Endoscopic treatment of tracheobronchial malignancy. Experience with Nd-YAG and CO2 lasers in 506 operations

Laser technology and the endoscope have been combined for the palliation of obstructive tracheobronchial malignant lesions. The neodymium-yttrium-aluminum-garnet (Nd-YAG) laser was used to treat 249 patients (447 operations), and the CO2 laser was used on 34 patients (59 operations). Hemorrhage, the major complication in both groups of patients, was more easily controlled with the Nd-YAG laser. One patient in the CO2 laser group died, and one patient in the group being treated with Nd-YAG laser bronchoscopy died. The Nd-YAG laser can be applied more efficiently through a fiber system, with better optic control and secure hemostasis. The commonest indications for treatment were dyspnea, obstructive pneumonia, and hemoptysis. Extrinsic compression was the most frequent reason for failure. The Nd-YAG laser, most often applied through open rigid bronchoscopes under general anesthesia, has become our treatment of choice for the palliation of tracheobronchial malignancy.     

Experience of Nd-YAG laser treatment in roentogenographically occult bronchogenic squamous cell carcinoma]

Out of 201 patients with roentogenographically occult bronchogenic squamous cell carcinoma, 165 lesions underwent surgical operations, while 41 lesions underwent non-invasive therapy. The 5-year survival rate including all causes of death, was significantly higher in the surgical operation group than that in the non-invasive therapy group (83% vs 43%). Among 14 cases who received Nd-YAG laser treatment, one case died but 4 cases are alive bearing cancer. Since time span of follow-up period is short, it is hard to say that the prognosis of the Nd-YAG laser therapy in fair. Nd-YAG laser treatments were effective for cancers which did not invade beyond bronchial cartilage. From the bronchoscopic examinations and studies with resected lungs, we suggest that Nd-YAG laser treatments may be effective when cancer is extended within 10 mm wide and has only a slight findings in bronchoscopy.     

Endoscopic Nd-YAG laser treatment of tracheobronchial lesions]

Eight cases treated with Nd-YAG laser via fiberoptic bronchoscopy were studied. Four of them were primary lung cancer, one was tracheal invasion of thyroid cancer and three were postintubation lesions of trachea. In six cases, Nd-YAG laser treatment was effective for enlargement of the airway lumen and improvement of their symptoms. In the cases of advanced lung cancer, not only local findings of the tumor but also clinical stage and possibility of adjuvant therapy must be considered to apply this procedure. In the cases of postintubation tracheal stenosis (except polypoid lesions), T-tube stenting or surgical reconstruction must be followed after laser treatment. Nd-YAG laser treatment can be useful for the tracheobronchial lesions such as primary tracheal tumors, lung cancer, metastatic tumors, postintubation tracheal stenosis and so on if applied precisely.     

Nd-YAG laser therapy of tracheobronchial lesions by malignant tumor]

Thirty-seven patients with tracheobronchial lesions by malignant tumor were treated with Nd-YAG laser. Thirty-seven patients were twenty-three males and fourteen females and ages ranged from 34 to 79 years. Diseases included were primary tracheal tumor in 3 cases, lung cancer in 16 (8 squamous cell carcinoma, 5 adenocarcinoma, 2 large cell carcinoma, 1 small cell carcinoma), cancer of adjacent organs in 9 (5 thyroid cancers, 4 esophageal cancers), and metastatic cancer to the lung or mediastinal lymph nodes in 9 (4 renal cell carcinoma, 2 thyroid cancer, one patient respectively, colon cancer and breast cancer). Intermittent irradiation of YAG laser was done for 0.5 second at 30-40 Watt through flexible bronchoscope under local anesthesia. It was repeated 1 to 41 times (mean 4.1 times) and energy amount was 148 Joules to 18,513 Joules (mean 3,305 J). The result was; stenosis disappeared in 22 cases (59.4%), improved in 14 (37.8%), and in one case YAG laser therapy discontinued due to intractable bleeding. The Nd-YAG laser therapy for tracheobronchial lesions by malignant tumor is very useful to improve dyspnea or atelectasis.     

Preliminary experience with an 810 nm wavelength diode laser in ENT surgery

The 810 nm diode laser delivers light with similar physical characteristics to the 1064 nm neodymium-yttrium aluminium garnet (Nd-YAG) laser. The diode laser was used in 25 ENT operations instead of the Nd-YAG laser. The laser has worked well and is a suitable surgical alternative to the Nd-YAG laser, with substantial advantages in terms of reliability and low cost ownership. The system size is 391×387 × 160 mm, and it weighs only 11 kg. The high efficiency of the laser diodes allows the system to be run from a standard wall socket electrical supply of less than 1 amp.     

Uvulopalatopharyngoplasty with CO2, contact ND-YAG or combined CO2 and ND-YAG laser beams

Three different surgical lasers, ie CO₂, contact Nd-YAG and Combolaser (combined simultaneous and co-axial CO₂+Nd-YAG laser beam), were used for 76 uvulopalatopharyngoplasty (UPPP) operations. The effects of different lasers on intra-operative bleeding, operation time and post-operative pain were compared. Sixty patients with obstructive sleep apnoea syndrome (OSAS) and 16 patients with socially disturbing snoring were operated on. The CO₂ laser was used in 24 patients, contact Nd-YAG was used in 27 patients and Combolaser was used in 25 patients. The Combolaser was associated with significantly less intra-operative bleeding and a shorter operation time. During the immediate recovery period, post-operative pain was most mild after operations with the CO₂ laser when graded according to need for analgesics, or by the patients' subjective evaluation. Concerning possible post-operative complaints or overall outcome of the UPPP operation, no differences were found between the lasers.     

Endoscopic Nd-YAG laser therapy and tracheobronchial surgery]

We applied endoscopic Nd-YAG laser therapy to eight cases before the tracheobronchial surgery (six lung cancers and two metastatic tracheal tumors). The preoperative application of Nd-YAG laser is a useful choice for the release of air way stenosis, the defining the border of tumor extension and the securing endotracheal intubation for anesthesia. More cases come into the category of surgical indication when Nd-YAG laser is applied, combined with chemotherapy and/or radiation. Preoperative evaluation of the limit of tracheobronchial resection as well as the method of the reconstruction are essential, however, the precise line of the dissection should be determined by knowing the histological finding of the resected by during the operation to make sure of the operative radicality.     

Experimental and clinical use of the YAG laser in the management of pulmonary neoplasms.

Animal experiments were performed with evaluation of the use of the neodymium-YAG (yttrium-aluminum-garnet) laser in the trachea, bronchi, and pulmonary parenchyma. Histologic evaluation of incisions into the lung was assessed by multiple sections over a 5-week period and comparisons were made of incisions closed with chronic catgut or coagulated with electric cautery or by the laser. These studies indicated that the laser is more effective in controlling parenchymal bleeding and air leaks than either the cautery or chromic catgut and produces less local tissue reaction. The Nd-YAG laser has been used clinically to treat patients with inoperable obstructing and bleeding carcinomas of the trachea and main bronchi to open the involved airway and to restore pulmonary function. Fifteen patients have had 26 treatments using the Nd-YAG laser. Total laser time was limited to 15 minutes with 0.5-second pulses of 50 to 80 watts being delivered via the fiberoptic and straight bronchoscope as indicated. It is extremely effective in controlling hemoptysis from recurrent endobronchial lesions, and obstructing lesions in the trachea and main stem bronchus can be treated quite successfully with excellent palliation. It is apparent that continued clinical use of the Nd-YAG laser as palliative therapy for bleeding and obstructing tumors of the tracheobronchial tree is indicated and expanded use at the time of thoracotomy to control lung parenchymal bleeding and air leaks should be considered in the future.     

Endobronchial Neurogenic Tumors Treated by Transbronchial Electrical Snaring and Nd-YAG Laser Abrasion: Report of Three Cases

Neurogenic benign tumors arising from the trachea and bronchus are relatively rare. We experienced three cases of neurofibroma of the bronchus which were successfully treated by transbronchial electrical snaring and Nd-YAG laser abrasion. The first was a 67-year-old man with right lung cancer, who was pointed out to have a neurofibroma in the left main bronchus. The second was a 34-year-old man with an obstruction in the right main bronchus due to neurofibroma. The third was a 66-year-old woman with a complete obstruction in the left main bronchus due to schwannoma. All patients were successfully treated to remove the tumors and obtain a patency of the bronchus by transbronchial electrical snaring and Nd-YAG laser abrasion. We also review 23 reported cases of endobronchial neurogenic tumors and discuss the efficacy of endoscopic treatments for endobronchial neurogenic tumors.     

Nd-YAG laser for general surgery

We report here our clinical experiences with Nd-YAG laser on general surgery, and evaluate the results of this procedure. From December 1979 to December 1981, we applied Nd-YAG laser to various operations as a hemostatic and cutting tool. For hemostasis, we used conventional quartz fiber which was covered with sterile tube, and hemostatic efficacy was examined especially in the subcutaneous bleeding and the bleeding from solid organs. For cutting, we used special devices, ie, Medilas YAG surgical probe (noncontact-type probe), and a laser blade (contact-type probe), and performed four liver resections. It is concluded that the hemostatic efficacy of Nd-YAG laser to various bleeders was proved in general surgical procedures, and furthermore this laser can cut tissue if we utilize these devices. When comparing these two devices, we would prefer the contact-type probe.     

A controlled trial of Nd-YAG laser vs photodynamic therapy for advanced malignant bronchial obstruction

A prospective randomized study was set up to evaluate the efficacy of photodynamic therapy (PDT) compared with Neodymium Yttrium Aluminium Garnet (Nd-YAG) laser used endoscopically in patients with stage III inoperable lung cancer and substantial (>50%) endobronchial luminal obstruction: of the 26 patients in the study 11 were allocated to Nd-YAG laser treatment (Group I) and 15 to PDT (Group II). Patients were assessed clinically, radiologically, functinally and endoscopically before and at 1 monthly intervals after treatment for 3 months, then 3 monthly when applicable. Age, sex, pulmonary function and mean percentage of bronchial luminal opening before treatment were comparable in the two groups, and not statistically different. At 1 month after treatment all patients had subjective amelioration of their symptoms and objectively responded to treatment by a substantial increase in bronchial luminal opening. There was however a significantly greater improvement in the PDT (Group II) than the Nd-YAG laser treatment Group I (p<0.0006). The bronchial disobliteration was attended by improvement in pulmonary function which again was significantly greater in Group II (PDT) than in Group I (Nd-YAG). It was concluded that endoscopic PDT in patients with extensive lung cancer and major airway obstruction is more effective than Nd-YAG laser treatment.     

The effectiveness of the Nd-YAG laser in destroying superficial bladder tumours

Fifty-five bladder tumours, in 12 patients, were treated by coagulation using the neodymium-yttrium aluminium garnet (Nd-YAG) laser. All the tumours were superficial, grade I or II, and varied in size from 5 to 30 mm. Laser energy was applied using a quartz-fibre delivery system via a rigid cystoscope under general anaesthesia. Up to ten tumours were treated at any one cystoscopy. One patient underwent transurethral resection of tumours larger than 30 mm combined with laser coagulation of smaller lesions. Fifty-four tumours were completely destroyed by the laser. Six patients (50%) had recurrent tumours on review cystoscopies performed one to eight months after the initial treatment. However, only one tumour was found at the site of previous laser coagulation, indicating incomplete tumour destruction. This was successfully eradicated by a further laser coagulation. Coagulation of superficial bladder tumours with Nd-YAG laser energy during rigid cystoscopy under general anaesthesia is therefore an effective treatment for superficial non-invasive bladder tumours, although the recurrence rate is unaffected.     

Endoscopic management of post-traumatic prostatic and supraprostatic strictures using Neodymium-YAG laser.

We assessed the feasibility, efficacy and long-term results of endoscopic management using Neodymium-YAG (Nd-YAG) laser as a day care procedure in patients with post-traumatic supraprostatic and prostatic strictures. Three patients with post-traumatic prostatic and supraprostatic obliterative strictures underwent Nd-YAG laser core through urethrotomy as a day care procedure. Patient age ranged between 12 and 14 years. Mean duration of injury was 16 months. The length of stricture was assessed by bi-directional endoscopy prior to the procedure in all cases. Core through procedure was carried out using Nd-YAG laser under the guidance of a cystoscope placed antegradely. Patients were discharged on the same day with urethral catheter. Foley catheters were removed at 6 weeks. Nd-YAG laser core through procedure was carried out successfully in all cases with negligible blood loss in a mean time of 48 min. There were no intraoperative or postoperative complications. Patients were discharged on the same day. Follow-up cystogram was conducted at 6 weeks and urethroscopy at months. At a mean follow-up of 23 months, patients were asymptomatic and voiding well. Nd-YAG laser core through urethrotomy is a safe and effective procedure. It is a less invasive alternative to more complex urethroplasty procedures for patients with post-traumatic prostatic and supraprostatic strictures. It can be carried out as a day care procedure in carefully selected patients and has no complications.     

Nd-YAG laser treatment of primary and recurrent pilonidal sinus

A pilonidal sinus usually contains hair and extensive vascularization due to inflammation, which theoretically gives Nd-YAG laser waves the potential to destroy the deep fistula systems of the sinus without affecting the overlying skin. We describe our preliminary experience with Nd-YAG laser waves in the treatment of pilonidal sinus. A total of 41 consecutive patients with pilonidal sinus underwent the intended Nd-YAG laser treatment. Structured telephone interviews were carried out in 37 patients (90%). The median duration of treatment and observation time were 5.1 months and 15.2 months, respectively. Three patients (7%) received additional surgery: two had granulomas removed via a minor excision, and one requested more traditional surgery. At follow-up, 28 out of the 37 patients (75.7%) reported freedom from symptoms without supplementary treatment, and 30 (81%) were symptom-free after supplementary laser treatment and minimal surgery, if needed. We have identified a potential treatment for pilonidal sinus that is extremely gentle compared with conventional surgery. We aim to substantially increase the cohort of patients undergoing this treatment and follow up these patients with a register-based technique with a comparable control group. The Nd-YAG laser may prove to be an attractive treatment alternative for pilonidal sinus.     

Endoscopic Nd-YAG laser treatment and adjuvant therapy of metastatic lesions of airway

Endoscopic Nd-YAG laser treatment and adjuvant therapy were performed in 44 cases with metastatic lesions of airway. The best results were obtained in 31 cases (93.9%) out of 33 cases complaining of ventilatory disturbance in which endoscopic Nd-YAG laser treatment was indicated as an emergency procedure. In most of these cases with metastatic lesions of airway consisted of respiratory tract invasion from mediastinal lymph nodes in cases of esophageal cancer or lung cancer. In these cases, after laser treatment for ventilatory disturbance, the patients condition improved to the extent that adjuvant therapy could be performed. Adjuvant therapy was performed in 38 cases, there were 7 cases treated surgically (resection of the metastatic lesions of airway in 3 cases, tracheal tube stent operation in 4 cases 0, 28 radiotherapy in 28 cases (Linac irradiation in 24 cases, 60Co intraluminal irradiation of the trachea in 4 cases 0, and 32 cases were treated with chemotherapy. Tracheal tube stent operation was useful for maintenance of the tracheal lumen following laser treatment, and 60Co intraluminal irradiation was effective for the residual intratracheal tumor. The 1-year survival rate of 44 cases with metastatic lesions of airway was 42% and the 2-year survival rate was 22%, so this result suggested endoscopic Nd-YAG laser treatment and adjuvant therapy for metastatic lesions of airway was useful to prolong survival time. However the main value of this modality is for the rapid relief of severe ventilatory disturbance due to obstructive airway lesions.     

Separate and combined use of Nd-YAG and carbon dioxide lasers in liver resections: A preliminary report

A series of 15 patients have undergone liver resection by laser, 10 by use of the carbon dioxide laser alone, one with the neodymium-doped yttrium aluminium garnet laser (Nd-YAG) alone, and four with combined use. Partial and anatomical liver resections have been done without mortality or haemorrhagic complications, although initial haemostasis was always difficult with the CO₂ laser alone. Bile leakage occurred in four patients, but it stopped spontaneously in three. Histology showed a necrotic zone less than 2 mm deep when the CO₂ laser was used alone, but the zone was 5–6 mm deep with the Nd-YAG laser and 1.6–1.8 mm deep when the two were used in combination. Thus, the most effective cutting, with good haemostasis and minimum damage to the underlying liver, was achieved with the combined lasers. A precise superposition of the two spots was achieved with a new handpiece prototype.     

Therapeutic application of Nd-YAG laser treatment for the chest surgery area]

Laser therapy is now a well-established procedure and an accepted method of treatment in thoracic surgery. Therefore, using Nd-YAG laser (Model Md-50 Y) at hospital, we had discussed for the technique and its indication of laser therapeutic application against chest diseases. The following results were obtained; 1) The first object of endoscopic laser therapy is to keep the normal air-way from tracheobronchial stenosis or its bleeding as fast as possible. 2) As this laser techniques are not only the quick expansion of the residual lung but also relative absence of air-leak and blood loss, they are indicated for open lung biopsy or partial resection of metastatic lung tumors, particularly in patients with poor pulmonary function. 3) In conjunction with standard surgical technique of chest surgery, this laser treatment provides numerous other possibilities which facilitate the achievement of the therapeutic goal of surgical operation on the lungs.     

Application of the Nd-YAG laser for surgical resection of pulmonary metastases]

We used Nd-YAG laser equipment for operations on pulmonary metastatic tumors in order to preserve the residual pulmonary functions simultaneously with local curability by utilizing the features of the contact and non-contact types of equipment. The subjects were patients showing no lymph node metastasis in the preoperative diagnosis. The equipment used was Nd-YAG laser model 6,000 with a surgical probe and contact tip attached. Thoracotomy was performed by a method involving minimum invasion in accordance with the tumor localization to prevent reduction of the postoperative respiratory function as much as possible. An incision was made in the pleura and lung using the contact tip with an output of about 25 Watts with the surgical margin separated sufficiently from the tumor, and the tumor was resected. Coagulative hemostasis was apt to occur in the small vessels. To eliminate postoperative hemostasis and residual tumors, non-contact type irradiation was performed at the surgical margin at an output of about 50-70 Watts. Finally, the pleura were sutured. This method has been used so far on 10 cases of pulmonary metastatic tumors, and in all cases, the amount of hemorrhaging during the operation was small, the operating time was short and the postoperative reduction in respiratory function was slight. In cases of bilateral multiple pulmonary metastases, as many as 30 resections were performed, but no recurrences have been seen in any of the cases to date. Although the usefulness of this method still cannot be confirmed because of the small number of cases involved, this method seems promising from the standpoints of local curability and preservation of pulmonary functions.     

Longterm comparison of soft palate scars after UPPP made by CO2, contact Nd-YAG or combined CO2 and Nd-YAG laser beams

C0₂ laser, contact Nd-YAG laser and Combolaser (combined CO₂ and Nd-YAG laser beam) vary distinctively in the way they interact with target tissue. To study the quality of mature scars produced by these lasers, the ultrastructure and amount of collagen in soft palate scars after 60 uvulopalatopharyngoplasty (UPPP) operations were analysed. The CO₂ laser was used in 19, contact Nd-YAG in 21 and Combolaser in 20 operations. At a clinical follow-up examination carried out, on average, 51 (range 34–74) months postoperatively, a specimen was obtained from the soft palate scar for collagen analysis. Postoperative complaints of the patients were acknowledged. No differences between the laser groups were observed concerning the gross appearance of the scars or the amount and ultrastructure of collagen. Neither the frequency nor the quality of post-operative symptoms showed any differences between the lasers. Although the initial tissue effects are different, long-term remodelling produces nearly identical soft palate scars after the use of CO₂, contact Nd-YAG and Combolaser beams.     

New laser hysteroscope for neodymium-YAG endometrial ablation

A multichannel operating hysteroscope was developed for use with the Nd-YAG laser. The telescopes measure 350 mm in length, with a 4 mm outer diameter (OD), and are available with 0 degree or 30 degrees objectives. The operating sheath incorporates two isolated operating channels (2 mm OD) through which an Nd-YAG quartz fiber and an aspiratory cannula can be inserted simultaneously. The design of this instrument permits constant or intermittent aspiration of debris from the intrauterine milieu and very clear vision throughout the operative procedure. The entire cavity of the uterus may be flushed with the distending medium by injecting the liquid through the instillation channel and opening one of the two operating channels.