André Duranceau

Clinical spectrum of bronchogenic cysts of the mediastinum and lung in the adult

Bronchogenic cysts are closed sacs considered to be the result of an abnormal budding of the respiratory system. They are lined by ciliated epithelium and have focal areas of hyaline cartilage, smooth muscle, and bronchial glands within their walls. They are seldom seen in the adult, and most are thought to be asymptomatic and free of complications. During a 20-year period, 86 patients underwent resection of a bronchogenic cyst of the mediastinum (66 patients) and lung (20 patients). There were 47 women and 39 men whose ages ranged from 16 to 69 years. Seventy-two percent of patients (67% with mediastinal cysts and 90% with cysts of the lung) were symptomatic at the time of operation, and the majority had two or more symptoms. Despite extensive investigations, which in some cases included computed tomographic scanning (n = 12) and angiography (n = 22), a positive diagnosis was never made preoperatively even if it was suspected in 57% of patients. In nearly all patients, the operative approach was that of a posterolateral thoracotomy. All but two mediastinal bronchogenic cysts could be locally excised, but all bronchogenic cysts of the lung required pulmonary resection (lobectomy, 13; limited resection, 6; pneumonectomy, 1). Major operative difficulties were encountered in 35 patients, all of whom were symptomatic preoperatively. Thirty-three patients had a complicated cyst; the complications consisted of fistulization (n = 16), ulcerations of the cyst wall (n = 13), hemorrhage (n = 2), infection without fistulization (n = 1), and secondary bronchial atresia (n = 1). Overall, 82% of patients had a bronchogenic cyst that was either symptomatic or complicated or both.(ABSTRACT TRUNCATED AT 250 WORDS)

Long-term effect of total fundoplication on the myotomized esophagus.

From 1978 to 1983, 17 patients had an esophagocardiomyotomy with an added short total fundoplication as an antireflux procedure. Thirteen had achalasia and 4, diffuse esophageal spasm. All patients initially had the usual symptoms of these motor disorders. Early after the operation all became asymptomatic, but over the years of follow-up, symptoms reappeared in 14 of 17 patients, and 5 required reoperation. The distal esophageal transverse diameter showed progressive dilatation from 3.9 cm preoperatively to more than 6 cm after 10 years of evolution. Over the same period, deterioration in the esophageal emptying capacity caused esophageal stasis to increase from 32% to 75%. Manometric changes were significant after the operation: resting pressures in the esophageal body decreased from 10.5 to 4.4 mm Hg (p < 0.001) proximally and from 12.2 to 4.6 mm Hg distally (p < 0.001). Peak contraction pressures became significantly weaker: 38 to 30 mm Hg in the proximal esophagus (p < 0.001) and from 49.2 to 28.1 in the distal esophagus (p < 0.001). Tertiary contractions were unchanged distally, but peristalsis reappeared in more than 30% of all swallows in the proximal half of the esophageal body. The resting pressure gradient in the lower esophageal sphincter area was reduced from 25.5 to 7.4 mm Hg by the operation. This gradient remained stable over 10 years of follow-up. No significant acid exposure was documented in 8 patients undergoing 24-hour pH recordings after their operation. Endoscopy revealed dilatation and retention without evidence of reflux esophagitis damage. Total fundoplication when associated with esophageal myotomy results in improved symptoms in the early postoperative phase.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparative Esophageal and Anorectal Motility in Scleroderma

Esophageal and anorectal pressures were recorded in 26 patients (4 men and 22 women) with scleroderma. Eleven patients suffered from a localized form of the disease and 15 from progressive systemic sclerosis. The latter only had marked functional abnormalities in esophageal and anorectal motility. Mean resting pressure at the lower esophageal sphincter of patients with progressive system sclerosis and controls was, respectively, 6 +/- 2 and 25 +/- 1 mmHg (p less than 0.001); mean closing pressure was 5 +/- 5 and 48 +/- 3 mmHg (p less than 0.001); coordination of opening the lower esophageal sphincter with the oncoming contraction in the distal esophagus was 0% and 68% +/- 5% (p less than 0.001); and relaxation (fall of the lower esophageal sphincter pressure to resting levels in the stomach) was 18% +/- 12% and 98% +/- 1% (p less than 0.001). The rectoanal inhibitory reflex was of lesser amplitude than normal in 74% of patients with progressive system sclerosis and was absent in 13%. Quantitative analysis demonstrated a significant reduction in response to rectal distention with 20 or more ml of air (p less than 0.001). There was a correlation between the amplitude of the lower esophageal sphincter relaxation and the amplitude of the rectoanal inhibitory reflex in response to rectal distention with 30-50 ml of air (p less than 0.05 to p less than 0.025). Our data show that in systemic sclerosis, anorectal motility is as frequently abnormal as esophageal motility.

Results of the Collis-Nissen gastroplasty in patients with Barrett's esophagus.

BACKGROUND Barretts esophagus (BE) is an advanced stage of gastroesophageal reflux disease. Medical treatment and standard antireflux operations show a high failure rate. An elongated gastroplasty, wrapped by a total fundoplication should provide a tension-free repair with adequate protection against reflux. The aim of this study is to review the operative effects of a Collis-Nissen gastroplasty to treat reflux in Barretts esophagus. METHODS From January 1989 to December 1997, 45 patients with BE (38 men, 7 women) aged 53.5 years, underwent a Collis-Nissen gastroplasty. Mean follow-up is 35.9 months (range, 6 to 110 months). Pre- and postoperative evaluations included symptom assessment, esophagogram, endoscopy, manometry, 24-hour pH study, and esophageal emptying scintigrams. RESULTS There were no operative deaths. All reflux symptoms were controlled. Acid reflux was significantly reduced (percent time exposure decreased from 10% to 1%) and lower esophageal sphincter (LES) pressure were restored to normal (LES gradient increased from 4 mm Hg to 11 mm Hg). LES incomplete relaxation was noted in 50% of patients postoperatively. Endoscopically, mucosal damage from reflux healed but the columnar mucosa with intestinal metaplasia persisted. CONCLUSIONS The Collis-Nissen gastroplasty, in patients with BE, controls reflux disease, its symptoms, and the mucosal damage associated with this condition. It restores the LES gradient but increases the resistance to bolus transit. There is no regression of the abnormal mucosa despite reflux control.

Preoperative embolization in the management of a mediastinal paraganglioma

Parangliomas are rare and highly vascular tumors of neuroendocrine cell origin which are treated by complete surgical resection. Preoperative embolization to reduce perioperative bleeding complications, although described in paragangliomas of the neck and carotid body, has never before been described in the case of a mediastinal paraganglioma. The following is a presentation of such a case of mediastinal paraganglioma, in which embolization was used successfully before surgical resection.

Cricopharyngeal myotomy for neurogenic oropharyngeal dysphagia

BACKGROUND Forty patients (18 women, 22 men) with incapacitating oropharyngeal dysphagia of neurologic origin underwent cricopharyngeal myotomy. The subjective and objective response to myotomy was analyzed retrospectively with a mean postoperative follow-up of 48 months (range 1 to 255 months). RESULTS Radiologic evidence of functional obstruction caused by incoordination and incomplete relaxation of the upper esophageal sphincter was significantly reduced. Manometric recordings of resting and closing pressures of the upper esophageal sphincter were also significantly altered by the myotomy. Resting pressures decreased from 65 to 18 mm Hg and closing pressures dropped from 69 to 22 mm Hg. The relaxation time and poor coordination at the level of the upper esophageal sphincter, observed in the preoperative period, persisted after the operation. Radionuclide emptying studies in which a single liquid bolus was used showed persistent hypopharyngeal stasis with a 20% retention of radioactive material at 120 seconds. Subjectively, 33 patients initially had frequent aspiration episodes. Twenty became free of symptoms after myotomy (p < 0.01) and in six others the symptoms were improved. Overall, seven patients claimed to be free of symptoms of dysphagia and no longer had pharyngo-oral or pharyngonasal regurgitations and aspirations after their operation. Twenty-three other patients had improvement in symptoms. Ten patients reported no change in symptoms. All of them either were unable to swallow voluntarily or had dysarthria when assessed before the operation. One retropharyngeal hematoma is the only postoperative complication recorded. The operative mortality was 2.5% (1/40). CONCLUSIONS Cricopharyngeal myotomy palliates neurogenic oropharyngeal dysphagia in patients with intact oral-phase deglutition.

Antireflux Operations in Patients With Scleroderma

Fourteen patients with scleroderma underwent antireflux operations (10 short Nissen, 2 Collis-Nissen, 1 Collis-Belsey, and 1 vagotomy and antrectomy with Roux-en-Y). Esophageal function was assessed preoperatively and postoperatively with a follow-up range of 8 to 181 months (mean, 65 months). Reflux symptoms were relieved in 10 of the 14 patients (p < 0.01), as shown by a decrease in their 24-hour acid exposure of from 15% to 7.5% (p < 0.05). However, the lower esophageal sphincter pressure gradient created by the operations did not increase significantly (3.7 +/- 3.4 mm Hg to 5.5 +/- 3.5 mm Hg). The esophageal acid exposure decreased sufficiently to promote some alleviation of the esophagitis. Radiologic signs of stenosis regressed in 6 of 7 patients. Postoperative endoscopic assessment revealed complete or partial healing of erosions seen preoperatively in 6 of the 7 patients so studied, and healing of all ulcers in 3 patients. Twelve patients continued to have columnar metaplasia. Manometric studies disclosed no significant changes in propulsion and contractility. Distal esophageal resting pressures rose significantly from 6.2 to 9.4 mm Hg (p < 0.05 mm Hg), suggestive of stasis. Radionuclide transit studies, however, showed no significant decrease in the esophageal emptying capacity after operation. It is concluded that conventional antireflux operations in patients with scleroderma can palliate reflux damage without jeopardizing esophageal function.

Oropharyngeal Dysphagia and Oculopharyngeal Muscular Dystrophy

Oculopharyngeal muscular dystrophy is an autosomal dominant transmitted condition seen mainly in French Canada. The largest number of publications on these patients concerns a Quebec family whose descendants have spread throughout the United States. Families of different ethnic origins have also been reported from around the world, although there is no evidence that the neuromuscular disease reported is the same, despite the similarity of the syndrome. When severe oropharyngeal dysphagia results, these patients can significantly benefit from a cricopharyngeal myotomy.

Cricopharyngeal myotomy in the management of neurogenic and muscular dysphagia

Oropharyngeal dysphagia results from disruption of the integrated mechanism of swallowing. Neurogenic dysphagia is caused by central nervous system disorders or by cranial nerve involvement and it may be distinguished from muscular dysphagia such as that seen mostly in oculopharyngeal muscular dystrophy (OPMD). Based on our 20-year experience in a university hospital thoracic surgery service, we describe the results of the clinical evaluation, the laboratory testing and the surgical management of a recent subgroup of patients experiencing dysphagia from neurogenic and muscular disorders.

Thoracoscopic localization of intraparenchymal pulmonary nodules using direct intracavitary thoracoscopic ultrasonography prevents conversion of VATS procedures to thoracotomy in selected patients

OBJECTIVES To investigate the feasibility, accuracy, and effect on conversion rates of intracavitary video-assisted thoracoscopic surgery ultrasonography (VATS-US) for localization of difficult to visualize pulmonary nodules. METHODS The study consisted of a prospective cohort of VATS-US for localization of intraparenchymal peripheral pulmonary nodules. Patients with pulmonary nodules not touching the visceral pleura on the computed tomography scan, who were scheduled for VATS wedge resection, were prospectively enrolled. The lobe of interest was examined: visually, using finger palpation when possible, and using the instrument sliding method. The nodule was then sought using a sterile ultrasound transducer. The primary outcome measure was the prevention of conversion to thoracotomy or lobectomy secondary to positive VATS-US findings in patients with nodules that were not identifiable using standard VATS techniques. RESULTS Four different surgeons performed 45 individual VATS-US procedures during a 13-month period. Intracavitary VATS-US was able to detect 43 of 46 nodules. The sensitivity of VATS-US was 93%, and the positive predictive value was 100%. The lung nodules were visualized by thoracoscopic lung examination in 12 cases (27%), palpable by finger in 18 cases (40%), and palpable using the instrument sliding technique in 17 cases (38%). In 20 cases, lung nodules were not identifiable using any of the traditional techniques and were identified only with VATS-US. VATS-US, therefore, prevented conversion to thoracotomy or lobectomy without tissue diagnosis in 43% (20/46) of cases. CONCLUSIONS Intracavitary VATS-US is a real-time, feasible, reliable, and effective method of localization of intraparenchymal pulmonary nodules during selected VATS wedge resection procedures and can decrease the conversion rates to thoracotomy or lobectomy.