Use of Proteolytic Enzymes in the Treatment of Proteinaceous Esophageal Food Impaction.

BACKGROUND: Proteinaceous esophageal food impaction typically requires endoscopic intervention. An alternative approach is the use of proteolytic enzymes. Concerns regarding the use of proteolytic enzymes include the risk of perforation and aspiration pneumonitis. OBJECTIVE: We retrospectively reviewed our series of 69 patients treated with papain to determine the safety and efficacy of proteolytic enzymes. METHODS: Patients were retrospectively reviewed if treated for an esophageal food impaction from 1999 through 2008. RESULTS: Median age was 56 years (range 19-91 years), with 46 male and 23 female patients. In 27 patients (39%) this was their first presentation, in 14 (20%) it was the second, and 28 (41%) had multiple previous episodes. Meat was the cause in 49 (71%), chicken in 6 (9%), fish in 3 (4%), and unspecified in 11 (16%). All patients presented with dysphagia for solids, 56 (81%) could not tolerate liquids. Papain solution, 1 tsp in 8 oz of water, was given to patients in an unlimited quantity. Papain was successful in relieving the obstruction in 60 patients (87%). The remaining 9 patients (13%) underwent endoscopy with successful retrieval. No patient suffered a perforation, either with papain ingestion or endoscopy. There were no episodes of pneumonitis or pneumonia. CONCLUSIONS: We have used proteolytic enzymes with a high success rate and with minimal complication. Further, if proteolytic enzymes fail, endoscopy can be performed safely and effectively. We recommend the use of proteolytic enzymes as the initial management in all patients with proteinaceous food impaction of the esophagus.

High-frequency chest-wall compression during the 48 hours following thoracic surgery.

BACKGROUND: Postoperative pneumonia continues to be a leading cause of mortality and morbidity after thoracic surgery. High-frequency chest-wall compression (HFCWC) is an established therapeutic adjunct for patients with chronic pulmonary disorders that impair bronchopulmonary secretion clearance. We studied the feasibility of applying HFCWC following thoracic surgery. METHODS: Twenty-five consecutive adult patients who underwent a variety of thoracic operations received at least one HFCWC treatment in the first 2 postoperative days, along with routine postoperative care. HFCWC was applied at 12 Hz, for 10 min. Routine hemodynamic and pulse oximetry data were collected before, during, and after HFCWC. We also collected qualitative data on patient tolerance and preference for HFCWC versus percussive chest physiotherapy. RESULTS: No major adverse events were encountered. Hemodynamic and pulse oximetry values remained stable before, during, and after HFCWC. Eighty-four percent of the subjects reported little or no discomfort during therapy, and the subjects who expressed a preference preferred HFCWC to conventional chest physiotherapy by more than two to one. CONCLUSIONS: HFCWC is a safe, well-tolerated adjunct after thoracic surgery. The observation of hemodynamic stability is especially important, considering that the patients were studied in the early postoperative period, during epidural analgesia.

Rheumatoid pleural effusion in the absence of arthritic disease.

Rheumatoid pleural effusion is an unusual complication of rheumatoid disease that typically presents subsequent to other more common manifestations of rheumatoid illness. The case of a 72-year-old woman with a rheumatoid pleural effusion is discussed. The patient presented with dyspnea, but without any history of rheumatoid arthritis. The patient was treated by thoracentesis, followed by video-thoracoscopy and pulmonary decortication. Postoperatively, the patient's effusion partially reaccumulated. Steroid therapy resulted in prompt and permanent resolution of the effusion. The patient remains asymptomatic 1 year after her presentation. The biochemical, serologic, and cytologic characteristics of rheumatoid effusions are reviewed.