Carcinoma of the esophagus: basis for hope.

On the basis of this experience and results, the frequently expressed idea that one should seek primarily only palliative measures in carcinoma of the esophagus is decried. While it is impossible to predict the outcome in many individual cases, it is also apparent that gratifying long-term results in addition to palliation can be achieved if one is perseverant and persistent in the application of sound principles in the management of this disorder. It is obvious that earlier diagnosis leads to better outcome and it is felt that this is gradually being seen. When the disease is extensive and not amenable to standard therapeutic approach, one hopes that with improved lasers, immunologic therapy and chemotherapy there will be additional hope. This report documents the merits of surgery and radiation combined for loco-regional carcinoma of the esophagus.

Nonreflux complications of hiatal hernia.

Patients with massive incarcerated hiatal hernia and no appreciable esophagitis present with a distinctly different clinical picture from those with hiatal hernia and reflux peptic esophagitis. In a recent review, 17 patients were encountered with this problem. The patients were often elderly and presented with the following grave complications: upper gastrointestinal obstruction; upper gastrointestinal bleeding, both acute and chronic, from gastric ulcerations; and perforated gastric ulcerations. In these patients, the surgical approach is better accomplished through the abdominal route. These patients should be distinguished from those with a shortened esophagus resulting from chronic reflux peptic esophagitis who often require thoracotomy for surgical correction.

Should drains be used in routine cholecystectomy?

Retrospective analysis failed to demonstrate that drainage in routine cholecystectomy was associated with the reported incidence of wound complications. The overall complication rate was increased in those patients in whom drains were used. This is believed to be due to the patient selection rather than the use of drains in that the most difficult operative cases received drains. Those patients who did not have drainage did not experience related problems, but drains may diagnose and treat the occasional bile leak. Incidental appendectomy increased the incidence of wound infection.

Surgical treatment of intractable esophagitis.

An operative technique combining a 360-degree fundoplication which is stabilized by anchoring the gastroesophageal junction to the middle arcuate ligament was used in a series of 140 patients since 1973. The patients were evaluated 1 year or more after surgery with clinical and radiographic assessment, regardless of complaints. Clinical results have been good in 91%. There has been no operative mortality and minor transient morbidity. X-rays done at least 1 year after surgery were compared with results obtained in 88 patients who had a modification of Hill's posterior gastropexy performed during the earlier years of this experience. The incidence of x-ray abnormalities with the posterior gastropexy was reduced from 23.5% to 5% when fundoplication was used in combination with a posterior gastropexy. The anchorage of the esophagogastric junction to the middle arcuate ligament allows a relatively loose fundoplication and thereby has reduced the incidence of disabling gas-bloat. Stabilizing the fundoplication prevents the occurrence of other complications related to fundoplication such as disruption, migration, and obstruction. This technique avoids the use of sutures in the esophageal wall, thus reducing the potential for perforation, fistula, or injury to the vagus nerves.

Carcinoma of the esophagus. Observations of 40 years.

The long-term results of treatment of primary carcinoma of the esophagus continue to be poor, and attempts to improve them remain as challenging as any that exist in the field of malignant neoplasia today. Even so, there has been improvement, and this report contrasts age, race, sex, levels of involvement, methods of treatment, and results in our first series of 170 cases, seen between 1940 and 1951, with those in our last series of 300 cases, seen between 1967 and 1975. In the latter group, among those treated by megavoltage radiation as the sole theoretically curative method, the five-year survival rate was 1.0%. Among operable patients, there were 15 who had resection without preliminary radiation, with a mortality rate of 40% (6/15), a two-year survival rate of 13% (2/15), and a five-year survival rate of 7.0% (1/15). Also among operable patients, there were 75 who had resection following radiation therapy with a mortality rate of 19% (14/75), a two-year survival rate of 20% (15/75), and a five-year survival rate of 10% (7/75). These rates contrast with a five-year survival rate of 0.5% in the 1940-1951 series. Improvements in methods of treatment and adjuncts, such as nutrition, radiation, and operation, are cited. Even so, results in our last group did not show improvement over those in the 1962-1967 series. Therefore, we have begun a new program involving the use of chemotherapy in conjunction with radiation therapy and resection in those cases in which it may be applicable.

Surgical treatment of midgut nonrotation in the adult patient.

For a period of four years, five adult patients with nonrotation of the intestine and midgut volvulus have been treated. Two distinct clinical presentations were encountered. The chronic presentation is that of colicky abdominal pain, often present for many years, which is corrected by surgical intervention. The acute presentation with strangulation of the intestine may occur without pre-existing symptoms. Knowledge of this entity and a high index of suspicion are necessary for the diagnosis because massive gangrene of the intestine may result from a delay in treatment. Prophylactic surgical treatment in the asymptomatic patient is recommended to prevent this catastrophic occurrence.

Dirofilaria immitis (dog heartworm) as a pulmonary lesion in humans.

Dirofilaria immitis, the dog heartworm, has been identified in the pulmonary granulomas of 5 patients from the greater Charleston area; this is the largest series of such cases from one medical center. The patients had no pulmonary symptoms. On roentgenogram the lesions were all about 2 cm in size, of uniform light opacity, and located near the pleural surface. Thoractomy was performed in each instance because of the possiblity of carcinoma. The association of granuloma formation, pulmonary infarct, and eosinophilic infiltration led to the suspicion of dirofilaria, which was confirmed in each case.

Carcinoma of the esophagus. Long-term results.

Between 1940 and 1967, we treated 609 patients with primary carcinoma of the esophagus by three different methods. In the first group of 170 patients, surgical resection predominated. In the next 166 patients, radiation therapy was used as the primary method. In a third group (135 patients) and a fourth group (138 patients), radiation therapy was followed by resection in the operable cases. After comparing the results of the three methods, we believe that radiation therapy followed by resection produces the best results. Moreover, this approach is justified by the discovery of residual carcinoma in most surgical specimens from patients who have had radiation therapy.