Ming-Ho Wu

Thymic carcinoma: Involvement of great vessels indicates poor prognosis

BACKGROUND Thymic carcinoma is a rare, indolent, and invasive cancer. This study investigated the treatment results of thymic carcinoma and clinical prognostic factors. METHODS From June 1988 to January 2002, 38 patients were enrolled in this study with the diagnosis of thymic carcinoma in the Cheng-Kung University Hospital based on Rosais and Muller-Hermelinks classification. Clinical and pathologic data were retrospectively reviewed. Survival analysis was performed using the Kaplan-Meier, log rank, and Wilcoxon tests. Statistical significance was defined as p < 0.05. RESULTS Pathology revealed 14 poorly differentiated, 6 moderately differentiated, and 8 well-differentiated squamous cell carcinomas; 8 lymphoepithelioma-like carcinomas; and 2 other carcinomas. Pathologic staging using the Masaoka system included 6 stage II, 23 stage III, and 9 stage IV patients. Six biopsies, five debulkings, and 27 complete resections were performed. All patients were followed from 15 months to 10 years 9 months, with an average of 53.8 months. Median survival time was 81 months, and median recurrence time was 52 months. Eighteen patients are still alive, and 7 are alive with disease. Well-differentiated squamous cell carcinoma had better prognosis than other carcinomas (p = 0.022). Complete resection significantly increased survival rate (p < 0.001). Tumor invasion of the superior vena cava, pulmonary vessels, or aorta were significant predictors for poor prognosis (p = 0.016, 0.002, and 0.002, respectively). CONCLUSIONS Only patients with thymic carcinoma who underwent complete resection had long-term survival. Prognosis of thymic carcinoma seemed mainly dependent on tumor invasion of the great vessels.

Aortoesophageal fistula induced by foreign bodies.

Two patients with aortoesophageal fistula induced by foreign bodies were surgically treated during a period of 10 years. The first patient was surgically treated through a right thoracotomy, which failed on account of exsanguination. In the second patient, a Sengstaken-Blakemore tube was inserted for esophageal tamponade. The aorta was successfully repaired through a left thoracotomy after occlusion of the esophagus and the aorta above and below the fistula. Therefore, we recommend preoperative esophageal tamponade and occlusion of the esophagus and the aorta through a left thoracotomy as the most successful approach.

Esophageal reconstruction for hypopharyngoesophageal strictures after corrosive injury

OBJECTIVE To evaluate the surgical outcome of patients with caustic stricture of the hypopharyngoesophagus. MATERIALS AND METHODS During a 25-year period, we performed esophageal reconstruction in 152 patients with diffuse or multiple caustic esophageal stricture. Of them, esophageal substitute was pulled up and anastomosed to the hypopharynx in 50 (33%) patients, and anastomosed to the cervical esophagus in the other 102 (67%) patients. Patients whose esophageal substitute anastomosed to the hypopharynx were enrolled to the present study. Among these 50 study patients, 13 underwent ablation of damaged organs and feeding jejunostomy in acute stage of corrosive injury, and the remaining 37 patients were initially organ preserved with or without feeding gastrostomy or jejunostomy. Six patients had respiratory distress caused by laryngotracheal stricture. The ileocolon (28/50) was commonly used as an esophageal substitute in reconstruction and most substitutes (43/50) went through the substernal route. RESULTS There was one operative death. Eight (16%) patients had major early postoperative complications. Six patients underwent revision for late stenosis of hypopharyngeal anastomosis, and one redoing reconstruction using the jejunum because of failure of the transplanted ileocolon. Postoperatively, swallow function and maintaining body weight were considered good in 42 patients (84%) after an average of 8 months follow-up. Five of six patients who underwent concomitant tracheostomy or laryngosurgery for laryngotracheal stricture got unsatisfactory result. The surgical outcome of the study patients was worse than that in patients with esophageal substitute anastomosed to a healthy cervical esophagus. In the later group of patients, 95/102 (93%) had good swallow function and only 7/102 (6.8%) had major early complications. CONCLUSION Caustic stricture of the hypopharyngoesophagus is a challenging reconstructive problem. A successful reconstruction requires a correct hypopharyngeal opening and anastomosis, a good esophageal substitute, and a patent esophageal route and airway.

Aggressive resection of the airway invaded by thyroid carcinoma

The aim of this study was to investigate the hypothesis that outcome following concomitant airway resection is superior to that after shaving of the tumour in patients with airway invasion of thyroid carcinoma.

Activation of STAT3 in thymic epithelial tumours correlates with tumour type and clinical behaviour.

The STAT3 (signal transducers and activators of transcription 3) signalling pathway plays a pivotal role in oncogenesis and appears essential for postnatal maintenance of thymic architecture and thymocyte survival. The association of STAT3 activation with thymic epithelial tumours (TETs) and myasthenia gravis (MG) has not been elucidated. In this study, 118 cases of TET and 25 non‐neoplastic thymic tissue samples were evaluated for STAT3 and phospho‐STAT3 (pSTAT3) expression immunohistochemically. In addition, 44 normal thymuses of different ages were included for comparison. It was found that STAT3 activation in thymic epithelial cells (TECs), as evidenced by pSTAT3 expression and/or nuclear STAT3, was present in the majority of non‐neoplastic thymuses (88%, 22/25), including those from young children, but not in fetal thymus. In thymoma (n = 73), activated STAT3 was noted at a significantly higher frequency in the cases of lymphocyte‐rich thymoma (ie types AB, B1, and B2, 46%, 23/50) in comparison with lymphocyte‐depleted thymoma (types A and B3, 1/23) (p = 0.009). Thymoma with activated STAT3 tended to present at an earlier stage, show complete resectability and less aggressive behaviour, and have a higher correlation with MG than the STAT3‐negative/inactive group (p < 0.05). In contrast, thymic carcinoma with activated STAT3 (14/45, 31%) had significantly higher rates of unresectability, vascular invasion, and regional lymph node metastasis (p < 0.05). These data provide the first evidence that constitutive STAT3 activation is seen in both benign and neoplastic thymic tissue and is associated with the persistence of thymic tissue and the presence of MG. It is likely to be induced by different factors in thymoma and thymic carcinoma. Copyright

Outcome of acid ingestion related aspiration pneumonia

BACKGROUND The objective of this study is to assess the incidence and long-term results of a rarely discussed medical problem -- aspiration pneumonia resulting from the intentional ingestion of acid. MATERIALS AND METHODS The medical records of 370 patients treated at one tertiary care institution for corrosive acid injury during a 12-year period were reviewed retrospectively. The study subjects included any patients who were found to have acid ingestion related aspiration pneumonia confirmed by chest film within 24h of injury. All available data of these patients with or without aspiration pneumonia were analyzed. RESULTS Of the 370 patients with corrosive acid injury, 15 (4.2%) had acid-aspiration pneumonia which was related to their intentional ingestion of a strong acid, hydrochloric acid (pH<1). The data for 14 patients with aspiration pneumonia and 268 without aspiration pneumonia was complete and available for analysis. Patients with aspiration pneumonia were found to be significantly older (52.2+/-6.2 to 41.7+/-0.9 years old, P=0.017), had a higher incidence of nasogastric tube irrigation (35.7-6.0%, P=0.000), had more conscious disturbance (50.0-17.5%, P=0.016), and required more endotracheal tube intubation (50.0-3.0%, P=0.000). Aspiration pneumonia was found to significantly increase the mortality rate in acid injured patients who required emergency abdominal surgery (87.5-32.0%, P=0.000) and in those who did not (28.5-5.1%, P=0.05). Two of the six survivors of aspiration pneumonia later developed laryngeal sequelae. CONCLUSIONS Aspiration pneumonia rarely occurs as a consequence of acid ingestion. When it does occur, it greatly increases the mortality rate of those involved. For those who survive, physicians can expect some laryngotracheal sequel in long-term follow-up.

Surgical treatment of pediatric lung abscess.

Eight pediatric patients with lung abscesses underwent surgical intervention in our hospital during a 7-year period. All the abscesses were associated with severe sepsis or complicated by a bronchopleural fistula that did not respond to medical treatment and tube thoracostomy. Seven patients required unilateral thoracotomies, and one patient with bilateral lesions required simultaneous bilateral thoracotomies. One tension pneumatocele required a preceding pneumonostomy. All patients underwent decortication and at least one additional surgical procedure consisting of: lung debridement plus bronchial closure (n = 4); lobectomy (n = 2); bisegmentectomy (n = 3); and/or segmentectomy (n = 1). There were no operative deaths, but two patients had persistent air leakage that was treated by bronchial closure. The average hospital stay was 22 days (postoperative 10.1 days). All the patients recovered completely. For many pediatric lung abscesses that do not respond to medical treatment and simple drainage procedures, surgical intervention is indicated and can shorten the hospital stay.

Esophageal reconstruction for esophageal strictures or resection after corrosive injury

A total of 75 esophageal reconstructions were performed for caustic esophageal strictures (65 patients) or postcaustic resection (10 patients) at Naval General Hospital and National Cheng-Kung University Hospital from September 1976 to April 1991. Reconstructive procedures included bypass in 61 patients, replacement of the esophagus through the substernal route in 10, and replacement of the esophagus through the posterior mediastinum in 4. Esophageal substitutes used for reconstruction were a long segment of the ileum and the ascending colon in 42 patients; a short segment of the ileum and the ascending colon in 18; the ascending colon and transverse colon in 3; the ascending, transverse, and left colon in 1; the transverse and left colon in 6; the jejunum in 2; and the stomach in 3. All but two of the esophageal substitutes were isoperistaltic. There were 28 postoperative complications in 24 (32%) of the 75 patients. Cervical anastomotic leakage occurred in 5 patients (6.7%). There were no operative deaths. Postoperatively, swallow function was considered good in 67 patients (89.3%). In this experience, isoperistaltic transposition of the transverse and left colon provided the best results.

Massive Upper Gastrointestinal Bleeding after Acid-corrosive Injury

Our purpose was to delineate the characteristics and outcome of massive upper gastrointestinal bleeding (UGI) caused by acid-corrosive injury and to determine its management protocol. From June 1988 to June 2000, all patients with the history of acid-corrosive injury at our institution were reviewed. Patients with massive UGI bleeding (hematocrit level < 25% or transfusion of three or more units of whole blood required to restore normal vital sign) were enrolled into this study. Altogether, 12 (3.2%) of 378 patients with acid-corrosive injury developed massive bleeding: 8 gastric bleeding, 2 duodenal bleeding, and 2 first gastric and then duodenal bleeding. Gastric bleedings started an average of 12.1 days after the initial injury (range 9–21 days). Duodenal bleeding usually occurred later, at 10.1 days (range 6–18 days) after a gastric or esophagogastric operation. Nine of the ten patients with gastric bleeding underwent surgery during the subacute stage: three esophagogastrectomy, three gastric mucosectomy with gastrostomy and jejunostomy, and three total or subtotal gastrectomy. Operative findings were hemorrhagic gastritis with diffuse mucosal bleeding. Two of four patients with duodenal bleeding underwent duodenotomy with suture-ligation of bleeding vessels, and the other two had conservative treatment. Nine patients (75%) had postoperative complications. One patient (8%) died from complications of surgery performed to stop duodenal bleeding. Massive UGI bleeding rarely occurs after acid-corrosive injury; but when it does, it occurs during the subacute stage. Aggressive surgical treatment is mandatory for gastric bleeding. How duodenal bleeding can be better managed requires further study.

Early Surgical Correction for Isolated Gastric Stricture following Acid Corrosion Injury

Objective: To evaluate the feasibility and long-term results of early gastric surgery for patients with isolated gastric stricture following acid corrosion injury. Materials and Methods: Upper gastrointestinal (UGI) series was routinely performed around the 4th week after acid corrosion injury. Patients with gastric stricture and no risk of delayed esophageal stricture underwent early solitary gastric surgery, which was defined when performance of the procedure took place within 2 months of the injury. Results: From June 1988 to June 2000, 35 of 378 patients with acid corrosion injury developed isolated gastric stricture. Twenty-four (68.6%) lesions were located in the antrum, and 11 (31.4%) in the gastric body. Postprandial vomiting presented earlier for the antral stricture group (17.6 ± 1.1 versus 25.4 ± 3.4 days after injury; p = 0.005). The UGI series was performed from 16 to 41 days after injury (average 25 days). Of the 35 acid corrosion injury patients in this study, 4 were excluded because of late referrals to our institution or the patient’s hesitation which resulted in delayed surgery. The remaining 31 patients underwent gastric surgery 35.7 ± 3.2 days after ingestion (34.6 ± 3.6 and 38.1 ± 3.4 days for cases of antral and gastric body stricture, respectively). Surgical procedures consisted of hemigastrectomy (n = 16), antrectomy (n = 2), gastroenterostomy (n = 2), subtotal gastrectomy (n = 6), and total gastrectomy (n = 5). There were 4 cases of postoperative complications (12.9%) including adhesion ileus (n = 2), wound infection (n = 1), and massive, postoperative UGI bleeding (n = 1). Surgical mortality was zero. All patients tolerated oral intake well after surgery. During the minimum follow-up period of 1 year, 1 patient developed esophagojejunostomy stenosis, which was resolved by dilation, and there was 1 case of dumping syndrome, which was treated by diet control. Conclusion: Early surgery correction is feasible and safe if patients with isolated gastric stricture following acid corrosion injury are carefully selected. All patients in our study recovered early, with a low morbidity rate.