Improved surgical palliation of advanced carcinoma of the esophagus.

Fifty-four patients with far-advanced carcinoma of the esophagus were operated on between the years 1974 and 1976. No attempts were made to resect the lesion. The stomach was used fifty-three times to bypass the lesion and the right colon was used once. In twenty-eight patients the stomach was placed substernally and the anastomosis was done in the neck. Twenty-five patients had the anastomosis to the esophagus done in the chest. The thirty day operative mortality was 7.4 per cent and the average survival was five months. These figures compared favorably with a group of thirty-five patients with far-advanced carcinoma of the esophagus seen between the years 1971 and 1973 and handled with a variety of modalities. In this group the thirty day mortality was 31.4 per cent (11/35) and the average survival was three and a half months.

Carcinoma of the pancreas.

Pancreatic carcinoma remains a difficult problem in surgery. High mortality and overall discouraging results of pancreaticoduodenectomy misled some physicians to believe that surgery is ineffective in management of pancreatic carcinoma. Patients with pancreatic carcinoma in two major hospitals from 1963 through 1976 were analyzed. Results of pancreaticoduodenctomies and palliative operations are reported.

Pulmonary tuberculosis after gastric resection.

Reviewing the charts of tuberculosis patients during a span of seventeen years, we found a large number of gastrectomized patients. In our general hospital population, the incidence of tuberculosis was 3.2%. Among the gastrectomized patients, the percentage of tuberculosis was 6.3%. Of our tuberculosis patients 1.9% had gastrectomy, whereas of our general population 0.67% had gastrectomy. We were unable to arrive at any definite conclusions regarding the causative relationship between gastrectomy and tuberculosis. It is a retrospective study with all the fallacies, but the data does show an extremely significant difference between the incidence of gastrectomy in the general hospital population and the incidence of gastrectomy in histories of patients admitted with tuberculosis. It appears that a patient having gastrectomy runs a considerably greater risk of having tuberculosis in later life than a patient admitted for other reasons. Clinically, we were impressed with the widespread character of the disease in association with the poor nutritional status in the majority of the patients. We, therefore, could not avoid associating the loss of stomach substance with its nutritional function and the development of tuberculosis. As a consequence, we recommend a purified protein derivative test for all pateints undergoing gastric surgery. If the test proves to be positive, it is suggested the patient be given a course of isoniazid for one year. In the face of negative purified protein derivative test, we repeat the test at six month intervals. Should a conversion of the purified protein derivative occur, the patient is started on the course of isoniazid therapy. Our current belief is that more conservative methods of gastric surgery, that is, pyloroplasty, vagotomy, or antrectomy, should be substituted for gastrectomy in the treatment of duodenal ulcer disease to preserve a more normal gastric physiologic structure.