Esophagogastrectomy for carcinoma in cirrhotic patients.

Esophagogastrectomy for carcinoma of the esophagus or cardia has been performed in 32 patients with histologically proven hepatic cirrhosis. Thirty-one esophagogastrectomies were performed through a separate abdominal and right thoracic approach in 25 patients, a left thoracoabdominal approach in five patients, and without thoracotomy in two patients. One patient had a colon interposition. Seven patients died after operation (21%) as a result of anastomotic leakage in two patients, hepatorenal in four patients and portal thrombosis in one patient. The type of procedure did not influence mortality. The most common postoperative complication was the development of ascites (68%), and when associated with hepatorenal syndrome (in four patients) there was significant mortality (p less than 0.05). Sepsis was present in the terminal stages of all nonsurvivors. A prothrombin time less than or equal to 60% of normal values was the only significant preoperative predictive factor of mortality, with none of the three patients surviving below this level (p less than 0.05). It is concluded that the presence of cirrhosis is not a contraindication to esophagogastrectomy for carcinoma when curative resection can be undertaken. Hepatic reserve is the determinant factor of operative prognosis. Operative risk is acceptable if patients are classified as Child's class A, and prothrombin time is over 60% of normal values. Operation should be delayed when acute alcoholic hepatitis is present. Intraoperative discovery of cirrhosis is not a contraindication to resection when the above criteria are met.

[X-ray computed tomography and percutaneous drainage change the indications for reoperation after digestive surgery]. / La tomodensitométrie et le drainage percutané modifient les indications de réintervention après chirurgie digestive.

In order to assess the major clinical biological and radiological signs of an intra-abdominal abscess following digestive surgery as well as the place of automatic reoperation, this retrospective study analysed 79 patients requiring intensive therapy for such a complication since 1982. Surgery consisted in oesophagectomy (n = 38), hepatectomy or cholecystectomy (n = 12), pancreatic surgery (n = 17) and colectomy (n = 12). A postoperative abdominal abscess was recognized in 75 patients consisting in intrathoracic or intra-abdominal oesophageal fistulas (n = 31), pancreatic abscesses and fistulas (n = 17), peri- or intrahepatic abscesses (n = 11), colonic fistulas (n = 12) and acalculous cholecystitis. With regard to the intensity of symptomatology the patients have been allocated into 2 groups. In group I, including 12 patients, the infectious syndrome occurred early (3 first postoperative days), was severe and associated with positive blood cultures in 60% of cases. The patients were reoperated without previous CT-scanography. Four died postoperatively. In group II, including 67 patients, the symptomatology was more discrete. CT-scanography was highly beneficial, with discovery of an abscess in 90% of cases. In 20 patients, the abscess has been punctured and drained successfully by percutaneous route. In 6 patients with negative CT-scanography, an automatic reoperation resulted in the discovery of an abscess in 2 cases. Five out of 6 of these patients died postoperatively. It is concluded that in case of intraabdominal complication following digestive surgery: a) in case of early and severe symptomatology, a rapid reoperation is mandatory; b) CT-scanography has a high diagnostic value for abscess recognition in patients with discrete and delayed symptomatology; c) nearly one third of the abscesses can be treated successfully by percutaneous drainage; d) the value of automatic reoperations remains unsubstantiated.

[A surgical etiology of respiratory distress in necrotizing pancreatitis: pancreato-bronchial fistula. 3 cases]. / Une étiologie chirurgicale de la détresse respiratoire au cours de la pancréatite nécrosante: la fistule pancréatico-bronchique. Trois observations.

Adult respiratory distress syndrome (ARDS) is a frequent feature in acute pancreatitis, but précise etiology of hypoxemia remains unclear. Determinations of lipase and amylase levels are made in samples of bronchial secretion, in three intubated patients receiving assisted ventilation for severe hypoxemia occurring in the course of pancreatitis. This determination appeared to be valuable to incriminate the responsibility of a pancratico-bronchial fistula. In the first case, emergency laparotomy was able to show the fistulous track. In the second described case, an endoscopic retrograde pancreatography was performed, showing a fistula from pancreatic body to left bronchial tree. In the third case, the presence of a bronchial fistula was proved by a fistulography trough the abdominal pancreatic necrosis. A decrease of arterial PO2 followed pancreatography and fistulography. The surgical treatment was splenopancreatectomy, necrosectomy associated with left pulmonary lobectomy, and necrosectomy with colonic diversion. In the third case, pancreatico-bronchial fistula was the final evolution of an infected intra-abdominal necrosis, despite multiple surgical drainages. In the first and second cases, surgical treatment obtained a prompt and uneventful recovery. Few published cases of pancreatico-bronchial fistulae are reported. A retrospective study of 12 ARDS was made among 40 patients underwenting laparotomy, with an objective recognition of necrotizing pancreatitis, from 1980 to 1987. A pancreatico-bronchial fistula could be incriminated in three cases of these 12 ARDS. Such a prevalence of 25% has to be reevaluated after serial determinations of lipase and amylase levels in bronchial samples of intubated patients suffering from ARDS in the course of pancreatic disease.(ABSTRACT TRUNCATED AT 250 WORDS)

[Postoperative agitation. A new cause]. / Agitation post-opératoire. Une nouvelle cause.

Thirty-three patients, operated on between 1981 and 1986, and presenting post-operative confusion and restlessness are analyzed. Two groups are identified: group 1 are patients who regularly received BZD before their present hospitalization; in group 2 patients were given high-dose BZD in the early postoperative period. Symptoms were anxiousness in 15 patients, restlessness in 14, myoclonia in 14, delirium in 3, coma and seizures in 1. BZD withdrawal syndrome was considered after the other causes of post-operative agitation were eliminated and the diagnosis was confirmed by the administration of BZD that relieved the symptoms and by the plasmatic concentration of BZD. This syndrome appears 1 to 5 days after BZD withdrawal and severity of symptoms seems to be directly proportional to the doses and duration of BZD therapy. Propranolol was proposed to reduce the intensity of the symptoms. Nevertheless, progressive withdrawal of BZD remains the best way for managing such patients.

[Aseptic tracheobronchial aspiration]. / Aspiration trachéobronchique aseptique.

Nosocomial lung superinfection is a frequent feature in ICU hospitalized patients. Up to 60 per cent of these patients may develop pneumonia, depending on the severity of their underlying disease. Necessary tracheobronchial irrigations and succions expose patients requiring mechanical ventilation to a risk of bacterial contamination by water containing infections particles. The "no touch method", elsewhere described, using disposable material and serious asepsis, try to diminish rate of one of the risk factors for acquired pneumonia. The use of a single-dose plastic bottle of sterile normal saline (solution ophta-ORL Faure) for tracheal irrigation is a clean and very low cost-price method, that minimize the risk of extrinsic contamination.

[Acute respiratory distress caused by pancreatico-bronchial fistula in acute pancreatitis. Apropos of 2 cases]. / Détresse respiratoire aiguë par fistule pancréatico-bronchique au cours d'une pancréatite aiguë. A propos de deux observations.

The adult respiratory distress syndrome (ARDS) is a frequent feature of acute pancreatitis. Amylase and lipase values were determined in samples of bronchial secretions in two patients with endotracheal intubation and under supportive ventilation for severe hypoxemia occurring during the course of acute pancreatitis. A pancreatico-bronchial fistula was suggested in both cases. In one case, an endoscopic retrograde pancreatography was performed and demonstrated a fistula between the pancreatic body and the left bronchial tree. Arterial pH values decreased following pancreatography. Splenopancreatectomy was performed in one case, and necrosectomy associated with left pulmonary lobectomy in the other. Documented cases of pancreaticobronchial fistulas have been rarely reported to date. A retrospective study of 10 patients with ARDS was made among 32 patients undergoing laparotomy for objectively recognized necrotizing pancreatitis. A pancreatico-bronchial fistula could be incriminated in three cases. This 30 p. 100 prevalence has to be re-evaluated in the light of serial determinations of amylase and lipase levels in patients with ARD and endotracheal intubation in the course of pancreatic disease. In these patients, high levels of amylase and lipase in bronchial secretions, the use of iso-osmolar X-ray colloids could be helpful in protecting the alveolar membrane against osmolar injury during pancreatography.

Results of esophagogastrectomy for carcinoma in cirrhotic patients. A series of 23 consecutive patients.

Esophagogastrectomy for carcinoma of the esophagus or cardia has been performed in 23 patients with histologically proven hepatic cirrhosis. All but two patients were classified as Child's class A and all but three had a prothrombin time over 60% of normal values. Twenty-two esophagogastrostomies were performed through a separate abdominal and right thoracic approach in 15 patients, a left thoracoabdominal approach in five patients, and without thoracotomy in two patients. One patient had a colon interposition. Six patients died after operation (26%) as a result of anastomotic leakage in two patients, hepatorenal in three patients and portal thrombosis in one patient. The type of procedure did not influence mortality. The most common postoperative complication was the development of ascites (65%), and when associated with hepatorenal syndrome there was a significant mortality (p less than 0.05). Sepsis was present in the terminal stages of all nonsurvivors. A prothrombin time less than or equal to 60% of normal values was the only significant preoperative predictive factor of mortality, with none of the three patients surviving below this level (p less than 0.05). It is concluded that the presence of cirrhosis is not a contraindication to esophagogastrectomy for carcinoma when curative resection can be undertaken. Hepatic reserve is the determinant factor of operative prognosis. Operative risk is acceptable if patients are classified as Child's class A and prothrombin time is over 60% of normal values. Operation should be delayed when acute alcoholic hepatitis is present. Intraoperative discovery of cirrhosis is not a contraindication to resection where the above criteria are met. This strict selection allows one to anticipate a lower mortality rate.

[pH and the bacteriology of gastroplasties after esogastric resection]. / pH et bactériologie des gastro-plasties après résection oeso-gastrique.

A study of pH of digestive fluid in 24 patients six days after esophagogastric resection (EGR) showed conservation of acidity (pH: 3 or less) in one-thirds of cases. Immediate postoperative course was invariable with respect to incidence of pneumopathy and fistulae. Fungal infection is almost a constant finding in digestive grafts together with microbial pullulation, with a linear relation to pH. Ecology of germs was that of digestive flora of patients with obstruction, selected by the antibiotic cover administered. Group D streptococci and Gram negative bacilli were usually resistant to cephalosporins. Regurgitation pneumopathy therefore requires modification of antibiotic therapy and possible antifungal treatment. When functional disturbance is provoked by EGR, as for example a reflux syndrome; only those patients (1/3) with a pH of 3 or less can obtain relief from treatment with antacids.

Radicality in esophageal cancer surgery.

This study concerns a series of 355 carcinomas of the thoracic esophagus treated over a six-year period. 5 points of the pre operative work up are discussed: total endoscopy, respiratory and hepatic function as most of the patients were heavy smokers and alcoholics, nutritional status and C.T. scan in order to precise the preoperative nutrition value and the true correlation between surgical and CT scan findings. As far as curative resection is concerned, the indications of cervical and intra-thoracic anastomoses and of phi en bloc- posterior mediastinectomy versus blunt dissection are discussed. The mortality rate in this series of 135 curative resections was 8 p. cent due to pulmonary infection and to fistulas. The late results are studied according to the Japanese classification. The overall five-year actuarial survival is 19 p. cent, and 30 p. cent for the group of curative resection in stage 0, 1 and II.

[Pulmonary complications after gastrografin inhalation during radiographic control of esophageal anastomosis]. / Complications pulmonaires après inhalation de gastrografine lors du contrôle radiologique des anastomoses oesophagiennes.

Tracheal penetration of water soluble contrast media (gastrografin) for X-ray control, after gastro-oesophageal anastomosis, resulted in acute pulmonary oedema in two patients. In this type of surgery, mediastinal dissection was responsible for recurrent nerve injury. Inhalation was due to this recurrent nerve palsy. The pulmonary oedema could be related to gastrografin high osmolarity. Therefore, to prevent this complication, previous laryngeal cavity examination is recommended before carrying out the X-ray investigations. In case of recurrent nerve paralysis, barium sulphate or lipiodol should be preferred because of their lack of effect on the lungs.

Surgical implications of malnutrition and immunodeficiency in patients with carcinoma of the oesophagus.

A nutritional and immunological assessment was respectively performed in 75 patients with squamous cell carcinoma of the oesophagus. Abnormal nutritional and/or immunological values were present in 37 patients (50 per cent) and absent in 38. The tumour was resectable in 27 patients (71 per cent) with normal values and only in 11 among the 37 (29 per cent) with abnormal values (P less than 0.001). Complications after resection including death, pneumonia and anastomotic failure were not significantly different in the two groups of patients except for anastomotic failure. This observation suggests that reduction of surgical complications by preoperative nutritional therapy might be expected only in few patients with oesophageal carcinoma.

[Current treatment of thoracic oesophageal carcinoma (author's transl)]. / Traitement actuel des cancers de l'oesophage thoracique.

Always severe and increasingly frequent carcinoma of the thoracic oesophagus now ranks among the most worrying malignancies. However, the authors' experience concur with recent publications to demonstrate that an a priori pessimistic attitude is no longer justified. The considerable progress achieved in pre- and post-operative care and surgical techniques has reduced to 10% the operative mortality rate and has made surgery the best prospect of comfortable and, possibly, prolonged survival. Radiotherapy and chemotherapy still have a place in the treatment, either alone when surgery is contra-indicated or combined with surgical excision.

[Should undernutrition be corrected prior to surgery in patients with cancer of the oesophagus or cardia? (author's transl)]. / Faut-il corriger la dénutrition des malades ayant un cancer de l'oesophage ou du cardia en période pré-opératoire?

A prospective study of 40 patients with cancer of the oesophage or cardia considered for surgery showed that 27 had no evidence of protein or calorie deficiency, while 13 had undernutrition. The 18 patients who benefited from ablative surgery belonged to the group with normal nutritional status; none of the undernourished patients could have benefited from resection. Only controlled studies will show whether or not correcting undernutrition is advantageous, but the number of people with both resectable tumour and corrigible undernutrition is probably very small.

EEA stapler and omental graft in esophagogastrectomy: experience with 30 intrathoracic anastomoses for cancer.

Experience with the EEA stapler device used in 30 esophagogastric resections for cancer with intrathoracic anastomosis, is reported. The mortality rate was 13.3%. The anastomotic failure rate was 3.3% (1/30) with only one death; three asymptomatic blind fistulas were found on a routine contrast examination of the anastomosis. It is felt that esophagogastric EEA stapled anastomosis associated with an omental graft is a very safe technique.