- Email: [email protected]
ENDOSCOPIC LASER RESECTION IN INOPERABLE TRACHEOBRONCHIAL AND OESOPHAGEAL TUMOURS
1126
The main weapon against persistent aggressive disease is cytotpxic therapy, although the benefits and costs of these agents have not been clearly established. Because the features of Reiter’s syndrome closely resemble psoriatic arthritis, methotrexate has been widely used. Whilst uncontrolled studies of small numbers of patients treated with doses of up to 50 mg weekly suggest benefit, 16-10 the frequency of hepatic damage has discouraged its use. However, there are indications that methotrexate is less likely than cyclophosphamide or azathioprine to promote carcinogenesis21-23 and that maintenance doses as low as 5-15 mg given as one or two weekly doses may be effective. As an alternative, azathioprine is popular although there have been few published reports of its use in Reiter’s syndrome. In the only placebo controlled study, azathioprine given orally at a dose of 1-2 mg/kg over 2 months appeared beneficial in 5 of 6 patients.24 In 1, treatment was withdrawn because of nausea but none of the 8 patients entering the study showed any drug-related laboratory abnormalities. More recently, interest has been reawakened in the use of sulphasalazine for both seropositive and seronegative arthritis. 2526 This drug may be especially rational in patients with arthritis associated with covert inflammatory bowel disease, and results of preliminary studies are encouraging. The good news about treating Reiter’s syndrome is that the natural history of the disease means that it will remit spontaneously in most patients so that the minimum of medication is often acceptable. The bad news is that severe disease is often resistant to anti-inflammatory therapy but such patients are insufficiently numerous for adequate blind studies of cytotoxic regimens to be readily carried out. It makes sense to treat such patients as one would a case of severe psoriatic arthritis although it remains important to determine whether the real benefits of cytotoxic therapy outweigh the short-term and longterm potential hazards. Reiter’s syndrome has lately been the subject of major scientific advances with respect to the role of
genetic factors28,29 and infective agents10 in pathogenesis. Perhaps, therefore, we can at last look forward to the development of new and effective methods of curing the disease by eradicating the offending microbial antigen or by selectively blocking the inflammatory response to its presence.
ENDOSCOPIC LASER RESECTION IN INOPERABLE TRACHEOBRONCHIAL AND OESOPHAGEAL TUMOURS have reported good results for of endoscopic palliation inoperable tracheobronchial and tumours with the neodyrriium yttrium oesophageal aluminium garnet (Nd YAG) laser. Should this technique now become routine clinical practice? The laser vaporises or coagulates tumour tissue, which is then removed piecemeal with biopsy forceps (best for tracheobronchial lesions) or sloughs spontaneously (best for gastrointestinal lesions). Only exophytic tumours are accessible to laser resection; the aim is to debulk tumours which are causing luminal obstruction or to coagulate bleeding tumours. The laser has advantages over radiotherapy and chemotherapy in that relief of symptoms is almost immediate and there is no systemic toxicity. Tumour will recur in due course but treatment can be repeated as often as required. In the major airways the laser is especially valuable in patients who are too breathless for radiotherapy and in those who relapse after maximum radiotherapy. Unfortunately only a minority of patients have suitable, predominantly intraluminal tumours. The carbon dioxide laser was the first to be used for tracheal lesions but it requires rigid optics. In the early 1980s use of the Nd YAG laser through optical fibres was reported from FranceJapan,3and the UK.4 Fibreoptic bronchoscopy, under local3-5 and general6 anaesthesia, and rigid bronchoscopy2,7,8 have all been used as a means of introducing the optical fibres. For this purpose most workers now favour rigid bronchoscopy under general anaesthesia, which gives better operative control and facilitates extensive tumour clearance in a single session.9
SEVERAL groups
27. Mielants
JF, Maberry JD, Stone OJ. Reiter’s syndrome treated with folic acid antagonists Arch Dermatol 1966; 99: 335-39. Farber GA, Forshner JG, O’Quinn SE Reiter’s syndrome: Treatment with methotrexate. JAMA 1967; 200: 171-73. Chess YC, Chan HL. Reiter’s disease responding to methotrexate. Singapore Med J
16. Mullins 17. 18.
1978; 18: 136-38. 19. Owen ET, Cohen ML. Methotrexate m Reiter’s disease. Ann Rheum Dis 1979; 38: 48-50. 20. Lally EV, Ho G. A review of methotrexate therapy in Reiter’s syndrome. Semin Arthr Rheum 1985; 15: 139-45. 21. Bailin PL, Tindall JP, Roenigk HH, Hogan MD. Is methotrexate therapy for psoriasis carcinogenic? JAMA 1975; 232: 359-62. 22. Nylors A, Jensen H. Frequency of malignant neoplasms in 248 long-term methotrexate treated psoriatics: a preliminary study Dermatologica 1983; 167: 260-62. 23. Diggle GE. Iatrogenic neoplasia. In: D’Arcy PF, Griffin JP, eds. Iatrogenic diseases 3rd ed. Oxford: Oxford University Press, 1986: 811-56. 24. Calm A. A placebo controlled, cross-over study of azathioprine in Reiter’s syndrome. Ann Rheum Dis 1986, 45: 653-55. 25. McConkey B, Amos RS, Durham S, Forster PJG, Hubball S, Walsh L. Sulphasalazine in rheumatoid arthritis. Br Med J 1980; 280: 442-44. 26. Pullar T, Hunter JA, Capell HH. Sulphasalazine m rheumatoid arthritis: a double blind comparison of sulphasalazine with placebo and sodium aurothiomalate Br Med J 1983; 287: 1102-04.
H, Veys EM HLA-B27 related arthritis and bowel inflammation. Part 1. Sulfasalazine (salazopyrin) in HLA-B27 related reactive arthritis. J Rheumatol 1985; 12: 287-93. 28. Brewerton DA, Caffrey M, Nicholls A, Walters D, Oates JK, James DCO. Reiter’s disease and HL-A27. Lancet 1973; ii: 996-98. 29. Woodrow JC. Genetic aspects of the spondyloarthropathies. Clin Rheum Dis 1985; 11: 1-24. 1. La Foret FJ, Berger RL, Vaughan CW. Carcinoma obstructing the trachea. Treatment by laser resection N Engl J Med 1976; 294: 941. 2. Toty L, Personne C, Colchen A, Vourc’h G. Bronchoscopic management of tracheal
lesions using the neodymium-yttrium-alummium-garnet laser Thorax 1981; 36: 175-78. 3. Oko K, Ohtami T, Amemiya R. Laser surgery in the trachea and bronchus via the fibreoptic bronchoscope In: Proceedings of 4th Congress of International Society for Laser Surgery. Tokyo: Inter Group Corp 1981 14-16 4. Hetzel MR, Millard FJC, Ayesh R, Bndges C, Nanson EM, Swam CP. Laser treatment for carcinoma of the bronchus. Br Med J 1983; 286: 12-16. 5 Hetzel MR, Millard FJC, Williams IP, Bridges C. Endoscopic argon laser treatment of bronchial carcinoma. Thorax 1981, 36: 235 6. Kvale P, Eichenhom M, Radke JR, Miks V YAG laser photoresection of lesions obstructing the central airways. Chest 1985; 87: 283-88. 7 Duman JF, Cavaliere S, Beamis J. Principles of safety in application of Nd YAG laser in bronchology Chest 1984; 86: 163-68. 8. Hetzel MR, Nixon C, Edmonstone WM, et al. Laser therapy in 100 tracheobronchial tumours. Thorax 1985; 40: 341-45 9 George RJM, Garrett CPO, Nixon C, Hetzel MR, Nanson E, Millard FJC Laser treatment of tracheobronchial tumours; local or general anaesthesia? Thorax 1987; 42: 656-60
1127
French studies on large numbers of patients2,7 have reported excellent results but without objective measurements. British8 and American10 studies have shown improvement in pulmonary function and symptom scores in 68% and 63% of patients, respectively. Ventilation perfusion scans also improve." Similar studies with the carbon dioxide laser have not shown such good results.12 Operative mortality is 0.4—2%.7,8,10 Results are best in incomplete obstruction of the trachea and main bronchi. Laser endoscopy is the ideal method of resuscitation for acute stridor in tracheal tumours. 13 Complete collapse of a lung is more difficult to treat,8,10 although preoperative bronchography may improve results.14 Some 60% of tumours causing haemoptysis will respond8 and lifethreatening haemorrhage may be controlled. 15 There are no data on the effect of laser treatment on survival because of the ethical difficulties of studying a control group in such circumstances. 16 Nevertheless, palliation with the laser gives good quality of life during survivals of 4 months to 2
years.7,8,10 Photodynamic therapy, in which a parenteral haematoporphyrin derivative is absorbed by the tumour and then excited with red light from an argon dye laser, has been used in similar patients.17 This technique appears less safe than the YAG" but has greater potential for attempted cures in earlier but inoperable tumours.18 . Encouraging results are also seen with laser therapy of inoperable oesophageal tumours.19 Most of these patients can only be offered palliation. Although surgery provides the best palliation if the patient is fit enough, morbidity and mortality are high.2O Radiotherapy may increase the longterm prognosis for localised lesions but takes several weeks to relieve dysphagia .2’ Laser therapy can complement insertion of a prosthetic tube for rapid relief of dysphagia. Since the technique was first described in 198222 most reports have described treatment with the Nd YAG laser and flexible endoscopes under intravenous sedation; general anaesthesia is seldom necessary.23 It is often difficult to identify the oesophageal lumen and therefore wiser to spread treatment over several sessions, letting necrotic tissue slough before re-treating. There is a small risk of perforation, but this is less than with prosthesis insertion (the risk is highest if dilatation is used or after 10. Gelb F, Epstein JD. Laser treatment of lung cancer. Chest 1984; 86: 662-66. 11. George PJM, Clarke G, Tolfree S, Hetzel MR. Does laser treatment improve lung perfusion? Thorax 1987; 42: 227. 12. Gilmartin JJ, Veale D, Cooper BG, Keavey PM, Gibson GJ, Morritt GN. Effects of laser treatment on respiratory function in malignant narrowing of the central airways. Thorax 1987; 42: 578-82. 13. George PJM, Garrett CPO, Hetzel MR. Role of the neodymium YAG laser m the management of tracheal tumours Thorax 1987, 42: 440-44. 14. George PJM, Edwards D, Hetzel MR. Laser treatment for complete endobronchial obstruction. The value of preoperanve bronchography. Lasers Med Sci 1986; 1: 287. 15. Edmonstone WM, Nanson EM, Woodcock AA, Millard FJC, Hetzel MR. Life threatening haemoptysis controlled by laser photocoagulation. Thorax 1983; 38: 788. 16. Beamis JF, Sharpsay SM. More about the YAG. Chest 1985; 87: 277-78 17. Vincent RG, Dougherty TJ, Rao U, Boyle DG, Potter WR. Photoradiation therapy in advanced carcinoma of the trachea and bronchus. Chest 1984; 85: 29-33. 18. Konaka C, Kato H, Hayata Y. Lung cancer treated by photoradiation therapy alone. Survival for more than 3 years. Lasers Med Sci 1987; 2: 17-21. 19. Cox J, Bennet JR. Light at the end of the tunnel? Palliation of oesophageal carcinoma. Gut 1987; 28: 781-85. 20. Watson A. A study of the quality and duration of survival following resections, endoscopic intubation and surgical intubation in oesophageal carcinoma. Br J Surg 1982; 69:585—88. 21. Earlham R, Cuntra-Melo JR. Oesaphageal squamous cell carcinoma. A critical review of radiotherapy. Br J Surg 1980; 67: 457-61. 22. Fleischer D, Kessler F, Haye O. Endoscopic Nd YAG laser therapy for carcinoma of the oesophagus. A new palliative approach. Am J Surg 1982; 143: 280-83. 23. Bown SG, Hawes R, Matthewson K, Swam CP, Boulos P, Clark CG. Endoscopic laser palliation for advanced malignant dysphagia. Gut 1987; 28: 799-807.
radiotherapy).24 It is unwise to treat submucosal lesions or stenosis from extrinsic tumour. Lasers can be used in any region accesible to endoscopy, including the cervical oesophagus and gastric outlet where prostheses can not be inserted. After insertion of
a prosthesis, dietary restriction is whereas after laser therapy about one-third of necessary,19 can eat an patients essentially normal diet, a third to a half can eat a range of solids, and the rest have less satisfactory results. 23,25 The interval before recurrence of dysphagia tends to be short (5-22 weeks), although some patients survive many months without problems.23,26 Wider coagulation of the tumour to stimulate fibrous tissue formation may delay recurrence but can occasionally cause strictures which then require dilatation or a prosthesis.23 Tumour overgrowing a prosthesis may, however, be treatable by laser. The short duration of response to the laser is a stimulus to further research in both oesophageal and bronchial tumours. Combined laser and intracavitary isotope radiation may prolong response. Is high-tech laser treatment justified in patients with terminal cancer? Although lasers are expensive their cost compares favourably with ([,40 000-[,50 000) radiotherapy equipment and cytotoxic drugs. Rapid palliation of distressing symptoms enables the patient to spend more time at home, with reduced health service costs. Most established treatments for these tumours are aimed only at palliation and in these circumstances new treatments are wholly justified if they have fewer side-effects. Multidisciplinary use oflasers28 further reduces their-cost; in Britain the DHSS is now supporting a national medical laser centre (University College Hospital, London) to assess the value of lasers to the Health Service.
CAPD—THE WHITE KNIGHT? MOST British renal units
were
established between 1964
initially the UK kept pace with its European neighbours. Subsequently the rate of development slowed and 1970 and
and standards in Britain fell further and further behind those of all other developed countries. Some observers even wondered whether there was a disease of British nephrologists that prevented them realising the dimensions of their problem. The truth was that great efforts were made to maximise rather limited resources: no other country had as high a proportion of patients on home haemodialysis and no other European country outside Scandinavia had as high a transplant rate. There were simply too few units with too few hospital dialysis places. Hospital haemodialysis is important because this form of treatment is required to back up all other methods. The advent of continuous ambulatory peritoneal dialysis (CAPD) was greeted with such enthusiasm in the UK that within months of the first reports at the European Dialysis and Transplant Association
M, Escourrou J Complications observed during laser treatment of tumours of the upper digestive tract Acta Endoscopica 1985; 15: 13. 25. Mellow MH, Pinkas H Endoscopic laser therapies for malignancies affecting the oesophagus and gastroesophageal junctions. Analysis of technical and functional efficacy. Arch Intern Med 1985; 145: 1442-46. 26. Rieman JF, Ell C, Lux G, Demling L. Combined therapy of malignant stenoses of the upper gastrointestinal tract by means of laser beam and bouginage. Endoscopy 1985; 24. Davalaux
17: 43-48. 27. Bader M, Dittler HJ, Ultsch B, Ries
G, Stewart JR. Palliative treatment of malignant of the upper gastrointestinal tract using a combination of laser and afterloading therapy Endoscopy 1986; 18 (suppl 1) 27-36. 28. Bown SG. Laser endoscopy. Br Med Bull 1986; 42: 307-13. stenoses
The main weapon against persistent aggressive disease is cytotpxic therapy, although the benefits and costs of these agents have not been clearly established. Because the features of Reiter’s syndrome closely resemble psoriatic arthritis, methotrexate has been widely used. Whilst uncontrolled studies of small numbers of patients treated with doses of up to 50 mg weekly suggest benefit, 16-10 the frequency of hepatic damage has discouraged its use. However, there are indications that methotrexate is less likely than cyclophosphamide or azathioprine to promote carcinogenesis21-23 and that maintenance doses as low as 5-15 mg given as one or two weekly doses may be effective. As an alternative, azathioprine is popular although there have been few published reports of its use in Reiter’s syndrome. In the only placebo controlled study, azathioprine given orally at a dose of 1-2 mg/kg over 2 months appeared beneficial in 5 of 6 patients.24 In 1, treatment was withdrawn because of nausea but none of the 8 patients entering the study showed any drug-related laboratory abnormalities. More recently, interest has been reawakened in the use of sulphasalazine for both seropositive and seronegative arthritis. 2526 This drug may be especially rational in patients with arthritis associated with covert inflammatory bowel disease, and results of preliminary studies are encouraging. The good news about treating Reiter’s syndrome is that the natural history of the disease means that it will remit spontaneously in most patients so that the minimum of medication is often acceptable. The bad news is that severe disease is often resistant to anti-inflammatory therapy but such patients are insufficiently numerous for adequate blind studies of cytotoxic regimens to be readily carried out. It makes sense to treat such patients as one would a case of severe psoriatic arthritis although it remains important to determine whether the real benefits of cytotoxic therapy outweigh the short-term and longterm potential hazards. Reiter’s syndrome has lately been the subject of major scientific advances with respect to the role of
genetic factors28,29 and infective agents10 in pathogenesis. Perhaps, therefore, we can at last look forward to the development of new and effective methods of curing the disease by eradicating the offending microbial antigen or by selectively blocking the inflammatory response to its presence.
ENDOSCOPIC LASER RESECTION IN INOPERABLE TRACHEOBRONCHIAL AND OESOPHAGEAL TUMOURS have reported good results for of endoscopic palliation inoperable tracheobronchial and tumours with the neodyrriium yttrium oesophageal aluminium garnet (Nd YAG) laser. Should this technique now become routine clinical practice? The laser vaporises or coagulates tumour tissue, which is then removed piecemeal with biopsy forceps (best for tracheobronchial lesions) or sloughs spontaneously (best for gastrointestinal lesions). Only exophytic tumours are accessible to laser resection; the aim is to debulk tumours which are causing luminal obstruction or to coagulate bleeding tumours. The laser has advantages over radiotherapy and chemotherapy in that relief of symptoms is almost immediate and there is no systemic toxicity. Tumour will recur in due course but treatment can be repeated as often as required. In the major airways the laser is especially valuable in patients who are too breathless for radiotherapy and in those who relapse after maximum radiotherapy. Unfortunately only a minority of patients have suitable, predominantly intraluminal tumours. The carbon dioxide laser was the first to be used for tracheal lesions but it requires rigid optics. In the early 1980s use of the Nd YAG laser through optical fibres was reported from FranceJapan,3and the UK.4 Fibreoptic bronchoscopy, under local3-5 and general6 anaesthesia, and rigid bronchoscopy2,7,8 have all been used as a means of introducing the optical fibres. For this purpose most workers now favour rigid bronchoscopy under general anaesthesia, which gives better operative control and facilitates extensive tumour clearance in a single session.9
SEVERAL groups
27. Mielants
JF, Maberry JD, Stone OJ. Reiter’s syndrome treated with folic acid antagonists Arch Dermatol 1966; 99: 335-39. Farber GA, Forshner JG, O’Quinn SE Reiter’s syndrome: Treatment with methotrexate. JAMA 1967; 200: 171-73. Chess YC, Chan HL. Reiter’s disease responding to methotrexate. Singapore Med J
16. Mullins 17. 18.
1978; 18: 136-38. 19. Owen ET, Cohen ML. Methotrexate m Reiter’s disease. Ann Rheum Dis 1979; 38: 48-50. 20. Lally EV, Ho G. A review of methotrexate therapy in Reiter’s syndrome. Semin Arthr Rheum 1985; 15: 139-45. 21. Bailin PL, Tindall JP, Roenigk HH, Hogan MD. Is methotrexate therapy for psoriasis carcinogenic? JAMA 1975; 232: 359-62. 22. Nylors A, Jensen H. Frequency of malignant neoplasms in 248 long-term methotrexate treated psoriatics: a preliminary study Dermatologica 1983; 167: 260-62. 23. Diggle GE. Iatrogenic neoplasia. In: D’Arcy PF, Griffin JP, eds. Iatrogenic diseases 3rd ed. Oxford: Oxford University Press, 1986: 811-56. 24. Calm A. A placebo controlled, cross-over study of azathioprine in Reiter’s syndrome. Ann Rheum Dis 1986, 45: 653-55. 25. McConkey B, Amos RS, Durham S, Forster PJG, Hubball S, Walsh L. Sulphasalazine in rheumatoid arthritis. Br Med J 1980; 280: 442-44. 26. Pullar T, Hunter JA, Capell HH. Sulphasalazine m rheumatoid arthritis: a double blind comparison of sulphasalazine with placebo and sodium aurothiomalate Br Med J 1983; 287: 1102-04.
H, Veys EM HLA-B27 related arthritis and bowel inflammation. Part 1. Sulfasalazine (salazopyrin) in HLA-B27 related reactive arthritis. J Rheumatol 1985; 12: 287-93. 28. Brewerton DA, Caffrey M, Nicholls A, Walters D, Oates JK, James DCO. Reiter’s disease and HL-A27. Lancet 1973; ii: 996-98. 29. Woodrow JC. Genetic aspects of the spondyloarthropathies. Clin Rheum Dis 1985; 11: 1-24. 1. La Foret FJ, Berger RL, Vaughan CW. Carcinoma obstructing the trachea. Treatment by laser resection N Engl J Med 1976; 294: 941. 2. Toty L, Personne C, Colchen A, Vourc’h G. Bronchoscopic management of tracheal
lesions using the neodymium-yttrium-alummium-garnet laser Thorax 1981; 36: 175-78. 3. Oko K, Ohtami T, Amemiya R. Laser surgery in the trachea and bronchus via the fibreoptic bronchoscope In: Proceedings of 4th Congress of International Society for Laser Surgery. Tokyo: Inter Group Corp 1981 14-16 4. Hetzel MR, Millard FJC, Ayesh R, Bndges C, Nanson EM, Swam CP. Laser treatment for carcinoma of the bronchus. Br Med J 1983; 286: 12-16. 5 Hetzel MR, Millard FJC, Williams IP, Bridges C. Endoscopic argon laser treatment of bronchial carcinoma. Thorax 1981, 36: 235 6. Kvale P, Eichenhom M, Radke JR, Miks V YAG laser photoresection of lesions obstructing the central airways. Chest 1985; 87: 283-88. 7 Duman JF, Cavaliere S, Beamis J. Principles of safety in application of Nd YAG laser in bronchology Chest 1984; 86: 163-68. 8. Hetzel MR, Nixon C, Edmonstone WM, et al. Laser therapy in 100 tracheobronchial tumours. Thorax 1985; 40: 341-45 9 George RJM, Garrett CPO, Nixon C, Hetzel MR, Nanson E, Millard FJC Laser treatment of tracheobronchial tumours; local or general anaesthesia? Thorax 1987; 42: 656-60
1127
French studies on large numbers of patients2,7 have reported excellent results but without objective measurements. British8 and American10 studies have shown improvement in pulmonary function and symptom scores in 68% and 63% of patients, respectively. Ventilation perfusion scans also improve." Similar studies with the carbon dioxide laser have not shown such good results.12 Operative mortality is 0.4—2%.7,8,10 Results are best in incomplete obstruction of the trachea and main bronchi. Laser endoscopy is the ideal method of resuscitation for acute stridor in tracheal tumours. 13 Complete collapse of a lung is more difficult to treat,8,10 although preoperative bronchography may improve results.14 Some 60% of tumours causing haemoptysis will respond8 and lifethreatening haemorrhage may be controlled. 15 There are no data on the effect of laser treatment on survival because of the ethical difficulties of studying a control group in such circumstances. 16 Nevertheless, palliation with the laser gives good quality of life during survivals of 4 months to 2
years.7,8,10 Photodynamic therapy, in which a parenteral haematoporphyrin derivative is absorbed by the tumour and then excited with red light from an argon dye laser, has been used in similar patients.17 This technique appears less safe than the YAG" but has greater potential for attempted cures in earlier but inoperable tumours.18 . Encouraging results are also seen with laser therapy of inoperable oesophageal tumours.19 Most of these patients can only be offered palliation. Although surgery provides the best palliation if the patient is fit enough, morbidity and mortality are high.2O Radiotherapy may increase the longterm prognosis for localised lesions but takes several weeks to relieve dysphagia .2’ Laser therapy can complement insertion of a prosthetic tube for rapid relief of dysphagia. Since the technique was first described in 198222 most reports have described treatment with the Nd YAG laser and flexible endoscopes under intravenous sedation; general anaesthesia is seldom necessary.23 It is often difficult to identify the oesophageal lumen and therefore wiser to spread treatment over several sessions, letting necrotic tissue slough before re-treating. There is a small risk of perforation, but this is less than with prosthesis insertion (the risk is highest if dilatation is used or after 10. Gelb F, Epstein JD. Laser treatment of lung cancer. Chest 1984; 86: 662-66. 11. George PJM, Clarke G, Tolfree S, Hetzel MR. Does laser treatment improve lung perfusion? Thorax 1987; 42: 227. 12. Gilmartin JJ, Veale D, Cooper BG, Keavey PM, Gibson GJ, Morritt GN. Effects of laser treatment on respiratory function in malignant narrowing of the central airways. Thorax 1987; 42: 578-82. 13. George PJM, Garrett CPO, Hetzel MR. Role of the neodymium YAG laser m the management of tracheal tumours Thorax 1987, 42: 440-44. 14. George PJM, Edwards D, Hetzel MR. Laser treatment for complete endobronchial obstruction. The value of preoperanve bronchography. Lasers Med Sci 1986; 1: 287. 15. Edmonstone WM, Nanson EM, Woodcock AA, Millard FJC, Hetzel MR. Life threatening haemoptysis controlled by laser photocoagulation. Thorax 1983; 38: 788. 16. Beamis JF, Sharpsay SM. More about the YAG. Chest 1985; 87: 277-78 17. Vincent RG, Dougherty TJ, Rao U, Boyle DG, Potter WR. Photoradiation therapy in advanced carcinoma of the trachea and bronchus. Chest 1984; 85: 29-33. 18. Konaka C, Kato H, Hayata Y. Lung cancer treated by photoradiation therapy alone. Survival for more than 3 years. Lasers Med Sci 1987; 2: 17-21. 19. Cox J, Bennet JR. Light at the end of the tunnel? Palliation of oesophageal carcinoma. Gut 1987; 28: 781-85. 20. Watson A. A study of the quality and duration of survival following resections, endoscopic intubation and surgical intubation in oesophageal carcinoma. Br J Surg 1982; 69:585—88. 21. Earlham R, Cuntra-Melo JR. Oesaphageal squamous cell carcinoma. A critical review of radiotherapy. Br J Surg 1980; 67: 457-61. 22. Fleischer D, Kessler F, Haye O. Endoscopic Nd YAG laser therapy for carcinoma of the oesophagus. A new palliative approach. Am J Surg 1982; 143: 280-83. 23. Bown SG, Hawes R, Matthewson K, Swam CP, Boulos P, Clark CG. Endoscopic laser palliation for advanced malignant dysphagia. Gut 1987; 28: 799-807.
radiotherapy).24 It is unwise to treat submucosal lesions or stenosis from extrinsic tumour. Lasers can be used in any region accesible to endoscopy, including the cervical oesophagus and gastric outlet where prostheses can not be inserted. After insertion of
a prosthesis, dietary restriction is whereas after laser therapy about one-third of necessary,19 can eat an patients essentially normal diet, a third to a half can eat a range of solids, and the rest have less satisfactory results. 23,25 The interval before recurrence of dysphagia tends to be short (5-22 weeks), although some patients survive many months without problems.23,26 Wider coagulation of the tumour to stimulate fibrous tissue formation may delay recurrence but can occasionally cause strictures which then require dilatation or a prosthesis.23 Tumour overgrowing a prosthesis may, however, be treatable by laser. The short duration of response to the laser is a stimulus to further research in both oesophageal and bronchial tumours. Combined laser and intracavitary isotope radiation may prolong response. Is high-tech laser treatment justified in patients with terminal cancer? Although lasers are expensive their cost compares favourably with ([,40 000-[,50 000) radiotherapy equipment and cytotoxic drugs. Rapid palliation of distressing symptoms enables the patient to spend more time at home, with reduced health service costs. Most established treatments for these tumours are aimed only at palliation and in these circumstances new treatments are wholly justified if they have fewer side-effects. Multidisciplinary use oflasers28 further reduces their-cost; in Britain the DHSS is now supporting a national medical laser centre (University College Hospital, London) to assess the value of lasers to the Health Service.
CAPD—THE WHITE KNIGHT? MOST British renal units
were
established between 1964
initially the UK kept pace with its European neighbours. Subsequently the rate of development slowed and 1970 and
and standards in Britain fell further and further behind those of all other developed countries. Some observers even wondered whether there was a disease of British nephrologists that prevented them realising the dimensions of their problem. The truth was that great efforts were made to maximise rather limited resources: no other country had as high a proportion of patients on home haemodialysis and no other European country outside Scandinavia had as high a transplant rate. There were simply too few units with too few hospital dialysis places. Hospital haemodialysis is important because this form of treatment is required to back up all other methods. The advent of continuous ambulatory peritoneal dialysis (CAPD) was greeted with such enthusiasm in the UK that within months of the first reports at the European Dialysis and Transplant Association
M, Escourrou J Complications observed during laser treatment of tumours of the upper digestive tract Acta Endoscopica 1985; 15: 13. 25. Mellow MH, Pinkas H Endoscopic laser therapies for malignancies affecting the oesophagus and gastroesophageal junctions. Analysis of technical and functional efficacy. Arch Intern Med 1985; 145: 1442-46. 26. Rieman JF, Ell C, Lux G, Demling L. Combined therapy of malignant stenoses of the upper gastrointestinal tract by means of laser beam and bouginage. Endoscopy 1985; 24. Davalaux
17: 43-48. 27. Bader M, Dittler HJ, Ultsch B, Ries
G, Stewart JR. Palliative treatment of malignant of the upper gastrointestinal tract using a combination of laser and afterloading therapy Endoscopy 1986; 18 (suppl 1) 27-36. 28. Bown SG. Laser endoscopy. Br Med Bull 1986; 42: 307-13. stenoses