Early enteral feeding compared with parenteral nutrition after oesophageal or oesophagogastric resection and reconstruction.

After resective and reconstructive surgery in the gastrointestinal tract, oral feeding is traditionally avoided in order to minimize strain to the anastomoses and to reduce the inherent risks of the postoperatively impaired gastrointestinal motility. However, studies have given evidence that the small bowel recovers its ability to absorb nutrients almost immediately following surgery, even in the absence of peristalsis, and that early enteral feeding would preserve both the integrity of gut mucosa and its immunological function. The aim of this study was to investigate the impact of early enteral feeding on the postoperative course following oesophagectomy or oesophagogastrectomy, and reconstruction. Between May 1999 and November 2002, forty-four consecutive patients (thirty-eight males and six females; mean age 62, range 30-82) with oesophageal carcinoma (stages I-III), who had undergone radical resection and reconstruction, entered this study (early enteral feeding group; EEF). A historical group of forty-four patients (thirty-seven males and seven females; mean age 64, range 41-79; stages I-III) resected between January 1997 and March 1999 served as control (parenteral feeding group; PF). The duration of both postoperative stay in the Intensive Care Unit (ICU) and the total hospital stay, perioperative complications and the overall mortality were compared. Early enteral feeding was administered over the jejunal line of a Dobhoff tube. It started 6 h postoperatively at a rate of 10 ml/h for 6 h with stepwise increase until total enteral nutrition was achieved on day 6. In the controls oral enteral feeding was begun on day 7. If compared to the PF group, EEF patients recovered faster considering the duration of both stay in the ICU and in the hospital. There was a significant difference in the interval until the first bowel movements. No difference in overall 30 d mortality was identified. A poor nutritional status was a significant prognostic factor for an increased mortality. Early enteral feeding significantly reduces the duration of ICU treatment and total hospital stay in patients who undergo oesophagectomy or oesophagogastrectomy for oesophageal carcinoma. The mortality rate is not affected.

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.

Life-saving muscle flaps in tracheobronchial dehiscence following resection or trauma.

OBJECTIVE: In the presence of acute inflammation and necrosis of the wall, tracheo-bronchial defects are difficult to manage. The absence of adequate vascularization and the contaminated area prevent successful direct re-suturing. METHODS: In order to restore a sufficient blood supply we used a pedicled latissimus dorsi or a pectoralis major flap that was entered into the thorax after a 10-cm resection of the second rib. A portion of the muscle was fitted into the tracheo/bronchial defect by reinforced sutures. The remaining muscle was sutured to the tissue surrounding the defect. This method was applied in various septic conditions: Bronchial defects; complete dehiscence of the right (n = 6) or left (n = 1) main bronchus at the carinal level following resection for lung cancer (n = 4) or for tuberculous (n = 2) on nontuberculous pleuropneumonia (n = 1). Tracheal defects; (1) destruction of one third of the tracheal circumference involving the cricoid down to the fourth ring following tracheotomy in presence of a septic sternum after intrathoracic goiter and Bechterew's disease; (2) 30% dehiscence of the anastomosis and septic sternum following tracheal resection; (3) Mediastinitis involving tracheal and esophageal wall following a 7 cm long iatrogenous laceration of the intrathoracic trachea. RESULTS: In one case the latissimus dorsi developed venous stasis on day 2 and was replaced by the pectoralis major muscle which showed uneventful healing. In all other patients the muscle flap resulted in an uneventful closure of the defect and recovery. CONCLUSIONS: Large, well vascularized, pedicled muscle flaps ensure a safe closure of tracheo-bronchial defects or dehiscences even in presence of gross necrosis and sepsis.

"Adjuvant" external radiation of the mediastinum in radically resected non-small cell lung cancer.

OBJECTIVE: The effect of postoperative external beam radiation in MO non-small cell lung cancer resected with curative intention was evaluated in a randomized trial. METHODS: In 155 patients (121 males, 34 females; mean age: 59 years) 105 lobectomies, 12 bilobectomies and 38 pneumonectomies with radical lymph node dissection to the contralateral side were carried out. Histology revealed squamous cell (n = 68), adeno- (n = 53), large cell (n = 21), adenosquamous (n = 6) or bronchioloalveolar type (n = 7) carcinomas. The pathologic stages T1 (n = 38), T2 (n = 89), T3 (n = 28); NO (n = 39), N1 (n = 67), and N2 (n = 49) were evenly distributed between the two treatment groups: group A (72 patients) had no further oncologic treatment, while group B (83 patients) had external beam radiation to the mediastinum (50-56 Gy, 8 or 23 MeV photons, 2 Gy/day, 5 days a week) beginning 4 weeks after the operation. RESULTS: The overall 5-year survival rate of the whole collective was 24.1% without any significant difference between the radiotherapy group B (29.7%) and the control group A (20.4%) (log-rank test: P > 0.05). The overall 5-year recurrence-free survival rate was 20.1%, with no difference between groups B and A (radiotherapy: 22.7, controls: 15.6%, long-rank test: P > 0.05). There was no difference in the incidence of distant metastases (external beam radiation: n = 32; controls: n = 38). The rate of local recurrences at the bronchial stump or in the mediastinum, however, was significantly reduced in the radiotherapy group (n = 5) compared with 17 in the controls (P < 0.01 chi-square test). A multivariate analysis confirmed the independent influence of postoperative radiotherapy on the incidence of local recurrence. CONCLUSIONS: External radiation of the mediastinum in radically resected non-small cell lung cancer reduces the risk of local recurrence, but has no influence on distant metastastic spread and overall survival.

[Hyperbaric surgery and oxygen therapy in clostridial myonecrosis]. / Hyperbare Chirurgie und Sauerstofftherapie der clostridialen Myonekrose.

116 patients with verified clostridial myonecrosis were treated by means of a regimen of combined cyclic hyperbaric oxygenation at 3 ata and repeated necrectomy. With proximal localization of gas gangrene in the elbow or knee (n = 55) 34.5% of patients survived, whilst with peripheral localization at the limbs (n = 44) the survival rate was 88.6% amputation being avoided in 21 of these cases. Abdominal localization (n = 17) was associated with the lowest survival rate (23.5%). In spite of severe clostridial toxicity in 80.1% of patients at the time of admission, the overall mortality was 50.8%.

Rotating brush for video-assisted thoracoscopic pleural abrasion.

We present a simple device enabling parietal pleural abrasion during video-assisted thoracoscopic surgery (VATS). The rotating brush facilitates safe pleurodesis in patients with pneumothorax obviating the need for additional chemical agents or pleurectomy.

Evaluating intraoperative radiation therapy (IORT) and external beam radiation therapy (EBRT) in non-small cell lung cancer (NSCLC). Five years experience.

A pilot study on intraoperative radiation therapy (IORT) combined with external beam radiation therapy (EBRT) in nonresectable non-small cell lung cancer (NSCLC) was performed in 31 patients (mean age: 66.2 years, range: 51-80; 10 anatomically and functionally, 21 functionally, nonresectable; 20 squamous-cell, 11 adenocarcinoma). The tumor was exposed by lateral thoracotomy and a staging lymph node dissection was performed (final staging 7 T1, 16 T2, 8 T3; 11 nodal positive). Ten to 20 Gy IORT (energy: 7-20 MeV electrons) were delivered to the tumor. Unilateral continuous positive airway pressure ventilation of the diseased lung was used to reduce the amount of healthy lung tissue in the IORT port and to minimize the ventilatory movement. Secondary collimation and direct shielding of radio-sensitive structures within the IORT port by aluminium sheets were used to further reduce collateral damage. Four weeks after IORT, 46 Gy EBRT (2 Gy/day 5 times a week; 8-23 MeV photons) were administered to the mediastinum and to the tumor-bearing area on an outpatient basis. In nodal positive cases the mediastinal dose was increased to 56 Gy. Twenty-three patients were evaluable. In 13 complete, in 8 partial (50-97% regression) and in 2 minor response has been achieved. Five patients experienced a recurrence (local only: 2; local and distant: 1; distant only: 2). Twelve patients died of underlying cardio-respiratory disorders within 6 to 25 months after IORT; 7 died of cancer. The overall 5-year survival rate including the incidental deaths is 14.7%. The recurrence-free survival rate is 53.2%.

Closure of bronchial defects using a pedicled pericardial flap.

A technique for closure of lateral or terminal defects in the bronchial wall after tissue-saving procedures, which obviates the need for sleeve resection in few selected situations, is described. Its main advantages are a low risk of surgical complications at the suture line and easy performance.

The importance of early detection and therapy of reexpansion pulmonary edema.

Three cases are reported of unilateral pulmonary edema, two following rapid reexpansion after prolonged tension pneumothorax, with total collapse of the right lung and one after reexpanded atelectasis following left intrabronchial obstruction. In all cases decrease of blood pressure and tachycardia not responding to intravenous fluid substitution were already present within the first 15 min after chest drainage or after removal of the intrabronchial obstruction. The preexistent dyspnea failed to improve. A cloudy opacity of the reexpanded lung was found immediately after drainage in 2 cases. After immediate application of a continuous positive airway pressure mask no more extensive therapy was necessary in one patient. The two others in whom treatment was begun with more than 1 hour delay required artificial ventilation and adrenergics for 2 and 4 days, respectively.

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.