Gregory V. Stiegmann

Photodynamic therapy with porfimer sodium versus thermal ablation therapy with Nd:YAG laser for palliation of esophageal cancer: a multicenter randomized trial

BACKGROUNDnPhotodynamic therapy (PDT) is a different type of laser treatment from Nd:YAG thermal ablation for palliation of dysphagia from esophageal cancer.nnnMETHODSnIn this prospective, multicenter study, patients with advanced esophageal cancer were randomized to receive PDT with porfimer sodium and argon-pumped dye laser or Nd:YAG laser therapy.nnnRESULTSnTwo hundred thirty-six patients were randomized and 218 treated (PDT 110, Nd:YAG 108) at 24 centers. Improvement in dysphagia was equivalent between the two treatment groups. Objective tumor response was also equivalent at week 1, but at month 1 was 32% after PDT and 20% after Nd:YAG (p < 0.05). Nine complete tumor responses occurred after PDT and two after Nd:YAG. Trends for improved responses for PDT were seen in tumors located in the upper and lower third of the esophagus, in long tumors, and in patients who had prior therapy. More mild to moderate complications followed PDT, including sunburn in 19% of patients. Perforations from laser treatments or associated dilations occurred after PDT in 1%, Nd:YAG 7% (p < 0.05). Termination of laser sessions due to adverse events occurred in 3% with PDT and in 19% with Nd:YAG (p < 0.05).nnnCONCLUSIONSnPhotodynamic therapy with porfimer sodium has overall equal efficacy to Nd:YAG laser thermal ablation for palliation of dysphagia in esophageal cancer, and equal or better objective tumor response rate. Temporary photosensitivity is a limitation, but PDT is carried out with greater ease and is associated with fewer acute perforations than Nd:YAG laser therapy.

Increased secondary bile acids in a choledochal cyst: Possible role in biliary metaplasia and carcinoma

Abstract Choledochal cysts are uncommon congenital or acquired lesions of the biliary tree. The incidence of biliary tract carcinoma in patients with choledochal cysts is 5–35 times greater than that of the general population. Factors responsible for the increased risk of carcinoma are unknown. The case of a young woman who underwent excision of a choledochal cyst 16 years after initial diagnosis and treatment by choledochocystduodenostomy is reported. Metaplasia of the epithelial lining of the cyst was found in the resected specimen. The relative composition of bile acids in cyst contents was as follows: lithocholate, 2%; deoxycholate, 88%; chenodeoxycholate, 5%; and cholate, 5%. Virtually all bile acids were recovered in unconjugated form. In contrast, the bile acid composition of hepatic bile was as follows: lithocholate, 0%; deoxycholate, 34%; chenodeoxycholate, 43%; and cholate, 23%. Bile acids were fully conjugated. These data suggest that stasis of bile within choledochal cysts contributes to bacterial overgrowth and generation of unconjugated secondary bile acids.

Extended resection of fixed rectal cancer.

Between 1980 and 1987, we operated on 23 patients (16 men and 7 women) with fixed rectal cancer. Two patients had primary tumors. Twenty‐one patients had recurrent disease (anterior resection, 8; abdominoperineal resection, 13). Eighteen patients had prior irradiation (40 Gy to 120 Gy). Resection was possible in 20 patients (16 for cure and 4 for palliation). Operations included extended proctectomy (n = 4), standard pelvic exenteration (n = 4), and sacropelvic exenteration (n = 12). One (5%) patient died postoperatively and five (25%) others had significant postoperative complications. With a follow‐up time of 1 to 48+ months (median, 18 months), nine patients are dead of disease (operative death included), four are living with disease, two are dead free of disease, and eight (50% of those undergoing curative resection) are living free of disease. The results suggest that resection of fixed rectal cancer is feasible in many patients and of potential long‐term benefit to approximately 50% of those in whom curative resection is possible.

Continent ileocolonic urinary reservoirs for filling and lining the post-exenteration pelvis+

Pelvic exenteration has a high complication rate due, in large part, to the extensive raw surfaces and dead space it creates. Numerous techniques have been used to control this space and line these surfaces, but none, to date, has proven to be a reliable solution. We investigated the use of continent ileocolonic urinary reservoirs as a new flap to fill and line the pelvis in 17 patients, and found that our historical complication rate of 44% for pelvic exenteration was reduced to 18%. These reservoirs appear to be an improved method of managing the post-exenteration pelvis.

Advanced laparoscopic surgery

1. 적응증 1992년 처음 복강경 간절제술에 대한 보고 이후 초기에는 낭, 혈관종, 선종 등 양성 질환에 주로 시 행돼오다 악성질환으로 적용이 점차 확대되었다. 최근 문헌고찰에 의하면 지금까지 보고된 환자들의 50%가 악성질환이었고 그 악성질환 중 간세포암(52%)과 대장암 간전이(35%)가 대부분을 차지하였다. 병변의 위치의 경우 주로 2, 3, 4, 5, 6 분절에 대해 시행되었으나 최근에는 미상엽과 7, 8분절과 같이 후, 상부 구역에 대해서도 시행이 되고 있으며, 수술의 범위에서도 설상절제술과 같은 제한적 간절제술 에서 좌간/우간 절제술, 확대 좌/우간 절제술, 중앙이구역 절제술과 같은 대량 간절제술이 제한적이지 만 보고되고 있다. 최근 문헌고찰에 따르면 지금까지 보고된 수술예의 45%에서 설상절제술이나 분절절 제술이, 20%에서 좌외구역절제술이, 9%에서 우간절제술이, 7%에서 좌간절제술이 시행되었다. 하지만 아직 대량간절제술이나 후상부 구역에 대한 간절제술은 경험이 있는 술자에 의해서만 주로 시행되고 있다.

Therapeutic Endoscopy in Gastrointestinal Surgery

Therapeutic Endoscopy in Gastrointestinal Surgery is an innovative monograph by a leader in this rapidly emerging field. Dr Chung more than adequately demonstrates that the combination of therapeutic endoscopy (performed by surgeons or physicians) with operative gastrointestinal surgery results in a whole that is more than the sum of its parts. This book is designed to improve the care of patients with selected gastrointestinal disorders by integrating the successful techniques developed by therapeutic gastrointestinal endoscopists with the principles and techniques of operative gastrointestinal surgery. This goal is well accomplished, and the result is a work that highlights the advantages, disadvantages, limitations, and liabilities of each approach. The work is organized into three main sections: (1) endoscopic management of gastrointestinal hemorrhage, (2) endoscopic management of obstructive jaundice, and (3) endoscopic treatment of obstructing intraluminal lesions and foreign bodies. Twelve separate chapters convey the authors comprehensive knowledge of both operative gastrointestinal surgery

Radiation Treatment Technique and Surgical Results-Reply

In Reply .—Dr Pieters raises several questions about a lack of details in our report regarding previous radiotherapy given to patients. Our article, however, was not about radiotherapy. Rather, it discussed techniques and results of radical surgery in patients with previously irradiated bulky or recurrent anorectal cancers; many of these cancers had been declared inoperable. We summarized the previous surgery or irradiation received by these patients to show the type of population we were dealing with and to show that reirradiation was not a useful option. We did not believe that further details of previous treatment, such as resection margins, irradiation port size, or dose fractionation, would have significantly added much to this discussion, nor would they have been of much use to surgeons trying to figure out how to operate on such patients. While this may have been an oversight, it was certainly not an egregious oversight, as Dr

Atlas of Gastrointestinal Endoscopy

Atlas of Gastrointestinal Endoscopy is a magnificent endoscopic photographic collection that begins in the esophagus and goes on to include all areas of the gastrointestinal tract accessible to the endoscopist. Hundreds of brilliantly captured photographic images are supplemented with carefully executed color drawings and explanatory figures to make this work the premier atlas of gastrointestinal endoscopy of the 1980s. A brief but adequate text covers some technical aspects of diagnostic endoscopy and supplements the photographs in providing the reader with almost all that needs to be known about what may be seen through a gastrointestinal endoscope. This book is written primarily for the diagnostic endoscopist, with small sections dealing with therapeutic maneuvers such as foreign-body removal, endoscopic retrograde cholangiopancreatography, endoscopic hemostasis, and polypectomy. Designed primarily to convey endoscopic images to the reader, the descriptions of individual therapeutic procedures are truncated but adequate for a work of this nature. The reader,