A self-expanding esophageal nitinol stent was implanted under fluoroscopic guidance in 40 patients with malignant esophageal strictures and clinically significant dysphagia. The strictures were caused by squamous cell carcinoma (n = 14), adenocarcinoma (n = 12), recurrent anastomotic carcinoma (n = 8), and mediastinal tumors (n = 6). Eight stents were balloon dilated to maximum diameter immediately after insertion. Sixteen stents self-expanded to maximum diameter within 24 hours, and the other stents expanded to maximum diameter during further observation. There were no serious stent-related complications, and the dysphagia was reduced considerably in all patients immediately after stent insertion. Persistent tumor bleeding occurred in two patients, and ingrowth of tumor into the stent was seen in eight patients. Two stents occluded due to tumor ingrowth but were successfully recanalized with endoscopic laser coagulation. At the end of the study, 28 patients were dead with a mean survival of 2.9 months (range, 0.1-7.0 months), and 12 patients were alive with a mean follow-up of 8.8 months (range, 4.0-15.0 months).
The reaction of the normal esophageal wall to inserted self-expanding nitinol stents was studied in pigs. An inflammatory reaction with increasing fibrotic activity and degeneration of the muscular layers in the esophageal wall was demonstrated. Five patients with severe dysphagia secondary to benign esophageal strictures also underwent insertion of self-expanding nitinol stents. All of the stents expanded completely, with subsequent regression of dysphagia. One treated esophagus was resected and showed deep implantation of the stent meshwork in the esophageal wall. Significant stenoses secondary to tissue hyperplasia, located at the edges of the stent, occurred in two patients. These results show that self-expanding nitinol stents may be used for palliation of dysphagia in patients with benign esophageal strictures. Because of the observed reactions in the esophageal wall, such treatment should be restricted to selected patients until more experience has been gained.
Eighty-three patients with bile duct calculi were entered in a prospective randomized study of endoscopic sphincterotomy (ES) and stone removal (group 1) versus surgery alone (group 2), and were followed for more than 5 years. In group 1 endoscopic stone clearance was successful in 35 of 39 patients. Thirteen patients subsequently had cholecystectomy with (n = 7) or without (n = 6) biliary symptoms and one had a cholecystostomy for acute cholecystitis. Two patients have had mild biliary colic or pancreatitis. Two patients died from gallbladder carcinoma after 9 days and 18 months. In group 2 bile duct stones were cleared surgically in 37 of 41 patients. Late complications occurred in two patients (incisional hernia and recurrent stone). One patient with gallbladder carcinoma was cured and another died after 16 months. Early major and minor complications occurred in three and four respectively of 39 patients in group 1, and in three and six respectively of 41 patients in group 2. There were no deaths. During follow-up the total morbidity rate reached 28 percent (11 of 39) and 5 percent (two of 41) (P = 0.005) and the non-biliary related mortality rate was 31 percent (12 of 39) and 10 percent (four of 41) (P = 0.02) in groups 1 and 2 respectively. Nine patients in group 1 and two in group 2 died from heart disease (P = 0.02). Total hospital stay was 2-42 (median 13) days and 6-36 (median 16) days in groups 1 and 2 respectively (P not significant). Endoscopic and surgical treatment of bile duct calculi in middle-aged and elderly patients with gallbladder in situ are equally effective in the long term. However, the significantly increased mortality rate from heart disease in patients treated endoscopically compared with those treated surgically might speak in favour of operation.
Endoscopic sphincterotomy, but not interval cholecystectomy, reduced the overall incidence of recurrent pancreatitis, but not of late biliary complications. Some 31 per cent of the patients required cholecystectomy, suggesting that routine cholecystectomy should be considered in fit patients following acute pancreatitis.
These findings confirm that endoscopic treatment alone in this group of patients is a feasible treatment principle. Recognition of the registered risk factors might be helpful when selecting patients for subsequent cholecystectomy.
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