Self-expanding stents for the palliation of esophageal and gastric cardia cancer

Twenty-one endoscopic tube implantations were carried out in 24 patients with malignant stenosis of esophagus and gastric cardia using self-expanding metallic stents. The indications to endoscopic intubation were advanced stage of the tumor in 17 cases and risk factors which made resection inadvisable in 7 cases. In 3 patients it proved impossible to implant a stent endoscopically because the Authors were not able to pass the guide wire through the stenosis, while correct stent placement was achieved in 21 patients. Functional results were good in 18 patients, while 3 patients did not have any improvement of symptoms. Complications occurred in 9 patients (42.85%): 2 bleedings, 3 neoplastic obstructions, 1 food obstruction and 3 distal dislodgements of the prostheses were observed, but could readily be corrected. No death occurred. The median survival time was 151 days (range 25-545). This study suggests that endoscopic placement of metallic self-expanding stents is safe and has to be preferred to plastic stents for easier implantation and lower morbidity.     

Choledochoduodenostomy for palliation in unresectable pancreatic cancer

Bcl-2 and bax are cellular proteins that are important in the regulation of apoptosis. Overexpression of bcl-2 protein is associated with prolonged cell survival, whereas overexpression of bax correlates with increased apoptosis after injury. It has been suggested that the ratio of bcl-2 and bax determines a cell's susceptibility to apoptosis. We studied bcl-2 and bax expression by immunohistochemical methods in 46 cases of B-cel non-Hodgkin's lymphoma characterized by the Revised European-American Lymphoma (REAL) classification to determine whether expression of these two proteins correlated with the histological subtype or the predicted clinical behavior (indolent v aggressive). For each case, both the percentage of cells staining as well as the intensity of staining of bcl-2 and bax were recorded, and a bcl-2-bax protein ratio (BBPR) was calculated. Bax staining was identified in 100% of the lymphomas studied. In contrast, bcl-2 staining was seen in only 67%. Bcl-2 expression correlated with the subtype of lymphoma with positive staining in 100% of small lymphocytic lymphomas, 80% of follicle center lymphomas, 38% of diffuse large cell lymphomas, 33% of high-grade B-cell Burkitt's-like lymphomas, 0% of Burkitt's lymphomas, and 0% of B-cell lymphoblastic lymphomas. The BBPR of indolent lymphomas (mean, 1.8) was significantly greater than the BBPR of aggressive lymphomas (mean, 0.6) (P < or = .002). This suggests that bax and bcl-2 expression may be linked to biological behavior in non-Hodgkin's B-cell lymphomas.     

Application of Duhamel''s operation for the surgical treatment of rectal cancer

This study was carried out to examine recruitment of loudness measured by the classical and the modified, self-recording alternate binaural loudness balance tests in 20 normal subjects and in 14 patients with various kinds of ear pathology. In spite of individual variability, the modified method, when used as described in this study, does provide an indication of the presence or absence of loudness recruitment.     

High-energy transurethral microwave thermotherapy for large severely obstructing prostates and the use of biodegradable stents to avoid catheterization after treatment

OBJECTIVE: To assess the use of high-energy transurethral microwave thermotherapy (TUMT) for large severely obstructing benign prostatic hyperplasia (BPH) and to compare the use of a biodegradable stent with that of a urethral Foley catheter after TUMT. PATIENTS AND METHODS: The study comprised 30 men (mean age 71 years, range 49-82) scheduled for prostatectomy for symptomatic BPH. Pre-operative investigations included the measurement of urinary free flow rate, residual urine volume (ultrasonographically), a digital rectal examination, transrectal ultrasonography, a symptom score, cystoscopy, cystometry and pressure-flow. The obstruction was graded according to the Sch?fer nomogram. The patients were treated using the Prostatron (EDAP-Technorned, France) TUMT system; the software used provided a maximum power of 70 W. Patients were catheterised after treatment with either a Foley catheter or a biodegradable stent. After 3 months, the measurements and obstruction grading were repeated, and the effect of the stent assessed. RESULTS: In the entire group, the mean (SD) free flow increased from 7.7 (2.4) to 14.0 (3.3) mL/s, the residual urine decreased from 125 (86) to 23 (25) mL and the symptom score decreased from 16 (8) to 5 (4). The mean (SD) degree of obstruction decreased from 81.0 (16) to 62.6 (15). The biodegradable stent completely avoided post-treatment retention. CONCLUSION: High-energy TUMT can be used on large severely obstructing prostates with major subjective and objective improvements. The biodegradable stent is useful in relieving the problems of catheterization after treatment.     

Preoperative combined modality treatment for rectal cancer

The encouraging results achieved with adjuvant postoperative combined modality therapy in patients with resectable rectal cancer has prompted an increased interest in preoperative combined modality therapy. Based on the potential of such regimens to deliver higher chemotherapy doses, enhance downstaging, and decrease acute toxicity in patients with unresectable disease, this approach is attractive in patients with resectable rectal cancer. Randomized trials of preoperative vs postoperative combined modality therapy using combinations of bolus fluorouracil and leucovorin are in progress.     

Preoperative radiotherapy for adenocarcinoma of the rectosigmoid

Ninety-seven patients with adenocarcinoma of the rectosigmoid have been treated with high dose (5000-6000 rad) preoperative irradiation from 1960 through 1972 at the University of Oregon Health Sciences Center. Fifty-seven were initially clinically resectable and 40 were initially inoperable. Forty of the 57 initially clinically resectable patients had "curative" resections and are at risk for more than 5 years. An increase in 5-year survival (from 38% to 53%) and an absence of pelvic recurrence have occurred in those patients receiving preoperative irradiation and "curative" resection. Four of the 40 initially inoperable patients are alive without tumor. Three of the four survivors had irradiation and surgery; one had irradiation only. An additional four patients had no evidence of tumor at death. Tumor was totally sterilized by irradiation and nine patients and reduced to microfocal extent in an additional three of the 97 patients. Incidence of complications was no greater than has been reported in a surgical series from the same institution.     

Stent endoprosthesis for obstructing colorectal cancers

We present the case of a patient in whom hypotension, sudden cardiopulmonary arrest, and coma developed after a massive dose of a seemingly harmless cathartic agent. The diagnosis of hypermagnesemia was made 9 hours after the patient's admission, when the serum magnesium concentration was 21.7 mg/dL (8.9 mmol/L). The patient's condition improved with IV calcium, saline solution infusion, and cardiorespiratory support. The elimination half-life of magnesium in this case was 27.7 hours. Few cases have been reported in which patients have survived with serum levels greater than 18 mg/dL (7.4 mmol/L). This case provides evidence that hypermagnesemia may occur in patients with normal kidney function. The diagnosis of hypermagnesemia should be considered in patients who present with symptoms of hyporeflexia, lethargy, refractory hypotension, shock, prolonged QT interval, respiratory depression, or cardiac arrest.     

Local excision of rectal cancer

The prospect of treating a rectal cancer often leads to significant fear among patients because of the possibility of a permanent colostomy. Although radical resection, in particular abdominoperineal resection, has been used effectively for rectal cancer treatment, other techniques such as local excision with or without adjuvant therapy have been used with significantly less morbidity than that of the abdominoperineal resection, with excellent cure rates. There are essentially three local excision techniques that can be used to remove a small rectal cancer completely. Selection criteria are critical for choosing the appropriate patient for these techniques. Tumors must be less than 4 cm in diameter and take up less than 40% of the rectal wall circumference. They also need to be relatively close to the dentate line and have no evidence of any invasion into the mesorectum or perirectal nodes. Preoperative staging with endorectal ultrasonography, computed tomography, and digital examination helps select appropriate patients. Retrospective series have shown significant success using local excision techniques, with local recurrence rates ranging from 0% to 11% for early-stage lesions. Prospective series have shown similar recurrence rates. Postoperative function with or without adjuvant therapy has not been adequately documented along with quality of life and must be part of any future reports on local excision techniques as well as all rectal cancer treatment studies. Local excision does, however, seem to provide adequate treatment in well selected patients and provides a less morbid alternative to the treatment of rectal cancer than radical resection, particularly abdominoperineal resection, which obligates the patient to a permanent colostomy.     

Complete remission after radiotherapy for recurrent rectal cancer

Although the efficacy of radiotherapy for the palliation of recurrent or inoperable cancer has been proven, it results in complete tumor remission only rarely. We report a case of pelvic recurrence in which complete histological remission followed radiotherapy. A 68-year-old man developed a small pelvic recurrence near the rectal stump 8 months after a Hartmann procedure for rectal cancer. Histologic examination of the biopsy specimens revealed adenocarcinoma consistent with the primary tumor. He received radiotherapy to the whole pelvis, with a total dose of 39.4 Gy administered in 22 fractions over 4 weeks, with a continuous infusion of 5-fluorouracil as a radiosensitizer. After regression of the tumor was confirmed, resection of the pelvic recurrence was performed. Histologic examination of the resected specimen revealed no tumor. Thirty-six months after the second operation, the patient was alive with no evidence of disease. The experience of our case and a review of the literature suggests that small pelvic recurrences may be more responsive to radiotherapy than larger ones.     

Observations on surgical anatomy for rectal cancer surgery

BACKGROUND/AIMS: The investigators studied the surgical anatomy of the main structures involved in the mobilization of the rectum (Denonvilliers' fascia, mesorectum, middle rectal artery, superior and inferior hypogastric plexuses). METHODOLOGY: The study was carried out on 20 cadavers (17 unembalmed and 3 embalmed). To study Denonvilliers' fascia, ten embryos and fetuses (11 mm to 80 mm CRL) were also examined. RESULTS: Denonvilliers' fascia originates from the fusion of the primary pouch of Douglas. The two leaves making up this structure are easily separated. The mesorectum surrounds the rectum on three sides; it is easily separated from the presacral fascia and its connective tissue is bordered by a thin membrane. The middle rectal artery varies in appearance rate, origin, size, distribution and anastomosis. It runs under the lateral ligament and also sends branches to the genital apparatus. Of the two hypogastric plexuses, the inferior is the most difficult one to identify. Its superior branches extend to the rectum, and the inferior ones to the genital apparatus. Because the anterior part contains the parasympathetic nerves and the middle rectal artery, this region is at major risk during surgical dissection. CONCLUSIONS: A sound understanding of the surgical anatomy of the rectum enables the surgeon to perform a more correct and reasonable procedure in terms of both the extent of surgical treatment and the preservation of important anatomical structures.     

Local treatment of rectal cancer

While abdominoperineal resection with permanent colostomy is still required for most distal [corrected] rectal cancers, sphincter-saving local treatment by means of local excision, electrocoagulation or endocavitary contact radiation can be used for some highly selected distal tumors. Local treatment avoids a permanent colostomy and is associated with much lower morbidity and mortality rates than abdominoperineal resection. Strict criteria for patient selection are essential to successful local treatment. Optimal candidates include patients exhibiting the following features of rectal cancer: a distal rectal cancer less than 8 cm from the anal verge; a tumor with a diameter of 3 cm or less; a tumor that is well to moderately well differentiated histologically, and a tumor that is limited to the bowel wall. Preoperative studies such as transrectal ultrasonography enhance the accuracy of preoperative staging. In properly selected patients, the results of local treatment are equivalent to those of abdominoperineal resection of comparable tumors. Close follow-up is essential, and tumor recurrence can be treated for cure by abdominoperineal resection.     

Outcome of treatment of rectal cancer

To demonstrate the trend and treatment outcome of rectal cancer after the advent of adjuvant therapy, all case notes of rectal cancer patients admitted to Chulalongkorn Hospital from 1985-1994 were reviewed and cases were followed until 1996. Mean follow-up period was 685.3 days (8-3, 193 days). Most rectal tumors were Dukes' C (43.8%), well-differentiated (54.1%) and at the distal third (53.4%). AP resection remained the most common procedure before and after the advent of adjuvant therapeutic options (62.3%). Of 146 patients treated by curative operations, 60 had adjuvant therapies of which radical radiotherapy with or without chemotherapy was the most common. However, chemotherapy was increasingly employed as the neoadjuvant and as combined chemoradiotherapy. There was a preferential selection of less well-differentiated, more distal, more Dukes' C disease and younger patients for the adjuvant therapy (p < 0.05). Recurrence rate in the adjuvant group was not different from the surgery group despite significant poorer prognostic indicators (17.4% & 21.7%, p = 0.53). Mortality was higher in Dukes' B + C patients in adjuvant group (17.3% & 3.4%, p = 0.02). The outcomes were not different among Dukes' A patients. The complications; i.e. wound problems, gut obstruction; did not increase with the adjuvant treatment. No adverse effect was observed on the healing of colorectal or coloanal anastomoses in the adjuvant group.     

Importance of endoscopic ultrasonography staging for treatment of rectal cancer

Endorectal sonography should be used to stage primary rectal cancer within the middle and lower third of the rectum. The endosonographic staging of rectal cancer together with new surgical techniques has a strong impact on surgical decisions. Primarily, it contributes to choosing a sphincter-saving procedure.