Andre Duranceau

Malignant Tracheoesophageal Fistula

Malignant tracheoesophageal fistula occurs infrequently in patients with esophageal and lung cancer. However, the occurrence of this entity is very distressing for the patient since it leads to rapid deterioration and death due to overwhelming pulmonary infection. A review of cases reported in the recent world literature is presented. The only effective treatment is to exclude the fistula from the alimentary tract. This may be achieved by intubation or operation. Intubation is probably associated with a lower mortality but is less certain to control the fistula. Single-stage operative exclusion and bypass is preferred under ideal circumstances. However, the patients condition may dictate that a two-stage operation be performed--first, operative exclusion of the fistula and then, if the patients respiratory and nutritional state improves sufficiently, restoration of alimentary continuity at a later date.

Mucosal damage in the esophageal remnant after esophagectomy and gastric transposition.

Objective:To assess development of mucosal damage in the esophageal remnant in regard to the level of the esophagogastrostomy reconstruction either in a right chest or in a left neck position. Summary Background Data:Esophagectomy with gastric interposition creates an in vivo human model of pathologic esophageal reflux with the potential for long-term reflux disease complications. Methods:Eighty-four esophagectomy patients were assessed over time by symptoms, endoscopy and biopsies of their esophageal remnant after the operation. The anastomosis was in the right upper chest (n = 36) or in a left cervical position (n = 48). Visual quantification of damage, details of histopathology, and time period since surgery were recorded. Results:Twenty-nine patients (81%) with a right chest reconstruction had reflux symptoms when compared with 25 patients (53%) with a neck reconstruction (P = 0.007). Visualized reflux esophagitis was observed in 31 patients (81%) with chest anastomoses and in 22 patients (46%) with cervical anastomoses (P = 0.006). Documented mucosal damage and columnar lined metaplasia were significantly more frequent in the chest anastomosis group than the cervical group. The median of all mucosal damage and columnar lined metaplastic-free evolution were 13 ± 3 and 20.5 ± 6 months for the intrathoracic anastomosis, and 22 ± 6 months and 40 ± 8 months for the cervical anastomosis (P = 0.087). Two factors affecting the development of metaplasia were included in the multivariate analysis: an intrathoracic anastomosis (P = 0.018) and the presence of a previous Barrett esophagus (P = 0.064). Conclusions:When a gastric transplant is used after esophagectomy, a high prevalence of mucosal damage is observed in the esophageal remnant independently of the level of reconstruction. A left cervical anastomosis favors less reflux symptoms, less visualized damage, and delays the development of mucosal damage over time.

Proliferative Activity in Barrett’s Esophagus Before and After Antireflux Surgery

ObjectiveTo assess proliferation in the columnar-lined esophageal mucosa before and after antireflux surgery. Summary Background DataIntestinal metaplasia persists in Barrett’s mucosa after reflux control. It remains at risk for uncontrolled cellular proliferation and adenocarcinoma formation. MethodsForty-five patients with Barrett’s esophagus had a mean follow-up of 4 years after a Collis-Nissen gastroplasty. Proliferative activity was assayed immunohistochemically for Ki-67 expression in 73 preoperative and 176 postoperative biopsies. Correlation with manometric and 24-hour pH results was obtained. ResultsThe Collis-Nissen gastroplasty restored the median lower esophageal sphincter gradient from 5.5 mmHg before surgery to 14.5 mmHg at 24 months and 12.9 mmHg at 48 months after surgery. The median esophageal acid exposure was reduced from 8% to 1% and 1% of recording time, respectively. The median Ki-67 labeling index increased from 28.5% before surgery to 36.1% at 12 to 23 months. It returned to preoperative level (26.9%) at 24 to 47 months. After surgery, abnormal intraesophageal acid exposure was documented in 12 patients but could not be correlated with sphincter pressure. After surgery, the pattern of proliferation in patients with acid exposure less than 4% in their esophagus showed significant differences when compared with the proliferation pattern of patients where abnormal intraesophageal acid exposure was recorded. New present dysplasia was observed only in patients with abnormal acid exposure. ConclusionsIn Barrett’s mucosa, from preoperative values, proliferation peaked early after surgery and then decreased to preoperative levels. Despite sphincter restoration and global reflux control, abnormal esophageal acid exposure persisted in 12 patients. Patients with abnormal esophageal acid exposure displayed more proliferation and more dysplasia.

Uncut collis-nissen gastroplasty: early functional results

BACKGROUNDnThis study reviewed the short-term results of the uncut Collis-Nissen gastroplasty.nnnMETHODSnFrom 1990 through 1993, 27 consecutive patients (16 men, 11 women) underwent an uncut Collis-Nissen gastroplasty. Mean age was 59 years (range, 30 to 75 years). Three patients had a previous failed antireflux procedure. Indications for operation were gastroesophageal reflux disease resistant to medical treatment in 18 patients and symptomatic hiatal hernia in 9 patients. Fourteen patients had Barretts esophagus and 4 had a peptic stricture. Complete esophageal function testing including barium swallow, endoscopy, manometry, and 24-hour pH recording was performed in 26 of 27 patients preoperatively and postoperatively.nnnRESULTSnFive patients (19%) had complications, which included atelectasis in 2, cardiac dysrhythmia in 2, and prolonged ileus in 1. There were no operative deaths. Follow-up was complete in all patients and ranged from 8 to 45 months (mean, 22 months). Subjectively, symptoms of reflux were resolved in all patients. Six patients complain of slow esophageal emptying and 3 have occasional episodes of dysphagia. None required postoperative dilation. Ulcers and erosions healed in all 26 patients who underwent endoscopy but recurred in 2 at 21 and 36 months postoperatively. Mean lower esophageal sphincter gradient increased from 8.3 mm Hg preoperatively to 14.6 mm Hg (p = 0.0001). Total percent of acid exposure decreased from 8.0% preoperatively to 1.7% (p = 0.003).nnnCONCLUSIONSnWe conclude that the uncut Collis-Nissen procedure provides acceptable short-term control of gastroesophageal reflux disease.

Sleeve recording of upper esophageal sphincter resting pressures during cricopharyngeal myotomy

OBJECTIVEnThe manometric effects of a 6-cm cricopharyngeal myotomy are recorded while the operation is being performed from cervical esophagus to the cricopharyngeus and then to the hypopharynx.nnnSUMMARY BACKGROUND DATAnCricopharyngeal myotomy is used in the treatment of oropharyngeal dysphagia of different causes. The operation decreases the resting pressure in the upper esophageal sphincter (UES). The components responsible for this decrease have not been clarified.nnnMETHODSnFourteen patients with oropharyngeal dysphagia underwent a sleeve recording of the UES resting pressures under general anesthesia before and after sequential myotomy of the pharyngoesophageal junction. Patients were assessed in the awake state before and after the whole myotomy.nnnRESULTSnUpper esophageal pressures remain unchanged after division of 2 cm of the cervical esophageal muscle. Section of 2 cm of the cricopharyngeal area results in a significant decrease of the sphincter resting pressure (p < 0.01). The division of 2 cm of hypopharyngeal muscle results in a further significant reduction of the resting pressure (p < 0.005).nnnCONCLUSIONSnExtension of the cricopharyngeal myotomy over hypopharyngeal musculature produces a more significant decrease of UES resting pressure.

Late retrograde perfusion of donor lungs does not decrease the severity of primary graft dysfunction.

BACKGROUNDnThe ideal preservation strategy has yet to be established in lung transplantation. This clinical study compares primary graft dysfunction using antegrade and retrograde perfusion of donor lungs.nnnMETHODSnOver a 6-year period, 153 consecutive patients underwent lung transplantation in our institution. Group I consists of 65 patients who received lungs preserved with an antegrade flush of modified Euro-Collins solution. Group II includes 65 patients who received lungs preserved with an antegrade flush of low-potassium dextran (LPD) solution. Group III consists of 23 patients who received lungs preserved with an antegrade and a preimplantation retrograde flush of LPD solution. Endpoints evaluated were the following: acute lung injury (ALI) score, time to achieve a fraction of inspired oxygen (Fio2) of 40% and a positive end-expiratory pressure (PEEP) of 5, length of ventilation, length of intensive care unit (ICU) stay, 90-day operative mortality, and patient survival rates.nnnRESULTSnThe patient demographic data, underlying diagnosis, number of single and double lung transplants, use of cardiopulmonary bypass, and mean ischemic times were similar in all 3 groups. The mean ALI score (6.2, 5.8, and 6.0) and the median length of ventilation (23.5, 24.0, and 27.0 hours) in groups I, II, and III, respectively, were not significantly different. The length of ICU stay, the 90-day operative mortality, and the survival rates were not significantly different in the 3 groups.nnnCONCLUSIONSnOur results suggest that late retrograde perfusion of donor lungs does not decrease the severity of primary graft dysfunction when compared with standard antegrade techniques.

An experimental model of pulmonary embolism.

Abstract Previous experimental studies have contributed to the diagnosis and management of pulmonary embolism in patients. However, most experimental techniques to produce pulmonary embolism used material with a structure and composition quite unlike the pulmonary emboli which occur in patients. This report describes a method to induce pulmonary embolism by using a subcutaneously implanted prosthetic graft for thrombus formation. Dogs were prepared by anastomosis of the graft from the distally ligated carotid artery to the proximally ligated femoral artery to provide initial blood flow which led to gradual graft occlusion by laminar deposition of fibrin and blood elements. Seven of 10 animals examined developed a large quantity of formed thrombus within the graft 5 days following implantation. A subsequent intravenous administration of a quantity of 0.2 g/kg of animal weight produced a massive pulmonary embolus which caused hemodynamic alterations in all 36 animals studied and proved lethal in four. Pulmonary embolism was induced in 20 dogs and the systemic arterial pressure, pulmonary arterial pressure, pulmonary arterial blood flow, left atrial pressure, static and dynamic lung compliance were observed for a 2-hr period. One group of 10 dogs was subjected to pulmonary embolism using fresh autologous blood clot, and the other group of 10 dogs was subjected to formed thrombus obtained by gradual occlusion of a prosthetic graft anastomosed to the carotid and femoral arteries and placed subcutaneously. Neither group of animals demonstrated significant alterations of systemic blood pressure. However, two animals died and two other animals developed significant hypotension in the group of 10 animals subjected to formed thrombus pulmonary embolism. None of the animals subjected to autologous blood clot developed significant hypotension. The pulmonary artery pressure increased in animals subjected to clot but returned to control values within 60 min. A much larger increase in pulmonary artery pressure was observed following embolism using formed thrombus and the pulmonary artery pressure remained elevated for the duration of study. Pulmonary mean blood flow did not change significantly in dogs subjected to clot but decreased significantly for a 60-min period in dogs subjected to formed thrombus. Left atrial pressure increased and static and dynamic compliance decreased significantly in dogs subjected to formed thrombus embolism, but no significant changes occurred in dogs which received fresh blood clot. This study documented significant differences in hemodynamic and ventilatory alterations induced by material with different mechanical properties. In addition, these observations indicate that the approach to inducing pulmonary embolism using thrombus recovered from a subcutaneous graft represents a useful experimental technique for evaluation of pulmonary embolism.

Major airway laceration secondary to endobronchial ultrasound transbronchial lymph node biopsy.

A 48-year-old woman underwent complete mediastinal lymph node staging for non-small-cell lung cancer. After convex endobronchial ultrasound (EBUS)-guided transbronchial biopsy of the subcarinal lymph node station (station no. 7), it was noted that a laceration had occurred in the left mainstem bronchus. The tear occurred at the medial cartilaginous-membranous junction, seemed to be full thickness into the mediastinum, and was approximately 1.5cm long. The cytologic results of all lymph node biopsies were negative and the patient underwent right upper and middle lobe bilobectomy 12 hours after the EBUS procedure. This is the first report of a serious airway injury occurring during convex EBUS lymph node biopsy.

Results of the Collis-Nissen gastroplasty to control reflux disease in patients who have Barrett's esophagus.

Barretts esophagus is an end-stage gastroesophageal reflux complication with a potential for malignant transformation. This condition probably is involved in esophageal cancer being perceived today as the most rapidly increasing cancer in Western countries. Numerous observations suggest that standard antireflux operations fail over time because of long-term inflammatory and fibrotic changes in the esophageal wall that cause shortening of the esophagus. The addition of esophageal elongation by gastroplasty provides a reliable repair by creation of a tension-free repair, whereas the durable antireflux effects are provided by the total fundoplication around the neoesophagus. The restored LES tone further helps control the mucosal damage and the chronic inflammatory changes. Complete regression of the abnormal mucosa still does not occur, and persistent irritation of that mucosa still entails the risk for progression toward dysplasia. The natural history of the columnar-lined mucosa in BE may be altered by medical or surgical intervention. It is too early to judge in which settings these interventions will be meaningful.

Comparative changes in ventilatory dead space following micro and massive pulmonary emboli.

Ventilatory dead space measurements have been described and used as a simple, rapid, and reliable method to diagnose pulmonary vascular obstruction [3]. Robin [9, lo] was one of the first to suggest the utilization of ventilatory dead space as a physiologic approach to the diagnosis of acute pulmonary embolism. However, cardiac failure, emphysema, chronic obstructive lung disease, and any lung disease that produces ventilation perfusion abnormalities will usually alter the normal ventilatory dead space [7]. Therefore, the perfusion lung scan and pulmonary arteriogram remain the primary means of objectively diagnosing pulmonary embolism. In previous studies using small emboli, the correlation between ventilatory dead space and the arterial partial pressure of oxygen (P,OZ) showed that ventilatory dead space was an even more reliable index of pulmonary arterial obstruction than the P,O, alone [3]. In subsequent experiments, it was found that the changes in V were not as impressive with massive pulmonary emboli as they were with small emboli. The present work was undertaken to evaluate the changes in I/ following massive, mediumsized, and micro pulmonary emboli.