The effectiveness of a saline mouth rinse regimen and education programme on radiation-induced oral mucositis and quality of life in oral cavity cancer patients: A randomised controlled trial.

Radiation therapy (RT) and concurrent chemotherapy RT (CCRT) generate radiation-induced oral mucositis (OM) and lower quality of life (QOL). This study assessed the impact of a saline mouth rinse regimen and education programme on radiation-induced OM symptoms, and QOL in oral cavity cancer (OCC) patients receiving RT or CCRT. Ninety-one OCC patients were randomly divided into a group that received saline mouth rinses and an education programme and a control group that received standard care. OM symptoms and QOL were assessed with the WHO Oral Toxicity Scale, MSS-moo and UW-QOL. Data were collected at the first postoperative visit to the radiation department (T0) and at 4 weeks and 8 weeks after beginning RT or CCRT. Patients in both groups had significantly higher levels of physical and social-emotional QOL at 8 weeks after beginning RT or CCRT compared to the first visit. Patients in the saline rinse group had significantly better physical and social-emotional QOL as compared to the standard care group at 8 weeks. Radiation-induced OM symptoms and overall QOL were not different between the groups. We thus conclude the saline rinse and education programme promote better physical and social-emotional QOL in OCC patients receiving RT/CCRT.

Factors associated with healthcare professional's rating of disfigurement and self-perceived body image in female patients with head and neck cancer.

The purpose of this study was to determine factors associated with self-perceived body image in female patients with head and neck cancer (HNC), and factors associated with healthcare professional's rating of disfigurement, as well as the correlation between patient and observer ratings. This cross-sectional study recruited 105 women with HNC at a large medical centre. Measures of facial disfigurement and body image, as well as demographic and clinical characteristics, were collected. Multivariate multiple linear regression modelling was used to identify factors associated with healthcare professional's rating of disfigurement and patient self-perceived body image. Disfigurement ratings by healthcare professionals were positively associated with patient self-perceived body image. Medical treatment, cancer stage, radiation dose and cancer site were significantly associated with disfigurement. Medical treatment was an important predictor of perceived body image. These findings indicate a moderate prevalence of disfigurement among women with HNCs. Patients with more disfigurement were more likely to have dissatisfaction with their body image. Nursing professionals need to carefully assess the appearance of women with HNC. Camouflage interventions can be used to help appropriately cope with the disfigurement, and to achieve improved satisfaction with their body image.

Prognostic factors in pathological stage IB nonsmall cell lung cancer greater than 3 cm.

Significant heterogenity of stage IB (sixth edition of the TNM staging system) nonsmall cell lung cancer (NSCLC) has been identified, and further subclassification according to tumour size has been proposed. The aim of this study is to evaluate the prognostic factors in patients with resected stage IB NSCLC > 3 cm. From January 1980 to December 2000, 525 patients underwent surgical resection for stage IB NSCLC > 3 cm at Taipei Veterans General Hospital, Taipei, Taiwan. The clinicopathological characteristics of these patients were retrospectively reviewed. The 5- and 10-yr overall survival rates were 44.9% and 27.3%, respectively. Age (p < 0.001), tumour size (p = 0.002), extent of pulmonary resection (p = 0.002), histological type (p = 0.005) and number of mediastinal lymph nodes dissected/sampled (p = 0.004) were significant predictors for overall survival in multivariate analysis. Patients with tumour size >7 cm, or > 5 to ≤ 7 cm, had a worse survival than those with tumour size > 3 to ≤ 5 cm. However, visceral pleural invasion did not influence overall survival. Stage IB NSCLC with a diameter > 3 cm may be subclassified according to tumour size regardless of visceral pleural invasion.

Post-recurrence survival in completely resected stage I non-small cell lung cancer with local recurrence.

OBJECTIVE: Resection is the best treatment for patients with stage I non-small cell lung cancer (NSCLC). Patterns of disease recurrence after complete resection in stage I NSCLC have not been well demonstrated. The aim of this study was to evaluate the prognostic predictors of post-recurrence survival in patients with resected stage I NSCLC with local recurrence. METHODS: The clinicopathological characteristics of 123 patients with local recurrence after complete resection of stage I NSCLC in Taipei Veterans General Hospital between 1980 and 2000 were retrospectively reviewed. Post-recurrence survival and their predictors were analysed. RESULTS: The patterns of local recurrence included local only in 74 (60.2%) and both local and distant in 49 (39.8%) patients. The 1 and 2 year post-recurrence survival rates for the 74 patients with local only recurrence were 48.7% and 17.6%, respectively. Tumour size (p = 0.033) and treatment for initial recurrence (p<0.001) were significant predictors for post-recurrence survival in 74 patients with local only recurrence in univariate analyses. The hazard of death was greater in patients with larger tumour size. Treatment for initial recurrence (p = 0.001) was still a significant prognostic indicator in multivariate analyses. Patients who underwent reoperation after local recurrence survived longer than those who received chemotherapy and/or radiotherapy and those that received no treatment. CONCLUSIONS: Treatment for initial recurrence is a prognostic predictor for post-recurrence survival in resected stage I NSCLC with local recurrence. Complete surgical resection should be considered in selected candidates with resectable local recurrent disease.

Chylothorax following extended thymectomy for myasthenia gravis.

UNLABELLED: The effectiveness of extended thymectomy for the treatment of myasthenia gravis is well documented. Most of the postoperative complications have been related to respiratory distress or wound complication, but chylothorax following thymectomy has been reported as a rare complication. From January 1995 to December 2004, 217 patients underwent extended thymectomy for myasthenia gravis at Taipei Veterans General Hospital. Three cases (1.38%) developed chylothorax after operation. Injury to the unseen division of the mediastinal lymphatics and branches from the thoracic duct during extensive dissection of perithymic fat tissue, which is seldom performed in classical thymothymectomy procedures, may have been the main cause of this complication. Two of the cases received conservative treatment and recovered uneventfully. The other patient (0.46%) underwent ligation of the thoracic duct 3 months later, which also resulted in the complication being cured. CONCLUSIONS: Post-thymectomy chylothorax is rare and seems to be related to extended thymectomy. Even a small invasive procedure such as VATS for extended thymectomy formyasthenia gravis could be complicated by chylothorax. We recommend that if chylothorax develops after thymectomy, conservative treatment is the treatment of choice; however, thoracic duct ligation is a useful method for treating long-term unhealed chylothorax.

The effectiveness of thymectomy on seronegative generalized myasthenia gravis: comparing with seropositive cases.

OBJECTIVES: To investigate the efficacy of thymectomy between patients with seronegative myasthenia gravis (SNMG) and seropositive myasthenia gravis (SPMG). METHODS: We present here the first Taiwanese retrospective paired cohort study comparing the effectiveness of thymectomy among 16 seronegative and 32 seropositive MG patients after matching for age-of-onset and time-to-thymectomy, and following up over a mean of 35 +/- 20 (7-86) months. Clinical characteristics and complete stable remission (CSR) rates were compared and analyzed between the groups. RESULTS: There were no major clinical differences between the two groups except for our finding of a lower percentage of SNMG receiving preoperative plasmapheresis or human immunoglobulin than SPMG (31% for SNMG vs 72% for SPMG, P = 0.007). CSR rates calculated using the Kaplan-Meier method were similar in the two groups (38% for SNMG vs 50% for SPMG, P = 0.709). The median time for CSR was 47.4 months for SNMG and 48.2 months for SPMG. Thymic hyperplasia were the most common pathology (69% for SNMG vs 88% for SPMG, P = 0.24). During the follow-up period, we found no group difference on prednisolone or pyridostigmine dosages. Significant postoperative dosage reductions on pyridostigmine, but not on prednisolone, were found in both groups. CONCLUSIONS: Thymectomy has a comparable response among SNMG and SPMG in our study. Thymic hyperplasia is prevalent in our SNMG patients and thymectomy may also be a therapeutic option to increase the probability of remission or improvement in SNMG. More prospective controlled trial will be helpful in the future.

Topoisomerase 2alpha plays a pivotal role in the tumor biology of stage IV thymic neoplasia.

BACKGROUND: Microsatellite studies in histologic types B3 and C thymic neoplasia detected gains on chromosome 17q, which contains the Her-2/neu and its juxtaposed topoisomerase 2alpha (T2alpha) genes. The study aimed to evaluate their impact on tumor biology and survival of advanced thymic neoplasia patients. METHODS: From 1991 to 2005, 36 consecutive stage IV thymic carcinoma patients were treated, 18 men and 18 women, aged 11 to 84 years. There were 22 thymic carcinoma, 13 type B3, and 1 type B2 thymoma. Patients received treatment consisting of surgical resection, combination chemotherapy with the CAP (cyclophosphamide, Adriamycin, cisplatin) regimen, or radiation therapy potentiated by high-dose weekly 5-fluorouracil infusion. Permutations of these 3 treatment modalities were prescribed as necessary. RESULTS: T2alpha gene amplification was detected in 4 of 14 thymic carcinoma and 1 of 15 type B3 thymoma. Three thymic carcinoma patients had Her-2/neu coamplification and these 3 patients had rapidly growing tumor and extensive disease at initial diagnosis. CAP was prescribed in 28 patients and 20 patients responded (response rate, 71.4%, 95% confidence interval [CI]: 52.8% to 85%); all responders overexpressed (> or = 10% nuclei positive) the T2alpha protein, whereas 4 nonresponders had very low expression. T2alpha overexpression predicts CAP response, and its absence predicts resistance (P = .001). Overall survival was significantly prolonged if the tumor was resectable (P = .001), of type B3 histology (P = .0039), and had no Her-2 gene amplification (P = .0081). CONCLUSION: T2alpha and Her-2/neu genes play a pivotal role in the tumor biology, CAP response, and survival of advanced thymic neoplasia patients.

Factors influencing the outcome of transsternal thymectomy for myasthenia gravis.

BACKGROUND: Thymectomy is one of the current treatment strategies for patients with myasthenia gravis (MG); however, the selection criteria for surgery remain controversial. METHODS: The demographic data and the surgical results of 168 patients with MG who underwent transsternal thymectomy from June 1986 to December 2000 were retrospectively reviewed. Follow-up information was obtained by review of the hospital records or telephone contact. The postoperative status of MG was assessed at the interval of 1, 3 and 6 months and then annually. The complete remission rate (CRR) between groups was compared. RESULTS: A total of 168 patients, including 69 male patients and 99 female patients, with a mean age of 38.3 years (range 13-80 years), were analyzed. The symptom duration before operations was from 1 to 312 months with a mean of 33.8 months. Complete follow-up information was obtained on 154 patients (91.6%) with a mean follow-up duration of 98.9 months. Complete remission was achieved in 89 of 154 patients (57.8%) and marked clinical improvement in 47 patients (30.5%). Total improvement rate was 88.3%. Seventeen of 24 patients (70.8%) with ocular MG and 18 of 35 patients (51.4%) with thymoma had reached complete remission during the follow-up period. The CRR increased with each consecutive year and reached the plateau in the fourth postoperative year. There was no surgical mortality. The complication rate was 16.6%. Univariate analysis demonstrated that age <35 years old (P = 0.0001), symptom duration before operation <24 months (P = 0.01) and absence of preoperative steroid treatment (P = 0.04) were favorable prognostic factors. Multivariate Cox regression analysis revealed age <35 years old (odds ratio = 3.645, P = 0.001), symptom duration before operation <24 months (2.311, P = 0.041) were favorable prognostic factors for patients having transsternal thymectomy. CONCLUSIONS: Transsternal thymectomy is feasible in the management of patients with MG at all stages with high improvement rate and low surgical morbidity. Those patients aged 35 years or less at operation, with symptoms developed <24 months before operation, may benefit more from thymectomy. MG patients with thymoma did as well as patients without thymoma, and 18 of 35 patients with thymoma had reached complete remission during the follow-up period. Thymectomy seems to be beneficial also for ocular MG.

Intravenous immunoglobulin in the preparation of thymectomy for myasthenia gravis.

OBJECTIVES: A clinical trial including six patients was conducted to assess the effect of intravenous immunoglobulin (IVIg) in the preparation of thymectomy for patients with myasthenia gravis (MG). MATERIAL AND METHODS: Six consecutive patients of type IIB MG treated with IVIg at a dose 0.4 g/kg daily for 5 days before thymectomy were enrolled in this study. RESULTS: All patients responded positively to this treatment. Improvement began to occur 1-9 days after starting the injection (mean 3.33 days), and reached a maximum in 3-19 days (mean 6.50 days). Thymectomy was performed 9-13 days (mean 11.20 days) after starting the injection in five of the six patients with uneventful post-operative courses. CONCLUSION: IVIg might be an alternative to plasmapheresis (PE) in the prethymectomy preparation of MG patients, and thymectomy should be performed within 2 weeks after IVIg treatment to minimize the perioperative complications. Controlled trial vs PE enrolling more patients is needed to assess the significance of the IVIg in the preparation of thymectomy for patients of MG.

Resectional treatment for thyroid cancer with tracheal invasion: a long-term follow-up study.

HYPOTHESIS: Transmural invasion of the trachea by well-differentiated thyroid carcinomas is a locally advanced disease condition. It frequently causes deaths owing to airway obstruction. We hypothesized that resection of the invaded trachea followed by primary anastomosis provides the opportunity for cure. DESIGN: A retrospective review study of medical records. SETTING: The surgical department of a tertiary referral center. PATIENTS: Eight patients with well-differentiated thyroid carcinomas, complicated with tracheal invasion resulting in bleeding and airway obstruction, operated on by tracheal resection and immediate anastomosis, were included. INTERVENTIONS: All patients received total thyroidectomy and neck lymph node dissection as well as segmental tracheal resection followed by primary reconstruction. Postoperative radioactive sodium iodine I 131 treatment and suppression therapy with thyroxine were applied to all of them. MAIN OUTCOME MEASURE: Postoperative follow-up of serum levels of human thyroglobulin and abnormal radioactive iodine 131I from whole body scan. RESULTS: Seven patients are alive. Of these patients, 5 had no evidence of disease: (3 had no evidence of cancer for more than 10 years' follow-up), 2 had regional lymph node metastasis, and 1 had lung metastases. The remaining patient had anastomotic site recurrence with airway obstruction and needed tracheostomy to relieve stridor. She was lost to follow-up 39 months after undergoing the initial operation. CONCLUSIONS: Patients with mucosal invasion of the trachea by well-differentiated thyroid carcinomas should be treated by surgical resection followed by primary reconstruction when technically feasible. This facilitates postoperative care, and it is possible to achieve long-term survival with improvement of the quality of life and possible cures.

Digoxin prevents ouabain and high salt intake-induced hypertension in rats with sinoaortic denervation.

Digoxin prevents ouabain-induced hypertension in rats. In the present study, we tested whether this effect of digoxin depends on its sensitizing effect on baroreflex function or is due to an antagonistic action on exogenous ouabain or endogenous ouabain-like activity ("ouabain") in the brain. In Wistar rats, resting mean arterial pressure (MAP) was significantly increased by long-term subcutaneous (SC) ouabain (75 microg/d) plus high salt (8%) intake for 12 days (but not after only 5 days). In rats with chronic sinoaortic denervation (SAD), MAP was increased within 5 days of ouabain treatment to the same extent as MAP after 12 days of treatment in intact rats. The effect of ouabain and high salt was prevented when digoxin was given SC concomitantly via osmotic minipump (200 microg x kg(-1) x d(-1)). Resting MAP was not changed in rats treated with digoxin alone. In a second set of rats with chronic SAD or sham surgery, high salt intake was given for 14 days, with or without SC digoxin (200 microg x kg(-1) x d(-1)) or intracerebroventricular (ICV) antibody Fab fragments (200 microg/d), which bind "ouabain" with high affinity. On day 14, MAP, central venous pressure, heart rate, and renal sympathetic nerve activity were recorded in conscious rats at rest and in response to air-jet stress, IV phenylephrine and nitroprusside, and acute volume expansion with 5% dextrose IV. In rats with SAD versus sham surgery, high salt significantly increased resting MAP as well as excitatory responses of MAP, heart rate, and renal sympathetic nerve activity to air stress. These effects of high salt in rats with SAD were prevented by digoxin or Fab fragments. Arterial baroreflex function was blunted but cardiopulmonary baroreflex function was not affected in rats with SAD. Digoxin and Fab fragments had no effects on either function. In an in vitro assay for the inhibitory effects on Na+, K(+)-ATPase activity, 20 ng of ouabain caused 29% inhibition, but 20 ng of ouabain plus 13 or 53 ng of digoxin caused only 16% or 4% inhibition, respectively. These data indicate that the arterial baroreflex opposes sympathoexcitatory responses to ouabain and "ouabain" in the brain, thereby delaying ouabain- and preventing high salt-induced hypertension in Wistar rats. In addition to possible effects on the arterial baroreflex, digoxin appears to act centrally to prevent the sympathoexcitatory and pressor effects of increased brain "ouabain" or ouabain.

Leiomyosarcoma of the gastric cardia and fundus.

BACKGROUND: Gastric leiomyosarcoma is rare among gastric malignancies, and only 20% of the cases are located in the gastric cardia or fundus. It has clinical manifestations different from tumors in other sites of the stomach. We reviewed cases of leiomyosarcoma of the gastric cardia or fundus to evaluate their clinicopathologic characters and patient survival. METHODS: From May, 1981, to June, 1998, a total of 15 patients who underwent curative resection of leiomyosarcoma of the gastric cardia or fundus were retrospectively identified and studied. All the clinical and pathologic data were reviewed and recorded. RESULTS: There were 11 men and four women. Their mean age was 59.1 years (range, 37-73 years). Tarry stools and epigastric fullness and pain were the most common symptoms, followed by body weight loss. All 15 patients had submucosal tumors in the gastric cardia or fundus, as shown by endoscopy, barium contrast radiography and computerized tomography. The incidence of esophageal involvement by the tumors was quite low. The mean tumor size was 10 cm, ranging from 4 cm to 20 cm. Locoregional organs were involved in nine patients. The median and mean survivals were 17.8 months and 31.7 months, respectively (range, 10.1-80.1 months) after curative resection. The three-year and five-year survival rates were 53% and 22%, respectively. CONCLUSIONS: The definitive preoperative diagnosis of the tumor is difficult before surgery, even though imaging studies show positive findings. Surgical resection with an adequate safe margin of normal tissue is the treatment of choice. Tumor size, serosal invasion with locoregional organ involvement and high tumor grade were the prognostic factors in the study.

Brain "ouabain", a neurosteroid, mediates sympathetic hyperactivity in salt-sensitive hypertension.

This review addresses recent developments in the neurobiology of an endogenous inhibitor of brain Na+, K+ - ATPase, "ouabain". "Ouabain" is present in hypothalamic and medullary neurons and mediates sympathoexcitatory and pressor responses to acute and chronic increases in cerebrospinal fluid (CSF) sodium concentration as well as mediates the sympathoexcitatory and pressor responses to high dietary sodium intake in SHR and Dahl-S rats, and sympathetic hyperactivity in the congestive heart failure. Some of these actions of "ouabain" in the CNS take place in the median preoptic nucleus and ventral part of the AV3V region. Despite recent advances in unveiling a biological role for "ouabain" its structure, biosynthetic and metabolic pathways as well as actual control mechanisms remain unresolved.

Surgery for achalasia: long-term results in operated achalasic patients.

Achalasia is a functional disorder of the alimentary tract due to decreased or absent peristalsis of the esophageal body and obstructive outlet of the esophagus. Surgical treatment, eg. esophagomyotomy of the lower esophageal sphincter (LES), was one choice for resolving the problem and its effect was affirmative from reviews of many internationally authorized articles. However, few reports have ever questioned the long-term effects of it. From January 1968 to May 1996, 159 esophageal achalasic patients, 90 males and 69 females, were admitted due to dysphagia or food regurgitation. One hundred and forty-five patients had received 158 operations related to this benign motor disorder. The majority of patients received either modified Heller esophagomyotomy (M) or M plus modified Belsy Mark IV antireflux procedure (M+W) for primary treatment of their esophageal disorder, while conditional selection with addition of esophageal resection as advanced procedures for failure of primary surgery. We retrospectively studied these patients, collected their preoperative and postoperative clinical results, analyzed the causes of recurrent symptoms, compared the long-term results in different surgical procedures and searched for the pathogenesis of their failure. The results disclosed that the overall success rate for both methods was 73.1% with 85.7% for patients receiving M+W (56) and 64.9% of M (77) only. Through long-term follow-up, we had an improvement rate of 97.4% at an early stage and 53.3% for M at a late stage and 98.4% and 55.6% for M+W, respectively. The postoperative natural course of achalasic patients could be seen and progressive deterioration of the operated patients with time was noted. Several factors might contribute to the causes of unsuccessful surgery. We summarized them as incomplete myotomy, fused or healed myotomy, gastroesophageal reflux (GER), mucosal hernia and co-combined antireflux procedure by hypercalibrated or floppy wrapping. Esophagomyotomy or myotomy plus antireflux procedure for the esophagus could be concluded to rather effective in the long-term but palliative treatments for achalasia chronic deterioration of the results could be found for both of them. Defective myotomy and GER may be the major causes for their failure. The choice of types of surgery between M and M+W was not the cause of the unsuccessful results whereas the operative strategy and procedures would have a certain significance on the long-term effect.

Blockade of brain 'ouabain' prevents the impairment of baroreflexes in rats after myocardial infarction.

BACKGROUND: The purpose of this study was to test whether increased brain "ouabain" contributes to impairment of both arterial and cardiopulmonary baroreceptor reflexes in congestive heart failure (CHF). METHODS AND RESULTS: Two to 5 days after coronary artery ligation (MI) or sham surgery in male Wistar rats, chronic intracerebroventricular (ICV) infusion was started with either antibody Fab fragments, which bind ouabain and related steroids with high affinity, or gamma-globulins as control (200 microg x 12 microL[-1] x d[-1] for both) with osmotic minipumps implanted subcutaneously. After 8 weeks of infusion, in conscious rats, mean arterial pressure (MAP), heart rate (HR), central venous pressure (CVP), and renal sympathetic nerve activity (RSNA) were recorded at rest and in response to ramp changes in blood pressure (BP) induced by intravenous phenylephrine and nitroprusside and to changes in CVP elicited by acute volume expansion with 5% dextrose. Compared with sham rats, in MI rats with ICV gamma-globulins, resting MAP was significantly lower and CVP increased, and both arterial and cardiopulmonary baroreflex control of RSNA and HR were attenuated. ICV Fab fragments prevented the decrease in resting BP and largely prevented impairment of arterial and cardiopulmonary baroreflex control of both RSNA and HR. CONCLUSIONS: These data indicate that increased brain ouabain plays a major role in the impairment of baroreflexes in rats with CHF after myocardial infarction.

Sympathoexcitatory effect of hypothalamic/hypophysary inhibitory factor in rats.

We recorded changes in arterial blood pressure, heart rate, and renal sympathetic nerve activity in response to intracerebroventricular injection of bovine hypothalamic/hypophysary inhibitory factor and ouabain in conscious Wistar rats. Ouabain at 0.3 to 0.6 microgram caused dose-related increases in blood pressure, heart rate, and nerve activity (peak increases: 19 +/- 2 mm Hg, 42 +/- 4 beats per minute, and 48 +/- 4%, respectively; P < .05 versus basal). These responses were all blocked by central antibody Fab fragments, which bind ouabain and related steroids with high affinity. The inhibitory factor significantly increased blood pressure but decreased heart rate and nerve activity. Dose-dependent increases in blood pressure as well as heart rate and nerve activity were observed when the inhibitory factor was injected after intravenous injection of the vasopressin antagonist D-(CH2)5Tyr-(Me)AVP. Central Fab fragments, however, did not affect these responses. Both ouabain and the inhibitory factor inhibited Na+,K+-ATPase activity in vitro. Fab fragments blocked this inhibition by ouabain but not by the inhibitory factor. These data indicate that the ouabainlike sympathoexcitatory effect of this factor is masked probably by a potent central effect on vasopressin release. In contrast to rat brain "ouabain," this factor does not exhibit a high affinity for the Fab fragments, supporting the previous finding that this compound is structurally a nonouabain Na+,K+-ATPase inhibitor.

Leakage of intrathoracic oesophagovisceral anastomoses in adenocarcinoma of the gastric cardia: changes in serial APACHE II scores and their prognostic significance.

OBJECTIVE: To evaluate changes in serial Acute Physiology and Chronic Health Evaluation (APACHE) II scores in patients with intrathoracic oesophageal anastomotic leaks and to assess their prognostic significance. DESIGN: Retrospective study. SETTING: Teaching hospital, Taiwan. SUBJECTS: 18 patients (4%) who developed intrathoracic oesophageal anastomotic leaks in a total of 491 patients who underwent oesophagogastrectomy for adenocarcinoma of the gastric cardia between 1980 and 1994. MAIN OUTCOME MEASURE: APACHE II scores in those that survived (n = 10) compared with those who died (n = 8). RESULTS: Of the 18 patients, 8 (44%) died. The preoperative general condition, biochemical data, and perioperative APACHE II scores were similar in the two groups. Leakage from the oesophageal anastomoses caused similar degrees of sepsis in the two groups in terms of APACHE II scoring, but the APACHE II scores of survivors started to decline within a week of initial management. In contrast, the APACHE II scores of those who died had increased one week after the leak had been diagnosed despite initial management. There were significant differences in the APACHE II scores of survivors and those who died from one week after leakage until discharge or death (p < 0.001). Only one patient (1/9) survived if the APACHE II score one week after diagnosis of the leak was more than 10. None died of the leak if the APACHE II scores were equal to or less than 10 after a week. CONCLUSIONS: Adequate surgical drainage, antibiotic cover according to the microbiological picture, and nutritional support are essential in the management of intrathoracic oesophageal fistulas. Early reoperation to close early leaks by simple suture or secondary wrapping and to improve local drainage is recommended. The APACHE II scoring system is valuable in evaluating the severity of sepsis caused by intrathoracic oesophagovisceral anastomosis leaks and may serve as an indicator of adequate management. Aggressive surgical measures should be considered if APACHE II scores rise during initial management.

Surgical treatment of endobronchial tuberculosis.

The incidence of tuberculosis remains fairly high in some developing countries. Endobronchial tuberculosis may cause bronchostenosis, with potentially severe respiratory symptoms, atelectasis and secondary pneumonitis. Thirty-two surgically treated cases of tuberculous bronchostenosis (33 operations) are presented. In 13 cases-segmental resection or lobectomy was performed with bronchoplastic procedures. Anastomotic stenosis necessitated pneumonectomy 5 years later in one of the 13 and one patient had wound infection. Nineteen patients underwent pulmonary resection without bronchoplasty. Apart from the patient with anastomotic stenosis, all 32 were symptom-free in the follow-up period. Forced expiratory volume was significantly improved in the ten tested patients with bronchoplasty. The results suggest that surgical treatment is safe for endobronchial tuberculosis with poor response to specific chemotherapy. In addition to checking progression of the disease, bronchoplasty helps to preserve lung function. Appropriate chemotherapy should be given for 9-12 months perioperatively to prevent recurrence and restenosis.

Emergency surgical intervention for severe corrosive injuries of the upper digestive tract.

BACKGROUND: In treating severe corrosive injury of the esophagus and stomach, prompt diagnosis, adequate fluid resuscitation and warranted surgical intervention are the most important factors in rescue of critically ill patients. The purpose of this study was to evaluate the need for, and the advantages of, a surgical approach to treatment of such corrosive injuries to the upper gastrointestinal (UGI) tract, as well as to select the most suitable technique to achieve a good survival rate. METHODS: From January 1983 to December 1991, 220 patients were treated for caustic ingestion injury to the UGI tract. A retrospective review of their records allowed targeting of 27 patients with severe corrosive injury that surgical intervention was required. In this study, peritoneal sign was taken as the key indicator for early emergency operation. The age, sex, elapsed time from injury to operation, the sort and quantity of caustic agent used, injury mechanism, clinical manifestations, alternative surgical treatment methods and causes of death were also reviewed and analyzed in this study. RESULTS: The patients included 13 men and 14 women, of whom the majority were adults (96.3%) who had attempted suicide (85.2%). All of them had taken liquid corrosive agents, usually hydrochloric acid (63%). Eighteen underwent emergency operations; the other nine received only supportive treatment, given their terminal status. The mortality rates for patients with surgery and supportive treatment were 66.7% and 100%, respectively. Four patients died after undergoing esophagectomy with resection of the stomach using the thoracoabdominal method. Only three of the eight patients who received esophageal stripping combined with resection of the stomach through the abdomen died (37.5%). CONCLUSIONS: The time elapsed between injury and development of peritoneal sign is a good indicator of the severity and extent of the injury. When peritoneal sign manifests at a very early stage, it is an indicator that the corrosive injury is very advanced in its progress and that, no matter what procedures were performed, the outcome would be the same. Yet if there were a six-hour gap then aggressive surgical management can rescue some patients. It is recommended based on experience here, that when using the surgical approach, resection of the stomach with stripping of the esophagus is superior to the thoracoabdominal method.

Carcinosarcoma of the lung: an analysis of 6 operated cases.

BACKGROUND: Carcinosarcoma of the lung is a rare malignant pulmonary neoplasm, and constitutes 0.1% to 0.3% of all lung tumors. Typically, these tumor have both carcinomatous and sarcomatous components with a poor prognosis due to late diagnosis and early metastases. METHODS: From July 1980 to December 1993, six patients with pulmonary carcinosarcoma who underwent surgical treatment were studied. None of them had accurate tissue diagnosis before operation except one case with peripheral variant carcinosarcoma who was diagnosed by percutaneous transthoracic fine needle biopsy under sonographic guidance. All of our patients had a huge peripheral lung tumor 3.8 to 10 cm in diameter. Pneumonectomy was done in two patients, and lobectomy in three. The other patient had unresectable tumor. RESULTS: The histopathological components in carcinoma were epidermoid carcinoma in and adenocarcinoma in 3. Differentiation of sarcomatous lesions included spindle cell sarcoma in 3, fibrosarcoma in 2 and undifferentiated mesenchymal sarcoma in one patient. In the resectable group, 1 was at stage II and 4 were at stage IIIa. None of the patients survived more than 2 years due to distant metastasis and cachexia. The mean survival was 140 days. CONCLUSIONS: The carcinomatous portion tends to metastasize to regional lymph nodes whereas the sarcomatous part gives rise to systemic dissemination. Due to early systemic dissemination and poor prognosis, combination of extensive surgical intervention resection with aggressive postoperative chemotherapy and radiotherapy might be a reasonable consideration to improve survival in primary pulmonary carcinosarcoma.