What is the role of prosthesis insertion in esophageal carcinoma?

We review our experience with 13 patients in whom esophageal dilation was used for palliation of malignant esophageal obstruction and with five patients treated with esophageal prostheses for malignant esophagorespiratory fistula. Twelve of the 13 patients with dilation alone received satisfactory palliation and were able to eat a soft or regular diet. Four of five patients with esophagorespiratory fistulas had esophageal dilation followed by insertion of a esophageal prosthesis and received good palliation. Endoscopic insertion of esophageal prosthetic devices has become increasingly popular as a palliative procedure, despite lack of controlled trials either proving efficacy of this therapy or comparing it to radiation therapy with or without dilation of the esophagus. The reported mortality and morbidity rates for esophageal prosthesis insertion are higher than those reported for radiotherapy. There is little to suggest that prostheses are better than or even equal to radiotherapy alone or radiotherapy and bougienage. We review the reported series (greater than 2300 cases) of push-through prostheses insertions in esophageal cancer and compare prosthesis insertion to other therapy. The need for a carefully controlled trial of the different forms of therapy is emphasized, and guidelines for such a study are suggested.