Acquired esophago-respiratory fistulas require emergency surgical treatment. The proper choice of operative approach is largely dependent on the precise diagnosis. Preoperative intensive care and metabolic balance are important factors in this report. Radical operative treatment depends on the basic disease, local inflammation and lung complications.

During the last 15 years we have treated 147 patients with acute purulent mediastinitis (APM). According to the aetiology of the disease, 2 major groups were defined. The first group included the cases of oesophageal origin--112 patients (dilatation--38 patients, foreign body extraction--29 patients, lye injuries--11 patients, oesophagoscopy--8 patients, sharp foreign body--6 patients). The second group consisted of patients with mediastinitis of non-oesophageal origin--35 patients (tracheo-bronchial disease--21 patients, tooth infection--8 patients, cervical infection). Symptoms of the mediastinal infection were typical; nevertheless, early diagnosis (within first 12 h) was obtained in only 43.5% of cases. Therapy for all patients included general stabilisation, broad spectrum antibiotics and immunotherapy. In 86 patients, mediastinal drainage was performed with additional suture of the oesophageal wall or plication with a gastric or diaphragmatic patch in 9 cases. Oesophagectomy and delayed colon transplant was the method used in 61 patients. Mortality included 21 patients (14.3%). The cause was broncho-pneumonia in 9 patients, endotoxic shock in 7 and renal failure in 3 patients.

A prospective study to investigate the source of pathogenic organisms responsible for infective complications of patients undergoing major oesophageal surgery was undertaken in 138 consecutive patients (38 female and 100 male) with obstructive lesions of the oesophagus, aged 24 to 86 years (mean 67 years). In all patients, the upper alimentary tract (UAT) was opened as part of the surgical procedure and 20.3% had pathogens present in their sputum before surgery. On direct culture of the contents of stomach or oesophagus at operation, 61% showed pathogenic organisms. Twenty-five patients suffered from 28 infections, predominantly pleuropulmonary infection (n = 19) but also wound sepsis (n = 8) and generalised infection (n = 1). Pathogenic organisms could not be cultured from the tracheobronchial tree immediately postoperatively. There was no correlation between preoperative sputum microbiology and postoperative infection. There was, however, a definite correlation (66% of cases) between pathogens of UAT content collected at operation and those responsible for postoperative infection. We conclude that it is relevant and important to regularly obtain samples of UAT content at operation to plan antibiotic regimes.

During the past 24 years we have treated 786 patients with esophageal and cardia carcinoma. En bloc resection of the tumor has been performed in only 461 (65.2%) of them and in 246 (34.7%) of the cases various palliative operations have been undertaken. Most of the patients were in stage II or III of the disease with squamous cell carcinoma in 80.5% and adenocarcinoma in 19.5% of them. The method of choice for the treatment of the patients with cardia and lower third of the esophagus carcinoma (n - 315) were blunt esophagectomy followed by colon (n - 256), stomach (n - 54) and/or jejunal (n - 9) substitution. The histology results confirmed the oncologic radical zone of resection of the esophagus from 8 cm above the tumor to 10-12 cm below in the stomach wall. This is the reason why substitution of the esophagus with stomach tube is very often impossible and the colon substitution remains the method of choice for such patients. The other important factor is radical resection of the tumor with the surrounding tissue, organs and lymph nodes involved (resection en bloc). The hospital mortality included 28 patients (7.3%) from the radically operated who also underwent esophageal substitution (n = 378). For these patients the 3-year survival rate is 51% (n - 191) and 5-year survival 46% (n - 172).