A retrospective analysis of 50 patients who had been observed to aspirate gastric contents was performed to define better the course of patients with this syndrome. The patients invariably had a disturbance of consciousness, most commonly due to sedative drug overdose or general anesthesia. The onset of clinical signs occurred prompty after aspiration and tended to be similar in all patients, irrespective of their subsequent course or outcome. These findings usually included fever, tachypnea, diffuse rales, and serious hypoxemia. Cough, cyanosis, wheezing, and apnea were each seen in approximately one third of the cases. Apena, shock, and early severe hypoxemia were particularly ominous events. Initial roentgenograms revealed diffuse or localized alveolar infiltrates, which progressed during the next 24 to 36 hours. Subsequent clinical courses followed 3 patterns: 12 per cent of the patients died shortly after aspiration; 62 per cent had rapid clinical and radiologic improvement, with clearing, on average, within 4.5 days; 26 per cent demonstrated rapid improvement, but then had clinical and radiographic progression associated with recovery of bacterial pathogens from the sputum and a fatal outcome in more than 60 per cent. Treatment from the outset by adrenocortical steroids or antimicrobial agents had no demonstrable effect on the outcome. The clinical features of aspiration of gastric contents are characteristic and distinguish it from other forms of aspiration-related lung disease.

Pulmonary aspiration of gastric contents

In a prospective randomized trial the clinical results after transhiatal oesophagectomy with reconstruction in the anterior mediastinum (51 patients) or posterior mediastinum (45 patients) were compared. There were no differences in age, preoperative risk factors, tumour stage and local (surgical) complications between the two groups. However, reconstruction in the posterior mediastinum was associated with significantly fewer days spent in the intensive therapy unit (9 versus 14), fewer cardiopulmonary complications (13 versus 25 per cent) and lower mortality (30-day mortality rate 2 versus 6 per cent; hospital mortality rate 4 versus 10 per cent). These data show superiority of reconstruction in the posterior mediastinum after transhiatal oesophagectomy. This route is strongly recommended, particularly for patients with cardiopulmonary risk factors.

Anterior versus posterior reconstruction after transhiatal oesophagectomy: A randomized controlled trial

Patients with metastatic breast cancer have traditionally been considered incurable with conventional treatment. However, 5–10% of those patients survive more than 5 years, and 2–5% survive more than 10 years. Recent studies suggest that the survival of patients with metastatic breast cancer has been slowly improving. In this review, we examine the possible curative approach for a certain group of patients with metastatic breast cancer. We identify that patients most likely to benefit from such an aggressive approach are young and have good performance status, adequate body functional reserve, long disease-free interval before recurrence, oligometastatic disease, and low systemic tumor load. An aggressive multidisciplinary approach including both local treatment of macroscopic disease and systemic treatment of microscopic disease can result in prolonged disease control in certain patients with metastatic breast cancer. Whether patients with prolonged disease control are “cured” remains controversial.

Improvement of survival and prospect of cure in patients with metastatic breast cancer

Assessment of metastatic breast cancer response to chemoembolization with contrast agent enhanced and diffusion-weighted MR imaging.

Mondor's disease (MD) is a rare disease that manifests with a palpable cord-like induration on the body surface. In general, MD is a self-limited, benign thrombophlebitis that resolves in four to eight weeks without any specific treatment. Cases of MD can be roughly categorized into three different groups based on the site of the lesion as follows: original MD of the anterolateral thoracoabdominal wall, penile MD with dorsum and dorsolateral aspects of the penis, and axillary web syndrome with mid-upper arm after axillary surgery. The diagnosis of MD is rather straightforward and based on a physical examinations. However, some case occur "secondary" with another underlying disease, including malignancy, a hypercoagulative state, and vasculitis. Therefore, it is critical to identify MD precisely, evaluate any possible underlying disease, and avoid any unnecessary invasive tests or treatment. In this paper, we comprehensively review the clinical characteristics of MD.

Mondor's Disease: A Review of the Literature.

The progress of postoperative chest X-ray films was analyzed in patients who had undergone radical surgery for esophageal cancer at the second Department of Surgery, Osaka University Medical School from 1969 to 1981. We subsequently reached a conclusion that abnormal shadows were caused by the intratracheal aspiration of oropharyngeal secretions or gastric contents. In particular, the aspiration of gastric contents was considered to be a factor in the occurrence and aggravation of pneumonia. In order to prevent aspiration of gastric contents, a drainage tube was inserted into the stomach as a reconstructive organ and endotracheal intubation was maintained for more than 24 hours post-operatively in order to suction the tracheobronchial secretion. Consequently, the frequency of occurrence and the aggravation of pneumonia decreased and the operative mortality rate improved significantly.

An important role of silent aspiration of gastric contents as a cause of pulmonary complications following surgery for esophageal cancer.

Fourteen patients who had liver metastases from breast cancer were treated with trans-arterial chemo-embolization (TACE) or intra-arterial chemotherapy via percutaneously inserted catheters. The patients were divided into two groups: Group A: Long-term survivors who lived longer than three years; and Group B: Short-term survivors who died within three years. Then we compared them based on the background factors, efficacy of intra-arterial chemotherapy, and so on. There was a tendency that Group A had a longer disease-free interval and took more time to formulate liver metastases than that of Group B. All of the four patients of Group A are alive, and the longest survivor is living six years and four months after being diagnosed with liver metastases. In Group B, every patient died from liver failure, but one had died from respiratory failure. The objective response rate was 38.5%, and four of the five responders were long-term survivors. Therefore, it is possible that a good prognosis can be obtained when the hepatic arterial infusion chemotherapy effectively controls liver metastases that regulate life.

[Long-term survivors with liver metastasis from breast cancer who were received intra-arterial chemotherapy].

Pulmonary complications after surgery for esophageal cancer are the most frequent and have a great influence on the surgical results. We reported at the 2nd World Meeting of the International Society for Diseases of the Esophagus (ISDE) that pneumonia was the most frequent of the postoperative pulmonary complications and that aspiration of gastric content is the most important factor causing pneumonia after radical surgery for esophageal cancer [1]. Therefore, in order to prevent aspiration (silent or massive) of gastric content or saliva, gastric tube drainage, endotracheal intubation, and mechanical ventilation were performed on postoperative patients [2]. In this report, postoperative pulmonary complications were analyzed referring to chest X-ray and the clinical course, and the states of these patients were compared before and after the application of these preventive methods.

Pulmonary Complications Following Surgery for Esophageal Cancer

A 37-year-old woman was admitted to the hospital for an early gastric cancer. She was a member of a family who have venous thromboembolic episodes in a high incidence, and had been diagnosed as having hereditary antithrombin III (ATIII) deficiency, with the ATIII activity of 56.8%. This time a distal gastrectomy was performed with a diagnosis of IIc cancer of the angular notch. For perioperative management antithrombin III concentrates were administered and the plasma ATIII level (ATIII activity) was maintained at values in excess of 80% for postoperative one week. No thrombotic complications occurred as judged by clinical examination. It has been confirmed that any operation can increase a risk of association of thrombosis in this congenital disorder. When ATIII consumption is enhanced (for example, during sugical procedures), usual antithrombotic therapies such as administration of heparin are not enough and replacement therapy may be necessary in order to normalize ATIII level.

A case of early gastric cancer associated with congenital antithrombin iii deficiency

症例は59歳の女性. 幼小児期よりcafe-au-lait spots, 皮膚腫瘤があり, von Recklinghausen病と診断されていた. 右上腹部腫瘤の精査目的にて来院. 腹部超音波検査およびCT検査で, 右腎前方に壁の一部に石灰化を伴った嚢腫状の, 4×4cmの腫瘤を認めた. 後腹膜奇形腫と診断し, 腫瘤摘出術を行った. 内部は黄色粘調な液体で満たされ, 毛髪が存在していた. 病理組織検査では, 皮膚および皮膚附属器官, 軟骨, 甲状腺組織が認められ, 良性の成熟奇形腫と診断された. 成人の後腹膜奇形腫は, 非常にまれで, 本邦では31例報告されており, これらを集計検討した. その診断にはCTが非常に有用であるが, 良悪性の鑑別は, 病理組織学的検索以外は不可能と思われた. 悪性例が31%を占めるため, 早期診断, 手術が必要であると考えられた.

Katsuhiro Kawasaki

Papers

An important role of silent aspiration of gastric contents as a cause of pulmonary complications following surgery for esophageal cancer.

[Long-term survivors with liver metastasis from breast cancer who were received intra-arterial chemotherapy].

Pulmonary Complications Following Surgery for Esophageal Cancer

A case of early gastric cancer associated with congenital antithrombin iii deficiency

A Case of Retroperitoneal Teratoma in Adult Accompanied with von Recklinghausen's Disease