Background and aim. The optimal management of tracheal disruptions is still controversial. It is usually postulated that lesions wider than 1 or 2 centimetres and/or lesions of full-thickness should be treated by surgery at an early stage. Such a statement is not supported by any proven evidence. On the contrary, the conservative management of such injuries has also produced very good results according to recent reports. The aim of this study is to investigate whether conservative treatment can be safely used for wide tracheal lacerations and to assess any possible association between clinical features and modality of treatment. Methods. Records of all patients with iatrogenic and traumatic tracheal disruptions observed between January 1992 and December 2006 were collected and retrospectively reviewed. Data regarding mechanism of injury, clinical and morphological features and modalities of treatment were registered. All possible associations between clinical features and modalities of treatment were investigated. Results. 23 patients were observed overall. There were 6 males and 17 females with a median age of 58 years (range 20-84 yrs). 15 patients had undergone single tube intubation. One patient had his trachea injured during an esophagectomy. Ruptures were secondary to blunt (n=5) and open (n=2) trauma in 7 patients. Lesions varied in length between 1 and 7 centimetres (median length 3 centimetres) and all were full-thickness. The time interval until diagnosis varied between 0 and 72 hours (median 6 hours). Respiratory failure was evident in 7 patients. 16 patients (69.5%) with lacerations ranging in length between 1 and 5.5 centimetres (median length 2.75 cm) underwent conservative treatment. Seven patients (30.5%) underwent surgery. The follow up was completed for 16 patients and varied between 15 and 105 months (median 22.5). One patient died after surgical treatment. No mortality or late major sequelae were registered after conservative treatment. Female sex, absence of respiratory failure and delayed diagnosis was associated with the conservative treatment. Conclusions. Conservative treatment can play a major role even in cases of wide tracheal lacerations. Clinical rather than morphological features should be regarded as main criteria for treatment. The conservative treatment is particularly indicated in the case of stable respiratory parameters independent of the size and the depth of the lesion.
The relationship between the diaphragmatic hiatus, the infra-diaphragmatic esophagus and a manometric tube were examined in 10 patients not suffering from hiatal hernia or gastroesophageal reflux. During surgery, two metal markers were attached to the diaphragmatic hiatus and two others were fixed at the vertex of the angle of His. X-ray examinations were taken during manometric recordings of the high pressure zone (HPZ) both at rest and during relaxation. Comparison between the radiographs showed that during swallowing the manometric tube did not move with respect to the vertebral bodies; contraction of the esophagus caused complete disappearance of the infra-diaphragmatic esophagus. It was also observed that during pressure drop in the HPZ (so-called lower esophageal sphincter relaxation), the manometric recording site is located below the vertex of the angle of His, i.e. in the gastric cavity. These findings provide the basis for a hypothesis to explain the passage of a solid bolus through the lower esophagus into the stomach.
A 14-year-old boy had a car accident causing injury of the pancreas and abdominal trauma. He was then urgently operated for necrotic hemorrhagic pancreatitis with subsequent drainage, but developed afterwards a pancreatic pseudocyst, which was treated by means of a pseudocyst-jejunostomy with a Roux-en-Y loop. Six months later, the patient was urgently hospitalized following an acute abdominal crisis. Sonography suggested an ileal intussusception which was confirmed by surgical exploration showing the presence of an invagination of the defunctionalized loop into the efferent section while the pseudocyst had completely healed. This very unusual complication following cyst jejunostomy is here described and commented.
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