RESUMEN
A 76-year-old man was admitted to our hospital with vertigo. Previously he had been extensively examined because of an increased erythrocyte sedimentation rate without any clinical symptoms. Physical examination revealed 60 mmHg blood pressure difference between the two arms. Color duplex ultrasound examination revealed bilateral extreme narrowing of the external carotid and axillobrachial artery with a dark, hypo-echoic halo around the lumen. This condition was recognized as a specific sign for giant cell arteritis (GCA), described originally in cases of temporal arteritis. The diagnosis was confirmed by biopsy of the temporal artery. In contrast to the typical cranial form of GCA -- our patient showed an unusual, bilateral large-vessel manifestation. The diagnosis was based on ultrasound images rather than on symptoms that characterize the well-known temporal form. This observation emphasizes the role of color duplex ultrasonography in the diagnosis and follow-up of GCA.
Asunto(s)
Arteria Braquial , Enfermedades de las Arterias Carótidas/diagnóstico por imagen , Enfermedades de las Arterias Carótidas/etiología , Arteria Carótida Externa , Arteritis de Células Gigantes/complicaciones , Arteritis de Células Gigantes/diagnóstico por imagen , Ultrasonografía Doppler en Color , Anciano , Humanos , MasculinoRESUMEN
After resective and reconstructive surgery in the gastrointestinal tract, oral feeding is traditionally avoided in order to minimize strain to the anastomoses and to reduce the inherent risks of the postoperatively impaired gastrointestinal motility. However, studies have given evidence that the small bowel recovers its ability to absorb nutrients almost immediately following surgery, even in the absence of peristalsis, and that early enteral feeding would preserve both the integrity of gut mucosa and its immunological function. The aim of this study was to investigate the impact of early enteral feeding on the postoperative course following oesophagectomy or oesophagogastrectomy, and reconstruction. Between May 1999 and November 2002, forty-four consecutive patients (thirty-eight males and six females; mean age 62, range 30-82) with oesophageal carcinoma (stages I-III), who had undergone radical resection and reconstruction, entered this study (early enteral feeding group; EEF). A historical group of forty-four patients (thirty-seven males and seven females; mean age 64, range 41-79; stages I-III) resected between January 1997 and March 1999 served as control (parenteral feeding group; PF). The duration of both postoperative stay in the Intensive Care Unit (ICU) and the total hospital stay, perioperative complications and the overall mortality were compared. Early enteral feeding was administered over the jejunal line of a Dobhoff tube. It started 6 h postoperatively at a rate of 10 ml/h for 6 h with stepwise increase until total enteral nutrition was achieved on day 6. In the controls oral enteral feeding was begun on day 7. If compared to the PF group, EEF patients recovered faster considering the duration of both stay in the ICU and in the hospital. There was a significant difference in the interval until the first bowel movements. No difference in overall 30 d mortality was identified. A poor nutritional status was a significant prognostic factor for an increased mortality. Early enteral feeding significantly reduces the duration of ICU treatment and total hospital stay in patients who undergo oesophagectomy or oesophagogastrectomy for oesophageal carcinoma. The mortality rate is not affected.
Asunto(s)
Infecciones Bacterianas/prevención & control , Nutrición Enteral , Neoplasias Esofágicas/dietoterapia , Neoplasias Esofágicas/cirugía , Nutrición Parenteral , Adulto , Anciano , Anciano de 80 o más Años , Estudios de Casos y Controles , Cuidados Críticos , Neoplasias Esofágicas/mortalidad , Esofagectomía , Femenino , Gastrectomía , Humanos , Masculino , Persona de Mediana Edad , Estado Nutricional , Periodo Posoperatorio , Procedimientos de Cirugía PlásticaRESUMEN
OBJECTIVE: If the colon cannot be used for reconstruction after total esophago-gastrectomy, alternatives have to be sought. METHODS: From 1990 to 2001, retrosternal jejunum loop interposition was performed in 35 patients (male/female: 29:6; mean age 59.2, range 16-83 years) due to cancer in 32 cases and to esophageal perforation in three cases. In all patients reconstruction with stomach or colon, respectively, was impossible on behalf of the underlying histology, of previous resection of the stomach and impedient colonic diseases. A jejunal segment with abundant arcades was chosen, preserving a strong, distal arteriovenous mesenteric pedicle, while 2-3 proximal mesenteric vessels were severed. The loop was pulled up retrosternally, establishing a cervical end-to-side esophagojejunostomy. A Roux-en-Y anastomosis was done in a convenient position. RESULTS: Two patients died perioperatively due to mediastinitis and consecutive multiorgan failure (one Boerhaave's syndrome, one suicidal ingestion of acid). In one case the oral part of the loop developed venous congestion and was replaced by a free jejunal transplant. The perioperative course of 32 patients was uneventful. Seventeen patients are up and well (1-8.5 years). Sixteen patients died of metastatic disease. The functional results are satisfactory. In about 50% of patients recurrent dilatations became necessary due to anastomotic scars. However, none of the patients complained about severe dysphagia. CONCLUSION: In cases of impedient colonic diseases, the pedicled, retrosternal jejunal loop with cervical anastomosis is an alternative for reconstruction after total esophagogastrectomy.
Asunto(s)
Neoplasias Esofágicas/cirugía , Esofagectomía/métodos , Gastrectomía/métodos , Yeyuno/trasplante , Neoplasias Gástricas/cirugía , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Anastomosis en-Y de Roux/métodos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Cuidados Posoperatorios/métodos , Complicaciones Posoperatorias , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
About 10% of all trauma patients sustain rib fractures. The average age is 58. Men are more often affected than women. Hemothorax, pneumothorax, and lesions of the lung are not uncommon. Very rare are injuries of the pericardium, aorta, and subclavia caused by fractured ribs. We present a very unusual case where a broken rib caused a severe diaphragmatic hemorrhage with a hemothorax and acute hypovolemia. The primary chest X-ray was thought to be without pathology. Arterial bleeding without exact localization could be found with computed tomography. Thoracotomy revealed the correct diagnosis and the cause of bleeding.
Asunto(s)
Diafragma/lesiones , Hemotórax/etiología , Fracturas de las Costillas/complicaciones , Choque/etiología , Anciano , Arterias/lesiones , Arterias/cirugía , Diagnóstico Diferencial , Diagnóstico por Imagen , Diafragma/irrigación sanguínea , Hemotórax/diagnóstico , Hemotórax/cirugía , Humanos , MasculinoRESUMEN
OBJECTIVES: The management of patients with iatrogenous, instrumentally caused esophageal disruptions is still a controversially discussed challenge for any physician. We reviewed indications, morbidity, and mortality of esophagectomy compared to less aggressive treatment schemes in the light of our single-unit experience. PATIENTS AND METHODS: We reviewed the cases of 38 consecutive patients suffering from iatrogenous esophageal disruption treated within the last 10 years at the University Medical School Graz. RESULTS: Severe sepsis was diagnosed in seventeen patients; fourteen of the seventeen patients were treated by esophagectomy followed by primary or secondary reconstruction at a mortality rate of 28.6 % (four of fourteen patients). All fourteen patients thus treated had major preexisting esophageal pathologies. In three of the total seventeen cases reviewed, conservative treatment modalities were used. The mortality rate in the non-septic group treated by direct suturing (n = 21) was 4.8 % (one of twenty-one patients). Major preexisting esophageal pathology was present in thirteen. The overall mortality was 13.2 % (five of thirty-eight patients). CONCLUSION: The strategy of primary repair for iatrogenous esophageal injury should only be adopted in patients with minor or without intrinsic esophageal disease, and in the absence of severe sepsis suggesting mediastinitis. Severe sepsis following iatrogenous esophageal trauma should prompt the decision for esophagectomy where anatomically and/or oncologically possible.
Asunto(s)
Perforación del Esófago/cirugía , Enfermedad Iatrogénica , Enfermedades del Esófago/cirugía , Perforación del Esófago/complicaciones , Perforación del Esófago/mortalidad , Esofagectomía , Esófago/diagnóstico por imagen , Esófago/cirugía , Humanos , Radiografía , Estudios Retrospectivos , Sepsis/etiologíaRESUMEN
BACKGROUND AND OBJECTIVES: Photosan, a mixture of porphyrin oligomers as sensitizer for photodynamic therapy (PDT), carry the risk of prolonged photosensitivity of the skin. New sensitizer such as 5-aminolaevulinic acid (ALA) with low rates of skin phototoxicity appear to be promising alternatives. The aim of this study was to evaluate the efficacy of ALA compared to Photosan for PDT in malignant tracheo-bronchial stenosis. Reduction of tumor stenosis, increase in quality of life, and phototoxicity were considered as primary objectives. Improvement in clinical symptoms due to reduction of tumor stenosis, for example hemotysis, dyspnea, and poststenotic pneumonia were considered as secondary objectives. PATIENTS AND METHODS: After diagnostic work-up, photosensitization was done in 16 patients with ALA (60 mg/kg BW, oral, 6-8 hours prior to PDT) and in 24 patients with Photosan (2 mg/kg BW, i.v., 48 hours before PDT). The light dose was calculated as 100 J/cm(2) tumor length. Light at 630 nm was applied using a pumped dye laser. In both groups, additional hyperbaric oxygenation was applied at a level of 2 absolute atmospheric pressure. RESULTS: Stenosis diameter and Karnofsky performance status showed a significant improvement in favor of the Photosan-group, P = 0.00073 and 0.00015, respectively. In both groups no sunburn occurred due to phototoxicity of the sensitizer. CONCLUSION: Despite the limitations of a non-randomized study, photosensitization with Photosan seems to be more effective in PDT of malignant tracheo-bronchial stenosis compared to ALA.
Asunto(s)
Ácido Aminolevulínico/uso terapéutico , Enfermedades Bronquiales/tratamiento farmacológico , Neoplasias Pulmonares/complicaciones , Fotoquimioterapia , Fármacos Fotosensibilizantes/uso terapéutico , Porfirinas/uso terapéutico , Estenosis Traqueal/tratamiento farmacológico , Adenocarcinoma/complicaciones , Anciano , Ácido Aminolevulínico/efectos adversos , Enfermedades Bronquiales/etiología , Carcinoma de Células Escamosas/complicaciones , Constricción Patológica/tratamiento farmacológico , Constricción Patológica/etiología , Disnea/etiología , Femenino , Hematoporfirinas , Humanos , Oxigenoterapia Hiperbárica , Neoplasias Pulmonares/mortalidad , Masculino , Persona de Mediana Edad , Cuidados Paliativos , Fármacos Fotosensibilizantes/efectos adversos , Proyectos Piloto , Porfirinas/efectos adversos , Estudios Prospectivos , Tasa de Supervivencia , Estenosis Traqueal/etiologíaRESUMEN
BACKGROUND AND OBJECTIVE: Polyhematoporphyrin (Photosan) as sensitizers for photodynamic therapy (PDT) in advanced esophageal cancer carry the risk of prolonged photosensitivity of the skin. New sensitizers such as 5-aminolaevulinic acid (ALA) with low rates of skin phototoxicity appear to be promising alternatives. The aim of this study was to evaluate the efficacy of ALA compared to Photosan for PDT in advanced esophageal carcinoma regarding phototoxicity of the skin, reduction of dysphagia, tumor stenosis, and tumor length and Karnovsky performance status. STUDY DESIGN/MATERIALS AND METHODS: After diagnostic work-up, photosensitization was done in 22 patients with ALA (60 mg/kg body weight, oral, 6-8 hours prior to PDT) and in 27 patients with Photosan (2 mg/kg body weight, i.v., 48 hours before PDT). The light dose was calculated as 300 J/cm fibre tip. Light at 630 nm was applied using a pumped dye laser. In both groups, additional hyperbaric oxygenation was applied at a level of 2 absolute atmospheric pressure. RESULTS: Improvement regarding dysphagia, stenosis diameter, and tumor length could be obtained in both treatment arms with a significant difference in favour of the Photosan-group, P = 0.02; P = 0.0000; and P = 0.000014, respectively. The Karnovsky performance status also improved in both groups and showed no significant difference (P = 0.12). The median survival time for the ALA-group was 8.0 months, compared with 9.0 months for the Photosan group. No sunburn or other major treatment related complication occurred in both treatment arms. Thirty-day mortality was 0%. CONCLUSION: Despite the limitations of a non-randomized study, photosensitzation with Photosan seems to be more effective in PDT of advanced esophageal carcinoma compared to ALA.
Asunto(s)
Adenocarcinoma/tratamiento farmacológico , Adenocarcinoma/mortalidad , Ácido Aminolevulínico/uso terapéutico , Carcinoma de Células Escamosas/tratamiento farmacológico , Carcinoma de Células Escamosas/mortalidad , Neoplasias Esofágicas/tratamiento farmacológico , Neoplasias Esofágicas/mortalidad , Hematoporfirinas/uso terapéutico , Fotoquimioterapia/efectos adversos , Fármacos Fotosensibilizantes/uso terapéutico , Adenocarcinoma/patología , Anciano , Anciano de 80 o más Años , Ácido Aminolevulínico/efectos adversos , Carcinoma de Células Escamosas/patología , Trastornos de Deglución/tratamiento farmacológico , Trastornos de Deglución/patología , Dermatitis Fototóxica/etiología , Neoplasias Esofágicas/patología , Femenino , Hematoporfirinas/efectos adversos , Humanos , Estado de Ejecución de Karnofsky , Masculino , Persona de Mediana Edad , Fármacos Fotosensibilizantes/efectos adversos , Proyectos Piloto , Tasa de Supervivencia , Resultado del TratamientoRESUMEN
BACKGROUND/AIMS: Boerhaave's syndrome accounts for 30-40% of esophageal disruption. The current literature regarding the management of these patients and problems in treatment remains controversial. METHODOLOGY: Between 1988 and 1998, 14 patients with Boerhaave's syndrome were treated in our unit. Five primary repairs and 9 esophagectomies were performed. A retrospective review of these patients' records was carried out. The patients were divided into two groups. Group I: minor esophageal leak, local mediastinitis and hyperdynamic septic shock. All 5 cases were treated by primary repair. Group II: moderate to severe esophageal leak, severe mediastinitis and hypodynamic septic shock. All 9 cases were treated by transthoracic esophagectomy. RESULTS: Group I: No postoperative mortality. The mean ICU stay was 4.6 days. The mean hospitalization time was 14 days. Group II: The postoperative mortality was 22.2%. The mean ICU stay was 28 days. The mean hospitalization time was 45 days. CONCLUSIONS: The choice of which operative approach should be made in patients with Boerhaave's syndrome requires critical assessment of the patient's overall status, the duration of leak and the extent of mediastinal and pleural contamination.
Asunto(s)
Enfermedades del Esófago/cirugía , Anciano , Anciano de 80 o más Años , Enfermedades del Esófago/diagnóstico por imagen , Esofagectomía , Femenino , Humanos , Tiempo de Internación , Masculino , Mediastinitis/diagnóstico por imagen , Mediastinitis/cirugía , Persona de Mediana Edad , Radiografía , Estudios Retrospectivos , Rotura Espontánea , Choque Séptico/diagnóstico por imagen , Choque Séptico/cirugía , Síndrome , Resultado del TratamientoRESUMEN
BACKGROUND: Hematoporphyrin derivatives (HpD) as sensitizers for photodynamic therapy (PDT) in advanced esophageal cancer carry the risk of prolonged photosensitivity of the skin. New sensitizers such as 5-aminolaevulinic acid (ALA) with low rates of skin phototoxicity appear to be promising alternatives. The aim of this study was to evaluate the efficacy of ALA compared with HpD for PDT in advanced esophageal carcinoma regarding phototoxicity of the skin, reduction of dysphagia, tumor stenosis and length, and Karnovsky performance status. METHODS: After diagnostic workup, photosensitization was done in 22 patients with ALA (60 mg/kg body weight, oral, 6 to 8 hours before PDT) and in 27 patients with a hematoporphyrin derivative (2 mg/kg body weight, intravenously, 48 hours before PDT). The light dose was calculated as 300 J/cm fiber tip. Light at 630 nm was applied using a pumped dye laser. In both groups, additional hyperbaric oxygenation was applied at a level of 2 absolute atmospheric pressure. RESULTS: Improvement regarding dysphagia, stenosis diameter, and tumor length could be obtained in both treatment arms with a significant difference in favor of the HpD group (p = 0.02; p = 0.0000; and p = 0.000014, respectively). A questionnaire of patients in the HpD group confirmed that the ability of swallowing a meal was superior compared with the discomfort from limitation to sun exposure. No sunburn or other major treatment-related complication occurred in both treatment arms. CONCLUSIONS: Despite the limitations of a nonrandomized study, photosensitzation with HpD seems to be more effective in PDT of advanced esophageal carcinoma compared with ALA.
Asunto(s)
Adenocarcinoma/tratamiento farmacológico , Ácido Aminolevulínico/uso terapéutico , Carcinoma de Células Escamosas/tratamiento farmacológico , Neoplasias Esofágicas/tratamiento farmacológico , Derivado de la Hematoporfirina/uso terapéutico , Fotorradiación con Hematoporfirina , Adenocarcinoma/patología , Anciano , Anciano de 80 o más Años , Carcinoma de Células Escamosas/patología , Neoplasias Esofágicas/patología , Esófago/efectos de los fármacos , Esófago/patología , Femenino , Estudios de Seguimiento , Derivado de la Hematoporfirina/efectos adversos , Humanos , Masculino , Persona de Mediana Edad , Estadificación de Neoplasias , Resultado del TratamientoRESUMEN
OBJECTIVE: Any treatment of tracheo-esophageal fistulae in end-stage malignant stenosis of the esophagus must be weighed against associated morbidity and mortality. In a prospective study we investigated benefits and risks of the use of one type of coated, self-expandable stent. PATIENTS AND METHODS: We treated four male and two female patients, (mean age 68.3 years, range: 38-90 years), with malignant esophago-tracheal fistula non-resectable due to advanced tumour stage and/or functional reasons. All were in a poor general condition suffering from aspiration pneumonia and malnutrition. Four out of the six patients had had one or multiple extra- or endoluminal palliative treatments at a mean interval of 191 days (range: 7 days-15 ms) since the last intervention. The fistulae were sealed by using a covered, self-expandable stent (ULTRAFLEX esophageal stent system, Microinvasive, Boston Scientific Corporation, Boston, MA). RESULTS: Stenting did not cause any technical problems and all fistulae were successfully sealed in a one-step procedure. The median hospital stay was 4.6 days (range: 3-9 days). Except for one late stent induced recurrent fistula treated by re-stenting and tracheostomy, we did not observe any stent associated complications. Five patients died of tumour generalization. The median survival of the patients who died was 78 days (range: 35-129 days). One patient is alive and well at 120 days after stenting. CONCLUSION: In spite of the small number of patients the results suggest that this type of stent represents a safe and efficient approach for palliative endoscopic treatment of this high risk group. Local pretreatment does not preclude the successful use of the self-expandable coated stent.
Asunto(s)
Adenocarcinoma/terapia , Carcinoma de Células Escamosas/terapia , Materiales Biocompatibles Revestidos , Neoplasias Esofágicas/terapia , Esofagoscopía , Stents , Fístula Traqueoesofágica/terapia , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Cuidados PaliativosRESUMEN
BACKGROUND/AIMS: Esophagectomy and reconstruction with retrosternal stomach interposition implies bilateral truncal vagotomy, which supposedly causes gastric functional impairment. METHODOLOGY: Esophagectomy and reconstruction with retrosternal stomach interposition was performed on 15 men (mean age: 58.4 years) and 3 women (mean age: 43.6 years). The stomach was pedicled on the right gastric and right gastroepiploic artery without performing pyloroplasty. The cervical side-to-end anastomosis was sutured manually. The functional results were assessed 2-4 years postoperatively, by determining 24-hour qualitative intragastric pH-measurement, fluoroscopical gastric emptying studies, fasting gastrin levels, and endoscopy with biopsy studies. RESULTS: Endoscopy and biopsy confirmed esophagitis in 12 patients, gastritis in 15 and a gastric ulcer in 1 case. Fluoroscopic examination documented a normal passage of contrast medium in 17, slight impairment in 1 case treated by balloon dilatation of the pylorus. Qualitative intragastric pH-measurement revealed a total pH < 3 in 22.5-98.05% of measuring events (mean: 74.31%) within 24 hours, in 18 cases. Only 4 patients had pH < 3 in less than 50%. Fasting gastrin levels (normal range: 25-110 mU/L) varied from 48.78 mU/L-168.20 (mean: 85.23 mU/L). Only 3 patients had levels > 110 mU/L (maximum: 168.20 mU/L). CONCLUSIONS: Acid-related diseases may also occur after truncal vagotomy and retrosternal stomach interposition. Routine follow-up endoscopy and biopsy studies should be done to prevent inflammatory complications and maintain the patient's quality of life.
Asunto(s)
Esofagectomía/métodos , Determinación de la Acidez Gástrica , Complicaciones Posoperatorias/diagnóstico , Estómago/cirugía , Vagotomía Troncal , Adulto , Anciano , Anastomosis Quirúrgica , Femenino , Vaciamiento Gástrico/fisiología , Gastrinas/sangre , Gastritis/diagnóstico , Humanos , Masculino , Persona de Mediana Edad , Úlcera Gástrica/diagnósticoRESUMEN
OBJECTIVE: Ruptures of the tracheobronchial tree present a life-threatening situation. Nevertheless, therapy is still controversial. Though conservative treatment by antibiotics and intubation with the cuff inflated distal to the tear is favored by some authors, surgical repair is unavoidable in many cases. METHODS: We present a series of 31 patients (mean age 43.6 years, range 8--72 years) with iatrogenous or post-traumatic tracheobronchial ruptures treated since 1975. Fifteen ruptures were longitudinal tears of the trachea, not extending lower than a distance of 3 cm from the bifurcation, 11 involved the bifurcation and/or the main bronchi. The total length of the longitudinal tears ranged from 2 to 12 cm, five were transverse near complete abruptions of the trachea or main bronchi. Involvement of the full thickness of the wall with free view into the pleural space or to the esophageal wall was present in 29 cases. Twenty-nine out of the 31 patients underwent surgical repair and two were treated conservatively. The length and depth of the lesion, the degree of subcutaneous emphysema, pneumothorax and/or pneumomediastinum as well as clinical signs suggesting incipient mediastinitis were considered when making the decision for surgery. RESULTS: Twenty-five out of the 29 patients experienced an uneventful recovery. Four patients died of sepsis unrelated to the tracheobronchial trauma. One of the two patients who underwent conservative therapy also recovered uneventfully. The other one died because of multi-organ failure due to underlying myocardial infarction. CONCLUSIONS: Conveniently localized short lacerations, especially if they do not involve the whole thickness of the tracheal wall, can be treated with antibiotics and intubation with the cuff inflated distal to the tear, avoiding high intra-bronchial pressures also after eventual extubation. In all other cases surgical repair is to be preferred.
Asunto(s)
Bronquios/lesiones , Bronquios/cirugía , Tráquea/lesiones , Tráquea/cirugía , Adolescente , Adulto , Anciano , Niño , Femenino , Humanos , Masculino , Enfisema Mediastínico/etiología , Persona de Mediana Edad , Neumotórax/etiología , Insuficiencia Respiratoria/etiología , Estudios Retrospectivos , Rotura , Enfisema Subcutáneo/etiologíaRESUMEN
BACKGROUND AND OBJECTIVE: Photodynamic tumor therapy (PDT) is based upon a photochemical reaction that is limited by the availability of molecular oxygen in the target tissue. The use of hyperbaric oxygenation (HBO) increases the amount of oxygen available for the process may thereby enhance the efficacy of PDT. We investigated the acute effects on tumor stenosis after combined PDT/HBO. PATIENTS AND METHODS: Thirty patients (22 males, 8 females, mean age: 68.8 years; range: 44-78 years) with inoperable non-small cell bronchogenic carcinoma and endobronchial stenosis were studied prospectively. Photosensitization was carried out using a hematoporphyrin-derivative 2 mg/kg BW 48 hours prior to PDT. The light dose was calculated as 300 J/cm fiber tip. The assessment of outcome 1 and 4 weeks after PDT/HBO was performed by endoscopy, chest X-ray, spirometry, laboratory parameters, subjective report of dyspnea, and Karnofsky performance status. RESULTS: At one and four weeks after the treatment, the patients felt a significant improvement of dyspnea and hemoptysis along with an objective subsiding of poststenotic pneumonia, though spirometric parameters revealed no significant difference. A significant reduction of tumor stenosis (P < 0.05) and an improvement of the Karnofsky performance status (P < 0.05) were documented 1 and 4 weeks after PDT/HBO. No therapy related complications were observed. CONCLUSIONS: Although the small number of patients does not allow to draw definitive conclusions to be drawn, the results suggests that combined PDT/HBO represents a new, safe, and technically feasible approach. It enables efficient and rapid reduction of the endoluminal tumor load and helps conditioning the patient for further treatment procedures.
Asunto(s)
Carcinoma Broncogénico/terapia , Carcinoma de Pulmón de Células no Pequeñas/terapia , Neoplasias Pulmonares/terapia , Adulto , Anciano , Terapia Combinada , Femenino , Estudios de Seguimiento , Humanos , Oxigenoterapia Hiperbárica , Masculino , Persona de Mediana Edad , Fotoquimioterapia , Proyectos Piloto , Estudios ProspectivosRESUMEN
OBJECTIVES: Photodynamic tumor therapy (PDT) is based upon a photochemical reaction that is limited by the availability of molecular oxygen in the target tissue. The use of hyperbaric oxygenation (HBO) increases the amount of oxygen available for the process may thereby enhance the efficacy of PDT. We proved in a prospective, non-randomized clinical pilot study the acute effects on malignant bronchial stenosis and the technical feasibility of combined PDT/HBO. METHODS: Forty patients (29 males, 11 females, mean age: 64.3 years; range 39-82 years) with inoperable, advanced malignant bronchial tumor stenosis were studied prospectively. Photosensitization was carried out using a hematoporphyrin-derivative 2 mg/kg bw 48 h prior to PDT. The light dose was calculated as 300 J/cm fiber tip. The assessment of outcome 1 and 4 weeks after PDT/HBO was done by endoscopy, chest X-ray, spirometry, laboratory parameters, subjective report of dyspnea and Karnofsky performance status. RESULTS: At 1 and 4 weeks after the treatment the patients felt a significant improvement of dyspnea and hemoptysis alongside with an objective subsiding of poststenotic pneumonia, though spirometric parameters revealed no significant difference. A significant reduction of tumor stenosis (P<0.05) and an improvement of the Karnofsky performance status (P<0.05) were documented 1 and 4 weeks after PDT/HBO. No therapy related complications were observed. CONCLUSION: Although the small number of patients does not allow to draw definitive conclusions, the results suggest that combined PDT/HBO represents a new, safe and technically feasible approach. It enables efficient and rapid reduction of the endoluminal tumor load and helps conditioning the patient for further treatment procedures.
Asunto(s)
Enfermedades Bronquiales/etiología , Enfermedades Bronquiales/terapia , Neoplasias de los Bronquios/complicaciones , Neoplasias de los Bronquios/terapia , Oxigenoterapia Hiperbárica , Cuidados Paliativos , Fotoquimioterapia , Adenocarcinoma/complicaciones , Adenocarcinoma/patología , Adenocarcinoma/terapia , Adulto , Anciano , Anciano de 80 o más Años , Neoplasias de los Bronquios/tratamiento farmacológico , Neoplasias de los Bronquios/patología , Carcinoma de Células Grandes/complicaciones , Carcinoma de Células Grandes/patología , Carcinoma de Células Grandes/terapia , Carcinoma de Células Escamosas/complicaciones , Carcinoma de Células Escamosas/patología , Carcinoma de Células Escamosas/terapia , Constricción Patológica , Femenino , Humanos , Masculino , Persona de Mediana Edad , Proyectos Piloto , Estudios ProspectivosRESUMEN
OBJECTIVES: The photochemical reaction of photodynamic therapy (PDT) depends on the presence of molecular oxygen. Due to anoxic regions in tumor tissue and vascular shutdown during PDT the efficiency is limited. Therefore, the use of hyperbaric oxygen which increases the oxygen in tumor tissue, as well as the amount of singlet oxygen, may enhance the efficiency of PDT. PATIENTS AND METHODS: After diagnostic work-up, photosensitization was carried out with a hematoporphyrin-derivate 2 mg/kg BW 48 h prior to PDT. The light dose was calculated as 300 J/cm fiber tip. Thirty-one patients were treated by PDT alone and 44 patients received PDT under hyperbaric oxygen at a level of two absolute atmospheric pressure. RESULTS: Improvement regarding stenosis-diameter could be obtained in both treatment arms with no significant difference (P=0.82). The dysphagia-score and tumor-length also decreased in both groups and showed a significant difference in favour of the PDT/HBO-group (P=0. 0064 and P=0.0002, respectively). The median overall survival for the PDT-group was 7 months and for the PDT/HBO-group 12 months (P=0. 0098). CONCLUSION: According to this prospective non-randomized study, combined PDT/HBO represents a new approach in the treatment of esophageal and cardia cancer which appears to have enhanced the efficiency of PDT.
Asunto(s)
Carcinoma/terapia , Neoplasias Esofágicas/terapia , Unión Esofagogástrica , Oxigenoterapia Hiperbárica , Fotoquimioterapia , Anciano , Anciano de 80 o más Años , Carcinoma/diagnóstico , Carcinoma/mortalidad , Terapia Combinada , Neoplasias Esofágicas/diagnóstico , Neoplasias Esofágicas/mortalidad , Femenino , Humanos , Oxigenoterapia Hiperbárica/efectos adversos , Oxigenoterapia Hiperbárica/métodos , Oxigenoterapia Hiperbárica/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Fotoquimioterapia/efectos adversos , Fotoquimioterapia/métodos , Fotoquimioterapia/estadística & datos numéricos , Modelos de Riesgos Proporcionales , Estudios Prospectivos , Estadísticas no ParamétricasRESUMEN
BACKGROUND AND OBJECTIVE: Dose dependence of light cannot be discussed on the basis of dose alone. On a more fundamental scientific level, the propagation of light in tissue depends on optical parameters of treated tumor tissue. In a prospective, nonrandomized study, in vivo optical parameters of esophageal carcinoma were studied. STUDY DESIGN/MATERIALS AND METHODS: Nineteen intraoperative measurements of tumor optical parameters in six patients with esophageal carcinoma were performed. After diagnostic work-up and clinical staging, right-sided, posterolateral thoracotomy, and dissection of the esophagus were carried out. The tumor site was exposed and continuous endoluminal irradiation was started during determination of light penetration at the level of the adventitia of the esophagus. The tumors were located exactly between the endoluminal irradiation source and measurement probe in the thoracic cavity. Measurements were performed on tumors having different diameters to show the relationship between tumor diameter, extinction coefficient, and light penetration depth. RESULTS: The endoluminal incident intensity was 18.5 mW/cm(2). At a tumor diameter of 4, 6, 8, and 9 mm measured intensity of 5.12, 2.28, 0.88 and 0.65 mW/cm(2), an extinction coefficient of 0.321, 0.349, 0.381, and 0.373, as well as penetration depth of 3.21, 2.87, 2.62, and 2. 68 mm, respectively, could be measured. The correlation of tumor optical parameters, tumor diameter, penetration depth, and treatment time were expressed by the relative correction factor for different tumor diameters. CONCLUSION: The knowledge of tumor optical properties seems to be necessary to adapt dosimetry to the individual situation and manage optimal results of PDT in esophageal cancer.
Asunto(s)
Carcinoma/diagnóstico , Neoplasias Esofágicas/diagnóstico , Rayos Láser , Óptica y Fotónica , Fotoquimioterapia , Anciano , Carcinoma/tratamiento farmacológico , Neoplasias Esofágicas/tratamiento farmacológico , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios ProspectivosRESUMEN
OBJECTIVES: The role of image-guided pigtail catheter drainage in the treatment of pleural empyema is associated with different outcomes, dependent on the stage of the disease. No agreement concerning its use exists. METHODOLOGY: Fourteen patients at a fibropurulent stage of pleural empyema initially treated with computed tomography (CT) or ultrasonically guided pigtail catheter drainage were reviewed. All patients were admitted with clinical symptoms of sepsis. Chest X-ray, CT scan and/or ultrasonography and thoracentesis with biochemical examination revealed multiloculated pleural empyema. Despite the diagnosis of multiloculated empyema, CT or ultrasonically guided pigtail catheter drainage was performed. However, septic symptoms deteriorated and all cases proceeded to thoracotomy with decortication. RESULTS: Image-guided drainage failed in all patients. Septic symptoms disappeared within 24-48 h after decortication. The patients recovered without sequela, were discharged 6-15 days (mean: 9.2 days) postoperatively and were able to return to normal physical activity. CONCLUSIONS: Computed tomography or ultrasonically guided pigtail catheter drainage can not be recommended in the case of a fibropurulent stage of empyema thoracis.
Asunto(s)
Drenaje/métodos , Empiema Pleural/terapia , Adulto , Anciano , Algoritmos , Cateterismo/métodos , Árboles de Decisión , Empiema Pleural/diagnóstico por imagen , Empiema Pleural/cirugía , Femenino , Humanos , Tiempo de Internación , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Toracotomía , Tomografía Computarizada por Rayos X , Insuficiencia del Tratamiento , UltrasonografíaRESUMEN
UNLABELLED: Background and Objective We wanted to determine the role of additional photodynamic therapy in a multimodal approach for the treatment of patients with advanced cancer of the gastro-esophageal junction. Study Design/Materials and Methods We reviewed 53 patients, after endoluminal palliation, with advanced cancer of the gastro-esophageal junction. Combined dilatation and retrograde tumor disobliteration with Nd-YAG laser before photodynamic therapy (PDT), brachyradiotherapy, or both, became necessary in 12 patients. Brachyradiotherapy was carried out in all patients. PDT before brachyradiotherapy was performed in 25 patients. The endoluminal treatment was completed by external beam irradiation in 30 patients (15 cases with PDT and 15 without PDT) with an at least fair performance status. RESULTS: Photodynamic therapy showed a significant difference regarding the mean opening of the tumor stenosis (mean, 6.4 mm; P = 0.0002), the mean decrease in tumor length (3.1 cm; P = 0.00001) and the increase in median survival (13. 8 months; P = 0.001). The combined multimodal approach by using PDT, brachyradiotherapy and external beam irradiation showed a median survival of 16.8 months. However, additional external beam irradiation showed no significant difference (P = 0.11). The rate of severe complications was 5.7%. The mortality rate was 1.9%. CONCLUSION: Photodynamic therapy has been shown to be an effective treatment for palliation of advanced cancer at the gastro-esophageal junction. The use of PDT combined with irradiation was associated with an acceptable survival rate, low rates of complications and reasonable quality of life.
Asunto(s)
Braquiterapia , Carcinoma/tratamiento farmacológico , Neoplasias Esofágicas/tratamiento farmacológico , Unión Esofagogástrica , Terapia por Láser , Fotoquimioterapia/métodos , Adulto , Anciano , Anciano de 80 o más Años , Análisis de Varianza , Braquiterapia/métodos , Carcinoma/radioterapia , Carcinoma/cirugía , Terapia Combinada , Neoplasias Esofágicas/radioterapia , Neoplasias Esofágicas/cirugía , Femenino , Humanos , Terapia por Láser/métodos , Masculino , Persona de Mediana Edad , Estadificación de Neoplasias , Análisis de Supervivencia , Resultado del TratamientoRESUMEN
BACKGROUND AND OBJECTIVE: The photochemical reaction of photodynamic therapy (PDT) depends on the presence of molecular oxygen. Because of anoxic regions in tumor tissue and vascular shutdown during PDT, the efficiency is limited. Therefore, the use of hyperbaric oxygen, which increases the oxygen in tumor tissue, as well as the amount of singlet oxygen, may enhance the efficiency of PDT. STUDY DESIGN/MATERIALS AND METHODS: After diagnostic work-up, photosensitization was carried out with a hematoporphyrin-derivate 2 mg/kg body weight 48 hours before PDT. The light dose was calculated as 300 J/cm of fiber tip. Twenty-three patients were treated by PDT alone and 29 patients received PDT under hyperbaric oxygen at a level of two absolute atmospheric pressures. RESULTS: Improvement regarding dysphagia and stenosis-diameter could be obtained in both treatment arms with no significant difference (P = 0.43 and P = 0. 065, respectively). The tumor length also decreased in both groups and showed a significant difference in favour of the PDT/HBO group (P = 0.002). The mean overall survival was 11.3 months. The mean survival time for the PDT group was 8.7 months and for the PDT/HBO group 13.8 months (P = 0.021). CONCLUSION: According to this pilot study, combined PDT/HBO represents a new approach in the treatment of esophageal and cardia cancer, which appears to have enhanced the efficiency of PDT.
Asunto(s)
Carcinoma/terapia , Neoplasias Esofágicas/terapia , Fotorradiación con Hematoporfirina/métodos , Oxigenoterapia Hiperbárica/métodos , Fármacos Fotosensibilizantes/uso terapéutico , Neoplasias Gástricas/terapia , Anciano , Carcinoma/tratamiento farmacológico , Cardias , Terapia Combinada , Neoplasias Esofágicas/tratamiento farmacológico , Femenino , Estudios de Seguimiento , Hematoporfirinas , Humanos , Masculino , Proyectos Piloto , Estudios Prospectivos , Neoplasias Gástricas/tratamiento farmacológico , Análisis de SupervivenciaRESUMEN
BACKGROUND AND STUDY AIMS: Experimental studies have shown that the cytotoxicity of porphyrins and related substances is mediated mainly by singlet oxygen and that hypoxic cells are less affected by porphyrins and light. In a clinical pilot study we assessed the use of photodynamic therapy (PDT) under hyperbaric oxygen (HBO), compared with PDT under normobaric conditions, in patients with advanced esophageal carcinoma. PATIENTS AND METHODS: After diagnostic work-up and staging, photosensitization in all patients was carried out using hematoporphyrine derivate (HpD) (2 mg/kg bodyweight 48 hours prior to PDT). We then applied light at 630 nm (KTP-Nd: YAG laser with DYE box) at dose of 300 J/cm, delivered by a fiber with a radial light-diffusing cylinder (length 1 cm), inserted through the biopsy channel of the endoscope. Of the patients, 14 (12 with stage III cancers, and two with stage IV cancers) were treated by PDT alone, and 17 patients (15 with stage III cancers, and two with stage IV cancers) received PDT under HBO at a level of 2 absolute atmospheric pressures (ATA). Transcutaneous PO2 levels of 500-750 mm Hg under HBO, compared with transcutaneous PO2 levels of 60-75 mm Hg under normobaric conditions, were measured. RESULTS: Improvements regarding dysphagia and stenosis diameter were obtained in both treatment arms with no significant differences (P = 0.36 and 0.14, respectively). The tumor length also decreased in both groups and showed a significant difference in favour of the PDT/ HBO group (P = 0.002). Kaplan-Meier statistics showed median overall survival for the PDT group and the PDT/HBO group as 7.0 and 12 months respectively. The 12-month survival rate was 28.6% for the PDT group and 41.2% for the PDT/HBO group. Logrank test showed a difference in survival in favor of the PDT/HBO group (P = 0.059). No major treatment-related complication occurred, and the 30-day mortality rate was 0%. CONCLUSIONS: Combined PDT/HBO represents a new approach in the treatment of esophageal cancer which, in this pilot study, appears to have enhanced the efficiency of PDT.