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ABSTRACT: BACKGROUND: Esophageal stents provide immediate palliation of malignant dysphagia; however, radiotherapy (RT) is a superior long-term option. We review the outcomes of combined esophageal stenting and RT for patients with malignant dysphagia. METHODS: We retrospectively reviewed patients with esophageal stents placed for palliation of malignant dysphagia from esophageal stricture, esophageal extrinsic compression, or malignant tracheoesophageal fistula (TEF). We excluded patients with radiation-induced TEF in the absence of tumor. We analyzed and compared outcomes between patients with no RT, RT before stent placement, and RT after stent placement. RESULTS: We placed stents in 45 patients for esophageal stricture from esophageal cancer (n = 30; 66.7 %), malignant TEF (n = 8; 17.7 %), and esophageal compression from airway, mediastinal, or metastatic malignancies (n = 7; 15.6 %). Twenty patients (44.4 %) had no RT; 25 patients had RT before stent placement (n = 16; 35.6 %), RT after stent placement (n = 8; 17.8 %), or both (n = 1; 2.2 %). Median follow-up was 30 days. Complications requiring stent revision were similar with or without RT. Subjective symptom relief was achieved in 68.9 % of all patients, with no differences noted between groups (p = 0.99). The 30-day mortality was 15.6 %. Patients with RT after stent placement had a longer median survival compared to those without RT (98 vs. 38 days). CONCLUSIONS: Esophageal stent placement with RT is a safe approach for malignant dysphagia.
Annals of Surgical Oncology 07/2012; · 4.17 Impact Factor
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ABSTRACT: Esophageal injury is a rare but catastrophic complication of anterior cervical spine surgery. Cases of esophageal perforation may be discovered intraoperatively, or as late as 10 years after surgery. In the current study we aim to review the principles of care and provide an algorithm that can be employed for successful management of this complex problem.
We performed a retrospective, Institutional Review Board-approved review of esophageal injuries resulting from anterior cervical spine surgery that were managed at our institution between January 1, 2007 and July 31, 2009. We collected demographic information, perioperative data, and final outcomes. Data were analyzed using descriptive statistics.
We identified 6 patients who met our criteria. All patients presented with esophageal leaks, neck abscesses, and osteomyelitis. Similarly, all had been treated prior to transfer, without resolution of their leak. After debridement, removal of hardware, long-term antibiotic therapy, maximization of nutrition, and supportive care, 80% of patients resumed oral intake (median time 66.5 days). Mortality was 16.7%.
Neck exploration with removal of hardware, debridement, and open neck wound management are the basic principles of care. Management is often prolonged and requires multiple procedures; however, with persistence, closure is possible in the majority of patients. Our report serves as a guide for the treatment of this devastating problem.
The Annals of thoracic surgery 10/2010; 90(4):1128-33. · 3.74 Impact Factor
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ABSTRACT: Intussusception is a rare but worrisome cause of bowel obstruction in patients following Roux-en-Y gastric bypass. When intussusceptions is discovered in the general adult population, most often there is a "lead-point"; however, following bariatric procedures, this may not be true. There appears to be an increased incidence of this condition in open compared to laparoscopic Roux-en-Y gastric bypass procedures. Intussusception is often difficult to diagnose, especially in this population. Symptoms and signs can be very vague, and even computed tomography may not be accurate in diagnosing this condition. A high index of suspicion is required to successfully diagnose intussusception, and treatment often requires exploration and bowel resection. Herein, we report a case that follows several of these trends and suggests other possible contributions to intussusception. We also review other cases of intussusception after laparoscopic gastric bypass reported in the literature.
Obesity Surgery 12/2009; 20(8):1191-4. · 3.29 Impact Factor
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ABSTRACT: Endogenous opioids are integral in modulating drug reward, but it is believed that these may act through several mechanisms including hypothalamic-pituitary-adrenocortical (HPA) and dopamine pathways. This study was developed to examine how nicotine dependence alters endogenous opioid regulation of prolactin response, a peripheral marker of dopaminergic activity. Smokers and nonsmokers completed two sessions during which placebo or 50mg of naltrexone was administered, using a double-blind, counterbalanced design. Blood samples and mood measures were obtained during a resting absorption period, after exposure to two noxious stimuli (cold pressor and thermal pain), and during an extended recovery period. Opioid blockade increased prolactin response, indicating an inhibitory effect of the endogenous opioid system on prolactin, possibly mediated by reduced stimulatory effects of dopamine on this hormone. These responses were attenuated in smokers relative to nonsmokers. There was also a gender disparity in prolactin response, with women showing a stronger response to endogenous opioid modification than men regardless of smoking status. The attenuated effects of opioid blockade may reflect dysregulated opiodergic and dopaminergic effects. Results extend previous reports showing blunted opioid regulation of the HPA response in dependent smokers.
Pharmacology Biochemistry and Behavior 12/2009; 95(1):1-5. · 2.53 Impact Factor
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ABSTRACT: Stress has been cited as an important precipitator of smoking relapse. Dysregulation of neurobiological pathways related to stress might mediate effects of stress on smoking relapse. This study assessed the extent to which beta endorphin response to stress is associated with early smoking relapse. Forty-five smokers interested in smoking cessation were recruited and attended a laboratory session 24 h following the beginning of their abstinence period. During this session beta endorphin samples were collected before and after performing two acute stressors (public speaking and cognitive tasks). Participants also attended four weekly follow-up sessions to assess their smoking status. Results were compared between smokers who relapsed within the 4-week follow-up period and those who maintained abstinence over the same period. The acute stressors were associated with significant increases in measures of craving and withdrawal symptoms (ps<0.01). While baseline measures of beta endorphin did not differ between relapsers and successful abstainers (F<1), results demonstrated that smokers who relapsed exhibited attenuated beta endorphin response to the two stressors relative to those who maintained abstinence over the same period (ps<05). These results support recent evidence indicating that a dysregulated stress response is a key component in predicting smoking relapse.
Pharmacology Biochemistry and Behavior 09/2008; 90(3):357-62. · 2.53 Impact Factor
