Combined pectoralis flap and gastric pull-up for pharyngeal reconstruction.

Background: The gastric transposition flap, "gastric pull-up," is one of the standard techniques of reconstruction after total laryngopharyngectomy. Under certain circumstances, this method may provide insufficient tissue for a tension-free closure. In these circumstances, the surgeon could either close under tension, risking the viability of the flap and probable fistula; create a pharyngostome; or recruit additional tissue.

A universal method for the mutational analysis of K-ras and p53 gene in non-small-cell lung cancer using formalin-fixed paraffin-embedded tissue.

The p53 tumor suppressor gene has been found to be altered in almost all human solid tumors, whereas K-ras gene mutations have been observed in a limited number of human cancers (adenocarcinoma of colon, pancreas, and lung). Studies of mutational inactivation for both genes in the same patient's sample on non-small-cell lung cancer have been limited. In an effort to perform such an analysis, we developed and compared methods (for the mutational detection of p53 and K-ras gene) that represent a modified and universal protocol, in terms of DNA extraction, polymerase chain reaction (PCR) amplification, and nonradioisotopic PCR-single-strand conformation polymorphism (PCR-SSCP) analysis, which is readily applicable to either formalin-fixed, paraffin-embedded tissues or frozen tumor specimens.

Chemoradiotherapy of esophageal carcinoma.

Background: Chemoradiotherapy has demonstrated efficacy in esophageal cancer but rarely is curative. To improve local control and decrease metastases, a 7-month regimen was used with standard-dose radiotherapy (RT), cisplatin (DDP), and continuous infusion (CI) 5-fluorouracil (5-FU) in patients with locoregional squamous/adenocarcinoma of the esophagus.

Methods: Initial treatment consisted of RT to the esophagus (4000-5000 cGy) for 5-6 weeks, CI 5-FU (300 mg/m2/day) concurrent with RT, and DDP (25 mg/m2/day x 3) for Days 1-3 and 21-23.

Diagnosis of acute diffuse pulmonary infiltrates in immunosuppressed patients by open biopsy of the lung.

Herein is a review of the results of open biopsies of the lung performed upon immunosuppressed patients between the years 1982 and 1988. The goal was to assess the safety and value of the procedure on a group of patients who are many times in extremis because of multiorgan failure. Obtaining the correct diagnosis and establishing treatment poses a challenge.

Chemo/radiation with and without surgery in the thoracic esophagus: the Wayne State experience.

Wayne State University was the site of one of the initial experiences with combination chemotherapy, radiation, and surgery for carcinoma of the thoracic esophagus. This review analyzes all the patients seen with thoracic esophageal carcinoma from 1980 to 1984 inclusive, plus an additional 22 patient pilot study. The great majority of patients seen were treated with combination radiation and chemotherapy, which may have a greater applicability than dose esophagectomy.

Primary adenocarcinoma of the esophagus.

Of 163 patients with carcinomas of the esophagus seen between 1975 and 1982, 11 (6.7%) had a primary adenocarcinoma. Although the high ratio of men to women (10:1) was similar to that seen in patients with squamous cell carcinoma of the esophagus, the mean age of those with adenocarcinoma was younger (57 years).

Combined therapies for squamous-cell carcinoma of the esophagus, a Southwest Oncology Group Study (SWOG-8037).

Conservative treatment of esophageal cancer with radiation therapy has afforded few long-term survivors. In order to improve outcome, patients with locoregional disease were treated using a combined modality approach. Patients were treated with chemotherapy consisting of a 96-hour continuous infusion of 5-fluorouracil (5-FU), 1,000 mg/m2/d, days 1 to 4 and days 29 to 32; cisplatin 75 mg/m2, day 1 and 29; and radiation 3,000 rad, days 1 to 19.

Nonoperative therapy for squamous-cell cancer of the esophagus.

Based on the surgical pathology and survival for patients in previous trials using a neoadjuvant program of chemotherapy (5-fluorouracil [5-FU]-cisplatin) and radiation (3,000 cGy) before surgery for squamous-cell cancer (SCC) of the esophagus, a nonoperative pilot trial was designed to test if survival and recurrence would differ from our historical controls if routine esophagectomy was eliminated. Twenty patients were treated. The protocol called for the delivery of 5-FU infusion (1,000 mg/m2/d X 4 d) days 1 to 4 and 29 to 32 with cisplatin (100 mg/m2) day 1 and 29 sandwiched around external beam radiation (3,000 cGy over 3 weeks).

Acute injuries of the diaphragm. An analysis of 165 cases.

The records of 165 patients with diaphragmatic injuries seen at Detroit Receiving Hospital from July 1980 through June 1985 were reviewed. Causes included gunshot wounds in 89 patients, stab wounds in 65, and blunt trauma in 11. Mortality rates were 18%, 5%, and 27%, respectively, deaths being caused primarily by bleeding from associated injuries.

Emergency thoracotomy: a four-year review.

The case records of 200 patients who had emergency thoracotomy for penetrating trauma were reviewed. The mortality was 47% (93/200) for the entire series, 27% (21/79) for stab wounds and 60% (72/121) for gunshot wounds. Of 55 patients who underwent thoracotomy in the emergency department, 8 (15%) survived.

Cardiac tamponade due to an iatrogenic pericardial-diaphragmatic hernia.

Because of its ease, safety, and effectiveness, surgeons are increasingly using the subxiphoid approach to drain pericardial effusions and to insert epicardial pacemakers. Although we could find no previous reports of iatrogenic pericardial-diaphragmatic hernias in the literature, experience with a recent patient who developed this problem after a subxiphoid pericardial drainage suggests that it may become much more frequent. Physicians should strongly suspect this complication in patients with a triad of previous subxiphoid pericardial incision and signs of bowel obstruction and tamponade.

Left subcostal approach to the pericardium.

The subcostal approach, which we used in this series, gives a broader exposure to the pericardium than the straight subxiphoid exposure. It was described 40 years ago, and for some reason, is not being used widely.

Analysis of adenocarcinoma in Barrett's esophagus utilizing a staging system.

Based on a retrospective review of nine patients with adenocarcinoma in a Barrett's esophagus and the reports of similar cases in the literature, a staging system for this malignancy was devised. A progression of changes could be identified that corresponded to the stages. These changes consisted of dysplasia progressing to carcinoma in situ and invasive malignancy with metastases.

Iatrogenic hiatal and diaphragmatic hernias.

Seven patients with hernias occurring after Belsey hiatal hernia repair are described. These hernias were of two types. Four occurred through the hiatus, had the appearance of a parahiatal hernia, and were attributed to the failure to correct a shortened esophagus.

Management of bronchopleural fistulas.

During the ten years 1972 to 1981, 16 patients with persistent bronchopleural fistulas were treated. Eleven patients had postoperative fistulas, and five had fistulas which were spontaneous in origin. The spontaneous fistulas were due to tuberculosis (three) and lung abscess (two).

Preoperative chemotherapy and radiation therapy for patients with cancer of the esophagus: a potentially curative approach.

Twenty-one patients with squamous cell cancer of the esophagus were entered into a pilot clinical trial using preoperative chemotherapy (5-fluorouracil and cis-platinum) and radiation with the intent of improving cure rate and survival. After the preoperative treatment was complete, 15 patients (71%) were resected for cure. Seven (47%) of 15 had no histologic evidence of cancer in the resected esophagus, but two of these had microscopic cancer in resected lymph nodes.

Celestin tube use: radiographic manifestations of associated complications.

Celestin intubation of the esophagus is occasionally employed in the palliation of unresectable esophageal carcinoma and in the obturation of malignant tracheoesophageal fistulas. Fourteen of 192 patients with carcinomas of the esophagus had Celestin tubes inserted at our institution between October 1977 and October 1982. Although tube insertion carries a low operative risk, there is significant subsequent morbidity associated with its use.

Management of malignant bronchoesophageal fistulas.

Twenty-four patients with a bronchoesophageal fistula due to a malignant lesion were seen during the eight years from 1974 to 1981. Twenty of the patients had carcinoma of the esophagus, and four patients had carcinoma of the lung. All three patients who had a Celestin tube inserted had gastric reflux, and in two, the fistula was not completely occluded.

Combined modality therapy for esophageal squamous cell carcinoma.

Of 55 patients with esophageal squamous cell carcinoma, 30 with localized disease were treated with a combined modality for curative intent. Treatment consisted of mitomycin C (10 mg/m2 day 1) and continuous infusion 5-FU (1000 mg/m2 day, days 1-4, 29-32) (CT), radiation (XRT) (3000 rad, days 1-21) with nutritional support, and surgery (days 49-64). Surgery consisted of celiotomy, esophagectomy and esophagogastrostomy +/- postoperative ventilatory support.

Axillary thoracotomy.

Between 1978 and 1981, we have used a vertical axillary thoracotomy in 106 patients for 109 operations. The approach provides a fast and easy entrance into the thoracic cavity. Exposure was adequate.

Eradication and palliation of squamous cell carcinoma of the esophagus with chemotherapy, radiotherapy, and surgical therapy.

Between April, 1977, and March, 1981, 86 unselected patients with proved squamous cell carcinoma of the esophagus were treated with a combination of chemotherapy and radiotherapy followed by operation whenever feasible. The preoperative chemotherapeutic agents used initially were 5-fluorouracil, and mitomycin C. After December, 1979, cis-platinum was used instead of mitomycin C.