RESUMO
Photodynamic therapy (PDT) is a local photochemical tumor treatment that consists of a photosensitizing agent in combination with laser irradiation of a distinct wavelength. In some case reports and small non-randomized pilot studies, PDT has proved feasible in patients with hilar bile duct cancer. Those studies showed an astonishing long survival time of the treated patients. In the yet published two randomized controlled studies, PDT showed a significant extension of survival compared to sole bile duct stenting. A possible explanation for this improved survival is a suspected anti-tumor immunological effect induced by PDT. PDT reaches the same level of survival time as incomplete resection. The main complication is a high risk of severe bacterial cholangitis and liver abscesses requiring peri-interventional antibiotics. Skin phototoxicity, which at the beginning of PDT was the most dreaded potential complication, seems to play an ancillary role using mild light protection. As the available photosensitizers, mainly hematoporphyrin derivative (HPD), are not very effective in terms of depth of tumor necrosis, newer photosensitizers with light absorption in the near infrared spectrum and therefore deeper penetration depth are currently under investigation.
RESUMO
Despite immediate surgical repair of the entry site in acute thoracic aortic dissection with visceral malperfusion, the results are poor. Primary restitution of visceral flow by intervention might be one way to cope with this problem, but probably causes ischemia/reperfusion associated problems after prolonged complete visceral ischemia. In this report, we demonstrate a successful attempt of controlled delay of thoracic aortic surgical repair after visceral flow restitution with stable hemodynamics.
Assuntos
Aneurisma da Aorta Torácica/cirurgia , Dissecção Aórtica/cirurgia , Implante de Prótese Vascular , Cuidados Críticos , Isquemia/cirurgia , Radiografia Intervencionista , Traumatismo por Reperfusão/prevenção & controle , Vísceras/irrigação sanguínea , Idoso de 80 Anos ou mais , Dissecção Aórtica/complicações , Dissecção Aórtica/diagnóstico por imagem , Dissecção Aórtica/fisiopatologia , Aneurisma da Aorta Torácica/complicações , Aneurisma da Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/fisiopatologia , Ponte Cardiopulmonar , Evolução Fatal , Feminino , Humanos , Isquemia/diagnóstico por imagem , Isquemia/etiologia , Isquemia/fisiopatologia , Masculino , Pessoa de Meia-Idade , Fluxo Sanguíneo Regional , Traumatismo por Reperfusão/diagnóstico por imagem , Traumatismo por Reperfusão/etiologia , Traumatismo por Reperfusão/fisiopatologiaRESUMO
BACKGROUND: The results of preliminary studies of photodynamic therapy (PDT) for palliation of patients with bile duct cancer with hematoporphyrin derivative have been good. Rapid elimination of a photosensitizer could potentially shorten the time requirement for shielding from light. This would enhance the benefit of this form of palliative treatment. Therefore the feasibility of PDT was investigated for nonresectable bile duct cancer by using 5-aminolevulinic acid. METHODS: Four patients with nonresectable bile duct cancer underwent cholangiography, cholangioscopy, and intraductal US before PDT. Light activation was performed 5 to 7 hours after oral administration of 5-aminolevulinic acid. All patients had an endoprosthesis placed in the bile duct after PDT. RESULTS: Cholangioscopy 72 hours after PDT revealed superficial fibrinoid necrosis. However, 4 weeks after PDT there was no significant reduction in bile duct stenoses. Two patients had infectious complications develop, but phototoxicity was not observed. CONCLUSIONS: Although superficial tumor necrosis was evident, PDT with 5-aminolevulinic acid failed to significantly reduce malignant bile duct obstruction. Therefore 5-aminolevulinic acid-PDT cannot be recommended for the palliative treatment of bile duct cancer.
Assuntos
Ácido Aminolevulínico/administração & dosagem , Neoplasias dos Ductos Biliares/diagnóstico , Neoplasias dos Ductos Biliares/tratamento farmacológico , Cuidados Paliativos/métodos , Fotoquimioterapia/métodos , Administração Oral , Idoso , Idoso de 80 Anos ou mais , Colangiografia , Colangiopancreatografia Retrógrada Endoscópica/métodos , Feminino , Seguimentos , Humanos , Masculino , Projetos Piloto , Sensibilidade e Especificidade , Índice de Gravidade de Doença , Resultado do TratamentoRESUMO
OBJECTIVES: Preliminary results of photodynamic therapy (PDT) of bile duct cancer have shown astonishingly good results in the reduction of cholestasis, improvement of quality of life, and even prolongation of the survival time. Unfortunately, the existing dye laser systems are large and costly, and their maintenance is expensive. Therefore, we investigated the feasibility of a diode laser system for PDT of nonresectable bile duct cancer. METHODS: Eight patients with nonresectable bile duct cancer were treated. Forty-eight hours after i. v. application of 2 mg/kg body weight of Photosan-3, light activation was performed by a transpapillary (four patients) or percutaneus (four patients) access. We used a cylindrical diffusor tip and illuminated using a wavelength of 633+/-3 nm and a total energy of 200 J/cm2. All patients were additionally provided with bile duct endoprostheses after PDT. RESULTS: Four weeks after initial PDT all patients showed a marked reduction of bile duct stenosis. The median serum bilirubin value declined from 5.8 mg/dl (2.0-10.1) to 1.0 mg/dl (0.8-4.4). The median survival time at the time of writing is 119 days (52-443). Five patients are still alive. In four patients we could change from percutaneous to transpapillary drainage after PDT, two patients showed infectious complications. CONCLUSION: PDT with the diode laser system seems to be effective in reducing malignant bile duct stenosis. This treatment is minimally invasive and has a low specific complication rate. Randomized, controlled studies comparing PDT with the insertion of endoprostheses and long term follow-up of results are needed to confirm the promising short term results.
Assuntos
Neoplasias dos Ductos Biliares/tratamento farmacológico , Colestase/tratamento farmacológico , Terapia a Laser , Cuidados Paliativos/métodos , Fotoquimioterapia/métodos , Idoso , Neoplasias dos Ductos Biliares/complicações , Neoplasias dos Ductos Biliares/mortalidade , Colangiografia , Colestase/diagnóstico por imagem , Colestase/etiologia , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Qualidade de Vida , Taxa de SobrevidaRESUMO
BACKGROUND: Data concerning the association of juxtapapillary duodenal diverticula (JPDD) with biliopancreatic disorders are inconsistent, but an association between bile duct stones and JPDD is widely accepted. The aim of this study was to investigate the frequency of JPDD and its association with biliopancreatic disorders in patients undergoing ERCP. METHODS: A retrospective analysis was conducted of 5497 consecutive ERCP procedures performed in 2925 patients. Matched-pair analysis yielded 350 pairs of patients with and without JPDD, matched for definite risk criteria such as age, gender, and indication for ERCP. RESULT: The incidence of JPDD was 12%. Patients with JPDD were significantly older than patients without JPDD (71 vs. 62 years; p < 0.0019) and had a significantly higher bleeding rate after endoscopic sphincterotomy (8.8% vs. 4.8%; p = 0.039). The presence of JPDD correlated with gallbladder stones (29.4% vs. 20.8%; p = 0.039), bile duct stones (46% vs. 33.1%; p < 0.001), and recurrence of bile duct stones (6.6% vs. 1.4%; p = 0.002). There were no significant differences in frequency of acute and chronic pancreatitis as well as pancreas divisum. After multivariate logistic regression analysis, technically difficult ERCP, bleeding after endoscopic sphincterotomy, and bile duct stones remained as independent risk factors. CONCLUSION: JPDD appears to be a risk factor for complications of endoscopic sphincterotomy and for gallbladder stones, bile duct stones, and their recurrence.
Assuntos
Ampola Hepatopancreática/diagnóstico por imagem , Colangiopancreatografia Retrógrada Endoscópica , Colelitíase/diagnóstico por imagem , Divertículo/diagnóstico por imagem , Duodenopatias/diagnóstico por imagem , Cálculos Biliares/diagnóstico por imagem , Pancreatite/diagnóstico por imagem , Adulto , Idoso , Ampola Hepatopancreática/cirurgia , Colelitíase/cirurgia , Divertículo/cirurgia , Duodenopatias/cirurgia , Feminino , Seguimentos , Cálculos Biliares/cirurgia , Humanos , Masculino , Análise por Pareamento , Pessoa de Meia-Idade , Pancreatite/cirurgia , Hemorragia Pós-Operatória/diagnóstico por imagem , Estudos Retrospectivos , Fatores de Risco , Esfinterotomia EndoscópicaRESUMO
We report about a 27-year-old patient with Crohn's disease presenting with two complications; Portal vein thrombosis and multiple liver abscesses. Conservative treatment with antibiotics and percutaneous catheter drainage was successful, the liver abscesses disappeared. 18 months later the patient presented in best condition. Ultrasound showed cavernous transformation of the portal vein system and splenomegaly, discrete esophageal varices were seen by esophagogastroscopy. This is an example for an excellent course under conservative therapy of liver abscesses, on the other hand it is the first reported case of a patient with a combination of portal vein thrombosis and multiple liver abscesses in Crohn's disease.