Esophagojejunostomy after total gastrectomy for caustic injuries.

The objective of the study was to compare outcomes of emergency esophagogastrectomy (EGT) and total gastrectomy with immediate esophagojejunostomy (EJ) in patients with full-thickness caustic necrosis of the stomach and mild esophageal injuries. After caustic ingestion, optimal management of the esophageal remnant following removal of the necrotic stomach remains a matter of debate. Between 1987 and 2012, 26 patients (men 38%, median age 44 years) with isolated transmural gastric necrosis underwent EGT (n = 14) or EJ (n = 12). Early and long-term outcomes of both groups were compared. The groups were similar regarding age (P = 0.66), gender (0.24), and severity of esophageal involvement. Functional success was defined as nutritional autonomy after removal of the jejunostomy and tracheotomy tubes. Emergency morbidity (67% vs. 64%, P = 0.80), mortality (17% vs. 7%, P = 0.58), and reoperation rates (25% vs.14%, P = 0.63) were similar after EJ and EGT. One patient (8%) experienced EJ leakage. One patient in the EJ group and 13 patients in the EGT group underwent esophageal reconstruction (P < 0.0001). Aggregate in hospital length of stay was significantly longer in patients who underwent EGT (median 83 [33-201] vs. 36 [10-82] days, P = 0.001). Functional success after EJ and EGT was similar (90% vs.69%, P = 0.34). Immediate EJ can be safely performed after total gastrectomy for caustic injuries and reduces the need of further esophageal reconstruction.

[Colonic interposition for esophageal replacement after caustic ingestion]. / Reconstruction oesophagienne pour séquelles de brûlure caustique: coloplasties, mode d'emploi.

Retrosternal coloplasty is the gold standard for esophageal reconstruction after caustic injury of the digestive tract. Complete preoperative otolaryngology evaluation and the control of the psychiatric disease are key factors for success. In the absence of controlled studies, the choice between the right and the left colon graft relies on the anatomy of the blood supply to the colon and on the individual surgeon's preference. Treatment of associated pharyngeal and laryngeal injuries is mandatory at the time of esophageal reconstruction. In experienced hands mortality rates are less than 5% but specific postoperative complications (graft necrosis, leakage, anastomotic stricture) are high. The low risk of cancer development in the by-passed esophagus does not justify routine esophagectomy at the time of reconstruction. Sixty to eighty percent of patients would finally retrieve nutritional autonomy after coloplasty for caustic injury. Late acquired dysfunctions of the coloplasty (anastomotic strictures, graft redundancy) requiring revision surgery occur frequently and might jeopardize an already fragile functional result. Timely diagnosis and treatment of such complications and the necessity of continuous psychological surveillance justify the need for long term follow up in these patients.

[Pharyngo-esophagoplasty by right coloplasty for the treatment of post-caustic pharyngo-laryngeal-esophageal burns: a report of 13 cases]. / La pharyngo-oesophagoplastie par transplant colique droit dans le traitement des séquelles de brûlures caustiques pharyngo-laryngo-oesophagiennes: à propos de 13 cas.

We report a new technique of pharyngoesophagoplasty by right coloplasty, indicated in postcaustic severe pharyngeal stenosis, analyzing the anatomical and functional results in terms of respiratory tract and phonation as well as digestive tract outcome. We compared our results with those obtained with other procedures. Between March 1995 and September 1998, pharyngoesophagoplasty by right coloplasty was performed in 13 patients. All had severe hypopharyngeal stricture with total obliteration of the two piriform sinuses and the upper esophageal sphincter. Nine patients underwent emergency esophagectomy or esogastrectomy by stripping and four had a cicatricial esophagus. Eight patients underwent tracheotomy before the pharyngoplasty due to burns of the laryngeal margin or airway infections. There was no perioperative mortality. The retrospective analysis in February 1998 with a follow-up of 22 months disclosed two deaths, one from septic shock following pneumnia and one suicide. For the 11 other patients, respiratory function had been restored successfully as the tracheostomy tube had been removed. Eight of the patients were on regular oral diet and the jejunostomy tube had been removed. Three had mild dysphagia and the oral diet was supplemented by jejunostomy tube feedings. These results were most successful compared with those obtained with 29 other patients. Pharyngo-esophagoplasty by right colonic transposition appears to be the method of choice for the reconstruction of post-caustic pharyngeal and esophageal stenosis.

Reoperation for secondary uremic hyperparathyroidism: are technical difficulties influenced by initial surgical procedure?

BACKGROUND: Parathyroid surgery in patients with uremia and secondary hyperparathyroidism is performed either by subtotal parathyroidectomy or total parathyroidectomy with immediate reimplantation. The aim of this study was to compare the results of reoperation for persistent or recurrent hyperparathyroidism after parathyroidectomy according to which initial operative procedure was used. PATIENTS AND METHODS: Eighty-nine patients had reoperation for persistent (28 patients) or recurrent (61 patients) hyperparathyroidism after 53 subtotal parathyroidectomies and 36 total parathyroidectomies with immediate reimplantation. Results of the reoperation were assessed in terms of success rate, morbidity, and operative findings. RESULTS: The success rate of reoperation in patients with persistent hyperparathyroidism was 89% and was independent of the initial type of surgery. Success rates of reoperation for recurrent hyperparathyroidism after initial subtotal parathyroidectomy and total parathyroidectomy with immediate reimplantation were 87% and 70%, respectively (P = .02). Hypertrophy of the parathyroid remnant was the main cause of recurrence after subtotal parathyroidectomy. After total parathyroidectomy with immediate reimplantation, recurrence was located in the graft in half the patients, while hyperplastic tissue was found in the neck or the mediastinum in the other half. CONCLUSIONS: Subtotal parathyroidectomy provides the best conditions for successful reoperation in case of recurrent hyperparathyroidism and should become the surgical treatment of choice for secondary hyperparathyroidism.

Extensive abdominal surgery after caustic ingestion.

OBJECTIVE: To report the authors' experience in extensive abdominal surgery after caustic ingestion, and to clarify its indications. SUMMARY BACKGROUND DATA: After caustic ingestion, extension of corrosive injuries beyond the esophagus and stomach to the duodenum, jejunum, or adjacent abdominal organs is an uncommon but severe complication. The limit to which resection of the damaged organs can be reasonably performed is not clearly defined. METHODS: From 1988 to 1997, nine patients underwent esophagogastrectomy extended to the colon (n = 2), the small bowel (n = 2), the duodenopancreas (n = 4), the tail of the pancreas (n = 1), or the spleen (n = 1). Outcome was evaluated in terms of complications, death, and function after esophageal reconstruction. RESULTS: Five patients required reintervention in the postoperative period for extension of the caustic lesions. There were two postoperative deaths. Seven patients had secondary esophageal reconstruction 4 to 8 months (median 6 months) after initial resection. Three additional patients died 8, 24, and 32 months after the initial resection. Three survivors eat normally, and one has unexplained dysphagia. CONCLUSIONS: An aggressive surgical approach allows successful initial treatment of extended caustic injuries. Early surgical treatment is essential to improve the prognosis in these patients.

Early localization and reoperation for persistent primary hyperparathyroidism.

BACKGROUND: Reoperation for persistent primary hyperparathyroidism is often performed after a delay of 4-6 months. Success can be expected in over 90 per cent of cases but exploration is technically difficult and there is the possibility of creating permanent hypoparathyroidism and vocal cord paralysis. This is a study of early localization and reoperation. METHODS: In a consecutive series of 273 patients who had surgery for primary hyperparathyroidism, three remained hypercalcaemic and in three the abnormal parathyroid was not found at initial exploration. They underwent early (6-48 h) single-tracer 99mTc Sestamibi scintigraphy with factor analysis of dynamic structures (FADS) and single photon emission computed tomography (SPECT) followed by reoperation within 24-72 h. RESULTS: Scintigraphy with FADS and SPECT was helpful in all six patients, who were cured by reoperation with no morbidity or symptomatic hypocalcaemia. CONCLUSION: Reoperation for persistent primary hyperparathyroidism is possible and may be easier within days of an initially unsuccessful procedure. With the intact 1-84 parathyroid hormone measurement, the diagnosis is accurate. Single-tracer 99mTc Sestamibi scintigraphy with FADS and SPECT is non-invasive, easily and rapidly performed, and was accurate in these six patients.

Can the morbidity of esophagectomy be reduced by the thoracoscopic approach?

Esophagectomies have a high morbidity rate, mainly related to pulmonary complications. The aim of this work was to assess whether the thoracoscopic approach could reduce this morbidity. We have made a prospective study of the results of 29 attempts of esophagectomy using a right thoracoscopic approach. There were 20 males and 9 females having an average age of 47. The indication was a squamous cell carcinoma in 22 patients, an adenocarcinoma in 1 patient, a melanoma in 1 patient, and a caustic stenosis in 5. The whole esophagus was mobilized thoracoscopically and the esophagectomy was completed through the abdomen. The reconstruction was achieved using a gastric pull-through and a cervical anastomosis. There were five failures for the following reasons: unresectable carcinoma (one case), large tumor making a thoracoscopic dissection unsafe (two cases), and incomplete lung collapse making the exposure of the posterior mediastinum difficult (two cases). The average time of the thoracoscopic procedure was 135 min. The postoperative course was uneventful in all but five patients who had a pulmonary complication: atelectasis (three cases), right purulent pleural effusion (one case), acute respiratory disease syndrome (one case). The latter complication was lethal. Four out of five respiratory complications occurred in patients for whom the dissection was considered difficult. Among the other complications, there were five anastomotic leakages and three cases of laryngeal nerve palsy. The mortality rate was 3.8%. These initial results do not show a real benefit of the thoracoscopic approach for esophageal dissection, especially with respect to difficult esophagectomies. Further evaluation of the technique is needed.

[Can a reduction of morbidity of esophagectomy be expected with the thoracoscopic approach?]. / Peut-on espérer réduire la morbidité de l'oesophagectomie grâce à l'abord thoracoscopique?

OBJECTIVE: Oesophagectomies have a high morbidity rate, mainly related to pulmonary complications. The aim of this work was to assess whether the thoracoscopic approach could reduce this morbidity. PATIENTS AND METHODS: We conducted a prospective study of the results of 26 attempts of esophagectomy using a right thoracoscopic approach. There were 17 males and 9 females having an average age of 47. The indication was a squamous cell carcinoma in 19 patients, an adenocarcinoma in 1 patient, a melanoma in 1 patient and a caustic stenosis in 5. The whole oesophagus was mobilized thoracoscopically, and the eosophagectomy was completed through the abdomen. The reconstruction was achieved using a gastric pull-through and a cervical anastomosis. RESULTS: There were 5 failures for the following reasons: unresectable carcinoma (1 case), large tumour making a thoracoscopic dissection unsafe (1 case) and incomplete lung collapse making the exposure of the posterior mediastinum difficult (2 cases). The average time of the thoracoscopic procedure was 135 min. The post-operative course was uneventful in all but 5 patients who had a pulmonary complication: atelectasis (3 cases), right purulent pleural effusion (1 case), acute respiratory distress syndrome (1 case). The latter complication was lethal. Four out of 5 respiratory complications occurred in patients for whom the dissection was considered as difficult. Among the other complications, there were 5 anastomotic leakages and 3 laryngeal nerve palsy. The mortality rate was 3.8%. CONCLUSION: These initial results do not show a real benefit of the thoracoscopic approach for eosophageal dissection, especially for difficult oesophagectomies. Further evaluation of the technique is needed.

[The diagnostic value of thoracoscopy in solid masses of the mediastinum]. / Intérêt diagnostique de la thoracoscopie dans les masses solides du médiastin.

Despite the accuracy of percutaneous biopsy of mediastinal masses under CT scan or sonographic control, there is still a need for surgical biopsy either because of difficult location or because of insufficiency of the percutaneous biopsy, especially for those of the tumors requiring an immunological classification. The thoracoscopic approach of mediastinal masses is an alternative to the usual surgical biopsies performed through thoracotomy, sternotomy or anterior mediastinotomy. The procedure is performed under general anaesthesia and one-lung ventilation. In a series of 44 cases, an histological diagnosis was obtained in 41 cases (93.1%). There was one haemorrhagic complication requiring thoracotomy (2.3%). The mean post-operative duration of stay was 3.2 days. We conclude that thoracoscopy is the method of choice in case of failure or contraindication of percutaneous biopsy. There is still a role for mediastinoscopy for laterotracheal lymph nodes.