Celestin Tube Research Articles

Celestin tube disruption

Two cases of disruption of a Celestin tube with distal displacement are described. In each case the tube was removed and the method of treatment is discussed. Regular insertion and retrieval of Celestin tubes using endoscopy is suggested for benign lower oesophageal strictures.

Evaluation of the prognostic factors in gastric cancer: the effect of chemotherapy on survival.

This is a retrospective review of 328 consecutive patients with histologically confirmed gastric adenocarcinoma diagnosed in one centre between 1974 and 1984. Of these patients, 128 (39 per cent) had a curative resection, 32 (9.8 per cent) had a palliative resection, 33 (10.0 per cent) had a gastro-enterostomy, 26 (7.9 per cent) had a Celestin tube inserted, 58 (17.7 per cent) had a laparotomy alone, and 51 (15.5 per cent) had no surgical procedure. The 5 year survival was 11 per cent but all long term survivors were patients who had a curative resection. Using multivariate analysis the best predictor of survival after curative resection was the presence or absence of serosal involvement (P = 0.0004). Patients with a long history of presenting symptoms (greater than 6 months) survived longer than those with a short history (P = 0.001). The impact of chemotherapy on the survival of 202 patients with advanced gastric cancer was analysed by multivariate analysis. The median survival of the 50 patients receiving combination chemotherapy was better than that of the 152 who did not (median survivals 160 versus 71 days; P less than 0.001). When deaths occurring within 14 days of diagnosis were excluded, the significance value dropped to P = 0.02. Comparison of the groups treated between 1974 and 1979, when 8 per cent of 92 patients received chemotherapy, with 1980-1984, when 45 per cent of 110 patients received chemotherapy, showed no significant difference in survival.

The Celestin tube in the palliation of carcinoma of the oesophagus and cardia.

A series of 105 patients with dysphagia due to inoperable carcinoma of the oesophagus or cardia of the stomach, and 11 patients with dysphagia secondary to malignant medistinal nodes, was treated by intubation with a Celestin tube. The hospital mortality was high but 81 patients left hospital and 29 were still alive at 6 months. The prognosis for those with dysphagia due to malignant posterior mediastinal nodes was very poor, with no survivors at 6 months. Oesophageal perforation was a serious operative complication, with a hospital mortality of 83 per cent. Chest and wound infections were the most common postoperative complications occurring in 28 and 20 per cent of the patients, respectively. The restoration of swallowing was satisfactory in the majority of survivors although readmission with a blocked or displaced tube was not uncommon.

The Celestin tube in the treatment of benign oesophageal strictures

Celestin tubes have been used in two groups of patients with advanced benign oesophageal strictures. Group 1 consisted of 22 elderly, poor risk patients in whom intubation alone, via a gastrotomy, has provided good symptomatic relief of dysphagia. In 11 younger, better risk patients (group 2), it has been used as a temporary indwelling dilator in combination with repair of the hiatus hernia and has been removed at a mean of 5 months postoperatively. Seventy-three per cent of patients have remained free of recurrence when followed up for 2 years.

Complications associated with the use of the Celestin tube for benign oesophageal obstruction

Two cases are described in which disruption of a Celestin tube took place after being lodged in a benign oesophageal stricture for 14 months. One patient presented with apparent acute pancreatitis and the other with a minor gastrointestinal bleed.

Endoscopic insertion of palliative oesophageal tubes in oesophagogastric neoplasms.

Fifty-five patients have undergone fibreoptic endoscopy under diazepam sedation with attempted insertion of a Celestin tube by the Nottingham introducer for an unresectable oesophagogastric malignant stricture. There were 4 perforations in 48 successful intubations (8.3 per cent), 3 patients subsequently dying and the fourth healing spontaneously. There were 4 proximal tube displacements; 3 patients later returned with bolus obstruction. Thirty-five (73 per cent) of the 48 patients who were successfully intubated left hospital with relief of dysphagia for periods ranging from 10 days to 18 months until death (mean 5.5 months). Of the 13 deaths in hospital, 6 occurred as a result of the procedure (mortality rate 12.5 per cent). We conclude that endoscopic insertion of palliative oesophagogastric tubes is relatively safe, simple to perform and could replace surgical introduction. It is technically more difficult in cases of gastric neoplasm involving the cardia.

Severe Complications Caused by Dissolution of Latex with Consequent Self-Disintegration of Esophageal Plastic Tubes

A case of decisive material degeneration of an esophageal Celestin tube is described: a 50-year-old man with adenocarcinoma of the distal esophagus received a Celestin tube for palliative endoscopic treatment and 8 months later presented with suddenly occurring complete dysphagia. Dissolution of the latex layer in the proximal as well as the distal part of the tube had caused self-disintegration of the Celestin tube and had liberated the monofilament nylon coil which completely obstructed the lumen of the tube. Endoscopic tube removal was only possible by careful attachment of a balloon catheter and peroral extraction after insufflation with contrast medium up to 5 atm. A Medline-based review of the literature revealed different but predominantly severe complications (perforation, hemorrhage, obstruction, and peritonitis) based on material fatigue of the latex layer in esophageal Celestin tubes. At least 6 months after placement of a Celestin tube, regular fluoroscopic controls should be performed to detect early disintegration of the tube. Indication for the placement of Celestin tubes in patients with benign esophageal strictures and longer life expectancy should be assessed very critically.

Survival of proximal third gastric carcinoma.

Proximal third gastric carcinoma is a distinct clinical entity compared with tumors located in other parts of the stomach with a rapid increasing incidence and a poor prognosis. This study was done to evaluate therapy for, and survival of, patients with gastric cardia carcinoma. Clinical features and prognosis of 49 patients with proximal third gastric carcinoma between 1985 and 1995 (mean age 69.7 years) were evaluated. In 20 of the 49 patients, laparotomy was excluded because of widespread disease and/or poor clinical condition at presentation. Palliative therapy consisted of gastric tube implantation (n = 4), dilation (n = 3), or radiotherapy (n = 4). In 9 patients, no specific palliative therapy was indicated. Twenty-nine patients underwent laparotomy (59%). In 13 patients, a total gastrectomy with esophagojejunostomy was performed, and in 7 patients a partial gastrectomy was performed. In 9 cases, the tumor was irresectable. In 8 of these 9 patients, a Celestin tube was implanted. Median survival in all patients was 7 months and the expected probability of survival after 50 months was zero. The median survival of patients who underwent a resection was significantly better than in those in whom no resection was performed (23 vs. 4 months, P = 0.047). We conclude that long-term survival of patients with proximal third gastric carcinoma is poor. However, long-term survival may be best warranted when patients present at an early stage and resection can be performed.

Expandable esophageal prostheses: recognition, insertion techniques, and positioning.

Adam W. Nevi&, Richard A. Kozarek2, Reiley Kidd1 O all cases of gastroesophageal carcinoma. fewer than half are resectable. and only a small number of those resections will lead to cure. Even after ‘ curative” surgery. about 2Oc4 of these patients will have further dysphagia caused by either recurrence or anastomotic stricture. For these reasons. palliative measures have come to the forefront of therapy. Treatments include palliative resection or bypass. irradiation, periodic bougienage. chemotherapy. tumor ablation with a neodymium-yttriumaluminum-garnet (Nd-YAG) laser. placement of a conventional rigid esophageal stent, placement of a feeding gastrostomy tube. or a combination of these measures I I I. Malignant esophageal obstructions have been treated palliatively with esophageal prostheses for more than 1(X) years. The first prostheses. fashioned out of ivory and boxwood. were passed orally and fixed externally. including tying the prosthesis to a mustache in one case 12). Blind placement of prostheses ultimately evolved into open insertion of Celestin tubes. which required laparotomy. These procedures were plagued by high procedure-related niorbidity and nx)rtality. The advent of fiberscopic endoscopy and fluoroscopic guidance signiticantly improved the safety of placement of rigid esophageal stents. However, the placement of these rigid stents was by no means risk-free. Preparatory esophageal bougienage to 2to 4-French sizes larger than the prostheses over 4-5 days before placement of the rigid stent was the standard; acute procedure-related complications approached 20c/ ith death reported 8.f{k of the time ill a meta-analysis of published series 131Acute complications included bleeding. perforation. dyspnea (from tracheal compression ). and tube malposition. Long-term complications. in turn. have included migration. erosion with bleeding. or esophagotracheal fistulas, tumor overgrowth of the proximal or distal end, chronic aspiration. and tube occlusion by a food bolus. Expandable esophageal stents have been introduced in the hope of diminishing procedural and subsequent stent-related complications. The Food and Drug Administration has recently approved four metallic expandable prostheses that are now commercially available on the United States market for the treatnient of malignant dysphagia (Fig. I ): Gianturco Zstent (Wilson-Co k, Winston-Salem, NC), Wallstent (Schneider. Minneapolis. MN). Ultraflex nitinol mesh stent (Microvasive, Natick, MA). and the EsophaCoil (Instent. Eden Prairie. MN). The theoretic advantages of expandable metal prostheses over conventional rigid stents include easier placement of the stent in an acutely angled stenosis and an overFig. 1.-The four currently available metallic stents on the United States market: Ultraflex nitinol mesh stent )Microvasive, Natick, MA) (A), Wallstent Schneider, Minneapolis, MN) (B), Gianturco Z-stent (WilsonCook, Winston-Salem, NC) (C), and EsophaCoil (Instent, Eden Prairie, MN) (D). Each prosthesis is available in various lengths and diameters.

Self-Expanding Nitinol Stent for Malignant Obstructive Dysphagia–Initial Experience

Between July 1992 and December 1994, a total of 31 patients with inoperable or unresctable malignant obstruction of the esophagus or esophagogastric junction were palliated with self-expanding nitinol stents. They were 33 to 86 years old, 55% being 70 years or older. Twenty patients were male. Twenty patients (65%) had squamous cell carcinoma, 10 (32%) had adenocarcinoma and one (3%) had undifferentiated carcinoma. Twenty-five patients (81%) required prestenting dilatation with balloons, bougies or laser. Stent implantation was successful in 30 patients (97%) but failed in one. Two patients had minor complications and one patient with advanced disease died in the hospital one week after the procedure. All stended patients experienced significant short-term relief of dysphagia. Twenty-two patients (73%) were seen at least once after discharge in a follow-up visit. Twenty (66%) were still swallowing satisfactorily when last seen four to 32 weeks after stenting. We conclude that the new nitinol stent represents an important and valuable addition to the treatment options available for palliation of malignant dysphagia.

Displacement of a Celestin Tube: An Unusual Cause of Difficult Intubation

Displacement of a Celestin Tube: An Unusual Cause of Difficult Intubation

Recanalization of tube overgrowth: a useful new indication for laser in palliation of malignant dysphagia

Overgrowth of an esophageal prosthesis by cancer is a late complication of insertion which presents a difficult management problem. We have treated 14 such patients; 9 had Celestin tubes and 5 Atkinson tubes in situ for a median of 7 months. The median patient age was 75 years; 3 had squamous cell carcinomas and 11 adenocarcinomas; 12 were at the lowest thoracic esophagus or cardia, and 2 were anastomotic. Eleven tubes were overgrown at the top, two at the bottom only, and one at both ends. Dysphagia was graded from 0 to 4 (0 = normal; 4 = dysphagia for liquids). All patients but one improved with treatment. The median pre-treatment grade was 4 (range, 2 to 4) and post-treatment was 2 (0 to 3). This improvement was significant (p less than 0.01) Wilcoxon-signal rank). Most patients required only one or two endoscopies. The median survival was 9 weeks from first laser session (range, 3 to 36 weeks). We feel these results justify laser treatment in most patients in whom cancer overgrowth causes blockage of an esophageal prosthesis.

Experience with a transnasally fixed endoprosthesis for treating esophageal anastomotic leakage

Eight patients suffering from leakage around the esophagus were treated with a transnasally fixed Celestin tube. All of the subjects had exhibited an anastomotic dehiscence after having undergone esophageal resection, cardia resection or total gastrectomy. Following treatment, in all cases the anastomoses healed quickly with no complications.

Complications of esophageal prostheses: roentgenologic manifestations.

We reviewed the roentgenographic findings in 15 patients who had endoscopic placement of a new type of esophageal prosthesis for obstruction caused by a malignant neoplasm. Each patient was evaluated with an esophagogram. Chest roentgenography and computerized tomography were used to confirm abnormalities seen on esophagography. The complication rate was 74% (11 cases), and included five cases of migration or malposition, two cases of perforation, and one case of obstruction. The recognition of postprocedural complications is paramount to their successful management. The complications associated with this new esophageal prosthesis are no different from those reported with the Celestin tube, though the frequency may be higher.

Esophageal perforation.

Sixty-nine patients with perforation of the esophagus were treated at the University of California, San Francisco, from 1977 to 1988. The perforation was iatrogenic in 33 (48%) of the patients, spontaneous in 8 (12%), and a result of external trauma in 23 (33%). Clinical findings included chest pain in 36 (52%) of 69 patients, subcutaneous emphysema in 22 (32%) of 59 patients, and pneumomediastinum in 21 (36%) of 59 patients. Esophagograms demonstrated the perforation in 40 (93%) of 43 patients. Treatment delays of more than 24 hours occurred in about half of spontaneous and iatrogenic perforations, but when the perforation was due to external trauma, treatment was delayed infrequently. Operative therapy in 59 (86%) of the patients included primary closure in 44 patients, drainage alone in 9 patients, and Celestin tube placement in 1 patient. Four patients with benign strictures had esophagectomy, and 4 patients with achalasia had Heller myotomy in addition to closure of the perforation. Eight (12%) of the patients were treated nonoperatively. For thoracic perforations, nonoperative treatment was reserved for patients who were diagnosed late but who had minimal evidence of sepsis. Seven (10%) of the patients died. Factors that influenced outcome included cause of perforation, anatomic location, and patient age. Our study shows that a high index of suspicion, aggressive use of esophagography, and individualized treatment are necessary for the best results when treating esophageal perforation.

A simple technique for intraluminal irradiation in oesophageal tumours using the high-dose-rate Microselectron.

The majority of oesophageal cancers present at an incurable stage and any treatment is aimed at relieving unpleasant symptoms, the most important of which is dysphagia. Unless this is satisfactorily relieved, the demise of the patient is usually rapid with marked weight loss and gross wasting. Unpleasant terminal events ensue as the patient finally cannot even swallow his own saliva. Palliative external-beam radiotherapy has been used with limited success but the established methods of relieving the obstruction include repeated dilatation and the insertion of specially designed tubes at oesophagoscopy (e.g. Mousseau-Barbin or Celestin tubes). Recently, laser treatment has been used with benefit. None of these methods are ideal for palliation as they usually require hospital admission and often repeated oesophagoscopy, and may be associated with major morbidity. An easy method of palliating these patients has been eagerly awaited.

A comparison of endoesophageal tubes

We reviewed our use of endoesophageal tubes for the palliation of patients with carcinoma of the esophagus from 1973 through 1986. Celestin tubes were implanted by means of laparotomy and traction. Proctor-Livingston tubes were implanted by pulsion with frequent laparotomy for staging. All Atkinson tubes were placed by means of the pulsion method without simultaneous laparotomy in any case. Patients with an Atkinson tube had fewer complications, including aspiration, sepsis, reflux, and pneumonia. Mean hospital stay was shortened to 4 days when the Atkinson tube was used, and hospital death rate was 6% versus 42% when either the Celestin or Proctor-Livingston tube was used. Mean long-term survival (108 days) was significantly lengthened when Atkinson tubes were used. A comparison of all patients receiving tubes revealed a less frequent prevalence of reflux when the distal end of the tube was positioned above the gastroesophageal junction. Laparotomy resulted in significantly more episodes of aspiration, sepsis, reflux, and pneumonia. Laparotomy was also associated with a 41% hospital death rate versus 17% when laparotomy was not performed. Hospital days were shortened to 7 versus 16 days when laparotomy was not performed. The Atkinson tube provided improved palliation and decreased morbidity and mortality in our hands. These benefits were probably the results of ease of insertion without the use of a laparotomy and the ability in most cases to position the distal end of the tube above the gastroesophageal junction.

Respiratory tract fistulae in recurrent aerodigestive cancers after chemotherapy.

Bronchoesophageal fistulae, a form of respiratory tract fistula, occurred in four patients with squamous cell carcinoma arising in the esophagus or left bronchus after cytoreductive chemotherapy. All four had locoregional cancer, recurrent after high-dose external radiation therapy. Esophageal cancer was treated with sequential intravenous cisplatin 100 mg/m2 (day 1) and 5-fluorouracil (5-FU) 40 mg/m2/hour X 120 (days 2-7). Lung cancer was treated with sequential intravenous cisplatin 100 mg/m2 (day 1), 5-FU 40 mg/m2/hour X 72 (days 2-5), and etoposide 80 mg/m2/day X 3 (days 2, 3, and 4). All patients had symptomatic relief and tumor regression after oncolytic chemotherapy, which was well tolerated with no hematologic toxicity. After the second or third cycle of chemotherapy, bronchoesophageal fistula occurred in all four patients with manifestations of pneumonia, which proved fatal in two patients. The other two patients were effectively palliated for 14 and 36+ weeks after celestin tube placement. Bronchoesophageal fistula should be managed by antibiotics and respiratory support followed by elective placement of celestin tube in most patients and by esophageal exclusion or esophageal bypass in a few select patients. In aerodigestive cancers, respiratory tract fistula may be a rare and potentially fatal complication of chemotherapy induced tumor lysis.

Oesophageal perforation--a review of 37 cases.

We have reviewed 37 cases of ruptured oesophagus treated at St Vincent's Hospital from 1976 to 1986. Their age ranged from 20 to 89 years (mean 64 years) and 59% were female. The causes of rupture were spontaneous (9), foreign body (5), diagnostic oesophagoscopy (8), oesophagoscopy and dilatation (5), balloon dilatation (3), palliative intubation (6) and patient self dilation (1). Eighty-six per cent of perforations occurred in the lower third of the oesophagus. The most common means of diagnosis was a positive contrast swallow (90%) and/or the presence of cervical or mediastinal air (49%). Eighteen patients underwent surgical treatment which consisted of a combination of thoracotomy, drainage and repair, or laparotomy and Celestin tube insertion, with or without chest drainage. Two patients underwent oesophageal diversion. The overall mortality in all patients was 30% (37% non-operative and 22% operative group). We conclude that the management of ruptured oesophagus demands an individual approach depending upon the site and aetiology of perforation and the underlying disease. The condition is a disease of the elderly and continues to have a high morbidity and mortality.

Inoperable oesophageal and cardia cancer:Benefits from Celestin Intubation

During a 12-year period, 77 consecutive patients with unresectable malignant stricture of the oesophagus or cardia were treated with a Celestin tube for relief of dysphagia of varying degree. Pull-through technique and gastrotomy were used for insertion of the tube in 72 patients, and endoscopy in five. One-third of the patients benefited from the operation, i.e. experienced good palliation and no serious complications. The mortality rate was 27%. The authors conclude that all patients with difficulty in swallowing saliva should be intubated, as good palliation was achieved in all such patients. When there is dysphagia for liquid food, insertion of a Celestin tube may be considered, but intubation should not be done when dysphagia is confined to solid foods.