Nissen fundoplication for gastroesophageal reflux disease. Evaluation of primary repair in 100 consecutive patients

One hundred consecutive patients had a primary Nissen fundoplication for gastroesophageal reflux disease. None of the patients had previous gastric or esophageal surgery or evidence of esophageal stricture or motility disorder. The primary symptom was persistent heartburn in 89 patients and aspiration in 11. An abnormal pattern of esophageal acid exposure was documented in all patients with 24-hour esophageal pH monitoring. By actuarial analysis, the operation was 91% effective in the control of reflux symptoms over a 10-year period. The incidence of postoperative symptomatic gas bloat and increased flatus was lower in patients with preoperative abnormal manometric measurements of the distal esophageal sphincter (p less than 0.05). Three modifications in operative technique were made during the course of the study to minimize the side effects of the operation. First, enlarging the caliber of the bougie to size the fundoplication reduced the incidence of temporary swallowing discomfort from 83 to 39% (p less than 0.01). Second, shortening the length of the fundoplication decreased the incidence of persistent dysphagia from 21 to 3% (p less than 0.01). Third, mobilizing the gastric fundus for construction of the fundoplication increased the incidence of complete distal esophageal sphincter relaxation on swallowing from 31 to 71% (p less than 0.05). This was done to prevent the delayed esophageal acid clearance secondary to incomplete sphincter relaxation observed after operation in five of 36 studied patients. It is concluded that by proper patient selection and the incorporation of the above surgical techniques, the Nissen fundoplication can re-establish a competent cardia and provide relief of reflux symptoms with minimal side effects.

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.

Development of the 24-hour intraesophageal pH monitoring composite scoring system

We describe in detail our logic for deriving a system to score 24-hour intraesophageal pH records of patients with gastroesophageal reflux. This system uses a uniform scoring unit and pH monitoring parameters taken from both the day and nighttime segments of the pH record. The score quantitates the degree of departure that a patient's reflux pattern exceeds physiologic reflux found in asymptomatic control volunteers, and directly correlates with the degree of reactive epithelial change characteristic of reflux esophagitis. Even though the scoring system was derived over 11 years ago, its logic and scoring principles are consistent with new concepts that concern the pathophysiology of gastroesophageal reflux disease.

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.

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.

Length of the distal esophageal sphincter and competency of the cardia

Pressure and abdominal length of the distal esophageal sphincter are important factors in maintaining competency of the cardia against challenges of intraabdominal pressure. Some patients with normal distal esophageal sphincter pressure and position may have reflux which could be due to the inability of the cardia to overcome challenges of intragastric pressure. Three experimental studies and one clinical study were designed to evaluate this problem. The results showed that the resistance to flow through the cardia is related to the integrated effect of distal esophageal sphincter pressure and length; the ratio of distal esophageal sphincter to intragastric pressure necessary to maintain competency is inversely related to the length of sphincter present; gastric dilatation has an adverse effect on the degree of competency achieved by a given distal esophageal sphincter length; and patients with an overall distal esophageal sphincter length of 2 cm or less measured at rest in the fasting state are subject to reflux caused by gastric dilatation, increased intragastric pressure independent of intraabdominal pressure, or both.

CAMP chemotherapy for metastatic non-oat cell bronchogenic carcinoma. A 7-year experience (1975-1981) with 160 patients

Between January 1975 and December 1981, 160 patients with metastatic non-oat cell bronchogenic carcinoma (MNOBC) were treated with cyclophosphamide, doxorubicin, methotrexate, and procarbazine (CAMP), or with a CAMP-like regimen. Forty-two (26%) of these patients demonstrated an objective response to the chemotherapy with a median survival of 61 weeks. Thirty-nine (24%) patients had stable disease (SD) with a median survival of 45 weeks. Seventy-nine patients (49.4%) were nonresponders with a median survival of 15 weeks. There was a significant difference in survival times between the responders and the SD patients, and between the responders and SD patients and the nonresponders. Responses were seen in 11% of the patients with squamous cell carcinoma and in 37% of the patients with adenocarcinoma. There was a significant difference in the response and SD categories in favor of adenocarcinoma over squamous cell carcinoma. Once a response was achieved, the median survival of the patients with adenocarcinoma was not significantly longer than that of the patients with squamous cell carcinoma.

Evaluation of brush cytology as an independent technique for detection of esophageal carcinoma

In this study the accuracy of indirect brush cytology for detection of esophageal carcinoma is evaluated against current standard methods of diagnosis and is compared with the known accuracy rate of endoscopically directed brush cytology. A standard endoscopic nylon brush placed inside a nasogastric tube was used in 203 patients with various esophageal problems. Correct diagnosis was made in 78% of cancers, 95% of potentially premalignant cases, and 100% of cases of normal esophageal mucosa with both indirect and directed brushing procedures. The technique meets most requirements of a new screening procedure as being simple, safe (no complications), relatively inexpensive, and acceptable to patients (98% compliance). Currently it is employed to monitor high-risk esophageal conditions and post-treatment courses of patients with pharyngoesophageal tumors for local recurrence or a new primary lesion in the esophagus.

Pharyngoesophageal dysfunctions. The role of cricopharyngeal myotomy

Eighteen patients were evaluated for primary symptoms of cervical dysphagia and/or laryngeal aspiration and subsequently had a cricopharyngeal myotomy. Twelve patients had a neurologic lesion as the cause of the symptoms. Four patients had a Zenker's diverticulum as demonstrated by barium contrast roentgenograms. Two patients complained of persistent suprasternal dysphagia following one or more antireflux repairs for gastroesophageal reflux disease. Esophageal manometry identified a pharyngoesophageal motor disorder in all but four patients, two of the four with Zenker's diverticulum and the two who had an antireflux procedure. The results show that cricopharyngeal myotomy should be reserved for patients with an identifiable motor disorder confined to the pharyngeal phase of swallowing, ie, failure of the pharyngeal pump or cricopharyngeal incoordination and/or incomplete relaxation. Exceptions to this rule are as follows: Zenker's diverticulum, in which an abnormality may not always be detected but of which the results of surgery demonstrate the effectiveness of this procedure; and pharyngoesophageal complaints associated with reflux, most of which resolve with the restoration of distal esophageal sphincter competence. In those few patients in whom these conditions persist, a cricopharyngeal myotomy may be beneficial. Caution should be used in applying the procedure to individuals who have had multiple antireflux repairs.

Diagnosis and management of synchronous lung cancers

The findings in 28 patients with synchronous lung cancers are reviewed. Mediastinoscopy and systemic staging were performed to exclude the possibilities that one pulmonary lesion was metastatic from the other or that both represented systemic metastases from another tumor. Nineteen patients underwent resection of both tumors. Median survival was 25 months for four patients with definite Stage I synchronous cancers (no nodal involvement; different cell types, bronchoscopically separate endobronchial lesions or arising from separate foci of carcinoma in situ) and was 27 months for seven patients with possible synchronous Stage I cancers (no nodal involvement; similar cell types; located in separate lobes). Median survival was 11 months for 16 patients having Stage II or III lung cancer accompanied by a second synchronous lung cancer. In the absence of hilar or mediastinal nodal involvement and systemic metastases, synchronous tumors should be considered separate primaries when located in different lobes, even if they have similar histologic features. Prognosis of synchronous cancers is related to the presence or absence of nodal metastases. Pneumonectomy is the operation of choice for synchronous unilateral tumors. With bilateral tumors, sequential resection starting with the most advanced lesion is appropriate. Preservation of lung tissue without compromising the cancer operation is critical.

Phase I trial of an implanted battery-powered, programmable drug delivery system for continuous doxorubicin administration

A second generation, implantable drug administration device (DAD, Medtronic, Inc, Minneapolis) which contains a 20-mL drug reservoir, a lithium-thionyl-chloride battery, a peristaltic roller pump, a microprocessor circuit, and an acoustic transducer has entered clinical trials. After surgical placement, drug is entered into and removed from the DAD percutaneously through a Silastic "fill port" using a standard gauge needle and syringe. The pump is noninvasively programmed using a hand-held telemetry wand to administer the drug in a continuous infusion, bolus, or bolus-delay mode. Because of the apparent improved therapeutic index of continuous-infusion doxorubicin (CID), a phase I trial of the Medtronic DAD with CID was begun. Thirteen pumps in 13 patients have functioned for a median of 153 days (range, 11 to 395 days) with one pump still functioning. Four pumps ceased function at 170, 278, 331, and 370 days, respectively; there was a catheter-tip clot on one of the pumps that later malfunctioned. All other pumps functioned until the death of the respective patients. In 84 pump refills, without drug extravasation, the median drug delivery error (actual residual volume--calculated residual volume/calculated residual volume X 100%) was 14%. Doxorubicin was compatible with all components of the drug pathway and did not significantly decompose during two weeks in the drug reservoir. The starting dose of CID was 2.0 mg/m2/d and the maximum tolerated dose was 4.1 mg/m2/d (range, 3.5 to 5.5). A median cumulative doxorubicin dose of 244 mg/m2 per patient (range, 10 to 583 mg/m2) has been infused.(ABSTRACT TRUNCATED AT 250 WORDS)

Operation for diagnosis and treatment of pericardial effusions

An experience with 32 consecutive patients with pericardial effusions is reviewed and presented. Malignant effusions: Twenty patients had underlying malignancy. Five had no symptoms, nine had ambiguous symptoms, and six had pericardial tamponade. Initial treatment in eight was pericardiocentesis, which provided diagnosis and treatment in one but was clinically unsuccessful in seven and caused right ventricular puncture in one. Subxiphoid pericardial window in 19 patients showed malignant involvement in six but documented a nonmalignant effusion in 13. There were no operative complications, and no effusions have recurred with long-term follow-up. Only two patients with true malignant effusions had significant long-term survival as compared with 11 of 13 with benign effusions. Uremic effusions: Six patients with renal failure required intervention, three for hemodynamic compromise and one for possible infection. Diagnostic pericardiocentesis documented a sterile effusion in one patient. Five patients had subxiphoid pericardial window without recurrence of effusion. One patient required reexploration for rectus muscle bleeding. Other effusions: All six patients had hemodynamic compromise. Pericardiocentesis was successful in three of four patients but effected resolution in none. Subxiphoid pericardial window was performed in all. The effusion recurred in a patient with periarteritis nodosa, and a patient with viral myocarditis developed a left ventricular pseudoaneurysm that required operation.

CONCLUSIONS

Subxiphoid pericardial window provides definitive diagnosis and treatment for pericardial effusions of all causes with low morbidity rates whereas pericardiocentesis is safe but usually ineffective/unproductive; many effusions in patients with cancer are not related to malignant pericardial involvement and documentation is important for treatment planning.

Duodenogastric reflux and reflux esophagitis

Twenty-seven patients with gastroesophageal reflux were prospectively investigated to define the role of duodenogastric reflux in the development of reflux esophagitis. Duodenogastric reflux was detected and quantified by pH monitoring of the gastric environment 5 cm distal to the distal esophageal sphincter. Alkaline duodenogastric reflux was identified by the occurrence of spontaneous, intense gastric alkalinization during fasting periods. Patients with reflux with esophagitis were distinguished from those without esophagitis by having fewer of these episodes and, consequently, more acid stomachs than had patients without esophagitis. As previously shown, refluxers with esophagitis also had more frequent acid gastroesophageal reflux and prolonged gastric emptying. These findings suggest that refluxers with esophagitis have a functional gastropyloric disturbance resulting in delayed gastric emptying, decreased frequency of alkaline duodenogastric reflux episodes, and more frequent acid gastroesophageal reflux than do refluxers without esophagitis.

Esophageal carcinoma with respiratory tract fistula

An experience with 27 patients with malignant respiratory tract fistula (RTF) is presented. The RTF was related to carcinoma of the thoracic esophagus in all the patients, involved the trachea in 11, left main bronchus in 7, right main bronchus in 3, and was more distal in 6 patients. Metastases were detectable in only four patients (15%) at the time of RTF diagnosis. Bronchoscopy examination in 13 patients prior to RTF development showed tracheobronchial invasion or impingement in all. The RTF was present at initial presentation in 11 patients (Group I), and developed after/during radiation therapy (RT) in 16 patients (Group II). Median survival from tumor diagnosis was 17 weeks in Group I and 37 weeks in Group II, while survival from RTF diagnosis was 16 weeks in Group I and II weeks in Group II.

Trial of vindesine, etoposide, and cisplatin in patients with previously treated, advanced-stage, non-small cell bronchogenic carcinoma

Twenty-two patients with advanced-stage, non-small cell bronchogenic carcinoma were treated in a pilot study with a combination of vindesine, etoposide, and cisplatin (VEDDP). All patients had been previously treated with a non-cisplatin-containing regimen and had documentation of progressive disease. Median duration of VEDDP therapy was 2.6 months. Only one patient had a minor response. Median survival from start of protocol therapy was 3.7 months; the overall survival from start of primary therapy was 13.5 months. The only significant variable possibly affecting survival was achieving a minor response or stable disease (5.0 months for minor response/stable disease from start of VEDDP vs 3.2 months for progressive disease, P = 0.016). Hematologic toxicity was moderate to severe in 14 patients and prevented completion of two full cycles in seven patients. We conclude that VEDDP is ineffective in inducing a response in patients with refractory, advanced-stage non-small cell bronchogenic carcinoma in the dose and kinetic schema used in this pilot study.

The use of serum albumin for further classification of Stage III non-oat cell lung cancer and its therapeutic implications

The use of the preadmission serum albumin level for predicting survival was evaluated in 81 patients with Stage III disease, 59 with unresectable and 22 with resectable primary tumors. A serum albumin of less than 3.4 gm/dl in a patient with unresectable Stage III disease indicates a poor prognosis with an accuracy that supersedes that obtained from a clinical assessment of the anatomical extent of disease. Seventeen of the 22 patients with resectable Stage III disease had a preadmission level of albumin of 3.4 gm/dl or greater. The median survival was 20.5 months, which was statistically longer than 9.9 months for 12 patients with unresectable Stage III M0 disease and an albumin level of 3.4 gm/dl or greater (p less than 0.05). Five of the 22 patients who underwent resection had a preadmission albumin level of less than 3.4 gm/dl. The median survival for these patients was 9.7 months compared with 20.5 months for those with a level of 3.4 gm/dl or greater. These findings suggest that resection of Stage III disease in patients with an albumin level of 3.4 gm/dl or greater prolongs survival. Another group of 5 patients with resectable Stage III disease and an albumin level of less than 3.4 gm/dl were force-fed an elemental diet while undergoing a regimen of preoperative radiation therapy. There was no improvement in survival, and 3 died of the disease prior to resection.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of paraesophageal hernia on sphincter function and its implication on surgical therapy

Fifteen patients with a paraesophageal hernia were studied with 24 hour esophageal pH monitoring and esophageal manometry to clarify the physiologic aspects of the cardia and resolve controversies over the type of surgical repair. The results were compared with those obtained in 34 randomly selected patients with a sliding hernia and 18 normal control subjects. Sixty percent of the patients with a paraesophageal hernia had an incompetent cardia on 24 hour pH studies which was associated with a lower esophageal sphincter of normal pressure, short overall length, and a small segment exposed to abdominal pressure. In comparison, 70 percent of patients with a sliding hernia had an incompetent cardia which was associated with a lower esophageal sphincter of low pressure, normal overall length, and a short segment exposed to abdominal pressure. With either type of hernia, symptoms were not helpful in determining the competency of the cardia. When urgent surgery is necessary, repair should include an antireflux procedure. If facilities and time permit, more specific evaluation of the cardia can be performed, and if competent, the repair should be limited to reduction of the stomach and closure of the defect.

Barrett's esophagus. Comparison of benign and malignant cases

Using strict criteria for diagnosis, 23 patients having benign Barrett's esophagus, and 20 patients with adenocarcinoma arising in this epithelium have been analyzed. Evidence supports severe gastroesophageal reflux as a cause of Barrett's esophagus. Successful antireflux surgery leads to stabilization and possibly regression of the dysplasia in Barrett's epithelium, and can be followed by squamous epithelial regeneration in some. Antireflux surgery is advocated in all patients with Barrett's esophagus demonstrated to have abnormal reflux regardless of symptoms. The malignant potential of the columnar epithelium is higher in men who smoke, in patients with intestinal-type metaplasia who continue to have severe reflux, and in patients who develop dysplasia. In those with high grade dysplasia, the probability of carcinoma is high and esophagectomy should be seriously considered in the hopes that the pathological stage of the neoplasm is still favorable.

Lack of efficacy of vinblastine and cisplatin in patients with progressive small cell carcinoma of the lung

Twenty patients with small cell carcinoma of the lung resistant to primary therapy, or relapsing after an objective response to initial treatment, were treated with vinblastine plus high-dose cisplatin chemotherapy. One patient achieved a partial remission lasting 4 months, while 19 patients had no objective response to this regimen. The median survival from the time of disease progression to death was 2.5 months (range, 1-7), with an overall median survival of 13 months (range, 5-31; diagnosis to death). In our patients, vinblastine plus cisplatin given as salvage therapy did not produce a significant response rate or survival prolongation.

Treatment of modified Stage II (T1 N1 M0, T2 N1 M0) non-small cell bronchogenic carcinoma. A combined modality approach

Twenty patients with postsurgical, modified Stage II (T2 N1 M0, T1 N1 M0) non-small cell bronchogenic carcinoma were seen between 1974 and 1981 and were evaluated in a retrospective manner. Fifteen patients had T2 N1 M0 lesions, while 5 patients had T1 N1 M0 disease. Eight patients were treated with surgical resection alone, of whom seven had died, with a median survival of 12.0 months. Four patients received surgical resection and postoperative radiation therapy, of whom two have died, with a median survival not reached at 37 months. Eight patients were treated with surgical resection, radiation therapy, and adjuvant chemotherapy including cyclophosphamide (C), doxorubicin (A), methotrexate (M), and procarbazine (P). Six patients are alive and free of disease, with a median survival not yet reached at 72 months. There is a significant survival advantage for the 12 patients treated with combined modality therapy (surgical resection + radiation therapy; surgical resection + radiation therapy + chemotherapy) compared to the eight patients treated with SR alone (p less than 0.01), and for the eight patients receiving chemotherapy versus the 12 patients who did not (p less than 0.01). In spite of thorough clinical and surgical staging, patients with T1 and T2 primary tumors with N1 disease have a high relapse rate, predominantly in metastatic sites. Adjuvant radiation therapy and chemotherapy appear to benefit these patients with modified Stage II non-small cell bronchogenic carcinoma.

Barrett's esophagus. Functional assessment, proposed pathogenesis, and surgical therapy

Esophageal function was assessed with manometry and 24-hour pH monitoring of the distal esophagus in 22 patients with histologically proven Barrett's esophagus (BE), 31 consecutive patients with endoscopic grade 2 or 3 esophagitis, and 33 normal volunteers. Patients with BE had less lower esophageal sphincter (LES) pressure, but similar length of sphincter exposed to the abdomen, than patients with esophagitis. Both groups had significantly less LES pressure and abdominal length than normal subjects. Patients with BE had statistically more esophageal acid exposure than patients with esophagitis, and both differed markedly from normal subjects. They also had a greater number of reflux episodes lasting longer than five minutes than patients with esophagitis, suggesting that the severity of acid exposure was due to a defect in esophageal clearance. The extent of Barrett's mucosal change was related to the level of LES pressure and the number of reflux episodes that were five minutes or longer in duration. We concluded that BE is related to a mechanical incompetency of the cardia and a decrease in esophageal clearance that requires reconstruction of the cardia for effective therapy.

Guided biopsies of abnormalities on nuclear bone scans. Technique and indications

A guided biopsy technique has been developed for evaluation of solitary bone abnormalities, identified by gallium 67 or technetium 99 bone scans, in patients with normal or ambiguous x-ray findings. Continuous gamma camera monitoring is used to guide staining of the bone abnormality and overlying tissues with methylene blue. This staining is followed by open biopsy of the marked bone. This technique was utilized in 15 patients, 12 of whom had bronchogenic carcinoma. The most commonly involved bones (13/15) were ribs. None of the patients had an identifiable, gross abnormality at operation, and the marked area was indistinguishable from neighboring tissues. Diagnostic tissue was obtained by each biopsy and there were no complications associated with this technique. The primary applicability of this technique is for both pretreatment and re-treatment staging of bronchogenic carcinoma in patients who have ambiguous nuclear bone scan abnormalities.

Potentially curable cancer of the esophagus

This study assesses factors in staging which may define potentially curable esophageal cancer, and reports experience with exfoliative cytology for diagnosis of asymptomatic cases. The extent of neoplasm in 91 esophagectomy specimens is reviewed and compared to two-year survival rates of patients without evident disease. Metastases to lymph nodes, and muscular penetration by the cancer, but not tumor size, cell type differentiation, or location independently and significantly influenced prognosis. A technique for inexpensive brush cytology of the esophagus and preliminary results demonstrating capability of this method to detect asymptomatic esophageal cancer are described. Early diagnosis of esophageal neoplasm before wall penetration and lymph node spread can lead to improved survival rates from surgical treatment.

Esophageal function in patients with angina-type chest pain and normal coronary angiograms

Ten per cent of patients with angina pectoris have normal coronary arteries and cardiac function and, despite this reassurance, continue to have chest pain. Since pain of cardiac or esophageal origin is clinically difficult to differentiate, 50 patients with severe chest pain, normal cardiac function, and normal coronary arteriography with ergotamine provocation were evaluated with a symptomatic questionnaire and esophageal function test. On 24-hour esophageal pH monitoring, 23 patients had abnormal reflux, and 27 were normal. There was no difference in the incidence and severity of chest pain, esophageal symptoms, or medication taken between refluxers and nonrefluxers. Ten refluxers and ten nonrefluxers had chest pain on exercise electrocardiography. Thirteen refluxers documented chest pain during the pH monitoring period, and in 12 it coincided with a reflux episode. Fifteen nonrefluxers documented chest pain during the monitoring period, and in only one did it coincide with a reflux episode. Of the 23 refluxers, 12 were treated with medical therapy and 11 by a surgical antireflux procedure, and all followed for two to three years. Ten (91%) of the 11 surgically treated patients are totally free of chest pain compared with five (42%) of the 12 medically treated patients. All 12 patients who had chest pain coincide with a documented reflux episode responded positively to antireflux therapy, eight surgical and four medical. It is concluded that 46% of patients complaining of angina pectoris with normal cardiac function and coronary arteriography have gastroesophageal reflux as a possible etiology. Seventy-three per cent of these patients have total abolition of chest pain by either surgical or medical antireflux therapy. Patients whose experience of chest pain coincided with a documented reflux episode on 24-hour esophageal pH monitoring had a 100% response to medical or surgical therapy. Overall, surgical therapy gave better results (91%) but was associated with an 18% temporary morbidity. Objective evaluation of reflux status and its correlation to the symptom of chest pain by 24-hour pH monitoring allows for selective therapy in these difficult to manage patients.

The role of the esophageal body in the antireflux mechanism

The competency of the cardia depends on the interaction of the distal esophageal sphincter (DES) pressure and the length of the DES exposed to the positive-pressure environment of the abdomen. These two components were measured in 20 normal control volunteers and 126 patients with objectively proved gastroesophageal reflux. The results, when plotted on a grid with the horizontal bar representing the length of the abdominal esophagus and the vertical bar representing the DES pressure, indicated that factors in addition to the mechanical components of the cardia were important in the antireflux mechanism. The 24-hour esophageal pH records from the patients and the antireflux mechanism. The 24-hour esophageal pH records from the patients and normal subjects were analyzed as to the number of reflux episodes that occurred per hour while the patients were in the supine position and the ability to clear the refluxed acid by the propulsive "P"pump" of the body of the esophagus. It was concluded that the antireflux mechanism of the esophagus consists of a valvular cardia and a propulsive "pump" action of the body of the esophagus. The failure of either may lead to abnormal acid exposure but can be compensated by one or the other in normal subjects. Failure of both invariably leads to abnormal acid exposure. The cardia can fail either mechanically (i.e., having inadequate valvular components) or functionally (i.e., having normal valvular component but abnormal number of reflux episodes per hour). The latter suggests gastric pathology. Precise diagnosis of the reason for abnormal acid exposure is needed to develop a rational basis for therapy.

Prognostic factors in patients with non-small cell bronchogenic carcinoma and brain metastases

Prognostic factors were examined in 38 patients with nonsmall cell lung carcinoma and brain metastases. The most important factors were the response to total therapy (corticosteroids, radiotherapy, and chemotherapy) and the presence of brain metastases alone; these factors had the most impact on survival. Age, sex, histologic type of lung cancer, and initial performance status were not prognostically important. Our results indicate that certain subgroups of patients with nonsmall cell lung carcinoma and brain metastases have a favorable prognosis and should be treated aggressively.

Bronchogenic carcinoma located in the aortic window. The importance of the primary lesion as a determinant of survival

Thirty-four patients with an aortic window lesion were carefully staged with gallium scans and mediastinoscopy according to the TNM classification system for carcinoma of the lung. All were in Stage III. Twenty-five patients had non-oat cell carcinomas (15 squamous cell, eight adeno-, two large cell) and nine had oat cell carcinomas. Quantitative ventilation-perfusion lung scans were particularly helpful in verifying the subaortic location of the tumor by showing a less than 20% interference with pulmonary blood flow or ventilation secondary to left mainstem bronchus or pulmonary artery invasion. Decision for resectability in 13 Stage III M0 patients was based on the length of the uninvolved proximal left main pulmonary artery seen on pulmonary arteriogram. Eight patients (seven non-oat cell and one oat cell) had resection after radiation and prior to chemotherapy (after two cycles of chemotherapy and prior to radiation therapy for the oat cell) with a resultant survival rate better than those of M0 and M1 non-oat cell or oat cell patients without resection. The survival rates of nine non-oat cell M0 patients, nine non-oat cell M1 patients, and eight oat cell patients, all without resection, were not statistically different. This similarity in survival rates is explained by the observation that 38% of the non-oat cell M1, 71% of the non-oat cell M0, and 63% of the oat cell patients died from complications of their primary tumor. Patients with aortic window lesions, irrespective of their histology, have an extremely poor prognosis due to the high incidence of lethal complications of their primary tumor. Complete resection when feasible, as judged by pulmonary arteriography, provides the best control of the primary tumor and, as a consequence, gives longer survival.

VP16-213 in combined modality treatment of small cell carcinoma of the lung

Thirty-four previously untreated patients with histologically proven small cell carcinoma of the lung were treated with a combined modality therapy program that incorporated VP16-213, an epipodophyllotoxin derivative, into the chemotherapy regimen. Initial therapy for two cycles was with V-CAM, VP16-213, cyclophosphamide, doxorubicin and methotrexate. Following two cycles of V-CAM each patient received radiation therapy consisting of 4000 rads to the primary site, both hila and the mediastinum, as well as 2000 rads as prophylaxis to the whole brain. After a one-week rest period the patients received monthly cycles of V-CAM until death. Of 10 patients with stage IIIM0 disease, 7 had a complete response (CR), 1 a partial response (PR) and 2 had progressive disease. The median survival was still not reached by approximately 18 months. Of 24 patients with supraclavicular and/or metastatic disease there were only 5 patients with a CR, 11 with a PR and 8 with progressive disease. Their median survival was approximately 9 months. The 70% overall response rate and 9.3-month median survival of the entire group are essentially the same results as those in previously reported studies. There appears to be no additional benefit when VP16-213 is incorporated into our combined modality program.

Interaction of lower esophageal sphincter pressure and length of sphincter in the abdomen as determinants of gastroesophageal competence

This study defines the components of distal esophageal sphincter function which predict gastroesophageal competence and examines the mechanisms by which three antireflux procedures restore competence to the cardia. In a prospective study, the reflux status of 391 patients was determined by 24 hour pH monitoring. Distal esophageal sphincter pressure and length of sphincter exposed to the positive pressure environment of the abdomen was measured by esophageal infusion manometry. Similar pre- and postoperative studies were performed in 45 patients who were randomized to three equal groups for the Hill, Belsey and Nissen antireflux procedures. Two hundred sixty-seven (68 percent) of the 391 patients had a positive 24 hour pH test. Competence of the cardia was related to pressure in the distal esophageal sphincter, to the length of sphincter in the abdomen and to an interaction between both (all p less than 0.05). Thus, competence of the cardia requires an adequate pressure and length of sphincter in the abdomen. In determining competence, the pressure and length effects are not additive, but have an interacting relationship. Sphincter pressure and abdominal length are independently corrected by surgery. Restoration of competence requires increases in both. The gastric fundic wrap best augments distal esophageal sphincter pressure by application of normal functioning smooth muscle to the lower esophagus. Sphincter dynamics are normal after a wrap as the gastric fundus and distal esophageal sphincter share the functions of synchronous contractions and simultaneous relaxation on deglutition.

Relationship of a hiatal hernia to the function of the body of the esophagus and the gastroesophageal junction

One hundred two patients referred to our Esophageal Function Laboratory without endoscopic evidence of esophagitis were divided into two groups on the basis of the presence of a hiatal hernia on endoscopic examination. Fifty-three patients had a hiatal hernia and 49 did not. Both groups and 30 normal volunteer subjects had esophageal manometry and 24 hour esophageal pH monitoring. The incompetency of the cardia in patients with a hiatal hernia was dependent upon loss of components responsible for the antireflux mechanism, mainly a decrease in distal esophageal sphincter pressure and a decrease in the length of the sphincter exposed to the positive-pressure environment of the abdomen. These deficiencies were not related to the presence of a hiatal hernia and were similar to those of patients with an incompetent cardia without a hiatal hernia. Patients with a hiatal hernia and an incompetent cardia had significantly more esophageal exposure to refluxed acid than without a hiatal hernia. On the basis of the number of reflux episodes that lasted 5 minutes or longer and radioisotope transit studies, this increased acid exposure was due to both a loss of competency of the cardia and poor esophageal clearance secondary to the presence of a hiatal hernia. Reduction of the hernia and anchoring the distal esophagus into the abdomen not only may improve the antireflux mechanism, but corrects the clearance abnormality as well. The presence of a hiatal hernia has a detrimental effect on the clearance function of the body of the esophagus and may aggravate the effects of gastroesophageal reflux due to an incompetent cardia.

Evaluation of elevation of the head of the bed, bethanechol, and antacid form tablets on gastroesophageal reflux

To ascertain how elevation of the head of the bed, bethanechol, and antacid foam tablets affect gastroesophageal reflux, we used prolonged intraesophageal pH monitoring in 55 symptomatic patients. Acid exposure was separated into reflux frequency and esophageal acid clearance time and recorded during the day in the upright posture and recumbent at night. Values before and during each therapy were compared to physiologic reflux in 15 asymptomatic controls. Ten patients slept with the head of the bed elevated and had a 67% improvement in the acid clearance time (P less than 0.025); however, the frequency of reflux episodes remained unchanged. Twelve patients given 25 mg of bethanechol 4 times a day had a 50% decrease in recumbent acid exposure only (P less than 0.05), due to a trend towards decreased reflux episodes and acid clearance in time. Bethanechol combined with head of bed elevation in 19 other patients decreased both reflux frequency (30%) and acid clearance time (53%, all P less than 0.05). Antacid foam tablets failed to significantly diminish acid exposure. Nocturnal reflux responded the best to those therapies tested.

Twenty-four-hour pH monitoring of esophageal function. Its use in evaluation in symptomatic patients after truncal vagotomy and gastric resection or drainage

The incidence and character of gastrointestinal reflux after truncal vagotomy and gastric resection or drainage were studied prospectively in 42 symptomatic patients. Gastroesophageal reflux, proven by 24-hour pH monitoring, occurred in 31 patients. Initial symptoms of heartburn, regurgitation, or dysphagia were similar in patients with and without reflux. Eighteen patients had pure acid, nine had acid-alkaline, and four had pure alkaline reflux. Reflux occurred predominantly in the supine position. Esophagitis occurred only in patients with reflux and was not dependent on the pH of refluxed material. Reflux was eventually controlled by antireflux repair in 19 and by colon interposition in three patients. Twenty-four-hour esophageal pH monitoring is beneficial in evaluating symptoms after gastric surgery. It quantifies both acid and alkaline reflux, provides an objective assessment of the patient's subjective complaints, and gives a rational basis for management.

Prognostic significance of immunological tests in lung cancer

We performed a battery of tests on peripheral blood samples from 94 patients with lung cancer to determine the extent to which immunological depression was due to abnormal lymphocyte function, as compared to changes in the number of lymphoid cells in the peripheral blood or in the efficiency of purification of cells in Ficoll-Hypaque gradients in preparation for testing. The percentage of lymphocytes in the gradient-derived cell suspension (%LG) was the most informative test. It decreased significantly with advancing stage of cancer and could predict survival of patients with uniform stage. The %LG correlated with survival better than any other test when multivariate analyses of all test combinations were performed. Low values of %LG reflected both the depressed lymphocyte counts and the altered buoyant density of the leucocytes of many patients with advanced cancer. A large proportion of the depression in other immune function tests was statistically attributed to changes in %LG. We concluded that this simple measurement provides valuable information about patients with lung cancer.

Small-cell carcinoma of the lung: a five-year experience with combined modality therapy

In the past five years, we have treated 89 patients with small-cell carcinoma of the lung with radiotherapy plus one of three chemotherapy programs. The 24 patients with disease confined to the chest (Stage IIIMO) had an 87% response rate to the combined modalities (79% complete responses) and a median survival of 18 months; 13 patients with disease confined to the chest and ipsilateral supraclavicular nodes (Stage IIIMOSCN +) had an 84% response rate (69% complete responses) and 11-month median survival; the 52 patients with distant metastases (Stage IIIMI) had a 71% response rate (15% complete responses) and eight-month median survival. Survival was not affected by adding prophylactic cranial irradiation to the latest regimen, although the CNS relapse rate was reduced. We conclude that our three chemotherapy programs to date differ very little in their effect on survival of patients with metastatic disease. New and more vigorous approaches, possibly including surgery, need to be tested for the management of disease confined to the chest. The designation of patients as Stage IIIMOSCN + is valid because such patients have better survival rates than patients with distant metastatic disease.

Malignant mesothelioma: a metastasis to the face

Malignant mesothelioma can be a confusing disease, resembling either carcinoma or sarcoma. Although it usually causes death rapidly by local and regional spread, distant metastases may be seen more frequently as more effective therapy controls local disease and prolongs life. Our patient's local and then regional mesothelioma was controlled by aggressive treatment, which allowed him nearly two years of productive life before a metastasis to the right infraorbital region occurred. He died shortly thereafter with widesspread metastases. This is the first reported case of mesothelioma metastatic to the face. This case also emphasizes the association of malignant mesothelioma with asbestos exposure, and points out advances in pathologic techniques that aid in the diagnosis of the disease.