Palliativtherapie der malignen Ösophagusobstruktion mit selbstexpandierenden Metallendoprothesen

A total of 23 self-expanding metal stents were implanted in 17 patients (12 men, 5 women; mean age 66 [44-83] years) with inoperable malignant obstruction of the oesophagus or the oesophago-gastric junction. A primary success was achieved in all, a good functional result in 16 (94%). There were no complications. In the follow-up period (mean of 15.2 +/- 13 weeks) re-obstruction by the tumour process occurred in three patients. Twelve patients died after a mean survival time of 15.8 +/- 14 weeks. In ten of these the stent was still patent at death, while two had again developed dysphagia. The cumulative patency rate of the stents was 79%. These observations indicate that self-expanding metal stents can achieve satisfactory palliation in dysphagia due to a malignancy. The mortality and morbidity rates of the method seem to be less than those of other palliative measures.

[Stent implantation as a palliative therapeutic measure in tumor-induced stenoses of the large veins of the body]

PURPOSE

Self-expandable metallic stents were used to treat patients with malignant venous obstructions to determine their effectiveness in producing symptomatic palliation.

METHODS

20 patients with a total of 28 tumour-induced obstructions of the superior vena cava (n = 13), the inferior vena cava (n = 4), the subclavian (n = 4), the innominate (n = 5) and the iliac veins (n = 2) were treated with self-expandable metallic stents. 38 Gianturco stents and 21 Wallstents were applied. Patients were heparinised during the procedure and up to three days afterwards.

RESULTS

In all patients correct positioning of the stents was achieved. In 16 patients stent placement resulted in relief of their symptoms. In 8 patients the symptoms completely disappeared without recurrence until death as a result of tumour progression. The follow-up ranged from 10 days to 14 months. In 8 still living patients no re-obstruction occurred (follow-up average three months). In one patient thrombotic stent occlusion occurred 6 days after the procedure; the v. cava superior was reopened again by local urokinase therapy. Three patients finally developed re-occlusion due to tumour progression. In one patient stent placement was complicated by migration of the Gianturco stent one day after stent implantation and reocclusion of the subclavian vein.

CONCLUSION

The application of self-expandable metallic stents in patients with malignant venous obstruction is a useful palliative therapy.

Surgical palliation of head and neck cancer

Palliative care in head and neck cancer has not been studied systematically. Patients with incurable head and neck tumors may live months and even years. Ideal palliation should enable them to engage in a normal life before death ensues. It is likely that our improving ability to treat these tumors without achieving cures will cause people to live longer with their cancer. Hence, the need for palliation will probably increase. Also, treatments that cure patients produce conditions that require palliation. Achievement of the best possible function is the major consideration in dealing with head and neck tumors. Difficulty with speech, swallowing, oral hygiene, and laodorous tumors are all common. Depression too should be addressed in a comprehensive fashion by the "head and neck team". The surgeon, radiotherapist, and medical oncologist will need help from dentists, prosthodontists, dental hygienists, psychiatrists, physiatrists, occupational and physical therapists, visiting nurses, nutritionists, and social workers. Palliative care in the hospital is the least desirable, although often unavoidable. Proper hospice support will benefit patients and their families.

Time-dependent efficacy of bacterial filters and infection risk in long-term epidural catheterization

BACKGROUND

Epidural infection represents a serious albeit infrequent complication of long-term epidural catheterization. The catheter hub is regarded as the main point of entry for microorganisms among the three possible routes (hematogenous, insertion site, hub) of microbial colonization of the inserted catheter. The current study was aimed at evaluating whether frequent changing of antimicrobial filters carries an increased risk of catheter hub contamination and the time-dependent efficacy of commonly used antimicrobial filters after prolonged use.

METHODS

In the first part of the study, a microbiologic survey (skin, filter, hub, and catheter tip) was performed weekly in a group of 47 patients with cancer bearing subcutaneously tunneled catheters managed at home. Subsequently, the time-dependent efficacy of 96 micropore filters (32 Portex, 32 Sterifix-Braun, 32 Encapsulon TFX-Medical) differing in surface areas and/or composition of the filtering membrane was evaluated in a laboratory study. Filters were perfused, under the usual conditions of clinical use (flow resistance, injection pressure, temperature), every 8 h up to 60 days, with 5 ml of two different analgesic solutions, either sterile or containing 1.5 x 10(5)/ml of Streptococcus milleri I. Eight filters of each type subsequently were flushed with a S. milleri suspension (0.5 McFarland) after 7, 14, 28, and 60 days of continuous perfusion, and the resulting filtrates were cultured.

RESULTS

In 16 of 19 positive hub cultures, the same microorganisms (species, biotype, antibiotype) were cultured from skin and filters. A statistically significant positive trend was found between the number of filter changes and the rate of positive hub cultures (chi 1(2) trend 5.11; P = 0.02). A high correlation coefficient was found between number of positive skin cultures and number of positive filtrates (r = 0.88; P = 0.01) and between number of positive filtrates and number of positive hub cultures (r = 0.93; P = 0.003). Cultures obtained from Portex and Sterifix-Braun filters yielded no bacterial growth (64/64) throughout the study period. Cultures from Encapsulon TFX-Medical filters showed bacterial growth 2/8 at seventh day, 7/8 at the 14th day, and 16/16 from the 28th day onward.

CONCLUSIONS

Our data indicate significant correlation between the incidence of catheter hub colonization and the filter-change frequency, when the skin close to the filter-hub connection is contaminated. Our results also show that Portex and Sterifix-Braun bacterial filters, when perfused with reduced volumes at low injection pressures, maintain an unmodified antimicrobial function for at least 60 days. Based on these data, it appears clinically feasible to reduce the frequency of filter changes during long-term epidural catheterization, with a consequent possible decrease of epidural catheter colonization.

Endoscopic palliation of oesophageal carcinoma with Atkinson prosthesis

To assess the degree of palliation, the associated morbidity and mortality and to compare our results with other published series, we reviewed our use of the Atkinson prosthesis in 100 consecutive patients for the palliation of unresectable oesophageal carcinoma. The group had a mean age of 71.2 +/- 2.3 years. All prostheses were placed by the pulsion method. Intubation was successful in 91%. Improvement in swallowing was seen in 82.1%. Major early procedure-related morbidity was high at 23% with 11 perforations (11%). Procedure-related mortality was 12%. Those aged 70 years or more had a 34.5% risk of morbidity and 15.5% risk of dying from the procedure. Late procedure-related complications requiring further endoscopic procedures occurred in 27%. Our 7 day mortality was 14.7% (14 patients) and 31 patients (32.6%) had died within 30 days, usually from the disease itself. Those surviving the procedure (> 7 days) had a mean survival of 105 (range 9-735) days. We obtained acceptable palliation but with a significant morbidity and mortality. Endoscopic intubation remains a useful palliative treatment for patients with unresectable carcinoma of the oesophagus and cardia.

Palliative, intraarterial chemotherapy for advanced head and neck cancer using an implantable port system

PURPOSE

Intraarterial drug therapy for head and neck cancer has been used for more than 30 years. However, because of catheter-related complications occurring quite frequently, this method was abandoned in many institutions. The development of subcutaneously implantable injection ports has renewed interest in regional drug delivery.

PATIENTS AND METHODS

This study reports the authors' experience with 11 injection ports implanted in 10 patients suffering from advanced or recurrent head and neck cancer.

RESULTS

The regional chemotherapy was well tolerated; the predominant side effects were hemialopecia and mild unilateral mucositis.

CONCLUSIONS

These results suggest that regional, intra-arterial chemotherapy using implantable injection ports should be considered for palliative treatment of advanced head and neck cancer.

[Radiotherapy of malignant obstructive jaundice]

Brachytherapy using the afterloading technique with iridium 192 and percutaneous irradiation using 16 MV photons are used for the irradiation of malignant obstructive jaundice. Mostly, however, a combination of both methods can be used to advantage. In bile duct tumors and Klatskin tumors, the endoluminal part can be treated using brachytherapy. The extralumenal growth and, if necessary, all affected regional lymph node areas can be treated by a 3D planned, percutaneous, moving field technique. Intraoperative radiotherapy can be used in a few cases as booster irradiation of tumor conglomerates at the porta hepatis. The decision to use irradiation must be made very carefully since solid tumors are usually involved that require a high target dose, the application of which can lead to unacceptable side effects. The radio-oncological spectrum is therefore confined predominantly to palliative therapy.

[Self-expandable metal prostheses. A new alternative palliative therapy of malignant stenotic lesions of the esophagus]

The treatment of malignant esophageal stenoses is a serious problem which may have a surgical solution at diagnosis in only a selected number of cases. Chemotherapy and radiotherapy are the main palliative treatments; surgery has a high morbidity and mortality rate. The insertion of esophageal prostheses could be an alternative palliative treatment. From January 1991 to November 1993, 41 autoexpandable metallic prostheses (12 Wallstent type, 19 Strecker type and 1 Rosch-Uchida type) have been implanted in 30 patients with esophageal cancer one with lung cancer and two with radiation induced esophagitis. Technical success resulted in 28 patients; an initial failure requiring a new prosthesis insertion occurred in 5 patients. Technical aspects and results are analyzed.

[The palliative treatment of venous stenoses in tumor patients with self-expanding vascular prostheses]

During 53 months 14 patients with tumour-induced obstructions of the superior vena cava (n = 8), the inferior vena cava (n = 2) and iliac veins (n = 4) were treated with self-expandable metallic stents. 21 Wall stents and 5 Gianturco double stents were applied. The follow-up lasted from 2 weeks to 16 months (range = 5.7 months). All patients showed a marked relief of inflow obstruction after stent placement. 6 of 7 patients, who died of their disease during follow-up, were asymptomatic regarding vein obstruction until their death (3 weeks to 16 months). In 6 of 7 still living patients no re-obstruction occurred during follow-up (2 to 16 months). Patency rate was 82%. These results suggest that self-expanding stents are a successful palliative therapy of malignant vein obstructions.

Minimally invasive palliative tumor therapy guided by imaging techniques: the UCLA experience

Imaging-guided palliative therapy of recurrent and/or inaccessible head and neck tumors may soon become clinically practical since sensitive and noninvasive monitoring techniques of energy deposition in tissues are now available. Interstitial tumor therapy (ITT) is a technique whereby a source of energy (laser, radiofrequency, ultrasonic, cryoenergy, etc.) is directly applied into tumors at various depths. Recent studies have demonstrated the efficiency of ultrasound (UTZ) and magnetic resonance imaging (MRI) for real and/or "near" real time tumor and vessel identification as well as monitoring and quantifying energy-induced tissue damage. We now report our initial clinical experience with patients in which UTZ and/or MRI-guided ITT techniques were successfully applied for the treatment of recurrent, nonresectable, local, and/or metastatic head and neck carcinomas. Patients were treated on an outpatient basis either in the operating room or in an upgraded specially equipped SIGNA 1.5T MR suite. Most patients tolerated these procedures well and were successfully palliated for periods ranging from 3 months to 5 years posttreatment. The upgrades introduced in a standard MRI suite, the clinical experience, and future perspectives will be reviewed.

Intraluminal brachytherapy in the treatment of oesophageal cancers--some preliminary results

Cancer of the oesophagus is the sixth commonest cancer in males in Singapore. The majority occur in the elderly and patients are often debilitated at presentation. Treatment is often aimed at palliation only. In this article, the preliminary results of 15 patients treated solely on a high dose rate remote afterloading Gammamed brachytherapy machine with an Iridium 192 (Ir192) source are reported. The patients were given 15 Gray (Gy) in a single or two 7.5 Gray fractions. All the patients treated had some improvement of their dysphagia, and seven out of 11 (63%) evaluable patients had symptom improvement lasting at least 11 weeks.

Use of the Edmonton Injector for parenteral opioid management of cancer pain: a study of 100 consecutive patients

In this retrospective study, we reviewed the patterns of use of the Edmonton Injector (EI) in 100 consecutive cancer patients. Seventy-eight patients used the EI for an average of 23 +/- 27 days. The main reasons for starting the EI were nausea (37 patients) and severe pain (31 patients). The median opioid dose equivalent to parenteral morphine (MEDD) was 264 +/- 443 mg/day. The mean duration of the subcutaneous injection site was 6.5 +/- 9.2 days. The most frequent reasons for change were accidental needle pulling (59%) and erythema (12%). Only two patients developed local infection (1% of 196 sites). The average cost of treatment was $1.65 Canadian per patient per day. No mechanical problems or refusals to start or continue treatment were detected. We conclude that the EI is a safe and simple device that allows for cost-effective parenteral administration of opioids for cancer pain.

Treatment of overuse patellofemoral pain. Prospective randomized controlled clinical trial in a military setting

The efficacy of treatment of overuse patellofemoral pain with an elastic knee sleeve with a silicone patellar ring was compared with a simple elastic sleeve and with no treatment in a prospective study of 395 army recruits. During 14 weeks of basic training, 84 knees were diagnosed as having overuse patellofemoral pain. Recruits treated with a simple elastic knee sleeve had a statistically significant better comfort score and more had their pain resolved by the end of training than those treated with elastic knee sleeves with a silicone patellar ring. The mean pain score at the end of training decreased more among recruits who were treated with a simple elastic knee sleeve than among recruits who received no treatment, but this difference was not significant. Among the treatment options tried, the simple elastic knee sleeve was no more effective than no treatment at all, but it was more effective than the more elaborate patellar brace.

Pleuroperitoneal shunt for malignant pleural effusions: a one-year experience

Malignant pleural effusions are often debilitating conditions for the patient with advanced cancer. Traditionally, treatment has been repeated thoracentesis or tube thoracostomy with installation of sclerosing agents. This, however, required the patient to be hospitalized and subjected to the pain and inconveniences of the chest tubes. The drainage also had to be low enough for sclerotherapy to be effective. In 1982, the pleurovenous shunt was modified and the pleuroperitoneal shunt became a feasible alternative to sclerotherapy. We started using the Denver pleuroperitoneal shunt in July 1991. Seventeen shunts were inserted into 13 patients over a 1-year period ending June 30, 1992. All patients were relieved of their dyspnea. The average length of patency was 2.5 months, and fewer than 25% of the shunts clotted. Our favorable experience with the shunt has lead us to recommend the Denver pleuroperitoneal shunt for the treatment of recurrent malignant effusions.

The effects of cold therapy on postoperative pain in gynecologic patients: a prospective, randomized study

OBJECTIVE

The purpose of the study was to determine the effect of cold therapy on the subjective assessment of pain, analgesic requirements, and wound complications in female patients undergoing major abdominal surgery.

STUDY DESIGN

Twenty-seven patients were entered in the study in a prospective, randomized fashion. The Hot/Ice Thermal Blanket was applied to 13 patients, and 12 patients were in the control group. All patients underwent exploratory laparotomy and received postoperative pain relief with intravenously self-administered morphine sulfate through a patient-controlled analgesic pump.

RESULTS

Compared with the control group (0.363 +/- 0.118 mg/kg/day), the cold pack group used more morphine sulfate on the first postoperative day (0.529 +/- 0.236 mg/kg/day, p < 0.05). The mean amount of morphine sulfate used by both groups was similar on postoperative day 2.

CONCLUSION

We conclude that the cold pack does not improve postoperative pain control in gynecologic patients undergoing exploratory laparotomy.

Flushable exo-endodrainage: a modified palliative approach to non-resectable malignant biliary obstruction

The introduction of new imaging techniques has markedly improved the diagnosis of hepatobiliary disorders. Due to their anatomic situation, a substantial percentage of malignancies located near the hilus is not suitable for surgical management. We discuss an effective palliative intervention to relieve jaundice. In many instances drainage is a superior choice when biliodigestive anastomoses are not technically feasible and palliative resection carries a high complication rate. We present an irrigatable exo-endodrainage method employing a modified port-a-cath system as a new alternative. In four patients, all older than 75 years, this system was implanted because of jaundice due to unresectable malignant stenosis of the extrahepatic bile duct. One patient (80 years old) died of pre-existing acute necrotizing pancreatitis, although hyperbilirubinemia was found to decrease on the 7th postoperative day. The other three patients showed complete normalization of their bilirubin levels and their port-a-cath systems remained open until their death (at 3 weeks, 6 months and 7 months respectively).

[Metal endoprostheses for endoscopic therapy in malignant bronchial tumors]

Self-expanding metal stents were implanted in the trachea or main bronchus in 12 patients (eleven men, one woman; mean age 60 +/- 8 years) with nonresectable bronchial carcinoma (n = 11) or tracheal metastasis of a hypernephroma (n = 1). They all had pulmonary complications caused by tumour stenoses (group I: severe dyspnoea [n = 6], group II: retention pneumonia [n = 4] or lung abscess [n = 2] after unsuccessful antibiotic treatment). The procedure was undertaken after local anaesthesia with a flexible bronchoscope (in the first three cases still with a rigid bronchoscope under general anaesthesia) under fluoroscopic control. Immediate reduction in dyspnoea occurred in five of the six patients in group I. In five of the six patients in group II antibiotics cured the infection after stent placement. The therapeutic effect was immediate in severe dyspnoea and retention of secretions. The clinical improvement lasted longer in patients with abscess and retention pneumonia than those with dyspnoea (41 +/- 16 vs. 26 +/- 10 days). If strict indications are observed in cases with malignant bronchial stenosis, implantation of self-expanding stents provides rapidly effective, well-tolerated palliation.

Dose changes in long- and medium-term intrathecal morphine therapy of cancer pain

Intrathecal morphine analgesia for the treatment of cancer pain was administered using implanted ports and drug delivery systems (DDS) in 79 patients. Effective control of the pain was achieved in nearly all patients; in only two patients was the use of the DDS discarded because of relative ineffectiveness. Fifty-three manual drug release systems (41 lumbar, 12 ventricular) and 26 lumbar ports were used. Forty patients survived more than 2 months; the maximum survival time was 560 days (mean survival time, 80 days with a port system, 100 days with a manual DDS). Patients still alive at the time of this study, i.e., with unknown survival time, were excluded. The initial mean daily dose was 8.5 mg in lumbar ports, 2.75 mg in lumbar DDS, and 0.2 mg with intraventricular application. Dose change patterns disclosed no alteration of the initial dose in 18 of 26 port patients, an initial increase in 4, a preterminal increase in 3, and a single intermittent increase in 1 patient. Of 40 lumbar DDS patients, 13 showed a constant dose, 9 an initial, 3 a preterminal, and 5 an intermittent increase. Three patients with less than 2 months' survival time had a rather continuous increase. All long-time survivors (i.e., with more than 2 months' survival time) reached a plateau and remained there until a preterminal if any increase occurred. These findings suggest the morphine dosage to be indicative of the progress of the disease rather than of a drug tolerance.(ABSTRACT TRUNCATED AT 250 WORDS)

[Palliative minimally invasive therapy in inoperable elderly patients]

The results of palliative endoscopic therapeutic maneuvers in patients over 80 years of age were retrospectively analyzed, covering a time period of 26 months. Aims of the therapeutic modalities were the recanalization of stenoses of the gastrointestinal tract, the long-term enteral nutrition or the abolition of a malignant obstructive jaundice. Appropriate procedures were combined bougienage and laser therapy, implantation of esophageal bridging tubes, percutaneous endoscopic gastroenterostomy (PEG), and the implantation of biliary endoprosthesis after endoscopic papillotomy. We evaluated (during the period January 1, 1990 until February 29, 1992) a total of 89 patients with various diseases, all of whom, at the time of examination, were candidates for surgery, either due to the extent of a tumor or due to a significant reduction of the physical status. The complication rate of the procedures of 2.9%, and the lethality risk of 0.9% showed no increase compared to patients of younger age. Therefore, minimal invasive endoscopic therapeutic procedures are strongly indicated in inoperable patients suffering from various diseases. Symptoms may be eliminated or significantly reduced with a few procedures which can be repeated many times.

Metallic stents in biliary disease

The development of self-expanding metallic endoprostheses which can be implanted easily, with minimal trauma, has revolutionized the non-surgical treatment of both benign and malignant biliary strictures. The Wallstent (Medinvent SA, Lausanne, Switzerland), a pliable, tubular stainless steel mesh, is the metallic stent of choice for treatment of malignant strictures and can be implanted in a single session resulting in a shortened hospital stay for patients undergoing palliation of irresectable biliary tumours. Although follow-up is currently rather limited, it appears that the occlusion rate of Wallstents will be lower than that of plastic endoprostheses and no cases of stent migration have been reported. The Gianturco zigzag stent (Cook Inc., Bloomington, Ind, USA) should not be used in malignant strictures because of rapid occlusion due to tumour ingrowth through the struts. However, it exerts a strong, continuous, outward radial force and is ideally suited for use in the small, but difficult to manage, group of patients with benign biliary strictures which recur despite surgery and repeated balloon dilations.

Management of malignant hilar biliary obstruction by endoscopy. Results and prognostic factors

Between January 1983 and December 1987, 103 patients who had hilar biliary obstruction (59 men, 44 women, median age 73 years) were referred to our institution. The causes of hilar biliary obstruction were carcinoma of the bile ducts (55), hepatic metastases or hepatocellular carcinoma (30), and carcinoma of the gallbladder (18). When endoscopic retrograde cholangiography was performed, the stricture was classified as type I in 28%, type II in 41%, and type III in 31% of the patients. In 92 patients, we tried to insert endoscopically a 10, 11, or 12 F Amsterdam type prosthesis; it proved possible in 66 (74%), and the prosthesis proved functional without further procedure in 49 cases (53%); no combined percutaneous and endoscopic method was used. At death or discharge, 45 patients (49%) had a successful drainage. Cholangitis was the main procedure-related complication and occurred in 25 patients. The 30-day mortality was 43%. Results varied according to type of stenosis: successful drainage was performed in 15% of the patients with type III stenosis, compared with 86% when the stenosis was of type I. Under a multivariate analysis the independent prognostic factors of 30-day mortality were: (1) development of infectious complications after endoscopic attempt at drainage (P less than 0.0001), and (2) absence of successful drainage (P less than 0.0001). In conclusion, endoscopic endoprosthesis placement allows a sufficient drainage in 53% of the cases. In type III stenosis, the high rate of 30-day mortality leads us the conclusion that endoscopic drainage must be avoided.

Does ND-YAG laser extend the indications for resection of pulmonary metastases?

Surgery forms part of a combined oncological concept in the management of pulmonary metastases. The following questions are relevant for its role: Does survival depend on the type of primary tumor? Are there any prognostic factors? What are the limits on radical resection? We analyzed retrospectively 657 patients who had undergone 759 resections of pulmonary metastases between 1973 and 1990. After conducting in vitro and in vivo experiments with the non-contact neodymium aluminum garnet (Nd-YAG) laser with a generating and delivery power of 10-120 W at the site of operation for 0.1-9.9 s, we have treated 65 patients by laser resection and/or vaporization since January 1990. Our preferred surgical approach was median or transverse thoracotomy. The 5-year survival of all resected patients was 30%, ranging from 21% (soft tissue sarcoma) to 60% (testicular carcinoma). Statistically significant differences in prognosis were seen related to the type of primary tumor, the disease-free interval, the caval or portal type of metastatic spread, the number of metastases and the potential degree of radical resection. The potential degree of conventional radical resections (wedge, anatomical sub-/segmental) was negatively influenced by the number of metastases (n > 9: 79% "radical" surgery = 38% 5-year survival). Laser treatment allowed parenchyma-preserving resection in cases of metastases of more than 0.5 cm in diameter, and vaporization in smaller ones. Resection with the intention of achieving complete remission was possible in up to 72 unilateral metastases. The complication rate was comparable to conventional resections.

Palliative treatment of esophageal carcinoma using laser and tumor probe therapy

Laser therapy and BICAP tumor probe therapy offer effective and safe means of palliating obstructive esophageal cancer. Future developments may allow more precise application of these techniques, based on more sensitive means of identifying abnormal tumor tissue. The development of endoscopic ultrasonography and the use of tissue sensitizing agents (such as hematoporphyrin derivatives) may allow more accurate means of differentiating normal from abnormal tissue. This may lead to more precise and extensive tumor destruction, less injury to normal tissue, and less potential for complication. As the use of both of these modalities becomes more widespread, their role in the treatment of esophageal cancer will continue to grow.

Transoval administration of opiates into trigeminal cistern for cancer pain. Preliminary report

A new method for administration of opiates into the ventriculo-cisternal system for intractable pain due to cancer is presented. Five patients suffering from such pain underwent the permanent implantation of a subcutaneous reservoir connected to a thin catheter inserted into the trigeminal cistern. The indications are those of the intraventricular way. Percutaneous trigeminal opiates administration (PTO) proved to be a valid and simple alternative method to intrathecal and intraventricular morphine.

[Continuous epidural treatment of cancer pain using a portable infusion pump]

Treatment of cancer pain with opioids through an epidural catheter, with a portable infuser has been recorded in 20 patients retrospective. In general there was a good acceptance of the treatment, which often could liberate the patients from close contacts to the pain clinic. There were not recorded adverse effects in relation to the infuser treatment. One patient had systemic adverse effects because of a very high daily opioid dose. The Pharmacia Deltec infuser employed has proven very secure and easy to handle.

[Self-expanding and expandable bile duct prostheses]

The main problem of conventional endoscopic or percutaneous biliary drainage is the clogging of plastic endoprostheses. Therapeutic advances may be achieved by self-expanding or balloon-expandable braided or slit metal stents due to their large lumen and small surface area. Preliminary clinical studies show excellent early results but a divergent long-term clinical outcome depending on the selection of patients, the implantation technique or the type of the stent. If a long-distance overlap of biliary stenoses is achieved the metal stents may be superior to plastic prostheses due to a reduction of the risk of bile encrustation.

The management of malignant esophago-respiratory fistulas with a cuffed prosthesis

Peroral intubation with a standard prosthesis fails to occlude inoperable malignant esophago-respiratory fistulas located above the narrowed segment, or when there is little or no stricture at all. Ten patients with malignant esophago-respiratory fistulas were intubated perorally with a prosthesis surrounded by a foam ruber cuff contained in a silicone sheath, in which a vacuum can be created. The type of fistula was esophago-bronchial in 6 patients, esophago-tracheal in 3 patients, and gastro-tracheal in 1 patient. The fistula was located above the stricture in 8 patients and in a malignancy without a stricture in 2 patients. The diameter of the opening of the fistula ranged between 1 and 3 cm. Complications with the cuffed tube were recurrent leakage after a period of 30 days in situ in 1 patient, and compression of the trachea immediately after intubation in 1 patient. Adequate palliation, that is, no symptoms related to the fistula, good transit of food and discharge from hospital within a few days was achieved in 9 patients for an average period of 37.2 days (10-84 days). The cuffed esophageal prosthesis can improve the quality of life in patients with malignant esophago-respiratory fistulas that do not respond to conventional intubation.

Palliative treatment of bile duct tumoral compression by an endoprosthesis: clinical results

The palliative therapy of stenoses of the biliary tract is a difficult choice. Because percutaneous or endoscopic drainage methods are fraught with complications, an endoprosthesis for surgical intubation of the biliary tract has been developed. Thirty patients were treated by this method. After choledochotomy, the endoprosthesis is positioned surgically above the sphincter of Oddi, thereby avoiding ascending cholangitis. Twenty-nine patients (13 with gallbladder cancer, 11 with cholangiocarcinomas, 5 with metastases) presented with neoplastic compression, and one patient had an early postoperative stricture with loss of substance after right hepatectomy for hepatic metastases. The operative mortality was 3.3% (one pulmonary complication). Resolution of jaundice was obtained in all but two patients, and pruritus always resolved. The mean survival time for the patients with cholangiocarcinoma was 12.2 months and 6.33 months for those with gallbladder cancer. Indices of satisfaction (Bismuth's method) were 71% (gallbladder cancer), 93.5% (hilar cholangiocarcinoma), and 92% (metastatic compressions). This new type of surgical endoprosthesis is an alternative in the palliative treatment of neoplastic hilar compression because it is well tolerated, has a low rate of operative mortality or morbidity, and affords an acceptable quality of life for the patients.

Pleuroperitoneal shunt for recurrent malignant pleural effusions

The therapeutic options available for the management of malignant pleural effusions associated with a restricting malignant cortex remain unsatisfactory. The efficacy of pleuroperitoneal shunts was evaluated in 16 patients with recurrent malignant effusions. There were no operative deaths; one patient died on the third postoperative day as a result of lymphangitis carcinomatosa. The median hospital stay was five (range 3-21) days. Palliation was obtained in all but one of the other 15 patients. There was no appreciable reaccumulation of pleural fluid as judged by radiography. Two patients developed occlusion of the shunt. In one case this was due to blood clots in the pleural catheter and necessitated insertion of a new shunt. The other shunt was removed because of obstructing infected fibrin debris, and a rib resection was performed. There were eight deaths related to the underlying malignancy after a mean interval of 7.3 (range 1.5-23) months. The other six patients are still alive, with a mean survival of 11.0 (range 5-20) months, and have achieved good symptomatic relief. The insertion of a pleuroperitoneal shunt can offer effective palliation for patients with recurrent malignant pleural effusions.

Palliative therapy of malignant esophageal stricture with the bipolar tumor probe and prosthetic tube

Patients with malignant esophageal stricture and dysphagia were prospectively randomized to receive palliative therapy with the bipolar tumor probe (17) or prosthetic tube insertion (13). Both treatments gave good relief of dysphagia compared with pretreatment values on a dysphagia score, the results being statistically significant (p less than 0.005). However, there was no difference in the improvement achieved by one method compared with the other. The tumor probe was not difficult to use and complication rates were comparable. In the Atkinson tube group, two patients developed complications related to the position of the prosthesis and in three others food blocked the tube. Treatment with the tumor probe needed repeating at intervals (median, 28 days; range, 2 to 86 days) in all but four individuals to maintain palliation, with each patient needing a median of two treatments (range, 1 to 8). The probe may have advantages in very high esophageal lesions and may facilitate the treatment of tumor overgrowth or undergrowth of a tube. The prosthetic tube may give long-lasting relief of dysphagia and remains the treatment of choice for bronchopulmonary fistulas.

Treatment of endometriosis with a Nd:YAG tissue-contact laser probe via laparoscopy

The neodymium:yttrium-aluminum garnet (Nd:YAG) laser was used via laparoscopy in 84 patients complaining of infertility and/or pelvic pain. All patients in the study had biopsy-proven or visually confirmed pelvic endometriosis. The Nd:YAG laser was used in conjunction with sapphire probes as a touch technique on tissue. Problems usually encountered, such as mirror alignment, beam focus, and smoke plume, with carbon dioxide laser systems were avoided, and use of the laser in a liquid environment was possible. Restoration of fertility was seen in 39.7% with short follow-up; pain relief was excellent, especially in conjunction with uterosacral denervation.

Use of silicone stents in the management of airway problems

We report the use of a silicone rubber T tube for the management of complex airway problems in 47 patients during the past 15 years. The tube has been used for palliation in 11 patients with malignant obstruction of the airway, and as the sole treatment or as an adjunct to operation in 36 other patients. Based on the satisfactory results with the use of these tubes, we have utilized silicone stents in the bronchus and bifurcation prostheses at the carina. In the past, we have inserted the T tubes through a tracheostomy stoma. More recently, we have used a technique for endoscopic placement of the T tubes in which the horizontal limb is pulled out through the tracheostomy stoma. This technique facilitates introduction of the tube and maintains the airway during insertion. The use of silicone stents provides an important tool in the management of complicated airway problems, and we anticipate their increased use in the future.

A comparison of endoesophageal tubes. Improved results with the Atkinson tube

We reviewed our use of endoesophageal tubes for the palliation of patients with carcinoma of the esophagus from 1973 through 1986. Celestin tubes were implanted by means of laparotomy and traction. Proctor-Livingston tubes were implanted by pulsion with frequent laparotomy for staging. All Atkinson tubes were placed by means of the pulsion method without simultaneous laparotomy in any case. Patients with an Atkinson tube had fewer complications, including aspiration, sepsis, reflux, and pneumonia. Mean hospital stay was shortened to 4 days when the Atkinson tube was used, and hospital death rate was 6% versus 42% when either the Celestin or Proctor-Livingston tube was used. Mean long-term survival (108 days) was significantly lengthened when Atkinson tubes were used. A comparison of all patients receiving tubes revealed a less frequent prevalence of reflux when the distal end of the tube was positioned above the gastroesophageal junction. Laparotomy resulted in significantly more episodes of aspiration, sepsis, reflux, and pneumonia. Laparotomy was also associated with a 41% hospital death rate versus 17% when laparotomy was not performed. Hospital days were shortened to 7 versus 16 days when laparotomy was not performed. The Atkinson tube provided improved palliation and decreased morbidity and mortality in our hands. These benefits were probably the results of ease of insertion without the use of a laparotomy and the ability in most cases to position the distal end of the tube above the gastroesophageal junction.

Photodynamic laser therapy to alleviate complete bronchial obstruction: comparison of CT and bronchoscopy to predict outcome

Photodynamic laser therapy is used in the palliation of advanced lung cancer. To minimize the complications of this form of therapy, physicians must evaluate correctly the extent of extraluminal disease. We undertook a study to compare CT and bronchoscopy in the evaluation of extent of disease before laser therapy in 20 patients with complete bronchial obstruction. The relative contribution of intraluminal and extraluminal tumor to the obstruction and its influence on response to therapy was assessed by using both techniques. Adequate response was defined as greater than or equal to 50% relief of the obstruction on bronchoscopy performed within 1 week of therapy and by any improvement of the postobstructive atelectasis and consolidation on follow-up chest radiographs. Nine patients had predominately intraluminal tumor on both CT and bronchoscopy before laser therapy. Eight of these had a bronchoscopic response and radiographic improvement after therapy. Ten patients had predominately extrinsic compression by tumor on CT. Of these, only two had a bronchoscopic response and none had radiographic improvement after treatment. The differences in bronchoscopic and radiographic response between the two groups were significant (p less than .01). In the 10 patients with predominately extraluminal tumor on CT, bronchoscopy agreed with CT in suggesting mainly extrinsic compression in five, but it incorrectly suggested mainly intraluminal tumor in the remaining five. In one patient with a left upper-lobe tumor, the relative intra- and extraluminal components could not be assessed on CT. We conclude that in complete bronchial obstruction, CT is superior to bronchoscopy in evaluating the extent of extrinsic compression by tumor. The presence of predominately extraluminal tumor compression on CT correlates with a poor response to laser therapy.