Jacques Jougon

We report two cases of pulmonary aspergilloma (PA) in a cavity formed after percutaneous radiofrequency ablation (PRFA), a rare complication that has only been described once in the literature. The first patient was a 59-year-old white woman treated for a secondary lung nodule of an advanced hepatocellular carcinoma. One month after PRFA, a consolidation of a cavity was noticed with an “air crescent sign,” and aspergilloma serology was highly positive. A bisegmentectomy was performed due to the proximity of the lesion to mediastinal vessels and the absence of significant regression after antifungal treatment. Histological examination confirmed the diagnosis of PA. The second patient was a 61-year-old white man followed-up for a non-small-cell lung cancer. A cavitation with thick margins in the ablation zone was noticed 6 months after PRFA. A biopsy was performed, and aspergilloma was diagnosed. Medical treatment with itraconazole was administered for 13 months, and there was significant regression.

Subclavicular lymph nodes are one of the deeper lymph node groups of the lymphatic network located in the axillary region. As its location is surrounded by vessels and nerves, biopsy of subclavicular lymph nodes is not possible without eye control. We describe a new, mini-invasive technique for accessing the thoracic outlet region. Video-axillaroscopy is a reliable mini-invasive technique for targeting biopsies of lymph nodes in the axillary region. It is safer and more accurate than radio-guided techniques. Exploration of this region might benefit treatment of lymphoma and breast cancer and applications might emerge for thoracic outlet syndromes.

In this article, a new technique for turn-over jejunal graft without kinking of its mesenteric vessels is described. Graft necrosis occurred on a left colon oesophageal reconstruction performed for a 56-year-old-woman. A salvage oesophageal reconstruction was performed by a long-segment, supercharged, pedicled anisoperistaltic ileum. Regurgitations were permanent in spite of medical treatment. Segmental reverse of ileum loops was used to turn over the direction of peristaltism without mesenteric twisting. The technique has never been described previously.

Congenital cystic adenomatoid malformation is rare in adults, and often asymptomatic. We describe a case of malignant degeneration of a congenital cystic adenomatoid malformation in a 77-year-old man. Congenital cystic adenomatoid malformation must be considered a premalignant lesion, even in older patients. Rigorous preoperative staging must be undertaken. Anatomic resection with extensive lymphadenectomy remains the treatment of choice.

A simple technique to improve external surgical treatment of Zenker's diverticulum is presented. A rigid esophageal endoscopy is performed just before the operation. The diverticulum is explored and washed. A single lumen tracheal tube is inserted into the esophageal lumen to serve as a stent. The technique is safe and easy and improves the bacterial control of the operation field.

A man riding a bike crashed against a bridge and fell into a riverHe was rescued just before drowningChest radiography and CT scan showed gravel filling almost all his bronchial treeThree hours were necessary to take out all the gravel by rigid bronchoscopy (Figs. 1 and 2).

We agree with Dr Andrew D. Muir and Alastair Graham that the cornerstone of management of oesophageal perforation is prompt diagnosis. We also agree with them that resuscitation measures as they describe must be the management before referring the patient to a thoracic surgery department. However, the main message to give is that oesophageal perforation is a surgical emergency. Mediastinal and pleural lavage with debridment of necrotic tissue is the main treatment of pleural and mediastinal abscess and one of the main aims of resuscitation is to allow the patient to undergo that surgical treatment as soon as possible [1].

Thank you for giving us the opportunity to discuss again the management of esophageal perforation in Boerhaave's syndrome. Dr Foroulis reported one case of a 42-year-old man who suffered from Boerhaave's syndrome with 48h of free interval before treatment. Primary repair was attempted but failed. In the case reported, presentation was very serious mimicking descending mediastinitis rather than Boerhaave's syndrome in which unilateral pleural empyema is more often associated with other side inflammatory pleural effusion than bilateral empyema. Dr Foroulis did not detail medical history of the patient. One may suppose alcohol abuse or debilited condition or other immunosuppressive condition, which explain the severity of septic shock in this young patient.

Boerhaave's syndrome is the most sinister cause of esophageal perforation responsible with mortality rate ranging from 20 to 30%. Combination of mediastinal contamination with microorganisms, gastric acid and digestives enzymes, long free interval between injury and initiation of treatment causes severe mediastinitis which is fatal in most untreated cases. The aim of this paper is to emphasize primary esophageal repair and resuscitation whatever the free interval from rupture and repair. A retrospective review of patients treated for Boerhaave's syndrome in our department from January 1980 to February 2003 was performed. The principle of treatment was surgical treatment and avoidance of esophageal exclusion or esophagectomy whichever was possible. There were 25 patients (17 males and 8 females). All patients were operated on by primary esophageal repair, except for three who underwent immediate exclusion of the esophagus and one patient who deceased on arrival before being operated. Patients were classified according to free interval between perforation and treatment: group 1 (n=9; 36%) within the 24 h (range from 12 to 24 h) and group 2 (n=16; 64%) more than 24 h (range from 2 to 17 days). Altogether 6 patients deceased (24%). In hospital mortality rate for groups 1 and 2 was, respectively, 44% (four patients) and 13% (two patients), not significantly different. Mean hospital stay was 63 days. Two patients developed anastomotic leakage needing esophagectomy and retrosternal coloplasty in one or more steps. One patient developed pleural abscess treated by percutaneous drainage. Three patients presented temporary symptomatic esophageal stenosis, of whom one underwent dilation. Long free interval before treatment does not preclude primary esophageal repair in Boerhaave's syndrome. Esophageal exclusion may be more often than not avoided in most cases.