A case of malignant gastric outlet stenosis palliated with self-expandable metallic stent and responding to TS-1, an oral fluorouracil derivative

We report a case of advanced gastric cancer with antral stenosis that responded to an oral anticancer agent, TS-1, after metallic stent insertion. A 59 year-old man was admitted to our hospital because of abdominal distension and vomiting after meals. The diagnosis was advanced gastric cancer with antral stenosis and multiple liver metastases. FP therapy (CDDP 80 mg/m2 day 1 div, 5-FU 700 mg/m2 day 1-5 continuous div) was administered. Although endoscopic findings showed improvement after the first course, the condition of the patient did not improve. We therefore inserted a self-expandable metallic stent into the antral stenosis. After implantation, the patient was able to have regular meals, leave the hospital and return to work. TS-1 (120 mg daily), an oral fluorouracil derivative, was administered in the outpatient setting. A partial response (PR) was obtained after 2 courses with regression of multiple liver metastases and the primary tumor.     

Self-expandable metallic stent for palliation of unresectable esophagogastric malignancies

While self-expandable metallic stents (EMS) have been reported to be useful for palliation of unresectable esophagogastric malignancies, complications accompanying such stenting also have been pointed out. Both advantages and disadvantages of EMS stenting are discussed on the basis of 25 cases of esophageal cancer and 5 cases of gastric cancer treated in our institute. Although dysphagia improved in 26 of the 30 patients with stenosis, only 14 of the patients who had been able to ingest more than 1,200 kcal of food could be discharged to their homes. Complications were noted in 12 (48%) of the esophageal cancer patients and 4 (80%) of the gastric cancer patients, including incomplete sealing of esophagorespiratory fistula in 6, tumor ingrown in 3, mucosal hyperplasia in 2, stent migration in 2 and reflux of digestive juice in 1. The patients with complications took food for shorter periods than those who had no complications. Successful patient outcomes can be achieved by the prevention of complications accompanying stenting and mastering the techniques to overcome those complications described above.     

A case report of esophageal cancer with tracheoesophageal fistula--improving the quality of life by using a covered self-expandable metallic stent

We present the case of a 64-year-old male who was diagnosed with esophageal cancer with tracheal invasion and distant lymph node metastases, and he received chemoradiation therapy. The therapy resulted in complete remission. However, he was unable to eat anything because of missed swallowing caused by a large tracheoesophageal fistula. The placement of a covered self-expandable metallic stent (SEMS) improved his quality of life and palliated dysphagia for 3 months. Stenting in the cervical or upper esophagus may cause discomfort. However, the placement of a covered SEMS is one of the useful palliative treatments for esophageal cancer with tracheoesophageal fistula.     

Self-expandable covered metallic esophageal stent impregnated with beta-emitting radionuclide: an experimental study in canine esophagus

PURPOSE: A specially designed self-expandable covered metallic stent impregnated with the beta-emitting radioisotope 166Ho (166Ho, energy: 1.85 and 1.76 MeV, T12: 26.8 h) was developed at our institute for the purpose of intraluminal palliative brachytherapy, as well as for treating malignant esophageal stricture and swallowing difficulty. The aim of this study was to evaluate the tissue response to brachytherapy and the safety of the radioactive metallic stent with regard to the normal canine esophagus before clinical application. METHODS AND MATERIALS: 166Ho was impregnated into the polyurethane membrane (50 micron thickness) covering the outer surface of a self-expandable metallic stent (diameter, 18 mm; length, 40 mm). Stents with radioactivity 4.0-7.8 mCi (Group A, n = 15), 1.0-1.8 mCi (Group B, n = 5), and 0.5-0.7 mCi (Group C, n = 5) were placed in the esophagi of 25 healthy beagle dogs, and the stents were tightly anchored surgically to prevent migration. The estimated radiation dose calculated by Monte Carlo simulation was 194-383 Gy in Group A, 48-90 Gy in Group B, and 23-32 Gy in Group C. The dogs were killed 8-12 weeks after insertion of the stents, and histologic examinations of the esophageal walls were performed. RESULTS: In Group A, 3 of 15 dogs died of wound infection, so specimens were obtained from only 12 dogs; all 12 cases showed esophageal stricture with mucosal ulceration. Microscopically, severe fibrosis and degeneration of the muscular propria were found in 3 dogs, complete fibrosis of the entire esophageal wall was found in 7 dogs, and esophageal fibrosis with radiation damage within periesophageal soft tissue was found in 2 dogs. However, esophageal perforation did not develop, despite extremely high radiation doses. In Group B, glandular atrophy and submucosal fibrosis were found, but the muscular layer was intact. In Group C, no histologic change was found in 3 dogs, but submucosal inflammation and glandular atrophy with intact mucosa were found in 2 dogs. CONCLUSIONS: A radioactive, self-expandable covered metallic stent can be used as an alternative therapeutic modality for the palliative treatment of malignant esophageal stricture.     

Usefulness of esophageal stenting by using a covered self-expandable metallic stent for esophagorespiratory fistula associated with esophageal carcinoma

We report three cases of esophagorespiratory fistula associated with esophageal carcinoma successfully treated with esophageal stenting by using a covered self-expandable metallic stent (SEMS). All three cases had advanced esophageal carcinoma at middle thoracic esophagus with esophagorespiratory fistula at the level of esophageal carcinoma. Case 1 is a 58-year-old man who had lung abscess due to esophagopulmonary fistula caused after induction chemoradiotherapy. He underwent a surgical resection of the affected lung and intraoperative esophageal stenting with dietary intake starting on day 26 after stenting. Case 2 is a 60-year-old man with esophagopulmonary fistula caused after primary chemotherapy. He started to take an oral intake on day 3 after esophageal stenting. Case 3 is a 68-year-old man with esophagobronchial fistula detected at the first medical examination. He started to take an oral diet on day 7 after esophageal stenting. All three cases had a rapid improvement of respiratory symptoms, pneumonia and malnutrition by esophageal stenting leading to marked improvement of impaired general condition. Esophageal stenting is a useful method for palliation of esophageal carcinoma with respiratory fistula.     

A patient with bile duct cancer who showed rapid obstruction after insertion of a non covered stent, but in this case obtained a stent opening and better QOL after reinsertion of a covered stent

A 73-year-old man is presented with jaundice. Dynamic CT showed a papillary mass in the common bile duct. Percutaneous transhepatic cholangiography revealed a filling defect in the middle common bile duct. Poorly differentiated adenocarcinoma was demonstrated from a papillary mass in the common bile duct by biopsy specimens obtained under p. ercutaneous transhepatic cholangioscopy. Based on these findings, upper to middle bile duct cancer was diagnosed. An unresectable tumor was defined by involving the main portal vein and common hepatic artery at surgical exploration. A non-covered expandable metallic stent was placed 8 days after the operation. However, since contrast radiography showed tumor protrusion in the stent next day after the insertion, a covered stent was placed. Stent obstruction did not occur, and the patient was discharged from the hospital with a good quality of life. A covered stent can be more potentially and clinically effective than a non-covered stent especially for a papillary tumor in the bile duct.     

A case of carcinoma of the esophagogastric junction with marked eosinophil infiltration

A case of carcinoma of the esophagogastric junction with marked eosinophil infiltration is reported. The patient was a 56-year-old man. He had complained of abdominal discomfort for three months. After examination, a total gastrectomy was performed. Carcinoma of Borrmann III type was found at the esophagogastric junction. Pathohistological findings showed that mucinous adenocarcinoma and marked eosinophil infiltration were present in the primary lesion and metastatic lymph nodes, but there was no evidence of eosinophilia. These results suggested that the tumor might produce eosinophil chemotactic factor. However, the factor could not be detected.     

A case of recurrent gall bladder cancer responding to chemotherapy with gemcitabine after endoscopic metallic biliary stent implantation

A 71-year-old male complaining of jaundice was referred to our hospital. He had undergone cholecystectomy for gall bladder cancer. Computed tomography showed the biliary duct was obstructed by recurrent gall bladder cancer at the hepatic hilum. After endoscopic metallic biliary stent implantation, gemcitabine(700 mg/m(2) day)was administered once a week for two weeks followed by a week of no treatment. After three courses of the chemotherapy, computed tomography showed that the tumor at the hepatic hilum was no longer visible and that the serum CA19-9 level was reduced to normal. Grade 2 appetite loss and grade 3 neutropenia were observed as adverse reactions to the treatment. Gemcitabine therapy after endoscopic intervention was safe and effective in this case of recurrent gall bladder cancer with obstructive jaundice.     

人工胃底折叠重建His角的抗反流作用——附食管胃连接部癌102例分析

目的探讨人工胃底折叠重建His角预防食管胃连接部癌根治术后吻合口反流的价值。方法食管胃连接部癌根治术中利用人工胃底折叠重建His角，使其接近恢复食管胃连接部的生理解剖。术后通过上消化道造影及胃镜检查来评定其抗反流效果。结果实验组51例，无手术死亡，无吻合口狭窄及吻合口瘘，上下切缘均无癌残留。其中6例有反流症状，反流发生率11．8％；对照组51例，有反流者22例，反流发生率43．1％。两组反流发生率差别有统计学意义（P〈0．001）。结论该术式具有较好的抗反流作用，且具有操作简单、安全等优点。     

A case of adenocarcinoma of the esophagogastric junction successfully treated with chemoradiation therapy

The patient was an 80-year-old female with chief complaint of anemia. She was diagnosed as a type 3 gastric cancer (por/tub2) of the esophagogastric junction by gastrointestinal endoscopy in November 2010. CT scan revealed no distant metastasis and we diagnosed as c-stage II B (T4aN0M0). However, severe COPD was detected by the respiratory function test. Considering her age and respiratory function, we decided that total gastrectomy under general anesthesia was difficult. She was treated with radiation( 50.4 Gy/28 Fr) and the combination chemotherapy of S-1( 80 mg/m2, day 1-21) plus low-dose CDDP (6 mg/m2, day 1-5, 8-12, 15-19) during her hospitalization, and treated with S-1 mono-therapy as an outpatient. The tumor was reduced and the hemorrhage was not seen though the response was SD. Moreover, she did not experience any adverse event of grade 3 or more. The chemoradiation therapy appears to be effective for patients of adenocarcinoma of the esophagogastric junction.     

A case of rapidly growing recurrent thyroid carcinoma performed tracheobronchial expandable metallic stent (EMS) therapy

The case is a 60-year-old female who underwent an operation as a right lobectomy of the thyroid and the resection of neck enlarged cystic lymph nodes in 2006. Pathological results were adenomatous goiter and the metastatic lymph nodes of papillary thyroid carcinoma. The primary lesion of thyroid carcinoma was not found. In four years after the operation, the local recurrence with anaplastic formation of the tumor occurred and tracheobronchial expandable metallic stent( EMS) therapy was performed to the tracheal stenosis. But she died of rapidly enlargement of the anaplastic thyroid carcinoma in two months after stent therapy. It was necessary to observe this case severely after the first operation because the primary lesion of the thyroid carcinoma was not resected. The tracheobronchial EMS therapy was effective to the respiratory failure for a short-term caused by the tracheal stenosis of the thyroid anaplastic carcinoma.     

食管带膜自扩金属支架姑息治疗晚期食管癌

目的：观察和评价Ｇｉａｎｔｕｒｃｏ－Ｚ食管带膜自扩金属支架姑息治疗晚期食管癌吞咽梗阻或合并食管呼吸道瘘／纵隔瘘的疗效及并发症。材料和方法：在Ｘ光及金属食管镜指引下，应用Ｇｉａｎｔｕｒｃｏ－Ｚ食管带膜金属支架姑息治疗晚期食管癌１５例，其中６例合并食管呼吸道瘘，２例食管纵隔瘘。食管扩张器扩张后，安放入支架１６个，长６～１４ｃｍ，直径１８ｍｍ。结果：全部支架安放成功，进入预定位置，支架扩张满意。吞咽困难评级（０～４级）平均从３．３８±０．４０级降至１．１３±０．１４级，食管呼吸道瘘／纵隔瘘被阻断，生活质量评分（Ｋａｒｎｏｆｓｋｙ评分）平均提高２８．４±５．１２。无出血穿孔等严重并发症，６例出现短期胸骨后痛，１例支架下端肿瘤过长，需安放与第一个支架部分重叠的第２个支架。随访至１９９７年３月，１２例死亡，平均生存４．１０±０．８２月，２例仍存活分别已生存４、３月。结论：Ｇｉａｎｔｕｒｃｏ－Ｚ食管带膜自扩金属支架用于姑息治疗恶性食管梗阻，食管呼吸道瘘／纵隔瘘，操作简单、安全、姑息效果好，并发症少，生活质量明显提高。     

颞骨恶性肿瘤15例的临床分析

目的：探讨颞骨恶性肿瘤的临床诊断和治疗。方法：回顾性分析我科1989年1月～2001年12月间收治的15例颞骨恶性肿瘤患的临床资料。结果：66．7％的颞骨恶性肿瘤患有慢性中耳炎病史；根据其不同的临床分期采用单纯手术、手术加术后放疗的治疗方法，用生命表法计算，总的5年生存率为44．5％。Ⅰ组、Ⅱ组、Ⅲ组和Ⅳ组的5年生存率分别为100％、66．7％、33．33％和25．7％。1例胚胎性横纹肌肉瘤和1例成骨肉瘤术后1年内死亡。结论：颞骨恶性肿瘤的早期诊断可以提高疗效；对颞骨恶性肿瘤的病因、临床分期及治疗等还有待进一步的探讨。     

A case of delayed colonic perforation after metallic stent placement for advanced descending colon cancer during bevacizumab-based chemotherapy

A 73-year-old man with advanced descending colon cancer and peritoneal metastases underwent a self-expandable metallic stent placement under fluoroscopic guidance on October 2007. The stent placement was successful without early complication. After 6 courses of FOLFOX4 followed by 7 courses of FOLFIRI, he received Bevacizumab-based chemotherapy from August 2008. In April 2009, he was admitted to our hospital with severe abdominal pain due to perforation of descending colon. Although emergent surgery was performed, he developed DIC and died on the 21 postoperative days. This case suggests that metallic stent placement for colorectal cancer cases might increase the risk of bowel perforation during Bevacizumab-based chemotherapy.     

Evaluation of the endoprosthesis by metallic stent and tube stent for malignant biliary stenosis

We evaluated the effect of biliary endoprotheses for 20 malignant stenosis patients by an expandable metallic stent and hydrophilic heparinized tube (H-PSD) connected to an implantable port (IP), which reduces bacterial adherence. Group A consisted of 6 patients of cholangiocarcinoma who underwent hepatic arterial infusion chemotherapy associated with radiotherapy. Groups B and C consisted of 8 and 6 patients of stage IVa and IVb pancreatic carcinoma, respectively, who underwent hepatic and splenic arterial infusion chemotherapy following transcatheter peripancreatic arterial embolization. The 50% patent time was 12 months, 6 months and 7 months in groups A, B and C and the 50% overall survival time was 16 months, 23 months and 13 months, respectively. There were two complications, 1 case of infection around the IP in which the IP was withdrawn, and 3 cases of cholangitis in which we had easy access to the bile duct via IP. This technique appears to offer significant benefit in selecting patients with this type of biliary obstruction.     

国产覆膜支架治疗食管癌致食管-气管瘘临床观察

目的：评价国产覆膜支架治疗恶性食管一气管瘘的疗效，并对有关技术问题进行探讨。方法：全组共30例．男性18例，女性12例，年龄45～65岁，20例有放疗史。采用国产CZES-Ⅱ型覆膜食管支架，在X线电视监视下引入导丝。首先将食管狭窄处进行扩张，沿导丝插入支架输送器，支架和瘘口准确定位后，释放支架。术后定期随访，评价疗效。结果：30例中除3例瘘口未能封堵外，其余27例均放置成功（90％），植入后口服泛影葡胺证实瘘口被封堵，术后患者呛咳立即停止，恢复进食。随访1～12个月，未发现食管-气管瘘复发及支架移位。结论：采用国产覆膜食管支架治疗食管-气管瘘是一种简便、安全、有效、患者易于接受的姑息性治疗方法。