Treatment of iatrogenic and traumatic tracheal disruptions.

BACKGROUND AND AIM: The optimal management of tracheal disruptions is still controversial. It is usually postulated that lesions wider than 1 or 2 centimetres and/or lesions of full-thickness should be treated by surgery at an early stage. Such a statement is not supported by any proven evidence. On the contrary, the conservative management of such injuries has also produced very good results according to recent reports. The aim of this study is to investigate whether conservative treatment can be safely used for wide tracheal lacerations and to assess any possible association between clinical features and modality of treatment. METHODS: Records of all patients with iatrogenic and traumatic tracheal disruptions observed between January 1992 and December 2006 were collected and retrospectively reviewed. Data regarding mechanism of injury, clinical and morphological features and modalities of treatment were registered. All possible associations between clinical features and modalities of treatment were investigated. RESULTS: 23 patients were observed overall. There were 6 males and 17 females with a median age of 58 years (range 20-84 yrs). 15 patients had undergone single tube intubation. One patient had his trachea injured during an esophagectomy. Ruptures were secondary to blunt (n = 5) and open (n = 2) trauma in 7 patients. Lesions varied in length between 1 and 7 centimetres (median length 3 centimetres) and all were full-thickness. The time interval until diagnosis varied between 0 and 72 hours (median 6 hours). Respiratory failure was evident in 7 patients. 16 patients (69.5%) with lacerations ranging in length between 1 and 5.5 centimetres (median length 2.75 cm) underwent conservative treatment. Seven patients (30.5%) underwent surgery. The follow up was completed for 16 patients and varied between 15 and 105 months (median 22.5). One patient died after surgical treatment. No mortality or late major sequelae were registered after conservative treatment. Female sex, absence of respiratory failure and delayed diagnosis was associated with the conservative treatment. CONCLUSIONS: Conservative treatment can play a major role even in cases of wide tracheal lacerations. Clinical rather than morphological features should be regarded as main criteria for treatment. The conservative treatment is particularly indicated in the case of stable respiratory parameters independent of the size and the depth of the lesion.

[Complications of Barrett's esophagus: indications for esophageal resection with special reference to high-grade dysplasia]. / Complicanze dell'esofago di Barrett: indicazioni alla resezione esofagea. Con particolare riferimento alla displasia di alto grado.

BACKGROUND: Columnar lined oesophagus (Barrett's oesophagus) can sometimes be associated with complications such as stricture, ulcer and dysplasia. In some selected cases there is an indication for oesophageal resection. METHODS: From 1983 to 1997, 12 patients underwent oesophagectomy for "complicated" Barrett's oesophagus. All patients had gastroesophageal reflux and Barrett metaplasia for many years. Ten of them were symptomatic, and pH-manometric alterations as well as alterations were noted at biliary scintigraphy. Ten patients had intestinal metaplasia. Two patients had previous antireflux operations. Four had a long (3-5 cm) and undilatable stricture. One was affected by a perforating ulcer. One patient had an indefinite grade dysplasia but endosonography revealed high suspicion of cancer. Six patients had a high-grade dysplasia. Operative technique consisted of a transhiatal oesophagectomy in nine cases and a laparotomic and right thoracotomic oesophagectomy (Ivor-Lewis) in two. RESULTS: There was no 30-day mortality; three post operative complications were observed. One of the four patients suffering from stricture died four years after intervention due to non-related causes; the other three are still living and regularly feed per os after 12, 9 and 7 years. The patient with ulcer is still living after 6 years and regularly feeding per os. The patient suffering from an indefinite grade dysplasia had an adenocarcinoma (stage IIa) on the operative specimen. The patient is still living after 2 years. Three patients operated for high-grade dysplasia had an adenocarcinoma on the specimen. Two patients (stage I) are living after 3 and 5 years. One patient (stage IIa) died after 19 months with recurrence. CONCLUSIONS: In case of non neoplastic "complicated" Barrett's oesophagus the indication for the oesophageal resection can be considered as the extreme useful therapy only after an accurate selection of patients. Especially in case of high-grade dysplasia, the great incidence of unexpected adenocarcinoma indicates oesophagectomy for patients who are suitable for surgery.

[Intrathoracic perforation of the gastric fundus as a late complication of an unknown post-traumatic rupture of the diaphragm]. / Perforazione intratoracica del fondo gastrico quale complicanza tardiva di rottura post-traumatica misconosciuta del diaframma.

The Authors report a case of gastric perforation into the left pleural cavity due to the herniation of the gastric fundus into the thorax in a patient who suffered from a thoraco-abdominal trauma four months before. A few physiopathological aspects of post-traumatic rupture of the diaphragm with a delayed presentation are discussed. Clinical and radiological typical elements of the chronic undiscovered diaphragmatic herniation are underlined and the events related to the complications (strangulation, perforation) are described. Finally, a few therapeutical principles are discussed.

[Our experience with toracic outlet syndrome]. / La nostra esperienza nelle sindromi dello stretto toracico superiore.

The Authors report their experience in 290 cases of thoracic outlet syndrome (TOS) and 71 cases of Paget-Schroetter syndrome, that is a condition due to thrombosis of the subclavian and/or axillary vein. They point out that diagnosis is mainly clinical-instrumental and the ulnar nerve conduction velocity (UNCV) test is of fundamental importance. The Authors emphasize how the good results obtained could be related to the complete removal of the first rib and to the axillary approach that they strongly support.

Delayed development and rupture of an aortic aneurysm after closed abdominal trauma.

A case is reported of a patient who, following the surgical repair of a lesion of the superior mesenteric artery secondary to a closed abdominal trauma, slowly developed an aneurysm of the abdominal aorta which subsequently ruptured. Surgical management of the aneurysm by aortic graft implantation proved successful.

Relationships between diaphragmatic hiatus and infra-diaphragmatic esophagus: a combined X-ray and manometry study.

The relationship between the diaphragmatic hiatus, the infra-diaphragmatic esophagus and a manometric tube were examined in 10 patients not suffering from hiatal hernia or gastroesophageal reflux. During surgery, two metal markers were attached to the diaphragmatic hiatus and two others were fixed at the vertex of the angle of His. X-ray examinations were taken during manometric recordings of the high pressure zone (HPZ) both at rest and during relaxation. Comparison between the radiographs showed that during swallowing the manometric tube did not move with respect to the vertebral bodies; contraction of the esophagus caused complete disappearance of the infra-diaphragmatic esophagus. It was also observed that during pressure drop in the HPZ (so-called lower esophageal sphincter relaxation), the manometric recording site is located below the vertex of the angle of His, i.e. in the gastric cavity. These findings provide the basis for a hypothesis to explain the passage of a solid bolus through the lower esophagus into the stomach.