Vascular amyloidosis causing spontaneous mediastinal haemorrhage with haemothorax.

Bleeding diathesis is a recognised complication of amyloid disease. Localised and generalised bleeding manifestations are usually associated with intravascular coagulopathy related to isolated or multiple coagulation factor deficiencies. Recently, there have been reports of haemorrhage due to amyloid deposition in blood vessel walls and in the perivascular region leading to increased fragility and poor haemostasis. We report a case of spontaneous mediastinal haemorrhage due to amyloid involvement of vascular tissue in the absence of coagulopathy.

Airway fire during tracheostomy: prevention strategies for surgeons and anaesthetists.

Airway fires are an uncommon but real and devastating complication of tracheostomy. One such fire in a 31-year-old man is described. Surgical fires are discussed, and 15 reported cases of tracheostomy fire are reviewed. A tracheostomy protocol, adopted by our department and designed to avoid this life-threatening complication, is described. Surgeons and anaesthetists involved in tracheostomy must understand the fire hazard and how to avoid it.

Comparison of long-term results of total fundoplication gastroplasty and Belsey Mark IV antireflux operations in relation to the severity of oesophagitis.

OBJECTIVE: Belsey Mark IV (BM IV) and total fundoplication gastroplasty (TFG) were the standard anti-reflux operations in two consecutive periods in Nottingham City Hospital Thoracic Surgery Unit. The aim of this study was to compare the long-term results obtained by these two procedures emphasizing their relation to the severity of the oesophageal mucosal damage. METHODS: Ninety patients (50 females and 40 males with a mean age of 57 years) who had a BM IV operation between 1976 and 1983 and 86 patients (46 females and 40 males, with a mean age of 56.5 years) undergoing a TFG procedure between 1983 and 1986 were evaluated. All patients were assessed preoperatively by means of clinical history, barium meal and endoscopy. In addition, 72 of the patients having a TFG had prolonged pH monitoring and manometric studies. The unit policy is for life-long follow-up. The symptoms at review were assessed and graded according to the criteria published by Orringer et al. (Orringer MB, Skinner DB, Belsey RHR. Long-term results of the Mark IV operation for hiatal hernia and analyses of recurrences and their treatment. J Thorac Cardiovasc Surg 1972;63:25-33). RESULTS: In the BM IV group there was one post-operative death (1.1%). The median follow-up was 11 years (range 3-18 years). Overall good results were achieved in 64 patients (71.9%). In patients without oesophagitis (n = 24) the success rate was 91.7% while for grades I (n = 17), II-III (n = 36) and IV (n = 12) oesophagitis this was 76.5, 66.7 and 41.7%, respectively (P = 0.01). The actuarial success rate at 10 through to 18 years was 71.0%. In the TFG group there was no postoperative death. The median follow-up was 10 years (range 2-14 years). Overall good results were achieved in 78 patients (90.7%). In the absence of oesophagitis (n = 10) the success rate was 90.0% and for grades I (n = 12), II-III (n = 26) and IV (n = 38) oesophagitis this was 91.6, 92.3 and 89.4%, respectively. The actuarial success rate at 10 through to 14 years was 90.3%. The differences in the overall success rate (P = 0.002), the success rates forgrades II-III (P = 0.02) and IV (P = 0.001) oesophagitis and the long-term actuarial success rates (P = 0.001) were significant. CONCLUSION: These data provide evidence on the superiority of the TFG against the BM IV in achieving long-term relief of reflux symptoms in the presence of severe oesophagitis. We believe that failure of BM IV in this setting is due to obvious or subtle oesophageal shortening.

Surgery for esophageal cancer in elderly patients: the view from Nottingham.

OBJECTIVE: Our aim was to compare the outcome of esophageal resection for carcinoma in elderly patients (aged over 70 and over 80 years) with that of younger patients managed within a single specialist thoracic surgery unit. PATIENTS AND METHODS: Between January 1987 and November 1997, 523 patients underwent esophagectomy for carcinoma in the Nottingham City Hospital Thoracic Surgery Unit. The patients were divided into 3 groups by age: group I, under 70 years (n = 337); group II, 70 to 79 years (n = 150), and group III, 80 to 86 years (n = 36). These groups were compared with regard to preoperative medical status, operability and resectability, complications, operative mortality, and longterm survival. RESULTS: Patients in groups II (6.0%) and III (2.8%) had fewer preexisting respiratory problems than patients in group I (12.5%), and the patients in group III had fewer preexisting cardiovascular problems (16.7%) than patients in groups I (25.2%) and II (32.7 %). Although patients in group III were generally less likely to have operable lesions (64.3%), no significant differences in resectability rate were detected among the 3 groups (80.8%, 77.7%, and 80%). Elderly patients (groups II and III) had a higher incidence of overall (34% and 36.1%), respiratory (24.7% and 19.4%), and cardiovascular (7.3% and 11.1%) complications than those aged under 70 years (24.6%, 16.3%, and 2.1%, respectively). However, operative mortality (4.7%, 6.7%, and 5.6%) and 5-year survivals inclusive of operative mortality (25.1%, 21.2%, and 19.8%) were similar among the 3 groups. CONCLUSIONS: Accumulated experience in all aspects of perioperative management may account for a low hospital mortality in elderly patients despite a greater operative risk. The survival benefit is similar to that in the younger age groups, enforcing the view that esophagectomy within specialist thoracic units can be safely offered (in appropriately selected patients) with acceptable long-term survival in all age groups.

Troponin T release with warm and cold cardioplegia.

Cardiac troponin T (cTnT) levels were measured in 41 patients undergoing elective coronary artery surgery. Twenty-one patients received continuous warm antegrade blood cardioplegia to maintain asystole whilst 20 patients received antegrade cold blood cardioplegia intermittently. Serum levels of cTnT were determined preoperatively and at 0, 6, 12 and 18 h postbypass. Peak cTnT levels and total cTnT release (calculated from the area under the curve postoperatively) were found to be significantly higher (p < 0.05: Mann-Whitney) when cold cardioplegic solutions were used. Continuous warm cardioplegia results in lower cTnT release than intermittent cold blood cardioplegia suggesting that the former may provide better myocardial preservation.

Comparative analysis of proteins secreted in vitro by isolated seminiferous tubules from man and the rat.

The aims of this study were to provide an overall comparison of the in-vitro protein secretory profile of seminiferous tubules (ST) isolated from man and the rat, and to identify specific proteins secreted by both species. Two-dimensional SDS PAGE was used to compare the profile of proteins secreted by cultured ST from 15 men undergoing orchidectomy with those secreted by ST isolated at stages VI-VIII of the spermatogenic cycle from normal adult rats, and by ST at the same stages isolated from rats pretreated with methoxyacetic acid (MAA) in order to deplete both pachytene spermatocytes and round spermatids. Two abundant groups of proteins not present in the medium of rat ST were secreted consistently by human ST, though the profile of proteins secreted by human ST was otherwise more variable than in the rat. Twelve proteins secreted by ST isolated from humans were identified as possible homologues of rat ST-secreted proteins, including the major rat Sertoli cell products SGP-1 and SGP-2, and an androgen-regulated protein which derives in the rat from round spermatids. Otherwise, the majority of the 12 potential homologues corresponded to proteins which in the rat are secreted by ST from both normal and germ cell-depleted testes or by ST from germ cell-depleted testes only, suggesting that they are probably secreted by Sertoli cells and/or peritubular cells. Based on the potential homology of the proteins identified, our results suggest, first, that these proteins may play an important role in spermatogenesis and second, that the profile of proteins secreted by human ST is more akin to that secreted by ST isolated from germ cell-depleted rats.

Negative testicular biopsy and asynchronous bilateral testicular germ cell tumour.

A case is described of a patient who was recently found to have a second primary testicular cancer 3 years after his first orchidectomy and negative contralateral testis biopsy.

Seminal fluid analysis and fine-needle aspiration cytology in the diagnosis of carcinoma in situ of the testis.

Surgical biopsies and fine-needle aspirates of peri-tumoural seminiferous tubules were taken from freshly-excised orchidectomy specimens. In addition, patients with suspected germ cell tumour provided a peri-operative sample of seminal fluid. All three tissue preparations were investigated using flow cytometry, immunochemistry for placental-like alkaline phosphatase and enzymochemistry for alkaline phosphatase. Biopsy and fine-needle aspiration cytology provide the greatest diagnostic accuracy for carcinoma-in-situ using these techniques. Seminal fluid analysis did not provide a satisfactory diagnostic yield in the series of patients presented. A seminal plasma placental-like alkaline phosphatase immunoassay failed to discriminate CIS because of the high level of background germ cell alkaline phosphatase.