[Non-malignant esophagotracheal fistulas in adults. Experience with 35 cases]. / Les fistules oeso-trachéales non malignes de l'adulte. Expérience de trente-cinq cas.

Esophagotracheal fistula always constitutes a serious, life-threatening complication. Fistulae occurring during medical intensive care with mechanical ventilation are currently the most frequent. Their diagnosis was strongly suspected by clinical examination of the patient, but was always confirmed by endoscopy which revealed their exact site in relation to the vocal cords or carina, essential information for the choice of incision when it is decided to perform surgery. Twenty-five patients were treated medically. Treatment was always combined with gastrointestinal resting, control of gastro-oesophageal reflux and broad-spectrum systemic antibiotics. There were 19 deaths and 6 fistulae closed spontaneously. Three of these 6 patients developed a secondary tracheal stenosis, 2 of which were treated surgically by resection-anastomosis. Ten fistulae were closed surgically with a good long-term result. The indication for surgery was essentially based on the patients general and infectious status and on his or her respiratory autonomy. Technically, we always combined direct suture of the two organs with interposition of muscular or pleural tissue.

[Gastroesophageal reflux and respiratory manifestations: diagnostic approach, therapeutic indications and results]. / Reflux gastro-oesophagien et manifestations respiratoires: attitude diagnostique, indications thérapeutiques et résultats.

The authors report a study of 140 patients presenting with a non-allergic respiratory tract disease (121 cases of asthma--19 cases of spasmodic cough). Gastro-oesophageal reflux was detected by 24-hour pHmetry in 86 of these patients. In 34 of them (i.e. 40% of cases), the gastro-oesophageal reflux appeared to be responsible for the initial respiratory tract symptoms. These 34 patients were submitted to a therapeutic trial of high dose anti-H2 therapy for at least two months. Only those patients in whom a marked improvement or even complete resolution of the respiratory tracts symptoms was observed underwent anti-reflux surgery. Out of the 13 patients undergoing surgery, there were two failures and 11 good results after a follow-up of more than 18 months.

[Gastric esophagoplasty in the treatment of cancer of the esophagus]. / L'oesophagoplastie gastrique dans le traitement des cancers de l'oesophage.

Between March 1982 and December 1987, 112 patients with oesophageal cancer were treated by gastroplasty following oesophagectomy to restore gastrointestinal continuity. This technique was used in all oesophageal cancers regardless of their site, with the exception of paryngo-oesophageal and oesophago-cardio-fundal cancers. The overall mortality of 12.5% fell to below 6% during the last two years. The postoperative course was straightforward in 54.5% of cases. The most frequent complications were respiratory tract complications (19 cases of ARDS out of 112 patients, i.e. 17%) and fistulae at the oesophago-gastric anastomosis (9 cases out of 112, i.e. 8%). The secondary complications were dominated by anastomotic stenoses (19/98, i.e. 19.3%).

Lower oesophageal reflux during priming with vecuronium.

We have studied the effects of vecuronium given in divided doses (priming principle) on the frequency of acid reflux into the oesophagus. Two groups of 16 patients were studied. After induction with thiopentone 6 mg kg-1 and fentanyl 3 micrograms kg-1, patients in one group were given vecuronium 0.01 mg kg-1 as a priming dose, followed by an intubation dose of 0.1 mg kg-1 4 min later. Patients in the other group were given no priming dose. Lower oesophageal pH was monitored continuously and acid reflux was defined as a decrease in pH to less than 4.0. One patient in each group had acid reflux during the time course of the induction. This study suggests that vecuronium 0.01 mg kg-1 given as a priming dose does not increase the risk of acid reflux into the oesophagus.

[Angina-like chest pain of esophageal origin]. / Douleur angineuse d'origine oesophagienne.

Chest pain of oesophageal origin closely resembles chest pain of coronary origin, and the distinction between these two sources of pain is crucial to give the patients a precise prognosis and to use the appropriate therapeutic approach. Once the coronary origin has formally been excluded, the oesophageal origin can be confirmed by several examinations of varying sensitivity and specificity. To date, prolonged oesophageal manometric and pH recordings give highly reliable results as they establish a cause-effect relationship between pain and the phenomena recorded. Besides, these methods have refined the therapeutic approach since they also inform on the mechanisms of oesophageal pain.

Techniques, results and complications of oesophageal dilatation.

The scope of therapeutic endoscopy, especially in the context of oesophageal dilatation, has greatly expanded in recent years. In this chapter we have described the currently used wire-guided systems and their dilatation technique. This technique can be used with most dilatation instrumentation now on the market. Perforation, the major risk of dilatation, is now rare (0.22% out of 909 dilatations with Savary-Gilliard bougies). Finally, we have presented the results of our own comparative studies for the Eder-Puestow, Savary Gilliard and Biomed systems and those of other authors for systems with which we have had no experience. In our opinion Savary-Gilliard bougies are the best, not only because of their greater flexibility and progressivity but also because of the improved safety tip of the guide wire.

[Esophageal spasm: a common cause of spontaneous precordial pain]. / Le spasme oesophagien: une cause fréquente de précordialgies spontanées.

Fifty-eight consecutive patients were investigated for spontaneous chest pain without symptoms of effort angina, previous myocardial infarction or other signs of cardiac disease, to determine the incidence of oesophageal spasm. The character of the chest pain, its context and the results of resting ECGs were analysed. An ECG recorded during chest pain was available in 23 cases and exercise stress testing was performed in 43 cases. Coronary angiography was carried out in all patients. The coronary arteries were normal or showed little change in 44 patients. Further investigations were ordered: oesophageal manometry (42 cases), echocardiography 44 cases) and ergometrine provocation tests (44 cases). The patients were then divided into 4 groups: 23 patients (40 p. 100) with coronary artery disease; either atheroma (14 cases) or spasm (9 cases); 8 patients (13,5 p. 100) with non-coronary cardiac pathology (myocardial hypertrophy or mitral valve prolapse); 15 patients (26 p. 100) with oesophageal spasm alone; 12 patients (20,5 p. 100) with no obvious organic disease. Often simulating spontaneous angina, clinically and electrocardiographically, oesophageal spasm may sometimes be distinguished (6 out of 15 cases) by the finding of painful dysphagia on swallowing ice-cold liquid. The condition is confirmed by oesophageal manometry which shows abnormalities of oesophageal contraction. In addition, 13 out of 15 patients in our series had hypotonia of the gastro-oesophageal sphincter. Dyskinetic phenomena and this hypotonia should be taken into consideration in the treatment of this condition.

[Treatment of Grave's disease by radio iodine. Observation of 277 patients (author's transl)]. / Le traitement de la maladie de Basedow par l'iode radio-actif. Surveillance de 277 patients de l à 23 ans.

277 patients treated by radio iodine for Graves' disease were observed during a one to twenty three years period. 24 % relapse, always during the first three years. Hypothyroidism is ineluctable : 20 % from the first year and 3,4 % more each year. Goiter increases the delay for hypothyroidism occurrence. There is no linkage between hypothyroidism and radio iodine dose. Radio iodine does not cure graves' disease but give a "non hypo-non hyper" status, before secondary hypothyroidism.