Influence of thoracic epidural analgesia on outcome after resection for esophageal cancer.

BACKGROUND: Many series have reported a lessening of the incidence of anastomotic dehiscence after thoracoabdominal resection of esophageal carcinomata. This has resulted in fatal respiratory complications assuming a relatively greater role as a cause of death after such procedures. This study was conducted to investigate the impact of the routine use of thoracic epidural analgesia on respiratory complications after resection for esophageal carcinoma. METHODS: The incidence of respiratory complications and the effect on outcome were studied in two groups of patients undergoing thoracoabdominal esophagogastrectomy for esophageal cancer during a 15-year period. The first group comprised 81 patients who underwent operation from 1975 through 1985 in whom thoracic epidural analgesia was not used; the second group comprised 75 patients who underwent operation from 1985 through 1990 in whom thoracic epidural analgesia was used routinely. RESULTS: In the latter group, the incidence of respiratory complications was 13%, and no fatal respiratory complications occurred, compared with corresponding figures of 30% and 5% in the nonepidural group. The 30-day/hospital mortality during the first period was 9.8% and 6.6% in the 75 patients in whom thoracic epidural analgesia was used routinely. CONCLUSIONS: The results of this study suggest that the routine use of thoracic epidural analgesia during thoracoabdominal esophagogastrectomy for esophageal cancer reduces the incidence of fatal and nonfatal respiratory complications and should be incorporated into routine surgical management of operable esophageal cancer.

A benign gonadal stromal tumor of the testis of spindle fibroblastic type.

Non-Leydig cell gonadal stromal tumors of the testis are rare and most are benign. Criteria for determining malignancy are poorly defined. A gonadal stromal tumor of spindle fibroblastic cells presented in a 34 year old male. The patient remains alive and well with no evidence of metastasis 3 years following surgery. Light and electron microscopical features of the tumor are described.

Acute streptococcal necrotising fasciitis.

Two cases of acute streptococcal necrotising fasciitis are reported. Both patients were taking nonsteroidal antiinflammatory drugs when they developed this infection. Urgent surgical debridement was undertaken and resulted in a successful outcome in both patients. The clinical and histopathological features of this condition are reviewed.

Evaluation of preserved bovine tendon xenografts: a histological, biomechanical and clinical study.

Glutaraldehyde treated bovine tendon xenografts have been introduced into clinical trials as human knee ligament replacements recently, following animal experiments. This paper reports a further clinical study in which complications arose from implant debris. A laboratory study showed that the implants were not absorbed or integrated into the tissues of the host animals, as had been claimed by the originators. Mechanical tests of tendon reconstructions showed that the implants were not functional. It was concluded that this material is not suitable for clinical use within the knee joint as a cruciate ligament prosthesis.

Osteoporosis with hip fracture: changes in calcium regulating hormones.

It has been suggested that there are two distinct types of involutional osteoporosis in women. Loss of ovarian function causes spine and wrist fractures in middle-aged women whilst a decline in renal endocrine function and bone formation is responsible for fractures, especially of the hip, in elderly women. We have investigated calcium regulation in post-menopausal women with hip fractures in their seventh decade together with non-osteoporotic controls of similar age. The major findings were reduced secretion of calcitonin (P less than 0.01) and 1,25 dihydroxy-vitamin D (P less than 0.025) in the osteoporotics as compared with controls. No differences in plasma levels of calcium, parathyroid hormone and 25 hydroxyvitamin D were observed. Our results show some similarities with those reported in both proposed types of osteoporosis, suggesting considerable overlap between them. Secondary hyperparathyroidism does not appear to be a usual feature of osteoporotic women with hip fracture up to age 75 years. Our hormonal findings are more in keeping with marked oestrogen deficiency, suggesting that loss of ovarian function is a major determinant of the osteoporosis in these women.

Tibial tubercle advancement for anterior knee pain. A temporary or permanent solution.

In a prospective study of 29 consecutive cases of tibial tubercle advancement, the patients were assessed on the Larson knee chart preoperatively, three years postoperatively, and again after a minimum of six years (range, six to eight years; mean, 7.2 years). Only one patient was lost to follow-up evaluation. The overall results show that at three years, 65.5% of the knees were excellent or good, 13.8% were fair, and 20.7% were poor. By six years a significant change occurred in five knees. Four knees deteriorated, while one improved. The remainder maintained their three-year postoperative grade. The patients provide clinical evidence to support the biomechanical and morphological observations that form the basis of the Maquet principle. Two considerations influence the final result: surgical complications (three out of four cases with complications had a poor result) and the preoperative status (in patellofemoral osteoarthritis a preoperative Larson score of over 60 is necessary for a satisfactory outcome).

Glutaraldehyde treated bovine fibrocartilage arthroplasty for the scaphoid: a case history and discussion.

Avascular necrosis of the proximal pole of the carpal scaphoid following fracture often leads to degeneration and carpal collapse. Replacement arthroplasty as a treatment for this condition using a variety of materials has not been universally successful. A case is described in which a new arthroplasty material-glutaraldehyde treated bovine fibrocartilage-was used as a spacer to restore carpal height.

Detection of mycobacterial antigen and antibodies in the cerebrospinal fluid of patients with tuberculous meningitis.

An immunodiagnostic test for the detection of a soluble nonprotein mycobacterial antigen by reverse passive haemagglutination with IgM murine monoclonal antibody was developed. The test was used to analyse the cerebrospinal fluid of 89 patients with tuberculous meningitis (TBM) from India and 127 control subjects from India and the UK. The antigen was demonstrable in 88% of culture-positive and 73% of culture-negative TBM patients. However, it was also detected in 21% of Indian patients with pyogenic meningitis, and in 8% of Indian and 1% of UK control subjects. Antibodies binding to a soluble mycobacterial extract were detected at low titre in 68% of all subjects with TBM and in 37% of Indian cases of pyogenic meningitis. Because patients with TBM had raised levels of the antigen and of antibodies to the antigen, the possible role of immune complexes in the pathogenesis of the disease is briefly discussed.

Late degenerative changes after meniscectomy. Factors affecting the knee after operation.

Late degenerative changes are known to follow meniscectomy, but there is little agreement on their incidence or on which patients are most at risk. A total of 210 patients have been reviewed 10 to 22 years after meniscectomy, and long leg radiographs taken of both knees. Radiological degeneration was seen in 18%, while 7% had significant symptoms and signs. Statistical analysis showed increased changes in older patients, in those with abnormal leg alignment, and in those who had undergone lateral as against medial meniscectomy. Our findings emphasise the important mechanical function of the meniscus and support the current cautious approach to meniscectomy, especially for patients in high risk groups. They also indicate the value of early high tibial osteotomy for symptomatic varus deformity after medial meniscectomy.

Idiopathic avascular necrosis of the scaphoid. A report of two cases.

Two cases of idiopathic avascular necrosis of the scaphoid are reported and it is suggested that the aetiology could be the same as that recently described for Keinboeck's disease by Beckenbaugh et al. (1980). The condition described in this paper is a different entity from that described by Preiser (1910), which was probably not an osteochondritis but an undiagnosed fracture.

Extradural analgesia in labour. A comparison of 2-chloroprocaine hydrochloride and bupivacaine hydrochloride.

Chloroprocaine hydrochloride 2% and bupivacaine hydrochloride 0.375% in 10-ml doses of plain solutions were studied in a randomised blind manner as the agents for continuous lumbar extradural analgesia in labour. Twenty-four patients were assessed for the speed of onset, duration of action, degree of motor blockade, dermatomal spread, arterial hypotension, and the incidence of unblocked segments. Chloroprocaine showed a quicker onset time and a shorter duration of action than bupivacaine. Chloroprocaine exhibited more marked motor blockade and a lower incidence of unblocked segments. The dermatomal spread and effect on arterial pressure were similar in both groups.

Subarachnoid injection during extradural analgesia for labour using 2-chloroprocaine.

An obstetric patient had a subarachnoid block during attempted extradural analgesia for labour. The sensory block extended to T1 and was accompanied by hypotension. The analgesia lasted 3 hr. after which sensory and motor function recovered quickly. The local anaesthetic agent used was 2% 2-chloroprocaine.

A rapid immunofluorescent procedure for the detection of specific IgG and IgM antibody in sera using Staphylococcus aureus and latex-IgG as absorbents.

Sera from adults with toxoplasmosis and individuals with anti nuclear antibodies were examined for the presenceof specific IgM and IgG antibodies and for the occurrence of anti-immunoglobulin ("RF") activity both before and after absorption with freeze-dried preparations of protein A-containing Staphylococcus aureus. Such absorption removed most of the IgG present in sera without interfering with the detection of IgM antibody by immunofluorescence, but was relatively ineffective in the removal of "RF". "RF" activity, demonstrable by slide agglutination, was removed by absorption with latex coated with IgG. In order to prevent the possibility of false positive IgM staining in immunofluorescence tests, it is concluded that sequential absorption with latex-IgG particles and protein A-positive staphylococci is essential. Such absorption is technically simple and can be performed on small volumes of serum.