Biomedical subjects
Publications and source records attributed to A G Little.
A patient with three synchronous, Stage I neoplasms of the ovary, kidney, and lung, who underwent resection of all lesions at the same operative procedure, is presented. The incidence of multiple primary malignancies and the prognosis for Stage I cancers of the ovary, kidney, and lung are reviewed.
Selection of therapy for carcinoma of the proximal esophagus is controversial. We reviewed our experience with 41 patients with carcinoma of the esophagus within 24 centimeters of the incisor teeth to address this issue. Thirty-seven patients had squamous cell carcinoma, three had adenocarcinoma and one patient had a mucoepidermoid carcinoma. Seventeen patients underwent surgical therapy, which consisted of a resection in 15, colonic bypass in one patient and extracorporeal bypass in one. Ten patients underwent postoperative radiation therapy. Radiation therapy was the primary treatment in 23 patients and chemotherapy alone in one patient. The three month mortality rate was similar for patients with tumor resection and for those receiving radiation therapy as the primary treatment. Median survival time for patients undergoing resection and adjuvant radiation therapy was 12 months and seven months for those receiving only irradiation. Statistical analyses were not performed because patients with radiation only had more advanced disease, invalidating comparison. In terms of palliation, ten of the patients who had radiation therapy could eat solid food, seven could only swallow liquids and six had persistent, complete obstruction. All 12 of the survivors who had a resection were able to eat solid food. Although the one month mortality rate is higher for those treated surgically than with radiation therapy, the three month mortality rates are similar. Surgical treatment provides better palliation and a reasonable survival time and is preferred for patients with resectable disease who are physiologically fit enough to undergo operation. A benefit of postoperative adjuvant radiation therapy is undefined but probably present.
The cases of 50 consecutive patients requiring operative treatment for esophageal strictures were reviewed to evaluate results and develop principles of management. Forty-eight had gastroesophageal reflux disease and 2 had chronic lye strictures. Of the patients with gastroesophageal reflux disease, 21 had a Barrett's esophagus. Esophageal dilations had been performed in 29 patients, 12 of whom also had undergone previous surgical procedures. Preoperative dilations by our group were used to determine further intervention. Patients with dilatable strictures were randomized to either a Nissen or a Belsey operation. In this group, there were no operative deaths, and excellent or good clinical results were obtained in 28 of 34 (82%) patients, with no significant differences noted in the outcomes between the two operations. Patients with undilatable strictures, Barrett's ulcer, or mucosal dysplasia underwent resection plus colon interposition (N = 12) or resection plus gastric interposition (N = 4). Two of the patients in the Nissen operation group later required resection and colon interposition, bringing that total to 14. Resection plus colon interposition resulted in excellent or good results in 71% of patients, with a 7% operative mortality. These results suggest that a standard transthoracic antireflux procedure can be performed with a low risk when strictures are dilatable. Excellent or good results were obtained in 82% of patients, which is equivalent to results for more complex operations. There was no significant difference in the outcome for the transthoracic Nissen procedure compared with the Belsey procedure. In addition, when required, resection plus colon interposition provided excellent or good results in 71% of the patients.
To address the controversy regarding the choice of operation for achalasia, the cases of 57 patients having operation, 38 for the first time (Group 1) and 19 with a previous procedure (Group 2), were reviewed. Surgical emphasis was on hiatal dissection to maximize exposure and use of the Belsey fundoplication to achieve cardiac competence without obstruction. Operative mortality was 1 (1.8%) of 57 patients. In group 1, 21 of the 38 had prior pneumatic dilations. All were treated with esophagomyotomy and a Belsey fundoplication. Clinical results are excellent or good in 30 (88%) of the 34 patients for whom follow-up is available, and are similar in patients with and without prior dilation. Lower esophageal sphincter (LES) pressure decreased from 22.3 to 7.7 mm Hg (p less than 0.001), and pH testing shows no reflux in any of 13 patients. In Group 2, previous operations were esophagomyotomy in 13, esophagomyotomy plus a Nissen fundoplication in 3, and a Nissen fundoplication only in 3. The initial operation failed because of inadequate myotomy in 6 patients, an obstructive Nissen fundoplication in 6, and reflux esophagitis in 7. In these 7 patients, acid reflux testing documented reflux due to cardiac incompetence and delayed clearance. Reoperations included takedown of a Nissen fundoplication in 6, esophagomyotomy and Belsey procedure in 15, Belsey procedure in 1, and resection plus colon interposition in 2. Clinical results are excellent or good in 12 (75%) of the patients with follow-up. These conclusions can be drawn. (1) Esophagomyotomy and Belsey fundoplication lowers LES pressure and provides good results with low risk, even after pneumatic dilation.(ABSTRACT TRUNCATED AT 250 WORDS)
Pleural effusions are resistant to standard therapy, which causes discomfort and can require prolonged hospitalization. As an alternative, pleuroperitoneal shunting for pleural effusions of various etiologies was evaluated. We implanted 36 shunts in 29 patients. Two patients had bilateral shunts and five had shunt revisions. The effusion was related to a malignancy in 22 patients, postoperative chylothorax in two patients, and other causes in five patients. Therapeutic thoracentesis had been attempted in 28 patients, and eight had had chest tube placement previously with attempted sclerosis. Seven patients had a trapped lung syndrome. There was no operative mortality. All patients were deemed ready for discharge from the hospital if they had recovered from the operation within 48 hours. Five patients had poor results, either because of a moribund status or their refusal or inability to pump the shunt. Of the remaining 24 patients, four had good results with temporary improvement, and excellent results were achieved in 20 patients (83.3%), who experienced symptomatic relief and stabilization or regression of pleural effusion until the time of their death. Patients with chylothorax experienced complete resolution. The 14 patients with malignant effusions had a median survival of 4 months, and there were no instances of peritoneal tumor seeding. In conclusion, pleuroperitoneal shunting is an alternative therapy for pleural effusions that requires a limited hospitalization only, is associated with minimal and short-term discomfort, achieves excellent results in properly selected patients, and is the only viable therapy when lung expansion cannot be achieved.
This collective review addresses the issue of transfusion-induced immunosuppression as it relates to patients undergoing cancer surgery. Patients receiving perioperative blood transfusions have a significantly worse prognosis than patients undergoing cancer surgery without a perioperative transfusion. It is thought that this is because transfusions produce a nonspecific immunosuppression by increasing the number and/or activity of suppressor T lymphocytes, decreasing the number of natural killer cells, and inducing anti-idiotypic antibodies. This risk, particularly when considered with the other risks of transfusion such as hepatitis or the acquired immunodeficiency syndrome (AIDS), suggests that criteria for transfusion of these patients should be stringent and related to an unequivocal need for replenishment of RBCs.
We reviewed 123 consecutive patients who underwent esophageal function testing to determine the prevalence and clinical characteristics of the syndrome of high-amplitude peristaltic contractions (HAPC). Twenty-eight patients (23%) were found to have HAPC, including 16 males and 12 females with a median age of 54 years. Barium esophograms yielded no evidence of motility disorders, while 35% of those tested had pathologic gastroesophageal acid reflux. Twenty (71%) were initially referred for evaluation of angina-like chest pain, and 8 were referred with other symptoms. Of those with chest pain, 19 initially underwent extensive evaluation for coronary artery disease before the diagnosis of HAPC. Symptoms of heartburn, regurgitation, and dysphagia were absent or minimal in most patients. Lower esophageal sphincter pressure was normal in 27 patients, and lower esophageal sphincter relaxation was normal in all patients. Mean distal esophageal peak peristaltic pressure was 147.8 mm Hg, while the highest peak peristaltic pressure for each patient averaged 193.2 mm Hg. Seven patients had mean peristaltic wave durations of more than 7 seconds. Patients with atypical chest pain or those with typical angina in whom coronary artery disease is eliminated as a possible cause should be evaluated for HAPC with esophageal manometry. Patients with symptoms are usually successfully treated with smooth muscle relaxants, and surgical intervention is rarely necessary.
Patients who are considered for major pulmonary resection are normally evaluated by spirometry and clinical assessment. Despite this, the morbidity and mortality rates are high after these operations. We retrospectively reviewed results of lung resection performed during a period of 7.5 years in 237 patients to identify other important predictors of morbidity and mortality. There were 144 male and 93 female patients with a mean age of 59.4 +/- 11.4 years. The indication for operation was lung cancer in 199 (76 stage I, 34 stage II, 89 stage IIIA-B), benign disease in 34, and metastatic disease from other primary tumors in four. Lobectomy or bilobectomy was performed in 164 patients and pneumonectomy in 73. Data on 38 preoperative and operative risk factors were correlated with information on 24 postoperative events grouped into four major categories: death, pulmonary complications, cardiovascular complications, and other problems. Logistic regression analysis and chi 2 analysis were used to identify the relationship of the preoperative risk factors to the grouped postoperative complications. The diffusing capacity of the lung for carbon monoxide was the most important predictor of mortality (p less 0.01) and was the sole predictor of postoperative pulmonary complications (p less than 0.005). This diffusing capacity can reveal the existence of emphysematous changes in the lung, even when spirometric values are acceptable, and it usually should be a part of the evaluation of patients being considered for pulmonary resection.
A case of an ulcer developing within previously documented Barrett's epithelium is reported. The patient had symptoms of gastroesophageal reflux for many years and Barrett's esophagus beginning 21 cm from the incisor teeth was documented by endoscopy one year earlier. Hospitalization was necessitated by an upper gastrointestinal bleed which was found to be due to an ulcer at 29 cm from the incisors. There was no inflammation of the surrounding columnar epithelium nor was there any esophagitis within the squamous epithelium. This case documents that ulcers in Barrett's esophagus can arise de novo within the columnar epithelium despite the hypothesis that this epithelium is present because it is more resistant to acid/peptic damage than squamous epithelium. This suggests that some ulcers in Barrett's epithelium may be due to spontaneous degeneration of the epithelium as this patient had no esophagitis, suggesting that gastroesophageal reflux was not causing diffuse damage.
Seventy-eight patients with modified Stage II or Stage IIIM0 adenocarcinoma of the lung were evaluated retrospectively with regard to the impact of prophylactic cranial irradiation (PCI) (30 Gy in 15 fractions) in preventing central nervous system (CNS) metastases. Twenty patients received PCI and 58 did not. There were no significant differences between these groups with respect to age, sex, stage, or median survival (17.4 months with PCI versus 16.9 months without PCI; P = 0.6). One (5%) of 20 patients receiving PCI developed CNS metastases, compared with 14 (24%) of 58 patients not receiving PCI (P = 0.06). The time from diagnosis to development of CNS metastases and survival after CNS involvement was 51 weeks and 14 weeks, respectively, for the patient who received PCI; and a median time of 50 weeks and 26 weeks, respectively, for the patients not receiving PCI. In nine (64%) of the 14 non-PCI patients the CNS was the first and only site of relapse. A Cox regression analysis demonstrated that nodal involvement was significantly associated with an increased risk of CNS metastases. These data suggest that PCI may decrease the incidence of CNS metastases, and that it may be beneficial in the management of patients with N1 or N2 disease.
To evaluate the influence of the composition of refluxed material in the pathogenesis of esophagitis, a dog model was used to allow esophageal reflux of gastric secretions, duodenal pancreaticobiliary secretions, and a combination of both. Control dogs had only an esophageal incision. Incompetence of the cardia was established in five other groups by transecting the distal sphincter and creating a hiatal hernia. Two groups received moderate or maximal histamine stimulation of gastric secretion. A gastrojejunostomy, pyloromyotomy, and duodenal closure distal to the papilla were added in the other three groups, creating duodenogastric reflux; two were stimulated with histamine and one had a truncal vagotomy and no histamine. Radiologic, manometric, and pH studies showed that incompetence of the cardia was obtained. The dogs were killed 4 wk postoperatively and evaluated for gross and microscopic evidence of esophagitis. Erosive esophagitis was found only in dogs with reflux of gastric juice following maximal acid stimulation. Microscopic reflux changes in esophageal mucosa were seen in all groups; again, changes were most pronounced in dogs with maximal gastric stimulation. The combination of duodenogastric reflux and moderate gastric stimulation produced more significant alterations in microscopic reflux criteria than did moderate gastric stimulation alone. Our conclusions are as follows: In a dog model of gastroesophageal reflux of various combinations of gastric and duodenal secretory components, erosive esophagitis occurred only with maximal gastric stimulation in the absence of duodenogastric reflux. All reflux combinations, however, produced some degree of microscopic changes, suggesting they could eventually cause gross changes with a lengthened experimental time span.
Adenosquamous carcinoma of the lung is a rare and poorly described entity. At the University of Chicago between 1974 and 1985, 2.3% (20/873) of patients with lung cancer had well-differentiated adenosquamous carcinoma. As in non-small cell lung cancer, patients with Stage I disease were amenable to operation with 60% (3/5) free from disease between one and six years postoperatively. However, Stage II adenosquamous carcinoma (14 patients) exhibited highly aggressive behavior with rapid progression of disease (mean interval, 2.1 months). Despite combinations of surgery (6 patients), chemotherapy (6 patients, one response), and radiotherapy (10 patients, no response), median survival for patients with Stage III adenosquamous carcinoma was 5.0 months, worse than that for Stage III small cell cancer (9.6 months), adenocarcinoma (9.0 months), and squamous cancer (7.8 months).
We retrospectively reviewed the records of 41 patients with an isolated anterior mediastinal mass to identify whether the traditional surgical approach of resection for both diagnosis and therapy is the optimal approach to these tumors. In addition to plain chest radiographs, clinical evaluation included computed tomography (CT) in 23 and gallium scintigraphy in 23. The initial intervention was attempted excisional therapy in 16 and mediastinoscopy for biopsy in 25. Pathological diagnoses included lymphoma (13), thymoma (11), germ cell tumor (6), carcinoid (2), bronchogenic carcinoma (2), and other benign processes (7). Based on histological findings, nonoperative therapy was the most appropriate treatment in 61%. The clinical selection of the surgical approach was not aided by patient age, symptoms, or findings on CT. The gallium scan was positive in 13 of 15 patients for whom nonoperative therapy was appropriate, and was normal in 7 of 8 for whom excision was indicated. Mediastinoscopy is useful in the diagnosis of anterior mediastinal masses, and may eliminate unnecessary thoracotomy, especially when a gallium scan is positive.
The pulmonary effects of pericardial effusion were studied in eight anesthetized dogs, with emphasis on lung mechanics, O2 exchange, and extravascular thermal lung volume (ETV) accumulation, while warm saline was instilled into the pericardium to elevate pericardial pressure. The results were compared with those from four time-controlled and sham-operated dogs. ETV, as measured by a double-indicator technique, increased from 8.1 +/- 0.8 ml/kg at a pericardial pressure of 0 mm Hg to 12.9 +/- 2.1 ml/kg at 11.0 mm Hg (p less than .01). In the control group, ETV increased from 6.5 +/- 0.7 to 8.2 +/- 0.5 ml/kg over an equal time span. This increase in ETV in the experimental dogs was inversely related to pulmonary compliance, which decreased by 29% as ETV increased (p less than .05), whereas in the time-controlled group of animals it decreased by 8.8%. Arterial PO2 did not deteriorate during the protocol in either group. Histologic examination showed increased interstitial fluid, but neither alveolar fluid nor septal edema, and gravimetric measurements of lung liquid were also consistent with interstitial fluid accumulation in experimental but not control animals. These findings are concordant with the clinical observation that alveolar edema is rarely seen in the presence of pericardial tamponade. Conceivably, progression from interstitial to alveolar edema did not occur both because of the low pulmonary blood flow that occurs as part of pericardial tamponade physiology and/or because the hydrostatic pressures were not elevated enough to produce higher rates of fluid transudation.
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Pulmonary edema is a rare but potentially lethal complication following the drainage of a pericardial effusion. Certain risk factors have been cited, including markedly increased RA pressure, chronic hypertension, congestive heart failure, angina and valvular disease. Patients with these concurrent problems should be monitored closely using pulmonary artery thermodilution catheters. Aggressive treatment, including diuretics, vasodilators, cardiotonic agents and early intubation with PEEP should be undertaken if the PCWP and PA pressures paradoxically increase after pericardial drainage.