Conservative management of iatrogenic oesophageal perforations--a viable option.

OBJECTIVE: Iatrogenic Oesophageal perforations are a dreaded complication and there is no consensus as to their best management. The aim of our study was to assess the results of conservative management in these cases. METHODS: Twenty-six patients with iatrogenic perforations of the oesophagus treated over a 10-year period were reviewed retrospectively. They were managed conservatively by keeping them nil by mouth on intravenous fluids and intravenous antibiotics. Out of these 26, nine were patients of carcinoma of the oesophagus while the remaining 17 had benign pathologies. Twenty-two were diagnosed within 6h, while the remaining four were diagnosed over 24h after perforation. Twenty-three of the 26 were caused by oesophageal dilatations. RESULTS: Twenty-two (84.6%) of the 26 survived on this regimen. Out of the four that died, two had advanced carcinomas and died of chest complications, one died of a myocardial infarction and the fourth was an old debilitated man who died of renal failure. All four who died had extension of the leak into the pleural cavity. Early diagnosis and treatment is of critical importance and is only possible by maintaining a high index of suspicion. CONCLUSIONS: Conservative management when applied to cases of iatrogenic oesophageal perforations gives results comparable to or better that those reported in series where early surgical intervention was practised. Extension of the leak into the pleura carries a worse prognosis.

A new method of temporary epicardial atrioventricular pacing utilizing bipolar pacing leads.

PURPOSE: We evaluated a convenient method of temporary atrioventricular pacing utilizing bipolar epicardial pacing leads that offer better sensing and pacing performance. DESCRIPTION: Fifty-one patients undergoing coronary artery bypass grafting had atrial and ventricular bipolar leads implanted. The ventricular leads were inserted onto the front of the right ventricle, and the atrial leads were inserted into the lateral muscular part of the right atrium near the interatrial groove. Sensing values, pacing thresholds, and impedance were measured on all leads on postoperative days 0, 2, and 4, and complications of insertion and removal were noted. EVALUATION: The method was convenient and there were no complications during insertion or removal. The mean pacing threshold increased from 1.1 V to 1.5 V in both the atrial and ventricular leads from day 0 to day 4 (not significant). The mean sensed p wave amplitude decreased from 2.2 mv to 2.0 mv (not significant), and the mean sensed R wave amplitude decreased from 6.2 mv to 4.1 mv (p = 0.001) from day 0 to day 4. In spite of this significant drop in the sensed R wave amplitude, this value remained in an acceptable range. There was also a significant decrease in impedance, but overall all values were in an acceptable range assuring safe and effective pacemaker function. Only one atrial lead (2%) and three ventricular leads (6.1%) failed to pace on day 4. CONCLUSIONS: We conclude that this temporary epicardial pacing method is safe, convenient, and less time consuming. Satisfactory pacing and sensing performance was achieved with low thresholds and minimal complications.

Seeding of stage I thymoma into the chest wall 12 years after needle biopsy.

It is known that benign encapsulated thymoma can pursue an aggressive clinical course on rare occasions. It may recur locally, it may be invasive, or it may metastasize. We present a case of local seeding into the chest wall, presenting 12 years after core needle biopsy and complete excision of the mediastinal tumor. We draw attention to the malignant clinical behavior of some benign stage I thymomas.