RESUMEN
Descending necrotising mediastinitis can complicate oropharyngeal infection and has a high associated mortality. We present three cases treated in our department and propose a treatment algorithm based on our experience and literature review. The primary oropharyngeal infection was peritonsillar abscess in two cases and odontogenic abscess in one. Two patients underwent cervicotomy and later thoracotomy. The third underwent cervicotomy with transcervical mediastinal drainage and later required pericardial drainage via a subxiphoid incision. All recovered fully and were discharged within 6 weeks. To enable successful treatment, diagnosis needs to be prompt and surgical drainage adequate. Thoracic management of the chest is essential.
Asunto(s)
Algoritmos , Mediastinitis/complicaciones , Mediastinitis/cirugía , Absceso Peritonsilar/complicaciones , Absceso Peritonsilar/cirugía , Adolescente , Adulto , Femenino , Humanos , Masculino , Mediastinitis/diagnóstico por imagen , Disección del Cuello , Necrosis/complicaciones , Necrosis/diagnóstico por imagen , Necrosis/cirugía , Absceso Peritonsilar/diagnóstico por imagen , Succión , Toracoscopía , Toracotomía , Tomografía Computarizada por Rayos XRESUMEN
OBJECTIVE: The diagnosis and management of oesophageal perforation continues to challenge clinicians. We present our experience of perforated oesophagus in a Tertiary Referral Centre for Thoracic and Oesophageal Surgery. METHODS: Between 1985 and 2000, 75 patients (40 male) with oesophageal perforation were treated in out unit; age range 24-89, median 63. Retrospective review of these cases has been performed. RESULTS: There were 12 deaths (16%). With increases in time from perforation to diagnosis, there was a stepwise increase in the mortality rate. Immediate diagnosis 5%; early diagnosis (1-24h) 14%; late diagnosis (>24h) 44% (P>or=0.002). Site of perforation, aetiology, and treatment strategy had no influence on mortality. The only independent predictor of mortality identified was time to diagnosis from perforation (beta 0.429, P=0.001). Time to definitive management in those undergoing an operative procedure had no influence on outcome with multivariate analysis. CONCLUSIONS: Prompt recognition of the diagnosis of oesophageal perforation and rapid institution of supportive measures, followed by an appropriate, patient specific treatment option optimises the chance of a successful outcome. The wide range of presentation of oesophageal perforation necessitates individualisation of treatment.
Asunto(s)
Perforación del Esófago/terapia , Adulto , Anciano , Anciano de 80 o más Años , Drenaje , Perforación del Esófago/diagnóstico , Perforación del Esófago/etiología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Factores de Tiempo , Resultado del TratamientoRESUMEN
AIMS: In vitro transfection experiments show that the nm23 gene suppresses metastasis, although the evidence from clinical studies is contradictory. The purpose of this study was to investigate whether nm23 selectively influences systemic, pleural, and lymphatic metastasis in non-small cell lung cancer (NSCLC). METHODS: Forty two patients undergoing resection of NSCLC and lymph node sampling were enrolled prospectively. In each case, a bone marrow aspirate, pleural lavage, and lymph nodes were assessed using immunohistochemistry for epithelial antigens and morphology. The intensity of nm23-H1 immunoreactivity of the primary tumour was compared with the internal control of normal bronchial epithelium in 32 cases where available. The microvessel count (MVC) of each tumour was determined using immunohistochemistry for the endothelial cell marker CD34. RESULTS: Tumour cell dissemination was detected in the bone marrow in 18 patients, in the pleura in seven, and in the lymph nodes in 21. Increased immunoreactivity for nm23 was found in the primary tumour in six patients, with none having tumour cells in the bone marrow, compared with 12 of 26 patients who showed nm23 immunoreactivity equal to or less than the control (Fisher's exact test: p = 0.043). This effect was confirmed to be independent of the MVC on multivariate analysis. There was no significant difference in the incidence of pleural or lymphatic tumour cell dissemination between the two groups. CONCLUSION: nm23 appears to be a suppressor of systemic, but not lymphatic, metastasis in primary NSCLC.
Asunto(s)
Carcinoma de Pulmón de Células no Pequeñas/secundario , Neoplasias Pulmonares/metabolismo , Neoplasias Pulmonares/patología , Proteínas de Unión al GTP Monoméricas/metabolismo , Proteínas de Neoplasias/metabolismo , Células Neoplásicas Circulantes/metabolismo , Nucleósido-Difosfato Quinasa , Factores de Transcripción/metabolismo , Anciano , Neoplasias de la Médula Ósea/secundario , Carcinoma de Pulmón de Células no Pequeñas/metabolismo , Carcinoma de Pulmón de Células no Pequeñas/patología , Femenino , Humanos , Metástasis Linfática , Masculino , Persona de Mediana Edad , Análisis Multivariante , Nucleósido Difosfato Quinasas NM23 , Neovascularización Patológica/metabolismo , Neoplasias Pleurales/secundario , Estudios Prospectivos , Manejo de Especímenes/métodosRESUMEN
OBJECTIVES: This study compares the posterior auscultatory triangle thoracotomy incision (muscle sparing) with full posterolateral thoracotomy (where latissimus dorsi muscle is always cut across its full width), with particular attention to the difference between latissimus dorsi muscle strength, post operative pain and chronic wound related symptoms. METHODS: Ten patients who had undergone auscultatory triangle thoracotomy (ATT) at least 1 year previously were matched with ten patients who had undergone posterolateral thoracotomy (PLT). Each pair was matched for age, sex, dominant hand, side of the operation, time since operation and presence or absence of history of previous muscle training. Latissimus dorsi muscle strength was assessed by testing the shoulder adduction strength through an arc of 90-0 degrees using isokinetic technique. Early post-operative pain was assessed indirectly by calculating the analgesic requirement in the first 5 post-operative days. A subjective assessment of chronic post-thoracotomy pain was made using a questionnaire presented to the patients at the time of muscle testing. Variability of the torque curves, recorded as coefficient of variance at the time of muscle strength testing, provided objective measurements of chronic pain. Data were analysed using two sample t-tests. RESULTS: All patients reported at least one chronic post-thoracotomy symptom. There was no significant difference between the two groups in terms of acute or chronic wound pain and other long term wound related symptoms. Shoulder adduction strength was 24% greater in ATT than PLT (95% confidence limits=1-43%, P=0.04). CONCLUSIONS: All thoracotomy patients have long term wound related symptoms. This situation is not improved by performing a muscle sparing incision. However thoracotomy through the triangle of auscultation can preserve latissimus dorsi strength which is compromised in a posterolateral thoracotomy incision. We therefore recommend that a muscle sparing thoracotomy be considered for patients where preservation of muscle strength is deemed important, providing the operation is not compromised due to inadequate access.
Asunto(s)
Músculos/fisiopatología , Músculos/cirugía , Dolor Postoperatorio/fisiopatología , Toracotomía/métodos , Adolescente , Adulto , Anciano , Fenómenos Biomecánicos , Drenaje , Femenino , Humanos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Toracotomía/estadística & datos numéricos , Factores de TiempoRESUMEN
Anabolic steroids increase appetite and muscle mass. This randomized, double-blind trial investigates any nutritional benefits of anabolic steroid in patients after surgery for esophageal cancer. Forty patients were recruited: 19 patients had five injections of 50 mg nandrolone decanoate and 21 patients received placebo over 3 months, starting 1 month after surgery. Measurements of body weight, mid-arm muscle circumference (MAMC) and appetite were taken over a 6-month period. Nutrition was optimized by dietary advice and by esophageal dilatation if required. Percent ideal weight, percent ideal MAMC and appetite score did not show significant differences between steroid and placebo groups, but there was a trend to an increase over 6 months for percent ideal MAMC in the test group. With this protocol, we have experienced minimal side-effects. However, we have not demonstrated any therapeutic benefit with low-dose steroid. An increased dose schedule over a longer period might produce a significant response.
Asunto(s)
Anabolizantes/administración & dosificación , Carcinoma de Células Escamosas/cirugía , Neoplasias Esofágicas/cirugía , Nandrolona/administración & dosificación , Trastornos Nutricionales/tratamiento farmacológico , Estado Nutricional/efectos de los fármacos , Complicaciones Posoperatorias/tratamiento farmacológico , Anciano , Anciano de 80 o más Años , Antropometría , Carcinoma de Células Escamosas/complicaciones , Distribución de Chi-Cuadrado , Método Doble Ciego , Neoplasias Esofágicas/complicaciones , Femenino , Humanos , Inyecciones Intramusculares , Masculino , Persona de Mediana Edad , Trastornos Nutricionales/etiología , Complicaciones Posoperatorias/etiología , Estudios Prospectivos , Estadísticas no Paramétricas , Resultado del Tratamiento , Aumento de Peso/efectos de los fármacosRESUMEN
BACKGROUND: The issue of performing simultaneous pulmonary resection and cardiac surgery in patients with coexisting lung carcinoma and ischaemic heart disease remains controversial. We report our experience and review the literature. METHODS: Thirteen patients (male ten, female three; mean age 65 years) underwent simultaneous cardiac surgery and pulmonary resection. Lung pathology consisted of primary lung carcinoma (n = 10), benign disease (n = 2) and carcinoid (n = 1). Lung resections included pneumonectomy (n = 3), lobectomy (n = 4), segmentectomy (n = 1) and local excision (n = 5). Cardiac procedures consisted of coronary artery bypass grafting (CABG) in 11, aortic valve replacement in one and mitral valve repair with CABG in one patient. In all but one case the lung resection was performed prior to heparinization and cardiopulmonary bypass (CPB). In two patients, with suitable coronary anatomy, myocardial revascularization without CPB was performed to reduce morbidity. RESULTS: There was no hospital mortality. Postoperative blood loss and ventilation requirements were reduced in the patients who were operated on without CPB. Prolonged ventilatory support was required in two cases. All patients with benign pathology are alive. In the lung cancer group there have been five late deaths: disseminated metastatic disease (n = 3), anticoagulant related haemorrhage (n = 1) and broncho-pleural fistula (n = 1). Of the remaining five patients four are alive and disease free 7-23 months post-operatively; one patient has recurrent disease 40 months post-operatively. CONCLUSIONS: Simultaneous pulmonary resection and cardiac surgery is associated with acceptable operative morbidity and mortality. In patients with lung carcinoma long-term survival was determined by tumour stage. The avoidance of CPB may be advantageous by decreasing blood loss and ventilation requirements.
Asunto(s)
Puente de Arteria Coronaria , Neoplasias Pulmonares/complicaciones , Neoplasias Pulmonares/cirugía , Isquemia Miocárdica/complicaciones , Isquemia Miocárdica/cirugía , Neumonectomía , Anciano , Puente Cardiopulmonar , Femenino , Humanos , Masculino , Persona de Mediana Edad , Respiración Artificial , Resultado del TratamientoRESUMEN
We have reported the results of a previous Phase II trial of two courses of neoadjuvant mitomycin (6 mg/m2), ifosfamide (3 g/m2) and cisplatin (50 mg/m2) (MIC) in squamous or anaplastic carcinoma of the oesophagus. In this current study, we have investigated whether there was any clinical benefit in extending the preoperative treatment to four courses for patients who responded after two courses. Response was assessed by barium swallow, which was compared with previous barium swallows performed prior to any treatment and after the second course of MIC. Of an initial 43 patients, 27 (63%) were assessed as responders after two courses of MIC. Twenty of these 27 patients were entered into the study with a view to receiving two further courses of MIC prior to surgery. Seventeen completed four courses. Five patients were complete responders after two courses and remained complete responders after four courses. Twelve patients were partial responders after two courses; six of these became complete responders after four courses, five remained partial responders, and one showed progression. Haematological toxicity and alopecia were increased after extending the number of courses beyond two. On pathological assessment, three patients with a complete response after four courses, and one with a complete response after three courses, had microscopic clearance of tumour. Extension beyond two courses of neoadjuvant MIC gives an improvement in response, as judged by barium assessment, but increases toxicity, cost of treatment and delay before surgery. Although the numbers are small, the results suggest that a worthwhile improvement in the radiological response of squamous or anaplastic oesophageal tumours may be gained by proceeding beyond two courses of MIC. A randomized trial, with larger numbers of patients, is needed to show whether there is any improvement in radiological and pathological response rates and in survival to be gained by the extension of treatment beyond two courses.
Asunto(s)
Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Carcinoma de Células Escamosas/cirugía , Carcinoma/cirugía , Neoplasias Esofágicas/cirugía , Adulto , Anciano , Alopecia/inducido químicamente , Antibióticos Antineoplásicos/administración & dosificación , Antibióticos Antineoplásicos/efectos adversos , Antibióticos Antineoplásicos/economía , Antineoplásicos/administración & dosificación , Antineoplásicos/efectos adversos , Antineoplásicos/economía , Antineoplásicos Alquilantes/administración & dosificación , Antineoplásicos Alquilantes/efectos adversos , Antineoplásicos Alquilantes/economía , Protocolos de Quimioterapia Combinada Antineoplásica/administración & dosificación , Protocolos de Quimioterapia Combinada Antineoplásica/efectos adversos , Protocolos de Quimioterapia Combinada Antineoplásica/economía , Sulfato de Bario , Carcinoma/diagnóstico por imagen , Carcinoma/tratamiento farmacológico , Carcinoma de Células Escamosas/diagnóstico por imagen , Carcinoma de Células Escamosas/tratamiento farmacológico , Quimioterapia Adyuvante , Cisplatino/administración & dosificación , Cisplatino/efectos adversos , Cisplatino/economía , Medios de Contraste , Esquema de Medicación , Neoplasias Esofágicas/diagnóstico por imagen , Neoplasias Esofágicas/tratamiento farmacológico , Femenino , Costos de la Atención en Salud , Enfermedades Hematológicas/inducido químicamente , Humanos , Ifosfamida/administración & dosificación , Ifosfamida/efectos adversos , Ifosfamida/economía , Masculino , Persona de Mediana Edad , Mitomicinas/administración & dosificación , Mitomicinas/efectos adversos , Mitomicinas/economía , Radiografía , Ensayos Clínicos Controlados Aleatorios como Asunto , Inducción de RemisiónRESUMEN
BACKGROUND: Many current methods of esophageal resection have drawbacks that result in inadequate proximal resection, inadequate lymphadenectomy, and difficult gastric and splenic access. We describe a technique that allows reliable and safe access to the chest, abdomen, and neck. STUDY DESIGN: From 1988 to 1995, 113 patients (82 men; mean age 65.3 +/- 4.5 years) with carcinoma of the esophagus or esophagogastric junction (middle third in 34, lower third in 41, and cardia in 38) underwent total thoracic esophagectomy. The histology was adenocarcinoma in 71 (62.8%), squamous cell carcinoma in 32 (28.3%), and undifferentiated carcinoma in 10 (8.9%) of the patients; 57 tumors (50.5%) were stage III. The esophagus and stomach were mobilized through a left thoracoabdominal incision. After completion of the esophageal resection, the fundus of the stomach was sutured to the esophageal stump to allow later delivery of the stomach into the neck. The esophagogastric anastomosis was performed with continuous single-layer absorbable suture through a left oblique cervical incision. RESULTS: The mean duration of the operation was 309.2 +/- 47.9 minutes. Hospital stay ranged from 5 to 49 days (median, 12 days). The perioperative mortality rate was 4.4%. Anastomotic leak occurred in six patients (5.3%), one of whom died. The proximal resection margin was microscopically free of tumor in all cases, and with a minimum followup period of 18 months, there has been no anastomotic recurrence in any patient. Actuarial survival at 1 year was 63.4% +/- 4.9%, at 3 years 41.4% +/- 5.9%, and at 5 years 22.7% +/- 6.3%. CONCLUSIONS: Total thoracic esophagectomy through the left chest with a separate left cervical incision allows clear access to the esophagus and stomach and good tumor clearance. This procedure may be performed with a low rate of anastomotic leakage, a very low mortality rate, and no anastomotic tumor recurrence.
Asunto(s)
Adenocarcinoma/cirugía , Carcinoma de Células Escamosas/cirugía , Neoplasias Esofágicas/cirugía , Esofagectomía/métodos , Adenocarcinoma/mortalidad , Adenocarcinoma/patología , Adulto , Anciano , Carcinoma de Células Escamosas/mortalidad , Carcinoma de Células Escamosas/patología , Neoplasias Esofágicas/mortalidad , Neoplasias Esofágicas/patología , Esofagectomía/estadística & datos numéricos , Unión Esofagogástrica/cirugía , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Estadificación de Neoplasias , Complicaciones Posoperatorias/epidemiología , Estudios ProspectivosRESUMEN
We describe a patient who had lipothymoma with red cell aplasia, hypogammaglobulinemia, and lichen planus. Parathymic syndromes described in association with lipothymomas also include myasthenia gravis, hyperthyroidism, lymphangioma, aplastic anemia, chronic lymphocytic leukemia, and Hodgkin's disease. The behavior of lipothymoma is generally benign, although local recurrence was noted in 1 patient who had an incomplete resection. Lipothymoma should be considered in the diagnosis of mediastinal tumors and parathymic syndromes, and also in patients with cardiomegaly, phrenic nerve palsy, and a widened mediastinum.
Asunto(s)
Agammaglobulinemia/complicaciones , Liquen Plano/complicaciones , Lipoma/complicaciones , Aplasia Pura de Células Rojas/complicaciones , Timoma/complicaciones , Neoplasias del Timo/complicaciones , Adulto , Humanos , Lipoma/diagnóstico por imagen , Lipoma/patología , Masculino , Radiografía , Timoma/diagnóstico por imagen , Timoma/patología , Neoplasias del Timo/diagnóstico por imagen , Neoplasias del Timo/patologíaRESUMEN
From January 1982 to December 1986, 167 patients (121 men and 46 women) with non-small cell lung cancer and a clinically negative mediastinum were found to have N2 lymph node metastases at thoracotomy and underwent pulmonary resection. Ages ranged from 31 to 86 years (median, 66 years). Adenocarcinoma was present in 70 patients (41.9%), squamous cell carcinoma in 64 (38.3%), large cell carcinoma in 20 (12.0%), adenosquamous cell carcinoma in 7 (4.2%), and bronchoalveolar cell carcinoma in 6 (3.6%). Forty-seven patients (28.1%) underwent mediastinoscopy; all results were negative. Pneumonectomy was performed in 64 patients, bilobectomy in 4, lobectomy in 76, segmentectomy in 2, and wedge excision in 21. Twenty patients had an incomplete resection. Thirty-five patients (21.0%) had complications, and the operative mortality was 4.8% (8 of 167 patients). Sixty-seven patients (40.1%) received adjuvant radiation therapy. The 5-year survival for the 147 patients who underwent complete resection was 23.7%. In contrast, 19 of the 20 patients (95.0%) who underwent incomplete resection died within 3 years. Other factors that significantly affected the 5-year survival were the number and location of metastatic lymph node stations, age, type of resection, and whether adjuvant radiation therapy was administered. We conclude that, when N2 disease is found at thoracotomy, complete resection is warranted to achieve long-term survival.
Asunto(s)
Carcinoma de Pulmón de Células no Pequeñas/cirugía , Neoplasias Pulmonares/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Carcinoma de Pulmón de Células no Pequeñas/mortalidad , Carcinoma de Pulmón de Células no Pequeñas/patología , Femenino , Humanos , Neoplasias Pulmonares/mortalidad , Neoplasias Pulmonares/patología , Metástasis Linfática , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias , Estudios Retrospectivos , Tasa de SupervivenciaRESUMEN
Leakage from an oesophagogastric anastomosis has a high morbidity and mortality. Recent evidence suggests that mechanical tissue stapling devices can decrease the rate of anastomotic breakdown but at the expense of an increase in the occurrence of fibrotic strictures at the anastomosis site. This study examines the rate of leakage and stricture in hand sutured and stapled anastomoses. A retrospective study was made of 221 oesophagogastric anastomoses following resection for carcinoma between 1977 and 1986. There were 122 sutured and 99 stapled anastomoses. Leak occurred in 21 sutured (17.2%) and 7 stapled (7.1%), P less than 0.05. If the stapled anastomosis was completely satisfactory and required no reinforcing sutures, the breakdown rate was in fact only 3% (2/69), P less than 0.01. A stapled anastomosis which required reinforcement had a similar chance of breakdown as a sutured anastomosis (16.7%). There was little difference in the performance of registrars in training and consultants at hand-sewn anastomoses with leakage rates of 13.7% and 18%, respectively; P greater than 0.05. The registrars, however, did not improve with the use of the stapler with a leakage rate of 14.3% compared to the consultants' rate of 1.75%, P less than 0.05. Involvement of the limits of resection with tumour slightly favoured breakdown--15.5% compared to 11.6% if the limits were free from tumour, P greater than 0.05. The incidence of malignant strictures was similar in both groups but benign stricture was more common in the stapled group--13% (13/99) compared to 1.6% (2/122), P less than 0.01. The mechanical stapler brings uniformity to the anastomosis but cannot compensate for deficiencies in surgical technique.