Perforated esophageal intervention focus (PERF) study: a multi-center examination of contemporary treatment.

The treatment of esophageal perforation (EP) remains a significant clinical challenge. While a number of investigators have previously documented efficient approaches, these were mostly single-center experiences reported prior to the introduction of newer technologies: specifically endoluminal stents. This study was designed to document contemporary practice in the diagnosis and management of EP at multiple institutions around the world and includes early clinical outcomes. A five-year (2009-2013) multicenter retrospective review of management and outcomes for patients with thoracic or abdominal esophageal perforation was conducted. Demographics, etiology, diagnostic modalities, treatments, subsequent early outcomes as well as morbidity and mortality were captured and analyzed. During the study period, 199 patients from 10 centers in the United States, Canada, and Europe were identified. Mechanisms of perforation included Boerhaave syndrome (60, 30.1%), iatrogenic injury (65, 32.6%), and penetrating trauma (25, 12.6%). Perforation was isolated to the thoracic segment alone in 124 (62.3%), with 62 (31.2%) involving the thoracoabdominal esophagus. Mean perforation length was 2.5 cm. Observation was selected as initial management in 65 (32.7%), with only two failures. Direct operative intervention was initial management in 65 patients (32.6%), while 29 (14.6%) underwent esophageal stent coverage. Compared to operative intervention, esophageal stent patients were significantly more likely to be older (61.3 vs. 48.3 years old, P < 0.001) and have sustained iatrogenic mechanisms of esophageal perforation (48.3% vs.15.4%). Secondary intervention requirement for patients with perforation was 33.7% overall (66). Complications included sepsis (56, 28.1%), pneumonia (34, 17.1%) and multi-organ failure (23, 11.6%). Overall mortality was 15.1% (30). In contemporary practice, diagnostic and management approaches to esophageal perforation vary widely. Despite the introduction of endoluminal strategies, it continues to carry a high risk of mortality, morbidity, and need for secondary intervention. A concerted multi-institutional, prospectively collected database is ideal for further investigation.

Serum calcitonin after pentagastrin stimulation in patients with bronchogenic and breast cancer compared to that in patients with medullary thyroid carcinoma.

Serum immunoreactive calcitonin (iCT) was measured in the peripheral blood of 29 normocalcemic patients with bronchogenic carcinoma of various pathological types and nine patients with breast cancer before and after pentagastrin stimulation. These results were compared to those found in 22 normal subjects and 30 patients with histologically proven medullary carcinoma of the thyroid. Our results revealed that 1) serum iCT levels may be abnormally high in all pathological types of bronchogenic carcinoma and in patients with breat cancer; 2) the basal level of serum iCT may be normal, but it is abnormally high after pentagastrin stimulation; 3) the increment rise of iCT after pentagastrin stimulation in the bronchogenic and breast cancer patients was significantly less than that seen in patients with medullary carcinoma of the thyroid (P less than 0.001).

Pulmonary sequestration.

Pulmonary sequestration is a congenital anomaly in which an aberrant systemic artery arising from the thoracic or upper abdominal aorta supplies part of the lungs, usually the lower lobe. The sequestered lung may be anatomically distinct from the remainder of the lobe (extralobar), or may be included in the substance of the lobe, in which case it may or may not have bronchial communication with the rest of the bronchial tree. The patients present, often in the first two decades of life, with recurrent and severe bronchopulmonary infections. Associated anomalies are present, especially in the extralobar variety. Nine cases of sequestration are reviewed, stressing significant clinical, radiological, and arteriographic findings. Preoperative demonstration of the anomalous vessel by aortography has contributed significantly to the planning and safety of the surgical procedure, which was generally a lower lobectomy. Eight out of nine patients survived the procedure.

Congenital mitral stenosis.

This report presents a 15 year review of the surgical treatment of 9 patients with congenital mitral stenosis seen at the Columbus Children's Hospital. The over-all mortality rate was 45 per cent. Seven patients had associated lesions, mostly coarctation of the aorta and patent ductus arteriosus. In the planning of the operative procedure, distal obstructive lesions of the left heart should generally be relieved first. The mitral valve should be explored with the use of cardiopulmonary bypass and the anatomic type of the valve determined. Type I valves will often respond to open valvulotomy, whereas Type II and III valves must be replaced.

The role of preoperative mesenteric arteriography in colon interposition.

In a series of mesenteric arteriograms, the marginal artery in the right colon was present in six of 20 studies (30 percent); in the left colon it was present in all of the 20 cases studied (100 percent). Such preoperative knowledge of the vascular pattern permits the surgeon to choose a suitable segment of bowel for successful colon interposition and assists him in shortening the operative time. When this information was applied in 19 consecutive left colon interpositions, only one major suture line dehiscence in the neck was encountered (5.3 percent).

Primary intratracheal neurilemoma.

We report a case in a 38-year-old white woman of a benign primary intratracheal neurilemoma that recurred 12 years after an initial endoscopic excision. Of the 12 intratracheal neurilemomas that have previously been reported, all occurred in white persons in an age range of 6 to 71 years and most were located in the lower trachea and produced symptoms of cough and wheezing.

Isolated traumatic aortic valvular insufficiency with rapid pulmonary deterioration. Report of two cases.

Blunt trauma followed by aortic valvular insufficiency occurs rarely. Valve replacement or repair has most often taken place several months or years after injury; only a few cases have been reported of acute operative intervention performed within a few days after injury. However, we herein report two cases of isolated aortic valvular trauma in young men, in whom fulminant pulmonary edema ensued so rapidly that urgent aortic valve replacement was necessitated within hours after injury.

Comparison of biopsy-proven Pneumocystis carinii pneumonia in acquired immune deficiency syndrome patients and renal allograft recipients.

Pneumonia unresponsive to antibacterial agents in patients with acquired immune deficiency syndrome (AIDS) has become a new indication for lung biopsy. In 14 patients, transbronchial or open-lung biopsy demonstrated Pneumocystis carinii. An additional 12 patients, who were immunosuppressed after renal transplantation, were seen with P. carinii pneumonia. The diagnosis was established by transbronchial biopsy in the majority of patients. All patients were treated initially with trimethoprim plus sulfamethoxazole. Pentamidine was added after diagnosis if improvement did not occur. Both groups demonstrated reversal in the T cell helper: suppressor ratio. We compared these two groups of immunocompromised patients with respect to clinical presentation, lung pathology, response to therapy, and survival. Patients with AIDS were seen with a two- to three-week prodrome of fever, lymphadenopathy, weight loss, and malaise followed by hypoxia and leukopenia within 12 hours. Transplant patients became acutely ill with fever and hypoxia within 24 to 36 hours. In both groups, chest roentgenogram showed bilateral diffuse infiltrates; sputum cultures were generally negative; and lung biopsy demonstrated Gomori-Jones periodic acid-methenamine-silver-positive P. carinii. Mortality was substantially higher in patients with AIDS (50% versus 8%). This difference may be explained by the fact that the T cell defect in AIDS has an infectious cause, while the defect in the renal allograft recipient is pharmacologically mediated.

Cerebral Ischemia during carotid endarterectomy with severe but reversible changes.

Electroencephalographic monitoring of a patient during carotid endarterectomy demonstrated severe ipsilateral voltage suppression with preservation of rhythms when the common carotid artery was clamped. Because the atheromatous plaque extended almost to the base of the skull, it was impossible to insert a shunt. Occlusion time was 19 minutes. After carotid flow was re-established, there was a rapid recovery of voltage. The patient awoke with a profound hemiparesis, but this cleared almost completely within a week. The EEG changes indicated severe ischemia, but, though function was transiently impaired, there was no apparent cerebral necrosis. This case represents the most severe yet reversible episode of ischemia during carotid clamping reported to date. Preservation of EEG rhythms, even in the face of voltage suppression, may have been a favorable sign.

Solitary fibrous tumour presenting as a pedunculated lung mass with associated lung atresia: report of a case.

This case report describes a solitary fibrous tumour presenting as a pedunculated mass arising from an almost completely atretic right middle lobe of lung. The intraoperative findings and pathologic diagnostic criteria used are described. To our knowledge, this is the first case report of a solitary fibrous tumour associated with partial lung atresia.

Intrathoracic esophageal perforation with the Angelchik antireflux prosthesis: report of a new complication.

Esophageal perforation associated with migration of an Angelchik antireflux prosthesis into the thorax is reported. After initial nonoperative management, this patient was treated by an esophagogastrectomy with a favorable outcome. The complications associated with this prosthesis are reviewed briefly.

The contribution of surgery to the management of carcinomatous pulmonary metastases.

The presence of carcinomatous pulmonary metastases is a common clinical problem viewed by many physicians as beyond the realm of definitive surgical considerations. However, a number of patients dying with pulmonary metastases will have the totality of their disease confined to the lungs. In this select population, there is some potential for long term control or effective palliation through aggressive surgical management. This study quantitatively assesses the value of surgery in this setting and examines the prognostic effect of several important clinical variables. A single set of criteria were adhered to in the selection of patients. Cases were stratified in accordance with the intent of surgery, namely, 1) complete control and ablation of all known disease, or 2) reduction of total tumor burden to examine the possibilities for enhanced control by adjunctive therapeutic modalities.

Heparin-induced thrombocytopenia: association with a platelet aggregating factor and arterial thromboses.

Eleven patients with heparin-induced thrombocytopenia were studied. Thrombocytopenia appeared 3-16 days following the initiation of prophylactic or therapeutic doses of heparin. The mean lowest platelet count recorded was 48,000/mm3. When heparin was stopped, recovery from thrombocytopenia began within 24 hours and was complete by ten days. Two patients developed fatal thromboses, and two others had myocardial infarctions while thrombo-cytopenic. In the serum of seven patients, including three of the four with arterial thrombosis, a heparin-dependent platelet aggregating factor was present. The factor caused release of platelet 14C serotonin but did not lyse platelets. It was present in the globulin fraction of all positive sera, and in one serum studied it was isolated in the IgG/IgA immunoglobulin fraction. The factor was not present in 16 normal sera or in the sera of 15 nonthrombocytopenic patients receiving heparin. Our observations suggest that heparin-induced thrombocytopenia is common and that, in some patients it may be accompanied by severe arterial thrombosis. In vivo platelet aggregation is a possible explanation for the thrombocytopenia and the thrombosis in this disorder.

Intravenous hyperalimentation as an adjunct to colon interposition for carcinoma of the esophagus.

Ten consecutive malnourished patients with undifferentiated squamous cell carcinoma of the esophagus underwent operation for colon interposition. They received intravenous hyperalimentation preoperatively and/or postoperatively for an average time of 21.5 days and had an average weight gain of 6.5 lb. There was no significant gastrointestinal morbidity, but one patient succumbed to aspiration pneumonia. All ten patients had postoperative gastrografin swallow radiography which showed no leaks in either anastomosis. With proper use of intravenous hyperalimentation, morbidity and mortality following colon interposition in the malnourished patient for either palliative or curative bypass can be decreased to acceptable levels.