Carl W. Janssen

Perforation of the intrathoracic oesophagus. A report of nineteen cases.

A series of 19 patients with perforation of the intrathoracic oesophagus is presented. Recent perforations were treated by primary suture. All these patients survived, although the suture did not hold in all cases. Old perforations, together with recent ones that leaked after suturing, were treated by drainage and gastrostomy. Two of these patients died; they were the only patients in whom the first attempt at drainage was unsatisfactory and thus had to be revised. The treatment of oesophageal perforations seems to be in accordance with the long-established principles of treatment of other gastro-intestinal and genito-urinary fistulas: firstly to restrict primary suturing to non-inflammatory tissue, and secondly to apply the principles of secondary healing by means of decompression and drainage.

Aorto-Oesophageal Fistula Complicating Carcinoma of the Oesophagus: Review of the Literature and Report of a Case Following Irradiation and Cytostatic Therapy

Aortic perforation complicating carcinoma of the oesophagus is extremely uncommon. In keeping with findings in the literature, the aortic wall in this case was damaged by secondary changes following irradiation and Bleomycin treatment. Extensive necrosis of normal tissues was a prominent feature and it is suggested that the action of radiation in combination with cytostatic therapy on normal tissues need further investigation.

Death during pneumonectomy from endobronchial tumour embolus. A case report.

A case is reported in which the patient died during pneumonectomy from endobronchial embolus of a tumour resulting in obstruction of the main bronchus of the normal lung. It is believed that the complication might have been prevented by the use of a double-lumen endobronchial tube. If generally employed, this precaution would also lessen the risk of intra-operative spread of smaller tumour emboli that may cause implantation metastases.

Age and sex distribution of intestinal type and diffuse gastric carcinoma

A twelve‐year series of 375 patients with gastric carcinoma has been studied. Primary tumours were classified as intestinal type (58%) or diffuse (26%), whereas 16% were unclassifiable. The relative age and sex incidence rates of intestinal type and diffuse gastric carcinoma were estimated using the age and sex distribution of individuals in Norway as the basis for calculation. There was no difference in the rates of diffuse gastric carcinoma between the sexes. On the other hand, the rate of men with intestinal type carcinoma was more than twice as high as that of women. This difference was consistent within each age group from adolescence to senescence. The findings indicate that Lauréns two types of gastric carcinoma are aetiologically different. The rates of both types increased with age up to the 70–79 age group, whereas the rates in octogenarians tended to be lower than in septuagenarians. A comparison of our data with the data of incidence of gastric cancer in Norway indicates that some of the older patients do not come for surgery.

Sublimate Intoxication of Rat: A Pilot Scheme of Mortality and Renal Damage According to the Amount of Sublimate

A series of rats was given different doses of sublimate as a one-time subcutaneous injection. the greatest polyuric effect without retention of urea, morphological renal damage, or mortality was obtained with 4 mg sublimate per kg body weight. Given 10 mg sublimate per kg body weight or more, all rats were rendered oliguric or anuric with extensive necrosis of the cells of the proximal tubules of the kidneys. Most of these rats died during the experimental period of 5 days. Support is given to the theory that sublimate intoxication affects both the glomerular filtration rate and the tubular reabsorption rate. Polyuria may thus be attributable to a discrepency between these two functions. Oliguria and anuria seem to be caused by a severe impairment of the glomerular function.

The influence of the host on the course of gastric carcinoma

Immunoglobulins (Ig) and some complement components (C) were quantified in sera from patients with gastric carcinoma before surgery and at regular intervals during a 5-year follow-up. The preoperative concentrations of C1-INH and C4 were higher (P < 0.0005 and P < 0.005) and IgG lower (P < 0.0005) in 50 patients with recurrence than in 46 5-year survivors. The prognostic significant of C1-INH was superior to that of the extent of disease (F-values 37.1 and 26.1). The preoperative immune data classified 76% of the patients correctly as to recurrence and no recurrence. Also, the preoperative C1-INH concentration had a highly significant effect on time to recurrence of cancer (P = 0.0007), adjusting for age and disease extent. After surgery the mean IgG concentrations were within normal range and without difference between the two groups. On the other hand, the concentrations of C1-INH and C4 in the individual patients in both groups remained the same from before to after surgery and throughout the observation period (P = 0.34). Apparently, the serum levels of C1-INH and C4 do not reflect the bearing of cancer. We therefore suggest that these variables represent an independent immune state that is appropriate to the host. A comparison of our variables with those of healthy individuals seems to support this idea. This immune state has a significant influence on whether a resected gastric cancer will recur, and also on how soon recurrence may be manifest.

The influence of age on the growth and spread of gastric carcinoma.

A twelve year series of 375 patients with gastric carcinoma has been studied. Patients were divided into TNM Groups. Tumours were classified as intestinal-type and diffuse. The patients with T1-3NOMO diffuse tumour were ten years younger than the patients with T1-3NOMO intestinal-type tumour. The mean age increased from T1 through T2 to those with T3 tumour. The age differences between the T-stages were the same in both groups, which indicate that once started, the diffuse and the intestinal-type tumours infiltrate the gastric wall at about the same rate. Among the patients with intestinal-type tumour, those with lymph node or distant metastases were three to seven years younger than the patients without metastases. On the other hand, the patients with diffuse tumour and metastases were as many years older than the patients without metastases. Apparently, tumour spread is age dependent and different between the two types of gastric carcinoma. The ill repute of the diffuse gastric carcinoma may therefore be explained by the advanced stage of that tumour at the time of treatment as compared to the intestinal-type tumour. The diffuse tumour seems to be clinically more silent and to give symptoms at a later stage than the intestinal-type tumour.

Serum C1-esterase inhibitor, an essential and independent prognosticator of gastric carcinoma

The preoperative concentrations of IgG were lower (P less than 0.002) and the concentrations of C4 and C1-INH higher (P less than 0.01 and P less than 0.001) in 29 patients with recurrence after potentially curative resection of gastric carcinoma, than in 31 patients alive and disease-free 5 years after surgery. These differences between the two groups of patients were consistent within each of six groups of disease extent. In each of the two groups of patients, the preoperative concentrations of IgG, C4 and C1-INH had no significant variation with the extent of disease (P greater than 0.05 or greater). Of our variables, C1-INH was the most potent prognosticator and discriminated between patients with and without recurrence with 80% accuracy. Furthermore, the predictive prognostic value of C1-INH at the time of surgery was superior to the prognostic value of the extent of disease (F values 27.00 and 12.69). Apparently, the preoperative C1-INH concentration is an essential and independent prognostic parameter of gastric carcinoma. We assume that C1-INH reflects an additional prognostic feature appropriate to the tumour or the host. Our finding that the interval between surgery and death from recurrence had an inverse relation to the preoperative C1-INH concentration also supports this assumption.

Esophageal Perforation - An Unusual Complication following Nissen Fundoplication for Esophagitis

Esophageal perforation is a rare complication following Nissen fundoplication. This paper presents 3 patients with esophageal perforation – 2 following open and 1 after laparoscopic surgery. Two of th

New Instrument: A Modified Kocher's Sound for Heller's Myotomy

Myotomy of the lower oesophagus in patients with achalasia of the oesophagus is a procedure that bears Heller‘s name. Heller (1914) advocated two 8-cm incisions, one anteriorly and one postetiorly. Zaaijer (1923) found little difference in the result when one incision was made instead of two. The incision must be of adequate length, from the lower part of the dilated oesophagus across the narrow segment and down to the wall of the stomach. It is important that all muscular strands are divided. Care must be taken not to cut through the mucous membrane. If this should occur, the perforation must be carefully closed. Modern textbooks seem to agree that uneventful healing can be expected, which is also my experience (Janssen, 1976). Traditionally, accidental opening of the oesophageal mucosa is regarded as an obvious hazard (Steichen, Heller & Ravitch, 1960). The outcome of a peroperative oesophageal perforation may be fatal, even if it is immediately discovered and closed (Foster, Jolly. Sawyers & Daniel, 1965; McBurney, 1969).