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Objective: The attempted migration of approximately 50,000 Cubans in the summer of 1994 created a large patient population detained at Guantanamo Bay, Cuba. This study examined the roles and results of the 59th Air Transportable Hospital (ATH) in treating surgical problems within that population during Operation Sea Signal. Methods: The surgical case log of the 59th ATH was used to identify all patients operated on at the 59th ATH during the interval of August 1994 to April 1995. These case records and the individual records of the three 59th ATH surgeons were used to determine the types of cases performed, complications, and outcomes. Results: A total of 333 operations were performed at the 59th ATH in three types of surgery: (1) elective (267); (2) emergency for nonself-inflicted conditions (46); and (3) emergency for self-inflicted conditions (20). The total perioperative complication rate was 2.4% (8/333), and the wound infection rate for clean surgical cases was 0.87% (2/229). Conclusions: Elective surgery may be performed in a field environment with acceptable complication and wound infection rates. Humanitarian missions will be faced with considerable pathology from pre-existing conditions within the population cared for. The humanitarian mission may be complicated by political situations that may encourage malingering and self-injurious behavior within the population cared for. The latter events have not been previously encountered in humanitarian missions involving the U.S. military and must be considered by policy makers and mission planners in planning future humanitarian missions.

Background: This study examined the success and safety of cervical exploration in patients with asymptomatic primary hyperparathyroidism compared with those with symptomatic disease. Methods: Records of patients undergoing cervical exploration for primary hyperparathyroidism from June 1990 to October 1996 were reviewed. Patients were divided into three groups: (1) asymptomatic, (2) symptomatic, and (3) afflicted (those with associated complications). Information collected consisted of preoperative and postoperative symptoms, serum calcium and parathyroid hormone levels (PTH), and descriptions of pathologic and operative findings. Results: Sixty-one patients were identified. Nineteen (31%) had no symptoms, 21 (34%) had subjective symptoms, and 21 had associated conditions, as described. Average preoperative and postoperative calcium levels were 11.5 mg% and 8.5 mg%, respectively. Average PTH levels also fell from 142 pg/mL to 49 pg/mL after surgery. Preoperative and postoperative calcium and PTH levels for the three groups showed no significant differences. The success of surgery in identifying pathology ranged from 90.5% to 95%, and again showed no difference among the three groups. Long-term morbidity (>6 months) in all groups was 0%. Conclusions: Cervical exploration and parathyroidectomy for asymptomatic primary hyperparathryoidism is safe and has similar success rates in identifying pathology and correcting biochemical abnormalities compared with patients with symptomatic disease.

This report describes a technique in which temporary extra-anatomic revascularization of an amputated part was used to preserve a free flap while tumor resection and chest wall reconstruction were performed.A patient with multiple local recurrences of basosquamous carcinoma of the shoulder underwent forequarter amputation with en bloc resection of the upper chest wall. During the resection, an elbow disarticulation of the amputated limb was performed. The vascular pedicle of the amputated forearm was joined to the dorsalis pedis vessels of the foot. Following completion of tumor resection and chest wall reconstruction, the forearm was disconnected from the foot and re-anastomosed to thoracic vessels, and a circumferential fasciocutaneous free flap was then harvested and inset.No ischemic flap complications occurred, and the patient recovered well. Ample time was afforded for complete tumor resection with negative margins and prosthetic reconstruction of the chest wall.The technique of temporary, simultaneous extra-anatomic revascularization of an amputated part for later free flap harvest may be helpful in avoiding potentially long flap ischemia times in selected complex oncologic resections.

Intraoperative radiation therapy (IORT) has been used successfully in the treatment of malignancies, alone and as an adjunct to surgical resection. This study examined a single institution's experience with combined IORT and surgical resection in the treatment of advanced cancer. The records of 41 consecutive patients undergoing intraoperative radiation therapy (IORT) at the Fox Chase Cancer Center, from July 1987 through March 1990, were retrospectively reviewed. All patients had locally advanced disease, of whom 73% had failed previous multimodality therapy and 44% had undergone prior radiation therapy (XRT). The 2-year actuarial survival for the entire cohort was 72%. Disease-free survival was 47% at 1 year and 5% at 2 years. The only important prognostic factor predicting outcome was status of the surgical margin. Positive surgical margins decreased the 2-year actuarial survival from 100% to 59%, and increased the local failure rate from 21% to 52%. Margin status had no effect on the later development of metastatic disease. Higher IORT doses, field sizes > 7 cm, and multiple IORT fields were used for larger tumors and larger amounts of residual disease. These parameters alone did not correlate with improved local control. This analysis suggests the usefulness of aggressive surgical resection with IORT in extending survival for locally advanced or recurrent cancer. Negative margin status is the best predictor of a favorable outcome and should be used to select patients who may benefit from IORT. The use of radiation sensitizing agents should be explored in patients with positive margins, since in-field failure continues to be the major pattern of failure. IORT in conjunction with aggressive surgical resection should continue to be studied in prospective randomized clinical trials.

Photodynamic therapy has been proposed as a new modality for the local treatment of neoplasms limited to the pleural surface. Clinical use of photodynamic therapy will involve exposure of large surface areas of normal intrathoracic organs to tumoricidal doses of photodynamic therapy. This study details the pathologic changes that occur within the lung, heart, trachea, and diaphragm of Sprague-Dawley rats after administration of tumoricidal photodynamic therapy. Animals were injected with the photosensitizer Photofrin-II (Quadralogic Technologies, Vancouver, B.C., Canada), 10 mg/kg intraperitoneally, 24 hours before surface illumination of a portion of the target organ with gold vapor laser light (628 nm) (124 joules/cm2). Control animals were treated with light alone. After endotracheal intubation and mechanical ventilation, the lung and heart were exposed via left thoracotomy. The trachea was dissected in the neck, and the diaphragm was visualized via celiotomy. One site was treated per animal. Animals were killed at 24 hours, 48 hours, 72 hours, 1 week, 1 months, and 6 months after therapy. Histologic injury was numerically assessed by a single observer blinded to treatment and time of organ harvest. The Wilcoxon matched-pair signed-rank test was used to determine the statistical significance of differences between treated and control groups. Twenty-four hours after treatment the lung, heart, and trachea of rats subjected to photodynamic therapy demonstrated parenchymal injury (p horac C ardiovasc S urg 1992;103:1218-23)

The attempted migration of approximately 50,000 Cubans in the summer of 1994 created a large patient population detained at Guantanamo Bay, Cuba. This study examined the roles and results of the 59th Air Transportable Hospital (ATH) in treating surgical problems within that population during Operation Sea Signal.The surgical case log of the 59th ATH was used to identify all patients operated on at the 59th ATH during the interval of August 1994 to April 1995. These case records and the individual records of the three 59th ATH surgeons were used to determine the types of cases performed, complications, and outcomes.A total of 333 operations were performed at the 59th ATH in three types of surgery: (1) elective (267); (2) emergency for nonself-inflicted conditions (46); and (3) emergency for self-inflicted conditions (20). The total perioperative complication rate was 2.4% (8/333), and the wound infection rate for clean surgical cases was 0.87% (2/229).Elective surgery may be performed in a field environment with acceptable complication and wound infection rates. Humanitarian missions will be faced with considerable pathology from pre-existing conditions within the population cared for. The humanitarian mission may be complicated by political situations that may encourage malingering and self-injurious behavior within the population cared for. The latter events have not been previously encountered in humanitarian missions involving the U.S. military and must be considered by policy makers and mission planners in planning future humanitarian missions.

The benefits of epidural narcotic analgesia (ENA) have been documented in mixed surgical populations. To assess the safety and utility of ENA after thoracic surgery and to assess potential interactions with intraoperative intravenous narcotics (IIN), we retrospectively examined the records of 130 consecutive patients having thoracotomy. The 116 patients who received ENA required a mean of 0.19 mg/kg of intravenous morphine sulfate (MS) within the first 48 postoperative hours, as opposed to 0.44 mg/kg for patients who did not receive ENA. The place in which nonepidural patients were extubated most frequently was the operating room (71%), followed by the intensive care unit (21%) and the recovery room (7%). Percentages were similar for epidural patients: 71% were extubated in the operating room, 20% in the intensive care unit, and 9% in the recovery room. Nonepidural patients had an immediate mean postoperative PCO2 of 39.2 mm Hg, epidural patients a mean of 40.1 mm Hg. There were no technical complications due to epidural catheter placement, and no reintubation was required within the first 72 postoperative hours. The concomitant administration of IIN did not produce a significant difference in postextubation PCO2 in either group of patients, although increasing doses resulted in a lower percentage of patients extubated in the operating room or recovery room. We conclude that ENA may be safely administered to patients having thoracotomy, and it diminishes the need for postoperative intravenous narcotics.

• We examined the possibility that tumor-released products inhibit lymphokine-activated killer cell activation. Lymphokineactivated killer cells from human peripheral blood lymphocytes were activated with recombinant interleukin 2 for 4 days in the presence of malignant effusions or conditioned media from cultured cell lines (10% vol/vol). Eight of 10 malignant effusions/media suppressed the induction of lymphokine-activated killer cell cytotoxicity, as measured in a 4-hour sodium chromate release assay. Seven of 10 effusions/media inhibited lymphokine-activated killer cell proliferation. Suppression was both dose and time dependent. A representative suppressive effusion was fractionated by agarose gel chromatography, treated with detergents disruptive of ionic bonds and lipids, and refractionated using polyacrylamide gel chromatography. Seven suppressive fractions ranging in molecular weight from 1 × 10 5 to 3× 10 5 d were isolated. It is speculated that this suppressor factor may represent a large multimeric structure with ionic-bonded individual suppressive components. ( Arch Surg . 1991;126:476-480)

The 11th case of primary leiomyosarcoma of the renal vein is reported. Unique features of this case included concomitant resection of an isolated hepatic metastasis, intraoperative radiation therapy, and the use of electron microscopy and immunohistochemical stains in confirming the diagnosis. A review of the previously reported cases shows a tendency toward slow tumor growth and infrequent recurrence (18%). Metastases are common (82%), primarily to the lung and liver. Aggressive surgical resection and adjuvant radiation therapy, including intraoperative radiation therapy, are recommended. Adjuvant chemotherapy should be considered, although its benefits at present are unclear.

The case of a 5-month-old girl with a large neuroblastoma of the thoracic inlet, an unusual location for this tumor, is presented. The patient had marked airway compromise due to tumor compression, with extension of the mass through the thoracic inlet into the base of the neck, also incorporating the right subclavian artery. The highly unusual location of this tumor is presented, and challenging technical aspects of its management are discussed.

Purpose: Peutz-Jeghers syndrome (P-J) is an autosomal dominant disorder that is characterized by polyps and mucocutaneous pigmentation. Many P-J patients will develop isolated polyps in the stomach, small bowel, or colon. Rarely small intestinal or colonic polyposis has been reported. We describe a unique case of isolated gastric polyposis of the P-J type causing chronic, refractory GI blood loss.

Airway management of patients with tracheobronchial compression due to mediastinal masses poses a difficult problem. A new technique of direct vision endotracheal intubation is described, and other adjunctive measures are reviewed.