Oesophageal tuberculosis: a review of eleven cases.

Tuberculous infection of the oesophagus is rare. This is confirmed by our present review of cases managed in our teaching hospitals over a period of 18 years which uncovered only 11 patients. The main presentation is that of dysphagia whose algorithm of investigation should seek to differentiate tuberculosis from carcinoma, the more common cause of this symptom. Of the 11 patients, 9 presented with dysphagia while 2 had haemorrhage; 7 had an abnormal plain chest radiograph, of whom 4 had a mediastinal mass lesion (3 were lymphadenopathy and one an abscess). All but one had an abnormal radio-contrast oesophagogram, including a mediastinal sinus in two and a traction diverticulum in another two. The mainstay of investigation was oesophagoscopy through which diagnostic biopsy material was obtained in half of the patients. In the other half diagnosis was by either biopsy of associated mediastinal (3) or cervical (1) lymph node masses or by acid fast bacilli positive sputum (1). The diagnosis was established post-mortem in one patient. Treatment was primarily non-operative with standard anti-tuberculosis drug therapy. Two patients underwent a diagnostic thoracotomy and one a drainage of mediastinal abscess together with resection and repair of oesophago-mediastinal sinus during the early part of the series. Outcome of management was very rewarding in 9 patients and death occurred in 2 patients, one of whom had his anti-tuberculosis drug therapy interrupted by severe hepatitis B virus infection. The other death occurred in a patient whose haemorrhage from an aorta-oesophageal fistula was not established ante-mortem. It is recommended that when biopsy material of the oesophagus is unobtainable or non-diagnostic in patients with dysphagia, especially with an abnormal chest radiograph or human immunodeficiency virus infection, effort should be made to obtain biopsy material from associated lymph nodes, even by thoracotomy if necessary, or culture of biopsy from the radiologically abnormal part oesophagus and sputum for mycobacteria, in order to establish the diagnosis of this rare but eminently treatable cause of dysphagia. Clinicians should be aware of tuberculosis of the oesophagus as a possible cause of haematemesis in patients with otherwise unexplained upper gastrointestinal haemorrhage.

Pneumonectomy in a patient with ventricular septal defect.

A young man with severe unilateral bronchiectasis and a ventricular septal defect presented for pneumonectomy. Intra-operative monitoring, which included continuous measurement of systemic and pulmonary oxygen saturations by oximetry, revealed transient reversal of the intracardiac shunt across the defect. The implications of this combination of cardiac and pulmonary disease for anaesthetic management are discussed.

Esophagopleural fistula after pneumonectomy for inflammatory disease.

The development of an esophagopleural fistula after pneumonectomy is one of the less common complications of pneumonectomy. Herein reported are seven cases over a period of 14 years, five from a series of 896 pneumonectomies performed for malignant or inflammatory disease in the Department of Thoracic Surgery and two referred after pneumonectomy elsewhere. The fistula was demonstrated by the escape of radiographic contrast material, methylene blue, or food particles into the pleural space or was observed at esophagoscopy. In all, the associated empyema was first treated by drainage, and surgical repair of the fistula was attempted in only three cases. In six cases the fistula had closed before the patient left hospital. In the seventh, the patient insisted on leaving the hospital while under treatment and before closure had occurred. One patient died of cor pulmonale 2 years after closure of the fistula. There has been no recurrence of the fistula in any of the patients observed. Conservative management is at variance with that of many authors.

Penetrating neck trauma with tracheal and oesophageal injuries.

Failure to recognize early that penetrating neck wounds include the cervical oesophagus greatly increases morbidity and mortality. From an analysis of experience over 5 years (1978-1983) it emerges that, while tracheal wounds are usually recognized early, cervical oesophageal injuries are not. It is empyema which complicates such oesophageal injury and which prompts referral to a Department of Thoracic Surgery, the patients by this time being mortally ill, with septicaemia and malnutrition. Neck penetration is usually left-sided, the injuring agent usually a knife, driven downwards and medially by a right-handed assailant. Empyema is usually right-sided. Early recognition and prompt referral are associated with a low morbidity and low mortality. Late recognition and late referral carry a high morbidity rate, prolonged convalescence in those who survive, and a mortality rate of nearly 25 per cent.

Tracheo-oesophageal fistula from blunt trauma. A case report.

Tracheo-oesophageal fistula is a rare complication of blunt trauma; by 1980 only 35 cases had been recorded. Presentation is usually delayed and the initial trauma severe. Fractures, pneumothorax, haemoptysis and surgical emphysema are not invariable features. Mediastinitis is rare, and surgical management is usually successful. The site of the fistula in the posterior wall of the trachea proximal to the main carina is remarkably constant. The membranous trachea is probably lacerated at the time of injury and the oesophageal wall contused. The contusion progresses to necrosis and a fistula is formed.

Peroperative antibiotics in the prevention of chest infection following cardiac operations.

Seventy-nine patients about to undergo cardiac operations were randomly allocated to two treatment groups in an attempt to reduce postoperative chest infections. The group receiving a short peroperative course of cefamandole, an antibiotic effective against both the pneumococcus and Haemophilus influenzae, had a significantly lower postoperative chest infection rate than the group receiving a 3-day course of cephradine, an antibiotic previously chosen to prevent intracardiac infection during the operation. By selecting an appropriate antibiotic it is possible, using a short peroperative course, to reduce the postoperative chest infection rate in patients undergoing cardiac operations.