Esophageal perforation: life threatening complication of endotracheal intubation.

OBJECTIVE: To raise awareness of this complication of tracheal intubation, to emphasize the gravity due to delayed diagnosis, and to advocate a surgical treatment. METHODS: Between April 1980 and January 2000, 97 patients were treated for esophageal perforation in our department. We reviewed the cases of perforation occurring after attempted tracheal intubation. Each case is presented. Discussion is focused on diagnosis and treatment. RESULTS: Esophageal perforation occurred after attempted endotracheal intubation in five cases among 58 iatrogenic perforations. There were four women and one man (mean age 72 years). In all cases, it was for a planned operation. Intubation was performed by a single lumen tube in three cases and a double lumen tube in two cases. Presenting symptoms were acute in one case and insidious in four cases. Free interval before diagnosis and treatment was long in all but one case, with an average of 179 h (range 5--432). Two patients suffered from septic shock when they were transferred. All patients were operated on. Two patients died. CONCLUSION: Post intubation esophageal perforation is one of the most life threatening esophageal perforation. Delayed diagnosis is the first cause of gravity. Prevention of this complication begins with recognition of a potentially difficult intubation. Good outcome follows from rapid diagnosis and early surgical treatment.

[Mortality from iatrogenic esophageal perforations is high: experience of 54 treated cases]. / La mortalité des perforations instrumentales de l'oesophage est élevée: expérience de 54 cas traités.

OBJECTIVE: To underline the severity of instrumental esophageal perforations and to discuss their management. PATIENTS AND METHODS: Data from patients treated for instrumental esophageal perforation were collected retrospectively from 1980 to 1995 then prospectively since 1995 to 2000. RESULTS: Fifty-four patients were treated for instrumental perforations. Perforation occurred after exploratory endoscopy (n = 24), endoscopic dilation (n = 13), attempted tracheal intubation (n = 5), foreign body extraction (n = 5), treatment of esophageal varices (n = 4), trans-esophageal echocardiography (n = 2), and duodenal prosthesis implantation (n = 1). Clinical manifestations were immediate in 18 cases and delayed in all others, with an interval before treatment ranging from 2 hours to 45 days (mean = 70 hours). All patients were operated after large spectrum antibiotherapy and intensive care, except 3 who were treated medically due to their poor general condition. Fourteen (26%) patients died, including the 3 non-operated ones. CONCLUSION: Instrumental esophageal perforations are associated with a high mortality, probably due to the poor general condition of the patients. Diagnosis of these perforations is often delayed. A good experience of endoscopic maneuveurs and adequate post-endoscopic monitoring could allow earlier surgical treatment with lower mortality.

[Plea in favour of external cervicotomy approach of Zenker's diverticulum: 73 cases reported]. / Plaidoyer pour un abord externe par cervicotomie du diverticule de Zenker: à propos de 73 cas.

INTRODUCTION: Zenker's diverticulum can be treated surgically or endoscopically. The aim of this study was to assess results of surgical approach with cervicotomy and diverticulectomy. PATIENTS AND METHODS: We retrospectively studied the data of 73 patients (50 men and 23 women; mean age, 69 ans; extrêmes: 43-98) consecutively operated on for a Zenker's diverticulum between 1987 and 2000. Surgical procedure included diverticulectomy associated with a large myotomy and oesophageal calibration. Both early and long-term results were compared with those of published series of patients treated by stapled esophagodiverticulostomy. RESULTS: Clinical manifestations were: dysphagia (97%), regurgitations (76%), aspirations (45%), weight loss (28%), lung infection (21%), or halitosis (3%). No patient died postoperatively. The early morbidity rate was 4% (3 patients). The mean delay for return of oral feeding and the mean length of hospital stay were respectively 6 and 8 days. At follow-up (mean follow-up, 6 years; extremes: 3 months-13 years), 72 patients (99%) were satisfied and 1 patient felt partially improved. Analysis of published results of series of endoscopic treatment revealed shorter lengths of hospital stay but less favourable long-term results. CONCLUSIONS: Early morbidity of surgical treatment of Zenker's diverticulum is low. Long term functional results could be better after surgical diverticulectomy with myotomy than after endoscopic stapled esophagodiverticulostomy.

[Solitary fibrous thoracic tumor: a rare tumor with unpredictable course]. / Tumeur fibreuse solitaire de la plèvre.

A 68-year-old woman presented chest pain and exercise-induced dypnea for one year. Diagnosis was a thoracic solitary fibrous tumor. These tumors are very rare. Clinical outcome is generally good except in 13% of the cases with a malignant component. Complete surgical resection is required.

Infected mediastinitis secondary to perforation of superior vena cava by a central venous catheter.

We describe the first case of infected mediastinitis associated with central venous catheter insertion. The rare occurrence of this complication may be explained by the fact that it results from central venous catheter-related bloodstream infection and catheter perforation of superior vena cava. The symptoms of this complication (chest pain, dyspnoea) are not specific. Diagnosis should be confirmed by chest x-ray and computerized tomography which show hydromediastinum and pleural effusion. Removal and subsequent culture of the catheter tip will confirm infection. Appropriate antibiotic therapy, guided by sensitivities of the cultured organisms, should be commenced. Any pleural effusion should be drained by thoracocentesis, and the pleural fluid cultured. In case of fever, bacteraemia or shock, a thoracotomy to drain mediastinal and pleural effusions may be considered.

Diffuse esophageal leiomyomatosis with perirectal involvement mimicking Hirschsprung disease.

We describe a 25-year-old woman with diffuse esophageal leiomyomatosis. During childhood, achalasia was mistakenly diagnosed in this patient. Subsequently, she underwent cardiomyotomy and developed symptoms of Hirschsprung disease. These symptoms were caused by infiltration of the esophageal and rectal walls by benign muscular hypertrophy. The pseudo-Hirschsprung disorder was manifested by chronic severe constipation, with consistent manometric findings. Clitoral hypertrophy and vulvar and periurethral leiomyoma were also present. Genetic analysis demonstrating deletion of the COL4A5/COL4A6 locus and the discovery of microscopic hematuria implied that the patient could transmit both diffuse leiomyomatosis and the Alport syndrome.