Analysis of 153 deaths after upper gastrointestinal endoscopy: room for improvement?

BACKGROUND: Upper gastrointestinal (GI) endoscopy is a widely used procedure that is generally considered to be safe. METHODS: Of a total of 33,854 patients who underwent upper gastrointestinal endoscopy during 1999 under the care of surgeons in Scotland, 153 (0.004%) died. We reviewed the case notes of these 153 patients. RESULTS: Death was directly related to endoscopy in 20 of 153 cases (13%), most commonly due to gastrointestinal perforation or acute pancreatitis. Ninety-one percent (139) of the patients undergoing endoscopy were American Society of Anesthesiologists grades (ASA) 3-5, and 88% received intravenous sedation; an anesthetist was present in 31 cases (20%). Oxygen was administered to 45% of patients during the endoscopy. In 56% of the procedures, there was monitoring of electrocardiograms (ECG), pulse oximetry, or blood pressure readings. CONCLUSIONS: Although deaths after endoscopy may be unavoidable, clinicians undertaking upper GI endoscopy or endoscopic retrograde cholangiopancreatography (ERCP) in ASA 3-5 patients should provide oxygen therapy and cardiovascular monitoring, and keep accurate records. The involvement of an anesthetist in airway management and the administration of intravenous sedation should be actively considered.

Total body irradiation for bone marrow transplantation in Edinburgh: techniques, dosimetry and results.

Total body irradiation, as practiced in Edinburgh as part of the preparation for bone marrow transplantation, is described as regards prescription, techniques, physical data and dosimetry. Clinical results are briefly summarised in terms of disease, status at transplant, survival figures, survival times and causes of death.

Early delayed radiation injury to the brainstem after radiotherapy for lymphoma of the tongue and neck.

We describe a case of severe early delayed radiation injury to the brainstem after curative radiotherapy using a standard therapeutic irradiation regimen for lymphoma of the base of the tongue with cervical lymphadenopathy. Magnetic resonance imaging showed a lesion in the brainstem corresponding to an area of neural tissue coincidentally irradiated. A literature review of this rare complication is presented.

Lomustine, vindesine and bleomycin (LVB) used in the treatment of relapsed advanced Hodgkin's disease. A prospective study on behalf of the East of Scotland and Newcastle Lymphoma Group (ESNLG).

Sixty-three patients with relapsed advanced Hodgkin's disease were treated with lomustine (CCNU), vindesine and bleomycin (LVB). Age range was 17-72 years, with 38 males and 25 females. Thirty patients achieved complete remission (CR) with a median duration of 24+ months (range 3-55). Nineteen continue in unmaintained CR. CR rates were highest for those patients who relapsed greater than 6 months after first line treatment and for those at second or subsequent relapse. CR rates were higher in those with nodal only relapse. Twenty-seven patients were non-responders and six were partial responders. These 33 patients were subsequently changed to alternative chemotherapeutic regimes and 26 failed to respond to any therapy and have since died. Only one patient is in unmaintained complete remission. The regimen was well tolerated by patients, and easy to administer. It produced no serious episodes of toxicity. We conclude that LVB is of value in the management of relapsed advanced Hodgkin's disease especially in chronic relapsing patients, and where relapse occurs greater than 6 months after the first line treatment. We are presently unsure whether it offers any advantage over reintroduction of first line treatment in the latter group.

Influence of therapy on local control and survival in stage I and II intermediate and high grade non-Hodgkin's lymphoma.

In a consecutive series of 113 patients with localized (Stage I and II) intermediate and high grade non-Hodgkin's lymphoma we have retrospectively analysed patterns of survival and relapse in relation to presenting features and therapy. Two patients were treated by complete surgical excision. Seventy-two were treated by radiotherapy (RT), 19 by chemotherapy (CT) and 20 by combined CT and RT. A number of different chemotherapy combinations were employed. Overall survival for Stage I patients was 68.3% at 5 years and 65.5% at 10 years; for Stage II patients it was 61.2% at 5 years and 52.2% at 10 years. Recurrence-free survival for Stage I patients was 51.4% at 5 years and 42.1% at 10 years; for Stage II patients it was 46.2% at both 5 and 10 years. Local control by radiation was achieved in 59/72 (82%) patients treated with less than 40 Gy and 19/20 (95%) treated with 40 Gy or more. There was no advantage for extended field irradiation when compared with involved field. Eleven of 19 (58%) patients treated by CT alone achieved complete response (CR). For patients responding completely to CT there was no clear advantage for irradiation of originally involved bulky sites. For patients with Stage II and bulky Stage I disease there was a significant (P = 0.05) improvement in recurrence-free survival (RFS) and a trend (P = 0.192) towards improved overall survival for patients treated by CT alone or together with RT compared with RT alone. Independent variables identified by multivariate analysis were age, with better survival for younger patients (P = 0.034) and histopathological group, with better survival for DPDL compared with DH (P = 0.015).

Low grade stage I and II non-Hodgkin's lymphoma: results of treatment and relapse pattern following therapy.

Sixty-four patients (37 stage I and 27 stage II) with low grade non-Hodgkin's lymphoma were treated by surgical excision alone (two patients) or with radiotherapy (53 patients), chemotherapy (five patients) or both (four patients). Actuarial survival was 80.7% at 5 years and 77.9% at 10 years. Actuarial recurrence-free survival at 10 years was 49.4% for stage I and 38.0% for stage II patients. Local control was achieved in 52 out of 56 (93%) patients treated with a radiation dose of 30 Gy or greater. There was no advantage for extended compared with involved, field irradiation. A multivariate analysis identified age, sex, stage and disease site as independent prognostic variables for survival.

Early clinical experience with bleomycin in the United Kingdom in series of 105 patients.

The results of treating a series of 105 patients (79 with advanced squamous cell carcinoma, 21 with advanced lymphoma, and 5 with miscellaneous tumours) with bleomycin are described. The drug was usually given as a single agent. Four patients with squamous cell carcinoma showed complete regression and there was partial regression in 25. Side effects were frequent, particularly skin changes and stomatitis; death from pneumonitis occurred in one patient.