M. Savary

Photodetection and photodynamic therapy of "early" squamous cell carcinomas of the pharynx, oesophagus and tracheo-bronchial tree

The efficacy of photodynamic therapy (PDT) alone was evaluated on 41 ‘early’ squamous cell carcinomas of the pharynx (10), oesophagus (15) and tracheo-bronchial tree (16). All lesions but two were synchronous second primaries in ENT-patients suffering from a more extensive cancer, governing the overall oncological prognosis.Photofrin I (3 mg/kg) or Photofrin II (2 mg/kg) were injected 72 h prior to the red light irradiation, supplied by an argon pumped dye laser. A diffusing cylinder was used to obtain a homogeneous light distribution at the tumour site (60 J to 150 J/cm2). In the oesophagus and bronchi, the results are good for cancers staged in situ or microinvasive at endoscopy (two recurrencies for 23 lesions treated). For more advanced cancers (submucosal in the oesophagus or invading the bronchial cartilage), the results are less satisfactory (three recurrencies for eight lesions treated). In the pharynx where light dosimetry is more difficult, the rate of recurrencies is higher (3/10 lesions treated). In the bronchi (one case) and oesophagus (one case), the longest disease-free survival is now 5 years.The irradiation of a non-cancerous zone of normal buccal mucosa on 25 patients having received HPD showed necrosis in all cases with light doses as low as 50mW/cm2 for 20 min (60 J cm−2), even with Photofrin II.We encountered six complications (three cicatricial stenosis, two fistulae, one severe sunburn), most of them resulting from the lack of selectivity of HPD. According to these experiments, PDT is efficient at destroying early squamous cell carcinomas in the pharynx, oesophagus and bronchi, but the tumour selectivity of HPD is poor in the digestive tract lined with squamous cell epithelium. The only hope for the future lies in the synthesis of a more selective and more stable photosensitizer. This discussion reviews possible directions of research for the development of new dyes (cationic dyes, dyes attached to monoclonal antibodies, etc), for PDT and hyperthermia, for photodetection of early cancers using a fluoro-endoscope, and finally, for tumour depth profiling in hollow organs using lasers of different wavelengths.

Partial cricoid resection with primary tracheal anastomosis for subglottic stenosis in infants and children

Fifteen infants and children with a severe subglottic stenosis underwent a partial cricoid resection with primary tracheal anastomosis. The etiology of the stenosis was congenital in 3 cases and was acquired after prolonged intubation in 12. Fourteen patients were tracheotomy dependent at the time of surgery, and 13 (87%) of the 15 were classified grade III (7 cases) and IV (6 cases) according to Cotton. The resection included the cricoid only in 5 cases and the cricoid and a segment of trachea (1 to 4 rings) in 10 cases.

Partial cricotracheal resection for severe pediatric subglottic stenosis : Update of the Lausanne experience

Until recently, severe pediatric subglottic stenosis (SGS) has been treated almost exclusively by laryngotracheoplasty procedures. Even in the most experienced centers, the results of single-stage operations for Cottons grade III and IV stenoses have been disappointing. This paper reports our experience on 31 partial cricotracheal resections for severe SGS in infants and children. The stenosis was congenital in 6 cases and acquired after prolonged intubation in 25 cases. Twenty-seven patients were tracheotomy-dependent at the time of surgery. Twenty-two cases were classified as grade III and 9 cases as grade IV stenoses according to Cotton. The decannulation rate was 97% (30 of 31 cases) after an open procedure. There were no fatalities and no lesions to the recurrent laryngeal nerves, but there was 1 complete restenosis. Twenty-seven patients show no exertional dyspnea, 3 have a slight stridor with some dyspnea while exercising, and 1 patient is not decannulated. The voice is normal in 21 cases, a dysphonia is present in 9 cases, and the patient with complete restenosis acquired an esophageal voice. Postoperative follow-up is longer than 10 years in 8 cases and longer than 5 years in an additional 6 cases. All patients who reached adulthood show normal growth of the larynx and trachea. Considering the excellent results obtained in this consecutive series of 31 cases, partial cricoid resection with primary thyrotracheal anastomosis should be considered an important treatment option for severe SGS in infants and children.

Cricotracheal resection for pediatric subglottic stenosis

Until recently, cricotracheal resection (CTR) has not been commonly accepted as a treatment modality for severe subglottic stenosis in the pediatric age group. The reasons have included the risk of a possible dehiscence at the site of the anastomosis, the likelihood of injury to the recurrent laryngeal nerves, and the interference with normal growth of the larynx. Thirty-eight infants and children with a severe subglottic stenosis underwent a partial cricoid resection with primary thyrotracheal anastomosis. Thirty-three patients were tracheotomy-dependent at the time of surgery and 34 were referred cases; 27 were classified as grade III, and 10 as grade IV stenoses according to new Cottons classification. Nineteen patients were younger than 3 years of age at the time of surgery. The tracheotomy was resected during the surgical procedure in 21 cases. Decannulation was achieved in 36/38 cases after an open procedure. There is one complete restenosis and one good result awaiting decannulation after further surgery for a Pierre Robin syndrome. The authors experienced no lesion of the recurrent laryngeal nerves and no fatality. Thirty-one patients show no exertional dyspnea, three a slight stridor while exercising, and two patients are not decannulated. The postoperative follow-up in longer than 10 years in eight cases. All patients show a normal growth of the larynx and trachea. Compared to laryngotracheoplasties, CTR gives better results for severe subglottic stenosis. This operation should become the treatment of choice for severe (grade III and IV) subglottic stenosis in infants and children.

Epidemiology and Natural History of Reflux Esophagitis

Studies describing the natural history of erosive reflux esophagitis in patients presenting with or without symptoms of gastroesophageal reflux are exceedingly rare. This study followed a first group of 759 patients receiving intermittent courses of medical therapy for initial Savary grades 1 to 3 reflux esophagitis (median follow-up period of 4.5 years). In 23% of cases, reflux esophagitis evolved as a recurrent progressive form of the disease, which may potentially cause attendant complications such as ulcer, stenosis, or short esophagus; to avoid unnecessary long-term medical treatment, surgery should be considered in these cases if the patient is fit for surgery. In the remaining 77% of cases, reflux esophagitis evolved as a benign form of the disease, either as an isolated episode of reflux esophagitis or as a recurrent but nonprogressive form of the disease. Another group of 1,022 patients presenting with initial Savary grades 1 to 4 reflux esophagitis (median follow-up period of 3 years) was studied to detect the appearance of columnar epithelium during the healing process. In 18% of all cases, follow-up endoscopies detected islands, tongues, or circumferential forms of columnar epithelium as patterns of healing of the initial erosions; these patients should undergo endoscopic surveillance for the detection of dysplasias, especially if a specialized type of epithelium is present on biopsy specimens.

CRICOTRACHEAL RESECTION FOR ADULT AND PEDIATRIC SUBGLOTTIC STENOSES: SIMILARITIES AND DIFFERENCES

Since the mid-1970s thoracic surgeons have used cricotracheal resection (CTR) in the adult population. Similar positive results have from then on been reported by different investigators using this technique. In contrast, otolaryngologists have typically used an anterior midline approach to the larynx and trachea for their laryngotracheal reconstructions (LTRs), both in adults and children. The fear of injury to the recurrent laryngeal nerve (RLN), the risk of a dehiscence of the anastomosis, and the interference with normal growth of the larynx in the pediatric age group were the main reasons put forward for not using a CTR for the cure of subglottic stenosis. In this article, we describe the similarities and differences in CTRs performed for adult and pediatric cases. The high rate (>90%) of success for severe pediatric SGS using CTR compares most favorably with LTR, which is still used in most otolaryngology departments. The reasons lie in the full resection of the stenosis and the restoration of a steady cartilaginous framework of the larynx and trachea with full mucosal lining on both sides of the anastomosis. Furthermore, CTR can be associated with a Rethi procedure for the cure of combined posterior glottic and subglottic stenoses. Good results from series of two different centers suggest that CTR will become the treatment of choice for pediatric severe SGS, as is presently the case in the adult population.

Is their prevalence in patients with Barrett’s esophagus overestimated?

The prevalence of adenocarcinoma in patients with Barrett’s esophagus ranges from 7% to 40% in patients undergoing endoscopy (Table 1) [2], and from 37% up to 85% in patients undergoing surgery [9, 12, 13].

Krikoidteilresektion mit primärer laryngotrachealer Anastomose bei subglottischen Stenosen im Kindesalter

Eine partielle Krikoidresektion mit primArer laryngotrachealer Anastomose wurde bei 15 SAuglingen und Kindern mit subglottischer Stenose durchgefiihrt. Die Atiologie dieser Stenosen war

Degeneration in peptic esophagitis

Whether coincidence or causal relationship, peptic esophagitis and cancer are associated in a not neghgible proportion of cases. In 240 operations for esophagitis, we found 41 cancers, i.e., 17%. It is said that chronic irritation of the esophagealmucosa may favor the development of an epithehoma at that site, a hypothesis often advanced during the course of caustic esophagitis or certain cases of longstanding mega-esophagus, and which may apply equally to peptic esophagitis. When this association is not recognized, the consequences may be catastrophic, as in the fohowing cases:

Does the persistence of histologic signs suggest that other factors than acidity could occur

Various histologic features have been described in connection with reflux esophagitis. In particular, these include hyperplasia of the basal layer, elongation of the vascular connective tissue papihae, infiltration of the lamina propria by lympho-plasmocytes [3] or by neutrophil and/or eosinophil granulocytes [8, 9, 12] and vascular changes [1,4].