Biomedical subjects
Publications and source records attributed to M Celerier.
Between 1968 and 1988, 679 patients were hospitalized for ingestion of caustic substances, and 87 had severe caustic burns of the entire esophagus, together with panparietal necrosis. Twenty-one of them had tracheobronchial necrosis with perforation. Fifteen have not been operated on; six have had operations, with success in four. We describe an original technique for repairing these tracheobronchial perforations with a pulmonary patch.
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Small cell neuroendocrine carcinomas are frequent in the bronchial tree, but are very are in the gastrointestinal tract. A 51-year-old woman underwent total esophagectomy for an ulcerated tumor of the lower third of esophagus. Pathologic examination showed an infiltrating small cell carcinoma, and immunohistochemical analysis proved it to be neuroendocrine. The patient died 2 months later from respiratory failure related to pleuritic metastases. Review of the 162 previously published cases showed a mean survival of 6.2 months, and rapid dissemination of metastatic disease, as in our case. As for small cell bronchial carcinoma, systemic chemotherapy should be considered for neuroendocrine carcinoma of the esophagus.
One hundred and five colonic interpositions were performed in 102 patients. The indications for operation were caustic stenosis in 57 cases (Group A) and esophageal cancer in 45 patients (Group B). The right colon was used in 97 cases and isoperistaltic transverse colon in 8 cases. Eighty-nine transplants were anastomosed to the cervical esophagus and 16 to the pharynx. The distal anastomosis was to the antrum in 67 cases, to the second duodenum in 37 cases, and to the jejunum in 1 case. The overall mortality rate was 8.6 percent (9 cases), 5.3 percent (3 cases) in group A and 13.6 percent (6 cases) in group B (p less than 0.05). The morbidity rate was significantly higher in group B than in group A (77.3 percent vs 53.7 percent, p less than 0.05). Ischemic necrosis (3 cases) and chronic ischemia of the transplant (7 cases) were the major complications. Strictures occurred at the proximal anastomosis significantly more often in group B (63 percent) than in group A (40 percent) (p less than 0.05). Seven failures occurred in 93 survivors, i.e. oral feeding was impossible. In conclusion, mortality and morbidity rates of coloplasty are high. The use of colon as an esophageal substitute is justified only in case of caustic stenosis with unavailable stomach.
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Eight patients underwent total gastrectomy for caustic ingestion. Oesophago-jejunostomy was performed in the same surgical session. One patient died from hemorrhage. Only one of the 7 survivors had a benign anastomotic fistula. Five healed without any sequelae, 2 underwent colonoplasty 3 months later, because of a secondary oesophageal stenosis. We conclude that it is feasible, in certain unusual cases, to restore gastrointestinal continuity after total gastrectomy for caustic necrosis: moderate oesophageal lesions (stage I or II) and ingestion of a caustic product that cause few oesophageal damage (acids, liquid chlorine bleach, ...).
Surgery is mandatory in severe caustic burns of the upper digestive tract, either as an emergency, or later because of secondary complications. Then, the patients who develop oesophageal stenosis require oesophagoplasty or oesophagopharyngoplasty. The first clinical survey must be performed in a surgery department with an intensive case unit. All patients undergo an oesophageal examination with a fiberoptic endoscope when admitted. Some of them need a fiberoptic bronchoscopy. The authors describe their experience over the 18 years up to now. Over 700 patients were admitted in the same department. The different surgical procedures are given, as well as guidelines for management.
Eighteen cases of severe chronic caustic stenosis of the hypopharynx and esophagus are presented. Restoration of digestive continuity was accomplished by retrosternal ileocolic transposition. The cervical approach and the position of anastomosis depended on the status of the hypopharynx. When one pyriform sinus remained open (type I, N = 4), an anterior suprahyoid approach was used in conjunction with lateral hypopharyngotomy because it facilitated the anastomosis and additional minor surgical procedures. When the hypopharynx was completely stenosed (type II, N = 14), a transepiglottic approach consisting of partial horizontal laryngectomy was used because it allowed excision of the supraglottic stricture, restoration of the oropharyngeal cavity, anastomosis to the posterior oropharyngeal wall, management of an eventual laryngotracheal stenosis, and elevation of the laryngeal inlet above the digestive anastomosis. After operation, several endoscopic examinations were required, sometimes combined with reoperation. Return of deglutition assuring normal nutrition was obtained in 61% of patients: 3 of 4 type I and in 8 of 14 type II.
The treatment of 484 adults with caustic ingestion injury is discussed. Signs and symptoms are an unreliable guide to injury and a chest X-ray and fibreoptic endoscopy should be performed as soon as possible. All of the 250 patients who developed superficial lesions of the oesophagus, stomach or duodenum experienced healing without sequelae. Forty-four patients required emergency surgery of whom twenty-four died and oesophagectomy without thoracotomy is now advocated for this group, followed by interval surgery to restore continuity. The remaining 190 patients suffered gastric or oesophageal ulceration without necrosis: 92 recovered without complication, 3 succumbed to aorto-oesophageal fistula, 12 survived following delayed surgery for complications and 83 developed oesophageal and/or gastric stenosis which subsequently required endoscopic or surgical treatment.
A case of splenic volvulus, a rare complication of a rare malformation, mobile spleen, is reported, only 150 similar cases being documented in the literature. The diagnosis can be suspected preoperatively by ultrasound imaging. Different etiologies of this lesion are discussed and the various complementary examinations allowing preoperative diagnosis described.
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We report a retrospective study of 52 patients with unresectable carcinomas of the esophagus treated with substernal bypass without resection. There were 49 squamous-cell carcinomas and 3 adenocarcinomas. The site of the tumor was the middle third of the esophagus in 32 patients, the upper third in 9, and the lower third in 11. The diagnosis of inextirpability was made preoperatively in 34 patients and at laparotomy in 18. Thoracotomy was never performed. The bypass procedure was ileocolic in 22 cases and gastric in 30 cases. No patient had postoperative chemotherapy or radiation therapy. The operative mortality rate was 9.6 p. 100 (5 cases) and the hospital mortality was 19.2 p. 100 (10 cases). Morbidity was 46 p. 100. Twenty-two cervical fistulas occurred; 19 closed spontaneously. Eighteen endoscopic dilatations and four reoperations were performed for 22 secondary stenoses of the cervical anastomosis. Median survival rate was 6.2 months. We conclude that substernal bypass is a valuable alternative for palliation of esophageal cancer but that its indications should be limited.
Caustic ingestion may cause severe necrosis of the upper digestive tract. Of 520 patients admitted in our department for caustic ingestion, 29 (5.5%) underwent emergency esophagogastrectomy because of transmural necrosis. We used a stripping procedure, which was performed through a cervicotomy and a laparotomy. This method allowed 18 patients (62%) to survive. Thus it appears to be a safer technique than open thoracic esophagectomy, which we used in our earlier experience.
A case of large intraluminal tumour located in the cervical portion of the oesophagus and removed by thoracotomy is presented. Detailed histological study was necessary, since hypervascularization and hypercellularity made it difficult to diagnose a fibrovascular polyp and to establish its histopathological prognosis. The patient has now been followed up for 7 years and remains cured. Intraluminal tumours are reviewed. Whether fibrovascular polyps should be removed surgically or endoscopically depends on their site and on their size.