Lajos Kotsis

Surgical aspects of 175 mediastinal goiters

OBJECTIVE Clinical picture and surgical management of 175 mediastinal goiters are discussed in this retrospective study. METHOD Between 1979 and 1996, 175 patients with intrathoracic goiters were operated on at the Thoracic Surgical Clinic in Budapest. The majority of the goiters were cervicomediastinal (n = 138, 79%), past the level of aortic arch, and the others were complete aberrant lesions (n = 37, 21 %). Of the patients, 40% (n = 70) were symptom-free, in the others the clinical picture was dominated by compressive symptoms, among them, in five instances, the initial false, long-lasting diagnosis was bronchial asthma and, in four cases, vena cava superior syndrome caused by advanced inoperable malignancy. Twenty-two percent of patients (n = 39) were operated on previously for cervical struma. Eleven percent (n = 19) of the patients had hyperthyroid symptoms. In 124 cases the goiters were located in the anterior mediastinum. The majority (n = 96) of cervicomediastinal goiters (n = 138) could be removed through a cervical access, in the others an additional sternotomy (n = 31), or anterior thoracotomy (n = 11) were necessary. For resection of complete intrathoracic goiters (n = 37) standard thoracotomy (n = 30) or median sternotomy (n = 7) were used guided by retrotracheal or substernal position. RESULTS Hospital mortality was 1.1%. Minor complications occurred in 46 cases (26%) and laryngeal nerve palsy in 14 patients (8%). Tracheomalatia developed in 18 patients (10%) which were mainly solved by tracheal intubation for 4-6 days. Ninety-four percent (n = 165) of the lesions proved to be diffuse colloid or adenomatous goiters by histology and 10 were (mostly follicular type) carcinomas. CONCLUSIONS Unrecognized mediastinal goiters can produce asthma like symptoms, which may lead to late or misdiagnosis and deficient treatment. Once the diagnosis and exact extent of mediastinal goiter is established, multimodal surgical approaches are indicated for its safe removal - before occurrence of compressive symptoms.

Management of malignant tracheoesophageal fistulas with a cuffed funnel tube

BACKGROUND A detachable cuffed flange tube for the assessment of malignant tracheoesophageal fistulas by a minimal invasive surgical insertion technique is presented. The funnel cuff of this tube seals the space between the esophageal wall and the flange of conventional tubes above the fistula at the level of the suprastrictural dilatation. METHODS Twenty-eight patients having a malignant esophagorespiratory fistula with associated primary or secondary esophageal stricture, except 1, underwent esophageal intubation with this prosthesis between 1983 and 1996. RESULTS All insertion attempts, without previous esophageal dilation, were successful. The overall mortality was 7.4%. The cuffed funnel has provided hermetic water-tight exclusion of the fistula in all instances. Intraabdominal septic complications, reflux, or tube displacement have never occurred after use of this intubation technique. CONCLUSIONS For occlusion of malignant respiratory tract fistulas this cuffed flange tube proved to be superior to conventional esophageal prostheses.

A transhiatalis sebészet járatlan ösvényei

Absztrakt A szerzők a transhiatalis műtetek ket uj, az irodalomban meg nem kozolt indikaciojat ismertetik. Recidiv bronchuscarcinoma miatti bal oldali pulmonectomiat kovető, jobb oldali spontan nyelőcsőrupturaban laparotomias transhiatalis megoldast vegeztek. A 2,5 cm-es repedest a szalagokkal lehuzott nyelőcsovon, a mediastinumban, csomos Vicryl-oltesekkel zartak es cseplesszel boritottak. A műtetet jobb mellűri es mediastinalis drenezessel, gastro- es jejunostomiaval fejeztek be. A masodik műtet soran also-hatso mediastinalis tumort (8×5 cm), incarceralt massziv hiatusherniat, megrovidult nyelőcsovet es a mediastinumba penetralo kisgorbuleti ulcust oldottak meg. Az időskor es rossz legzesfunkcio miatt, laparotomiat kovetően, a kiszelesitett hiatuson at, első lepesben a kornyezetevel szivosan osszetapadt hiatusservet es a megrovidult, perioesophagitises nyelőcsovet tettek szabadda. Ez utan a hatso mediastinumban, a gerincoszlop mellett magasra terjedő, kisgorbuletről kiindulo, okolnyi, jol kapszulalt kep...

The risk of surgical procedures for the treatment of malignant respiratory fistulas

The series published by Davydov and associates [1] on extended resection of esophageal carcinoma associated with fistula seems to be unique in the recent literature. Although the paper reflects the high skill and courage of the authors some theoretical and practical questions remain open. The first one is that is it justified to perform extended esophageal resection in an advanced stage of the disease when even by combined resections (lung, pericardium, diaphragm, etc.) oncologically an RO status cannot be obtained? The majority of the esophageal surgeons with waste experience (Akiyama, Skinner, Siewert, etc.) consider that esophageal carcinomas invading into the mediastinum are not suitable for resection. The effort of the authors to perform such surgery is remarkable, but the high postoperative morbidity (40%) and mortality rate (13.6%) reveal the high risk of such kind of surgery. The second one is that when the fistula is associated with airway invasion and stricture, removal of the tumor is contraindicated by technical and oncological reasons. In the by-pass group of the patients the rout, the type of the ten esophagogastric by-pass and the level of the proximal anastomosis is not clearly indicated in the text. I agree with the authors that exclusion by-pass of tracheoesophageal fistulas offer the best palliation and nutritional conditions if the patients can tolerate such type of surgery. The magnitude of this procedure is well demonstrated by the 20% postoperative mortality of this series. In our 59 malignant esophagorespiratory fistulas only one patient was in a condition permitting exclusion by-pass operation. In the other 57 cases with severely affected respiratory function and/or malnutrition by inoperable esophageal or bronchial carcinoma, fistula obliteration by esophageal intubation [2] was the unique treatment modality as in other large series [3]. In the most critical fistulas with airway invasion and stricture, as a first step we performed airway stenting, followed by esophageal intubation in ten patients. Like other authors we found that the airway stents alone cannot exclude such fistulas, so combination with esophageal tube or stent implantation [4,5] is mandatory. Using our composite cuffed funnel tube with minimal invasive insertion technique [2] the overall mortality rate was 5.4% and the postoperative morbidity only 1.8%. All our survivors had resumed on oral soft diet. In the large majority of such fistulas palliation with special esophageal tubes or esophageal and bronchial stent, may be considered a low risk, effective management.

Transhiatal simultaneous resection of a benign mediastinal pseudotumor and hiatal hernia repair

The usefulness of transhiatal access is a new recognition of the modern oesophageal surgery [1±5]. We present a patient with a complex mediastinal pathology managed by this way. A 68-year-old man has been admitted for massive haematemesis which had subsided on conservative therapy. Chest X-ray showed a lower-posterior retrocardiac shadow on the right side. On CT scan a huge (8 £ 5 cm) well deliminated mass in lower-posterior mediastinum at the right side of the vertebral column was seen. On the barium meal examination incarcerated massive hiatal hernia [4] secondary short oesophagus and intramediastinally penetrating high lesser curvature ulcer was discovered. The ulcer proved to be benign on histological examination. In addition slight oesophagitis and reduction of FEV1 with 30% has been detected The basic problem was which is the best approach for a histologically not veri®ed, lower-posterior, presumable benign mediastinal tumor associated with a complicated hiatal hernia? To reduce the magnitude of intervention one-stage transhiatal approach was decided. Through a midline laparotomy, the vertically enlarged hiatus provided a comfortable exposure for both lesions. Dissection of the incarcerated and ®rmly adherent advanced hiatal hernia and of the short oesophagus from the periesophageal attachments was extensively done. The following step was removal of an encapsulated, huge lipomatosus mass from the posterior mediastinum, extending high on the right side of the vertebra, arising from the lesser curvature of the stomach. The penetrating high lesser curvature ulcer was then excised and sutured. Finally a Toupe type 2708 posterior, tension-free, abdominal fundoplication and fundopexy around the reconstructed hiatus was carried out. The 7-day contrast material examination showed abdominal position of the stomach and absence of re ̄ux. The patient was discharged at that day with a normal chest X-ray. Histopathologically the tumor was a benign ®brolipomatosis. The follow-up period was free from recurrence. Transhiatal approach has been advocated previously for management of several oesophageal problems [1±4] and recently for closure of spontaneous rupture [5]. Regarding to our patient with such a complex pathology our intention was to use instead of a combined left or right thoracoabdominal approach a limited invasive and well tolerable access. The enlarged transhiatal rout proved to be a useful exposure for both mediastinal and abdominal diseases and subsequent surgery. Nevertheless the benign nature of the encapsulated pseudotumor and its easy dissection from the surrounding mediastinal tissue was an important prerequisite to perform resection by this way. As regard to the type of fundoplication used, after a previous extended dissection of the lesser curvature with subsequent, supposed disturbance of gastric wall vascularization, creation of a conventional Collis gastroplasty tube and fundoplication seemed to us dangerous. Therefor abdominal partial posterior fundoplication (Toupet type) was performed The value of our option has been con®rmed by the uneventful postoperative curse. This experience suggests that for some particular lowerposterior mediastinal, oesophageal or thoracoabdominal problems transhiatal access through the enlarged hiatus seems to be a useful alternative or even superior of traditional mediastinal approaches.