Radionuclide transit in patients with colon interposition.

To assess radionuclide transit in interposed segments of the colon, we examined 25 patients with colon interposition for benign esophageal disease. No such assessment has been reported previously. The most common indications for operation were esophageal strictures that developed after lye ingestion and reflux strictures not responding to other treatment. The operations were performed without thoracotomy by blunt esophageal dissection in 80% of the patients. There were 18 antiperistaltic and seven isoperistaltic colon grafts. A large-field gamma camera and computer system were used. Data were collected at time intervals of 0.5 second during the first 30 seconds and at intervals of 30 seconds up to 20 minutes. The 5% and 90% stomach filling times, times to 50% and 25% activity levels, and residual activity levels as a percentage of the maxima were calculated in the upper, middle, and lower thirds of the colon grafts and of the normal esophagus of 10 healthy control subjects. The examinations were performed with the subject in a sitting position. All parameters showed that emptying of the colon graft was markedly slower than that of the normal esophagus. The intra-abdominal third of the graft had a residual activity of 50.5% +/- 15.7% after 20 minutes' observation. No differences between antiperistaltic and isoperistaltic grafts were observed. Reconstruction with proximal cologastric anastomosis and a short intra-abdominal colon graft segments is suggested.

Management of delayed esophageal perforation with mediastinal sepsis. Esophagectomy or primary repair?

Ninety patients with esophageal perforations were operated on at our institutions between 1970 and 1992. Thirty-four of them were seen after delayed diagnosis (> 24 hours) with mediastinal sepsis caused by perforation of the thoracic esophagus. There were 18 patients with spontaneous ruptures, 11 with instrumental perforations (including one caused during laparotomy), and 3 perforations caused by foreign bodies. One patient had perforation of an esophageal ulcer into the pericardium and another had perforation of an esophageal diverticulum into the mediastinum. Nineteen patients underwent primary repair of the perforation with cleansing and drainage of the mediastinum and the pleural cavity. The remaining 15 had primary extirpation of the thoracic esophagus, irrigation of the mediastinum with antibiotics, cervical esophagostomy, gastrostomy, and drainage of the mediastinum and pleural cavity. Nineteen of the 34 patients survived (hospital mortality 44%). Of patients with primary repair, only six survived (in-hospital mortality 68%), whereas only two patients treated with esophagectomy died (in-hospital mortality 13%). The difference was highly significant (p = 0.001). The most common cause of death was multiorgan failure resulting from sepsis. Postoperative complications developed in four patients treated with primary repair (two sepsis, one empyema, and one anuria) and in seven patients treated with esophagectomy (two empyema, two sepsis, one pneumonia, one mediastinal abscess, and one brain abscess). After healing of the mediastinitis, the esophagogastric continuity was reconstructed with colon in 11 patients and stomach in two patients. In the management of delayed esophageal perforation with mediastinal sepsis, esophagectomy is superior to primary repair alone, which often leads to mediastinal leakage, continued sepsis, and death.

Recurrent ulceration and colopericardial fistula as late complications of colon interposition.

Recurrent ulceration and colopericardial fistula as late complications of colon interposition occurred in a 48-year-old man who had undergone left colon antiperistaltic interposition for esophageal stricture caused by lye corrosion. To our knowledge, this complication has not been reported previously. Although its etiological process remains to be elucidated, this rare entity should be kept in mind after colonic interposition.

Colon interposition in the treatment of carcinoma of the esophagus and gastric cardia.

The stomach is the organ most used for restoring esophageal continuity after esophageal resection for malignancy. In the present series, we report our experience over a 20-year period (1965 through 1984) with an alternative method, colon interposition. Two hundred forty-eight patients (124 men and 124 women) underwent colon interposition. Seventy-one percent (175) of the tumors were squamous cell carcinomas, and 23% (58) were adenocarcinomas in the gastric cardia and lower esophagus. The left colon was the substitute of first choice and was used in 54% of the patients. Of the interpositions, 59% were antiperistaltic. Esophagectomy without thoracotomy was the method in 146 patients. The operative mortality was 16% (40 patients), and 3% (8 patients) sustained colon graft necrosis. Leakage in the upper anastomosis occurred in 4% (10). No dysphagia was experienced by 85%, 80%, and 76% of the patients during reexaminations 3, 6, and 12 months, respectively, after operation. The 1-year and 5-year survival for patients with squamous cell carcinoma was 40% and 10%, respectively, and for patients with adenocarcinoma, 50% and 12%, respectively. The data from this study suggest that colon interposition offers a good alternative for long-term relief of dysphagia in patients with carcinoma of the esophagus. The rate of complications is acceptable.

Nissen fundoplication. Results at 10 year follow-up.

Between 1970 and 1973, 94 patients underwent Nissen fundoplication for gastroesophageal reflux; 60 of the 94 patients returned for follow-up study in 1982. The same surgeon operated on all the patients, and another physician who did not participate in the treatment interviewed the attending patients. Four patients (7 percent) had persistent symptoms, 7 patients had recurrent symptoms (in 3, during the first postoperative year, and in four, 2 to 10 years postoperatively), and 47 (78 percent) had postfundoplication symptoms which were moderate in most but disturbing in some. Some technical details in the performance of the fundoplication could reduce the frequency of the fundoplication symptoms. Because recurrent symptoms may appear late, even 10 years or more after operation, a definitive evaluation of the results of Nissen fundoplication is impossible to perform.

Colon interposition. Long-term radiographic results.

Colon interposition was carried out in 12 patients with oesophageal carcinoma and on 38 patients with benign oesophageal disease an average of 71 months before the radiographic examination. Various ischaemic changes including "jejunization", loss of haustration and stricture formation were observed in 15 cases. In 12 patients one or several diverticula were seen in the colon graft. Reflux was observed in 17 cases in supine position. Double contrast technique in the examination of interposed colon is recommended.

Elastic tissue injury in human acute pancreatitis.

Pancreatic vessel wall alterations were studied in tissue material obtained from six patients subjected to resection of the gland for acute necrotizing pancreatitis. Special attention was paid to elastic tissue damage, which was studied using special stains in light and electron microscopy. Vascular wall elastic laminae showed changes varying from fragmentation to complete dissolution. The outer elastic lamina was more consistently affected. Elastic tissue damage was observed in pancreatic areas with minor acinar alterations and in vessels with otherwise relatively well-preserved walls. These observations suggest 1/ an early participation of elastase in the production of tissue damage in human acute pancreatitis and 2/ a primary role for elastic tissue injury in the vascular alterations leading to haemorrhage and tissue necrosis through ischaemia.

Esophagectomy and colon interposition for benign esophageal stricture.

Esophagectomy with colon interposition for nonmalignant esophageal stricture was evaluated in 41 patients, 18 with peptic and 23 with lye stricture. Four of the 41 patients died in the postoperative period and 12 had nonfatal complications of surgery. At long-term evaluation, 25 of 31 patients complained of postural regurgitation and 9 had disturbing symptoms related to retention in the graft. The long-term clinical and radiologic results showed no deterioration from the immediate postoperative period. The complications associated with colon interposition clearly restrict indications for its use in benign conditions. Interposition should be used in peptic stricture only when other methods have failed. In chronic lye stricture, interposition is justified by the irreversible nature of the lesion and its predisposition to malignant change.

Lye ingestion and carcinoma of the esophagus.

Fifteen cases of carcinoma of the esophagus associated with a history of lye ingestion are presented. They compromised 3% of the total patients treated for esophageal carcinoma in 1964-1986. The mean age of the ten women and five men was 57 years and the average time from corrosion injury to diagnosis of carcinoma was 58 years in the men and 47 years in the women. Most of the patients had accidentally swallowed liquid lye at 2-3 years of age. All 15 tumors were squamous cell carcinoma, and 11 were located at the level of the tracheal bifurcation. Esophageal resection was possible in ten cases. The survival rate in the total series was 40% at 1 year and 13% at 5 years. Because of the high carcinoma risk, patients with corrosion injury to the esophagus should be kept under surveillance that includes regularly repeated esophagoscopy, cytologic study of washings and biopsy at least when the time from the injury exceeds 20 years.

Migration of Kirschner pin from clavicle into ascending aorta.

Kirschner pins are widely used for fixation of bone, with few and very rarely serious complications. A case is described in which a Kirschner pin migrated in 10 days from the sternal end of the left clavicle into the lumen of the ascending aorta. The exact location of the pin remained unknown until right thoracotomy, during which X-ray examination revealed the unexpected situation. The pin was simply extracted by pushing it through the vessel wall. The patient recovered uneventfully. The complication could have been prevented by bending the outer part of the pins. The possible route of migration is discussed.

Colon interposition for esophageal disease: histologic finding of colonic mucosa after a follow-up of 5 months to 15 years.

Thirty-six patients, subjected to colon interposition for benign esophageal disease or carcinoma of the esophagus or gastric cardia, were studied by endoscopy for signs of mucosal disease in the interposed colon. Five months to 15 yr (mean 57 months) after the operation, endoscopic finding of the interposed colon was macroscopically normal in 28 patients. Signs of inflammation, including hyperemia or hyperemia and friability, were observed in seven patients. Histologic specimens obtained at endoscopy were examined microscopically, and the findings were compared with those seen in the preoperative graft. In two patients, chronic inflammatory changes were observed in the graft mucosa, consisting of mononuclear cell infiltration of the lamina propria accompanied by crypt dilatation and deformation. In one of these patients, the inflammation was in the proximal third of the graft, and it was also seen at the endoscopy. In the remaining 34 patients, the graft mucosa was microscopically comparable to normal. The alterations were unexpectedly few and mild considering the marked change in the location and function of the colonic segment.

Functional evaluation of interposed colon in esophagus. Manometric and 24-hour pH observations.

Colon interposition was performed on 22 patients for benign esophageal disease which had not responded to medical or other surgical treatment. Left colon was used as the interposed segment in 17 cases, transverse colon in two and right colon in three cases. All left colon grafts were positioned antiperistaltically. Manometric studies showed no basal or stimulated motor activity in any of the 22 grafts. The peristaltic activity in the esophageal remnant could be demonstrated in four patients. Thirteen patients were studied with 24-hour pH measurements. Distinct acid reflux to the lower colon graft was observed in only one case. Interposed colon thus was confirmed to function as a passive conduit without motor response to swallowing stimuli. The rarity of acid reflux after colon replacement of esophagus probably is due to the vagotomy usually performed during the operation and to the alkalinity of colon mucus.

Gastrointestinal symptoms after colon interposition.

To assess gastrointestinal symptoms after colon interposition, 12 patients with colon interposition for malign disease and 33 for benign esophageal disease were interviewed. A 7-day diary, including time of eating and gastrointestinal symptoms experienced by patients during and between meals, was kept by every patient. The observations of the interview and diary were compared. No patient had swallowing difficulties or heartburn. All could also eat solid foods; 24% had no gastrointestinal gastrointestinal symptoms during follow-up. Regurgitation, vomiting, and dumping symptoms were common, being observed in 22, 31, and 18% of the cases. There were no differences with these symptoms between patients with anti- or isoperistaltic colon grafts. The information from interviews agrees with the information recorded in the diaries. We conclude that various degree reflux symptoms are common after colon interposition, being experienced by almost half of the patients.

Copper sulfate corrosion and necrosis of the esophagus and stomach. Case report.

A case of corrosion and necrosis of the esophagus and stomach after ingestion of fluid containing copper sulfate, ethylene glycol and methanol is presented. Esophagectomy and gastrectomy were performed in a primary stage. Four months later reconstruction was carried out, using a right-sided isoperistaltic segment of colon. The mechanism of caustic chemical ingestion injuries and their treatment are discussed.

Ampicillin concentration in normal and pathological lung tissues after oral administration of bacampicillin.

Following oral administration of 800 mg bacampicillin, the concentrations of ampicillin were determined in normal (n = 16) and pathological (n = 12) lung tissue after 3.6 and 9 hours in a total of 28 patients. The serum concentration was determined simultaneously. The mean peak serum concentration (+/- SD) after one hour was 9.7 +/- 7.2 micrograms/ml. The mean concentration (+/- SD) in normal lung tissues were, after 3, 6 and 9 hours, 3.73 +/- 1.10 micrograms/ml, 1.06 +/- 0.99 micrograms/ml, 0.15 +/- 0.30 microgram/ml respectively, and in pathological lung tissues 0.95 +/- 0.31 microliters/ml, 0.86 +/- 1.11 micrograms/ml and 0.40 +/- 0.24 micrograms/ml respectively. Thus bacampicillin produced concentrations well above the MIC of the most important pathogen, Haemophilus influenzae, in both pathological and normal lung tissue.