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Biomedical subjects

M B Orringer

Publications and source records attributed to M B Orringer.

At least 109 records · Page 6Linked to original sources
PubMed1988

Aggressive treatment of chylothorax complicating transhiatal esophagectomy without thoracotomy.

Chylothorax is an unusual complication after transhiatal esophagectomy (THE) and in the past 10 years has occurred in 11 of 320 patients (3%) undergoing this operation for diseases of the intrathoracic esophagus. Four patients had benign esophageal disease: scleroderma reflux esophagitis (1), caustic stricture (1), and achalasia (2), and each had undergone at least one previous esophageal operation. Seven patients had intrathoracic esophageal carcinoma--two upper-third, two middle-third, and three distal-third lesions. Excessive chest tube drainage more than 72 hours after THE was the standard presentation, and the diagnosis of chylothorax was confirmed by the administration of cream through the jejunostomy feeding tube placed routinely at operation. The character of the chest tube drainage changed from serous to opalescent. Aggressive treatment of this complication was the rule, and every patient underwent a thoracotomy between 2 to 14 days (average, 6 days) after the diagnosis was established. Cream was administered through the jejunostomy tube before operation, and in each case the thoracic duct injury was readily identified and controlled with suture ligatures. There were no deaths in this group, and there was one recurrence of the fistula that required reoperation; all patients were discharged from the hospital within 3 to 29 days (average, 10 days) after thoracic duct ligation. It is concluded that early recognition of a chylothorax after transhiatal esophagectomy with prompt transthoracic ligation of the injured duct results in a shorter overall hospitalization and lower morbidity and mortality from this complication. The traditional conservative management of chylothorax with intravenous hyperalimentation and no or low-residue enteral feedings has little place in this nutritionally depleted patient population.

Adult↗
PubMed1988

Cervical esophagogastric anastomosis for benign disease. Functional results.

Ninety-one adult patients (average age 49 years) with various benign esophageal disorders treated by total thoracic esophagectomy and a cervical esophagogastric anastomosis have been followed up with personal interviews and examinations from 6 to 104 months (average 34 months). Outpatient esophageal dilation has been used liberally for any degree of postoperative cervical dysphagia. At their latest follow-up, 39 patients (43%) eat without dysphagia; four patients (4%) have mild dysphagia necessitating no treatment; 34 patients (37%) have undergone one to three dilations during the first 6 to 12 postoperative months for intermittent dysphagia; and 14 patients (16%) have more severe dysphagia necessitating regular anastomotic dilations (two thirds of these perform home self-dilations). Mild regurgitation of gastric contents has been experienced by 27 (30%), particularly when recumbent after eating, but only four patients sleep with the head of the bed elevated to prevent nocturnal regurgitation. No patient has had pulmonary complications resulting from aspiration. Twenty patients (22%) have had varying degrees of "dumping syndrome," generally transient and well controlled with medication. Two patients have required an additional gastric drainage operation 16 months and 82 months, respectively, after the esophagectomy. At their latest evaluation, 33% of the patients weigh 3 to 83 (average 19) pounds more than they weighed preoperatively, 38% weigh 5 to 40 (average 12) pounds less, and 29% have had no change in their weight. The stomach functions well as a visceral esophageal substitute and, like the esophagus, is more thick-walled and resilient than colon. Significant gastroesophageal reflux is uncommon after a properly performed cervical esophagogastric anastomosis. Postoperative dysphagia can be minimized by attention to technique in constructing the anastomosis. These data support our belief that the stomach is the preferred organ for esophageal replacement, not only for carcinoma, but also for benign diseases as well.

Aged↗
PubMed1987

Central lung masses: prediction with CT of need for pneumonectomy versus lobectomy.

To assess the possible role of computed tomography (CT) in predicting the need for pneumonectomy rather than lobectomy, the authors retrospectively analyzed the CT scans of 26 patients requiring pneumonectomy (n = 21) or lobectomy (n = 5) for resection of central pulmonary abnormality. Twenty-three patients had primary lung cancer, two had metastatic carcinoma, and one had a massive granuloma. Scans were evaluated for tumor involvement of bronchi and pulmonary arteries and veins and for evidence of tumor extension across a fissure. Findings were compared with detailed surgical and pathologic data. Pneumonectomy was necessary most commonly because of proximal bronchial tumor invasion (13 patients). CT showed poor sensitivity (50%-54%) in depicting central bronchial and central pulmonary artery involvement as well as transfissural tumor extent. The results suggest that CT is not highly accurate in predicting the lobectomy/pneumonectomy decision in patients with central lung masses.

Carcinoma, Bronchogenic↗
PubMed1987

Cisplatin, vinblastine, and mitoguazone chemotherapy for epidermoid and adenocarcinoma of the esophagus.

Thirty-six patients with adenocarcinoma or epidermoid carcinoma of the esophagus were entered into a phase II trial evaluating the combination of cisplatin 100 mg/m2 intravenously (IV) day 2, vinblastine 1.6 mg/m2 IV days 1 to 4, and mitoguazone (MGBG) 500 mg/m2 IV days 1 and 8. Twenty-nine patients (group A) were newly diagnosed with local-regional disease only and were candidates for transhiatal esophagectomy (THE). These patients received two courses of chemotherapy at 3-week intervals prior to surgery. Response was assessed by measuring changes in the primary tumor length and depth on serial biphasic contrast esophagrams and comparing this result with tumor measurements obtained from the surgical specimen. Complete (CR) and partial responders (PR) received three additional postoperative cycles. Seven patients had recurrent or metastatic disease (group B) and were treated every 4 weeks until disease progression. Of 34 patients evaluable for response, there was one pathologically confirmed CR and 15 PRs (47%). This consisted of 12 of 27 (44%) group A patients (seven of 11 epidermoid, five of 16 adenocarcinoma) and four of seven (57%) group B patients (two of four epidermoid, two of three adenocarcinoma). Toxicity included leukopenia in one third of treatment courses and thrombocytopenia in 21%. Nausea and vomiting occurred in 60% of patients, diarrhea in 18%, transient nephrotoxicity in 18%, peripheral neuropathy in 12%, and ototoxicity in 3%. Twenty-five group A patients underwent resection. Four chemotherapy nonresponders (NR) and one PR had known disease left at surgery; all others (80%) had gross total removal of their disease. The median survival time (MST) of the 29 group A patients was 14 months, with 21% alive at 36 months. The MST of group A chemotherapy responders was 15 months compared with 9 months for NRs (P = .032). Initial sites of recurrence in 14 patients were local-regional in six, distant only in six, both local-regional and distant in two. This regimen, administered in maximally tolerated doses, was active in epidermoid and adenocarcinoma histologies, recurrent disease and newly diagnosed patients. However, nearly all responses were PRs and the MST of resected patients was similar to a prior series of patients treated with esophagectomy alone. Observations from this pilot trial and those of others have led to a follow-up study, in progress, evaluating intensive preoperative chemotherapy and concurrent radiation therapy (RT).

Adenocarcinoma↗
PubMed1987

CT evaluation of mediastinal lymph nodes in lung cancer: influence of the lobar site of the primary neoplasm.

Previous reports have shown differences in the ability of CT to detect mediastinal lymph nodes, depending on the precise mediastinal location of the nodes. Poorest correlation between findings on CT and findings at autopsy has been described for left-sided lymph nodes, particularly those in the left peribronchial region (American Thoracic Society node station 10L), suggesting that cancers of the left lung might be less well staged by CT than cancers of the right lung. The relationship between the accuracy of mediastinal lymph node staging and the location of the primary lung cancer was examined in a retrospective study. In 103 patients with non-small-cell bronchogenic carcinoma who had preoperative CT evaluation of the mediastinum, the accuracy of preoperative staging was 81% for tumors of the right lung (70 patients) and 97% for tumors of the left lung (33 patients). The conclusion is that cancers of the left lung are staged at least as accurately as cancers of the right lung, despite the fact that left-sided mediastinal nodes are depicted more poorly on CT. Subcarinal and crossover (contralateral) nodal metastases and a low prevalence of metastasis involving only region 10L were the most important factors minimizing staging differences based on the site of the primary tumor.

Humans↗
PubMed1986

Early dilation in the treatment of esophageal disruption.

During the past four years, 11 patients with disruption of esophageal continuity have received dilation therapy prior to the healing of the fistula. In 7 patients undergoing transhiatal esophagectomy with a cervical esophagogastric anastomosis, anastomotic leaks within 2 to 13 days (average, 8 days) after operation were treated by drainage, bedside esophageal dilations to at least a 46F bougie, and supplemental jejunostomy tube feedings. Bougienage was performed within 1 to 12 days (average, 6 days) of the diagnosis of a leak, and oral intake was not discontinued for more than 72 hours average. Fistula drainage stopped within 1 to 12 days (average, 6 days) of dilation in all patients. Four patients referred with chronic intrathoracic esophageal disruptions (2, middle third and 2, distal third) following resection of diverticula (2), esophageal dilation (1), and trauma from Harrington rods (1) were also treated successfully by drainage, esophageal dilation, or both. Periesophageal inflammation associated with an esophageal leak, esophageal spasm due to local irritation, or relative anastomotic narrowing may all contribute to obstruction distal to an esophageal disruption and adversely affect spontaneous closure. Dilation of the leaking esophagus is not dangerous if performed carefully and selectively, and in fact may promote healing of the injury.

Adult↗
PubMed1986

Evaluation of response to preoperative chemotherapy in esophageal and gastric cardia cancer using biphasic esophagrams and surgical-pathologic correlation.

Twenty-two patients with newly diagnosed carcinoma of the esophagus and gastric cardia were treated with combination chemotherapy prior to transhiatal esophagectomy. The clinical response to chemotherapy was determined by obtaining measurements of the vertical length of tumor, tumor depth, lumen size, and extent of ulceration on serial biphasic contrast esophagrams. Response was defined as a greater than 50% decrease in the sum of the products of the maximum vertical length and depth of the esophageal tumor mass. To obtain an assessment of the accuracy of the radiographically determined tumor measurements the esophagram results were correlated with surgical pathologic tumor measurements in 19 patients. The technique of esophagram and the determination of tumor measurements were standardized by having one radiologist perform and interpret all studies. All patients were clinically staged using the TNM classification system of the American Joint Commission on Cancer Staging. Three patients had T1 lesions, fifteen were classified as T2, and four as T3 lesions. Radiographic measurements of the tumor from the preoperative esophagram were correlated with the surgical pathologic specimen in five patients prospectively and 14 patients retrospectively. Response was seen in nine patients. The radiographically measured vertical length of the tumor was within 1 cm of the surgical specimen measurement in four of five (80%) prospectively evaluated patients and in nine of 14 (64%) retrospectively evaluated patients. These results suggest that chemotherapy-induced tumor regression can be objectively evaluated with a reasonable degree of accuracy using serial biphasic esophagrams.

Adenocarcinoma↗
PubMed1986

The role of CT in staging radiographic T1N0M0 lung cancer.

Thirty-one patients with non-small-cell bronchogenic carcinoma and standard chest radiographs showing T1N0M0 tumors underwent preoperative chest and upper abdominal computed tomography (CT) with subsequent thorough surgical-pathologic correlation of their disease status. Eight patients (25.8%) had tissue-proven mediastinal or distant metastasis at presentation. In five (62.5%) of these eight patients the presence of unresectable disease was detected by CT and an unnecessary thoracotomy was avoided. These five patients comprised three with mediastinal lymph-node metastasis, one with adrenal metastasis, and one with a coexistent contralateral, proximal endobronchial tumor. Three patients with unresectable disease not detected by CT (CT false negatives) had metastasis to normal-sized mediastinal lymph nodes. There were two CT false-positive diagnoses of adrenal metastasis in patients proven by CT-guided aspiration to have benign adrenal masses, and these patients subsequently underwent curative lung resection. Although the data base is relatively small, the authors conclude that preoperative CT may be useful in evaluating patients with radiographic T1N0M0 lung cancer.

Adenocarcinoma↗
PubMed1986

Mediastinal lymph node detection and sizing at CT and autopsy.

Although CT has assumed a major role in the preoperative evaluation of the mediastinum in patients with lung carcinoma, there is no consensus as to its accuracy or efficacy in this setting. A potential source of CT error is inaccurate detection or sizing of lymph nodes in particular mediastinal locations because of inadequate contrast with surrounding tissue or partial volume effects. We imaged five cadavers with CT and then meticulously dissected the mediastinal nodes. The nodes were measured and categorized by using the lymph node mapping scheme of the American Thoracic Society. The short axis nodal diameter was the best CT predictor of nodal volume. Excellent correlation was found between CT and autopsy for lymph node detection in right-sided mediastinal lymph nodes; poorer CT/autopsy correlation was found for left-sided lymph nodes, especially in the lower left peribronchial region. These findings suggest that CT may be less accurate in identifying left-sided mediastinal metastases.

Adult↗
PubMed1986

Surgical treatment after the failed antireflux operation.

Eighty-seven adults have undergone reoperation for recurrent gastroesophageal reflux or complications of prior antireflux procedures. Operations performed included the transthoracic Collis-Nissen procedure (59), Collis-Belsey repair (14), Nissen fundoplication (one), repair of acute postoperative paraesophageal hernia (one), division of obstructing crural suture (one), and esophageal resection (23). Among the 73 patients undergoing an additional hiatal hernia repair, there were two postoperative deaths. Follow-up averages 28 months. Subjectively, results have been excellent or good (no or mild reflux symptoms or dysphagia) in 47 (67%); fair in eight (12%), who have moderate dysphagia or reflux symptoms controlled medically; and poor in 15 (21%), 12 of whom have required additional operations. Early postoperative esophageal dilations were required in 25 patients (36%) and regular dilations in seven (10%). Among the 23 patients undergoing esophageal resection, four had a distal esophagectomy and short-segment colon interposition and 19 had a transhiatal esophagectomy without thoracotomy; stomach was used for esophageal replacement in 14 and colon in five. There were no operative deaths. Follow-up averages 17 months. Thirteen patients have had esophageal dilations (nine early and four regularly), and one has clinically significant reflux. Overall, subjective results are good or excellent in 64 (76%). The results of "redo hiatal hernia operation" are far from ideal. Optimal surgical treatment after the failed antireflux operation requires careful analysis of the existing anatomy and experience to decide when esophageal resection is a safer and more reliable approach than another hiatal hernia repair.

Adult↗
PubMed1986

Adenocarcinoma of the distal esophagus and gastric cardia. Comparison of results of transhiatal esophagectomy and thoracoabdominal esophagogastrectomy.

Between 1965 and 1984, 72 patients underwent operation for adenocarcinoma of the distal esophagus or gastric cardia. A standard transthoracic esophagogastrectomy and esophagogastrostomy was performed in 43 and a transhiatal esophagectomy without thoracotomy and partial proximal gastrectomy was performed in 29. There was no significant difference between the two groups in age, sex, or TNM tumor staging. The perioperative complication rate was 86% in the esophagogastrectomy patients and 48% in the transhiatal esophagectomy patients (p less than 0.05). Mortality was higher in the esophagogastrectomy group (14%) than in the transhiatal esophagectomy group (7%). Average operative blood loss was greater in the esophagogastrectomy patients (2,510 versus 1,187 ml). Average postoperative hospitalization was longer for the esophagogastrectomy patients (22.2 days versus 12.3 days). Both differences are statistically significant (p less than 0.05). Late results, as evaluated by life-table analysis, showed no significant difference in survival between the two groups of patients. Because the morbidity and mortality rates of transhiatal esophagectomy are as low as or lower than those for esophagogastrectomy, late survival is as good, and palliation is superior (less suture-line tumor recurrence and reflux esophagitis), we believe that transhiatal esophagectomy is the preferred operative approach in patients with adenocarcinoma of the distal esophagus or gastric cardia.

Actuarial Analysis↗
PubMed1986

Timely evaluation of shoulder pain in a teenager.

First rib lesions can present as musculoskeletal pain involving the shoulder and arm. Chronic musculoskeletal symptoms must be pursued in an adolescent. Plain radiographs remain an integral part of the diagnostic plan. While delay in the diagnosis of a benign rib lesion may not jeopardize the outcome, brachial plexus compression can result from an enlarging mass. The outcome can be worse if the lesion is malignant.

Adolescent↗
PubMed1985

Esophageal motor dysfunction in an adult with a congenital tracheoesophageal fistula.

A preoperative barium esophagogram and esophageal manometry in an adult patient with an H-type congenital tracheoesophageal fistula revealed the typical esophageal motor abnormalities previously described following operative repair of esophageal atresia in infants. The upper esophageal sphincter contracted normally, the lower esophageal sphincter relaxation was weak and incomplete, and there was no active peristaltic wave within the esophagus. These findings support the theory that the abnormal esophageal motor function reported after repair of congenital tracheoesophageal fistula and esophageal atresia is on a congenital basis and is not directly attributable to operative trauma or denervation.

Aged↗