Impact of new radiotherapy modalities on the surgical management of cancer of the esophagus and cardia.

At the Cancer Control Agency of British Columbia, 483 patients with cancer of the esophagus and cardia were seen from 1970-1980. Four hundred and one out of 483 (83%) had tumors larger than 5 cm (T2) and in 288/483 (60%) the disease had extended beyond the esophageal wall (T3). The overall 5-year survival rate was only 9% for all patients treated by external irradiation. The 5-year survival for a selected group having esophagectomy was 20%. Most patients died of persistent cancer at the primary site (83%); the cause of death was aspiration pneumonia (82%) due to obstruction caused by the persistent cancer. Our most recent experience using intracavitary irradiation either prior to or after external irradiation in 211 patients has been safe and simple and preliminary analysis of treatment results suggests that it has improved the therapeutic ratio. The analysis of quality of life at 6 months following therapy as it relates to performance status, swallowing ability, weight, and pain indicated significant improvement in all of these parameters. Of 171 patients, 33% were still alive at 1 year, 26% at 2 years, and 19% at 3 years following treatment. Of 43 patients suitable for preoperative irradiation, only 26 patients were actually resected and 19 of them are still alive with no evidence of disease, 8 to 30 months. The rationale and technical aspects of the combined treatment are described in detail. Treatment results, complications and an outline for future programs based on this experience are also described.

Management of massive hemoptysis secondary to catheter-induced perforation of the pulmonary artery during cardiopulmonary bypass.

Pulmonary artery perforation by flow-directed catheters is associated with high mortality, particularly in heparinized patients. We report a recent case and discuss recognition and management.

Localized fibrous mesothelioma of pleura following external ionizing radiation therapy.

Carcinogenesis is a well-known complication of radiation exposure. Ionizing radiation also leads to an increased incidence of benign tumors. A 36-year-old woman had a localized fibrous mesothelioma of the pleura and an ipsilateral breast carcinoma 23 years after receiving external radiation therapy for treatment of a chest wall keloid.

Multicentricity of adenocarcinoma of the lung.

In a consecutive series of 62 lung resections for bronchogenic adenocarcinoma, 12 patients (19 percent) were found to have two or more adenocarcinomas on careful pathologic examination. These tumors all met the criteria for separate primary malignancy. In only two of the patients were the additional lesions suspected preoperatively. This incidence of multiple primary lung adenocarcinomas in apparently operable patients is several fold higher than would be anticipated from the literature. The phenomenon has important implications for preoperative radiologic evaluation, postoperative pathologic examination, assignment of TNM stage, and clinical follow-up of patients undergoing successful resection.

Airway involvement in ulcerative colitis.

Two patients with ulcerative colitis developed progressive obstructive pulmonary disease. In one, the abnormality was a sclerosing peribronchiolitis confined to small airways, while the other demonstrated a large airway fibrotic obliterative bronchitis. A review of airway involvement in ulcerative colitis and a discussion of the possible similarity to another extraintestinal manifestation of ulcerative colitis, sclerosing cholangitis, are presented.

Transhiatal esophagectomy for carcinoma of the esophagus and cardia. Experience with 160 cases.

We reviewed our experience from 1979 to 1990 with 160 cases of transhiatal esophagectomy for carcinoma of the lower esophagus and cardia to evaluate trends in patient selection, management, and outcome. Patients treated in the past 6 years (n = 110) and those treated before 1985 (n = 50) were similar in terms of age and sex distribution, medical history, and weight loss. The majority of tumors seen were adenocarcinoma, with patients in the latter group having significantly lower stages. Significant decreases in anesthetic time, units of blood transfusions, chest tube insertions, length of postoperative ventilation, incidence of postoperative pneumonia, and length of hospital stay were seen during the past 6 years. Wound infections increased significantly during the same period. The decrease in the 30-day mortality rate from 6% to 0.9% was not significant. Survival rates did not differ between groups, with overall rates of 62%, 40%, and 21% at 1, 2, and 5 years, respectively.

Mediastinal lymph node necrosis: a newly recognized complication of mediastinoscopy.

Eight cases of partial mediastinal lymph node necrosis identified at thoracotomy two to 17 days after cervical mediastinoscopy are described. In 6 cases, the involved nodes were grossly abnormal at operation, requiring frozen section interpretation. In the first 2 patients, the areas of nodal infarction were misinterpreted as necrotic tumor. Permanent sections from all 8 patients showed no evidence of tumor in the infarcted nodes. Factors predisposing to nodal infarction included right-sided tumor, central tumor, and large mediastinoscopic biopsy specimens. In all instances, the infarcted nodes were subcarinal and/or main bronchial. In 2 patients, left recurrent laryngeal nerve palsy occurred after mediastinoscopy. Necrosis in distal nodal areas should be recognized as a complication of thorough mediastinoscopic sampling, presumably due to interruption of arteries supplying these nodes. Awareness of this phenomenon by surgeons and pathologists may avert falsely positive gross or microscopic diagnoses of metastatic malignancy at thoracotomy.

Penetrating injury of the torso with impalement of the thoracic aorta: preoperative value of the computed tomographic scan.

A patient survived thoracoabdominal penetrating injury with impalement of the descending thoracic aorta from a crossbow bolt. The precise extent and nature of the injury were determined preoperatively by computed tomography. The injury to the aorta had not been suspected clinically before the computed tomographic scan.

Effect of routine fibrin glue use on the duration of air leaks after lobectomy.

The effectiveness of fibrin glue as a sealant to reduce postoperative air leaks after pulmonary lobectomy was evaluated in 28 consecutive patients between November 1988 and May 1989. A fibrin glue spray was used in 14 patients, and 14 patients served as controls. Assignment of either group was made before thoracotomy. Nine male and 5 female patients with a mean age of 63.8 years were in the fibrin glue experimental group, and 8 male and 6 female patients with a mean age of 59 years, in the control group. An equal number of complete and incomplete fissures were in each group. All fissures were handled in the same way (stapled). Two milliliters of fibrin glue was applied through a double-syringe delivery system and sprayed on the staple line and any cut surface of the inflated lung just before thoracotomy closure. The fibrin glue-treated group had a mean air leak duration of 2.3 +/- 3.7 days, chest tube drains for 6 +/- 4.1 days, and a postoperative hospitalization of 9.8 +/- 3.1 days. The control group had a mean air leak duration of 3.3 +/- 3.3 days (p = 0.94), chest tube drains for 5.9 +/- 3.9 days (p = 0.95), and a postoperative hospitalization of 11.5 +/- 3.9 days (p = 0.21). We conclude that the routine use of a fixed quantity of fibrin glue is not effective in reducing the duration of air leaks, chest tube drainage, or hospitalization after uncomplicated pulmonary lobectomy.

Anterior and middle mediastinum paraganglioma: complete resection is the treatment of choice.

Paraganglioma of the mediastinum is described to be an indolent and slow-growing tumor. After a patient presented to our center, we reviewed the world literature to evaluate the prognosis of this tumor. This review showed that paragangliomas are locally invasive and have a high local recurrence rate (44/79 or 55.7%) with a true metastatic capacity (21/79 or 26.6%). The overall survival is 62.0% (49/79), but only 36.7% (29/79) of patients could be considered as free of disease, with survival time of 98.2 +/- 11.7 months (mean +/- standard error). The survival with a complete resection is 84.6% (125.7 +/- 18.7 months) versus 50.0% (71.5 +/- 13.8 months) for patients with a biopsy or a partial excision and adjuvant treatment (p < 0.01). We acknowledge the limitation of this retrospective study, but a prospective trial is not possible because of the rarity of the tumor. We want to emphasize that paraganglioma of the anterior and middle mediastinum is an aggressive tumor, and complete surgical resection, using cardiopulmonary bypass if necessary, is highly recommended.

Lingular and right middle lobe biopsy in the assessment of diffuse lung disease.

It has been said that the lingula and right middle lobe should be avoided for open-lung biopsy because of nonspecific fibrosis and vascular changes. To determine if the diagnostic yields of lingular or right middle lobe biopsy specimens were unsatisfactory, we reviewed the results of open-lung biopsy in 73 adult patients; 26 were immunocompromised and 47, nonimmunocompromised. We found no evidence to suggest that these two sites were inherently inferior. In 20 of the nonimmunocompromised patients, computed tomography was performed prior to biopsy, and demonstrated no particular tendency for greater involvement of the lingula or right middle lobe. We conclude that lingular and right middle lobe biopsy is useful in the diagnosis of parenchymal lung disease and that these sites should not necessarily be avoided. Computed tomographic scanning prior to biopsy is helpful in guiding the surgeon to the appropriate sites from which to obtain biopsy specimens.

Esophagogastrectomy and the variant left hepatic artery.

A variant left hepatic artery occurs at a rate of approximately 10%. In standard esophagogastrectomy and some proximal gastric operations this variant artery is sacrificed, which has led to reported fatalities secondary to hepatic necrosis. We report our method of esophagogastrectomy in the presence of an aberrant left hepatic artery.

Factors affecting cervical anastomotic leak and stricture formation following esophagogastrectomy and gastric tube interposition.

Following esophagectomy, restoration of swallowing by gastric tube interposition with cervical esophagogastric anastomosis reduces morbidity and mortality associated with intrathoracic anastomoses at the expense of an increased incidence of both anastomotic leak and stricture formation. A retrospective study of 165 patients with either squamous cell carcinoma or adenocarcinoma of the distal esophagus or gastric cardia undergoing esophagogastrectomy with gastric tube interposition and cervical anastomosis at Vancouver, British Columbia, or London, Ontario, was undertaken. Forced-entry multiple logistic regression analysis of factors believed to influence anastomotic outcome was performed. Anastomotic leak occurred in 17% of patients; statistically significant correlation with low preoperative serum albumin (p = 0.005), running suture technique (p = 0.029), high intraoperative blood loss (p = 0.038), and the occurrence of postoperative delayed gastric emptying (p = 0.045) was found. Anastomotic strictures occurred in 31% of patients; a statistically significant correlation was found with preceding anastomotic leak (p = 0.001) and intraoperative blood loss (p = 0.042). Factors including preoperative radiotherapy and diabetes mellitus were not found to be significant.

Gastrointestinal function following esophagectomy for malignancy.

BACKGROUND: The frequency and causes of gastrointestinal complications following esophagectomy for malignancy are unknown. PATIENTS AND METHODS: We reviewed 295 esophagectomies performed for malignancy between January 1980 and September 1994 in order to determine the frequency and causes of early and late gastrointestinal complications. RESULTS: Compared to transhiatal and left thoracoabdominal esophagectomies, esophagectomies carried out through a right posterolateral thoracotomy with cervical esophagogastric anastomosis had a higher incidence of delayed gastric emptying (11%), pneumonia (26%), and hospital death (9%). The same operation had a higher incidence of gastroesophageal reflux (20%) and dysphagia requiring esophageal dilatation (53%). We found no independent effect of gastric drainage procedures, feeding jejunostomy, preoperative radiotherapy, pathology, or age on these outcomes. Women had no operative mortality, but a higher incidence of gastroesophageal reflux and diarrhea following esophagectomy. CONCLUSIONS: Surgical techniques aimed at improving gastric emptying following esophagectomy for cancer should improve operative morbidity and mortality.

A comparative study of structures comprising the thoracic outlet in 250 human cadavers and 72 surgical cases of thoracic outlet syndrome.

OBJECTIVE: We have hypothesized that variations in fibrous, muscular and osseous structures with the potential to entrap the brachial plexus occur within the thoracic outlet of the normal population; and that these variations are different in pattern and frequency from those in patients presenting with thoracic outlet syndrome (TOS). METHODS: Structural anomalies with potential for entrapping elements of the brachial plexus were examined following dissections of the posterior triangle of the neck in 250 human cadavers (N = 500 thoracic outlet dissections) and catalogued jointly by an anatomist and a thoracic surgeon. The pattern and frequency of anomalies in the 250 cadavers was compared to that encountered in 72 surgical cases of removal of the first rib for relief of symptomatic TOS (N = 72 procedures, 55 patients). RESULTS: Relevant structural variations were encountered in 46% of cadavers, exhibiting no left right or gender preference overall. When compared with the surgical group in which 100% exhibited structurally relevant anomalies, significant differences in pattern of anomalous structures and gender distribution were revealed. Anomalies posterior to the brachial plexus, ranging from fibrous bands to cervical ribs in both groups, were prevalent in the surgical group. A 'scissors-like' pattern, with neural entrapment by anterior and posterior anomalies was frequently encountered in females. CONCLUSIONS: Based on these data and embryological considerations, we propose a revised and simplified classification of impingement mechanisms within the anatomic thoracic outlet. Comparing these data to radiological imaging and observations at surgery, we offer a new perspective for the investigation and management of patients with TOS.

Thoracic outlet syndrome. Thoracic surgery perspective.

We have attempted throughout this review to identify the issues surrounding thoracic outlet syndrome as well as to highlight their origins. It should be clear that many aspects of TOS remain controversial from the definition of the entity through pathogenesis, diagnosis, and treatment. The conflicts surrounding TOS are underlined most poignantly in the many letters to the editor of the New England Journal of Medicine in response to Urschel's 1972 publication. It is incumbent upon those of us who treat patients with TOS to dispel the ignorance surrounding this syndrome with astute, accurate, and reproducible observations. We must clearly define TOS as a clinical entity such that we may analyze the characteristics of the patients we treat. We must continue to search for innovative and specific diagnostic criteria. We must quantitatively and reproducibly measure subjective end points of pain severity and quality of life. The use of these methods will provide yardsticks for therapeutic success and act as determinants for the natural history of TOS. The objectives of treatment will remain the alleviation of symptoms and the restoration of function. We have applied these principles to the formulation of a protocol in which we record, in a prospective manner, both routine and innovative clinical parameters. With quantification of subjective end points, we may be able to correlate clinical presentation with outcome. We also may be able to define with some accuracy this entity we call thoracic outlet syndrome.

Bilateral rudimentary first ribs as a cause of thoracic outlet syndrome.

First rib abnormalities are an uncommon cause of thoracic outlet syndrome. Cervical ribs are a much more frequent source of thoracic outlet syndrome, and in more than 95% of these patients, the symptoms are neurologic, not vascular. Rudimentary first ribs, however, uncommonly produce exclusively neurologic symptoms and usually manifest with vascular pathology. This article reviews a case of a patient with bilateral extensively neurologic thoracic outlet syndrome symptoms arising from bilateral rudimentary first ribs. The symptoms, pathologic features, and treatment, as well as an algorithm for working up patients with thoracic outlet syndrome, are discussed. Bilateral transaxillary first rib resection was curative in this patient and is the treatment of choice for either neurologic or vascular manifestations of thoracic outlet syndrome associated with rudimentary first ribs.

Postcoital catamenial pneumothorax. Report of a case not associated with endometriosis and successfully treated with tubal ligation.

A 39-year-old woman had a 7-yr history of recurrent right-sided pneumothoraces. These occurred within 1 to 2 days before or after the beginning of the menstrual cycle. The patient recalled often having developed the right-sided pleuritic pain of pneumothorax during or shortly after sexual intercourse. She had no symptoms or signs to suggest endometriosis. A trial of cyclic birth control pills was unsuccessful in preventing recurrent pneumothoraces. Finally, approximately a year ago, laparoscopic tubal ligation was performed. The patient has not had pneumothorax since. We conclude that in our patient, the catamenial pneumothorax was most likely related to transtubal passage of air during sexual intercourse. Passage from the peritoneum to the pleura presumably occurred through a congenital defect or fenestration of the right hemidiaphragm.

Tracheal tear during laryngopharyngectomy and transhiatal oesophagectomy: a case report.

A case is reported of a tracheal tear developing during laryngopharyngectomy and transhiatal oesophagectomy. Ventilation and oxygenation were managed by removing the tracheostomy tube and advancing a straight cuffed armoured tube via the tracheostomy into one main stem bronchus and applying CPAP to the other bronchus via a Foley catheter. Following gastrointestinal reconstruction, the membranous tracheal tear was repaired via a right lateral thoracotomy.

Left main bronchial-esophageal fistula: a complication of bronchial artery embolization.

Left bronchial-esophageal fistula is a rare complication of bronchial artery embolization. A case is presented with pathologic correlation. The pathophysiology of this complication is discussed as well as recommendations on how it may possibly be avoided.