Morphodynamics and pathology of blood vessels III--comparative morphologic study of contraction of smooth muscle cells of hollow viscera and its application to vasoconstriction and vasospasm.

The morphologic changes in the walls of hollow viscera caused by contraction and relaxation of smooth muscle cells were studied from autopsy and surgical specimens. The specimens studied included: esophageal spasm (corkscrew and nutcracker esophagus), contraction of the lower esophageal sphincter with marked esophageal dilatation, gaseous distension of the stomach, contraction of the gastric pylorus, bladder and anal sphincter, physiological segmental constriction of the small and large intestines, constriction and distension of the gallbladder, urinary bladder and bronchi, and postpartum contraction of the uterus. In contrast to distension, the constriction of hollow viscera shows marked reduction of the external circumference and diameter with thickening of the wall, contraction of smooth muscle cells, thickening of muscle bundles, remodeling of wall structure, and narrowing or obliteration of the lumen. Morphologic evidence of contraction of smooth muscle cells is demonstrated by varying degrees of typical lengthwise shortening of the cells and squeezing and folding of the nuclei depending on the degree of cytoplasmic contraction of the smooth muscle cells. Using these same classic morphologic signs, we have attempted to study constriction and distension of arteries and arterioles. We can demonstrate contraction of smooth muscle cells and remodeling of arterial and arteriolar walls in patients with spastic coronary artery thrombosis, cocaine-induced coronary artery thrombosis, acute constriction of mesenteric arteries with lacerations of arterial wall, and dissecting hemorrhages induced by large doses of intravenous infusion of vasoconstrictors for hemorrhagic shock, and in patients with sustained, accelerated, or malignant hypertension.

Cryoablation of unresectable malignant liver tumors.

BACKGROUND: Unresectable malignant liver tumors, particularly metastases of gastrointestinal origin, are rapidly lethal in a vast majority of patients, regardless of treatment. PATIENTS AND METHODS: We evaluated 58 patients by laparoscopy and/or laparotomy. Thirty-nine were treated with cryoablation of liver tumors using a liquid-nitrogen cryoprobe delivering a tumoricidal temperature of -196 degrees C with intraoperative ultrasound monitoring. Histologic evaluation showed that 25 patients had colorectal metastases, 3 had gastric tumors, 4 hepatocellular carcinomas, 6 carcinoids, and 1 gastrinoma. RESULTS: All patients who received complete cryoablation are alive with a mean follow-up of 14 months. Five whose treatment could not be completed died between 3 and 9 months postoperatively. Thirteen patients (28%) have recurrent disease and 20 (51%) have no evidence of disease. There were no operative mortalities. Postoperative transient elevation of liver function tests and thrombocytopenia were noted. All patients received postoperative chemotherapy. CONCLUSION: Cryoablation is an active and safe treatment for advanced liver malignancies.

Direct septum transversum incision to replace circumferential diaphragmatic incision in operations on the cardia.

Application of a simple anatomic approach to lesions of the cardia, both benign and malignant, in consecutive patients has demonstrated an excellent exposure with the same flexibility as the standard, circumferential, diaphragmatic, and abdominal incision used for the past 50 years. The technical details of the procedure and its application are described, along with the pertinent embryology, anatomy, and physiology that led to this approach.

Jejunal interposition.

Seventeen cases of jejunal interposition for distal esophageal lesions, primarily achalasia, eventuated in excellent clinical function in almost all patients. These results compare favorably with other reported series of the same procedure. The radiologic appearance of the anastomosis with the few complications that occur, however, have not been emphasized and are presented in this paper.

Zollinger-Ellison syndrome with esophagitis and Barrett mucosa.

Although esophageal disease in Zollinger-Ellison syndrome is being recognized with increasing frequency, Barrett esophagus is seen only rarely. Basal lower esophageal sphincter pressure is probably not different in Zollinger-Ellison syndrome and non-Zollinger-Ellison syndrome patients. Circulating gastrin, therefore, cannot be the major determinant of lower esophageal sphincter pressure in vivo. Total gastrectomy and resection of all metaplastic esophagus, when feasible, is the treatment of choice for patients with Zollinger-Ellison syndrome and Barrett mucosa.

Cervical tracheoesophageal fistula.

Four unusual cases of cervical tracheoesophageal fistula (TEF) are presented. The incidence, diagnosis and treatment of cervical TEF are discussed. Surgically, if the location is above the level of T2 a cervical approach may be utilized. The cases included a cervical "H" type TEF occurring in an adult. Congenital "H" type TEFs frequently occur in the neck. An adult presenting with a cervical "H" type TEF, having as an infant undergone repair of a thoracic TEF, is unique. Two layer closure of both trachea and esophagus with strap muscle interposition is preferred. The other cases include a TEF secondary to metastatic breast carcinoma, one associated with a stomal recurrence, and an acquired TEF following laryngectomy. Metastatic breast carcinoma resulting in a TEF is reported for the first time. Malignant TEF's are usually secondary to carcinoma of the esophagus, lung, or thyroid. Best palliation is achieved either by esophageal intubation, by colon bypass, or by gastric pull-up with esophageal exclusion. Stomal recurrence with TEF following laryngectomy is treated with one-stage resection and reconstruction with a pectoralis major myocutaneous flap and gastric pull-up. A patient 5 years post-laryngectomy illustrates an acquired non-malignant cervical TEF, a category which includes fistulas due to trauma, tracheotomy, or endotracheal tubes, instrumentation, and inflammatory disease. Prompt surgical closure as in congenital cases is the treatment of choice although select cases require medical therapy.

Esophageal perforations after forceful dilatation in achalasia.

The reported incidence of esophageal perforation after forceful dilatation in achalasia is between 1-5%. Over the past nine years we have treated five patients with this complication. After demonstrating the perforation with a Gastrografin swallow, a left posterolateral thoracotomy is made. The full-thickness laceration is sutured in two layers. A Heller esophagocardiomyotomy is then performed on the contralateral side of the esophagus. The muscular layer on either side of the esophagocardiomyotomy is mobilized well so as to allow easy closure of the outer muscular layer of the esophagus in the area of the laceration. There were no deaths and minimal morbidity in these five patients, and functional results were excellent. It is concluded that perforations of the esophagus after dilatation in achalasia should be operated on promptly and undergo closure of the laceration with a complimentary esophagocardiomyotomy.