The influence of age on gastro-oesophageal reflux: a re-appraisal of the DeMeester scoring system

OBJECTIVE

The statistical evaluation of the influence of age on the pattern of gastro-oesophageal reflux (GOR) identified by prolonged pH monitoring in asymptomatic subjects. Re-appraisal of the DeMeester scoring system for GOR.

METHOD

Prolonged pH monitoring was performed on 45 asymptomatic elderly adults with normal contrast oesophagogram, manometry and endoscopy. They included 36 males and nine females. The mean age was 66.6 years. The monitoring time ranged between 20 and 24 h, including one complete daily feeding cycle. GOR was defined as a reflux event with a pH of <4. The mean, standard deviation, kurtosis and skew were calculated for six parameters listed in the results. The mean values were compared with those of normal values determined by DeMeester et al. (in: Read NW, editor. Gastrointestinal motility: which test? 1989, pp. 43-52) from their study of 50 young healthy adults, and the t-test was applied to determine the statistical significance of differences. The 'null hypothesis' for each parameter was defined as 'the mean values of the elderly population are not statistically different from DeMeester's normal values'.

RESULTS

The means (+/-SD) of six parameters studied in pH monitoring were as follows: supine reflux time as a percentage of total study time, 2.94+/-5.18%; upright reflux time as a percentage of total study time, 4.14+/-5.71%; total reflux time as a percentage of total study time, 3.5+/-4.38%; duration of longest reflux episode, 14.98+/-24.92 min; number of reflux episodes lasting >5 min, 1.76+/-2.75; total number of reflux episodes during study, 13.49+/-11.31. These results were significantly different from the normal values reported by DeMeester. In addition, the data for each individual parameter was grossly skewed, as well as kurtotic, which implied that the data did not represent a normally distributed population. Moreover, we believe that the equation used for calculation of the DeMeester score, is inappropriate.

CONCLUSIONS

The null hypothesis is rejected as the mean values of these parameters in our group are significantly higher than those used as normal. This implies that the normal values defined by DeMeester would over-diagnose gastro-oesophageal reflux disease (GORD). Moreover, we have found that the formula used to calculate the DeMeester's score is not according to the principle it is based on. DeMeester's system scoring is therefore inappropriate.

Revisional surgery after colon interposition for benign oesophageal disease

Although the short-term results of colon interposition for replacement of the oesophagus in part or as a whole are known to be satisfactory, there have been several reports of functional problems associated with total replacement in the long-term follow-up of patients. We have retrospectively studied patients who have required revisional surgery for anatomical and functional sequelae over a 7- to 38-year period. Although the short-segment colon interpositions have been relatively trouble free, several mechanical and functional problems requiring revisional surgery have been encountered in the long-term follow-up of patients who underwent long-segment colon interposition.

Bronchoplasty for malignant and benign conditions: a retrospective study of 44 cases

OBJECTIVE

To study the different operative techniques employed, the problems encountered and the outcome in bronchoplastic procedures both during and after surgery.

PATIENTS AND METHODS

Forty-four patients with a mean age of 51.6 years (range 15-80 years) underwent bronchoplastic procedures in the period from 1976 to 1998. There were 27 males and 17 females. Forty-two of these had planned surgery. Two trauma patients had emergency surgery. Out of 42 planned operations, 27 suffered from cancer and 15 had benign lesions. Amongst the non-small cell lung cancer (NSCLC) group, the nodal status was N0 in nine patients, N1 in 12 and N2 in six. Bronchial sleeve resection with lobectomy was performed in 24 patients. Six patients had sleeve pneumonectomies. Fourteen others had bronchial sleeve resections without lobectomies, and bronchoplasties for trauma and stricture. Reconstruction was performed in the earlier years with stainless steel wire of 38/40 SS gauge (n=22), vicryl (n=4) and prolene (n=1). More recently, ethibond (n=18) was routinely used for this purpose. Anaesthesia was maintained via oro-tracheal intubation, interrupted when necessary with a short period of intubation of one or the other bronchus through the thoracotomy incision.

RESULTS

The mean operating theatre time, including the anaesthesia, was 207 min (range 120-375 min). The duration of stay in the high dependency unit (HDU) was no longer than 3 days. Post-operative problems included excessive bronchial secretions and partial atelectasis (one patient requiring therapeutic bronchoscopy), prolonged mechanical ventilation (n=1) and prolonged air leak (n=1). There was no per-operative, hospital, or 30 day mortality. Four out of 27 cancer patients lived more than 5 years, 12 died between 2 and 5 years, and 11 lived less than 2 years.

CONCLUSIONS

Whilst bronchoplasties require special anaesthetic techniques and stringent high dependency post-operative care, there is minimal operative morbidity and mortality. Acceptable duration of survival can be expected even in the cancer patients.

Massive intrathoracic extrapleural haemangiopericytoma: deployment of radiotherapy to reduce vascularity

Haemangiopericytoma is a rare, highly vascular, slow-growing tumour which has both malignant and benign varieties. We report a case of a 63-year-old man in whom it was treated by initial radiotherapy followed by complete surgical excision. The preoperative radiotherapy markedly reduced the vascularity of the tumour. A brief review of the pathology and nature of tumour is provided.

Functional and mechanical sequelae of colon interposition for benign oesophageal disease

OBJECTIVE

In an attempt to estimate the incidence and severity of the functional and mechanical problems associated with colon interposition for benign oesophageal disease, a retrospective analysis of a single centre experience was undertaken.

METHODS

Between 1961 and 1990, a total of 365 patients who survived the postoperative stay in hospital were followed up over 7-38 years and form the basis for this study. Upper gastro intestinal symptoms in these patients were investigated clinically, radiologically, endoscopically and in the oesophageal laboratory. Mechanical and functional abnormalities requiring surgical intervention for relief of symptoms were documented.

RESULTS

There were two late presentations of colo bronchial fistulae, two instances of persistent colo cutaneous fistulae, three cases of diaphragmatic herniation and two adenocarcinomata of the colo gastric junction in the patients with short segment colon interposition. Amongst the long segment colon interposition patients there was one hiatal obstruction, two thoracic inlet delays associated with pseudo diverticulosis and one hiatal obstruction. One other patient presented with an adenocarcinoma of the intrathoracic colon. There were four patients requiring revision of the cervical oesophago colic anastomosis, two of them on recurrent occasions. The remaining sequelae were functional and were associated with increasing redundancy of the colonic segments at different levels. There were 17 such patients, two of whom developed significant redundancy at two different levels.

CONCLUSIONS

Although the patients with short segment colon interposition developed predominantly avoidable iatrogenic complications, those undergoing long segment colon interposition developed functional sequelae requiring re-operations in later life.

Pedunculated intraluminal oesophageal fibrolipoma. A case report

Benign tumours of the oesophagus are rare. A patient with a pedunculated intraluminal tumour presented with dysphagia of recent onset and the tumour resected at open operation and histology was confirmed as a benign vascular fibrolipoma. We discuss the management and review the relevant literature.

Solitary fibrous tumour of the diaphragm

Solitary fibrous tumours are uncommon neoplasms that have been described as occurring in the pleura, peritoneum, lung, mediastinum, pericardium, nose and paranasal sinuses. This report describes the first known case of a solitary fibrous tumour of the diaphragm, occurring in a 60 year old woman with a two year history of respiratory symptoms. The lesion was initially misdiagnosed as an elevated left hemidiaphragm. The operative findings and histological appearance of the tumour are described. A review of the literature examines the various types and presenting features of solitary fibrous tumours as well as their clinical behaviour and postulated origin.

The relevance of abnormal motility patterns in intra-mural oesophageal leiomyomata

OBJECTIVE

Abnormal oesophageal motility patterns of the obstructive type in patients with gastro-oesophageal reflux without clinical evidence of obstruction raise the possibility of some co-existing problem.

METHODS

In order to elucidate the relevance of such motility we studied two patients who were diagnosed as manifesting gastro-oesophageal reflux without herniation on full oesophageal investigations including radiology, ambulatory pH metry and endoscopy. In both patients leiomyomata were enucleated from the gastro-oesophageal junction at the time of surgery for reflux and subsequent oesophageal motility studies showed a return to near normal patterns. We studied, in retrospect, the motility patterns of two other patients with dysphagia due to a leiomyoma in the middle and upper oesophagus, respectively, and in whom the diagnosis of an oesophageal leiomyoma was made on clinical and radiological criteria. One of these patients was also studied post-operatively.

RESULTS

A detailed study of these motility patterns shows exaggerated oesophageal contractions without features specific to achalasia cardia or localised oesophageal spasm, and that these features are reversed by surgical enucleation of the tumour.

CONCLUSIONS

In these four patients the abnormal motilities are attributable to the presence of the intramural tumours despite the absence of clinical evidence of obstruction.

Pharyngo-oesophageal dysphagia: surgery based on clinical and manometric data

High or pharyngo-oesophageal dysphagia (PD) is defined as difficulty in initiating the act of swallowing within 1s. It involves the mechanisms controlling the tongue, pharynx and upper oesophageal sphincter (UOS) and is associated with a wide variety of local, neurologic and muscular disorders, and can also occur after surgery in the area and in response to gastro-oesophageal reflux (GOR). Our study aims at defining the criteria for surgery in PD and to evaluate the clinical results of such treatment. Twenty-three patients who underwent surgery were evaluated with pharyngo-oesophageal motility and ambulatory 24-hr pH-metry. The following parameters were measured: 1) pharyngeal contraction amplitude, 2) duration, 3) repetitive pharyngeal contractions, 4) UOS tone, 5) percentage of UOS relaxation, 6) duration of relaxation, 7) UOS closing pressure, 8) UOS closing duration, 9) co-ordination of UOS closing pressure and upper oesophageal (UO) contractions. Preoperative manometry showed a variety of abnormalities in several of the parameters, such as prolonged pharyngeal contraction ("spasm"), unco-ordinated pharyngeal contractions and UOS relaxation, low amplitude pharyngeal contractions, unco-ordinated UOS closing tone and UO contractions and hypotonic UO. Surgery was directed at the specific abnormality in each patient taking into consideration the presence or absence of GOR. Seventeen patients (74%) had excellent results. Three other patients (13%), who had improved swallowing but who continued to have GOR complicated by some oesophageal dysmotility, oesophagitis and an oesophageal web, underwent subsequent anti-reflux surgery with relief of symptoms. In conclusion, pharyngo-oesophageal motility measurement is mandatory in PD, especially when a diverticulum is absent. Cricopharyngeal myotomy with or without diverticulectomy as indicated produces excellent results. Associated oesophageal problems have to be dealt with appropriately.

Oesophageal epiphrenic diverticulum: an unusual presentation and review

Epiphrenic pulsion diverticula are rare and often asymptomatic. We describe a case presenting in an unusual fashion, and review the controversy over the management of this condition with regard to the requirement for myotomy and antireflux surgery. We believe that both procedures are necessary, but believe that both procedures are necessary, but optimal management strategies are unlikely to be resolved as the rarity of the condition precludes largescale prospective studies.

Spontaneous pneumomediastinum

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Pathophysiologic basis for operation on Zenker's diverticulum

An increased resistance to bolus flow through the upper esophageal sphincter has in the past been considered the main cause of increased pharyngeal contraction and the subsequent development of Zenker's diverticulum (ZD). Our study was designed to elucidate the pathophysiologic characteristics of the swallowing mechanism and its possible role in the development of ZD. Fourteen patients with radiologically proved ZD and a matched control group of healthy volunteers with no gastrointestinal symptoms were investigated with esophageal manometry using the station pull-through technique. Although the mean amplitude of pharyngeal contraction was higher in the ZD group, there was no difference in the duration of contraction. The resting tone of the upper esophageal sphincter zone in patients with ZD was found to be lower than normal, but the closing pressure was higher and its duration longer. Though present in 2 patients, pharyngosphincteric incoordination was not the main feature in the ZD group. Sphincteroesophageal incoordination was noted in 9 patients, however. The mean amplitude of the upper esophageal contraction was higher and the duration longer in the ZD group. There was no upper esophageal peristalsis in 3 patients. An operation for the repair of ZD should therefore be undertaken only after careful interpretation of the manometric features of each patient.

Ambulatory motility patterns of the transposed short segment colon

Ambulatory manometry and pH-metry were performed on 10 asymptomatic patients who had undergone lower oesophageal replacement with the left hemicolon between two and 20 years previously. Recording of the ambient pH in the intrathoracic colon was carried out simultaneously. In every patient the recording, which lasted approximately eight hours, included upright, supine, prandial, and post-prandial periods. The results were analysed both visually and by computer. The emerging motility patterns showed three basic types of wave, based on amplitudes--low amplitude contractions (LAC) measuring < 60 mm Hg, medium amplitude contractions (MAC) of 60-100 mm Hg, and high amplitude contractions (HAC) of 100-200 mm Hg. Additional subtypes were identified in the LACs and MACs. Using software primarily designed for oesophageal motility, the proportion of propulsive (6%-55%) waves could be distinguished from simultaneous or mixed waves, or both. A proportion of propulsive waves was noted in patients who had undergone surgery 10 or more years previously. It is concluded that the transposed colon retains its normal motility pattern but some adaptation to its new location may occur in the long term.

Thoracoplasty in the context of current surgical practice

Although widely employed for well over a century as a procedure for reducing the capacity of the thoracic cavity, thoracoplasty in current practice has become a rarity. A retrospective analysis of 37 patients (29 men, 8 women) who underwent the procedure under the care of one thoracic surgeon in a 16-year period provides the basis for this presentation. Ages ranged from 23 to 82 years with a mean age of 58 +/- 12.8. The mean follow-up was 8.5 years. Nineteen patients underwent the procedure for complications after lung resection for lung cancer. There were four perioperative deaths in this group (21.1%) and 6 long-term survivors (31.6%). Eighteen patients without lung cancer underwent thoracoplasty as a planned treatment or for complications. There were no perioperative deaths, two late deaths, and 16 long-term survivors (88.9%) in the group. In the entire series, the overall perioperative mortality rate was 10.8% with no major long-term morbidity. Although proper timing and proper patient selection are essential in the use of thoracoplasty as a procedure to cope with the septic complications of lung cancer resection, it is overall a safe and successful procedure that has a relatively low mortality and that leads to considerable improvement in quality of life.

Pericardioperitoneal shunt for persistent pericardial effusions: a new drainage procedure

We report a pericardioperitoneal shunt procedure in 2 patients with persistent pericardial effusions in which the classic surgical methods of shunting were inappropriate.

Preoperative computed tomography of the brain in non-small cell bronchogenic carcinoma

BACKGROUND

Computed tomography of the brain is the most accurate diagnostic investigation for detecting intracranial tumours. A prospective study was undertaken to try to maximise the cost effectiveness of computed tomography of the brain in the preoperative evaluation of non-small cell lung cancer.

METHODS

All patients with non-small cell lung cancer who were free of neurological symptoms and were thought to be free of metastases from the results of routine investigations were subjected to computed tomography of the brain in the 12-24 hours immediately before surgery.

RESULTS

Of 158 such patients, five showed positive evidence of metastases, confirmed on craniotomy and excision biopsy; one of these patients was found to have a non-metastatic tumour (false positive). Five patients with a negative scan who underwent lung resection returned within 12 months with neurological defects and positive findings on further computed tomography (false negative). The predominant cell type in patients with positive and false negative scans was adenocarcinoma or adenosquamous carcinoma (7/10); the majority had nodal state N2.

CONCLUSIONS

Computed tomography of the brain should be carried out if mediastinal disease is suspected or confirmed in non-small cell lung cancer before proceeding to surgery.

Carcinoma developing in the neo-oesophagus following gastroplasty

Carcinoma developing after gastroplasty and fundoplication has been documented in only five cases. We report a further case occurring in a patient 4 years after initial surgery. The tumour originated in the newly created tubular extension. There was no evidence of a columnar lining in the true oesophagus prior to surgery. The development, technique and complications of gastroplasty and partial fundoplication are discussed with special mention of the diagnostic problems when a tumour develops in a patient who has undergone this procedure.

Cervical esophageal diverticulum associated with an impacted denture: a case report

The authors describe the case of a 19-year-old man who had swallowed his three-toothed radiolucent upper denture 2 years before the current admission. Although radiologic examination of the soft tissues of the neck and the results of barium meal examination were reported as normal immediately after the event, a barium meal examination 2 years later revealed formation of a cervical esophageal pouch, within which the denture was found at operation. The swallowing and possible impaction of a foreign body within the esophagus should prompt upper gastrointestinal endoscopy despite a negative result of a barium meal examination. Endoscopic removal is the treatment of choice, but surgery is appropriate in selected cases.

Randomized trial of one-dose versus six-dose cefazolin prophylaxis in elective general thoracic surgery

The objective of this study was to compare the efficacy of one to six doses of cefazolin as prophylaxis in general thoracic surgery using a randomized, double-blind design. Two-hundred eight consecutive patients admitted to a regional thoracic surgery unit for elective thoracotomy and lung resection were eligible for the trial. There were no wound infections in the one-dose group and two in the six-dose group (95% confidence intervals [CI]: -0.008, +0.048 [The positive number refers to the largest possible difference in favor of the one-dose group and the negative number, the largest possible difference in favor of the six-dose group]). Each group had eight postoperative chest infections (CI: -0.075, +0.077) and three empyemas (CI: -0.004, +0.050). Thirty-day mortality was 5% in the one-dose group and 4% in the six-dose group (CI: -0.053, +0.069). Postoperative duration of hospital stay, requirement for antibiotics, and the need for reoperation were comparable. These results suggest that six doses of cefazolin do not confer clinically important benefit beyond that obtained from a single dose for prophylaxis of wound infection in elective general thoracic surgery.

Limited thoracoplasty in the management of complicated pulmonary aspergillomas

Complicated pulmonary aspergilloma is a life threatening condition. Indications for surgery are few and the procedures conservative. Three patients were successfully treated with limited thoracoplasty. Limited thoracoplasty in combination with other conservative measures may provide effective palliation in selected cases.

A Predictive Index for Postoperative Deep Vein Thrombosis in Thoracic Surgery Patients

In a single-centre prospective trial 200 consecutive patients undergoing thoracic surgery were randomised to receive one of two prophylactic regimes against deep vein thrombosis (DVT). These were 5000 units of subcutaneous heparin twice a day, alone or combined with the wearing of graded compression stockings. The diagnosis of DVT was made clinically and with ¹³¹I labelled fibrinogen. Six DVTs developed in the stocking group and 11 in the non-stocking group. The results suggest that the use of stockings reduces the incidence of DVT when added to herparin but the difference is not statistically significant. To obtain a predictive index for the development of DVT, discriminant analysis was applied to the control and stocking groups separately and combined. Five simple clinical variables gave a true positive prediction rate, for the combined group, of 94% and a false positive prediction rate of 26%.

Recurrent idiopathic pneumomediastinum

A case is described of the rare syndrome of recurrent idiopathic pneumomediastinum which had been mistakenly diagnosed as recurrent spontaneous perforation of the oesophagus. The case illustrates the importance of distinguishing between pneumomediastinum and oesophageal rupture because of their markedly differing prognosis and management.

Leiomyomas of the lower respiratory tract

Leiomyomas account for about 2% of benign tumours of the lower respiratory tract. From the relatively few cases reported in the literature, it appears that these tumours most commonly occur in the fourth decade, although one third of patients are under the age of 20 years. The distribution of leiomyomas favours the distal part of the tracheobronchial tree and the most common site for tracheal lesions is the membranous portion of the lower third. Over 90% of pulmonary parenchymal leiomyomas, which themselves are more common in women, are incidental findings on chest radiographs whereas bronchial lesions are important causes of irreversible lung damage. Tracheal lesions may present as bronchial asthma. Accurate early diagnosis rests on a high index of clinical suspicion and histological examination of bronchoscopic biopsy specimens or frozen section material obtained at exploratory thoracotomy. Treatment could be conservative surgery, but 65% of reported cases have been managed by lobectomy or pneumonectomy as a result of advanced irreversible lung disease or unawareness of the benign nature of the lesion.

A modified Pearson gastroplasty

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Achalasia of the cardia associated with pulmonary sarcoidosis

The case of a patient with sarcoidosis and symptoms suggestive of achalasia cardia is presented. Because of increasingly severe dysphagia, cardiomyotomy was performed and biopsy specimens of the esophageal wall were obtained. Light and electron microscopy revealed lesions of the nerves in Auerbach's plexus consisting of an inflammatory process and demyelinization of the nerve fibers. Since the operation, the patient has been swallowing without difficulty. Although previous reports have described dysphagia in patients with sarcoidosis, presumably secondary to mechanical compression by adjacent lymph nodes or infiltration of the esophageal wall by sarcoid granulomata, this report documents for the first time that dysphagia can also be caused by direct involvement of the innervation of the esophagus by sarcoidosis.

Metastasising thymoma

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Preoperative carcinoembryonic antigen levels correlated with postoperative pathological staging in bronchial carcinoma

Serum carcinoembryonic antigen (CEA) levels were obtained before operation in 214 patients undergoing diagnostic tests for suspected bronchial carcinoma, and the results correlated with the postoperative, pathological stage of disease. Positive CEA levels (greater than 10 ng/ml) were observed in 40% (8/20) of stage 1, 58.5% (31/53) of stage 2, 85.2% (69/81) of stage 3, and 92.3% (24/26) of stage 4 patients with bronchial carcinoma. Furthermore, the mean CEA levels increased with stage of disease, and the differences between mean levels were found to be significant in stages 1 and 2 versus 3 and 4 (p less than 0.001). This suggests a positive correlation between the preoperative CEA level and tumour burden defined by pathological staging. When the results were compared with the histological type of lung carcinoma, CEA elevations occurred most frequently with adenocarcinoma, followed by undifferentiated and squamous cell carcinoma, reflecting perhaps the origin of this oncofetal antigen from the endodermally derived bronchial mucosa. These data indicate that preoperative serum CEA levels quantitatively reflect the extent of tumour assessed pathologically at operation and confirm the potential usefulness of this antigen as a biological tumour marker in the management of bronchial neoplasms.

Pulmonary sequestration

Pulmonary sequestration is an uncommon congenital abnormality in which nonfunctioning lung tissue is supplied by an anomalous systemic artery. Both the extralobar and intralobar forms probably develop from an accessory lung bud from the primitive foregut. Both forms are situated on the left side in about two-thirds of patients. The anomalous arterial supply usually originates from the descending thoracic aorta, and there may be a large left-to-left or left-to-right shunt through the sequestration. The sequestration may have a fistulous communication with the upper gastrointestinal tract. Congenital anomalies, particularly diaphragmatic hernia, are frequently associated with the extralobar form. Intralobar sequestration occasionally is an incidental finding on roentgenograms of the chest in an asymptomatic patient; however, the disorder is usually symptomatic and the most common presentation is recurrent pulmonary infection. Presentation may be characterized by gastrointestinal symptoms, congestive heart failure, hemoptysis or hemothorax. Extralobar sequestration is usually an incidental finding on routine roentgenograms of the chest or during the management of some other congenital anomaly. Infrequently, extralobar sequestration presents with symptoms similar to those seen with the intralobar form. Roentgenograms of the chest, upper gastrointestinal series and arteriography are the most helpful diagnostic aids. The usual treatment is resection of the sequestration by removal of only the sequestration in patients with the extralobar form and by lobectomy or segmental resection in patients with the intralobar form. The reported results of operation have generally been excellent.

Transection of the trachea secondary to blunt trauma

Tracheal injuries secondary to blunt trauma are not common and complete tracheal transection is even more unusual. Because the incidence of these treatable, but often lethal, injuries is increasing, more surgeons will encounter them. A report of the treatment of a case of tracheal transection due to blunt trauma with emphasis on avoiding unnecessary tracheostomy is presented, with a review of the literature.