[Esophageal perforations. Presentation of 23 cases]. / Perforaciones esofágicas. Presentación de 23 casos.

AIM: Esophageal perforations are the most serious perforations of the digestive tract and their treatment remains controversial. The aim of this study was to analyse the outcome of patients with esophageal perforations given surgical and conservative treatment. PATIENTS AND METHODS: Retrospective study of 23 patients with esophageal perforations, 8 cervical (35%) and 15 thoracic (65%). Medical treatment was indicated in patients who fulfilled Cameron's criteria (minimal signs of clinical sepsis; disruption contained in the mediastinum; drainage of the cavity back into the esophagus; minimal symptoms). The remaining patients underwent surgery. RESULTS: Two patients with cervical perforations (25%) met Cameron's criteria. Evolution after conservative treatment was favourable. The remaining patients (75%) were surgically treated: simple closure of the perforation was performed in four and drainage of the cervical abscess in two. Two of the patients who underwent surgery presented pleural hemorrhage, one of which was associated with pneumonia. Four patients with thoracic perforation (27%) met the criteria for conservative treatment. One presented respiratory distress syndrome during treatment and required intensive care. Evolution was favorable in all. The remaining 11 patients (73%) received surgical treatment: in five (46%) simple closure of the perforation was performed, in three (27%) bipolar exclusion was performed and in the remaining patients, other techniques were used. Morbidity was 82% (nine patients) mainly due to pneumonia and mortality was 46% (five patients). CONCLUSIONS: Treatment of esophageal perforation should be individualized. Conservative treatment should be considered in patients meeting Cameron's criteria as their evolution is favorable, with low morbidity and mortality and surgery is not necessary.

[Results of surgical treatment of esophageal cancer (209 cases)]. / Resultados del tratamiento quirúrgico del cáncer de esófago (209 casos).

We present a series of 209 patients with cancer of the esophagus over a 13-year period. Average age was 61.99 years and 87.56% of the patients were male. As for histological type, 59.8% of cases were epidermoid carcinomas and the remaining adenocarcinomas. In 76.55% of cases tumor stage was III or IV. Operability rate was 81.8% and resectability 57.89%. The most frequent resective procedure was oesophagogastrectomy through a right thoracotomy and laparotomy. Reconstruction of digestive continuity was achieved in 86.77% with the stomach; 53.72 of resections were judged to be "radical". Overall postoperative morbidity was 45.61%. Respiratory failure and anastomotic leakage accounted for most of morbidity. Anastomotic leakage was more frequent in patients undergoing bypass, with cervical anastomosis, and when the reconstruction was performed with the colon. Mortality rate was 14.04%, but fell to 7.69% in patients undergoing "radical" resection. Overall 5-year survival was 7.83% and 11.81% in patients undergoing resection. The more relevant prognostic factor was tumour stage; 5-years survival of patients with tumor stage I-II was 27.53%, and 0% for patients with tumour stage II or IV.

Results of surgical treatment of epidermoid carcinoma of the thoracic esophagus.

During 1979 to 1991, 125 patients with epidermoid carcinoma of the thoracic esophagus were admitted to our General Surgery unit. The average age was 60.1 years; 94.4 percent of the patients were male. The mean duration of symptoms was 3.65 months. The most frequent symptom was dysphagia in 97.19 percent, followed by weight loss in 64.48 percent. The most frequent location was the middle one-third in 58.4 percent. The tumor was well differentiated in 27.2 percent, moderately well differentiated in 41.6 percent and poorly differentiated in 31.2 percent. By preoperative staging, 1 patient was stage I, 24 were stage II, 86 were stage III and 14 were stage IV. The operability rate was 76 percent and the resectability rate was 48.8 percent. Resection was "curative" in 42.62 percent and palliative in 57.37 percent. Radiation therapy and chemotherapy were used only in those patients who did not undergo resection. All of the patients in whom resection was possible underwent a single-stage esophagogastrectomy. The postoperative mortality rate was 20 percent, but only 11.54 percent if we only consider those patients who underwent "curative" resection. The most frequent causes of mortality were respiratory complications and anastomotic leakage. The five year overall survival rate was 5.99 percent. In the resected group, the five year survival rate was 8.82 percent and in patients in whom resection was considered "curative," the rate was 20.86 percent.

Antireflux mechanism of Nissen fundoplication. A manometric study.

To analyze the mechanisms by which Nissen fundoplication controls gastroesophageal reflux, the pre- and post-operative manometric findings in 34 patients were compared. The postoperative assessment showed an increase in both the infradiaphragmatic length and basal pressure of the lower esophageal sphincter and a notable improvement in esophageal motility (increase in the amplitude of the waves and decrease in the mean percentage of deglutitions without response and tertiary waves) in those who preoperatively presented with defective esophageal peristalsis.

[Barrett esophagus: epidemiologic data and risk of becoming malignant]. / Esófago de Barrett: datos epidemiológicos y riesgo de malignización.

A series is presented of 152 patients diagnosed over a 9-year period by endoscopy and biopsy as Barrett's esophagus. We analyzed epidemiological data and the risk of malignancy, and calculated the prevalence and incidence in our series.

[Colorectal cancer: are diagnostic delay, degree of spread and survival related? Clinical analysis of 307 cases followed up for more than 4 years]. / Cáncer colorrectal: existe relación entre el retraso diagnóstico, su grado de extensión y la supervivencia? Análisis clínico en 307 casos seguidos más de cuatro años.

It seems logical to think that the longer the interval between the patient's first symptom of colorrectal cancer and operation, the greater the tumoral extension found by the surgeon will be, and the lower the postoperative survival. Nevertheless, there is much evidence to indicate that this may not always be true. We've analyzed the problem in 307 patients operated of colorectal cancer in our service from January 1979 to December 1984 and followed-up until now. We investigated the time interval from the first clinical symptom until operation, and survival. These variables were related to the Duke grade. As regards the preoperative interval, the average (in months) for Duke's grade A was 7.41 (sigma = 16.88), for D it was 7.41 (sigma = 9.47) and for C, 5.13 (sigma = 8.41). There were no statistically significant differences. As for survival, after four years all the grade A patients, 64% of the grade B patients and 35% of the grade C patients followed-up survived. We've found no relation between diagnostic delay and postoperative survival. These results suggest that it is not true that the longer the symptomatic period, the greater the tumoral spread. As such, diagnostic delay is not a good prognostic indicator for predecting tumoral spread or survival.