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Three cases of primary malignant melanoma of the oesophagus are presented and the literature is briefly reviewed. This rare disease affects predominantly males in the sixth decade of life or later and the clinical and radiologic features are indistinguishable from those of more common oesophageal carcinomas. The tumours are often polypoid, located mainly in the lower two-thirds of the esophagus, and their histologic features resemble those of lentigo maligna melanoma, but with more aggressive biologic behavior. Because of the potential for extensive intramucosal involvement, multicentricity and high local recurrence rate, surgical treatment requires radical excision with a much greater margin than for the common squamous cell carcinomas. Though the outlook is poor, surgery is the favoured treatment with palliative or curative intent, with a 5-year survival rate of 4.2%. Radiotherapy, chemotherapy and immunostimulation currently serve mainly as palliative or adjunctive measures.

Both epidural and paravertebral blocks are effective in controlling post-thoracotomy pain, but comparison of preoperative and balanced techniques, measuring pulmonary function and stress responses, has not been undertaken previously. We studied 100 adult patients, premedicated with morphine and diclofenac, allocated randomly to receive thoracic epidural bupivacaine or thoracic paravertebral bupivacaine as preoperative bolus doses followed by continuous infusions. All patients also received diclofenac and patient-controlled morphine. Significantly lower visual analogue pain scores at rest and on coughing were found in the paravertebral group and patient-controlled morphine requirements were less. Pulmonary function was significantly better preserved in the paravertebral group who had higher oxygen saturations and less postoperative respiratory morbidity. There was a significant increase in plasma concentrations of cortisol from baseline in both the epidural and paravertebral groups and in plasma glucose concentrations in the epidural group, but no significant change from baseline in plasma glucose in the paravertebral group. Areas under the plasma concentration vs time curves for cortisol and glucose were significantly lower in the paravertebral groups. Side effects, especially nausea, vomiting and hypotension, were troublesome only in the epidural group. We conclude that with these regimens, paravertebral block was superior to epidural bupivacaine.

Summary Six patients undergoing paravertebral blocks for chronically painful conditions Key wordsEquipment; thermal imaging. Anaesthetic techniques, regional; paravertebral block.Paravertebral analgesia is advocated for surgical procedures of the abdomen wherever the afferent input is predominantly unilateral e.g. nephrectomy, cholecystectomy, but it is particularly effective when used to treat the pain of posterolateral thoractomy [ 11. However, despite numerous studies showing the clinical safety and efficacy of this block [ 1-51, there appear to be some reservations which have been voiced in vague terms by some [6, 71 and more specifically by others [8]. The former include the suggestion that the technique is hazardous and ineffective and the latter that paravertebral spread rarely exceeds two dermatomes with evidence of sympathetic blockade being seen in fewer than 5% of patients. Rather than simply add further anatomical data, we undertook an objective physiological assessment of the extent of the somatic and sympathetic blockade achievable with a single percutaneous paravertebral injection. Patients and MethodsThe study was approved by the hospital ethics committee and informed consent was 'obtained from all patients. Percutaneous paravertebral blocks were perfonned in six patients presenting for treatment of chronically painful chest wall conditions (post-thoracotomy neuralgia, intercostal neuralgia and postherpetic neuralgia). Each patient underwent pre-operative automated cardiovascular data collection consisting of noninvasive pulse and blood pressures in the sitting and supine positions (Datascope 22001). Anterior, posterior and lateral thermographic control views of the naked trunk and limbs were obtained pre-operatively with a Starsight thermal imaging camera (Insight Vision Systems, Malver). Pre-operative pinprick testing was normal in all patients. The blocks were performed by a single operator experienced in this technique (J.R.) and the method used was that of Eason and Wyatt [2] supplemented with radiographic screening and the use of radio-opaque contrast medium. Following negative aspiration, 15 ml of 0.5% bupivacaine was injected over 60 s as a single bolus (with multiple aspirations) at a mean dermatomal level of T,,, with a range of T,-, to T,,,, . Postinjection data collection was undertaken by two observers (D.I. and S.P.S.C.) and consisted of pinprick mapping of the extent of the block, repeated thermographic imaging at 5min intervals until a stable image was obtained, 5min sitting and lying cardiovascular parameters and documentation of any side effects.

Twelve cases of oesophageal intramural pseudodiverticulosis are described and the findings in 85 previously reported cases are reviewed. The condition occurs in all age groups, predominantly in the sixth and seventh decades, with a slight predilection for males. The characteristic radiographic appearance is of multiple flask shaped outpouchings of 1-4 mm with narrow necks communicating with the oesophageal lumen. The source of the pseudodiverticula has been shown to be pathologically dilated excretory ducts of the submucous glands due to chronic submucosal inflammation. The distribution was segmental in 57 cases (59%) and diffuse in 40 (41%). Dysphagia is the main symptom and was found in 85 cases (88%); 88 cases out of 97 had radiological narrowing of the oesophagus; of these, 39 (44%) were in the upper oesophagus, 20 (23%) in the middle oesophagus, and 29 (33%) in the lower oesophagus. Treatment is directed towards management of the associated disorder, as the diverticula themselves rarely cause problems.

Radical en-bloc excision remains the treatment of choice in all primary malignant chest wall neoplasms except large solitary plasmacytomas where incisional biopsy followed by irradiation appears to be the method of preference. In Ewing's and Askin's tumours, additional chemotherapy and radiotherapy have to be used. The extent of surgical excision should only be limited by the amount of tissue necessary to remove for adequate malignant tissue clearance, since even large defects can be reconstructed with little functional disturbance.

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