Intraperitoneal chemo-hyperthermia with mitomycin C in cancer of the stomach with peritoneal carcinosis

We report 42 cases of gastric cancer with peritoneal carcinosis treated with intraperitoneal chemohyperthermia. Intraperitoneal chemohyperthermia was achieved with a closed sterile circuit containing mitomycin C, 10 mg/l producing an input temperature varying from 46 to 49 degrees C for 90 minutes. There were three postoperative deaths: one pulmonary embolism at day 4, one multiple organ failure et day 4, and one septic shock at day 25 due to a colonic fistula. Two patients suffered complications: one opening of the duodenal stump requiring reoperation on day 5, and one prolonged postoperative ileus lasting to day 10. Of the 12 patients with ascites, resorption was achieved in 8. In patients with early-stage peritoneal carcinosis (granulations less than 5 mm) survival at 1, 2 and 3 years was 90%, 61% and 41% respectively. For those with more extensive carcinosis, survival at 1 year was 10%. Five patients survived more than 30 months, three have survived to 34, 43 and 73 months. Intraperitoneal chemohyperthermia is a new treatment for carcinosis of gastric origin. These early results must be assessed further with larger controlled.     

Surgery of esophageal cancer in Liège: III. Clinical and radiographic evaluation of long-term quality of life after esophagectomy

OBJECTIVE: Functional evaluation of digestive transplants after oesophagectomy for cancer. MATERIAL AND METHODS: We evaluated alimentary comfort and quality of life and performed a videofluoroscopy (radiocinema) in 34 patients who were alive and disease-free one year or more after oesophagectomy for malignancy. There were 22 males and 12 females; mean age was 64 years. Twenty-three patients had a gastric pull-up and 11 a colonic graft. Mean follow-up was 36 months (range: 12-100 months). Possible correlations between clinical symptoms and radiographic observations were studied with Fisher's exact test. RESULTS: Most-cited symptoms were gurgling in 16 patients, early fullness during eating in 15, diarrhea in 14, postprandial sweating in 9, pyrosis in 8, nocturnal cough in 7, and dysphagia in 5. Most patients considered the side effects of the operation as mild to moderate and mean rating of alimentary comfort was 7.6/10. Twenty-five patients qualified their quality of life as good, 8 as satisfactory, and 1 as poor. Twenty-nine patients led active lives. Videofluoroscopic evaluation showed that colonic grafts emptied mainly by gravity, while active contractions were observed in the antrum of gastric transplants. There was a significant correlation between alimentary symptoms and radiographic distension of the transplant. Oro-pharyngeal abnormalities, site of proximal anastomosis, nature, motility, or active versus passive emptying of the transplant did not correlate with clinical complaints. CONCLUSIONS: In most patients quality of life and alimentary comfort are good after oesophagectomy and gastric or colonic interposition. Radiocinema is an adequate method to evaluate the dynamic of the transplant and shows a better emptying of gastric grafts, compared to colonic grafts, particularly when the proximal portion of the oesophagus triggers the progression.     

Complications of laparoscopic paraesophageal hernia repair

The complications of laparoscopic paraesophageal hernia repair at two institutions were reviewed to determine the rate and type of complications. A total of 76 patients underwent laparoscopic paraesophageal hernia repair between December 1992 and April 1996. Seventy-one of them had fundoplication (6 required a Collis-Nissen procedure). Five patients underwent hernia reduction and gastropexy only. There was one conversion to laparotomy. Traumatic visceral injury occurred in eight patients (11%) (gastric lacerations in 3, esophageal lacerations in 2, and bougie dilator perforations in 3). All lacerations were repaired intraoperatively except for one that was not recognized until postoperative day 2. Vagus nerve injuries occurred in at least three patients. Three delayed perforations occurred in the postoperative period (4%) (2 gastric and 1 esophageal). Two patients had pulmonary complications, two had gastroparesis, and one had fever of unknown origin. Seven patients required reoperation for gastroparesis (n = 2), dysphagia after mesh hiatal closure of the hiatus (n = 1), or recurrent herniation (n = 4). There were two deaths (3%): one from septic complications and one from myocardial infarction. Paraesophageal hernia repair took significantly longer (3.7 hours) than standard fundoplication (2.5 hours) in a concurrent series (P <0.05). Laparoscopic paraesophageal hernia repair is feasible but challenging. The overall complication rate, although significant, is lower than that for nonsurgically managed paraesophageal hernia.     

Topical clonidine for orofacial pain: a pilot study

BACKGROUND: To preserve postoperative digestive function in patients with esophageal carcinoma, jejunal or colonic segments on long vascular pedicles are transplanted and anastomosed between the esophagus and residual stomach. A postoperative survey showed pedicled jejunum transplantation to be superior in terms of digestive and absorptive functions, intraesophageal pressure, pH, and the quality of life of long-term postoperative survivors. Anastomotic leakage and necrosis of the pedicled intestinal graft are occasional complications; circulatory disorders of the pedicled intestine are a probable cause of both complications. STUDY DESIGN: To simulate pedicled jejunum transplantation, we prepared pedicled colonic segments from dogs and measured blood flow volume at the cut end of the oral side of the colonic segments using the hydrogen clearance method and at the nutrient vascular pedicle with an electromagnetic blood flowmeter. RESULTS: Resection of excess colon increased blood flow volume per unit weight of the colonic segment. CONCLUSIONS: It is essential to resect excess intestine and keep only the minimum length of pedicled intestinal graft needed for reconstruction of the esophagus.     

Esophageal cancer on the increase. Is Barrett esophagus the cause?

At the Dept of Surgery, Lund University, during the 10-year period 1985-95, 54 patients with adenocarcinoma of the gastro-oesophageal junction (17 with Barrett's epithelium, and 37 without) underwent oesophageal resection: oesophagectomy and gastric pull-up (n = 10), extended total gastrectomy (n = 37), or oesophageal resection and interposition of colon (n = 2) or jejunum (n = 5). Hospital mortality was 3.7% (2/54), and the mean duration of hospitalisation 13 days (range, 9-42). Long-term survival was significantly better in the Barrett's oesophagus subgroup than in the carcinoma of the cardia (non-Barrett's oesophagus) subgroup, the respective rates being 50% vs. 10% (p = 0.0052; Log rank test). The better survival in the Barrett's oesophagus subgroup is probably to be explained by the earlier stage of disease among these patients, in turn due to a history of gastro-oesophageal reflux, whereas the predominant symptom in the cardia carcinoma subgroup was dysphagia.     

Resection of pulmonary nodules using video-assisted thoracic surgery. The Thorax Group

BACKGROUND: The aim of this study was to assess the experience with video-assisted thoracic surgery for the resection of pulmonary nodules. METHODS: This voluntary registry (20 centers) included 388 patients with either benign (n = 171) or malignant (n = 217) pulmonary nodules. Pulmonary nodules were located using computed tomography scan-guided injection of methylene blue (59 patients) and hook wire technique (17 patients). RESULTS: Video-assisted thoracic surgery was converted into thoracotomy in 67 patients (17%) because of technical-emergency in 4, inability to complete resection in 33, and the need to perform lobectomy for cancer through thoracotomy in 30. In other patients, video-assisted thoracic surgery allowed wedge resection in 300 cases and lobectomy in 21 cases. No intraoperative and two postoperative deaths (0.56%) occurred. The complication rate was 8% (n = 31). Mean durations of chest tube placement and hospital stay were 3.3 days (range, 1 to 20 days) and 6 days (range, 1 to 25 days), respectively. Video-assisted thoracic surgery was judged by the surgeon to be a diagnostic procedure 226 times (58%) and a therapeutic procedure 162 times (42%). CONCLUSION: Video-assisted thoracic surgery appears to be safe and remains mainly a diagnostic procedure for malignant tumors.     

Coronary artery bypass graft surgery in dialysis patient

To determine the operative outcome of coronary artery bypass graft surgery (CABG) for severe coronary artery disease in long-term hemodialysis patients, we analyzed a group of 16 patients who underwent CABG over a ten-year period in our institution. Hospital mortality was 12.5% (2 of 16 patients). These two patients died of ischemic colitis and perioperative myocardial infarction, respectively. There were five late deaths: one patient died from myocardial infarction, one from uremia, one from gastro-intestinal bleeding, one from gastric cancer and one from unknown cause. There were four significant postoperative complications (morbidity 25%), consisted of one pulmonary tuberculosis, one sternal dehiscence secondary to mediastinitis, one mediastinal hematoma secondary to late bleeding from the LITA dissection area and one A-V shunt trouble. Graft patency rate within the first two months was 93% (30 to 42 in 13 patients). Hospital survivors experienced complete relief from angina. Actuarial survival was 68.8% at 3 years, 57.3% at 5 years and 28.6% at 7 years. This rate is not significantly different from the survival of all dialysis patients, but seems to be better than that of dialysis patients with not operated coronary artery disease. We concluded that CABG in dialysis patients can be accomplished with acceptable morbidity and mortality and effective relief of symptoms.     

Output of chyle as an indicator of treatment for chylothorax complicating oesophagectomy

BACKGROUND: The management of chylothorax complicating oesophagectomy remains controversial. Even if medical management alone can be successful, some authors advocate early reoperation. The aim of this retrospective study was to identify the clinical variables associated with a high probability of full recovery with medical treatment. METHODS: Among 850 Lewis procedures performed for oesophageal carcinoma, 23 patients (2.7 per cent) developed postoperative chylothorax despite systematic preventive ligation of the main thoracic duct. Patients who responded to conservative management were compared with those requiring reoperation for preoperative radiotherapy, unilateral versus bilateral pleural effusion, delay of occurrence of the chylothorax, and ratio of mean chylous output to body-weight 1 and 5 days after its onset. RESULTS: Conservative management was successful in 14 patients with a mean(s.d.) delay of 12(5) (range 7-21) days and there were no hospital deaths. Reoperation was necessary in nine patients; there were two postoperative deaths and no recurrence of the chylothorax. The only significant difference between reoperated and medically treated patients was the mean(s.d.) chylous output at day 5: 23.5(16.6) versus 6.7(5.5) ml per kg body-weight (P< 0.001). At this time, the output was less than 10 ml/kg in 12 of 14 patients in whom medical treatment was successful (sensitivity 86 per cent), and equal to or greater than this cut-off value in all the patients who underwent reoperation (specificity 100 per cent). CONCLUSION: The ratio of chylous output to body-weight on the fifth day after the onset of a chylothorax complicating oesophagectomy seems to reliably predict the success of continuing medical treatment.     

The comparative effects of postoperative analgesic therapies on pulmonary outcome: cumulative meta-analyses of randomized, controlled trials

We performed meta-analyses of randomized, control trials to assess the effects of seven analgesic therapies on postoperative pulmonary function after a variety of procedures: epidural opioid, epidural local anesthetic, epidural opioid with local anesthetic, thoracic versus lumbar epidural opioid, intercostal nerve block, wound infiltration with local anesthetic, and intrapleural local anesthetic. Measures of forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC), vital capacity (VC), peak expiratory flow rate (PEFR), PaO2, and incidence of atelectasis, pulmonary infection, and pulmonary complications overall were analyzed. Compared with systemic opioids, epidural opioids decreased the incidence of atelectasis (risk ratio [RR] 0.53, 95% confidence interval [CI] 0.33-0.85) and had a weak tendency to reduce the incidence of pulmonary infections (RR 0.53, 95% CI 0.18-1.53) and pulmonary complications overall (RR 0.51, 95% CI 0.20-1.33). Epidural local anesthetics increased PaO2 (difference 4.56 mm Hg, 95% CI 0.058-9.075) and decreased the incidence of pulmonary infections (RR 0.36, 95% CI 0.21-0.65) and pulmonary complications overall (RR 0.58, 95% CI 0.42-0.80) compared with systemic opioids. Intercostal nerve blockade tends to improve pulmonary outcome measures (incidence of atelectasis: RR 0.65, 95% CI 0.27-1.57, incidence of pulmonary complications overall: RR 0.47, 95% CI 0.18-1.22), but these differences did not achieve statistical significance. There were no clinically or statistically significant differences in the surrogate measures of pulmonary function (FEV1, FVC, and PEFR). These analyses support the utility of epidural analgesia for reducing postoperative pulmonary morbidity but do not support the use of surrogate measures of pulmonary outcome as predictors or determinants of pulmonary morbidity in postoperative patients. IMPLICATIONS: When individual trials are unable to produce significant results, it is often because of insufficient patient numbers. It may be impossible for a single institution to study enough patients. Meta-analysis is a useful tool for combining the data from multiple trials to increase the patient numbers. These meta-analyses confirm that postoperative epidural pain control can significantly decrease the incidence of pulmonary morbidity.     

Emerging role of laparoscopy in the diagnosis of lymphoma

PURPOSE: The results of laparoscopic procedures on patients with suspected or known lymphoma were analyzed to review the application and define the role of laparoscopy in lymphoma. PATIENTS AND METHODS: The hospital records of 94 patients who underwent 101 procedures between June 1993 and October 1996 were reviewed for demographic and clinicopathologic information. RESULTS: The procedure was diagnostic in 85 patients, either at primary presentation (48 patients), possible relapse (21 patients), in the course of treatment (eight patients), or of a liver lesion (eight patients). In the remaining 16 patients, it was used to stage possible intraabdominal disease. Twenty-seven patients had a previous unsuccessful diagnostic procedure. There were no operative deaths and eight postoperative complications (8%). The laparoscopy revealed non-Hodgkin's lymphoma (NHL) in 48 patients, Hodgkin's disease (HD) in 14 patients, other neoplastic conditions in six patients, and benign conditions in 33 patients. There was adequate information in all procedures in which lymphoma was diagnosed for treatment decisions. There was one false-negative and one nonresult for technical reasons. Ten patients commenced chemotherapy before discharge after a median delay of 3.5 days. In five of 24 patients (21%) with recurrent or persistent lymphoma, the precise diagnosis was significantly different from the original one. CONCLUSION: From our experience, laparoscopy can safely provide tissue samples of suspected lymphoma for full diagnostic analysis. It should be considered when percutaneous biopsy is not technically possible, when chromosomal or genetic analysis is needed for treatment decisions, or when the results of percutaneous biopsy are inadequate to make therapeutic decisions.     

Combined percutaneous-endoscopic therapy for recurrent pancreatitis and pancreas divisum

BACKGROUND: Oesophageal motility is often impaired in patients with megaduodenum and other forms of intestinal pseudo-obstruction in which a visceral myopathy or neuropathy may be present. Idiopathic longstanding megacolon with onset in adult life is still a poorly defined entity, which may also be part of a more widespread motility disorder but in which oesophageal motility has not been yet systematically studied. AIMS: To assess oesophageal motility in patients with longstanding idiopathic megacolon with onset in adult life. PATIENTS: 14 consecutive subjects with idiopathic megacolon whose symptoms began after the age of 10 and a clinical history of 2-22 years. METHODS: Standard barium enema, water perfused oesophageal manometry, and also anorectal manometry. RESULTS: Oesophageal motility was impaired in five patients (36%; 95% confidence intervals 16 to 61%). Normal peristalsis was substituted by low amplitude multiple peaked simultaneous contractions in four subjects and by undetectable contractions in one. In three of them the lower oesophageal sphincter did not relax after swallows; in the same patients anal relaxation after rectal distension was also undetectable. All five patients with impaired oesophageal motility had a colonic dilatation sparing the rectum. Three of them reported constipation and a history of pesudo-obstruction and the other two only abdominal distension. CONCLUSIONS: Oesophageal manometry should be performed in patients with longstanding idiopathic megacolon with onset in adult life, in particular if the rectum is not dilated and even in absence of pseudo-obstruction. This simple test may disclose a more widespread visceral neuropathy or myopathy. Such a diagnosis helps to better understand the cause of the colonic dilatation and may be clinically relevant for treatment of the patients.     

Perioperative severe rhabdomyolysis revealing susceptibility to malignant hyperthermia

Resection of extensive lung cancers invading thoracic vascular structures (T4 lesions) can yield long-term survival provided the margins and nodes are free of tumor. We report the resection of the suprahepatic inferior vena cava for direct tumor involvement by a pulmonary malignancy. The resection was performed without bypass, and the cava was subsequently reconstructed with a 22-mm-diameter Dacron graft. Patency was documented on postoperative magnetic resonance angiograms. The patient was discharged home on postoperative day 10 without complications and remains well 8 months after the operation. Potentially curative resections and reconstructions of suprahepatic inferior vena cava involved with pulmonary malignancies are possible and can be done without cardiopulmonary bypass.     

Systematic analysis of in-patients' circumstances and causes of death: a tool to improve quality of care

OBJECTIVES: To point out actions improving quality of care from a systematic analysis of causes and circumstances of death of hospital patients. DESIGN: All in-hospital patient deaths during 1993 and 1994. SETTING: Saint Luc University hospital. MAIN OUTCOME MEASURES: Immediate and original causes of death, other diagnoses or procedures, circumstances of death, place, members of hospital staff, family or friends with the patient, mention of "do not resuscitate", of unexpected death, of problems during the process of care and of autopsy performed. RESULTS: The mean age of the patients was 60 years. The proportion of men was 57%. The majority of patients died in their room. No family or friends, or members of hospital staff were observed for 17%. "Do no resuscitate" was mentioned for 38% of the patients and the proportion of unexpected death and autopsy was 15% and 28% respectively. The most frequent causes of death were malignant and cardiovascular diseases. At least one of the following diseases was mentioned on 14% of the forms; complications during care, septicaemia, pulmonary embolism, adverse effects of drugs or pressure ulcer. Mean length of hospital stay was 14.7 days. CONCLUSIONS: A systematic analysis of the causes and circumstances of death reveals the epidemiology of hospital deaths and highlights specific diseases, complications or circumstances that could be changed. This study creates the opportunity for possible further action, such as improvement in prevention of pulmonary embolism and support of the members of staff or the friends and family of the patient at the time of death.     

What is the infection risk of oesophageal dilatations?

Oesophageal dilatation is the most widely used treatment option for the management of oesophageal strictures. Complications include bleeding, a slight increase in body temperature, thoracic or abdominal pain, oesophageal perforation, brain abscess and bacteraemia. We performed a prospective study to evaluate the frequency of post-dilatation bacteraemia in nine patients subjected to a total of 50 dilatations. Bacteraemia was detected in 36 cases (72%), In all but three cases, however, it was transient and not associated with fever or other clinical complications. The organisms most commonly responsible (64%) were alpha-haemolytic streptococci (Streptococcus viridans), probably originating as contaminants from the oropharynx and oesophagus and introduced into the bloodstream during dilatation. Despite the relatively low incidence of bacteraemia-related postdilatation complications, the potential severity of such complications argues for the use of antibiotic prophylaxis as a routine measure prior to oesophageal dilatation. CONCLUSION: Oesophageal dilatation is associated with a high incidence of bacteraemia. The organisms most commonly responsible were alpha-haemolytic streptococci. We recommend the use of antibiotic prophylaxis as a routine measure prior to oesophageal dilatation.     

Motility related protein 1 (MRP1/CD9) expression in colon cancer

STUDY OBJECTIVES: To examine the incidence and clinical significance of prolonged air leak (PAL) in patients undergoing radical upper lobectomy and to determine potential risk factors for PAL in this group of patients. DESIGN: Retrospective review of a prospective database. SETTING: Experience of one thoracic surgeon at a tertiary care cancer center. PATIENTS: One hundred consecutive patients undergoing right upper lobectomy and mediastinal lymph node dissection for non-small cell lung cancer over an 11-year period. MEASUREMENTS: PAL was defined as an air leak lasting >7 days. Preoperative, intraoperative, and postoperative clinical data were collected and analyzed to determine the factors associated with PAL. RESULTS: PAL was the most prevalent postoperative complication, comprising 25.5% of all complications seen, and lasting an average of 12.1+/-5.3 days. In 21 of the 26 patients with PAL, this complication was the only morbidity identified. There was no statistically significant difference in patient age, gender, preoperative FEV1 and diffusion of carbon monoxide, exposure to neoadjuvant chemotherapy, status of pulmonary fissures, or pathologic stage between the PAL group vs the remaining 74 patients without this complication. A significantly greater proportion of patients with PAL had FEV1/FVC ratio < or =50% (6/26 vs 5/74; p=0.02). Patients with PAL had significantly longer median length of hospital stay (11 vs 7 days; p=0.0001). Moreover, PAL was the single most common reason for an extended length of hospitalization (21/58, 36% of all causes). CONCLUSION: PAL is an alarmingly common postoperative complication and is the most frequent cause of an extended length of hospital stay in patients undergoing radical upper lobectomy. Severe obstructive pulmonary disease predisposes patients to the development of this complication.     

Alpha-adrenergic receptors in human myometrium: changes during pregnancy

In order to investigate the effect of fibrin glueing on the treatment or prevention of air leakages, 114 patients undergoing pulmonary resections and pneumonectomies were studied in two treatment groups: surgery alone (59 patients) or analogous surgical treatment followed by the application of fibrin glue (55 patients). The patients were randomly assigned to treatment groups within two strata: pulmonary resections (63 patients) and pneumonectomies (51 patients). Intraoperatively, 81% of the patients undergoing pulmonary resection who suffered from air leakages after conventional suturing showed improved results of the airway-tolerance-pressure test after the application of fibrin glue (one-sided P value < 0.01; 95% confidence interval: 58-95%). Treatment with fibrin glue reduced the incidence of postoperative leakages significantly from 66% in the control group to 39% in the treatment group (one-sided P-value < 0.02; estimated risk reduction 41%; 95% confidence interval 2-65%). An additional reduction of the duration of post-operative air leakages by the treatment with fibrin glue could not be shown. In terms of minor response criteria, slight trends for an advantage of treatment with fibrin glue could be observed for the duration of stay in hospital and the number of patients with complications. There were no obvious trends concerning fever, intraoperative and postoperative intubation times, the amount of secretion from thoracic tubes and the general condition of the patients. No adverse drug event related to fibrin glueing was observed.     

Complications of thoracoscopy

BACKGROUND: The revolution in video technology has led to the acceptance of thoracoscopy as an important tool in thoracic surgery. METHODS: A review of all patients undergoing thoracoscopy at the University of Maryland between November 1991 and March 1995 was performed to identify the incidence of intraoperative and postoperative complications. In addition, the role of computed tomography for predicting intraoperative complications was analyzed. RESULTS: Three hundred forty-eight procedures were performed in 321 patients. Twenty-seven patients required conversion to thoracotomy for various indications. In 12 patients further resection was required after frozen section diagnosis confirmed lung carcinoma. Six patients were opened due to adhesions. Two patients were opened due to inability to find the lesion (this represents 1.6% of all solitary pulmonary nodules). Three cases were converted to thoracotomy for lesions that were too large to remove (representing 2.5% of all solitary pulmonary nodules resected). Two patients required conversion to thoracotomy because of inability to obtain one-lung ventilation. One case required a limited thoracotomy for a lost needle used for needle localization of a solitary intraparenchymal nodule, and 1 patient had emergent exploration for bleeding. Early postoperative complications developed in 10 patients. There were two explorations in the immediate postoperative period for bleeding. Prolonged air leak occurred in 3 patients, empyema in 2, and recurrent pneumothorax, pulmonary edema, and pneumonia in 1 patient each. Computed tomography failed to diagnose adhesions in the majority of patients requiring conversion to thoracotomy. CONCLUSIONS: Thoracoscopy is a safe and effective procedure with low intraoperative and postoperative complication rates.     

Pediatric lung transplantation. Indications, techniques, and early results

From July 1990 to April 1993, 36 lung transplantations in 33 patients were performed in our pediatric transplant program (0.25 to 23 years, mean age 10.3 years). Eight children had been continuously supported with a ventilator for 3 days to 4.5 years before transplantation and three were supported by extracorporeal membrane oxygenation. Indications for lung transplantation in this pediatric population included the following: cystic fibrosis (n = 13), pulmonary hypertension, and associated congenital heart disease (n = 10), pulmonary atresia, ventricular septal defect and nonconfluent pulmonary arteries (n = 3), pulmonary fibrosis (n = 6), and acute respiratory distress syndrome (n = 1). Three children underwent retransplantation for acute graft failure (n = 2) or chronic rejection (n = 1). Pulmonary fibrosis was related to complications of treatment of acute of myelogenous leukemia with bone marrow transplantation in two children and to bronchiolitis obliterans, bronchopulmonary dysplasia, interstitial pneumonitis, and Langerhans cell histiocytosis in four others. Thirteen children underwent lung transplantation and concomitant cardiac repair. Bilateral lung transplantation, ventricular septal defect closure and pulmonary homograft reconstruction of the right ventricular outflow tract to the transplanted lungs was performed in three children by means of a new technique that avoids the need for combined heart-lung transplantation. Two patients had ventricular septal defect closure and single lung transplant for Eisenmenger's syndrome, two had ligation of a patent ductus arteriosus and transplantation, three additional children underwent atrial septal defect closure and lung transplantation, and two underwent lung transplantation for congenital pulmonary vein stenosis. Eight early deaths and three late deaths occurred (actuarial 1-year survival 62%). Lung transplantation in children has been associated with acceptable early results, although modification of the adult implantation technique has been necessary. Lung transplantation and repair of complex congenital heart defects is possible; heart-lung transplantation may only be required for patients with severe left heart dysfunction and associated pulmonary vascular disease. Bronchiolitis obliterans remains a major concern for long-term graft function in pediatric lung transplant recipients.     

The intubating laryngeal mask: use of a new ventilating-intubating device in the emergency department

OBJECTIVE: Despite modern diagnostic methods and appropriate treatment, pleural empyema remains a serious problem. Our purpose was to assess the feasibility and efficacy of the video-assisted thoracoscopic surgery in the management of nontuberculous fibrinopurulent pleural empyema after chest tube drainage treatment had failed to achieve the proper results. METHODS: We present a prospective selected single institution series including 45 patients with pleural empyema who underwent an operation between March 1993 and December 1996. Mean preoperative length of conservative management was 37 days (range, 8-82 days). All patients were assessed by chest computed tomography and ultrasonography and underwent video-assisted thoracoscopic debridement of the empyema and postoperative irrigation of the pleural cavity. RESULTS: In 37 patients (82%), video-assisted thoracoscopic debridement was successful. In 8 cases, decortication by standard thoracotomy was necessary. There were no complications during video-assisted thoracic operations. The mean duration of chest tube drainage was 7. 1 days (range, 4-140 days). At follow-up (n = 35) with pulmonary function tests, 86% of the patients treated by video-assisted thoracic operation showed normal values; 14% had a moderate obstruction and restriction without impairment of exercise capacity, and no relapse of empyema was observed. CONCLUSIONS: Video-assisted thoracoscopic debridement represents a suitable treatment for fibrinopurulent empyema when chest tube drainage and fibrinolytics have failed to achieve the proper results. In an early organizing phase, indication for video-assisted thoracic operation should be considered in due time to ensure a definitive therapy with a minimally invasive intervention. For pleural empyema in a later organizing phase, full thoracotomy with decortication remains the treatment of choice.     

MPK38 expression is upregulated in immature T cells activated by concanavalin A

Between 1974 and 1994, 25 colonic interposition procedures were performed for esophageal replacement in 23 cases of esophageal atresia (EA) and 2 corrosive strictures. Nine patients had one-stage and 16 had two-stage reconstructions. The transthoracic route was used in 16 cases (64%) and the retrosternal route in 9 (36%). Average age at the time of operation in EA patients was 17 months (range 12-33), and the children with corrosive injuries were 3 and 6 years old. Mean age at follow-up was 11.8 years (2.3-20.5 years). There was no mortality in the series. One patient developed full-graft necrosis and had a gastric pull-up procedure later. One child had partial graft necrosis (3 cm at the cervical end), however, enough colon was available for reconstruction. Ten patients developed a leak from the cervical anastomosis (40%) and 7 developed a stricture at the cervical esophago-colonic anastomosis (28%). The strictures were treated by repeated esophageal dilatation, and 3 patients required revision of the anastomosis (12%). Other complications included acid reflux in 2 cases (8%), small-intestinal obstruction in 1 (4%), redundancy of the colon in 1 (4%), and chest infections in 2 (8%). Follow-up included assessment of the patient's symptoms, serial growth measurements (height and weight), and where relevant, endoscopy and a contrast swallow or meal. There was a 52% improvement in weight and height percentiles post-operatively. Each of the 19 patients who had barium swallows showed rapid transit and emptying without any significant delay or hold-up. Overall long-term results were excellent in 13 patients (52%), good in 7 (28%), and fair in 5 (20%). The colon conduit thus provides an excellent substitute esophagus in pediatric patients.