Resectional operations and long-term results in carcinoma of the esophagus.

The 5 year survival rate after resectional operations for carcinoma of the esophagus is still very low. Many factors have been identified as contributing to these poor long-term results. The main factor found in this study, comprising 102 patients undergoing resection out of 125 patients operated upon during a 10 year period, was nonradical resection. The main cause of nonradical resection was invasion of the tumor into the mediastinum, which was observed in 80% of the patients. In 43 of the 102 patients undergoing resection, the penetration of the carcinoma into the tissue surrounding the esophagus was observed only histologically. Thirty-three of the 38 hospital survivors in this group died within 2 years of the operation of recurrence of carcinoma. Fourteen of 17 survivors after resectional operations in whom the tumor growth was still limited to the esophagus were alive from 2 to 9 years (mean 6 years) after the operation, without evidence of recurrence.

Tumors of the thymus and thymic region: III. Clinicopathological studies on teratomas and tumors of Germ Cell type.

In a series of 82 patients with tumors of the thymus and thymic region there were 11 with teratomas and germinal tumors. Four of these patients had benign cystic teratomas, 4 had malignant teratomas, 1 had an embryonal carcinoma, and 2 had seminomas. The benign teratomas were removed by simple extirpation without complications. The malignant teratomas were highly invasive, and despite extensive operations and postoperative radiotherapy, 3 of the 4 patients died within 9 months. One patient with predominantly seminomatous differentation of the teratoma was alive and well more than 3 years after the operation. The patient with an embryonal carcinoma died after 4 months. One of the 2 patients with seminoma remained alive 20 years after radical excision and postoperative radiotherapy. The other, who had a huge seminoma, died during operation. The prognosis in patients with seminomas or with predominantly seminomatous structures in teratomas seems to be good after combined radical excision and radiotherapy, although nonradical resection followed by raditherapy may be justified in high-risk patients.

Tumors of the thymus and thymic region: I. Clinicopathological studies on thymomas.

A series of 43 patients with thymoma was reviewed. The patients were classified with respect to some factors of prognostic significance. The tumors were reclassified histologically, and a staging system with three defined stage-groups was applied to the series on the basis of operative findings and histological examination of surgical specimens. Surgical-pathological staging is of high prognostic and therapeutic importance in thymomas. Complete removal of the tumor was possible in the 25 patients with stage I or II disease and in 14 of the 18 patients with stage III tumors. Pleural metastases were observed in half of the patients with stage III disease. Even patients with extensive local spread or pleural metastases were subject to tumor resection. The treatment of choice is radical resection along in stage I; radical extirpation and, if indicated, postoperative radiotherapy in stage II; and radical resection whenever possible, even in cases of pleural spread, in stage III, with postoperative radiotherapy and chemotherapy. Myasthenia gravis is an indication rather than a contraindication to radical treatment of thymoma, although some patients may deterioratte. The importance of total thymectomy is stressed.

Tumors of the thymus and thymic region: II. Clinicopathological studies on Hodgkin's disease of the thymus.

Among 82 patients with a tumor in the thymic region, 17 had a lesion that fulfilled the criteria for Hodgkin's disease of the thymus; the histopathological differentiation of this entity from thymomas is discussed. All patients received surgical treatment and postoperative radiotherapy. After a mean observation time of 10 years there was no local recurrence and no death due to the disease, though 3 deaths were cuased by the treatment. New clinical manifestations occurred in 3 of the 14 long-term survivors: they were treated successfully by operation or irradiation. A very aggressive surgical approach involving extirpation of all tumor tissue, extensive excision of the surrounding tissues and adjacent lymph nodes, and supplementary radiotherapy seems to be the treatment of choice.

Surgical treatment of a large eventration of the left diaphragm.

Total eventration of the left diaphragm is a rare condition in adults. It is now generally accepted that surgery is indicated only in cases of distinct complaints involving abdominal or thoracic organs which can be related to this pathological condition. The accepted routine surgical procedure for treatment of the eventration is plication of the diaphragm without incision or excision of the pathologically changed part of the diaphragm. In rare cases, reinforcement of the very thin membrane with some foreign material may be necessary. We describe an adult patient with extensive eventration and severe symptoms in whom we used a special technique for restoration of the diaphragm with very good results.

Intrathoracic extrapulmonary hemangiopericytoma. Late local recurrence after radical extirpation of a large tumor.

A 39-year-old woman was operated upon for an extremely large hemangiopericytoma located in the right hemithorax. During intensive follow-up a local recurrence was observed 8 years after the radical extirpation of the well-encapsulated tumor, histologically assessed as generally benign. This and other observations give reason to suspect that the well-recognised puzzling clinical behavior of this rare tumor is a result of a potential pathological capacity of the abnormally vascularised fatty connective tissue through which the tumor is connected to the body. This tissue, if not radically extirpable, must be completely destroyed in some way during or after the operation in order to prevent recurrence.

Gastroplasty combined with partial fundoplication.

Gastroplasty, as proposed by Collis, combined with fundoplication of varying degree, has been increasingly used during recent years for management of hiatal hernia complicated by shortened oesophagus and oesophageal stricture. A modification of this procedure using 180 degree fundoplication and the transthoracic-transdiaphragmatic approach is described. Thirty consecutive patients have been subjected to the procedure since 1973. The clinical results and results of X-ray examinations and laboratory investigations of gastro-oesophageal reflux in 29 patients examined postoperatively are analysed. The concept of combining artificial lengthening of the oesophagus with fundoplication is considered to be a promising approach for solving the problems associated with the management of hiatal hernia complicated by shortened oesophagus.

A case of carcinoma in intralobar pulmonary sequestration.

A case of intralobar pulmonary sequestration with the unusual origin of an abnormal artery from the ascending aorta and with cancer localised in the sequestrated lung tissue is presented. The preoperative investigation failed to diagnose the cancer.

Foreign bodies in the mediastinum perforating the oesophagus.

A patient attempting suicide put four unsterile objects into a stab wound in his neck. These objects remained in the tissues unnoticed for about three months before they were removed from the upper mediastinum by operation. Owing to penicillin treatment, no diffuse mediastinitis developed but the oesophagus was perforated by the objects. In spite of severe damage to the gullet by the perforation and by operative incision, the oesophagus could be repaired without development of stenosis. The method of preventing stenosis is presented.

Pathogenesis of shrinking pleuritis with atelectasis--"rounded atelectasis".

The pathogenesis of "shrinking pleuritis with atelectasis" or "rounded atelectasis" is discussed on the basis of 37 operated patients and on experiments on cadaver lungs. Peroperative dissections with microscopic examinations and the results of experiments with the cadaver lungs support the concept that the lesion is caused by an inflammatory reaction in the visceral layer of the pleura, caused by asbestos fibers. The inflammation occurs in stages, with deposition of connective tissue that shrinks and causes considerable atelectasis of the underlying pulmonary parenchyma. Compression of the lung due to fluid collecting in the pleural cavity involved was not noted.

Surgical treatment of symptomatic gastroesophageal reflux recurring after hiatal hernia repair.

Experience of 30 cases with reoperation for recurrent symptoms after hiatal hernia repair is reported. The primary operation had been transabdominal in 21 cases (11 simple cruroplasty, 7 Nissen, 3 Hill) and transthoracic in 9 (5 Husfeldt, 4 simple cruroplasty). Stenosis and/or esophageal shortening were present in at least 8 patients at the primary operation. Symptoms recurred within a year in 26 of the 30 patients. A transthoracic approach was used for all reoperations. At the time of reoperation, 14 patients had no reflux complications or had esophagitis only. At follow-up (2-12 years) 13 were symptom-free and 1 was improved: X-ray showed hernia in one case and 3 had positive standard reflux test. Of the 16 patients with severe reflux complications before reoperation, 12 had shortened esophagus, combined with stricture in 6 cases, and 4 had isolated stricture. The results were less satisfactory in this complicated group, though all were postoperatively improved. There was no operative mortality. Initial failure to recognize esophageal shortening and inadequate repair were common causes of recurrent hernia. Symptomatic relief after reoperation was comparable with that after primary repair.

Long term results of operation for shrinking pleuritis with atelectasis.

During 14 years 34 patients were operated on for shrinking pleuritis with atelectasis. They were followed up after one to 14 years (mean 6.0) by interview, chest radiography, and spirometry. Most were in good condition, but a reduction in vital capacity had occurred in eight and in FEV1 in 15 patients. Radiographs were normal in 28 patients except for small pleural or parenchymal fibrotic changes. One patient had a suspected recurrence of shrinking pleuritis with atelectasis after nine years, suggesting continuation of the disease process despite operation.

Treatment of benign strictures and injuries of the oesophagus with a permanent oesophageal tube introduced through a cervical oesophagostomy. I. Method.

Permanent oesophageal tubes of various design have been used for treatment of severe benign oesophageal strictures and oesophageal injuries. A method in which the tube is introduced into the oesophagus through cervical oesophagostomy as proposed by Belinoff is presented and technical details are discussed.

Treatment of benign strictures and injuries of the oesophagus with a permanent oesophageal tube introduced through a cervical oesophagostomy. II. Clinical observations.

Eighty-four patients with severe benign oesophageal strictures and/or oesophageal perforation have been managed with a permanent oesophageal tube (POT) introduced through a cervical oesophagostomy. Sixty-eight patients had severe strictures of varying etiology. In these patients, the conservative treatment by bouginage could not be continued due to a stricture unyielding for dilatation or early recurrence of the stricture after a number of dilatations. Eleven of these patients had iatrogen oesophageal perforation at the time the treatment with POT was started. In 16 patients indication for treatment with POT was a severe injury of the oesophagus and in 15 of them it was transmural. The results of the treatment are considered to be satisfactory. The mortality rate, the final results and the factors determining poor results of the treatment are discussed. The treatment with POT introduced through a cervical oesophagostomy is considered to be a valuable method which can be used in cases with stricture and injuries of the oesophagus in which conventional conservative treatment is futile or impossible and resection of the oesophagus undesirable.

Hiatal hernia and shortened oesophagus.

The existence of an anatomically shortened oesophagus in patients with hiatal hernia, and its influence on the results of surgical repair of the hernia, is the subject of great controversy. One hundred and forty patients operated upon for hiatal hernia were studied for presence of shortened oesophagus. The method of examination and criteria for evaluation of the oesophageal shortening are described. The oesophagus was found to be anatomically shortened in 52 of these patients. None of the findings obtained at the preoperative examinations employed in the study could be used as a pathognomonic sign for diagnosing a shortened oesophagus. Irreducibility of the cardia below and the diaphragm, as observed radiologically, in association with other severe reflux complications, such as oesophageal stricture and/or ulcerative, makes it presence very likely, however. The incidence of shortened oesophagus in this series was higher in patients with a long history of symptomatic gastro-oesophageal reflux. The influence of the shortened oesophagus on the result of the surgical repairs used in this study, and aimed mainly at restoring the abdominal segment of the oesophagus, was clearly unfavourable.