Richard K. Hughes

Esophagogastrectomy. Superiority of the combined abdominal-right thoracic approach (Lewis operation).

Abstract The advantages of the combined abdominal-right thoracic approach to operating upon carcinoma of the esophagus (Lewis operation) are reviewed; they include elimination of the need for incision of the diaphragm or costal arch; easier mobilization of the esophagus; better visualization of the anastomosis through a high thoracotomy incision; and no interference by the heart and aortic arch. The operation is performed in one stage, using separate abdominal (upper midline) and thoracic (excision of the fourth rib) incisions. A careful two-layer anastomosis is performed using a separate circular opening in the stomach and invaginating the esophagus into the stomach by suturing the gastric serosa to the mediastinal fascia and pleura. Important principles of postoperative care include monitoring in the intensive care unit for five to seven days, use of a sump-type nasogastric tube, and frequent measurement of body weight, blood volume, blood gases, and electrolytes. Colloid infusions are preferred to crystalloid solutions in order to avoid fluid overload. Vigorous nasotracheal suction is important, and early tracheostomy is performed if bronchopulmonary secretions tend to accumulate. This operation was performed on 37 unselected patients during a seven-year period without operative mortality or anastomotic leak. Thirty-three patients had metastases at the time of resection, but all were relieved of dysphagia and the degree of palliation was very encouraging.

How to Shorten, Lengthen, or Untwist Saphenous Vein Grafts

A simple method is described to correct saphenous vein bypass grafts that inadvertently have been made too long or too short or have become twisted. The essential feature of the technique is the use of a Satinsky vascular clamp to hold the divided ends of the vein and maintain their alignment during the repair. The most accessible portion of the vein is used as the site for the repair, leaving the aortic and coronary artery ends of the graft intact. While we have not had need to use the technique frequently, we have found it to be a simple method and believe it to be useful when such instances arise.

Resection of the bronchial and the tracheal mucosa

Summary Proper treatment for independent carcinoma in situ of the bronchus or trachea has not been established. Bronchotomy or tracheotomy and mucosal resection might be one approach. In dogs, resection of the bronchial mucosa—complete circumferential rings 1 cm. wide—and tracheal mucosa—complete and incomplete circumferential rings 1 cm. wide—was followed by significant stricture and stenosis at the site of resection in every instance.