Endosonography is superior to angiography in the preoperative assessment of vascular involvement among patients with pancreatic carcinoma.

Surgical exploration in patients with pancreatic carcinoma without adequate preoperative attempts to determine resectability results in resection in only a minority of patients. Besides distant metastases, involvement of the major vessels is the most important parameter for determining resectability in patients with pancreatic adenocarcinoma. Angiography has been an integral part of pancreatic cancer staging. Lately, endoscopic ultrasound (EUS) has emerged as a more accurate tool in the diagnosis and staging of pancreatic cancer. We hypothesize that EUS is more accurate than selective venous angiography (SVA) for assessing resectability of pancreatic adenocarcinoma based on preoperative evaluation of vascular involvement. Twenty-one patients who met the inclusion criteria were prospectively evaluated with both EUS and SVA before undergoing surgical exploration for attempted curative resection. Vascular involvement was determined by EUS and SVA using previously described criteria. The sensitivity, specificity, and overall accuracy of EUS and SVA in assessing vascular involvement were compared, using surgical exploration as the gold standard. Endoscopic ultrasound had a higher sensitivity than SVA for detecting vascular involvement (86% vs. 21%, respectively; p = 0.0018). The specificity and accuracy of EUS for detecting vascular involvement was 71% and 81%, respectively. In contrast, the specificity and accuracy of SVA for detecting vascular involvement was 71% and 38%, respectively. Endoscopic ultrasound is significantly more sensitive than angiography for detecting vascu lar involvement in patients with pancreatic adenocarcinoma and, thus, may improve patient selection for attempted curative resection.

The difficult-to-place feeding tube: successful endoscopic placement using a mucosal clip.

BACKGROUND: Delivery of enteral feeding beyond the ligament of Treitz is often desirable, as it diminishes enterogastric reflux and potential for pulmonary aspiration of enteral feeding solution. However, standard or fluoroscopically guided techniques often fail. We describe three such cases in which enteral feeding tube placement was achieved endoscopically and secured using an endoscopic clip-fixing device. METHODS: A standard feeding tube attached to a mucosal clip by a silk suture was advanced endoscopically into the small intestine. Using a through-the-endoscope clip-fixing device, the tube was attached to the bowel wall. RESULTS: Three patients underwent the above procedure: a postgastrectomy patient with a functionally obstructed jejunal pouch and a previously failed fluoroscopically guided placement had a nasojejunal feeding tube successfully placed beyond the obstruction: a cancer patient with duodenal obstruction due to SMA syndrome, a surgical gastrostomy, and a previously failed fluoroscopic attempt had a dual lumen pergastrostomy feeding tube placed beyond the obstruction; and a patient with a refractory benign esophageal stricture underwent esophageal dilation followed by successful feeding tube placement into the proximal jejunum. In all patients, the tube functioned well without subsequent occlusion or dislodgement. CONCLUSIONS: Endoscopic placement of feeding tubes using a clip-fixing device is a useful technique in patients with normal and abnormal anatomy in whom reliable delivery of enteral feeding beyond the ligament of Treitz is desired.

The diagnosis and management of gastroesophageal reflux disease.

GERD is a common clinical problem. Generally, its clinical presentation and management are straightforward. Greater awareness of the numerous extraesophageal manifestations of the disease aids patients and physicians in appropriate recognition and treatment. Medical therapy is effective in the majority of cases but often requires long-term medication for acceptable symptom control. A small, but significant proportion of patients presents with or develops complications of GERD, most importantly Barrett's esophagus. Although the logistics of long-term surveillance of persons with Barrett's esophagus is unclear, the association of this metaplastic change with esophageal adenocarcinoma underscores the importance of regular follow-up.

Transjugular insertion of biliary stents (TIBS) in two patients with malignant obstruction, ascites, and coagulopathy.

Two patients with pancreatic malignancies presented with biliary obstruction which could not be treated from an endoscopic approach. Standard transhepatic biliary drainage was relatively contraindicated because of moderate ascites and coagulopathy related to underlying liver disease. In one patient, a transjugular, transvenous approach was used to deliver a Wallstent endoprosthesis across the distal common bile duct obstruction in a single step procedure. In the second case, a previously placed biliary Wallstent was revised with an additional stent from a similar approach. Transjugular biliary catheterization offers a valuable alternative approach for primary stent placement or revision in patients with contraindication to standard transhepatic drainage.

Endoscopic diagnosis and management of gastrointestinal malignancy.

The endoscopic diagnosis, staging, and therapy of gastrointestinal (GI) malignancies has advanced rapidly and dramatically over the past 15 years. Video-endoscopy has generally replaced fiberoptic endoscopy, and the digitally based fidelity, sharper resolution, and improved magnification of the video-endoscopic image offers a potentially better approach for the evaluation of mucosal abnormalities. Endoscopic diagnosis of GI malignancies has been enhanced by the recent development of selective vital staining techniques of mucosal abnormalities and more sensitive and aggressive biopsy techniques. The recent dissemination of endoscopic ultrasound has propelled preoperative TNM staging into a new realm of accuracy and has afforded additional potential for directed biopsy techniques. Therapy of GI malignancies has advanced through the development of thermal and nonthermal laser technology, tumor probes, expandable stents, and endoscopic resection techniques.

Preirradiation chemotherapy of supratentorial malignant primary brain tumors with intracarotid cis-platinum (CDDP) and i.v. BCNU. A phase II trial.

Thirty patients with histologically verified malignant supratentorial gliomas were treated with a preirradiation chemotherapy protocol consisting of two courses of intracarotid (i.c.) CDDP, 90 mg/m2, followed by i.v. BCNU, 200 mg/m2. Side effects from therapy were mild and self-limiting; no irreversible retinal or neurologic toxicity could be attributed to i.c. chemotherapy. Of the 27 patients who completed the chemotherapy portion of the protocol, tumor size on postchemotherapy computed tomography (CT) was decreased by greater than 50% in 13% as compared to the postoperative CT scan; in only 4% was the CT scan unequivocally increased in size. Twenty-five (83%) patients completed the entire protocol. Median time to tumor progression and survival in patients who completed the protocol was 53 (range of 13-130+) and 61 (range of 29-130+) weeks, respectively. Twenty-four percent of patients still have not demonstrated tumor progression at intervals greater than 1 year after diagnosis as judged by clinical and radiographic criteria. Tumor recurrences were always contiguous to the original tumor bed. We conclude that preirradiation chemotherapy may be administered safely and with low morbidity. Further study to determine an optimal timing between chemotherapy and radiation therapy is warranted.

Anticoagulation in patients with valvular heart disease, atrial fibrillation, or both.

Despite the availability of anticoagulant drugs for many years, there are still controversies regarding their use in many cardiovascular conditions. In this article, the pharmacology of warfarin and heparin are reviewed, and the clinical applications of these therapies in patients with valvular heart disease, atrial fibrillation, or both, discussed.

Intracavitary irradiation of renal pyelocalyceal transitional cell carcinoma with iridium-192.

A case of multicentric urothelial transitional cell carcinoma is presented, in which the patient underwent a left ureteronephrectomy and in the remaining right kidney recurrent transitional cell carcinoma was found in the inferior calyx. Because this area was accessible via a cutaneous nephrostomy, it is treated with a combination of external beam radiation and intracavitary implantation with iridium-192. The iridium was placed in the vicinity of the tumor using an angiographic procedure. The technique successfully preserved remaining renal parenchyma. The case illustrates how angiography skills and procedures can be applied in a novel brachytherapy application.

Dentures as artificial saliva reservoirs in the irradiated edentulous cancer patient with xerostomia: a pilot study.

Dentures which included a reservoir for dispensing artificial saliva were constructed for a trial group of patients with oropharyngeal cancer seen in the postirradiation period. The tumors were apparently under control, but the patients were suffering from xerostomia. Details of the design, construction, and use of such a device are presented. The subject of postirradiation xerostomia in the edentulous patients is reviewed, and recommendations for reducing the incidence and severity of this condition are given. The prosthesis contributed to successful oral rehabilitation of half the trial group of patients with postirradiation xerostomia.

A simple system for detecting patient movement during radiation therapy.

The authors described a system which detects patient movement while that patient is undergoing radiation treatment. The system consists of simple and inexpensive electronic circuitry using the laser localization lights commonly used with an isocentric linear accelerator. If the patient moves, a visual or audible signal alerts the radiation-therapy technologist who can interrupt treatment and reposition the patient. The verification of proper patient position using this technique compares favorably with the routine use of cerification radiographs.

The vacuum cassette for improved linear accelerator portal films.

The use of a commercially available vacuum cassette with lead screens for linear accelerator portal films is described. The vacuum cassette technique provides improved quality with no increase in patient discomfort or cost and avoids gemoetric distortion, compared to other currently available methods.

A device for insuring the congruency of opposed irregularly blocked fields.

A device for insuring the congruency of opposed irregularly blocked fields has been developed which permits the treatment of both fields of a parallel opposed pair without the realignment of any field-shaping standard non-divergent blocks. The device is an adaptor which attaches directly to the shadow tray or wedge holder and provides 2 channels for 1 Lucite shadow tray. A mirrow-image field is obtained without disturbing the position of the blocking array. Set-up times are decreased.