Parapharyngeal space tumours

Tumours in the parapharyngeal space have been difficult diagnostic and management problems. Consideration of the anatomy in three dimensions may be illustrated with computed tomography. Fifteen patients with parapharyngeal space tumours are presented, including six salivary gland tumours, four neurogenic tumours and five tumours from miscellaneous origin. The tumours were all treated by surgical excision. The preferred approach was the transcervical route. Additional procedures, including total conservative parotidectomy, were carried out depending on the pathology. Mandibulotomy was required for only one patient whose tumour had infiltrated the base of the skull and extended intracranially.

Prospective screening for multiple tumors of the upper aerodigestive tract: a simple routine procedure

Detection of a second primary at the time of initial work-up of patients with head and neck cancers has an important bearing on management planning. In a 12-month period, a series of 105 patients with an index head and neck primary (skin malignancies excluded) of the squamous cell type were subjected to the following screening procedure. Under topical anesthesia, with the patient in the sitting position, a small-size flexible bronchofiberscope (Olympus B3R) was introduced through the nose. As the scope was advanced, the nasal cavity, nasopharynx, oropharynx, hypopharynx, and larynx were examined. The tracheobronchial tree was also examined if the chest x-ray showed abnormal findings. The endoscope was then passed down to examine the esophagus, with oxygen insufflated via the biopsy channel at a rate of 1 liter per minute. The index primary sites included the tongue (20), alveolus (7), floor of mouth (2), palate (4), buccal mucosa (3), hypopharynx (17), and larynx (52). There was little patient discomfort and no complication. Nine patients (8.5%) were found to have simultaneous primary tumors including two patients with triple primaries and one with quadruple lesions. The additional tumors were in the following sites: esophagus (6), tonsil (2), floor of mouth (1), nasopharynx (1), bronchus (1), palate (1), and oropharynx (1). The treatment plans were changed in all nine patients with the discovery of multiple tumors. It is concluded that the panendoscopic screening in the manner described is simple, safe, and convenient and the information is contributory to treatment planning.

Tumours of the parotid--the value of clinical assessment

A series of 131 tumours of the parotid was reviewed retrospectively to ascertain the value of clinical features in distinguishing between malignant and benign tumours. The overall proportion of malignancy in this group of tumours was 17% (23 tumours). It was found that sex, age, size, duration of symptoms, and history of rapid enlargement were non-contributory to a diagnosis of malignancy, while the presence of facial nerve paralysis, skin infiltration or ulceration, and metastatic neck nodes were found only in patients with malignant tumours. A history of pain, hardness, and fixity, found in 30-50% of parotid cancers, were significant indicators of malignancy. As the yield of routine frozen section examination on all resected parotid tumours is low, it is recommended that if resources are limited, the examination be reserved for tumours highly suspicious of being malignant.

Use of the pectoralis major muscle flap for repair of a tracheoesophageal fistula

A case of tracheal rupture after a Lewis-Tanner esophagectomy in a patient with carcinoma of the esophagus was complicated by the formation of a tracheoesophageal fistula after initial direct repair. The fistula was successfully treated with a pectoralis major muscle flap moved into the superior mediastinum by a sternotomy and excision of the upper part of the sternum and adjacent costal cartilages.

A rheumatoid arthritis B cell subset expresses a phenotype similar to that in chronic lymphocytic leukemia

An abnormal subpopulation of B cells expressing the T1 antigen, which is normally restricted to T cells, was demonstrated in the peripheral blood of 16 patients with rheumatoid arthritis. This T1+ B cell population accounted for a mean of 19.6% (upper limit 48%) of the circulating B cells and did not correlate with clinical disease activity, rheumatoid factor, or drug treatment. The highest percentage of T1+ B cells found in the blood of 8 patients with connective tissue diseases, including systemic lupus erythematosus, was 5% of the B cells, and for normal controls, it was was 3% of the B cells. As previously reported, we confirmed that the T1+,Ig+ phenotype was a feature of leukemic cells in B-type chronic lymphocytic leukemia. The finding of increased numbers of T1+ B cells in patients with rheumatoid arthritis and those with B-type chronic lymphocytic leukemia raises the possibility that these cells play a role in a spectrum of diseases, including those involving autoimmunity and malignancy.

The development of the optic nerve in rodents

In mammals, normal visual function depends upon both the retinotopic organization of visual nuclei and their interconnections. We have investigated in rodents some developmental mechanisms contributing to this organization. On embryonic day 14, in the rat, retinal ganglion cells first project axons through glial channels on the retinal surface before reaching the optic stalk. We suggest that the sequence in which axons enter the stalk (central before peripheral) and their prominent fasciculation impose some retinotopic order amongst the emerging optic nerve fibres. At birth (embryonic day 21) there are over 240 000 axons in the optic nerve, all non-myelinated. However, within one week, the number falls to the adult value (100 000) and myelination, complete in the adult, commences. Axons lost include some which misproject--to the opposite eye or to inappropriate parts of central visual regions. The number of surviving retinal ganglion cells depends on the amount of appropriate target tissue available. It is well established that removal of one eye early in development increases the survival of axons in the remaining optic nerve. However, in a group of adult mice with congenital unilateral anophthalmia, we counted only 21 000 optic axons in the remaining nerve compared with the 31 000 in normal mice of the same strain. Degenerating axons were observed, suggesting that the defect is not a simple developmental failure, but is associated with active degenerative processes throughout life.

Efficacy of vancomycin plus rifampin in experimental aortic-valve endocarditis due to methicillin-resistant Staphylococcus aureus: in vitro-in vivo correlations

Studies of in vitro and in vivo bactericidal interactions of vancomycin plus rifampin against Staphylococcus aureus have yielded conflicting results. In this study the efficacy of this drug combination in experimental endocarditis due to a methicillin-resistant strain of S. aureus was investigated. Left-sided endocarditis was induced in 84 rabbits by an infecting strain that had been found to be synergistically killed by vancomycin plus rifampin in vitro when tested by the timed-kill curve technique; in contrast, the checkerboard technique had indicated that the two drugs were antagonistic against this strain. Infected animals received no therapy, vancomycin alone (30 mg/kg per day), rifampin alone (20 mg/kg per day), or both drugs (in the same doses). The combination was significantly more effective than the single-drug regimens in terms of (1) reduction of mean methicillin-resistant S. aureus vegetation titers (P less than .05-.0005), (2) rate and incidence of sterilization of vegetations (P less than .0005), and (3) rate of "radical" cure of endocarditis (P less than .005). Vancomycin alone and vancomycin plus rifampin were equally effective in reducing mortality and sterilizing renal abscesses. The use of vancomycin prevented the in vivo development of resistance to rifampin. No evidence that rifampin exerted an antagonistic effect on the in vivo bactericidal activity of vancomycin was found.

Amikacin + ceftazidime therapy of experimental right-sided Pseudomonas aeruginosa endocarditis in rabbits

We investigated the efficacy of a potent new antipseudomonal beta-lactam agent, ceftazidime, in a model of right-sided Pseudomonas endocarditis in 72 rabbits. Animals received either: no therapy (controls), amikacin (15 mg/kg/day), ceftazidime (100 mg/kg/day) or amikacin + ceftazidime. Amikacin + ceftazidime was significantly more effective than single-drug regimens in terms of reduction of mortality (p less than 0.01), prevention of pulmonary infarction (p less than 0.05), reduction of mean vegetation titers of Pseudomonas aeruginosa (p less than 0.05-p less than 0.0005), sterilization of vegetations (p less than 0.0005) and reduction in prevalence of bacteriologic relapses after therapy (p less than 0.005). There was no development of resistance in vivo to either amikacin or ceftazidime.

Endochondral pseudocyst of the auricle in Chinese

Thirty-one patients with endochondral pseudocysts of the auricle were seen over a four-year period in the Department of Surgery at the University of Hong Kong. The lesions chiefly affected Chinese males (90.3%); 80.6% involved the scaphoid fossa on the anterior surface of the pinna. They were usually asymptomatic and static in size. Excision of the anterior wall, followed by contour pressure dressing, gave cosmetically satisfactory results in 90% of the patients, and there were no recurrences. Pathologic studies revealed the absence of an epithelial lining as well as multiple cystic spaces that contained abundant glycosaminoglycans (acid mucopolysaccharides). We postulate that the overproduction of glycosaminoglycans engendered by repeated minor trauma to the cartilage was the primary cause of the pseudocysts.

The true pectoralis major myocutaneous island flap: an anatomical study

The pattern of blood supply to the clavicular and sternocostal portions of the pectoralis major muscle was studied in the cadaver with X-rays of injected specimens. The major blood supply to the sternocostal part was derived from the pectoral branch, although in about 50% of cases the clavicular branch provided minor contributions. This finding supports the clinical experience that it is safe to isolate the full length of the vascular pedicle, deep to the clavicular portion of the muscle, in the preparation of a pectoralis major myocutaneous flap.

Late problems after pharyngolaryngoesophagectomy and pharyngogastric anastomosis for cancer of the larynx and hypopharynx

The late problems of 136 patients who had undergone pharyngolaryngoesophagectomy and pharyngogastric anastomosis were studied. The proportions of patients who required long-term thyroxine supplementation were 67 percent, 13 percent, and 5.3 percent of the patients who had total thyroidectomy, hemithyroidectomy, and no thyroidectomy, respectively. The proportions of patients who required calcium and vitamin D supplementation were 67 percent, 23 percent, and 17 percent, respectively. Speech rehabilitation was unsatisfactory. Alimentary functions were satisfactory in that the majority of patients were able to take in solid food. Although a sensation of obstruction of food was occasionally felt, no organic abnormality was found in any patient. Regurgitation was noted in 23 percent of the patients, and hematemesis was an occasional symptom of gastritis or gastric ulcer, although symptomatic gastric ulcer was found in only two patients. It is concluded that the long-term morbidity after this extensive procedure is mild and acceptable. The operation is recommendable for extensive tumors of the laryngopharyngeal region.

In vitro bactericidal synergy of gentamicin combined with penicillin G, vancomycin, or cefotaxime against group G streptococci

The in vitro bactericidal interactions of penicillin G, cefotaxime, or vancomycin in combination with gentamicin were compared against 20 group G streptococci by the timed kill curve method. Synergy was noted at the following frequencies: penicillin plus gentamicin, 80%; cefotaxime plus gentamicin, 85%; vancomycin plus gentamicin, 90%. There was no bactericidal antagonism observed.

Bronchoscopy and carcinoma of the esophagus I. Findings of bronchoscopy in carcinoma of the esophagus

Tracheobronchial involvement frequently occurs in patients with carcinoma of the esophagus. A study of the results of 525 bronchoscopies performed on patients with carcinoma of the esophagus who were evaluated for surgery revealed that abnormalities were found in 33.9 percent. The incidence was highest for those with cervical and upper-third thoracic tumors; however, a significant number of lower-third thoracic and abdominal tumors also showed abnormalities (12.5 and 5 percent, respectively). The incidence was also higher with large tumors, but again, a significant number of apparently small tumors also showed abnormalities. The abnormalities could be broadly classified into two groups: those showing only impingement and those showing actual invasion. Further studies are needed to determine whether the tumors with impingement are resectable.

Bronchoscopy and carcinoma of the esophagus II. Carcinoma of the esophagus with tracheobronchial involvement

Involvement of the tracheobronchial tree, as observed through the bronchoscope, was in the form of impingement or invasion. Bronchoscopy was performed on 525 patients with carcinoma of the esophagus. Impingement was found in 91 patients and invasion in 87 patients. Forty-eight of the 63 patients with impingement and 7 of the 51 patients with invasion were found to have resectable tumors. Bypass operations were performed on the rest of the patients. The operative mortality was high for both bypass and resection procedures. The median survival for bypassed patients and resected patients were 4 months and 9 months, respectively. Four resected patients survived 3 years or more, 2 of whom had no evidence of recurrence. Most patients with impingement have resectable tumors and long-term survival is possible if the tumor can be resected.

The pectoralis major costomyocutaneous flap for mandibular reconstruction

In this paper we present a series of 14 pectoralis major costomyocutaneous flaps employed on patients who required mandibulectomy for oral tumors. Experience with this previously described technique is analyzed and its complications are presented. Although the pectoralis major muscle does not originate from the ribs, there appears to be enough blood supply by means of the delicate areolar connections and the periosteum to sustain the costal segment. In an attempt to improve the blood supply by means of the perichondrium, we have included a portion of the costal cartilage. In our series there were three failures resulting probably from technical errors. Apart from these, the results were satisfactory. However, the use of this procedure is relatively recent, and its long-term results are unknown at the moment.

Quantitative and morphological studies on developing optic axons in normal and enucleated albino rats

In the albino rat, the number of optic axons increases from 400 on embryonic day 15 to reach a peak of 240000 at birth, before declining to adult numbers (100000) by postnatal day 5. Throughout the period of loss of axons there are few signs of degeneration in the optic nerve, which does not change its diameter: the decrease in density of axons is matched by an increase in the cross-sectional area of individual axons. Myelination of the initially non-myelinated axons starts on day 5, when axonal numbers stabilize. Following neonatal removal of one eye, fewer axons than normal are present in the contralateral optic nerve up to day 5. The axons removed by enucleation may be retino-retinal axons, representing up to 40% of the 83000 fibres lost between postnatal days 2 and 5. There is no increase in the numbers of optic axons in the remaining nerve in adult animals; this appears to be due to the small absolute numbers of ipsilateral axons saved by enucleation. After enucleation, axons remain clear and undergo a "watery" degeneration after initially swelling, and the removal of degenerative products is accomplished within four days.

Influence of culture conditions on expression of the mucoid mode of growth of Pseudomonas aeruginosa

Five strains of Pseudomonas aeruginosa that are routinely distinguished by diagnostic laboratories on the basis of their colony morphology on agar media were grown in different media to assess the effects of culture conditions on mucoid growth, which we define as the copious production of exopolysaccharide. On brain heart infusion agar, only two of these strains (mucoid and gelatinous) grew as slimy mucoid colonies. None of the five strains produced a mucoid pattern of growth in Mueller-Hinton broth, in which all grew as turbid, nonmucoid, homogeneous suspensions of bacterial cells. When Mueller-Hinton broth was supplemented with Mg2+, all of the strains produced some mucoid aggregated growth, but growth in a modified version of the chemically defined medium of Vogel and Bonner, with elevated levels of Mg2+ and gluconate, produced patently mucoid growth in all strains. This mucoid growth in a liquid medium takes the form of large, coherent, slimy aggregates within the medium and of a "collar" of adherent microcolonies at the air-medium interface. Direct observations by light and electron microscopy showed the submerged aggregates and the adherent microcolonies to be composed of bacterial cells enmeshed in a copious exopolysaccharide matrix. When agar was added to the supplemented medium of Vogel and Bonner, only the mucoid and gelatinous strains produced slimy mucoid colonies on its surface. We conclude that both chemical and physical factors affect exopolysaccharide production by these clinical strains of P. aeruginosa and that the colony morphology on a single agar medium is an insufficient criterion for the designation of a given isolate as being mucoid or nonmucoid.

The role of the microcolony mode of growth in the pathogenesis of Pseudomonas aeruginosa infections

In nature Pseudomonas aeruginosa grows in two modes, the mobile "swarmer" cell and the glycocalyx-enclosed microcolony. The microcolony mode is numerically dominant perhaps because it provides adhesion in a favorable niche and protection from bacteriophages and phagocytic predators. When this organism colonizes the compromised human host, a broad spectrum of different types of infection is produced, ranging from asymptomatic persistent cystitis to the overwhelming bacteremia seen in neutropenic patients. These infections differ radically both in their degree of toxicity and invasiveness and in their susceptibility to control with specific antibodies and/or antibiotics. These differences may reflect the degree to which intact host defense mechanisms force the bacteria to adopt the defensive, microcolony mode of growth. As examples, the nearly intact host defense mechanisms and vigorous immune response of patients with cystic fibrosis force P. aeruginosa in pulmonary infections into a demonstrably cryptic, microcolony mode of growth that allows its persistence in the face of specific antibodies and antibiotics but limits its toxic activity and its dissemination. In contrast, the ruined defense mechanisms of burned skin allow the spread of bacteria in the mobile mode; toxic effects are seen in neighboring tissues, and a mixed mobile-microcolony reservoir population, whose mobile members can subsequently invade the circulatory system, is built up in the burned tissue. Thus, it is important to define the mode of bacterial growth in each type of P. aeruginosa infection and, where the microcolony mode is predominant, to understand the chemistry of the enveloping exopolysaccharide in order to limit its synthesis and/or facilitate its penetration by antibodies and antibiotics.

Serious infections due to group G streptoccocci. Report of 15 cases with in vitro-in vivo correlations

Serious infections due to group G streptococci have been infrequently reported. Fifteen such cases are described. Endovascular infection, particularly endocarditis, and septic arthritis were the most common clinical syndromes observed. Despite exquisite in vitro sensitivity of group G streptococci to penicillin G, the in vivo clinical response was disappointing in six of nine patients with either endocarditis or septic arthritis. The group G streptococcal isolates from the patients in this study were uniformly sensitive to the inhibitory and killing action of penicillin G, ampicillin, cefotaxime, cephalothin, cefoxitin, and vancomycin. In contrast, clindamycin, erythromycin, and chloramphenicol had relatively poor bactericidal activity against these strains, including several "tolerant" strains. Timed-kill studies with penicillin G revealed impaired killing of group G streptococci at in vitro conditions of high inocula and stationary growth phases. This may partially explain the poor clinical responses in cases of group G streptococcal endocarditis.

Immunogenicity of Pseudomonas aeruginosa outer membrane antigens examined by crossed immunoelectrophoresis

By crossed immunoelectrophoresis 36 different anode-migrating antigens were demonstrated in sonicated antigen preparations of Pseudomonas aeruginosa. We numbered these antigens to establish a reference precipitin pattern. Antigen no. 31 was identified as the lipopolysaccharide (LPS) antigen, because it was found to be responsible for the O-group specificity and because it reacted with anti-LPS monoclonal antibodies and with Limulus amoebocyte lysate. Purified outer membrane proteins F (porin), H2, and I used as antigens formed precipitins with the reference antibodies, thus establishing their antigenicity. LPS that copurified with protein F and slightly contaminated protein H2 was detectable as an extra precipitin (antigen no. 31). The use of monoclonal antibodies specific for smooth LPS and rough LPS revealed different antigenic determinants in the LPS molecule and suggested that antigen no. 5 could be the core region of the LPS which is equivalent to the rough LPS. Antibodies against these outer membrane antigens were detected in patients with chronic P. aeruginosa pneumonia and in patients with acute P. aeruginosa bacteremia. Antibodies with the same specificity were also found in rats chronically infected with P. aeruginosa 7 days postinfection. This demonstrates the surface accessibility and antigenic reactivity of outer membrane antigens.

Use of the Yarsagil aneurysmal clamp for end-to-side microvascular anastomosis: an experimental study in rats

The use of an aneurysmal microclamp for end-to-side microvascular anastomosis is described. It is atraumatic, can be applied easily and does not require complete mobilization of the recipient vessel.

In vitro immunoglobulin synthesis by lymphocytes from patients with rheumatoid arthritis. I. Effect of monocyte depletion and demonstration of an increased proportion of lymphocytes forming rosettes with mouse erythrocytes

We have investigated B cell function in nine patients with rheumatoid arthritis (RA) compared to sex and age matched controls in a pokeweed mitogen driven system. Levels of IgG and IgM synthesized in the supernatant were measured by a competition ELISA. We have found that cultured mononuclear cells from RA patients showed a defective Ig synthesis when depleted of monocytes. In contrast RA mononuclear cells not depleted of monocytes produced substantial levels of Ig after stimulation by the mitogen. The percentages of T and B lymphocytes in the peripheral blood of RA patients were normal; however, an increased number of lymphocytes formed rosettes with mouse erythrocytes indicating an abnormality in the B cell pool. These results demonstrate defective in vitro immunoglobulin synthesis by RA lymphocytes and show the importance of monocytes in this culture system.

Extralaryngeal spread of cancer of the larynx: a study with whole-organ sections

Thirty total laryngectomy and five pharyngolaryngoesophagectomy specimens were studied with the whole-organ sectioning technique. The horizontal plane of sectioning was chosen to study the pattern and degree of extralaryngeal spread in carcinoma of the larynx. There were 22 transglottic, 6 supraglottic, and 7 infraglottic tumors. Among them there were 1 T1, 2 T2, 5 T3, and 27 T4 lesions. Spreading anteriorly, the tumor was found to penetrate the thyrohyoid membrane in 7 (32%) out of 22 transglottic tumors. Among the entire group of 35 specimens the thyroid cartilage was penetrated in 18 cases (51%), and the infrahyoid strap muscles were invaded by tumor in 17 cases (49%). The cricothyroid membrane was penetrated in 19 cases (54%). Spreading posteriorly, the tumor reached or eroded the mucosa of the pyriform fossa in 15 cases (43%), including 10 total laryngectomy specimens. The postcricoid submucosa was involved by tumor in 13 cases (37%) among which 9 were total laryngectomy specimens. It is thus recommended that the wide-field technique should be used for laryngectomy. Awareness of the possibility of tumor reaching the mucosa of the pyriform fossa and the postcricoid area allows the surgeon to keep clear of tumor in performing total laryngectomy.

The preepiglottic and paraglottic spaces in relation to spread of carcinoma of the larynx

The submucosal compartments of the larynx were examined using a whole-organ sectioning technique. Seven specimens of normal larynx and 35 specimens of carcinoma of the larynx were studied. Victoria blue and van Gieson stains were used to demonstrate connective tissue elements. The preepiglottic space was distinctly separated from the paraglottic spaces by membranous partitions made up of collagen and elastic fibers. These partitions offer some resistance to tumor invasion in the early stages of laryngeal cancer, keeping the tumor from extending to the adjacent compartment while allowing it to spread freely within the same compartment. In the absence of mucosal extension across the midline, submucosal spread of tumor to the opposite side is unlikely. In view of possible cranial spread of tumor along the preepiglottic and paraglottic spaces, excision of all these spaces, together with the hyoid bone, is indicated in total laryngectomy.

Surgical management of benign oesophago-pleural fistula

Three cases of oesophago-pleural fistula are presented. Two resulted from foreign body perforation of the oesophagus and one followed left lower lobectomy for bronchiectasis. All three presented late; the time lapse ranged from 6 days to 2 months. An initial course of conservative treatment was given to all three patients. Alimentation via nasogastric tube feeding, gastrostomy or total parenteral nutrition was carried out. The pleural fluid grew the anaerobe, Bacteriodies melaninogenicus, in all three cases. Gram-negative aerobes, Escherichia coli and Proteus mirabilis, were also cultured. Closed intercostal drainage and a course of appropriate antibiotics were instituted. The patients were subjected to surgery after the infection had been brought under control. Simple repair was performed in two patients. Exclusion of the oesophageal leak with drainage and later reconstruction was carried out in the third patient. Although all three patients recovered, the morbidity was considerable. The duration of hospital stay ranged from 2 to 4 months.

Tracheostome construction during laryngectomy--a method to prevent stenosis

A new technique for construction of the tracheostome at the time of total laryngectomy is described. It involves making an X-shaped incision on the lower skin flap and four slits on the divided trachea. The result is a serrated suture line at the tracheocutaneous junction. The incidence of stenosis in 116 patients who did not have this method of construction was 31%. Sex difference and previous irradiation was not found to be related to the occurrence of stenosis. Of 25 patients who had the new method of tracheostome construction, only one patient had to wear a tube until she died at 7 months. The rest, followed up for at least 9 months, did not have stenosis. It is concluded that this new method of tracheostome construction will reduce the incidence of stenosis.

Therapy of experimental Pseudomonas endocarditis with high-dose amikacin and ticarcillin

Right-sided infective endocarditis due to Pseudomonas aeruginosa was induced in 130 rabbits. Animals received either: (1) no therapy (controls); (2) standard-dose amikacin (AMK) (15 mg/kg/day) plus ticarcillin (300 mg/kg/day), or (3) high-dose AMK (20 or 25 mg/kg/day) plus ticarcillin, for 20 days. Animals in each treatment group were evaluated at 10 days after therapy for bacteriologic relapse. Both standard- and high-dose AMK regimens significantly decreased mortality and Pseudomonas aeruginosa vegetation titers versus controls (p less than 0.01, p less than 0.05, respectively). Despite significantly higher serum AMK levels at 25 mg/kg/day, there was no significant difference in mean vegetation titers, percent of vegetations sterilized, or posttherapy bacteriologic relapse in the three treatment groups. AMK at 20 or 25 mg/kg/day (but not at 15 mg/kg/day) significantly reduced the incidence of pulmonary infarction versus untreated controls (p less than 0.01).

Oesophagoplasty for malignant obstruction of the oesophagus following previous partial gastrectomy

The management of 19 patients with malignant obstruction of the oesophagus who previously had undergone partial gastrectomy was reviewed. With stomach unavailable for oesophagoplasty, the jejunum was used in 12 patients, and the colon in seven patients, for reconstruction or bypass. The technique recommended is jejunal oesophagoplasty. Surgical intervention to restore swallowing in this group of patients has been associated with a 52% hospital mortality and a considerable morbidity. Because of the late stage of the disease, survival beyond two-three years after a successful operation has not been possible so far.

Retention of catheter fragment after thoracentesis: report of two cases

In the two cases presented here, retention of a portion of a plastic catheter in the pleural space occurred during thoracentesis. In both cases, the catheter was probably sheared off by the sharp beveled tip of the metal needle used to introduce the catheter. In one case, the retained catheter was removed during limited thoracotomy with local anesthesia. In the other case, attempts to remove the retained catheter during thoracentesis were unsuccessful, and no furather attempts were made. This complication of thoracentesis can be avoided by paying strict attention to the proper technique for insertion and withdrawal of the needle and the catheter.

Microbial flora of the mouse ileum mucous layer and epithelial surface

We have developed new methods to minimize fluid shear during preparation of specimens for electron microscopy and to retain the mucous blanket that covers the tissue surface of the ileum in mice. We also used general stabilization by nonspecific antibodies to minimize the collapse of the mucous layer during dehydration for electron microscopy. These methods allowed us to visualize the gradual progression of the mucous blanket from a thin diaphanous layer in newborn animals to a very thick (ca. 50 micrometers), coherent structure in older animals that contained a mixed population of bacteria and protozoa. Some bacteria, notably filamentous forms, were patently anchored to the epithelial tissue but projected into the mucous blanket, whereas others clearly existed within the mucous blanket and were unattached to the epithelial surface. Similarly, some protozoa were firmly attached to the tissue surface, whereas others were suspended in the viscous mucous blanket. In an adult animal, the mucous blanket was a very thick layer which actually occluded most of the tissue surface and contained a rich variety of bacteria and protozoa.

Loss of axons from the optic nerve of the rat during early postnatal development

The number of axons in the optic nerve of the newborn rat has been compared with the number present in the adult animal. Nerves taken from animals on the day of birth contain 242,000 +/- 29,000 (S.D.) fibres (n = 5). By the sixth postnatal day, the number of axons has fallen to the stable values of adults (99,000 +/- 3700, n = 8). Thus development of the rat's visual system during the first 5 days of life is associated with a loss of 60% of the axons present in the optic nerve at birth. Counts made on the remaining nerve after enucleation of one eye suggest that the presence of retino-retinal axons during the first 5 postnatal days cannot account for all of this reduction.

Intrathoracic gastric bypass for carcinoma of oesophagus found unresectable at exploration

Assessment of the resectability of carcinoma of the oesophagus or cardia may be inaccurate. At exploration, 8 patients in whom resection was contemplated were found to have unresectable lesions. An intrathoracic oesophagogastric bypass was performed without further change of position. Five patients were discharged from hospital and survived between 3 and 20 months before they finally succumbed to metastases. Each of them was able to take an ordinary diet. The aims of palliation were achieved.

Jejunal loop bypass and fundoplication for malignant esophagobronchial fistula

A new operation was designed to supplement the Kirschner operation for patients with locally advanced carcinoma of the esophagus and who, in addition, had had a gastrectomy for peptic ulcer disease. Bypass of the esophageal obstruction was by jejunal loop, and gastroesophageal reflux was prevented by fundoplication. Eighteen patients underwent this operation with a mortality of 27.8 per cent. Death occurred in one of the three patients with leakage of the esophagojejunal anastomosis. One patient had gangrene of the jejunal loop develop. Severe bronchopneumonia was the cause of death in all five. The functional result in the surviving patients was satisfactory and they lived for a mean period of 3.6 months postoperatively. It is not advocated that this operation replace the Kirschner operation, which we consider the operation of choice for locally advanced carcinoma of the esophagus, but as an alternative procedure in those patients in whom a previous gastric resection precluded a Kirschner operation.

Late result of sphincteroplasty in the treatment of primary cholangitis

Sphincteroplasty is one of the surgical procedures used in the treatment of primary cholangitis. We performed this operation on 342 patients over a 13-year period, with an operative mortality of 4.7%. Postoperative examination of 271 patients (average follow-up, seven years four months) showed that a good result was achieved in 226 patients, a fair result in 23 patients, and a poor result in 22 patients. Analysis of the reoperations in 17 patients showed that stone reformation is the most common finding, followed by sphincteroplasty stricture, liver abscess, and empyema of the gallbladder. When performed with proper indications in the management of primary cholangitis, sphincteroplasty is a safe procedure, and the majority of patients can expect good results.

Total parenteral nutrition versus gastrostomy in the preoperative preparation of patients with carcinoma of the oesophagus

Gastrostomy feeding has been a well established form of nutritional support for patients presenting with total dysphagia for carcinoma of the oesophagus. More recently, total parenteral nutrition has proved to be efficient and safe, offering an alternative to gastrostomy feeding. Twenty-four patients were randomly selected into two groups to compare the efficacy of total parenteral nutrition and gastrostomy feeding with respect to nitrogen balance and weight gain. Total parenteral nutrition was found to be superior to gastrostomy feeding in achieving an earlier positive nitrogen balance and greater weight gain during a 4-week period. However, gastrostomy feeding is still preferred as it is cheap, simple and safe, and allows patients to be active, mobile and self dependent. Total parenteral nutrition is reserved for those patients in whom an earlier operation is advisable.

Oesophageal microbial flora in carcinoma of the oesophagus

In 79 patients, with carcinoma of the oesophagus, oesophageal aspirates obtained at oesophagoscopy were cultured for aerobic and anaerobic organisms in an attempt to identify the microbial flora. The aspirate culture was correlated with the pathogens isolated when infective complications developed after operation. Bacteroides were isolated from the oesophagus in 39.2% of patients, streptococcus in 10.1% and coliform organisms in 7.6%. No growth was obtained in 35.4% patients. Forty-one patients underwent oesophageal resection. Six of these had the complication of empyema thoracis in the postoperative period. Two patients had identical organisms isolated from the oesophagus and the empyema. B. melaninogenicus was cultured from the pleural fluid in two patients whose oesophageal aspirate culture yielded no growth. Six patients developed wound infection, all with anastomotic cutaneous fistula. There was no demonstrable relationship between the organisms isolated from two sources. Prophylactic antibiotic administration should be directed against the bacteroides, since it is the most common organism isolated from within the oesophagus.