Limitations of laser treatment for malignant dysphagia

Recurrence after surgery in esophago-gastric junction adenocarcinoma: Current management and future perspectives

Recurrent esophago-gastric junction adenocarcinoma is not a rare event and its correct management is still debated. Many approaches for the treatment of these patients exist, but only few studies compare the different techniques. Most of the studies are retrospectives series and describe the experiences of single institutions in the treatment of recurrent esophageal and esophago-gastric junction cancers. Nowadays surgery is still the main and only curative treatment. Other alternative palliative therapies could be endoscopic stent placement and balloon dilation, photodynamic therapy, thermal tumor ablation (laser photoablation and Argon plasma coagulation), radiation therapy and brachytherapy, and chemotherapy. The aim of this review is to investigate the different rates, patterns and timings of recurrence of this tumor, and to explain the various approaches used for the treatment of recurrent esophago-gastric junction cancer.

Mucosal injury caused by argon plasma coagulation in rabbits

AIM: To investigate mucosal injury induced by argon plasma coagulation (APC) in rabbits.

METHODS: The mucosal injury of large intestine of rabbits was induced by APC with argon gas flow 2.0, 2.5, 3.0 and 4.0 L/min in two pulsed modes. Thickness of mucosa was measured by endoscopic ultra sound (EUS). Qualitative histologic analysis of each site of APC application was performed by light microscopy.

RESULTS: EUS showed high echo in mucosa while low echo in submucosa and muscularis propria. Depth of injury was significantly correlated with argon gas flow (P = 0.006), power setting (P = 0.023) and duration of pulse (P = 0.030).

CONCLUSION: APC is a safe method in treatment of colon disease. The lower argon gas flow and short durations have the lowest risk of deep tissue injury.

Endoscopic palliative treatment for esophageal and gastric cancer: techniques, complications, and survival in a population-based cohort of 948 patients

BACKGROUND

Under the auspices of the Scottish Audit of Gastric and Esophageal Cancer, we investigated treatment techniques, complications, and survival in a population-based cohort of patients undergoing endoscopic palliative therapy for esophageal or gastric cancer.

METHODS

A total of 948 patients undergoing endoscopic palliative therapy were identified prospectively and followed for a minimum of 1 year.

RESULTS

Expandable metal stent placement (506 patients) and LASER (117 patients) were the most frequently used treatment options. Stent placement was more common for grade 3 or 4 dysphagia. Delivery of endoscopic palliative therapy varied by region of residence (from 18% to 38% of patients, p < 0.001) but not by deprivation category. Complications were recorded in 16% of patients (155 of 948). Overall survival was 40% (95% confidence interval [CI], 36-43) at 6 months, 17% (95% CI, 14-19) at 12 months, and 10% (95% CI, 8-12%) at 18 months.

CONCLUSIONS

These data define the reality of endoscopic palliative therapy for patients with advanced esophageal or gastric cancer and provide a baseline against which future improvements in care can be measured.

Photodynamic therapy for esophageal cancer: a useful and realistic option

The use of light therapy for tissue destruction is highly attractive for the endoscopic and minimally invasive therapy of esophageal cancer. Photodynamic therapy (PDT) offers the possibility of palliation of advanced obstructing tumors. However, there are other competing techniques, which can be used to open the esophageal lumen. It has also proved very effective in providing prolonged palliation of patients with advanced irresectable cancer. Completely obstructing tumors, tortuous and long lesions, and tumors near the upper end of the esophagus are particularly suitable for photodynamic therapy. Patients with obstruction to an esophageal prosthesis are also well palliated with PDT. A more interesting and exciting development is its use for the eradication of early asymptomatic mucosal disease. Photodynamic therapy is particularly useful for the eradication of field cancerous change in patients with pre-malignant Barrett's esophagus, or early tumors in patients unfit for radical therapy.

The tissue effect of argon plasma coagulation on esophageal and gastric mucosa

BACKGROUND

Argon plasma coagulation is a diathermy-based non-contact therapeutic endoscopic modality that may have a lower risk of perforation than other tissue ablation techniques.

METHODS

Its effect was studied on three fresh esophageal and three fresh gastric resection specimens using power settings from 40 to 99 Watts at 90 degrees, with 1 mm separation using pulse durations of 1 and 3 seconds. A scoring system for depth of tissue damage was created and samples were analyzed blindly by a gastrointestinal histopathologist.

RESULTS

There was significantly greater damage to gastric tissue using a 3-second (compared with 1-second) pulse (p = 0.003) and marginally significantly greater damage to esophageal tissue using the 3-second pulse (p = 0.053). Tissue damage was related to power setting for gastric (p = 0.031) but not for esophageal tissue (p = 0. 065). Only 1 of 42 esophageal samples and 2 of 42 gastric samples examined showed damage extending into the muscularis propria.

CONCLUSIONS

Deep tissue damage that could lead to perforation was rare with argon plasma coagulation. The depth of gastric mucosal damage increased with increased pulse duration and increasing power settings, and, although the depth of esophageal mucosal damage was marginally related to pulse duration, it was not related to the power setting. (Gastrointest Endosc 2000;52:342-5).

An update in the palliative management of malignant dysphagia

BACKGROUND

Oesophageal cancer is generally associated with late presentation and poor prognosis. Therefore palliative surgery has been largely superseded by less invasive non-surgical techniques. Once palliation is indicated, the aims of the management should be: the maintenance of oral intake, minimizing hospital stay, relief of pain, elimination of reflux and regurgitation and the prevention of aspiration.

METHODS

This study was a review of all published English language data on the palliation of malignant dysphagia between 1994-1999. The Medline and Bids databases were searched and other references were derived from the material perused.

RESULTS AND CONCLUSIONS

Palliative treatment for oesophageal cancer should be individualized and relate to tumour stage, size and location, the patient's medical condition and his/her personal wishes. The palliative treatment largely includes self-expanding metal stents (SEMS), laser (including photodynamic therapy (PDT)) or a combination of the two to relieve symptoms, this may be employed with or without other treatments such as radiotherapy/chemotherapy (RT/CT) with the aim of reducing tumour bulk and possibly prolonging survival. A multi-disciplinary approach is vital in patients with advanced oesophageal cancer.

Advanced esophageal carcinoma

From 1976 until 1990 a total of 212 patients with squamous cell carcinoma of the thoracic esophagus were referred for surgical treatment. Resectability was 84.1% (161 of 191). Actuarial 5-year survival in patients with negative lymph nodes was 51.2% versus 12.4% in lymph node-positive patients. Therefore advanced carcinoma was defined to compromise all patients with involved regional (N1) or distal lymph nodes (M+Ly) as well as patients with T4 tumors or solid organ metastasis (M+org) irrespective of their lymph node status. Comparing complete (R0) versus incomplete (R1-R2) resections for stage III and IV carcinoma revealed 20% and 0% five-year survivals, respectively. There was no 5-year survival in the stage IV group. When excluding solid organ metastasis, the median survival shifted from 8.5 months after incomplete (R1-R2) to 20 months after complete (R0) resection. In 1991 three-field lymphadenectomy was initiated that included bilateral cervical lymphadenectomy. Thirty-seven patients have been treated so far (23 squamous cell carcinoma, 14 adenocarcinomas). Cervical lymph nodes were positive in 24.3% with an incidence up to 28.5% for distal-third carcinoma. Subsequently, 6 patients (16%) moved from M0 to M+Ly status. Our results confirm the key role of surgery not only in improving survival and locoregional tumor control but in refining the accuracy of staging advanced carcinomas provided complete resection is possible.(ABSTRACT TRUNCATED AT 250 WORDS)