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Biomedical subjects

H C Grillo

Publications and source records attributed to H C Grillo.

At least 19 recordsLinked to original sources
PubMed1992

Clinical manifestation of mediastinal fibrosis and histoplasmosis.

We treated 20 patients thought to have mediastinal fibrosis secondary to Histoplasma capsulatum. All but 1 were symptomatic. The most common symptoms were dyspnea (8), hemoptysis (6), postobstructive pneumonia (5), and superior vena caval obstruction (2). Nine patients had severe stenosis of the trachea, carina, or main bronchus. Special stains identified Histoplasma capsulatum in surgical specimens in 9 patients. Surgical procedures were done for 18 of 20 patients (resection of subcarinal mass, 6; right middle and lower lobectomy, 5; carinal pneumonectomy, 4; esophagoplasty, 4; sleeve resection, 3 (with right main bronchus in 1, right lower and middle lobectomy in 1, and carina in 1); right upper lobectomy, 1; middle lobectomy, 1; and bronchoplasty of left main bronchus, 1. There were 4 deaths, 3 after complications of carinal pneumonectomy and 1 in a patient with tracheobronchial obstruction that could not be dilated. Two patients were treated with amphotericin and 4 with ketoconazole. Sclerosing mediastinitis secondary to histoplasmosis presents tremendous surgical challenges because of the intense fibrosis encountered. Bronchoplastic procedures are possible in spite of the intense fibrosis. High mortality rates after carinal resection may be encountered. The exact role of antifungal therapy is as yet undefined.

Adolescent↗
PubMed1992

Laryngotracheal resection and reconstruction for subglottic stenosis.

Eighty patients with inflammatory stenoses of the subglottic larynx and upper trachea were treated by single-stage laryngotracheal resection and reconstruction. Fifty stenoses originated from postintubation lesions (endotracheal tubes, tracheostomy, cricothyroidostomy), 7 originated from trauma, 19 were idiopathic, and 4 were miscellaneous. Repair consisted of resection of the anterolateral cricoid arch in all patients, plus resection of posterior laryngeal stenosis where present, with salvage of the posterior cricoid plate, appropriate resection and tailoring of the trachea, and primary anastomosis using a posterior membranous tracheal wall flap to resurface the bared cricoid cartilage in 31 patients. One postoperative death resulted from acute myocardial infarction. Long-term results were excellent in 18 patients, good in 48, satisfactory in 8, and failure in 2. Three additional patients had good results at discharge but were followed up for less than 6 months.

Adolescent↗
PubMed1992

Postpneumonectomy syndrome: diagnosis, management, and results.

Airway obstruction may be caused by extreme mediastinal shift and rotation after right pneumonectomy or after left pneumonectomy in the presence of a right aortic arch. Eleven adults (aged 18 to 58 years) with severe symptoms were treated surgically between 5 months to 17 years after pneumonectomy (7 right, 4 left). An initial patient with only one functional lobe was treated unsuccessfully by aortic division and bypass graft. Ten underwent mediastinal repositioning. After two recurrences prostheses were used to maintain mediastinal position. Five patients who underwent such repositioning are doing well from 5 months to more than 5 years later. One died 1 month after operation probably of pulmonary embolism. One who showed residual airway collapse after operation has some recurrent obstruction. Three other patients who showed severe malacic obstruction of the airway after mediastinal repositioning variously underwent aortic division with bypass graft and tracheal and bronchial resection. One is well almost 6 years later. Two died postoperatively. Occurrence of the syndrome is unpredictable. Where malacic changes have not occurred, mediastinal repositioning may reasonably be expected to correct obstruction. Optimal treatment for concurrent severely malacic airways is unclear.

Adolescent↗
PubMed1992

Resectional management of thyroid carcinoma invading the airway.

Fifty-two patients had thyroid carcinoma invading the airway. Thirty-four underwent resection; 18 were male and 16 female. Age ranged from 17 to 79 years. Twenty-seven had resection with airway reconstruction (1 wedge excision, 10 sleeve tracheal resections, 6 tracheal resections with a portion of the cricoid cartilage, and 10 complex laryngotracheoplastic resections). Seven required cervicomediastinal exenteration with mediastinal tracheostomy; 3 of these had esophagectomy with colon interposition. Nineteen tumors were papillary, 6 follicular, 4 mixed papillary and follicular, 1 squamous, 2 undifferentiated giant cell, 1 anaplastic spindle cell carcinoma, and 1 carcinosarcoma. Three postoperative deaths occurred. Thirteen of the 31 survivors died of cancer from 1/4 to 10 1/4 years postoperatively (average, 4.4 years). Four died of other diseases. Fourteen are alive from 1/12 to 14 1/3 years postoperatively (average, 5.3 years). Only 2 patients had airway recurrence. Resection of the airway invaded by thyroid malignancy in the absence of extensive metastases offers prolonged palliation, avoids suffocation due to bleeding or obstruction, and may produce cure. Airway reconstruction should be performed whenever technically feasible.

Adenocarcinoma↗
PubMed1992

Bronchogenic carcinoma: analysis of staging in the mediastinum with CT by correlative lymph node mapping and sampling.

One hundred forty-three patients with bronchogenic carcinoma were studied prospectively with computed tomography (CT) to determine the accuracy of CT in the evaluation of mediastinal nodal metastases. Mediastinal lymph nodes were localized according to the lymph node mapping scheme of the American Thoracic Society and were considered abnormal if they exceeded 1 cm in short-axis diameter. All patients underwent surgical staging, which consisted of either mediastinoscopy alone or mediastinoscopy and thoracotomy. At the time of surgical staging, all accessible nodes were either removed or sampled. The sensitivity of CT for mediastinal nodes on a per-patient basis was 64%, with a specificity of 62%. The sensitivity of CT for individual nodal stations involved with tumor was only 44%. The presence of obstructive pneumonitis did not appreciably alter the sensitivity of CT, but the specificity was lower (43%). The likelihood of metastases increased with lymph node size; however, seven of 19 (37%) lymph nodes that measured 2-4 cm in short-axis diameter were hyperplastic and did not contain metastases. The relative insensitivity of CT makes formal nodal sampling at the time of mediastinoscopy or thoracotomy essential to detect lymph node metastases.

Adult↗
PubMed1992

Management of tumors of the trachea.

Experience in the management of primary tracheal tumors remains small because of their rarity. Adenoidcystic carcinoma (40%) and squamous cell carcinoma off%) are the most common histologies. They present with signs of airway obstruction or hemoptysis and are delineated by bronchoscopy, tomography, and CT scan. Two thirds of all tracheal tumors are resectable, followed by airway reconstruction. Postoperative irradiation appears to be indicated for malignant tumors. Surgical mortality in 147 resections was 5%, with most deaths following carinal reconstruction. Twenty of 41 patients with squamous cell carcinomas who underwent resection are alive without disease (some for more than 25 years) and 39 of 52 with adenoidcystic carcinoma (some for as long as 19 years).

Adult↗
PubMed1991

A pilot study of neoadjuvant chemotherapy with 5-fluorouracil and cisplatin with surgical resection and postoperative radiation therapy and/or chemotherapy in adenocarcinoma of the esophagus.

Fifteen patients with potentially resectable adenocarcinoma of the esophagus were treated with two cycles of preoperative chemotherapy with 5-fluorouracil (5-FU) and cisplatin (DDP). Response to chemotherapy was evaluated by comparative barium swallow, computerized chest tomography, esophagoscopy, and change in clinical symptomatology. Eleven patients (73%) were resected, two (13%) were explored and found inoperable, and two (13%) were not subjected to surgery (one because of death related to toxicity and one due to progressive disease). Ten of eleven patients (91%) had gross residual tumor. One patient (9%) had residual microscopic disease only. One patient (7%) had complete clinical responses (CCR), five (33%) had partial clinical response (PCR), and nine (60%) had no response (NR). Five of 15 patients (or 45% of resected patients) remain free of disease. Median survival time was 18.47 months for all patients and 23.83 months for resected patients.

Adenocarcinoma↗
PubMed1991

Main bronchial sleeve resection with pulmonary conservation.

Twenty-seven main bronchial resections (19 left, 8 right) were performed without pulmonary resection between 1975 and 1991. The patients were 17 men and 9 women with an average age of 35 years (range, 20 to 65 years). Tumors comprised 55% of the lesions, including 9 carcinoid tumors (33%), 2 mucoepidermoid tumors, 2 fibrous histiocytomas, 1 hemangiopericytoma, and 1 large cell carcinoma. Scarring and stenosis secondary to multiple causes occurred in 10 patients (37%). Two patients had miscellaneous lesions. Presenting symptoms included dyspnea (52%), wheezing or stridor (44%), cough (41%), hemoptysis (37%), and pneumonia (18%). Preoperative chest roentgenogram was abnormal in 60% of patients, whereas tomograms delineated the lesion in 94%. All patients had bronchoscopy for lesion evaluation. Anesthesia was accomplished through a long single-lumen endotracheal tube in 19 cases and a double-lumen tube in 8 cases. Mobilization and exposure techniques to create a tension-free anastomosis were critical for left main bronchial resections and included pretracheal mobilization (100%), neck flexion (100%), tracheal and main bronchial retraction (85%), aortic and pulmonary artery retraction (44%), and intrapericardial hilar release (33%). All resections were for cure; there was no operative mortality. Morbidity in 4 patients (15%) included an anastomotic stenosis (successfully reresected), prolonged air leak and pneumonia, transient recurrent nerve palsy, and atelectasis. Median 5-year follow-up revealed 92% of patients alive, with only one of two late deaths being disease-related. Main bronchial resection is an ideal technique for selected benign and malignant lesions, allowing complete pulmonary parenchymal preservation.

Adult↗
PubMed1991

J. Maxwell Chamberlain Memorial Paper. Role of staging in prognosis and management of thymoma.

Eighty-five patients operated on for thymoma from 1972 to 1989 were evaluated, 32 with myasthenia gravis and 53 without. Masaoka staging revealed stage I disease in 45 (53%), stage II in 23 (27%), stage III in 14 (16%), and stage IVa in 3 (4%). There was no operative mortality. Actuarial survival at 10 years was 63.7% for all patients: 78.3% for those in stage I, 74.7% for those in stage II, and 20.8% for those in stage III. There was no recurrence in patients in stage I. Mediastinal recurrence developed in 4 patients in stage II considered to have noninvasive disease by the surgeon. It is recommended that all patients be followed up for a minimum of 10 years and that all patients in stages II and III receive postoperative radiotherapy. The presence of myasthenia gravis is no longer considered as an adverse factor in survival.

Adolescent↗
PubMed1991

Bronchogenic carcinoma with chest wall invasion.

Bronchogenic carcinoma with chest wall involvement continues to present a major clinical challenge. We have treated 52 patients since 1973, excluding those with superior sulcus tumors. There were 37 male and 15 female patients with an average age of 62.9 years. Chest pain was an initial symptom in 37%. All patients had negative mediastinoscopy results. Squamous cell carcinoma was present in 53% and adenocarcinoma in 35%. The median number of ribs resected was two (range, one to six), and only 2 patients required chest wall reconstruction. Pathologic staging was T3 N0 M0 in 83% and T3 N1 M0 in 17%. Operative mortality was 3.8%. Absolute 5-year survival was 26.3%. Patients who had N1 disease had a 5-year survival of only 11%. Radiation therapy was employed in 46% for positive nodes or close margins. Bronchogenic carcinoma with chest wall invasion remains potentially curable if N2 nodes are not involved. The role of radiation therapy has not been clearly defined. Morbidity and mortality should be minimal.

Adenocarcinoma↗
PubMed1991

Management of acquired nonmalignant tracheoesophageal fistula.

Acquired, nonmalignant tracheoesophageal fistula is an uncommon and difficult problem to manage. The most common cause is a complication of endotracheal or tracheostomy tubes. Most are diagnosed while patients still require mechanical ventilation. We use a conservative approach until patients are weaned from ventilation. A tracheostomy tube is placed so that the balloon rests below the fistula, if possible, to prevent contamination of the tracheobronchial tree. A gastrostomy tube is placed for drainage and a separate jejunostomy tube for nutrition. Single-stage repair is done after the patient is weaned from mechanical ventilation. Esophageal diversion is rarely required. We have performed 41 operations on 38 patients. Simple division and closure of the fistula was done in 9 patients and tracheal resection and reconstruction in the remainder. The esophageal defect was closed in two layers and a viable strap muscle interposed between the two suture lines. There were four deaths (10.9%). There were three recurrent fistulas and one delayed tracheal stenosis. All were successfully managed. Of the 34 surviving patients, 33 aliment themselves orally and 32 breathe without the need for a tracheal appliance.

Adolescent↗
PubMed1991

Carinal resection for bronchogenic carcinoma.

Techniques are available for carinal resection and reconstruction for bronchogenic carcinoma involving the carina. Successful outcome depends on careful patient selection, thorough preoperative evaluation, careful anesthetic management, strict attention to surgical technique, and compulsive postoperative care. Since 1973 we have performed 37 carinal resections for bronchogenic carcinoma: 21 right carinal pneumonectomies, 7 carinal resections, 7 carina plus lobe resections, and 2 carina plus pneumonectomy stump resections. Five patients had diseased N2 nodes and 13 patients had diseased N1 nodes. Complications included pulmonary (8), vocal cord paresis (3), atrial fibrillation (9), anastomotic stenosis (4), and anastomotic separation (3). There were 3 early postoperative deaths (8%). All were related to adult respiratory distress syndrome and were unresponsive to aggressive treatment. There were 4 late postoperative deaths between 2 and 4 months (10.9%). All late postoperative deaths were related to anastomotic complications (stenosis [1] and separation [3]). There are 5 absolute 5-year survivors and an actuarial 5-year survival rate of 19%.

Adult↗
PubMed1990

The trachea.

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Bibliographies as Topic↗
PubMed1990

Cervical exenteration.

Cervical exenteration is a radical operation to remove the larynx, portion of the trachea, and the esophagus, and frequently requires a mediastinal tracheostomy. Highly selected patients with obstructing neoplasms of the esophagus and airway can be palliated and sometimes cured by this aggressive surgical approach. Fatal hemorrhage from pressure or exposure of the innominate artery is avoided by elective division of the artery (preoperative angiograms and intraoperative electroencephalographic control are essential), using the omentum to separate the trachea and great vessels, and removal of a bony plaque of chest wall to allow a well-vascularized bipedicled skin flap to drop into the mediastinum for the tracheocutaneous anastomosis. Eighteen exenterations were performed. Mediastinal tracheostomy was performed in 14 patients and division of the innominate artery was performed in 7. Esophageal replacement was predominantly with the left colon. Complications include esophageal leak (2 patients), stomal separation (2), transient hemiplegia (1), colonic obstruction by substernal tunnel (1), and need for prolonged mechanical ventilation (4). There was a single operative death. Postoperative survival was disease dependent. All patients achieved an excellent airway and relief from dysphagia.

Adult↗
PubMed1990

Primary tracheal tumors: treatment and results.

One hundred ninety-eight patients with primary tracheal tumors were evaluated in 26 years. One hundred forty-seven tumors were excised (74%): 132 (66%) by resection and primary reconstruction, seven by laryngotracheal resection or cervicomediastinal exenteration, and eight by staged procedures. Eleven more were explored. Forty-four squamous cell carcinomas were resected, 60 adenoid cystic, and 43 assorted tumors, benign and malignant. Eighty-two patients underwent tracheal resection with primary reconstruction, and 50 had carinal resection and reconstruction. Surgical mortality for resection with primary reconstruction was 5%, with one death after tracheal and six after carinal repair. Six patients had stenosis after tracheal or carinal resection; all underwent reresection successfully. Nearly all patients with squamous or adenoid cystic carcinoma were irradiated postoperatively. Twenty of 41 survivors of resection of squamous cell carcinoma are living free of disease (some for more than 25 years), 39 of 52 with adenoid cystic carcinoma (up to nearly 19 years), and 35 of 42 with other lesions (5 lost to follow-up). Comparison of length of survival of patients with squamous cell carcinoma and adenoid cystic carcinoma who are alive without disease with those who died with carcinoma supports surgical treatment (usually followed by irradiation). Positive lymph nodes or invasive disease at resection margins appear to have an adverse effect on cure of squamous cell carcinoma; such an effect is not demonstrable with adenoid cystic carcinoma.

Adolescent↗