Colon interposition for esophageal replacement: current indications and long-term function.

BACKGROUND: In contrast to the use of the stomach as an esophageal substitute, the use of the colon is becoming uncommon. METHODS: From 1985 to 1995, 60 patients underwent colon interposition for esophageal cancer (n = 37), benign stricture (n = 13), iatrogenic fistula (n = 5), achalasia (n = 3), or necrosis of a previous substitute (n = 2). A long isoperistaltic conduit based on the left colonic artery could be used in 52 patients (86.7%). The surgical route used was through the esophageal bed in 38 patients (63.3%), under the sternum in 21 patients, and under the skin in 1 patient. RESULTS: Colon interposition represented 18.5% of all operations performed for esophageal substitution during the study period. The choice of the colon resulted from an inadequate stomach in 33 cases (55%). The operative mortality rate was 8.3%. Seven patients (13.5%) required dilation of the esophagocolonic anastomosis. At last follow-up, 34 patients (65.4%) had no difficulty eating. Multivariate analysis identified the conduit position in the posterior mediastinum as the sole independent predictor of a good functional result (p = 0.002). CONCLUSIONS: Colon interposition for esophageal substitution, usually performed when the stomach is not available, provides satisfactory function when placed in the esophageal bed.

Long-term complications of extraperiosteal plombage.

BACKGROUND: As soon as complications due to migration of extraperiosteal plombage material had been documented, early removal became the rule. Some patients who have escaped this rule may still present with long-term complications. METHODS: Since 1980, 14 patients aged 54 +/- 10 years were admitted 28 +/- 11 years after collapse therapy. Eight presented with signs of infection, 4 with hemoptysis, and 2 with periscapular pain. Vascular erosion, suspected in 3 patients, was demonstrated with angiograms in 1. RESULTS: Ablation of the material was combined with excision of the devitalized ribs in 13 patients. Femorofemoral bypass was used in 2 patients for repair of an aortic erosion. Single ablation of subcutaneously migrated material was performed in a poor-risk patient. Operative bleeding was moderate except in 2 patients; 1 of them died intraoperatively during repair of an aortic erosion. A second patient died postoperatively with a massive pulmonary embolus on day 11. Infection was diagnosed in 8 patients (Mycobacterium tuberculosis, 4; and pyogens, 4). Operative outcome was satisfactory in all 12 operative survivors. A single patient presented with an infected apical space at 1 year and underwent complementary resection of the first rib. CONCLUSIONS: We recommend routine ablation of any residual plombage material whenever operative risk is acceptable because of the high incidence of spontaneous complications.

[Technique and results of colonic esophagoplasties]. / Technique et résultats des oesophagoplasties coliques.

From 1985 to 1995, 60 patients with a mean age of 52 +/- 12 years [24-78] underwent colon interposition for esophageal replacement. Indications were esophageal cancer (n = 37), benign stricture (n = 13), iatrogenic esophageal fistula (n = 5), achalasia with megaesophagus (n = 3), and necrosis of a previous substitute (n = 2). Colon interposition represented only 18.5% of all operations performed for oesophageal replacement during the same period. The colon was selected because of inadequate stomach in 33 cases (55%). Long-segment conduit based on the ascending branch of the left colonic artery was the preferred method and could be used in 52 patients (86.7%). The colon was placed in the esophageal bed in 38 patients (63.3%), substernally in 21 (35%), and subcutaneously in 1. Overall operative mortality and morbidity were 8.3% and 65% respectively. Five-year survival rate was 9% in the 37 patients with esophageal cancer. Seven patients (13.5%) required one or more dilatations of the esophagocolonic anastomosis. At last follow-up, 34 patients (65.4%) had no difficulty eating. Multivariate analysis identified the conduit position in the posterior mediastinum as an independent predictor of good functional result (p = 0.0018). We conclude that colon interposition for esophageal replacement provides satisfactory and durable function; however, early mortality and morbidity are substantial.

[Surgical treatment of esophageal cancer in patients over 70 years of age]. / Traitement chirurgical du cancer de l'oesophage chez les malades âgés de 70 ans et plus.

As the population continues to age, septuagenarian patients with esophageal cancer are frequently referred for surgical treatment. The aim of this study was to analyze with respect to their age the outcome of 386 patients who underwent esophagectomy and simultaneous reconstruction from 1979 to 1994. The portion of patients of 70 years of age and older (14.5%) has slightly increased during the period. Location to the lower third of the esophagus and adenocarcinoma type were prevalent in the 56 elderly patients (Group I), but postsurgical TNM staging was identical to that of the 330 younger patients (Group II). Other clinical features, i.e., preoperative weight loss and presence of co-morbid diseases, however, were comparable in both groups. Pulmonary function, as assessed by spirometry, was significantly worse among the older patients, but blood gas determinations were not different. Operative mortality was comparable among the 2 groups (10.7% vs 11.2%). Major morbidity included anastomotic leak (10.7% vs 13.6%) and pulmonary complications (17.9% vs 20.6%) in both groups. Long term survival was not different in elderly patents (5-year rate: 17%) when compared with that of younger patients (18.9%). These data suggest that 1) esophagectomy can be performed in selected septuagenarian patients with an acceptable risk, and 2) long-term survival with excellent functional status is attainable in this age group in a portion of these patients.

[Prognostic value of UICC-1987 classification in primary lung cancers]. / Intérêt pronostique de la classification UICC-1987 des cancers bronchiques primitifs.

In order to test the validity of the new 1987-UICC classification (4th ed.) for lung cancer, data from 456 patients who underwent pulmonary resection for bronchogenic carcinoma from 1980 to 1985 were analysed retrospectively. Overall survival rate was 32.7% at 5 years. Prognostic significance of the tumour formula (pTNM) was assessed by multivariate analysis: N lymph node involvement appeared to be the most pejorative factor (p < or = 10(-5)), followed by the T factor (p < or = 0.002) and the M factor (p < or = 0.01). Respective survival curves were compared. Excluding the correlation between T1 and T2 tumours, the prognosis became significantly more unfavourable as the values for the pTNM classification criterion rose. Differences in prognosis between stages I and II, II and III A, III B and IV were not statistically significant for methodological reasons and inappropriate regroupings. Thus, our results partially confirm the prognostic value of the new international staging system. Meanwhile, this classification constitutes a prerequisite for the evaluation of end-results of therapy and the estimation of prognosis.

[Bronchial cancer associated with atheromatous arteriopathy. Prognostic and therapeutic consequences in pulmonary excision]. / Association cancer bronchique et artériopathie athéromateuse. Conséquences pronostiques et thérapeutiques dans la chirurgie d'exérèse pulmonaire.

Between January 1980 and January 1985, 462 consecutive patients underwent lung resection for bronchogenic carcinoma. Eighty of these patients (17.3 percent) had atherosclerosis involving mainly the coronary arteries (40 percent). The mortality rate was significantly higher in patients with atherosclerosis (10 percent) than in those without it (4.7 percent), but the long-term survival was not affected with the presence of atherosclerosis. The lung carcinoma-atherosclerosis association raises two problems: what investigations should be carried out in this group of patients at risk, and what treatment should be given priority when vascular lesions are present and likely to become complicated by pulmonary surgery? However, the presence of atherosclerosis should not lead to a re-evaluation of the need for lung resection.

[Results of surgery of non-small cell primary bronchial cancers. Retrospective analysis of 452 resections]. / Résultats de la chirurgie des cancers bronchiques primitifs non microcellulaires. Analyse rétrospective de 452 exérèses.

Data from 452 patients who underwent pulmonary resection for a non small cell bronchogenic carcinoma from 1980 to 1985 were analysed retrospectively. The operative mortality rate was 5.5%. Mortality was significantly increased in patients who underwent enlarged resections for T4 tumors (20%; p < or = 0.05), and in patients who were 70 years and older (12.8%; p < or = 0.05). The overall 5-years survival rate was 32.7% at 5 years. Prognosis in patients who were 70 years and older was similar to that in younger patients. No difference in survival was observed in patients with lymph node metastases with regard to the operative procedure (pneumonectomy versus lobectomy). Survival in patients without lymph node metastases who underwent a lobectomy was similar to those who underwent a conservative resection. Prognostic significance of the histologic cell type and the tumor formula (pTNM) was assessed by multivariable analysis. There were statistically significant differences between squamous cell carcinoma and both adenocarcinoma (p < or = 10(-5)) and undifferentiated carcinoma (p < or = 0.01). This study confirmed the validity of the TNM classification (4th ed) for the accurate prognosis evaluation. Lymph node involvement appeared to be the most pejorative factor (p < or = 10(-5)).

[The danger present to the spinal cord arterial vasculature during surgery of nerve-tissue tumors of the posterior mediastinum]. / Danger représenté par la vascularisation artérielle médullaire au cours de la chirurgie des tumeurs nerveuses du médiastin postérieur.

The authors report one case of posterior mediastinal neurinoma with a Adamkiewicz artery arising at an atypical site. They stress the spinal cord complications following thoracic surgery. The value of spinal cord arteriography during preoperative examinations and for prevention of complications is discussed.

[Danger to spinal cord arterial vascularization during surgery for neurogenic tumors of the posterior mediastinum]. / Danger représenté par la vascularisation artérielle médullaire au cours de la chirurgie des tumeurs nerveuses du médiastin postérieur.

The authors report one case of posterior mediastinal neurinoma with a Adamkiewicz artery arising at an atypical site. They stress the spinal cord complications following thoracic surgery. The value of spinal cord arteriography during preoperative examinations and for prevention of complications is discussed.

[Preoperative staging of central bronchopulmonary cancer. X-ray CT-MRI-pulmonary digital subtraction angiography and surgery]. / Bilan pré-opératoire des cancers broncho-pulmonaires centraux. Corrélations TDM-IRM--angiographie pulmonaire numérisée et chirurgie.

In order to evaluate the reliability of medical imaging methods in the assessment of mediastinal invasion by lung cancers, a prospective study was conducted in 30 patients undergoing preoperative computed tomography (CT), magnetic resonance imaging (MRI) and pulmonary digital subtraction angiography. MRI improved the sensitivity of detection of surgically confirmed mediastinal lymphadenopathy, but its specificity in relation to histological results was poor and identical to that of CT. In terms of extension to vascular structures, MRI and CT gave comparable results for the pulmonary artery and vein with two false positives for the pulmonary veins and left atrium with the two methods. MRI was found to be superior to CT for the detection of invasion of the aortic arch. Digital subtraction angiography is not as reliable as the other two modalities, particularly for extension to the pulmonary vein for which it was found to be technically inappropriate. By means of sagittal and frontal scans, MRI was therefore found to be more effective than CT for examination of the subcarinal region and aorto-pulmonary window. In contrast, the persistence of false positives with the two methods and the impossibility of distinguishing between inflammatory lymph nodes and neoplastic lymph nodes means that thoracotomy can never be contraindicated on the basis of the results of imaging alone.

[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%).

[Surgical treatment of benign laryngotracheal stenosis. Apropos of 12 cases]. / Traitement chirurgical des sténoses laryngo-trachéales bénignes. A propos de douze observations.

The authors report a series of twelve benign laryngotracheal strictures. In almost every case, these lesions were secondary to tracheal intubation and consisted of extensive, circumferential and almost complete stenosis. All were treated surgically. The authors obtained enlargement of the airway be means of an interposed cartilaginous graft and an intraluminal prosthesis which was left in place. In nine cases, this procedure was combined with posterior cricotomy. One eight month old infant died during the postoperative period. Ten patients had an uneventful postoperative course with a satisfactory anatomical and functional result.

[Inoperable cancer of the esophagus: preliminary results of combined chemotherapy (5-fluorouracil-cisplatin) and radiotherapy]. / Cancers non opérables de l'oesophage: résultats préliminaires d'une chimiothérapie (5-fluorouracile-cisplatinum) avec radiothérapie concomitante.

The aim of this study was to appreciate the tolerance and efficacy of a new nonoperative therapy for inoperable esophageal squamous cell carcinoma based on chemotherapy (5FU-cisplatinum) and concomitant splitcourse radiation therapy. Twenty five symptomatic patients (24 males, 1 female, mean age: 59 yrs, range: 41-72 yrs) were included. Five had 2 esophageal carcinoma, 5 an associated upper respiratory tract tumor and 2, relapse after surgery. Nine patients had a tumor limited to the esophagus (stage I or II) but were considered at high surgical risk. Sixteen had stage III disease with mediastinal involvement in 13 cases, nodal involvement in 4 and distant metastasis in 7. Treatment consisted of 2 cycles of chemotherapy with 5-FU (1 g/m2/24 h by continuous infusion for 5 days, D1-D5 and D29-D33) and cisplatinum (70 mg/m2 IV bolus on D2 and D30). Radiation therapy was concomitant in 2 courses delivering 20 grays in 5 days (D1-D5 and D29-D33). On the first day of the treatment, peroral endoscopic dilation or Nd-YAG laser therapy was applied. At the end of treatment all the patients could eat. Histoendoscopic control was performed 8 weeks after the beginning of therapy. Seventeen of the 24 patients had a complete response with negative biopsies. Of the 7 patients with metastatic disease, only 4 were evaluable for response to chemotherapy: one with hepatic metastasis had a complete response for 12 months, 2 had stable disease and one progressive disease.(ABSTRACT TRUNCATED AT 250 WORDS)

Treatment of tracheobronchial lesions by laser photoresection.

One hundred eleven patients underwent 205 laser photo-irradiation treatments using a Neodynium YAG laser with a flexible bronchoscope or an open tube for various tracheobronchial conditions, such as obstructing bronchogenic carcinomas, bronchial adenomas, and postintubation tracheal stenosis. The procedure was performed with either local or general anesthesia. Results were especially rewarding with endobronchial tumors. Tracheal stenoses were best treated by a combination of laser surgery and tracheal dilatation. No complication was encountered. Specific indications suggested for laser surgery are resection of inoperable tracheobronchial tumors, correction of tracheal stenosis, removal of surgical sutures, retrieval of tissue-embedded foreign bodies, and cauterization of hemorrhaging endobronchial tissues.

[Treatment of tracheobronchial lesions with Laser Yag]. / Trattamento delle lesioni tracheobronchiali con Laser Yag.

Various tracheobronchial obstruction indications have been treated with laser yag neodyme with flexible fibre introduced into a bronchofibroscope. Experience covers 44 patients who underwent 75 photocoagulation sessions under local or general anaesthesia. Inoperable tracheo-bronchial tumours are the most frequent and spectacular indications. Malignant tumour, cylindromas, carcinomas and benign tumours are the best indications. Tracheal stenoses were treated in association with instrumental dilatation. The other indications proposed are resections of granulomas, resection of suture threads, extraction of peripheral foreign bodies and control of major haemorrhages. No complications were observed. The immediate effectiveness of this new technique is considerable. Long-term development depends on the aetiology of tracheobronchial stenosis.