Effects of en bloc esophagectomy on nutritional and immune status in patients with esophageal carcinoma

BACKGROUND AND OBJECTIVES

En bloc esophagectomy has been established as the treatment of choice for patients with resectable esophageal carcinoma. However, an extensive surgical procedure may result in further impairment of the patient's nutritional status and immune system. Thus a prospective study was undertaken to evaluate the perioperative sequential changes in patients' nutritional and immune status and the timing to institute postoperative adjuvant therapy.

METHODS

Thirty-seven patients (34 male, 3 female) who had undergone en bloc esophagectomy with gastric institution for epidermoid carcinoma of the esophagus were studied. The mean age was 62.3 years. The nutritional and immune assessments were performed preoperatively, on the third postoperative day, in the first week, second week, third week, and at the end of the first and third month. The biochemical studies for nutritional evaluation included serum albumin, cholesterol, iron, transferrin, magnesium, zinc, total iron binding capacity (TIBC), and nitrogen balance. Evaluation of the immune status consisted of: (1) total lymphocyte count, (2) lymphocyte subpopulation, (3) immunoglobulins, (4) complements (C3 and C4), (5) lymphocyte blastogenic responses, (6) tumor necrosis factor-alpha and interleukin-2 secretion activity from mononuclear cells, and (7) C-reactive protein (CRP) level.

RESULTS

All the parameters in nutritional assessment declined profoundly by the third postoperative day (P < 0.05). The most severe deterioration was in serum iron, followed by transferrin, TIBC, cholesterol, and zinc. Most of them returned to the preoperative levels within 2-3 weeks after surgery. However, the serum levels of iron, transferrin, and TIBC required a longer period of time (> 1 month) to return to normal. A remarkable increase of serum CRP was detected in the first postoperative week (P < 0.05), but immunoglobulins and complements decreased significantly yet variably (P < 0.05) in the second or third postoperative week before gradually returning to preoperative levels. Moreover, during the first week after surgery, CD3 and CD8 diminished following esophageal surgery, whereas CD20, CD4/CD8 ratio, and lymphocyte blastogenic responses increased significantly (P < 0.05).

CONCLUSIONS

Except for iron-related parameters, all the other nutritional parameters returned to the preoperative level by the third postoperative week. An adequate supplementation of iron and protein for 1-3 months after surgery is needed. En bloc esophagectomy might have only a mild and temporarily adverse effect on the host immune defense. Regarding the postoperative recovery of a patient's nutritional and immune status, postoperative chemo-radiotherapy is optimally instituted after the third postoperative week, instead of within 2 weeks of surgery.

Anatomic basis of cleft palate and velopharyngeal surgery: implications from a fresh cadaveric study

The purpose of this investigation was to apply the findings of an anatomic study of the levator veli palatini, palatopharyngeus, and superior constrictor muscles in 18 fresh cadaveric specimens of normal adults to analyze current controversies in velopharyngeal function and cleft palate surgery. The levator veli palatini was observed to form a muscular sling, suspending the velum from the cranial base. Its fibers occupied the middle 50 percent of the velum, lying in transverse orientation and without significant overlap across the midline. It is well placed to function as the prime mover in the velar component of velopharyngeal closure. The velar component of the palatopharyngeus consisted of two heads clasping the levator and inserting into the latter just short of the midline. Its pharyngeal component inserted into the superior constrictor in the lateral and posterior pharyngeal walls. Together, these two muscles formed a sphincter around the velopharyngeal port, suggesting that both muscles are involved in the pharyngeal component of velopharyngeal closure. Based on the premise that the goal of palatoplasty is to restore normal anatomy, the intravelar veloplasty has a sound basis, and theoretically improves both velar and pharyngeal wall function because it corrects the dysmorphology of both the levator and palatopharyngeus. Although the Furlow palatoplasty also reorients these velar muscles correctly in the transverse position, the resulting overlap of the levator and palatopharyngeus across the midline is morphologically abnormal. In addition, the use of large Z-plasty flaps in wide clefts may cause excessive lateral tension, increasing the risk of fistula formation and causing an impairment of velar stretch capacity. The raising of a vertical pharyngeal flap divides the fibers of the superior constrictor and has the potential to impair pharyngeal wall function. The sphincter pharyngoplasty interferes less with pharyngeal wall anatomy. The potential for an obstructive outcome seems to be related to the use of wide, long flaps and a tight, overlapping type of flap inset. In addition, the level of flap inset is important: an inset at the level of the uvula has the greatest risk of causing obstruction, whereas a higher inset at the level of attempted velopharyngeal closure seems to provide the best opportunity for achieving velopharyngeal competence while avoiding hyponasality and obstruction.

Downregulation of endothelin B receptors in cardiomyopathic hamsters

The mechanisms responsible for abnormal fluid retention in congestive heart failure (CHF) are unclear. Studies were conducted to elucidate how endothelin (ET) may contribute to salt and water retention. Cardiomyopathic (CM) hamsters with moderate heart failure were employed for in vivo and in vitro trials. Clearance methods were used to compare the level of renal function in CM hamsters and control animals. Radioligand binding studies were also performed to determine ET receptor distribution in the inner medullary collecting ducts. CM hamsters exhibited an attenuated response to ANF infusion (FENa: 2.7 +/- 0.5 vs. 5.9 +/- 0.8%, p < 0.01; FEH2O: 1.7 +/- 0.3 vs. 3.2 +/- 0.4%, p < 0.01; UcGMP: 11.2 +/- 2.3 vs. 16.6 +/- 2.0 pmol/min, p < 0.05) and a decrease in total ET receptor density (532 +/- 77 vs. 959 +/- 154 fmol/mg protein, p < 0.005). Particularly ETB receptors were significantly reduced (214 +/- 26 vs. 483 +/- 88 fmol/mg protein, p < 0.003). Enalapril therapy simultaneously restored the natriuretic and diuretic effects of ANF and ET receptor density in the diseased animals. These studies suggest that the renin-angiotensin-aldosterone system and ET hormonal system act together, via ETB receptor downregulation, to promote the abnormal fluid retention observed in CHF.

Lymph node metastasis in squamous cell carcinoma of the intrathoracic esophagus

BACKGROUND

In esophageal carcinoma lymph node metastasis is one of the most important factors of prognosis. This prospective study evaluated the incidence and extent of lymph node metastasis, and assessed the relationship between the depth of tumor invasion and lymph node metastasis in esophageal carcinoma.

METHODS

Between 1985 and 1996, tissue samples from 112 patients undergoing radical esophagectomy and gastric substitution for squamous cell carcinoma of the intrathoracic esophagus were collected. Patients with distant organ metastasis were excluded. All specimens were evaluated and sent for histopathologic examination.

RESULTS

In 108 men and four women with a mean age of 63.1 years, the average number of dissected lymph nodes in one surgical procedure, was 30 per person. The most commonly involved nodes were the periesophageal (42.9%) and the perigastric (42.9%) nodes, followed by the recurrent laryngeal nerve (23.8%) and thoracic paratracheal (22.2%) nodes. For tumors in the upper third of the esophagus, the most frequently involved nodal groups were the periesophageal (28.6%) and the paratracheal (28.6%) nodes, followed by the recurrent laryngeal nerve (21.4%) the deep cervical (21.4%), and the perigastric (21.4%) nodes. For tumors in the middle third of the esophagus, the periesophageal nodes (27.3%) were most commonly involved, followed by the perigastric (18.2%) and the subcarina (10.6%) nodes. For tumors in the lower third of the esophagus, the perigastric lymph nodes (37.5%) were the most common nodal metastatic site, followed by the celiac (18.8%) and the recurrent laryngeal nerve (18.2%) nodes. Depth of tumor invasion was also found to correlate significantly with lymph node metastasis (p = 0.0015).

CONCLUSIONS

Wide lymph node metastasis between the neck and the upper abdomen occurs frequently in squamous cell carcinoma of the esophagus. For potentially curable esophageal carcinomas, en-bloc esophagectomy with complete locoregional lymph node dissection may provide favorable local control of the lesion and more accurate tumor staging.

Effects of en bloc esophagectomy on nutritional and immune status in patients with esophageal carcinoma

BACKGROUND AND OBJECTIVES

En bloc esophagectomy has been established as the treatment of choice for patients with resectable esophageal carcinoma. However, an extensive surgical procedure may result in further impairment of the patient's nutritional status and immune system. Thus a prospective study was undertaken to evaluate the perioperative sequential changes in patients' nutritional and immune status and the timing to institute postoperative adjuvant therapy.

METHODS

Thirty-seven patients (34 male, 3 female) who had undergone en bloc esophagectomy with gastric institution for epidermoid carcinoma of the esophagus were studied. The mean age was 62.3 years. The nutritional and immune assessments were performed preoperatively, on the third postoperative day, in the first week, second week, third week, and at the end of the first and third month. The biochemical studies for nutritional evaluation included serum albumin, cholesterol, iron, transferrin, magnesium, zinc, total iron binding capacity (TIBC), and nitrogen balance. Evaluation of the immune status consisted of: (1) total lymphocyte count, (2) lymphocyte subpopulation, (3) immunoglobulins, (4) complements (C3 and C4), (5) lymphocyte blastogenic responses, (6) tumor necrosis factor-alpha and interleukin-2 secretion activity from mononuclear cells, and (7) C-reactive protein (CRP) level.

RESULTS

All the parameters in nutritional assessment declined profoundly by the third postoperative day (P < 0.05). The most severe deterioration was in serum iron, followed by transferrin, TIBC, cholesterol, and zinc. Most of them returned to the preoperative levels within 2-3 weeks after surgery. However, the serum levels of iron, transferrin, and TIBC required a longer period of time (> 1 month) to return to normal. A remarkable increase of serum CRP was detected in the first postoperative week (P < 0.05), but immunoglobulins and complements decreased significantly yet variably (P < 0.05) in the second or third postoperative week before gradually returning to preoperative levels. Moreover, during the first week after surgery, CD3 and CD8 diminished following esophageal surgery, whereas CD20, CD4/CD8 ratio, and lymphocyte blastogenic responses increased significantly (P < 0.05).

CONCLUSIONS

Except for iron-related parameters, all the other nutritional parameters returned to the preoperative level by the third postoperative week. An adequate supplementation of iron and protein for 1-3 months after surgery is needed. En bloc esophagectomy might have only a mild and temporarily adverse effect on the host immune defense. Regarding the postoperative recovery of a patient's nutritional and immune status, postoperative chemo-radiotherapy is optimally instituted after the third postoperative week, instead of within 2 weeks of surgery.

Reflex sympathetic dystrophy syndrome in stroke patients with hemiplegia-three phase bone scintigraphy and clinical characteristics

In an attempt to investigate the correlation between three phase bone scintigraphy (TPBS) and the clinical manifestation of reflex sympathetic dystrophy syndrome (RSDS) in the upper extremity of hemiplegia, we collected 30 patients with cerebral vascular accidents (CVA) confirmed by head computed tomography (infarction or hemorrhage) within 3 months of their CVA event. All patients received TPBS after admission. Clinical assessment for the development of the RSDS was done at least 3 months (268 +/- 120 days) after the stroke. The correlation between the development of RSD and certain clinical variables (including sex, age, side affected, caused of stroke, and motor stage) were analyzed. Twelve patients (40%) manifested definite or probable RSDS, as assessed by Tepperman's criteria, during the follow-up period. Nineteen patients (63%) exhibited radionuclide evidence of RSDS based on delayed bone scan criteria performed within 3 months (43 +/- 25 days) of the stroke. The positive delayed image of TPBS demonstrated a sensitivity = 92%; specificity = 56%; positive predictive value = 58%, and negative predictive value = 91%. The Kappa statistics for agreement between positive bone scan and RSDS development was 70% (Kappa = 0.43, p < 0.05). Neither sex, age, side affected, cause of stroke, or motor stage had a significant correlation with clinical RSDS. In conclusion, TPBS is a useful screening tool for the development of RSD in hemiplegic patients. However, the diagnosis of RSDS depends on the clinical evaluation and that TPBS as an adjunct assessment of RSDS must be interpreted with caution.

Mandibular odontogenic fibrosarcoma. Case report

A rare case of mandibular odontogenic fibroma is presented which transformed to a stage 1A odontogenic fibrosarcoma with a local recurrence after surgical resection and unusually delayed pulmonary metastases eight years later. Prolonged follow-up of these patients after complete surgical resection, including regular chest X-rays, is recommended.

The role of mucopolysaccharide induction in treatment of experimental osteoarthritis in rats by ultrasound

Therapeutic ultrasound has been used in the treatment of osteoarthritis for the relief of symptom and improvement of functional status. In recent study, we found that ultrasound enhances cartilage repair in experimental early stage osteoarthritis, and prevents deteriorative changes in later stages. In the present study, we further investigate the bioeffects of ultrasound on cartilage matrix of experimental arthritis. Fifty-four rats with three different degrees of papain induced osteoarthritis classified by 99m-Tc pertechnetate bone scan were collected for ultrasound treatment. The changes in their arthritic severity after sonication treatment and two months after treatment were measured using 99m-Tc bone scan. The histopathological changes were evaluated through light microscope after disarticulation sections (H.E. stain), and the changes in mucopolysaccharide density in cartilage matrix were measured using a Optimas scanner analyzer after Alcian blue staining. The results showed that the density of mucopolysaccharide rose in the initial stage of induced arthritis, and decreased progressively in the later stage. The density of mucopolysaccharide increased upon complete sonication more for the treated rats than for the controls, and this was closely related with the improvement in histopathological findings, but inversely with the changes in arthritic severity. In conclusion, therapeutic ultrasound enhances mucopolysaccharide synthesis of arthritic cartilage, and results in the repair of arthritic cartilage in the early stage of induced arthritis and the prevention of deteriorative changes in later stages.

Structure of the musculus uvulae: functional and surgical implications of an anatomic study

OBJECTIVE

The role of the musculus uvulae in velopharyngeal function, its morphologic status in cleft palate, and its fate in palatoplasty procedures are subjects of controversy. The aims of this investigation were to re-examine this velar muscle to clarify its anatomic characteristics, to analyze its role in speech physiology, and to study the surgical implications of this information for cleft palate repair.

METHODS

Its attachments, morphology, and relations were examined in 18 fresh human adult cadavers by detailed dissection under 3.2x magnification and light microscopy.

RESULTS

The musculus uvulae was observed to be a paired midline muscle extending between the tensor aponeurosis anteriorly and the base of the uvula posteriorly along the nasal aspect of the velum. It had no attachments to the hard palate.

CONCLUSIONS

These findings suggest that its action is to increase midline bulk on the nasal aspect of the velum, thus contributing to the levator eminence. It may also have an extensor effect on the nasal aspect of the velum, displacing it toward the posterior pharyngeal wall. Both of these actions would serve to maximize midline velopharyngeal contact. One clinical application of this anatomic information is that the muscle should be preserved in the dissection performed during intravelar veloplasty. Furthermore, it should be recognized that the musculus uvulae is invariably divided and reoriented incorrectly in the Furlow double opposing Z-plasty.

Studies on the hypotensive and bradycardic effects of 1-piperidinylmethyl-2-naphthol hydrochloride

The cardiovascular activity of TPI in lowering the blood pressure and heart rate in anesthetized rats was studied using pharmacological and physiological techniques. The hypotensive and bradycardiac actions induced by a bolus intravenous injection were significantly inhibited by pretreatment with atropine (0.1 mg/kg; i.v.). Vagotomy almost abolished the hypotensive response but moderate bradycardia still remained. Microinjection of TPI (1-10 nmol) into the nucleus tractus solitarii of brain stem produced a prominent dose related hypotensive and bradycardic effects. TPI also produced a decrease in the force of contraction of the isolated right atrium of guinea pig. These results suggest that the effects of TPI may involve an activation of the vagus nerve and suppressive action on myocardial tissue.

Revisit of primary malignant neoplasms of the trachea: clinical characteristics and survival analysis

A clinical review with an analysis of prognostic factors, including clinical characteristics, histological classifications, presenting symptoms/signs and treatment modalities, was conducted in 67 patients with primary malignant neoplasms of the trachea who were seen at the Veterans General Hospital-Taipei between 1979 and 1994. The incidence of tracheal cancer was 140 times less than lung cancer during this period. Delayed diagnosis of more than 6 months after onset of symptoms occurred in one-third of the patients owing to lack of specific symptoms/signs indicative of tracheal disease. Epidermoid carcinoma was the most frequent histological type encountered and accounted for half of the cases. Surgical resection was the first choice of treatment for all patients if the disease was locally confined, except for small cell carcinoma and lymphoma. Radiotherapy was given if the patient was not suitable for surgery. Single and multivariate analyses showed that clinical symptoms and signs were not related to prognosis, except for general malaise and acute respiratory failure. Patients suffering from adenoid cystic carcinoma and mucoepidermoid carcinoma had a better prognosis than other histological diagnoses. Whether the patient received radiotherapy or not proved to be a significant prognostic factor in the patients. Patients with tracheal cancers had a poorer prognosis than those with lung cancer.

Effects of sonication on articular cartilage in experimental osteoarthritis

OBJECTIVE

To investigate the histological effect of therapeutic ultrasound on arthritic cartilage of rats with various severities of induced osteoarthritis.

METHODS

Twenty-seven rats with 3 different stages (Grade I, II, III) of papain induced knee arthritis received 7 min pulse sonication treatment, 3 times/week for 4 weeks. Another 27 rats with the same severity of induced arthritis were studied as controls. The severity of arthritis and related histopathological changes of articular cartilage were evaluated by bone scan and histological findings with hematoxylin and eosin stain.

RESULTS

"Severity indexes" based on bone scan decreased after sonication treatment in each study group. Histopathological findings indicated marked cartilage repair in the early stage of induced arthritis (Grade I). However, progressive cartilage damage present in untreated Grade II, III induced arthritis was significantly reduced after sonication.

CONCLUSION

Therapeutic ultrasound enhances cartilage repair in the early stage, and has the effect of arresting further deteriorative damage in the later stage of induced arthritis.

A fresh cadaveric study of the paratubal muscles: implications for eustachian tube function in cleft palate

The aims of this anatomic investigation were to examine the levator veli palatini, tensor veli palatini, and salpingopharyngeus muscles in relation to normal eustachian tube function and to analyze the clinical implications of these data for tubal physiology in cleft palate individuals. Detailed dissections under 3.2x loupe magnification were conducted on the paratubal muscles of 15 fresh human adult cadaveric head specimens, paying particular attention to their cranial base anatomy. Each half of the cadaveric heads was examined separately, giving a sample size of 30. The cranial base origin of the levator veli palatini was the junction of the cartilaginous and bony parts of the eustachian tube. Contrary to statements in the existing literature, it had no origin from the quadrate area of the petrous temporal bone. In its path toward the velum, it was related inferiorly and lay almost parallel to the tube. The tensor veli palatini originated from the scaphoid fossa of the sphenoid bone and the tube. In contrast to previous descriptions, it was found to consist of a single sheet of muscle with no bilaminar structure. Its axis was oblique to that of the tube. The salpingopharyngeus was a slender muscle attached to the posteroinferior aspect of the pharyngeal end of the tube. It inserted into the palatopharyngeus inferiorly. These morphologic characteristics and anatomic relationships suggest that (1) the levator veli palatini opens the eustachian tube by isotonic contraction that results in displacement of the medial tubal cartilage and the tubal membrane, (2) the tensor veli palatini opens the tube directly by traction on the lateral tubal membrane and indirectly by rotation of the medial tubal cartilage by means of traction on the lateral tubal cartilage, (3) because of its consistently small size, the salpingopharyngeus is probably functionally the least important of the paratubal muscles, (4) the levator veli palatini is unable to cause tubal dilatation in cleft palate because it can only contract isometrically, and (5) tensor veli palatini function is probably unaffected by clefting. However, its mechanism of action may be disrupted iatrogenically by complete hamular fracture or division of its tendon.

Primary pulmonary malignant hemangiopericytoma associated with coagulopathy

A 34-year-old woman with a massive pulmonary malignant hemangiopericytoma and coagulopathy as a paraneoplastic syndrome is reported. Although coagulopathy may appear as a paraneoplastic syndrome and cause treatment to be more complicated and difficult, it can also be a useful marker to monitor the results of operation and tumor recurrence. This unusual case shows that primary pulmonary malignant hemangiopericytoma deserves aggressive surgical intervention with complete resection even under the circumstances of coagulation abnormality.

Estimated consumption and eating frequency of olestra from savory snacks using menu census data

Potential chronic (14-d average) and acute (single-day) estimated daily intakes (EDI) were computed for olestra, a fat replacement intended for use in preparing savory snacks. The EDI were computed from eating occasions reported during a 14-d Menu Census survey among 4741 consumers; values were increased by 10% for conservatism. The eating occasions included all meals and in-between meal occasions eaten at home or away. Data from only those individuals who ate savory snacks at least once during the 14 d were used; this included 3820 individuals (81% of the sample) and represented a total of 16,067 eating days (24% frequency). The estimated mean chronic intake ranged from 1.8 to 4.7 g/d, depending on age and gender; at the 90th percentile, the range was 4.1-11.0 g/d. For all ages and both genders, the estimated mean intake was 3.1 g/d. Estimated acute intakes at the mean and 90th percentile ranged from 5.5 to 16.5 g/d and from 10.2 to 24.0 g/d, respectively, depending on age and gender. For all ages and both genders, the estimated mean intake was 10.2 g/d. The lack of parity in the chronic and acute intake estimates indicates that savory snacks are not eaten on a daily basis by the majority of snack eaters. The survey data were analyzed to understand the potential temporal eating patterns of olestra from savory snacks. When snacks were consumed, on average, 69% of the eating occasions were with main meals and 31% were between meals. Savory snacks did not contribute a major fraction of total food to the diet; only 7 and 18% of main meals contained a savory snack food at the 50th and 90th percentile, respectively. For the 50th-percentile consumer (all ages, both genders), savory snacks were eaten four times during the 14-d survey period, and the eating occasions occurred on 3 d. Comparable results for 90th-percentile consumers were 10 eating occasions and 8 eating days.

The prognosis of patients with cervical spondylotic myelopathy

We studied 56 patients who received complete neurological examinations, image studies, or electrophysiological studies, and for these cervical spondylotic myelopathy was diagnosed at the Kaohsiung Medical College Hospital during the period 1988 to 1993. For the purposes of identifying possible prognosis factors and comparing the results of patients with conservative treatment versus operative treatment, we designed this study. Informed consent and a completed functional evaluation were obtained from 31 patients via physiatrist's visits. 17 patients (male = 11, female = 6) mean age 52 years old received conservative treatment and 14 patients (male = 11, female = 3) mean age 50 years old received operative treatment. For the conservative group, the average follow-up was 54 months and for the operative group, the average duration (from symptom and sign onset until operation) was 23 months. According to "The Japanese Orthopaedic Association Scale" and "The Recovery Rate Scale", we have evaluated the functional change of patients during the follow-up period and different possible prognosis factors have been analyzed. There is no significant difference in recovery rate whether patient's age is over 50 years old or whether the individual Pavlov ratio is smaller than 0.7. Interestingly, patients who received operation (anterior or posterior approach) within 18 months since symptom and sign onset were found to have a better recovery rate (p = 0.03). In our study, conservative management leads to 35% improvement and the operative management leads to 43% improvement. The results of proper cases selection and operation are superior to conservative treatment. If a patient has received a conservative treatment, routine re-evaluation is then very important for the early detection of progressive compression myelopathy signs.

AgNORs in lung cancer: correlation with DNA ploidy and degree of differentiation

OBJECTIVE

To assess the usefulness of enumerating argyrophilic nucleolar organizer regions (AgNORs) in assisting with the diagnosis, as well as its correlation with the degree of differentiation and DNA ploidy, in lung cancer.

STUDY DESIGN

The specimens, taken from 151 benign and malignant pulmonary tumors, were stained with silver nitrate before the number of AgNORs was counted. DNA ploidy was determined in 58 cases of lung cancers. All cases of adenocarcinoma and squamous cell carcinoma were histologically classified as well, moderately or poorly differentiated.

RESULTS

Lung cancers had more AgNORs than benign tumors, and small cell carcinomas had fewer AgNORs than non-NSCLC (P < .001). The mean AgNOR number in adenocarcinoma increased progressively in accordance with poorer differentiation (P < .001). There was no correlation between the number of AgNORs and DNA ploidy.

CONCLUSION

Counting AgNORs helps with the differential diagnosis of lung cancers. In adenocarcinoma of the lung, the AgNOR number increases as the degree of differentiation decreases.

Leakage of intrathoracic oesophagovisceral anastomoses in adenocarcinoma of the gastric cardia: changes in serial APACHE II scores and their prognostic significance

OBJECTIVE

To evaluate changes in serial Acute Physiology and Chronic Health Evaluation (APACHE) II scores in patients with intrathoracic oesophageal anastomotic leaks and to assess their prognostic significance.

DESIGN

Retrospective study.

SETTING

Teaching hospital, Taiwan.

SUBJECTS

18 patients (4%) who developed intrathoracic oesophageal anastomotic leaks in a total of 491 patients who underwent oesophagogastrectomy for adenocarcinoma of the gastric cardia between 1980 and 1994.

MAIN OUTCOME MEASURE

APACHE II scores in those that survived (n = 10) compared with those who died (n = 8).

RESULTS

Of the 18 patients, 8 (44%) died. The preoperative general condition, biochemical data, and perioperative APACHE II scores were similar in the two groups. Leakage from the oesophageal anastomoses caused similar degrees of sepsis in the two groups in terms of APACHE II scoring, but the APACHE II scores of survivors started to decline within a week of initial management. In contrast, the APACHE II scores of those who died had increased one week after the leak had been diagnosed despite initial management. There were significant differences in the APACHE II scores of survivors and those who died from one week after leakage until discharge or death (p < 0.001). Only one patient (1/9) survived if the APACHE II score one week after diagnosis of the leak was more than 10. None died of the leak if the APACHE II scores were equal to or less than 10 after a week.

CONCLUSIONS

Adequate surgical drainage, antibiotic cover according to the microbiological picture, and nutritional support are essential in the management of intrathoracic oesophageal fistulas. Early reoperation to close early leaks by simple suture or secondary wrapping and to improve local drainage is recommended. The APACHE II scoring system is valuable in evaluating the severity of sepsis caused by intrathoracic oesophagovisceral anastomosis leaks and may serve as an indicator of adequate management. Aggressive surgical measures should be considered if APACHE II scores rise during initial management.

The expression of genes modulating programmed cell death in normal human polymorphonuclear neutrophils

Normal human polymorphonuclear neutrophils (PMN) have a short life and die in progression via apoptosis. In order to understand the molecular basis of PMN apoptosis, the expression of apoptosis-related (Fas, Fas-ligand, p53, and c-myc) and survival-related (bcl-2) genes was detected by flow cytometry, Western blot and reverse transcription-assisted polymerase chain reaction (RT-PCR). We found that Fas and Fas-ligand (FasL) were expressed on the surface of most of the cells. However, the disappearance of FasL was much faster than Fas after 24 h incubation. p53 and bcl-2 were also expressed in the cytoplasm of most of the cells. In contrast, the expression of c-myc was negligible in PMN. The addition of monoclonal anti-human Fas antibody (25 micrograms/ml) to PMN suspension enhanced whereas anti-FasL antibody (25 micrograms/ml) suppressed PMN apoptosis in 48 h incubation. These results suggest that the activation of Fas pathway induced by Fas-FasL interaction among PMNs is one of the mechanisms for spontaneous PMN apoptosis. Lack of proto-oncoprotein c-myc expression in PMN is responsible for their non-proliferative property and may aggravate the spontaneous apoptosis of the cells.

Surgical treatment of endobronchial tuberculosis

The incidence of tuberculosis remains fairly high in some developing countries. Endobronchial tuberculosis may cause bronchostenosis, with potentially severe respiratory symptoms, atelectasis and secondary pneumonitis. Thirty-two surgically treated cases of tuberculous bronchostenosis (33 operations) are presented. In 13 cases-segmental resection or lobectomy was performed with bronchoplastic procedures. Anastomotic stenosis necessitated pneumonectomy 5 years later in one of the 13 and one patient had wound infection. Nineteen patients underwent pulmonary resection without bronchoplasty. Apart from the patient with anastomotic stenosis, all 32 were symptom-free in the follow-up period. Forced expiratory volume was significantly improved in the ten tested patients with bronchoplasty. The results suggest that surgical treatment is safe for endobronchial tuberculosis with poor response to specific chemotherapy. In addition to checking progression of the disease, bronchoplasty helps to preserve lung function. Appropriate chemotherapy should be given for 9-12 months perioperatively to prevent recurrence and restenosis.

Endoscopic pediatric plastic surgery

Although the advent of endoscopic technology is expanding the fields of reconstructive and aesthetic surgery in adults, there have been to date no reports of its use in the pediatric population. Because of its minimally invasive nature, yet wide range of exposure, endoscopic techniques have much appeal in this age group. Herein we present our initial experience with endoscopic pediatric plastic surgery. From February 1995 to December 1995, 41 patients were treated utilizing 5-mm and 10-mm endoscopes at Scottish Rite Children's Medical Center, Atlanta, GA. There were 19 males and 22 females. The mean age at surgery was 5.6 years (range, 7 months-15 years). The most common types of procedures performed were insertion of tissue expanders (N = 19), excision of facial dermoids (N = 7), torticollis release (N = 5), and excision of vascular lesions (N = 4). The remaining 6 patients underwent a variety of reconstructive procedures. The complication rate in the tissue expander group was 3 out of 39 expanders inserted (9.5%), and consisted of infection (N = 2) and rupture (N = 1). In the dermoid group, complications consisted of wound infection requiring reoperation (N = 1), and transient frontal paresis (N = 1). One patient in the hemangioma group had an incomplete resection necessitating open excision. The remaining patients all had satisfactory outcomes with no complications. The majority of the procedures were done on an outpatient basis. These results suggest that endoscopic techniques are eminently applicable in the pediatric population, providing the benefits of small and remote incisional wounds with complication rates that are comparable to those of conventional surgical treatment.

The differential diagnosis of posterior plagiocephaly: true lambdoid synostosis versus positional molding

The diagnosis and treatment of posterior plagiocephaly is one of the most controversial aspects of craniofacial surgery. The features of true lambdoid synostosis versus those of deformational plagiocephaly secondary to positional molding are inadequately described in the literature and poorly understood. This has resulted in many infants in several craniofacial centers across the United States undergoing major intracranial procedures for non-synostotic plagiocephaly. The purpose of this study was to describe the detailed clinical, imaging, and operative features of true lambdoid synostosis and contrast them with the features of positional plagiocephaly. During a 4-year period from 1991 to 1994, 102 patients with posterior plagiocephaly were assessed in a large multidisciplinary craniofacial program. During the same period, 130 patients with craniosynostosis received surgical treatment. All patients were examined by a pediatric dysmorphologist, craniofacial surgeon, and pediatric neurosurgeon. Diagnostic imaging was performed where indicated. Patients diagnosed with lambdoid synostosis and severe and progressive positional molding underwent surgical correction using standard craniofacial techniques. Only 4 patients manifested the clinical, imaging, and operative features of unilambdoid synostosis, giving an incidence among all cases of craniosynostosis of 3.1 percent. Only 3 among the 98 patients with positional molding required surgical intervention. All the patients with unilambdoid synostosis had a thick ridge over the fused suture, identical to that found in other forms of craniosynostosis, with compensatory contralateral parietal and frontal bossing and an ipsilateral occipitomastoid bulge. The skull base had an ipsilateral inferior tilt, with a corresponding inferior and posterior displacement of the ipsilateral ear. These characteristics were completely opposite to the findings in the 98 patients who had positional molding with open lambdoid sutures and prove conclusively that true unilambdoid synostosis exists as a specific but rare entity. Awareness of the features of unilambdoid synostosis will allow more accurate diagnosis and appropriate treatment of posterior plagiocephaly in general and in particular will avoid unnecessary surgical intervention in patients with positional molding.

Age-related 4,977 bp deletion in human lung mitochondrial DNA

The accumulation of mitochondrial DNA (mtDNA) mutations has been suggested to be an important contributor to human aging and degenerative diseases. The lung is exposed to ambient air and makes direct contact with the external environment. Numerous potentially noxious agents may damage lung tissues directly or indirectly through free-radical-mediated reactions. In previous studies, we demonstrated an age-dependent increase of mtDNA mutations in various human tissues. We hypothesize that the accumulation of the 4,977 bp (base pairs) deleted mtDNA in human lung tissues is also age-dependent. Using the polymerase chain reaction technique, we determined the incidence of the 4,977 bp-deleted mtDNA in 127 human lung specimens from 34-wk gestation to 79 yr of age. The results showed that 77 lung biopsies (60.6%) contained the 4,977 bp-deleted mtDNA, which started to appear in lung tissues after the fourth decade of life. The incidence apparently increased from 14.3% (one of seven) of the subjects in the 30- to 39-yr age group to 77.8% (two of 27) of the subjects in the 70- to 79-yr age group (p < 0.0001). The mean (+/- SEM) proportion of the 4,977 bp-deleted mtDNA in lung tissues significantly increased from 0.007 +/- 0.007% of the subjects in the 30- to 39-yr age group to 0.833 +/- 0.330% of those in the 70- to 79-yr age group (p < 0.005). Other factors such as sex, pulmonary function indices, and smoking status did not have statistically significant impact on the amount of the deleted mtDNA. These findings suggest that the accumulation of the 4,977 bp-deleted mtDNA is associated with aging human lung.

An intrinsic adrenergic system in mammalian heart

We have identified a previously undescribed intrinsic cardiac adrenergic (ICA) cell type in rodent and human heart. Northern and Western blot analyses demonstrated that ICA cell isolates contain mRNA and protein of enzymes involved in catecholamine biosynthesis. Radioenzymatic catecholamine assays also revealed that the catecholamine profile of adult rat ICA cell isolates differed from that of sympathetic neurons. Unlike sympathetic neuronal cells, isolated ICA cells have abundant clear vesicles on electron microscopy. Endogenous norepinephrine and epinephrine constitutively released by ICA cells in vitro affect the spontaneous beating rate of neonatal rat cardiac myocytes in culture. Finally, ICA cells could be identified in human fetal hearts at a developmental stage before sympathetic innervation of the heart has been documented to occur. These findings support the concept that these cells constitute an ICA signaling system capable of participating in cardiac regulation that appears to be independent of sympathetic innervation.