Biomedical subjects
F H Ellis
Publications and source records attributed to F H Ellis.
Carcinoma of distal esophagus and gastric cardia.
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Reoperative achalasia surgery.
Forty-six patients with esophageal achalasia required reoperation between January 1970 and January 1986. Three of these patients required a second reoperative procedure, for a total of 49 reoperations. Indications for reoperation were inadequate myotomy, 17; gastroesophageal reflux, 14; concomitant antireflux operation, six; incorrect diagnosis, four; carcinoma of the esophagus, four; megaesophagus, three; and paraesophageal hernia, one. Various procedures were employed at the time of reoperation, including revision of the myotomy, takedown or revision of a previously performed wrap, fundoplication, and resection. Of the 48 patients available for follow-up study over an average postoperative period of 5 years, the condition of 38 (79%) was considered to have been improved by reoperation. The best results were obtained by revision or takedown of a previous wrap (an improvement rate of 88.9%) and radical resective procedures (89% to 100%). We conclude that for good results to be achieved after reoperative achalasia procedures, the preoperative diagnosis must be accurate, the operation should be performed early before the development of megaesophagus, and a short but complete esophagomyotomy must be performed, preferably without the addition of an antireflux procedure. Elimination or revision of a previously performed fundoplication can be expected to be followed by good results. The precise indications for radical resective procedures have yet to be defined clearly, but their wider application to carefully selected patients with postoperative achalasia seems justified.
Results of valve reconstruction for mitral regurgitation secondary to mitral valve prolapse.
Mitral valve prolapse (MVP), often the result of myxomatous degeneration of the mitral valve, is the most commonly known pathologic entity leading to pure mitral regurgitation (MR). Reconstruction of the mitral valve rather than replacement is particularly applicable to this pathologic defect, but is not often used in the U.S. Experience with reconstruction of the mitral valve for MR secondary to MVP during the period January 1970 to January 1984 was reviewed. A total of 479 patients with mitral valve disease underwent operation during this period, 82 (17%) of whom had MR secondary to MVP. Thirty-one patients (6%) had valve reconstruction by a technique of leaflet plication and posteromedial anuloplasty. Eleven of these patients had associated cardiac disease requiring correction: 2 requiring aortic valve replacement and 9 requiring coronary artery bypass grafting procedures. One hospital death (3%) and 6 late deaths (19%) occurred, of which only 3 were related to cardiac factors. Major complications included recurrent MR in 5 patients and cerebral embolus in 1 patient. The adjusted 5-year survival rate was 89 +/- 6 (mean +/- standard error of the mean), and the overall survival rate of patients free of cardiac-related complications was 73 +/- 9%. Thus, reconstruction of the mitral valve is a highly effective surgical approach to the management of symptomatic patients with MR secondary to MVP, and its use is favored over replacement in the management of these patients.
Complications after use of the Angelchik antireflux prosthesis.
We report two cases of severe complications after insertion of an Angelchik antireflux prosthesis. In one case, the prosthesis migrated into the pelvis. In the other, severe dysphagia resulted from its insertion. In both instances, surgical removal was required. The high incidence of complications following the use of this prosthesis would suggest that other safer antireflux operations should be the preferred form of therapy.
Adult dysphagia lusoria. Treatment by arterial division and reestablishment of vascular continuity.
The case of a 27-year-old woman with dysphagia secondary to esophageal compression by an anomalous right subclavian artery is presented. Division of the anomalous vessel at its origin and revascularization of the right upper extremity by direct end-to-side anastomosis to the ascending aortic arch was accomplished through a right anterolateral thoracotomy. We believe this is the preferred surgical treatment of dysphagia lusoria in the adult.
Overview of the current management of carcinoma of the esophagus and cardia.
Esophagogastrectomy with esophagogastrostomy provides the best palliation for patients with carcinoma of the esophagus and cardia. It affords better palliation, longevity and overall survival than do other forms of therapy either singly or in combination. Treatment span is short, the patient is able to return to a reasonably normal life-style relatively quickly and the debilitating effects of dysphagia are relieved in most patients. Between January 1970 and July 1984 at the Lahey Clinic Medical Center, the overall operability rate was 80.3% and the resectability rate 87.2%. Four of 191 patients who underwent resection died for a hospital death rate of 2.1%. The overall 5-year survival rate was 16.3% and 81.2% of patients had successful palliation of dysphagia.
Carcinoma of the esophagus and cardia: current methods of treatment.
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Cancer of the esophagus and cardia. Role of surgery in palliation.
Palliation will remain the goal of therapy for cancer of the esophagus and cardia until early diagnosis permits improvement in long-term survival rates. Of the various surgical and nonsurgical techniques available for palliation, I prefer resection with esophagogastrostomy. This procedure can now be applied to most patients, with relatively low mortality and morbidity rates. The period of treatment is short compared with the time required for other forms of therapy, and satisfactory palliation can be achieved in nearly 85% of patients, with better survival rates than for other forms of therapy. Resection is the only method of treatment that provides any reasonable hope for cure. The overall five-year survival rate in my series is 21.6%. For early stage I lesions, the five-year survival rate is 43.4%.
Carcinoma associated with achalasia. Occurrence 23 years after esophagomyotomy.
Carcinoma developed in a 67-year-old woman with achalasia of the esophagus 23 years after esophagomyotomy. Postoperative manometric and radiologic studies showed satisfactory relief of esophageal obstruction. The development of carcinoma after an unusually long interval after adequate surgical treatment emphasizes the need for lifelong surveillance for this complication.
Reflux control by fundoplication: a clinical and manometric assessment of the Nissen operation.
Ninety-two Nissen fundoplications were performed for relief of symptoms of reflux in patients without stricture and in whom the wrap was left in the abdomen. Of these, 25 were reoperations. Reflux secondary to a hypotensive lower esophageal sphincter was associated with a sliding esophageal hiatus hernia in 61 patients, and surgical or other manipulative maneuvers were responsible for a hypotensive lower esophageal sphincter in 5 patients. No obvious cause could be determined in the remaining patients. The operation was transabdominal in 74 patients and by thoracotomy in 18 patients. Fifteen patients required ancillary operative procedures. Follow-up studies averaged 5 3/4 years in 82 patients and revealed permanent control of reflux in 74 of them (90.2%). Eighty percent of the patients were able to belch after operation. Overall patient satisfaction was achieved in 67 patients (81.7%). Among those who underwent operation for the first time, 84.5% achieved satisfactory results, whereas only 75% of those who underwent reoperation were benefited. Poorest results were caused by too tight a wrap, a complication that became rare after the size of the indwelling stent was increased to 42F. Esophageal manometry documented effective and significant augmentation of the amplitude and length of the lower esophageal sphincter from preoperative values of 7.2 +/- 0.5 mm Hg and 2.4 +/- 0.1 cm to postoperative values of 15.6 +/- 0.6 mm Hg and 4.1 +/- 0.1 cm (p less than 0.001). We conclude that if patients are properly selected and the wrap loosely fashioned, permanent control of reflux can be achieved by the classic Nissen fundoplication in 90% of patients with relatively few complications and a high degree of patient satisfaction.
Operation for esophageal achalasia. Results of esophagomyotomy without an antireflux operation.
Between January, 1970, and January, 1984, 113 patients with esophageal achalasia underwent 115 esophagomyotomies at the Lahey Clinic. Twenty-nine patients had been treated on one or more occasions by forceful dilation, and 18 had been operated upon before. Results are based on follow-up studies of 103 patients operated on 1 to 13.5 years ago (average follow-up period, 6.75 years). Six patients were lost to follow-up study, and six were operated upon less than a year ago. The condition of 94 patients (91%) was improved by operation. The improvement rate was 94% for those who underwent a primary operation and 76% for those who underwent reoperation. Only four of the nine poor results were caused by reflux esophagitis, and these patients are satisfactorily managed medically. Multiple regression analysis of risk factors including age, sex, duration of symptoms, severity of disease, length of follow-up, previous operation, and forceful dilations revealed that only previous operation correlated significantly with poor results (p = 0.0004). Preoperative and postoperative manometric assessment of the lower esophageal sphincter was made on some of these patients. The amplitude of lower esophageal sphincter pressure dropped from 32.5 +/- 1.6 (SEM) to 14.5 +/- 1.4 mm Hg, and the length of the lower esophageal sphincter decreased from 3.7 +/- 0.1 to 2.2 +/- 0.1 cm. These differences were highly significant (p = 0.001). After myotomy a short subhiatal remnant of the lower esophageal sphincter remains with pressure within the normal range, which minimizes the risk of postoperative gastroesophageal reflux. Because of the high success rate of limited esophagomyotomy and the low incidence of significant reflux symptoms after its use, we recommend that it be performed without an associated antireflux procedure.
Intraaortic balloon pump morbidity: a comparative analysis of risk factors between percutaneous and surgical techniques.
We reviewed our concurrent experience with percutaneous insertion versus surgical placement of the intraaortic balloon pump over a two-year period both to compare morbidity and to provide guidelines for the choice of method in particular patient groups and clinical settings. The effects on morbidity of sex, age, emergency placement, coexisting peripheral vascular disease, and duration of counterpulsation were determined. Sex was a highly significant factor, with low complication rates (3/29 or 10.3%) for percutaneous insertion in men and an inordinately high morbidity (12/17 or 70.6%) in women (Fisher exact test: p = 4.611 X 10(-5)). This difference may be due to the smaller size of the femoral artery in women. We conclude that percutaneous insertion is the preferred technique for most men but that direct exposure of the femoral artery should be employed in women. Given the serious morbidity encountered with each technique, there is no justification to broaden the indications for intraaortic balloon counterpulsation.
Complications of the Nissen fundoplication.
A more astute selection of patients and greater attention to technical details will preclude most complications. The first step is standardizing the technique, with avoidance of unnecessary ancillary maneuvers. Equally important is a thorough preoperative evaluation. With these considerations in mind, the authors believe that Nissen fundoplication is the preferred method of treatment for patients with uncomplicated gastroesophageal reflux refractory to medical therapy.
Esophagogastrectomy. A safe, widely applicable, and expeditious form of palliation for patients with carcinoma of the esophagus and cardia.
Of 262 patients with carcinoma of the esophagus or cardia seen at the Lahey Clinic between January 1970 and January 1983, 209 (79.8%) underwent surgical exploration. This report is confined to the 167 operations performed in the division of the senior author. Half of the tumors involved the esophagogastric junction with nearly equal numbers being located in the lower and upper halves of the thoracic esophagus and a relatively small number involving the cervical esophagus. The majority were adenocarcinomas of which 20 developed in a Barrett esophagus. Three of the squamous cell cancers developed in an achalasic esophagus. Of the resected tumors, 94 were classified as Stage III, 18 as Stage II, and 37 as Stage I. Esophagogastrectomy with esophagogastrostomy is the procedure of choice regardless of the level of the lesion. Of the 167 patients, 149 (89.2%) underwent resection with two deaths within 30 days of operation for a hospital mortality rate of 1.3%. There were 22 major complications (14.9%), which prolonged the hospital stay, and 14 minor complications (9.5%). Satisfactory palliation of dysphagia was achieved in 82.7% of the patients. The overall adjusted survival rate at 5 years was 21.7% +/- 7.5% (SEM) with a median survival time of 17.3 months. The 5-year adjusted survival rate according to stage was 43.4% for patients with Stage I lesions, 23.6% for Stage II lesions, and 12.8% for Stage III lesions (p = 0.0004). A multivariate analysis of risk factors involved in survival disclosed that neither age, sex, site of tumor, duration of symptoms, or cell type influenced survival, but stage of the disease had a profound effect. It is concluded that long-term survival of patients with carcinoma of the esophagus or cardia will probably not improve until early diagnosis is possible and that esophagogastrectomy by conventional techniques should be the treatment of choice until other forms of therapy prove superior to it both in terms of palliation and long-term survival.
Esophagectomy without thoracotomy for carcinoma of the esophagus.
During the past 2.5 years, 13 patients underwent esophagectomy for carcinoma of the esophagus without the use of a thoracotomy. During the same period, 81 operations on the esophagus or cardia were performed, 73 of which were esophagogastrectomies. Two patients died, for a hospital mortality rate of 2.7 percent. Of the 13 patients, there were 7 women and 6 men with an average age of 59.7 years. The lesion was located in the cervical esophagus in two, the upper thoracic esophagus in eight and the lower esophagus in three. One patient died on the 12th postoperative day, for a hospital mortality rate of 7.7 percent. Satisfactory relief of dysphagia was accomplished in all surviving patients, five of whom have died from the disease, for an average survival of 13.1 months. Seven are currently alive, with the longest period of survival 20.5 months. Esophagectomy without thoracotomy can be carried out with low mortality and morbidity rates. It is most applicable to patients with early lesions, particularly those in the cervical esophagus and the upper thoracic esophagus.
When should the esophagus be lengthened?
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Surgery for carcinoma of the lower esophagus and cardia.
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