Biomedical subjects
Publications and source records attributed to J A Thorpe.
We present a case of rupture of an intrahepatic choledochal cyst through the diaphragm resulting in a pleuro-biliary fistula and a right pleural empyema which was surgically treated. Hepatobiliary complications resulting in biliary empyema of the pleura are discussed.
OBJECTIVE: To evaluate the role of PDT in palliation of patients with inoperable oesophageal cancer and to identify subgroups in which this role is of particular significance. METHODS: Sixty-five patients (37 male, 28 female) aged 42-89 (mean 65.6) with advanced and inoperable oesophageal cancer were the subjects of this study. Inoperability was due to advanced stage of the disease in 61 and because of general condition in 4. Fifty-eight (89%) had previous treatments, other than PDT. All patients had dysphagia of whom 20 could not swallow fluid. Pre-PDT clinical, radiological and endoscopic examinations were carried out. Performance status (PS) and clinical staging was assessed. PDT protocol consisted of: intravenous injection of 2 mg/kg; photofrin (or equivalent polyhaematoporphyrin) followed 24-72 h later by endoscopic illumination using 630 nm laser light. MAIN OUTCOME MEASUREMENTS: (1) Relief of dysphagia generally and specifically in those with cervical and post-cricoid carcinoma who were previously treated by external beam radiotherapy (EBR) (n=6) and those with previous intubation or stent (n=9); (2) Survival. RESULTS: There was no PDT related mortality. Three patients (4.6%) developed a mild skin photosensitivity reaction. Dysphagia was relieved in all patients. The mean and median survival of the 58 patients who have died was 7. 7 and 6 months respectively. Seven patients are alive from 2-30 months (mean 16). Survival was not significantly influenced by tumour histology, location in the oesophagus, severity of dysphagia on admission, or by previous therapy. Survival was significantly influenced by Performance Status prior to treatment (P=0.03 log rank, for PS < or =2 vs. PS=3), an most significantly by the stage of the disease (P=0.0001 log rank, for Stage III vs. Stage IV). CONCLUSIONS: (1) PDT is safe and effective for palliation of dysphagia in inoperable oesophageal cancer. This is particularly important in post-cricoid and cervical oesophageal cancer previously treated by other methods and for patients with recurrent malignant obstruction who previously had intubation or stent placement. (2) Survival is influenced by better PS (< or =2) and in those with disease Stage III rather than patients in Stage IV. This study has not been able to determine the influence of complete tumour staging on survival because, apart from four patients, all others were Stages III and IV cancer.
OBJECTIVE: Non-specific disorders of oesophageal motility are common manometric findings in patients presenting with non-cardiac chest pain, dysphagia, odynophagia, regurgitation and symptoms of gastro-oesophageal reflux disease. Impairment of vagal function has been reported in gastro-oesophageal reflux disease and achalasia. The role of autonomic dysfunction in patients with non-specific oesophageal disorders is unknown. The aim of this study was to assess autonomic function in patients with non-specific disorders of oesophageal motility. METHOD: An automated computerized system (AUTOCAFT) was used to evaluate autonomic function in 62 patients presenting with non-cardiac chest pain and associated oesophageal symptoms. Cardiovascular reflex responses to deep breathing, Valsalva manoeuvre, posture and sustained handgrip were measured and results compared with 14 sex- and age-matched control subjects. RESULTS: Forty percent of patients with non-specific disorders of oesophageal motility proved to have significant abnormalities of vagal function. There was also a high incidence of gastro-oesophageal reflux (50%). CONCLUSIONS: There appears to be autonomic dysfunction in patients with non-specific oesophageal motility disorders. Autonomic function tests may prove to be a useful tool in the assessment of oesophageal function.
Morphometric X-ray absorptiometry (MXA) provides the potential to assess vertebral deformity using a technique with much lower radiation dose to the patient than standard radiographic procedures. MXA overcomes many other limitations such as cone beam distortion observed in conventional plane radiographs. A phantom has been designed to assess the accuracy of the MXA technique, to monitor long-term precision and to assess inter- and intra-operator variability. The phantom consists of two columns of 12 cylinders representing the vertebral bodies, one of regular components and one representing vertebral deformities. Each column may be inserted, as required, into a Perspex torso-mimicking block. Initial assessment on the Lunar Expert-XL demonstrates that the phantom provides image parameters reflecting those found clinically. Measurement of vertebral height was found to be consistently underestimated by 4.9%. Operator precision ranged from 0.6% for posterior height measurement to 1.0% for middle height measurement of the regular component column. The corresponding precision range for the column representing vertebral deformation was 0.6% (posterior) and 1.1% (middle). Analysis of 10 scans of each column by two independent operators demonstrated a few significant differences in height assessment confined to the 'thoracic' region of the regular column. However, inter-operator variability was found to increase with increasing complexity of vertebral shape producing several differences, particularly in posterior height assessment of the deformed column.
The Lunar Expert-XL is an example of the latest generation of fan beam densitometers, with the X-ray source and detector array mounted on a C-arm to enable supine lateral imaging. Image resolution for anteroposterior (AP) spine, femur, hand, forearm and lateral morphometry on the Expert-XL were assessed in vitro with the 07-541 Nuclear Associates line pair test pattern. Each scan type was investigated at all available tube currents and scan speeds, and at the maximum, minimum and default bed heights. The effect of soft tissue thickness on resolution was investigated by using varying amounts of Perspex attenuator. The in vitro median lateral (x-axis) resolutions at the default bed height for the default scan types were 0.9 line pairs (lps)/mm for the 5 mA fast AP spine and femur scans, and l.0 lps/mm for 1 mA fast hand, forearm and 5 mA fast morphometry scans. This equates to a resolution of about 1 mm. The best resolution achieved was 1.2 lps/mm (0.83 mm), obtainable on all scan modes with the bed at maximum elevation, but only consistently with the forearm mode. Lower tube current did not affect resolution but did change the range of soft tissue thickness over which an image could be resolved. Turbo scan modes greatly reduced longitudinal (y-axis) resolution but had little effect on lateral resolution. This study demonstrates the importance of including an assessment of resolution when validating new equipment, especially if morphometric investigations are to be conducted.
Spontaneous rupture of the common carotid artery is an extremely rare disorder. Presentation in an elderly gentleman as a widened mediastinum with cardiac compromise has not been previously reported. Emergency surgical exploration to decompress the airway revealed a 5-mm tear just proximal to the left common carotid artery bifurcation and a large para-oesophageal haematoma. The case is reviewed and the possible causes discussed.
We describe a patient who suffered right pleuritic chest pain and an exudative pleural effusion, leading to empyema formation. Thoracotomy revealed this to be due to a subphrenic abscess around spilled gall stones.
Morphometric X-ray absorptiometry (MXA) relies on accurate measurement of vertical dimensions of vertebrae from a lateral perspective. Deviations resulting from scoliotic curvature or poor patient positioning produce distortions of visible vertebral dimensions and may lead to analysis error. This study utilized a phantom developed at this centre to assess the effect of vertebral malalignment on the accuracy of the MXA technique on the Lunar Expert-XL. Measured vertebral heights were found to be consistently underestimated by an average of 3.7%. Precision ranged from 0.79% for anterior height measurement to 1.03% for middle height measurement. Vertebral malalignment was investigated as the effect of rotation around the anteroposterior, lateral and superoinferior axes. Rotation around the lateral axis produced little discernible effect. However, superoinferior axial rotation showed a change of more than two standard deviations in the mid/posterior ratios of biconcave vertebrae at comparatively small angles of rotation. Anteroposterior axial rotation produced an increase in observed height at small angles of rotation, and a rapid decrease in vertebral height as rotation increased. The results suggest that whilst kyphosis or lordosis of up to at least 5.8 degrees has a minimal effect on MXA, scoliosis of 4.6 degrees or above produces a distinctive effect on the defining crush height ratios.
OBJECTIVE: Dysphagia aortica describes swallowing difficulty caused by external compression from a tortuous or aneurysmal aorta. We present 5 cases in which dysphagia to solids accompanied a localised high pressure barrier (HPB) on manometry suggestive of dysphagia aortica, and explore other investigation modalities useful to confirm the diagnosis. METHODS: Four females and 1 male with a median age of 56 years (range 47-58) were investigated. All underwent investigation with endoscopy, chest radiography, CT scanning, barium swallow, and video solid bolus swallow in addition to oesophageal manometry and 24 h ambulatory pH monitoring. RESULTS: Median basal pressure rise at the mid oesophageal HPB was 45 mmHg (range 40-80). In addition to the HPB, 4 patients had manometric abnormalities of swallow activity and 2 patients had significant gastroesophageal reflux disease (GORD). Contrast enhanced computed tomography and barium swallow were normal in all cases. Video bolus swallow showed pronounced obstruction to transit at the aortic arch in 2 cases and excluded significant dysphagia aortica in 2 others. CONCLUSIONS: Dysphagia aortica commonly coexists with motility disorders and GORD. Video solid bolus swallow allowed us to determine the clinical significance of a manometric HPB in 4 out of 5 patients suspected on dysphagia aortica where standard evaluation would have failed. We recommend its use in those patients with a manometric HPB suggestive of dysphagia aortica in whom standard barium swallow is normal.
Operative control via a thoracic approach of chylothorax can be difficult to achieve, particularly if the chyle leak is secondary to previous thoracic surgery. This report describes the ligation of the thoracic duct at the level of the diaphragmatic hiatus, via an abdominal approach. This technique was the definitive management in four of the last 5 patients presenting with chylothorax in our unit. Typically the leak ceased within 24 h with early discharge of the patient from hospital.
A 36 year old man presented with chest symptoms had a radiological left upper mediastinal lesion, that was interpreted as an anterior mediastinal tumour, consistent with a thymoma. At operation an inflammatory pseudotumour was found in the left upper lobe of the lung, that was projecting across and in front of the mediastinum. The investigation and surgical management of these tumours are reviewed in the light of the presenting symptoms and radiological imaging.
This case report illustrates the occurrence of a large pleural effusion associated with long-term D-penicillamine therapy. This complication has not previously been reported.
A randomized control design was used to compare the effect of swaddling to standard positioning on neuromuscular development in very low birth weight (VLBW) infants (< 1,250 gm). The outcome of neuromuscular development was measured at 34 weeks postconceptional age using the Morgan Neonatal Neurobehavioral Exam (MNNE). The sample included 50 infants who met criteria for birth weight, age and who were classified as appropriate for gestational age. Exclusion criteria were also used. The infants were randomly assigned to the experimental group or the comparison group. Data analysis included descriptive and inferential statistical techniques. The results demonstrated that swaddled infants had higher total scores on the MNNE as compared to infants with standard positioning. Swaddling appears to be a positioning technique that can enhance neuromuscular development of the very low birth weight infant.
We have measured changes in gastric tissue oxygen tension (PtO2, mmHg), with a modified Clark oxygen electrode, in eight patients (median age 59 years, range 52 to 74) undergoing oesophagectomy for carcinoma. Operations were performed with a cervical anastomosis and the stomach mobilised on the right gastric and gastroepiploic arteries. Tissue oxygen tension was measured in the gastric fundus at 4 points: (1) before mobilisation, (2) after mobilisation with the stomach in the abdomen, (3) with the fundus lifted to the neck and (4) after anastomosis. From a mean of 77 mmHg before mobilisation, PtO2 was halved to 36 mmHg after mobilisation with no further fall after transposition to the neck or anastomosis. Arterial oxygen concentration (PaO2), mean arterial pressure (MAP) and oxygen delivery (DO2) were similar at each point. Tissue oxygen tension was correlated with PAO2 at points 1 and 4 but MAP only at point 1 and DO2 not at all. These findings document the relationship of gastric PtO2 to mobilisation of the stomach and demonstrate the important influence of PaO2 on PtO2.
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Liposarcoma is one of the most common soft tissue sarcomas found in adults, yet it rarely develops in the alimentary tract. This report describes the pathological features and management of a liposarcoma of the esophagus.
A woman who had a large primary malignant melanoma of the oesophagus, with evidence of submucosal invasion and several local metastases, underwent resection two years after the onset of retrosternal pain and has survived for 12 years with no recurrence.