Management of non resectable malignant esophageal stricture and fistula

OBJECTIVE

The palliation of dysphagia caused by esophageal carcinoma and other inoperable tumours obstructing the esophagus presents a challenge for the thoracic surgeon, in particularly when associated with fistula (F). In a prospective study over the last 5 years, we have evaluated the effectiveness of different approaches and types of prostheses to solve the above problem.

METHOD

Thirty three patients (mean age: 63.5 years, range 42-76, M/F:24/9) with inoperable tumours obstructing the esophagus underwent intubation and/or palliative surgery according to the following protocol: (1) Preoperative esophagography; (2) endoscopy and biopsy; (3) dilatation and insertion of prosthesis usually under general anaesthesia; and (4) re-evaluation the following day, in 30 days and as required thereafter. Prosthesis used were: Atkinson 3, Wilson-Cook (plain) 12, Wilson-Cook (cuffed) 4, Strecker (metallic self-expandable) 13. The patients were divided in three groups according to the extension of the disease: group A (n = 19) plain malignant strictures, group B (n = 5) strictures with respiratory Fs, group C (n = 9) strictures with mediastinal or pleural Fs.

RESULTS

All patients of group A had successful palliation irrespectively of prosthesis used and site of obstruction. One patient required two stents. There was no death and 50% survival at 6 months was 70%. In group B, a cuffed prosthesis successfully closed two bronchoesophageal Fs, while three patients underwent retrosternal bypass surgery. There was one death on the 26th postoperative day. In group C, one Strecker, two plain Wilson-Cook and two cuffed Wilson-Cook stents, although initially succeeded, in due course, failed to block the Fs in five patients who subsequently underwent bypass surgery with one death. With four patients both leak and dysphagia were significantly improved with the use of self-expandable stents therefore, not requiring surgery. Overall, there were two deaths but no failure in palliating dysphagia. Longer survival was 20 months. Patients with fistulae had poorer prognosis as compared to those suffering from plain malignant stricture (P = 0.01).

CONCLUSIONS

Plain malignant inoperable oesophageal strictures can be successfully palliated with intubation. Complicated with fistula strictures, however, are difficult to manage and have a poor prognosis. Due to the fact that bypass surgery is associated with an increased mortality, it should be kept for those with late stent failures and fistula recurrences.

Primary hemangiosarcoma of the mediastinum

A case of a 44-year-old female who had an intrathoracic mass that was found to be a hemangiosarcoma of the anterior mediastinum is reported. Radical surgical incision through a right anterior thoracotomy was performed, followed by post-operative radiotherapy. Since this is a rare tumor at this location, the clinical and radiological findings, the histopathological appearances and its therapeutic management are discussed. Radiologists, surgeons and oncologists should in the differential diagnosis of a mediastinal mass include that of a tumor of vascular origin, even if it is rare. Radical excision followed by post-operative radiotherapy, especially in cases where the tumor has been partially excised, is the treatment of choice.

Video-assisted thoracoscopy in the evaluation of penetrating thoracic trauma

The management of patients who present with penetrating thoracic trauma but are haemodynamically stable may be subjective and imprecise. We report our initial experience with the use of video-assisted thoracoscopy in a series of five patients in whom accurate assessment was achieved and unnecessary thoracotomy avoided.

Nonischemic ventricular tachycardia: surgical or medical treatment?

Fifty-two consecutive patients with nonischemic ventricular tachycardia (VT) were seen between 1985 and 1991. Twenty-two patients underwent surgery, while in the remaining 30, the VT was well controlled on medication. In the surgical group, arrhythmogenic right ventricular dysplasia (ARVD) was the cause of VT in 12 patients, cardiomyopathy (CM) in 6, posttetralogy of Fallot repair in 2, myocarditis in 1, and myocardial hamartoma in 1. The mean number of drugs tried and found ineffective was 5.5. There were three early deaths; 13 patients are symptom-free without taking any medication. In the medical group, the pathology associated with the VT was myocarditis in 2 patients, CM in 11, and ARVD in 2. In ten patients, VT appeared idiopathic, 1 was exercise-induced, 3 were catecholamine sensitive, and 1 presented with long QT syndrome. Beta blockers controlled the symptoms in 43% of the patients, amiodarone in 20%, and flecainide in 17%. The mortality was higher in the surgical group, but 95% of them are VT-free, compared with those on medical treatment (55%) over the last 8 years' follow-up. In conclusion, the nonischemic VT is a serious condition. Medical therapy is usually effective, but if it fails, VT surgery should be considered.

Autotransfusion after coronary artery bypass surgery: is there any benefit?

Postoperative salvage autotransfusion of shed mediastinal blood, using the cardiotomy reservoir, is an inexpensive technique whose efficacy and safety are evaluated in this study. We randomized 75 consecutive patients into two groups. The autotransfusion group (n = 42) received autotransfusion after the completion of the coronary artery bypass grafting (CABG) until the drainage was < or = 50 mL per hour for 2 consecutive hours. The control group (n = 33) was treated with standard chest drainage. Both groups received homologous blood transfusion when the hematocrit fell below 30%. Packed red cells were required post-operatively in 84.8% of the control group and 80.9% of the autotransfusion group (p = NS). Postoperative colloid fluid replacement (excluding autotransfusion fluid) did not differ significantly between the groups. The prothrombin time was significantly higher in the autotransfusion group 24 hours postoperatively (p = 0.03). The fibrin degradation products were elevated only in the serum of the autotransfusion patients (p < 0.002). More febrile patients were seen in the autotransfusion group although not significantly more than the controls. The autotransfusion group received more red cells than the control group, but it lost more red cells in the mediastinal drains. In conclusion, the autotransfusion of shed mediastinal blood has not proved beneficial in reducing the postoperative requirements in homologous blood in patients undergoing coronary artery bypass grafting (CABG).

Packing the chest: a useful technique for intractable bleeding after open heart operation

Mediastinal bleeding can be a problem after cardiac surgery, either as a result of coagulation derangements or technical problems. We evaluated 100 patients, treated with temporary chest packing for intractable bleeding, of 9,383 undergoing open heart operations during a 10-year period. Preoperatively, 60 of these patients had one or more predisposing factors for bleeding. There were four predominant sites of hemorrhage: general ooze, needle holes of the aortic and atrial suture lines, inaccessible origin, and another specific place. The chest was packed in the operating room in 84 patients and in the intensive care unit in 16. Four methods of temporary chest closure were used: the skin alone, partial sternal approximation plus skin closure, full closure, and the wound open and covered by a Steri-drape dressing. The bleeding was controlled in 65 patients who had been packed once, and in 29 patients after reexploration and multiple packings, for a total of 94 patients (94%). Sternal wound infection, generalized sepsis, and sternal dehiscence was present in 24 patients, 8 of whom died. The venue for inserting or removing the packs did not affect the incidence of infections. Our experience suggests that packing of the chest after cardiac procedures for intractable bleeding allows a reasonable patient salvage rate and complication risks.

Open heart operation in patients suffering from hereditary spherocytosis

Hereditary spherocytosis is a clinically heterogeneous, genetically determined red blood cell membrane disorder resulting in hemolytic anemia. Structural or functional disorders of the cytoskeletal proteins result in the formation of spherocytes, which lack the strength, durability, and flexibility to withstand the stresses of the circulation. This problem can be accentuated by the deleterious effects of the heart-lung machine. Three patients with hereditary spherocytosis underwent open heart operation with no deaths and no serious complications resulting from the hematologic defect. Splenectomy is recommended, although not essential, before a cardiac operation, and mechanical valves should perhaps be avoided.

Fracture of the wire stent in a Carpentier-Edwards porcine bioprosthesis

A 60-year-old woman underwent mitral and aortic valve replacement with Carpentier-Edwards supra-annular bioprosthesis in 1986. Six years later rapidly progressing exercise dyspnea and orthopnea made hospital admission necessary. At chest x-ray and cardiac catheter examination one of the wire struts of the mitral bioprosthesis was found completely broken causing cusp prolapse. Surgical findings at reoperation confirmed the diagnosis. No apparent cause of the stent fracture was found.

Improved techniques in the surgical treatment of hepatic hydatidosis

We evaluated 64 patients with hepatic hydatidosis who were treated during 1982 to 1988. The main clinical manifestations were epigastric pain (84 per cent), hepatomegaly (31 per cent), fever (30 per cent) and jaundice (25 per cent). Five patients were asymptomatic. All diagnoses were established by ultrasonography and computed tomography, or both (sensitivity rates of 95 and 93 per cent, respectively). Treatment was exclusively surgical and there were no deaths. In the five patients in group 1, total cystectomy was done without morbidity. The 19 patients in group 2 underwent a limited capsectomy, evacuation of the cyst, omentoplasty, suturing of the biliary communications and drainage of the residual cavity, with a rate of morbidity of 42 per cent. In the 40 patients in group 3, a wide capsectomy and unroofing of the cyst were done, the contents were removed, the cavity edges were hemostatically oversewn and the residual hepatic cavity was drained through a high vacuum, closed drainage system. Omentoplasty was not routinely done. With this technique, the rate of morbidity was reduced to 2.5 per cent. Of 64 patients, 32 were observed for an average of 42 months with a recurrence rate of 9 per cent. Because of the low rate of postoperative morbidity, recurrence and the shorter period of hospitalization, the surgical technique used in group 3 seems to be an efficient method for hepatic hydatidosis.