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Background: Carcinoma of the cardia of stomach or carcinoma of the esophagocardiac (EC) junction has a poor prognosis. Proximal subtotal gastrectomy is often performed for a smaller tumor. It achieves a prognosis similar to that of total gastrectomy and prevents pernicious anemia. A better functional result was expected than that total gastrectomy did from us, but the clinical observation was surprising. Most patients had symptoms of reflux esophagitis after surgery. All of these patients were reevaluated., Methods: From November, 1990 to March, 1996, there were 27 patients who received proximal subtotal gastrectomy at this hospital. Twenty of these were involved in this study. Floppy Nissen's fundoplication was performed during operation as a anti-reflux procedure. Continuous 24-h pH monitoring, esophageal manometry, and endoscopic examination were performed for study., Results: Most of the patients had symptoms of gastroesophageal reflux. 80% (16/20) of the patients were found to have reflux esophagitis under endoscopy. The patients had higher pH scores (mean 85.8 +/- 45.6) than normal (< 17.5), lower pressure of LES (8.03 +/- 7.01 mmHg), shorter total lengths (mean 1.60 +/- 0.56 cm) and intraabdominal lengths (mean 1.29 +/- 0.30 cm) of new lower esophageal sphincters., Conclusions: Clearly there was failure to prevent reflux esophagitis through floppy Nissen's fundoplication. Severe gastroesophageal reflux did appear after proximal gastric resection. A gastric remnant with safe cut-margin is often too short to perform complete wrapping. Proximal subtotal gastrectomy is not recommended for early cancer of the cardia of the stomach.

Background: It is imperative that the surgeon promptly determine the severity of any acute injury of the upper gastrointestinal (UGI) tract by caustic material ingested and the definite therapy be instituted. Prognostic factors of such injuries have not been clearly demonstrated in previous reports. Here, some prognostic factors and recommended emergency surgical indications in clinical assessment are discussed., Methods: Forty-six patients (22 men and 24 women; age range 19 to 77 years), sustaining acute corrosive injuries to the UGI tract, were retrospectively assessed from November 1990 to May 1993. Immediate management was given to prevent shock, to identify any associated injury and to observe patency of the airway. Emergency operation was performed if any signs of peritonitis, mediastinitis or sepsis were present. Age, sex, time interval between ingestion and initial resuscitation, consciousness, peritoneal sign, shock index, pH value and [HCO3-] in arterial blood gas were evaluated as prognostic factors with respect to mortality. Chi-square test with Yates' correction was used. A p value less than 0.05 was regarded as statistically significant., Results: Suicide attempt by caustic ingestion was in 40 patients (87%) and ingestion was accidental in 6 (13%). Acidic injury was specified in 36 patients (78.3%). In 14 severely injured patients, emergency exploratory laparotomy with or without esophagogastrectomy was performed in 9 (19.6%), of whom 2 survived. The other five patients were treated conservatively, and all died. Overall mortality rate was 26.1% (12/46). A significantly higher mortality rate was observed in patients with age > or = 50 years, positive peritoneal sign, shock index > 1, pH below 7.2 and bicarbonate concentration below 16 mEq/L as revealed by arterial blood gas (p < 0.05)., Conclusions: The prognostic factors related to a higher mortality rate included age 50 years old or more, positive peritoneal sign, shock index above 1, pH below 7.2 and [HCO3-] below 16 mEq/L in arterial blood gas. Recognition of these factors indicates further detailed study will be required to propose a caustic injury score for predicting severity. Nevertheless, emergency operation is recommended if there are positive signs of peritonitis or mediastinitis, shock index above 1, pH below 7.0 and [HCO3-] below 10 mEq/L in arterial blood gas.

Experimental en-bloc double lung transplantation was first reported by Dark et al. to broaden the indications for heart-lung and single lung transplantations. They used puppies as an acute model: however primates are optimal in expecting improving survival. In this study we used Taiwan cynomolgus monkeys for 20 enbloc double lung transplants. The animals weighing 2.4-8.0 kgs. were divided into two groups: one with surface cooling and profound hypothermia and the other one with bypass using heart lung machine. For surface cooling group the average ischemic time was 58.5 minutes, and the result was disappointing: The best survivor sustained only 8 hours after transplant, and 5 died on table. In the group with bypass, the perioperative course was rather smooth. The animals could restore their respiratory function after transplant. Postoperative bleeding was the major course of complication. All the animals died within one day. During operation, evidence of tuberculosis and filariasis were observed. While some problems have to be solved before a clinical trial starts, clinical en-bloc double lung transplant is technically feasible.

Primary mediastinal seminoma is a rare neoplastic disease. Only 133 cases have been reported in the literature. Five patients with primary mediastinal seminoma had been treated at VGH from 1974 to 1986. All of them received exploratory thoracotomy but only two of them were resectable. Postoperative radiation therapy was given regardless of resection. One had additional chemotherapy due to nodal involvement. All five patients showed complete resolution and were alive and free of disease for an average follow-up period of 42.6 months (range, 5-82 months). So we conclude that mediastinal seminoma is a rare neoplastic disease and can be treated primarily by surgery. Irradiation can also induce complete remission and long term survival in those with unresectable tumors.