Palliation of malignant dysphagia.

Palliation of malignant dysphagia SIR,-Dr Barr et al are to be congratulated on their work examining the role of laser and laser + intubation in the palliation of malignant dysphagia.' We would agree with their conclusion that laser therapy should be restricted to specialist centres, and others have highlighted that, apart from operator expertise, high capital cost is another reason for restricting its availability to designated centres.2 So what happens to these patients elsewhere? Dissatisfaction with intubation as a palliative technique prompted us to examine the role of endoscopic tumour destruction using ethanol injections. This technique of ethanol-induced tumour necrosis (ETN) has recently been described,3 and fulfils the criteria suggested by Cox and Bennett for an ideal palliative technique .4 It is quick, safe, painless, needs only a short inpatient stay, and has a low complication rate. The results achieved compared favourably with all published results of laser pallia-tion. As with laser, apparent complete occlusion of the lumen does not prevent this technique being used. The cost of ETN is considerably less than that of either laser or intubation as there is no initial capital cost and no maintenance cost. The only treatment cost (apart from that of endoscopy) is that of the ethanol for injection. The technique can be quickly learnt by experienced therapeutic endoscopists. We believe that there is an imperative need to institute a prospective randomised trial of laser therapy v ETN. If results were comparable, one would have to conclude not as Barr et al have stated that 'both techniques [laser and intubation] should be available for the management of patients with malignant dysphagia' but 'first line treatment for palliation of malignant dysphagia is ETN. If this treatment fails treatment by laser or intubation should be considered.'tive randomised trial of laser therapy only and laser therapy followed by endoscopic intubation for the palliation of malignant dysphagia.