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The influence of porosity on the degradation rate of poly(L-lactic acid) (PLLA) films was investigated in vitro and in vivo. Non-porous, porous and “combi” (porous with a non-porous layer) PLLA films were used. Changes in Mw, Mn, polydispersity (Mw/Mn) ratio, melting temperature (Tm), heat of fusion, tensile strength, E-modulus, mass and the remaining surface area of cross-sections of the PLLA films were measured. In general, during the degradation process, the porous film has the highest Mw, Mn, Mw/Mn ratio and Tm, while the non-porous film has the lowest. In contrast, the highest heat of fusion values were observed for the non-porous film, indicating the presence of relatively smaller molecules forming crystalline domains more easily. The tensile strength and E-modulus of the non-porous film decrease faster than those of the porous and the combi film. None of the three types of films showed massive mass loss in vitro nor a significant decrease in remaining polymer surface area in light microscopical sections in vitro and in vivo. Heavy surface erosion of the non-porous layer of the combi film was observed after 180 days, turning the combi film into a porous film. This is also indicated by the changes in tensile strength, Mw, Mw/Mn, Tm and heat of fusion as a function of time. It is concluded that non-porous PLLA degrades faster than porous PLLA. Thus, in our model, porosity is an important determinant of the degradation rate of PLLA films.

• A skin island carried by pectoralis major muscle has been used to reconstruct an intraoral defect created after resection of a tumor. To our knowledge, what happens to the skin after its mobilization from the chest wall into the mouth has not been documented. To answer this, a wedge biopsy of the intraoral skin island on the pectoralis muscle was performed in 14 patients under local anesthesia. The skin biopsy specimen was subjected to scanning electron microscopic and histologic examination. The interval between the reconstructive surgery and the biopsy ranged from ten to 66 months (mean, 32 months). The results revealed desquamation of the epidermis and loss of appendages. The degree of desquamation was maximal when the skin island was used to replace the whole of the floor of the mouth and least when it was used for the lateral portion.(Arch Otolaryngol Head Neck Surg 1989;115:360-363)

During the past 13 years, 86 patients with carcinoma of the esophagus situated at the superior mediastinal segment were admitted and treated at the Queen Mary Hospital, Hong Kong. Only 17 of these patients underwent resection. The resection technique was based on what was described in 1957 by Waddell and Scannell and by Cauchoix and Binet. The whole of the esophagus was removed in each case and the reconstruction, using the stomach, was accomplished by anastomosing the fundus to the cricopharyngeus. In 1 patient an isolated jejunal segment was used in the esophagoplasty, while in another the colon was utilized. There were 3 postoperative deaths, 1 due to a gastrotracheal fistula from erosion by the tracheostomy tube, a second due to hemorrhage, and a third due to bronchopneumonia. Four patients are currently alive and well without evidence of cancer. The longest survivor has lived for 5 years and 3 months. Ten of the patients who were discharged from the hospital lived for from 2 to 15 months, with an average of 8.7 months. This compares favorably with the 6.9 months average survival reported by Procter in patients with carcinoma of the upper third of the esophagus who were treated by radiotherapy. While the mortality rate is still high, the results are encouraging and continued use of surgical treatment is certainly warranted. Au cours des 13 dernières années, 86 malades atteints de cancer de l'oesophage médiastinal supérieur ont été admis au Queen Mary Hospital, Hong Kong. Une résection a pu être réalisée dans 17 cas seulement. La technique d'exérèse est inspirée des descriptions de Waddell et Scanneil et de Cauchoix et Binet (1957). Dans chaque cas, l'oesophage a été réséqué en totalité et remplacé par l'estomac, dont le fundus est anastomosé au crico-pharyngien. Dans 1 cas cependant, l'oesophagoplastie a été faite par transplant jéjunal, et dans 1 autre cas en utilisant le colon. Il y a eu 3 décès postopératoires: 1 fistule gastro-trachéale par érosion par le tube de trachéotomie, 1 hémorragie, et 1 bronchopneumonie. Quatre patients sont actuellement en vie sans signe de récidive cancéreuse. La plus longue survie est de 5 ans 3 mois. Dix malades ont survécu 2–15 mois, avec une moyenne de 8.7 mois. Ces résultats sont au moins aussi favorables que ceux de Procter qui a une survie moyenne de 6.9 mois pour les cancers du 1/3 supérieur de l'oesophage traités par radio-thérapie. La mortalité est certes encore élevée, mais les résultats encourageants justifient l'utilisation du traitement chirurgical.

• Replacement of circumferential defects of the pharynx with skin-lined flaps rolled into a tube had the problem of anastomotic stricture formation. To prevent and correct stenosis at the mucocutaneous junction, an interdigitating anastomotic line produced by making vertical slits on the skin edge and the esophageal stump edge is used. It allows for maintenance of the lumen despite suture line contraction.(Arch Otolaryngol Head Neck Surg 1987;113:428-431)

Between 1964 and 1979, a total of 1,536 patients with carcinoma of the thoracic esophagus were treated at this center. Of these, 142 patients with unresectable tumor underwent the Kirschner operation for palliation. In this operation, esophageal obstruction is bypassed by subcutaneous or retrosternal gastric esophagoplasty, and the thoracic esophagus defunctionalized by a long Roux-en-Y jejunal loop to the abdominal esophagus. Dysphagia is thus relieved and aspiration of esophageal and gastric contents into the respiratory tract avoided. Any patient who was not discharged from the hospital for any reason and eventually died in the hospital is counted as a mortality. The hospital mortality for these 142 patients was 41.5% (59 patients). In recent years, there has been a reduction in mortality rate. The most common cause of death was progressive bronchopneumonia (72.9%). Leakage of anastomosis occurred in 67 patients (47.2%), but most healed on conservative treatment. The ability to eat normally was restored in 69% of survivors, and another 28% were able to tolerate a soft diet. Although temporary postoperative aspiration was occasionally encountered when the patient started oral feeding, once swallowing was established, tracheobronchial aspiration did not occur. The mean survival of the discharged patients was 5.0 months. Malignant cachexia from growth of the primary tumor accounted for 61.4% of late deaths; metastatic disease, 10.8%; and cardiopulmonary insufficiency, the remainder. One patient is alive more than 5 years after operation, and presumably was cured by postoperative radiotherapy. Although the mortality rate of the Kirschner operation is substantial, other forms of treatment also have significant mortality rates but with less palliative potential. Therefore, we would recommend this operation for the palliation of unresectable carcinoma of the esophagus. Nous avons traité, entre 1974 et 1979, 1536 malades atteints de cancer de l'oesophage thoracique. Une opération palliative de KIRSCHNER a été réalisée pour 142 tumeurs non résécables. Dans cette opération, l'obstacle oesophagien est court-circuité par une gastroplastie sous-cutanée ou rétro-sternale, et une longue anse jéjunale en Roux-Y est anastomosée à l'oesophage abdominal. L'opération pallie la dysphagie et évite l'aspiration dans les voies respiratoires du contenu oesophagien et gastrique. Pour les 142 malades, la mortalité hospitalière (tous les malades morts pendant leur séjour à l'hÔpital, quelle qu'en soit la cause) a été de 41.5% (59 cas). Elle a été réduite au cours des dernières années. La cause de décès la plus fréquente a été la bronchopneumonie (72.9%), Un lachage de la suture est survenu chez 67 malades (47.2%) mais a, dans la majorité des cas, guéri par traitement conservateur. Parmi les survivants, 69% peuvent manger normalement et 28% de plus peuvent prendre un régime semi-liquide. Après l'opération, on observe parfois une aspiration trachéo-bronchique au moment où l'alimentation est reprise; mais, une fois le méchanisme de déglutition rétabli, cette complication ne se reproduit plus. La survie moyenne pour les malades sortis de l'hÔpital est de 5.0 mois. Les décès tardifs sont dus, dans 61.4% des cas à une cachexie maligne par croissance de la tumeur primitive, dans 10.8% à des métastases, et dans le reste à une insuffisance cardio-respiratoire. Un malade est en vie plus de 5 ans après l'opération, probablement guéri par la radiothérapie postopératoire. La mortalité de l'opération de KIRSCHNER n'est pas négligeable. Mais les autres thérapeutiques possibles ont également une mortalité lourde et leur capacité de palliation est beaucoup moins bonne. Nous recommandons donc cette opération palliative chez les malades atteints de cancer non résécable de l'oesophage.

During the last 14 years, pharyngogastric anastomosis following pharyngolaryngoesophagectomy was performed in 157 patients, among whom 67 had carcinoma of the hypopharynx, 7 had carcinoma of the cervical esophagus, and 83 had carcinoma of the larynx involving the hypopharynx. The operative procedure was that described previously by Ong in 1960, and modified in 1971. The overall hospital mortality was 31%, which in the last 2 years of the study had fallen to 18%. It was found that the mortality was higher in patients with poor cardiopulmonary status and in patients whose tumors had extended into the vallecula, thus requiring resection of the posterior third of the tongue. Previous failed radiotherapy increased the risk of leakage of the anastomosis. The immediate results of the operation can be improved if the surgeon ensures that a healthy stomach is prepared, a secure anastomosis is performed, and the vulnerable blood vessels are protected. Postoperative function in terms of swallowing ability was good, but rehabilitation of speech was poor. The 5-year survival rate was 17.8%. The longest surviving patient is still alive 10 years after the original operation. The most common cause of long-term failure was the development of metastatic disease. Improvement in survival results may require the use of adjuvant therapy to operative treatment. Nous avons, au cours des 14 dernières années, réalisé une pharyngo-laryngo-oesophagectomie avec anastomose pharyngo-gastrique chez 157 malades; 67 cancers de l'hypopharynx, 7 cancers de l'oesophage cervical et 83 cancers du larynx envahissant l'hypopharynx. La technique opératoire utilisée est celle qui a été décrite par ONG en 1960 et modifiée en 1971. La mortalité hospitaliére globale a été de 31%; pour les deux dernières années, elle a été réduite à 18%. La mortalité est plus élevée chez les malades dont l'état cardiopulmonaire est précaire et dans les cas où la tumeur, étendue jusqu'à la base de la langue, exigeait la résection du 1/3 postérieur de celle-ci. La radiothérapie préopératoire augmente le risque de lachage des anastomoses. Pour améliorer les résultats postopératoires précoces, il faut que l'estomac soit sain et bien préparé, que l'anastomose soit réalisée dans des conditions parfaites, que les vaisseaux vulnérables soient protégés. La récupération fonctionnelle est bonne pour la déglutition, mais pauvre pour la parole. La survie à 5 ans est de 17.8%. Notre plus longue survie est de 10 années après l'opération initiale. Les métastases sont la cause la plus fréquente d'échecs à long terme. Pour améliorer la survie, il faudra peut-Être compléter la chirurgie par des thérapeutiques adjuvantes.