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Biomedical subjects

H C Grillo

Publications and source records attributed to H C Grillo.

At least 91 records · Page 5Linked to original sources
PubMed1989

Endoscopic relief of malignant airway obstruction.

The ability to manage acute airway obstruction can be life-saving. Airway relief should be expeditious and immediate, with low morbidity and mortality. It should not interfere with future definitive therapy. In patients with terminal malignancy, it should be economical in cost and should minimize hospitalization. We used biopsy forceps and the rigid bronchoscope to "core out" 56 patients with obstructing airway neoplasms. The location of the obstruction was trachea in 16 patients, carina in 24, main bronchi in 8, and distal airway in 8. Improvement in the airway was accomplished in 90% of patients. A single bronchoscopy was sufficient in 96%. Nineteen complications occurred in 11 patients: pneumonia in 5, bleeding in 3, pneumothorax in 2, hypoxia/hypercarbia in 2, arrhythmias in 6, and laryngeal edema in 1. There were four deaths within 2 weeks of core-out related to respiratory failure. Further therapy consisted of resection in 28.6% (tracheal in 9, carinal in 3, pulmonary in 4), irradiation alone or in combination with chemotherapy in 60.7%, and no therapy in 10.7%. Palliation of symptoms and establishment of an airway in acute obstruction is the goal. Survival depends on the effectiveness of the proposed treatment. We find this time-honored method superior to use of the laser.

Adult↗
PubMed1988

Transthoracic esophagectomy: a safe approach to carcinoma of the esophagus.

Transthoracic esophagogastrectomy is a safe operation. Mechanical staplers and a cervical anastomosis have been emphasized to avoid catastrophic consequences of anastomotic leaks in the chest. Transhiatal esophagectomy has been proposed to bring the anastomosis into the neck. It is meant to be a palliative procedure and consequently denies the patient the best chance for surgical cure. The emphasis should be on anastomotic technique and sound principles of surgical oncology. Since 1980, we have performed 104 esophagectomies for carcinoma of the esophagus. We used a left thoracoabdominal incision for distal tumors (64) and the Ivor Lewis technique (40) for more proximal tumors. A two-layer inverting interrupted silk suture technique was used for all anastomoses. More than 90% of the procedures were performed by resident staff. The operative mortality was 2.9% (3 patients). There were no anastomotic leaks. Five patients required between one dilation and three dilations postoperatively. A positive smoking history was present in 83 patients and substantial alcohol use, in 33. Median estimated blood loss was 500 ml, and 60% of patients required no transfusions. Major complications included pneumonia (12 patients) and reexploration for bleeding (2). Minor complications included atelectasis (71 patients), atrial fibrillation (9), ventricular arrhythmias (9), urinary tract infection (3), and wound infection (2). Squamous cancer was present in 31 patients and adenocarcinoma, in 73. Positive lymph node metastases were present in 75%. Anastomotic recurrence was documented in 6 patients. Standard techniques of esophagogastrectomy and a two-layer anastomosis will give excellent results with low mortality and acceptable morbidity.

Actuarial Analysis↗
PubMed1988

Preoperative chemotherapy, surgical resection, and selective postoperative therapy for squamous cell carcinoma of the esophagus.

In an attempt to improve on the long-term survival rate of patients with esophageal squamous cell carcinoma, we designed a study in which treatment included preoperative chemotherapy with fluorouracil and cisplatin, surgical resection, and selective postoperative chemotherapy or radiation therapy. Between 1981 and 1986, 35 patients with potentially resectable lesions were entered into the study. After chemotherapy, 13 of 35 patients (37%) had a complete clinical response, 7 (20%) had a partial response, and 15 (43%) had no response. One patient sustained a serious toxic reaction (renal failure). Twenty-seven patients underwent surgical resection, with 1 hospital death (3.7%). Selective postoperative radiotherapy or chemotherapy was administered to 69%. The actuarial survival of all resected patients at 42 months was 54% (standard error, 10%). Multivariate analysis showed significant factors associated with 3-year survival were: (1) complete clinical response to chemotherapy; (2) absence of wall penetration in the specimen; and (3) microscopic or no disease in the specimen. We conclude that this multimodality treatment method improves the intermediate-term survival of patients with squamous cell carcinoma of the esophagus.

Antineoplastic Combined Chemotherapy Protocols↗
PubMed1988

Surgical management of tracheal strictures.

Tracheal strictures are complications of prolonged endotracheal intubation or tracheostomy. Successful management requires knowledge of tracheal anatomy, principles of anesthesia, and principles of tracheal surgery. Strictures involving up to one half of the adult trachea can be successfully managed by resection and primary anastomosis in over 90 per cent of the patients.

Anesthesia↗
PubMed1988

The omentum in the management of complicated cardiothoracic problems.

The pedicled omentum finds use in cardiothoracic surgery for management of complicated problems and prevention of serious complications. Its blood supply is excellent and is capable of inducing neovascularity. Based on the right gastroepiploic artery, it reaches anywhere in the thorax or neck. Its bulk helps to fill infected spaces. Thirty-seven patients have been treated with the pedicled omentum. In 16 patients the goal was preventive, to avoid bleeding, anastomotic leakage, or infection or to provide a source of fibroplasia or neovascularity. In eight patients with cervical exenteration the flap protected against innominate artery erosion and esophageal leakage, generally in an irradiated field. In six patients it permitted primary healing of heavily irradiated trachea--formerly unlikely. It was also used to provide coverage of a chest wall prosthesis in two patients. In 21 patients the omentum was used to obtain healing in the presence of infection. Bronchopleural fistulas were successfully closed in eight of nine patients. Six mediastinal infections that developed after cardiac operations were successfully treated. Four unusual vascular infections necessitated the use of omentum. Two patients had closure of esophageal perforations buttressed with omentum. This series demonstrates the efficacy of the omentum in the management of complex cardiac, vascular, esophageal, tracheal, bronchial, pleural, and chest wall problems.

Bronchial Fistula↗
PubMed1987

Small cell carcinoma of the lung. A progress report of 15 years' experience.

To assess the results of therapeutic advances in the treatment of small cell carcinoma of the lung (SCCL) achieved during the past 15-year period at a single large institution, 508 patients treated between 1968 and 1982 were divided into two groups: 157 patients (66 in the category of limited-stage disease and 91 in the extensive-stage disease category) treated with low-dose small-volume radiotherapy (RT) (time dose fractionation [TDF] 49-66) and with cyclophosphamide alone or a COPP program during the first period of 7 years (1968-1974); 351 patients (180 in limited and 171 in extensive stage) treated with multidrug chemotherapy (CT) and high-dose large-volume RT (TDF 73-89) during the second period of 8 years (1975-1982). For patients with limited-stage cancer, 5-year actuarial survivals were 3% versus 7% for the periods 1968-1974 versus 1975-1982, respectively, P less than 0.01. For patients with extensive-stage cancer, the median survival time (MST) and 2-year actuarial survivals were 5 months and 2% versus 7 months and 4% for the periods 1968-1974 versus 1975-1982, respectively. To evaluate the outcome of a contemporary approach, i.e., CT alone, with RT reserved for locoregional failure, 180 patients with limited-stage cancer who were treated (1975-1982) were further analyzed for MST, 2- and 5-year actuarial survival figures, and local-tumor control rates according to the therapeutic approaches employed: CT + RT (112); CT alone (36); RT alone (17); and surgery (S) +/- CT +/- RT (15). Although the 36 patients in CT alone seems a small number, 17 of the 36 patients were enrolled in this approach in 1981-1982, reflecting a shift of emphasis from RT to CT. The MST and 2-year actuarial survival figures were 11 months and 0% versus 13 months and 21% for CT alone versus CT + RT respectively, P less than 0.05. CT + RT achieved a 5-year cure rate of 8%. S +/- CT +/- RT or RT alone also achieved 5-year cure rates of 8% and 10.5%, respectively, in selected subsets of patients. Local relapse rates were 80% (29/36) versus 25% (28/112) for CT alone versus CT + RT. These data emphasize the importance of thoracic RT given at the early phase of treatment to improve long-term survival for patients with limited-stage SCCL.

Actuarial Analysis↗
PubMed1987

Pulmonary and systemic contribution to canine tracheobronchial blood flow.

To investigate the quantity and pathophysiological relationship of pulmonary and bronchial artery supply to the tracheobronchial tree in dogs in absence and in presence of increased tissue metabolic requirements, pulmonary and bronchial blood flow to the trachea and bronchi was determined by the radioactive microsphere method in nine adult mongrel dogs. Microspheres were injected into the right atrium of three dogs (pulmonary injection group) and into the left ventricle of four dogs (systemic injection group) just before and three, eight and fourteen days after resection and anastomosis of the right main bronchus. The remaining two dogs served as controls without surgery. After the fourth injection, the tracheobronchial tree was harvested, divided into segments, and the radioactivity counted in each segment. At baseline the systemic flow to the tracheobronchial tree expressed as percentage of cardiac output was 0.188% +/- 0.121 and the pulmonary blood flow was 0.007% +/- 0.004 (mean +/- S.D.). Three, eight and fourteen days after transection and anastomosis of the right main stem bronchus, the systemic blood flow to the bronchial segments proximal and distal to the anastomosis increased significantly whereas pulmonary blood flow did not change. Depending on the anatomical segment considered the systemic contribution was between 5 and 100 times larger than the pulmonary one, both at baseline and after transection and anastomosis of the right main stem bronchus, but the ratio diminished in more distal segments where pulmonary blood flow was larger. It is concluded that the systemic blood contribution to the canine tracheobronchial tree is larger than the pulmonary one and that, in the presence of increased metabolic needs, it responds more promptly with increased blood flow.

Animals↗
PubMed1987

Superior sulcus lung tumors. Results of combined treatment (irradiation and radical resection).

Twenty-one patients underwent combined therapy (irradiation and radical resection) for a Pancoast tumor at the Massachusetts General Hospital between 1976 and 1985. All patients underwent en bloc removal of the apical chest wall and underlying lung. In addition four patients required subclavian artery resection, and in five patients a portion of the vertebral body was resected. There were three operative deaths. Median survival was 24 months and actuarial survival rate was 55% at 3 years and 27% at 5 years. Long-term palliation of pain was achieved in 72% of the patients. Involvement of the subclavian artery, vertebral body, or rib did not preclude long-term survival. Computed tomographic scanning in these patients is often indeterminate regarding invasion of chest wall structures but is more helpful than plain films alone. When compared to recent series in which irradiation alone was used, the combined approach appears to produce better results.

Actuarial Analysis↗
PubMed1987

Bronchial sleeve resection with and without pulmonary resection.

Sleeve resection with and without pulmonary resection is safe, effective, and appropriate treatment for a wide range of endobronchial lesions including neoplasms of low-grade malignant potential and selected cases of bronchogenic carcinoma. Sixty-three patients underwent 64 sleeve resection procedures (47 with concomitant pulmonary resection and 17 without) at the Massachusetts General Hospital between 1962 in 1986 with a 30 day mortality rate of 4.7%. Applicability of the technique for bronchial lesions which do not require concomitant pulmonary resection is emphasized. Types of disease included a heterogeneous collection of 31 benign tumors, neoplasms of low-grade malignant potential, and bronchostenosis and 33 bronchogenic carcinomas. Actuarial disease-free survival rate for the former group was 100% at 5 years. Quality of life was excellent for this group. Five-year survival rates for bronchogenic carcinoma (24 squamous cell, seven adenocarcinoma, two undifferentiated) were 58% +/- 25% (+/- standard error), 69 +/- 18%, and 38% +/- 13% in Stages I, II, and III, respectively. The 5 year survival rate of 31% +/- 16% in 14 patients selected because of decreased respiratory reserve compared with 60% +/- 14% in 19 patients for whom sleeve was the operation of choice on the sole basis of anatomic suitability. Sleeve resection is the ideal form of excisional therapy for benign endobronchial tumors, bronchostenosis, tumors of low-grade malignant potential, and for selected cases of carcinoma.

Adult↗
PubMed1986

Resectional management of airway invasion by thyroid carcinoma.

Invasion of the trachea by thyroid carcinoma is best managed by resection with airway reconstruction. Localized extension of tumor may also require esophageal resection or radical resection including laryngectomy with mediastinal tracheostomy. Twenty-two patients (12 with papillary, 3 with follicular, 4 with mixed papillary and follicular, and 3 with undifferentiated carcinoma) underwent resection--16 with airway reconstruction and 6 with cervicomediastinal en bloc resection with mediastinal tracheostomy. Eleven had prior thyroidectomy. Ten of those having airway restitution required cylindrical tracheal resection, 5 had resection of trachea with a portion of the larynx, and 1 had wedge resection. Three undergoing laryngotracheal resection also needed esophagectomy. Colon reconstruction was used. Fifteen of the 16 having airway reconstruction had good surgical results with speech preservation. One died of complications due to prior irradiation. One of 6 undergoing radical resection died postoperatively. Six of the 20 survivors died of recurrence in 1 2/3 to 9 years, and 2 others died of other diseases. Three who had known pulmonary metastases at the time of palliative operation are alive between 2 and 3 2/3 years postoperatively, and a fourth who has pulmonary metastases is alive 6 1/6 years later. Eight patients are alive without disease from 1/12 to 8 3/4 years. Only two patients had airway recurrence. Resection and primary reconstruction of the trachea invaded by carcinoma of the thyroid should be done in the absence of extensive metastases when technically feasible. It offers prolonged palliation, avoidance of suffocation due to bleeding or obstruction, and an opportunity for cure. In carefully selected patients with massive regional involvement, radical excision with laryngectomy and esophagectomy is also appropriate.

Adenocarcinoma↗
PubMed1986

Right-pneumonectomy syndrome: radiologic findings and CT correlation.

The clinical history and radiographic and bronchoscopic findings were reviewed retrospectively in five patients with right-pneumonectomy syndrome, a rare, delayed complication of pneumonectomy of the right lung. Four patients had undergone pneumonectomy in childhood or adolescence. Presenting symptoms of dyspnea and recurrent pulmonary infections in the left lung were associated with radiographic evidence of marked rightward and posterior deviation of the mediastinum, counterclockwise rotation of the heart and great vessels, and herniation of the left lung into the right, anterior side of the chest. Computed tomography, performed in four patients, best demonstrated resultant compression of the distal trachea and left main bronchus between the aorta and pulmonary artery. Malacia of the major airways (n = 4 cases) and mediastinal shift was visualized only with fluoroscopy and was confirmed by bronchoscopy. Because of the morbidity and mortality associated with dyspnea and recurrent pulmonary infections, proper radiologic evaluation is crucial, and surgical intervention is often necessary.

Adolescent↗
PubMed1986

CT of adenoid cystic carcinoma of the trachea.

The CT features of six cases of adenoid cystic carcinoma of the trachea are presented and compared to the bronchoscopic, surgical, and pathologic findings. CT accurately demonstrated extratracheal extension of tumor, which occurred in all six cases and which was not visible on standard chest radiographs. This information was helpful in planning the surgical approach. However, CT consistently underestimated the longitudinal extension of the lesion because of partial volume averaging and the tendency of adenoid cystic carcinoma to grow submucosally. CT was also a poor predictor of mediastinal organ invasion. Because recent advances in tracheal resection and carinal reconstruction have made many of these lesions resectable, CT is frequently used in the evaluation of the operability of patients with adenoid cystic carcinoma. However, its usefulness in this regard is limited, and conventional techniques such as standard tomography continue to play a role in preoperative assessment.

Adult↗
PubMed1986

Complications of tracheal reconstruction. Incidence, treatment, and prevention.

Between 1962 and 1982, 416 primary tracheal reconstructions and 21 staged reconstructions were performed. Since then 80 additional tracheal reconstructions have been accomplished (to April of 1985). The first 20 years of our experience (1962 to 1982) have been scrutinized to identify complications and describe their management in patients operated on for tumors or postintubation lesions only. Because the series includes all cases, commencing in 1962 when tracheal surgery was not well developed, many complications reflect a learning experience. The first and second halves of the series have therefore been compared. Measures to prevent complications are discussed.

Granulation Tissue↗
PubMed1985

Substernal goiter. Analysis of 80 patients from Massachusetts General Hospital.

Eighty patients at the Massachusetts General Hospital underwent resection of substernal goiter in the years 1976 to 1982. Mean age of the 50 women and 30 men was 56 years, and 10 (19 percent) had undergone prior thyroid surgery. The most common symptoms were cervical mass (69 percent), dysphagia (33 percent), and dyspnea (28 percent); 13 percent were asymptomatic. On examination, cervical mass was present in most (90 percent) but not all patients, 51 percent were obese, and more than one third had tracheal deviation. Fifty-one of 52 patients tested were euthyroid and one was mildly hypothyroid. Chest radiographs showed tracheal deviation in 79 percent and soft tissue mass in 56 percent. Seventy-eight patients underwent resection through a cervical collar incision only; one had cervical incision plus upper partial sternotomy; and one required cervical incision plus full median sternotomy. Pathologic examination revealed multinodular goiter in 41 (51 percent), follicular adenoma in 35 (44 percent), and Hashimoto's thyroiditis in 4 (5 percent). Mean goiter weight was 104 g, and the mean greatest dimension was 9 cm. Occult papillary carcinoma was found in two patients. There were no deaths or major complications. Analysis of our data indicate the following: (1) Substernal goiter may exist in the absence of symptoms or signs. (2) Extensive radiologic evaluation and thyroid function testing are rarely required. (3) With rare exceptions, substernal goiter represents an extension of a cervical growth through the thoracic inlet and can be approached through a cervical collar incision. (4) Histologically, these are multinodular goiters or follicular adenomas, although Hashimoto's thyroiditis may occur. (5) Given the small but present risks of acute stridor or occult malignancy and the negligible surgical risk, operation should be recommended. (6) Patients should be followed since, with or without levothyroxine, goiters may recur.

Adult↗
PubMed1985

Substernal goiter.

The literature on substernal goiter from the seventeenth century to the present is reviewed. Substernal goiter may be defined as any thyroid enlargement that has its greater mass inferior to the thoracic inlet. Truly ectopic mediastinal goiters are rare, and most substernal goiters arise from and maintain some attachment to the cervical thyroid gland. Patients are generally in the fifth decade of life, and women predominate. Most patients experience dyspnea, stridor, or dysphagia, but 15 to 50% are asymptomatic; symptoms are often positional, and acute stridor may occur. Ten to twenty percent have no cervical mass or tracheal deviation on examination, and virtually all patients are euthyroid. Standard chest roentgenograms are often diagnostic, but computed tomographic or radioactive iodine scans may be helpful. The presence of a substernal goiter in all but the highest-risk patients is an indication for resection, usually through a cervical collar incision; an occasional patient will require sternotomy or thoracotomy. Death or major complications should be rare postoperatively. Substernal goiters are adenomatous and benign, but carcinoma occurs in 2 to 3% and may be occult. Patients should be followed closely, as these goiters may recur.

Adolescent↗
PubMed1985

Benign metastasizing meningioma. Case report.

A patient with a histologically benign intracranial meningioma was found, at the time of initial presentation, also to have a pulmonary tumor. Fine-needle aspiration cytology of the lung mass was consistent with metastatic meningioma. When resected, the pulmonary tumor was found to be histologically benign. The patient has remained well and disease-free for 28 months. Only four other patients with apparently benign metastasizing meningiomas have been described previously.

Humans↗
PubMed1984

Changing times in surgical management of bronchopulmonary carcinoid tumor.

The bronchopulmonary carcinoid tumor occurs at all levels from trachea to lung periphery. It should be managed by conservatism in airway or lung resection. The long-term survival is excellent: 82% at 10 years in this series of 111 resected patients. The atypical carcinoid tumor (10% of this series) has a more ominous prognosis and requires special surgical attention. Six conceptual changes in the evolution of management of the tumor are presented (the "changing times").

Adolescent↗