[Treatment of large, esophageal perforations and mediastinitis with a covered, removable metallic endoprosthesis and mediastinal drainage]. / Nagy nyelocso-perforatio és mediastinitis kezelése eltávolítható, bevont fémprotézissel és mediastinalis drenázzsal.

The application of covered metallic stents in the treatment of benign strictures and perforations is still in the early stages, because their removal is difficult and may cause tissue proliferation. The therapeutic effect and the efficiency of a new method for the extraction of a removable metallic stent were examined in three patients treated for oesophageal perforation. Two of the three patients were dilated with a balloon catheter because of corrosive oesophageal stenosis, and the oesophagus was perforated. In one patient mediastinal drainage, and jejunostomy and in the other primary suturing and drainage were performed. Sepsis and mediastinitis developed due to the oesophageal perforation and the fistula caused by the mediastinal drain in the first patient, and the insufficiency of the suture in the second patient. The oesophageal defects were sealed on day 8 and 10 after the perforation, and surgery by a covered stent. In the third patient, the oesophageal rupture caused by the dilatation and the attempt to stent a malignant obstruction was sealed with a covered stent within 2 hours. Parenteral nutrition and broad-spectrum antibiotic therapy were started. Three days after the interventions, swallowing tests with water-soluble contrast medium (Gastrografin) did not reveal any extravasations. Feeding via a nasogastric tube, and later oral feeding was started. After transient mediastinal drainage, the stents were removed on day 35 and 74 after implantation. Both openings healed completely. Restenoses above the stents were dilated again. The rupture of the malignant oesophagus in the third patient, following early, permanent stenting, healed without drainage and with no complications. Even with mediastinitis and concomitant sepsis, large oesophageal perforations can be treated successfully with removable, covered metallic stents and adequate mediastinal drainage.

Esophagus reconstruction with free jejunal transfer.

Following pharyngolaryngectomy, reconstruction is one of the most challenging surgical procedures. Here we review our own experiences using a microvascularly transferred free jejunal graft. This method was performed in 22 patients (19 male and 3 female, aged 40-63 years). Seven patients underwent neoadjuvant chemo-radiotherapy. Eighteen patients had immediate reconstruction after pharyngolaryngectomy, and 4 patients had delayed reconstruction because of complications from previous surgeries (2 stenoses, and 2 recurrent cancers). The duration of surgery ranged from 5-9 h (mean, 6.3 h), and the ischemic time of the graft was 70-125 min (mean, 88 min). This method has several advantages: it is a one-step operation; the graft is covered by self-cleaning mucosa; the development of fistulas and stenoses is rare; and the technique provides good swallowing. Owing to its good blood supply, this reconstructive method can also be used in previously irradiated areas.