Prospective randomized clinical trial comparing brachytherapy and laser photoablation for palliation of esophageal cancer.

Twenty-three consecutive patients with advanced esophageal cancer were randomized to receive either endoluminal irradiation or laser photoablation treatment. Initial improvement in dysphagia scores was observed in 83% (brachytherapy) and 91% (laser). This improvement in dysphagia was maintained at 2 months in 75% (brachytherapy) and 81% (laser). Performance scores improved in 33% (brachytherapy) and 36% (laser). Both treatments were well tolerated, required a minimum of inpatient treatment time, and allowed patients to die without terminal admission to district referral centers. Retreatments were three times as common with laser therapy, but the frequency of treatment failures was equal. Minor complications, especially transient early dysphagia, was more common in the brachytherapy group, although the only major complication (perforation) occurred in the laser group. No procedure-related deaths occurred in either group.

New method for dealing with late-presenting spontaneous esophageal ruptures.

A new technique is described for dealing with late-presenting spontaneous esophageal ruptures. This method requires only a short period of general anesthesia to drain the periesophageal abscess by a drainage tube inserted into the abscess cavity from the esophagus with the aid of a gastroscope and fluoroscopy. Gastric fluids are diverted from the esophageal rupture with a gastrostomy, and a jejunostomy is used for enteral feeding. The esophagus is retained, and closure of the fistula with resumption of normal swallowing is documented with serial sinograms.

Flexible bronchoscopy via the laryngeal mask: a new technique.

Malignant tracheal tumours often cause airway obstruction and this may be aggravated by vocal cord paralysis due to invasion of the recurrent laryngeal nerve. Conventional endoscopic techniques performed under general anaesthesia do not give a simultaneous view of vocal cord function and the distal airways. The technique of bronchoscopy via the laryngeal mask allowed full assessment of the cause of stridor in a patient with a malignant tracheal tumour that was causing airways obstruction and vocal cord paralysis.

Self adjusting stent in the management of malignant tracheo-oesophageal fistula.

The development of a malignant oesophago-respiratory fistula is a distressing situation which often leads to an early death. Dissatisfaction with the high levels of mortality and morbidity associated with the surgical bypass procedures, coupled with the failure of many of the oesophageal tubes, to completely occlude the fistula, has led to the development of a new cuffed tube (Wilson Cooke tube). This tube has the potential to not only relieve dysphagia but also to occlude the fistula without risk of pressure necrosis.

Laser photoresection in the preoperative assessment of a bronchial adenoma.

Preoperative laser photoresection of a bronchial adenoma allowed more accurate evaluation and better planning of the operative procedure.

Instrumental perforation of the esophagus in benign disease.

Over a period of seven years, a total of 1,831 endoscopic procedures were performed in patients with benign esophageal disease. These comprised flexible esophagoscopy (848), flexible esophagoscopy and dilation (924), pneumatic dilation (29), and rigid esophagoscopy (30). There were 14 episodes of perforation: 1 was cervical, 2 were abdominal, and 11 were perforations of the intrathoracic esophagus (7 occurred at or immediately above a stricture). The diagnosis was made immediately in 9 and within six hours in all but 1 patient. Treatment was emergency surgery in 12 patients, 2 of whom died. The major cause of death was respiratory failure. The overall incidence of perforation was 0.76%. The incidence of perforation was 0.35% (3/848) for flexible esophagoscopy alone, 0.38% (3/792) for dilation with Maloney mercury-weighted bougies, and 3.8% (5/132) for dilation with other bougies. Our experience indicates that instrumental perforation in benign esophageal disease carries a considerable mortality rate in spite of prompt recognition and surgical treatment. Successful dilation with mercury-weighted bougies can be achieved in 86% of benign strictures with an incidence of perforation similar to that for flexible esophagoscopy alone. Difficult strictures and the use of other bougies are associated with a tenfold higher incidence of perforation.

Fulminant cardiac tamponade: an exceedingly rare presentation of squamous carcinoma of the bronchus in a male patient.

A 49 year old man presented with near-fatal, fulminant, haemorrhagic cardiac tamponade. He responded well to emergency pericardiocentesis and subsequent investigation revealed the cause to be an unknown squamous carcinoma of the bronchus with pericardial involvement. He died 13 weeks later. Such a dramatic presentation of this type of tumour in a male patient has not been previously described.

Intracavitary irradiation in palliation of carcinoma of oesophagus and cardia.

Palliative treatment by intracavitary irradiation using the 'Selectron' has been used in 40 patients with advanced carcinoma (all histological types). Relief of dysphagia occurred in 65%. This treatment method is suggested as an effective alternative to intubation.

Pulsion intubation versus traction intubation for obstructing carcinomas of the esophagus.

Eighty-eight patients were intubated to relieve the dysphagia of malignant esophageal obstruction. Because of advanced metastatic disease or poor general condition, 49 patients could not be operated on and were intubated endoscopically. Under radiographic control, the Nottingham Introducer was used to position Atkinson or modified Celestin tubes. In 39 other patients, palliative resection could not be done or liver metastasis was found at preliminary exploration with a view to esophagectomy. In these patients, Celestin tubes were inserted by the traction technique. The pulsion intubation group was older than the traction intubation group but comparable in other respects. Hospital stay was significantly shorter for the pulsion intubation group (8.4 versus 18.6 days). Hospital mortality rates were comparable (14.3% in the pulsion intubation group versus 23.1% in the traction intubation group), and survival did not differ (93 days in the pulsion intubation group versus 137 days in the traction intubation group). Overall complication rates were similar, but there were two significant differences: (1) wound infection or dehiscence was a major problem in the traction intubation group, occurring in 23% of the patients; and (2) tube obstruction or displacement occurred more frequently in the pulsion intubation group (18.3% versus 5.1%) but did not constitute a serious problem. Perforation occurred in 4 patients (8.2%) in the pulsion intubation group but was fatal in only 1. Pulsion intubation offers distinct advantages over traction intubation in that hospital stay is decreased and morbidity reduced.

Use of autosuture during oesophageal and pharyngeal diverticulectomy.

Although autostapling for the gastrointestinal tract is well established, some doubt exists over whether such techniques are suitable for the closure of diverticula consisting of mucosa alone. Seven cases of pharyngeal pouch and 2 cases of oesophageal diverticulum were treated by excision and closure using a stapling device. This has proved to be a satisfactory method of closure when appropriate-size staples are used.