Management of malignant biliary stricture with self-expanding metallic stent

Background: Self-expanding metallic mesh stents are designed to remain patent longer than polyethylene (PE) stents, which generally clog in 3 to 4 months. Though more expensive, metal stents may therefore be a better choice for malignant strictures. Methods: From January 1991 to October 1995, we performed ERCP in 212 patients with malignant or benign strictures, and 34 ultimately had insertion of a metallic stent. These stents were placed by the percutaneous transhepatic route in 17 patients and endoscopically in 17. Results: Metallic stent insertion was successful in each case and relieved the preoperative jaundice and cholangitis. There were no procedure-related deaths; complications were pancreatitis (one) and hemorrhage (one). Overall stent patency was 6.2 months. Three of 34 stents occluded due to tumor ingrowth at 3, 4.5, and 8 months and were treated by placing a new PE stent through the blocked metal stent. The remaining 31 stents remained patent until patient death (n= 15, mean survival = 4.9 months) or are still open (n= 16, mean patency = 12.2 months). Conclusions: Self-expanding metal stents provide effective palliation of malignant biliary strictures and should be considered an alternative to open surgery. Metal stents remain patent much longer than PE stents and usually a single session of metal stenting can palliate biliary obstruction for life. Received: 20 March 1996/Accepted: 9 May 1996     

Self-expanding Polyflex plastic stents in esophageal disease: various indications,complications, and outcomes

Background Esophageal stenting has become an important technique in the treatment of different clincal problems such as malignant or benign stenosis, anastomotic leaks after surgery, or fistulas. In this study we present our experience with the self-expanding Polyflex plastic stent in various indications, arising complications, and patient’s outcomes. Methods Over a three-year period, 35 patients underwent self-expanding Polyflex plastic stent placement for esophageal stenosis (n = 23) with 22 malignant, and for perforations, fistulas, or anastomotic leaks after surgery (n = 12). The short-term efficacy and long-term outcomes were analyzed. Results In patients with stenosis, implantation was performed without any complications in 91% (21/23). In one patient perforation occurred while passing the stenosis; in another patient the stent dislocated during the insertion procedure. Dysphagia score improved from 3.0 to 1.0 after stenting. In all patients with perforations, fistulas, or anastomotic leaks (n = 12), stents were placed successfully without any complication. Complete sealing of the mucosal defect was proven by radiography in 92% (n = 11) and healing was seen in 42% (n = 5). If indicated, stent removal was performed without any complications. Stent migration (n = 13; 37%) was the most common long-term complication. Conclusions The placement of self-expanding Polyflex plastic stents is a highly sufficient and cost-effective treatment for malignant and benign esophageal disorders. Because the long-term results were highly favorable, self-expanding plastic stent placement could be used as the initial treatment for various conditions.     

The ‘buoy’ stent: evaluation of a prototype indwelling ureteric stent in a porcine model

OBJECTIVE

To assess a prototype ureteric ‘buoy’ stent with a 10 F upper body tapering to a 3F tail, developed to potentially reduce stent‐related irritative symptoms while providing an adequate mould for healing after endopyelotomy.

MATERIALS AND METHODS

Eighteen Yucatan minipigs had the stent placed either into the intact ureter (phase I) or after Acucise proximal endoureterotomy (phase II). Buoy stents were compared to 10/7 F endopyelotomy stents and to standard 7 F stents in phases I and II, respectively. The pigs were assessed for vesico‐ureteric reflux, hydronephrosis and infection, before stent insertion and at harvest. Stents were weighed before and after placement and the removal force was measured. Pressure/flow studies, antegrade nephrostograms and specimens for histopathology from the renal pelvis, ureter and vesico‐ureteric junction (VUJ) were obtained at harvest.

RESULTS

Thirteen minipigs survived the entire study. Ureteric flow with the stents in situ was better for buoy stents than for 10/7 F stents (P < 0.005). Ureteric flow after endoureterotomy and subsequent stent removal was similar for buoy stents and standard 7 F stents. None of the stents refluxed. There was no difference between stents in removal force, weight change or incidence of hydronephrosis. At 1 and 12 weeks, buoy stents tended to produce lower histopathological alteration scores than control stents, especially at the VUJ (phase I, 2.0 vs 3.9, P = 0.092; phase II, 0.6 vs 1.7, P = 0.18).

CONCLUSIONS

The novel buoy stents are easily placed and removed via the urethra. They can cause less VUJ inflammation than standard stents while allowing for adequate ureteric flow and healing after proximal endoureterotomy.     

Is Esophageal Adenocarcinoma Occurring Late After Antireflux Surgery Due to Persistent Postoperative Reflux?

Background Gastroesophageal reflux is the main risk factor for esophageal adenocarcinoma, but there is no strong support for a protective effect of antireflux surgery. We tested the hypothesis that esophageal adenocarcinoma that develops with long latency after antireflux surgery might be due to persistent postoperative reflux. Methods A nationwide population-based case-control study in collaboration with 195 relevant Swedish hospital departments and tumor registries during the study period 1995–1997. Frequency-matched control persons were randomly selected from the population register. All study participants were personally interviewed regarding background data, exposures, symptoms, conditions, diseases, surgery, and medications. Differences between cases and controls in the occurrence of daily, long-standing antireflux medication 5 years or later after antireflux surgery were estimated using Fisher’s exact test. Results One hundred and eighty-nine out of 216 (88%) eligible cases of esophageal adenocarcinoma and 820 of 1,128 (73%) controls were prospectively enrolled. Seven (3.7%) patients and 8 controls had undergone antireflux surgery at least 5 years before the interview. All 7 case patients had Barrett’s mucosa. Four of the case patients had used postoperative antireflux medications continuously (mean duration 10.2 years), while none of the control persons reported such use (P = 0.026). There was no difference in mean body mass index between patients with and without postoperative reflux (P = 0.81). No differences between the patients and controls were found regarding age, sex, body mass index, or tobacco smoking status. Conclusions Esophageal adenocarcinoma occurring late after antireflux surgery might at least partly be due to persistent postoperative reflux. Further research is required to establish the role of antireflux surgery in the etiology of this tumor.     

Initial experience with a newly developed antirefluxive ureter stent

The objective of this study was to assess the functional efficacy of newly developed antirefluxive ureter stents (DJ), by performing immediate post-stenting cystograms on patients with acute ureteral obstruction requiring a DJ stent, and assessing stent-related symptoms by means of ureteral stent symptoms questionnaire (USSQ). Patients with acute hydronephrosis requiring internal drainage were randomized to receive either an antirefluxive DJ or a conventional DJ (7 Fr., 26 cm, polyurethane, Urovision(?), Germany). Mean stone size was 6.64 ± 3.33 and 6.5 ± 3.54 mm. Immediately after correct placement of the DJ, 200 ml of diluted contrast media was introduced into the bladder under fluoroscopic control to detect vesicoureteral reflux (VUR). Patients completed German versions of the USSQ on days 2 and 7 following stent placement, and 1 week after stent removal. The results were analyzed. 13 conventional and 16 antirefluxive stents were placed in 29 patients. Reflux was documented in eight conventionally stented patients (62.5%). Two of the 16 patients with antirefluxive stents (22%) presented reflux. 1 week after stent implantation, the mean pain value was 1.1 in the antirefluxive group and 3 in the standard group (p < 0.062). Flank pain during micturition occurred after 2 days in seven patients (58%) with standard stents and in three patients (33%) with antirefluxive stents (p < 0.23). 1 week after stent insertion, flank pain had dropped to 40% in the standard group and 11% in the antirefluxive group (p < 0.3). Our initial experience showed that the antirefluxive system might be effective in terms of reflux prevention and reduction of stent related symptoms especially during sexual intercourse.     

Left side thoracoscopically assisted gastroplasty

Laparoscopic antireflux surgery is the procedure of choice for gastroesophageal reflux disease (GERD). However, many clinicians have reservations about its application in patients with complicated GERD, notably those with esophageal shortening. In this report, we present our experience with the laparoscopic management of the shortened esophagus. A total of 235 patients with primary GERD underwent laparoscopic antireflux procedures, 38 of whom were suspected preoperatively to have a shortened esophagus. Of the 235 patients, 8 (3.4%) needed a left thoracoscopically assisted gastroplasty in addition to laparoscopic Toupet repair (n= 4) or Nissen fundoplication (n= 4). Complications included pleural effusion (n= 1), pneumothorax (n= 2), and minor atelectasis (n= 1). The average hospital stay was 3 days. Results were satisfactory in 7 of 8 patients, with a mean follow-up of 20.2 months (range, 9–34 months). The surgical management of the shortened esophagus is difficult. However, the role of minimally invasive techniques is justified. Early results are appealing, with less morbidity, satisfactory control of GERD related symptoms, and a shortened hospital stay. Received: 3 August 1999/Accepted: 10 November 1999/Online publication: 17 April 2000     

Effect of semifundoplication with subtotal gastrectomy for prevention of postoperative gastroesophageal reflux

BACKGROUND: Postgastrectomy patients often experience reflux esophagitis and a compromised quality of life. We hypothesized that reconstructive methods with antireflux procedures at operation should prevent reflux esophagitis and improve the likelihood of a better quality of life in patients after distal gastrectomy for gastric carcinoma. Our antireflux procedure was a subdiaphragmatic semifundoplication. We aim to substantiate, with objective arguments, potential advantages of Billroth I simple reconstruction versus Billroth I with semifundoplication. STUDY DESIGN: This study evaluated 60 patients who had Billroth I reconstruction with semifundoplication (30 patients; F group) and simple Billroth I reconstruction (30 patients; B group) after distal gastrectomy for gastric cancer. Assessments were made preoperatively and 6 months or later after surgical intervention. Results of the procedure, clinical evaluation (reflux symptoms), and esophageal alkaline reflux by ambulatory 24-hour pH memory were satisfactory. RESULTS: Operative evaluation time and procedural complications did not differ significantly between the two gastrectomy groups. Reflux symptoms only occurred in 12 patients in the B group. Lower esophageal sphincter pressure of patients in the B group was significantly lower than that of patients in the F group and in preoperative states (p < 0.05). The mean appearance of alkaline esophageal reflux in the F group and the B group were 2.6% and 13.6%, respectively (p < 0.01). Patients with semifundoplication had a significantly better quality of life and less physiologic regurgitation than patients with simple Billroth I. CONCLUSIONS: This study demonstrated that Billroth I reconstruction with semifundoplication for gastric cancer is not only effective for patients with a postoperative life expectancy, but also prevents reflux esophagitis after gastrectomy. We believe that our method is an effective and simple surgical option for many patients with gastric cancer.     

A prospective randomized single-blind comparison of ureteral stents composed of firm and soft polymer

PURPOSE: Ureteral stents are composed of different polymers and it is unclear if stent composition influences patient comfort. We compared the impact of stents composed of firm and soft polymer on patient health related quality of life. MATERIALS AND METHODS: A total of 130 patients requiring insertion of ureteral stents during the treatment of urinary calculi were randomized to receive a stent composed of firm (Percuflex, group 1) or soft (Contour, group 2) polymer. Patients were asked to complete the Ureteric Stent Symptoms Questionnaire, a validated instrument, at weeks 1 and 4 with the stent in situ and 4 weeks after its removal, this served as the main outcome measure. Additional assessments included difficulty in stent insertion and the need for early stent removal. RESULTS: There were 78 men and 38 women in total (61 in group 1 and 55 in group 2) with a mean age of 51 years (range 22 to 79) and no difference in age between the 2 groups (p = 0.9). Comparison of the results of the Ureteric Stent Symptoms Questionnaire survey at weeks 1 and 4 with stent in situ revealed no significant differences in the domain scores of urinary symptoms (p = 0.9 and p = 0.8), pain (p = 0.8 and p = 0.6) and general health (p = 0.6 and p = 0.4). Similarly, there were no differences in the number of days with reduced activities, work performance (p = 0.7) and sexual dysfunction between the 2 groups. A similar number of patients (8 and 7 in groups 1 and 2, respectively) required stent removal earlier than planned due to stent related symptoms. CONCLUSIONS: This randomized study showed no difference in the impact on patient quality of life between ureteral stents composed of firm or soft polymer.     

Application of rectal stents for palliation of obstructing rectosigmoid cancer

Background: The rationale of palliative endoscopic treatment is to avoid a colostomy in patients with advanced disease and limited life expectancy. This study was conducted to evaluate the role of endoscopic stent implantation for palliation of obstructing rectal cancer. Methods: Overall, 19 patients (aged 47–87 years) with nonresectable or metastatic rectal cancer were treated by stent insertion after laser recanalization or dilation. Three types of stents, i.e., plastic tubes (n= 8), self-expanding mesh stents (n= 6), and endocoil stents (n= 5), were used to maintain luminal patency. Results: Endoscopic stent implantation was successfully performed in all 19 patients. Long-term luminal patency and satisfactory bowel function were achieved in 16 of 19 patients (84%). After a median follow-up of 6 months, eight of the patients have died and eight are still alive without evidence of recurrent obstruction. Dislocation of the endoprosthesis occurred in two of eight plastic tubes and one of five mesh stents. Recurrent obstruction due to tumor ingrowth was only observed in patients treated with self-expanding mesh stents (n= 2). In spite of reinsertion and laser therapy a colostomy was required in three of 19 patients. There was no evidence of treatment failure in five patients who received endocoil stents. None of the patients experienced serious complications related to the endoscopic procedure. Conclusions: Endoscopic stent implantation seems to be a safe and efficient palliative approach to selected patients with obstructing rectal cancer. Currently, self-expanding coil stents are superior to other devices because of lower risk of dislocation and tumor ingrowth. Received: 10 May 1996/Accepted: 11 November 1996     

Long-term outcomes of laparoscopic antireflux surgery for gastroesophageal reflux disease (GERD)-related airway disorder

A strong link exists between gastroesophageal reflux disease (GERD) and airway diseases. Surgical therapy has been recommended as it is more effective than medical therapy in the short term, but there is little data on the effectiveness of surgery long-term. We analyzed the long-term response of GERD-related airway disease after laparoscopic anti-reflux surgery (LARS). Methods In 2004, we contacted 128 patients with airway symptoms and GERD who underwent laparoscopic antireflux surgery (LARS) between 12/1993 and 12/2002. At median follow-up of 53 months (19–110 mo) we studied the effects on symptoms, esophageal acid exposure, and medication use and we analyzed the data to determine predictors of successful resolution of airway symptoms. Results Cough, hoarseness, wheezing, sore throat, and dyspnea improved in 65-75% of patients. Heartburn improved in 91 % (105/116) of patients and regurgitation in 92% (90/98). The response rate for airway symptoms was the same in patients with and without heartburn. Almost every patient took proton pump inhibitors (PPIs) preoperatively (99%, 127/128) and 61% (n = 78) were taking double or triple dose. Postoperatively, 33% (n = 45) of patients were using daily anti-acid therapy but no one was on double dose. The only factor that predicted a successful surgical outcome was the presence of abnormal reflux in the pharynx as determined by 24-hour pharyngeal pH monitoring. One hundred eleven (87%) patients rated their results as excellent (n = 78, 57%) or good (n = 33, 24%). Conclusion LARS provides an effective and durable barrier to reflux, and in so doing improves GERD-related airway symptoms in ∼70% of patients and improves typical GERD symptoms in ∼90% of patients. Pharyngeal pH monitoring identifies those patients more likely to benefit from LARS, but better diagnostic tools are needed to improve the response of airway symptoms to that of typical esophageal symptoms.     

Tailoring Antireflux Surgery: A Randomized Clinical Trial

A hypothesis has been formulated that mandates the adjustment of antireflux surgery to either a total or a partial wrap depending on the motor function of the esophagus to avoid dysphagia and other obstructive complaints. This hypothesis has been tested in a randomized, clinical trial where 106 chronic gastroesophageal reflux patients were allocated to either a total Nissen-Rossetti (n= 53) or a Toupet partial posterior (n= 53) fundoplication, irrespective of their preoperative esophageal motor function. All patients were followed at least 3 years, during which time none had a relapse of moderate to severe reflux symptoms. Motor dysfunctions defined as peristaltic amplitude ≤ 30 mmHg in the distal third and failed primary peristalsis with or without > 20% simultaneous contractions were noted in 67 patients preoperatively, but these patients did not have a specific symptom profile (e.g., dominated by obstructive symptoms) nor did seven patients with “aperistaltic esophagus.” The incidence of dysphagia decreased from 20% preoperatively to 8% (mild) at 3 years after the operation with no difference between the surgical procedures. We were unable to demonstrate a relation between preoperative manometric findings and postoperative symptoms when assessed in the total group or when subdivided by the type of fundoplication (r < 0.3). Flatulence occurred more frequently among those with a total fundic wrap (p < 0.01). When patients representing motor dysfunction (see above) were specifically analyzed, we again observed no difference in outcome between those having a total or a partial fundic wrap. In conclusion, the concept of tailoring antireflux surgery based on the preoperative motor function of the esophagus in patients with chronic gastroesophageal reflux disease was not supported by the results of this clinical trial.     

Quality of Life Associated with Surgery for Esophageal Cancer: Differences between Collar and Intrathoracic Anastomoses

Postoperative survival and complication rates have traditionally been the standard parameters of outcome after oncologic surgery. In tumors with poor patient survival, such as esophageal cancer, studies about quality of life are rare. The objectives of this study were to assess outcomes in terms of quality of life in patients with esophageal cancer when investigating differences between two surgical reconstructive procedures: intrathoracic anastomosis and collar anastomosis. A total of 108 patients with esophageal cancer had undergone surgery for esophageal cancer in our department from 1992 to 2000. Median survival was 36 months with no significant differences between patients undergoing collar or intrathoracic anastomosis. After determining the survival status, questionnaires on quality of life were sent to all patients 1 to 2 years after surgery. We received data from 46 patients. The responders were divided into groups of intrathoracic anastomosis (n = 24) and collar anastomosis (n = 22). Patients with the collar anastomosis showed significantly better physical and social functioning and global health status. From the viewpoint of postoperative quality of life, reflux-related symptoms were the major problem for patients with an intrathoracic anastomosis. These symptoms cause significant insomnia and impair social and physical function. The study showed that assessing quality of life with specific and general instruments is helpful for determining the differences between surgical procedures where standard parameters such as survival have their limitations.     

Adjuvant therapies using biliary stenting for malignant biliary obstruction

The aim of this study was to analyze the patency of expandable metallic stents in malignant biliary obstruction and to evaluate the efficacy of adjuvant therapy accompanied by biliary stenting. We analyzed 29 patients in whom bile duct stenting was performed for malignant biliary obstruction. Their types of disease were: hilar ductal carcinoma (n = 8), gallbladder carcinoma (n = 11), and pancreatic carcinoma (n = 10). Initially, 46 expandable metallic stents were placed in 29 patients. In 23 of the 29 patients, adjuvant therapy was administered. Seventeen patients underwent radiotherapy, and 16 patients received various systemic chemotherapies. In principle, hyperthermia was performed twice a week, simultaneously with radiotherapy. Patient survival and the probability of stent patency were calculated using actuarial life table analysis. There was no significant difference in stent patency among the patients according to type of disease. Hyperthermia did not influence the stent patency rate. The median stent patency time was significantly greater in the chemo-radiation group than in the no-adjuvant therapy group: 182 days versus 68 days, respectively (P = 0.017). Moreover, a significant increase was seen in the median survival time in the chemo-radiation group: 261 days versus 109 days (P = 0.0337). Complications occurred in 9 patients (31.0%). Stent occlusion occurred in 6 patients (20.7%), with all of these patients managed successfully using a transhepatically placed new expandable metallic stent, employing the stent-in-stent method. Stent migration occurred in 2 patients after radiotherapy. Adjuvant therapies such as radiotherapy and systemic chemotherapy, in combination with stent insertion, resulted in an increase in the patency period of expandable metallic stents and in increased patient survival time. Received: August 18, 2000 / Accepted: December 1, 2000     

Effectiveness of laparoscopic fundoplication in relieving the symptoms of gastroesophageal reflux disease (GERD) and eliminating antireflux medical therapy

Background: Recent reports have suggested that antireflux surgery should not be advised with the expectation of elimination of medical treatment. We reviewed our results with laparoscopic fundoplication as a means of eliminating the symptoms of gastroesophageal reflux disease (GERD), improving quality of life, and freeing patients from chronic medical treatment for GERD. Methods: A total of 297 patients who underwent laparoscopic fundoplication (Nissen, n = 252; Toupet, n = 45) were followed for an average of 31.4 months. Preoperative evaluation included endoscopy, barium esophagram, esophageal manometry, and 24-h pH analysis. A preoperative and postoperative visual analogue scoring scale (0–10 severity) was used to evaluate symptoms of heartburn, regurgitation, and dysphagia. A GERD score (2–32) as described by Jamieson was also utilized. The need for GERD medications before and after surgery was assessed. Results: At 2-year follow-up, the average symptom scores decreased significantly in comparison to the preoperative values: heartburn from 8.4 to 1.7, regurgitation from 7.2 to 0.7, and dysphagia from 3.7 to 1.0. The Jamieson GERD score also decreased from 25.7 preoperatively to 4.1 postoperatively. Only 10% of patients were on proton pump inhibitors (PPI) at 2 years after surgery for typical GERD symptoms. A similar percentage of patients (8.7%) were on PPI treatment for questionable reasons, such as Barretts esophagus, sensitive stomach, and irritable bowel syndrome. Seventeen patients (5.7%) required repeat fundoplication for heartburn (n = 9), dysphagia (n = 5), and gas/bloating (n = 3). Conclusions: Laparoscopic fundoplication can successfully eliminate GERD symptoms and improve quality of life. Significant reduction in the need for chronic GERD medical treatment 2 years after antireflux surgery can be anticipated. Presented at the combined meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) and the 8th World Congress of Endoscopic Surgery, New York, NY, USA, 13–16 March 2002     

Management of acute malignant large-bowel obstruction with self-expanding metal stent

Background Colorectal stents are being used for palliation and as a “bridge to surgery” in obstructing colorectal carcinoma. The purpose of this study was to review our experience with self-expanding metal stents (SEMS) as the initial interventional approach in the management of acute malignant large bowel obstruction. Methods Between February 2002 and May 2006, 67 patients underwent the insertion of a SEMS for an obstructing malignant lesion of the left-sided colon or rectum. Results In 55 patients, the stents were placed for palliation, whereas in 12 they were placed as a bridge to surgery. Stent placement was technically successful in 92.5% (n = 62), with a clinical success rate of 88% (n = 59). Two perforations that occurred during stent placement we retreated by an emergency Hartmann operation. In intention-to-treat by stent, the peri-interventional mortality was 6% (4/67). Stent migration was reported in 3 cases (5%), and stent obstruction occurred in 8 cases (13.5%). Of the nine patients with stents successfully placed as a bridge to surgery, all underwent elective single-stage operations with no death or anastomotic complication. Conclusions Stent insertion provided an effective outcome in patients with malignant colonic obstruction as a palliative and preoperative therapy.     

Is laparoscopic refundoplication feasible in patients with failed primary open antireflux surgery?

Background: Due to the widespread availability and acceptance of minimal-access surgery, laparoscopic antireflux surgery has become the standard procedure for the treatment of severe gastroesophageal reflux disease (GERD). However, open and laparoscopic antireflux procedures sometimes result in failure, so that redosurgery is required in some cases. The aim of this prospective study was to evaluate the surgical outcome and quality of life of patients who underwent refundoplication after the failure of primary open antireflux surgery. Methods: Twenty patients with a mean age of 52 years (range, 33–69) underwent laparoscopic refundoplication after primary open antireflux surgery. Four of them had undergone surgery twice previously. Preoperative and postoperative data, including esophageal manometry, 24-h pH monitoring, and assessment of quality of life, were reviewed prospectively. Quality of life was evaluated using the Gastrointestinal Quality of Life Index (GIQLI). Results: In 18 patients (90%), the reoperation was completed successfully laparoscopically. Two others (10%) required conversion to an open procedure. One of them had an injury of the gastric wall; in the other case, severe bleeding of the spleen necessitated the conversion. The average operating time was 245 min. Preoperatively, the main symptoms were recurrent reflux in 14 cases and a combination of re-reflux and dysphagia in six cases. The anatomic findings were telescope phenomenon (n = 6), hiatal disruption (n = 10), and wrap breakdown (n = 4). Postoperatively, two patients suffered from dysphagia and required pneumatic dilatation. The lower esophageal sphincter (LES) pressure increased significantly from a preoperative value of 6.08 mmHg to 12.2 mmHg at 3 months and 11.9 mmHg at 1 year after surgery. The DeMeester score decreased from a preoperative value of 69.8 to 17.1 at 3 months and 14.6 at 1 year postoperatively. The GIQLI score increased from a preoperative value of 84.9 points to 119.6 points at 3 months and 120.1 points at 1 year. Conclusion: Laparoscopic refundoplication after the failure of a primary open intervention is an effective procedure that can be performed safely by experienced laparoscopic surgeon. The procedure yields excellent functional results and leads to significant improvement in the patient's quality of life.     

Indwelling ureteral stents: evaluation of symptoms,quality of life and utility

PURPOSE: We report the prevalence of symptoms associated with ureteral stents, their impact on health related quality of life and utility analysis based on the validation studies of the new ureteral stent symptom questionnaire (USSQ). MATERIALS AND METHODS: A total of 85 consecutive adult patients with unilateral indwelling ureteral stents who were asked to participate during the validation phases of the USSQ were considered for this analysis. They were asked to complete the USSQ and the EuroQol, a weighted utility instrument, 4 weeks after stent insertion and removal. In addition, 40 patients were asked to complete these questionnaires 1 week after stent insertion to assess the prevalence of symptoms and utility values at different times. RESULTS: Of the 85 patients 62 (73%) with a mean age of 50 years completed the necessary questionnaires. Urinary symptoms and pain that affected work performance and general health were important stent related problems. Of the patients 78% reported bothersome urinary symptoms that included storage symptoms, incontinence and hematuria. More than 80% of patients experienced stent related pain affecting daily activities, 32% reported sexual dysfunction, and 58% reported reduced work capacity and negative economic impact. The mean EuroQol utility values, which indicate patient satisfaction with treatment, were significantly reduced following stent insertion. CONCLUSION: Urinary symptoms and pain associated with indwelling ureteral stents interfere with daily activities and result in reduced quality of life in up to 80% of patients. Stents are associated with negative functional capacity and reduced utility values. The results have implications in terms of routine clinical practice, patient counseling and future stent research.     

Characterization of urinary tract symptoms and quality of life in patients with double-pig-tailed ureteral stents

ObjectivesTo prospectively assess the prevalence of urinary tract symptoms caused by indwelling ureteral stents and how they affect their quality of life using an specific questionnaire.Material and methodsA total of 100 patients with unilateral indwelling ureteral stents were asked to complete an specific questionnaire that include questions on urinary symptoms: dysuria, frequency of urination, incomplete empting, urgency, incontinence, haematuria and bother or pain associated with urinary stents affecting the daily activities of the patients. They were also asked to compete International Prostate Symptoms Score questionnaire and a question on quality of life. Pain was assessed from 0 to 10 using a VAS (visual analogic scale).Results46 men and 54 women, mean age 54 years, completed the study. Mean time after stent insertion was 6.5 weeks. The cause of the insertion was in 40% due to the size of the stone, previous to ESWL, 33% due to urinary tract obstruction, 25% due to infection, and the others after a surgical procedure. 95% of patients with stent positioning without general anesthesia complaint of pain during the procedure. 89% of patients reported bothersome urinary symptoms, named in order of frequence: nycturia, frequence voiding, incomplete empting, dysuria, urgence, haematuria and incontinence. More than 70 % of patients experienced pain that impaired daily activities, in 52% pain was located at the flank and in 47 % at the bladder. 60 % of patients signalled that they were not satisfied with their quality of life with the indwelling catheter.ConclusionsUrinary symptoms and pain related to indwelling double pig tailed ureteral stens affect the daily activities and reduces the quality of life of 60% of patients.     

SELF-EXPANDABLE METAL STENTS FOR MALIGNANT DYSPHAGIA

Background : The use of self-expandable metal stents in relieving dysphagia for patients with incurable malignant oesophageal strictures was retrospectively evaluated. Methods : Between September 1993 and August 1996, 66 male and 16 female patients with a median age of 72 years received self-expandable metal stents for malignant dysphagia. Six patients had concurrent tracheo-oesophageal fistulas. All patients were stented under sedation and stent insertion was performed under fluoroscopic guidance. Results : Stent placement was successful in 80 patients (98%). There were seven early complications (inaccurate positioning (n = 3), migration (n = 1), incomplete expansion (n = 1), intractable pain (n = 1), and perforation (n = 1)). Two complications were lethal and three were treated endoscopically. Mean dysphagia grade improved from 3.2 ± 0.7 to 1.8 ± 0.9 (P < 0.05) after implantation. All tracheo-esophageal fistulas were successfully occluded. Upon a median follow-up of 8 weeks (range: 2–20 weeks), 30 complications developed in 21 patients (tumour overgrowth (n = 15), food bolus obstruction (n = 7), tumour ingrowth (n = 2), buckling of stent (n = 2), tracheo-esophageal fistula (n = 2), bleeding (n = 1), and gastric wall herniation through metal coils (n = 1)). Median survival was 13 weeks (range: 1–82 weeks). Conclusion : Self-expandable metal stents provide useful palliation in patients with incurable malignant dysphagia.     

Pharyngeal pH monitoring better predicts a successful outcome for extraesophageal reflux symptoms after antireflux surgery

Background

Gastroesophageal reflux disease can be associated with extraesophageal symptoms (hoarseness, cough, asthma, and globus). However, these symptoms may have a multifactorial etiology. Proximal pH monitoring has been proposed as a means of identifying patients where reflux is the cause of the extraesophageal symptoms. The aim of this study was to determine whether proximal esophageal or pharyngeal pH monitoring better identified patients with extraesophageal symptoms that improved after antireflux surgery.

Methods

A retrospective chart review was performed to identify all patients who had esophageal and pharyngeal pH monitoring before an antireflux operation. A composite score was used to define an abnormal result with each test. A successful outcome was defined as improvement or resolution of extraesophageal symptoms.

Results

There were 20 patients identified. Antireflux surgery led to a successful outcome in 14 patients (70 %). Restech better identified patients with extraesophageal symptoms who had a successful outcome with antireflux surgery (12 of 14 [86 %] based on abnormal Restech versus 5 of 10 [50 %] based on abnormal proximal probe, p = 0.06). Comparing only the 15 patients who had both proximal esophageal and pharyngeal pH monitoring, Restech again better identified those who had a successful outcome with antireflux surgery (9 of 10 [90 %] based on abnormal Restech versus 5 of 10 [50 %] based on abnormal proximal probe, p = 0.05). The positive and negative predictive values for symptomatic improvement after a fundoplication were better for an abnormal Restech score than for an abnormal proximal esophageal score (80 vs. 71 % and 60 vs. 38 %, respectively). In two patients with a successful outcome, Restech was the only positive test.

Conclusions

In patients with extraesophageal reflux symptoms, proximal esophageal pH monitoring failed to identify half of the patients who had a successful outcome after antireflux surgery. In contrast, an abnormal Restech pH test was present in 90 % of patients with a successful outcome. Further, a negative Restech study more reliably indicated the absence of reflux-induced extraesophageal symptoms. Our results indicate that Restech pharyngeal pH monitoring should be utilized in the evaluation of patients with extraesophageal symptoms that may be associated with reflux disease.