PURPOSE: To evaluate prospectively the efficacy of plastic-covered metallic endoprostheses in patients with malignant esophageal fistulas and perforations.MATERIALS AND METHODS: Thirty-nine patients with incurable esophageal carcinoma who developed esophagorespiratory fistulas (n = 20) or perforations (n = 19) were treated with plastic-covered metallic stents.RESULTS: Covered Wallstent endoprostheses were placed in 36 patients and covered Gianturco stents in three. All 19 perforations and 18 of 20 fistulas were successfully closed (clinical success rate, 95%). Symptoms of aspiration or dysphagia improved in all successfully treated patients. Mean survival was 81.8 days (range, 1-370 days). One patient with a closed perforation developed a fistula 16 weeks later and was treated with a second, overlapping stent; three patients with recurrent fistulas were treated with additional esophageal stents (one patient) or tracheal stents (two patients). In four patients, stent migration (two Gianturco and two Wallstent endoprostheses) necessitated placement of an additional stent.CONCLUSION: Covered metallic stents offer effective treatment for perforations and fistulas in patients with esophageal malignancy. Patients with recurrent fistulas can be treated with additional stents. Fistulas close to the upper esophageal sphincter may be closed with placement of parallel covered metallic stents in the esophagus and trachea.

Abstract Palliation of oesophageal carcinoma consists mainly of the treatment of dysphagia. However, 5 per cent of patients with oesophageal cancer also develop a fistula between the oesophagus and trachea. The symptoms of aspiration are devastating and are difficult to treat with low morbidity. Untreated, most patients die from a combination of respiratory infection and starvation1. Recently, covered expanding metal stents have been shown to be an excellent treatment for oesophageal fistula and perforation2,3 and seem to be more effective than conservative treatment, plastic tubes or surgical bypass treatment methods. However, patients who present with a high tracheo-oesophageal complex fistula adjacent to the cricopharyngeal sphincter are particularly difficult to treat. A method is described that enables control of high tracheo-oesophageal fistulas.

Adequate palliation of dysphagia due to inoperable oesophageal carcinoma is difficult to achieve with low morbidity. Thirty-three patients (21 men and 12 women of mean(s.e.m.) age 69(2) years) with inoperable carcinoma of the oesophagus underwent insertion of self-expanding metal stents. In 22 patients the tumours were in the lower third of the oesophagus, in eight in the middle third and in three in the upper third, A stent was inserted as primary palliative therapy in 14 patients, after failed laser therapy in 13 and after oesophageal perforation following other treatments in six. Patients presented with dysphagia of grade 3 or 4. Three types of stent were used: Wallstent, Strecker and Gianturco; stents were inserted under fluoroscopic guidance after balloon dilatation of the stricture. All attempted insertions of metal stents were successful, Dysphagia reduced from grade 3 or 4 to 0 or 1. There were no perforations related to insertion. Patients who had stents inserted to seal previous perforations left hospital a median 7 days later. Dysphagia recurred in six patients, due to migration of the stent (three), blockage by food bolus (one) and tumour overgrowth (two). These problems were easily treated. Self-expanding metal stents seem to offer excellent palliation with minimal morbidity for patients with inoperable carcinoma of the oesophagus.

Although biliary vesicles are considered to be the primary source of cholesterol found in cholesterol gallstones, difficulties in quantitatively separating the different cholesterol transport modes in bile still remain. Proton nuclear magnetic resonance spectroscopy (1H-NMR) offers an alternative approach. Investigations were carried out on both model biles and human gallbladder bile samples: (i) to follow the effect of increasing sodium glycocholate concentrations on the 1H-NMR spectra of arachidonic acid rich-phospholipid, and cholesterol-lecithin vesicles, (ii) to compare the concentrations of total phospholipids in bile determined enzymatically with those obtained by integration of the phospholipid choline head group resonance peak, and (iii) to examine the relationship between biliary cholesterol nucleation time (NT) and the areas of the biliary lipid 1H-NMR peaks. It was found that the molecular motions of vesicle phospholipid, as determined by 1H-NMR, were restricted by saturation with cholesterol. In bile from patients with cholesterol gallstones, the reduced NMR fluidity of the phospholipid choline-head group indicated that the proportion of cholesterol-phospholipid vesicles containing more than 50% cholesterol, on a molar basis, was increased. The ratios of the N+(CH3)3 and = CH proton resonance peaks showed no overlap between samples with cholesterol gallstones and shorter NT and those with either no gallstones or pigment stones and longer NT. 1H-NMR spectroscopy indicates in a non-invasive manner those biles which are prone to cholesterol crystal formation.

BACKGROUND:For symptomatic patients with gallbladder stones and a patent cystic duct who wish to retain their 'functioning' gallbladders, percutaneous cholecystolithotomy (PCCL) offers an alternative to open or laparoscopic cholecystectomy. However, there are few data on the risks and benefits of this approach or on the long-term outcome.METHODS AND RESULTS:In 21 patients with symptomatic calcified gallstones, PCCL was successful (gallstone clearance) in 17 (81%). Four to 62 (median, 35) months after clearance 9 of the 17 remained symptom-free and stone-free, whereas 4 developed biliary sludge at 7, 30, 32, and 35 months, 2 of whom subsequently developed gallstones. In four other patients gallstones recurred without evidence of preceding biliary sludge at 9, 16, 19, and 27 months, corresponding to an actuarial gallstone recurrence rate at 36 months of 53.4 +/- SEM 15.1%, and a combined stone/sludge recurrence rate of 63.4 +/- 13.5%.CONCLUSIONS:PCCL is moderately effective but, because of the frequency of complications and sludge/stone recurrence, is likely to have only a limited residual role in the era of laparoscopic cholecystectomy.

In a five year study, 55 patients with radiolucent gall stones were treated with the combination of 7.5 mg chenodeoxycholic acid (CDCA) and 5.0 mg ursodeoxycholic acid (UDCA)/kg/day--that is, half the monotherapeutic doses. Side effects were few but four patients could not tolerate the prescribed bile acids because of diarrhoea or nausea. Analysis of fasting duodenal bile confirmed that CDCA+UDCA converted supersaturated into unsaturated bile but the saturation indices did not predict the dissolution response. By actuarial analysis, the confirmed (by ultrasound x2) complete gall stone dissolution rates in all 55 patients were mean (SEM) 29 (7)% at 12 and 44 (8)% at 24 months. The advent of routine computed tomography before treatment enabled comparison of dissolution efficacy in those screened by computed tomography (n = 24), whose maximum gall stone attenuation was less than 100 Hounsfield units, with that in those not screened (n = 29). Although stone size and number were comparable, patients screened by computed tomography had significantly better dissolution rates (p less than 0.025) than those not screened in this way. At 12 months, partial or complete gall stone dissolution rates were 93 (7)% in the screened and 55 (11)% in the non-screened patients. At 18 months, complete dissolution rates were 64 (12%) and 20 (9)% respectively. Computed tomography before treatment is cost effective in selecting those patients likely to achieve gall stone dissolution on treatment with UDCA+CDCA.

The cholesterol of gallstones comes from the vesicular rather than the micellar phase of bile. Progress in this field has been limited because conventional analytical methods disturb the distribution of cholesterol between the two phases. The resonance of the cholesterol C6 proton occurs at a chemical shift of 5.4 ppm, to be shown by 2D NMR to be specific for biliary cholesterol, and arises only from the micellar mode. Thus integration of the C6 proton resonance peak area provides a direct non-invasive determination of the cholesterol distribution in human bile.

Conference Abstract| March 01 1991 High Resolution 1H Nuclear Magnetic Resonance Spectroscopy (NMRS) to Determine the Distribution of Cholesterol (CHOL) and Phospholipid (PL) between the Micellar and Vesicular Phases of Human Bile in Vitro: Pilot Studies JPM Ellul; JPM Ellul 1Gastroenterology Unit, UMDS, Guy's Campus, London SE1 9RT Search for other works by this author on: This Site PubMed Google Scholar H Parkes; H Parkes *NMRS Unit, Birkbeck College, University of London, Gower Street, London WC1. Search for other works by this author on: This Site PubMed Google Scholar GM Murphy; GM Murphy 1Gastroenterology Unit, UMDS, Guy's Campus, London SE1 9RT Search for other works by this author on: This Site PubMed Google Scholar RH Dowling RH Dowling 1Gastroenterology Unit, UMDS, Guy's Campus, London SE1 9RT Search for other works by this author on: This Site PubMed Google Scholar Clin Sci (Lond) (1991) 80 (s24): 30P–31P. https://doi.org/10.1042/cs080030Pc Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Twitter LinkedIn Cite Icon Cite Get Permissions Citation JPM Ellul, H Parkes, GM Murphy, RH Dowling; High Resolution 1H Nuclear Magnetic Resonance Spectroscopy (NMRS) to Determine the Distribution of Cholesterol (CHOL) and Phospholipid (PL) between the Micellar and Vesicular Phases of Human Bile in Vitro: Pilot Studies. Clin Sci (Lond) 1 March 1991; 80 (s24): 30P–31P. doi: https://doi.org/10.1042/cs080030Pc Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search Search Dropdown Menu toolbar search search input Search input auto suggest filter your search All ContentAll JournalsClinical Science Search Advanced Search This content is only available as a PDF. © 1991 The Biochemical Society and the Medical Research Society1991 Article PDF first page preview Close Modal You do not currently have access to this content.