Mario N. Gomes

Endoscopic ultrasound for staging esophageal cancer, with or without dilation, is clinically important and safe

BACKGROUND To fully evaluate patients with esophageal cancer by endoscopic ultrasonography (EUS), the transducer must pass through the entire tumor to the cardia to scan the celiac axis. Dilation may be necessary. Published information suggests that dilation with EUS carries a sizeable risk. METHODS In order to assess the complication rate associated with dilation prior to EUS in patients with esophageal cancer and the clinical significance of dilation for complete EUS staging, we reviewed the records of all patients who had undergone EUS for esophageal cancer. RESULTS Sixty-three patients underwent EUS staging of esophageal cancer. Thirty-nine (62%) had lesions through which the EUS scope was passable (Group I). Ten (16%) patients (Group II) had lesions through which an EUS scope (diameter 13 mm) was unable to pass even after dilation. Fourteen patients (22%) had lesions that were dilated to allow passage of the EUS scope (Group III). All patients in Groups II and III had confirmation of EUS staging by CT and/or surgery. In Group II, five patients had tumors defined as T4 (50%) and five as T3 (50%). In Group III, nine (64%) had T4 tumors, four (29%) had T3, and one (7.7%) had T2. No complications were encountered in any group. CONCLUSION EUS, either alone or after dilation, is a safe procedure and the complete EUS examination with celiac node visualization adds prognostically significant information.

Solitary fibrous tumors : A series of lesions, some in unusual sites

Solitary fibrous tumor (SFT) is a rare neoplasm that, in addition to its classic presentation as a pleural-based mass, can also be encountered in unusual sites. The main difficulty in making the diagnosis of SFTs results from the unfamiliarity with its diverse clinical and pathologic features. This series of SFTs, some with unusual clinicopathologic presentation, included nine women and two men, ranging in age from 28 years to 74 years (five in pleura, one in lung parenchyma, one in breast, and four in mediastinum). The tumors were locally excised in eight cases and were resected along with portions of lung parenchyma in three. A panel of immunohistochemical stains was used to characterize these tumors. They were all vimentin-positive and, with the exception of one case, CD34-positive. Tumors were negative with antibodies directed against cytokeratin, factor VIII-related antigen, S-100 protein, muscle-specific actin, and smooth-muscle actin. Various diagnoses were initially rendered for these clinically and pathologically diverse lesions by the examining pathologists. Awareness of the various gross and microscopic patterns of these tumors, the possibility of occurring in unusual sites, and the use of immunohistochemical stains, particularly CD34, should eliminate most of the difficulties in arriving at a correct diagnosis. One patient died of metastatic breast cancer; all other patients were alive and well with a median follow-up of 17 months.

The relative roles of aggressive wound care versus revascularization in salvage of the threatened lower extremity in the renal failure diabetic patient.

&NA; Current literature indicates poor survival and limb salvage rates in renal failure diabetic patients who present with ulcerated or gangrenous lower extremities. Even in those limbs that were successfully revascularized, the amputation rate was as high as 37 percent. This has led some to advocate immediate amputation when treating the threatened limb of a renal failure diabetic patient. The authors reviewed all renal failure diabetic patients in their wound registry to determine whether such pessimism was warranted. The authors then analyzed the relative roles of revascularization and aggressive wound care on long‐term limb salvage. Forty‐five consecutive renal failure diabetic patients with 71 wounds in 54 limbs were identified. Twenty‐seven patients had chronic renal insufficiency, 15 patients had end‐stage renal disease, and three patients received kidney transplants. The revascularization procedures (46 percent of all limbs) included angioplasty, femoral‐popliteal, femoral‐distal, and popliteal‐distal bypasses. Forty‐three amputations in combination with 67 soft‐tissue repairs (delayed primary wound closure, skin grafts, local flaps, pedicled flaps, and free flaps) were necessary to close the defects. After a mean follow‐up of over 3 years, the data indicate that 79 percent of wounds healed, 89 percent of all limbs were salvaged, and 49 percent of patients survived. Revascularization improved the threatened limbs salvage rate from negligible to a level similar to that of the adequately vascularized limb. Fifteen out of 71 wounds did not heal because of the patients early postoperative death, ischemia not amenable to revascularization, or noncompliance. Six below‐knee amputations were performed (one despite a patent bypass and five in adequately vascularized patients). The average time for wounds to heal in the revascularized patients was 79 days versus 71 days in adequately vascularized patients. There was an overall 43 percent complication rate. Of the patients who were alive after the 3‐year follow‐up, 73 percent were independently ambulating, whereas 27 percent were bound to wheelchair or bed. Eighty‐two percent of patients were very satisfied with the salvage attempt, 18 percent were moderately satisfied, and all patients said they would go through the process again. The authors believe that salvaging the threatened extremity in the renal failure diabetic patient is justified whether or not the limb requires revascularization. Revascularization improved the limb salvage rate, patient survival, and days for wounds to heal to a level comparable to that of the adequately vascularized limb. The key to subsequently achieving high salvage rates is the quality of perioperative wound care (e.g., serial debridements, antibiotics, dressings) and the timing and selection of appropriate soft‐tissue coverage. (Plast. Reconstr. Surg. 109: 1281, 2002.)

Metastatic cancer. A relative contraindication to vena cava filter placement.

From October 1979 to November 1984, 41 patients underwent placement of vena cava filters for prevention of pulmonary emboli. After filter placement, no pulmonary emboli were documented. No patient died due to filter placement. However, 20 of these 41 patients are dead. Eighteen deaths were caused by cancer. Ten (24%) patients died within 2 months of filter placement. Five (12%) patients died prior to hospital discharge. All ten of these patients had known, widely metastatic cancer. Among the ten patients who died more than 2 months after filter placement, six had well‐differentiated, slow growing tumors. Only three of these patients had brain metastases. Among the 21 survivors only two suffered from cancer. Strict adherence to accepted indications for vena cava filter placement required operative procedures on a small but significant number of patients who demonstrated no significant improvement in quality of life or time out of hospital. Filter placement in patients with aggressive cancers and proven metastases should be performed only after analysis of predicted survival and after detailed discussions with patients and referring physicians. Filter placement in patients with aggressive metastatic cancer may cause discomfort, risk, and expense with little hope for improvement of hospital course, longevity, or quality of life. Cancer 59:161–163, 1987.

Severe aortic regurgitation from systemic hypertension (without aortic dissection) requiring aortic valve replacement: Analysis of four patients

Clinical and morphologic observations are described in four patients who had severe aortic regurgitation from severe systemic hypertension unassociated with aortic dissection; each patient underwent aortic valve replacement. Although aortic regurgitation of minimal or mild degree is well recognized to occur in patients with systemic hypertension, severe degrees of aortic regurgitation are rare in such patients; aortic valve replacement in such patients has not previously been reported. Why these four patient had such severe aortic regurgitation was not determined. Although systemic hypertension is rarely a cause, it nevertheless must be added to the list of causes of severe pure aortic regurgitation.

Severe aortic regurgitation secondary to idiopathic aortitis

Clinical and morphologic features are described in two relatively young adults with aortic regurgitation secondary to chronic aortitis. The regurgitation in each was severe enough to require aortic valve replacement. Both patients had normochromic, normocytic anemia, considerable weight loss despite congestive cardiac failure, and negative serologic tests for syphilis. These systemic manifestations in association with the aortitis suggest that both had Takayasus arteritis. In addition, one patient had total occlusion at the origin of one subclavian artery (classic pulseless disease). Takayasus arteritis must be added to the list of causes of severe aortic regurgitation.

Transcutaneous Oxygen Monitoring during Bronchoscopy and Washout for Cystic Fibrosis

The anesthetic management of young patients with cystic fibrosis (CF) undergoing bilateral diagnostic bronchoscopy and bronchoscopic washout presents difficulties. These patients may have severe pulmonary disease leading to chronic hypoxemia and, in the advance states, hypercapnia (1,2). Gas exchange abnormalities arise from ventilation-perfusion (V/Q) mismatch, bronchiolar spasm, air trapping, and extensive mucous plugging of the small airways and alveoli. Superimposed acute infection promotes sputum retention. Bronchoscopy and bronchial washing (BBW) with the mucolytic agent of 5% acetylcysteine saline solution loosens mucous plugs and improves general bronchial toilet. However administration of anesthesia coupled with prolonged bronchoscopy and mucolytic instillation may be hazardous if not managed with skill and attention (3-5). Because pulmonary lesions in CF account for most of the morbidity and mortality associated with the disease, relief of bronchial tree obstruction and removal of mucoplugs through skillful BBW seems to be logical and mandatory (6). Oxygenation during BBW depends on the position of the bronchoscope, the volume of instillate, and the position of the patient; fluctuations of Po, are so rapid that intermittent arterial blood gas (ABG) sampling is not an adequate therapeutic guide. However, changes in oxygenation are reflected relatively rapidly by transcutaneous oxygen (tc/02) monitors. We present our experience with continuous tc/O, monitoring us-

A Comparison of the Reliability of Two Techniques of Left Double-lumen Tube Bronchial Cuff Inflation in Producing Water-tight Seal of the Left Mainstem Bronchus

A double-lumen endobronchial tube (DLT) bronchial cuff inflation technique that reliably ensures effective water-tight isolation of the two lungs has not been determined. In this study, 20 patients undergoing thoracic surgery requiring a left DLT had the bronchial cuff of the DLT inflated by one of two techniques. In Group 1, the cuff was inflated to produce an air-tight seal of the left bronchus using the underwater seal technique. In Group 2, the cuff was inflated to a pressure of 25 cm H2 O. After bronchial cuff inflation in both groups, water-tight bronchial seal was tested by instilling 2 mL of 0.01% methylene blue (MB) above the bronchial cuff of the DLT. Fifteen minutes later, fiberoptic bronchoscopy was performed via the bronchial lumen of the DLT to determine whether MB had seeped past the bronchial cuff. Cuff volume was 0.75 +/- 0.64 and 0.76 +/- 0.46 mL, cuff pressure was 30.1 +/- 27.0 and 25.0 +/- 0.0 cm H2 O (mean +/- SD), and MB was positively identified in two and five patients in Groups 1 and 2, respectively. The difference in cuff volume and pressure and the higher MB seepage in Group 2 compared with Group 1 was not statistically significant. In both groups, MB seepage occurred only when the bronchial cuff volume was <1 mL and when the patients were positioned in the left lateral decubitus position. These findings suggest that the risk of aspiration is greatest when the DLT is positioned in the dependent lung and when the bronchial cuff volume is <1 mL. Implications: Water-tight sealing of the left bronchus by DLT bronchial cuff was tested after cuff inflation using two different techniques. Neither air-tight bronchial seal nor cuff pressure of 25 cm H2 O guaranteed protection against aspiration. The risk of aspiration was greatest when the DLT was positioned in the dependent lung and when the bronchial cuff volume was <1 mL. (Anesth Analg 1998;87:1027-31)

Intravascular Fasciitis Clinically Mimicking an Axillary Peripheral Nerve Sheath Tumor A Case Report and Review of the Literature

Intravascular fasciitis is one of the benign myofibroblastic pseudosarcomatous proliferations, among which nodular fasciitis is the prototype. These lesions are important as they may mimic a variety of sarcomas and other lesions on both clinical and pathologic grounds. This report describes the features of one such lesion that arose within the brachial artery and invested nerve trunks of the brachial plexus. The patient presented with symptoms of arm fatigue and hand numbness. There were no neurological or vascular findings on physical examination. The clinicopathologic differential diagnosis is discussed. Also, surgeons are cautioned to involve a vascular etiology in their differential diagnosis and seek the help of a vascular surgeon when the lesion juxtaposes the axillary artery or vein.