Pathogenesis of esophagitis in patients with gastroesophageal reflux

Endoscopic examination of 50 patients with gastroesophageal reflux showed 26 with and 24 without esophagitis. Distal esophageal sphincter (DES) characteristics of the two groups were similar. All patients had abnormal acid gastroesophageal reflux (GER) on 24-hour pH monitoring of the distal esophagus compared to normal subjects. Patients with esophagitis did not have significantly greater acid exposure than those without esophagitis. Abnormal alkaline GER occurred in only five patients, two with and three without esophagitis. Esophageal clearance was impaired in patients with esophagitis compared to patients without esophagitis as determined by the acid clearance test and the number of reflux episodes of 5 minutes' duration or longer during 24-hour esophageal pH monitoring. Patients with esophagitis also had more frequent reflux episodes than those without esophagitis. Gastric emptying was significantly delayed in patients with esophagitis compared to those without esophagitis who were similar to normal subjects. When patients were analyzed in terms of position of reflux, combined refluxers had the highest, supine refluxers intermediate, and upright refluxers the lowest incidence of esophagitis. Gastric emptying in combined and supine refluxers was similar to the group of patients with esophagitis. Upright refluxers were distinguished by rapid gastric emptying compared to normal subjects and, as such, are a unique entity. We conclude that the development of esophagitis in a patient with an incompetent cardia is related to impaired esophageal clearance and delayed gastric emptying.

Management of esophageal perforation

Early diagnosis of esophageal perforation is critical. The importance of performing sufficient surgery at the first procedure whenever possible is emphasized. If early primary closure cannot be achieved, then the initial therapeutic method of choice is resection or diversion followed by reconstruction. Drainage of the perforated esophagus alone does not appear to be satisfactory treatment. Our experience indicates that later elective surgery for the management of patients undergoing successful initial resuscitation from esophageal perforation may be accomplished with an acceptable mortality rate.

The benefits of open lung biopsy in patients with previous non-diagnostic transbronchial lung biopsy. A guide to appropriate therapy

In a 17-month period, 20 immunosuppressed patients underwent transbronchial biopsy of the lung for diagnostic evaluation of a pulmonary infiltrate of unknown etiology. In 19 patients, the transbronchial biopsy was nondiagnostic. Thirteen of the 19 patients were critically ill and were referred for an open lung biopsy. Eleven (85 percent) of these 13 patients left the hospital after open lung biopsy and appropriate medical treatment. Two patients who were receiving mechanical ventilation at the time of open biopsy succumbed to the combination of their underlying disease and respiratory failure. There were no deaths directly attributed to the open lung biopsy. Of the six patients whose condition appeared stable and who did not undergo open lung biopsy, two died from unrecognized progress of their underlying malignant disease. The remainder recovered. We conclude that open lung biopsy is safe in and beneficial to the diagnosis and subsequent treatment of unknown pulmonary infiltrates in immunosuppressed patients who previously had a nondiagnostic fiberoptic transbronchial biopsy of the lung.

Technique, indications, and clinical use of 24 hour esophageal pH monitoring

The technique of 24 hour esophageal pH monitoring (24 hour pH test) is described. Experience with the 24 hour pH test in 393 patients with suspected esophageal disease has shown the clinical usefulness of the test in objectively determining the presence of gastroesophageal reflux. The test was effective in evaluating atypical symptoms of gastroesophageal reflux such as respiratory symptoms and chest pain and, in children, failure to thrive and recurrent pneumonia. The 24 hour pH test was particularly useful in evaluating patients who were referred with other abdominal or thoracic disease and had, in addition, symptoms suggestive of gastroesophageal reflux on history. The test helped to unsnarl the cause of recurrent symptoms after an esophageal myotomy for achalasia or an antireflux procedure. Of 179 patients with typical symptoms of gastroesophageal reflux, 27% had normal 24 hour test results and were subsequently diagnosed as having another cause for their symptoms. Of 146 patients who had normal findings on esophagoscopy, 54% were shown to have abnormal gastroesophageal reflux on 24 hour pH monitoring, indicating lack of sensitivity of endoscopy to detect reflux. In addition, the 24 hour pH test identified patterns of abnormal reflux and indicated those patients most at risk for development of stricture. The test is well tolerated by the patients, simple to use, and dependable when performed and read as described. The clinical use of the 24 hour pH test brings objectivity to the evaluation of exophageal disease that has hitherto not been available.

Intra-abdominal pressure and manometric data of the distal esophageal sphincter. Their relationship to gastroesophageal reflux

Nineteen patients with abnormal gastroesophageal reflux (13 with and six without hiatal hernia) had esophageal manometry and simultaneous 24-hour monitoring of esophageal pH and intra-abdominal pressure (IAP). Only 8% of all IAP challenges induced a reflux episode. This incidence increased to 13% in patients with a distal esophageal sphincter (DES) pressure of less than 5 mm Hg and an abdominal esophageal length of less than 1 cm, whereas it was only 6% in patients with a greater DES pressure and a longer abdominal esophagus. At the same time, there was an average of 2.7 reflux episodes per hour, of which 38.7% were caused by a challenge of IAP indicating that other mechanisms, besides changes in abdominal pressure, can cause reflux. There was no difference in DES pressure, length of abdominal esophagus, and the effect of IAP challenges in patients with and those without a hiatal hernia.

The role of gallium-67 scanning in the clinical staging and preoperative evaluation of patients with carcinoma of the lung

Gallium-67 scanning was evaluated in 100 patients with proved carcinoma of the lung. It was valuable in separating primary from secondary lung tumors, determining the extent of contralateral hilar or mediastinal lymph node involvement, and detecting distant organ metastases. In addition to multiplane whole-body Ga-67 tomographic scanning, colloid liver scans, bone scans, and computerized axial tomography scans of the brain were obtained to determine the presence of distant metastasis. The gallium scan detected 11 of 12 occult metastases and identified 7 of 7 liver, 9 of 14 brain, 4 of 4 soft tissues, 1 of 4 contralateral lung, and 9 of 11 bone metastases. The whole-body gallium scan accurately detected or excluded extrathoracic metastatic disease in 11 of 12 patients examined postmortem within three months of a gallium scan. An approach is recommended using gallium scanning along with chest roentgenograms for clinical staging and preoperative evaluation of patients with carcinoma of the lung. Specific organ scans should be reserved for the occasional symptomatic patient with a negative gallium scan or for clarification of an indeterminate gallium scan.

Gastroesophageal reflux and pulmonary aspiration: incidence, functional abnormality, and results of surgical therapy

The incidence of aspiration, the causative esophageal pathophysiology, and the results of surgical therapy were evaluated in 100 patients with abnormal gastroesophageal reflux documented by 24-hour esophageal pH monitoring. Based on historical evidence, 48 patients were suspected to be aspirators. Eight patients had documented episodes of aspiration (drop on esophagela pH, followed by acid taste in mouth and onset of cough or wheezing spell) during the monitoring period. Nine patients were considered to be potential aspirators because they presented oral acid regurgitation without development of pulmonary symptoms. In five patients a primary respiratory disorder (PRD) induced gastroesophageal reflux. The remaining 78 patients had abnormal reflux without aspiartion or regurgitation. Aspirators had a 75% incidence of esophageal motor abnormality on manometry, and the clearance of refluxed acid was significantly delayed in the supine position. A history of heartburn and endoscopic evidence of esophagitis were present in only half of the patients who were documented aspirators. Potential aspirators were spared from aspiration by rapid esophageal clearance of refluxed acid unaffected by changes in body position. Patients with a PRD had higher distal esophageal segment (DES) pressure and normal esophageal motility with minimal esophagitis. Nonaspirators significantly improved their clearance while in the supine position, emphasizing the protective effect of esophageal peristalsis against aspiration. An antireflux procedure in five aspirators raised the DES pressure significantly and returned the reflux status to normal by 24-hour pH-monitoring standards. The incidence of aspiration appears to be less than that suspected by history and is due to a motor disorder that interferes with the ability of the esophagus to clear reflex acid. Abnormal pulmonary symptoms can induce or result from gastroesophageal reflux and, when the latter occurs, an antireflex procedure stops both reflux and aspiration.

Prospective randomized evaluation of intrathoracic intercostal nerve block with bupivacaine on postoperative ventilatory function

This prospective and randomized study demonstrates the beneficial effect of intrathoracic intercostal block with bupivacaine on the recovery of pulmonary function after thoracotomy. A significantly (p less than 0.05) better forced expiratory volume was seen in the treated group in the early post-operative period. Similar findings were observed in forced vital capacity. Also, the requirements for analgesics were decreased in the treated group. We believe that intrathoracic intercostal block with bupivacaine when properly utilized can be a good adjuvant in the improvement of pulmonary function after thoracotomy.

Clinical and in vitro analysis of determinants of gastroesophageal competence. A study of the principles of antireflux surgery

The analysis of esophageal manometry and 24 hour esophageal pH monitoring in 266 consecutive patients indicates that the competency of the cardia depends upon the amplitude of the distal esophageal high pressure zone and the length of the abdominal esophagus. These two determinants of competency were examined using human esophagi in a unique in vitro model which allowed control of these parameters, as well as intraabdominal, intragastric, and intrathoracic pressures. The following principles of the function of the abdominal esophagus were graphically illustrated: (1) Competency of a segment of intraabdominal esophagus without intrinsic tone occurs only when intraabdominal pressure is equal to or greater than intragastric pressure. (2) Competency of a segment of intraabdominal esophagus without intrinsic tone is directly related to its length. (3) The length of intraabdominal esophagus necessary to maintain competency is indirectly related to variations in intraabdominal pressure. (4) Competency of a segment of intraabdominal esophagus is augmented by the presence of intrinsic tone, and the shorter the length, the greater the intrinsic tone needed. (5) Competency of a segment of intraabdominal esophagus is augmented by negative intrathoracic pressure. These findings beautifully illustrate the mechanical valvelike function of the abdominal esophagus and the objectives to be accomplished in the surgical treatment of gastroesophageal reflux.

Clinicopathologic correlations demonstrating the failure of 67gallium scanning in determining response to radiotherapy

Scanning of the chest using radioactive 67gallium citrate was performed in 12 patients with stage 3MO bronchogenic carcinoma prior to and following preoperative radiotherapy (3,000 rads). This was done to determine if scanning with 67gallium would be predictive in determining radiotherapeutic response. All 12 patients underwent resection of their primary bronchogenic carcinoma, and comparisons of chest x-ray films and 67gallium scans obtained before and after irradiation and of surgical specimens were made. The scan using 67gallium showed improvement in nine of the 12 patients; however, in five of these nine patients, the improvement on the scan using 67gallium was not paralleled by objective regression of the tumor on the chest x-ray film. Viable tumor was observed in the resected specimen in all 12 patients. We conclude that a scan with 67gallium should not be used to evaluate radiotherapeutic response.

Technique and experience with 24-hour esophageal pH monitoring in children

The technique and scoring system of 24-hr pH esophageal monitoring has been modified to evaluate gastroesophageal reflux in infants and children. The data from two pediatric controls and five clinical cases are presented and compared to normal adult values. This test has better objectivity, precision, sensitivity, and reliability than contrast studies, endoscopy, esophageal biopsy, acid perfusion, or acid reflux tests. The 24-hr pH monitoring assists the evaluation of sphincter maturation, pulmonary disease, and the significance of body position. With more experience, this technique could identify children at risk fo developing severe complications of reflux esophagitis and aid in the selection of candidates for surgical intervention.

Local nerve block anesthesia for peroral endoscopy

Local glossopharyngeal and superior laryngeal nerve block anesthesia for peroral endoscopy was performed on 500 patients (313 bronchoscopies, 162 esophagoscopies, 25 combined bronchoesophagoscopies). The technique allows easy insertion of rigid and flexible scopes or awake tracheal intubation of conscious patients. Glossopharyngeal nerve block causes temporary abolition of the gag reflex and loss of tactile sensation over the posterior third of the tongue and the lateral and posterior wall of the oropharynx and hypopharynx. Superior laryngeal nerve block results in loss of tactile sensation over the posterior surface of the epiglottis and the mucosa of the larynx and upper trachea. Ten of the 500 patients (2%) had an inadequate glossopharyngeal block, and 4 of the 313 patients who had a bronchoscopic examination had an inadequate superior laryngeal block. In the remaining patients, excellent anesthesia was obtained with good patient acceptance and minimal morbidity.

Gallium-67 scanning for carcinoma of the lung

Gallium-67 citrate scanning was prospectively evaluated in 55 patients who had lung lesions suspected to be primary carcinoma on chest x-ray films and in whom subsequent histologic diagnosis was obtained. Of 47 patients with histologically proved carcinoma of the lung, 44 (94 per cent) had a positive 67Ga scan. No patient with a positive scan had a benign lesion, so that the positive scan accuracy rate was 100 per cent. All 8 patients with a benign lesion and 3 patients with a malignant lesion had negative scans, for a negative scan accurary rate of 72 per cent for benign lesions. These results give statistical validity for the usefulness of the 67Ga scan in diagnosing carcinoma of the lung (p less than 0.001). Tumor cell type had little effect on the sensitivity of 67Ga scan. The 67Ga scan was equally useful in the evaluation of peripheral and central lesions. There was little difference amount T1, T2, and T3 classified lesions in their ability to take up 67Ga. The 67Ga scan was competitive with mediastinoscopy in assessing mediastinal lymph node metastases and provides a noninvasive method of assessing hilar lymph node metastases. There was a good correlation between the clinical staging of patients with lung cancer based on a chest x-ray film and 67Ga scanning and the staging after surgical treatment based on the histology of the resected specimens.

Cyclophosphamide, adriamycin, methotrexate, and procarbazine (CAMP)--effective four-drug combination chemotherapy for metastatic non-oat cell bronchogenic carcinoma

Twenty-three patients with metastatic non-oat cell bronchogenic carcinoma (MNOBC) were treated with cyclophosphamide, adriamycin, methotrexate, and procarbazine (CAMP) after radiation therapy. Objective responses were seen in 11 of 23 patients (48%) with a projected median survival time of 12.5 months for responding patients and patients with stable disease. Lung, liver, and cutaneous sites of involvement proved to be highly responsive; bone involvement was less responsive. CAMP is an effective combination in the treatment of MNOBC and its use in patients with less advanced disease should be explored.

Permanent extracorporeal esophagogastric tube for esophageal replacement

Six patients are presented in whom an extracorporeal esophagogastric tube bypass was employed in lieu of standard methods of esophageal reconstruction. These tubes, obtained from Japan, have functioned well in 4 of the 6 patients. This approach offers an alternative to gastrostomy feedings alone in a patient with advanced esophageal disease in whom no other method of surgical reconstruction can be offered.

Immunology and thoracic surgery

This report reviews the current status of three types of diseases in which knowledge of immunology is changing the practice of thoracic surgery. Evidence is presented for myasthenia gravis being an autoimmune disease. Thymectomy is widely considered to be the therapy of choice for patients with generalized myasthenia regardless of age or sex. Opportunistic pulmonary infections of unusual types are being encountered frequently in patients receiving immunosuppressive drugs for organ transplantation or malignancy. The important role of bronchial brushing and open lung biopsy is stressed. Immunotherapy of several types is currently being investigated experimentally and clinically and promises to change therapy for bronchogenic and esophageal neoplasms.

Functional evaluation of the interposed colon as an esophageal substitute

Five Rhesus monkeys and four human adults with colonic reconstruction of the esophagus have been studied by manometric, fluoroscopic and reflux tests. Transit through the graft is mainly under the influence of gravity. Infrequent colon contractions can be propulsive, and sequential haustral contractions give the appearance of peristalsis. The diaphragmatic hiatus and esophagocolic anastomosis are the sites of weak barriers to reflux which are readily overcome by abdominal compression and gastric distension. Esophageal peristalsis is necessary to return refluxed material and cricopharyngeus muscle is the final barrier to regurgitation.

Lung cancer: An immunologic viewpoint and the prospects for immunotherapy

The size of the lung cancer problem and the dismal results of conventional therapy justify close attention to the possibilities of immunotherapy. Lung cancer patients, like other tumor patients, are often relatively immunosuppressed although an immune response directed against autochthonous tumor cells can usually be demonstrated. All conventional forms of therapy, surgery, chemotherapy, and particularly radiation therapy, are further immunosuppressive, which, there is reason to believe, jeopardizes a successful outcome. Immunotherapy seeks to counteract this either by nonspecfic immunoenhancement or by enhancing reactivity to tumor specific antigens. The results of immunotherapy trials in lung cancer patients suggest that survival can be prolonged and survivorship increased by immunotherapy, although the benefit is inconclusuve at present. Optimal conditions for immunotherapy, as presently understood, are outlined. Practical questions about the optimal use of current immunotherapy regimens need to be answered, but a more aggressive approach to lung cancer therapy when combined with immunotherapy seems justified. Im pariicular, the criteria for operability will need to be redefined, particularly as regards oat cell cancer and large tumors which cannot be completely resected but in which "debulking" may contribute to the success of subsequent radiation and immunotherapy. Possible future immunotherapy regimens applicable to lung cancer are proposed, with the reservation that their success is likely to be directly related to their practicability.

Polypoid sarcomas of the esophagus. A rare but potentially curable neoplasm

Five patients with polypoid esophageal sarcoma are reported. All had dysphagia similar to that occurring in epithelial carcinoma of the esophagus. The clinical diagnosis of sarcoma was suspected when barium swallow showed a large polypoid lesion. Biopsy was often inconclusive concerning the nature of the lesion except to identify it as a neoplastic process. In spite of their large size, the tumors remained superficial within the esophageal wall. Nodal or distant organ metastasis was absent in 4 of the 5 patients. The histology of these tumors suggests that so-called carcinosarcoma is an epithelial carcinoma of the esophagus with varying amounts of spindle cell features and should be considered separately from sarcoma arising from mesenchymal tissue. Unlike carcinoma, esophageal sarcoma has a favorable prognosis following radical resection, and recent advances in esophageal surgery have decreased the mortality and morbidity of esophagectomy.

Midgut nonrotation in adults. An aggressive approach

Five adults with midgut nonrotation were treated at Tripler Army Medical Center between January 1, 1966 and January 1, 1974. These patients usually presented with vague epigastric or lower abdominal symptoms. Initial diagnosis was generally based on barium enema studies revealing an entirely left-sided colon. However, on upper gastrointestinal series the absence of a normal duodenal "c" loop with straightening is also seen. Duodenal obstructive bands are rarely documented radiographically. Surgical intervention is frequently delayed in these patients due to the "atypical" symptoms and lack of correlation of these symptoms with objective radiographic changes. The high incidence of associated duodenal ulcer disease, the frequent occurrence of bowel obstruction, the persistence of chronic abdominal pain in the untreated patients, and the resolution of symptoms after anatomic correction point to the need for an aggressive approach to treatment in those patients who have chronic recurrent symptoms secondary to midgut nonrotation.

Evaluation of the Nissen antireflux procedure by esophageal manometry and twenty-four hour pH monitoring

Fifteen normal volunteers without symptoms of gastroesophageal reflux and sixteen patients with symptoms of gastroesophageal reflux unresponsive to medical management and having endoscopic esophagitis had esophageal manometry and twenty-four hour pH monitoring of the distal esophagus. The symptomatic patients underwent a Nissen antireflux procedure and were restudied at four months. After surgery, patients had less reflux, a higher sphincteric pressure, and an equal amount of sphincter within the abdomen as did asymptomatic control subjects.

Respiratory insufficiency secondary to acute pancreatitis

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The effect of heterologous anti-lymphocyte seerum on mouse hemopoietic stem cells

The present study has demonstrated that rabbit anti-mouse lymphocyte serum (RAMLS) has the capability of destroying bone marrow cells and suppressing hemopoietic stem cell function. The in vitro incubation of bone marrow suspensions with RAMLS caused extensive cell lysis with an apparent preferential destruction of lymphoid, erythroid, and blastoid elements. Using the spleen colony assay, the number of functional hemopoietic stem cells was found to be markedly reduced in bone marrow populations exposed to RAMLS in vitro. Further, this loss of stem cell function could be produced by exposing marrow suspensions to small concentrations of antiserum which did not produce detectable cytotoxic effects on the general marrow population. A similar effect of RAMLS upon hemopoietic stem cells was found in vivo. The intravenous injection of RAMLS into lethally irradiated mice immediately after the infusion of isogeneic marrow cells reduced the number of spleen colonies formed, indicating that the antiserum could exhibit a deleterious effect upon stem cells in the bloodstream of the intact animal. Normal animals treated with daily subcutaneous injections of RAMLS for 3 wk had a significantly reduced marrow content of functional hemopoietic stem cells, suggesting that RAMLS can affect stem cells located in situ in the bone marrow. The experiments indicate that RAMLS possesses potential marrow toxicity.