Fifteen patients with malignant biliary obstruction from carcinoma of the bile ducts, gallbladder, and pancreas (Group I) or metastatic disease (Group II) were treated with intraluminal radiation therapy (ILRT) at Memorial Sloan-Kettering Cancer Center. In 11 cases ILRT was used as a central boost in combination with 3000 cGy external beam radiation therapy (ERT). No significant treatment toxicity was observed. Cholangiographic response was observed in 2 of 12 evaluable patients. In no patient was long-term relief of jaundice without indwelling biliary stent achieved. Survival from treatment in eight Group I patients treated with ILRT +/- ERT was 3 to 13 months (median, 4.5). Survival in seven similarly treated Group II patients was 0.5 to 8 months (median, 4.0). Additional data for ten similar patients referred for ILRT but treated with ERT alone are presented. Analysis of this and other reports indicate the need for prospective controlled trials of the role of this regimen in the management of malignant biliary obstruction before wider application can be recommended.
Nine surgeons from rural and remote communities in the United States share early experiences preparing for the COVID-19 pandemic. Relating experiences remarkably different from health care providers in urban areas in America most affected by the first stages of the outbreak, they tell the challenges of organizing resources in facilities already struggling with poverty-stricken communities far from established health care resources and supplies. From Alaska to Appalachia and the Navajo Nation to the rural midwest, they show the leadership and professionalism that exemplify rural surgery.
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