Barbed reposition pharyngoplasty (BRP) for OSAHS: a feasibility, safety, efficacy and teachability pilot study. "We are on the giant's shoulders"

A new palatal procedure for snoring/obstructive sleep apnea (OSA) is described. The procedure was named as barbed reposition pharyngoplasty (BRP). The technique is described step by step. The new surgical technique was carried out in ten adult OSA patients with mean age of 53.4 ± 12.4 years (average 30-70) with confirmed retropalatal obstruction. In this pilot study; we assessed the feasibility by calculating the number of cases that failed to be operated and converted to other palatal technique during the same surgical setting, safety was assessed by evaluating both intra-operative and post-operative complications, teachability measured by the learning curve of our team members (the time of surgical procedure). In this study, the technique is proved to be feasible in all cases. There were no significant intra-operative or post-operative complications. Objective clinical improvement was confirmed by polysomnography 6 months post-operative with significant decrease in mean AHI from 43.65 ± 26.83 to 13.57 ± 15.41 (P = 0.007), daytime sleepiness assessed by Epworth Sleepiness Scale from 11.6 ± 4.86 to 4.3 ± 2 (P < 0.01), ODI from 44.7 ± 27.3 to 12.9 ± 16.3 (P = 0.004). Operative time decreased over the course of the study with an initial steep ascent in technical skill acquisition followed by more gradual improvement, and a steady decrease in operative time to as short as 20 min. Our preliminary results suggest that BRP technique is feasible, safe and effective in management of OSA patients. Moreover, it is easy to learn even for not experienced surgeons, less time consuming and with no significant complications.

European position paper on drug-induced sedation endoscopy (DISE)

BACKGROUND

Although drug-induced sedation endoscopy (DISE) represents the most widespread diagnostic tool for upper airway endoscopic evaluation of snoring and obstructive sleep apnea hypopnea syndrome (OSAHS), many controversies exist about how to perform the sedation, the indications for DISE, and how to report DISE findings. The present position paper reports on a consensus as proposed by a group of European experts in the field of DISE after discussion during a recent dedicated meeting.

METHODS

The authors have evaluated all the available evidence reported in the literature and have compared experience among various departments in leading European centers in order to provide a standardization of the DISE procedure and an in-depth insight in the main aspects of this technique.

RESULTS

A proposal of the DISE procedure standardization has been achieved with a general agreement concerning the terminology, indications, contraindications, required preliminary examinations, setting, technical equipment required, staffing, local anesthesia and nasal decongestion, patient positioning, basis and special diagnostic maneuvers, and the applied sedation drugs and observation windows. Otherwise, no consensus has been reached on a scoring and classification system.

CONCLUSIONS

Although consensus has been reached on several aspects of the DISE procedure, some topics remain open to future research, such as a better analysis of the importance of positional aspects during DISE and a further comparison of the differences in degree, level and pattern of upper airway collapse observed during DISE versus during natural sleep and awake endoscopy. Finally, a universally accepted scoring and classification system is lacking.

Clinical outcomes and complications associated with TORS for OSAHS: a benchmark for evaluating an emerging surgical technology in a targeted application for benign disease

BACKGROUND

The aim of this study was to create benchmarks for evaluating clinical outcomes and complications of transoral robotic surgeries (TORS) in a multicenter setting.

METHODS

243 TORS for obstructive sleep apnea/hypopnea syndrome (OSAHS) operations, carried out between 2008 and 2012, were analyzed at 7 different centers. The average hospitalization was 3.5 days. The mean patient age was 50 ± 12 years, the average BMI at the time of the procedure was 28.53 ± 3.87 and the majority of the patients were men (81%).

RESULTS

The mean preoperative and postoperative apnea/hypopnea index was 43.0 ± 22.6 and 17.9 ± 18.4, respectively (p < 0.001). The mean preoperative and postoperative Epworth Sleepiness Scale score was 12.34 ± 5.19 and 5.7 ± 3.49, respectively (p < 0.001). The mean pre- and postoperative lowest O2 saturation was 79.5 ± 8.77 and 83.9 ± 6.38%, respectively (p < 0.001).

CONCLUSIONS

Patients undergoing TORS as part of a multilevel approach for the treatment of OSAHS have a reasonable expectation of success with minimal long-term morbidity.

Combined transoral robotic tongue base surgery and palate surgery in obstructive sleep apnea-hypopnea syndrome: expansion sphincter pharyngoplasty versus uvulopalatopharyngoplasty

BACKGROUND

Transoral robotic surgery (TORS) for obstructive sleep apnea-hypopnea syndrome is a relatively young technique principally devised for managing apneas in the tongue base (TB) area and supraglottic larynx. This procedure is included in the so-called "multilevel surgery" often including a palatal and nasal surgery.

METHODS

We carried out a retrospective analysis in order to understand in detail the relative impact on apneas of the 2 different procedures carried out in the palate area (expansion sphincter pharyngoplasty and uvulopalatopharyngoplasty). We evaluated 2 groups, each of 12 cases, which were sorted according to the primary selection criteria of statistically comparable preoperative apnea-hypopnea index (AHI), sex, age, body mass index (BMI), and volume of removed TB tissue.

RESULTS

Postoperative AHI registered was of 9.9 ± 8.6 SD for the expansion sphincter pharyngoplasty group and 19.8 ± 14.1 SD for the uvulopalatopharyngoplasty group.

CONCLUSION

As the palate component of our multilevel procedure, expansion sphincter pharyngoplasty, including conventional nose surgery and robotic surgery, seems to be superior to uvulopalatopharyngoplasty.

Awake versus sleep endoscopy: personal experience in 250 OSAHS patients

Identifying the site of obstruction and the pattern of airway change during sleep are the key points essential to guide surgical treatment decision making for Obstructive Sleep Apnoea-Hypopnoea Syndrome in adults. In this investigation, 250 cases were retrospectively analyzed in order to compare the pharyngolaryngeal endoscopic findings detected in the awake state, with those obtained in drug-induced sedation, by means of the Sleep Endoscopy technique. All endoscopic findings have been classified according to the semi-quantitative NOH staging. The awake and sedation NOH resulted identical in 25% of the cases only, while the discrepancies involved the oropharyngeal and hypopharyngeal sites, respectively in about 33% and 50% of the patients. The laryngeal obstructive role detected during sedation in almost 33% of the cases was both unforeseen and relevant, with all the consequent implications in the treatment choices particularly for the surgical cases.

Surgery vs ventilation in adult severe obstructive sleep apnea syndrome

BACKGROUND AND PURPOSE

Management of severe obstructive sleep apnea-hypopnea syndrome (OSAHS) is challenging and needs multidisciplinary cooperation. Ventilation is considered the gold standard of treatment in severe OSAHS. The aim of the study was to compare the therapeutical efficacy of a type of surgery (maxillomandibular advancement [MMA]) vs a ventilatory treatment modality (autotitrating positive airway pressure [APAP]).

MATERIALS AND METHODS

At the ENT Department of Forlì Hospital (University of Pavia), in strict cooperation with the Sleep Lab of the University of Bologna, a prospective randomized controlled trial was designed and performed. After fully informing them, 50 consecutive patients who have severe OSAHS were enrolled and randomized into a conservative (APAP) or surgical (MMA) section. Demographic, biometric, polysomnogram (PSG) and Epworth Sleepiness Scale profiles of the 2 groups were statistically not significantly different.

RESULTS

One year after surgery or continuous APAP treatment, both groups showed a remarkable improvement of mean Apnea-Hypopnea Index (AHI) and Epworth Sleepiness Scale levels; the degree of improvement was not statistically different.

CONCLUSIONS

Given the relatively small sample of subjects studied and the relatively brief follow-up, MMA proved to be a valuable alternative therapeutical tool in our adult and severe OSAHS patient group, with a success rate not inferior to APAP.

Hyoidthyroidpexia as a treatment in multilevel surgery for obstructive sleep apnea

CONCLUSION

This type of surgery is effective in patients with obstructive sleep apnea syndrome (OSAS), but may not be effective in obese patients or those with a preoperative apnea hypopnea index (AHI)>35. For these reasons, the careful study and selection of patients is fundamental in the surgical treatment of OSAS.

OBJECTIVES

Evaluation of the efficacy of hyoid surgery combined with oropharynx and nose surgery in the treatment of OSAS.

SUBJECTS AND METHODS

A total of 109 OSAS patients underwent hyoidthyroidpexia as a treatment in multilevel surgery. Before surgery all patients were treated with continuous positive airway pressure (CPAP) therapy for at least 6 months and underwent preoperative and postoperative polysomnography. The preoperative examination was composed of upper airways endoscopy, lateral cephalometric radiograph, calculation of body mass index (BMI), and subjective analysis of daytime sleepiness.

RESULTS

In all, 67/109 patients (61.5%) with postoperative AHI<20 were defined as 'responders', while the other 42 patients (38.5%) were defined as 'non-responders'. The correlation between preoperative BMI and postoperative AHI revealed that non-responders had a much higher average BMI compared with responders. Moreover, when analyzing median preoperative and postoperative AHI, it emerged that non-responders had a much higher preoperative AHI compared with responders.

The METIS project for generalist ultrasonography

Reorganization of the community healthcare system and the growing presence of group practices in the field of general medicine have increased the demands placed on primary-care medicine, in terms of the skills required and the level of responsibility. Satisfying the need for rapid, effective primary-care solutions to the health problems of citizens is easier thanks to technological and medical advances that provide high level equipment at costs within the reach of general practitioners (GPs). In the near future, trained GPs equipped with appropriate diagnostic scanners will be able to handle up to 40% of the requests of ultrasound examinations of each primary-care group (each PCG includes approximately 15,000-20,000 citizens). The Italian Federation of General Practitioners (Federazione Italiana dei Medici di Medicina Generale - FIMMG) and its Scientific Society, METIS, have organized national courses for those GPs who wish to become generalist ultrasonographers, in a joint effort with the two most important Italian scientific societies of imaging, the Italian Society of Ultrasonology in Medicine and Biology and the Italian Society of Medical Radiology.

Sleep-related stridor due to dystonic vocal cord motion and neurogenic tachypnea/tachycardia in multiple system atrophy

Sleep-disordered breathing and sleep-related motor phenomena are part of the clinical spectrum of multiple system atrophy (MSA). Stridor has been attributed to denervation of laryngeal muscles or instead to dystonic vocal cord motion. We studied 3 patients with nocturnal stridor in the setting of MSA. All patients underwent nocturnal videopolysomnography (VPSG) with breathing and heart rate, O(2) saturation and intra-esophageal pressure recordings, and simultaneous EMG recordings of the posterior cricoarytenoid, cricothyroid, and thyroarytenoid muscles and continuous vocal cord motion evaluation by means of fiberoptic laryngoscopy. VPSG/EMG and fiberoptic laryngoscopy documented normal vocal cord motion without denervation during wake and stridor only during sleep when hyperactivation of vocal cords adductors appeared in the absence of significant O(2) desaturation. All patients had tachycardia and tachypnea and paradoxical breathing during sleep, erratic intercostalis and diaphragmatic EMG activity and Rem sleep behavior disorder. One of the patients had restless legs syndrome with periodic limb movement during sleep and excessive fragmentary hypnic myoclonus. In conclusion, our patients with MSA had nocturnal stridor due to sleep-related laryngeal dystonia. Stridor was associated with other abnormal sleep-related respiratory and motor disorders, suggesting an impairment of homeostatic brainstem integration in MSA.

Human immunodeficiency virus infection: personal experience in changes in head and neck manifestations due to recent antiretroviral therapies

Both the incidence and prevalence of human immunodeficiency virus infection are increasing in the world. Diseases of ENT districts are more frequent in human immunodeficiency virus-infected patients and involve all the otolaryngological sites. The otorhinolaryngological manifestations in association with HIV infection are mainly atypical, so common in the clinical practice, really aspecific and very frequent in ENT daily routine (such as sinusitis, otitis, etc.) and, therefore, immunodeficiency may not be suspected. In other cases, ENT evidence is more peculiar or unusual, such as opportunistic infections, rare neoplasm and tumours with an unusual course, giving a very high suspect of a human immunodeficiency virus-related infection. The most frequent malignant neoplasm is Kaposi's Sarcoma which is extremely rare in non-human immunodeficiency virus-infected subjects; the second most frequent is non-Hodgkin's lymphoma with 50% in extranodal sites (oral and maxillary sinus). Following a review of the literature, modifications caused by current antiretroviral treatment on head and neck manifestations of human immunodeficiency virus infection have been evaluated. Highly active antiretroviral therapy is a new therapeutic strategy, based on poly-chemo-therapeutic schemes, providing simultaneously two or more anti-retroviral drugs. We have used highly active antiretroviral therapy in human immunodeficiency virus infection since 1997, substituting previous mono-chemotherapy based on Zidovudine or Didanosine alone. Highly active antiretroviral therapy is extremely efficient in reducing the viral load of human immunodeficiency virus and increasing CD4+ T-lymphocyte count. These biological effects are associated with an improvement in immune functions. To evaluate the effects of highly active antiretroviral therapy on otorhinolaryngological manifestations in human immunodeficiency virus infection, we performed a retrospective study on 470 adults, observed over 14 years (1989-2002) and constantly receiving the same treatment, with follow-up from 7 to 80 months. A total of 250 subjects underwent mono-antiretroviral chemotherapy (1989-1996), while 220 underwent highly active antiretroviral therapy (1997-2002). The results of the retrospective study showed that highly active antiretroviral therapy has greatly improved the control of the immune-deficiency (increasing the range of CD4+), reducing the number of otorhinolaryngological manifestations (also tumours). On the other hand, 2 patients presented sudden unilateral hearing loss following treatment: toxicity due to association of new drugs cannot be excluded.

Role of skin-lined tracheotomy in obstructive sleep apnoea syndrome: personal experience

Permanent tracheotomy was the first surgical procedure proposed for the treatment of severe obstructive sleep apnoea syndrome and is still the only surgical option that ensures, even in very severe cases, complete elimination of apnoea and, in turn, clinical remission. Improved knowledge of the causes of obstructive sleep apnoea syndromes and the increasing therapeutic options (instrumental, medical and surgical) have resulted in cases requiring tracheotomy as the only indispensable therapeutic option becoming more rare. At present, the only indications are in very occasional conditions of life-threatening obstructive sleep apnoea syndromes and in patients on whom continuous positive airway pressure is not tolerated or is not effective (severe deoxygenation or hypercapnia, severe respiratory disorder index, severe obstructive sleep apnoea syndrome-related arrhythmias, severe excessive daytime sleepiness, heart diseases or ischaemic encephalopathy exacerbated by obstructive sleep apnoea syndromes, obstructive pneumopathy exacerbated by obstructive sleep apnoea syndromes, severe obstructive sleep apnoea syndromes with few chances of resolution with other surgical procedures or failure of the latter). Moreover, it is the only therapeutic solution in rare nocturnal laryngeal stridor due to multisystemic atrophy (in which obstructive sleep apnoea syndrome is due to nocturnal laryngospasm of neurologic origin). Therapeutic tracheotomy must be permanent (tracheostomy) and, therefore, preferably carried out with a specific technique (skin-lined tracheotomy), able to guarantee greater stability, less risk of granulation tissue, wider opening of the tracheostomy, sufficient reversibility. In our experience, very few patients (10 cases) withsleep disorder breathing have been submitted to skin-lined tracheotomy. Of these, the majority were submitted to surgery for severe apnoea due to nocturnal laryngospasm on account of multisystemic atrophy (n = 7), while only 3 cases of obstructive sleep apnoea syndromes were submitted to skin-lined tracheotomy, i.e., 0.7% of the 424 patients operated on for obstructive sleep apnoea syndrome and 1.7% of the 175 operated on for severe, or very severe, obstructive sleep apnoea syndromes (RDI > 40). Skin-lined tracheotomy was not followed by important complications and expected results were achieved with immediate disappearance of daytime symptoms and considerable improvement in nocturnal apnoea. Besides sleep-related disorders, numerous clinical situations with indications for a permanent tracheotomy may benefit from the skinlined technique, such as severe laryngeal or tracheal stenoses, laryngeal diplegias, miasthenia gravis, lateral amyotrophic sclerosis, intractable aspiration, severe emphysema.

Temporary tracheotomy in the surgical treatment of obstructive sleep apnea syndrome: personal experience

Aim of the study is a retrospective analysis on the use of temporary tracheotomy in our snoring surgery experience. From September 1996 to April 2002, 1103 snoring surgery procedures have been carried out on various sites of the upper airways in 530 patients (mean age 50 years, 81% males) prevalently related to severe Obstructive Sleep Apnea Syndromes (33%). Of these patients, 472 (89%) were operated upon under general anaesthesia, whereas 58 (11%) received local anaesthesia. Of the 472 patients operated upon under general anaesthesia, 17 (3.6%) underwent temporary tracheotomy, which in 10 (2.1%) were programmed and only in 7 (1.5%) were non-programmed, having been performed in 2 cases in an emergency setting, in 3 cases in an urgency setting due to respiratory obstruction immediately after removal of intubation and in 2 cases in conditions of urgency, due to respiratory obstruction occurring during post-operative hospitalisation (both performed within 6 hours of regaining consciousness). The only complication observed was a brief laryngeal diplegia, a complication, moreover, not reported in the literature. No criteria exist concerning indications for temporary tracheotomy programmed according to the type of surgery on the hypopharynx; personal experience reveals that: a) temporary tracheotomy is frequently necessary after genioglossus advancement (3/10 operated upon for genioglossus advancement not associated with a programmed temporary tracheotomy); b) temporary tracheotomy is rarely necessary after hyoid suspension (1/98 patients being submitted to hyoid suspension not associated with programmed temporary tracheotomy). Temporary tracheotomy should, in our opinion, be taken into consideration in snoring surgery techniques, particularly in the presence of the not infrequent urgency or emergency situations occurring in patients with Obstructive Sleep Apnea Syndromes. With the use of temporary tracheotomy, no deaths occurred in the present study population.

[Semont maneuver vs. particle repositioning maneuver: comparative study]

In the present study 80 consecutive cases of PPV of the posterior semicircular canal are presented, with the purpose to evaluate the effectiveness of the treatment and to analyze the secondary Ny and re-test as indicators of the effectiveness of the therapeutic maneuver. The patients were treated in 40 cases with Particle Repositioning Maneuver (PRM) and in the other 40 with the Semont Maneuver, in an attempt to determine the secondary Nystagmus induced during treatment and any residual Paroxysmal Positional Nystagmus (PPNy) upon repetition of the Hallpike positioning after 15 minutes (re-test). Recovery was achieved in 80% of cases after the first session and in 95% of cases with the third session. PRM seemed to be slightly more effective. Secondary liberating Ny was frequently evoked (80%) and was reliable (75%) with the Semont Maneuver, while PRM yielded the liberating Ny in only 25% of cases, with lower reliability (70%). Reliability of the re-test with the Hallpike maneuver was high (80%) and the difference between the two techniques was negligible (78% in PRM and 85% in Semont). In conclusion, in terms of indicators of effectiveness, the Semont liberating Maneuver appears better in that it combines high therapeutic effectiveness (75% recovery in a single session) with a like percentage of liberating Ny (80%): this makes it possible to reserve the re-test and repetition of the therapeutic maneuver, performed during the same session, only in those cases that do not present liberating Ny (20% of cases). On the other hand, when the PRM is used, it appears better to rely on the high likelihood of effectiveness (85% in a single session) and then review the case directly at the next check-up rather than perform the Hallpike re-test in all cases that did not present the liberating secondary Ny (75%). In this way it is possible to select a small number of patients (22%) that still show PPNy (positive re-test) and for whom the therapeutic maneuver must be repeated.

Long-term effects of a nationwide control program on the seropositivity for Trypanosoma cruzi infection in young men from Argentina

Unselected nationwide cohorts of Argentine men 18 years of age summoned for military service were tested for antibodies to Trypanosoma cruzi each year from 1981 to 1993. After an initial screening using indirect hemagglutination test, the positive sera were retested by titrated indirect hemagglutination and immunofluorescence antibody tests at 39 laboratories or at the national reference center in Buenos Aires. Nearly 1.8 million men were examined for T. cruzi antibodies using the same standardized procedures under a quality assurance program. The prevalence of seropositivity for T. cruzi decreased significantly from 5.8% in 1981 to 1.9% in 1993, but the decrease was not homogeneous among provinces within each region or constant over time. Prior to the nationwide control campaign initiated in 1961-1962, 15 provinces had high (> 20%) percentages of houses with domiciliary infestation by Triatoma infestans bugs, which decreased to nine provinces in 1982, and four provinces in 1992. The observed decrease in the prevalence of seropositivity for T. cruzi may be mostly attributed to the spraying with insecticides to eliminate the domiciliary populations of Triatoma infestans. The lack of a sustainable triatomine surveillance program set a limit to the decrease of seropositivity rates and prompted a revised strategy based on community participation.

[Effectiveness indices in "Particle Repositioning Maneuver" by Parnes and Price-Jones]

The Parnes and Price-Jones "Particle Repositioning Maneuver" (PRM) was used to treat Paroxysmal Positional Vertigo (VPP) in 36 consecutive cases, studying both any induced secondary nystagmus and any persistent Paroxysmal Positional Nystagmus (PPNy) upon repetition of the Hallpike positioning after 15 minutes (re-test). The purpose of the study was to evaluate the ability to use secondary Ny and the retest to predict maneuver effectiveness. Although the PRM was quite effective (PPNy disappeared in 86% of the cases after a single session), the low observation frequency reduced the feasibility of using secondary Ny. On the other hand the systematic introduction of the Hallpike re-test into clinical practice does not offer the desired cost/benefit ratio because of the time required to prevent false negatives due to PPNy fatigue. In fact, secondary Ny was only evoked in 12 out of 36 cases (33%) and of these only 9 out of 36 (25%) presented direction congruous with canalolith release (liberating Ny). The predictive value of evoked liberating Ny appeared further reduced by the persistence of PPNy upon subsequent re-testing in two cases and in one case by the persistence of the disorder upon follow-up. The Hallpike test appears a more reliable indicator of effectiveness as it proved in agreement with subsequent clinical findings in 80% of the cases. The present results lead one to conclude that, when using PRM in cases where no secondary liberating Ny was found (75%), we should rely on the high effectiveness of this procedure (86% of the cases resolved in a single session) rather than perform a Hallpike retest. Thus it is possible to select a small number of patients (22%) still presenting PPNy (positive retest) and requiring repetition of the therapeutic maneuver.

[Clinical features and diagnosis of mucocutaneous leishmaniasis in patients of an endemic area in Salta]

A total of 39 patients with a clinical diagnosis of mucocutaneous leishmaniasis, in an endemic area for leishmaniasis in Salta, Argentina, were examined between June 1990 and December 1992. Of these cases, 87% (34/39) presented the cutaneous simple form, 10.3% the cutaneous multiple form and 2.6% the mucosal form. Lesions were more frequently located in legs and arms (71.8%), followed by trunk and multiple location (10.3%). Of the patients, 43% were housewives, students or children, suggesting that the infection could be contracted in the domestic or peridomestic environment. Of 39 patients diagnosed, in 22 (56.4%) the parasite was found. Direct microscopy (smear) permitted a diagnosis in 13 (59.4%) of these 22 patients. Among these, 5 (22.7%) had positive diagnosis by culture, and 9 (40.9%) by inoculation in hamsters. Ten parasite isolates (45.4%) were obtained. The smear is recommended as a diagnostic method for epidemiological surveillance due to the sensibility demonstrated herein and its easy application in the endemic area. The time of clinical evolution, from the appearance of the lesion up to the detection of the patient by Sanitary Agents, was approximately 90 days. This would be related to the frequency of the visits, usually every 3 months. Only one of 30 treated patients had a relapse at 6 months, due to non fulfillment of the treatment.

Diagnostic role of videothoracoscopy in mediastinal diseases

OBJECTIVE

In order to assess the role of videothoracoscopy in the diagnosis of mediastinal diseases, we report a retrospective analysis of 52 cases of mediastinal biopsy performed with this technique.

METHODS

Between January 1992 and December 1996 52 patients (39 men and 13 women, mean age 53 +/- 29 years) with mediastinal lesions were referred to our department for videothoracoscopic biopsy. There were eight lesions in the anterior mediastinum, while the remaining 44 were in the middle (25 right and 19 left). The adenopathies were solitary or located in positions not within reach of the mediastinoscope, or combined with pulmonary nodules or diffuse pulmonary diseases.

RESULTS

The procedure was performed from the right side in 30 cases and from the left side in 22. In nine cases the complete excision of the mass was achieved. In the eight patients with pulmonary disease a wedge resection was carried out at the same time. Diagnosis was achieved in all cases of mediastinal and lung disease (100%). No conversion to open thoracotomy and no intraoperative complications occurred. The mean hospital stay after surgery was 2.3 +/- 1.3 days in the 49 (94.2%) patients with no complications. The postoperative complications consisted of one case of fatal pulmonary embolism and two cases of prolonged air leak. conclusion: This analysis shows that videothoracoscopy is an effective and reliable method of obtaining a diagnosis of solitary unilateral mediastinal lesions or of adenopathies not within reach of the mediastinoscope. In some cases it also allows the complete excision of the mass. If a procedure on the lung such as a wedge resection is needed, it can be performed at the same time. Since this is a strictly unilateral procedure, it cannot be used in routine preoperative lung cancer staging.

Leishmania (Viannia) braziliensis: biological behavior in golden hamsters of isolates from Argentine patients

This study reports intraspecific variations of native isolates of Leishmania (Viannia) braziliensis from patients with leishmaniasis from Salta, Argentina. These isolates induced skin lesions in golden hamsters, initially showing rapid development, reaching their largest size between 28 and 35 days postinfection (PI). Thereafter, the infections were self-limiting and total regression was observed at 80-150 days PI. The majority of the native isolates were characterized by low infectivity in the experimental animals, and a classic pattern of dissemination to systemic organs was established. However, unusual features for L. braziliensis were displayed by two isolates; one showed evidence of high infectivity in hamsters characterized by a short prepatent period and larger, severe and persistent lesions at the inoculation site. The other isolate, of low infectivity, showed cutaneous metastasis and recurrent systemic dissemination in the same animals, suggesting dissociation between infectivity and pathogenicity. Metastasis has been frequently described in hamsters infected with L. (V) guyanensis and L. (V) panamensis, but not in infections induced by L. (V) braziliensis, as was observed in this study. Active and/or regressive histopathologic lesions were observed, depending on the stage of the infection. An exudative and mixed inflammatory pattern with microabscesses and necrotic areas was observed during early infection, while well-defined granulomas and collagen formation were the predominant features detected at a later time. Amastigotes were easily detected in the tissues, although in low numbers. Schaumann bodies were always detected. The characterization of the unique features of these native isolates, and the verification of their reproducibility in vitro and in vivo will be useful tools in tests related to immunoprophylaxis and chemotherapy.

Chemoembolization in liver malignant involvement. Experiences on 17 cases

INTRODUCTION

Liver invasion is the major cause of organ failure in patients with primary liver cancer and metastatic large bowel cancer. Furthermore it causes high morbidity in many other carcinomas. The normal liver presents a double circulation: 75% from portal circulation and 25% from hepatic artery. In malignant primary and secondary lesions the blood support is given by hepatic artery. Antineoplastic drugs mixed to selectively injecting embolic particles, such as polyvinyl alcohol and gelatin powder (Gelfoam), can be injected to infarct tumors and to obtain a therapeutical advantage. Chemoembolization using an emulsion of Lipiodol ultra-fluid (LUF) and drugs is a recent tool in liver regional therapy. LUF has been shown to be taken up hepatocellular carcinoma and retained for a long period of time in the tumor bed. Chemoembolization causes massive shrinkage due to ischemia and increasing the local drug intensity and drug exposure. Our study reports the results of multi-agents chemoembolization (MACHEM) in 17 patients bearing massive liver involvement.

MATERIAL AND METHODS

From January 1988 we treated 17 patients (5 HCCs, 7 large bowell carcinomas, 1 gastric cancer, 1 ocular melanoma, 1 pancreas, 1 soft tissue sarcoma, 1 carcinoid) using a transfemoral approach to cannulate the celiac axis and then the hepatic artery. The catheter was advanced into the vessel responsible for the majority of the tumor blood supply and a mixture of Gelfoam, radiopaque contrast media, followed by chemotherapy (mitomycin 10 mg/sqm, cisplatin 20 mg/sqm, epirubicin 20 mg/sqm) mixed to LUF was injected until vascular stasis occurred. After chemoembolization, analgesics and anti-pyretics were administered. Liver function tests were monitored daily.

RESULTS

Objective tumor regression was observed in 11 out 15 full evaluable patients; the median duration of survival was 9.5 months. Within 8 weeks shrinkage, due to development of necrosis, appeared in the tumors. One patient with high levels of 5-HIAA due to carcinoid, demonstrated more than 75% decreasing in urinary excretion. In 6 patients out 8 with CEA elevation a clear reduction was documented as well in 2 HCCs out 5 with alfa-fetoprotein elevation.

DISCUSSION

The palliation of HCC and metastatic liver disease have been extremely disappointing. Systemic chemotherapy produces in HCC a response rate of no more than 20% and does not increase the median survival. Venook obtained 24% of PRs and liquefaction in 35 out 50 HCC treated with chemoembolization. Some results have been also demonstrated in the treatment of metastatic liver tumors by Carrasco, Daniels and Modiano. Moertel stressed that chemoembolization could be incorporated in the initial management of carcinoid. Because of the difference in chemoembolization protocols it is difficult to compare the relative efficacy of this tool, although encouraging response rates have been reported in palliation of bulky tumors. In our study Gelfoam given before LUF and antineoplastic agents mixture produce a distal arteriolar occlusion and this would facilitate the migration of the polychemotherapy emulsion toward the tumor. Our MACHEM program has been shown to have significant activity even in heavily pretreated patients with an acceptable toxicity. We conclude that hepatic arterial chemoembolization will be improved by mean of better combination of chemotherapy with embolizing agents in well selected patients.

[The correlation of bacteriobilia/wound infections in elective biliary surgery]

The authors report their experience concerning the cultural study of bile samples taken during elective biliary surgery. All the operations were carried out after a randomized preoperative antibiotic prophylaxis. Among the 138 cases examined the presence of surgical infections (wound infection) was taken into account. A lack of correlation between the germs present in the bile and those isolated from samples of complicated cases, was registered. However, the Authors emphasize that, although antibiotic prophylaxis gives a reduced percentage of postoperative infections, it is unable to sterilize the bile.

[Aztreonam and clindamycin in short-term antibiotic prophylaxis in colorectal surgery: results of a multicenter studies]

The Authors studied the effects of a short-term prophylaxis (Aztreonam + Clindamycin) administered to 259 patients operated on for colo-rectal diseases. Thirteen wound sepsis (5.15%) and 49 different infections (19.44%) occurred in this group of patients. The study confirms the link between P.N.I. greater than 50 and the incidence of wound infections. The incidence of urogenital sepsis was correlated with the catheterization period (greater than 6 days), operative time (greater than 200 min.), hospitalization (greater than 12 days) and age (greater than 70 years). General tolerance to the antibiotics was good.

[Esophago-jejunal anastomosis using an end-to-end anastomosis stapler. Clinico-radiologic study of early complications in 75 cases]

Personal experience with 75 consecutive cases of terminolaterale oesophagojejunal anastomosis by EEA Stapler is reported. A total of 6 intraoperative technical problems were encountered (8%) and consisted either of incomplete suturing of the anastomosis or stapling of the jejunal wall. Postoperative radiology revealed 5 dehiscences (6.6%) and 1 stenosis (1.33%). One patient with dehiscence died (1.33%) of septic complications. One dehiscence of the afferent jejunal stump and minor pleuropulmonary complications were observed in 3 cases. After a brief review of the literature, it is concluded that oesophagojejunal anastomosis by EEA Stapler produces a low incidence of postoperative complications such as the dehiscence, stenosis or bleeding.