Biomedical subjects
Publications and source records attributed to G N Pradhan.
A case of spontaneous rupture of the oesophagus (Boerhaave's syndrome) following acute myocardial infarction is presented. Conservative management with chest drainage and parenteral, later jejunostomy, feeding was successful. Progress was monitored with methylene blue swallow. A review of the literature revealed only two previous cases of this type.
A retrospective review of 81 cases of primary chest wall tumours was carried out to analyse their clinical, radiological and surgical features. There were 37 malignant and 44 benign lesions; 72 were found in the ribs and nine in the sternum, of which five were malignant and four benign. Benign tumours of the ribs outnumbered malignant ones by a ratio of 5:4. The distinction between benign and malignant lesions is difficult clinically and radiologically unless cortical destruction and soft tissue swelling are present. The pathological differentiation is also not possible in all cases. All the patients with benign tumours were treated by excision with no recurrences or deaths. The overall 5-year survival for primary malignant chest wall tumours was 43% and 10-year survival was 27%. These were the results of radical en bloc excisions. Based on our experiences we believe that all tumours of the bony chest wall should be considered potentially malignant and wide excision should be performed, not only to provide adequate tissue for diagnosis but also to allow the best chance of cure in malignant lesions.
A rare case of metastatic malignant melanoma of the esophagus 11 years after wide excision of a cutaneous malignant melanoma is presented and the relevant literature reviewed. Symptomatic esophageal metastasis is unusual in malignant melanoma. Although the eventual outlook is poor in such cases, worthwhile palliation can be achieved by prompt diagnosis and treatment.
Nine cases of primary sternal tumour were retrospectively reviewed in regard to clinical, radiologic and surgical features. The tumours were chondrosarcoma (4), chondroma (3), solitary plasmacytoma (1) and osteochondroma (1). All the benign lesions were excised without complication or recurrence. Three chondrosarcomas were radically excised en bloc, and one was only locally excised because of gross involvement of underlying structures. The solitary plasmacytoma was treated with incisional biopsy and radiotherapy. Two of the three patients with radical excision of sternal chondrosarcoma were alive after 5 years. Careful preoperative assessment, including use of computed tomography, is important. Wide excision should be the procedure of choice for all sternal tumours, since differentiation between benign and malignant lesions may be difficult in cartilaginous tumours, which are the commonest types.
Primary malignant melanoma of the esophagus is an uncommon neoplasm. The world literature reports only 139 cases. It is mainly a disease of older age, predominantly in the 6th and 7th decades, with a male-to-female ratio of 2 to 1. Of all published cases, 60 (43.16%) occurred in the lower third, 40 (28.77%) in the middle third, 25 (17.98%) at the junction of the middle and lower thirds, and 14 (10.07%) in the upper third. Dysphagia was the commonest symptom and was found in 79.5% of cases. The tumors were polypoid, pedunculated, often pigmented, and usually presented as clinically advanced neoplasms. The histological and cytological features were similar to those of lentigo maligna melanoma, but with a more aggressive biological behavior. Hematogenous and lymphatic metastases were common. The overall survival was 9.8 months, and two-thirds of the patients died within a year of diagnosis, irrespective of therapeutic modalities. Deaths were disease-related in 85% of cases. It is concluded that, for operable patients, radical surgical resection is the treatment of choice, either for palliation or for cure, with a 5-yr survival of 4.2%. Irradiation is useful as a palliative or adjuvant measure. The roles of chemotherapy and immunostimulation need further evaluation.
One hundred and ten patients underwent gastroesophageal resections performed transdiaphragmatically by way of a left thoracotomy. Eighty-one patients had tumors distal to the inferior pulmonary vein and had en bloc dissections, while the remaining 29 had midthoracic tumors, which required a two-rib thoracotomy. There were 73 men and 37 women with a median age of 64 years (a range of 40 to 75 years). The postoperative mortality rate was 2.7 per cent, and morbidity, mainly caused by respiratory complications, occurred in 21 patients (19 per cent), with no patients requiring ventilatory support. There were no anastomotic leaks. Adequate analgesia was provided by the use of a subpleural catheter delivering a continuous infusion of bupivacaine. The left thoracotomy provides an effective method for undertaking esophageal resections with low mortality and morbidity rates. This approach should be more widely used in the surgical management of patients with intrathoracic esophageal tumors.
Others have demonstrated the effectiveness of intercostal analgesia with bupivacaine hydrochloride (Marcain Plain; Astra). We present a greatly simplified method of effecting this. Our method is dependent on an intact pleura. To date, we have utilized this technique in 81 patients. Seventy-five (92.6%) required no additional analgesic in the first 24 hours following operation and 66 (81.5%), in the subsequent four days. Only 2 patients had postoperative pulmonary complications. No complication related either to the procedure or to the infusion of bupivacaine occurred. The technique as described here is a safe and reliable method of providing analgesia without any side effects after thoracotomy.
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