopy has become the treatment of choice in rural western Kenya.
METHODS:
A review of prospectively gathered data on all patients treated with SEMS for palliation of EC between 1999 to December 1, 2007 was undertaken. Demographic factors, pre and post stenting dysphagia scores, morbidity, mortality, and survival were documented when available. Tumor specifics were also noted.
RESULTS:
A total of 746 stents were placed in 715 patients. The median age at presentation was 62 (14-99). Perforation during pre-stenting dilation occurred in 37 cases (2% of all dilations), one of which resulted in death. Stent migration occurred in 2 cases (0.3%), and late stent occlusion from tumor overgrowth occurred in 38 patients (5%), 28 were treated with a second stent. Median survival was 33 weeks (4-186). The mean pre-stenting dysphagia score was 3.33 (scale 0-4 with 4 representing complete dysphagia) while mean dysphagia score at time of death was 2 (p<0.001). The majority of stents were placed on an outpatient basis without sedation, and no patients required fluoroscopy.
CONCLUSIONS:
SEMS provide excellent palliation of advanced esophageal cancer. They can be placed with minimal equipment and low morbidity and mortality. Placement of SEMS should therefore be considered appropriate technology and preferred treatment in resource-limited settings.
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