Esophageal Dysmotility in Patients Undergoing Photodynamic Therapy

doi:10.4065/76.10.987

Mayo Clinic Proceedings

Volume 76, Issue 10, October 2001, Pages 987-989

https://doi.org/10.4065/76.10.987 Get rights and content

Objective

To study the esophageal motility of patients with esophageal adenocarcinoma or Barrett esophagus with high-grade dysplasia before and after photodynamic therapy.

Patients and Methods

In this prospective study conducted between January 1998 and October 1999, esophageal motility testing of the lower esophageal sphincter and esophageal body was performed with a water-perfused catheter, 2 days before and at least 3 weeks after patients underwent photodynamic therapy for esophageal adenocarcinoma or Barrett esophagus. Results were classified as normal motility, ineffective esophageal motility, or aperistalsis.

Results

Twenty-three patients were studied, 13 with carcinoma and 10 with Barrett esophagus. Overall, 11 patients (48%) had normal motility, 6 (26%) had ineffective esophageal motility, and 6 (26%) had aperistalsis. Five patients with aperistalsis had carcinoma. Follow-up tracings after photodynamic therapy found that 6 patients (26%) had normal motility, 7 (30%) had ineffective esophageal motility, and 10 (43%) had aperistalsis.

Conclusions

Esophageal dysmotility is common in patients with esophageal adenocarcinoma or Barrett esophagus. Photodynamic therapy may worsen esophageal motility in some patients. Dysphagia after photodynamic therapy therefore may be related to underlying esophageal dysmotility and may not always be caused by stricture or underlying carcinoma.

Section snippets

PATIENTS AND METHODS

Twenty-three consecutive patients with esophageal adeno-carcinoma with Barrett esophagus or Barrett esophagus with high-grade dysplasia presenting for PDT were prospectively enrolled in the study between January 1998 and October 1999. Esophageal adenocarcinoma patients were treated with PDT for persistent or recurrent neoplasm after chemoradiation therapy or for newly diagnosed obstructing neoplasms without prior therapy. All adenocarcinoma patients underwent a complete clinical evaluation,

RESULTS

During the study period, 23 patients were referred to our center for PDT; 10 patients had Barrett esophagus with high-grade dysplasia, and 13 patients had adenocarcinoma. There were 20 men and 3 women, and the mean age was 72 years (range, 50–86 years). Manometric findings before and after PDT are summarized in Table 1, Table 2, Table 3 and Figure 1. Overall, 11 patients (48%) had normal motility prior to PDT, including 5 cancer patients (22%) who had previously undergone chemoradiation

DISCUSSION

Photodynamic therapy has been approved for the palliative treatment of dysphagia in patients with obstructing esophageal cancer since 1995. Previously, we had treated patients who suffered persistent dysphagia despite excellent tumor photoablation and recanalization of the esophageal tumor. This observation raised the question of whether esophageal motility abnormalities might explain this persistent dysphagia and whether this dysmotility was related to the underlying disease, previous

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Traditionally, management of early cancer (stages 0–IIA) has comprised esophagectomy, either alone or in combination with chemotherapy and/or radiotherapy. Recent efforts to improve outcomes and minimize side-effects have focussed on minimally invasive, endoscopic treatments that remove lesions while sparing healthy tissue. This review assesses their safety and efficacy/effectiveness relative to traditional, non-endoscopic treatments for early esophageal cancer.
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Citation Excerpt :
Deterioration of esophageal motility can occur after photodynamic therapy for esophageal carcinoma or Barrett’s esophagus. Of 23 patients, 13 with esophageal carcinoma and 10 with Barrett’s esophagus, 11 had normal motility, 6 had ineffective esophageal motility, and 6 had aperistalsis; 5 of those with aperistalsis had carcinomas (112c). Follow-up tracings after photodynamic therapy showed that 6 had normal motility, 7 had ineffective esophageal motility, and 10 had aperistalsis.
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However, this is the largest series of patients with HGD treated with PDT reported from the United States. It has been reported that patients with HGD treated with PDT may have underlying esophageal dysmotility, which may contribute to dysphagia.28 This could have influenced the performance of esophageal dilation in patients.
Stricture formation is the leading cause of long-term morbidity after photodynamic therapy (PDT). Risk factors for stricture formation have not been studied.
To assess risk factors for stricture formation in patients undergoing PDT for Barrett's esophagus with high-grade dysplasia (HGD).
Retrospective cohort study.
Barrett's Unit, Mayo Clinic, Rochester, Minnesota.
Records of patients undergoing PDT for HGD were reviewed. Patients underwent PDT by using either bare cylindrical diffusing fibers (2.5-5.0 cm in length) or balloon diffusers with 5- to 7-cm windows. Univariate and multivariate logistic regression analyses were performed to assess risk factors for stricture formation.
Esophageal stricture formation.
Thirty-five of 131 patients (27%) developed strictures. On multivariate analysis, statistically significant predictors of stricture formation were the following: EMR before PDT was odds ratio (OR) 2.7, 95% confidence interval (CI) 1.13-6.59; a prior history of esophageal stricture was OR 2.7, 95% CI 1.15-6.47; and the number of PDT applications was OR 2.2, 95% CI 1.22-4.12. The OR for stricture formation in patients when centering balloons were used was 0.41, 95% CI 0.11-1.46, P = .168, indicating that centering balloons did not significantly decrease the risk of stricture formation.
Retrospective single-center study; small proportion of patients treated with centering balloons.
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Original ArticleEsophageal Dysmotility in Patients Undergoing Photodynamic Therapy

Objective

Patients and Methods

Results

Conclusions

Section snippets

PATIENTS AND METHODS

RESULTS

DISCUSSION

Am J Med

Am J Gastroenterol

Am J Surg

Ann Thorac Surg

Gastroenterol Clin North Am

Gastroenterology

Gastroenterology

Ineffective esophageal motility (IEM): the primary finding in patients with nonspecific esophageal motility disorder

Dig Dis Sci

Malignant pseudoachalasia

Surg Endosc

Esophageal obstruction 14 years after treatment for Hodgkin's disease

Cancer

Original Article
Esophageal Dysmotility in Patients Undergoing Photodynamic Therapy