Laser photocoagulation in the treatment of malignant dysphagia

BACKGROUND: Dysphagia secondary to carcinoma of the oesophagus and gastric cardia is the principal symptom requiring palliation in those patients who present with late-stage disease or who are unfit for surgery. The primary aim of the present study was to determine the safety and efficacy of laser photocoagulation in the palliation of malignant dysphagia. Secondary aims were to look at reasons for failure and predictors of outcome; to determine the most appropriate second line therapy for treatment failures; and to look at the results of treatment for early stage disease. METHODS: Sixty-seven patients treated over a 6-year period with endoscopic Nd:YAG laser photocoagulation were evaluated and the quality of swallowing assessed before and at intervals after treatment. RESULTS: Ninety per cent of patients achieved successful initial palliation. This was sustained in 76% after 3 months of treatment. Within a month before death 71% of patients were palliated but 29% required the addition of second-line treatment to achieve this. Complications were infrequent. There were no deaths attributable to laser treatment. Five of 10 patients treated with radiotherapy developed fibrous stricturing that required endoscopic dilatation. No variables were independently predictive for treatment failure. Six patients with early stage disease experienced prolonged survival. CONCLUSIONS: We conclude that laser photocoagulation offers safe and effective palliation of malignant dysphagia in this group of patients and is appropriate as first-line therapy.     

Fractionated high dose rate intraluminal brachytherapy in palliation of advanced esophageal cancer

PURPOSE: To optimize the dose of fractionated brachytherapy for palliation of advanced esophageal cancer. METHODS AND MATERIALS: One hundred and seventy-two patients with advanced esophageal cancer were randomized to receive 12 Gy/2 fractions (group A); 16 Gy/2 fractions (group B), and 18 Gy/3 fractions (group C) by high dose rate intraluminal brachytherapy (HDRILBT). Treatment was given weekly and dose prescribed at 1 cm from the source axis. Patients were followed up monthly and assessed for dysphagia relief and development of complications. RESULTS: Twenty-two patients died before completing treatment due to advanced disease and poor general condition. The overall survival was 19.4% at the end of 12 months for the whole group (A--9.8%, B--22.46%, C--35.32%; p > 0.05). The dysphagia-free survival was 28.9% at 12 months for the whole group (A--10.8%, B--25.43%, C--38.95%; p > 0.05). Forty-three patients developed fibrotic strictures needing dilatation (A--5 of 35, B--15 of 60, C--23 of 55; p = 0.032). Twenty-seven patients had persistent luminal disease (A--11, B--6, C--10), 15 of which progressed to fistulae (A--7, B--2, C--6; p = 0.032). There was no effect of age, sex, race, histology, performance status, previous dilation, presenting dysphagia score, presenting weight, grade, tumor length, and stage on overall survival, dysphagia-free, and complication-free survival (p > 0.05). On a multivariate analysis, brachytherapy dose (p = 0.002) and tumor length (p = 0.0209) were found to have a significant effect on overall survival; brachytherapy dose was the only factor that had an impact on local tumor control (p = 0.0005), while tumor length was the only factor that had an effect on dysphagia-free survival (p = 0.0475). When compared to other forms of palliation currently available (bypass surgery, laser, chemotherapy, intubation, external radiotherapy), fractionated brachytherapy gave the best results with a median survival of 6.2 months. CONCLUSIONS: Fractionated brachytherapy is the best modality for palliation of advanced esophageal cancer. It offers the best palliation to patient when compared to all other modalities currently available. The optimal brachytherapy dose ranges between 16 Gy in two fractions and 18 Gy in three fractions given a week apart.     

Chemotherapy followed by surgery compared with surgery alone for localized esophageal cancer

BACKGROUND: We performed a multi-institutional randomized trial comparing preoperative chemotherapy followed by surgery with surgery alone for patients with local and operable esophageal cancer. METHODS: Preoperative chemotherapy for patients randomly assigned to the chemotherapy group included three cycles of cisplatin and fluorouracil. Surgery was performed two to four weeks after the completion of the third cycle; patients also received two additional cycles of chemotherapy after the operation. Patients randomly assigned to the immediate-surgery group underwent the same surgical procedure. The main end point was overall survival. RESULTS: Of the 440 eligible patients with adequate data , 213 were assigned to receive preoperative chemotherapy and 227 to undergo immediate surgery. After a median possible study time of 55.4 months, there were no significant differences between the two groups in median survival: 14.9 months for the patients who received preoperative chemotherapy and 16.1 months for those who underwent immediate surgery (P=0.53). At one year, the survival rate was 59 percent for those who received chemotherapy and 60 percent for those who had surgery alone; at two years, survival was 35 percent and 37 percent, respectively. The toxic effects of chemotherapy were tolerable, and the addition of chemotherapy did not appear to increase the morbidity or mortality associated with surgery. There were no differences in survival between patients with squamous-cell carcinoma and those with adenocarcinoma. Weight loss was a significant predictor of poor outcome (P=0.03). With the addition of chemotherapy, there was no change in the rate of recurrence at locoregional or distant sites. CONCLUSIONS: Preoperative chemotherapy with a combination of cisplatin and fluorouracil did not improve overall survival among patients with epidermoid cancer or adenocarcinoma of the esophagus.     

Use of concurrent chemotherapy, accelerated fractionation radiation, and surgery for patients with esophageal carcinoma

BACKGROUND: The results of a Phase II study of concurrent chemotherapy and accelerated fractionation radiation therapy followed by surgical resection for patients with both adenocarcinoma and squamous cell carcinoma of the esophagus are presented. Pretreatment and postinduction staging were correlated with pathologic findings at surgery to assess the role of surgical resection and the predictive value of noninvasive staging techniques. METHODS: Patients received 2 induction courses with 4-day continuous intravenous infusions of cisplatin (20 mg/m2/day) and 5-fluorouracil (1000 mg/m2/day) beginning on Day 1 and Day 21, concurrent with a split course of accelerated fractionation radiation (1.5 grays [Gy] twice daily, to a total dose of 45 Gy). All patients were subsequently referred for surgical resection. A single, identical postoperative course of chemotherapy and 24 Gy accelerated fractionation radiation was planned for patients with residual tumor at surgery. RESULTS: Seventy-four patients were entered on this study; 72 patients were considered eligible and evaluable. Induction toxicity included nausea (85%), increased dysphagia (90%), neutropenia (<1000/mm3) (43%), thrombocytopenia (<20,000/mm3) (10%), and reversible nephrotoxicity (8%). Sixty-seven patients (93%) underwent surgery, and 65 (90%) were found to have resectable tumors. Twelve of these patients (18%) died perioperatively, and 18 (27%) had no residual pathologic evidence of disease. Resolution of symptoms and normalization of radiographic studies, endoscopy, or esophageal ultrasound did not identify pathologic complete responders accurately. No patient completing induction therapy and surgery experienced a locoregional recurrence. The Kaplan-Meier 4-year projected recurrence free and overall survival rates were 49% and 44%, respectively. CONCLUSIONS: Although this regimen is feasible, there was significant preoperative toxicity and perioperative mortality. Nonetheless, the recurrence free and overall survival rates were encouraging. However, no staging tool can predict a pathologic complete response after induction therapy accurately, suggesting a continued need for surgical resection.     

Survival of patients with carcinoma of the esophagus treated with combined-modality therapy

Since 1985, 229 cases of carcinoma of the esophagus have been considered for entry into a protocol with the use of preoperative chemotherapy and radiation therapy followed by surgical intervention as the primary element of treatment. One hundred sixty-five patients (93 with adenocarcinoma and 72 with squamous cell carcinoma) had esophagogastrectomy. The 5-year survival of the protocol patients who underwent resection was 25% for both groups--squamous cell carcinoma and adenocarcinoma. Of the protocol patients with squamous cell carcinoma who underwent resection, 40% had a sterilized specimen, whereas of those with adenocarcinoma, 20% had a sterilized specimen. If the patient had a sterilized specimen, the 5-year survival was approximately 60% for adenocarcinoma and 40% for squamous cell carcinoma. Those patients with adenocarcinoma and Barrett's esophagus had a 5-year survival of 55%. Of the patients who underwent only esophagectomy and esophagogastrectomy and had not been entered into the protocol, none lived beyond 3 years. The operative mortality rate for those who had esophagogastrectomy was 5%. Sixty-four patients completed the radiation therapy and chemotherapy but did not undergo surgical procedures because of progressive disease or refusal. Of those patients who completed chemotherapy and radiation therapy without surgical intervention, 5-year survival was 18% in patients with squamous cell carcinoma, whereas no patients with adenocarcinoma survived beyond 3 years. The finding of a sterilized specimen after esophagectomy is a favorable prognostic factor in patients with adenocarcinoma or squamous cell carcinoma. The finding that patients with Barrett's esophagus and adenocarcinoma have an improved chance for survival is perhaps related to an earlier diagnosis. It is clear that some patients with squamous cell carcinoma who did not undergo surgical procedures did have a sterilized specimen, because the survival in this group approached 20% at 5 years.     

Endoscopic therapy of esophageal cancer

In the management of esophageal cancer, endoscopy has evolved from a tool used to provide biopsy confirmation of suspected tumor to an integral part of the staging and ongoing treatment of patients. Endoscopic ultrasound is currently the most accurate means for T and N staging. Improved endoscopic techniques like dye staining and aggressive biopsy protocols can identify very early stage tumors in high-risk groups and allow curative surgery. Patients with early-stage tumors who are not surgical candidates can also be treated with endoscopic mucosectomy, photodynamic therapy, or Nd:YAG laser and still have a chance of long-term cure. Palliation of advanced tumors remains the major role of endoscopy in patients with esophageal cancer. A variety of techniques have proven effective over the years, including dilatation, laser, and rigid prostheses. Newer developments like bipolar probes, injection therapy, photodynamic therapy, and brachytherapy offer potential applications. The development and continuing improvements in both coated and uncoated expandable metal stents have been perhaps the greatest recent advance in endoscopic palliation of malignant dysphagia and esophagorespiratory fistulas. With the increasing array of endoscopic treatments and palliative techniques, emphasis must be placed on considering functional status; tumor characteristics like stage, location, and shape; patient wishes; and local expertise in tailoring treatment plans for each situation.     

Radiographic appearances of esophageal stents

Among patients with esophageal carcinoma and associated dysphagia, more than 60% have unresectable disease at presentation. In such cases, the goal of treatment is primarily palliation of the dysphagia; treatment options include surgery, radiation therapy, laser ablation, and placement of stents. Beginning with the first stent-made of boxwood and silver in 1885-evolution in design led to the creation of large-diameter, rigid plastic stents placed at laparotomy and eventually placed by means of endoscopy. However, complications such as perforation, hemorrhage, dislodgment, pressure necrosis, and occlusion were frequently encountered with these stents. The development of small-diameter, expandable metal stents eliminated some of these complications. Metal stents have greatly reduced procedure-related morbidity and mortality, but complications such as perforation, malposition, migration, tumor ingrowth and overgrowth, food obstruction, and tracheoesophageal fistula persist. An efficacious and increasingly used method of treating malignant dysphagia, esophageal stent placement must undergo further improvements to reduce the frequency of complications, particularly migration and tumor ingrowth.     

Clinical impact of transcutaneous bilirubinometry as an adjunctive screen for hyperbilirubinemia

BACKGROUND: Advanced carcinoma of the lower neck with direct extension to the superior mediastinum is a major therapeutic challenge. Complete removal of the tumors requires a radical operation in order to remove the larynx, portions of trachea and esophagus, and to construct a tracheostomy stoma with intrathoracic trachea. METHODS: We present our experience and technique for removal of difficult tumors in this region and construction of mediastinal tracheostomy. A technique for reconstruction of a very short segment of distal trachea is also proposed. Twelve mediastinal tracheostomies were performed; all except 3 patients underwent total laryngopharyngectomy and resection of tumor with gastric pullup. RESULTS: There were 2 operative deaths, 1 from tracheoinnominate artery fistula and the other from cerebral infarction. Complications included pharyngeal fistula (2 patients), respiratory failure (1), and osteomyelitis of sternum (1). Postoperative survival was disease-dependent. All patients who survived the operation achieved good airway patency and relief of dysphagia. CONCLUSIONS: The method of airway reconstruction by mediastinal tracheostomy is an advance in surgical treatment of malignancies in the cervicothoracic region. By careful selection of patients, successful operation resulted in good palliation and sometimes cure with acceptable quality of life.     

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.     

Advances in the treatment of esophageal carcinoma

Recent changes in the epidemiology of esophageal carcinoma now recognize adenocarcinoma as the predominant histologic cell type. Barrett's esophagus and dysplasia in this epithelium identify patients who are at risk of developing invasive adenocarcinoma. This neoplasm is not a single entity with a consistently poor prognosis, and disease stage is important for determining therapy. These findings offer the potential for further development of therapeutic regimens. Endoscopic esophageal ultrasound is an accurate and reproducible staging tool. It allows the physician to determine clinical stage and modify treatment. T2 N0 M0 or lesser stage tumors have acceptable surgical cure rates, and patients should undergo immediate resection. Patients with more advanced T3 or N1 tumors have a potential for cure but do poorly with surgery alone. These patients should be considered for multimodality therapy. Palliative therapy should be given to patients with hematogenous metastatic disease. Treatment stratification by stage proves that esophageal carcinoma is not a uniformly fatal disease without hope for cure.     

Incidence of community-acquired pneumonia and Chlamydia pneumoniae infection: a prospective multicentre study

Squamous carcinoma of the esophagus is a disease with a poor prognosis which fortunately occurs seldom in the United States. Because patients present with more advanced disease here, surgical therapy has not equaled results reported from Asia. Although, claims of equality have appeared in the literature, radiation therapy alone has not been very effective for this disease. There are a myriad of small reports which extol a variety of combined approaches. Based upon a review of these series it is obvious that a Phase III trial is required to establish the best multimodality therapy for management of squamous carcinoma of the esophagus. Components of such a trial are reviewed and suggestions are made for design and reporting of such a trial.     

The effects of steroid hormones on electrical activity of excitable cells

BACKGROUND/AIM OF STUDY: Laser therapy is effective in relieving malignant dysphagia, but repeated treatments at 4 to 6 week intervals are usually required. This prospective randomised trial is designed to determine if addition of brachytherapy offers any advantages over laser therapy alone. METHODS: Patients with inoperable carcinoma of the oesophagus were randomised to receive either endoscopic Nd:YAG laser therapy alone, or laser followed by brachytherapy. Patients who developed worsening dysphagia during follow-up were offered further treatment as appropriate. RESULTS: Fourteen patients were randomised to receive laser only, and 12 to receive laser followed by brachytherapy. Of these 12, one was lost to follow-up and four did not receive brachytherapy because they were unfit, had extension into the cardia or had mainly extrinsic compression. These 4 are included on an 'intention-to-treat' basis. The mean therapeutic interval for the brachytherapy group was significantly longer, 83 days compared to 36 days for the laser group (p = 0.026). There were no differences in the degree of dysphagia relief, number of endoscopic procedures or survival times. CONCLUSION: The preliminary results of this trial suggest that brachytherapy in addition to laser therapy prolongs the first therapeutic interval. However, no long-term advantages have been shown.     

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.     

Patient satisfaction and symptom relief after anal dilatation

Anal dilatation is used as a simple method of treatment and has been used for both anal fissure and haemorrhoids. This study examined longer-term results among a cohort of 162 patients, 132 of whom responded to a detailed questionnaire, an 82% response (66 patients were male; age range 17-75 years, median 42 years). Follow-up ranged from 16 months to 36 months (median 27 months) after anal dilatation (68 patients for fissure, 32 for haemorrhoids, and 32 for both). In the early months after dilatation, 83% had symptomatic improvement and 76% remained improved. Five (7%) patients with fissure and 11 with haemorrhoids (17%) required further hospital treatment, while 10% and 17%, respectively, had received further treatment from their general practitioners (GPs). Seventy-one percent said they would have a further anal dilation if symptoms recurred. There was no difference in results obtained by surgeons of different seniority. Complications--bleeding (29%) and difficulty controlling flatus (15%) or faeces (8%)--resolved in all cases. The results of anal dilatation for fissure are generally satisfactory in the longer term, with a trend toward better symptom relief in patients with fissure compared with those with haemorrhoids. We do not recommend anal dilatation as the sole treatment of patients with haemorrhoids, but it may be a useful adjunct to other treatments such as banding or sclerotherapy. Morbidity was generally acceptable and the majority of our patients would be prepared to have this procedure again if their symptoms were to return.     

The role of neoadjuvant therapy in surgically resectable esophageal cancer

OBJECTIVE: To determine the effect of neoadjuvant therapy (NT) (preoperative chemotherapy, radiation therapy, or both) in surgically resectable esophageal cancer. DESIGN: A retrospective review over a 20-year period. SETTING: A tertiary academic medical center. PARTICIPANTS: All patients undergoing surgical resection for esophageal cancer (N = 316) over this time period. MAIN OUTCOME MEASURES: Perioperative morbidity and mortality, local and distant recurrences, and overall survival. RESULTS: Patients undergoing NT (n = 106) had prognostic factors similar to those treated with surgery alone (n = 210). No increase was noted in surgical morbidity with NT (anastomotic leaks, reoperation rates, complications, or extended hospital stays). Overall survival was not improved by NT (median survival, 14 months) except in the subset of patients (11/83) who responded completely (100% histological necrosis) to preoperative chemotherapy (median survival, 79.2 months; P < .02). Complete response to radiation therapy alone was not associated with improved survival. Partial necrosis of the primary tumor was seen in 13 (15%) of 83 patients but conferred no survival advantage. Complete response to preoperative chemotherapy was associated with squamous cell pathological features and excellent performance status as measured by preanesthesia evaluation. CONCLUSIONS: The addition of NT did not increase perioperative morbidity or mortality. Only the subset of patients who had a complete response to preoperative chemotherapy showed a survival advantage. Excellent performance status and squamous cell pathological features were associated with an increased chance of complete pathological response following preoperative chemotherapy.     

Endoscopically guided balloon dilatation of benign esophageal strictures in 6 cats and 7 dogs

Benign esophageal strictures in 6 cats and 7 dogs were treated with endoscopically guided balloon dilatation. Six of 13 had a history of anesthesia within 3 weeks prior to the onset of signs; 8 animals had a single stricture, and 5 had multiple strictures, for a total of 19 strictures. Four of the 19 strictures were in the upper esophagus, 11 were in the middle esophagus, and 4 were in the lower esophagus. The luminal diameters ranged from 1 to 18 mm, with a mean of 5.1 mm. Twelve animals survived the immediate postprocedure period and had a total of 50 dilatation procedures performed; the mean number of procedures per animal was 4.2 (range, 2 to 8). Complications included mild bleeding and tearing (11 of 13), moderate bleeding (1 of 13), and esophageal perforation (1 of 13). The cat with the perforation was subsequently euthanized. Follow-up information was available on the 12 remaining animals; 9 were known to be alive 6 to 59 months (mean, 28.2 months) after dilatation. Two were euthanized, 1 for persistence of signs and the other for unrelated causes. One animal died of possible aspiration pneumonia. Three of 13 animals had complete and 9 had partial resolution of signs. Of the 9 animals with partial resolution, 7 were substantially better with dietary modification, 1 was moderately better, and 1 had minimal improvement. Eleven of 13 animals (85%) had a successful outcome with moderate to complete resolution of signs. Thus, it is concluded that endoscopically guided balloon dilatation is an effective and relatively safe treatment for benign esophageal strictures in dogs and cats.     

Massive hemorrhage caused by a perforating Gianturco-Z stent resulting in an aortoesophageal fistula

Squamous cell carcinoma of the tonsil has a relatively poor prognosis. Aggressive surgery, radiation therapy and combinations of irradiation and surgery have been employed but there exists some controversy about the efficacy of these treatment modalities. The purpose of this paper is to compare the efficacy of treatment between the surgery followed by radiation therapy and the preoperative radiation therapy followed by surgical resection. The medical records of 33 patients treated for squamous cell carcinoma of the tonsil at the Department of Otolaryngology-Head and Neck Surgery, Korea University Hospital between 1989-1993 were reviewed retrospectively. None of the patients were stage I, but stage II, III, and IV were four, five, and 24 patients, respectively. There were 30 males and three females. The most common histopathology was moderately differentiated squamous cell carcinoma (20/33). The 13 patients treated initially with surgery had an overall three-year survival rate of 38.5%, and the rate for the 20 patients treated initially with radiation was 40%. The main pattern of treatment failure was a local recurrence and neck metastases, and pathologic differentiation thought to be an important prognostic factor. Complications are fewer in patients treated initially with surgery (23.1%) than patients initially treated with radiation (50.0%). There is no difference in the efficacy between the two therapeutic groups.     

A case of spontaneous aorto-caval fistula demonstrated with spiral computerized tomography

A primitive neuroectodermal tumor (PNET) is very rare and the prognosis of this tumor is poor. A 32-year-old woman complaining of dysphagia and back pain was admitted to our hospital for the posterior mediastinal tumor. The tumor originated from the muscle layer of esophagus and en bloc resection of the tumor combined with the affected part of esophagus was performed. Histopathological diagnosis of the resected tumor was PNET. She received adjuvant chemotherapy. Eight months after the surgery, recurrent tumors in the right mediastinum and the retrooperitoneal space was resected completely. But after the second surgery, dissemination occurred recurrently. These recurrent tumors revealed high sensitivity for radio-therapy. However, she died of rapid recurrence 22 months after the first surgery. In Japan, our case is the second case of PNET in the posterior mediastinum and the first case of PNET arising from the muscle layer of esophagus.     

Percutaneous endoscopic gastrostomy to treat upside-down stomach before stent insertion in a patient with distal esophageal carcinoma

A 89-yr-old woman presenting with dysphagia due to an obstructing adenocarcinoma of the distal esophagus was additionally diagnosed to have an upside-down stomach creating a sharp angulation at the esophagogastric junction. Gastric anatomy had to be restored before palliative stent insertion. As the patient was judged unfit for surgery, the stomach was repositioned endoscopically and fixed to the abdominal wall by percutaneous endoscopic gastrostomy. In the same sitting, a metal stent was placed. Effective palliation of dysphagia was achieved until the patient died of an unrelated cause 5 months later.     

Simultaneous endoluminal dilatation and conventional surgery. Importance of programmed revascularization of the legs

OBJECTIVE: evaluate the benefit of synchronous arterial reconstruction and endoluminal balloon dilatation for occlusive arterial disease during non-urgent procedures. METHOD: late results of forty arterial reconstructions combining open surgery with simultaneous endoluminal dilatation have been reviewed. Balloon dilatation was performed on iliac (N = 18), femoral (N = 18), popliteal (N = 3) and infra-popliteal arteries (N = 2). Reasons were rapidity in 31 cases, local reasons in five cases (such as brievity of available vein for bypass), heavy operative risk in two cases and partial failure of transluminal angioplasty in two cases. RESULTS: during the first post-operative month, there were one death (due to sepsis) and two reocclusions (one of the dilated artery and the other of the bypass). They were successfully reoperated. At the moment of the study, the mean follow-up being thirty months, seven patients are deceaded (six of them from intercurrent disease), one has been amputated, three suffer intermittent claudication and twenty-nine are cured (but eight of them have been reoperated). CONCLUSION: synchronous arterial reconstruction and transluminal dilatation are a good option in case of multiple arterial occlusive disease particularly in poor risk patients and when inflow or outflow of bypasses should be improved. Associated balloon dilatation is very useful in case of too short vein graft or arterial stenosis due to a clamp injury. Nowadays in our department, these combined procedures are more and more frequent One stage procedure is associated with less complications, shorter length of hospitalization and lower cost.