Barrett's oesophagus: endoscopic diagnosis and follow-up

Barrett's oesophagus (BO), or replacement of the squamous mucosa by a specialized intestinal metaplasia due to gastro-oesophageal reflux disease (GORD), predisposes to adenocarcinoma. It is estimated that 6 to 12% of patients undergoing GI endoscopy have short BO (< 3 cm), and 1% have a long BO. Macroscopic diagnosis of BO is sometimes difficult and, in case of doubt, endoscopy should be redone after a period of efficient anti-secretory treatment. Diagnosis of BO is histological and should be confirmed by biopsies. The incidence of adenocarcinoma is globally estimated at 0.5% patient by year of follow-up, and exists for both short and long BO. Due to this low incidence, screening for BO is only justified in patients at high risk for adenocarcinoma (male gender, age > 50 ans, old GORD in a young patient). Low-grade dysplasia (LGD) then high-grade dysplasia (HGD) precedes adenocarcinoma. Histological diagnosis of LGD is difficult: the main cause of confusion is inflammation so diagnosis of LGD must be confirmed after a 3-month high-dose anti-secretory treatment. Diagnosis of HGD is easier but multiple biopsies are needed to determine the focal or multifocal disposition of HGD. The benefit of follow-up of BO is debated. Aged patients should be followed only if dysplasia is present. When dysplasia is absent, an endoscopic control with biopsies is desirable within 3 to 5 years. In case of dysplasia, the latter must be confirmed by another examination of biopsies, particularly in case of suspicion of HGD and after antisecretory treatment. In case of LGD, endoscopy with biopsies should be redone 6 months later to screen for HGD, then every year if LGD is confirmed. In case of HGD, the 5-year risk of cancer is 60% so surgical or endoscopic treatment is usually proposed. If HGD follow-up is decided, it should be performed on a 3- to 6-month basis.     

Seromuscularis rupture of the oesophagus after vomiting: a rare cause of hemothorax

We report a case of seromuscularis rupture of the oesophagus occurring after an episode of vomiting and revealed by a left hemothorax. Diagnosis was established at thoracoscopy and was related to the nosologic setting of post-emetic syndromes. All unusual pleuropulmonary symptoms after vomiting must make evoke this diagnostic hypothesis.     

Peroperative rescue procedure after failure of oesophagojejunostomy following total gastrectomy

Leakage of oesophagojejunostomy is a severe complication of total gastrectomy. We present a technique allowing preoperative preservation of a defective oesophagojejunostomy: this technique involves closure of the cervical esophagus with stapler, double-lumen transanastomotic tube, mediastinal drainage and feeding jejunostomy.     

Reinterventions for complication and defect of coloesophagoplasty

AIM OF THE STUDY: To report a series of 17 patients operated for a complication oesophagocoloplasty, with evaluation of therapeutic modalities, and both early and distant results. MATERIALS AND METHOD: From 1985 to 2003, 17 patients with a mean age of 50 years (range: 23-76) were reoperated after coloplasty pediculated on left superior colic vessels. Initial diseases were caustic ingestion (N=7), cancer (N=6), oesophageal perforation (N=2), gastric lymphoma (N=1) and oesotracheal fistula (N=1). Coloplasty has been performed as a first-intent procedure in 13 cases and as a second-intent procedure after failure of a previous operation in 4 cases. Nine patients were initially operated in another center and were subsequently referred in our unit. Complications needing reoperation were graft necrosis in 8 cases (47%) and stricture in 9 cases (53%). All patients with necrosis were reoperated within the 10 first postoperative days. RESULTS: Necroses were treated by complete (N=5) or partial (N=3) resection of the coloplasty. Strictures were treated by resection-reanastomosis (N=3), right ileocoloplasty (N=2), colic stricturoplasty (N=2), a free antebrachial flap (N=1) and a tubulized latissimus dorsi myocutaneous pedicled flap (N=1). The 30-day mortality rate was 12% (N=2) and the overall morbidity rate was 66%. All deaths occurred after reoperation for necrosis. Eleven patients (65%) kept or recovered digestive continuity (including the 9 with stenosis) and 8 (73%) eat normally. Four patients with transplant necrosis died before reestablishment. Four patients operated for necrosis died before restoration of digestive continuity and 2 patients are still awaiting restoration. CONCLUSION: Use of colon as an oesophageal substitute is risky. Reoperations for stenosis allows satisfactory oral feeding, while reoperation for necrosis is associated with both high early mortality and a low rate of restoration or digestive continuity. This later requires a range of complex surgical procedures.     

Minimally invasive esophagectomy: prospective evaluation of laparoscopic gastric mobilization

OBJECTIVE: Esophagectomy carries high morbidity, mainly due to respiratory complications. In digestive surgery, postoperative outcome is generally improved by minimally invasive surgery. A prospective study was conducted to evaluate feasibility and postoperative outcome of minimally invasive esophagectomy (MIE). METHODS: From July 2001 to June 2004, 20 patients underwent esophagectomy with laparoscopic gastric mobilization (LGM) for squamous cell carcinoma (N=11), adenocarcinoma (N=7), Barrett's esophagus with high-grade dysplasia (N=1), and long peptic stricture (N=1). Tumours (N=19) were located on the cardia (N=5), on the lower third of the oesophagus (N=10), on the median third (N=3), and on the upper third (N=1). Following LGM, transthoracic (N=19) or transhiatal (N=1) oesophagectomy was performed. RESULTS: Complete LGM was achieved in all cases. Mean operative time for LGM was 197+/-48 minutes. In the 19 patients operated for tumours, 18 underwent R0 resection. Eleven patients (55%) developed postoperative complications, mainly (30%) respiratory. Intrathoracic anastomotic leakage occurred in 2 patients, with favourable outcome. Pylorospasm (N=1) was the only intraabdominal complication. One patient died (5%). CONCLUSION: Esophagectomy with LGM is feasible with few specific complications. However, no decrease in morbidity could be observed with this technique. Further studies are required to evaluate if thoracoscopy could improve the postoperative course after LGM and to validate oncologic safety of MIE.     

移植肾破裂的治疗及预后

目的探讨移植肾破裂的治疗及预后。方法回顾性分析19例,21例次移植肾破裂患者临床资料。临床表现均为移植肾区突发疼痛,伴移植肾区肿胀、血压降低、少尿及血红蛋白降低。B超发现移植肾被膜不连续,移植肾周积液量明显增加。结果移植肾破裂时间平均为术后20 d。移植肾单一裂口15例,多发裂口4例。急诊手术治疗14例,其中移植肾切除5例,1例切除后死亡。移植肾破裂修补9例,其中3例修补后因再次破裂行移植肾切除,肾功能恢复5例,1例修补后死亡。保守治疗5例,其中2例因病情恶化行移植肾切除,肾功能恢复2例,死亡1例。病理证实移植肾破裂的主要原因为急性排斥反应和急性肾小管坏死。结论移植肾破裂主要原因为急性排斥反应和急性肾小管坏死,治疗应慎重采用保守治疗和修补术式,可采用移植肾切除术。     

An unrecognized oesophageal rupture

Perforation of the abdominal oesophagus from blunt trauma is an extremely rare injury. We report a case of an initially unrecognized oesophageal injury. The patient underwent an immediate laparotomy for haemorrhagic shock. The diagnosis was made by tomodensitometry and was delayed by modified radiological interpretation secondary to laparotomy. Finally, the outcome was favourable.     

Endoscopic treatment of Barrett's oesophagus

Aims of the treatment of Barrett's oesophagus (BO) are disappearance of symptoms and inflammatory complications of gastro-oesophageal reflux disease (GORD), prevention of occurrence of dysplasia and adenocarcinoma, and early treatment of high-grade dysplasia (HGD) and adenocarcinoma. Anti-secretory treatment with proton-pump inhibitors (PPI) must result in disappearance of both symptoms and oesophagitis. The only correction of symptoms, as well as normalization of pHmetry, are not considered as adequate criteria for efficiency of treatment. It has not been demonstrated that treatment with PPI prevented occurrence of dysplasia and adenocarcinoma so the only BO is not an indication for treatment with PPI, which results in only partial regression of height and/or surface of BO. Endoscopic ablation of BO, combined with PPI, allows complete regression of intestinal metaplasia in about 50% of cases. Photodynamic therapy (PDT) seems the best technique for treatment of HGD and mucosal adenocarcinoma. This treatment is not indicated in case of low-grade dysplasia, since its benefit on survival is less clear than for HGD. Endoscopic treatment does not suppress the need for prolonged endoscopic follow-up since BO recurs in approximately one third of patients. For HGD isolated or associated with mucosal adenocarcinoma (proven by endoscopic ultrasound), endoscopic treatment can consist in mucosectomy or ablation with PDT or plasma argon coagulation (PAC) of these lesions if localized, possibly followed by complete ablation of BO by PAC, and always associated with an efficient treatment of GORD by PPI or anti-reflux surgery. Submucosal adenocarcinomas must be treated by oesophagectomy if allowed by the general condition of the patient.     

外伤性肝破裂52例诊治体会

目的分析肝脏外伤的特点及其诊治方法。方法对1996年1月-2005年12月年本院收治创伤性肝破裂52例进行回顾性分析。其中Ⅲ级以上的严重肝破裂37例。手术治疗51例,手术方式包括单纯修补、清创性肝切除、肝周填塞止血:非手术治疗1例。结果:手术组:治愈49例,术后死亡2例:非手术组1例治愈结论:I级单纯性外伤性肝破裂可保守治疗;手术是治疗创伤性肝破裂的主要措施。确切止血,仔细结扎胆管,充分通畅的引流及术后抗生素扣支持治疗是防止并发症的关键。     

The mechanics of corneal deformation and rupture for penetrating injury in the human eye

Penetrating eye injuries are surgical emergencies with guarded visual prognosis. The purpose of the current study was to determine the force required to rupture the cornea with a penetrating object, and to study how this force is affected by the object geometry. Thirty-six human cadaveric eyes from donors of various ages were characterized for diameter, axial length, and pre-test intraocular pressure. In order to investigate the effects of specimen storage time on the tissue response, half of the specimens were tested within two weeks of donor expiration, and half of the specimens were stored at −4 °C for 12–18 months. Indenters of three different diameters (1.0, 1.5, and 2.0 mm) were lowered into the apex of the cornea until rupture. Resistance to displacement (stiffness), displacement at failure, and the force at failure were determined. Multi-variable regression analysis was used to determine associations of the input variables (indenter size, test speed, and tissue postmortem time) on the mechanics of the tissue response. Twenty-nine of the 36 specimens failed at the indenter location in the cornea, four failed at the limbus, and three failed in the sclera near sites of muscle attachment. The average force at failure caused by the 1.0 mm, 1.5 mm, and 2.0 mm indenters increased from 30.5 ± 5.5 N to 40.5 ± 8.3 N to 58.2 ± 14.5 N, respectively (p < 0.002). The force at failure was associated with the donor age (p < 0.001), and globe diameter (p < 0.041), but was not associated with pre-test intraocular pressure, tissue postmortem time, axial length, or speed of the indenter. This study has quantified the force-displacement and failure response of a large series of human cadaveric eyes subjected to penetrating indentation loads on the cornea. The results provide useful data for characterizing the relationship between corneal rupture and the geometry of a penetrating object.     

Barrett's oesophagus: the rationale for surgical resection

Surgical resection has a limited place in the management of Barrett's oesophagus with high-grade dysplasia, except when failure of endoscopic mucosectomy is likely (extended Barrett's oesophagus, nodular or ulcerated lesions at endoscopy). For superficial carcinoma, it is often difficult to differentiate mucosal carcinoma (carrying a risk of nodal metastasis less than 7%) from submucosal carcinoma (carrying a risk of nodal metastasis ranging from 16 to 47%), oesophagectomy is routinely indicated if operative risk is low. When operative risk is not minimal, endoscopic mucosectomy is indicated for lesions limited to the mucosa and the proximal third of submucosa; for lesions extending beyond, an oesophagectomy must be discussed. These indications must take into account both age and general condition of the patient, as well as the expertise in oesophageal surgery of the group.     

Results of surgical resection of squamous cells carcinoma of the oesophagus with or without preoperative radiochemotherapy: comparative and retrospective study

AIM OF THE STUDY: The aim of the study was to assess preoperative radio-chemotherapy for squamous cell carcinoma of the esophagus. MATERIAL AND METHODS: This study was a retrospective comparison between radio-chemotherapy followed by surgical resection (RCPO) and surgery alone. The RCPO group included patients with tumor located in the middle or lower third of the esophagus, staged T2 or T3 tumors without distant metastases by pretherapeutic assessment. These patients were matched with patients who underwent immediate surgery, who constituted the surgical group (CHIR). Both groups were matched for gender, age, tumor localization (middle or lower third), T stage, and surgical procedure. Each group included 77 men and 9 women, 50 tumors of the middle third and 36 of the lower third of the oesophagus, and 19 tumors T2 and 67 T3 ones. RESULTS: Morbidity of both groups was not significantly different. The mortality was 4% in the group CHIR and 12% in the group RCPO (P =0.07). The rate of radical resection (R0) was significantly higher in the RCPO group (74% vs. 51%; P =0.001). The overall 5-year survival rate was 38% after R0 surgery and 11% after R1 or R2 surgery (P <0.0001). After R0 surgery, the 5-year survival rate was 47% in the CHIR group and 32% in the RCPO group (P =0.06). CONCLUSION: Preoperative radiochemotherapy increases the rate of radical surgical resection without significant increase in postoperative morbidity and mortality.     

Perforation of intestinal leiomyosarcoma: A case report

Introduction and ImportanceThe majority of gastrointestinal sarcoma is gastrointestinal stromal tumors and intestinal leiomyosarcoma is rare. Small intestinal mesenchymal tumors are often large at diagnosis, and they commonly present with bleeding or intussusception. We report a perforation associated with intestinal leiomyosarcoma.Case PresentationA 66-year-old man presented with severe epigastric pain. A physical examination showed tachycardia and a diffusely tender and rigid abdomen. Computed tomography showed a massive tumor and free air. A laparotomy was performed to treat lower digestive perforation. Massive tumor, which invaded surrounding intestine, was 20 cm in size at the ileum. The involved intestine was perforated. We confirmed that feeding artery was superior mesenteric artery and performed partial intestinal resection. His clinical course was uneventful and discharged 10 days postoperatively. The pathological findings showed spindle shaped and the tumor invaded the mucosa at the perforated site. Immunohistochemical spectrum resulted c-kit negative, S-100 negative, Desmin positive, alpha smooth muscle actin(αSMA) positive and Ki-67 30–40 %. The pathological findings were leiomyosarcoma.DiscussionGastrointestinal sarcoma is sometimes found by bleeding. In our patient, leiomyosarcoma invaded surrounding intestine, it made the intestine wall frail and caused perforation. The intestinal perforation which was involved by leiomyosarcoma has been rarely reported to the best of our knowledge since WHO refined leiomyosarcoma.ConclusionsAlthough intestinal leiomyosarcoma is rare, we should know that it can involve surrounding intestines and make them perforated.     

Interest of circulatory assistance mobile unit for cardiovascular surgical pathology support at distance of specialized centers: about a case of papillary muscle rupture

Papillary muscle rupture is a classical, but not frequent life-threatening complication of myocardial infarction. The only treatment consists in mitral valve surgical replacement. It should be performed in a hospital with specialized critical care and a cardiac surgery unit. The problem we are talking about in this article is the transfer of very instable patients in a specialized center before surgery. We also discuss the interest of mobile unit of cardiac assistance to manage patients in hospital without cardiac surgery then to transfer them. We discuss also the initial management in the cardiac surgery and critical care unit.     

外伤性脾破裂317例诊治分析

目的：探讨在条件有限的基层医院中脾破裂患者的诊疗方法。方法：回顾性分析瓦努阿图共和国维拉中心医院8年间住院的317例脾破裂患者的临床资料，分析B超诊断的出血情况和非手术治疗、手术治疗的结果。结果：B超诊断被膜下出血者30例，真性脾破裂者287例。参考B超结果对29例患者采用非手术治疗，288例采用手术治疗。结论：B超诊断脾破裂阳性率高，诊断出血量与手术结果较符合；参考B超结果选择符合脾切除术指征的病例进行手术是治疗脾破裂确切有效的手段。     

Spontaneous rupture of the oesophagus: Endoscopic treatment in the primary stage

A case of spontaneous rupture of the oesophagus occurring in the right wall of the midoesophagus is reported. The treatment, conservative in the primary stage of the disease, is described. This consisted of per-oesophageal drainage of the mediastinum, effected endoscopically. In spite of complications—an empyema in the right pleura and an oesophagocutaneous fistula—the treatment was successful, resulting in a complete cure about two years after the accident. The patient has remained in good health since then.     

自发性食管破裂的外科治疗

目的探讨自发性食管破裂的临床特点及外科治疗。方法回顾性分析我院自2000-2006年间收治的自发性食管破裂患者5例,分析其临床表现及外科治疗方法。结果5例患者中4例得到早期手术而痊愈,1例晚期手术患者术后并发症脓胸及急性肾功能衰竭而死亡。结论提高对自发性食管破裂的认识,早期手术主是治疗成功的关键。