The value of extensive lymphadenectomy in cancer of the lower esophagus and cardia

Between 1980 and 1997, 1194 patients with a malignant tumor of the lower esophagus have been observed and treated in our Institution. There were 555 patients (46.5%) presenting with squamous-cell carcinoma, 101 (8.5%), with Barrett's adenocarcinoma and 538 (45%) with cardia adenocarcinoma. Most patient underwent a transthoracic esophagectomy with esophagogastroplasty; transhiatal approach was mainly reserved to high-risk patients. Over the past two years sixty-three patients (42 with adenocarcinoma and 21 with squamous cell carcinoma) underwent enlarged mediastinal lymphadenectomy. Three patients (4.7%) died post-operatively: one sepsis, in pulmonary embolism and one myocardial infarction. Four patients (6.3%) developed pulmonary complications: no patient had recuriential palsy. Pathologic exam revealed 1342 nodes (807 thoracic and 827 abdominal). Twenty patients (31.7%) had mediastinal nodal metastases, of which 8 in the upper mediastinum. Median follow-up was 19 months (2-36 months). Seven of the sixteen patients with recurrent disease (12 systemic, 3 mediastinal and 1 anastomotic) died. The number of metastatic nodes increased with serial section and even more with immunohistochemical staining technique (from 11.7% to 13% to 15.5%, respectively). Two patients were up-staged from M0 to M1 because of peripancreatic nodal micrometastases. We conclude that enlarged mediastinal lymphadenectomy allowed to detect upper mediastinal lymph node metastases in 12.8% of patients without increasing post-operative complication rate. A longer follow-up is required to evaluate the impact on long term survival.     

Surgical treatment of cancer of the esophagus and cardia

The purpose of the present study was to evaluate the results following surgical resection for cancer of the gastro-oesophageal junction. From 1. january 1988 to 1. april 1996 radical resection was intended in 107 patients at the Department of Thoracic and Cardiovascular Surgery at Odense University Hospital. Resection was possible in 75 patients. The operative mortality was 6.7% insufficiency of the gastro-oesophageal anastomosis was found in 6.7%. Five year survival was 24.1%. However in 52 patients where the resection was found to be radical the five-year survival was 35.3%. The results show that oesophago-gastrectomy could be performed with low mortality and morbidity. Long term survival is still low. To improve the results efforts should be directed toward earlier diagnosis, better selection and minimising post-operative complications.     

Oesophagogastrectomy for carcinoma of the oesophagus and cardia

A retrospective review was undertaken of all oesophagectomies performed within a single unit over a 12-year period. In all, 298 patients with primary oesophageal cancer underwent resection between March 1979 and December 1991. Four patients had a three-stage oesophagogastrectomy, 27 a thoracoabdominal oesophagogastrectomy and 267 a Lewis procedure. Dysphagia was the predominant presenting symptom. The duration of symptoms was not related to the stage of disease. Before diagnosis, 52 per cent of patients tolerated symptoms for 2-4 months. Adenocarcinoma was found in 180 tumours and squamous cell carcinoma in 103. Half of the patients had evidence of metastatic spread at the time of laparotomy or thoracotomy. The 30-day mortality rate was 10 per cent and the overall actuarial 5-year survival rate of all patients 23 per cent. The actuarial 5-year survival rate of patients without lymph node involvement was 39 per cent compared with 17 per cent for those with positive nodes (P < 0.05). Five of eight patients who had anastomotic leakage died. The almost unselected nature of this series, coupled with the favourable results of oesophagectomy, support the contention that resection remains the preferred mode of treatment for carcinoma of the oesophagus of all histological types.     

Localization of recurrent disease after extended lymph node dissection for carcinoma of the thoracic esophagus

BACKGROUND: The role of aggressive locoregional dissection in the treatment of carcinoma of the thoracic esophagus is controversial. The extent of disease spread for which resection can be performed is not yet fully established. STUDY DESIGN: Of 230 patients who underwent extended lymph node dissection, including the cervical nodes, the overall hospital mortality rate was 4.8 percent. Recurrent carcinoma was clinically confirmed by periodic follow-up examination with diagnostic imaging in 83 patients. We examined the exact anatomic sites of recurrent lesions and the clinical courses of patients. Recurrence patterns were classified into locoregional, distant, and mixed types. RESULTS: Recurrence of the carcinoma was locoregional in 35 patients, distant in 38 patients, and mixed in ten patients. The frequency of locoregional recurrence was significantly lower in patients with less than eight positive nodes and in patients without invasion of neighboring organs. Locoregional recurrence in the dissected area was mainly found in the region around the recurrent nerves and the main bronchi. Lymph nodes outside of the dissected area developed recurrence only in cases of markedly advanced disease apart from the abdominal para-aortic nodes. The group with locoregional recurrence and the group with distant recurrence had similar clinical courses over time. In patients in whom recurrent lesions could be treated with resection and adjuvant therapy, the one-year survival rate after recurrence was 83 percent. CONCLUSIONS: Unless the disease was markedly advanced, systematic lymph node dissection in our procedures yielded good locoregional control. The relatively low rate of distant recurrence with acceptable hospital mortality rates favors an extensive operation. When recurrent lesions were localized macroscopically, surgical removal of the recurrent lesions offered good palliation.     

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

We tested the hypothesis that extravascular adenosine induces the release of vasodilatory products from endothelial cells lining skeletal muscle vessels. Endothelium-intact (n = 35) and -denuded (n = 5) dog semitendinosus intramuscular arteries were isolated, cannulated, and placed in 100-mL baths containing Krebs-Henseleit bicarbonate buffer (Krebs) at 37 degrees C and gassed with 95% O2--5% CO2. Each vessel, as well as a parallel tubing segment (avascular control), was perfused at 3.5 +/- 0.2 mL/min (inflow pressure 94 +/- 2 mmHg; 1 mmHg = 133.3 Pa) with Krebs containing 100 microM phenylephrine, 6% dextran, and 15 units/mL superoxide dismutase. Perfusate from all segments dripped onto endothelium-denuded dog femoral artery rings. The addition of 10 microM acetylcholine to the perfusate to test the functional integrity of endothelium-intact donor segments did not alter resistance in vessel segments or change force in rings. The addition of 100 microM adenosine to the extravascular bath decreased resistance 1.5 +/- 0.4 mmHg.mL-1.min-1 in vessel segments but was without effect on downstream rings. When acetylcholine was retested in the presence of extravascular adenosine, a relaxation (16 +/- 6%) occurred in rings receiving perfusate from endothelium-intact segments but not endothelium-denuded or tubing segments. This relaxation was eliminated by N omega-nitro-L-arginine (10 microM), a nitric oxide synthase inhibitor, and was attenuated to 4 +/- 1% by 8-phenyltheophylline (10 microM), an adenosine receptor antagonist. Thus adenosine, in conjunction with acetylcholine, acting through a receptor-mediated event, resulted in the release of nitric oxide from the endothelium of perfused intramuscular arteries, indicating the potential for extravascular conditions to influence the release of endothelium-derived products.     

Total en bloc spondylectomy for primary malignant vertebral tumors

A novel method of nuclear magnetic resonance (NMR) is described which promises to be preferable to known general methods at sample length scales below approximately 100 microm. Its advantages stem from the seemingly paradoxical combination of a homogeneous static magnetic field and detection of a mechanical force between a spin-bearing sample and a magnet assembly. In contrast to other methods of force-detected nuclear magnetic resonance (FDNMR), the method is characterized by better observation of magnetization, enhanced resolution, and no gradient (BOOMERANG), and it is generally applicable with respect to sample composition, pulse sequence, and magnetic field strength. Further advantages of portability and low cost stem from the small instrument volume and mass and promise to extend the use of NMR to new applications and environments. A sensitivity analysis, relevant to spectroscopy or imaging, quantifies the advantage of BOOMERANG relative to magnetic induction using microcoils and to FDNMR methods that rely on large gradients of the magnetic field at the sample.     

Effect of blood transfusion on survival after esophagogastrectomy for carcinoma

BACKGROUND: There is growing evidence that blood transfusion is associated with clinical factors that can lead to transfusion-induced immunosuppression. This effect can be beneficial or deleterious. METHODS: The effect of perioperative allogeneic blood transfusion on survival was studied retrospectively in 524 patients who were discharged from the hospital after esophagogastrectomy for carcinoma performed in a single unit over a 10-year period. RESULTS: The median operative blood loss for the series was 500 mL (range, 50 to 3,750 mL). Three hundred thirty-five patients (64%) received a perioperative allogeneic blood transfusion related to esophagogastrectomy, and 189 (36%) did not. The median perioperative blood transfusion administered was 900 mL (range, 300 to 12,950 mL). Perioperative allogeneic blood transfusion was associated with reduced survival for patients in stage III (p < 0.05) at 1 year, but no significant difference was found in this stage at 3 or 5 years after resection. Stage III disease accounted for 250 (48%) of the 524 patients discharged. CONCLUSIONS: Although perioperative allogeneic blood transfusion does not affect long-term survival after esophagogastrectomy for carcinoma, it does have a significant association with short-term survival in a group whose overall survival is often limited after resection. Attention should be directed toward minimizing operative blood loss and transfusing only for factors known to be clinically important, such as oxygen delivery and hemodynamics, not arbitrary hemoglobin levels.     

Total vertebrectomy for en bloc resection of lung cancer invading the spine

We describe a technique of total vertebrectomy for en bloc resection of a non-small cell lung cancer with vertebral invasion through a combination of thoracic and enlarged posterior approaches, and present our entire experience of total and partial vertebrectomy for tumors invading vertebral bodies or the costovertebral angle.     

Rational lymphadenectomy in patients with cervical nodes metastasis for carcinoma of the lower third esophagus

BACKGROUND: Modern hair restoration procedures may involve, individually or in combinations, flaps, grafts consisting of plugs, slits, strips, minigrafts, or micrografts, with or without alopecia reduction. OBJECTIVE: To review the density achieved using mini-micrografting technique compared with that accomplished by plug methodology. METHODS: Hair counts per square centimeter were done on both mini-micrografted and plug cases from the author's practice. RESULTS: Comparable density (terminal hair per square centimeter) was noted to occur with either technique but accomplished with fewer sessions using mini-micrografting methodology and relatively dense packing of grafts. CONCLUSION: The density issue is a nonissue if comparable numbers of hair are transplanted per square centimeter.     

Intralesional excision compared with en bloc resection for giant-cell tumors of bone

We reviewed the results for forty consecutively seen patients, each of whom had been managed by one surgeon for a giant-cell tumor of bone in an extremity between 1976 and 1990. Twenty patients had been managed with an en bloc resection and twenty, with an intralesional excision of the tumor with adjunctive local insertion of methylmethacrylate or phenol. All patients had been followed for a minimum of two years. Both en bloc resection and intralesional excision were found to be excellent oncological procedures. There were fewer complications and better functional results after the intralesional procedure than following the en bloc resection.     

Transplantation of pediatric en bloc cadaver kidneys into adult recipients

BACKGROUND: To maximize the renal donor pool, cadaveric pediatric en bloc kidneys have been transplanted as a dual unit by some transplant centers. We compared the short- and long-term outcomes of adult recipients of cadaveric pediatric en bloc renal transplants versus those of matched recipients of cadaveric adult kidneys. METHODS: Thirty-three adults who received pediatric en bloc kidney transplants between April 1990 and September 1997 were retrospectively identified and were compared with 33 matched adults who received adult cadaveric kidney transplants. The groups were identical for transplantation era, immunosuppression, recipient sex, race, cause of renal failure, mean weight, and follow-up duration (37.8 vs. 37.5 months). The mean recipient age study versus control was lower (36.3 vs. 48.9 years, P=0.0003). Results. There was no difference between the en bloc and adult donor groups in the 3-year patient survival rates (95% vs. 87%, P=0.16) or the 3-year graft survival rates (87.3% vs. 84.2%, P=0.35). Further, there was no difference in en bloc patient or en bloc graft survival time stratified by recipient age (14-44 vs. >45 years, P=0.11), en bloc donor age (<24 vs. >24 months, P=0.39), or recipient weight (<60, 61-75, >75 kg; P=0.60). Differences in serum creatinine (mg/dl) for the en bloc versus the control group at the time of discharge (3.0 vs. 7.8 mg/dl, P=0.06), at 1 year (1.4 vs. 2.0 mg/dl, P=0.06), and at 2 years (1.1 vs. 1.6 mg/dl, P=0.14) had dissipated by the time of the 5-year follow-up examination (1.1 vs. 1.6 mg/dl, P=0.14). Vascular complications were more prevalent in the en bloc group: renal vein thrombosis (one case), thrombosis of donor aorta (two cases), arterial thrombosis of one renal moiety (two cases), and renal artery stenosis (two cases). There were no differences between groups in delayed graft function, acute or chronic rejection, posttransplant hypertension, posttransplant protein-uria, or long-term graft function. CONCLUSIONS: Collectively, these data indicate that transplanting pediatric en bloc kidneys into adult recipients results in equivalent patient and graft survival compared with adult cadaveric kidneys. Further, the data also suggest that pediatric en bloc kidneys need not be strictly allocated based on recipient weight or age criteria.     

Improved survival of en bloc renal allografts from pediatric donors

PURPOSE: We developed a technical and immunological protocol to increase survival of renal transplants from pediatric donors. MATERIALS AND METHODS: En bloc kidneys (22) were procured from donors weighing 2 to 14 kg. (1 to 60 months old) and transplanted into adult recipients. In group 1 (12 patients) sequential therapy was used for kidneys with more than 35 hours of cold storage and immediate triple therapy (cyclosporine, azathioprine and prednisone) was used for those with less than 35 hours of cold storage. In group 2 (10 patients) OKT3 induction therapy was used. Mean followup was 4.7 years. RESULTS: Mean blood pressure at 1 and 4 years was not significantly different between the groups. Mean serum creatinine was not significantly different between the groups at 1 year but it was significantly less in group 2 at 4 years (1.9 +/- 1.0 versus 1.2 +/- 0.24 mg./dl., p <0.05). At 1 year of followup the complication rate was 75% in 9 of 12 patients in group 1, including 4 infections or leaks (2 lost), 6 rejections (3 lost) and 3 cases of thrombosis or hemorrhage, and 20% (p <0.01) in group 2 (1 patient had the hemolytic uremic syndrome leading to graft loss). Graft survival was significantly greater in group 2 at all 4 years of followup (p = 0.05). CONCLUSIONS: The success of pediatric en bloc renal transplantation can be enhanced by induction therapy in healthy recipients.     

Imaging of en bloc renal transplants: normal and abnormal postoperative findings

Escherichia coli possesses a hexameric citrate synthase that exhibits allosteric kinetics and regulatory sensitivity, and for which the gene (gltA) has previously been cloned and sequenced. A citrate-synthase-deficient strain of E. coli (K114) has been mutated to generate a revertant (K114r4) that produces a dimeric citrate synthase with altered kinetic and regulatory properties. On cloning and sequencing the gltA gene from both K114 and K114r4, a single mutation was found that caused the replacement of Asp362 with Asn. Asp362 has been previously shown to be a catalytically essential residue in E. coli citrate synthase, and we demonstrate that the hexameric enzyme produced on expression of the gltA gene from K114 and K114r4 is inactive. The dimeric citrate synthase from K114r4 has been purified and shown to be immunologically distinct from the wild-type hexameric enzyme. Determination of its N-terminal amino acid sequence demonstrates that the mutant citrate synthase is encoded by a gene distinct from the E. coli gltA gene. The N-terminal sequence is compared with those of other eukaryotic, eubacterial and archaebacterial citrate synthases.     

A novel technique for management of the en bloc bladder cuff and distal ureter during laparoscopic nephroureterectomy

PURPOSE: The optimal technique of excising the juxtavesical ureter and bladder cuff during laparoscopic nephroureterectomy is still evolving. We report on a novel transvesical needlescopic (2 mm. instrumentation) assisted technique of en bloc retrieval of the juxtavesical ureter and bladder cuff during laparoscopic radical nephroureterectomy for upper tract transitional cell carcinoma. MATERIALS AND METHODS: Retroperitoneal laparoscopic nephroureterectomy was performed in 8 patients using this technique. Two needlescopic ports (2 mm.) inserted suprapubically into the bladder were used in combination with a cystoscopically positioned Collins knife. RESULTS: Satisfactory circumferential detachment of the bladder cuff and en bloc mobilization of 3 to 4 cm. of the intact pelvic extravesical ureter were achieved transvesically in each case in a manner comparable to open surgery. CONCLUSIONS: This technique simulates established open surgical principles of treating the distal ureter during laparoscopic nephroureterectomy.     

Modified approach for the selective treatment of temporal lobe epilepsy: transsylvian-transcisternal mesial en bloc resection

1. Intracerebronventricular (i.c.v.) injection of gamma-mangostin (10-40 nmol/mouse), a major compound of the fruit hull of Garcinia mangostana Lin., like ketanserin (10, 20 nmol/mouse, i.c.v.) inhibited 5-fluoro-alpha-methyltryptamine (5-FMT) (45 mg kg(-1), i.p.)-induced head-twitch response in mice in the presence or absence of citalopram (a 5-hydroxytryptamine (5-HT)-uptake inhibitor). 2. Neither the 5-FMT- nor the 8-hydroxy-2-(di-n-propylamino)tetralin (5-HT1A-agonist)-induced 5-HT syndrome (head weaving and hindlimb abduction) was affected by gamma-mangostin or ketanserin. 3. The locomotor activity stimulated by 5-FMT through the activation of alpha1-adrenoceptors did not alter in the presence of gamma-mangostin. 4. 5-HT-induced inositol phosphates accumulation in mouse brain slices was abolished by ketanserin. Gamma-mangostin caused a concentration-dependent inhibition of the inositol phosphates accumulation. 5. Gamma-mangostin caused a concentration-dependent inhibition of the binding of [3H]-spiperone, a specific 5-HT2A receptor antagonist, to mouse brain membranes. 6. Kinetic analysis of the [3H]-spiperone binding revealed that gamma-mangostin increased the Kd value without affecting the Bmax value, indicating the mode of the competitive nature of the inhibition by gamma-mangostin. 7. These results suggest that gamma-mangostin inhibits 5-FMT-induced head-twitch response in mice by blocking 5-HT2A receptors not by blocking the release of 5-HT from the central neurone. Gamma-mangostin is a promising 5-HT2A receptor antagonist in the central nervous system.