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Biomedical subjects

A G Little

Publications and source records attributed to A G Little.

At least 73 records · Page 4Linked to original sources
PubMed1987

Colon interposition for benign esophageal disease.

We reviewed 53 consecutive patients with benign disease who underwent esophageal resection followed by colon interposition to assess operative morbidity and long-term results. Indications were gastroesophageal reflux in 32 patients, advanced motility disorders in eight, esophageal perforation in six, and strictures not related to reflux in seven. There were two operative deaths (3.8%). Fourteen other patients (26.4%) had 18 major complications including three graft infarcts, two graft perforations, and four anastomotic leaks, one of which required surgical treatment. Follow-up was complete in 83% of patients and averaged 5 years. Eight patients required dilations; and 15 underwent late reoperations for stricture, persistent symptoms, or anastomotic leak. Of the 20 patients who did not have pyloroplasty done at the initial resection, five (25%) required a subsequent gastric emptying procedure. Results were rated by patients (subjectively) and physicians (objectively, based on symptoms and the need for further therapy) as 1 = excellent, 2 = good, 3 = fair, and 4 = poor. The patients' ratings averaged 1.89, with 27 patients (75%) claiming good or excellent results despite symptoms of postprandial fullness in 78% and dysphagia in 42%. Objective ratings averaged 2.05, with 28 of 39 patients (72%) rating the results as excellent or good. Despite a 30% major complication rate and a 37% late reoperative rate, colon interposition for benign esophageal disease can be accomplished with low mortality and high patient acceptance and remains our preferred technique for reconstruction of benign esophageal disease.

Adolescent↗
PubMed1986

Pleuroperitoneal shunting for malignant pleural effusions.

Traditional therapy for malignant pleural effusions includes thoracentesis or tube drainage with instillation of irritants to achieve pleurodesis. This can require a lengthy hospitalization, causes pain and discomfort, and has an appreciable failure rate. Because of these drawbacks, the authors used a shunting device to transfer fluid to the peritoneal cavity in 17 patients with malignant pleural effusions. Eleven patients had undergone previous therapeutic thoracenteses and three had chest tube placement with failed sclerosis. The shunt was a subcutaneous valved pump chamber with attached pleural and peritoneal catheters, which used manual compression to transfer fluid against the normal abdominal/pleural pressure gradient. Operative placement under local or general anesthesia was performed without complication. Five patients achieved minimal benefit, either because of moribund status or their inability to compress the pump effectively. In the other 12 patients, there was radiographic evidence of diminished or stabilized pleural effusion; respiratory symptoms were effectively palliated, and no further treatment for their effusion was required. Peritoneal dissemination of malignant cells has not been clinically detected. We feel that pleuroperitoneal shunting is a valid new method for treatment of malignant pleural effusions which can effectively palliate respiratory symptoms with low morbidity. Advantages include the absence of external tubing and the possibility for only a short hospitalization or even outpatient placement. Shunting is applicable for patients who are able to perform the requisite pumping and is particularly suitable for those with trapped lungs or who have failed attempted pleural sclerosis.

Catheterization↗
PubMed1986

Local recurrence of resectable non-oat cell carcinoma of the lung. A warning against conservative treatment for N0 and N1 disease.

Ninety-five patients with non-oat cell lung cancer underwent resection of all apparent disease and were followed for a minimum of 36 months. Incidence of recurrence was 34% in 47 patients with N0 disease, 65% in 32 patients with N1 disease, and 81.3% in 16 patients with N2 disease (P less than 0.02 and P less than 0.005, respectively). Seventy-five percent of the recurrences with N0 disease were local, compared with 28.6% with N1 disease (P less than 0.01) and 15.6% with N2 disease (P less than 0.005). Presumably some of the patients with N0 disease could have been cured by eradication of local disease with a pneumonectomy. Patients with N1 disease had a greater rate of local recurrence when treated with lobectomy compared with pneumonectomy, and as with N0 patients, some could have been cured by eradication of local disease with the more extensive procedure. Patients with N2 disease were more apt to have distant before local recurrence, which obviates the benefits of a more extensive resection. The incidence of distal recurrence was statistically greater in N1 than in N0 disease (P less than 0.001) and similar between N1 and N2 disease. It was concluded that, when N0 and N1 disease is present, a more extensive procedure should be considered, even though it appears that all disease would be removed by a conservative resection.

Adult↗
PubMed1986

Protochemotherapy in non-small cell lung carcinoma. An attempt to increase surgical resectability and survival. A preliminary report.

Twenty patients with Stage IIIM0 (T3N2) non-small cell lung cancer were treated with vindesine, etoposide, and Platinol (cisplatin) (ELETOP) chemotherapy in an attempt to decrease tumor size and increase resectability and survival. ELETOP chemotherapy induced a 70% response rate (all partial responses) within 6 weeks, and three patients were able to undergo curative resection. Toxicities with ELETOP were moderately severe, with leukocyte and platelet nadirs on day 15. This pilot study demonstrates the feasibility of protochemotherapy in non-small cell lung cancer.

Adult↗
PubMed1986

Manometric evaluation of the feline esophagus.

Fifteen healthy mongrel cats were manometrically evaluated to quantitate esophageal function and to establish the feline esophagus as an appropriate model for investigations relevant to human physiology and pathology. Detailed findings are presented in the paper. Characteristics of the upper and lower esophageal high-pressure zones and of esophageal body motility were found to be similar to human values. Response to bethanechol stimulation was also similar to that seen in humans. This study establishes normal manometric values for the feline esophagus and validates it as an appropriate model for investigations of esophageal physiology and pathophysiology.

Animals↗
PubMed1986

Pleural involvement in stage IIIM0 non-small-cell bronchogenic carcinoma. A need to differentiate subtypes.

Forty-one patients with two subtypes of stage IIIM0 non-small-cell lung cancer treated over a 7-year period were evaluated. The first group of 20 patients had ipsilateral parietal pleural involvement not contiguous with the primary tumor but no distant metastases. Fifteen had positive pleural fluid cytology, seven with positive pleural biopsy in addition; four had extensive pleural studding or a positive biopsy but no effusion; and one had negative pleural fluid cytology. Treatment consisted of radiation therapy followed by combination chemotherapy in all. Due to symptoms, eight patients first had fluid drainage with or without sclerosis and two patients had a pleurectomy. Nine had progressive pleural disease despite the local treatment. To all modalities of therapy, only two patients had a partial response. One patient who had a pleurectomy lived 25 months. Median survival was 6.9 months. Cause of failure involved local progression in 17 patients. There was no difference in median survival by age, sex, histology, side of effusion, location of nodal disease, or use of local therapy. The second group of 21 patients had localized involvement of the parietal pleura by the primary tumor. There was deeper chest wall invasion in nine. All patients were rendered free of known disease by surgical resection, were stage T3N0-2M0, and received radiation and chemotherapy in addition to resection. The median survival was 13.5 months. There was local recurrence in nine patients but only one developed an effusion. Five patients were alive at 29-82 months. No variable unfavorably influenced survival except a central versus peripheral primary. Thus, the median survival of the patients in the first group with multiple sites of pleural involvement was similar to that of patients with distant metastases but with the cause of failure primarily local progression. In the majority of patients in the second group, parietal pleural and chest wall involvement, even with nodal metastases, did not translate into local failure, and long-term survival was possible.

Age Factors↗
PubMed1986

Physiologic evaluation of esophageal function in patients with achalasia and diffuse esophageal spasm.

To evaluate function of the normal and pathologic esophageal body under more physiologic conditions than those utilized for traditional laboratory testing, manometry was performed before and during eating using a catheter assembly containing three peripheral transducers. Studies were evaluated from seven normal volunteers, 18 typical achalasia patients (eight before and 10 after esophagomyotomy), and eight patients with diffuse esophageal spasm (DES) as characterized by frequent simultaneous and repetitive contractions. In the preprandial period, all had similar frequencies of esophageal contractions, although there was a wide range. During eating, the frequency of contractions increased in all groups; however, the contraction frequency in unoperated achalasia patients, 12.7 +/- 5.0 contractions/min, significantly exceeded the frequency in normal volunteers of 4.9 +/- 1.3 contractions/min, p less than 0.01. The frequency was lower in operated achalasia patients, 9.4 +/- 6.5 contractions/min, but still exceeded that of normal volunteers, p less than 0.01. Patients with DES also had more frequent contractions, 10.5 +/- 9.7 contractions/min, than did the normal volunteers, p less than 0.01. The mean pressure of esophageal contractions for both achalasia groups was similar and was significantly lower than for the normal volunteers. Pressure in the DES patients was intermediate. It is concluded that patients with achalasia have lower pressure but more frequent contractions than normal volunteers during eating, and this spasm-like activity may be a more important pathophysiologic factor in their dysphagia than previously recognized. Esophagomyotomy does decrease the frequency of these contractions. Frequency, but not pressure, of contractions differs from normal in patients with DES.

Eating↗
PubMed1986

Selection of operation for esophageal cancer based on staging.

The concept of en bloc removal of tissue surrounding the esophagus was applied to intrathoracic esophageal cancers, and the first 80 cases were operated on by this technique between 1969 and 1981. Analysis of prognostic factors showed that only penetration through the esophageal wall and lymph node spread influenced survival. Since 1981, a new staging system based on wall penetration (W) and lymph nodes (N), as well as systemic metastases (M), and similar to the modified Dukes' system for colon cancer has been used to select patients before and during surgery for en bloc resection if favorable pathology (W1, N0, or N1) could be anticipated. When curative resection was not attainable, based on preoperative and operative staging, a standard esophagectomy was considered for relief of symptoms when necessary. From July 1981 to June 1984, 68 esophageal cancers were referred to us, and 31 were resected by the en bloc method, 21 by standard esophagectomy, and 16 were not resected. The success of preoperative staging was confirmed, as only nine of the 31 en bloc cases demonstrated both W2 and N2 pathology. The proportion of W2N2 cases subjected to en bloc esophagectomy was less (p less than 0.01) than that in the preceding series. This selection of cases showed a favorable deviation in the survival curve following en bloc esophagectomy since 1981 compared to the earlier interval. Patients treated by en bloc esophagectomy had a significantly greater survival than they did following standard esophagectomy at all time intervals after 6 months. There was no difference in hospital mortality or complications between the two operations. Further evidence for the value of the new staging system was shown by the significant difference in survival curves between those with favorable versus unfavorable staging and treated by en bloc esophagectomy. Among all cases resected between 1981 and 1984, 18-month survival in W1 stage was 67% compared to 35% for W2 disease. Survival with N0 disease was 58% versus 43% for N1 stage and 21% for N2 stage. The favorable survival rates after en bloc resection in those with limited (less than W2N2) disease support the concept of selecting patients for curative surgery based on preoperative and operative staging. Preoperative radiation therapy caused a significant decline in patient survival at 6 and 12 months and has been abandoned.(ABSTRACT TRUNCATED AT 400 WORDS)

Adenocarcinoma↗
PubMed1986

The relationship between alternative assessments of self-care ability in the elderly.

The self-care performance of 126 residents of old people's homes was assessed by self-report, informant rating and performance test. Scores on all three scales were related but associations were low and gross disagreements between measures were found in almost half of the cases. The associations between self-report and the other two measures were significantly lower than those between informant and performance ratings. There was no evidence of systematic bias in self-report related to cognitive or to affective impairment. It is probable that the three scales measure different aspects of dependency.

Activities of Daily Living↗
PubMed1986

The retention of new information in senile dementia.

Paired associate learning performance of demented patients was assessed repeatedly over six months. Patterns of change of performance for repeated and for changing items were compared. Performance on changing items progressively declined, performance on repeated items was maintained at initial levels. This difference was significant and indicates that these patients are able to retain same information over one- and two-month intervals.

Alzheimer Disease↗
PubMed1986

Pericardioscopy as adjunct to pericardial window.

A technique for pericardioscopy at the time of subxiphoid pericardial window was evaluated in 17 patients undergoing surgery for clinically suspected malignant pericardial effusion. Best results were obtained using a rigid mediastinoscope for inspection of the posterior and lateral pericardial surfaces. No complications ensued, although many patients experienced cardiac arrythmias which always resolved with removal of the scope. Pericardioscopy revealed cancer transgressing the pericardium near the pulmonary veins in one patient, and this would have been missed without pericardioscopy. Pericardioscopy confirmed palpable metastatic deposits on the inferior pericardial surface in two other patients. In 14 patients, pericardioscopy did not reveal malignancy, although four of these patients had both positive fluid cytologic findings and malignant infiltration of the pericardial biopsy. In one patient a palpable but not visible nodule was proved to be an extrinsic hepatic metastasis. Pericardioscopy is a safe intervention chiefly applicable in patients with central tumors and pericardial effusion in whom subxiphoid pericardial window is not clearly diagnostic at the time of surgery.

Adult↗
PubMed1986

Postoperative recurrence of lung cancer: detection by whole-body gallium scintigraphy.

The records were reviewed of 111 consecutive patients who had lung cancer resected and who were followed with serial postoperative whole-body gallium scans. Scans were obtained preoperatively at intervals of 3-6 months for about 1 year after surgery and subsequently at yearly intervals. The period of follow-up varied from 1 1/2 to 8 years. Of 55 patients who developed tumor recurrence, a gallium scan was the first indicator of recurrence in 11 (20%) and was judged helpful in confirming or localizing a recurrence in another 14 patients (25%). False-positive rates were determined from 175 postoperative scans in the other 56 patients who did not suffer recurrence. Of these 175 scans, 15 (9%) demonstrated abnormalities that were sufficiently suspicious that an additional diagnostic procedure, other than chest radiography, was performed for clarification. However, in no case did the gallium scan result adversely affect the management of the patient. Our data demonstrate that routine postoperative whole-body gallium scanning can facilitate early detection of recurrence in some cases. Judicious use of gallium scanning in cases with clinically suspected recurrence can enable prompt localization, diagnosis, and treatment of recurrent tumor.

Bone Neoplasms↗
PubMed1986

The role of adjuvant therapy after resection of T1 N1 M0 and T2 N1 M0 non-small cell lung cancer.

Thirty-four consecutive patients with non-small cell lung cancer plus N1 nodal metastases (eight with T1 N1 M0 and 26 with T2 N1 M0) were retrospectively reviewed. Nineteen had adenocarcinoma, 11 had squamous disease, and four had large cell carcinoma. Eleven patients had surgical resection alone (32.3%), with a median survival of 13 months. Seven patients (20.6%) had resection followed by radiation therapy, with a median survival of 19.2 months. Sixteen patients (47.1%) had resection followed by radiation therapy and chemotherapy, consisting of cyclophosphamide, doxorubicin, methotrexate, and procarbazine. Median survival for the latter group was 45.5 months, significantly greater than for those treated with resection alone (p less than 0.005). We did not observe any relationship between survival and age, cell type, number or location of diseased hilar nodes, distance of tumor from the resected bronchial margin, tumor size, the presence or absence of visceral pleural involvement, or the type of resection performed. Resection in combination with adjuvant radiation therapy and chemotherapy offers improved median survival over resection alone in patients with T1 N1 M0 and T2 N1 M0 non-small cell lung cancer.

Adenocarcinoma↗
PubMed1986

Modified stage I (T1N0M0, T2N0M0), nonsmall cell lung cancer: treatment results, recurrence patterns, and adjuvant immunotherapy.

We analyzed 96 patients who had surgery with T1N0M0 or T2N0M0 nonsmall cell lung cancer (NSCLC) to identify survival rates and recurrence patterns in well-staged patients and to evaluate adjuvant therapy. Preoperative staging included chest x-ray, gallium 67 scanning, and bronchoscopy in all patients. At thoracotomy, multiple mediastinal lymph node sites were routinely sampled. The results included an operative mortality rate of 5.2%, and the actuarial 5-year survival rate of all patients was 70.0%. Survival of T1N0 (n = 44) and T2N0 (n = 47) patients was 72.1% and 68.3%, respectively (p = NS). Survival was not affected by type of surgery, cell type, sex, age, or race. Late death was due to recurrence in 12 patients, a new airway malignancy in three, and a noncancer problem in six. Disease recurred in 15 patients: four (9.1%) T1N0 patients versus 11 (23.4%) T2N0 patients, p less than 0.05. Recurrence was local in four patients and distant in 11. Second lung cancers developed in six patients at a mean interval of 65.7 months after resection. A prospective, randomized trial of systemic immunotherapy with bacillus Calmette-Guerin (BCG) skin scarification was carried out in 29 patients. Survival in those patients receiving BCG was 85.9% compared with 63.9% for control subjects (p = 0.075) and 69.6% for patients not in the study (p = 0.077). The following conclusions can be made: Resection for well-staged, modified stage I NSCLC results in a 5-year survival rate of 70%. Nearly half the deaths are unrelated to recurrence of the original cancer. Recurrences are more frequent in T2N0 patients, but there is no survival difference compared with T1N0 patients. Systemic recurrences are more frequent than local recurrences, and there is an appreciable incidence of second lung cancers. Adjuvant chemotherapy or radiation therapy does not seem justified, but systemic immunotherapy holds sufficient promise to warrant further investigation.

Adult↗
PubMed1986

Effect of incomplete obstruction on feline esophageal function with a clinical correlation.

This study was performed because of the observation of unexplained esophageal dysfunction in patients with incomplete esophageal obstruction. A Gore-Tex band, measuring 110% of resting esophageal circumference, was placed about the esophagus at the gastroesophageal junction of 17 cats to produce incomplete obstruction by limiting the normal distention that occurs with swallowing. Esophageal manometry was performed before surgery and at 1 and 4 weeks after surgery. Lower esophageal high-pressure zone pressure was not influenced, but sphincter relaxation was impaired. Evaluation of esophageal body contractions showed that simultaneous contractions increased from 0% before surgery to 68% at 1 week and 85% at 4 weeks after surgery (p less than 0.001 versus preoperative for both comparisons). The incidence of repetitive contractions increased from 3.1% before surgery to 10.5% at 1 week and 10.9% at 4 weeks after surgery (p = NS). The average contraction pressure decreased from 22.5 mm Hg before surgery to 13.9 mm Hg at 4 weeks after surgery (p less than 0.05). Barium swallows showed esophageal dilatation, that was confirmed on gross examination. Histologic examination was remarkable only for retention esophagitis. Sham surgery in three cats with identical mobilization of the gastroesophageal junction did not affect motility. Motility returned to normal after the band was removed in three cats. Manometric evaluation of 15 patients with distal esophageal peptic strictures and 17 patients with excessively tight antireflux repairs showed a significantly increased (p less than 0.001) frequency of simultaneous contractions, 35% and 34%, compared with the 2.1% of 25 normal subjects. The following conclusions can be drawn: Partial obstruction alters feline esophageal body function and these achalasia-like changes are reversible on relief of the obstruction and similar motility aberrations occur in patients because of mechanical or functional distal obstruction; this suggests that dysmotility can synergistically contribute to dysphagia.

Animals↗
PubMed1986

Regional accuracy of computed tomography of the mediastinum in staging of lung cancer.

To determine the regional accuracy of computed tomography of the mediastinum in staging lung cancer, we compared the results of preoperative computed tomographic staging to pathologic findings in lymph nodes taken at mediastinoscopy and/or thoracotomy in 61 patients. Twenty-two patients had adenocarcinoma, 24 had squamous cell carcinoma, eight had large cell tumors, and seven had small cell cancer or mixed cellular types. Sixteen patients had Stage I, eight had Stage II, and 37 had Stage III disease. Thirteen patients had mediastinoscopy only, and the remaining 48 patients had thoracotomy. Computed tomographic staging of the mediastinum as a whole had an accuracy of 88% with a negative predictive index of 96.1%. In examining the differential regional accuracy within the mediastinum we found results in the aortopulmonary window to be inferior to those of other regions, with an accuracy of 80% and a negative predictive index of 83.3%. The reliability of computed tomographic scan staging varied relative to cell type. The accuracy rate in adenocarcinoma was 94.7% compared to 70.6% in squamous cell carcinoma. Computed tomography is accurate for staging the mediastinum in lung cancer, and this accuracy holds over the regions of the mediastinum except the aortopulmonary window. Computed tomography is more accurate for staging adenocarcinoma than squamous cell cancer.

Adenocarcinoma↗
PubMed1986

Reoperation for failed antireflux operations.

UNLABELLED: Experience with gastroesophageal reflux in patients without prior operations has yielded understanding of pathophysiology, surgical techniques, and results. Less is known about patients with failed antireflux operations. This report of 61 patients undergoing repeat antireflux procedures addresses this issues. Not included are patients with gastroesophageal reflux after ulcer operations or with inappropriate antireflux operations for motility disorders. Group A patients (n = 34) had only one previous operation, Group B (n = 19) had two, and Group C (n = 8) had three or more. Group C had significantly (p less than 0.05) more dysphagia and less heartburn than Group A. This observation correlated with findings from manometry, pH testing, and endoscopy, which showed progressively worse esophageal body function and a greater incidence of severe esophagitis and esophageal leak, but less gastroesophageal reflux, in Group C than B and in Group B compared to A. Operative mortality was 4.9%. Repeat antireflux operations in the 58 survivors were as follows: Group A included 25 standard antireflux procedures and seven bowel interpositions, and 75% were transthoracic. Group B included 16 antireflux procedures and one bowel interposition, and 82% were transthoracic. Group C included four antireflux procedures and three interpositions, and all were transthoracic. Clinical results were excellent or good in 85% in Group A, 66% in Group B, and only 42% in Group C (A versus C, p less than 0.05). Surgical complications increased from 27% in Group A to 75% in Group C (p less than 0.05). CONCLUSIONS: Patients with one prior operation and recurrent gastroesophageal reflux are similar to patients with no prior operations. Results of repeat antireflux operations deteriorate with increasing operations because of impaired esophageal function and progressive tissue destruction. Therefore, second reoperations must be definitive and resection and reconstruction with healthy tissue considered. A transthoracic approach is preferable for first reoperations and mandatory after multiple antireflux procedures.

Adolescent↗