RöFo : Fortschritte auf dem Gebiete der Röntgenstrahlen und der Nuklearmedizin, 1992
36 patients with liver metastases due to colorectal carcinoma under treatment with arterial perfu... more 36 patients with liver metastases due to colorectal carcinoma under treatment with arterial perfusion chemotherapy of the liver with 5-fluoro-2-desoxyuridine (FUDR) via a subcutaneous pump were investigated by axial liver CT at 6-monthly intervals. In all examinations a dynamic CT scan with intravenous bolus injection of contrast medium was carried out following a native scan. Changes in tumour size were documented by means of 1. volumetry and 2. bidimensional measurement according to WHO criteria. Since we were not able to assess small newly developing lesions within the liver using the volumetric classification, the WHO-classification showed much higher sensitivity in cases of progressive disease. In addition, volumetric determination of tumour size by means of region-of-interest technique proved to be rather impracticable in clinical routine compared to bidimensional measurement.
To compare the effectiveness of an antireflux stent with that of a standard open stent in prevent... more To compare the effectiveness of an antireflux stent with that of a standard open stent in preventing symptoms of gastroesophageal reflux in patients with inoperable distal esophageal cancer. Fifty consecutive patients with inoperable distal esophageal tumors underwent placement of either a standard open or an antireflux stent across the cardia. Stents were allocated randomly before assessment of the stricture. All patients were followed up prospectively by the departmental research nurses. Technical and clinical success, reflux symptoms, complications, and reintervention rates were assessed. P values of observed differences were calculated by using the chi(2) and log-rank tests as appropriate. The technical success rate was 100%. Improvement in dysphagia was identical in both groups (three points on a five-point scale). Twenty-four (96%) of 25 patients with standard open stents had symptoms of esophageal reflux; 19 (76%) of 25 required treatment. Three (12%) of 25 patients with antireflux stents reported esophageal reflux; one (4%) of 25 required treatment. This difference was significant (P <.001). There was no significant difference in survival, complications, or reintervention rate. One case of late esophageal perforation occurred in each group. One patient died of aspiration within 24 hours after insertion of a standard open stent; no procedure-related deaths occurred with the antireflux stent. This antireflux stent is as safe and effective as the standard open stent in relieving malignant dysphagia and was successful in reducing symptomatic gastroesophageal reflux.
To assess the technical success, clinical outcomes and complications of radiologically guided bal... more To assess the technical success, clinical outcomes and complications of radiologically guided balloon dilatation of benign strictures developing after treatment for head and neck cancer. Forty-six balloon dilatations were performed in 20 patients. All dilatations were performed over a guidewire. Technical success was 100 per cent. Fifteen of the 20 patients demonstrated clinical improvement in dysphagia scores. Improvement in dysphagia was temporary in all patients (median 102 days), with multiple dilatations usually required (total dilatations ranged from one to seven). Immediate complications were encountered in six of the 46 (13 per cent) dilatations and were all minor. Late complications occurred after two procedures (4 per cent): localised perforation (later complicated by secondary infection) and recurrence of a previous, small, pharyngo-cutaneous fistula. Radiologically guided balloon dilatation is straightforward to perform and is well tolerated, but there is a small risk of perforation. Relief of symptoms is likely to be temporary, requiring multiple subsequent dilatations. A minority of patients will obtain no symptomatic relief.
We present our initial experience with a new biodegradable (BD) esophageal stent in two patients,... more We present our initial experience with a new biodegradable (BD) esophageal stent in two patients, one for a therapy-resistant benign esophageal stricture, and the other as a temporary measure during curative radiotherapy for oesophageal carcinoma. The BD stents need to be loaded into a conventional pull-back delivery system but are then placed in a standard fashion. Pre-dilatation should be avoided to reduce the risk of migration, however if migration occurs the stents can be left to dissolve in the stomach. The stents are radiolucent but easily identified on CT with minimal artefact and thus might even aid with radiotherapy planning. BD stents offer an exciting new strategy for therapy-resistant benign strictures as well as a supportive measure for oesophageal cancer undergoing non-surgical treatment.
Shoulder pain is known to retard rehabilitation after stroke. Its causes and prognosis are uncert... more Shoulder pain is known to retard rehabilitation after stroke. Its causes and prognosis are uncertain. This study describes the incidence of poststroke shoulder pain prospectively, in an unselected stroke population in the first 6 months after stroke and identifies risk factors for developing pain. 297 patients with possible stroke were screened and stroke diagnosed in 205 cases. The 152 patients entered the study of which 123 patients were assessed up to 6 months. This cohort, with a mean age of 70.6 years, was examined at 2 weeks, 2, 4, and 6 months. A history of shoulder pain, Barthel score, anxiety and depression score were recorded. Full neurological and rheumatological examination was undertaken, using the contralateral side as a control. Pain outcome and stroke outcome was recorded at subsequent visits. 52 (40%) patients developed shoulder pain on the same side of their stroke. There was a strong association between pain and abnormal shoulder joint examination, ipsilateral sensory abnormalities and arm weakness. Shoulder pain had resolved or improved at 6 months in 41 (80%) of the patients with standard current treatment. Shoulder pain after stroke occurred in 40% of 123 patients surviving, consenting and not too unwell to participate. This included 52 patients of an original cohort of 205 patients presenting with stroke. Eighty percent of patients made a good recovery with standard treatment Patients with sensory and or motor deficits represent at risk sub-groups.
It is well recognized that myocardial ischemia can occur during endoscopic retrograde cholangiopa... more It is well recognized that myocardial ischemia can occur during endoscopic retrograde cholangiopancreatography (ERCP). Acute arrhythmias and ST segment changes have been reported by a number of authors, but the longer-term sequelae with regard to permanent myocardial damage are not known. The aim of this study was to determine the presence or absence of significant injury to the heart muscle. Sixty-two patients undergoing therapeutic ERCP were assessed clinically and with electrocardiography (ECG) for the presence of ischemic heart disease before the procedure. Extensive intraprocedural monitoring was carried out, postprocedural ECGs were recorded, and serum troponin T levels were measured. The ECGs were evaluated blindly by a single cardiologist. In 61 of the 62 patients, no changes were observed between the ECGs before and after the procedure. One patient had postprocedural T wave inversion but a normal troponin T level, excluding myocardial damage. One patient with mild renal insufficiency and treated heart failure had borderline troponin T elevation (0.05 microg/l) but no ECG changes. No complications of ERCP occurred. Whilst ECG and rhythm changes indicating transient myocardial ischemia do occur during ERCP, there is no evidence that myocardial damage takes place as a consequence of this.
The aim of the study was to compare two steerable endoscopic retrograde cholangiopancreatography ... more The aim of the study was to compare two steerable endoscopic retrograde cholangiopancreatography (ERCP) catheters with regard to speed and safety in cannulating the common bile duct. A standard cannula, a short-nosed sphincterotome, and a bendable catheter were used. At two tertiary centres, a total of 312 patients were randomly assigned to receive treatment with one of three catheters and either by a trainee or an expert endoscopist. When cannulation failed, a further attempt was made with a different catheter. If this failed, a change in operator or other manoeuvres followed. The following were assessed: time to cholangiography and deep cannulation, number of attempts and success rates of cannulation, number of pancreatic duct injections, success of catheter cross-over, and complication rates. Both steerable catheters were significantly better for the initial cholangiogram than the standard catheter (standard catheter 75 %, bendable catheter 84 %, sphincterotome 88 %; P = 0.038), with no significant differences between the bendable catheter and the sphincterotome. Both were also better for deep cannulation of the bile duct (standard cannula 66 %, bendable catheter 69 %, sphincterotome 78 %; P = 0.15). When the standard catheter failed, a steerable catheter succeeded in 26 % of cases. Trainees experienced greater benefit from using steerable catheters. For experts, the bendable catheter was the quickest to achieve cholangiography and deep cannulation. Further manoeuvres had an 85-90 % success rate in allowing biliary access. Twenty of 23 needle-knife papillotomies (87 %) were successful when other methods had failed. The overall ERCP success rate was 97 %. Pancreatitis occurred in 5.3 % of cases. Steerable catheters allow faster access and can succeed when a standard catheter fails. If cannulation is difficult, changing the catheter should be considered at an early stage. Needle-knife papillotomy is a successful technique in expert hands.
RöFo : Fortschritte auf dem Gebiete der Röntgenstrahlen und der Nuklearmedizin, 1992
36 patients with liver metastases due to colorectal carcinoma under treatment with arterial perfu... more 36 patients with liver metastases due to colorectal carcinoma under treatment with arterial perfusion chemotherapy of the liver with 5-fluoro-2-desoxyuridine (FUDR) via a subcutaneous pump were investigated by axial liver CT at 6-monthly intervals. In all examinations a dynamic CT scan with intravenous bolus injection of contrast medium was carried out following a native scan. Changes in tumour size were documented by means of 1. volumetry and 2. bidimensional measurement according to WHO criteria. Since we were not able to assess small newly developing lesions within the liver using the volumetric classification, the WHO-classification showed much higher sensitivity in cases of progressive disease. In addition, volumetric determination of tumour size by means of region-of-interest technique proved to be rather impracticable in clinical routine compared to bidimensional measurement.
To compare the effectiveness of an antireflux stent with that of a standard open stent in prevent... more To compare the effectiveness of an antireflux stent with that of a standard open stent in preventing symptoms of gastroesophageal reflux in patients with inoperable distal esophageal cancer. Fifty consecutive patients with inoperable distal esophageal tumors underwent placement of either a standard open or an antireflux stent across the cardia. Stents were allocated randomly before assessment of the stricture. All patients were followed up prospectively by the departmental research nurses. Technical and clinical success, reflux symptoms, complications, and reintervention rates were assessed. P values of observed differences were calculated by using the chi(2) and log-rank tests as appropriate. The technical success rate was 100%. Improvement in dysphagia was identical in both groups (three points on a five-point scale). Twenty-four (96%) of 25 patients with standard open stents had symptoms of esophageal reflux; 19 (76%) of 25 required treatment. Three (12%) of 25 patients with antireflux stents reported esophageal reflux; one (4%) of 25 required treatment. This difference was significant (P <.001). There was no significant difference in survival, complications, or reintervention rate. One case of late esophageal perforation occurred in each group. One patient died of aspiration within 24 hours after insertion of a standard open stent; no procedure-related deaths occurred with the antireflux stent. This antireflux stent is as safe and effective as the standard open stent in relieving malignant dysphagia and was successful in reducing symptomatic gastroesophageal reflux.
To assess the technical success, clinical outcomes and complications of radiologically guided bal... more To assess the technical success, clinical outcomes and complications of radiologically guided balloon dilatation of benign strictures developing after treatment for head and neck cancer. Forty-six balloon dilatations were performed in 20 patients. All dilatations were performed over a guidewire. Technical success was 100 per cent. Fifteen of the 20 patients demonstrated clinical improvement in dysphagia scores. Improvement in dysphagia was temporary in all patients (median 102 days), with multiple dilatations usually required (total dilatations ranged from one to seven). Immediate complications were encountered in six of the 46 (13 per cent) dilatations and were all minor. Late complications occurred after two procedures (4 per cent): localised perforation (later complicated by secondary infection) and recurrence of a previous, small, pharyngo-cutaneous fistula. Radiologically guided balloon dilatation is straightforward to perform and is well tolerated, but there is a small risk of perforation. Relief of symptoms is likely to be temporary, requiring multiple subsequent dilatations. A minority of patients will obtain no symptomatic relief.
We present our initial experience with a new biodegradable (BD) esophageal stent in two patients,... more We present our initial experience with a new biodegradable (BD) esophageal stent in two patients, one for a therapy-resistant benign esophageal stricture, and the other as a temporary measure during curative radiotherapy for oesophageal carcinoma. The BD stents need to be loaded into a conventional pull-back delivery system but are then placed in a standard fashion. Pre-dilatation should be avoided to reduce the risk of migration, however if migration occurs the stents can be left to dissolve in the stomach. The stents are radiolucent but easily identified on CT with minimal artefact and thus might even aid with radiotherapy planning. BD stents offer an exciting new strategy for therapy-resistant benign strictures as well as a supportive measure for oesophageal cancer undergoing non-surgical treatment.
Shoulder pain is known to retard rehabilitation after stroke. Its causes and prognosis are uncert... more Shoulder pain is known to retard rehabilitation after stroke. Its causes and prognosis are uncertain. This study describes the incidence of poststroke shoulder pain prospectively, in an unselected stroke population in the first 6 months after stroke and identifies risk factors for developing pain. 297 patients with possible stroke were screened and stroke diagnosed in 205 cases. The 152 patients entered the study of which 123 patients were assessed up to 6 months. This cohort, with a mean age of 70.6 years, was examined at 2 weeks, 2, 4, and 6 months. A history of shoulder pain, Barthel score, anxiety and depression score were recorded. Full neurological and rheumatological examination was undertaken, using the contralateral side as a control. Pain outcome and stroke outcome was recorded at subsequent visits. 52 (40%) patients developed shoulder pain on the same side of their stroke. There was a strong association between pain and abnormal shoulder joint examination, ipsilateral sensory abnormalities and arm weakness. Shoulder pain had resolved or improved at 6 months in 41 (80%) of the patients with standard current treatment. Shoulder pain after stroke occurred in 40% of 123 patients surviving, consenting and not too unwell to participate. This included 52 patients of an original cohort of 205 patients presenting with stroke. Eighty percent of patients made a good recovery with standard treatment Patients with sensory and or motor deficits represent at risk sub-groups.
It is well recognized that myocardial ischemia can occur during endoscopic retrograde cholangiopa... more It is well recognized that myocardial ischemia can occur during endoscopic retrograde cholangiopancreatography (ERCP). Acute arrhythmias and ST segment changes have been reported by a number of authors, but the longer-term sequelae with regard to permanent myocardial damage are not known. The aim of this study was to determine the presence or absence of significant injury to the heart muscle. Sixty-two patients undergoing therapeutic ERCP were assessed clinically and with electrocardiography (ECG) for the presence of ischemic heart disease before the procedure. Extensive intraprocedural monitoring was carried out, postprocedural ECGs were recorded, and serum troponin T levels were measured. The ECGs were evaluated blindly by a single cardiologist. In 61 of the 62 patients, no changes were observed between the ECGs before and after the procedure. One patient had postprocedural T wave inversion but a normal troponin T level, excluding myocardial damage. One patient with mild renal insufficiency and treated heart failure had borderline troponin T elevation (0.05 microg/l) but no ECG changes. No complications of ERCP occurred. Whilst ECG and rhythm changes indicating transient myocardial ischemia do occur during ERCP, there is no evidence that myocardial damage takes place as a consequence of this.
The aim of the study was to compare two steerable endoscopic retrograde cholangiopancreatography ... more The aim of the study was to compare two steerable endoscopic retrograde cholangiopancreatography (ERCP) catheters with regard to speed and safety in cannulating the common bile duct. A standard cannula, a short-nosed sphincterotome, and a bendable catheter were used. At two tertiary centres, a total of 312 patients were randomly assigned to receive treatment with one of three catheters and either by a trainee or an expert endoscopist. When cannulation failed, a further attempt was made with a different catheter. If this failed, a change in operator or other manoeuvres followed. The following were assessed: time to cholangiography and deep cannulation, number of attempts and success rates of cannulation, number of pancreatic duct injections, success of catheter cross-over, and complication rates. Both steerable catheters were significantly better for the initial cholangiogram than the standard catheter (standard catheter 75 %, bendable catheter 84 %, sphincterotome 88 %; P = 0.038), with no significant differences between the bendable catheter and the sphincterotome. Both were also better for deep cannulation of the bile duct (standard cannula 66 %, bendable catheter 69 %, sphincterotome 78 %; P = 0.15). When the standard catheter failed, a steerable catheter succeeded in 26 % of cases. Trainees experienced greater benefit from using steerable catheters. For experts, the bendable catheter was the quickest to achieve cholangiography and deep cannulation. Further manoeuvres had an 85-90 % success rate in allowing biliary access. Twenty of 23 needle-knife papillotomies (87 %) were successful when other methods had failed. The overall ERCP success rate was 97 %. Pancreatitis occurred in 5.3 % of cases. Steerable catheters allow faster access and can succeed when a standard catheter fails. If cannulation is difficult, changing the catheter should be considered at an early stage. Needle-knife papillotomy is a successful technique in expert hands.
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Papers by Hans-ulrich Laasch