Sunday, January 7, 2007

On being sick and Esophageal Stents

Yikes, It has been a while since I have been really sick, but now with twins, a lot more bugs seem to find a way to me. I actually had to stay home from work Friday, and was sleeping 16-20 hours a day on Friday and Saturday with a bad adenovirus. Could not swallow without severe pain from my swollen tonsils; could not talk; chills, shakes, sweats, myalgias. It is curious how being sick reminds you just how miserable it is to be a 'patient.' You just feel so vulnerable. Honestly my Palliative Performance Score probably got down to a 30%. Not good if you look at it for prognosis. I think I am going to live with my PPS now being up to 80%. Anyway since I am feeling better, I figure the least amount of work I could do is put up a new post.

Well, I sure am glad I decided to read my copy of European Journal of Gastroenterology & Hepatology, because there was a pretty insightful article on using self-expandable plastic stents (SEPS) in esophageal cancers. I have not seen a lot of SEPS or SEMS (metal) in practice here in Kansas City or in North Carolina, and I am not sure if it is a population selection, geographic bias, or something else. But this article reminded me to suggest these as a possible option for patients with severe dysphagia or aphagia from esophageal cancer which usually presents as very aggressive and inoperable. The study enrolled 69 patients with advanced inoperable esophaeagl cancer, of which 66 received SEPS. The reasons they think SEPS may be advantageous over rigid plastic or metal stents that have been the standard is because SEPS (and SEMS) have more flexibility, less tumor ingrowth/overgrowth, less migration, and less need for pre-dilatation (or is it dilation?). This study was to show that SEPS can be done successfully for symptom reduction.

To be enrolled you had to have a dysphagia score of 3 (liquid only) or 4 (no PO intake). Interstingly the mean Karnofsky was 78.3 (range 50-100). Patients were followed to death and survival range was from 40-312 days (mean 129). For the procedure, all patients received pethidine. Don't know what pethidine is? Well it is the International Nonproprietary Name (INN) for a drug you recognize as meperidine. Still a favorite by anesthesiologists, OR's and procedure suites everywhere. At least in one time doses it chances to accumulate and cause seizures is much less.

All patients had improved swallowing after stent placement, but 40% had moderate to severe pain after stent placement that required mild-to moderate analgesia (not further clarified in the article) They do note they had lost 41 of 69 patients by week 26. This is a great demonstration of what we are learning about cachexia. It is not just about the calories you take in.

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