Care of the obesity surgery patient requiring immediate-level care or intensive care.

Most bariatric surgery patients are triaged directly to the medical surgical floor postoperatively. However, patients at high risk due to comorbid factors, who have failed postoperative extubation or have suffered intraoperative complication, may require intensive care unit (ICU) or intermediate-level care (IMC). The special needs of the morbidly obese IMC/ICU patient include: triage, mobility, visiting, fluid resuscitation, management of sleep apnea, airway management, transporting for out of ICU procedures, and preventing pressure ulcers. Traditional approaches to nursing care require new thought when dealing with the massively obese. Our experiences with the special needs of these critically ill morbidly obese bariatric surgery patients are described.

Making the most of your time: the benefits of converting patient education programs into continuing nursing education.

Educating hospital staff and patients is a time-consuming, yet essential component to a successful bariatric surgery program. The process of converting patient education and support group sessions into continuing education opportunities for hospital staff is described. This also provides hospital staff with direct exposure to patient testimony of concerns and obstacles to following treatment plans.

Squamous cell carcinoma of the stomach: a study of four patients with comments on histogenesis.

The histogenic origin of squamous carcinoma of the stomach (SCS) is controversial. We report the case of a 55-year-old man who developed SCS following successful chemotherapy for generalized well-differentiated lymphocytic lymphoma. The patient's stomach contained both squamous carcinoma arising in squamous metaplasia and chronic atrophic gastritis with intestinal metaplasia. This case is compared to three additional cases of SCS where no such antecedent mucosal changes were evident. The SCS literature is reviewed and the histogenesis regarding the development of pure squamous tumors of the stomach is discussed.

Sarcoma of the breast. A study of 32 patients with reappraisal of classification and therapy.

A retrospective clinicopathologic review of 32 patients with mammary sarcoma exclusive of angiosarcoma or lymphoma was performed. For 25 patients with previously untreated lesions, the median tumor diameter was 4 cm and 14 patients had high or intermediate grade lesions. One of 22 patients treated by mastectomy and one of three patients treated by local excision died of sarcoma yielding an actuarial 5-year survival of 91%. None of the 25 patients had received adjuvant chemotherapy and only one treated by mastectomy had post-operative radiation therapy. Seven other patients were referred for treatment of recurrent mammary sarcoma. In this group, median size of the primary tumor was 6 cm and four had high or intermediate grade histology. Tumor control was achieved for only one of five patients with local recurrence and neither of the two with distant metastases. Median survival was 6 months following initiation of treatment for recurrence. Whenever possible breast sarcomas should be classified according to histologic cell type and grade. For lesions not readily classified, the terms unclassified or anaplastic sarcoma should be used. The diagnosis of stromal sarcoma is best reserved for those infrequent sarcomas that can be traced to the specialized periductal and perilobular stroma of the breast. Total mastectomy is recommended for most patients with postoperative radiation therapy indicated when the adequacy of the margin is in doubt. The role of adjuvant chemotherapy in the primary management of mammary sarcoma is yet to be determined.

Changing trends in the management of squamous carcinoma of the tongue.

An analysis of 412 patients with primary squamous carcinoma of the tongue seen from 1969 through 1978 reveals that the age and clinical stage of patients with tongue cancer have remained constant when compared with previous reports from our hospital. The proportion of female patients has increased, and we are seeing more patients with tumors located in the base of the tongue. Treatment methods are changing. Mandible-sparing procedures were used more often, and significantly more patients received primary and adjuvant radiotherapy in the early study period. At the same time, there were fewer composite neck, tongue, and jaw resections and fewer laryngectomies, although more patients had elective treatment of the neck. The overall determinate cure rate has not changed since the 1957 through 1963 period. Age, sex, and adjuvant radiotherapy did not seem to affect survival. When patients with oral tongue primary lesions were compared with those with tumors in the base of the tongue, the prognosis seemed to be better in those with oral primary lesions when the patient had stage I or II disease. Finally, patients with tongue cancer have at least a 1 in 5 chance of development of a second aerodigestive tract malignancy and require lifelong scrutiny. Although current therapy results in lower morbidity, the proportions of patients with stage III and IV tumors remain high, and the cure rates remain disappointingly stable.

Resection of pulmonary metastases from nonseminomatous testicular tumors. Correlation of clinical and histological features with treatment outcome.

Clinical and histological correlates of survival in patients undergoing complete resection of pulmonary metastases from nonseminomatous testicular carcinoma were determined in 25 Stage C patients aged 17-38 years treated from 1969-1978. All patients had orchiectomy and retroperitoneal lymphadenectomy. Nineteen patients received combination chemotherapy before resection, and all received chemotherapy after resection. Three patients had four additional thoracotomies for pulmonary recurrence. Survival was measured from time of first thoracotomy to time of last followup or death. Actuarial survival for the entire group at one, two, and five years was 80, 63, and 59%, respectively. Median follow-up of the survivors was 3.5 years. Patients in low tumor burden groups such as those with no tumor in retroperitoneal nodes, with unilateral metastases, or with single metastases had better prognosis, as did patients whose primary tumors were moderately well differentiated. Characteristics of pulmonary metastases that favorably influenced the prognosis were the presence of mature teratoma, presence of few mitoses, lack of mononuclear infiltrate, and lack of desmoplastic response. These findings confirm the effectiveness of multimodality therapy which includes the resection of pulmonary metastases for Stage C nonseminomatous carcinoma of the testes. In addition, they suggest that consideration should be given to the stratification of prospective clinical trials on the basis of tumor burden and histologic characteristics of the primary and metastatic lesions.

Factors prognostic for survival in patients with malignant melanoma spread to the regional lymph nodes.

To establish clinical and histologic determinants of survival, records of all UCLA patients with resectable melanoma metastatic to the lymph nodes during the years 1954-1976 were reviewed. These 150 patients were treated first with wide excision, lymphadenectomy, and with radiation/chemotherapy and/or additional surgery only if further recurrences developed. None received adjuvant immunotherapy or chemotherapy. In 97 of 139 patients with identified primary tumors, slides of the primary lesion were reviewed. Putative prognostic factors included age, sex, parity, site of primary tumor, presence of satellitosis, clinical status of nodes, histologic characteristics of primary lesion (Clark's level, thickness of tumor, presence/width of ulceration, and number of mitoses/HPF), time from biopsy of primary tumor to lymphadenectomy, and number of positive nodes. kaplan-Meier estimates of survival for the entire group at one, two, five, and ten years were 73, 55, 37, and 33%, respectively. Median follow-up period of survivors was four years. Univariate analyses using the log-rank test showed that thickness of the primary lesion (p less than 0.001), width of ulceration (p = 0.003), absence of ulceration (p = 0.024), and number of positive nodes (p = 0,.033) were prognostic for survival. In multivariate analysis by the Cox procedure, thickness of the primary (p = 0.001) and number of melanoma-containing nodes (p = 0.043) were prognostic for survival. Location of the primary tumor became marginally significant (p = 0.12) in the multrivariate model. These findings demonstrate the prognostic importance of characteristics of both the primary lesion and extent of regional dissemination. Future prospective randomized trials for (adjuvant) therapy of Stage II melanoma should be stratified by these variables.

Pulmonary resection for metastatic sarcoma.

Surgical resection plays an important role in the treatment of sarcoma that is metastatic to the lung. Multiple bilateral metastases are not contraindications to surgery. The rapidity of growth and the response to chemotherapy can be accurately determined by the tumor doubling time. Preoperative chemotherapy provides an in vivo measurement of tumor sensitivity, and the response to chemotherapy correlates with prognosis. Since residual microscopic pulmonary disease appears to be responsible for most failures after thoracotomy, attention should be directed toward delivering more effective adjuvant therapy to the lungs.

Lymphocyte surface markers and cytotoxicity following cryopreservation.

The effects of cryopreservation (CP) on lymphocyte subpopulation distribution and functional activity in blastogenic and cytotoxicity assays were tested. Peripheral blood lymphocytes (PBL) from 12 healthy human donors were obtained by Ficoll-Hypaque separation. Half of each sample was tested fresh, while the other half was cryopreserved and then thawed and tested the same day. Each sample of CP-PBL was compared to fresh PBL from the same donor in simultaneous assays. Following CP there was a significant reduction in the percentage of E, EA gamma, and EA mu rosette-forming cells with a reciprocal increase in EAC rosette-forming cells. The blastogenic response to alloantigens was stable following CP while blastogenesis in unstimulated control cultures was significantly reduced. Mixed lymphocyte culture (MLC)-induced cell-mediated lympholysis (CML) was consistently and significantly diminished by CP. Cytotoxicity in 4 h chromium release NK (K562), ADCC, and LDCC assays was also significantly diminished by CP. In contrast, cytotoxicity was unaffected in an 18 h cytotoxicity assay against adherent cultured melanoma target cells.

Intralesional BCG immunotherapy of pulmonary tumors.

A new method of baccile Calmette Guérin (BCG) immunotherapy has been evaluated in 25 patients with lung cancer. This technique involves the direct intratumor injection of BCG in patients with pulmonary tumors. Four patients underwent transbronchoscopic injections of tumor, with significant resolution of tumor in three. Twenty-one patients underwent percutaneous injection with the aid of fluoroscopic imaging. Twenty of these 21 underwent pulmonary resection. Toxicity was limited to fever and malaise. The severity of this toxicity was closely related to the magnitude of reactivity to PPD. There were no intraoperative or postoperative complications occasioned by BCG injection. The histologic features were characterized by granulomatous inflammatory reactions in the tumors and the regional lymph nodes. These histologic findings are identical to those seen in animal tumor models in which potent systemic antitumor immunity is induced. BCG intratumor injection is technically feasible and safe, and it is appropriate to begin phase 2 and phase 3 clinical trials.