Management of delayed diagnosed esophageal perforation

The esophageal perforation can be fatal unless diagnosed promptly and treated effectively. The high mortality rate related to delayed treatment is due to an inability to effectively close the perforation site to prevent leakage and ongoing sepsis. This study was performed on patients who were referred to three hospitals of Shaheed Beheshti and Tehran Universities of Medical Sciences during two years. All patients admitted in these hospitals with esophageal perforation lasting for more than 24 hours were studied. There were 24 patients [12 males, 12 females] with the mean age of 37.5 yrs. The most frequent symptoms and signs were: Chest and abdominal pain in 11 cases [45.83%], empyema in 11 cases [45.83%], fever in 10 cases [41.66%], pleural effusion in 8 cases [33.33%] and emphysema in 3 cases [12.5%]. The most common causes of esophageal perforation were use of devices during esophagoscopy and foreign bodies in 13 cases [54.17%], iatrogenic trauma in 4 cases [16.67%], Boerhaave's syndrome in 4 cases [16.67%], ingestion of burning chemicals in 2 cases [8.33%] and esophageal cancer in 1 case [4.17%].Four [16.66%] of all patients died while others were discharged with no significant complication in long time. This study was performed on patients referred to university hospitals; therefore, the results are different from those of community. Most of the perforations were due to intraoperative negligence or device manipulation. The outcomes of the whole procedures were good concluding that late diagnosed esophageal perforations can be managed surgically with good results but with a longer period of hospitalization

surgical management of complicated pulmonary hydatid cysts

Iran is recognized as an endemic area for lung hydatids. Surgical removal of some hydatid cysts may have srious morbid consequences. To determine the characteristics of these special cysts, a retrospective survey was carried out on patients admitted to Modarres Hospital in Tehran between 1989 and 1998. We have found that reptured, bilateral, lung located, and giant cysts [>10 cm] cause more surgical and anesthetic complications, thus we named them "complicated cysts". Of 110 patients, 62[56.4%] had complicated hydatid cysts. Of these, 2 individuals died during anesthesia induction because of hypoxemia. Since sudden severe hypoxemia did not respond to all essential measures, the patients were returned to the supine position [from lateral decubitus position], then rigid bronchoscopy was performed for drainage of cyst secretions and fragments of laminated membrane. At the time of induction of anesthesia, the contents of a ruptured cyst may spill into the airway and cause hypoxemia and even death. In order to prevent this complication, two different approaches were used: [1] A chest tube was introduced into the cyst through the chest wall and its contents were drained; [2] Patients were placed in the sitting position during intubation. Double lumen endotracheal tube [DLT] may allow salvage of unaffected lung from inadvertent leakage of cyst contents or laminated membrane emboli formation, but it does not guarantee asafe operation. Thus, rigid bronchoscopy should always be available. Cystostomy was the most common surgical technnique performed in our center [80%]. Massive air leakage, bronchial fistula, and permanent lobar collapse were the main indications for lung resection in our series. Surgical complication rates of our study were higher than reports from the west. Coordination and cooperation of experienced surgeous and anesthetists can result in better outcomes following complicated cyst removal