Endoscopic treatment of postradiation strictures.

BACKGROUND: Esophageal stricture is a rare complication of radiotherapy: reports on its incidence and management are therefore anecdotal. METHODS: From January 1978 to September 1992, 44 patients presenting with an esophageal stricture related to a previous radiation treatment were endoscopically dilated at the Endoscopy Division of the Istituto Nazionale Tumori of Milan. RESULTS: Esophageal recanalization was obtained in 95% of the patients treated, and in 79% of these normal eating habits were restored. No strict correlation was observed between radiation dose and severity of the stricture, or time elapsed between first treatment and endoscopic dilation. CONCLUSIONS: In our experience, endoscopic dilation was a safe effective procedure and represented an effective palliative tool in dysphagic patients with esophageal strictures due to previous local radiotherapy.

Palliation of tracheobronchial malignant obstruction with metal stents in emergency conditions.

BACKGROUND: Endoluminal obstruction, caused by tracheobronchial malignancies, can require urgent treatment in case of severe respiratory distress. In emergencies, self-expanding metal stents can be endoscopically employed to solve acute symptoms. METHODS: Between April 1992 and August 1996, 7 patients were treated by positioning of metal stents in emergency conditions and observed to verify the immediate efficacy of endoscopic therapy. Tracheal stenosis, stenosis of trachea and right main bronchus and obstruction of trachea and left main bronchus were present in 5, 1 and 1 patient, respectively. Metal stents for intravascular use (Wallstent, Schneider, Zurich, Switzerland) were positioned on a guide wire by fiber- or video-bronchoscope, after local anaesthesia, monitoring the arterial oxygen saturation of every patient. RESULTS: In six patients breathlessness was resolved immediately. The last patient, suffering from severe mediastinal involvement, died from cardiac failure. No complication occurred. Mean survival was 40 days. CONCLUSIONS: Self-expanding metal stent placement is an easy and safe method, does not require general anaesthesia, is less traumatic and well tolerated, is quick to be performed and then can be used in emergencies. Nevertheless, it is impossible to remove the stent in case of malpositioning. Although this group is small, endobronchial stenting using metallic prostheses permits immediate ventilation and palliation of large airway obstruction.

Endoscopic treatment of gastric carcinoids.

Carcinoids are the most common endocrine tumours, and arise from a multipotential primitive stem cell; the gastric location represents 2% of all carcinoids. From 1979 to 1992 at the Endoscopy Division of Istituto Nazionale Tumori, Milan, 2 patients suffering from single gastric carcinoid were endoscopically treated by electro-resection. No complication occurred during the treatment; 2 year- and 5-year-follow-up was performed in these patients, and no recurrence are observed. Surgical treatment represents the therapy of choice for gastric carcinoids, but endoscopic resection can represent an alternative in selected cases (lesions less than 1 cm or carcinoids with multicentric growth). Endoscopy can be used also in patients at high surgical risk.

[A case of cloacogenic carcinoma with extra-visceral localization]. / Su di un caso di carcinoma cloacogenico a localizzazione extra-viscerale.

Cloacogenic carcinoma is a rare form of neoplasia (4-14% of tumours of the colon-rectum) which occurs on the transitional epithelium of anal canal. An extra-visceral location is rare. The paper reports a case of cloacogenic carcinoma sited on the perianal skin, treated with radiotherapy and local surgical excision. It is important to perform a biopsy and a thorough endoscopic examination of all ano-perianal lesions in order to separate those of dermatological relevance from those of surgical relevance, and at the same time to determine the exact histological type of the latter group so as to select the correct therapeutical approach.

Endoscopic treatment of polyps in the resected stomach.

Between 1974 and 1992, at the Department of Diagnostic and Surgical Endoscopy of Istituto Nazionale Tumori, in Milan, 27 patients with resected stomach and suffering from epithelial polyps of the gastric stump (10 lesions) and/or anastomosis (25 lesions), were endoscopically treated using electroresection (13 cases), electrocoagulation (2 cases), combined methods (electroresection plus Nd:YAG photocoagulation) (1 case) and biopsy forceps (19 cases). Complications occurred in 4 cases and consisted of hemorrhage. Seven patients developed 15 recurrences. Endoscopic treatment of polyps in patients with resected stomach is a safe and effective treatment, considering the low rate of complication.

Prevention and treatment of complications after endoscopic prostheses placement in tumors of the upper gastrointestinal tract.

Endoscopic intubation is a popular palliative method to resolve immediately malignant dysphagia. However, the complication rate is still high. Between 1978 and 1993, at the Division of Diagnostic and Surgical Endoscopy of Istituto Nazionale Tumori in Milan, 305 patients suffering from malignant dysphagia, were endoscopically treated by insertion of an endoprosthesis. We report the analysis of data regarding our complication rate, compared with the literature, and our experience in preventing managing complications related to this endoscopic procedure.

Endoscopic treatment of malignant dysphagia.

Palliative endoscopic treatment of dysphagia in patients with inoperable oesophageal cancer includes: dilation, Nd:YAG laser photocoagulation and intubation, used alone or in combination. Such procedures are usually performed on an outpatient basis and are associated with a low rate of morbidity and mortality. From 1978 to 1988, 476 patients (401 males, 75 females) were treated at the Endoscopy division of the National Cancer Institute of Milan for inoperable primary or recurrent malignancies of the oesophagus or cardia or for extra-oesophageal neoplasms causing dysphagia. Dilation was used in 172 cases, Nd:YAG laser photocoagulation in 90, prosthesis insertion in 72, dilation and laser in 97, and prosthesis and laser in 45. Functional improvement was reported in 75% of patients after dilation, in 89% after laser treatment, in 80% after intubation, in 80% after dilation and photocoagulation, and in 89% after laser and intubation. The median duration of dysphagia-free interval was 4 weeks in dilated patients, 6-8 weeks in photocoagulated patients and 20 weeks intubate patients. Overall median survival was 6.2 months. The complication rate was: 1.4% in dilation treatment, 1.4% in laser photocoagulation, and 8.8% in prosthesis intubation. Mortality related to endoscopic treatment was 2.1% (10/476 patients). Relief of dysphagia is one of the most important goals of palliative treatment in patients with inoperable oesophageal neoplasms. Moreover, endoscopic palliation improves the quality of life in the patients, with a low complication rate.

[Endoscopic polypectomy of the stomach]. / Polipectomia endoscopica nello stomaco.

Until 1970 endoscopy of the digestive tract was the only diagnostic method available. After this date, the introduction of endoscopic polypectomy enabled patients affected by these lesions to be treated, and at the same time considerably reduced their length of stay in hospital. The paper reports the results of 346 gastric polypectomies performed in 187 patients from 1974 to the present.

[Occlusive neoplastic pathology of the large intestine (a clinical contribution)]. / Patologia neoplastica occlusiva del grosso intestino (contributo clinico).

The Authors report an investigation on 42 patients with large bowel occlusions for neoplastic lesions. Obstruction complications were localized in 69% in sigmoid colon and recto-sigmoid junction. This pathology involved old patients with one or more associated affections. The Authors explain reflections on surgical treatment, on necessity of therapeutic approach in high-risk patients, and of large bowel surgery with oncologic radical treatment.

[Cancer of the rectum: analysis of incidence and survival at the Casale Monferato Provincial Hospital]. / Cancro del retto: analisi dell'incidenza e della sopravvivenza presso l'ospedale provinciale di Casale Monferrato.

Between 1978 and 1984, 34 patients carrier of rectal neoplasms, were observed and treated in Divisione di Chirurgia Generale of Casale Monferrato Hospital. Twenty of such patients had been operated with curative procedures and 14 with palliative procedures. At the moment of this investigation 14 patients were still alive. The survival rate at 5 years, referred to '78, '79, '80, '81, respectively was 37.2%. For the last three years, the fifth year delay time shall be waited. The survival rates per year, have been reported her, for the whole period of the investigation. The AA, have evaluated the gross incidence rate for male and female patients (3.1 and 2.1 respectively). Survival and incidence data have been composed to those reported in the literature. Whilst survival rates agree with those from other authors, the incidence rates result considerably lower than those from other West Countries. It could be abscribed to an underestimation of the actual number of rectal neoplasm bearing patients, which could escape the investigation because diagnosticed and treated elsewhere. It should be noted nevertheless that the Casale Hospital supplies a scarcely industrialized urban area, and a wide rural environment, so that resident population might be included within one of the groups partially protected by environmental and alimentary conritions against the disease. In conclusion the AA. consider of a primary importance the development of centres suitable for base medicine aimed at assuring a real and effective prevention activity.

[Carcinoma of the colon. Statistico-epidemiologic study carried out at Casale Monferrato Hospital]. / Carcinoma del colon. Indagine statistico-epidemiologica condotta presso l'Ospedale di Casale Monferrato.

The authors report here on the results of a statistical and epidemiological review of cases of carcinoma of the large bowel observed in the General Surgery Division of the Casale Monferrato Hospital. After supplying introductory data on the diffusion of the disease, risk factors and statistical aspects, the authors report data on 137 cases of large bowel carcinomatous neoplasms observed and treated over the period 1978-1984, complete with tables summarising the neoplastic localizations aid the types of operation performed. After calculating the operative mortality and both the absolute and relative survival rates, the authors analyze the results of the survey, comparing the findings obtained with those reported in the literature by various authors.

[Carcinoma of the prostate: statistico-epidemiologic study at Casale Monferrato Hospital (1980-84)]. / Carcinoma della prostata: indagine statistico-epidemiologica presso l'Ospedale di Casale Monferrato (1980-84).

An investigation on prostatic dancer is reported by AA., along a five years period (80-84) in Casale Monferrato territory (USSL 76, Piedmont) incidence rate (29,8) aid mortality data (27,7) are also reported in comparison to those reported in "Registro Tumori del Piemonte (Turin)", "Registro Tumori Lombardia (Varese)" and ISTAT (national territory). A. marking differencies among reported data, give some explanation about disagreement. AA.'s further assert that the given under-estimation of the incidence rate is due to the different diagnosis in different USSL. The over-estimation of death rate is partially given first by people come back in primitive country of origin, and second by data acquired in original countries, about death.

[The endoscopic treatment of gastric adenomas]. / Trattamento endoscopico degli adenomi gastrici.

Endoscopic polypectomy is the treatment of choice in symptomatic polyps of the stomach. From 1974 to 1989, at the Endoscopy Division of National Cancer Institute of Milan, 37 patients underwent endoscopic polypectomy, to remove 55 gastric adenomas. Areas of malignancy were revealed in 3 patients. Two of them, not operable for advanced age and poor general conditions, are controlled endoscopically. Endoscopic polypectomy can be performed on an outpatient basis or with a short period of hospitalization. It represents the only form of therapy in not operable patients. Furthermore this method allows to prevent the malignant transformation of the adenomas, which, as reported in the literature, ranges between 3.4% to 66.5%. Our experience confirms the validity of this technique which is safe and effective.