Benign complications of expandable metal stents used in the palliation of oesophageal carcinoma: two case reports.

We describe two patients who were treated with self-expanding metal stent (SEMS) insertion as palliation of malignant oesophageal strictures. Both patients re-presented with dysphagia several months after SEMS insertion due to benign strictures. Initial treatment with balloon dilation and medical management had limited success so both patients had further SEMS inserted across the secondary benign strictures. This provided very good symptomatic relief. Chemotherapy and chemo-radiation in patients with inoperable oesophageal carcinoma are prolonging patient survival. As patients survival lengthens benign complications of SEMS may become an increasing clinical problem.

Risk-adjusted prediction of operative mortality in oesophagogastric surgery with O-POSSUM.

INTRODUCTION: The present study was designed to develop a dedicated oesophagogastric model for the prediction of risk-adjusted postoperative mortality in upper gastrointestinal surgery (O-POSSUM). METHODS: Using 1042 patients undergoing oesophageal (n = 538) or gastric (n = 504) surgery between 1994 and 2000 the Portsmouth predictor equation for mortality (P-POSSUM) scoring system was compared with a standard logistic regression O-POSSUM model and a multilevel O-POSSUM model using the following independent factors: age, physiological status, mode of surgery, type of surgery and histological stage. RESULTS: The overall mortality rate was 12.0 per cent (elective mortality rate 9.4 per cent and emergency mortality rate 26.9 per cent). P-POSSUM overpredicted mortality (14.5 per cent), particularly in the elective group of patients. The multilevel model offered higher discrimination than the single-level O-POSSUM and P-POSSUM models (area under receiver-operator characteristic curve 79.7 versus 74.6 and 74.3 per cent). When observed to expected outcomes were evaluated, the multilevel O-POSSUM model was found to offer better calibration (Hosmer-Lemeshow chi(2) statistic 10.15 versus 10.52 and 28.80). CONCLUSION: The multilevel O-POSSUM model provided an accurate risk-adjusted prediction of death from oesophageal and gastric surgery for individual patients. In conjunction with a multidisciplinary approach to patient management, the model may be used in everyday practice for perioperative counselling of patients and their carers.

Chest pain following oesophageal stenting for malignant dysphagia.

AIM: The palliative use of self-expanding metallic stents has been widely reported to relieve dysphagia in cases of oesophageal carcinoma. Little has been documented on the severity of chest pain following oesophageal stenting. The aim of this study was to investigate the association of pain with oesophageal stenting for malignant dysphagia. METHODS: Fifty-two patients with inoperable oesophageal carcinoma underwent stent placement between 1995-1999. Daily opioid analgesic requirements (mg of morphine equivalent doses) were monitored for 3 days before and 7 days after stenting. The degree of palliation was expressed as a dysphagia score (0-3). Hospital stay, readmission days, stent complications and patient survival time were also recorded. RESULTS: Twenty-six patients (50%) required opioid analgesia for chest pain (median dose: 80 mg morphine/day) within 48 h of the procedure compared to 11 (21.2%) patients before stenting (P = 0.0041). A significant increase was evident in the analgesic consumption following stent deployment (P < 0.001). The dysphagia score improved by a median value of 1 (CI 0.25)P < 0.001, with a re-intervention rate of 11.5%. The median survival time was 40 days post stenting (range 1-120). CONCLUSION: A significant proportion of patients developed chest pain after oesophageal stenting, requiring high dose opioid analgesia. As the origin of the pain is still unknown, pre-emptive analgesia may a play role in reducing stent-related morbidity and possibly in-hospital stay.

Laparoscopic cholecystectomy injury: an unusual indication for liver transplantation.

The introduction of laparoscopic cholecystectomy has been associated with a rise in the number of reported bile duct injuries (0.3%-0.8%). Significant vascular injuries are rare (0.16%), but may lead to life-threatening complications. We present a case report of a patient undergoing transplantation for a laparoscopic cholecystectomy injury.

Does pre-scan oxygen improve ultrasonic imaging of the pancreas?

Ultrasonic imaging of the pancreas is often impaired by overlying bowel gas. Oxygen therapy has, in the past, been shown to be effective in reducing the gas in the cysts of pneumatosis coli. Using the same hypothesis, a randomized, single blind study comparing ultrasonic imaging of the pancreas with and without prior oxygen therapy was carried out. Fifty-eight consecutive patients with acute abdominal complaints were randomized to two groups: Group 1, control - no oxygen (n = 30, 14 male, 16 female, mean age 61.9 +/- 17.8 years); Group 2, treatment (n = 28, 14 male, 14 female, mean age 61.4 +/- 14.5 years) received oxygen therapy (100% humidified at 101/min for 8-10 h prior to the ultrasound). Pancreatic visualization was graded good, moderate or poor. Mean paO2 in Group 1 was 10.9 +/- 1kP and in Group 2 was 36 +/- 10.5kP (P < 0.001 unpaired t-test). Pancreatic visualization was: GOOD-Group 1, 8; Group 2, 19; MODERATE - Group 1, 8; Group 2, 4; POOR - Group 1, 14; Group 2, 5. Oxygen therapy is a safe, cheap, non-invasive method of improving pancreatic visualization and may act by reducing overlying bowel gas.

Hepatic metastases: interstitial laser photocoagulation with real-time US monitoring and dynamic CT evaluation of treatment.

Fifty-five liver metastases in 21 patients were treated with interstitial laser photocoagulation (ILP). Tumors were irradiated with a neodymium yttrium aluminum garnet laser via optical fibers passed through 19-gauge needles inserted under ultrasound (US) guidance. Heating of the tumor was evident at real-time US as an expanding and coalescing echogenic zone around the needle tips. After ILP, dynamic computed tomography (CT) showed laser-induced necrosis as a new area of nonenhancement. Necrosis of tumor volume was more than 50% in 82% (45 of 55) of the tumors, and 100% necrosis was achieved in 38% (21 of 55). Metastases smaller than 4 cm in diameter were treated more effectively and required fewer treatment sessions than did those larger than 4 cm. Complications were minor and included severe pain in four cases, persistent pain for up to 10 days in 11 cases, and asymptomatic subcapsular hematoma (four cases) and pleural effusion (six cases) seen with CT. ILP is safe and effective for liver tumor destruction, and US and CT are useful in different aspects of treatment monitoring.

Interstitial laser coagulation of the prostate. An experimental study.

We describe a percutaneous, low power, interstitial method of controlled coagulation of prostatic tissue by laser light which may prove an alternative or adjunct to existing therapy for benign and malignant prostatic disease. One or more 200-600 micron diameter fibres were implanted within the substance of the elderly male beagle prostate (n = 11) through which Neodymium-Yttrium Aluminium Garnet (Nd-YAG) laser energy could be transmitted. Using longer exposures (400-1500s) and lower powers (1-2W) than used in routine endoscopic laser therapy, well defined areas of coagulative necrosis could be created with little tissue charring or damage to the fibre. For an energy dose of 1000J a lesion approximately 1 cm in diameter resulted at 4 days. Ultrasound scanning methods could detect the fibre(s), the area(s) of coagulation and the healed lesions. Treatments were well tolerated. At 6 weeks the treated areas of canine prostate healed by fibrosis surrounding an area of cystic degeneration. Multiple fibre experiments produced larger volume lesions relevant to more extensive cancer or to the coagulation of benign adenomatous hyperplasia causing outflow symptoms. This technique may prove of value for the treatment of moderate benign enlargement of the prostate and for the destruction of small, focal prostatic tumours.

Interstitial laser hyperthermia: a new approach for treating liver metastases.

The palliative management of hepatic metastases remains unsatisfactory. There is a need for a simple non invasive technique which can stop or retard the rate of tumour growth. In principle, Interstitial Laser hyperthermia may fulfil such a role. In experimental studies, this technique produced precise in situ necrosis within solid organs which healed safely. In a pilot feasibility study, we treated ten patients with a total of 18 hepatic metastases on 31 occasions using a percutaneous approach to achieve an overall objective response rate of 44%. The treatment proved simple to perform, was well tolerated and produced radiological evidence of necrosis in small metastases (diameter less than or equal to 3 cm). However, further research is required before the technique can be regarded as established. Its future role in most cases will be to control the growth of discrete hepatic metastases unsuitable for resection. In instances where the extent of necrosis can be matched accurately to tumour volume, the potential for cure exists.

Ultrasound features of low power interstitial laser hyperthermia.

Low power interstitial laser hyperthermia (ILH) is a reliable means of producing in situ thermal necrosis. Ultrasonic studies have been carried out of the changes that occur in canine liver during ILH performed at laparotomy. With a single fibre delivering Nd-YAG laser at 1-1.5 W for 670 s an hyperechoic region developed at the fibre tip measuring 5-6 mm in diameter; around this developed an area of hypoechoic change (up to 500s) giving a total area of changed echogenicity of 14-16 mm. With a multiple fibre system using 4 laser fibres simultaneously the sonographic changes were a summation of the changes seen with a single fibre, the hypoechoic areas overlapping. With this four fibre system the creation of large (3.5 x 2.8 cm) areas of thermal necrosis was possible. There was good correlation between the sonographic and pathological measurements of the region of thermal change. The sonographic studies showed the extension and overlap of regions of thermal necrosis and allowed visualization and accurate measurement of the area undergoing change. The same combined technique has been successfully applied in a small number of clinical cases and may be of use in the treatment of tumours in solid organs.

Multiple-fibre low-power interstitial laser hyperthermia: studies in the normal liver.

Multiple four-fibre low-power interstitial laser hyperthermia was performed in the canine liver to establish the parameters with which large areas of thermal necrosis could be made. Using 1.5 W for 670 s (4020 J in total) and a fibre spacing of 1.5 cm, lesions with dimensions of 3.6 x 3.1 x 2.8 cm were achieved in 75 per cent of those attempted. There was no mortality and a low morbidity rate. These lesions could be visualized in both their development and resolution using ultrasonography. Healing occurred by 1 year. Temperatures in the centre of the heated region were 60 degrees C, which is more than enough to cause thermal cell death. There was good correlation between the temperatures recorded, the sonographic changes seen, and the pathological evidence of necrosis. Multiple-fibre low-power interstitial laser hyperthermia performed with ultrasonic guidance may be of use in the treatment of liver tumours.

Role of interstitial therapy in the treatment of liver cancer.

Conventional palliative management of inoperable focal hepatic tumours remains unsatisfactory. Interstitial techniques such as cryotherapy, alcohol injection, low power laser hyperthermia and interstitial radiotherapy offer alternative approaches. Cryotherapy is an effective and precise technique for inducing tumour necrosis. It can only be performed at laparotomy making it relatively invasive and retreatment impractical. Alcohol is cheap and can be injected percutaneously. However, inhomogeneous distribution produces imprecise and nonreproducible lesions. Low power laser hyperthermia produces precise and reproducible areas of necrosis that are roughly spherical in shape. At present, this technique is most effective for small tumours. Interstitial radiotherapy remains the least evaluated of all the interstitial techniques. Unlike cryotherapy and low power laser hyperthermia, the biological effect of ethanol injection and interstitial radiotherapy cannot be monitored in real time by ultrasound. With the exception of cryotherapy, all methods can be applied percutaneously with low morbidity and mortality. None of these techniques is established, but they may offer the prospect of cure in cases where all areas of tumour can be positively identified and fully treated. However, in most instances the intention is to control the growth of relatively small discrete volumes of tumour within the hepatic parenchyma.

The influence of immunosuppression on peptic ulceration following renal transplantation and the role of endoscopy.

Peptic ulceration is common in patients undergoing renal transplantation. With a change in routine immunosuppression from azathioprine and steroids to cyclosporin, or cyclosporin and low-dose steroids and azathioprine, less peptic ulceration might be expected. This was investigated in two groups of patients undergoing renal transplantation. Group 1 (n = 90) received azathioprine and prednisolone; Group 2 (n = 44) received cyclosporin and low-dose azathioprine and prednisolone. Patients from both groups were endoscoped 7-14 days after operation, when peptic ulceration, oesophagitis, gastritis, and duodenitis were assessed. Whilst Group 2 differed significantly in receiving more methylprednisolone than Group 1 (P less than 0.05), there was no difference between the two groups with regard to the incidence of peptic ulceration or inflammatory lesions. In both groups there was a trend for those treated with methylprednisolone for rejection to develop ulcers or inflammatory lesions when a total dose of more than 2 g had been given by the time of endoscopy. Any possible reduction in the incidence of peptic ulceration after transplantation is outweighed by the continued use of high-dose methylprednisolone to treat episodes of rejection. The true incidence of peptic ulceration after transplantation is much higher than if presenting symptoms alone are the starting point for investigation. Regular post-transplantation endoscopy allows prompt diagnosis and treatment, with attainment of a very low mortality rate (0.75% overall, or 4% in those with peptic ulcers) from peptic ulceration in patients undergoing renal transplantation.

Interstitial laser hyperthermia: a new approach to local destruction of tumours.

The use of local hyperthermia to treat cancer of the internal organs has been limited by the difficulty of controlling delivery of heat and limiting the effects to the tumour, but this can be overcome by using laser light transmitted through thin flexible fibres. Laser energy was delivered to tumours through fibres inserted percutaneously through needles directly into the centre of the tumour area. Ultrasound scanning was used to locate the tumour, position the fibres correctly within the tumour, and monitor the development of thermal necrosis in real time during laser exposure and through the subsequent period of healing. Five patients were treated (one with a tumour of the breast, one with a subcutaneous secondary tumour, one with a recurrent pancreatic tumour, and two with secondary tumours in the liver). Tumour necrosis was found on ultrasonography or computed tomography in all, and there were no immediate or delayed complications. In one patient the size of the isolated secondary tumour in the liver had not increased over 10 months, and he subsequently showed no other evidence of residual cancer. To develop this technique careful studies are essential to ensure that in every case the extent of thermal necrosis produced by absorption of the laser light can be matched to the full extent of the tumour being treated and that there is always sufficient adjacent normal tissue to ensure safe healing. These preliminary results suggest that this simple technique can be applied safely and effectively to common tumours in humans; more extensive trials in a range of cancers of solid organs are warranted.

Contact laser or conventional cholecystectomy: a controlled trial.

There have been claims that the use of lasers in surgery is associated with reduced operative blood loss, trauma, postoperative pain and improved postoperative mobility. With the development of sapphire probes capable of transmitting neodymium yttrium aluminium garnet (Nd: YAG) laser light, it is now feasible to perform direct-contact low-power laser surgery. In a small randomized controlled trial, we have compared cholecystectomy performed by conventional methods (n = 11) with the same operation performed by contact laser (n = 10). Operative time, blood loss, operative stability, analgesic requirement, mobility and response to the trauma of surgery were compared. The only differences between the two groups were a significantly increased wound infection rate (P = 0.051) in the laser surgery group and a significantly increased length of operating time (P = 0.001). Thus, the laser did not confer any advantage over conventional surgery.

Gastrointestinal haemorrhage from a second source in patients with colonic angiodysplasia.

Angiodysplasia of the colon is increasingly recognized as a cause of obscure gastrointestinal haemorrhage. On review of 71 patients with angiodysplasia, 40 came to surgery. Of these, nine (22.5 per cent) were also found to have small bowel lesions, either at the original laparotomy (7) or later when further investigations were performed for recurrent bleeding. Angiodysplasia can only be confidently diagnosed as the source of blood loss if seen to be actively bleeding. If a synchronous small bowel lesion is seen, we recommend that it should be removed at the same time as the colectomy.

The palliative endoscopic treatment of inoperable oesophagogastric and rectal cancers: a low power direct contact laser technique.

The palliative treatment of inoperable cancers of the oesophagus, gastric fundus and rectum can be difficult and unsuccessful. Laser beam irradiation therapy offers good palliation in the majority of patients but requires several treatment sessions to achieve this. We describe a small series of patients treated with a new direct contact low power laser technique using artificial sapphire probes. After one treatment, in patients with malignant dysphagia, two thirds could swallow solids and in patients with rectal cancers bleeding was stopped or reduced and diarrhoea stopped. The interval before a second treatment was needed was three and a half weeks. We feel this technique is a useful adjuvant to conventional laser therapy of inoperable gastrointestinal tract tumours, especially in providing effective palliation in one treatment session.