Caries prevention with xylitol lozenges in children related to maternal anxiety. A demonstration project

AIM

This was to compare the effect of a prevention program between children of anxious and non-anxious mothers.

METHODS

Mothers (n=120) with high and low dental anxiety scores (DAS>15 and DAS <8, respectively), and with high levels of mutans streptococci (>10(5)cfu/mL) were recruited at a maternity clinic of Tartu, Estonia. Two groups: 30 highly anxious, and 30 non-anxious mothers used xylitol (6 g/day) for 33 months and a non-treatment group of 60 mothers, both highly and low anxious (30 in each sub-group), acted as controls. All mothers were interviewed for oral health habits and education, and their dental health was examined. Due to discontinued participation 75% of the children (n=90) were examined at 2 and at 3 years of age.

RESULTS

Anxious mothers brushed less frequently (p=0.014), had a longer time since their last dental visit (p<0.0001), and a lower level of education (p<0.0001) than their non-anxious counterparts. However, maternal anxiety had no effect on children's dental health, contrary to the caries prevention program which was effective both at 2 and at 3 years of age (p<0.01; OR 6.6, 1.8-25.0 and OR 3.9, CI 1.5-10.0, respectively).

CONCLUSION

Children benefited from the caries prevention program, irrespective of maternal anxiety.

Similarity of the effects of erythritol and xylitol on some risk factors of dental caries

Several sugar alcohols (polyols) have been promoted as potential sugar substitutes in caries limitation. However, differences in the effects of simple alditol-type sugar alcohol homologues on dental plaque have not been compared in clinical tests. The effects of 6-month use of erythritol (a sugar alcohol of the tetritol type), xylitol (a pentitol) and D-glucitol (sorbitol, a hexitol) were investigated in a cohort of 136 teenage subjects assigned to the respective polyol groups or to an untreated control group (n = 30-36 per group). The daily use of the polyols was 7.0 g in the form of chewable tablets, supplemented by twice-a-day use of a dentifrice containing those polyols. The use of erythritol and xylitol was associated with a statistically significant reduction (p < 0.001 in most cases) in the plaque and saliva levels of mutans streptococci. The amount of dental plaque was also significantly reduced in subjects receiving erythritol and xylitol. Such effects were not observed in other experimental groups. Chemical analyses showed D-glucitol to be a normal finding in dental plaque while xylitol was less consistently detected. Erythritol was detected in measurable amounts only in the plaque of subjects receiving this polyol. Erythritol and xylitol may exert similar effects on some risk factors of dental caries, although the biochemical mechanism of the effects may differ. These in vivo studies were supported by cultivation experiments in which xylitol, and especially erythritol, inhibited the growth of several strains of mutans streptococci.

Frequent exposure to invasive medical care in early childhood and operative dental treatment associated with dental apprehension of children at 9 years of age

AIM

This was to study prospectively a cohort of children as to whether behaviour at a 3-year examination, exposure to medical care and operative dental treatment are associated with each other, and with the level of dental apprehension at 9 years of age.

METHODS

Data were collected at three subsequent dental examinations of 126 children (67 boys, 59 girls). Cooperation, general health condition and operative dental treatment during the preceding 3 years were obtained at dental examinations with 3-year intervals, i.e. at 3, 6 and 9 years of age. Children's dental apprehension was assessed at the age of 9 years. The data were analysed using an ordinal logistic regression model.

RESULTS

Dental apprehension at 9 years of age was associated with frequent exposure to invasive medical care (p<0.001) and past experience of operative dental care (p<0.002), but not with cooperation at 3 years of age (p=0.124).

CONCLUSION

Frequent invasive medical care in early childhood and operative dental treatment, tooth extractions in particular, are associated with dental apprehension at 9 years of age.

A randomized, controlled trial comparing thoracoscopy and limited thoracotomy for lung biopsy in interstitial lung disease

BACKGROUND

Lung biopsies are frequently needed to diagnose diffuse interstitial lung diseases. A prospective randomized, controlled trial comparing limited thoracotomy (open lung biopsy) and thoracoscopy for lung biopsy was done.

METHODS

Ambulatory patients with a clinical diagnosis of diffuse interstitial lung disease were randomized to thoracoscopy or limited thoracotomy. Data on postoperative pain, narcotic requirements, operating room time, adequacy of biopsy, duration of chest tube drainage, length of hospital stay, spirometry, and complications were collected.

RESULTS

A total of 42 randomized patients underwent lung biopsy (thoracoscopy 20, thoracotomy 22). The two study groups were comparable with respect to age, gender, corticosteroid use, and preoperative spirometry. Visual analog scale pain scores were nearly identical in the two groups (p = 0.397). Total morphine dose was 50.8 +/- 27.3 mg in the thoracoscopy group and 52.5 +/- 25.6 mg in the thoracotomy group (p = 0.86). Spirometry (FEV1) values in the two groups were not significantly different on postoperative days 1, 2, 14, and 28 (p = 0.665). Duration of operation was similar in both groups (thoracoscopy 40 +/- 30 minutes, thoracotomy 37 +/- 15 minutes; p = 0.67). The thoracoscopy and thoracotomy groups had equivalent duration of chest tube drainage (thoracoscopy 38 +/- 28 hours, thoracotomy 31 +/- 26 hours; p = 0.47) and length of hospital stay (thoracoscopy 77 +/- 82 hours, thoracotomy 69 +/- 55 hours; p = 0.72). Definitive pathologic diagnoses were made in all patients.

CONCLUSIONS

There is no clinical or statistical difference in outcomes for thoracoscopic and thoracotomy approaches. Both thoracoscopy and thoracotomy are acceptable procedures for diagnostic lung biopsy in diffuse interstitial lung disease.

Simple technique for sizing and positioning tracheal stents

Accurate placement of tracheobronchial stents is essential, since little adjustment can be made once the stent is deployed. We describe the use of an inexpensive tool, a radio-opaque ruler, to aid in the proper positioning of tracheobronchial stents.

Sex-associated differences in survival of patients undergoing resection for lung cancer

BACKGROUND

The increasing incidence of lung cancer among women prompted us to assess whether sex-associated differences exist in the presentation and survival of patients who undergo major lung resection for lung cancer.

METHODS

We performed a retrospective review of patients who had major lung resection for lung cancer from January 1980 to June 1998.

RESULTS

There were 265 men and 186 women. Women were younger (60.7+/-0.8 versus 63.6+/-0.6 years; p = 0.005). Adenocarcinoma was more common among women (48% versus 40%; p = 0.001). Pathologic stages for men were: I = 43%, II = 26%, IIIA = 25%, IIIB or IV = 6%, and for women: I = 52%, II = 20%, IIIA = 22%, IIIB or IV = 6% (p = 0.146). Median survival was better for women (41.8 versus 26.9 months; p = 0.006). This was due both to a difference in stage at presentation and to a better median survival rate for adenocarcinoma compared with squamous cell cancer. The data suggest an association between sex and survival, although this failed to reach statistical significance. Sex influenced survival with a relative risk for women of 0.67 (95% confidence interval 0.35 to 1.29; p = 0.231 adjusted for stage, cell type, age, and spirometry).

CONCLUSIONS

There are sex-associated differences in the presentation and possibly in the survival of patients with lung cancer. This finding has possible implications regarding the selection of patients for therapy and for the design of randomized therapeutic trials.

A randomized comparison of indwelling pleural catheter and doxycycline pleurodesis in the management of malignant pleural effusions

BACKGROUND

The purpose of this study was to compare the effectiveness and safety of a chronic indwelling pleural catheter with doxycycline pleurodesis via tube thoracostomy in the treatment of patients with recurrent symptomatic malignant pleural effusions (MPE).

METHODS

In this multi-institutional study conducted between March 1994 and February 1997, 144 patients (61 men and 83 women) were randomized in a 2:1 distribution to either an indwelling pleural catheter or doxycycline pleurodesis. Patients receiving the indwelling catheter drained their effusions via vacuum bottles every other day or as needed for relief of dyspnea.

RESULTS

The median hospitalization time was 1.0 day for the catheter group and 6.5 days for the doxycycline group. The degree of symptomatic improvement in dyspnea and the quality of life was comparable in each group. Six of 28 patients who received doxycycline (21%) had a late recurrence of pleural effusion, whereas 12 of 91 patients who had an indwelling catheter (13%) had a late recurrence of their effusions or a blockage of their catheter after the initially successful treatment (P = 0.446). Of the 91 patients sent home with the pleural catheter, 42 (46%) achieved spontaneous pleurodesis at a median of 26.5 days.

CONCLUSIONS

A chronic indwelling pleural catheter is an effective treatment for the management of patients with symptomatic, recurrent, malignant pleural effusions. When compared with doxycycline pleurodesis via tube thoracostomy, the pleural catheter requires a shorter hospitalization and can be placed and managed on an outpatient basis.

Lung cancer staging and treatment in multidisciplinary trials: Cancer and Leukemia Group B cooperative group approach. Thoracic Surgeons of CALGB

BACKGROUND

Aggressive routine surgical staging is necessary to evaluate patients to be treated on cooperative oncology protocols. Less than 1% of lung cancer patients in the United States are currently being treated in a clinical trial. Only with results from large, prospective trials can the questions of neoadjuvant and adjuvant therapy be answered.

METHODS

An outline describing the schema of preoperative patient evaluation, surgical staging, and the definition of surgical staging and resection procedures appropriate for patients considered for cooperative group protocol is presented. Current Cancer and Leukemia Group B (CALGB) protocols are used in the discussion as examples of this systematic approach.

CONCLUSIONS

Over the next few years, it will be important to enter the maximum number of patients into combined modality studies to identify the role of neoadjuvant treatment in lung cancer. Entry of patients into protocols will also make their pathological specimens and clinical information available for basic science research related to treatment results. Adherence to a logical sequence of patient evaluation as outlined above will optimize patient care, as well as accrual to cooperative group studies.

Assessment of pulmonary complications after lung resection

BACKGROUND

We assessed the utility of maximum oxygen consumption during exercise (MVO2) and diffusing capacity for carbon monoxide (DL(CO)) in the prediction of postoperative pulmonary complications, and the effect of such complications on postoperative length of hospital stay and the cost of hospitalization.

METHODS

Candidates for lung resection were prospectively studied by preoperative measurement of DL(CO) (expressed as a percentage of predicted [DL(CO)%]) and MVO2. Postoperative pulmonary complications, duration of postoperative hospitalization, and the cost of hospitalization were assessed.

RESULTS

Forty patients had lung resection with no operative mortality. The postoperative length of hospitalization was longer for the 13 patients who developed pulmonary complications compared with the 27 patients who did not (7.7+/-0.8 vs 5.0+/-0.4 days, respectively; p = 0.007), and the cost of hospitalization in the former group was higher ($11,530+/-$1,959 vs $6,578+/-$406, respectively; p = 0.031). Diffusing capacity was higher in patients without than in patients with pulmonary complications (DL(CO)% 90.1+/-5.0 vs 65.3+/-5.9; p = 0.0034). The mean MVO2 did not differ between the groups (17.8+/-0.9 vs 16.3+/-1.2). DL(CO)% predicted pulmonary complications (p = 0.006).

CONCLUSIONS

DL(CO)% predicts the likelihood of pulmonary complications after major lung resection, which are associated with increased length of hospital stay and cost.

Surgical strategies for metastatic lung cancer

The role of surgery in the management of synchronous and metachronous metastatic lung cancer is examined. The approach to lung cancer metastatic to the brain is summarized and the literature on the surgical management of solitary adrenal metastasis from lung cancer is reviewed.

Diffusing capacity predicts operative mortality but not long-term survival after resection for lung cancer

OBJECTIVES

We sought to determine whether diffusing capacity influences operative mortality and long-term survival after resection for lung cancer.

METHODS

We retrospectively reviewed the case histories of patients who underwent major resection for lung cancer. The association between operative mortality and predicted postoperative diffusing capacity was examined. Long-term survival among operative survivors was compared between the groups with high and low predicted postoperative diffusing capacity.

RESULTS

The group comprised 410 patients with a mean age of 62.3 years. We performed 273 lobectomies, 35 bilobectomies, and 102 pneumonectomies. A total of 32 operative deaths (7.8%) were associated with low predicted postoperative diffusing capacity (P <.001). If we examine only operative survivors, there is no significant difference in survival data between patients with a predicted postoperative diffusing capacity of less than 50 and those with a predicted figure of 50 or more (stage I, 111 vs 90 months; stage II, 26 vs 32 months; stage IIIa 32 vs 26 months; log rank P >.5 for each). On the basis of the Cox proportional hazards model, predicted postoperative diffusing capacity did not have a statistically significant effect on long-term survival (estimated hazard ratio corresponding to a 20-point decrease in predicted postoperative diffusing capacity = 1. 13; 95% confidence interval: 0.92 to 1.37).

CONCLUSION

A poor diffusing capacity is associated with high operative mortality but does not adversely affect long-term survival after major lung resection among operative survivors. Improving the perioperative management of patients undergoing major lung resection may enable inclusion of more patients with reduced diffusing capacity in the candidate pool for surgery, thus maximizing survival for early-stage lung cancer.

Clinical trials in general surgical journals: are methods better reported?

BACKGROUND

Reports of clinical trials often lack adequate descriptions of their design and analysis. Thus readers cannot properly assess the strength of the findings and are limited in their ability to draw their own conclusions. A review of 6 surgical journals in 1984 revealed that the frequency of reporting 11 basic elements of design and analysis in clinical trials was only 59%. This study attempted to identify areas that still need improvement.

METHODS

Eligible studies published from July 1995 through June 1996 included all reports of comparative clinical trials on human subjects that were prospective and had at least 2 treatment arms. A total of 68 articles published in 6 general surgery journals were reviewed. The frequency that the previously identified 11 basic elements of design and analysis were reported was determined.

RESULTS

Seventy-four percent of all items were reported accurately (a 15% increase from the previous study), 4% were reported ambiguously, and 23% were not reported; improvement was seen in every journal. The reporting of eligibility criteria and statistical power improved the most. For 3 items, reporting was still not adequate; 32% of reports provided information about statistical power, 40% about the method of randomization, and 49% about whether the person assessing outcomes was blind to the treatment assignment.

CONCLUSIONS

Improvements have been made in reporting surgical clinical trials, but in general methodologic questions poorly answered in the 1980s continue to be answered poorly in the 1990s. Editors of surgical journals are urged to provide authors with guidelines on how to report clinical trial design and analysis.

Phase I study of vinorelbine, cisplatin, and concomitant thoracic radiation in the treatment of advanced chest malignancies

PURPOSE

The cisplatin-vinorelbine regimen has superior activity in advanced non-small-cell lung cancer (NSCLC). We conducted a phase I trial to identify the maximum-tolerated dose (MTD) and dose-limiting toxicities (DLTs) of this regimen with concomitant thoracic radiation (RT) in patients with advanced chest malignancies.

PATIENTS AND METHODS

Patients with advanced chest malignancies that required RT were enrolled onto this phase I study of standard chest radiation (30 daily 2-Gy fractions for a total of 60 Gy) and concurrent chemotherapy with cisplatin starting at 100 mg/m2 every 3 weeks and vinorelbine starting at 20 mg/m2/wk.

RESULTS

Thirty-seven patients were treated on this study. Two of three patients treated at the maximum-administered dose of cisplatin 100 mg/m2 per cycle and vinorelbine 25 mg/m2/wk experienced acute DLT (neutropenia), which required deescalation. The dose level of cisplatin 100 mg/m2 and vinorelbine 20 mg/m2/wk, although tolerated acutely, produced delayed esophagitis, which proved dose-limiting. The recommended phase II dose was cisplatin 80 mg/m2 every 3 weeks and vinorelbine 15 mg/m2 given 2 of every 3 weeks with concomitant chest RT.

CONCLUSION

Concomitant chemoradiotherapy with cisplatin and vinorelbine is feasible. The recommended phase II dose is cisplatin 80 mg/m2 every 3 weeks with vinorelbine 15 mg/m2 given twice over 3 weeks on a day 1/day 8 schedule. Esophagitis is the DLT, with neutropenia occurring at higher dose levels. A Cancer and Leukemia Group B (CALGB) phase II trial is currently underway to evaluate further the efficacy and toxicities of this regimen in unresectable stage III NSCLC.

Polyol-combinant saliva stimulants: a 4-month pilot study in young adults

Several studies indicate that xylitol (X) consumption is associated with certain biochemical changes in dental plaque and whole saliva. In making X-containing saliva stimulants more cost-effective and palatable, manufacturers may use maltitol syrup (MS, which normally contains some sorbitol and higher polyols) or polydextrose (PD, a polysaccharide molecule with a mass > 22 kDa) as bulking agents. Combinations of X with MS and PD have not been tested regarding their salivary effects. One hundred and eighty-eight young subjects (mean age, 22 years) of both sexes were divided into three groups of equal size for a 4-month study. The subjects in one group used X-MS dragees (in 7 daily episodes; 8 g X per day), while the subjects in another group used X-PD dragées in as many daily episodes (8 g X per day). Subjects in the third (comparison) group did not receive saliva stimulants. Paraffin-stimulated whole saliva samples were collected at baseline, after 2 months, and at endpoint. The usage of X-MS was associated with a significant (P < 0.05) reduction in the salivary sucrase activity. After 4 months, the activity of enzymes hydrolyzing N(alpha)-benzoyl-DL-arginyl-p-nitroaniline was significantly reduced in all groups, while the levels of free sialic acid were reduced in group X-PD only (P < 0.05). These salivary changes most likely reflected microbial shifts in the oral cavity and suggest that information from saliva studies may be of avail when deciding which bulking agents should be used in xylitol-based saliva stimulants.

Mortality after esophagectomy: risk factor analysis

Esophageal resection is associated with a high incidence of operative mortality, suggesting the need for predictors of operative risk. A retrospective analysis was performed for esophagectomy patients using univariate and multivariate analyses; relative risks (RR) were calculated. Of the 269 patients, 35 (13%) died. The optimal model for the preoperative prediction of risk of mortality was defined by age (p = 0.001; RR = 2.6) and performance status (p = 0.04; RR = 1.9). Delimiting the data pool using a calculated risk of 0.2 accurately identified outcomes in 79% of patients and predicted 41% of deaths. The optimal model for the overall prediction of risk of mortality was defined by age (p = 0.001; RR = 3.9), intraoperative blood loss (p < 0.001; RR = 1.7), pulmonary complications (p = 0.002; RR = 6.6), and the need for inotropic support (p = 0.003; RR = 10.2). The individual risk of mortality after esophagectomy can be predicted preoperatively with a model based on patient age and performance status. The findings underscore the importance of preoperative evaluation of cardiopulmonary function, meticulous operative technique, and aggressive respiratory care in the management of the esophagectomy patient.

Pericardial cyst causing right ventricular outflow tract obstruction

Pleuropericardial cysts are rare. Rarer still are cardiopulmonary complications caused by their presence. We report the case of a pericardial cyst producing high-grade right ventricular outflow tract obstruction and its subsequent management. The clinical importance of transesophageal echocardiography is highlighted.

Outcome after failed initial therapy for rupture of the esophagus or intrathoracic stomach

Survival after rupture of the esophagus or intrathoracic stomach is improving, but continued leakage after initial therapy remains a problem. We retrospectively reviewed patients with rupture of the esophagus or intrathoracic stomach to determine the prevalence of continued leakage after initial therapy and how this complication affects outcome. Our review included 58 patients, 38 (66%) of whom had preexisting esophageal disease. The etiology of perforation was spontaneous rupture in 17, penetrating trauma in four, and iatrogenic injury in 35; two patients had perforation from other causes. Initial therapy consisted of drainage in eight, primary repair in 24, resection in 18, bypass in two, and observation in six. The overall mortality rate was 12% (7 of 58 patients) and continuing leaks were identified in 21% (12 of 58 patients). These leaks were unrelated to patient age, existence of prior disease, or delay in therapy but were more common after initial treatment by primary repair with or without pleural flap coverage compared to other management strategies (6 of 9 vs. 6 of 49; P < 0.001). Salvage therapy with survival was possible in 10 (83%) of 12 patients by means of esophagectomy in four, exclusion in one, drainage in two, or observation in three. Continuing leaks can be avoided by providing soft tissue coverage other than pleura over a primary repair and by not leaving an intrathoracic esophageal stump. Aggressive management of continuing leaks results in survival in more than 80% of patients.

Use of pleural catheter for the management of simple pneumothorax

STUDY OBJECTIVE

We assessed the use of a pleural catheter (Thoracic Vent) to determine its effectiveness in treating simple pneumothorax (PTX) and in preventing recurrent PTX.

DESIGN

A retrospective review was conducted of 84 patients treated with a pleural catheter for iatrogenic (52) and spontaneous (11 primary, 21 secondary) PTX between 1989 and 1994.

PATIENTS

There were 45 men and 39 women with a mean age of 50.4 years (range, 18 to 85 years).

RESULTS

Mean time to lung reexpansion was 0.5 +/- 0.1 days. Forty-five (57%) patients manifested an air leak after catheter placement for 2.0 +/- 0.2 days. The duration of time to catheter removal was 3.3 +/- 0.2 days. Seventy-one (85%) patients had resolution of PTX with this therapy alone. Thirteen patients (15%) failed to resolve their PTXs and required subsequent tube thoracostomy alone (6) or surgical therapy (7). Four of 11 patients who required tube thoracostomy also failed to respond to this therapy. Treatment failure was more common among patients with spontaneous PTX than with iatrogenic PTX (34% vs 4%; p < 0.005). During a mean follow-up of 3.0 +/- 0.2 years, 6 (7%) patients suffered recurrent PTX an average of 23 days after initial therapy.

CONCLUSION

This pleural catheter is effective in the management of simple iatrogenic and spontaneous PTX.

Results of myotomy and partial fundoplication after pneumatic dilation for achalasia

BACKGROUND

We questioned whether results of myotomy for achalasia are influenced by previous pneumatic dilation and whether surgical outcome is influenced by a dilation-related perforation necessitating urgent operation.

METHODS

We performed a retrospective analysis of 60 patients who underwent transthoracic myotomy and fundoplication from 1977 to 1995. Dysphagia, heartburn, pain, and regurgitation were scored on a scale of 0 to 3 and results were classified according to combined symptom score.

RESULTS

Dilation was performed before myotomy once in 15 patients, twice in 25, 3 times or more in 9, and never in 11 patients. Operation was urgent due to perforation in 6 patients (10%). There was no postoperative leak or mortality. Overall symptom score at last follow-up (57 +/- 8 months; 90% of patients) was improved compared with preoperative score (2.1 +/- 0.3 months versus 5.1 +/- 0.2 months; p < 0.0001). Outcome was unrelated to whether or not a perforation occurred (excellent/good outcomes in 100% and 88%, respectively) or to whether or not preoperative dilations had been performed (excellent/good outcomes in 90% and 89%, respectively).

CONCLUSIONS

Myotomy and partial fundoplication is an effective technique for management of achalasia. Results are unaffected by the need for urgent operation for perforation and are unrelated to whether pneumatic dilation is performed preoperatively.

Chondromyxoid fibroma of the sternum

We report the fourth case of chondromyxoid fibroma of the sternum described in the literature. The clinical, radiographic, pathologic and treatment aspects of this case are presented, and the literature on chondromyxoid fibroma in this unusual location is reviewed.

Thoracoscopic splanchnicectomy: technique and case report

Division of the greater and lesser splanchnic nerves using a thoracoscopic approach is presented. Splanchnicectomy has been described by several surgeons as a means of palliating chronic pancreatic pain caused by either alcohol-related chronic pancreatitis or pancreatic cancer. Thoracoscopy represents a minimally invasive approach to the splanchnic nerves. Current three-chip cameras enable a sixfold to eightfold magnification of intrathoracic structures, and the nerves are easily identified. The role of this operation in the thoracic surgeon's armamentarium awaits larger series of patients with longer follow-up.

Vinorelbine (Navelbine), cisplatin, and concomitant radiation therapy for advanced malignancies of the chest: a Phase I study

Most patients with advanced solid tumors of the chest will have local and/or distant disease progression despite standard therapy. Vinorelbine (Navelbine; Burroughs Wellcome Co, Research Triangle Park, NC; Pierre Fabre Medicament, Paris, France) is a new semisynthetic vinca alkaloid with single-agent activity in lung cancer that recently also has been shown to act as a radiosensitizer in vitro. This study aims to define the maximum tolerated dose and dose-limiting toxicity when vinorelbine is given with cisplatin and concomitant radiation therapy. To date, 25 patients with advanced malignancies of the chest have been treated in a dose-escalation trial of vinorelbine administered once weekly with cisplatin (100 mg/m2 every 21 days) and concomitant thoracic radiation therapy (2 Gy/d x 30 fractions for 60 Gy). Vinorelbine was initially given at 20 and 25 mg/m2/wk. Acute dose-limiting toxicity was myelosuppression, which was seen at a vinorelbine dose of 25/mg/m2/wk, with grade 4 neutropenia in two of three patients and one treatment-related death from neutropenic sepsis. At vinorelbine 20/mg/m2/wk, no acute dose-limiting toxicity was seen, but grade 3 or 4 esophagitis developed in three of six patients near the end or after completion of radiation therapy. We subsequently decreased the administration of vinorelbine to weeks 1, 2, 4, and 5. Tolerance appears to be greater with this schedule; however, severe or life-threatening esophagitis at the completion of therapy continues to be observed. Given these preliminary results, it appears feasible to treat patients with advanced chest malignancies with concomitant cisplatin, vinorelbine, and radiation therapy. The significant dose reduction of vinorelbine that is necessary with concomitant radiation therapy provides the first in vivo evidence of a strong radiosensitizing effect of vinorelbine. The schedule is currently being modified to reduce the incidence of esophagitis.

Parasternal mediastinotomy (Chamberlain procedure)

The indications for and technical considerations related to the performance of a parasternal mediastinotomy (Chamberlain procedure) are described. The results, including diagnostic yield, morbidity, and mortality of the procedure, are reviewed. Its current role in the thoracic surgeons' armamentarium is discussed.

Belsey Mark IV antireflux procedure

The unmodified version of the Belsey Mark IV antireflux procedure is described. Specific indications for use of this procedure to treat gastroesophageal reflux disease are listed. Patient preparation and anesthetic considerations are discussed.

Anatomy and physiology of the pleural space

The pleural cavity is created between the 4th and 7th week of embryologic development and is lined by the splanchnopleurae and somatopleurae. These embryonic components of visceral and parietal pleurae develop different anatomic characteristics with regard to vascular, lymphatic, and nervous supply. Both pleurae have two layers: a superficial mesothelial cell layer facing the pleural space and an underlying connective tissue layer. Various ultrastructures of the pleura show a close relationship to the basic functions of the pleural membranes, such as local inflammatory response and maintenance of the pleural fluid. The latter function is especially important in the mechanical coupling of the lung and chest wall. The fluid in the pleural space transmits transpleural forces involved in normal respiration, and the maintenance of the optimal volume and thickness is regulated closely. Fluid is filtered into the pleural space according to the net hydrostaticoncotic pressure gradient. It flows downward along a vertical pressure gradient, presumably determined by hydrostatic pressure and resistance to viscous flow. There also may be a net movement of fluid from the costal pleura to the mediastinal and interlobar regions. In these areas, pleural fluid is resorbed primarily through lymphatic stomata on the parietal pleural surface.

Surgical decision analysis: esophagectomy/esophagogastrectomy with or without drainage?

Decision analysis was used to compare three management strategies for patients undergoing esophagogastrectomy for carcinoma of the esophagus or gastric cardia: drain all patients with either pyloromyotomy or pyloroplasty, drain no patient, or perform a test that stratifies patients into high-risk and low-risk groups for development of gastric outlet obstruction and drain the high-risk group. Results indicate that a "drain all" approach is appropriate in clinical settings where the risk of gastric outlet obstruction is greater than 10%, as long as the drainage procedure is 95% effective. If a test were developed to stratify patients, it would have to have a sensitivity of 80% when its specificity was 100%, and would require a higher sensitivity as the specificity fell below 100%.

Cervical esophageal diverticulum associated with an impacted denture: a case report

The authors describe the case of a 19-year-old man who had swallowed his three-toothed radiolucent upper denture 2 years before the current admission. Although radiologic examination of the soft tissues of the neck and the results of barium meal examination were reported as normal immediately after the event, a barium meal examination 2 years later revealed formation of a cervical esophageal pouch, within which the denture was found at operation. The swallowing and possible impaction of a foreign body within the esophagus should prompt upper gastrointestinal endoscopy despite a negative result of a barium meal examination. Endoscopic removal is the treatment of choice, but surgery is appropriate in selected cases.

Randomized trial of one-dose versus six-dose cefazolin prophylaxis in elective general thoracic surgery

The objective of this study was to compare the efficacy of one to six doses of cefazolin as prophylaxis in general thoracic surgery using a randomized, double-blind design. Two-hundred eight consecutive patients admitted to a regional thoracic surgery unit for elective thoracotomy and lung resection were eligible for the trial. There were no wound infections in the one-dose group and two in the six-dose group (95% confidence intervals [CI]: -0.008, +0.048 [The positive number refers to the largest possible difference in favor of the one-dose group and the negative number, the largest possible difference in favor of the six-dose group]). Each group had eight postoperative chest infections (CI: -0.075, +0.077) and three empyemas (CI: -0.004, +0.050). Thirty-day mortality was 5% in the one-dose group and 4% in the six-dose group (CI: -0.053, +0.069). Postoperative duration of hospital stay, requirement for antibiotics, and the need for reoperation were comparable. These results suggest that six doses of cefazolin do not confer clinically important benefit beyond that obtained from a single dose for prophylaxis of wound infection in elective general thoracic surgery.

Hepatic resection for metastatic disease

Hepatic resection for metastatic disease is reviewed in 30 patients (mean age 58.9 years). The primary site was the colorectum in 25; the other primary tumours were leiomyosarcoma, plasmacytoma, and adenocarcinoma (all of gastric origin), ocular melanoma and an unknown primary. Operative procedures included 7 wedge resections, 5 segmentectomies and 21 lobectomies (11 right, 4 extended right and 6 left). Major complications in seven patients included intraoperative hemorrhage in three, two of whom died, bile-duct injury in two, small-bowel infarction in one and cerebrovascular accident in one. Operative death rate was 6.7% (2 of 30). Thirteen patients were alive and free of disease a mean of 24 months after hepatic resection while 5 more were alive with disease at a mean of 36.9 months. Life-table analysis projected a 5-year survival of 50.3% for those with colorectal primaries, with no apparent difference in survival between patients with single (55.0%) and multiple (54.0%) metastases. Improved survival was projected for patients with metachronous (66.6%) versus synchronous (45.0%) tumours, primary Dukes' class A or B (66.1%) versus Dukes' class C (46.0%) tumours and those having wedge resection or segmentectomy (66.6%) versus lobectomy or extended lobectomy (48.0%). Hepatic resection for metastatic disease can be done with acceptable morbidity and mortality and the expectation of substantially prolonged survival particularly in patients with metachronous lesions or Dukes's A or B colorectal primary lesions.

Palliative percutaneous transhepatic biliary drainage: assessment of morbidity and mortality

The results of palliative percutaneous transhepatic biliary drainage were assessed retrospectively in 16 cases and prospectively in 7 between 1982 and 1985. Causes of biliary obstruction were metastatic cancer (nine), pancreatic cancer (nine), cholangiocarcinoma (three) and gallbladder cancer (two). Internal drainage was established in 78.3%. In the 19 patients who died, the mean duration of drainage was 3.6 months. Early morbidity was 17.4%. Late septic morbidity occurred in 11 patients (48%) (a total of 28 episodes). Late deaths (31.2%) resulted from upper gastrointestinal hemorrhage, hepatic abscess, septic shock, subhepatic abscess and peritonitis. Percutaneous transhepatic biliary drainage is associated with substantial morbidity (67.4%) and mortality (35.5%) from infection. Palliation was modest; only eight patients spent more than half their survival time at home, and 10 patients never left hospital. Clinical trials are required to assess the risk-to-benefit ratio and role of percutaneous transhepatic biliary drainage versus surgical bypass in patients with lesions amenable to surgery, and biliary drainage versus no treatment in patients whose tumour cannot be bypassed.

Operative vs percutaneous drainage of intra-abdominal abscesses. Comparison of morbidity and mortality

This retrospective case-controlled study compares the morbidity and mortality of 27 percutaneously drained (PD) abscesses with 27 that were surgically drained (SD). Patients were matched for age, sex, diagnosis, and abscess etiology and location. There was no difference in severity of illness (acute physiology score [APS] = 8.3 vs 10.2), comparable morbidity (29.6% vs 40.7%), or mortality (11.0% vs 7.4%) between PD and SD groups. Duration of drainage was significantly longer in the PD group; however, this is explained in part by the 48% vs 18.5% difference in associated fistulae. Failures of the SD group had a higher mean APS (15) than both failures of the PD group (APS = 9.3) and successes of the SD group (APS = 8.6). All three PD group deaths and half of the SD group deaths were related to ongoing sepsis. Surgical drainage of intra-abdominal abscess is as successful as PD. Percutaneous drainage is reasonable initial treatment for intra-abdominal abscess; however, early assessment of clinical status and frequent reassessment are mandatory to ensure that failures are dealth with early. We present a drainage algorithm.