Sreedharan Aravamuthan, Harris Keith, Crellin Adrian, Forman David, Everett Simon M
Department of Gastroenterology, United Lincolnshire Hospitals NHS Trust, Lincoln County Hospital, Greetwell Road, Lincoln, Lincolnshire, UK, LN2 2YE.
Cochrane Database Syst Rev. 2009 Oct 7(4):CD005048. doi: 10.1002/14651858.CD005048.pub2.
The majority of oesophageal and gastro-oesophageal cancers are diagnosed at an advanced stage and palliative treatment is the realistic management option for most patients. The optimal intervention for the palliation of dysphagia in these patients has not been established.
To systematically analyse and summarise the efficacy of different interventions used in the palliation of dysphagia in primary oesophageal carcinoma.
We undertook a search according to the Cochrane Upper Gastrointestinal and Pancreatic Diseases model using the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE, EMBASE and CINAHL and major conference proceedings up to August 2005. The literature search was re-run in August 2006 and March 2007.
Randomised controlled trials (RCTs) in patients with inoperable or unresectable primary oesophageal cancer who underwent palliative treatment. We included rigid plastic intubation, self-expanding metallic stent (SEMS) insertion, brachytherapy, external beam radiotherapy, chemotherapy, oesophageal bypass surgery, chemical and thermal ablation therapy, either head-to-head or in combination. The primary outcome was dysphagia improvement. Secondary outcomes included recurrent dysphagia, technical success, procedure related mortality, 30-day mortality, adverse effects and quality of life.
One author assessed the eligibility criteria of each study and extracted data regarding outcomes and factors affecting risk of bias.
We included 2542 patients from 40 studies. SEMS insertion is safer and more effective than plastic tube insertion. Thermal and chemical ablative therapy provide comparable dysphagia palliation but have an increased requirement for re-interventions and adverse effects. Anti-reflux stents provide comparable dysphagia palliation to conventional metal stents. Some anti-reflux stents might reduce gastro-oesophageal reflux compared to conventional metal stents. Brachytherapy might be a suitable alternative to SEMS in providing a survival advantage and possibly a better quality of life.
AUTHORS' CONCLUSIONS: Self-expanding metal stent insertion is safe, effective and quicker in palliating dysphagia compared to other modalities. However, high-dose intraluminal brachytherapy is a suitable alternative and might provide additional survival benefit with a better quality of life. Self-expanding metal stent insertion and brachytherapy provide comparable palliation to endoscopic ablative therapy but are preferable due to the reduced requirement for re-interventions. Rigid plastic tube insertion, dilatation alone or in combination with other modalities, chemotherapy alone, combination chemoradiotherapy and bypass surgery are not recommended for palliation of dysphagia due to a high incidence of delayed complications and recurrent dysphagia.
大多数食管癌和胃食管癌在晚期才被诊断出来，姑息治疗是大多数患者现实的治疗选择。对于这些患者吞咽困难的最佳干预措施尚未确定。
系统分析和总结用于缓解原发性食管癌吞咽困难的不同干预措施的疗效。
我们按照Cochrane上消化道和胰腺疾病模型进行检索，使用Cochrane对照试验中心注册库（CENTRAL）（Cochrane图书馆）、MEDLINE、EMBASE和CINAHL以及截至2005年8月的主要会议论文集。2006年8月和2007年3月重新进行了文献检索。
对无法手术或无法切除的原发性食管癌患者进行姑息治疗的随机对照试验（RCT）。我们纳入了硬塑料插管、自膨式金属支架（SEMS）置入、近距离放疗、外照射放疗、化疗、食管旁路手术、化学和热消融治疗，包括直接比较或联合使用。主要结局是吞咽困难改善情况。次要结局包括吞咽困难复发、技术成功率、手术相关死亡率、30天死亡率、不良反应和生活质量。
由一位作者评估每项研究的纳入标准，并提取有关结局和影响偏倚风险因素的数据。
我们纳入了40项研究中的2542例患者。SEMS置入比塑料管置入更安全、更有效。热消融和化学消融治疗在缓解吞咽困难方面效果相当，但再次干预需求和不良反应增加。抗反流支架在缓解吞咽困难方面与传统金属支架相当。与传统金属支架相比，一些抗反流支架可能会减少胃食管反流。近距离放疗在提供生存优势和可能更好的生活质量方面可能是SEMS的合适替代方案。
与其他方式相比，自膨式金属支架置入在缓解吞咽困难方面安全、有效且更快。然而，高剂量腔内近距离放疗是一种合适的替代方案，可能会提供额外的生存益处和更好的生活质量。自膨式金属支架置入和近距离放疗在缓解吞咽困难方面与内镜消融治疗相当，但由于再次干预需求减少而更可取。由于延迟并发症和吞咽困难复发的发生率较高，不建议使用硬塑料插管、单纯扩张或与其他方式联合、单纯化疗、联合放化疗和旁路手术来缓解吞咽困难。
