Bilateral ureteric obstruction secondary to metastatic carcinoma of the oesophagus

Ureteric involvement by metastatic tumour from squamous cell carcinoma of the oesophagus has not yet been described, and we report here a case of this condition.

Speech sounds: evaluation of a device for their visual presentation

Two experiments were designed to evaluate a prototype device developed to provide a visual presentation of speech sounds as a potential assistive device for hearing-imparied persons. In the 1st experiment, the ability of adults with unimpaired hearing to recognize the visual patterns of 3 vowels spoken by 3 different speakers was assessed, and in the 2nd experiment, visual and auditory distinctiveness of the 3 vowels was compared. Results showed that subjects received different speech information from the Visual Speech Spectrum Analyzer (VISSA) and the normal auditory system; however, differences were judged minor. The device has potential as a speech therapy aid and may prove helpful to hearing imparied persons.

Alcohol tolerance and gastric emptying after replacement of the oesophagus with the stomach

Alcohol tolerance and gastric emptying were studied in ten patients before and three months after oesophagectomy and gastric replacement. There was no change in alcohol tolerance, but gastric emptying was accelerated. It is postulated that intestinal absorption may be impaired at three months after operation.

Pharyngocutaneous fistula complicating total laryngectomy

A series of 124 total laryngectomies for carcinoma is reviewed. The postoperative morbidity is discussed, and pharyngocutaneous fistula was found to occur in 30 patients. Its management is reviewed, and consideration is given to its relation to preoperative irradiation. This was found to increase its incidence and adversely affect the prospects of successful closure.

Surgical treatment of carcinoma of the hypopharynx and cervical oesophagus

From 1964 to 1979 a total of 1,702 patients with carcinoma of the oesophagus were admitted into the University Department of Surgery, Queen Mary Hospital, Hong Kong. Among these the tumour was situated at the hypopharynx in 112 cases and at the cervical oesophagus in 36 cases. The treatment of choice for resectable tumours of these sites was pharyngo-laryngo-oesophagectomy (81 cases). Reconstruction with pharyngo-gastric anastomosis was preferred (76 cases). Other methods of reconstruction were indicated only when the stomach had been resected previously. Although the hospital mortality after pharyngo-laryngo-oesophagectomy was 31% this was the only means by which a long term survival could be achieved. Occasionally even when the trachea was infiltrated by tumour, salvage could be attempted by including the posterior wall of the trachea in the resection and repairing with an in-turned delto-pectoral flap. Although the actuarial survival of patients after pharyngo-laryngo-oesophagectomy was only 9%, all the patients who survived the operation were relieved of their distressing symptom of dysphagia.

Production of mucoid microcolonies by Pseudomonas aeruginosa within infected lungs in cystic fibrosis

Direct electron microscopic examination of postmortem lung material from cystic fibrosis patients infected with Pseudomonas aeruginosa has shown that these bacterial cells form distinct fiber-enclosed microcolonies in the infected alveoli. Similar examination of bronchoscopy material from infected cystic fibrosis patients showed that the fibres of the enveloping matrix are definitely associated with the bacterial cells. The fibers of the extracellular matrix stain with ruthenium red and are therefore presumed to be polyanionic. When mucoid strains of P. aeruginosa were recovered from cystic fibrosis patients and grown in a suitable liquid medium, they were found to produce large microcolonies whose component cells were embedded in a very extensive matrix of polyanionic fibers that could be stabilized by reaction with antibodies to prevent collapse during the dehydration steps of preparation for electron microscopy. When these mucoid strains of P. aeruginosa were used to produce pulmonary infections of rats by the agar bead method, the infected alveoli contained large fiber-enclosed bacterial microcolonies. We conclude that the cells of P. aeruginosa that infect cystic fibrosis patients form microcolonies that are enveloped in a fibrous anionic matrix and that these microcolonies can be duplicated in in vitro cultures and in animal model systems.

Carcinoma of the tongue: factors affecting the results of surgical treatment

Sixty-five cases of carcinoma of the tongue treated by surgery were reviewed. The types of operation included hemiglossectomy, subtotal and total glossectomy with or without hemimandibulectomy and laryngectomy. Simultaneous neck dissection was usually performed except for patients who had radiotherapy and did not have clinical lymph node involvement. The hospital mortality and five-year survival rates were analysed for individual subgroups of patients classified according to clinical and pathological features. The overall hospital mortality rate was 21.5 per cent. The size of the tumour and the presence of extension posteriorly, to the opposite side and to the floor of the mouth increased the mortality. Lesions situated on the dorsum fared worse than those at the edge or undersurface. Clinically and pathologically involved lymph nodes adversely affected the mortality. The more extensive the resection, the higher the mortality. Old age and previous failed radiotherapy also increased mortality. The overall five-year survival rate was 46 per cent. Long term survival was not so much affected by the size of the primary tumour and degree of local extension as was the hospital mortality. Clinical as well as pathological staging of regional lymph nodes were more important in influencing long term survival. Recurrence after radiotherapy had a worse prognosis than previously untreated tumours.

Surgical treatment of cervical lymph nodes in carcinoma of the tongue

A series of 56 cases of carcinoma of the anterior two-thirds of the tongue treated surgically was reviewed. Lymph node metastasis occurred in 50% of cases. There was 22% false-negative clinical assessments of lymph node status for the ipsilateral side of the neck. Because of these and the difficulty in ensuring early treatment of subsequent node metastasis, concurrent ipsilateral radical neck dissection is recommended. When the ipsilateral side of the neck was involved the contralateral side has 22% false-negative assessments. Elective radical neck dissection for the contralateral side is recommended in this situation. The overall five-year survival was 50.6%, and was greatly affected by the status of the neck lymph nodes.

Primary sarcomas of the jaw

Nine cases of primary sarcoma of the jaw seen over a period of 14 years are presented. They consisted of four osteosarcomas, three fibrosarcomas, one myxosarcoma and one Ewing's sarcoma. The treatment of choice for osteosarcomas of the mandible is hemimandibulectomy with disarticulation at the temporomandibular joint. Bone graft reconstruction from the iliac crest should be done at a second stage. Palliative maxillectomy for extensive fibrosarcoma of the maxilla served to relieve one patient of local symptoms for more than a year. Myxosarcoma, a variant of fibrosarcoma, and Ewing's sarcoma of the jaw, are very rare conditions, and since these lesions are usually very extensive radiotherapy is the treatment of choice.

Salvage operations for malignant obstruction of the oesophagus

Two patients with locally advanced carcinoma of the oesophagus, who did not obtain palliation with radiotherapy, underwent salvage operations to restore their ability to swallow. One patient was subjected to pharyngolaryngo-oesophagectomy together with excision of the involved posterior tracheal wall. Reconstruction was by pharyngoglossogastrostomy, with a deltopectoral flap used to replace the tracheal defect. The second patient, who had cervical metastases and severe pulmonary complications, underwent a jejunal loop bypass operation. Both patients were able to eat normally before dying many months later from metastatic disease. Salvage operation should be considered for patients with primary tumours which appear to be slow-growing, even though locally advanced and free of widespread disease. Worthwhile palliation is obtained when the operation, either resection or bypass, has been successful.

Acute pancreatitis in Hong Kong

A series of 311 Chinese patients with acute pancreatitis admitted to Queen Mary Hospital, Hong Kong, over a 10-year period is reviewed. Biliary tract disease was associated with pancreatitis in 52.4 per cent of patients and 77.9 per cent of them had stones, mud or parasites in the common bile duct. Fever and jaundice were present in 55 per cent and 41.2 per cent of patients respectively. Because of the prevalence of recurrent pyogenic cholangitis among the indigenous population, emergency operation, with the aim of common duct decompression, was conducted in 54.3 per cent of patients during the acute episode, with a mortality rate of 14.8 per cent. Five of 142 patients (3.5 per cent) died whilst on conservative treatment and all 5 had haemorrhagic pancreatitis. The overall mortality rate was 9.6 per cent. Exploration of the common bile duct, which was carried out in 57.4 per cent of patients in the acute phase, was not associated with a higher mortality than when laparotomy alone was performed, and 19 patients had sphincteroplasty without any death. Subtotal pancreatectomy was performed in 2 patients with haemorrhagic pancreatitis with 1 death.

Gastric histology and function in patients with intrathoracic stomach replacement after esophagectomy

The histological changes and gastric function alterations in 19 patients who had intrathoracic stomach replacement following esophagectomy were studied. Atrophic gastritis was noted in 13 of the 19 patients. The mechanical response of the stomach to distention by food was largely retained. The basal and maximal acid output was reduced markedly, and the serum gastrin was elevated. An association between the degree of gastritis, the percentage of gastric motility at rest, and acid secretion is demonstrated. These changes are consistent with patients with duodenal ulcer following vagotomy and dyloroplasty. Postprandial elevation in serum gastrin was noted in patients with or without vagotomy. The lack of significant difference in integrated gastrin response suggests that the vagus may not be important in the control of postprandial gastrin release.

Chylothorax following resection of the oesophagus

Chylothorax complicating operations on the oesophagus has been reported infrequently; it carries a mortality rate of about 50 per cent. A search of the literature has yielded only 10 cases. This paper reports 4 further cases which occurred among 685 resections of the oesophagus, giving an incidence of 0.6 per cent. The diagnosis should be confirmed with lymphangiography. Treatment should be early exploration and ligation in patients in whom the thoracic duct has been divided at operation. If the duct has been injured during blind dissection a period of conservative treatment is advisable. Parenteral nutrition is a useful adjunctive treatment.

Acute suppurative cholecystitis: a retrospective study of 173 cases

Over a 14-year period we treated 2,290 cases of non-malignant biliary tract conditions, and among them were 173 cases of acute suppurative cholecystitis, an incidence of 7.6%. A correct preoperative diagnosis of acute suppurative cholecystitis was made in only about half the cases because features of recurrent pyogenic cholangitis dominated the clinical picture on many occasions. The diagnosis was confirmed in all cases at operation. Cholecystectomy (88%) was performed whenever this was found to be safe, and cholecystostomy (12%) was carried out only in poor-risk patients or when operative difficulties were encountered. The overall mortality of operation was 5.8%. Old age, preoperative shock, delay of operation and the presence of free perforation affected the prognosis adversely.

The effects of experimental division of the vascular pedicle of a transposed subcutaneous ileal loop

The effects of immediate division of the neurovascular pedicles of ileal loops implanted in the subcutaneous tissues for four weeks were studied in eight mongrel dogs. The structural and functional changes were studied by examining sections under light and electron microscopy and by comparing D-xylose absorption and motility patterns. Arteriograms were done to show the new subcutaneous collaterals supplying the loops. Of the eight dogs, four had loops showing normal histological appearances and D-xylose absorptive functions after division of the pedicles. In the remaining four dogs, the loops showed evidence of pseudomembranous changes in some areas, resulting in patching necrosis possibly due to inadequate collaterals. The absorption of D-xylose was impaired in these dogs. Perhaps a longer period of transposition and a gradual division of the vascular pedicle would improve the results. The motility pattern did not change after division of the pedicle, though the response to intravenous carbachol was significantly delayed.

Factors influencing morbidity and mortality in esophageal carcinoma

In 1977, 152 patients with carcinoma of the esophagus were admitted under our care. The lesions were located from the hypopharynx to the cardiac portion of the stomach. A prospective study was conducted and the results (mortality and morbidity) were analyzed by computer. Resection was possible in 88 patients and a bypass procedure in 15. On exploration in five patients, the disease was found to be so extensive that no further operative procedures were undertaken. The mortality rate was high, hospital deaths being included in the operative mortality statistics. The best results were obtained by applying the Lewis-Tanner one-stage esophagectomy. When the disease was extensive, a bypass procedure using the Kirschner operation and postoperative irradiation was the method of choice. When the general condition of the patient was poor, the best procedure was a staged esophagectomy, with the reconstruction being undertaken at a later date.

Unresectable malignant obstruction of the bile ducts

Over a 13-year period we encountered 135 patients with malignant obstruction of the bile ducts, and in 81 of these patients only palliative surgery was possible. The type of operation was largely determined by the site and nature of the obstruction and the condition of the patient. The operative mortality of palliative operation was 37%. Relief of jaundice or pruritus was obtained in 68%, and this figure included a number of patients who died in the first 30 days. The majority of survivors lived for between three and four months after operation, although occasional patients have lived for more than one year.

Changes in metabolism of major food components in patients with intrathoracic replacement of the oesophagus with the stomach

In 19 patients in whom the stomach had been used as an intrathoracic replacement after osephagectomy the absorption of fat, carbohydrate and protein was studied. There is no single pattern of disturbance of such absorption. Protein digestion and absorption occur earlier and more rapidly than in normal subjects, probably as a result of accelerated gastric emptying.

Use of adenosine 5'-triphosphate as an indicator of the microbiota biomass in rumen contents

A number of techniques were tested for their efficiency in extracting adenosine 5'-triphosphate (ATP) from strained rumen fluid (SRF). Extraction with 0.6 N H(2)SO(4), using a modification of the procedure described by Lee et al. (1971), was the most efficient and was better suited for extracting particulate samples. Neutralized extracts could not be stored frozen before assaying for ATP because large losses were incurred. The inclusion of internal standards was necessary to correct for incomplete recovery of ATP. The ATP concentration in rumen contents from a cow receiving a ration of dried roughage (mainly alfalfa hay) ranged from 31 to 56 mug of ATP per g of contents. Approximately 75% of the ATP was associated with the particulate material. The ATP was primarily of microbial origin, since only traces of ATP were present in the feed and none was found in "cell-free" rumen fluid. Fractionation of the bacterial and protozoal populations in SRF resulted in the isolation of an enriched protozoal fraction with a 10-fold higher ATP concentration than that of the separated rumen bacteria. The ATP pool sizes of nine functionally important rumen bacteria during the exponential phase of growth ranged from 1.1 to 17.6 mug of ATP per mg of dry weight. This information indicates that using ATP as a measure of microbial biomass in rumen contents must be done with caution because of possible variations in the efficiency of extraction of ATP from rumen contents and differences in the concentration of ATP in rumen microbes.

Observations of pressure waves in stomach, jejunal, and colonic loops used to replace the esophagus

The motility characteristics of the stomach, upper jejunum, and right colon were studied in 25 patients in whom these organs were used to replace the resected esophagus. The pattern of motility in all three replacement organs generally was similar to that recorded in normal individuals by other workers. But the stomach replacement showed a greater percentage of Type 1 waves, and Type II contractions were weaker. Activity in the jejunal replacements was much reduced. A propagated pressure wave was observed on swallowing water in the jejunal replacements. The nature of this wave needs further elucidation. The functional result was good, except in patients with a weak or without an upper esophageal sphincter. Patients experienced no pain during the test and no side effects were observed.