A randomized comparison of dilatation alone versus dilatation plus laser in patients receiving chemotherapy and external beam radiation for esophageal carcinoma

Most patients with carcinoma of the esophagus have advanced disease at presentation. Since cure is usually not possible, the goal of treatment is the palliation of dysphagia. Palliative modalities include bougies, balloons, stents, tumor probe, laser, surgery, chemotherapy, and radiation. In recent years, combined chemotherapy and radiation has shown promising results. However, the relief of dysphagia is slow and frequently incomplete. We compared the effectiveness of dilatation alone versus dilatation plus Nd-YAG laser therapy for the relief of dysphagia while assessing the role of chemotherapy and radiation as an adjunct to surgery. Fifteen patients with squamous cell carcinoma of esophagus who were deemed fit for intensive chemotherapy and radiation were randomized to receive either dilatation alone (N = 7) or dilatation plus laser (N = 8); the end-point for initial success was the passage of a 45 French Savary dilator, and the relief of dysphagia. At entry, 13 of these 15 patients were judged potentially resectable. However, after chemotherapy and radiation, only 3 of 13 (20%) patients could be offered surgery; the remainder were considered too poor a surgical risk. Follow-up was for 30 months, or until death. Further dilatations were performed as needed for relief of dysphagia. No difference was observed between the laser plus dilatation and the dilatation alone group with respect to the degree of dysphagia, weight record, quality of life index (Karnofsky score), or mortality rate. Our results indicate that in patients undergoing chemotherapy and radiation for esophageal carcinoma, dilatation alone provides adequate palliation of dysphagia, and in these patients, chemotherapy and radiation is a poor adjunct to surgical treatment.     

Comparison of vacuum extraction delivery between the conventional metal cup and the new soft rubber cup

The authors present a safe, conservative method of endless-loop bougienage (ELB) through the oral cavity and esophagus to a gastrostomy without general anesthesia in three children with corrosive esophageal burns treated since 1966. Esophagogastroscopy was performed to evaluate for esophagitis at an early phase after ingestion of the caustic substance. When esophageal stricture formation was recognized after subsequent conservative treatment, a feeding gastrostomy was made. A continuous string loop with plummets of progressively larger size was positioned to pass through the patient's oral cavity and esophagus to the gastrostomy. Strictures were found in the upper esophagus in two patients and in the middle and lower esophagus in one. The gastrostomy was performed 15 months, 20 days, and 2 months after the injury, respectively, and the periods of ELB were 3, 5, and 2(1/2) years, respectively. The patients were able to start eating at 26, 42, and 29 months after injury, respectively. They are now 30, 18, and 17 years old, and slight dysphagia remains in patients 1 and 2. No patient developed esophageal carcinoma at the site of the corrosive stricture. Our method of ELB through the patient's oral cavity and esophagus to the gastrostomy appears to be safe, reliable, and useful. We believe that most caustic esophageal strictures in children can be treated by this conservative measure.     

Cervical arachnoid cysts after craniocervical decompression for Chiari II malformations: report of three cases

OBJECTIVE AND IMPORTANCE: We describe three cases in which ventrally situated cervical arachnoid cysts led to spinal cord or cervicomedullary compression after repeat craniocervical decompression for Chiari II malformations. CLINICAL PRESENTATION: All three patients underwent craniocervical decompression when their Chiari malformations became symptomatic. The first patient developed chronic vertiginous spells and headache and was treated with repeated craniocervical decompression procedures during several years. Seven months after undergoing her third decompression procedure, she developed severe dizzy spells, which were determined to be of brain stem origin. The second patient had a small, asymptomatic arachnoid cyst anterior to the brain stem discovered at age 6 years. After undergoing repeat craniocervical decompression for headaches 8 years after undergoing his first procedure, the patient developed severe neck pain and acute quadraparesis. A third patient underwent repeat craniocervical decompression at age 14 years for cranial nerve dysfunction. Postoperatively, he acutely developed paresis of extraocular movements and incoordination of the upper extremities. All three patients were found to have anteriorly situated arachnoid cysts compressing the brain stem and/or cervical spinal cord. INTERVENTION AND TECHNIQUE: Fenestration of the arachnoid cyst or drainage with cystoperitoneal shunting adequately treated acute brain stem or cervical spinal cord compression. All three patients had achieved satisfactory relief from their acute symptoms of neural compression at their follow-up examinations. CONCLUSION: An association between spinal arachnoid cysts and neural tube defects has previously been reported. However, the development of previously undetected spinal arachnoid cysts after craniocervical decompression was unexpected. We hypothesize that extensive craniocervical decompression may alter the cerebrospinal fluid pressure dynamics in such a way that the anterior subarachnoid space, previously compressed, may dilate. Occasionally, because of perimedullary arachnoiditis, the cerebrospinal fluid may become loculated and act as a mass. Direct fenestration or shunting may successfully treat this problem, and less extensive craniocervical decompression may avoid it.     

Expression of CD1a monocytes cultured with supernatants from periodontally diseased gingival epithelial cells

MATERIAL AND METHODS: We evaluated the role of color Doppler US-guided compression in the non-invasive treatment of femoral artery pseudoaneurysms after cardiac catheterization, including 22 PTCA procedures. The diagnosis of 32 pseudoaneurysms in 32 patients was accomplished by detection of the typical US-Doppler pattern consisting of the swirling color Doppler flow and the "to and fro" pulsed Doppler waveform at a mean 3.6 days (1 to 14) after the cardiac catheterization. Thirteen patients had multiple cavity pseudoaneurysms (2 to 4). All the patients immediately underwent compression therapy. RESULTS: Treatment was successful in 42/49 cavities (86%) and 25/32 patients (78%), usually after 1 to 3 compression cycles of 6 to 8 minutes duration. Only one recurrence was noted at the 24 hour US-Doppler follow-up. In all cases, pain relief during compression was an excellent clinical sign of hemostatic plug formation and conversion from pseudoaneurysm to simple hematoma. Failures occurred among patients under high dose anticoagulants in spite of 4 to 10 compression cycles. COMMENTARY: In conclusion, color Doppler US-guided compression of post-cardiac catheterization pseudoaneurysms should be the first line therapeutic modality, even in cases of multiple cavities and among patients under effective anticoagulation therapy.     

The surgical procedure in the Mallory-Weiss syndrome

The authors dealt with treatment of 112 patients aged 27-70 years with the Mallory-Weiss syndrome. The diagnosis was confirmed by esophagogastroduodenoscopy. Diathermocoagulation was used in order to arrest bleeding. In profuse bleeding the margins of the mucosa fissures were first infiltrated with a solution of adrenaline. The Blakemore [correction of Bleikmorr] probe compression method was also used. Organ-saving operations were performed for continuing and recurrent bleedings. Two elderly patients with severe coexistent disease died. The authors consider that patients with the Mallory-Weiss syndrome must be treated by conservative methods. Operations for disruptions of the esophagus mucosa and acute blood loss will entail great risk.     

Diurnal variation of adrenocortical activity in chronic fatigue syndrome

The nutcracker esophagus, a primary motor disorder, is frequently associated with noncardiac chest pain. However, there are no data on whether its diagnosis, as in other esophageal motility disorders, is delayed. Since the disorder is frequently heralded by alarming symptoms such as chest pain and dysphagia, diagnosis should be made as soon as possible. In this study we assessed the diagnostic delay, if any, in patients with the nutcracker esophagus. Moreover, we were interested in whether the abnormalities described in the distal esophagus could also involve the entire viscus. Fifty-four subjects (age range 23-78 yr) with the nutcracker esophagus were assessed for clinical and manometric variables as an overall group and after dividing them into subgroups according to their symptoms. The manometric variables were compared with those obtained in 61 controls (age range 21-67 yr). Overall, a diagnosis of nutcracker esophagus was made after an average period of 36 +/- 6 months, and surprisingly, this was not different in the various subgroups complaining of either chest pain, dysphagia, or both. Analysis of manometric variables showed that the mean amplitude of contractions was significantly higher in the patients' group at all esophageal body levels, even in the proximal portions. Again, there were no significant differences among the subgroups of nutcracker esophagus with respect to the symptoms. Notwithstanding the presence of alarming symptoms, such as chest pain and dysphagia, the nutcracker esophagus is diagnosed on average after 3 years from the onset of symptoms. Manometric assessment seems to confirm that this entity may indeed represent a primary esophageal motor disorder. The major dysfunction is due to an abnormal increase of contraction amplitude of the entire esophageal body.     

Delayed stenosis after esophageal reconstruction with colon interposition 35 years ago

BACKGROUND: The long-term complication of an anastomotic stenosis with a poststenotic diverticulum in the case of lye chemical burn of the esophagus at the age of 2 prompted us to present this very rare case, in which 35 years ago the defect was bridged with a section of colon. PATIENTS: In case in point, secondary surgical correction was performed six years after the accident. Thirty-five years later, our patient developed a stenosis of the proximal esophagus which made surgical intervention necessary. RESULTS: In this paper, we describe the problems caused by chemical burns in this case (lye), the surgical treatment, and possible complications. CONCLUSIONS: Reliable procedures include reconstruction with a jejunal transplant, pectoralis major flap, microvascular myocutaneous flap, and retrosternal plastic surgery of the colon. A report on diagnostic procedure and operative care is presented.     

Orbital mass in a child causing somnolence, nausea and bradycardia

Aorto-esophageal fistula due to ruptured thoracic aortic aneurysm is very rare but is associated with extremely high mortality. An 81-year-old woman was admitted due to repeated hematemesis. Endoscopic examination revealed ulceration with blood clot on the mid-esophagus and compression of an extra-esophageal mass. The thoracic CT scan revealed an aorto-esophageal fistula due to a ruptured descending thoracic aortic aneurysm. Surgery was performed on April 3, 1996. We report an aorto-esophageal fistula managed successfully in one stage by resection and replacement of the aortic aneurysm with a prosthetic graft and total esophageal resection. The esophagus was reconstructed using orthotopic gastric interposition with omentopexy around the prosthetic aortic graft. The postoperative course was uneventful and there have been no signs of mediastinal sepsis, graft infection or pyothorax 12 months postoperatively. We suggest that the resection of both the aneurysm and the esophagus as well as the immediate reconstruction of the esophagus by orthotopic gastric interposition to obliterate the retrosternal space are important technique in the management of intrathoracic infections.     

Pediatric hemifacial spasm: the efficacy of microvascular decompression

Hemifacial spasm (HFS), generally a disease of the elderly, is caused by vascular compression of the seventh nerve. Vascular compression is thought to result from atherosclerotic changes within the vessels of the posterior fossa, and therefore rarely presents in childhood. Here we describe our experience with 12 patients with onset of HFS during childhood (age 18 or less) and who had surgical exploration of the cerebellopontine angle. These patients represent less than 1.2% of the patient population with HFS operated upon at this institution during the study period. Nine patients had follow-up data extending over 83 months. All 12 patients were found to have microvascular compression of the seventh nerve at the time of surgery. The most common operative finding was compression of the seventh nerve by a vein, alone or in combination with a branch of the anterior inferior cerebellar artery. At the time of discharge and after a mean follow-up period of 125 months, microvascular decompression resulted in complete relief of spasm in 67% of the patients.     

Facial pain in a case of cranial dystonia: a case report

A 76-year-old man had shown sustained excruciating facial pain in the maxillary region for more than 30 years. Since he was suffering from blepharospasm, facial electromyography was performed and revealed a perioral dystonia. This possible cause of facial pain might have been overlooked had dystonia not been considered and electromyographical studies performed. Repeated intramuscular perioral injections of botulinum toxin brought about complete pain relief. This case shows that involuntary activity of facial muscles can cause a severe chronic pain syndrome. Possible mechanisms include irritation of ascending trigeminal fibers, muscle ischemia due to compression of blood -vessels, or release of pain-producing substances.     

Results of esophageal cancer surgical treatment in multiple primary neoplasms

Available are the results of surgical treatment of 11 patients with cancer of the esophagus revealed metachronously through 6 months--3 years after treatment of oro-pharyngeolaryngeal cancer (5 patients) and diagnosed synchronously with cancer of the stomach (3 patients), the lung (2 patients) and leiomyoma of the esophagus (1 patient). Radical operations on the esophagus were performed in all the patients, in synchronous tumors they were one-stage surgical intervention. Postoperative complications such as pneumonia were observed in the majority of patients, who previously underwent radiation or combined treatment for laryngeal cancer, as well as in all patients, who were operated on the esophagus and the lung in one stage. The necessity of active bronchial sanation in pre- and postoperative period of patients after treatment of laryngeal cancer and advisability of two-stage surgical treatment of synchronous tumors of the esophagus and the lung, the operation for lung cancer being performed at the second stage of treatment, are stressed in conclusion. In synchronous involvement of the esophagus and the stomach one-stage intervention on these organs is the most advisable.     

Misplacement of endoscopic biliary endoprostheses

We report the case of a 72 year-old man with advanced, stage IV, prostate cancer who underwent osteosynthesis of the cervical spine for nerve root decompression due to metastasis which was causing severe pain in his right upper limb. After three months in the hospital, he developed occlusive thrombosis of the right axillosubclavian vein as a complication of prolonged catheterization of the right subclavian vein for treatment of septicemia secondary to a hospital acquired pneumonia. The patient received thrombolytic therapy with IV streptokinase in the contralateral arm in the following dosage: 250,000 units in 15 minutes followed by 100,000 units per hour during five days. This led to total recanalization of the thrombus, with significant reduction of the arm edema. Twenty-four hours after the end of the thrombolytic therapy, the patient started to complain of dysfagia to solids and liquids and a contrasted esophagogram revealed extensive extrinsic compression of the esophagus due to a probable retroesophageal hematoma. The patient required enteral nutrition via nasoenteral tube during three months after which swallowing returned to normal and a repeat upper GI series confirmed that the hematoma had been reabsorbed, with normal passage of contrast through the esophagus. On late follow-up, the patient did not show evidence of any sequelae of deep venous thrombosis nor any residual dysfagia and is currently in use of elastic stockings and low molecular weight heparin.     

Reversibility of lumbar epidural lipomatosis in obese patients after weight-reduction diet

We present three obese patients with symptomatic lumbar epidural lipomatosis. All three were treated with a calorie-controlled diet and considerable weight reduction was achieved. MRI demonstrated a reduction in the epidural fat and relief of thecal sac compression in all three; two also improved clinically.     

Laparoscopic Nissen fundoplication

A technique for laparoscopic Nissen fundoplication is described and a series of 11 cases is presented. The technique secures the patient to the operating table with three safety straps and the patient is then placed in a reverse Trendelenburg position with the hips flexed. The surgeon operates from the patient's right side using two midline trocar sites as the main operating ports. Other ports provide retraction and laparoscope access. The liver retractor is held by a mechanical arm. Once the esophageal peritoneum has been opened, the esophagus and diaphragmatic crura are dissected out and elevated by a Penrose drain sling. The short gastrics are divided and the fundus is brought posterior to the esophagus passing from left to right. A large Maloney dilator is placed in the esophagus and the fundal wrap is sutured to the anterior aspect of the stomach by three sutures; the inferior--most of which incorporates the anterior wall of the esophagus. Once the fundoplication is completed, the dilator is replaced by a nasogastric tube. Postoperatively, patients are given clear liquids and when these are tolerated the nasogastric tube is removed. Most patients are discharged on the second or third postoperative day. Operating time averaged 147 min, and all patients returned to unrestricted activity within 2 to 3 weeks. All patients reported complete relief of gastroesophageal reflux. Average follow up was 120 days with a median of 148 days. Long-term follow up is in progress.     

Vascular compression and cranial nerve diseases

This paper offers a review of cranial nerve rhizopathies caused by vascular compression of cranial nerves in the posterior cranial fossa. We present our results of microvascular decompression for trigeminal neuralgia, hemifacial spasm, and glossopharyngeal neuralgia caused by compression of the 5th, 7th and 9th cranial nerves, respectively. After a median observation time of 38 months, 20 of 25 patients with trigeminal neuralgia were completely free of pain, and one patient reported more than 50% pain relief. Four out of five patients treated for hemifacial spasms were completely free of spasms. Of two patients treated for glossopharyngeal neuralgia, one reported complete pain relief, whereas the other reported less than 50% pain relief. No serious complications occurred. The results of microvascular decompression reported in the literature reviewed, including results of the treatment of tinnitus and positional vertigo due to compression of the 8th cranial nerve, hypertension due to compression of the 10th cranial nerve and spastic torticollis due to compression of the 11th cranial nerve. It is concluded that the rationale behind microvascular decompression is supported by an extensive amount of data.     

Barrett's esophagus

The columnar replacement of squamous epithelium in the lower esophagus is the result of gastroesophageal reflux. Whether the squamous cells are replaced or undergo metaplasia is still conjectural. This neoepithelium is unstable in the presence of continued reflux and prone to complications of stricture, ulceration, and adenocarcinoma. Considerable evidence supports the hypothesis that duodenal contents play a role in the development of Barrett's esophagus and its complications. The increasing incidence of adenocarcinoma in Barrett's esophagus is of concern in the Western World. Surveillance programs in some centers have been successful in early diagnosis, and excellent survival periods have been reported following resection in these cases. Both medical and surgical antireflux treatment is successful in symptom relief, but even in the absence of symptoms, reflux may continue. Surgery offers better overall results than proton pump inhibition of gastric acid and has been more popular since less aggressive (minimally invasive) techniques have been popularized. Mucosal ablation and antireflux measures by medicine or surgery are still in the experimental stages but hold considerable promise for the future.     

Portal and mesenteric vein thrombosis in a patient heterozygous for a mutation (Arg506-->Gln) in the factor V gen (factor V Leiden)

Neurological complications such as spinal cord compression has rarely been reported both in the solitary type of osteochondroma or in multiple osteochondromas. We report a a 65-year-old patient with a thoracic osteochondroma involving the neural arch of T6, and the corresponding rib, who was followed-up for 5 years. Approximately 3 years after partial surgical removal, the lesion manifested as a dumbbell mass passing through the neural foramen leading to cord compression, and a hemilaminectomy was performed with subtotal tumor excision. A clinical follow-up 2 years later revealed normal findings.     

Defining treatment

Method of orthograde and retrograde forced bouginage for treatment of 533 patients with cicatricial strictures of the esophagus was used during 1975-1995 years (486 procedures). In comparison with routine methods it has shown high effectiveness and safety. Perforation of the esophagus was detected only in 2 (0.43%) patients. Good and favourable immediate results were obtained in 95.1% patients. Follow-up results up to 20 years are available for 336 (71.8%) patients. Good result was obtained in 78.6% patients, favourable--in 16.1%, poor results--in 5.2%. It is emphasized, that the principal method for treatment of patients with cicatricial strictures of the esophagus is bouginage. The method of orthograde and retrograde bouginage of the esophagus contributes to steady remission of the disease in 95% of patients.     

Hyaline cartilage: in vivo and in vitro assessment with magnetization transfer imaging

PURPOSE: To determine whether the percentage of vertebral lesion filling and the leakage of methyl methacrylate have any clinical significance at follow-up. MATERIALS AND METHODS: Forty percutaneous vertebroplasties were performed for metastases (30 cases) and myeloma (10 cases) in 37 patients. A computed tomographic scan was obtained 1-8 hours after methyl methacrylate injection and was used to assess the percentage of lesion filling by methyl methacrylate and the leakage of methyl methacrylate into the epidural tissues, neural foramina, intervertebral disks, venous plexus, and paravertebral tissue. The results were correlated with those obtained at clinical follow-up. RESULTS: Partial or complete pain relief was sustained in 36 of 37 patients. Pain relief was not proportional to the percentage of lesion filling. Clinical improvement was maintained in most patients. The 15 epidural leaks, eight intradiskal leaks, and two venous leaks of methyl methacrylate had no clinical importance. Two of eight foraminal leaks produced nerve root compression that required decompressive surgery. One of 21 paravertebral leaks produced transitory femoral neuropathy. CONCLUSION: Pain relief can occur despite insufficient lesion filling. In most patients, intradiskal and paravertebral leaks of cement had no clinical importance.     

Spinal aneurysmal cyst with medullary compression. Apropos of a case with preoperative embolization

The authors report the case of a vertebral aneurysmal bone cyst, at the thoracic level, with spinal cord compression. 16 months after operation, the initial neurological signs reappeared. Selective angiography pointed out a good picture, through not specific, of the lesion; the embolisation, then performed, provided considerable relief for the complete removal of the important vascular bone formation. The diagnostic, therapeutic and pathogenic problems of the vertebral aneurysmal bone cysts are discussed.