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May 1984, Volume 34, Issue 5

Case Reports

Selected Abstracts

A Multifactorial Analysis of Melanoma-ifi, Prognosic Factors in Melanoma Patients with Lymph Node Metastase (Stage II). Charles M. Baich, Seng-jaw Soong, Tariz M. Murad and others.Ann.Surg., 1981, 193:377.
THE UNIVERSITY OF Albama Melanoma Registry lists 650 patients with melanoma since 1960 with nodal metastasis in 28 per cent or 185 patients who underwent surgical treatment. Twelve prognostic features were examined. These included: substage of disease; remission duration; anatomic location; age sex; number of metastatic nodes; melanoma thickness; level of invasion; lymphocytic infiltration; pigmentation and growth pattern. Only two of these factors had a significant prognostic indicaticn of survival.
The number of metastatic nodes had a direct correlation in that patients with one metastatic node had a significantly better survival than two or more. Ulceration was found to be an extremely important prognostic factor. Ulceration was the only characteristic of the primary melanoma that predicted the risk of subsequent nodal metastasis and continued to be an important predictive factor once nodal metastasis bad occurred. Interestingly, although tumor thickness of the primary tumor is an important factor in predicting the risk of nodal metastasis, it had no predictive value on the clinical course cf the patient once nodal metastasis - had occurred. Level cf invasion did not predict the subsequent clinical course once nodal metastasis had occurred.
-Kenneth R. Tucker

Management of Dissecting Aneurysms of the Aorta. Leif Bergdahi and Viring Olov Bjork. Scand. J. Thorac-. Cardiovasc. Surg., 1980, 14: 91.
ASCENDING AORTIC dissections and descending dissections appear to have both different clinical profiles and prognoses. During the period from January 1957 to March 1978, 42 patients with dissecting aortic aneurysms were seen at the Thoracic Surgical Clinic, Karolinska Sjukhuset and form the basis of this report. There were 15 Type I, eight Type II and 19 Type III dissections according to DeBakey’s classification.
The hospital mortality in the patients with involvement of the ascending aorta was 35 per cent after operation, 6 of 17 patients, compared with 67 per cent in patients who did not undergo operation. Eight patients who were operated upon are still alive after a mean follow-up period of four years and four months. Only one of six patients who did not uidergo operation is alive after one year and one month. Resuspension of the aortic commissures gave generally unfavorable results. Surgical treatment is therefore recommended in patients with Type I and II dissecting aneurysms.
The early mortality rate in patients with descending aneurysms was 67 per cent, six of nine patients, after operation, compared with 30 per cent, three of ten after conservative therapy and all the five patients who underwent emergency operation died early. Two patients who were operated upon are alive 16 and 17 years postoperatively. Five nonoperated patients are living nine months to ten years after diagnosis, mean follow-up period five years. Initial medical treatment is therefore recommended in patients with descending aortic dissections. Operation should be performed if the dissection continues with occlusion of a major aortic branch or if there is impending rupture.
-Shuichiro Sugimura

The Management of Nomnalignant Intrathoracic Esophageal Perforations. Richard J. Finley, F. Griffith Pearson Richard D. Weisel and other. Ann. Thorac. Surg., 1980, 30: 575.
BETWEEN THE YEARS 1973 to 1978, eight patients with delayed, 48 hours to 14 days, non malignant esophageal perforations were seen at Torento General Hospital. Pain, vomiting, fever, shock, respiratory insufficiency and leukocytosis were seen in the majority of the patients. They were all treated operatively and all survived.
In four patients with spontaneous midesophageal ruptures, thoracotomy and direct suture closure provided the best mode of treatment. When perforation was seen in the lower esophagus, three patients, it was treated with suture closure and was reinforced with gastric patch. In the last patient, due to severe empyema, cervical esophagostomy and esophageal diversion were used. Localized leaks developed in two patients who responded to conservative therapy. Aggressive operative treatment for delayed esophageal rupture in order to eliminate continued chemical and bacterial contamination is strongly recommended.
-Ali N. Shariatzadeh

Long-Segment Colon Substitution for the Esophagus. Eart W. Wilkins, Jr. Ann. Surg., 1980, 192: 722.
ONE HUNDRED PATIENTS who underwent colon esophagus substitution over a 23 year period are reviewed. The operation was performed for carcinoma in 72 patients and for various benign conditions, including lye stricture, in 38 patients. The left colon was used in 68 patients and the right in 32 patients. All colons were placed isoperistaltically. The over-all operative mortality was nine per cent. There were seven cervical leaks and seven patients with colon necrosis. All leaks healed spontaneously, whereas colon necrosis was responsible for four of nine patients who died.
Fifty-nine of 72 patients who were operated upon for carcinoma of the esophagus were dead within 12 months. Four patients survived five years, 6.9 per cent. Narrowing in the proximal anastomosis developed in eight long term surviving patients. In one patient, recurrent carcinoma was responsible for the stricture. The remaining patients were managed with esophagoscopy and bougienage. Only two patients from this group eventually required reoperation. Nine colon esophagus substitutions have functioned for more than ten years.
Colon esophagus substitution is an effective treatment for benign and malignant obstmction of the esophagus. Careful attention to details of vascular. supply and anastomotic techniques will minimize complications. Long term observation confirms the suitability of the colon as an esophageal substitute.
-Giacorno A. DeL aria

Esophagogastrostomy with the EEA Stapler. Phillip N. West, John P. Marbarger, Mark N.Martz and Charles L. Roper Ann. Surg., 1981, 193: 76.
ESOPHAGOGASTRIC ANASTOMOSIS was per. formed with the end-to-end anastomosis stapling device in 31 patients who underwent esophageal resections. Anastomoses were accomplished at all levels between the diaphragm and the neck. Routine barium cine-esophagograms that were obtained at seven days after operation failed to demonstrate an anastomotic leak in any patient. The operative mortality rate was 3 per cent, one of 31 patients died of pneumonia. Technical problems occurred during the operation in three patients and all were corrected intraoperatively. All patients were able to swallow normally at the time of hospital discharge. Late anastomotic stricture occurred in five patients and response to dilation occurred in all but one patient who had local recurrence of tumor.
Although the numbers are too small to draw definite conclusions, the use of the largest end-to-end anastomosis stapling device cartridge which the esophageal lumen will accept was recommended. Successful use of the instrument requires strict attention to technical detail and awareness of possible pitfalls. Several of these are emphasized in the discussion.
-Martin J. Fischer

The Current Role of Thymectomy for Myasthenia Gravis. Steven Mintz, Scott R. Petersen, David Macfarland and others. Am. J. Surg.,1980, 140: 734.
FIFTY-TWO PATIENTS who were treated for myasthemu gravis over a nine year period are reviewed Thymectomy,performed through a median siciiiotomy incision, was accomplished in 27 of these patients. Indications in patients for a thymectomy included failure of medical therapy, 78 per cent, acute illness in a patient under 25 years ef age, 18 per cent and suspicion of thymoma, 4 per cent. There were no postoperative deaths and all patients were alive for the follow-up period.
Twenty-two patients, 81 per cent, benefited from thymectomy. Four patients, 15 per cent, had complete remission and 18 patients, 66 per cent, had substantial improvements in their disease. Success was more likely in patients who were less than 30 years of age, 86 per cent versus 77 per cent. Women were more likely than men to have a pronounced clinical response, 89 per cent versus 62 per cent.
Thymectomy can be safely performed in patients with myasthenia gravis. It is particularly indicated in young women patients. With proper selection, a good response can be expected in the majority of operative patients.
-Giacomo A. DeL aria

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