Charles E. Eastridge

Lower Esophageal Ring: Experiences in Treatment of 88 Patients

The lower esophageal ring is an unusual clinical disorder of the esophagus and consists of a thin submucosal circumferential scar that forms in the lower esophagus. It is probably an acquired lesion resulting from repeated insults to the lower esophageal mucosa. The symptom of dysphagia results from esophageal obstruction, and the degree of obstruction is directly related to the internal diameter of the ring. Episodic aphagia results from impaction of food at the site of the ring. Since 1970, 88 patients have been seen with either dysphagia or episodic aphagia. Sixty-five with chronic limited reflux were treated primarily by oral dilation. Two of them required an antireflux procedure at a later date because of accentuation of reflux symptoms. Eighteen patients received surgical treatment initially because of severe reflux disease. Treatment consisted of interruption of the ring combined with an antireflux procedure. Five patients received no treatment. Lower esophageal ring may be managed satisfactorily through oral dilation, resulting in relief of dysphagia. If reflux disease is present or is accentuated by dilation and cannot be controlled medically, then the appropriate antireflux procedure should be done.

Wedge Resection for Non-small Cell Lung Cancer in Patients with Pulmonary Insufficiency: Prospective Ten-Year Survival

Background: Possibility of curative resection by lobectomy for non–small cell lung cancer is often denied patients with compromised pulmonary reserve. Analysis of survival of such patients treated by wedge resection was compared with that of patients treated by standard resection, with both groups followed for 10 years. Design: A prospective 5-year cohort study. Methods: From 1988 to 1992, an observational cohort of 127 consecutive resected patients at Memphis VA Medical Center was divided into those receiving lobectomy in 81 cases and pneumonectomy in 15 cases (group I) versus 31 patients with compromised pulmonary reserve (group II), who had complete tumor excision by wedge resection. Preoperative clinical staging was corrected to surgical–pathological staging after demonstration of its superiority. Survival estimates were obtained by Kaplan–Meier method with curves compared by log rank tests, with all-cause mortality calculated from date of surgery. Results: Extent of disease in group I was 58% stage I, 19% stage II, and 23% stage III. In group II, extent of disease was 84% stage I, 3% stage II, and 14% stage III. Group I median survival was 26 months with 30% 5-year survival; for group II, median survival was 30 months and 32%. Kaplan–Meier survival plots showed similar curves in groups I and II. Realizing less extent of disease in group II, another Kaplan–Meier plot restricted to stage I and II patients showed overlapping survival curves for groups I and II. Conclusion: Survival during 10-year observation was similar for patients with pulmonary insufficiency treated by wedge resection to that of patients receiving standard resection in this single-institution consecutive cohort.

Central venous pressure monitoring: A useful aid in the management of shock☆

Abstract Monitoring of the central venous pressure is a relatively simple clinical procedure. It is invaluable in assessing promptly the hemodynamic abnormality causing the state of shock and its rapid correction. The level of the central venous pressure at any single measurement is often less significant than the response of the central venous pressure to rapid trial infusions. In general, patients in shock with low central venous pressures have either a volume deficit or, rarely, peripheral pooling. Suitable volume expanding fluids may be administered rapidly and safely. If the central venous pressure and blood pressure are restored to normal, a volume deficit existed. If repeated infusions fail to restore the blood pressure and central venous pressure, pooling in the periphery due to vascular failure must be concluded. Elevated or rising central venous pressure indicates myocardial insufficiency, and further infusions should be curtailed with efforts then directed toward improving myocardial function.

Pleural aspergillosis diagnosed by computerized tomography.

As shown by the case we have reported, patients with a chronic pneumothorax and nodular, thickened pleura may have pleural aspergillosis. We recommend that when such patients have CT of the chest, the examiner use the alternate dependent position to look for mobile pleural debris.