Should oesophageal stents be used before neo-adjuvant therapy to treat dysphagia in patients awaiting oesophagectomy? Best evidence topic (BET)

Patients who develop significant dysphagia secondary to a potentially curable oesophageal cancer pose a significant clinical problem. Their nutritional needs can be met either by dietary supplementation, insertion of an oesophageal stent or through nasogastric or surgical feeding tube placement. We sought to determine whether, in patients about to start neo-adjuvant therapy prior to oesophagectomy, the use of oesophageal stent improves clinical outcomes. A best evidence topic in upper gastrointestinal surgery was written according to a structured protocol in order to answer this question. Two hundred and forty eight papers were found, of which eleven level III and one level IV study were considered to best address the clinical question. These indicate that whilst oesophageal stents do successfully relieve dysphagia throughout neoadjuvant therapy, they are not consistently associated with maintenance of, or improvement in, serum albumin or body weight. They are, however, commonly associated with stent migration and chest discomfort, both of which may frequently result in the need for stent removal or replacement. There is additional evidence within the manuscripts reviewed to demonstrate that the use of oesophageal stents in the neoadjuvant setting can lead to significant complications in a small proportion of patients which can compromise opportunity for curative surgery. The use of stents in this situation cannot be recommended.