Palliation in cancer of the oesophagus – what passes down an oesophageal stent

Introduction: Self-expanding metal stents are becoming an increasingly popular method of palliation of dysphagia in advanced oesophageal carcinoma. Approximately 10% require intervention post-placement because of blockage (Angorn, 1981). This could be prevented by effective dietary advice. We set out to write evidence-based dietary guidelines for patients undergoing oesophageal stent insertion. A comprehensive literature search failed to identify evidence to support the present guidelines used by manufacturers and dietitians on foods allowed or to avoid and the use of fizzy drinks to ‘clean’ the stent. Only reference on the ability to consume a semi-solid or solid diet was made (Nedin, 2002). We therefore tested the ability of 50 foods to pass through a stent and the efficacy of fizzy water in unblocking an occluded stent. Method: Normal mouthfuls of raw and cooked, peeled/unpeeled fruit and vegetables, casseroles, griddle or grilled plain meat, poultry or fish, eggs, nuts, dried fruit and bread in various forms were tested. An adult female chewed a ‘normal’ mouthful of each test food and at the point of swallowing the bolus of food was passed into an expanded Ultraflex metal covered stent (internal diameter 18 mm). If occlusion occurred, water was dribbled through the stent, simulating swallowing fluid, in an attempt to unblock the stent. If the occlusion remained, the stent was agitated to mimic advice given about moving around to unblock a stent in a patient. If it remained occluded, a smaller amount of food, approximately half a mouthful, was chewed for twice as long and re-tested. To test the efficacy of fizzy water to clear an occlusion, we compared the ability of water, warm water and fizzy water to unblock a stent artificially occluded with a bolus of bread. Results: Foods that occluded the stent but passed through if eaten in half mouthfuls and chewed for twice normal chewing time included sandwiches, dry toast, apple, tinned pineapple, fresh orange segments with pith removed, up to six sultanas, chopped dried apricot, boiled egg, muesli, meat and poultry. Dry meat, fruit with pith, skins of capsicum peppers and tomatoes, more than seven sultanas and dried apricots caused occlusion. Nuts and vegetables such as lettuce, which are cited in many diet sheets as items to avoid (Nedin, 2002), passed through the stent when chewed to a normal level. The volumes of fluid required to unblock a stent occluded with bread were 5 l of fizzy water, 3.5 l of cold water or 1 l of warm water. Conclusion: If a patient has good dentition and can chew well and take small mouthfuls and prepare and cook food appropriately, it is likely that they can enjoy a wide variety of solid foods. The use of fizzy drinks to maintain the patency of the stent in patients prone to reflux is questionable, warm fluids may be more efficacious. Based on these initial findings we are updating our dietary guidelines for patients undergoing oesophageal stent insertion and hope to audit stent occlusion following implementation.