Report of the use of hyperbaric oxygen therapy (HBO2) in an unusual case of secondary infertility.

We report the use of hyperbaric oxygen therapy (HBO2) in the treatment of an unusual case of secondary infertility. The patient had failed to conceive after a 1-year period of in-vitro fertilization, during which oral sildenafil had also been administered. However she became pregnant after an IVF cycle and the use of adjunctive HBO2 and sildenafil, which was administered intravaginally on this occasion. There is currently very little evidence to support the use of HBO2 in this context. The possible mechanisms of action of HBO2 in this case are discussed.

Use of the intra-aortic balloon pump for dilatation of benign tracheobronchial strictures.

Tracheobronchial benign stenoses may cause life-threatening emergencies. Here, we will describe a novel technique for the management of tracheal and bronchial stenoses using an intra-aortic balloon pump. The intra-aortic balloon pump was used for dilatation of a postoperative tracheal stricture in a 43-year-old man and a bronchial stricture in a 29-year-old woman with Wegener's granulematosis. There were no intraoperative or postoperative complications in either patient, and the stenosis was relieved successfully in each patient. The intra-aortic balloon pump can be used safely and effectively for the management of difficult tracheobronchial strictures.

Oesophageal strictures: new indication for intra-aortic balloon pumps?

Oesophageal strictures regardless of aetiology are a difficult and challenging problem facing the oesophageal surgeon. Various methods and techniques have been described and are routinely used in clinical practice with varying rates of efficacy and complications. We describe here a novel graded atraumatic technique for the management of oesophageal strictures using intra-aortic balloon pumps.

Breath-hold MRI in evaluating patients with pectus excavatum.

Pectus excavatum (PE) is a congenital condition in which the sternum is displaced posteriorly with associated changes in the adjacent costal cartilages. The aetiology of PE is uncertain although various underlying abnormalities of the diaphragm have been implicated. There is sparse information regarding the use of fast MRI in evaluating the deformity. Our aims were to use fast MRI to evaluate static and respiratory-related dynamic chest wall characteristics, the extent of cardiac displacement and diaphragmatic excursion in patients. FLASH and TurboFLASH MR sequences in axial and coronal planes were performed on the thoraces of six young patients with PE and six individually matched healthy controls during full inspiratory and full expiratory breath-holds. The Pectus Index was derived from chest wall measurements using axial images. The distances of the left and right cardiac borders from the midline were measured using axial images, and excursion of the dome of each hemidiaphragm was measured using coronal images. The degree of sternal depression worsened substantially in expiration. Anterior chest wall movement was similar in the two groups. Patients had significantly flatter chests than the controls. There was a trend towards leftward cardiac displacement in the patients (maximum distance between left heart border and midline during full expiration 99.5 mm in patients and 91.8 mm in controls). The right diaphragmatic dome excursion was greater than the left in the controls (53.6 mm and 47.4 mm, respectively), but this was not seen in the patients (50.2 mm and 50.4 mm, respectively). It is concluded that fast MRI is very informative in evaluating skeletal abnormalities, chest wall motion, and cardiac and diaphragmatic changes seen in PE.

An in vitro assessment of tissue compression damage during circular stapler approximation tests, measuring expulsion of intracellular fluid and force.

Circular staplers are among the many instruments used during minimally invasive or open surgery that should approximate soft tissue within safe compression limits. Previous in vivo suture-line blood flow measurement has suggested a safe thickness reduction limit of 25 per cent during circular stapling procedures. The present work investigates in vitro assessment of the maximum safe compression of large and small porcine intestines, measuring the required compressive force and the expelled intracellular fluid (measured as a potassium solution). A test-rig mounted on a materials testing machine allowed staplers of three sizes to compress tissue samples to thicknesses ranging from 90 to 45 per cent of original thickness. The expelled fluid was collected in 40 ml of 0.9 per cent NaCl and analysed in a flame photometer. The force measurements indicated that the small intestinal tissue samples underwent a sharp increase in stiffness over a strain range of 0.19-0.34. The large bowel tissue underwent a similar increase in stiffness over a planar compressive strain range of 0.19-0.40. The regularity of the potassium output results was limited, making it difficult to draw firm conclusions, although there was some indication that the potassium output from small intestinal tissue may change from erratic to approximately linear at a strain of approximately 0.19, while that of the large bowel tissue appeared to be approximately linear over the entire strain range tested. From the force measurements, it is concluded that strain-induced structural change may help provide a useful definition of safe tissue approximation. The possible implications for reduced dehiscence (wound disintegration) and stricture incidence in stapled anastomoses are discussed.

Prognostic factors for malignant mesothelioma in 142 patients: validation of CALGB and EORTC prognostic scoring systems.

BACKGROUND: The incidence of malignant mesothelioma is increasing. There is the perception that survival is worse in the UK than in other countries. However, it is important to compare survival in different series based on accurate prognostic data. The European Organisation for Research and Treatment of Cancer (EORTC) and the Cancer and Leukaemia Group B (CALGB) have recently published prognostic scoring systems. We have assessed the prognostic variables, validated the EORTC and CALGB prognostic groups, and evaluated survival in a series of 142 patients. METHODS: Case notes of 142 consecutive patients presenting in Leicester since 1988 were reviewed. Univariate analysis of prognostic variables was performed using a Cox proportional hazards regression model. Statistically significant variables were analysed further in a forward, stepwise multivariate model. EORTC and CALGB prognostic groups were derived, Kaplan-Meier survival curves plotted, and survival rates were calculated from life tables. RESULTS: Significant poor prognostic factors in univariate analysis included male sex, older age, weight loss, chest pain, poor performance status, low haemoglobin, leukocytosis, thrombocytosis, and non-epithelial cell type (p<0.05). The prognostic significance of cell type, haemoglobin, white cell count, performance status, and sex were retained in the multivariate model. Overall median survival was 5.9 (range 0-34.3) months. One and two year survival rates were 21.3% (95% CI 13.9 to 28.7) and 3. 5% (0 to 8.5), respectively. Median, one, and two year survival data within prognostic groups in Leicester were equivalent to the EORTC and CALGB series. Survival curves were successfully stratified by the prognostic groups. CONCLUSIONS: This study validates the EORTC and CALGB prognostic scoring systems which should be used both in the assessment of survival data of series in different countries and in the stratification of patients into randomised clinical studies.

Surgical staplers: a review.

For almost two centuries, surgeons have been using mechanical devices to join tissue. One of the most successful methods is that of stapling, which has become very common in more recent times. The range of staplers consists of five established stapler categories (circular, linear, linear cutting, ligating and skin staplers), along with recent variations which lend themselves to minimally invasive surgery. Within each category, several commercial models are available, many of which have their own unique features. The procedures which are enhanced by these instruments are many and varied. Applications have been further expanded and improved by the instrument design developments seen in recent years. This review attempts to present a rationalized overview of the array of stapling instruments, with relevant procedures. The authors believe that surgical stapling may be greatly enhanced by further research and development, taking the instrument designs and procedures further into the realm of minimally invasive surgery.

Intracranial metastases from malignant pleural mesothelioma.

Although intracranial metastases from malignant pleural mesothelioma are rare, their presence should be suspected in cases of high-grade mesothelioma and should possibly be included in routine preoperative evaluation. An unusual case of cerebral metastases from pleural mesothelioma is presented and the literature is reviewed.

Use of expandable wire stents for malignant airway obstruction.

The symptoms of progressive dyspnea and stridor in the setting of malignant airway obstruction are severe and distressing. Conservative nebulizer and oxygen therapy offer little relief, and conventional stenting with T tubes requires a tracheostomy. In this article, we describe our experience with stenting in the treatment of malignant mediastinal disease using the Gianturco expanding metal-wire stents. The technique of placement is simple and the procedure was successful in all 21 cases. Relief of stridor was immediate and the dyspnea usually abated. These benefits continued through the mean survival period after stenting of 134 days (range, 2 to 799 days). The patients required only brief hospitalization (2.83 days) before returning home or to the referring institution. It appears that expandable wire stents may offer a simple yet effective intervention in the palliative treatment of mediastinal malignancy.

Total oesophageal duplication associated with dextrocardia and situs inversus.

A case of complete oesophageal duplication in association with dextrocardia and situs inversus is presented.

Tracheo-graft fistulae following pharyngo-laryngo-oesophagectomy. A cause and its prevention.

Tracheo-graft fistulae developed in two patients who required intermittent positive pressure ventilation and intubation with conventional cuffed tracheostomy tubes following resection of post-cricoid carcinomata by pharyngolaryngo-oesophagectomy. Pressure necrosis of the posterior tracheal muscle and the anterior wall of the graft occurred as a direct result of compression of these structures between the tracheostomy cannula and air cuff, and the vertebral bodies at the thoracic inlet. This post-operative complication has not been encountered in subsequent resections since the introduction and routine use of a modified cuffed tracheostomy tube. The adjustable neck plate guards against trauma to the tracheostome, inadvertent intubation of one of the major bronchi in each individual patient and the siting of the cuff beyond the thoracic inlet. Unintentional over-inflation of air cuffs remains a hazard whereas only ambient air re-expands the foam cuff. This property of the cuff also ensures against surgical injury to the posterior tracheal wall during the operation. Pressure necrosis of the posterior tracheal wall by the main tracheostomy cannula is minimised by suitably modifying the curvature and length of the cannula for use in patients with end-tracheostomies.

Cuffed tube tracheostomy in the dog.

A surgical technique of performing tracheostomy in dogs requiring prolonged intubation with either cuffed or uncuffed tubes is described. Cannulae used in humans are anatomically unsuitable for the dog. The cannula and cuff described in this paper did not predispose to severe mechanical trauma to the trachea and we attempted to minimize factors that may predispose to tracheal damage during the period of intubation and the subsequent development of late tracheal injuring after extubation. A simple method of humidification in these healthy dogs proved adequate; neither tenacious tracheobronchial secretion nor the retention of secretions were seen.

Tracheal damage associated with cuffed tracheostomy tubes. Aspiration of gastric content as a cause of local damage in tracheotomised dogs.

Dogs were subjected to tracheostomy and intubation with low pressure cuffed tracheostomy tubes. Various mixtures of bile, gastric secretion and 0-1 N Hydrochloric acid were injected into the trachea via a small catheter attached to the main tracheostomy cannula to simulate the effect of aspirated gastric contents. Bronchoscopic observations were made during the study to investigate the local effects of secretions pooling above the cuff, in contact with the tracheal wall. Gross pathological changes were observed when the animals were sacrificed at the end of the study. The constituents of a mixture of bile and gastric juice increased the severity of tracheal damage due to mechanical trauma and sepsis. Healing was delayed and the reparative process was abnormal. This experimental study indicates that the combination of bile and acid pepsin reaching the tracheal wall may also be a major factor which predisposes to the development of early and late tracheal injury.

A manometric study of the upper oesophagus in the dog following cuffed-tube tracheostomy.

Intraluminal oesophageal pressures were measured in dogs after tracheostomy and intubation with either uncuffed or cuffed tracheostomy tubes. Possible explanations for disordered swallowing following tracheostomy were found in those animals intubated with cuffed tracheostomy tubes: (a) Increased intraluminal pressures were measured in the oesophagus at the level of the cuffs. (b) Significantly increased pressures were found also 5 and 10 cm below the pharyngo-oesophageal junction. (c) The upper oesophageal sphincter relaxed incompletely.

Tracheal size following tracheostomy with cuffed tracheostomy tubes: an experimental study.

In view of the severe damage caused by unyielding, low residual volume cuffs, various modifications to the cuff of an intratracheal tube have been introduced. The merits of two low-pressure cuffs were assessed in an experimental study in dogs; both cuffs produced little visible damage to the tracheal wall in dogs intubated continuously over a two-week period. A modified technique of producing tantalum tracheobronchograms without distrubing the mucous blanket or traumatizing the tracheal wall is described. These tantalum radiological studies demonstrated a progressive temporary increase in size of the trachea at cuff level over the period of intubation with these cuffs. The implications of such a progressive weakness occurring in the tracheal muscle are discussed.