Robert F. Wong

Placement of Polyflex stents in patients with locally advanced esophageal cancer is safe and improves dysphagia during neoadjuvant therapy

BACKGROUND Patients with locally advanced esophageal cancer who require neoadjuvant therapy have significant dysphagia. OBJECTIVES To prospectively evaluate Polyflex stents to treat malignant dysphagia and to ameliorate weight loss in patients with locally advanced esophageal cancer who will undergo neoadjuvant therapy. DESIGN A prospective nonrandomized study. SETTING Tertiary-referral cancer center. PATIENTS Thirteen patients with esophageal cancer (11 adenocarcinoma, 2 squamous-cell carcinoma). All patients were men, with a mean age of 63 years. INTERVENTIONS EUS followed by stent placement. MAIN OUTCOME MEASUREMENTS Dysphagia scores and patient weights. RESULTS There were no perforations and no episodes of bleeding. Immediate complications included chest discomfort in 12 of 13 patients. The mean dysphagia score at the time of stent placement was 3. Mean dysphagia scores obtained at 1, 2, 3, and 4 weeks after stent placement were 1.1 (P = .005), 0.8 (P = .01), 0.9 (P = .02), and 1.0 (P = .008), respectively. Stent migration occurred at some point in 6 of 13 patients (46%). LIMITATIONS A single center and small size of study. CONCLUSIONS Simultaneous EUS staging and Polyflex stent placement is safe and allows oral feeding during neoadjuvant therapy. Dysphagia scores improved in a statistically significant manner. Stent migration was a common event, although not all patients with a migrated stent will require stent replacement, because migration may be a sign of tumor response to neoadjuvant therapy.

Complications involving the mediastinum after injection of Enteryx for GERD

The Food and Drug Administration approved the use of Enteryx (Microvasive Endoscopy, Boston Scientific Corp, Natick, Mass) for the treatment of GERD in April 2003. Enteryx is a biocompatible polymer that is injected intramuscularly into the lower esophageal sphincter (LES). The injections are made under fluoroscopy to ensure correct placement of the substance and to avoid inadvertent submucosal or transmural injection. The injection solution contains ethylene vinyl alcohol, which is dissolved in dimethyl sulfoxide (DMSO) and is mixed with tantalum, a radiopaque contrast agent. After injection into tissue, the DMSO rapidly dissipates by diffusion and the polymer precipitates as a spongy material. The latter initiates an acute and, eventually, chronic inflammatory response, leading to fibrous encapsulation of the polymer. Preliminary studies have shown Enteryx to be efficacious for control of symptoms and allows discontinuation of pharmacotherapy for GERD. The most common complication with Enteryx injection is chest pain, which occurs in over 90% of patients and usually is mild. Dysphagia also is fairly common, occurring in approximately 20% of patients, but this usually is of short duration and does not require therapy. To date, a major complication of Enteryx injection has not been reported. However, reported here are two cases of serious complications involving the mediastinum after Enteryx injection for GERD.

Retrievable Esophageal Stents for Benign Indications

Until recently, esophageal stents have not been a realistic option for the management of benign disease owing to difficulty removing the stents and associated high complication rates. However, progress in esophageal stent design has led to the development of retrievable esophageal stents. Clinical experience has shown promise for the management of benign esophageal diseases with retrievable stents, including refractory strictures, esophageal leaks, fistula and perforations. They have been shown to be safe and effective, though stent migration remains a concern. This article reviews the current designs, indications, efficacy and complications of retrievable esophageal stents.

Approaches to endoscopic ampullectomy.

Purpose of review Ampullary tumors, usually adenomas, are often encountered during endoscopic evaluation, especially in patients with familial adenomatous polyposis (FAP). Because of the risk of progression to adenocarcinoma, ampullary adenomas should be treated. Endoscopic therapy is an appropriate option and recent experience highlights the effectiveness and safety of this approach. Recent findings Several authors have published experiences with endoscopic ampullectomy. In the current era, endoscopic ampullectomy is performed like a snare polypectomy using a side-viewing duodenoscope. Tumors are removed either en bloc or in a piecemeal fashion with retrieval of all tissue. Because of the potential for incidental carcinoma when all tissue is removed, complete retrieval is essential. Although initially used as primary therapy, thermal ablation, such as ionized argon coagulation (IAC), is now commonly used as adjunctive therapy. Prophylactic pancreatic or biliary stent placement is also performed to minimize risks of pancreatitis, jaundice, cholangitis, and stenosis. Endoscopic therapy is effective in removing more than 80% of adenomas, though several sessions may be necessary. Complications are reported in 20% of patients from most series and include acute pancreatitis, bleeding, perforation, orifice stenosis, and, rarely death. Recurrence of the adenoma can occur, especially in FAP patients, and warrants periodic surveillance. Summary Endoscopic ampullectomy appears to be an effective method for treating ampullary tumors. However, complications are significant and only well-trained and experienced endoscopists should perform ampullectomy. Future research should focus on multicenter, randomized clinical trials to determine the best therapeutic approach for patients with ampullary tumors and to determine methods to decrease complication rates associated with endoscopic therapy.

Simultaneous Endoluminal Sonography and Manometry to Assess Anal Sphincter Complex in Normal Subjects

The purpose of this study was to usesimultaneous anal manometry and high-frequencyendoluminal ultrasonography (EUS) to determine therelationship between resting anal pressure andcross-sectional area of the internal and external anal sphincters.Eleven normal subjects underwent simultaneous anal EUSand manometry using catheters containing both pressureports and ultrasound transducers. Resting pressure and cross-sectional area of the sphincters weremade throughout the anal sphincter complex. The lengthof the internal anal sphincter (IAS) by sonography (27± 5 mm) was significantly less than the length of the high pressure zone (HPZ) by manometry(44 ± 8 mm; P < 0.001). Maximum IAScross-sectional area (CSA) occurred 10 ± 6 mmproximal to the peak resting pressure. The resting analpressure correlated with external anal sphincter (EAS) CSA (r =0.77), but not with IAS CSA (r = –0.17). The sumof EAS CSA and IAS CSA correlated strongly with restingpressure (r = 0.85). In conclusion, the IAS is shorter than the HPZ, with a significant distanceseparating maximum IAS CSA from peak resting pressure.The sum of the IAS and EAS CSAs, but not that of the IASalone, correlated with resting pressure. Thus, this study suggests that the EAS, in addition to theIAS, contributes to resting anal pressure.

Therapeutic endoscopy and endoscopic ultrasound for gastrointestinal malignancies.

Gastrointestinal endoscopy and endoscopic ultrasound not only provide strategies to diagnose and stage malignancy, but also to administer palliative and definitive care. Options for anticancer therapy include endoscopic mucosal resection, photodynamic therapy, thermal therapy, self-expanding metal stents and recently, endoscopic ultrasound-guided therapy, such as intratumoral injection. This review summarizes the available endoscopic techniques with a discussion of indications and recent clinical data pertaining to gastrointestinal malignancy. This review will inform the reader of emerging treatment options and stress the importance of incorporating gastroenterologists into the multidisciplinary approach in the management of gastrointestinal cancers.

Endoscopic Celiac Plexus Blockade Via Direct Intraneuronal Injection Versus Perineuronal Injection: Results of a Pilot Study

Endoscopic Celiac Plexus Blockade Via Direct Intraneuronal Injection Versus Perineuronal Injection: Results of a Pilot Study

Ultrasound-Guided Therapy

Utilizing-high frequency sound waves to define internal structures, ultrasound (US) provides an opportunity not only to diagnose disease but also to target treatment to malignant tumors. US has several advantages over other radiology-assisted techniques that highlight its important role as a component of anticancer therapy. US provides an opportunity to administer therapy with real-time guidance. In other words, the physician can deliver treatment while synchronously visualizing the US images to ensure proper targeting.