Gastropulmonary fistula after bariatric surgery.

The Roux-en-Y gastric bypass is one of the most common operations for morbid obesity. Although rare, gastropulmonary fistulas are an important complication of this procedure. There is only one recently reported case of this complication. The present report describes the serious nature of this complication in a patient after an uneventful laparoscopic gastric bypass surgery.

Computed tomography demonstration of systemic arterial supply to lung without sequestration.

We present two cases of systemic arterial supply to lung without sequestration diagnosed confidently based on imaging findings on computed tomography scan, thereby obviating the need for invasive diagnostic procedures.

Fine needle aspiration biopsy of anaplastic thyroid carcinoma developing from a Hürthle cell tumor: a case report.

BACKGROUND: Anaplastic thyroid carcinoma is a highly malignant tumor in elderly people with a long history of multinodular goiter and is usually associated with a rapidly fatal clinical evolution. The tumor often develops as a result of anaplastic transformation of a slowly growing papillary carcinoma or follicular neoplasm. CASE: An 85-year-old woman had a multinodular goiter and had been asymptomatic, with a normal white blood cell count and chest radiograph three months prior to her hospital admission for the treatment. The tumor presented with low grade fever, leukocytosis, multiple metastatic lung nodules and enlargement of the intrathoracic thyroid in a period of three months, causing compression of the esophagus and trachea. Despite a total thyroidectomy, the tumor recurred within one month and caused dysphagia and death. CONCLUSION: FNAB permitted the diagnosis of an anaplastic thyroid carcinoma arising from an intrathoracic Hürthle cell tumor.

Esophageal perforation: a rare complication of Zollinger-Ellison syndrome.

Spontaneous perforation of the esophagus is a rare manifestation of Zollinger-Ellison syndrome (ZES). Failure to recognize its existence can lead to an unsuccessful treatment of the esophageal perforation. We present a rare case of reflux esophagitis-induced esophageal perforation in a patient with ZES. Presence of a gastrinoma should be considered when recurrent or complicated reflux esophagitis is encountered.

Glomus tumor of the trachea.

Extracutaneous glomus tumors are uncommon and rarely occur in the trachea. We describe a 73-year-old man with a glomus tumor of the trachea who presented with cough, dyspnea, chest pain, and hemoptysis. A curative segmental tracheal resection with primary reconstruction was performed with no recurrence at 6-year follow-up. The clinicopathologic features of this unusual neoplasm are discussed with a review of the literature.

The stomach as a microvascularly augmented flap for esophageal replacement.

We present a case of difficult esophageal reconstruction after total esophagectomy for iatrogenic perforation in a diseased esophagus. The stomach was used for esophageal reconstruction as a retrosternal microvascularly augmented flap; the vascular supply to the stomach had been interrupted during previous abdominal operations. The blood supply to the stomach conduit was restored by separate arterial and venous anastomosis between the right internal thoracic vessels and the left gastric vessels.

Cervical mediastinoscopy incisional metastasis.

Tumor deposit in the cervical mediastinoscopy incision is a rare complication of this operation when it is done to stage lung cancer. The etiology of this complication remains unclear. We present the case of a patient with this condition, discuss the cause and management, and review the literature.

Clinical characteristics and the impact of surgery and chemotherapy on survival of patients with advanced and metastatic bronchioloalveolar carcinoma: a retrospective study.

We retrospectively analyzed data from the clinical charts of 126 patients with bronchioloalveolar carcinoma (BAC) referred to the Ottawa Regional Cancer Center. The patient group consisted of 49 men (39%) and 77 women (61%). The mean age at diagnosis was 64 years. Most patients were smokers (85%). At diagnosis, 53% were stage Ia-IIIa and 47% were stage IIIb and IV. Forty-one percent of the patients with advanced and metastatic stages (IIIb, IV) underwent surgery. Multifocal disease was present at diagnosis in 41% of the patients, including 6% who had stage IIIb multifocal disease confined to a single lobe. Surgery was associated with prolonged survival in patients with multifocal unilobar or multilobar disease (P = 0.0001). While this apparent benefit of surgery may have been due to selection bias, it supports further exploration of surgery as therapy for multifocal disease. While patients receiving chemotherapy for advanced disease did not survive longer than patients not receiving chemotherapy, chemotherapy was used primarily in patients with more aggressive disease, suggesting that selection bias may have contributed to its apparent lack of benefit. Of the 30 patients treated with chemotherapy, only 3 (10%) achieved an objective response. One third of the patients (34%) developed distant metastases, with a predilection for the brain and bone.

Inflammatory aetiology of primary oesophageal achalasia: an immunohistochemical and ultrastructural study of Auerbach's plexus.

AIM: Achalasia is a disease of the oesophagus characterized by increased lower oesophageal sphincter (LOS) tone, absence of LOS relaxation with swallowing and aperistalsis of the body of the oesophagus. The aetiology and pathogenesis of idiopathic achalasia is still controversial. METHODS AND RESULTS: We examined 16 oesophageal biopsies and one low oesophagectomy specimen from patients with achalasia. The control group was composed of five autopsy cases with no history of oesophageal disorders, three cases of diffuse oesophageal spasm, one of gastro-oesophageal reflux disease and one patient with oesophageal carcinoma. Sections were immunostained for neurofilaments NF70 and NF200, S100 protein and neurone-specific enolase. Biopsies with inflammatory infiltrates, were in addition immunostained with antibodies against leucocyte common antigen as well as for CD20, CD43, CD68 and CD45RO. All biopsies were examined after plastic embedding, and electron microscopy (EM) was performed on samples containing autonomic plexus. An inflammatory infiltrate of varying intensity was present along the nerve fascicles and around ganglion cells in 90% of the cases of achalasia. T-lymphocytes predominated in all these cases. The autonomic nerves showed loss of fibres and degenerative changes which were discernible only by EM. Although there was no convincing neuronal loss or signs of active neuronal degeneration in biopsied cases, the oesophagectomy specimen revealed total absence of neurones and significant loss of nerve fibres. The control group showed normal plexuses and no inflammation. CONCLUSION: Degeneration and significant loss of nerve fibres associated with predominant T-cell lymphocytic inflammatory infiltrate around the myenteric plexus support the concept for the inflammatory, probably autoimmune, aetiology of autonomic nervous system injury in primary achalasia.

Basaloid carcinoma of the lung with bronchiolo-alveolar cell differentiation. A case report.

AIMS: We report a case of pulmonary basaloid carcinoma with bronchiolo-alveolar cell differentiation. PATIENTS AND RESULTS: A 75 year-old presented with a tumor measured 2.0 cm and was located in the periphery of the left upper lobe. Histologically, the lesion consisted of nests of basaloid cells, and lumina and clefts lined by tumor cells with features of mucous cells or type II pneumocytes or with mixed features. CONCLUSIONS: Previously reported basaloid carcinomas of the upper aero-digestive tract and lung have been purported to have an aggressive behavior. The tumor in the present study had features of a histopathological low grade tumor including a low mitotic rate, no tumor necrosis and a growth pattern at the periphery similar to that of bronchiolo-alveolar carcinoma.

Angiosarcoma of the chest wall.

Angiosarcoma is a rare and highly malignant tumor of vascular origin. The causative factors include trauma, radiation, foreign bodies, thorium dioxide, and viral infections. We report a case of angiosarcoma occurring in a thoracotomy incision 17 years after operation for stage I lung cancer.

Postpneumonectomy syndrome: recognition and management.

STUDY OBJECTIVE: Postpneumonectomy syndrome (PPS) results from extreme shift and rotation of the mediastinum after pneumonectomy producing symptomatic proximal airway obstruction and air trapping. Herein, we review our experience in the treatment of PPS. PATIENTS: Five patients with PPS were treated at our institution between 1991 and 1997. Four patients had previous right pneumonectomy; one patient had left pneumonectomy. Dyspnea was the presenting symptom in all five patients. The time interval to onset of symptoms and to surgical correction ranged from 6 months to 9 years (median: 6 months) and 9 months to 29 years (median, 21 months) after pneumonectomy, respectively. INTERVENTION: The clinical diagnosis of PPS was confirmed with chest radiograph, two-dimensional echocardiography, pulmonary function tests, CT scan, and awake fiberoptic bronchoscopy. Correction of PPS required reexploration of the pneumonectomy space followed by anterior pericardiorrhaphy and insertion of a saline solution-filled Silastic prosthesis (Dow Corning; Midland, MI) for the purpose of correcting the overshift of the mediastinum. There was no morbidity or mortality. RESULTS: All patients had relief of dyspnea. Corrective repositioning of the mediastinum was confirmed by chest radiograph, CT scan, and awake fiberoptic bronchoscopy. There was a mean increase in the cross-sectional diameter, as measured by CT scan, of the obstructed bronchus by 166.7% (range, 100 to 300%) in four patients. One patient had no change in the measured diameter. Postoperatively, the peak expiratory flow rate increased by a mean of 44.2% (range, 40 to 49%) in all five patients. CONCLUSION: The presence of PPS should be considered in all patients presenting with progressive dyspnea after pneumonectomy. Repositioning of the mediastinum with a saline solution-filled prosthesis and anterior pericardiorrhaphy is easily performed and provides immediate and lasting symptomatic relief.

Immediate postoperative enteral feeding results in impaired respiratory mechanics and decreased mobility.

OBJECTIVE: The authors set out to determine whether immediate enteral feeding minimizes early postoperative decreases in handgrip and respiratory muscle strength. SUMMARY BACKGROUND DATA: Muscle strength decreases considerably after major surgical procedures. Enteral feeding has been shown to restore strength rapidly in other clinical settings. METHODS: A randomized, controlled, nonblinded clinical trial was conducted in patients undergoing esophagectomy or pancreatoduodenectomy who received immediate postoperative enteral feeding via jejunostomy (fed, n = 13), or no enteral feeding during the first 6 postoperative days (unfed, n = 15). Handgrip strength, vital capacity, forced expiratory volume in one second (FEV1), and maximal inspiratory pressure (MIP) were measured before surgery and on postoperative days 2, 4, and 6. Fatigue and vigor were evaluated before surgery and on postoperative day 6. Mobility was assessed daily after surgery using a standardized descriptive scale. Postoperative urine biochemistry was evaluated in daily 24-hour collections. RESULTS: Postoperative vital capacity (p < 0.05) and FEV1 (p = 0.07) were consistently lower (18%-29%) in the fed group than in the unfed group, whereas grip strength and maximal inspiratory pressure were not significantly different. Postoperative mobility also was lower in the fed patients (p < 0.05) and tended to recover less rapidly (p = 0.07). Fatigue increased and vigor decreased after surgery (both p < or = 0.001), but changes were similar in the fed and unfed groups. Intensive care unit and postoperative hospital stay did not differ between groups. CONCLUSIONS: Immediate postoperative jejunal feeding was associated with impaired respiratory mechanics and postoperative mobility and did not influence the loss of muscle strength or the increase in fatigue, which occurred after major surgery. Immediate postoperative enteral feeding should not be routine in well-nourished patients at low risk of nutrition-related complications.

Optimal treatment of descending necrotising mediastinitis.

BACKGROUND: Descending necrotising mediastinitis is caused by downward spread of neck infection and has a high fatality rate of 31%. The seriousness of this infection is caused by the absence of barriers in the contiguous fascial planes of neck and mediastinum. METHODS: The recent successful treatment of seven adult patients with descending necrotising mediastinitis emphasises the importance of optimal early drainage of both neck and mediastinum and prolonged antibiotic therapy. The case is also presented of a child with descending necrotising mediastinitis, demonstrating the rapidity with which the infection can develop and lead to death. Twenty four case reports and 12 series of adult patients with descending necrotising mediastinitis published since 1970 were reviewed with meta-analysis. In each case of confirmed descending necrotising mediastinitis the method of surgical drainage (cervical, mediastinal, or none) and the survival outcome (discharge home or death) were noted. The chi 2 test of statistical significance was used to detect a difference between cases treated with cervical drainage alone and cases where mediastinal drainage was added. RESULTS: Cervical drainage alone was often insufficient to control the infection with a fatality rate of 47% compared with 19% when mediastinal drainage was added (p < 0.05). CONCLUSIONS: Early combined drainage with neck and chest incisions, together with broad spectrum intravenous antibiotics, should be considered standard care for this disease.

Postpneumonectomy syndrome with an ipsilateral aortic arch after left pneumonectomy.

BACKGROUND: Previous reports have described bronchial obstruction after left pneumonectomy (so-called post-pneumonectomy syndrome) in the presence of a right aortic arch with the bronchus being compressed between the ascending aorta and thoracic spine. This study reports on 4 patients with left postpneumonectomy syndrome in the presence of a normally located left aortic arch and ascending thoracic aorta. METHODS: The case histories of 4 patients with this syndrome were reviewed and several features common to all 4 were noted. In each case, the obstruction was thought to be due to a clockwise rotation of the mediastinum with bronchial compression occurring between the right main pulmonary artery and thoracic spine. RESULTS: Three patients were treated by repositioning of the mediastinum, and all 3 obtained relief of their dyspnea. In these cases, permanent repositioning was ensured by the insertion of a prosthesis filled with saline solution. The fourth patient was successfully treated by resection of a portion of the adjacent thoracic vertebra. CONCLUSIONS: Postpneumonectomy syndrome can occur after a left pneumonectomy in the absence of a right aortic arch. We suggest that mediastinal repositioning with a prosthesis filled with saline solution is simple, is safe, and results in complete relief of preoperative symptoms.

Revascularization of the ischemic gastric tube using the left internal thoracic artery.

Ischemia of the gastric tube during use as an esophageal substitute may have serious consequences. We describe a method to correct substernal gastric tube ischemia using the left internal thoracic artery as a source of arterial inflow to a short gastric artery. This permitted successful reconstruction of the upper alimentary tract in this patient.

Trachea-innominate artery fistula and concomitant critical cerebrovascular disease.

To avoid the laborious task of investigating the cerebrovascular circulation in the midst of a trachea-innominate artery fistula, we strongly recommend preoperative cerebrovascular investigations in all patients about to undergo mediastinal tracheostomy. Paramount to this dictum remains the possibility of asymptomatic cerebrovascular disease. Inadequate preoperative cerebrovascular assessment may result in, as described in this report, the possibility of significant postoperative neurologic morbidity or mortality. Angiography should assist the surgeon in deciding which method of cerebral arterial reconstruction is best suited to the individual circumstance. We recommend the avoidance of innominate artery reconstruction even with the interposition of autologous tissues, as the operative field remains grossly infected.

Classification of cystic and bullous lung disease.

Cystic and bullous diseases of the lung are of special interest, referring to a wide variety of pathologic conditions. A thorough knowledge of these conditions and associated pathophysiology is necessary in planning the best type of treatment.