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.

Retrosternal pedicled jejunum interposition: an alternative for reconstruction after total esophago-gastrectomy

OBJECTIVE

If the colon cannot be used for reconstruction after total esophago-gastrectomy, alternatives have to be sought.

METHODS

From 1990 to 2001, retrosternal jejunum loop interposition was performed in 35 patients (male/female: 29:6; mean age 59.2, range 16-83 years) due to cancer in 32 cases and to esophageal perforation in three cases. In all patients reconstruction with stomach or colon, respectively, was impossible on behalf of the underlying histology, of previous resection of the stomach and impedient colonic diseases. A jejunal segment with abundant arcades was chosen, preserving a strong, distal arteriovenous mesenteric pedicle, while 2-3 proximal mesenteric vessels were severed. The loop was pulled up retrosternally, establishing a cervical end-to-side esophagojejunostomy. A Roux-en-Y anastomosis was done in a convenient position.

RESULTS

Two patients died perioperatively due to mediastinitis and consecutive multiorgan failure (one Boerhaave's syndrome, one suicidal ingestion of acid). In one case the oral part of the loop developed venous congestion and was replaced by a free jejunal transplant. The perioperative course of 32 patients was uneventful. Seventeen patients are up and well (1-8.5 years). Sixteen patients died of metastatic disease. The functional results are satisfactory. In about 50% of patients recurrent dilatations became necessary due to anastomotic scars. However, none of the patients complained about severe dysphagia.

CONCLUSION

In cases of impedient colonic diseases, the pedicled, retrosternal jejunal loop with cervical anastomosis is an alternative for reconstruction after total esophagogastrectomy.

Management of iatrogenous esophagus perforation

OBJECTIVES

The management of patients with iatrogenous, instrumentally caused esophageal disruptions is still a controversially discussed challenge for any physician. We reviewed indications, morbidity, and mortality of esophagectomy compared to less aggressive treatment schemes in the light of our single-unit experience.

PATIENTS AND METHODS

We reviewed the cases of 38 consecutive patients suffering from iatrogenous esophageal disruption treated within the last 10 years at the University Medical School Graz.

RESULTS

Severe sepsis was diagnosed in seventeen patients; fourteen of the seventeen patients were treated by esophagectomy followed by primary or secondary reconstruction at a mortality rate of 28.6 % (four of fourteen patients). All fourteen patients thus treated had major preexisting esophageal pathologies. In three of the total seventeen cases reviewed, conservative treatment modalities were used. The mortality rate in the non-septic group treated by direct suturing (n = 21) was 4.8 % (one of twenty-one patients). Major preexisting esophageal pathology was present in thirteen. The overall mortality was 13.2 % (five of thirty-eight patients).

CONCLUSION

The strategy of primary repair for iatrogenous esophageal injury should only be adopted in patients with minor or without intrinsic esophageal disease, and in the absence of severe sepsis suggesting mediastinitis. Severe sepsis following iatrogenous esophageal trauma should prompt the decision for esophagectomy where anatomically and/or oncologically possible.

[Arterial vascular injury of the diaphragm caused by serial rib fracture]

About 10% of all trauma patients sustain rib fractures. The average age is 58. Men are more often affected than women. Hemothorax, pneumothorax, and lesions of the lung are not uncommon. Very rare are injuries of the pericardium, aorta, and subclavia caused by fractured ribs. We present a very unusual case where a broken rib caused a severe diaphragmatic hemorrhage with a hemothorax and acute hypovolemia. The primary chest X-ray was thought to be without pathology. Arterial bleeding without exact localization could be found with computed tomography. Thoracotomy revealed the correct diagnosis and the cause of bleeding.

Comparison of 5-aminolaevulinic acid and porphyrin photosensitization for photodynamic therapy of malignant bronchial stenosis: a clinical pilot study

BACKGROUND AND OBJECTIVES

Photosan, a mixture of porphyrin oligomers as sensitizer for photodynamic therapy (PDT), carry the risk of prolonged photosensitivity of the skin. New sensitizer such as 5-aminolaevulinic acid (ALA) with low rates of skin phototoxicity appear to be promising alternatives. The aim of this study was to evaluate the efficacy of ALA compared to Photosan for PDT in malignant tracheo-bronchial stenosis. Reduction of tumor stenosis, increase in quality of life, and phototoxicity were considered as primary objectives. Improvement in clinical symptoms due to reduction of tumor stenosis, for example hemotysis, dyspnea, and poststenotic pneumonia were considered as secondary objectives.

PATIENTS AND METHODS

After diagnostic work-up, photosensitization was done in 16 patients with ALA (60 mg/kg BW, oral, 6-8 hours prior to PDT) and in 24 patients with Photosan (2 mg/kg BW, i.v., 48 hours before PDT). The light dose was calculated as 100 J/cm(2) tumor length. Light at 630 nm was applied using a pumped dye laser. In both groups, additional hyperbaric oxygenation was applied at a level of 2 absolute atmospheric pressure.

RESULTS

Stenosis diameter and Karnofsky performance status showed a significant improvement in favor of the Photosan-group, P = 0.00073 and 0.00015, respectively. In both groups no sunburn occurred due to phototoxicity of the sensitizer.

CONCLUSION

Despite the limitations of a non-randomized study, photosensitization with Photosan seems to be more effective in PDT of malignant tracheo-bronchial stenosis compared to ALA.

Does new photosensitizer improve photodynamic therapy in advanced esophageal carcinoma?

BACKGROUND AND OBJECTIVE

Polyhematoporphyrin (Photosan) as sensitizers for photodynamic therapy (PDT) in advanced esophageal cancer carry the risk of prolonged photosensitivity of the skin. New sensitizers such as 5-aminolaevulinic acid (ALA) with low rates of skin phototoxicity appear to be promising alternatives. The aim of this study was to evaluate the efficacy of ALA compared to Photosan for PDT in advanced esophageal carcinoma regarding phototoxicity of the skin, reduction of dysphagia, tumor stenosis, and tumor length and Karnovsky performance status.

STUDY DESIGN/MATERIALS AND METHODS

After diagnostic work-up, photosensitization was done in 22 patients with ALA (60 mg/kg body weight, oral, 6-8 hours prior to PDT) and in 27 patients with Photosan (2 mg/kg body weight, i.v., 48 hours before PDT). The light dose was calculated as 300 J/cm fibre tip. Light at 630 nm was applied using a pumped dye laser. In both groups, additional hyperbaric oxygenation was applied at a level of 2 absolute atmospheric pressure.

RESULTS

Improvement regarding dysphagia, stenosis diameter, and tumor length could be obtained in both treatment arms with a significant difference in favour of the Photosan-group, P = 0.02; P = 0.0000; and P = 0.000014, respectively. The Karnovsky performance status also improved in both groups and showed no significant difference (P = 0.12). The median survival time for the ALA-group was 8.0 months, compared with 9.0 months for the Photosan group. No sunburn or other major treatment related complication occurred in both treatment arms. Thirty-day mortality was 0%.

CONCLUSION

Despite the limitations of a non-randomized study, photosensitzation with Photosan seems to be more effective in PDT of advanced esophageal carcinoma compared to ALA.

Photosensitization with hematoporphyrin derivative compared to 5-aminolaevulinic acid for photodynamic therapy of esophageal carcinoma

BACKGROUND

Hematoporphyrin derivatives (HpD) as sensitizers for photodynamic therapy (PDT) in advanced esophageal cancer carry the risk of prolonged photosensitivity of the skin. New sensitizers such as 5-aminolaevulinic acid (ALA) with low rates of skin phototoxicity appear to be promising alternatives. The aim of this study was to evaluate the efficacy of ALA compared with HpD for PDT in advanced esophageal carcinoma regarding phototoxicity of the skin, reduction of dysphagia, tumor stenosis and length, and Karnovsky performance status.

METHODS

After diagnostic workup, photosensitization was done in 22 patients with ALA (60 mg/kg body weight, oral, 6 to 8 hours before PDT) and in 27 patients with a hematoporphyrin derivative (2 mg/kg body weight, intravenously, 48 hours before PDT). The light dose was calculated as 300 J/cm fiber tip. Light at 630 nm was applied using a pumped dye laser. In both groups, additional hyperbaric oxygenation was applied at a level of 2 absolute atmospheric pressure.

RESULTS

Improvement regarding dysphagia, stenosis diameter, and tumor length could be obtained in both treatment arms with a significant difference in favor of the HpD group (p = 0.02; p = 0.0000; and p = 0.000014, respectively). A questionnaire of patients in the HpD group confirmed that the ability of swallowing a meal was superior compared with the discomfort from limitation to sun exposure. No sunburn or other major treatment-related complication occurred in both treatment arms.

CONCLUSIONS

Despite the limitations of a nonrandomized study, photosensitzation with HpD seems to be more effective in PDT of advanced esophageal carcinoma compared with ALA.

Successful endoscopical sealing of malignant esophageotracheal fistulae by using a covered self-expandable stenting system

OBJECTIVE

Any treatment of tracheo-esophageal fistulae in end-stage malignant stenosis of the esophagus must be weighed against associated morbidity and mortality. In a prospective study we investigated benefits and risks of the use of one type of coated, self-expandable stent.

PATIENTS AND METHODS

We treated four male and two female patients, (mean age 68.3 years, range: 38-90 years), with malignant esophago-tracheal fistula non-resectable due to advanced tumour stage and/or functional reasons. All were in a poor general condition suffering from aspiration pneumonia and malnutrition. Four out of the six patients had had one or multiple extra- or endoluminal palliative treatments at a mean interval of 191 days (range: 7 days-15 ms) since the last intervention. The fistulae were sealed by using a covered, self-expandable stent (ULTRAFLEX esophageal stent system, Microinvasive, Boston Scientific Corporation, Boston, MA).

RESULTS

Stenting did not cause any technical problems and all fistulae were successfully sealed in a one-step procedure. The median hospital stay was 4.6 days (range: 3-9 days). Except for one late stent induced recurrent fistula treated by re-stenting and tracheostomy, we did not observe any stent associated complications. Five patients died of tumour generalization. The median survival of the patients who died was 78 days (range: 35-129 days). One patient is alive and well at 120 days after stenting.

CONCLUSION

In spite of the small number of patients the results suggest that this type of stent represents a safe and efficient approach for palliative endoscopic treatment of this high risk group. Local pretreatment does not preclude the successful use of the self-expandable coated stent.

Acute effects of combined photodynamic therapy and hyperbaric oxygenation in lung cancer--a clinical pilot study

BACKGROUND AND OBJECTIVE

Photodynamic tumor therapy (PDT) is based upon a photochemical reaction that is limited by the availability of molecular oxygen in the target tissue. The use of hyperbaric oxygenation (HBO) increases the amount of oxygen available for the process may thereby enhance the efficacy of PDT. We investigated the acute effects on tumor stenosis after combined PDT/HBO.

PATIENTS AND METHODS

Thirty patients (22 males, 8 females, mean age: 68.8 years; range: 44-78 years) with inoperable non-small cell bronchogenic carcinoma and endobronchial stenosis were studied prospectively. Photosensitization was carried out using a hematoporphyrin-derivative 2 mg/kg BW 48 hours prior to PDT. The light dose was calculated as 300 J/cm fiber tip. The assessment of outcome 1 and 4 weeks after PDT/HBO was performed by endoscopy, chest X-ray, spirometry, laboratory parameters, subjective report of dyspnea, and Karnofsky performance status.

RESULTS

At one and four weeks after the treatment, the patients felt a significant improvement of dyspnea and hemoptysis along with an objective subsiding of poststenotic pneumonia, though spirometric parameters revealed no significant difference. A significant reduction of tumor stenosis (P < 0.05) and an improvement of the Karnofsky performance status (P < 0.05) were documented 1 and 4 weeks after PDT/HBO. No therapy related complications were observed.

CONCLUSIONS

Although the small number of patients does not allow to draw definitive conclusions to be drawn, the results suggests that combined PDT/HBO represents a new, safe, and technically feasible approach. It enables efficient and rapid reduction of the endoluminal tumor load and helps conditioning the patient for further treatment procedures.

Boerhaave's syndrome: a continuing challenge in thoracic surgery

BACKGROUND/AIMS

Boerhaave's syndrome accounts for 30-40% of esophageal disruption. The current literature regarding the management of these patients and problems in treatment remains controversial.

METHODOLOGY

Between 1988 and 1998, 14 patients with Boerhaave's syndrome were treated in our unit. Five primary repairs and 9 esophagectomies were performed. A retrospective review of these patients' records was carried out. The patients were divided into two groups. Group I: minor esophageal leak, local mediastinitis and hyperdynamic septic shock. All 5 cases were treated by primary repair. Group II: moderate to severe esophageal leak, severe mediastinitis and hypodynamic septic shock. All 9 cases were treated by transthoracic esophagectomy.

RESULTS

Group I: No postoperative mortality. The mean ICU stay was 4.6 days. The mean hospitalization time was 14 days. Group II: The postoperative mortality was 22.2%. The mean ICU stay was 28 days. The mean hospitalization time was 45 days.

CONCLUSIONS

The choice of which operative approach should be made in patients with Boerhaave's syndrome requires critical assessment of the patient's overall status, the duration of leak and the extent of mediastinal and pleural contamination.

Indications for surgery in tracheobronchial ruptures

OBJECTIVE

Ruptures of the tracheobronchial tree present a life-threatening situation. Nevertheless, therapy is still controversial. Though conservative treatment by antibiotics and intubation with the cuff inflated distal to the tear is favored by some authors, surgical repair is unavoidable in many cases.

METHODS

We present a series of 31 patients (mean age 43.6 years, range 8--72 years) with iatrogenous or post-traumatic tracheobronchial ruptures treated since 1975. Fifteen ruptures were longitudinal tears of the trachea, not extending lower than a distance of 3 cm from the bifurcation, 11 involved the bifurcation and/or the main bronchi. The total length of the longitudinal tears ranged from 2 to 12 cm, five were transverse near complete abruptions of the trachea or main bronchi. Involvement of the full thickness of the wall with free view into the pleural space or to the esophageal wall was present in 29 cases. Twenty-nine out of the 31 patients underwent surgical repair and two were treated conservatively. The length and depth of the lesion, the degree of subcutaneous emphysema, pneumothorax and/or pneumomediastinum as well as clinical signs suggesting incipient mediastinitis were considered when making the decision for surgery.

RESULTS

Twenty-five out of the 29 patients experienced an uneventful recovery. Four patients died of sepsis unrelated to the tracheobronchial trauma. One of the two patients who underwent conservative therapy also recovered uneventfully. The other one died because of multi-organ failure due to underlying myocardial infarction.

CONCLUSIONS

Conveniently localized short lacerations, especially if they do not involve the whole thickness of the tracheal wall, can be treated with antibiotics and intubation with the cuff inflated distal to the tear, avoiding high intra-bronchial pressures also after eventual extubation. In all other cases surgical repair is to be preferred.

Photodynamic therapy enhanced by hyperbaric oxygen in acute endoluminal palliation of malignant bronchial stenosis (clinical pilot study in 40 patients)

OBJECTIVES

Photodynamic tumor therapy (PDT) is based upon a photochemical reaction that is limited by the availability of molecular oxygen in the target tissue. The use of hyperbaric oxygenation (HBO) increases the amount of oxygen available for the process may thereby enhance the efficacy of PDT. We proved in a prospective, non-randomized clinical pilot study the acute effects on malignant bronchial stenosis and the technical feasibility of combined PDT/HBO.

METHODS

Forty patients (29 males, 11 females, mean age: 64.3 years; range 39-82 years) with inoperable, advanced malignant bronchial tumor stenosis were studied prospectively. Photosensitization was carried out using a hematoporphyrin-derivative 2 mg/kg bw 48 h prior to PDT. The light dose was calculated as 300 J/cm fiber tip. The assessment of outcome 1 and 4 weeks after PDT/HBO was done by endoscopy, chest X-ray, spirometry, laboratory parameters, subjective report of dyspnea and Karnofsky performance status.

RESULTS

At 1 and 4 weeks after the treatment the patients felt a significant improvement of dyspnea and hemoptysis alongside with an objective subsiding of poststenotic pneumonia, though spirometric parameters revealed no significant difference. A significant reduction of tumor stenosis (P<0.05) and an improvement of the Karnofsky performance status (P<0.05) were documented 1 and 4 weeks after PDT/HBO. No therapy related complications were observed.

CONCLUSION

Although the small number of patients does not allow to draw definitive conclusions, the results suggest that combined PDT/HBO represents a new, safe and technically feasible approach. It enables efficient and rapid reduction of the endoluminal tumor load and helps conditioning the patient for further treatment procedures.

Acid-related diseases following retrosternal stomach interposition

BACKGROUND/AIMS

Esophagectomy and reconstruction with retrosternal stomach interposition implies bilateral truncal vagotomy, which supposedly causes gastric functional impairment.

METHODOLOGY

Esophagectomy and reconstruction with retrosternal stomach interposition was performed on 15 men (mean age: 58.4 years) and 3 women (mean age: 43.6 years). The stomach was pedicled on the right gastric and right gastroepiploic artery without performing pyloroplasty. The cervical side-to-end anastomosis was sutured manually. The functional results were assessed 2-4 years postoperatively, by determining 24-hour qualitative intragastric pH-measurement, fluoroscopical gastric emptying studies, fasting gastrin levels, and endoscopy with biopsy studies.

RESULTS

Endoscopy and biopsy confirmed esophagitis in 12 patients, gastritis in 15 and a gastric ulcer in 1 case. Fluoroscopic examination documented a normal passage of contrast medium in 17, slight impairment in 1 case treated by balloon dilatation of the pylorus. Qualitative intragastric pH-measurement revealed a total pH < 3 in 22.5-98.05% of measuring events (mean: 74.31%) within 24 hours, in 18 cases. Only 4 patients had pH < 3 in less than 50%. Fasting gastrin levels (normal range: 25-110 mU/L) varied from 48.78 mU/L-168.20 (mean: 85.23 mU/L). Only 3 patients had levels > 110 mU/L (maximum: 168.20 mU/L).

CONCLUSIONS

Acid-related diseases may also occur after truncal vagotomy and retrosternal stomach interposition. Routine follow-up endoscopy and biopsy studies should be done to prevent inflammatory complications and maintain the patient's quality of life.

In vivo determination of tumor optical parameters in esophageal carcinoma

BACKGROUND AND OBJECTIVE

Dose dependence of light cannot be discussed on the basis of dose alone. On a more fundamental scientific level, the propagation of light in tissue depends on optical parameters of treated tumor tissue. In a prospective, nonrandomized study, in vivo optical parameters of esophageal carcinoma were studied.

STUDY DESIGN/MATERIALS AND METHODS

Nineteen intraoperative measurements of tumor optical parameters in six patients with esophageal carcinoma were performed. After diagnostic work-up and clinical staging, right-sided, posterolateral thoracotomy, and dissection of the esophagus were carried out. The tumor site was exposed and continuous endoluminal irradiation was started during determination of light penetration at the level of the adventitia of the esophagus. The tumors were located exactly between the endoluminal irradiation source and measurement probe in the thoracic cavity. Measurements were performed on tumors having different diameters to show the relationship between tumor diameter, extinction coefficient, and light penetration depth.

RESULTS

The endoluminal incident intensity was 18.5 mW/cm(2). At a tumor diameter of 4, 6, 8, and 9 mm measured intensity of 5.12, 2.28, 0.88 and 0.65 mW/cm(2), an extinction coefficient of 0.321, 0.349, 0.381, and 0.373, as well as penetration depth of 3.21, 2.87, 2.62, and 2. 68 mm, respectively, could be measured. The correlation of tumor optical parameters, tumor diameter, penetration depth, and treatment time were expressed by the relative correction factor for different tumor diameters.

CONCLUSION

The knowledge of tumor optical properties seems to be necessary to adapt dosimetry to the individual situation and manage optimal results of PDT in esophageal cancer.

Combined photodynamic therapy and hyperbaric oxygenation in carcinoma of the esophagus and the esophago-gastric junction

OBJECTIVES

The photochemical reaction of photodynamic therapy (PDT) depends on the presence of molecular oxygen. Due to 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.

PATIENTS AND METHODS

After diagnostic work-up, photosensitization was carried out with a hematoporphyrin-derivate 2 mg/kg BW 48 h prior to PDT. The light dose was calculated as 300 J/cm fiber tip. Thirty-one patients were treated by PDT alone and 44 patients received PDT under hyperbaric oxygen at a level of two absolute atmospheric pressure.

RESULTS

Improvement regarding stenosis-diameter could be obtained in both treatment arms with no significant difference (P=0.82). The dysphagia-score and tumor-length also decreased in both groups and showed a significant difference in favour of the PDT/HBO-group (P=0. 0064 and P=0.0002, respectively). The median overall survival for the PDT-group was 7 months and for the PDT/HBO-group 12 months (P=0. 0098).

CONCLUSION

According to this prospective non-randomized 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.

Effect of photodynamic therapy in a multimodal approach for advanced carcinoma of the gastro-esophageal junction

Background and Objective We wanted to determine the role of additional photodynamic therapy in a multimodal approach for the treatment of patients with advanced cancer of the gastro-esophageal junction. Study Design/Materials and Methods We reviewed 53 patients, after endoluminal palliation, with advanced cancer of the gastro-esophageal junction. Combined dilatation and retrograde tumor disobliteration with Nd-YAG laser before photodynamic therapy (PDT), brachyradiotherapy, or both, became necessary in 12 patients. Brachyradiotherapy was carried out in all patients. PDT before brachyradiotherapy was performed in 25 patients. The endoluminal treatment was completed by external beam irradiation in 30 patients (15 cases with PDT and 15 without PDT) with an at least fair performance status.

RESULTS

Photodynamic therapy showed a significant difference regarding the mean opening of the tumor stenosis (mean, 6.4 mm; P = 0.0002), the mean decrease in tumor length (3.1 cm; P = 0.00001) and the increase in median survival (13. 8 months; P = 0.001). The combined multimodal approach by using PDT, brachyradiotherapy and external beam irradiation showed a median survival of 16.8 months. However, additional external beam irradiation showed no significant difference (P = 0.11). The rate of severe complications was 5.7%. The mortality rate was 1.9%.

CONCLUSION

Photodynamic therapy has been shown to be an effective treatment for palliation of advanced cancer at the gastro-esophageal junction. The use of PDT combined with irradiation was associated with an acceptable survival rate, low rates of complications and reasonable quality of life.

Computed tomography or ultrasonically guided pigtail catheter drainage in multiloculated pleural empyema: a recommended procedure?

OBJECTIVES

The role of image-guided pigtail catheter drainage in the treatment of pleural empyema is associated with different outcomes, dependent on the stage of the disease. No agreement concerning its use exists.

METHODOLOGY

Fourteen patients at a fibropurulent stage of pleural empyema initially treated with computed tomography (CT) or ultrasonically guided pigtail catheter drainage were reviewed. All patients were admitted with clinical symptoms of sepsis. Chest X-ray, CT scan and/or ultrasonography and thoracentesis with biochemical examination revealed multiloculated pleural empyema. Despite the diagnosis of multiloculated empyema, CT or ultrasonically guided pigtail catheter drainage was performed. However, septic symptoms deteriorated and all cases proceeded to thoracotomy with decortication.

RESULTS

Image-guided drainage failed in all patients. Septic symptoms disappeared within 24-48 h after decortication. The patients recovered without sequela, were discharged 6-15 days (mean: 9.2 days) postoperatively and were able to return to normal physical activity.

CONCLUSIONS

Computed tomography or ultrasonically guided pigtail catheter drainage can not be recommended in the case of a fibropurulent stage of empyema thoracis.

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.

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.

The effect of external beam irradiation after endoscopic palliation of esophageal carcinoma

The aim of this study was to verify the value of additional external beam irradiation (EBR) after endoscopic palliation, regarding quality of life and survival rate. From January 1988 to December 1995, 99 patients with esophageal carcinoma (squamous cell carcinoma 61; adenocarcinoma 38) were reviewed, there were 84 males (mean age: 67 years) and 16 females (mean age: 65 years). Seventeen patients were in stage IIb, 45 stage III and 37 patients in stage IV. HDR-brachyradiotherapy (mean: 14.7 Gy) was carried out in all patients. Additional EBR (mean: 47.8 Gy) after endoluminal palliation was done in 51 cases. At 6-months follow-up swallowing of a semi-solid diet at least was possible in all patients and dysphagia was found with significant difference in favour to EBR only in stage IV (p=0.011). The Karnovsky performance status showed a difference in favour of EBR for stage III and IV (p=0.040 and p=0. 049, respectively). The median overall survival for EBR compared to no EBR was 10 and 7 months, with a 12 months survival rate of 60% and 16% (p=0.0012). However, considering different stages and EBR versus no EBR a significant difference in survival could only be found for stage IIb (p=0.031), a trend in favour of EBR could be found for stage III (p=0.0985) and stage IV (p=0.0543). Tumor regrowth 6-12 months after treatment occurred in 31 cases and was successfully treated with Nd-YAG laser in 25 and stenting in 6 cases. Postirradiation fibrotic stenosis occurred in 12 cases. Improved survival rates after additional EBR can only be expected in stage IIb. However, in case of advanced esophageal carcinoma and fair performance status, EBR after endoluminal palliation help to maintain quality of life.

Differential lung ventilation and emergency hyperbaric oxygenation for repair of a tracheal tear

PURPOSE

To report the anaesthetic management of a case of tracheal rupture, using different types of ventilation and additional hyperbaric oxygenation (HBO).

CLINICAL FEATURES

An 8 cm postintubation tracheal tear was repaired in a 66-yr-old woman with acute myocardial reinfarction, mediastinal and subcutaneous emphysema, cardiac failure and unrecognized lymphoma. Intraoperative monitoring included dual oximetry: arterial (SaO2) and mixed venous saturations (SvO2). Maintenance of free surgical access and a series of life-threatening events like dislocation of the jet catheter required many ventilation modes. An episode of supraventricular tachycardia was interrupted by cardioversion. Differential lung ventilation with a combination of conventional and high-frequency jet ventilation (HFJV) modes preserved oxygenation (PO2 139.2 mm Hg, PCO2 42.4 mm Hg, FiO2 1.0) until acute tube obstruction and decrease of saturation values (SaO2 58%, SvO2 45%) required emergency HBO: immediate cardiac and respiratory stabilization was provided by double-lung HFJV and apneic oxygenation under hyperbaric conditions at 2.5 atmospheres absolute for 35 min (SaO2 100%). The patient recovered from surgery but died of non-Hodgkin lymphoma.

CONCLUSION

The combination of different ventilation modes including HFJV and the additional use of HBO resulted in sufficient oxygenation during tracheal repair.

Four-year experience with pleural abrasion using a rotating brush during video-assisted thoracoscopy

BACKGROUND

Due to the high recurrence rate in primary spontaneous pneumothorax (PSP), surgical therapy is currently a well-accepted method of treating this condition. There is no general agreement about the best time for surgical intervention (i.e., after the first or second episode) or the optimal surgical approach,--i.e., tube thoracocenteses, thoracotomy, or video-assisted thoracoscopy (VATS) with or without pleurectomy or pleurodesis. The aim of this study was to verify the efficacy of VATS and mechanical brush pleurodesis using a rotating electrical brush system.

METHODS

We treated 47 patients with PSP between June 1993 and June 1997. Follow-up ranged from 20 to 56 months. There were 38 male and nine female patients with a mean age of 26 years. Emergency thoracocenteses due to tension pneumothorax became necessary in three patients. All patients were treated by VATS and mechanical brush pleurodesis. Wedge resection was done if bullae or blebs were present (68.1%).

RESULTS

Operating time was 20-60 min (mean, 35). There were no intraoperative complications and no conversions to conventional surgery. In the first few postoperative days, postoperative pain was controlled with nonsteroidal antirheumatic drugs and additional morphines. Drainage time was 3-7 days (mean, 4). Hospitalization time was 4-8 days (mean, 5). The recurrence rate was 2.1% (one patient). No postoperative bleeding or wound infection occurred in any of our patients.

CONCLUSIONS

VATS combined with mechanical brush pleurodesis using the electrical brush system is a highly effective and safe treatment for patients with recurrent primary spontaneous pneumothorax.

Local and systemic treatment in small cell carcinoma of the esophagus

Primary small cell carcinoma of the esophagus is a rare and aggressive disease. We report on our experience with two patients having a small cell cancer of the esophagus, being treated with photodynamic therapy combined with irradiation and induction-chemotherapy as well as a review of literature. Both patients were admitted with severe dysphagia, weight loss and a Karnovsky performance status of 90. Diagnostic work-up revealed tumor-stenosis in the proximal third in one and in the distal third in the other case. Clinical staging showed T4N2M0 and T3N2M0, pure small cell carcinoma. Due to dysphagia and lymph node enlargement, local and systemic therapy were considered as first-line treatment. Restaging after three cycles of induction-chemotherapy revealed partial response in both cases. Esophagectomy as a second-line treatment was considered. However, in the preoperative period, one patient developed motorical aphasia. The CT-scan of the brain showed multiple brain metastases. External beam irradiation and further chemotherapy was initiated. The patient died 12 months after admission. The other patient revealed anatomical inoperability at the staging laparoscopy. External beam irradiation and a second session of PDT was performed. The patient is still alive, 12 months after his first admission. The biological behavior of this aggressive disease and metastases in about 50% of patients at admission, as well as significant dysphagia makes combined systemic and local treatment necessary. Nevertheless, after reviewing the literature, esophagectomy and adjuvant chemotherapy may have an advantage pertaining to survival time when anatomical and functional operability is given.

Does hyperbaric oxygen enhance the effect of photodynamic therapy in patients with advanced esophageal carcinoma? A clinical pilot study

BACKGROUND AND STUDY AIMS

Experimental studies have shown that the cytotoxicity of porphyrins and related substances is mediated mainly by singlet oxygen and that hypoxic cells are less affected by porphyrins and light. In a clinical pilot study we assessed the use of photodynamic therapy (PDT) under hyperbaric oxygen (HBO), compared with PDT under normobaric conditions, in patients with advanced esophageal carcinoma.

PATIENTS AND METHODS

After diagnostic work-up and staging, photosensitization in all patients was carried out using hematoporphyrine derivate (HpD) (2 mg/kg bodyweight 48 hours prior to PDT). We then applied light at 630 nm (KTP-Nd: YAG laser with DYE box) at dose of 300 J/cm, delivered by a fiber with a radial light-diffusing cylinder (length 1 cm), inserted through the biopsy channel of the endoscope. Of the patients, 14 (12 with stage III cancers, and two with stage IV cancers) were treated by PDT alone, and 17 patients (15 with stage III cancers, and two with stage IV cancers) received PDT under HBO at a level of 2 absolute atmospheric pressures (ATA). Transcutaneous PO2 levels of 500-750 mm Hg under HBO, compared with transcutaneous PO2 levels of 60-75 mm Hg under normobaric conditions, were measured.

RESULTS

Improvements regarding dysphagia and stenosis diameter were obtained in both treatment arms with no significant differences (P = 0.36 and 0.14, respectively). The tumor length also decreased in both groups and showed a significant difference in favour of the PDT/ HBO group (P = 0.002). Kaplan-Meier statistics showed median overall survival for the PDT group and the PDT/HBO group as 7.0 and 12 months respectively. The 12-month survival rate was 28.6% for the PDT group and 41.2% for the PDT/HBO group. Logrank test showed a difference in survival in favor of the PDT/HBO group (P = 0.059). No major treatment-related complication occurred, and the 30-day mortality rate was 0%.

CONCLUSIONS

Combined PDT/HBO represents a new approach in the treatment of esophageal cancer which, in this pilot study, appears to have enhanced the efficiency of PDT.

Self-expandable coated stent after intraluminal treatment of esophageal cancer: a risky procedure?

BACKGROUND

Stenting is a well established palliative treatment for stenotic malignant disease of the esophagus. Because of its merely mechanical potential other tumoricidal techniques are often done before stenting.

METHODS

We did esophageal stenting in 11 patients (9 men and 2 women) using a self-expanding coated stent system. Three tumors were localized in the proximal, four in the middle, and four in the distal third of the esophagus. In 9 patients tumors were locally or functional nonresectable, 1 patient refused an operation, and 1 had a recurrence after esophagojejunostomy. One patient had had pretreatment by repetitive dilatation and local hyperthermia, 9 had had photodynamic therapy followed by endoluminal iridium 192 high-dose rate brachyradiotherapy, and 1 patient was admitted with esophagotracheal fistula. The interval between the last endoluminal treatment and stent insertion was between 3 and 29 days (mean, 11 days).

RESULTS

In 7 patients (63.7%) no complications were observed. Four patients (36.3%) died of major complications within 1 week. Postmortem examination confirmed that the pressure of the fully expanding stent to the esophageal wall caused the rupture.

CONCLUSION

The use of self-expanding coated stents in pretreated esophageal tumors is associated with a high risk of perforation due to pressure of the indwelling tube in a less resistant esophageal wall.

Is aggressive surgery in pleural empyema justified?

OBJECTIVE

High risk and a long hospitalization time are often quoted as negative aspects of aggressive surgery in pleural empyema. We did a retrospective analysis evaluating outcome and duration of hospitalization in patients treated according to an aggressive schedule.

METHODS

Since 1989 we have treated 101 patients with pleural empyema (72 males, 29 females; mean age 50.3 years, range 11-91 years; 77 metapneumonic empyema, 24 empyema following trauma or abdominal surgery). Sixty-nine patients had had unsuccessful conservative pre-treatment (antibiotics, thorcozentses, drainage/irrigation, VATS). Thirty-one were critically ill patients. In eight cases a seropurulent stage of empyema was present, 17 patients had fibrinous membranes, 30 an organizing stage with and 46 without well identifiable dissection plane. Eighty-five patients proceeded to thoracotomy. Pulmonary abscesses or indurative pneumonia necessitated wedge-resection, lobectomy, or pneumonectomy in 29 cases. In the presence of gross necroses or callosities not amenable to decortication primary open-window thoracostomy (n = 22) was carried out. In six cases a secondary open-window thoracostomy was carried out because of persisting putrid secretion and sepsis persisting after decortication or after drainage. The thoracostomy was closed when clean granulative tissue developed. Sixteen patients underwent only drainage and irrigation because of an early stage or because of a general condition not permitting thoracotomy.

RESULTS

Three patients died due to severe sepsis not responding to treatment, one had fatal bleeding from a duodenal ulcer (mortality rate 3.9%). The others were able to resume their preoperative activities. The median duration of hospitalization was 14 days (mean 21.1 days; SEM 1.7 days).

CONCLUSION

Aggressive surgery for pleural empyema beyond the seropurulent stage ensures rapid relief from sepsis at a low mortality rate even in very ill patients.

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.

Treatment of invasive pulmonary aspergillosis in severely neutropenic children with malignant disorders using liposomal amphotericin B (AmBisome), granulocyte colony-stimulating factor, and surgery: report of five cases

Five children with malignancies developed invasive pulmonary aspergillosis during chemotherapy-induced neutropenia. All patients were treated with liposomal amphotericin B and human recombinant granulocyte colony-stimulating factor. Two patients did not recover from bone marrow aplasia and died from organ-infiltrating fungal invasion. Two patients who recovered from bone marrow aplasia survived after surgery of the pulmonary lesions. The fifth patient had a complete resolution of invasive pulmonary aspergillosis after neutrophil recovery without surgical intervention. We conclude that not only the antifungal treatment but also the recovery of granulocytes are important in localizing invasive forms of Aspergillus infections in patients with profound immunosuppression.

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.

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.

Clinical features and therapy of "typical" and "atypical" bronchial carcinoid tumors (grade 1 and grade 2 neuroendocrine carcinoma)

Between 1971 and 1992, 55 patients with grade 1 (G1) (n = 32) or grade 2 (G2) (n = 23) neuroendocrine bronchial carcinomas (males: 26, females: 29; mean age: 47.7 years, range: 13-77 years) were treated. The sexes were evenly distributed in the two groups. Patients with G1 were significantly younger than those with G2 tumors (43.3 vs 53.7 years; P < 0.05). There were no statistically significant differences between G1 and G2 concerning peripheral or central localization, laterality or maximum tumor diameters. Patients with G1 had a higher incidence of tumor-related symptoms and a longer mean duration of these symptoms (21.8 months) than G2 cases (14 months) but the differences were not statistically significant either. No case displayed any symptoms of hormonal activity. Fifty-two patients underwent resection, one was non-resectable for anatomical, and one for functional, reasons; a third refused an operation. We performed 8 pneumonectomies, 36 lobectomies (8 by using bronchoplasty), 2 bronchotomies and 6 segmental resections. Twelve G2 cases had N1 or N2 lymph node metastases, two intrapulmonary metastases were removed. After a median observation time of 55.7 months the 10-year survival rate for the total collective is 90.6%. For G1 it is 100%, compared with 76.4% for G2 patients, 3 of whom died of the tumor (P < 0.05; significant). In univariate analysis: age over 48 years, lymphatic invasion, and lymph node metastasis were also significantly correlated with a poor survival rate. Multivariate analysis proved lymphatic permeation to be the only independent prognostic factor (the survival rate was 100% where there was no invasion, but only 74% where this had occurred).

Open-window thoracostomy in pleural empyema

Open-window thoracostomy (OWT) was performed in 21 cases of empyema. The indications were postpneumonectomy empyema with (n = 6) or without (n = 1) fistula, early recurrent empyema after decortication (n = 6), chronical empyema in ill elderly patients with (n = 5) or without fistula (n = 2), and total unilateral lung gangrene with a large fistula of the main bronchus after radiotherapy and chemotherapy (n = 1). All cases presented with severe sepsis, eight of them with acute septic shock, and six with signs of multiorgan failure. Three to five ribs were resected, the muscles and skin were sutured to the ribs confining the window located at the lowest point of the empyema cavity, while the intercostal muscles of the resected ribs were used to close fistulae. The cavity was packed with dressings every day. In all cases, the sepsis subsided immediately after OWT. With the exception of one patient with postpneumonectomy empyema, who died of contralateral pneumonia on day 36, no surgery-related complications were seen. Four further patients died of unrelated causes 2, 4, 5, and 7 months, respectively, after OWT. In one of them, the OWT had been closed. Up to this time, obliteration and closure of the cavity has been carried out in 7 cases by using thoracoplasty (n = 2) or predicted muscle flaps (n = 5) either in the early course or after a delay of 11 to 23 months, with fair functional and cosmetic results. In one further case, operative closure has been planned. In seven of the eight remaining patients, four of whom declined further operations, the cavities closed spontaneously, despite their initial size after intervals of between 11 and 21 months.

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.

[Thoracic wall and lung trauma. Diagnosis, clinical aspects, surgical indications and technic]

Diagnosis, pathophysiology, clinical course, indication for and technique of operative procedure are described for treatment of flail chest, pneumothorax, hematothorax, lung rupture and contusion, and for tracheobronchial injuries. A simple "finger-troicart" technique for thoracocentesis and chest tube is mentioned as well as the value of early and simultaneous fiberoptic exploration of the trachea, bronchi and esophagus.

[Intraoperative radiotherapy (IORT) at the Graz University Clinics: results of a pilot study on non-small cell lung carcinoma]

A pilot study was undertaken during which 15 patients with non-small cell pulmonary carcinomas were exposed to an intraoperative irradiation; twelve out of them were submitted to an additional percutaneous photon therapy. The criteria used to select these patients were functional inoperability, exclusion of remote metastases, and a Karnofsky index greater than 70. Central and peripheral tumors of the stages T1-3, N0-2 were included into the study after histological confirmation of the diagnosis. The local regression rate of the primary tumor can be assessed quite well despite the short follow-up time of 4.5 to 16 months (10 months on an average) which does not yet allow to make a conclusion as to a prolongation of the disease-free survival time. Already two months after the end of external irradiation, a complete remission (CR) was seen in three patients (25%), a partial remission (PR) in seven patients (67%), and a minor remission (MR) in one patient. In the course of further follow-up, the number of complete remissions increased to six (50%). We are encouraged by the small morbidity and a therapeutic response higher than average to continue with this therapy method in patients who, for the time being, are still selected according to strict criteria.

[Clinical use of new organ-saving technics in splenic surgery]

During a period of 19 months, 22 organ preserving splenic operations were performed. Eleven of these, were severe third degree traumatic bursting ruptures, which were treated using a resorbable compressive mesh. An intralienal pancreatic cyst, a case of splenomegaly suspicious for lymphoma, one traumatic and two accidental polar lesions were treated by partial splenic resection using stapler. In two patients with traumatic and four with accidental first and second degree lienal lesions, collagen tampon and fibrin adhesive were employed. None of these patients required a second laparotomy. Aside from an edematous tail pancreatitis, no complications arose. Two patients succumbed to their severe cranial injuries. In the same period, four posttraumatic splenectomies were performed. Thus, excluding incidental and technical splenectomies, the application of the described methods resulted in orthotopic splenic preservation in 78% of traumatic splenic ruptures.

Pitfalls in intraoperative frozen section histology of mediastinal neoplasms

We evaluated the reliability of intraoperative frozen section histology in 149 mediastinal tumours of which 106 lesions were localized in the anterior, 18 in the central and 25 in the posterior mediastinum. Gross non-resectability was ruled out by preoperative imaging. No preoperative cytological or histological diagnosis was obtained in any case. At thoracotomy, 3 biopsies from 3 different sites of the tumour were processed for frozen section as well as for paraffin histology and immunohistochemistry. In 67 of 73 benign lesions (91%), the intraoperative diagnosis was correct, 5 cases could not be classified by frozen section and 1 case had to be revised. Only 28 of 76 malignant lesions (36.8%) were diagnosed correctly by intraoperative frozen section. In 27 cases (35.5%), no intraoperative classification was possible and in 21 patients (27.6%), the diagnosis was wrong with the consequence of surgical overtreatment for lymphoma misinterpreted as thymic cancer in 3 cases. In patients in whom preoperative investigations suggest borderline resectability, a staged procedure to obtain histology prior to definitive surgery could prevent overtreatment.

Reinforced staple line in severely emphysematous lungs

In severely emphysematous or otherwise destroyed lung parenchyma, staples often cut through, which causes prolonged postoperative air leakage. A mechanical suture line reinforced by a polydioxanone ribbon is a simple, safe, and effective method for closure of air leaks, resection, or biopsy in such cases.

Solitary coin lesion in patients with malignant melanoma: an indication for thoracotomy?

In five patients solitary pulmonary lesions were detected radiographically during routine follow up after malignant melanoma. Surgical removal was done in each case under the tentative diagnosis of metastases. Histologically, two lesions turned out as benign chondroma, one as organized pulmonary infarction and one as bronchogenic carcinoma. Only in one patient was a melanoma metastasis present. The findings underline the usefulness also in malignant melanoma of a surgical approach in suspected solitary pulmonary metastases.

[Fournier gangrene with involvement of the thigh--radical restoration by exarticulation of the femur. Case report]

We report a case of Fournier's gangrene of the scrotum, involving the right lower extremity. Radical surgical intervention (hip joint exatriculation) was necessary.

Triple diaphragmatic rupture with disruption of the pericardium: pericardial reconstruction by lyophilized dura allograft

A patient is described with the unusual findings of intrapericardial diaphragmatic rupture combined with total disruption of the pericardium and partial abruption of the diaphragm from its costal origin. Through a third traumatic diaphragmal leak, the small intestine had prolapsed intercostally without contact to the pleural space. Surgical repair was done by direct diaphragmatic suturing and lyophilized dura allograft reconstruction of the left pericardial circumference. Postoperatively, atrioventricular block secondary to myocardial contusion necessitated pacemaker implantation. The patient left the hospital five weeks after the injury.