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.

Prospective randomized comparison of polyvinyl bougies and through-the-scope balloons for dilation of peptic strictures of the esophagus.

We prospectively compared the efficacy of polyvinyl bougies (Savary type) passed over a guide wire and through-the-scope balloons for the dilation of peptic esophageal strictures in a randomized study. Thirty-four patients, 17 in each treatment arm, were studied. At entry, dysphagia was assessed according to a six-point scale (0, unable to swallow; 5, normal). The end-point for dilation was to size 45F or 15 mm. Discomfort during the procedure was graded on a four-point scale (0, no discomfort; 1, mild; 2, moderate; 3, severe discomfort). Follow-up visits were at 1 week, 1 month, 3 months, and every 3 months thereafter for 2 years. At the 1-week visit, the size of esophageal lumen was measured by 8-, 10-, and 12-mm pills. Both devices effectively relieved dysphagia. By life-table analysis, stricture recurrence during the first year of follow-up was similar in both groups, but during the second year, the risk of recurrence was significantly lower in patients whose strictures were dilated with balloons. Other advantages of balloons included the need for fewer treatment sessions to achieve the defined end-diameter for dilation (1.1 + 0.1 versus 1.7 + 0.2, p < .05), and less procedural discomfort (p < .05). The differences in luminal size after dilation, measured by the barium pill test, were not significant. Ability to pass the 12-mm pill and absence of dysphagia were correlated. Our results indicate that both devices are effective in relieving dysphagia, but balloons may have a long-term advantage.

Clinical applications of nuclear medicine in gastroenterology.

Nuclear medicine (NM) has traditionally been a non-nursing field. This specialty has grown rapidly and continues to expand. Most nurses have had very limited exposure to nuclear medicine, except in the area of patient preparation for the nuclear medicine department. Because this specialty has had significant advances that require patient monitoring in many diagnostic and therapeutic procedures, nurses will benefit by learning more about this field and by equipping themselves to care for pre- and postprocedural patients. This article is an overview of the nuclear medicine process and its most common clinical applications in the GI field as they relate to nursing practice.

A scoring system to predict rebleeding after endoscopic therapy of nonvariceal upper gastrointestinal hemorrhage, with a comparison of heat probe and ethanol injection.

We prospectively and randomly compared heat probe and ethanol injection in 80 patients with major nonvariceal upper gastrointestinal hemorrhage who were bleeding actively or had endoscopic stigmata associated with a high risk for rebleeding. We also attempted to predict which patients would rebleed within 72 h after successful endoscopic therapy, using a three-component scoring system. Heat probe and ethanol injection proved to be similar in efficacy and safety. Active bleeding was controlled with equal success with heat probe and ethanol injection (92% vs. 82%), and there was no difference in the rebleeding rate (11% vs. 13%). The scoring system was useful in predicting which patients would rebleed. Significant differences were seen in the mean values of all three scores, and specific cut-offs in the pre-endoscopy and post-endoscopy scores predicted patients who rebled. High likelihood ratios and post-test probabilities for rebleeding were found for the number and severity of concurrent illnesses, but not for endoscopic stigmata, implying that the excess risk associated with stigmata is eliminated after effective endoscopic therapy, and clinical factors become the primary determinants of rebleeding.

A new approach to esophageal varices: endoscopic variceal ligation.

Bleeding from esophageal varices is a devastating complication of portal hypertension and is associated with a high mortality rate. The management goals for this group of patients are to achieve hemostasis in the acute phase, reduce variceal size, reduce the potential of rebleeding and eliminate varices with a follow-up program. For the past two decades, the gold standard of treatment has been endoscopic sclerotherapy but at the expense of many complications, which often cause serious morbidity. Endoscopic variceal ligation was developed as an alternative to endoscopic sclerotherapy. The experience to date shows that the goals of therapy can be achieved with fewer complications than those associated with sclerotherapy.

Endoscopic variceal ligation in patients who have failed endoscopic sclerotherapy.

Endoscopic variceal ligation has been developed as an alternative to endoscopic sclerotherapy. We report a series of 12 men with a history of bleeding esophageal varices who were treated with endoscopic variceal ligation after they had failed sclerotherapy. Hemostasis was achieved in all 10 patients who were bleeding at the time of initial endoscopy and again in those who subsequently re-bled. Over a follow-up period of up to 22 months, varices have been and remain eradicated in five patients; in four others, a reduction in grade was noted before death (two patients), liver transplant, or loss to follow-up (one patient each); two patients died before they could be re-evaluated, while in the remaining patient, no reduction in variceal grade was noted before loss to follow-up. No complication was recorded after 35 endoscopic treatment sessions involving a total of 245 rubber band ligations. Our results indicate that endoscopic variceal ligation may be used with success in patients who fail sclerotherapy.