Treatment of corrosive burns of the esophagus

Forty patients with caustic ingestion have been treated between 1955 and 1975. Strong alkali was the corrosive in 95%, and 80% were under 10 years old. Early esophageal stricture developed in 18 patients four weeks after lye ingestion. Among these, esophageal bougienge restored an adequate lumen in two patients with short, soft annular strictures, and right colon interposition was used for esophageal subsitution in ten who had long, dense strictures. We recommend early diagnostic esophagoscopy, to the uppermost level of burn injury only, to determine the presence and severity of the esophageal injury. If esophagoscopy reveals esophageal burn injury, corticosteroid and antibiotic therapy are continued. If no burn injury is visualized, the patient is spared unnecessary treatment. Long, dense strictures unresponsive to bougienage place the patient at risk from instrumental perforation, and these patients should undergo colon interposition through a substernal extrapleural tunnel.     

Vibration bouginage in the cicatricial strictures of esophagus

In 66 patients for the dilation of the cicatricial stricture of the esophagus vibration method was used. In 48 patients the vibrator was attached to proximal end of the bouge, in 18 patients the vibration device was introduced directly in the area of the stricture. The suggested method provided an easy and fast dilation of the stricture in 63 patients. In 3 cases surgical treatment was carried out because multiple strictures in separate areas resulted in complete obliteration of the esophagus. There were no complications due to the vibrobouginage. For the treatment of inflammatory disorders of the esophagus and for prophylaxis of the scar formation in the area of stricture in 29 patients the therapeutic laser irradiation was used. This treatment has ensured promising results.     

Bougienage of esophagus in critical burn strictures

Bougienage was made in 625 patients with burn strictures of the esophague which made up 59.4% of all patients (1053) who have undergone treatment since 1966 to October 1977 in Research Center of Surgery. Indications and contraindications for bougienage are discussed. In patients with short strictures (146) good effect was obtained in 83.1% of cases, in long strictures (803) the bougienage was effective in 61.1% of patients, in total strictures (104) good and favourable results were obtained in 26.2% of cases. Bougienage is an important method of treatment for patients with burn strictures of the esophagus, as well as a method of preoperative preparation.     

Clinical technique and success of the esophageal stent to prevent corrosive strictures

Membrane potential, Vm, and K+ (86Rb+) fluxes have been measured simultaneously on individual cells of Acetabularia mediterranea. During resting state (resting potential approx. -170 mV) the K+ influx amounts to 0.24-0.6 pmol-cm-2-s-1 and the K+ efflux to 0.2-1.5 pmol-cm-2s-1. According to the K+ concentrations inside and outside the cell (40:1) the voltage dependent K+ flux (zero at Vm = EK = -90 mV) is stimulated approx. 40-fold for Vm more positive than EK. It is calculated that during one action potential (temporary depolarization to Vm more positive than EK) a cell looses the same amount of K+, which leaks in during 10-20 min in the resting state (Vm = -170 mV). Since action potentials occur spontaneously in Acetabularia, they are therefore suggested to have a significant function for the K+ balance of this alga.     

Oesophageal replacement in the management of corrosive strictures: when is surgery indicated?

The accidental ingestion of corrosive agents is a major cause of oesophageal strictures in children. The mainstay of treatment is repeated dilatations. Despite this, a significant number of patients eventually require oesophageal bypass. We reviewed the records of all cases managed with this condition at the University of Cape Town teaching hospitals between 1976 and 1994. Dilatation therapy alone was successful in 14 out of 39 patients (41%). Morbidity of failed dilatation therapy included repeated hospital admissions over an average 11.5 months and 17 dilatations each. Oesophageal perforations occurred in 7 cases (18%). Early factors predictive of failure of conservative treatment were: delay in presentation of more than 1 month; severe pharyngo-oesophageal burns requiring a tracheostomy; oesophageal perforation; and a stricture longer than 5 cm on radiological assessment. The size of dilators accepted during early bougienage also correlated with eventual outcome. These criteria may be useful in predicting which patients will not respond to repeated dilatations. Early surgical intervention in such cases will prevent fruitless dilatations and related complications.     

Management of acid-peptic esophageal strictures

A new, nontoxic material extracted from Aspergillus fumigatus, is described with complement-depletion capacity both in vivo and in vitro. Extracts of the mycelium of A. fumigatus were found to haemolyse sheep red blood cells, to be lethal for mice and to convert C3 into its faster electrophoretic form when incubated with normal human serum. Conversion did not take place when purified C3 was used, suggesting that serum factors were required in the reaction. Adsorption of the extracts with activated carbon or heating at 100 degrees C for 30 min yielded detoxified materials devoid of both toxic and haemolytic properties but still capable of converting serum C3. In guinea pigs, administration of detoxified extracts was followed by complement depletion lasting not less than 48 h. Heating (100 degrees C for 30 min) extracts which had been previously detoxified by carbon adsorption resulted in a partial loss (40%) of their complement-inhibitory capacity indicating that part of the anticomplementarity of AFE was due to a heat-stable substance.     

Opportunistic infections occurring during highly active antiretroviral treatment

OBJECTIVE: To analyse the characteristics of opportunistic infections in patients receiving highly active antiretroviral treatment (HAART). DESIGN AND METHODS: A retrospective study performed in seven hospitals, included all patients starting treatment by ritonavir or indinavir between 26 March and 31 December 1996. Patients were evaluated for the development of AIDS-defining events. Clinical evaluation, plasma HIV-1 RNA quantification, CD4 cell count were recorded at baseline and at the onset of the event. RESULTS: Four hundred and eighty-six patients were included: 44.2% had a CD4 cell count below 50 x 10(6) cells/l. Fifty clinical events were recorded in 46 patients with a mean follow-up of 6.1 months, of which 34 events (68%) were observed during the first 2 months of HAART. Eighteen of these occurred despite a reduction of viral load by at least 1.5 log10) and a 100% increase of the CD4 cell count compared with that at the onset of the event, corresponding to 11 cytomegalovirus infections, five mycobacterial infections, one case of cryptococcosis, and one case of Varicella-Zoster virus-related acute retinal necrosis. Among the 16 events observed after the second month, six occurred despite a marked biological improvement, corresponding to a recurrence in five of six patients who had stopped their maintenance therapy. Events were one cytomegalovirus infection, two mycobacterial infections, one episode of oesophageal candidiasis and one cryptococcal meningitis. CONCLUSION: In patients at high risk of developing an opportunistic infection prior to the institution of a HAART regimen, prophylaxis should not be discontinued during the first 2 months of treatment, and maintenance therapy should be carried on despite a significant increase in the CD4 cell count.     

Surgical treatment of late esophageal perforations

The salvage of patients with late esophageal perforations is a formidable surgical undertaking. The basic objectives of surgical therapy should be: prompt debridement and control of sepsis by establishing an adequate, controlled route of decompression drainage, salvage of all viable and functional esophagus (except in massive disruptions with circumferential loss), adequate support of life control systems, and establishment of an appropriate alternate route for supportive alimentation. The method of treatment used in the group of patients reported here satisfies all these objectives. Our experience justifies further consideration of this technique in dealing with this catastrophic illness.     

Surgical treatment of cicatricial biliary strictures

BACKGROUND/AIMS: Cicatricial biliary strictures are usually associated with high morbidity and mortality rates, frequently related to technical difficulties of their surgical repair, mainly in hilar lesions. Interference with bile duct blood supply during surgical attempts for correction is a major factor for unsuccessful results. The aim of this study is to evaluate, after an extended follow-up period, the results obtained with a modified technique for surgical correction of cicatricial biliary strictures. METHODOLOGY: The medical records of 57 patients surgically treated for cicatricial biliary strictures between January 1984 and July 1995 were reviewed and the immediate and long term results retrospectively analyzed. Patients consisted of 46 females and 11 males. The average age was 43 years. The etiology of the biliary lesion was: cholecystectomy alone (23); cholecystectomy with duct exploration (8); T tube CBD drainage (6); Biliary-enteric anastomosis stricture (16); choledochoplasty (2) and trauma (2). In 28 cases (49.1%) the stricture was located in the upper third of the bile duct, in 28 (49.1%) in the middle third and in one case (1.7%) it was low. All patients were submitted to longitudinal Roux-en-Y hepaticojejunostomy with mucosa apposition after dissection of the anterior aspect of the biliary tract. No transanastomotic stents were used. RESULTS: Ten patients (17.5%) presented 11 postoperative complications: biliary fistula (4), duodenal fistula (1), wound infection (5), and acute pancreatitis (1). Average hospital stay was 11 days and there were no postoperative mortalities. The follow-up study was possible in 54 patients and ranged from one to ten years, with an average of 2.9 years. Four patients of 28 (14%) with hilar lesions developed stricture recurrence and cholangitis episodes, whereas no patients bearing lesions below the biliary junction had such complications. CONCLUSION: Roux-en-Y hepaticojejunostomy with mucosa apposition without transanastomotic stent performed after minimal dissection of the biliary duct, thus avoiding major interference with the bile duct blood supply, is a safe and efficient method for the surgical repair of cicatricial biliary strictures. Using this technique excellent results can be obtained in the lesions below the biliary junction and acceptable results may be achieved in patients with hilar lesions.     

Management of dysplasia in the columnar-lined esophagus

The management of patients with high-grade dysplasia in Barrett's esophagus is complex and controversial with regard to electing continued endoscopic biopsy surveillance until an early adenocarcinoma is detected or proceeding with partial esophagogastrectomy. Clinical recommendations to patients for either option should be individualized and based on several parameters reflecting patient and clinician factors. Available data on interpretational variation in the diagnosis of dysplasia; limitation of diagnostic errors with the use of a rigorous, systematic endoscopic biopsy protocol; new information on the apparent benign natural history of high-grade dysplasia in some patients; and the morbidity and mortality of esophageal resection all suggest that recommendation for continued endoscopic biopsy surveillance is an appropriate clinical practice in selected patients. Ongoing research investigations on high-grade dysplasia in Barrett's esophagus aim to reduce the potential for diagnostic errors, simplify cancer surveillance, and develop therapeutic interventions that are safer than but as effective as surgery.     

Onlay island flap urethroplasty in the treatment of urethral strictures

A skin island flap was used to create a neourethra in 65 patients aged 2 to 66 years with prolonged or multiple stricture of the anterior urethra. Before, all patients were treated repeatedly and unsuccessfully by open or endoscopic surgery. The principle of the used onlay technique was to supplement the missing lumen of the urethra by an island, usually preputial flap. In case of as missing segment of the urethra the original inlay-onlay technique was applied. After a mean follow-up period of 27 months 12 complications (18.4%) were recorded, six strictures of the proximal anastomosis, three fistulas and three dehiscences of the glans. CONCLUSION: The onlay island flap urethroplasty makes it possible to cure prolonged and multiple strictures of the urethra in one stage and with a relatively low complication rate.     

The Celestin tube in the treatment of benign oesophageal strictures

Celestin tubes have been used in two groups of patients with advanced benign oesophageal strictures. Group 1 consisted of 22 elderly, poor risk patients in whom intubation alone, via a gastrotomy, has provided good symptomatic relief of dysphagia. In 11 younger, better risk patients (group 2), it has been used as a temporary indwelling dilator in combination with repair of the hiatus hernia and has been removed at a mean of 5 months postoperatively. Seventy-three per cent of patients have remained free of recurrence when followed up for 2 years.     

Endoscopic treatment of Barrett esophagus

The purpose of the treatment of Barrett epithelium in the distal oesophagus is to reduce or even eliminate the increased risk of malignant degeneration in it. This can be achieved by removing the Barrett epithelium, whether or not dysplastic, and to have it replaced by normal squamous epithelium. Drug treatment or surgical antireflux treatment of Barrett epithelium has hardly any effect on the length of the Barrett epithelium or on the occurrence of malignancy. Various forms of endoscopic ablative therapy (laser coagulation, multipolar electrocoagulation, photodynamic therapy and argon plasma coagulation), in combination with antireflux treatment enable removal of the Barrett epithelium with regeneration of squamous epithelium. However, islets of Barrett epithelium may be found beneath the regenerated squamous epithelium and there is also the possibility of malignant potential of pluripotent stem cells left behind in the oesophagus. Future studies will have to afford insight into long-term results, the costs, the side effects of the various methods of treatment and the quality of life of patients during and after treatment of the Barrett oesophagus.     

The use of urethral stents for the treatment of urethral strictures

Three types of urethral stents can be used in the treatment of recurrent strictures: Urolume/Wallstent is a self-expanding mesh which is incorporated into the urethral epithelium; the ASI Titanium stent is a short rigid mesh of Titanium wire which is also incorporated into the urethra; Nitinol is a flexible spring in one or two parts connected by a steel wire. It remains endoluminal. The Urolume/Wallstent has been used since 1987. It is indicated in iatrogenic strictures. No statistical results are presented. The ASI stent should be reserved for strictures of the prostatic and posterior urethra. The Niticol UroCoil system can be used at all levels of the urethra; two models are available: simple or twin. The author has inserted 65 stents in 56 patients. The stent was removed after one year in 41 patients. The use of these stents has considerably decreased the number of repeated dilatations and urethrotomies.     

Leiomyosarcoma of the esophagus: results of surgical treatment

BACKGROUND: This study examined the results of surgical treatment of leiomyosarcoma of the esophagus. METHODS: Between January 1920 and December 1996, 17 patients (9 men and 8 women) with leiomyosarcoma of the esophagus were treated surgically at the Mayo Clinic. Median age was 58 years and ranged from 26 to 76 years. Symptoms included dysphagia in 11 patients (64.7%) and odynophagia in 6 (35.3%). The tumor was located in the middle third of the esophagus in 10 patients (58.8%) and in the cervical esophagus in 7 (41.2%). Procedures performed included esophagogastrectomy in 9 patients (Ivor Lewis in 5, left thoracoabdominal in 3, and transhiatal in 1), enucleation in 3, transgastric excision in 1, and exploration without resection in 4. RESULTS: The procedure was considered curative in 11 patients (64.7%). There was one operative death (mortality, 5.9%). Complications occurred in 3 patients (17.6%) and included anastomotic leak in 2 and bleeding requiring reoperation in 1. Growth pattern was infiltrating in 7, polypoid in 5, and intramural in 5. Histologically, the tumor was grade 1 in 6 patients, grade 2 in 2, grade 3 in 7, and grade 4 in 2. The tumor was postsurgically classified as stage I in 2 patients, stage IIA in 7, stage IIB in 1, stage IIIA in 5, stage IV in 1, and unknown in 1. Six patients (35.3%) received adjuvant treatment. Follow-up was complete in 16 patients (94.1%) and ranged from 1 to 182 months (median, 48 months). Five- and 10-year actuarial survivals were 47.0% and 31.0%, respectively. Seven patients (41.2%) are currently alive (median survival, 72 months); all underwent curative resection. Factors affecting survival included completeness of resection, growth pattern, postsurgical stage, tumor grade, and tumor location (p < 0.05). CONCLUSIONS: We conclude that leiomyosarcoma of the esophagus is rare. Complete resection provides long-term survival.     

Surgical treatment of cancer of the esophagus and cardia

The purpose of the present study was to evaluate the results following surgical resection for cancer of the gastro-oesophageal junction. From 1. january 1988 to 1. april 1996 radical resection was intended in 107 patients at the Department of Thoracic and Cardiovascular Surgery at Odense University Hospital. Resection was possible in 75 patients. The operative mortality was 6.7% insufficiency of the gastro-oesophageal anastomosis was found in 6.7%. Five year survival was 24.1%. However in 52 patients where the resection was found to be radical the five-year survival was 35.3%. The results show that oesophago-gastrectomy could be performed with low mortality and morbidity. Long term survival is still low. To improve the results efforts should be directed toward earlier diagnosis, better selection and minimising post-operative complications.     

Microstructural changes occurring during the gaseous reduction of magnetite

The reduction of dense magnetite samples in H₂/H₂O and H₂/N₂ gas mixtures between temperatures of 723 and 1373 K has been investigated. A detailed study of partially reduced samples using conventional metallographic and scanning electron microscopy (SEM) techniques has enabled the conditions for the formation of a number of different product microstructures to be clearly defined. The reaction mechanisms involved in various continuous and discontinuous growth processes are discussed. Formerly with the University of Queensland.