Costs remain a significant problem. Those of you who are golfers who put titanium in your woods to hit the ball farther know that’s a very expensive metal. So some of these stents using nitinol and other compounds, the cost is still very high and that’s a major concern when we look at cost effectiveness. Our group last spring presented some information. This was a randomized study, a small number of patients, but we tried to really get to this issue of cost and cost effectiveness. Comparing patients who only received laser photoablation therapy to stent placement. Again, this was the Schneider Wallstent that was used. Again, a small number of patients but effectiveness was about the same, but the patients in the stent group had fewer initial treatment sessions, fewer need for re-interventional sessions, and total endoscopic sessions overall were much less than the patients in the laser group. If you look at the cost – although the stent itself was $1,700 or so – overall the cost to the patient in their remaining lifetime was much higher for those patients who received laser therapy than for stent therapy. So our conclusions were that it’s a more cost-effective form of therapy for patiens for palliative care.
One point to keep in mind, those patients who have a tracheoesophageal fistula, as seen here – a little small slit, or a much more significant opening here, we can almost see the lung parenchyma – what can you do? There are three stents on the market, the Wallstent, the Z stent and the Ultraflex which are covered and again the covering is designed to kind of fit against the esophageal wall and provide a barrier for secretions and other things. Actually the Ultraflex, as shown here, because it is so flexible it can nicely conform to the esophageal wall. It works well for tracheoesophageal fistulas, just to kind of serve as a good barrier.
In summary, it’s important to keep in mind the characteristics of the tumor; is it exophytic? Is extrinsic compression present? What are your goals of palliative therapy? Is the patient going to undergo adjuvant therapy? If that’s the case, we usually don’t recommend placement of an expandable metal stent as hopefully with shrinkage of the tumor you wouldn’t want the stent to just to simply fall into the stomach. The expandable stents have certainly gained a strong hold in the 1990’s. Generally they are thought to be very safe. They are technically much easier to put in place, rather than the rigid devices. Their effect is immediate, and generally minimal follow-up is necessary for most patients. The main drawback is their cost, but as I mention, I think cost-effectiveness still weighs towards the stents. The ideal situation, what’s in the best interest of your patients, will certainly … if the endoscopist is comfortable and can offer the patient a complete spectrum of palliative techniques.