Acute gastric distension necessitating gastrostomy after anesthetic induction for surgical correction of type III esophageal atresia

IPPV during anaesthesia for management of oesophageal atresia with tracheo-oesophageal fistula (TOF) can cause gastric insufflation. We report such a complication in a one-day-old newborn, who developed, 15 min after induction, a distension of the abdomen, hypoxia and bracdycardia. An emergency gastrostomy was performed. His status improved rapidly and surgery could be completed. TOF was located at the carina and had a large calibre. To avoid gastric distension in such cases, the tip of the tube is located just proximal to the carina, but distal to the fistula to prevent intubation of the latter. Difficulties are due to position of the fistula (carina, main bronchi) or its large bore. Gastric distension carries a risk of regurgitation and inhalation of gastric contents, elevation of hemidiaphragm and lung compression, decreased tidal volume, decreased venous return, cardiovascular collapse and cardiac arrest. When insufflation peak pressures are low, gastrostomy is benefitful, as in our case, as the tidal volume loss through the stomach is acceptable. In case of high insufflation pressures because of co-existing lung disease, gastrostomy is better avoided, as most if not all the tidal volume may be lost through the stomach.     

Clinical photodynamic therapy for superficial cancer in the oesophagus and the bronchi: 514 nm compared with 630 nm light irradiation after sensitization with Photofrin II

Photodynamic therapy (PDT) for cancer in the oesophagus and bronchi with red (630 nm) light may occasionally lead to wall perforation and fistula. Therefore, we investigated the clinical use of a less penetrating wavelength (514 nm) for the curative treatment of nine superficial carcinomas in the oesophagus and bronchi after photosensitization with Photofrin II. Tumours without infiltration beyond the submucosa in the oesophagus and beyond the lamina propria in the bronchi were considered as superficial cancers. The outcome and complications were compared with those of 13 superficial cancers treated with PDT and 630 nm light. In addition, we evaluated histologically the extent of the long-term tissue damage and scarring following treatment of six oesophageal cancers with either green or red light. At first endoscopic control, 7-10 days after PDT, tissue necrosis simply matched the illuminated area, without evidence of selective tumour damage. Six of nine tumours treated with 514 nm light had a complete response compared with nine of 13 after 630 nm irradiation. No perforation or fistula occurred in either treatment group. However, severe chest pain and fever with or without pleural effusion, consistent with occult perforation, were observed in three patients after 630 nm illumination in the oesophagus. Histologically, fibrous scarring in the three distinct sites treated with green light was limited to the superficial layers of the oesophagus. After red light treatment, transmural fibrosis with marked thinning of the oesophageal wall was evident in two of the three specimens available for inspection. These results indicate that PDT with 514 nm light has the potential to cure superficial cancer in the oesophagus and bronchi with essentially the same probability of success as red light. In the oesophagus, green light prevents deep tissue damage, thus reducing the risk of perforation.     

Surgical treatment of coronary artery-pulmonary artery fistula

We experienced 4 cases of left coronary artery-pulmonary artery fistula. Two cases had small fistulas associated with atherosclerotic coronary lesions, and the other 2 had large fistulas with aneurysmal enlargement. In the former 2 cases, ligation of the fistulas and closure of the opening of fistula into the pulmonary artery through pulmonary arteriotomy were performed together with coronary artery bypass grafting and left ventricular aneurysmectomy. In one of the latter 2 cases, the fistula arising from the anterior descending branch was ligated and the opening of fistula draining into the pulmonary artery was closed through pulmonary arteriotomy. In another case, both openings of the fistula into the anterior descending branch and the pulmonary artery were closed from inside through incision of the dilated fistula. In all 4 cases, operations were performed using cardiopulmonary bypass and retrograde coronary perfusion, which could afford good heart protection even in cases with coronary lesions and coronary steal phenomenon. All cases went an uneventful postoperative course. Postoperative angiograms showed disappearance of the fistulas in 3 cases. In one case, however, residual fistula was found because a fine fistula might be overlooked. In such a case with complicated fistulas with aneurysmal enlargement, fistulas should be examined carefully through incision of the enlarged anomalous vessels. In this paper, diagnosis, operative indication and treatment for coronary artery-pulmonary artery fistula were discussed.     

Incomplete Boerhaave syndrome of the cervical esophagus

It is known that an acute postemetic injury may evoke a spontaneous rupture of the oesophagus. This spontaneous rupture may produce an intramural hematoma or a laceration of the oesophagus wall. The intramural hematoma is restricted to the esophageal wall and may produce a fistula into the lumen of the oesophagus (with creation of a double lumen) or into the mediastinum (haematoma of the mediastinum). On the other hand the rupture may extend from the mucosa (lesion of Mallory-Weiss) into the complete wall of the oesophagus (Boerhaave's Syndrome). There are reports on a lesion of the exterior muscular layer of the third distal half of the oesophagus, which had evoked an acute haemorrhage into the mediastinum and has been defined as a variant of Boerhaave's syndrome. We now describe a similar case which is confined to the cervical oesophagus and has been treated without surgical intervention.     

Cycloserine-induced decrease of cerebroside in myelin

OBJECTIVE: A rare but serious complication of angioaccess surgery for hemodialysis is the so called steal syndrome presenting as ischemia distal to an arteriovenous fistula. The main problem of various surgical techniques to correct steal is subsequent thrombosis of the fistula or persistence of distal ischemia. INTERVENTIONS: This paper describes an unknown technique for correction of ischemic steal consisting of ligation of the artery just distal to the take-off of the fistula and arterial bypass from the artery proximal to the take-off of the fistula to the artery distal to ligation. PATIENTS: Six patients with chronic renal insufficiency (3 male, 3 female) with patent upper arm cephalic fistulas presented with severe hand ischemia. RESULTS: Symptoms improved in all 6 patients immediately after operation. Successful hemodialysis could be maintained using the original fistula. CONCLUSIONS: The described technique is maybe the procedure of choice for the correction of fistula induced ischemic steal.     

Daily variation patterns of airborne allergenic pollen in southwestern Spain

Vein aneurysms have been reported in both the deep and superficial vein system of the lower extremities. In the iliofemoral area of the deep system the most common presentation is of an abdominal or iliac fossa mass while thromboembolism is not uncommon. The aneurysms are thought to result mainly from a congenital weakness of the vein wall, with an AV fistula present in over 50% of cases. Existing AV fistulae must be ligated; however, as the results of simple AV fistula or vein ligation are poor, reconstruction should always be attempted. Aneurysm excision with an end-to-end anastomosis might be feasible in the proximal iliac segment while the use of PTFE grafts or the LSV seems appropriate in cases of attempted reconstruction. In the popliteal area there is agreement on the aetiology (congenital, traumatic, post operative and after an AV fistula formation), the symptomatology (mainly thromboembolism) and the diagnosis (duplex scanning). Symptomatic cases should be treated surgically since the reported surgical results are excellent while the incidence of recurrent pulmonary embolism in patients treated conservatively exceeds 80%. Asymptomatic popliteal vein aneurysms could remain under close observation only but, if complicated with thromboembolism during the follow-up period, surgery should be performed immediately. The crural and superficial veins represent a minor danger and can be easily treated with ligation and/or excision with excellent results.     

Malignant esophageal-respiratory fistula and esophageal stenosis treated with a Gianturco-Z-stent

Oesophago-respiratory fistula in most instances in a complication of advanced malignant tumours of the oesophagus or the lung. In our patient group eleven oesophago-respiratory and one gastro-respiratory fistulas were encountered. Three patients were operated upon. In one of them with achalasia, early oesophageal carcinoma was discovered in the background of the fistula. Two patients had fistulas without of oesophageal narrowing, therefore, stent implantation into the trachea and bronchus was performed. One of them was previously managed endoscopically with lyodura plug and fibrin glue, but only temporary occlusion of the fistula was obtained. In five patients, seven conventional oesophageal prosthesis (6 Cook, 1 Rüsch) were used to close the fistulas. In one of these patients, three oesophago-respiratory fistulas developed one after the other at the level of the prosthesis funnel. They were closed with three prostheses connected with short silicone tubes. In the last two patients, Gianturco-Z stent was employed. Its advantages over the plastic prostheses include small basic and lager final luminal diameter, lesser predilatation, easier implantation, lower complication and mortality rate. The silicone coated and double funnel stent with expansile force is effective in fistulas closure. On implantation, stent shortening in minimal, allowing precise placement of the stent even in proximal malignant oesophageal stenosis with oesophago-bronchial fistula. The high price of the stent is compensated for by the lower complication rate, shorter hospitalization and subsequent reduction is hospital expenses. Therefore these metal stents should be financed by the National Health Service, at least in specialized centers for managing patients with dysphagia.     

Laparoscopic gastrostomy: report on 20 cases

At the surgical clinic of the Faculty Hospital in Ostrava-Poruba since November 1993 till June 1998 20 laparoscopic gastrostomies were performed. The main indication was to ensure enteral nutrition in patients where, due to obstruction of the oesophagus, it was impossible to implement percutaneous puncture gastrostomy. The surgical procedure lasted on average 37 minutes and was completed successfully in all patients. Three patients died within thirty days. This procedure made it possible that eighty percent of the patients could be discharged from hospital and go home.     

Percutaneous gastrostomy with T-fastener gastropexy: results of 316 consecutive procedures

PURPOSE: To assess the rates of technical success and complications associated with radiologic gastrostomy or gastrojejunostomy performed with T-fastener gastropexy. MATERIALS AND METHODS: In 316 consecutive patients, radiologic gastrostomy or gastrojejunostomy with T-fastener gastropexy was performed over a 10-year period. Results of the procedures were reviewed. Results of follow-up were available for all patients. RESULTS: Of 316 procedures, 314 were successful (technical success rate, 99.4%). Six (1.9%) major complications occurred; 50% occurred in patients with peritoneal involvement from ovarian carcinoma. Ten (3.2%) minor complications occurred. Four minor complications occurred in patients with ovarian cancer and ascites. The 30-day mortality rate was 3.8% (12 patients) with one procedure-related death (0.3%). CONCLUSION: A T-fastener gastropexy may have a protective role in prevention of leakage of gastric contents into the peritoneum in patients with ascites. Ascites need no longer be considered a contraindication for radiologic gastrostomy. A gastropexy enables routine use of larger gastrostomy tubes and ready replacement of a displaced tube even before the development of a mature tract.     

Surgical treatment of a fistula between the right pulmonary artery and the left atrium: presentation of two cases and review of literature

OBJECTIVE: A direct communication between the pulmonary artery and the left atrium is a rare anomaly. On the basis of two cases of our own and a literature review of 49 cases, we focus on clinical presentation, anatomy, diagnosis, and the role of surgery. METHODS: Two cases of a fistula between the right pulmonary artery and the left atrium are described in a girl of 4 years and a boy of 15 years. Both presented with unexplained cyanosis. Diagnosis was made on echocardiography and angiography. The fistula was ligated using extracorporeal circulation in the first case and not in the second case. RESULTS: The surgical results were successful with resolution of the cyanosis. CONCLUSIONS: In newborns, urgent surgery may be necessary. In other patients, early elective surgical correction should be performed to prevent complications, especially systemic and cerebral emboli, cerebral abscesses, and rupture of aneurysmal fistulas. Complete cure can be achieved by ligation and possible division or by intracardiac repair.     

Congenital broncho-oesophageal fistula. A case report

A case of broncho-oesophageal fistula causing bronchiectasis of the left lung is reported. Oesophagorespiratory fistulas without atresia of the oesophagus often have an insidious clinical course and most commonly present in adulthood. This rare congenital anomaly should be considered as a cause of chronic pulmonary sepsis. The clinical, radiographic and therapeutic features of this lesion are discussed.     

Repair of aortoesophageal fistula after aortic grafting

This report describes repair of an aortoesophageal fistula caused by a previously placed thoracic aortic graft. The diagnosis was made by esophagoscopy. The repair consisted of femoral-to-femoral cardiopulmonary bypass, excision of the old graft, placement of a new graft, esophagectomy, cervical esophagostomy, gastrostomy, and later reconstruction by cervical esophagogastrostomy.     

Complications of endonasal paranasal sinus surgery--diagnostic and therapeutic consequences

BACKGROUND: Functional endoscopic sinus surgery has been proven the therapeutic method of choice in surgical therapy of chronic sinusitis. On the other hand, endonasal sinus surgery may cause severe complications even when performed by a skilled surgeon. This is easily explained by the close vicinity of many functionally important structures to the operative site. CASE REPORTS: Three histories are reported that involve possible complications even in apparently simple cases. Diagnostic and therapeutic consequences are discussed. In a case previously diagnosed histologically as chronic unspecific sinusitis, an endonasal biopsy resulted in endocranial bleeding requiring neurosurgical intervention. Midline granuloma was found to be the correct diagnosis. Another patient was seen with a normal X-ray of the sinuses and solitary polypoid structure in his left nose. Polypectomy was planned and a CT scan was performed, which demonstrated a meningocele. Transfacial surgery was then performed to remove the meningocele. Another patient presented with a traumatic impression of the frontal sinus, and open reposition by transfacial surgery of the frontal and ethmoid sinus was planned. When CT scans revealed an uncovered optic nerve in the sphenoid sinus of the fractured side, we abandoned ethmodectomy and performed reposition of the frontal sinus as the only surgical procedure. RESULTS AND CONCLUSIONS: In this paper, we show typical complications of endonasal sinus surgery and strategies for avoiding them. If any complication occur, prompt treatment is required. Three groups of complications can be defined: perforation of frontobasal dura resulting in cerebrospinal fluid (CSF) fistula, severe bleeding, and orbital or optic nerve injury. When the surgeon discovers an intraoperative complication, possible consequences must be considered immediately to minimize side effects for the patient. A CSF fistula should be closed in the same procedure, and transfacial surgery may be necessary. Hemorrhage resulting from an ethmoidal artery may require frontoorbital surgery and ligation of this vessel. If retrobulbar hemorrhage caused by retraction of an ethmoid artery occurs, immediate intervention is necessary. Usually a transfacial approach, resection of the medial orbital wall and retrobulbar decompression are performed. In some cases lateral canthotomy may be the best way to drain haematoma and decompress the optic nerve. Subsequently, orbital revision and ligation of the retracted artery must be performed. Any delay can result in persistent visual loss. We conclude that the extranasal frontoorbital approach should be part of the residency training program in ENT departments. Any surgeon performing endonasal sinus surgery must be trained in transfacial emergency procedures, which should be part of anatomic preparations in teaching courses, thus avoiding severe damage in case of intraoperative complication.     

Metal stents in patients with malignant and benign esophageal stenoses

The authors used between October 1993 and January 1997 in 131 patients with inoperable malignant or benign stenosis of the oesophagus an expansible metal stent. In 25 patients the stenosis was in the upper third of the oesophagus, in 44 in the medium part, in 53 in the lower third of the oesophagus and in 9 patients in the area of the anastomosis. All patients suffered at the time when the stent was introduced from marked dysphagia (stage 3-4 according to the international classification). In 45 patients the authors introduced more than one stent. 112 patients suffered from malignant stenosis (67 squamous cell carcinoma, 27 adenocarcinoma, 9 pulmonary or bronchogenic carcinoma, in two instances lymphoma, in two instances leiomyosarcoma and in five patients another type of tumour). Seventeen patients suffered from benign stenosis (8 complications of reflux oesophagitis, 3 stenosis in the anastomosis, in two instances corrosion by acid, 2 cases of epidermolysis bullosa oesophagi and one post-radiation stenosis). In these patients repeatedly before introduction of the stent dilatation of the stenosis by means of a balloon dilatation catheter was attempted. In two instances the etiology of the stenosis was obscure. Complications related to the procedure proper or after insertion of the stent were recorded in 49 patients-dislocation of the stent 23x, occlusion of the stent 17x, development of a fistula 6x, ulceration 16x, haemorrhage 4x, hyperplasia of the mucosa 21x, ileus 2x, inadequate expansion of the stent 8x.     

Postoperative percutaneous endoscopic gastrostomy/jejunostomy

In order to cure complications appeared in the postoperative period two patients were treated with percutaneous endoscopic gastrostomy/jejunostomy (PEG, PEGJ) with the purpose of long-lasting enteral feeding and decompression. The indications of PEG/PEGJ were the following: external gastric fistula in one case and anastomotic leakage in one case. In the patients the PEG was located by intraoperative X-ray examination, this method was not published earlier. Regarding complications of the early postoperative period the PEG and the PEGJ are considered useful and expedient procedures with the aim of lasting enteral feeding and decompression.     

Feeding tubes for tube feeding

Several techniques are available for the provision of enteral nutritional support. Nasal tubes, gastrostomy tubes and jejunostomy tubes can be distinguised. Nasal tubes are used for short-term support, gastrostomy tubes (preferably via a percutaneous endoscopic gastrostomy) for long-term support (over 4 to 6 weeks), while (needle catheter) jejunostomy tubes are most often used to provide early enteral nutrition immediately after operations on the proximal gastrointestinal tract. The most frequent complications are: with the nasal tube dislodging, clogging and aspiration, with the gastrostomy tube peristomal infection and with the jejunostomy tube, obstruction. It should further be noted that the quantity of enteral nutrition prescribed and that actually administered may differ substantially so that patients with a feeding device may even become malnourished. With proper patient selection and secure control of the energy balance, feeding tubes are simple (temporary) devices that improve the patient's health and quality of life.     

Endoscopic sclerotherapy versus variceal ligation in the long-term management of patients with cirrhosis after variceal bleeding. A prospective randomized study

BACKGROUND/AIMS: Long-term endoscopic injection sclerotherapy of oesophageal varices prevents rebleeding in patients with cirrhosis surviving an acute variceal bleeding episode. However, this treatment is associated with a substantial complication rate. Endoscopic band ligation is a newly developed technique in an attempt to provide a safer alternative. The aim of this study was to compare the efficacy and safety of injection sclerotherapy versus variceal ligation in the management of patients with cirrhosis after variceal haemorrhage. METHODS: Seventy-seven patients with cirrhosis who proved to have oesophageal variceal bleeding were studied. After initial control of haemorrhage by sclerotherapy, 40 of the patients were randomly assigned to sclerotherapy and 37 to ligation. Both procedures were performed under midazolam sedation at intervals of 7-14 days until all varices in the distal oesophagus were eradicated or were too small to receive further treatment. RESULTS: The eradication of varices required a lower mean number of sessions with ligation (3.7 +/- 1.9) than with sclerotherapy (5.8 +/- 2.7, p = 0.002). The mean duration of follow-up was similar in both groups (15.6 months +/- 7.3 and 15 +/- 7.4, respectively). The proportion of patients remaining free from recurrent bleeding against time was significantly higher in the ligation group as compared to the sclerotherapy group (chi 2 = 3.86, p = 0.05). Only 13 patients (35%) developed complications in the ligation group as compared to 24 (60%, p = 0.05) in the sclerotherapy group. The mortality rate was similar in both groups (20% and 21%, respectively). CONCLUSIONS: Variceal ligation is better than sclerotherapy in the long-term management of patients with cirrhosis after variceal haemorrhage which was initially controlled with sclerotherapy.     

Species differences in carcinogenesis

The prognosis for carcinoma of the oesophagus is generally dismal especially when patients present late. Any clues to early diagnosis and management and identification of rapidly progressive variants are therefore helpful. Reports and review of the literature are presented with respect to four unusual cases of oesophageal carcinoma treated in the University of Ilorin Teaching Hospital in 1985 and 1986. Four men aged 59, 60, 55 and 60 years respectively presented with multiple polypoid carcinoma of the oesophagus, malignant oesophago-bronchial fistula at the level of the left main stem bronchus, achalasia co-existing with oesophago-gastric carcinoma and a small focus of carcinoma of the distal thoracic oesophagus presenting with widespread thoracic metastases and malignant pleural effusion mimicking advanced bronchogenic carcinoma. The unusual clinico-pathological features with the autopsy findings in the last case can influence diagnosis, management and prognosis of oesophageal cancer in general and of such cancer associated with pre-malignant conditions like achalasia and oesophageal polyps in particular.     

Progress in oesophagoscopy. The role of the conventional oesophagoscope as against the supple fibroscope (author's transl)

In the history of endoscopy, laryngologists have played an important role in knowledge of the oesophagus. For those familiar with gastroscopy, the supple fibroscope represents a diagnostic instrument which may be used for observation of the oesophagus with the exception of natural or pathological areas of stenosis. It offers considerable possibilities in the photographic documentation of lesions. It is relatively easy to perform though not completely harmless. The rigid oesophagoscope remains an effective method of investigation of the whole oesophagus, including the oesophageal opening. It remains the best method for the performance of endoscopic surgery and in particular the extraction of foreign bodies. It is not dangerous in the hands of a competent and trained operator. Rather than opposing each other, the two instruments may be seen to be complementary.     

Circadian rhythm of cortisol in patients after reconstruction surgery of the esophagus using various intestinal segments for transplantation

The authors determined the circadian rhythm of cortisol expressed as blood 11-hydroxycorticosteroid level (11 OHCS) in group of healthy subjects and in 3 groups of patients after the formation of an artificial oesophagus from the jejunum, large intestine and ileum and caecum. In all examined patients the normal circadian rhythm of 11 OHCS was maintained. In patients with oesophagus made up of jejunum and large intestine mean level 11 OHCS in blood was insignificantly higher in comparison with a group healthy subjects. In group patients with the oesophagus made up of ileum and caecum the 11 OHCS level in blood was significantly lower in comparison to the group of healthy subjects and to patients with oesophagus made up of jejunum and large intestine.