Hermes C. Grillo

POSTINTUBATION TRACHEAL STENOSIS. TREATMENT AND RESULTS

A total of 503 patients underwent 521 tracheal resections and reconstructions for postintubation stenosis from 1965 through 1992. Fifty-three had had prior attempts at surgical resection, 51 others had undergone various forms of tracheal or laryngeal repair, and 45 had had laser treatment. There were 251 cuff lesions, 178 stomal lesions, 38 at both levels, and 36 of indeterminate origin. Sixty-two patients with major laryngeal injuries required complete resection of anterior cricoid cartilage and anastomosis of trachea to thyroid cartilage, and 117 had tracheal anastomosis to the cricoid. A cervical approach was used in 350, cervicomediastinal in 145, and transthoracic in 8. Length of resection was 1.0 to 7.5 cm. Forty-nine had laryngeal release to reduce anastomotic tension. A total of 471 patients (93.7%) had good (87.5%) or satisfactory (6.2%) results. Eighteen of 37 whose operation failed underwent a second reconstruction. Eighteen required postoperative tracheostomy or T-tube insertion for extensive or multilevel disease. Twelve died (2.4%). The most common complication, suture line granulations (9.7%), has almost vanished with the use of absorbable sutures. Wound infection occurred in 15 (3%) and glottic dysfunction in 11 (2.2%). Five had postoperative innominate artery hemorrhage. Resection and reconstruction offer optimal treatment for postintubation tracheal stenosis.

Tracheal replacement: a critical review.

This review discusses the need for tracheal replacement, distinct from resection with primary anastomosis, the requirements for replacement, and the many efforts over the past century to accomplish this goal experimentally and clinically. Approaches have included use of foreign materials, nonviable tissue, autogenous tissue, tissue engineering, and transplantation. Biological problems in each category are noted.

Primary tracheal tumors: treatment and results.

One hundred ninety-eight patients with primary tracheal tumors were evaluated in 26 years. One hundred forty-seven tumors were excised (74%): 132 (66%) by resection and primary reconstruction, seven by laryngotracheal resection or cervicomediastinal exenteration, and eight by staged procedures. Eleven more were explored. Forty-four squamous cell carcinomas were resected, 60 adenoid cystic, and 43 assorted tumors, benign and malignant. Eighty-two patients underwent tracheal resection with primary reconstruction, and 50 had carinal resection and reconstruction. Surgical mortality for resection with primary reconstruction was 5%, with one death after tracheal and six after carinal repair. Six patients had stenosis after tracheal or carinal resection; all underwent reresection successfully. Nearly all patients with squamous or adenoid cystic carcinoma were irradiated postoperatively. Twenty of 41 survivors of resection of squamous cell carcinoma are living free of disease (some for more than 25 years), 39 of 52 with adenoid cystic carcinoma (up to nearly 19 years), and 35 of 42 with other lesions (5 lost to follow-up). Comparison of length of survival of patients with squamous cell carcinoma and adenoid cystic carcinoma who are alive without disease with those who died with carcinoma supports surgical treatment (usually followed by irradiation). Positive lymph nodes or invasive disease at resection margins appear to have an adverse effect on cure of squamous cell carcinoma; such an effect is not demonstrable with adenoid cystic carcinoma.

Potential impact on survival of improved tumor downstaging and resection rate by preoperative twice-daily radiation and concurrent chemotherapy in stage IIIA non-small-cell lung cancer.

PURPOSE The main objectives of this study were (a) to ascertain the feasibility and toxicity of preoperative twice-daily radiation therapy and concurrent chemotherapy, surgery, and postoperative therapy in stage IIIA (N2) non-small-cell lung cancer (NSCLC), and (b) to evaluate tumor response, resection rate, pathologic tumor downstaging, and survival. METHODS Eligibility included biopsy-proven N2 lesion (stage IIIA) by mediastinoscopy, Karnofsky performance score > or = 70, and weight loss less than 5% in the 3 months before diagnosis. The treatment program consisted of two courses of preoperative cisplatin, vinblastine, and fluorouracil (5-FU); 42 Gy concurrent radiation at 1.5 Gy per fraction in two fractions per day; surgery on day 57; and one more course of postoperative chemotherapy and 12 to 18 Gy of concurrent twice-daily radiation. RESULTS Forty-two patients with stage IIIA (N2) NSCLC (27 men and 15 women, age 38 to 77 years) were enrolled onto this prospective study. Forty of 42 patients tolerated the intended dose (42 Gy) of preoperative radiation and 37 of 39 resected patients received prescribed postoperative radiation. The intended dose of chemotherapy was given in 100%, 70%, and 60% of patients for the first, second, and third courses of chemotherapy. Marked dysphagia that required intravenous hydration was noted in 14% of patients (six of 42). Myelotoxicities included grade > or = 3 granulocytopenia in 23% and thrombocytopenia in 6% of 113 chemotherapy courses. Febrile neutropenia that required hospital admission was noted in 9% of 113 chemotherapy courses. Surgical resection was performed in 93% of patients. Treatment-related mortality was noted in 7% of patients. The overall survival rates by the Kaplan-Meier method were 66%, 37%, and 37% at 2,3, and 5 years, respectively, with a median follow-up time of 48 months. Pathologic examination of the surgical specimen showed a downward shift in tumor extent from stage IIIA (N2) to stage II (N1) in 33%, to stage I (NO) in 24% (10 of 42), and to stage 0 (TONO) in 9.5%, for a total of 67%. The degree of tumor downstaging was also translated into a survival benefit: 5-year survival rates from the time of surgery were 79%, 42%, and 18% for postoperative tumor stages 0 and I, II, and III, respectively (P = .04). CONCLUSION Concurrent chemoradiotherapy using twice-daily radiation is an effective induction regimen that resulted in 67% tumor downstaging, and an encouraging 37% 5-year survival rate. The degree of tumor downstaging may be a useful intermediate end point for survival benefit in stage IIIA (N2) NSCLC.

Collagenolytic activity during mammalian wound repair

Abstract Collagenolytic activity has been demonstrated in cultures of tissues from cutaneous mammalian wounds cultured on substrate gels of reconstituted collagen. As much as 90–100% of the insoluble collagen substrate was broken down at neutral pH, and at least 60% of the product was dialyzable. In wound edge cultures containing both epithelium and mesenchyme, collagenolysis was initially localized around the former. Variable collagenase activity was produced by granulation tissue alone, but none by dermis or by unwounded loose connective tissue. Unwounded skin revealed weaker collagenolytic potential. Recombination of separated epithelium and granulation tissue from wounds restored collagenase activity to high levels approximating that of unseparated tissues. Exposure of nonlytic granulation tissue to epithelium appeared to induce collagenolytic activity which continued in the mesenchymal tissue following removal of the epithelium. The activity of isolated epithelium decayed more rapidly than did that of the “activated” mesenchyme. Viable cells were required for collagenase production; freeze-thawing inactivated the explants. Enzyme activity could not be detected in tissue homogenates or extracts and whole serum applied daily to cultures blocked collagenolysis. Collagenase activity was not altered by vitamin C deficiency.

Surgical Management and Radiological Characteristics of Bronchogenic Cysts

Forty-two patients with bronchogenic cysts were treated over a 30-year period (1962 to 1991). The location was mediastinal in 37 and intrapulmonary in 5. Cysts were symptomatic in 21 patients (50%) and complications occurred in 11 (26%). The complications included infection in 5 patients, hemorrhage into the cyst in 2 patients, dysphagia due to esophageal compression in 2, adenocarcinoma arising from a bronchogenic cyst in an 8 1/2-year-old girl, and an esophagobronchopleurocutaneous fistula as a result of previous incomplete resection in 1 patient. Magnetic resonance imaging has been found to provide specific diagnostic information about bronchogenic cysts. All but 2 patients were treated with complete excision. One patient was managed by observation and another had drainage of the cyst by mediastinoscopy. Complications of treatment occurred in only 2 patients. One had a minor wound infection and the other had Clostridium difficile enterocolitis. Only 4 patients were lost to follow-up. No late complication or recurrence developed in those patients having complete excision. We recommend complete excision in most instances to confirm the diagnosis, relieve symptoms, and prevent complications.

Slide tracheoplasty for long-segment congenital tracheal stenosis

Resection and reconstruction of long congenital tracheal stenosis often is impossible or results in excessive anastomotic tension. Anterior tracheoplasty using a patch of pericardium or cartilage may result in granulation tissue needing repeated bronchoscopies, tracheostomy, and stents and may produce recurrent stenosis. Tracheoplasty may be performed by dividing the stenosis at midpoint, incising the proximal and distal narrowed segments vertically on opposite anterior and posterior surfaces and sliding these together. The stenotic segment is shortened by half, the circumference doubled, and the lumenal cross-section quadrupled. Approach is cervical or with partial sternotomy. Cardiopulmonary bypass is not necessary. Four patients (ages: 3 months, 3 1/2 years, 19 years, and 19 years) were so treated for stenosis of 36% to 83% of tracheal length. Blood supply was not impaired. Healing was excellent and complications were minimal.

Primary Reconstruction of Airway after Resection of Subglottic Laryngeal and Upper Tracheal Stenosis

Eighteen patients with low subglottic laryngeal stenosis and upper tracheal stenosis underwent resection of the anterior and lateral cricoid cartilage and upper trachea with reconstruction by primary laryngotracheal anastomosis. The posterior cricoid plate and recurrent laryngeal nerves were preserved. The distal trachea was tailored obliquely with an anterior prow and was anastomosed to the thyroid cartilage anteriorly and to the residual cricoid posteriorly. Where the stenosis was circumferential, scarred mucosa was resected from the anterior surface of the posterior cricoid lamina and the defect covered with a tailored flap of membranous tracheal wall. In 14 patients the lesions followed intubation injury. In 2 the stenosis was idiopathic. One stenosis resulted from inhalation burn and one from localized amyloidosis. Many patients had undergone previous surgical repairs. Sixteen patients had good to excellent results from six months to five and one-half years later. Reconstruction of the burned airway failed. One additional patient is still under treatment with a T tube.

Postpneumonectomy bronchopleural fistula after sutured bronchial closure: Incidence, risk factors, and management

OBJECTIVE Postpneumonectomy bronchopleural fistula remains a morbid complication after pneumonectomy. The incidence, risk factors, and management of postpneumonectomy bronchopleural fistula were evaluated in 256 consecutive patients who underwent pneumonectomy with a standardized suture closure of the bronchus. METHODS Pneumonectomy was performed for lung cancer in 198 cases, for other malignancy in 20 cases, and for benign causes in 38 cases. The bronchial stump was closed with interrupted simple sutures to emphasize a long, membranous wall flap. All stumps were covered by autologous tissue. RESULTS The incidence of postpneumonectomy bronchopleural fistula was 3.1%. Risk factors for bronchopleural fistula were the need for postoperative ventilation (p = 0.0001) and right pneumonectomy (p = 0.04). Five patients had bronchopleural fistulas as a result of pulmonary complications necessitating ventilation; the cause in the remaining three cases appeared to be technical. Reclosure was successful in five cases (mean postoperative day 12); in one case a pinhole fistula was healed by drainage alone. Two (25%) of the eight patients who had bronchopleural fistulas died. CONCLUSIONS Careful, sutured closure of the main bronchus with a tissue buttress after pneumonectomy yields excellent results. The most significant risk factor for bronchopleural fistula is a pulmonary complication necessitating ventilation. Contrary to previous reports, reclosure is usually successful even if performed late.

Transthoracic Esophagectomy: A Safe Approach to Carcinoma of the Esophagus

Transthoracic esophagogastrectomy is a safe operation. Mechanical staplers and a cervical anastomosis have been emphasized to avoid catastrophic consequences of anastomotic leaks in the chest. Transhiatal esophagectomy has been proposed to bring the anastomosis into the neck. It is meant to be a palliative procedure and consequently denies the patient the best chance for surgical cure. The emphasis should be on anastomotic technique and sound principles of surgical oncology. Since 1980, we have performed 104 esophagectomies for carcinoma of the esophagus. We used a left thoracoabdominal incision for distal tumors (64) and the Ivor Lewis technique (40) for more proximal tumors. A two-layer inverting interrupted silk suture technique was used for all anastomoses. More than 90% of the procedures were performed by resident staff. The operative mortality was 2.9% (3 patients). There were no anastomotic leaks. Five patients required between one dilation and three dilations postoperatively. A positive smoking history was present in 83 patients and substantial alcohol use, in 33. Median estimated blood loss was 500 ml, and 60% of patients required no transfusions. Major complications included pneumonia (12 patients) and reexploration for bleeding (2). Minor complications included atelectasis (71 patients), atrial fibrillation (9), ventricular arrhythmias (9), urinary tract infection (3), and wound infection (2). Squamous cancer was present in 31 patients and adenocarcinoma, in 73. Positive lymph node metastases were present in 75%. Anastomotic recurrence was documented in 6 patients. Standard techniques of esophagogastrectomy and a two-layer anastomosis will give excellent results with low mortality and acceptable morbidity.