Endoscopic management of advanced oesophageal cancer

Effective palliation of dysphagia is the goal in the majority of patients with oesophageal cancer. A number of methods have been developed to achieve this objective. The choice of method is determined mainly by the physical characteristics of the tumour causing the dysphagia. The low complication rate, ease of insertion as a result of small delivery systems, and the large stent diameters which are achieved with self-expanding metal stents, have made these an increasingly popular alternative compared to other methods.     

Results of irradiation treatment in patients with non-resectable oesophageal cancer

Forty-eight patients with non-resectable cancer of the oesophagus and oesophagogastric junction (Group A: Stage I/II, 32; Group B: Stage III/IV, 16) underwent intraluminal Iridium-192 high dose-rate afterloading therapy (5-7 Gy/session, total dose: 5-21 Gy, mean: 12.4 Gy) and external beam irradiation (Karnofsky > or = 80% 50-60 Gy/2 Gy per day; Karnofsky 60-79%: 30 Gy/3 Gy per day). Durable satisfactory palliation (intake of at least semi-solid food) was demonstrated in 96% of patients. The mean survival for group A was 19.1 months and that for group B, 6.9 months, with a 12-month survival rate of 66% (group A) and 0% (group B) (P < 0.001). Local tumour response and complication rate were significantly dose-related with a predicted response rate of 70.5%, and a complication rate of 50% at ERD 129.3 Gy.     

Laparoscopic Heller cardiomyotomy with intraoperative manometry in the management of oesophageal achalasia

Results of an ongoing clinical study treating achalasia patients with laparoscopic Heller myotomy and Dor anterior fundoplication are presented. 18 patients underwent surgery between August 1991 and July 1995. Completeness of myotomies and calibration of fundoplications were measured using intraoperative manometry. Only one intraoperative complication, a perforation of the mucosa sutured laparoscopically, was encountered. There were no surgical mortalities nor postoperative morbidities. Mean hospital stay was 3.4 days. Complete relief of dysphagia and modifications of radiological and manometric patterns were achieved in all patients. All patients remain asymptomatic at 2 to 48 months from surgery. These results compare favourably with those of traditional surgery and of pneumatic dilatation.     

Relationship between preoperative assessment of organ function and postoperative morbidity in patients with oesophageal cancer

Pre-eclampsia is a hypertensive disorder of human pregnancy that is a leading cause of premature delivery and fetal growth retardation. It is characterized by hypertension, reduced uteroplacental blood flow, proteinuria and oedema. Pre-eclampsia is associated with increased lipid peroxidation in the maternal circulation and in the placenta. Mitochondria are sources of oxygen radicals and are enriched with polyunsaturated fatty acids that are susceptible to peroxidation. Therefore, the mitochondria could be an important source of oxidative stress and lipid peroxidation. To study this, the level of lipid peroxidation in the mitochondrial fraction of placentae obtained from normally pregnant women (n=8) and women with pre-eclampsia (n=8) was examined. Placental tissues were homogenized and the mitochondrial fraction was isolated by ultracentrifugation. Mitochondrial lipid peroxides were estimated by malondialdehyde (MDA). NADPH and Fe++ were used to stimulate lipid peroxidation. Superoxide dismutase (SOD) was used to inhibit superoxide radicals and mannitol to inhibit hydroxyl radicals. The following results were found: (1) MDA levels were significantly greater in the mitochondrial fraction isolated from pre-eclamptic placentae than from normal placentae (27.4+/-3.0 versus 17.0+/-1.8 nmol/g tissue, mean+/-s.e., P<0.05); (2) the oxidative potential of the pre-eclamptic mitochondrial fraction was also higher than normal as evidenced by the significantly greater stimulation of lipid peroxidation by NADPH and Fe+ + (248+/-25 versus 164+/-35 nmol/g, P<0.05); (3) superoxide dismutase, but not mannitol, attenuated the lipid peroxidation induced by NADPH and Fe+ + demonstrating that superoxide is the radical responsible for mitochondrial lipid peroxidation in this system; and (4) the amount of mitochondrial protein was 47 per cent greater and the activity of the mitochondrial enzyme, citrate synthase, was 56 per cent greater in the pre-eclamptic placentae indicating an increase in the amount of mitochondria in the pre-eclamptic placentae. It is concluded that: (1) mitochondrial lipid peroxidation is increased in pre-eclampsia; (2) the amount of placental mitochondria is increased in pre-eclampsia; (3) placental mitochondria contribute to the abnormal increase in lipid peroxidation that occurs in pre-eclamptic placentae by both an increase in their amount and an increase in their susceptibility to oxidation; and (4) mitochondrial generation of superoxide could be an important source of oxidative stress in pre-eclampsia.     

The management of diabetes in patients with advanced cancer

Although a form of eating disorders had been described by Kampo (Chinese traditional medicine) physicians during the last quarter of the 18th century, the modern study on eating disorders in Japan dates from the end of the 1950s. With the rapid increase in the number of cases, research activities have become very active recently. Both the past and present status of eating disorders and of research activities relating to them in Japan are not well known in other countries. This study concentrates on a review of the literature, with a focus on prevalence, etiology, and symptoms.     

Detection of response to chemotherapy using positron emission tomography in patients with oesophageal and gastric cancer

BACKGROUND: The aim of the study was to determine whether 2-[18F]-fluoro-2-deoxy-D-glucose (FDG)-positron emission tomography (PET) could detect response to chemotherapy in patients with oesophageal and gastric cancer. METHODS: Fourteen patients underwent imaging before and after chemotherapy using FDG-PET. Computed tomography (CT), dysphagia scores and weight changes were used for comparison of evidence of response. Tumour to liver ratios (TLRs) and influx constants for FDG (K) were used for quantification purposes. RESULTS: Thirteen of 14 lesions were successfully imaged before therapy. Changes were seen in all follow-up scans, ranging from a complete response to a 15 per cent increase in tumour FDG uptake. Response was demonstrated by CT in four patients; all four had large reductions in FDG uptake after chemotherapy. Two patients with an increase in FDG uptake reported no improvement in dysphagia and continued to lose weight during therapy. CONCLUSION: Changes in tumour FDG uptake were seen in all tumours after chemotherapy. FDG-PET may have a role to play in the assessment of patients with upper gastrointestinal malignancy receiving chemotherapy.     

Selective approach to the treatment of oesophageal cancer

Between September 1985 and December 1994, 322 patients with oesophageal cancer were treated. Of the 190 patients who underwent operation, 173 had an oesophageal resection; in 124 this was performed as an abdominothoracic resection and in 49 by the transhiatal approach. The assessment of radicality after histological examination revealed a curative (R0) resection in 121 patients (70 per cent) and a palliative (R1-R2) resection in 52 (30 per cent). Prognosis was correlated with the extent of mediastinal lymph node dissection. In 77 patients with stage pT1-3 pN0-1 pM0 the 5-year survival rate was 40 per cent after abdominothoracic resection with two-field lymph node dissection and zero after transhiatal resection (P = 0.01). The authors propose a differentiated surgical approach involving abdominothoracic resection with two-field lymph node dissection for patients with limited tumours (pT1-3 pN0-1 M0) if the operative risk is tolerable. Transhiatal resection appears to be effective only in patients with early tumours (Union Internacional Contra la Cancrum stage 0).     

TP53 and oesophageal cancer

Mutations of the tumor suppressor gene TP53 have been detected in tumor tissues of a large variety of human malignancies and contribute to the development, progression and probably the prognosis of the disease. The pattern of somatic mutations in the TP53 gene in human tumors most often consists of a point mutation in one allele accompanied by loss or rearrangement of the second allele. Esophageal cancer is one of the most commonly mutated cancer, p53 mutations having an incidence greater than 80% in squamous cell carcinoma. The profile of distribution of these mutations in the TP53 gene is of interest to establish correlation between the exposure to carcinogens responsible for DNA mutations. The other form of esophageal cancer, Barrett's esophageal is a good model to study the role of TP53 in mammalian tumorigenesis.     

Cost-effectiveness of therapies for patients with nonvalvular atrial fibrillation

BACKGROUND: The most appropriate treatment(s) for patients with atrial fibrillation remains uncertain. OBJECTIVE: To examine the cost-effectiveness of anti-thrombotic and antiarrhythmic treatment strategies for atrial fibrillation. METHODS: We performed decision and cost-effectiveness analyses using a Markov state transition model. We gathered data from the English-language literature using MEDLINE searches and bibliographies from selected articles. We obtained financial data from nationwide physician-fee references, a medical center's cost accounting system, and one of New England's larger managed care organizations. We examined strategies that included combinations of cardioversion, antiarrhythmic therapy with quinidine, sotalol hydrochloride, or amiodarone, and anticoagulant or antiplatelet therapy. RESULTS: For a 65-year-old man with nonvalvular atrial fibrillation, any intervention results in a significant gain in quality-adjusted life years (QALYs) compared with no specific therapy. Use of aspirin results in the largest incremental gain (1.2 QALYs). Cardioversion followed by the use of amiodarone and warfarin together is the most effective strategy, yielding a gain of 2.3 QALYs compared with no specific therapy. The marginal cost-effectiveness ratios of cardioversion followed by aspirin, with or without amiodarone, are $33800 per QALY and $10800 per QALY, respectively. Cardioversion followed by amiodarone and warfarin has a marginal cost-effectiveness ratio of $92400 per QALY compared with amiodarone and aspirin. Strategies that include cardioversion followed by either quinidine or sotalol are both more expensive and less effective than competing strategies. CONCLUSIONS: Cardioversion of patients with nonvalvular atrial fibrillation followed by the use of aspirin alone or with amiodarone has a reasonable marginal cost-effectiveness ratio. While cardioversion followed by the use of amiodarone and warfarin results in the greatest gain in quality-adjusted life expectancy, it is expensive (ie, has a high marginal cost-effectiveness ratio) compared with aspirin and amiodarone. Finally, for patients who are bothered little by symptoms of atrial fibrillation, cardioversion followed by either aspirin or warfarin without subsequent antiarrhythmic therapy is the treatment of choice.     

Improvement of swallowing ability in advanced oesophageal cancer

Without different types of palliation the patients with inoperable oesophageal cancer have a poor quality of life, rapid weight loss which leads to death. The aim of palliation is the complete relief of dysphagia. Our modified procedure is a simplified way of a well known method described by Tytgat in 1986. The prosthesis is positioned under continuous visual control using only local anaesthesia. This method is safe and not expensive. During the last three years 73 consecutive patients were treated with palliative fiberoscopic intubation with Tygon prosthesis. 46 patients had esophageal carcinoma, 19 had gastric, 8 had pulmonary carcinoma obstructing the gullet. Among them 11 patients had bronchoesophageal fistula. The early complications were perforations (7) bleeding (2), and later complications: food impaction (5) tumor overgrowth (5) and tube migration (2). The mortality was 2%. All patients have received antibiotic prevention. Although the improvement of life quality is more important than extension of life, for many patients survival will be prolonged due to improved nutrition as a result of treatment. This study summaries our experience with this technique and analyzes the problems and complications encountered in our patients.     

Predictive value of symptom profiles in patients with suspected oesophageal dysmotility

The main aim of the study was to determine prospectively, in patients referred for oesophageal manometry, whether certain combinations of oesophageal symptoms are more likely than others to predict the presence of oesophageal dysmotility or a positive response to acid perfusion testing. In 524 consecutive patients, presenting predominantly with (non-cardiac) chest pain (n = 277), dysphagia (n = 186), or heartburn (n = 61), a standardized symptom assessment was completed before oesophageal manometry and acid perfusion testing. Half the patients in each group reported additional ('secondary') oesophageal symptoms as well as the predominant symptom. Oesophageal dysmotility was categorized in accordance with standard manometric criteria for achalasia, diffuse oesophageal spasm, nutcracker oesophagus, hypertensive lower oesophageal sphincter, or non-specific oesophageal motility disorder. In the predominant chest pain group, the prevalence of abnormal manometry was 33%; in the presence of secondary symptoms, especially dysphagia rather than heartburn, however, the prevalence was significantly (p < 0.01) increased. Also in the predominant chest pain group the prevalence of positive acid perfusion testing (44%) was significantly greater (p < 0.05) in those with than in those without secondary symptoms. In the predominant dysphagia group, the prevalence of abnormal manometry was higher than in the other two groups (56%; p < 0.001) but was not affected by the presence or absence of secondary symptoms; this latter finding was also true for the predominant heartburn group. The distribution of specific manometric disorders in any group was not related to the presence or type of secondary symptoms, although a combination of dysphagia and chest pain discriminated achalasia from other manometric disorders.(ABSTRACT TRUNCATED AT 250 WORDS)     

Results of surgical treatment of oesophageal cancer

The objective of this laboratory study was to compare root-end cavities prepared with sonic Retro-prep tips in a MM1500 Sonic Air handpiece with those created by burs in a conventional handpiece. A total of 80 single-rooted extracted human teeth with mature apices and straight canals were included in the study. Four groups of 20 extracted teeth were prepared as follows: I, a 3-4 mm root-end resection perpendicular to the long axis of the root, with a size 40 sonic Retro-prep tip creating an apical cavity 3 mm into root canal system; II, a 45 degrees bevel of the root-face removing a 3-4 mm root segment and root-end preparation as per group I; III, root-end resection as per group I, with an apical cavity prepared using a size 010 inverted cone bur 3 mm down the long axis of the root; IV, resection as per group II, followed by an apical cavity preparation with a size 010 inverted cone bur 3 mm into the root canal system. The apical root portion and root-end cavities were replicated and prepared for SEM analysis at x 20 and x 80 magnification. The degree of chipping associated with the margin of the root-end cavities, as evaluated with a standard grading system, and the incidence of root-face cracks were noted. Marginal chipping of root-end cavities prepared using sonic instrumentation was significantly worse than that produced by burs (P < 0.001). Perpendicular root-end resections showed significantly better scores than bevelled root-end resections (P < 0.005). The incidence of root-face cracking was low with no significant difference between the experimental groups.     

Learning curve for oesophageal cancer surgery

BACKGROUND: Surgical training and experience are frequently claimed to influence early and late outcome measures. The aim of this study was to examine any improvement in an individual surgeon's performance in one operation over a period of 7 years from initial appointment to date. METHODS: Patients undergoing Ivor Lewis subtotal oesophagectomy performed by a single surgeon between April 1990 and December 1996 were identified from a prospectively compiled oesophageal cancer database. Operating time (abdominal, thoracic and 'one-lung time'), blood loss, transfusion requirements (intraoperative and total), extent of lymphadenectomy (number of lymph nodes sampled), intensive treatment unit (ITU) stay, hospital stay, postoperative morbidity and mortality, pathological stage, grade and survival were recorded. RESULTS: The records of 150 patients were identified for analysis. The cohort was split into five groups, each of 30 patients operated on consecutively. Each of the groups was comparable for age, sex, smoking history, preoperative haemoglobin and creatinine levels, weight loss, American Society of Anesthesiologists' grade, and histological stage and grade of disease. Analysis of the variables pertaining to operation revealed a significant improvement with time including reduced single-lung operating time (P=0.01), reduced blood loss (P=0.03), reduced transfusion requirement (P < 0.0001), reduced ITU stay (P< 0.0001), reduced inpatient stay (P< 0.0001) and an increased yield of lymph nodes (P < 0.0001). CONCLUSION: This study showed a continuing improvement in a surgeon's performance over a 7-year period. With the current trend to shorter training periods there is a case for continuing supervision of the 'fully trained' surgeon within highly specialist units.     

Cost-effectiveness analysis of day care for patients with dementia disorders

In a cost-effectiveness analysis, the costs of 55 demented patients in day care (DC) and 45 patients on a waiting list were related to the effects on indices measuring quality of life. Based on one year's study, the costs per patient per day, was USD 55 for the DC-group and USD 63 for the controls (p > 0.05). Both groups deteriorated in the indices during the study year. The trend was that DC was both cheaper and better in the indices, and some of the underlying variables for the used indices also showed significantly better results in favour of DC. However, since the changes between the groups were not significant regarding the basic question at issue, it cannot be stated that DC is more cost-effective than a care organisation without DC. Different interpretations of the results are presented.