Esophageal leiomyomatosis involving trachea: surgical resection and repair.

We report the case of a 26-year-old man with diffuse esophageal leiomyomatosis involving the trachea. The tumor was resected by total esophagectomy and partial resection of the trachea and the left main bronchus. The tracheobronchial defect was repaired with a free forearm skin graft with satisfactory outcome. This approach offers good long-term prospects.

Soft-tissue reconstruction in thoracic surgery.

BACKGROUND: Reconstructive techniques using omental and myocutaneous flaps are widely used in the treatment of infected sternotomy wounds. To illustrate their wider role in thoracic reconstruction, we have retrospectively reviewed our experience over the last 5 years. METHODS: We used complex omental and myocutaneous flaps in 30 patients: 19 men and 11 women with a mean age of 53 +/- 4 years (range, 43 to 75 years). In 18 patients, these techniques were used to provide soft-tissue cover after chest wall resection, and in 12 cases complex myocutaneous flaps were used to obliterate chronic intrathoracic cavities. Rectus muscle was used in 11 of 24 muscle flaps, and omentum was used in 12 cases. There were 23 rotational flaps and seven free myocutaneous flaps with microvascular anastomosis. RESULTS: There were no operative deaths, and there were three complications. In 2 patients with infected lesions, loss of the free flap required subsequent revision. In 1 patient, infection developed underneath a prosthesis, which was treated with drainage and rib resection. In all other cases, the primary aim of the operation was achieved without complications. CONCLUSIONS: The vascularity of the omentum should encourage its wider use, especially when infection exists preoperatively. Excellent results can be achieved when using the rectus muscle as a complex myocutaneous flap. The use of free flaps should be reserved for difficult cases and used only in the absence of infection.

Cisplatin and 5-fluorouracil for symptom control in advanced salivary adenoid cystic carcinoma.

Adenoid cystic carcinoma is a relatively rare tumour which arises in the parotid and submandibular salivary glands. Initial management is surgical, often with post-operative radiotherapy, but local relapse is common and distant metastasis not infrequent. Chemotherapy is generally reserved for cases where symptoms are not controlled by other means, since the tumour is slow growing and the response rate frequently disappointing. Cisplatin and 5-fluorouracil (5-FU) both show single agent activity in this disease but had not been previously investigated in combination. All patients referred for palliative chemotherapy of metastatic, symptomatic, histologically confirmed adenoid cystic carcinoma between November 1990 and February 1994 were considered for this study. The drugs were administered as follows: cisplatin 100 mg/m2 with appropriate pre- and post-hydration and 5-FU on a 4-day schedule of 1 g/m2/day. A total of 11 patients (7 male, 4 female) with median age 53 years (range 34-69) received 46 courses of chemotherapy (median four, range one to six). All patients had prior surgery and 8 had previously received radiotherapy. There were no objective responses of > 50% reduction in tumour size. 3 patients had a minor response and two progressed on treatment. The symptomatic response rate, however, was 64%, which compares favourably with other previously reported regimens. Toxicity was manageable. The median time to tumour progression was 9 months (range 0-38) and median survival was 12 months (range 1-65). This cisplatin/5-FU regimen would appear to produce a low rate of objective response but useful palliative benefits in advanced symptomatic adenoid cystic carcinoma. Prior series suggest that a higher objective response rate may be possible with a platinum/anthracycline/fluorouracil combination, and investigation of such a regimen is warranted.

Recent experience with reconstructive surgery following major glossectomy.

In an attempt to monitor the impact of new reconstructive procedures and shifting interest away from routine preoperative radiotherapy, we have reviewed the 81 patients undergoing major glossectomy and reconstruction (MGR) at the Royal Marsden Hospital, London and Surrey, England, between 1975 and 1987. While there were four marginal and 13 major reconstructive failures, 11 of the latter were successfully managed with an alternative flap, thus providing a prompt and effective palliation for most of these patients. An evolution in our choice of reconstructive procedures as well as a recent trend toward using MGR as a primary therapeutic modality were noted. Data relating to speech following reconstruction and diet rehabilitation were encouraging, particularly with the use of the latissimus dorsi flap. Survival following MGR, however, was dismal due to early local and regional recurrence.

Study of effects of porcine skin and bovine dermis on the healing of split-skin graft donor sites in humans.

A study was undertaken of the effects of heterografts (lyophilized porcine skin or bovine dermis) on the healing of split-skin graft donor sites. When compared with a petrolatum gauze dressing, no advantages were found. Some disadvantages developed, however, which led us to discontinue their use.

Use of apron flap incision for neck dissection.

Neck dissection is one of the most commonly performed surgical procedures in the management of head and neck cancer. Different skin incisions with various modifications have been described in the literature. Three commonly used but conceptually different incisions were compared with respect to the incidence of wound dehiscence in a retrospective review. There were 166 patients with 184 neck dissections carried out using a triradiate (n = 85), modified MacFee (n = 25), or an apron flap incision (n = 74). The incidence of wound dehiscence in the three groups was 11 percent, 8 percent, and 0 percent for the triradiate, modified MacFee, and apron flap incisions, respectively. There was a statistically significant difference in the incidence of wound dehiscence between the apron flap incision and the triradiate incision groups (p = 0.004). The difference in wound dehiscence was not statistically significant between the apron flap incision and the modified MacFee incision groups (p = 0.06). Overall, there was a significant increase in the incidence of wound dehiscence in previously irradiated necks (p = 0.02), but this was significant only for the triradiate incision (p = 0.005) when analyzed individually. Comparison of triradiate, apron, and MacFee incisions did not show a statistically significant difference between the incisions with regard to other postoperative complications in terms of seroma, hematoma, wound infection, and fistula formation. The apron flap incision is the recommended approach in the presence of previous neck irradiation as it gives easier access than the MacFee incision. The robustness of the flap is because of the absence of a trifurcate point as well as a good vascular supply arising from arterial territory of the external carotid artery.

Axillary hyperhidrosis: surgical cure with aesthetic scars.

By using a technique in which the hair-bearing skin of the axilla is undermined through three small incisions the eccrine glands can be methodically removed. The resulting scarring is minimal and is aesthetically acceptable. In a series of 25 patients (50 axillae) 23 were totally cured of their hyperhidrosis. The remaining 2 patients were sufficiently improved not to require any further treatment. The technique may be undertaken under either local or general anaesthesia.

The anaesthetic management of patients undergoing free flap reconstructive surgery following resection of head and neck neoplasms--a review of 64 patients.

A retrospective study was made of 64 patients who underwent free flap reconstructive surgery following resection of neoplasms, mainly in the head and neck region, over a period of approximately 4 years, from 1983 to 1987, in the Royal Marsden Hospital, London. A brief history of free flap surgery is presented, followed by a description of the anaesthetic technique used, and the results of the study. The various ways in which anaesthetic management may influence the results of surgery are discussed.

The successful closure of a colono-cutaneous fistula in the neck.

A case is presented of the successful closure of a colono-cutaneous fistula in the neck, which developed twenty-one years after pharyngo-laryngectomy. A pectoralis major muscle flap and a delto-pectoral skin flap were used.

Seeding of a parotid pleomorphic adenoma.

Recurrent pleomorphic adenoma of the parotid usually occurs in the distribution of the primary procedure. There are numerous reports of widespread local recurrence and a few reported cases of distant metastases. Extensive seeding throughout the entire ipsilateral neck is rare. Treatment involves a combination of radical surgery and radiotherapy. The potential for malignant transformation demands close follow-up of younger patients particularly.

The repair of defects in the head and neck region with the latissimus dorsi myocutaneous flap.

There are many different flaps available for head and neck reconstruction. The latissimus dorsi myocutaneous flap has been widely used in this unit on 80 occasions in the past three years, both as a pedicled and as a free microvascular flap following the excision of head and neck malignancy, the commonest pathology being intraoral squamous cell carcinoma. There were nine cases of complete or substantial flap loss requiring a further reconstructive procedure. Few of the patients who underwent total glossectomy suffered from overspill or aspiration and the fistula rate was low. Reference is made to the anatomy and the technique of raising this versatile flap which provides a large volume of tissue and has been particularly useful following total glossectomy when combined with a hyoid hitch.

The use of free tissue transfer in reconstruction following head and neck tumour resection.

Experience in the use of free vascularised tissue flaps in reconstruction following major head and neck resections for malignant disease has been described. The benefits of the use of free flaps are improved function and cosmesis with more rapid rehabilitation and reduced in-patient stay in a group of patients, many of whom had a limited life expectancy. The disadvantages of this technique are the need for special equipment and for medical and nursing staff trained and experienced in this type of work.

Aggressive cutaneous squamous cell carcinoma of the head and neck in patients with chronic lymphocytic leukaemia.

We describe multiple cutaneous squamous cell carcinomas of the head and neck in five patients with chronic lymphocytic leukaemia (CLL). When associated with CLL, cutaneous squamous cell carcinomata behave in a much more aggressive manner than otherwise expected. Four patients developed local recurrence after primary treatment. All five patients developed lymph node metastases containing squamous cell carcinoma. Three of five patients (60 per cent) had multiple primary lesions. Whereas the increased incidence of second cancers in CLL and notably of skin cancers is documented, little has been written to describe the aggressive behaviour of these tumours. It is important, when treating these patients, to be aware of the high tendency towards local recurrence and lymph node metastasis and to consider an aggressive management plan and careful follow-up.

Malignant triton tumour of the palate--a case report.

The malignant Triton tumour is a malignant schwannoma with rhabdomyoblastic differentiation. This is the first report of this type of rare, aggressive sarcoma arising in the maxilla and only the third report of this type of pathology arising outside the context of von Recklinghausen's disease. Aspects of clinical and histopathological diagnosis are mentioned.

Pre-auricular full-thickness skin grafts.

The use of the pre-auricular region as a donor site for full-thickness skin grafts is described. It provides a valuable source of skin for the medial canthal-nose, eyelid-cheek areas, providing a good colour and texture match.

Free flaps in head and neck reconstructive surgery: a review of 77 cases.

Recent advances in surgical technique and instrumentation have ensured that success rates for microvascular free transfer can now exceed 90%. This paper reviews a prospective study of 77 free flaps performed at the Royal Marsden Hospital under the care of one surgeon (NMB) over a 2-year period. 76 patients who underwent 77 free flaps were studied. 68 patients had malignant tumours and 8 had benign lesions. The flap success rate was 95% and the mortality rate 0%. The major complication rate was 20% and the most common complication was a salivary fistula (12%). Microvascular free transfer to the head and neck is not associated with increased morbidity and mortality. It offers single stage, reliable, effective reconstruction using a wide variety of donor sites and tissues.

Omental transfer in acute and chronic sternotomy wound breakdown.

Median sternotomy is complicated by deep infection in 1-5% of cases. Internal mammary artery grafting (especially bilateral) may increase incidence and severity. Mediastinitis accompanied by sternal necrosis has a reported mortality up to 30%. The defect resulting from removal of dead bone requires reconstruction and skin cover. Twelve patients are presented in whom this defect was abolished by omental transposition. There were no deaths. Seven had chronically infected wounds (median time to operation 100 days) with very large defects following multiple debridements resulting in total sternectomy; these were treated by omental transposition and meshed split-skin grafting. Five were treated 'acutely' (median time to operation 28 days p less than 0.02) using smaller omental flaps and direct myocutaneous closure, despite total sternectomy being required in 4. One was bleeding from an infected aorto-saphenous anastomosis following povidone-iodine irrigation. Median total hospital stay in the acute group was 49 vs. 82 days in the chronic group (p less than 0.01) who also had 4 major complications (p NS). All wounds healed but further surgery was required to stabilise the chest wall in 1 of the 'Chronic' group. It is concluded that for severe sternal infection early radical removal of necrotic tissue, omental transposition, and direct closure reduces morbidity and hospital stay. In one patient bleeding from a septic aortic erosion we consider the procedure to have been life-saving.