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Ann Thorac Surg 1997;64:287-288
© 1997 The Society of Thoracic Surgeons
Department of Cardiothoracic Surgery, University of Cape Town Medical School, Observatory 7925, Cape Town, South Africa, e-mail:mdegroot{at}thoracic.cts.uct.ac.za
To the Editor:
An endemic zone of esophageal cancer lies within the confines of South Africa. Therefore, it was with great interest that I read the article "Treatment of Esophageal Obstruction With Covered, Self-Expanding Esophageal Wallstents" by Moores and Ilves [1]. Of additional interest in this issue was a related editorial, "Keeping an Open Mind While Restoring Esophageal Patency in Patients With Cancer and Esophagorespiratory Fistula," by Donald E. Low [2]. In these articles the authors discuss the indications, experience, and concerns regarding the use of the new varieties of expandable metal stents for obstruction of the esophagus. The articles were timely and deal with a broad range of issues. Two areas in particularly piqued my interest. First, both articles referred to the idea of expandable mesh stents as "new." In 1973 Didcott [3] published an article entitled "Oesophageal Strictures. Treatment by Slow Continuous Dilatation," in which a spring dilator of stainless steel wire mesh was described and illustrated. The product, its method of insertion, and clinical results bear striking resemblance to the uncovered Wallstent. Of particular note, the problem of removal of deployed mesh stents is overcome by the inclusion in the design of a nylon pursestring suture in the upper end of the mesh. This modification allows for grasping of the loop with a suitable hook or forceps, thereby collapsing the upper end, facilitating safe removal. The reason for its relegation to the depths of surgical literature is obscure as it would appear the concept precedes and in many ways is superior to the currently promoted products.
Second, the cost benefit relationship, as described by Dr Low, places this refinement of intubation out of reach of many patients who may benefit from the less traumatic method of insertions. Over the last 7 years my colleagues and I have intubated 423 patients for esophageal carcinoma; in the majority we have used a pulsion method with a Proctor-Livingstone tube (Roynhardt Ltd, Johannesburg, South Africa). In 51 patients the indication was a malignant tracheoesophageal fistula. The median survival was 98 days (95% confidence interval, 80 to 116 days) overall and 60 days (95% confidence interval 0 to 128 days) for the latter group with fistulas. The cost ratio between the locally produced tube and the imported Wallstent is more than 50 to 1, with the latter approximating the average per capita annual income of the country! The uniformly dismal outcome for these patients therefore cannot justify the cost. I fully agree with Dr Low's statement that standard pulsion-type tubes remain the standard unless specific indications exist for using more expensive alternatives.
References
Albany Cardiothoracic Surgeons, Pc Suite 301 319 S Manning Albany, Ny 12208.
To the Editor:
It is with some interest we read the letter from Dr De Groot of South Africa. The huge number of patients he sees with esophageal carcinoma gives him a wealth of experience in esophageal intubation. We would like to respond to some of his points.
We were unaware of Dr Didcott's esophageal stent. The stent that Dr Didcott described in 1973 was an uncovered, self-expanding wire stent that was used for slow, continuous dilation of benign esophageal strictures. The new covered, expandable stents have a distinct superiority in the treatment of carcinoma as relates to tumor ingrowth. Nevertheless, the method of stent retrieval described by Dr Didcott is fascinating. Certainly, the addition of this sort of feature to the present-day covered Wallstent would be of benefit. The major disadvantage of the covered Wallstent is the inability to remove it once it has been deployed.
Cost comparison of various treatment modalities, especially on an international level, is a very complicated issue. One cannot merely look at the out-of-pocket cost of a particular stent as the only factor in the cost benefit equation. Other factors that must be considered are ease of stent placement, type of anesthesia required, need for operating room time, risk of stent migration, perforation rate associated with stent placement, and, most important, the durability and quality of the palliation afforded to the patient.
The stent that we reported our experience with is not the final refinement in stent technology, and one can anticipate improvements in the future. As far as we know, there are currently four self-expanding stents being used for esophageal intubation at this time in this country. These include the Wallstent (Schneider; Minneapolis, MN), Gianturco (Wilson-Cook, Winston Salem, NC), Nitinol (Microvasive, Watertown, MA), and the Esopha-Coil (InStent, Eden Prairie, MN). With four companies competing in this market, I suspect that the technology will improve and that cost for these stents will go down due to forces of the marketplace. We do not agree with Dr De Groot that the older pulsion-type plastic tubes should be the standard tube for intubation of esophageal carcinoma. It remains our opinion that the self-expanding stent is easier and safer to place and provides better palliation due to its large internal diameter. A prospective, randomized trial comparing the self-expanding stent with the standard pulsion-type tube would be of value and would help answer some of the questions.
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