Biomedical subjects
Publications and source records attributed to C Ell.
A laser-resistant guide probe that can be placed endoscopically, for use in the laser treatment of impassable tumour stenosis is described. It meets the necessary requirements such as low level of absorption of YAG laser light (1,064 nm wavelength), high thermal stability and low heat conduction. So far, the probe has been used complication-free, in four patients.
Using a flashlamp pulsed Nd: YAG laser it is possible to destroy gallstones within a few seconds (median: 4 sec for stones less than 1.5 cc; 9.5 sec greater than 1.5 cc). In in vitro and animal studies it was shown that the median energy needed for stone destruction varies between 32 Joule for stones less than 1.5 cc and 80 Joules for stones greater than 1.5 cc. A 0.2 mm thick, flexible glass fibre makes possible retrograde laser lithotripsy by conventional endoscopes. Using a suitable technique the danger of thermal damage to tissue is small.
With the aid of a Q-switched Nd:YAG laser with energy transmission via a flexible glass fiber, it proves possible under laboratory conditions, to destroy gallstones reliably and reproducibly. Lithotripsy is effected mechanically via a laser-induced local shockwave.
Lumen-filling calculi in the common bile duct are frequently inaccessible to endoscopic treatment. With the aid of a flash lamp pulsed Nd:YAG laser, endoscopic retrograde lithotripsy of such calculi has now been successfully accomplished for the first time in man.
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The present state of palliative laser therapy of inoperable malignant tumor stenoses in the upper gastrointestinal tract is reviewed. Indications, contraindications, several different sources of energy and forms of energy application, as also the various technical procedures, are discussed. Finally, the authors' experience with palliative laser therapy in 62 patients, and the results of an international inquiry covering data obtained in 1,359 patients, are presented.
Alternatives to laser treatment of tumor stenoses of upper gastrointestinal tract include dilatation, implantation of bridging tubes, radiation therapy and chemotherapy. Based on the experience of 170 bridging tubes implanted and laser therapy in 70 patients with tumor stenoses (presented elsewhere) "tubes and laser" are compared. Complication rate, applicability in very proximal and distal stenoses are in favour of laser therapy, costs, hospitalisation time, possibility to occlude fistulae and short recurrence time after laser therapy are facts speaking for oesophageal bridging tubes. The question "tubes or laser" has to be answered by "tubes and laser" already.
The pharmacokinetics of high-dose metoclopramide (10 mg/kg body wt. in five infusions of 2 mg/kg body wt. each) was studied in 11 patients (5 females, 6 males) in two groups: group A with and group B (consisting of five patients) without forced diuresis. When the drug was infused, forced diuresis had no influence on the pharmacokinetics of metoclopramide (serum level after the 1st infusion was 851 +/- 361 ng/ml in group A versus 840 +/- 348 ng/ml in group B; after the 5th infusion it was 2,005 +/- 588 ng/ml in group A versus 2,463 +/- 1,350 ng/ml in group B). There were significant differences in the 24-h serum levels (582 +/- 308 ng/ml in group A versus 379 +/- 170 ng/ml in group B; P less than 0.05) and in the elimination half life (8.5 +/- 2.6 h in group A versus 6.1 +/- 1.1 h in group B; P less than 0.05). The results demonstrate that the dosage regimen originally suggested by Gralla for cytostatic drugs, with forced diuresis for high-dose metoclopramide therapy, may also be applied, with no dosage reduction, with to other cytostatic drugs which do not require forced diuresis.
Eighteen patients with malignant inoperable stenoses of the upper digestive tract were treated with a combination of laser (neodymium-YAG) coagulation and bougienage. Following treatment, 14 out of 18 patients (78%) were able to eat solid food again; the width of the lumen was greater than 11 mm in every case. Between 1 and 5 laser sessions (median 3.5) and between 1 and 2 (median 1) bougienages were required; per session, between 1,017 and 9,096 joules (median 3,362) were required, and a total of between 4,770 and 36,244 joules (median 8,763) were utilized per patient treated. To date, 6 patients remain free of dysphagia (at between 3 and 24 weeks), 1 patient has in the meantime been submitted to surgery. In 7 patients, recurrent stenosis occurred, which was again treated with the laser (3) or with an endoscopically implanted prosthetic tube (4). In 4 patients, the result was unsatisfactory. By way of major complications, merely one perforation occurred. We conclude that the combined use of laser coagulation and bougienage represents an effective and largely complication-free palliative treatment for malignant stenoses in the upper digestive tract.
A case of Kaposi's sarcoma in underlying acquired immunodeficiency syndrome (AIDS) with involvement of the colon and the terminal ileum is presented. The endoscopic and histological findings are described and the technical and clinical aspects of the results discussed.
In 29 patients (48 courses of chemotherapy), a randomized double-blind crossover study was undertaken to establish the antiemetic effectiveness of a combination of metoclopramide at a moderately high dose (5 mg/kg body weight) with 1 g methylprednisolone (treatment A) as compared with metoclopramide monotherapy (5 mg/kg body weight; treatment B). With cisplatin doses of 60 mg/m2, a good antiemetic effect (0-1 vomiting episodes in 24 h) was observed in 9 out of 10 patients under treatment A as well as under treatment B. With a cisplatin dose of 120 mg/m2, treatment A produced a good antiemetic effect in 9 out of 11 patients (82%), while treatment B produced such an effect in only 3 out of 11 patients (27%; p less than 0.5). The results obtained permit the following conclusions to be made: At doses of cisplatin of up to 60 mg/m2, the antiemetic effect produced by metoclopramide (5 mg/kg body weight) given alone is adequate. At doses of cisplatin of 120 mg/m2 and more, high-dose methylprednisolone has a good additive antiemetic effect vis-à-vis metoclopramide (5 mg/kg body weight). The antiemetic effect of this combination corresponds approximately to the antiemetic effect produced with high-dose metoclopramide (10 mg/kg body weight) administered alone.
Very marked nausea and vomiting are the most frequently observed side effects of modern cytostatic agents, and make it necessary to include powerful anti-emetic drugs in any oncological chemotherapeutic concept. The selection of suitable anti-emetics, however, often proves difficult. The reasons for this are discussed. A number of important basic rules that should be observed with any anti-emetic treatment are proposed. Finally, a standardised stepwise anti-emetic plan is suggested for discussion.
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A case of recurrent almost complete papillary stenosis after endoscopic papillotomy is presented. The stenosis was treated successfully, again by renewed endoscopic papillotomy, prior to fistulotomy. The endoscopic findings, the therapeutic procedure and the results are documented.
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