Tracheoesophageal Fistula Closed by Chemoradiotherapy in Lung Cancer

A 45-year-old man complaining of cough, dyspnea, and difficulty in swallowing was referred to our hospital. Chest CT scan showed a mediastinal mass compressing the trachea. He was diagnosed with poorly differentiated lung carcinoma by percutaneous needle biopsy. Bronchoscopy and upper gastrointestinal endoscopy revealed a tracheoesophageal fistula (TEF). Long-lasting febrile neutropenia made it impossible to continue chemotherapy, but a course of radiotherapy (total 61 Gy) was completed. The next endoscopy revealed closure of the TEF. Chemoradiotherapy (CRT) has been reported to close TEF in esophageal cancer, but the risk of a CRT-induced worsening of the fistula has dissuaded physicians from using CRT to treat TEF in lung cancer patients. CRT may serve as a palliative treatment for TEF in lung cancer as well as esophageal cancer.Key words: Chemoradiotherapy, Lung carcinoma, Tracheoesophageal fistula     

Tracheoesophageal fistula developing during chemotherapy for non-Hodgkins lymphoma

Lymphoma is an unusual cause of tracheoesophageal fistula (TEF). Most fistulas develop after radiation therapy and are a rare occurrence in patients treated with chemotherapy alone. The presence of a TEF is usually indicative of active lymphoma. This report describes a tracheoesophageal fistula that developed during chemotherapy for diffuse large cell lymphoma. © 1996 Wiley-Liss, Inc.     

Endonasal endoscopic dacryocystorhinostomy: our experience

Objectives

To study the outcome of endonasal endoscopic dacryocystorhinostomy (DCR) with or without mucosal flap preservation, without mitomycin local application, silicon tube stenting or laser assistance. To determine the duration of the surgical procedure of DCR, influence of simultaneously performed endonasal endoscopic procedures for concomitant sinonasal diseases.

Methods

Combined retrospective and prospective study in our tertiary referral center. 24 patients with chronic dacryocystitis underwent 25 standard endonasal endoscopic DCR procedures, 10 with and 15 without mucosal flap preservation. 6 of these had concomitant sinonasal diseases for which they underwent septoplasty or functional endoscopic sinus surgery (FESS) or both, simultaneously or as staged procedures. Relief from epiphora and patency of the nasolacrimal fistula was assessed by nasal endoscopy and syringing of the lacrimal apparatus at 1 week, 3 weeks and 3 months postoperatively.

Results

Out of 18 patients who underwent only DCR, 17 patients (94.44%) had complete relief from epiphora. Out of 6 patients who underwent 7 DCRs with concomitant sinonasal surgery, 5 patients (85.71%) had complete relief from epiphora. Overall 23 out of 25 DCRs (92%) had complete relief. In 15 of the 25 procedures, mucosal flap was excised completely. In remaining 10 procedures, flap was trimmed, repositioned to cover exposed bone around the newly created nasolacrimal fistula. In either situation, only one patient each had partial block of the nasolacrimal fistula. Average duration of the surgical procedure of DCR was 18 min.

Conclusion

Endonasal endoscopic DCR is a viable alternative to external DCR, co-existing sinonasal diseases can be managed simultaneously, as may be required in 25% of cases. It can be performed under 20 min without mucosal flap preservation, mitomycin local application, silicon tube stenting or laser assistance and can still provide a good success rate (92%) with less complications.     

Use of an Amplatzer Device for Endoscopic Closure of a Large Bronchopleural Fistula following Lobectomy for a Stage I Squamous Cell Carcinoma

Bronchopleural fistulas can occur as a rare but severe complication after pulmonary resection. Established guidelines for the proper treatment of patients with bronchopleural fistulas do not exist. Apart from attempts to close the fistula, emphasis is placed on preventive measures, early treatment with antibiotics, drainage of the empyema and aggressive nutritional and rehabilitative support. For inoperable patients, endoscopic procedures are the only therapeutic option. Unfortunately, large (>8 mm) or central bronchopleural fistulas are usually not suitable for such endoscopic management. Recently, some groups have published a few case reports about a novel technique for the endobronchial closure of bronchopleural fistulas, using an Amplatzer device, originally designed for transcatheter closure of cardiac septal defects. We applied the same technique as a life-saving treatment in a ventilated patient who was considered inoperable due to a high oxygen need. The operation was successful. The patient could be weaned from ventilation and was eventually discharged from the hospital to a rehabilitation facility several weeks after the insertion of the device. Until now, endoscopic techniques have only been useful for the treatment of small, peripheral, bronchopleural fistulas and even then only as a bridge to surgery in high-risk surgical patients. In this case report, we demonstrate that the use of an Amplatzer device can expand the importance of endoscopic techniques in the treatment of bronchopleural fistulas. An Amplatzer device, for endobronchial closure, can indeed be administered for large and central bronchopleural fistulas. Moreover, it can be considered as a definite alternative to surgery in inoperable patients.Key Words: Bronchopleural fistula, Amplatzer device, Endoscopic closure, Lung cancer     

Endoscopic techniques to diagnose and manage biliary tumors.

Malignancies of the bile duct are often suspected in patients with abnormal serum hepatic enzyme levels and obstruction of the biliary system. Although cross-sectional imaging can provide evidence for biliary obstruction and a malignancy arising from the bile duct, a definitive diagnosis is often obtained through the use of endoscopic procedures. Endoscopic retrograde cholangiopancreatography (ERCP), the most commonly performed procedure for cholangiocarcinoma, can provide a tissue diagnosis through brush cytology of the bile duct. Relief from biliary obstruction can be provided with temporary plastic stenting or permanent metal stenting. Photodynamic therapy guided by ERCP may provide improved palliation from biliary obstruction in the future. Endoscopic ultrasonography complements the role of ERCP and may provide a tissue diagnosis through fine-needle aspiration and staging through ultrasound imaging. High-resolution ultrasound images can provide detailed information regarding the relationship between a mass and the bile duct wall. Despite these advances in endoscopic techniques and imaging of the bile duct, a tissue diagnosis often remains elusive in many patients. In the future, molecular markers will be employed to improve the sensitivity for the detection of malignancy in bile duct samples obtained through brushing, aspiration, and biopsy.     

A modified prosthesis for the treatment of malignant esophagotracheal fistula

Esophagotracheal fistula is usually a sequela of irradiation or laser treatment of advanced carcinoma of the esophagus or the tracheobronchial tree. Resection of the tumor in these cases is not possible, and palliative bypass surgery is highly risky. The peroral placement of a prosthesis is less invasive, but conventional prostheses often fail to occlude the fistula. The authors regularly use an endoscopic multiple-diameter bougie for dilation. After dilation, a specially designed prosthesis is pushed through the tumor stenosis to block the fistula. This procedure can be done without general anesthesia. The funnels of conventional prostheses cannot cover the fistula when there is either a wide, proximal esophagus above the fistula or a high fistula. To cope with this particular situation, a special fistula funnel was developed. It perfectly occludes the fistulas in all patients. Of 21 patients, 19 were discharged without further aspiration.     

Review: Malignant tracheo-esophageal fistula: Use of esophageal endoprosthesis

Malignant tracheo-esophageal fistula (TEF) is a serious complication of cancer arising usually in the esophagus, lung, or tracheobronchial tree. Repeated aspiration and pneumonia lead to rapid deterioration and death. The prognosis is dismal and curative resections are curiosities. Surgical bypass of the lesion has been performed but is associated with 25–61% mortality. Other treatments have been employed, such as enterostomies, esophageal endoprostheses, and supportive care. The reported mortality of palliative procedures using endoprostheses, surgical bypass, or exclusion is almost identical. A retrospective review of the data over the past decade revealed a trend toward insertion of endoprostheses. Insertion of endoprostheses can be performed in an endoscopy suite, under sedation, and has fewer major complications than occur with a surgical approach. The periprocedure mortality rate for these patients is 15%, compared to a 29–47% perioperative mortality for patients undergoing surgery. Even so, patients after surgical procedures could survive for 8 months or more, which is better than survival after endoprosthesis intubation. We conclude that insertion of an esophageal endoprosthesis should be the usual preferred option for palliative treatment of malignant TEF. However, for special candidates a surgical procedure is a valid option. © 1996 Wiley-Liss, Inc.     

Self-expanding metal stents in gastrointestinal interventional radiology: technical problems

AIMS AND BACKGROUND: To analyze the procedural difficulties in the placement of metal stents in stenoses of the digestive tract and optimize the technique. METHODS: Twenty-nine patients with digestive tract stenoses were treated from January 1999 to December 2004. In 14 cases the stricture was anastomotic (9 colorectal, 3 esophageal, 1 gastroesophageal and 1 gastrojejunal), in 13 esophageal, in 1 gastric and in 1 duodenal. The stenosis was due to scarring in 5 patients and was malignant in 24 patients (primary in 17 cases and secondary in 7 cases). RESULTS: The procedure achieved technical success in all cases but 2. For each of the different segments the technical difficulties and the adopted procedural solutions were analyzed. CONCLUSIONS: The interventional radiology approach yielded results comparable to those reported for the endoscopic method and was always well tolerated. The need to rely on materials mostly designed for endoscopic use can make radiological use difficult in some cases.     

Potential diagnostic and prognostic significance of the transformation-enhancing factor(s) in the plasma cryoprecipitate of tumor patients

A biological activity which enhances cell transformation (TEF) in Rous sarcoma virus temperature-sensitive mutant-infected cultures has been evidenced in the plasma cryoprecipitate from patients affected with different types of neoplastic disease. In the present paper we report data on the analysis of TEF activity in the plasma cryoprecipitates from leukemic and tumor patients tested either before or during specific antineoplastic treatments. The screening of 57 cases of different neoplastic diseases and of 57 controls, healthy subjects or patients affected with other non-neoplastic diseases indicates that TEF activity is generally related to the presence of neoplasia. Furthermore, a follow-up of patients from the onset of the disease through its evolution during therapy suggests that variations of TEF activity in the plasma cryoprecipitate correlate well with the clinical and pathological conditions, thus indicating the TEF as a potential marker for monitoring cancer patients.     

Laser Assisted Double-Layer Endoscopic Repair of Laryngeal Clefts: Our Experience in 11 Cases

Laryngeal cleft is a rare congenital malformation of the respiratory tract leading to a high level of morbidity and mortality, recently being diagnosed with increased frequency. Management throughout the years included medical and surgical. The open surgical technique is more commonly used although it has higher risk and need longer post-operative care. Recently surgical endoscopic repair was introduced using different techniques. To evaluate the clinical features of infants and children presenting with laryngeal clefts, and review endoscopic management modality especially the technique and results of repair using double-layer (2 layers) technique. Outlining our experience with the surgical technique, complications arising from surgery as well as surgical outcome by evaluating the decannulation rate and cessation of the assisted feeding by the end of treatment. Retrospective case series study. Review of infant and children seen in our clinic with the diagnosis of laryngeal cleft from January 2012 till June 2014., and treated by CO₂ laser assisted double-layer endoscopic closure. The presenting symptoms, patient demographics, diagnostic procedure, cleft type, surgical outcome and complications all were evaluated. We revised the case notes of 34 patients with a workable diagnosis of Laryngeal cleft. A total of 11 patients met our criteria and were included in the study. Clefts typing was according to modified Benjamin–Ingles classification, type 1 (n = 9) and type 2 (n = 2). All clefts were closed endoscopically by CO₂ laser incision of the mucosa and two-layer endoscopic closure of the cleft without postoperative intubation or tracheotomy. They accepted oral feeding within 5 postoperative days (range 3–11 days). 5 out of 6 patients (83.3%) successfully stopped nasogastric feeding and 1 out of 2 patients successfully weaned from nasal cannula. One patient deceased few months after surgery due to other medical problems. Two patients needed redo after burst of the upper cleft stitches immediately after repair by iatrogenic cause during suctioning. The repair was stable in all patients during the second look 6 weeks after surgery with no recurrence or fistula formed. There were no clinically significant observed complications with this technique. After a mean follow up of 24 months, all children have a good voice, have no sign of residual aspiration, and less hospital admissions. Laryngeal cleft should be suspected in children presenting with recurrent pneumonia and difficulties during feeding. Endoscopic repair is a successful and safe technique for treating laryngeal clefts, and has short post-operative recovery without postoperative intubation or tracheotomy. Using the double-layer technique appeared to be promising but needs more comparative studies in the future.     

Endoscopic argon plasma coagulation for palliative treatment of malignant airway obstructions: early results in 47 cases.

Argon plasma coagulation (APC) is a new method of non-contact electrocoagulation, using high frequency current by means of ionized argon gas (argon plasma). Recently, this technique has become available for flexible endoscopic delivery through special probes. Aim of this study is to evaluate the efficacy, indications and the possible side effects of APC use in the palliative treatment of malignant airway obstructions and/or bleeding. Over a 24-month period, 47 patients underwent APC treatment for malignant neoplasms of the tracheobronchial system causing obstruction and/or recurrent bleeding. Immediate airway patency and haemostasis were obtained in 91.5% of cases (43/47). No complications or side effects caused by the treatment were observed. In two patients, the treatment allowed a radical surgical approach after induction chemotherapy. In all cases, APC proved to be highly effective and easy to perform. In our experience, APC has proven to be easy to perform, rapidly effective, safe and well tolerated by the patient, even after repeated application. This study highlights the value of endoscopic APC in the palliative management of tracheobronchial neoplasms.     

Breast cancer

Endoscopic breast conserving surgery was developed originally in JAPAN. Minimally invasive technique improved cosmetic shape of breast conserving surgery by reducing the size of scar and changing the position of surgical wounds. In the present time, transaxillary endoscopic partial mastectomy by using special lifting systems, transaxillary total mastectomy by using Co 2 inflation, endoscopic partial mastectomy, by areola approach, and endoscopic axillary lymphnode dissection were performed as standerd procedure. The clinical results were showed that the efficacy of breast conserving operation were equal compared with normal procedure. As indication of breast conserving operation, patients with the tumor, that was within 3 cm, were selected, and the volume of resected specimen were also keep below 30% of total volume of breast as cosmetic indication for prevent metamorphosis of breast. In the case with metamorphosis after operation, some kind of reconstraction will be necessary. Minimally invasive breast surgery was improved cosmesis of breast surgery, and the patients with early breast cancer will take more benefits by using this technique.     

Concept of foreign body-its past and present

Endoscopic endonasal dacryocystorhinostomy [EDCR] is considered to be a superior alternative technique to the conventional external dacryocystorhinostomy [DCR], both in primary and secondary cases. It is of particular value in children and young adults as it avoids an external scar. Sixteen cases of chronic dacryo-cystitis were treated by the endoscopic technique, including 8 revision cases of failed external approach. In all cases except one, a patent nasolacrimal fistula was noted, with a success rate of 93.7%. The authors share their experience in EDCR and review the relevant literature.     

The prevention and treatment of bronchial fistulae after pulmonectomy for lung cancer]

Bronchial fistula was found in 5.4% of 542 lung cancer patients treated with pneumonectomy. A relationship between occurrence of fistula and laterality of lesion, extent of surgery, procedure for closing the bronchial stump and gender was established. Bronchial fistula was most common following right-side pneumonectomy which is accounted for by postoperative anatomic conditions. To prevent bronchial fistula formation, mechanical suturing of the bronchial stump supplemented by procedure after Sweet should be performed. The bronchial stump should be shielded with adjacent tissue, as suggested by the authors.     

Endoscopic diagnosis and treatment of upper-tract urothelial tumors. A preliminary report

The technique of transurethral ureteropyeloscopy allows many standard cystoscopic procedures to be extended into the upper urinary tract. This endoscopic method was used to evaluate 31 patients suspected to have urothelial malignancies of the ureter or renal pelvis. Twenty-eight of the patients had the procedure successfully completed (90%), 11 of whom were found to have urothelial tumors. Diagnostic ureteroscopic biopsy in three of these patients revealed high-grade, multifocal tumors and was followed by nephroureterectomy (two patients) or partial ureterectomy (one patient). However, in eight patients, ureteroscopy and biopsy revealed apparently localized, low-grade tumors which were treated by ureteroscopic fulguration or resection. The latter patients have undergone endoscopic surveillance every 3 months (average follow-up, 21 months). The technique of ureteropyeloscopy permits endoscopic access into the ureter and renal pelvis, enabling tissue diagnosis and better preoperative cancer staging without surgical exploration. Although follow-up is short, selected patients with low-grade tumors may be treated primarily by endoscopic means.     

Cytologic examination of pure pancreatic juice in the diagnosis of pancreatic carcinoma. The endoscopic retrograde intraductal catheter aspiration cytologic technique.

BACKGROUND. Although cytologic examination of pure pancreatic juice obtained with a duodenofiberscope has been useful for the diagnosis of pancreatic carcinoma, the rate of false-negative results is reported to be high. To eliminate these false-negative results, the authors developed a new technique, endoscopic retrograde intraductal catheter aspiration cytology, especially for an accurate cytologic diagnosis of carcinoma of the body or tail of the pancreas. METHODS. The accuracy of conventional cytologic examination of pure pancreatic juice was assessed in 25 patients with pancreatic carcinoma, 29 patients with pancreatitis, and 52 control subjects. Pure pancreatic juice was collected from the pancreatic duct by endoscopic cannulation using a videoimaging duodenoscope after intravenous administration of secretin. The new endoscopic retrograde intraductal catheter aspiration technique was used in four patients with carcinoma of the body or tail of the pancreas and five patients with localized pancreatitis in whom a correct diagnosis was not made by previous cytologic examination of pure pancreatic juice. RESULTS. Positive cytologic findings were obtained in 76% of the patients with pancreatic carcinoma. Positive cytologic results were more frequent in patients with carcinoma of the head of the pancreas than in those with carcinoma of the body or tail. By the new technique, positive cytologic results were obtained in all of the patients with pancreatic carcinoma. This technique caused no severe complications. CONCLUSIONS. This procedure of endoscopic retrograde intraductal catheter aspiration cytology seems useful for diagnosis of pancreatic carcinoma.     

Biweekly docetaxel,fluorouracil, leucovorin,oxaliplatin (TEF) as first-line treatment for advanced gastric cancer and adenocarcinoma of the gastroesophageal junction: safety and efficacy in a multicenter cohort

Background

Docetaxel–cisplatin-5-FU chemotherapy is superior to 5-FU-cisplatin in terms of response rate and survival in advanced gastric cancer (AGC), but is more toxic. Oxaliplatin is better tolerated than cisplatin, which it can effectively replace in this setting. We hypothesize that incorporating docetaxel into a simplified FOLFOX regimen should be a tolerable and effective option in first-line treatment of AGC.

Methods

Data were collected at six  French centers from patients with metastatic or local AGC who received docetaxel, fluorouracil, leucovorin, or oxaliplatin (TEF) as first-line treatment. TEF was administered as follows: docetaxel (50 mg/m²), oxaliplatin (85 mg/m²), and leucovorin (40 mg/m²) on day 1, and 5-FU continuous infusion for 48 h (2400 mg/m²) every 2 weeks.

Results

Forty-one patients were enrolled. Performance status was grade 0 and 1 in respectively 27 and 58 % of patients; 17 patients had adenocarcinoma of the gastroesophageal junction; 37 patients had metastatic disease, 22 had a poorly differentiated or diffuse type. Objective response rate was 66 %, with a complete response in two patients (5 %). Median progression-free survival and overall survival were respectively 6.3 and 12.1 months. Tolerability was acceptable with no treatment-related deaths. The most frequent grade 3–4 toxicities were neutropenia (30 %) and neuropathy (12.5 %). Curative intent surgery after response to TEF was performed in seven patients (17 %).

Conclusion

TEF is an effective first-line treatment with an acceptable toxicity profile for patients with AGC. It may allow curative resection in initially unresectable patients. TEF should now be evaluated in prospective randomized trials.     

Diagnostic value of upper intestinal fiber endoscopy in primary small intestinal lymphoma. A prospective study by the Tunisian-French Intestinal Lymphoma Group

To assess the diagnostic value of upper intestinal fiber endoscopy in primary small intestinal lymphomas observed in an underdeveloped Mediterranean country, the endoscopic records of 40 patients (Group A) offering histologic evidence of lymphoma were compared with those of 80 patients (Group B) displaying clinical findings of small intestinal disease, but who eventually proved to be free of lymphoma after a complete work-up. The endoscopic procedure reached the jejunum in 91% cases and was well tolerated with only one reversible complication. Five primary endoscopic patterns could be defined, occurring either alone or in various combinations. The infiltrated pattern was the most sensitive (0.80) and specific (0.96) finding with predictive positive and negative values reaching 0.88 and 0.93, followed by the nodular pattern (sensitivity 0.60, specificity 0.84). Other primary lesions (ulcerations, mosaic pattern, mucosal fold thickening alone) were either nonsensitive or nonspecific or both. The infiltrated pattern proved to be more valuable than any association of primary lesion. Per endoscopic biopsies were diagnostic of lymphoma in 85% cases. These findings strongly suggest that upper intestinal fiber endoscopy, using long ending view instruments should be the first investigation in patients suspected of small intestinal lymphoma in developing Mediterranean countries.     

Novel treatment strategy using Trafermin® consisting of bFGF for intractable pancreatic fistula following gastrectomy for gastric cancer-a case report with literature reviews

Despite recent perioperative technological advances in gastric cancer, intractable pancreatic fistula is still a major critical complication following gastrectomy and should be specifically targeted in the effort to improve postoperative outcomes. We preliminary report here a successfully treated case with intractable pancreatic fistula using Trafermin? consisting of basic fibroblast growth factor (bFGF). A 67-year-old man underwent laparoscopic proximal gastrectomy with radical lymphadenectomy for early proximal gastric cancer (pT1bN0M0). After surgery, pancreatic fistula was occurred. Pancreatic fistula persisted for three months despite of surgical and several conservative treatments. After obtaining informed consent, we started to inject 50 μg/day of Trafermin? through a drainage tube into the dehiscence of pancreas. Consequently, pancreatic fistula was successfully closed within three weeks. Our novel treatment technique is simple, rapid and not costly. If informed consent was obtained from patients with low risk of recurrences, this technique should be recommended as one of the treatment choices for intractable pancreatic fistula following curative gastrectomy for gastric cancer.     

内窥镜,Nd：YAG激光对食管癌,贲门癌梗阻的姑息治疗

1988年12月至1989年12月,我们对19例晚期食管癌、贲门癌梗阻或严重狭窄的患者,在内窥镜直视下行Nd:YAG激光治疗。其中食管癌10例,贲门癌9例;鳞状细胞癌10例,腺癌9例。治疗前,7例肿瘤已将管腔梗阻。治疗功率30～50W;每次治疗剂量900～2500J,中位治疗剂量为1500J/次;平均每例治疗3次(范围1～7次);治疗总剂量1500～7250J,中位治疗总剂量4000J。治疗后,患者均能顺利进食半流质食物,缓解期1～7月,中位缓解期为3个月。