Assessment and management of dysphagia following pharyngolaryngectomy with free jejunal interposition: A series of eight case studies

The physiological and structural deficits contributing to swallowing complications in the pharyngolaryngectomy patient population are not homogeneous. Consequently, a team approach, involving medical investigations as well as clinical and radiological assessments of swallowing, is necessary to facilitate diagnosis of the underlying impairment and assist the medical/surgical and speech pathology team members in the process of individualizing the management plan for each patient. In the present study, the clinical assessment and management of eight pharyngolaryngectomy patients who presented with a decline in swallowing function unrelated to immediate postsurgical effects or direct effects of radiotherapy are reported. Clinical and radiological investigations revealed a heterogeneous group of factors contributing to their swallowing impairments and disability levels, including difficulty with graft and anastomotic patency and graft motility, impaired lingual coordination, increased bolus transit time, nasal and oral regurgitation, patient distress, and recurrence. Variation between the cases supported the need for differential intervention and management plans for all eight patients. Ratings of perceived swallowing disability, handicap, and well-being/distress levels at initial assessment and again six months following dysphagia intervention revealed a pattern of reduced levels of impairment, functional disability, and overall patient distress levels following informed intervention. The present case study data highlights the key role thorough clinical and radiological investigations play in the process of diagnosing the factors contributing to dysphagia and guiding the management of the resultant swallowing disability in the pharyngolaryngectomy population.

Dog peritoneal and pleural cavities as bioreactors to grow autologous vascular grafts

Objective: The purpose of this study was to grow artificial blood vessels for autologous transplantation as arterial interposition grafts in a large animal model (dog). Method and results: Tubing up to 250 mm long, either bare or wrapped in biodegradable polyglycolic acid (Dexon) or nonbiodegradable polypropylene (Prolene) mesh, was inserted in the peritoneal or pleural cavity of dogs, using minimally invasive techniques, and tethered at one end to the wall with a loose suture. After 3 weeks the tubes and their tissue capsules were harvested, and the inert tubing was discarded. The wall of living tissue was uniformly 1-1.5 mm thick throughout its length, and consisted of multiple layers of myofibroblasts and matrix overlaid with a single layer of mesothelium. The myofibroblasts stained for a-smooth muscle actin, vimentin, and desmin. The bursting strength of tissue tubes with no biodegradable mesh scaffolds was in excess of 2500 mm Hg, and the suture holding strength was 11.5 N, both similar to that in dog carotid and femoral arteries. Eleven tissue tubes were transplanted as interposition grafts into the femoral artery of the same dog in which they were grown, and were harvested after 3 to 6.5 months. Eight remained patent during this time. At harvest, their lumens were lined with endothelium-like cells, and wall cells stained for alpha-actin, smooth muscle myosin, desmin and smoothelin; there was also a thick adventitia containing vasa vasorum. Conclusion: Peritoneal and pleural cavities of large animals can function as bioreactors to grow myofibroblast tubes for use as autologous vascular grafts.