Introduction
Dysphagia and obstruction are among the most common indications for upper gastrointestinal
endoscopy in African countries [1]. In a survey conducted by the European Society of Gastrointestinal Endoscopy (ESGE)
International Affairs Working Group (IAWG), benign esophageal strictures as well as
malignant upper gastrointestinal obstruction were reported as some of the most prevalent
diseases leading to gastrointestinal endoscopy [1].
Management of esophageal obstruction may vary, depending on the cause of obstruction
as well as the availability of resources. According to the ESGE original guideline,
it could involve, for example, stent placement, radiotherapy/brachytherapy, or bypass
surgery [2]. For resource-limited settings, however, a number of additional factors need to
be considered before recommendations can be made. These involve economic considerations
and resource availability. Furthermore, patients in low-resource settings presenting
with malignant esophageal obstruction are often unfit for surgery due to presentation
with advanced malignant disease as well as comorbidities such as HIV/AIDS and tuberculosis
[3]. For such situations, self-expanding metal stents (SEMS) of the esophagus may provide
a suitable palliative option [3]
[4].
After the initial ESGE cascade guidelines on non-variceal upper gastrointestinal bleeding
(NVUGIH), we aimed this ESGE cascade guideline to standardize management of esophageal
stenting for benign and malignant disease in low-resource settings [2]
[5].
Methods
The cascade guideline methodology used has been described in previous cascade guideline
papers [1]
[5]. Briefly, resource-sensitive recommendations were selected from the original ESGE
guideline on esophageal stenting, but only those with an agreement of 50 % or more
for classification as being resource-sensitive by the International Affairs Working
Group (IAWG) were included in the revision process [2]. This process was guided by six African experts from Ghana, Nigeria, and Ethiopia.
Subsequently, the IAWG, together with the first author of the original guideline,
suggested a revision of the statements according to cascade methodology, for four
predefined levels of resource availability ([Table 1]) [6]. A modified Delphi process was then carried out with a panel of African gastroenterologists
who were invited from a contact list of ESGE, WEO, and European national societies
[1]
[6]. If a 75 % agreement was reached for all four levels of care (adaptations), the
statement was accepted [6]. If the panel members disagreed with one of the adaptations, they had the opportunity
to add a comment; thus, if an adaptation failed to reach agreement from 75 % of the
panel, the statement was revised according to the advice from the panel members. Subsequently,
a second Delphi round might be conducted to reach an agreement on all of the resource-sensitive
statements. Furthermore, if any panel member was unable to respond to specific statements
during the Delphi process, they could refuse to answer.
Table 1
Level of treatment care.
|
Predefined level
|
Definition
|
|
I: Basic
|
Core resources or fundamental services absolutely necessary for an endoscopy care
system to function. By definition, a health care system lacking any basic level resource
would be unable to provide endoscopic service to its patient population. It includes
diagnostic procedures (gastroscopy and colonoscopy) as well and fundamental monitoring
abilities (blood pressure, basic blood biochemistry).
|
|
II: Limited
|
Limited level: Second-tier resources or services that produce major improvements in
outcome, such as increased survival, but that are attainable with limited financial
means and modest infrastructure. It includes minor endoscopic procedures to improve
major clinical outcomes (i. e. sclerotherapy/adrenaline injection, band ligation,
plasma expanders, basic surgical interventions).
|
|
III: Enhanced
|
Enhanced level: Third-tier resources or services that are optional but important.
Enhanced-level resources may produce minor improvements in outcome but increase the
number and quality of therapeutic options. Most procedures that improves clinical
outcome are available (i. e. biliopancreatic endoscopy, electrosurgical unit, polypectomy/mucosectomy,
anesthesia back-up).
|
|
IV: Maximal
|
Maximal level: High-level resources or services that may be used in some high-resource
countries or be recommended in guidelines that assume unlimited resources. To be useful,
maximal-level resources typically depend on the existence and functionality of all
lower-level resources.
|
Cascade statements
Statement selection
Of the 18 recommendations in the original ESGE guideline, 11 were selected as being
resource-sensitive by the IAWG. Four adapted cascade statements – one for each level
– were created for each of the original recommendations, making a total of 44 adapted
cascade guideline statements.
The Delphi process
Overall, 19 experts participated in the Delphi process. Details of the participants
are provided in [Table 2]. A ≥ 75 % agreement was achieved for 41 of 44 proposed adaptations. Overall, three
cascade adaptations of three recommendations involving surgery as an alternative form
of treatment for malignant obstruction failed to achieve the ≥ 75 % agreement level.
Following the advice from the panel of experts, these statements underwent further
revision as described below.
Table 2
Characteristics of participants in the Delphi analysis.
|
Number of participants (n = 19)
|
|
Geographical area
|
|
|
3 (16)
|
|
|
3 (16)
|
|
|
6 (32)
|
|
|
6 (32)
|
|
|
1 (5)
|
|
Socioeconomic status of institution/hospital
|
|
|
0 (0)
|
|
|
8 (42)
|
|
|
11 (58)
|
Cascade adaptation
Each original recommendation with the accepted adaptations is reported in [Table 3]. The main resources that influenced adaptation of the original guidelines can be
categorized as follows:
Table 3
Statements and recommendations.
|
1. ESGE recommends placement of partially or fully covered self-expanding metal stents
(SEMSs) for palliation of malignant dysphagia over laser therapy, photodynamic therapy,
and esophageal bypass (strong recommendation, high-quality evidence).
I. Best supportive care/palliative care
II. Surgery
III. SEMS
|
|
3. For patients with longer life expectancy, ESGE recommends brachytherapy as a valid
alternative or in addition to stenting in oesophageal cancer patients with malignant
dysphagia. Brachytherapy may provide a survival advantage and possibly a better quality
of life compared to SEMS placement alone. (Strong recommendation, high-quality evidence.)
I. Best supportive care/palliative care
II. Surgery
III. SEMS
|
|
4. Esophageal SEMS placement is recommended as the preferred treatment for sealing
malignant tracheoesophageal or bronchoesophageal fistula (strong recommendation, low-quality
evidence).
I. Best supportive care/palliative care
II. Surgery
III. SEMS
|
|
5. Application of double stenting (oesophagus and airways) can be considered when
fistula occlusion is not achieved by esophageal or airway prosthesis alone (strong
recommendation, low-quality evidence).
I. Best supportive care/Palliative care
II. Best supportive care
III. Oesophageal stenting
|
|
8. ESGE suggests that SEMS placement with concurrent single-dose brachytherapy is
safe and effective for relief of dysphagia (weak recommendation, low-quality evidence).
I. Best supportive care/palliative care
II. Surgery
III. SEMS
|
|
10. ESGE suggests consideration of temporary placement of self-expandable stents for
refractory benign oesophageal strictures (weak recommendation moderate quality evidence).
I. Symptomatic treatment/best supportive care
II. Bougienage, ballon dilation, or surgery
III. SEMS
|
|
13. ESGE suggests that FCSEMSs be preferred over PCSEMSs for treatment of refractory
benign esophageal stricture, because of their lack of embedment and ease of removability
(weak recommendation, low-quality evidence).
I. Symptomatic treatment, best supportive care
II. Bougienage, ballon dilation, or surgery
III. FCSEMS
|
|
14. ESGE recommends the stent-in-stent technique to remove PCSEMSs that are embedded
in the esophageal wall (strong recommendation, low quality evidence).
I. Symptomatic treatment, best supportive care
II. Attempt to remove PCSEMSs using conventional methods such as rat tooth forceps
or APC
III. Stent-in-stent technique
|
|
16. If refractory benign esophageal stricture has not satisfactorily improved after
two separate treatments with temporary stenting, ESGE suggests alternative treatment
strategies such as self-dilation or surgical treatment (weak recommendation, low quality
evidence). In poor surgical candidates, ESGE recommends self-dilation with rigid dilators
(strong recommendation, low quality evidence).
I. Symptomatic treatment, best supportive care
II. Bougienage, surgery
III. Self-dilation
|
|
17. ESGE recommends that temporary stent placement can be considered for treatment
of leaks, fistulas, and perforations. No specific type of stent can be recommended
and duration of stenting should be individualized. (Strong recommendation, low-quality
of evidence).
I. Symptomatic treatment, antibiotics, nill by mouth, or fluid diet
II. Endoscopic closure attempt with clips, or surgery
III. Stent placement
|
|
18. ESGE recommends considering placement of a SEMS for treatment of esophageal variceal
bleeding refractory to medical, endoscopic, and/or radiological therapy, or as initial
therapy for patients with massive bleeding (strong recommendation, moderate quality
evidence).
I. Supportive care
II. Supportive care
III. Stent placement
|
Malignant strictures
In many impoverished parts of Africa, malignant esophageal strictures are more often
diagnosed in an advanced stage of disease [7]. For advanced tumor stages, palliative surgical options may be more readily available
than stenting for treatment of malignant esophageal strictures.
At the basic level, only best supportive care is available and palliative treatment
such as nasogastric feeding tubes or intravenous fluid supply may be the only available
option.
At the limited level, treatment of symptomatic cancer varies from region to region,
mainly depending on availability of surgery as a treatment option. Surgery can be
offered to patients with resectable tumors and longer life expectancy who are fit
enough to undergo surgery.
Stent placement should be offered to patients where the necessary infrastructure and
expertise are available, usually at the enhanced level.
Additional barriers are represented by the following factors:
-
Training – lack of availability of expert gastroenterologists with the necessary technical
skills for stent placement.
-
Infrastructure – lack of availability of stents, fluoroscopy, and other equipment
involved in stent placement. Furthermore, lack of availability of brachytherapy/radiotherapy
for treatment of malignant strictures.
Benign strictures
The most common causes of benign strictures in African countries include corrosive
and peptic aetiologies as well as achalasia [8]
[9].
Similar to treatment of malignant strictures, the lack of both surgery and endoscopy
resources will hinder clinically relevant treatment at the basic level. On the other
hand, at the limited level, periodic endoscopic dilation may be an affordable option.
Also, surgical treatment should be considered, depending on its availability.
Conclusions
Most of the original recommendations for esophageal stenting of malignant and benign
disease were successfully adapted to a cascade approach for resource-limited areas.
The cascade guidelines addressed limitations that were related to infrastructural
and human resources. For example, at the basic level, neither SEMS nor skilled gastroenterologists
are available for treatment of esophageal strictures, therefore, best supportive care
may be the only reasonable alternative. And even when expert gastroenterologists are
available, technological resources such as fluoroscopy or brachytherapy may limit
treatment of such patients. Palliative surgery may be an alternative, but also associated
with extensive use of resources and presumably with high mortality. Finally, even
when resources and expertise are available for endoscopic stenting or surgery, patients
and their families may not be able or willing to pay for the high financial costs
involved.
Two major limitations of the Delphi process need to be highlighted:
-
The total number of participants was low especially compared to the first ESGE cascade
guideline on NVUGIH [5].
-
Some participants may have had limited experience and expertise in treatment of esophageal
strictures or in the use of esophageal stents and brachytherapy/radiotherapy. This
was reflected in the high number of total “don’t know” answers (97 /627) given by
the participants.
