Endoscopic Nd-YAG laser therapy for palliation of upper gastrointestinal malignancy

Treating nausea and vomiting in palliative care: a review

Nausea and vomiting are portrayed in the specialist palliative care literature as common and distressing symptoms affecting the majority of patients with advanced cancer and other life-limiting illnesses. However, recent surveys indicate that these symptoms may be less common and bothersome than has previously been reported. The standard palliative care approach to the assessment and treatment of nausea and vomiting is based on determining the cause and then relating this back to the "emetic pathway" before prescribing drugs such as dopamine antagonists, antihistamines, and anticholinergic agents which block neurotransmitters at different sites along the pathway. However, the evidence base for the effectiveness of this approach is meager, and may be in part because relevance of the neuropharmacology of the emetic pathway to palliative care patients is limited. Many palliative care patients are over the age of 65 years, making these agents difficult to use. Greater awareness of drug interactions and QT(c) prolongation are emerging concerns for all age groups. The selective serotonin receptor antagonists are the safest antiemetics, but are not used first-line in many countries because there is very little scientific rationale or clinical evidence to support their use outside the licensed indications. Cannabinoids may have an increasing role. Advances in interventional gastroenterology are increasing the options for nonpharmacological management. Despite these emerging issues, the approach to nausea and vomiting developed within palliative medicine over the past 40 years remains relevant. It advocates careful clinical evaluation of the symptom and the person suffering it, and an understanding of the clinical pharmacology of medicines that are available for palliating them.

Endoscopic approaches for palliation of luminal gastrointestinal obstruction

Much of the workload of a typical gastroenterologist is devoted to screening patients for gastrointestinal malignancies. Efforts such as colorectal cancer screening via colonoscopy and endoscopic surveillance of patients with Barrett's esophagus are widespread and widely endorsed. In recent years, the armamentarium of endoscopy has broadened considerably and now affords physicians a variety of nonsurgical means to palliate malignant obstruction of the gastrointestinal tract. This article reviews endoscopic techniques to treat malignant esophageal, biliary, small bowel, and colonic obstruction.

Laser therapy for esophageal cancer. Results and additional endoscopic treatments

Between 1/1/1988 and 5/31/1991, we treated 96 patients with laser therapy to the esophagus. In 61 inoperable patients, laser therapy has been performed initially. In 64% of these 61 patients, laser therapy alone gave sufficient relief of symptoms until death. However, in 36% of the patients, additional endoscopical interventions had to be performed. In 14 patients (23%), a prosthesis became necessary; 13 patients (21%) needed a percutaneous endoscopical gastrostomy. We conclude that laser therapy has an important role in the treatment of esophageal cancer, but in a significant number of patients, it might not be sufficient alone.

Laser and photodynamic therapy of esophageal cancer

With proper selection of patients with non-operative esophageal cancer, palliative therapy with Nd:YAG laser enhances the quality of life by improving the patient's ability to swallow soft or solid food. Also, the use of non-thermal laser light to initiate the process of photodynamic therapy (PDT) is an additional laser technique that appears effective, not just in palliative treatment, but also in the cure of early esophageal cancer. For PDT, considerable work will be necessary to provide standard techniques in tumor staging, light and drug delivery and in light dosimetry. Ultimately, palliative and curative therapy of esophageal cancer will most likely incorporate multiple modalities, including surgery, radiation, chemotherapy, stents, laser and other thermal modalities, photodynamic therapy, and combinations of these methods.