Mu-Yen Lin

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.

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.

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.

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.

Bronchial Rupture Caused by Blunt Chest Injury

We have surgically treated six patients with bronchial rupture caused by blunt chest injury in the past 5 years. All injuries resulted from traffic accidents, except in one patient who was hit by a crane. Clinical manifestations included chest pain (n = 6), subcutaneous emphysema (n = 4), and dyspnea (n = 6). Roentgenographic findings were tension (n = 3) or nontension (n = 3) pneumothorax, subcutaneous emphysema (n = 4), pneumomediastinum (n = 3), deep cervical emphysema (n = 5), and delayed collapse of the affected lung (n = 3). Three patients had associated injuries: right clavicle and rib fractures in the first; right humeral, scapular, and multiple rib fractures and left sternoclavicular joint dislocation in the second; and left clavicle fracture in the third. These six patients all underwent immediate tube thoracostomy and then bronchoplasty. Bronchoplasty was performed within 3 days in four patients and on days 16 and 30, respectively, in the other two patients. The affected lung demonstrated full expansion in all patients immediately after bronchoplasty. Follow-up bronchoscopy showed good patency of all bronchi.

Intrathoracic muscle flap transposition in the treatment of fibrocavernous tuberculosis

BACKGROUND AND OBJECTIVE Conventionally, pulmonary resection with thoracoplasty is used to treat fibrocavernous complication of pulmonary tuberculosis. This operation is usually bloody, time-consuming with complicated postoperative course. To prevent massive blood loss and preserved pulmonary function, a more simplified operative procedure, cavernostomy combined intrathoracic muscle flap transposition was used and the outcome was evaluated in this study. DESIGN Retrospective review. METHODOLOGY Between December 1989 and June 1996, a total of ten patients with fibrocavernous pulmonary tuberculosis were managed using cavernostomy combined with intrathoracic muscle flap transposition. Five of them had concomitant aspergilloma within the cavity while three had multiple drug resistant pulmonary tuberculosis. The muscle flap was used to plombage the cavity and reinforce the closure of bronchopleural fistula after cavernostomy. RESULTS Six postoperative complications occurred in five patients, including reformation of cavity (2), bronchopleurocutaneous fistulae (3), and postoperative bleeding (1). The success or failure of intrathoracic muscle flap transposition on patients with fibrocavernous tuberculosis was significantly correlated with the size of the cavity (194.0+/-11.2 vs. 283.0+/-44.6 cm(3), P=0.016) and the number of bronchopleural fistulae (1.6+/-0.4 vs. 4.0+/-0.4, P=0.008). There was no operative death and in long term follow-up, there was no recurrence of hemoptysis or deterioration of pulmonary function in the successful group of patients. CONCLUSIONS Cavernostomy combined with intrathoracic muscle flap transposition can be used to treat well-selected fibrocavernous pulmonary tuberculosis patients, except on patients with large size cavity, multiple bronchopleural fistulae or multiple drug resistance tuberculosis.

Surgical results of 23 patients with tracheobronchial injuries.

Abstract The objective of this study was to evaluate the surgical results of tracheobronchial injuries. Between July 1988 and March 1996, tracheobronchial surgery was performed on 23 injured patients. According to the aetiology, the injuries were categorized as blunt injury (n= 13), cutting or penetrating injury (n= 5), and corrosive injury (n= 5). Blunt injuries included three complete laryngotracheal disruptions, one tracheal laceration, and eight bronchial ruptures. Cutting or penetration injuries included four laryngotracheal ruptures and one tracheal cutting wound. Corrosive injuries included one tracheal necrosis, one tracheal stenosis and three esophago‐ respiratory fistulae. Operative procedures that were performed on the tracheobronchus included tracheoplasty (n= 12), bronchoplasty (n= 7), sleeve resection of the trachea (n= 2) and bronchus (n= 2). Two hospital deaths were encountered, with a mortality rate of 8.7%. One patient with caustic injuiy died of bronchopleural fistula and empyema. The other patient died with multiple injuries from multiple organ failure which was unrelated to the bronchoplasty. One postoperative complication was restenosis of the trachea in a caustic injured patient, which was treated by a T‐tube insertion. In conclusion, tracheobronchoplasty is an effective life‐saving emergency procedure for the patients with tracheobronchial injuries.