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Biomedical subjects

H C Grillo

Publications and source records attributed to H C Grillo.

At least 37 records · Page 2Linked to original sources
PubMed1996

Postpneumonectomy bronchopleural fistula after sutured bronchial closure: incidence, risk factors, and management.

OBJECTIVE: Postpneumonectomy bronchopleural fistula remains a morbid complication after pneumonectomy. The incidence, risk factors, and management of postpneumonectomy bronchopleural fistula were evaluated in 256 consecutive patients who underwent pneumonectomy with a standardized suture closure of the bronchus. METHODS: Pneumonectomy was performed for lung cancer in 198 cases, for other malignancy in 20 cases, and for benign causes in 38 cases. The bronchial stump was closed with interrupted simple sutures to emphasize a long, membranous wall flap. All stumps were covered by autologous tissue. RESULTS: The incidence of postpneumonectomy bronchopleural fistula was 3.1%. Risk factors for bronchopleural fistula were the need for postoperative ventilation (p = 0.0001) and right pneumonectomy (p = 0.04). Five patients had bronchopleural fistulas as a result of pulmonary complications necessitating ventilation; the cause in the remaining three cases appeared to be technical. Reclosure was successful in five cases (mean postoperative day 12); in one case a pinhole fistula was healed by drainage alone. Two (25%) of the eight patients who had bronchopleural fistulas died. CONCLUSIONS: Careful, sutured closure of the main bronchus with a tissue buttress after pneumonectomy yields excellent results. The most significant risk factor for bronchopleural fistula is a pulmonary complication necessitating ventilation. Contrary to previous reports, reclosure is usually successful even if performed late.

Bronchial Fistula↗
PubMed1996

Survival and function after sleeve lobectomy for lung cancer.

Between 1962 and 1991, 72 patients (mean age 63.4 years) underwent sleeve lobectomy for primary lung cancer. Thirty-seven patients had adequate lung function and 35 were deemed unsuitable for pneumonectomy on the basis of inadequate pulmonary reserve (n = 31) or cardiac risk factors (n = 4). Squamous cell carcinomas (68%) and adenocarcinomas (26%) predominated. Upper lobectomy was performed in 48 patients, lower and middle lobectomy in 13, and right upper and middle bilobectomy in 11. Hospital mortality was 4% (3/72) and compares with a hospital mortality of 9% in 56 consecutive pneumonectomies between 1986 and 1990. Major complications occurred in 11% (bronchopleural fistula 1, persistent atelectasis 4, pneumonia 4). Adjusted actuarial survival after sleeve lobectomy at 1 and 5 years was 84% and 42%, compared with 76% and 44% after pneumonectomy. Five-year survival after lower and middle lobectomy in 13 patients (52%) was similar to that after upper lobectomy (46%), suggesting that in carefully selected patients the concept of sleeve lobectomy can be applied to all pulmonary lobes. N1 disease and compromised lung function were associated with lower survival (N1 38% vs N0 57%; compromised 20% vs adequate 55%). Comparison of preoperative and postoperative lung function and quantitative ventilation-perfusion isotope studies substantiated the preservation of pulmonary function in this group of patients. Sleeve lobectomy is the procedure of choice for anatomically suitable carcinomas or when reduced pulmonary reserve precludes extensive resection.

Adenocarcinoma↗
PubMed1996

Post intubation tracheal stenosis.

Although the etiology of post intubation tracheal stenosis has been well defined and methods for its prevention clarified, the lesions continue to occur and to be the most common indication for tracheal reconstruction. These lesions with specific characteristics at various levels--such as cuff and stomal--present with the signs and symptoms of airway obstruction. They are best handled in an emergency with systematic dilation. Under certain circumstances surgical repair is best deferred using repetitive dilations or intubation through an appropriately located stoma. Preferred management is surgical resection with primary reconstruction. Special techniques are necessary in cases in which larynx is also involved. With diagnostic precision and meticulous surgical technique, good or satisfactory results were obtained in nearly 94% of 503 surgically treated patients. Best results are obtained at an initial corrective operation performed by an experienced operator.

Dilatation↗
PubMed1996

Pediatric tracheal problems.

Awareness of the special problems of airway repair in children and precise application of principles of tracheal and laryngotracheal surgery are necessary for success in treating acquired pediatric airway lesions. Long segment congenital lesions require special techniques, which are still evolving.

Adolescent↗
PubMed1996

Postintubation tracheal stenosis.

Resection and reconstruction are the treatments of choice for postintubation tracheal stenosis, attested to by 94% good or satisfactory results in over 500 patients. Accurate diagnosis, appropriate patient selection, and experienced and precise surgical care are important in these treatments.

Clinical Trials as Topic↗
PubMed1996

Management of idiopathic tracheal stenosis.

Idiopathic laryngotracheal stenosis usually occurs in women, produces stenosis of 1 to 3 cm, is densely collagenous, and is unaccompanied by systemic disease. It may be successfully managed by one stage resection and reconstruction, most often including a portion of the lower larynx.

Clinical Trials as Topic↗
PubMed1995

[Resection and reconstruction of the carina in children and adolescents].

While resection of tracheobronchial segments has become a standard operation in adults, lesions of the carina in children are rare and their treatment is technically more demanding. Since 1980, 8 patients aged 8 to 19 years underwent surgical reconstruction of the carina. The indications were tumors in 5 and non-neoplastic lesions in 3. In 3 patients with tumor (2) and advanced histoplasmosis (1), resection of the carina was combined with parenchymal resection. The principles of operative repair include complete resection, with frozen section confirmation in tumors, particular emphasis on adequate mobilization of the airway in children to reduce anastomotic tension, and use of anesthetic techniques that facilitate early extubation. One patient (12.5%) died after complex airway reconstruction for extensive mediastinal fibrosis. Residual malacia in a patient with postpneumonectomy syndrome required successful re-resection. Seven patients remain free of anastomotic stricture and tumor recurrence during a mean follow-up of 62 months (range 5 to 132 months), with expected preservation of lung function. Late bronchoscopy in 5 patients 6 months to 11 years after operation demonstrated growth of the luminal diameter and patent anastomoses. Carinal reconstruction in children is occasionally required, succeeds in general, and does not result in late problems at the anastomosis.

Adolescent↗
PubMed1995

Reconstructive airway operation after irradiation.

After a patient died of anastomotic necrosis following a tracheal resection for the management of recurrent thyroid cancer invading the trachea, which had been treated 6 years previously by thyroid lobectomy and 4,800 cGy of radiation to control known residual disease, we explored methods to promote the healing of tissues damaged by irradiation. Between 1979 and 1992, 22 patients underwent major airway resection and reconstruction after receiving large doses of radiation. The average dose was 4,979 +/- 1,113 cGy (range, 3,150 to 6,840 cGy); the number of fractions, 20 to 38; and the average dose per fraction, 180 cGy (range, 150 to 200 cGy). The interval between irradiation and surgical treatment was 42 +/- 105 months (range, 1 to 480 months). Seven cervical, eight midtracheal, and five carinal resections were performed, as well as two mainstem sleeve resections. Omentum was used to protect the anastomosis in 15 patients (68%), a pericardial fat pad was used in 2, and pleura was used in 2. In 3 patients, sternohyoid muscle was placed between the anastomosis and a major vascular structure, but without a tissue wrap. Two patients (9.0%) died postoperatively. Anastomotic dehiscence was the cause of death in a patient treated for lymphoma, and adult respiratory distress syndrome was the cause in the other patient; this patient had undergone carinal pneumonectomy. Complications developed in 8 patients (36%). Two cervical dehiscences were treated by T-tube placement, 2 patients suffered wound infection, and 1 patient each suffered a myocardial infarction, dysphagia, hemoptysis, and bronchitis.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1995

Reinforced primary repair of thoracic esophageal perforation.

BACKGROUND: Treatment of esophageal perforation, especially when diagnosed late, remains controversial. METHODS: Twenty-eight patients were treated for thoracic esophageal perforation with reinforced primary repair regardless of time of presentation. RESULTS: Fifteen patients were treated early (< 24 hours) with no deaths. Two had contained postoperative leaks, which healed. Thirteen were treated late (mean, 5.5 days) with four deaths (3 with healed repairs). Postoperative leaks occurred in 7 patients; of the leaks, 4 healed, 2 became a controlled fistula, and 1 required reoperation. Primary healing with preservation of the native esophagus was achieved in 25 patients (89%). Among the 18 patients without evidence of sepsis preoperatively, post-operative leaks developed in 2 (11%). Ten patients had evidence of sepsis preoperatively, and postoperative leaks developed in 7 (70%). CONCLUSIONS: Patients who present with sepsis have an increased risk of postoperative leak and therefore should have the repair buttressed. Overall mortality was 14% and no deaths were due to persistent leaks or mediastinal sepsis. Reinforced primary repair retains the native esophagus and avoids the need for later reconstructive operations. In the absence of a nondilatable stricture or cancer, reinforced primary repair should be performed for most thoracic esophageal perforations, early or late.

Aged↗
PubMed1995

Postintubation tracheal stenosis. Treatment and results.

A total of 503 patients underwent 521 tracheal resections and reconstructions for postintubation stenosis from 1965 through 1992. Fifty-three had had prior attempts at surgical resection, 51 others had undergone various forms of tracheal or laryngeal repair, and 45 had had laser treatment. There were 251 cuff lesions, 178 stomal lesions, 38 at both levels, and 36 of indeterminate origin. Sixty-two patients with major laryngeal injuries required complete resection of anterior cricoid cartilage and anastomosis of trachea to thyroid cartilage, and 117 had tracheal anastomosis to the cricoid. A cervical approach was used in 350, cervicomediastinal in 145, and transthoracic in 8. Length of resection was 1.0 to 7.5 cm. Forty-nine had laryngeal release to reduce anastomotic tension. A total of 471 patients (93.7%) had good (87.5%) or satisfactory (6.2%) results. Eighteen of 37 whose operation failed underwent a second reconstruction. Eighteen required postoperative tracheostomy or T-tube insertion for extensive or multilevel disease. Twelve died (2.4%). The most common complication, suture line granulations (9.7%), has almost vanished with the use of absorbable sutures. Wound infection occurred in 15 (3%) and glottic dysfunction in 11 (2.2%). Five had postoperative innominate artery hemorrhage. Resection and reconstruction offer optimal treatment for postintubation tracheal stenosis.

Adolescent↗
PubMed1995

Treatment strategies for bronchopleural fistula.

Successful management of chronic postoperative bronchopleural fistula remains a challenge for thoracic surgeons. Forty-two patients (33 referred from other institutions) were treated for major postoperative bronchopleural fistula since 1978. Factors associated with bronchopleural fistula included right pneumonectomy (n = 23), left pneumonectomy (n = 8), long bronchial stump (n = 16), pneumonia (n = 13), radiation therapy (n = 12), stapled bronchial closure (n = 8), prolonged mechanical ventilation (n = 7), recurrent carcinoma (n = 6), and tuberculosis (n = 2). Patients had undergone an average of 3.3 surgical procedures to correct their bronchopleural fistulas during a mean interval of 24 months before our treatment. Bronchopleural fistulas were located in the right main bronchial stump (n = 23), left main bronchial stump (n = 8), right lobar bronchial stumps (n = 10), and tracheobronchial anastomosis (n = 1). Thirty-five patients were treated by suture closure of the bronchial stump, buttressed with vascularized pedicle flaps of omentum (n = 19), muscle (n = 13), or pleura (n = 2). In seven cases, direct suture closure was not possible, and omental (n = 6) or muscle (n = 1) flaps were sutured over the bronchopleural fistula. Suture closure without pedicle coverage was performed successfully in one case. Initial repair of the fistula was successful in 23 of 25 patients treated with omentum, in nine of 14 patients treated with muscle and in neither of two patients treated with pleural flaps. In nine patients with persistent or recurrent bronchopleural fistula after our initial repair, four underwent a second procedure (three successful) and five were managed with drainage only. The fistula was successfully closed in 11 of 12 patients who had received high-dose radiation therapy (nine with omentum). Overall, successful closure of bronchopleural fistula was achieved in 36 of 42 patients (86%). Four in-hospital deaths resulted from pneumonia and sepsis, two in patients with recurrent bronchopleural fistula after pleural flap closure. In 16 patients the empyema cavity was obliterated during definitive repair of the fistula. The cavity resolved with drainage in four others, nine had draining cavities at follow-up, and one was lost to follow-up. Ten patients required a total of 17 Clagett procedures and one had a delayed myoplasty. Direct surgical repair of chronic bronchopleural fistula may be achieved in most patients after adequate pleural drainage by suture closure and aggressive transposition of vascularized pedicle flaps. Omentum is particularly effective in buttressing the closure of bronchopleural fistulas.

Adult↗
PubMed1994

Slide tracheoplasty for long-segment congenital tracheal stenosis.

Resection and reconstruction of long congenital tracheal stenosis often is impossible or results in excessive anastomotic tension. Anterior tracheoplasty using a patch of pericardium or cartilage may result in granulation tissue needing repeated bronchoscopies, tracheostomy, and stents and may produce recurrent stenosis. Tracheoplasty may be performed by dividing the stenosis at midpoint, incising the proximal and distal narrowed segments vertically on opposite anterior and posterior surfaces and sliding these together. The stenotic segment is shortened by half, the circumference doubled, and the lumenal cross-section quadrupled. Approach is cervical or with partial sternotomy. Cardiopulmonary bypass is not necessary. Four patients (ages: 3 months, 3 1/2 years, 19 years, and 19 years) were so treated for stenosis of 36% to 83% of tracheal length. Blood supply was not impaired. Healing was excellent and complications were minimal.

Adult↗
PubMed1994

Evolution of treatment strategies for adenocarcinoma of the esophagus and gastroesophageal junction.

Between 1980 and 1988, 91 patients with adenocarcinoma of the esophagus were treated by surgical resection and selective postoperative therapy. Operative mortality was 2%. Pathologic stage was I in 4, II in 26, and III in 61. Actuarial 2- and 5-year survival was 24% and 8%. From 1987 to 1989, 16 patients with adenocarcinoma of the esophagus were treated with two cycles of 5-fluorouracil and cisplatin followed by surgical resection. There was 1 complete response (6%), 5 partial responses (31%), and 10 with no response (63%). Twelve patients had resection. Pathologic stage was I in 1, II in 4, and III in 8. There was one chemotherapy-related death and one surgical death. Actuarial 4-year survival is 42%. From 1990 to 1993, 22 patients with adenocarcinoma of the esophagus were treated with two cycles of etoposide, doxorubicin, and cisplatin followed by surgical resection. There was 1 complete response (5%), 11 partial responses (50%), and 10 with no response (45%). Eighteen patients had resection. Pathologic stage was 0 in 1, II in 8, and III in 9. There were no treatment-related deaths. The actuarial 2-year survival is 58%. Conclusions are necessarily limited because the patients were not treated in a randomized fashion. These preliminary results with preoperative chemotherapy appear improved (p = 0.04 and p = 0.004, respectively) as compared with results from 1980 to 1988 without preoperative chemotherapy.

Adenocarcinoma↗
PubMed1994

Tracheobronchial sleeve resection in children and adolescents.

Bronchoplastic techniques preserving lung parenchyma allow resection and reconstruction of the major bronchi and carina and are widely used in adults. The smaller and more delicate airways of children make such operations more demanding, but successful outcome can still be achieved with particular attention to technique. The authors treated 12 patients age 8 to 19 years (mean, 13.8 years) over a 12-year period. Ten patients had tumors of the airway: carcinoid (4), mucoepidermoid (2), malignant fibrous histiocytoma (1), adenocarcinoma (1), granular cell (1), and invasive fibrous tumor (1); and 2 had nonneoplastic strictures. Previous operative treatment included incomplete local excision in 2 and laser ablation in 1. Carinal resection and reconstruction was performed in 6 patients, main-stem bronchial resection in 3, and sleeve lobectomy in 3. There was one death after a complex airway reconstruction for extensive mediastinal fibrosis involving the airway. Postoperative morbidity consisted of prolonged atelectasis in 3 patients. Residual malacia in 1 patient with postpneumonectomy syndrome required further tracheobronchial resection. Follow-up is complete (mean, 64 months; range, 7 to 130). There has been no anastomotic stenosis or tumor recurrence. Preservation of lung function is expected in all patients. In 7 patients, bronchoscopy 4 months to 11 years postoperatively confirmed anastomotic patency and growth. The understanding of bronchoplastic techniques and precise attention to technical detail should allow these procedures to be successfully performed in pediatric patients.

Adolescent↗
PubMed1994

Temporary and permanent restoration of airway continuity with the tracheal T-tube.

The advantages of the tracheal T-tube compared with a regular tracheostomy tube are a physiologic direction of air flow, preservation of laryngeal phonation, and superior patient acceptance. Between 1968 and 1991, 140 patients aged 7 months to 95 years underwent placement of T-, TY- (n = 7), or a modified extended T-tube (n = 4). Primary diagnosis was postintubation stenosis in 86 patients, burn injury in 13 patients, malignant airway tumors in 12 patients, and various disorders in 29 patients. Stenting with a silicone rubber tube was temporary in 31 patients and 14 underwent later operative reconstruction. Definitive permanent insertion was performed in 49 patients. A modified tube was used in 4 patients with left main bronchial stenosis with effective long-term palliation in 3. Postoperative airway obstruction prompted placement in 32 patients. Positioning of the T-tube above the vocal cords in 12 patients for subglottic stenosis was effective in 10. The T-tube was not tolerated in 28 patients (20%) because of obstruction of the upper limb or aspiration. Five of 10 patients under the age of 10 years had airway obstruction necessitating tube removal. Long-term intubation in 112 patients exceeded 1 year in 49 patients and 5 years in 12 patients. Only 5 patients required tube removal for obstructive problems more than 2 months after placement. The tracheal T-tube restores airway patency reliably with excellent long-term results and represents the preferred management of chronic airway obstruction not amenable to surgical reconstruction.

Adolescent↗
PubMed1993

Idiopathic laryngotracheal stenosis and its management.

We describe idiopathic laryngotracheal and upper tracheal stenosis in 49 patients with no other cause for their stenosis. Traumatic, iatrogenic, infectious, and specific inflammatory processes were excluded. Histopathologically dense fibrosis of keloidal type thickened the lamina propria and choked the ducts of mucous glands but did not destroy cartilage. Thirty-five patients were treated by single-stage resection and reconstruction: 29 by laryngotracheal resection with laryngotracheoplasty and 6 by cricotracheal segmental resection. Thirty-two patients achieved good or excellent results in respiration and voice, 2 needed annual dilations, and 1 required permanent tracheostomy.

Adolescent↗