Experimental models of tracheobronchial stenoses: a useful tool for evaluating airway stents.

BACKGROUND: Stent implantation is a conservative alternative to open operation for treating benign tracheobronchial strictures. Most of the presently available stents were primarily designed for endovascular use. Their respiratory use entails a risk of iatrogenic complications. From a scientific and from an ethical point of view these risks justify preclinical evaluation of new respiratory stents in experimental models of central airway stenoses. Therefore, an attempt was made to develop such models in piglets and adult minipigs. METHODS: Tracheal stenoses were obtained by creating first a segmental tracheomalacia through extramucosal resection of cartilaginous arches. The fibrous component of the stenoses was then obtained through bronchoscopic application of a caustic agent causing progressive deep mucosal and submucosal injury. Stenoses of the main bronchi were created by topical application of the caustic agent only. RESULTS: These models demonstrated the typical features of benign fibromalacic tracheobronchial stenoses with constant recurrence after mechanical dilation. Preliminary experiments showed that short-term problems of tolerance of stent prototypes are easily demonstrable in these models. CONCLUSIONS: These experimental models, which simulate quite realistically human diseases, offer the opportunity to perfect new tracheobronchial stents specifically designed for respiratory use and to evaluate their long-term tolerance before their use in humans.

Pulmonary sequestration treated by video-assisted thoracoscopic resection.

An undiagnosed pulmonary sequestration showed abnormal vessels at video-assisted thoracoscopy. Mediastinal or lung masses which are situated at the base of the thorax must be dissected with great caution because of the possible existence of vascular malformations.

Barrett's esophagus and adenocarcinoma.

Sixty-two cases of Barrett's esophagus were observed among 707 patients with hiatal hernia (8.7%). The symptomatology of this condition is described. An additional 10 adenocarcinomas were associated with a Barrett's esophagus--a carcinoma prevalence of 13.8%. Differences in pathology and clinical manifestations of nonmalignant and malignant cases were determined. Fifty-one patients with nonmalignant Barrett's esophagus were operated upon conservatively, while 11 underwent resection. Our results favor conservative surgery via an abdominal approach. The patients with adenocarcinomas underwent esophageal resection with six apparent cures from 6 months to 5 years. Histological study showed specialized epithelium in 8 of 10 cases and severe dysplasia in 5. Our clinical study of Barrett's esophagus shows an incidence of malignancy equal to 1 new case per 274 patient-years (1.72%). It is still not firmly established whether correction of reflux will influence the level of columnar epithelium in the esophagus, esophageal dysplasia, and the risk of malignancy.

Gastro-oesophageal reflux and respiratory disorders treated by Hill's procedure.

A retrospective review of 132 patients with respiratory disorders associated with gastrooesophageal reflux is presented. The patients were operated upon according to Hill's technique. In 66 infants and children, recurrent lung infection was the most frequent indication for surgery. The mean duration of respiratory symptoms was 17 months. In 66 adults, asthma was the most frequent indication for surgery. The mean duration of respiratory symptoms was 9.7 years. Suppression of reflux was obtained by operation in 95% of infants and children, with disappearance of respiratory disorders in 78.6% and clinical improvement of symptoms in 16.4%. Suppression of reflux was confirmed in 94% of adults, with disappearance of respiratory disorders in 36% and improvement of symptoms in 28%. The correlation between disappearance of reflux after surgery and cure of respiratory disorders in infants and children must be seen in the light of the natural history of lower oesophageal sphincter maturation. Nevertheless, surgery shortens the period of risk in life-threatening situations. In adults, one patient out of two benefited from operation. Failures were more frequent in asthma and there was no characteristic type of asthma associated with reflux.

[Late portal vein thrombosis caused by hematoma after liver transplantation]. / Thrombose porte tardive par hématome après transplantation hépatique.

Late portal vein thrombosis of liver grafts is uncommon and is usually revealed by variceal bleeding. We herein report a case of thrombosis discovered in an adult 10 months after liver transplantation, due to stenosis of the portal vein by extrinsic compression, probably secondary to a biopsy-induced hematoma. Development of venous collateral circulation allowed for normal function of the liver graft.

[Alveolar sarcoma. Report of a case]. / Sarcome alvéolaire du poumon. A propos d'une observation.

Alveolar soft part sarcoma occurs mostly in the deep soft tissues. An unusual case of primary pulmonary alveolar soft part sarcoma is reported. A 39-year-old woman presented with thoracic pain revealing the tumor. The left lower lobe was surgically resected. The microscopic features of this tumor, including characteristic alveolar pattern and the PAS-positive crystals were typical of alveolar soft part sarcoma. Immunohistochemically, granular cytoplasmic reactivities were observed with antibodies against vimentin, myoglobin, methionine-enkephalin, S100 protein and neuron-specific-enolase. Electron microscopic study demonstrated numerous crystallized structures in the tumor cell cytoplasm. This is the third case of pulmonary alveolar soft part sarcoma, one arising from the pulmonary vein. The histogenesis of alveolar soft part sarcoma is still debated. Our case does not allow distinction between myogenic or neural origin of this tumor.

[Surgical treatment of gastroesophageal reflux by modified Hill's posterior cardiopexy. Apropos of 441 cases]. / Traitement chirurgical du reflux gastro-oesophagien par cardiopexie postérieure de Hill modifiée. A propos de 441 cas.

Between 1972 and 1986, 490 modified Hill's procedures were performed for gastro-esophageal reflux; 441 cases were retrospectively studied consisting of 245 males and 196 females, aged from 4 days to 83 years, with a mean age of 41 years. Average duration of gastrointestinal symptoms was 5.4 years. The proposed technique is described, allowing cardiopexy without intraoperative manometry. Mortality was 1.4% (6 cases); one death was due to surgery. Morbidity was 5.4% (24 cases). With a mean follow-up of 5.2 years, a clinical cure was obtained in 93.5% of cases. Causes of failures were analyzed: the only possible pre-operative factor was the presence of peptic stenosis. Pylorospasm appeared to be a post-operative cause of failure. The 28 patients for whom surgery failed were medically treated (18), dilated (5) or reoperated (5). Three new cardiopexies and 2 fundoplications cured the last 5 patients with a mean follow-up of 5.8 years. Recurrences of symptoms and discoveries of failure were generally detected early after the operation: 20 before 6 months (71%), 1 between 6 months and 1 year, 2 between 1 and 2 years, 3 between 3 and 4 years, 1 between 4 and 5 years.

[Respiratory signs associated with gastro-esophageal reflux. A retrospective study of 132 surgically treated cases in children and adults]. / Signes respiratoires associés à un reflux gastro-oesophagien. Etude rétrospective de 132 cas opérés chez l'enfant et chez l'adulte.

We carried out a retrospective study of 132 cases of respiratory disorders associated with gastro-oesophageal reflux involving 66 children, 42 boys and 24 girls, 4 days to 10 years old with a mean of 22 months. We also studied 66 adults, 37 men and 29 women, 16 to 74 years old. In the infants the mean duration of respiratory disorders was 17 months and a recurrent broncho-pulmonary infection was the principal indication (40 cases). Alimentary symptoms were present in 34 cases. There was evidence of reflux in 60 cases. The suppression of any reflux was obtained surgically in 95% of cases with a disappearance of the respiratory disorders in 78.6% of cases and their improvement in 16.4% of cases with a mean follow up period of 4.3 years. In the adults the mean duration of the respiratory disorders was 9.7 years and asthma was the principal cause (38 cases). Alimentary symptoms were present in 56 cases with evidence of reflux in 64 cases. A suppression of the reflux was achieved surgically in 94% of cases with a disappearance of the respiratory disorders in 36% of cases and their improvement in 28% of cases with a mean follow up period of 4.7 years. The correlation between the disappearance of reflux and the respiratory symptoms and signs in the children should perhaps be tempered by the natural history of the maturation of the inferior oesophageal sphincter. However surgery shortens the danger period in serious situations which are life threatening.(ABSTRACT TRUNCATED AT 250 WORDS)

[Reoperations for persistent or recurrent gastroesophageal reflux after surgical treatment]. / Réinterventions pour reflux gastro-oesophagien persistant ou récidivé après correction chirurgicale.

Thirty one cases of failed antireflux surgery were analyzed. The first operation had been performed on 24 patients with uncomplicated reflux and 7 patients with complicated reflux. There was an abnormality of the cardia in all cases. Twenty eight patients had been operated through an abdominal approach and 3 through a thoracic approach. The failure was diagnosed during the first year in 12 patients. The reflux became complicated in 17 cases. Oesophageal stenosis was the most common complication. Twenty four patients were reoperated through an abdominal approach and 7 through a thoracic approach. In 29 cases out of 31, an anatomical cause of the failure was found and rectified. Mortality was nil. The results of iterative surgery were good in 80 p. cent of cases after a mean follow up of 6 years.

Reflux esophagitis and carcinoma.

Early detection of a malignancy in reflux esophagitis should permit an effective surgical action if a causal time relation between reflux, esophagitis and carcinoma exists. In the medical literature on tumors of the esophagus associated with reflux esophagitis, it has been reported that they are adenocarcinomas in most instances. Squamous carcinomas are seldom mentioned. In a population of patients with five squamous carcinomas and 13 adenocarcinomas associated with reflux, three squamous carcinomas had developed on stage III or on a stenotic esophagitis and two squamous carcinomas were at the upper limit of a Barrett's esophagus. The 13 adenocarcinomas were associated with a Barrett's esophagus. No carcinoma was found to be associated with a low grade esophagitis. During the same time period, 224 patients were operated upon for a serious documented esophagitis (stage III, stenotic, Barrett's esophagus), including the 18 patients with carcinoma. Five hundred and thirty-four patients were operated upon for a lower grade esophagitis, with no associated carcinoma and 592 patients were operated upon for carcinoma of the esophagus. The five squamous carcinomas associated with reflux were resected and classified T1 N0. The 13 adenocarcinomas associated with reflux were resected and classified T1 N0 M0 (two patients), T2 N0 M0 (two), T3 N0 M0 (five), T3 N1 M0 (one patient), T3 N2 M0 (one) and T3 N3 M0 (two patients). Four patients with squamous carcinomas were alive after two, six, nine and 15 years. Eight patients with adenocarcinomas were alive after two years (one patient), three years (two patients), four years (three), five years (one patient) and seven years (one). Three carcinomas were diagnosed by routine endoscopy. The mean age of the patients with carcinoma associated with reflux was older than in the general carcinoma series, the relative number of females was higher and the use of alcohol and tobacco was not as frequent, but the differences were not significant. In squamous and columnar carcinomas, a long history was significant (p less than 0.001); in Barrett's esophagus, loss of weight (p less than 0.01), intestinal epithelium (p less than 0.001) and dysplasia (p less than 0.01) were also significant. In one patient, carcinoma was discovered during the follow-up evaluation of an antireflux procedure for Barrett's esophagus.(ABSTRACT TRUNCATED AT 400 WORDS)

[Role of accessory spleen in recurrent chronic hematologic diseases]. / Le rôle des rates accessoires dans les récidives d'hémopathies chroniques.

Among 533 patients who were splenectomized between 1967 and 1981 for a chronic haemopathy, 8 were reoperated because of the reappearance of an accessory spleen, which was responsible for the relapse of the disease. Five patients were followed for idiopathic thrombopenic purpura (ITP), 2 for hereditary spherocytosis and 1 for a Hodgkin disease (this patient had been operated for an abdominal exploration and splenectomy). In all patients, a hepato-splenic scintigram with Tc 99 m permitted the discovery of the accessory spleens and the exploration was completed by the study of the half lifetime and sequestration of platelets or red blood cells. The disappearance of the haemorrhagic syndrome after removal of the accessory spleen was frank and didn't need any complementary treatment for 3 cases of ITP and 2 cases of spherocytosis and was incomplete and had to be completed by a secondary treatment for 2 cases of ITP and for the Hodgkin disease. The analysis and the interpretation of the results of this study can be helpful to establish the diagnosis and decide the treatment of accessory spleens which are discovered by a relapse of a chronic haemopathy, primarily treated by splenectomy.

Hilar lymph nodes: identification with spiral CT and histologic correlation.

PURPOSE: To determine the appearance of normal hilar lymph nodes and associated soft tissue at spiral computed tomography (CT). MATERIALS AND METHODS: At spiral CT in 50 healthy patients, peribronchovascular hypoattenuated areas of 42 right and 45 left hila were systematically evaluated. Histologic results were correlated in five additional cases. RESULTS: Hilar lymph nodes were depicted (a) in the right hilum (lateral to A2 [n = 33 (79%)], medial [n = 29 (69%)] or lateral [n = 11 (26%)] to the interlobar pulmonary artery, and medial to the lower-lobe pulmonary artery [n = 30 (71%)], A7 [n = 9 (21%)], and A8-10 [n = 8 (19%)]; and (b) in the left hilum (lateral to A2 [n = 22 (49%)], medial to the interlobar pulmonary artery [n = 45 (100%)], and the lower-lobe pulmonary artery [n = 27 (60%)], and in the angles of bifurcation of A7 + 8 and A9 + 10 [n = 18 (40%)]). Hilar lymph nodes were seen to be triangular or linear and to be less than 3 mm wide except around the left-lower-lobe pulmonary artery. CONCLUSION: Spiral CT accurately depicts normal hilar lymph nodes and their major anatomic relationships.