Acquired benign esophago-airway fistulas.

MATERIALS AND METHODS: Over a period of 25 years, 35 patients with acquired benign esophago-airway fistulas were treated. Only two of them were female. The etiology of the communications was corrosive burns, penetrating wounds, postoperative and endoscopic lesions, esophageal diverticula, prolonged ventilatory assistance, pleural empyema and foreign bodies. Radical operative treatment was performed in 31 cases. In four of these the procedure was palliative, because of poor general condition and lung complications. The operative approach was chosen after precise endoscopic and contrast X-ray examinations. A cervical approach with partial median sternotomy to the third intercostal space was performed in 19 patients. In the rest of the patients a thoracotomy was performed. Simple excision of the fistula, longitudinal suture of the trachea and horizontal suture of the esophagus was the method of choice in nine patients. A flap from the left sternocleidomastoid was additionally interposed in front of the esophagus in 12 patients. In six cases circular resection, reconstruction of the trachea and plastic suture of the esophagus were performed. Esophagectomy with ensuing colon substitution was necessary in four patients. RESULTS: Excellent or good results were obtained in 29 of the 31 patients operated on. We had two deaths in the early postoperative period (6.8%) due to lung complications in patients with chemical burns of the esophagus. The operated patients were followed up for period ranging from 3 to 20 years. CONCLUSION: Acquired esophago-respiratory fistulas require emergency surgical treatment. The proper choice of operative approach is largely dependent on the precise diagnosis. Preoperative intensive care and metabolic balance are important factors in this report. Radical operative treatment depends on the basic disease, local inflammation and lung complications.

[Longitudinal sternotomy--a method for the surgical option in pulmonary and hepatic echinococcosis]. / Longitudinalnata sternotomiia--metod na operativen izbor pri ekhinokokoza na belite drobove i na cherniia drob.

Emphasis is laid on the utilization of longitudinal sternotomy as an operative method of choice, practicable in echinococcosis with bilateral pulmonary location, eventually associated with liver involvement. Experience had with performing longitudinal sternotomy in some of the patients operated in the clinic of thoracic surgery of the Higher Medical Institute--Sofia and in other surgical units throughout the country, covering the period 1985 through 1990, is shared. A clinical case of interest concerning bilateral lung echinococcosis, partially complicated, and associated with hydatid disease of the liver, is described. A new and rational treatment tactics yielding a very good outcome is introduced, namely--single-stage longitudinal sternotomy with right-side frenotomy and echinococcotomy of the lung and liver cysts according to well-established surgical tenets, with ensuing plastic reconstruction of the disrupted right hemidiaphragm integrity and osteosynthesis of the sternum.

[The use of low-frequency ultrasound in surgical practice in thoracic surgery]. / Prilagane na niskochestotniia ultrazvuk v khirurgichnata praktika v grudnata khirurgiia.

To gain better insight into the intimate mechanisms of action of low-frequency ultrasound in surgical practice, and to establish the indications for its practical implementation in concrete cases, the preliminary results in patients operated in the clinic of thoracic surgery of the State Institute Hospital of Pulmonary Diseases "St. Sofia"--Higher Medical Institute, Sofia, are reported. For the purpose the Russian ultrasound apparatus URSK-7N-18 is successfully employed. Following a concise technical characterization of the URSK-7N-18 parameters of action, clinical cases are described where ultrasound treatment with the apparatus is successfully used for the purpose of prophylaxis against pulmonary carcinoma recurrences, and serious purulent complications (mediastinitis, pleural empyema, subphrenic abscess). The method of intraoperative ultrasound treatment with the apparatus does not imply special qualification of the surgeon. The only requirement is to secure gradual filling of the respective cavity with normal serum, simultaneously with the ultrasound treatment, effected from the cavity bottom to its borders over a 10-minute period.

Colon substitution for radical treatment of cardia and lower third esophageal cancer.

During the past 24 years we have treated 786 patients with esophageal and cardia carcinoma. En bloc resection of the tumor has been performed in only 461 (65.2%) of them and in 246 (34.7%) of the cases various palliative operations have been undertaken. Most of the patients were in stage II or III of the disease with squamous cell carcinoma in 80.5% and adenocarcinoma in 19.5% of them. The method of choice for the treatment of the patients with cardia and lower third of the esophagus carcinoma (n - 315) were blunt esophagectomy followed by colon (n - 256), stomach (n - 54) and/or jejunal (n - 9) substitution. The histology results confirmed the oncologic radical zone of resection of the esophagus from 8 cm above the tumor to 10-12 cm below in the stomach wall. This is the reason why substitution of the esophagus with stomach tube is very often impossible and the colon substitution remains the method of choice for such patients. The other important factor is radical resection of the tumor with the surrounding tissue, organs and lymph nodes involved (resection en bloc). The hospital mortality included 28 patients (7.3%) from the radically operated who also underwent esophageal substitution (n = 378). For these patients the 3-year survival rate is 51% (n - 191) and 5-year survival 46% (n - 172).

Surgical treatment of acute purulent mediastinitis.

During the last 15 years we have treated 147 patients with acute purulent mediastinitis (APM). According to the aetiology of the disease, 2 major groups were defined. The first group included the cases of oesophageal origin--112 patients (dilatation--38 patients, foreign body extraction--29 patients, lye injuries--11 patients, oesophagoscopy--8 patients, sharp foreign body--6 patients). The second group consisted of patients with mediastinitis of non-oesophageal origin--35 patients (tracheo-bronchial disease--21 patients, tooth infection--8 patients, cervical infection). Symptoms of the mediastinal infection were typical; nevertheless, early diagnosis (within first 12 h) was obtained in only 43.5% of cases. Therapy for all patients included general stabilisation, broad spectrum antibiotics and immunotherapy. In 86 patients, mediastinal drainage was performed with additional suture of the oesophageal wall or plication with a gastric or diaphragmatic patch in 9 cases. Oesophagectomy and delayed colon transplant was the method used in 61 patients. Mortality included 21 patients (14.3%). The cause was broncho-pneumonia in 9 patients, endotoxic shock in 7 and renal failure in 3 patients.