Effective surgical therapy of esophagitis. Experience with Belsey, Hill, and Nissen operations.

During the years 1971 to 1978, 252 patients needed surgical treatment of primary or secondary esophagitis. Major operations performed were 73 Belsey Mark IV repairs, 55 Hill repairs, and 129 Nissen repairs. In the group with primary reflux, barium swallow tests and endoscopy were useful in confirming the diagnosis in patients with typical symptoms; routine biopsy, lower esophageal sphincter, manometry or an acid infusion test did not add to diagnostic certitude. If symptoms were atypical, a biopsy was helpful but manometry and acid infusion were not. Mean symptom scores in this group of patients were improved by each of the "valve-building" operations. Intraoperative dilation after mobilization of the esophagus coupled with a valve-building operation was successful in managing 26 of 29 strictures. Reoperation after an operation failed carried appreciable morbidity and mortality but resulted in good control of symptoms. Addition of a Belsey or Nissen procedure to myotomy for management of primary esophageal motility disorders diminished symptoms and did not cause disabling obstruction.

Traumatic bilateral carotid-cavernous sinus fistulas with progressive unilateral enlargement.

The authors present a patient with traumatic bilateral carotid-cavernous sinus fistulas associated with fracture of the sella turcica. Repeat angiography ten days after admission revealed that the left fistula had enlarged and was shunting the entire output of the left carotid artery and a portion of the output of the basilar artery. A muscle embolization procedure was sucessfully performed on the left side but was complicated by hemorrhage from the left cavernous sinus prior to closure. Problems associated with the enlargement of carotid-cavernous fistulas are discussed.

Immunoglobulin content in the bronchial washings of patients with benign and malignant pulmonary disease.

The bronchial washings of 58 patients with benign and neoplastic conditions involving the lungs were evaluated for immunoglobulin content. Levels in the washings from the diseased lung were compared with those from the normal contralateral lung. In normal patients and those with either bilateral inflammatory diseases or unilateral bronchiectasis or tuberculosis, the mean variation in igA/K and igG/K ratios between diseased and uninvolved lungs was minimal. In unilateral pneumonitis, however, igG/K was markedly elevated (P less than 0.01). Significant changes in the igA/K occurred on the affected side in patients with cancer. In the group with squamous-cell cancer. the mean elevation was 4.6 times that of contralateral lung (P less than 0.005), whereas with adenocarcinoma and undifferentiated carcinoma, the rise was 6.4 and 2.8 times, respecitvely (P less than 0.01 and P less than 0.01). Thus, carcinoma appears to alter local immunoglobulin production in the affected lung as compared to its normal counterpart. (N Engl J Med 295:694-698, 1976).