Lucius D. Hill

Incarcerated paraesophageal hernia

Of twenty-nine patients with paraesophageal hernia, incarceration and strangulation occurred in ten or 30.4 per cent. This high incidence of incarceration and strangulation with their serious sequelae is not appreciated. There was no mortality in patients operated on electiyely after insertion of a nasogastric tube for gastric decompression. In four patients in whom a nasogastric tube could not be passed making immediate operation mandatory, the mortality was 50 per cent. This experience suggests that paraesophageal hernia should be corrected unless the patient is not a candidate for surglery.

Choices of operation for subclavian-vertebral arterial disease

Subclavian-vertebral artery disease requires careful delineation of symptoms and offers a wide selection of operative procedures. The transition over a 10 year period from intra- to extrathoracic operations in a series of 35 patients is described.

Gastric emptying and gastroesophageal reflux: Effects of surgery and correlation with esophageal motor function

Abstract A new method of measuring gastric emptying for solids was developed and validated. With this new method, gastric emptying of solids was evaluated in 40 patients with gastroesophageal reflux. Gastric emptying of solids was delayed in 42 percent of patients independent of the severity of the reflux symptoms. Liquids emptied in a normal fashion, supporting the observations of others that liquid emptying is not a valid measure of gastric emptying. A high incidence of esophageal motor abnormalities was present in these patients when tested with radionuclide transit studies using a liquid bolus. The coexistence of esophageal and gastric emptying abnormalities was present in 45 percent of patients who had delayed gastric emptying of solids. Three months after surgical correction of reflux as measured by pH study, abnormalities in both the esophagus and stomach remained unchanged. Since the symptoms were corrected, delayed gastric emptying is not adequate indication for a gastric emptying procedure at the time of antireflux surgery.

Newer concepts of the pathophysiology of hiatal hernia and esophagitis.

Abstract 1. 1. The repair of hiatal hernia by current methods has been attended by recurrences rates of greater than 10 per cent series with careful objective postoperative studies. Poor results ranged from 12 to 58 per cent, indicating that present methods of repair are inadequate. 2. 2. To improve operative results this study of the pathophysiology of hiatal hernia is presented, indicating the importance of the terminal esophageal spincter and the phrenoesophageal ligament. There is ample of experimental and clinical evidence for the existence of the terminal esophageal sphincter. 3. 3. Intra-abdominal replacement and anchorage of the gastroesophageal junction correct the anatomy and function in hiatal hernia, except in the presence of a destroyed incompetent sphincter. 4. 4. Hiatal hernia with a grossly incompetent sphincter is uncommon and requires an ancillary procedure such as vagotomy and pyloroplasty. 5. 5. Vagotomy and pyloroplasty have been accompanined by undesirable side effects in 50 per cent of the patients upon whom vagotomies were performed in this series. Vagotomy should be employed only when the terminal esophageal sphincter is destroyed and there is concomitant duodenal ulcer. 6. 6. Results in fifty-eight operations for hiatal hernia using a new technic indicate that there has been no recurrent herniation over a two and a half year period, and that the preoperative tendency to reflux was corrected in all twenty-five patients who had postoperative pH and pressure studies. Induced reflux was detected on one occasion. Follow-up study on all patients indicates a good result in 96 per cent of the patients in this series as compared with 83 per cent in a previous report. 7. 7. Further follow-up study is necessary to confirm the impressions presented in this report.

Benign tumors and cysts of the esophagus

Abstract Seventeen cases of benign tumor of the esophagus are presented, with sixteen successful surgicaI removals. There were no deaths, no hospita1 morbidity and no recurrence of symptoms. The literature relative to this subject has been briefly reviewed.

Measurement of Esophageal Reflux by Scintigraphy

Gastroesophageal reflux and clearance of the refluxed material can be measured by plotting a time-activity curve from an esophageal area of interest after 1 mCi of99mTc sulfur colloid is placed in the stomach. Control subjects do not have peaks exceeding a value twice that of the baseline count levels. Reflux patients exceed this value, either spontaneously or after Valsalva maneuvers. This technique has a sensitivity which is greater than that of barium and equal to the sensitivity of a pH probe in patients with both moderate and severe reflux. Scintigraphic reflux was shown in 62% of moderate refluxes and 85% of those with severe reflux as defined clinically. Clearing of the refluxed material occurs rapidly in most patients if measured by this scintigraphic technique. This test can be performed rapidly with minimal radiation exposure and is noninvasive.

Experimentation as an aid in management of esophageal disorders

Abstract Simultaneous pressure and pH studies have been performed in over 200 subjects, with a wide variety of esophageal disorders, and in twenty normal subjects. From these studies the pH and pressure profiles have been clearly depicted in both health and disease. Combined studies with two pressure tubes in the esophagus have deomonstrated the progression of swallow waves in the normal subject, and the failure of the progression of swallow waves into the terminal esophagus in the patient with advanced esophagitis. Combined studies with a pressure tube placed in the esophagus and one in the stomach has allowed a measurement of the gradients across the gastroesophageal junction. The influence of these gradients in producing reflux indicates that the conventional maneuvers, such as the Mueller and Valsalva which are employed by the roentgenologist in an effort to produce reflux, often close the esophagus tightly and prevent reflux in spite of a large pressure gradient across the gastroesophageal junction. The most potent maneuvers that produce the highest pressure gradients across the junction have been inspiratory sniffing and simulated hiccoughs, or singultus. These have produced pressure gradients as high as 200 cm. of water across the sphincter and are the best means of producing reflux. In a final analysis, however, the most frequent condition under which we were able to demonstrate reflux has been the supine position with the patient relaxed. These studies have been standardized to the point where they are an integral part of the evaluation of the patient with esophageal disease. They are particularly helpful in detecting the early stages of esophagitis, achalasia, diffuse spasm, scleroderma, as well as other benign esophageal disorders. They have been useful in delineating the underlying mechanisms of esophageal disease. Pre- and postoperative studies on unusual conditions such as Schatzkis ring and high gastric diverticula have been illuminating. With these technics the surgeon has an objective means of determining the presence of early derangement of the esophagus preoperatively and thereby is in a better position to avoid many of the poor results in surgery which stem from an inaccurate diagnosis. In addition, postoperative studies and posttreatment studies serve to define objectively the effect of therapy. Our studies indicate that simple closure of the hiatus is an inadequate operation for reflux esophagitis. These studies also point out that reconstructing sutures should be applied in conjunction with the Heller operation in order to prevent reflux following this procedure. These studies have been helpful in differentiating the pain of angina pectoris from that of reflux esophagitis and in delineating reflux in those subjects in whom no demonstrable hernia or reflux could be demonstrated by conventional roentgenographic technics. Further studies to define the influence of vagotomy and other ancillary procedures employed in esophageal disease are in progress.

Intraoperative manometry: Adjunct to surgery for esophageal motility disorders

Intraoperative manometry can provide an objective means of determining the correct length of myotomy in patients with esophageal motility disorders. Of the patients in this series who underwent primary repair, 94 percent were relieved of pain and dysphagia. One patient required repeat myotomy for vigorous achalasia. After a mean follow-up period of 33 months, gastroesophageal reflux had not developed in any patient, indicating that myotomy with intraoperative manometry eliminates the need for an antireflux procedure. Such a procedure in these patients with poor esophageal motility can lead to dysphagia and obstruction, which is a very difficult problem to correct. We recommend intraoperative manometric be used routinely with myotomy for esophageal motility disorders.

Glove starch granulomatous peritonitis.

Summary Ten cases of rice starch granulomatous peritonitis are reported. An analysis of these patients plus a review of the carlier reported cases indicates a characteristic disease pattern of severe abdominal pain occurring two to six weeks after surgery, which is associated with a fulminant peritoneal reaction, ascites, adhesions, and diagnostic presence of starch-containing miliary nodules. It is our opinion that granulomatous peritonitis caused by rice starch powder is a more severe and violent process than that caused by corn starch powder. It is assumed that many less dramatic cases might be responsible for unexplained postoperative complications and delays in recovery. The importance of meticulous removal of powder, regardless of its constitution, from surgical gloves and equipment is imperative in the prevention of this problem.

Cervical esophageal web associated with Zenker's diverticulum

We reviewed 12 patients who underwent diverticulectomy and myotomy for Zenkers diverticulum. Fifty percent of these patients were found to have cervical esophageal webs that were resected at operation. The association of Zenkers diverticulum and esophageal webs is new. The present study demonstrates that it is not a rare relationship and that these webs can cause postoperative problems. We utilized the technique of open diverticulectomy and found that it facilitates cricopharyngeal myotomy and allowed intraoperative inspection of the esophageal lumen, thereby patients with coexisting intraesophageal pathologic abnormalities could be identified. This procedure can be performed within very acceptable limits of morbidity, as demonstrated in our study, although it is not recommended for surgeons who do not regularly operate on the esophagus. Surgeons should consider this technical approach to Zenkers diverticulum when the presence of cervical webs is known or suspected preoperatively. Cervical esophageal webs are a potential source of postoperative dysphagia. They should therefore be excised when encountered intraoperatively. The actual incidence of cervical esophageal webs and their potential role in the pathogenesis of cricopharyngeal muscle hypertrophy and Zenkers diverticulum will require additional study.