Herbert J. Smith

Gastric emptying of an indigestible solid in patients with end-stage renal disease on continuous ambulatory peritoneal dialysis

Using radiopaque markers, we evaluated gastric emptying in 10 male patients with end-stage renal disease on continuous ambulatory peritoneal dialysis and in 15 normal men. Dialysis patients were studied twice, once without peritoneal dialysate in the abdomen (drained) and once with 2 L of dialysate in the abdomen (full). Each normal man and 9 of 10 dialysis patients, when drained, emptied all 10 markers by 6 h after a test meal. In contrast, 5 of the 10 dialysis patients, when full, had delayed emptying of radiopaque markers. Thus, continuous ambulatory dialysis may delay gastric emptying of indigestible solids.

Evaluation and management of swallowing dysfunction following chemoradiation for head and neck cancer.

Purpose of reviewConcurrent chemoradiation offers excellent local control and survival for patients with locally advanced head and neck cancer while allowing anatomic organ preservation. Treatment toxicity is significant, however, often resulting in long-term dysphagia and aspiration. We review the prevalence of post-treatment swallowing dysfunction, describe current thinking about its pathogenesis and management, and signal possible directions for future research. Recent findingsApoptosis from chemoradiation induces abnormal motility of the upper aerodigestive tract, resulting in stasis of the bolus in all phases of the swallow, and resulting in aspiration when the larynx is not protected during swallow. Long-term scarring may result in stenosis of the upper digestive tract. Recent findings suggest the role of transforming growth factor beta 1 in the pathogenesis of normal tissue damage and late scarring induced by radiation. Aspiration is often silent, and therefore a modified barium swallow or videofluoroscopy are required for its diagnosis. Swallowing therapy may improve swallowing efficiency and reduce the aspiration rate, and should be started immediately. SummarySuccessful management of swallowing dysfunction following chemoradiation is a complex undertaking requiring a team approach. Collaboration among different specialists (physicians, speech pathologist, dietitian, and psychologists) remains the key to a desirable outcome.

Analysis of factors influencing aspiration risk following chemoradiation for oropharyngeal cancer

Our aim was to identify risk factors for aspiration following concurrent chemoradiation for oropharyngeal cancer. 46 patients with locally advanced oropharyngeal carcinoma underwent concurrent chemoradiation at our institution. All patients underwent modified barium swallow to assess dysphagia severity and to determine the need for continued tube feedings after treatment. Dysphagia severity was graded as 1-7. There were 5 Grade 2, 11 Grade 3, 5 Grade 4, 5 Grade 5, 10 Grade 6 and 10 Grade 7 scores. 25 patients (54%) developed aspiration (5 trace, 20 severe). The aspiration rate for T1-T2 and T3-T4 tumours was 31% and 67%, respectively (p = 0.03). There was no statistical difference in the aspiration rate between the base of the tongue and tonsillar carcinoma (p = 0.23). Despite anatomical organ preservation, most patients with locally advanced oropharyngeal carcinoma had moderate to severe dysphagia after chemoradiation. Patients with large tumours had a significant risk of developing aspiration following treatment.

Aspiration Rate following Nonsurgical Therapy for Laryngeal Cancer

The aim of this study was to evaluate the aspiration rate following nonsurgical therapy, i.e. chemoradiation or radiation alone for laryngeal cancer. Modified barium swallow was performed in 43 patients who complained of dysphagia following chemoradiation (n = 22) or radiation alone (n = 21) for laryngeal cancer. Patients were selected if they were cancer free at the time of the swallowing study. Dysphagia severity was graded on a scale of 1–7. Patients were grouped according to the dysphagia severity: no aspiration (grade 1–4), and severe (grade 5–7). Mean and median dysphagia grades were 4.4/5 and 3.5/3 for chemoradiation and radiation, respectively. Aspiration occurred in 12 patients (54%) of the chemoradiation group and 7 (33%) of the radiation alone group (p = 0.13). There was a higher proportion of patients with large tumor (T3–T4) in the chemoradiation group (64%) compared to the radiation group (5%) (p = 0.0001). Aspiration is a significant source of morbidity in patients treated for laryngeal cancer with chemoradiation or radiation alone. Aspiration occurred in both groups. Although the observed difference in aspiration rates did not achieve statistical significance, the higher aspiration rate in the chemoradiation group may be due to a higher proportion of large tumors, to the additional toxic effect of chemotherapy, or to the small number of patients in both groups. Diagnostic studies such as modified barium swallow should be part of future laryngeal cancer prospective studies to assess the prevalence of aspiration as it may be silent.

Unusual fistulae due to colonic diverticulitis

Examples of diverticulitis of the colon associated with fistulae to the left hip, inferior mesenteric vein, and portal vein resulting in the demonstration of intrahepatic abscesses, the vermiform appendix, and the skin are presented with a review of the literature. A case of a fistula to the epidural space is included.

Effectiveness of the Cough Reflex in Patients with Aspiration Following Radiation for Head and Neck Cancer

The effectiveness of the cough reflex in patients who aspirated following radiation for head and neck cancer was evaluated in 89 patients (49 chemoradiation, 33 postoperative radiation, and 7 radiation alone). All patients had modified barium swallow because of dysphagia. The cough reflex was graded as present and effective, ineffective, intermittently effective, or absent. All patients were cancer-free at the time of the swallowing study. The cough reflex was present and effective in 46 patients (52%), ineffective in 17 patients (19%), and absent in 26 patients (29%) on initial investigation. Among the 43 patients who had ineffective or absent cough reflex, their treatment was chemoradiation (26), postoperative radiation (13), and radiation alone (4). In 30 patients who had sequential modified barium swallow, the cough reflex was constantly effective, ineffective, or intermittently effective in 12 (40%), 13 (43%), and 5 (17%) patients, respectively. The cough reflex was frequently ineffective or absent in patients who aspirated following radiation for head and neck cancer. Cough may also be intermittently ineffective to protect the airways following radiation.

Metastasis to the colon from bronchogenic carcinoma

Two cases of primary carcinoma of the lung with clinically demonstrated colon metastases are presented. Such metastases may present with intermittent or continuous colonic obstruction, lower gastrointestinal tract bleeding, or anemia. The metastases may be synchronous or metachronous with respect to diagnosis of the lung lesion. Potential problems in management are discussed and the literature, relating to colonic metastasis from bronchogenic carcinoma, is reviewed.

Long-Term Aspiration following Treatment for Head and Neck Cancer

Background: Dysphagia and aspiration are long-term complications with life-threatening consequences following treatment of head and neck cancer. We would like to assess the prevalence of aspiration in patients with long-term persistence of dysphagia (1 year or more) following treatment for head and neck cancer and to identify potential risk factors of aspiration. Methods: Modified barium swallow (MBS) examinations were performed in cancer-free patients who complained of dysphagia following treatment for head and neck cancer. The severity of the dysphagia was graded on a scale of 1–7. Results: Between 1992 and 2004, 74 patients with dysphagia underwent MBS 12–152 months following treatment (median 29 months). There were 2 grade 1, 22 grade 3, 21 grade 4, 11 grade 5, 7 grade 6, and 11 grade 7 cases. Twenty-nine patients (39%) had long-term aspiration at a median follow-up of 25 months (range 12–82). Eighteen patients (24%) required permanent gastrostomy because of severe aspiration. Type of treatment and disease stage did not seem to influence long-term aspiration risk. Conclusion: Patients with long-term dysphagia after treatment for head and neck cancer are at risk of aspiration. MBS should be performed to identify these patients.

Analysis of the factors influencing dysphagia severity upon diagnosis of head and neck cancer

Our aim was to assess the influence of age, co-morbidity factors and tumour characteristics on dysphagia severity in the diagnosis of head and neck cancer. Modified barium swallow (MBS) examinations were performed in patients at diagnosis of head and neck cancer. Dysphagia was graded on a scale of 1 to 7 of increasing severity. Between 2000 and 2006, 236 patients with dysphagia underwent MBS at diagnosis of their head and neck cancer. 82 patients were scored as Grade 1, 88 as Grade 2, 29 as Grade 3, 15 as Grade 4, 9 as Grade 5, 5 as Grade 6, and 8 as Grade 7. Grade 3-7 dysphagia occurred in 20% and 31% of patients with T1-T2 and T3-T4 tumours, respectively (p = 0.004). Corresponding values for N0-N1 and N2-N3 tumours were 20% and 39%, respectively (p = 0.002). The percentage of patients with Grade 3-7 dysphagia was 5%, 29%, 33% and 52% for oral cavity, laryngeal, oropharyngeal and hypopharyngeal tumours, respectively, (p = 0.002). Age and co-morbidity factors (e.g. diabetes, hypertension, coronary artery disease, peripheral vascular diseases and arthritis) did not appear to have an impact on swallowing in this limited retrospective study. Patients with locally advanced stages (T3-T4, N2-N3) are at risk of severe dysphagia. Patients with oral cavity tumours appear to be less at risk of dysphagia than those with tumours in different anatomic locations. The role of age and co-morbidity factors should be investigated in future prospective studies.

Dysphagia severity and aspiration risk following oral cavity cancer surgery

ObjectivesWe assessed the severity of dysphagia before and after oral cavity cancer surgery.MethodsWe retrospectively reviewed modified barium swallow (MBS) studies of 12 patients who underwent surgery for oral cavity cancer. A MBS was performed before and after treatment to assess the severity of dysphagia and aspiration risk. All patients were cancer-free at the time of the posttreatment MBS. Dysphagia severity was graded from 1 to 7 on a scale of increasing severity.ResultsBefore surgery, seven cases were grade 1 and five were grade 2 dysphagia. At a median of 2 months (1–15 months) following surgery, grade 1–6 dysphagia was present in one, two, four, three, one, and one patient, respectively. In all, 17% (2/12) of the patients developed aspiration (grades 5–7). Seven patients (58%) experienced mild to moderate dysphagia. Only three patients (25%) had normal swallowing postoperatively. The two patients who developed aspiration had T3 tumors and underwent hemiglossectomies.ConclusionsDysphagia is common following surgery for oral cavity cancer. Diagnostic studies such as MBS should be included in future prospective oral cavity cancer studies to assess the dysphagia severity and for patient rehabilitation.