Polypoid tumor of the esophagus.

Five cases of an uncommon esophageal tumor consisting of a mucosal squamous cell carcinoma that surrounds a polypoid mass of spindle cells were examined. The spindle cell component was composed of elongated cells with blunt nuclei, admixed with multinucleated giant cells. Reticulin fibers enveloped individual cells, and abundant collagen was present. Thirteen to 69 mitotic figures occurred per 10 high-power fields. Electron microscopy showed dilated cisternae of rough endoplasmic reticulum and peripheral intermediate filaments within the cytoplasm. Intermediate-type junctions (zonulae adherens) and subplasmalemmal linear densities connected some cells. No tonofibrillar bundles or desmosomes (maculae adherens) were present. Immunoperoxidase stains detected no keratin in the spindle cells. Alpha-1-antichymotrypsin and alpha-1-antitrypsin were in the spindle cells in five of five and three of five cases, respectively. The absence of desmosomes, tonofibrillar bundles, and keratin and the presence of alpha-1-antitrypsin and alpha-1-antichymotrypsin favor fibrohistiocytic differentiation of the spindle cell component.

Adenocarcinoma of the stomach. Changing patterns over the last 4 decades.

A retrospective study was performed on 255 consecutive patients admitted to a single hospital from 1953-1983 with a follow-up of 100%. The number of proximal esophagogastric junction and fundus tumors increased significantly over the last 4 decades from 21% to 44% (p less than 0.001), accompanied by a significant decrease in antral carcinomas from 60% to 33% (p less than 0.01). Patients with proximal neoplasms were significantly more likely to be white (71% vs. 29%, p less than 0.001), whereas patients with antral cancer were significantly more likely to be black (64% vs. 36%, p less than 0.001). There were no significant differences in nodal status, presence of distant metastases, or the overall 5-year survival rate between these two sites. The 5-year survival rate for the entire group was 6%. Sixty-five patients (30%) underwent curative resection, and the 5-year survival rate in this group was 24%, which was significantly better than palliative procedures. The 5-year survival rate was strongly influenced by TNM stage, local invasiveness, nodal status, and presence or absence of distal metastases (p less than 0.001). Although the overall survival rate has not changed over the past 30 years, there were definite epidemiologic differences between proximal and antral lesions, which suggest that new treatment protocols should be designed to include the location of the neoplasm.

Esophageal cancer staging by CT: long-term follow-up study.

To evaluate the utility of computed tomographic (CT) staging in patients with esophageal cancer, the length of patient survival was compared with pretherapy CT findings in 89 patients. Regardless of therapy, patients with evidence of mediastinal invasion, liver metastases, or abdominal adenopathy had a statistically shortened survival (P less than .05). Specific CT criteria that predicted a shortened survival included evidence of tracheal, aortic, or pericardial invasion. Patients with evidence of both mediastinal invasion and abdominal metastases had a mean survival of 180.4 days; those with no evidence, 479.6 days. The presence of enlarged upper abdominal lymph nodes indicated the worst prognosis (mean survival, 90 days). The patients with squamous cell tumors were classified by the CT staging system, and survival data were compared according to surgical procedure. Patients who underwent attempted curative surgery did not have a statistically significant difference in survival by analysis of survival curves but demonstrated a longer mean survival than those who underwent palliative or no surgery.

Diagnosis and recommended management of esophageal perforation and rupture.

Over the past 47 years (1937 to 1984), a total of 127 patients with esophageal perforation or rupture were evaluated at Duke Medical Center or the Durham Veterans Administration Medical Center. In 13 patients, the diagnosis was established at the time of autopsy and in the remaining 114, the diagnosis was established clinically. The etiology, radiological findings, underlying esophageal disease, time interval between onset of symptoms and therapy, and eventual outcome were evaluated. Patients with anastomotic leaks and those in whom carcinoma resulted in perforation or fistula were excluded. Iatrogenic causes were responsible for 55% of perforations, followed by spontaneous rupture in 15%, foreign body perforation in 14%, and traumatic perforation in 10%. Of the 127 patients, 114 underwent treatment involving primary closure (43%), drainage alone (28%), resection (9%), or nonoperative therapy (20%). The overall mortality among these 114 patients was 21%. Fourteen patients sustained a major complication requiring additional operative intervention. The overall mortality among patients requiring reoperation was 57%. Survival was significantly influenced by a delay in treatment of greater than 24 hours. With the exception of nonoperative therapy, survival was improved for all forms of treatment instituted within 24 hours. Primary closure within 24 hours resulted in the most favorable outcome (92% survival). In addition to early treatment, other factors associated with a favorable outcome included traumatic perforation (100% survival), foreign-body perforations (94% survival), and iatrogenic causes (80% survival). Spontaneous rupture resulted in the lowest survival (37%). The incidence of esophageal perforation has increased dramatically since 1967.(ABSTRACT TRUNCATED AT 250 WORDS)

Surgical treatment of H-type tracheoesophageal fistula diagnosed in an adult.

A new method is described for the repair of a congenital tracheoesophageal fistula in an adult. This technique uses a fiberoptic bronchoscope and passes a flexible vascular guidewire across the tracheoesophageal fistula. This maneuver then simplifies the intraoperative identification of the tracheoesophageal fistula, which is exposed and repaired through a left transcervical approach.

Recurrent inguinal hernia.

An analysis of 584 operations for recurrent inguinal hernia was made in an attempt to determine the cause of the recurrence based on the anatomic findings. The recurrence was indirect in 300, direct in 241, and various other in 43 operations. The causes of the indirect recurrences appeared to be an unrecognized hernia, incomplete dissection or improper ligation of the sac, failure to narrow the cord, or inadequate reconstruction of the internal ring. No cause for the diffuse direct recurrences was apparent. Of the 241 hernias in Hesselbach's triangle, 144 were small localized defects, usually (112) just lateral to the symphysis. These were considered to be caused by the cutting action of a suture placed under tension. On the basis of these findings, suggestions are made for primary inguinal hernia operations.

Effect of lubrication of frictional properties of sutures.

The results of this study have provided an insight into the behavior of sutures in the environment of fluids. It has been shown that friction could both increase or decrease with lubrication, depending upon the nature of the application. In tests on straight sutures, lubricants have generally led to an increase in friction. This was found in the present investigation as well as in another study which measured friction in sutures soaked in serum. These results are explained on the basis that higher friction is expected to arise if the lubricant formed a multilayer film between the sliding surfaces. In this instance, the resistance to shear flow by the lubricant becomes the governing factor. On the other hand, if only a small amount of lubricant, such as a monolayer film, is present between surfaces, as expected within the structure of a snugged surgical knot, the lubricant may play the role of decreasing adhesion and, thus, friction.

Effect of suture material and construction on frictional properties of sutures.

The results overwhelmingly support the view that the coefficient of friction is not a material constant of the sutures but a function of several variables, including applied tension, suture construction and suture material. The coefficient of friction decreased with an increase in applied tension with the rate of change depending upon the suture material. Prolene and Ethilon had the highest frictional values among all sutures at low tension, but dropped to a position of lowest values at high tension. On an average, braided sutures gave higher frictional values than did the monofilament sutures. Sutures with special surface coatings (silicone or Teflon) generally gave lower values than did the sutures without any such coatings. Similar results were reported in other studies on coated materials. The differences in frictional profiles are governed by the differences in the viscoelastic nature of the suture materials. The unusual traces produced by Prolene were considered as being due to its high degree of stretch and elasticity. Others similarly found that Prolene behaved peculiarly due to a high degree of stretch. Finally, coefficient of friction is an important property of suture materials as it is expected to have a direct bearing on the security of knots. A careful study of this parameter under a variety of clinical conditions is essential to gain an understanding of the behavior of surgical knots in clinical practice. The present study gives detailed information on the frictional behavior of various types of surgical suture materials.

Management of an infected mucocele occurring in a bypassed excluded esophageal segment.

An infected mucocele of an excluded retained esophageal segment is an infrequently reported complication of esophageal bypass surgery. The subtle symptoms of this entity and its management are discussed.

Esophageal lesions after total laryngectomy.

Clinical and endoscopic evaluation of the post-total laryngectomy patient with dysphagia may be limited by postoperative fibrosis or strictures. The barium esophagogram is a valuable adjunctive tool in further assessing these patients, as both functional and anatomic abnormalities can be evaluated. A 10-year retrospective review yielded 204 patients who had had total laryngectomies for squamous cell carcinoma of the larynx; 85 of these patients had postoperative barium esophagograms. Dysphagia was the chief complaint in 73 of these 85 patients. The studies were reviewed for anatomic abnormalities of the surgically deformed pharynx (neopharynx) and the esophagus distal to it. While most patients (51%) with dysphagia had abnormalities in the neopharynx, 17 (23%) had abnormalities distal to the neopharynx; these included four esophageal carcinomas and 13 benign esophageal strictures. These results emphasize the importance of evaluating the entire esophagus and maintaining a high index of suspicion for distal esophageal disease in the total laryngectomy patient with dysphagia.

The continuing problem of carcinoma of the pancreas.

The courses of 208 patients with adenocarcinoma of the pancreas were reviewed. The lesion was located in the head of the pancreas in 142 patient, (68%) and of these, in 22 patients the diagnosis was confirmed histologically at postmortem examination; 21 patients underwent laparotomy and biopsy with a 33% operative mortality and a 3.4-month average survival; 89 patients underwent biliary and/or gastric bypass with a 24% mortality and 4.8-month average survival; 10 patients underwent pancreaticoduodenectomy with a 20% mortality and 14.6-month average survival. The lesion was located in the body or tail of the pancreas in 77 patients (32%); and, of these, 15 patients had histologic confirmation of clinical diagnoses at postmortem examination; 19 patients underwent biopsy of extra-abdominal metastases and survived an average of 1.4 months; 27 patients underwent laparotomy and biopsy with a 26% operative mortality and 3.5-month average survival; 4 patients underwent gastric and/or biliary bypass with a 50% mortality and 4.5-month average survival; one patient underwent noncurative distal pancreatectomy and survived 1 month postoperatively. No patient was cured of his disease. Of the 55 operative survivors of biliary bypass alone for carcinoma of the head of the pancreas, 5 (9%) required subsequent gastroenterostomy for duodenal obstruction.

Stapled esophagogastric anastomosis.

In a consecutive, nonrandomized series of 92 patients, esophagogastric anastomosis was performed with a suture technique in 32 patients and with a stapler in 60 patients. Only one anastomotic leak occurred in each group. Stricture later formed in three sutured anastomoses and in eight of the stapled anastomoses. A review of published reports shows anastomotic leak in 3.5 percent of the patients with stapled anastomoses. In patients with sutured anastomoses, leak occurred in approximately 10 percent. The improved results with the stapler do not alter the necessity for meticulous attention to technical detail.

Pseudosarcoma of the esophagus: barium swallow and CT findings.

Two new patients with pseudosarcoma of the esophagus are presented with the first report of the findings on computerized tomography (CT). The radiographic appearance in the two patients, with 24 previously reported, is reviewed. Barium esophagograms typically demonstrate a large, elongated polypoid mass in the middle or lower third of the esophagus that distends the lumen at the level of the lesion, but does not produce marked obstruction. There are no specific CT characteristics which differentiate pseudosarcoma from squamous cell carcinoma of the esophagus.

Computed tomography for staging esophageal and gastroesophageal cancer: reevaluation.

A reevaluation of computed tomography (CT) for staging carcinoma of the esophagus and gastroesophageal junction was performed in 76 patients. For comparison 26 patients without carcinoma of the esophagus with a normal mediastinum at surgery were included in the evaluation. Four radiologists evaluated the CT scans without knowledge of the diagnosis. After determining if there was an adequate amount of fat, they were asked to evaluate each case for the presence or absence of local invasion and distant metastases. The radiologists correctly identified all 26 normal patients. Eighteen of the 76 carcinoma patients had a paucity of fat, but only six were thought to have truly indeterminate scans. CT correctly identified 40 of the 44 esophageal carcinoma patients with mediastinal invasion and 11 of the 15 patients without invasion (accuracy 88%). CT correctly identified 15 of 19 patients with distant abdominal metastases and 28 of 30 patients without metastases (accuracy 88%). CT was only 50% accurate in predicting the presence or absence of invasion in the 12 patients with gastroesophageal junction tumors and only 58% accurate in predicting distant metastases. CT correctly staged 46 (94%) of 49 patients with esophageal carcinoma but only five (42%) of 12 patients with gastroesophageal junction tumors. These results confirm that CT should be used as a major staging method in all patients with esophageal carcinoma.

Chemical burns of the esophagus.

The ingestion of caustic chemical agents, usually accidentally by children, produces a range of injury from minor mouth burns to necrosis of the esophagus and stomach. The type of agent, amount, concentration, and duration of exposure are the determining factors. The treatment of the average burn has been fairly well standardized, but the serious injuries require prompt recognition of complications and appropriate therapy.

Benign tumors and cysts of the esophagus.

A large variety of benign tumors has been reported in the esophagus, but the leiomyoma is the most common. The importance of accurate diagnosis and appropriate treatment has been emphasized.

Complications and deaths after operations for esophageal carcinoma.

In a series of 908 patients with squamous cell carcinoma of the esophagus, 512 operations were performed on 503 of the patients. Postoperative mortality was the highest after bypass operations, being 41.5%. After palliative resection, mortality was 22.7% and after curative resection, 12.8%. Overall resection in 283 patients resulted in a 17% mortality. The postoperative mortality for all resections for carcinoma at the three levels was as follows: cervical and thoracic inlet, 17.6%; upper thoracic, 16.9%; and lower thoracic, 16.9%. The most frequent causes of death were anastomotic leak and pulmonary complications. Nonfatal complications occurred in 13.3% of the 512 operations.

Colonic interposition for esophageal substitution.

Sufficient information has now accumulated to permit a better definition of the role of colonic interposition for substitution of the esophagus. For children and young adults with a long life expectancy, the interposed colon provides a well-functioning and durable conduit. When the stomach cannot be used, the colon is the best alternative in most patients. Necrosis of the colon remains the most frequent fatal complication; leakage and stenosis of the proximal anastomosis remain problems. Although results of the usual radiologic examinations with barium show that the colon empties by gravity, manometric results may demonstrate progressive peristalsis, particularly in response to stimulus from a bolus of dilute acid.