Twenty-five patients with traumatic diaphragmatic hernia discovered at least five months after injury are described, of whom 18 were male and seven female. All but one hernia occurred on the left side. Stab wounds were the etiological factor in 22 patients and blunt trauma in three. The diagnosis was most often made by a chest or abdominal radiograph, but barium ingestion confirmed the diagnosis in ten patients. Intercostal drainage of gastric contents provided the diagnosis in two patients. In all nine patients initially approached by a thoracotomy or a thoracoabdominal incision, the hernia was easily reduced and the defect repaired. Although reduction and repair were easily accomplished by the abdominal route in seven patients, this approach was unsatisfactory or inadequate in six others. The colon and stomach were usually in the chest, and strangulation occurred in five patients. The mortality was 20% but rose to 80% when gangrene was present.
Ten patients with carcinoma of the lower third of the oexophagus who had oesophagogastrectomy followed by oesophagogastrostomy without a drainage procedure were investigated 6 months postoperatively. Postoperative symptomatic evaluation and modified Visick grading of the results were carried out by an independent observer. Objective assessment included fibre-optic endoscopy of the oesophagus, stomach and duodenum, gastric acid secretory studies and measurement of gastric emptying times following the ingestion of a barium food mixture. Eight of the 10 patients had an excellent or very good result and the remaining 2 were graded as satisfactory. No evidence of macroscopic oesophagitis or gastritis was detected and pyloric obstruction was never observed. Gastric emptying time was not prolonged. The results obtained support the concept that a drainage procedure is unnecessary after oesophagogastrostomy.
One hundred and eighty-one patients with carcinoma of the upper thoracic oesophagus were intubated perorally using a Procter-Livingstone tube. The mortality was 16-6 per cent but, in the patients who survived, the palliation achieved, as judged by improved swallowing, was considered satisfactory. Factors influencing the success of intubation are also considered.
The optimum method of restoring the ability to swallow in patients with oesophageal carcinoma remains controversial. This prospective randomized study evaluates the palliative potential of pulsion intubation v. retrosternal gastric bypass of the excluded oesophagus in 106 patients with unresectable carcinoma; 55 patients were intubated and 51 patients treated by gastric bypass. The operative mortality and morbidity, palliation of dysphagia and postoperative nutritional status were compared in the 2 groups. Intubation resulted in 3 deaths (5.5 per cent) and gastric bypass in 4 deaths (7.8 per cent). Intubation was complicated by chest infection in 13 patients (24 per cent) but complications related to the procedure occurred in only 5 patients and included tube migration (2), respiratory obstruction (1), bleeding (2) and oesophageal perforation (1). Gastric bypass was complicated by chest infection in 14 patients (27 per cent), but procedure-related complications were common and included pneumothorax (3), wound infection (6), subphrenic abscess (2), anastomotic leak (5) and purulent neck discharge (3). Palliation of dysphagia was achieved in 93 per cent of patients following intubation and 92 per cent of patients following bypass. Nutritional status improved more rapidly following bypass. Nutritional status improved more rapidly following intubation. Pulsion intubation is the preferred palliative procedure because of fewer complications and a lesser degree of postoperative catabolism.
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