Acid-related diseases following retrosternal stomach interposition.

BACKGROUND/AIMS: Esophagectomy and reconstruction with retrosternal stomach interposition implies bilateral truncal vagotomy, which supposedly causes gastric functional impairment. METHODOLOGY: Esophagectomy and reconstruction with retrosternal stomach interposition was performed on 15 men (mean age: 58.4 years) and 3 women (mean age: 43.6 years). The stomach was pedicled on the right gastric and right gastroepiploic artery without performing pyloroplasty. The cervical side-to-end anastomosis was sutured manually. The functional results were assessed 2-4 years postoperatively, by determining 24-hour qualitative intragastric pH-measurement, fluoroscopical gastric emptying studies, fasting gastrin levels, and endoscopy with biopsy studies. RESULTS: Endoscopy and biopsy confirmed esophagitis in 12 patients, gastritis in 15 and a gastric ulcer in 1 case. Fluoroscopic examination documented a normal passage of contrast medium in 17, slight impairment in 1 case treated by balloon dilatation of the pylorus. Qualitative intragastric pH-measurement revealed a total pH < 3 in 22.5-98.05% of measuring events (mean: 74.31%) within 24 hours, in 18 cases. Only 4 patients had pH < 3 in less than 50%. Fasting gastrin levels (normal range: 25-110 mU/L) varied from 48.78 mU/L-168.20 (mean: 85.23 mU/L). Only 3 patients had levels > 110 mU/L (maximum: 168.20 mU/L). CONCLUSIONS: Acid-related diseases may also occur after truncal vagotomy and retrosternal stomach interposition. Routine follow-up endoscopy and biopsy studies should be done to prevent inflammatory complications and maintain the patient's quality of life.

Effect of photodynamic therapy in a multimodal approach for advanced carcinoma of the gastro-esophageal junction.

UNLABELLED: Background and Objective We wanted to determine the role of additional photodynamic therapy in a multimodal approach for the treatment of patients with advanced cancer of the gastro-esophageal junction. Study Design/Materials and Methods We reviewed 53 patients, after endoluminal palliation, with advanced cancer of the gastro-esophageal junction. Combined dilatation and retrograde tumor disobliteration with Nd-YAG laser before photodynamic therapy (PDT), brachyradiotherapy, or both, became necessary in 12 patients. Brachyradiotherapy was carried out in all patients. PDT before brachyradiotherapy was performed in 25 patients. The endoluminal treatment was completed by external beam irradiation in 30 patients (15 cases with PDT and 15 without PDT) with an at least fair performance status. RESULTS: Photodynamic therapy showed a significant difference regarding the mean opening of the tumor stenosis (mean, 6.4 mm; P = 0.0002), the mean decrease in tumor length (3.1 cm; P = 0.00001) and the increase in median survival (13. 8 months; P = 0.001). The combined multimodal approach by using PDT, brachyradiotherapy and external beam irradiation showed a median survival of 16.8 months. However, additional external beam irradiation showed no significant difference (P = 0.11). The rate of severe complications was 5.7%. The mortality rate was 1.9%. CONCLUSION: Photodynamic therapy has been shown to be an effective treatment for palliation of advanced cancer at the gastro-esophageal junction. The use of PDT combined with irradiation was associated with an acceptable survival rate, low rates of complications and reasonable quality of life.

Review of severe osteoradionecrosis treated by surgery alone or surgery with postoperative hyperbaric oxygenation.

We reviewed 41 patients with osteoradionecrosis of the mandible. Each patient was treated by radical resection followed by external beam irradiation. The diagnosis of infected osteoradionecrosis was confirmed clinically, radiologically, and histologically. After operation had failed, 20/41 were given hyperbaric oxygen (HBO) as in 'salvage' treatment. Daily sessions of HBO 2.5 ATA for 60 minutes (mean: 29 sessions) were given. The other 21 patients were treated by operation and antibiotics alone. HBO group (n = 20): The overall success rate for HBO after operation had failed was 13/20. Repeated debridement as first-line treatment followed by postoperative HBO was successful in 12/19. In seven of 19 patients, partial mandibulectomy and microvascular transplantation were required as second-line treatment, and this was successful in five. Primary partial mandibulectomy and microvascular transplantation followed by HBO was successful in 1 patient. Non-HBO group (n = 21): Repeated debridement was successful in 10/11 patients. Partial mandibulectomy was required as second-line treatment in the remaining one. In the other 10, partial mandibulectomy and microvascular transplantation were successful as first-line treatment in four. In the remaining six, further surgical intervention became necessary and were successful for 5-17 months (mean: 13). With a success rate of 13/20, we do not recommend HBO for the treatment of osteoradionecrosis.

Hyperbaric oxygen and photodynamic therapy in the treatment of advanced carcinoma of the cardia and the esophagus.

BACKGROUND AND OBJECTIVE: The photochemical reaction of photodynamic therapy (PDT) depends on the presence of molecular oxygen. Because of anoxic regions in tumor tissue and vascular shutdown during PDT, the efficiency is limited. Therefore, the use of hyperbaric oxygen, which increases the oxygen in tumor tissue, as well as the amount of singlet oxygen, may enhance the efficiency of PDT. STUDY DESIGN/MATERIALS AND METHODS: After diagnostic work-up, photosensitization was carried out with a hematoporphyrin-derivate 2 mg/kg body weight 48 hours before PDT. The light dose was calculated as 300 J/cm of fiber tip. Twenty-three patients were treated by PDT alone and 29 patients received PDT under hyperbaric oxygen at a level of two absolute atmospheric pressures. RESULTS: Improvement regarding dysphagia and stenosis-diameter could be obtained in both treatment arms with no significant difference (P = 0.43 and P = 0. 065, respectively). The tumor length also decreased in both groups and showed a significant difference in favour of the PDT/HBO group (P = 0.002). The mean overall survival was 11.3 months. The mean survival time for the PDT group was 8.7 months and for the PDT/HBO group 13.8 months (P = 0.021). CONCLUSION: According to this pilot study, combined PDT/HBO represents a new approach in the treatment of esophageal and cardia cancer, which appears to have enhanced the efficiency of PDT.

Four-year experience with pleural abrasion using a rotating brush during video-assisted thoracoscopy.

BACKGROUND: Due to the high recurrence rate in primary spontaneous pneumothorax (PSP), surgical therapy is currently a well-accepted method of treating this condition. There is no general agreement about the best time for surgical intervention (i.e., after the first or second episode) or the optimal surgical approach,--i.e., tube thoracocenteses, thoracotomy, or video-assisted thoracoscopy (VATS) with or without pleurectomy or pleurodesis. The aim of this study was to verify the efficacy of VATS and mechanical brush pleurodesis using a rotating electrical brush system. METHODS: We treated 47 patients with PSP between June 1993 and June 1997. Follow-up ranged from 20 to 56 months. There were 38 male and nine female patients with a mean age of 26 years. Emergency thoracocenteses due to tension pneumothorax became necessary in three patients. All patients were treated by VATS and mechanical brush pleurodesis. Wedge resection was done if bullae or blebs were present (68.1%). RESULTS: Operating time was 20-60 min (mean, 35). There were no intraoperative complications and no conversions to conventional surgery. In the first few postoperative days, postoperative pain was controlled with nonsteroidal antirheumatic drugs and additional morphines. Drainage time was 3-7 days (mean, 4). Hospitalization time was 4-8 days (mean, 5). The recurrence rate was 2.1% (one patient). No postoperative bleeding or wound infection occurred in any of our patients. CONCLUSIONS: VATS combined with mechanical brush pleurodesis using the electrical brush system is a highly effective and safe treatment for patients with recurrent primary spontaneous pneumothorax.

Does hyperbaric oxygen enhance the effect of photodynamic therapy in patients with advanced esophageal carcinoma? A clinical pilot study.

BACKGROUND AND STUDY AIMS: Experimental studies have shown that the cytotoxicity of porphyrins and related substances is mediated mainly by singlet oxygen and that hypoxic cells are less affected by porphyrins and light. In a clinical pilot study we assessed the use of photodynamic therapy (PDT) under hyperbaric oxygen (HBO), compared with PDT under normobaric conditions, in patients with advanced esophageal carcinoma. PATIENTS AND METHODS: After diagnostic work-up and staging, photosensitization in all patients was carried out using hematoporphyrine derivate (HpD) (2 mg/kg bodyweight 48 hours prior to PDT). We then applied light at 630 nm (KTP-Nd: YAG laser with DYE box) at dose of 300 J/cm, delivered by a fiber with a radial light-diffusing cylinder (length 1 cm), inserted through the biopsy channel of the endoscope. Of the patients, 14 (12 with stage III cancers, and two with stage IV cancers) were treated by PDT alone, and 17 patients (15 with stage III cancers, and two with stage IV cancers) received PDT under HBO at a level of 2 absolute atmospheric pressures (ATA). Transcutaneous PO2 levels of 500-750 mm Hg under HBO, compared with transcutaneous PO2 levels of 60-75 mm Hg under normobaric conditions, were measured. RESULTS: Improvements regarding dysphagia and stenosis diameter were obtained in both treatment arms with no significant differences (P = 0.36 and 0.14, respectively). The tumor length also decreased in both groups and showed a significant difference in favour of the PDT/ HBO group (P = 0.002). Kaplan-Meier statistics showed median overall survival for the PDT group and the PDT/HBO group as 7.0 and 12 months respectively. The 12-month survival rate was 28.6% for the PDT group and 41.2% for the PDT/HBO group. Logrank test showed a difference in survival in favor of the PDT/HBO group (P = 0.059). No major treatment-related complication occurred, and the 30-day mortality rate was 0%. CONCLUSIONS: Combined PDT/HBO represents a new approach in the treatment of esophageal cancer which, in this pilot study, appears to have enhanced the efficiency of PDT.

Self-expandable coated stent after intraluminal treatment of esophageal cancer: a risky procedure?

BACKGROUND: Stenting is a well established palliative treatment for stenotic malignant disease of the esophagus. Because of its merely mechanical potential other tumoricidal techniques are often done before stenting. METHODS: We did esophageal stenting in 11 patients (9 men and 2 women) using a self-expanding coated stent system. Three tumors were localized in the proximal, four in the middle, and four in the distal third of the esophagus. In 9 patients tumors were locally or functional nonresectable, 1 patient refused an operation, and 1 had a recurrence after esophagojejunostomy. One patient had had pretreatment by repetitive dilatation and local hyperthermia, 9 had had photodynamic therapy followed by endoluminal iridium 192 high-dose rate brachyradiotherapy, and 1 patient was admitted with esophagotracheal fistula. The interval between the last endoluminal treatment and stent insertion was between 3 and 29 days (mean, 11 days). RESULTS: In 7 patients (63.7%) no complications were observed. Four patients (36.3%) died of major complications within 1 week. Postmortem examination confirmed that the pressure of the fully expanding stent to the esophageal wall caused the rupture. CONCLUSION: The use of self-expanding coated stents in pretreated esophageal tumors is associated with a high risk of perforation due to pressure of the indwelling tube in a less resistant esophageal wall.

Quantification of the dermal vascular response to hyperbaric oxygen with laser-Doppler flowmetry.

The vasoconstrictive response to hyperbaric oxygen (HBO2) therapy was non-invasively quantified in eight healthy volunteers at 1.95 and 2.5 atm abs (197.5 and 253.2 kPa; multiplace chamber, air environment) by laser-Doppler flowmetry (LDF). The sensors for continuous measurement of microvascular perfusion (flux) and skin temperature were localized on the thenar eminence. Transcutaneous oxygen (tcPO2) and carbon dioxide (tcPCO2) tensions, blood pressure, heart rate, respiration rate, peripheral oxygen saturation, and temperature of the hyperbaric chamber were recorded at five conditions: 1) baseline--air breathing at 1.0 atm abs, 2) after 15 min of HBO2 at 2.5 atm abs, 3) after 15 min of HBO2 at 1.95 atm abs, 4) 1 min after decompression with oxygen breathing at 1.0 atm abs, and 5) after 15 min of breathing air at 1.0 atm abs. Flux decreased continuously at conditions 2 (76.5%), 3 (50.6%), and 4 (37% of baseline, P < 0.05; Tukey test). Skin temperature fell below baseline at conditions 2, 3, 4 (P < 0.01, Tukey test), and 5 (P < 0.05, Tukey test, P < 0.001, analysis of variance). Range of correlation between inspired gas PO2 (PIO2) and alteration of flux 0.91 to 0.72, median -0.41. Correlation between PIO2 and tcPO2, r = 0.98. Chamber temperature and tcPCO2 remained stable. HBO2 reduced dermal microcirculation and temperature disproportionate to PIO2. LDF is suitable for use under hyperbaric conditions.

Air embolism with bilateral pneumothorax after a five-meter dive.

After an emergency ascent from very shallow depth, a diver suffered a triad of symptoms after bilateral barotrauma of the lungs: air embolism with subsequent paraparesis, pneumomediastinum, and bilateral pneumothorax. This is the first case of its kind in 20 yr of experience in the hyperbaric center at Graz. The patient was successfully treated by recompression with HBO.

Intraoperative plus external beam irradiation in nonresectable lung cancer: assessment of local response and therapy-related side effects.

Since 1987, 24 patients with inoperable non-small-cell lung cancer (NSCLC), stage T1-3 N0-2 M0, have undergone lymph node dissection and intraoperative radiation therapy (IORT) to the primary with 10-20 Gy. Patient selection criteria were nonresectability based on severe cardiorespiratory impairment, no radiological evidence of distant metastases and a Karnofsky performance status of greater than 80. In 18 patients the IORT procedure was followed by an external beam radiation series (EBR) including the tumor with 46 Gy and the regional lymph nodes with 46/56 Gy. The tumor response was assessed by CAT-scan volumetry before the institution of IORT, 4 weeks later, before the onset of EBR, 8 weeks after the combined treatment course and on a 3 months basis thereafter. Prospectively, MRI of the thorax with/without Gadolinium-DTPA was performed to examine contrast enhancement and signal behavior of the tumor, in an attempt to differentiate residual disease compared to therapy-related collateral damage. So far, 18 patients have completed the combined treatment course with a median follow-up of 11 months (range 4.5 to 25 months). The overall local response rate (CR and PR) was 88.2%. In detail, 11 complete responses, 6 partial responses and one minimal response were observed. The overall and recurrence-free survival at 25 months was 49.6% and 83.3%, respectively.

[Thoracic wall and lung trauma. Diagnosis, clinical aspects, surgical indications and technic]. / Thoraxwand- und Lungentrauma. Diagnostik, Klinik, Operationsindikation und Technik.

Diagnosis, pathophysiology, clinical course, indication for and technique of operative procedure are described for treatment of flail chest, pneumothorax, hematothorax, lung rupture and contusion, and for tracheobronchial injuries. A simple "finger-troicart" technique for thoracocentesis and chest tube is mentioned as well as the value of early and simultaneous fiberoptic exploration of the trachea, bronchi and esophagus.

[Permeability of the alveolocapillary membrane during unilateral lung lavage. An experimental study]. / Permeabilität der alveolokapillären Membran bei unilateraler Lungenlavage. Experimentelle Studie.

Experimental unilateral continuous lung lavage in a nonregenerating system containing 3000 ml isotonic crystalloid was performed in 12 pigs to determine the permeability of the alveolocapillary membrane under these conditions. The maximum time of lavage was 270 min. The concentrations of ions in both serum and fluid were determined at defined intervals. Exponential functions adjusted to the electrolyte changes in the fluid suggest different types of kinetics: sodium and urea adapted rapidly to serum concentrations. The half-time of the exponential function was short, the permeability constant high. Calcium, phosphate, and creatinine increased significantly, the permeability constant being lower than for urea. Potassium showed a linear increase, possibly due to influx from intracellular compartments. Total protein and albumin increased only initially, levelling far below the serum values. The low permeability constants of protein and albumin indicate an almost total lack of permeation, the initial increase possibly being due to washout of the epithelial lining fluid compartment. There was only a minimal loss of lavage fluid into the organism.

Malignant fibrous histiocytoma of the lung: prognosis and therapy of a rare disease. Report of two cases and review of the literature.

On the basis of 2 own patients and 18 cases reported in the literature, clinicopathological features of primary malignant fibrous histiocytoma of the lung are reviewed. Of the 20 patients (age-range: 14-75 yrs; 13 male, 7 female), 14 underwent resection. Recurrences were noted in 7 of them. 8 patients were free of disease at least 8 months postoperatively, one having undergone successful pulmonary metastasectomy. Postresection disease-free survival ranged from 8 months to 10 years. Adjuvant chemotherapy or irradiation (3/14) did not influence postoperative outcome. After chemotherapy, irradiation or conservative measures alone (6/20) survival did not exceed 12 months; remissions were not reported. The course was fatal within 12 months in 9/20 cases due to distant metastasis or local growth. 1 patient died of tumour-associated hypoglycemia. Age, sex, localization of the tumor and histologic subtype did not influence prognosis. Small tumors, asymtomatic at time of detection probably carry a better prognosis than larger ones.

Bilateral intralobar pulmonary sequestration: therapeutic implications.

Bilateral intralobar pulmonary sequestration within the lower lobes was suggested by computed tomography and confirmed by arteriography in a 27-year-old woman. Although one side was asymptomatic, both sequestrated areas were resected using staged bilateral thoracotomies. Histopathological examination showed massive inflammation in the symptomatic as well as the asymptomatic sequestrum. To our knowledge, this is the sixth reported case of bilateral intralobar pulmonary sequestration and the third for which bilateral resection has been performed.

Bronchial carcinoid arising in intralobar bronchopulmonary sequestration with vascular supply from the left gastric artery. Case report.

We report the unique case of a large, nonmetastasizing bronchial carcinoid tumor that arose within an intralobar bronchopulmonary sequestration in a 45-year-old man. The vascular supply to the sequestrated area within the left lower lobe as well as to the carcinoid tumor originated from atypical branches of the left gastric artery and the thoracic aorta. A left lower lobe lobectomy was performed. Histologically, a typical carcinoid tumor without lymph node metastases was found (T2 N0 M0). Seven years postoperatively, the patient is without signs of recurrence.

Reconstructive surgery for tracheobronchial injuries including complete disruption of the right main bronchus.

Important features of diagnostic and operative management and the postoperative course of tracheobronchial injuries as well as pathological findings at the anastomosis are discussed in a review of our 11 cases from the last 12 years. Diagnosis was established clinically, localization of the rupture was carried out by rigid or fiberoptic bronchoscopy. Tracheobronchial continuity was reestablished by end-to-end anastomosis of the ruptured bronchi, by direct suture of any tracheobronchial tears, or by patching inveterated lesions. Two cases of rupture of the right main bronchus are presented separately, considering clinical, diagnostic, operative and histopathologic criteria.