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Esophagogastrectomy for acid injury
CORRESPONDENCE
Ann Thorac Surg
739
1992;53:73842
with adult extracorporeal membrane oxygenation in the modern era. Ann Thorac Surg 1992;53:553-63. 3. NHLBI-NIH. Extracorporeal support for respiratory insufficiency. DHEW Publication, 1980. 4. Wright L. NIH Workshop on Neonatal ECMO and Diffusion of Technology. NIH/NICHHD (in press). 5. Gattinoni L, Pesenti A, Mascheroni D, et al. Low frequency positive pressure ventilation with extracorporeal CO, removal in severe respiratory failure. JAMA 1986;256:881-5.
on the posterior surface of the trachea and left bronchus, and 1 had no lesion. They both recovered. The excluded esophagus did not invite immediate danger in our experience, but it could produce a secondary mucocele (which was retrospective proof it was not very deeply burned, as endoscopy generally overestimates the lesions). So we suggest immediate exclusion of the esophagus in the majority of cases to avoid the supplementary trauma of resection, with subsequent esophagectomy during coloplasty to prevent the formation of a mucocele [6].
Michel E. Ribet, M D
Esophagogastrectomyfor Acid Injury To the Editor: In their article on emergency esophagogastrectomy for corrosive injury, Horvlth and collaborators [ l ] wrote that damage to the stomach is generally observed in the antrum and fundus, but acute necrosis usually affects the major part of the stomach and is only very rarely cured by partial resection. This has been our experience, too. They added that they always perform total esophagogastrectomy and the esophagus is resected without a thoracotomy. We behave differently concerning the esophagus
PI.
In a group of 80 patients treated for severe corrosive esophagogastric burns, total gastrectomy had to be performed in 20 patients because of necrosis and perforation. It was done within 24 hours in 12 patients: 5 had ingested an acid (2 >150 mL, 2 4 5 0 mL, 1 unknown quantity), 4 had ingested a base (1 >150 mL, 1 <150 mL, 2 unknown quantities), 2 had ingested bleach (>150 mL), and 1 had ingested formaldehyde (<150 mL). Gastrectomy was done between postinjury days 1 and 20 in 8 patients: 1had ingested an acid (<150 mL), 3 had ingested a base (2 >150 mL, 1 unknown quantity), and 4 had ingested bleach (>150 mL). The duodenum, cardia, and cervicothoracic esophagus were hand-sutured. A terminal cervical esophagostomy and a feeding jejunostomy were performed. Five of the 20 patients died in the postoperative period: of multiple small bowel perforation on day 9, of peritonitis on day 18, of systemic sepsis on days 2 and 18, and of a tracheoesophageal fistula on day 33. The 15 survivors had a second-stage retrostemal colon interposition bypassing the excluded esophagus. One died of complications of an esophageal mucocele at 4 years, 4 were found to have a nonsymptomatic small esophageal mucocele, and 1 had a regressive mucocele. When necrosis from ingestion of caustic material is present in the abdomen, aggressive operation is often necessary [3]. If the burns extend to the bowel and pancreas, extended resections with delayed sutures and with enterostomies offer the only chance of cure. What is to be done with the esophagus is more debatable: esophagojejunal anastomosis may be attempted in a small minority of well-selected cases, the esophagus can be sutured over a drain, it can be closed at both ends and excluded, or it can be resected. Blind resection is easy but may be unnecessary, and it may provoke a tear in the membranous part of the trachea. It has been advocated to stop extensive necrosis of the esophagus from reaching the trachea. However its mortality is high [4, 51. Those who resect the esophagus as a preventive measure also state that if endoscopy discloses necrosis of the trachea, one should refrain from performing an esophagectomy. In our series, all the patients who died had an autopsy. The esophagus was not the cause of death except in the case of the patient with a tracheoesophageal fistula that appeared on day 33: this was the only failure of exclusion. Two patients underwent emergency bronchoscopy because of respiratory disorders associated with stage 111 esophageal burns: 1of them had a white area
HSpital Calmette F. 59037 Lille Cedex France
References 1. Horvlth OP, Ollh T, Zentai G. Emergency esophagogastrectomy for treatment of hydrochloric acid injury. Ann Thorac Surg 1991;52:98-101. 2. Ribet M, Chambon JP, Pruvot FR. Oesophagectomy for severe corrosive injuries: is it always legitimate? Eur J Cardiothorac Surg 1990;4:347-50. 3. Gago 0, Ritter FN, Martel W, et al. Aggressive surgical treatment for caustic injury of esophagus and stomach. Ann Thorac Surg 1972;13:243-50. 4. Gossot D, Sarfati E, Celerier M. Early blunt esophagectomy in severe caustic burns of the upper digestive tract. J Thorac Cardiovasc Surg 1987;9418%91. 5. Hwang TL, Shen-Chen SM, Chen MF. Nonthoracotomy esophagectomy for corrosive esophagitis with gastric perforation. Surg Gynecol Obstet 1987;164:53740. 6. Mannell A, Epstein B. Exclusion of the esophagus: is this a dangerous manoeuvre? Br J Surg 1984;71:442-5.
Severe Endobronchial Hemorrhage To the Editor: In a recent article, Purut and co-workers [ l ] described a case of severe endobronchial hemorrhage during a coronary artery bypass operation due to pulmonary artery perforation by a SwanGanz catheter. The authors are to be commended for their successful and innovative use of an endobronchial balloon catheter without subsequent pulmonary resection to control the bleeding, but neither their report nor the accompanying discussion commented on the actual need for a Swan-Ganz catheter in their patient. In view of the recognized danger and expense of the Swan-Ganz catheter, it seems pertinent to question its use in a 64-year-old man with no recent infarction and normal cardiac function (ejection fraction 0.67) who was undergoing an operation described as ”elective.” Unfortunately, Swan-Ganz catheters are often inserted by anesthesiologists without the surgeon’s advice or consent, as may have occurred in Purut and coworkers’ patient. It is important to report complications related to Swan-Ganz catheters to document that use of a Swan-Ganz catheter is not innocuous and should not be routine. Information about cardiac output is rarely necessary intraoperatively in low-risk patients after coronary bypass, because such patients should not require inotropic support to be weaned from cardiopulmonary bypass [2, 31. (A Swan-Ganz catheter can always be inserted postoperatively if circumstances change.) Information about left ventricular filling pressures is useful, however, and can be easily and inexpensively obtained by inserting a left atrial pressure monitoring catheter. For the vast majority of surgeons who vent the
Ann Thorac Surg
739
1992;53:73842
with adult extracorporeal membrane oxygenation in the modern era. Ann Thorac Surg 1992;53:553-63. 3. NHLBI-NIH. Extracorporeal support for respiratory insufficiency. DHEW Publication, 1980. 4. Wright L. NIH Workshop on Neonatal ECMO and Diffusion of Technology. NIH/NICHHD (in press). 5. Gattinoni L, Pesenti A, Mascheroni D, et al. Low frequency positive pressure ventilation with extracorporeal CO, removal in severe respiratory failure. JAMA 1986;256:881-5.
on the posterior surface of the trachea and left bronchus, and 1 had no lesion. They both recovered. The excluded esophagus did not invite immediate danger in our experience, but it could produce a secondary mucocele (which was retrospective proof it was not very deeply burned, as endoscopy generally overestimates the lesions). So we suggest immediate exclusion of the esophagus in the majority of cases to avoid the supplementary trauma of resection, with subsequent esophagectomy during coloplasty to prevent the formation of a mucocele [6].
Michel E. Ribet, M D
Esophagogastrectomyfor Acid Injury To the Editor: In their article on emergency esophagogastrectomy for corrosive injury, Horvlth and collaborators [ l ] wrote that damage to the stomach is generally observed in the antrum and fundus, but acute necrosis usually affects the major part of the stomach and is only very rarely cured by partial resection. This has been our experience, too. They added that they always perform total esophagogastrectomy and the esophagus is resected without a thoracotomy. We behave differently concerning the esophagus
PI.
In a group of 80 patients treated for severe corrosive esophagogastric burns, total gastrectomy had to be performed in 20 patients because of necrosis and perforation. It was done within 24 hours in 12 patients: 5 had ingested an acid (2 >150 mL, 2 4 5 0 mL, 1 unknown quantity), 4 had ingested a base (1 >150 mL, 1 <150 mL, 2 unknown quantities), 2 had ingested bleach (>150 mL), and 1 had ingested formaldehyde (<150 mL). Gastrectomy was done between postinjury days 1 and 20 in 8 patients: 1had ingested an acid (<150 mL), 3 had ingested a base (2 >150 mL, 1 unknown quantity), and 4 had ingested bleach (>150 mL). The duodenum, cardia, and cervicothoracic esophagus were hand-sutured. A terminal cervical esophagostomy and a feeding jejunostomy were performed. Five of the 20 patients died in the postoperative period: of multiple small bowel perforation on day 9, of peritonitis on day 18, of systemic sepsis on days 2 and 18, and of a tracheoesophageal fistula on day 33. The 15 survivors had a second-stage retrostemal colon interposition bypassing the excluded esophagus. One died of complications of an esophageal mucocele at 4 years, 4 were found to have a nonsymptomatic small esophageal mucocele, and 1 had a regressive mucocele. When necrosis from ingestion of caustic material is present in the abdomen, aggressive operation is often necessary [3]. If the burns extend to the bowel and pancreas, extended resections with delayed sutures and with enterostomies offer the only chance of cure. What is to be done with the esophagus is more debatable: esophagojejunal anastomosis may be attempted in a small minority of well-selected cases, the esophagus can be sutured over a drain, it can be closed at both ends and excluded, or it can be resected. Blind resection is easy but may be unnecessary, and it may provoke a tear in the membranous part of the trachea. It has been advocated to stop extensive necrosis of the esophagus from reaching the trachea. However its mortality is high [4, 51. Those who resect the esophagus as a preventive measure also state that if endoscopy discloses necrosis of the trachea, one should refrain from performing an esophagectomy. In our series, all the patients who died had an autopsy. The esophagus was not the cause of death except in the case of the patient with a tracheoesophageal fistula that appeared on day 33: this was the only failure of exclusion. Two patients underwent emergency bronchoscopy because of respiratory disorders associated with stage 111 esophageal burns: 1of them had a white area
HSpital Calmette F. 59037 Lille Cedex France
References 1. Horvlth OP, Ollh T, Zentai G. Emergency esophagogastrectomy for treatment of hydrochloric acid injury. Ann Thorac Surg 1991;52:98-101. 2. Ribet M, Chambon JP, Pruvot FR. Oesophagectomy for severe corrosive injuries: is it always legitimate? Eur J Cardiothorac Surg 1990;4:347-50. 3. Gago 0, Ritter FN, Martel W, et al. Aggressive surgical treatment for caustic injury of esophagus and stomach. Ann Thorac Surg 1972;13:243-50. 4. Gossot D, Sarfati E, Celerier M. Early blunt esophagectomy in severe caustic burns of the upper digestive tract. J Thorac Cardiovasc Surg 1987;9418%91. 5. Hwang TL, Shen-Chen SM, Chen MF. Nonthoracotomy esophagectomy for corrosive esophagitis with gastric perforation. Surg Gynecol Obstet 1987;164:53740. 6. Mannell A, Epstein B. Exclusion of the esophagus: is this a dangerous manoeuvre? Br J Surg 1984;71:442-5.
Severe Endobronchial Hemorrhage To the Editor: In a recent article, Purut and co-workers [ l ] described a case of severe endobronchial hemorrhage during a coronary artery bypass operation due to pulmonary artery perforation by a SwanGanz catheter. The authors are to be commended for their successful and innovative use of an endobronchial balloon catheter without subsequent pulmonary resection to control the bleeding, but neither their report nor the accompanying discussion commented on the actual need for a Swan-Ganz catheter in their patient. In view of the recognized danger and expense of the Swan-Ganz catheter, it seems pertinent to question its use in a 64-year-old man with no recent infarction and normal cardiac function (ejection fraction 0.67) who was undergoing an operation described as ”elective.” Unfortunately, Swan-Ganz catheters are often inserted by anesthesiologists without the surgeon’s advice or consent, as may have occurred in Purut and coworkers’ patient. It is important to report complications related to Swan-Ganz catheters to document that use of a Swan-Ganz catheter is not innocuous and should not be routine. Information about cardiac output is rarely necessary intraoperatively in low-risk patients after coronary bypass, because such patients should not require inotropic support to be weaned from cardiopulmonary bypass [2, 31. (A Swan-Ganz catheter can always be inserted postoperatively if circumstances change.) Information about left ventricular filling pressures is useful, however, and can be easily and inexpensively obtained by inserting a left atrial pressure monitoring catheter. For the vast majority of surgeons who vent the