Conservative management of esophageal leaks by transluminal endoscopic drainage of the mediastinum or pleural space.

BACKGROUND: The management of postoperative leaks into the mediastinum or pleural cavities after esophageal surgery yields unsatisfactory results. A recently described method, drainage of the mediastinum or pleural cavity through suture line defects, has been used in our department with eight patients. METHODS: A suction tube was advanced over an endoscopically placed guide wire into the abscess from inside the esophagus, and gentle aspiration was used to remove saliva and secretions. Intravenous antibiotics and total parenteral nutrition were also given. RESULTS: The sepsis was rapidly controlled, and the abscess cavity progressively collapsed in all cases. Seven patients recovered and were discharged 34 to 61 days after operation; one died of concomitant complications. CONCLUSIONS: This method seems promising for the management of intrathoracic esophageal leaks.

Light-induced fluorescence spectroscopy of adenomas, adenocarcinomas and non-neoplastic mucosa in human colon. I. In vitro measurements.

In an attempt to evaluate whether induced fluorescence could be exploited to discriminate neoplastic from non-neoplastic tissue, fluorescence spectroscopy was performed at 450-800 nm on 83 biopsy specimens of colonic mucosa. Measurements showed that fluorescence spectra of adenoma, adenocarcinoma and non-neoplastic mucosa manifest dissimilar patterns. Nine variables, whose photophysical and/or biological bases need further investigation, were derived from the spectra. Discriminant functions between the groups of lesions were determined by using a stepwise discriminant analysis. The diagnostic test had a sensitivity of 80.6% and 88.2%, and a specificity of 90.5% and 95.2% in discriminating neoplastic from non-neoplastic mucosa and adenoma from non-neoplastic mucosa respectively. These results suggest that fluorescence spectroscopy has the potential to improve endoscopic diagnosis of premalignant and malignant lesions of colonic mucosa.

[Evaluations of 169 cases of decompression sickness treated in Italian hyperbaric centers 1980-1981]. / Alcune valutazioni su 169 casi di malattia da decompressione trattati nei Centri Iperbarici Italiani nel biennio 1980-1981.

An assessment was made of 169 cases of decompression sickness occurring during the period 1980-81. Nearly all (95,6%) were attributable to superficial planning and execution of the immersion and reascent to the surface marker as the result of panic. Breakdown in the diving apparatus was only responsible in 4.4% of cases. Irrispective of the intermediate decompression stages, the rate of reascent was more than 10 metres a minute in 71.6% of cases. Full recovery as a result of hyperbaric management was obtained in 78,2% type I sickness and 61.9% type II, with improvements in 17.3% and 35.1% respectively. The interval between emersion and treatment ranged from 1 to 72 hr, though the results of treatment were not significantly related to the rapidity of intervention (p greater than 0.05). Good results were dependent on the type of treatment employed, with a significantly better outcome (p less than 0.01) from U.S. Navy tables 2-2A, 3-3A, 4, 5 and 6 and the 2 + 6 recompression protocol, than from tables 5A and 6A.

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.

Prevalence and features of peripheral neuropathy in Parkinson's disease patients under different therapeutic regimens.

BACKGROUND: Recent reports suggest increased frequency of peripheral neuropathy (PN) in Parkinson's disease (PD) patients on levodopa compared with age-matched controls particularly during continuous levodopa delivery by intestinal infusion (CLDII). The aim of this study is to compare frequency, clinical features, and outcome of PN in PD patients undergoing different therapeutic regimens. METHODS: Three groups of consecutive PD patients, 50 on intestinal levodopa (CLDII), 50 on oral levodopa (O-LD) and 50 on other dopaminergic treatment (ODT), were enrolled in this study to assess frequency of PN using clinical and neurophysiological parameters. A biochemical study of all PN patients was performed. RESULTS: Frequency of PN of no evident cause was 28% in CLDII, 20% in O-LD, and 6% in ODT patients. Clinically, 71% of CLDII patients and all O-LD and ODT PN patients displayed a subacute sensory PN. In contrast, 29% of CLDII patients presented acute motor PN. Levodopa daily dose, vitamin B12 (VB12) and homocysteine (hcy) levels differed significantly in patients with PN compared to patients without PN. CONCLUSIONS: Our findings support the relationship between levodopa and PN and confirm that an imbalance in VB12/hcy may be a key pathogenic factor. We suggest two different, possibly overlapping mechanisms of PN in patients on CDLII: axonal degeneration due to vitamin deficiency and inflammatory damage. Whether inflammatory damage is triggered by vitamin deficiency and/or by modifications in the intestinal micro-environment should be further explored. Proper vitamin supplementation may prevent peripheral damage in most cases.

Small-cell carcinoma of the esophagus. Treatment by endoscopy.

A case of primary carcinoma of the esophagus is presented that consisted of poorly differentiated small-cell carcinoma. The patient underwent endoscopic treatment, first with an Nd:YAG laser and, finally, with bougienage and the insertion of a prosthesis in order to relieve dysphagia and improve the nutritional status and quality of life. Even though it is generally uncommon for laser therapy to be chosen as a primary mode of treatment, the results obtained should permit to overcome this lack of confidence in the choice of laser treatment for small-cell carcinoma of the esophagus.

Current role of laser and photodynamic therapy in gastrointestinal tumors and analysis of a 10-year experience.

Laser energy can be used for a variety of neoplastic diseases including benign tumors, early stage malignancies, and advanced carcinomas, either with curative intent or for palliation. Nd:YAG laser photocoagulation of 168 colorectal adenomas allowed a complete eradication in 70% of cases, after a mean follow-up of 22 months. Advanced and obstructing tumors were treated with Nd:YAG laser to recanalize the lumen. In the upper gastrointestinal tract the recanalization of the lumen by means of laser photocoagulation improved the quality of life and survival. In fact, in our series of 308 patients treated, 1-year survival was 23% in recanalized patients and 7% in nonrecanalized patients. In the lower gastrointestinal tract, 289 cancer patients were treated and an amelioration of symptoms related to the obstruction was obtained in 93%. The current indication for photodynamic therapy is mainly the treatment of flat or ulcerative early stage tumors in the esophagus and stomach of high risk patients. Out of 17 patients treated, 14 were locally cured.

Self-expanding mesh stent for endoscopic palliation of rectal obstructing tumors: a preliminary report.

The endoscopic insertion of self-expanding mesh stents in four patients affected by obstructing rectal malignant tumors is reported. The preliminary experience shows that, in the short term, normal defecation was achieved, with no complications. Longer follow-up is necessary to evaluate the duration and the quality of the palliative effect.

Endoscopic palliation of malignancies of the upper gastrointestinal tract using Nd:YAG laser: results and survival in 308 treated patients.

Three hundred eight patients with obstructing malignant tumors of the gastrointestinal tract were submitted to endoscopic Nd:YAG laser palliation. The number of sessions as well as the number of days and total energy required for initial recanalization of the stenosis were related to tumor length. Luminal patency was obtained in 94% of patients, but improved swallowing was achieved in 74% of patients. The technical success rate did not depend on tumor site, whereas functional positive results are related to the location of the stenosis, with worst results for tumors involving the upper third of the esophagus. Life-table analysis revealed that 1-year survival was 23% when a luminal patency was achieved and 7% when treatment failed.

Endoscopic treatment of gastrointestinal tumors: indications and results of laser photocoagulation and photodynamic therapy.

Both Nd:YAG laser and photodynamic therapy (PDT) have ideal indications in endoscopic treatment of gastrointestinal (GI) tumors. A retrospective analysis of 3,505 Nd:YAG laser treatments in 1,015 patients revealed that recanalization of inoperable tumors can be obtained in 93% and 97% of patients with upper and lower GI neoplasms, respectively. Subjective improvement of symptoms was achieved in 74% and 97%, respectively. The overall morbidity and mortality rates were 3% and 1%, respectively, for upper GI tumors and 3% and 0.5% for lower GI tumors. Colorectal adenomas were eradicated in 84% of cases, with a morbidity and mortality of 5% and 0%, respectively. Early stage esophageal and gastric carcinomas were treated with Nd:YAG laser when lesions had well-defined borders or protruded over the mucosal surface and with PDT (38 PDT cycles in 27 patients) in the case of undefined borders or ulcerated lesions. The cure rate was 73% for esophageal tumors and 85% for gastric tumors. Sunburns after photosensitization and local complications occurred in 7% and 6% of patients, respectively. No death was related to endoscopic treatment.

The use of videoendoscopy in the study of fluorescence.

Diagnosis of malignancies by means of fluorescence detection is effected, at present, using fiberoptic endoscopes. Difficulties in the detection of fluorescence arise from the low fluorescent efficiency of the most widely used drug (hematoporphyrin derivative), and from the loss of intensity of the signal within the fiberoptic bundles and the ocular lens of the fiberendoscope. The electronic video-endoscope, carrying a microchip camera at its tip, permits a more sensitive detection of fluorescence, since the signal is drawn directly from the cavities. Furthermore the electronic image, stored in a computer, can be manipulated to produce a more enhanced contrast between the fluorescence of normal and malignant tissues. An example of electronic manipulation would be the subtraction of the image obtained under green light excitation from that obtained under violet light excitation.

Rectal metal stents for palliation of colorectal malignant stenosis.

Thirteen patients with colorectal obstructing tumors were submitted to endoscopic insertion of self-expanding metal stents to restore luminal patency. The procedure was performed entirely under endoscopic control, without using fluoroscopy, during a 1-day hospitalization. The prostheses were correctly placed in 12/13 patients (92%), with no immediate complications. The mean follow-up is 7 months. Ten out of 12 patients (83%) had a permanent restoration of the luminal patency; they experienced no pain, tenesmus or any other discomfort during the follow-up period. In the remaining 2 patients long-term complications occurred and were treated by endoscopy in 1 case, and by surgical resection in the 2nd case. Self-expanding metal stents proved to be safe and effective; the main drawbacks, at present, are the lack of effectiveness of these devices in case of a fistula and their high costs.

Ultrasonography versus laparoscopy in the diagnosis of hepatic tumors.

129 patients, with suspected primary or secondary benign or malignant liver neoplasm after clinical, biochemical and/or instrumental investigation underwent liver ultrasound and laparoscopy. Echographic findings were compared with laparoscopy when liver neoplasms were detected by the latter. When laparoscopy was negative, to evaluate the diagnostic accuracy of the two methods employed, the following variously associated parameters were analysed: clinical follow-up, liver biochemistry, computed tomography, liver selective arteriography and explorative laparotomy. In the 129 patients examined, echography showed 86.7% diagnostic accuracy and laparoscopy 89.4%. The association of the two methods led to a diagnosis of hepatic lesion in 98.4% with no further diagnostic investigations. The two procedures can be considered complementary to such an extent that, in case of suspected primary or secondary liver neoplasm, the association of ultrasound and laparoscopy represents a quick and ultimate diagnostic approach. Furthermore, the association of these two procedures seems the least expensive and the most feasible, even in not particularly well equipped units.

Endoscopic treatment of upper gastrointestinal tract malignancies.

Palliative endoscopic treatment of the upper gastro-intestinal (UGI) tract includes: dilation, Nd:YAG laser photocoagulation and intubation, used alone or in combination. These procedures are usually performed on an outpatient basis and are associated with a low rate of morbidity and mortality. From 1978 to 1992, 836 patients were treated at the Endoscopy Division of the Istituto Nazionale Tumori, Milan, for inoperable primary or recurrent malignancies of the UGI-tract. Recanalization was obtained in 96% of patients treated; functional results have been computed according to the site and to the endoscopic method. Overall median survival was 6.2 months. The complication rate was 8%. Relief of dysphagia is the goal of palliative treatment in patients with inoperable neoplasms of the UGI-tract.

Ex vivo optical properties of human colon tissue.

Using a spectrophotometer equipped with an internal integrating sphere, the absorption (mu a) and the reduced scattering (microseconds') coefficients of ex vivo human colon tissues were evaluated from reflectance and transmittance measurements. Mu a and microseconds' varied from 47.7 to 1.0 cm-1 and from 14.2 to 6.2 cm-1, respectively, on passing from 300 nm to 800 nm. These results can be used to estimate the optical penetration depths when photodynamic therapy or light-induced fluorescence procedures are used.