To the Editor.\p=m-\Wewish to thank Dr Ellis for his comments on our article, "Esophagogastric Fistula" (Arch

Surg 110:826-828, 1975).

for adding the ancillary of procedure fundoplication or fundoplasty to the esophagocardiomyotomy for achalasia stemmed from our experience and belief than an adequate myotomy could not be done via thoracotomy without some disruption of the hiatal support structures in order to deliver the cardia into the surgical field. Among the early patients treated by us were two who had had esophagocardiomyotomies without ancillary procedures; in both, severe reflux esophagitis occurred. One other patient in our series had a concomitant sliding hiatus hernia. We therefore began adding fundoplication to myotomy to prevent reflux esophagitis, a complication of esophThe


agocardiomyotomy reported.



Since it has been shown the fundoplication raises esophageal pressure to normal range in most patients with hiatus hernia, and since esophagocardiomyotomy results in a return to normal of resting esophageal pressure in achalasia patients, we thought the aperistaltic esophagus would not be tasked with overcoming any sig¬ nificant obstruction by combining the


Clinical results in 12 patients with achalasia treated by combination of these procedures have been excellent in nine. Two patients have been lost

to follow-up, and one patient claims he has been made worse. This is a small experience compared to that of Dr Ellis, and we do appreciate his




Portsmouth, Va

More on Adrenalectomy for Metastatic Breast Cancer

To the Editor.\p=m-\Iam responding to the article by Brown et al, entitled "Bilateral Adrenalectomy for Metastatic Breast Carcinoma" (Arch Surg 110:77-81, 1975). Several of their findings were in agreement with our published results, as listed below: 1. Sulfokinase activity in breast cancer tissue is not a good predictive index for adrenalectomy.1 Since our preliminary report, more than 56 patients have been evaluated; results were



2. In evaluating 119 patients who had undergone adrenalectomy in our institution, we did not find any correlation of a tumor-free interval to sub-

sequent response to adrenalectomy. Forty percent of the patients with tu-

mor-free intervals of less than one year had responded to adrenalectomy, compared with 47% to 48% of patients with longer tumor-free intervals.1 However, other clinical criteria, such as age, menopausal status, and cytohormonal evaluation, are of minor importance in relationship to subsequent clinical response to adrenalectomy. 3. It has been suggested by Dao and others that tumor load in the liver reduces the response rate to ad¬ renalectomy. We have similar find¬


4. Patients who responded to adre¬ nalectomy had a favorable subsequent remission to chemotherapy.2 We are evaluating the results of a larger series of patients at the present time. We thought that the series of pa¬

tients evaluated in our institution and those at Virginia Commonwealth University were still rather small, es¬ pecially when they were subcategorized for evaluation. However, these results do alert us to be cautious in basing prediction of adrenalectomy on


dogma. Although




we are still continuing double-blind evaluation of estro¬


receptor and clinical response




manipulation, results so far

our institution and others have been most encouraging.4 In addition, patients with osseous métastases who experienced relief of bone pain after administration of levodopa also expe¬ rience objective remission from adre¬ nalectomy, similar to patients who have a positive estrogen receptor


BENJAMIN S. LEUNG, PHD Portland, Ore 1. Moseley HS, Fletcher WS, Leung BS, et al: Predictive criteria for the selection of breast cancer patients for adrenalectomy. Am J Surg

128:143-151, 1974. 2. Leung BS, Fletcher WS, Lindell TD, et al:


of response to endocrine ablation in advanced breast carcinoma. Arch Surg 106:515-519, 1973.

Leung BS, Moseley HS, Davenport GE, et Estrogen receptors in prediction of clinical responses to endocrine ablation, in McGuire WL, Carbone PP, Vollmer EP (eds): Estrogen Receptors in Human Breast Cancer. New York, Raven Press, 1975, pp 107-129. 4. McGuire WL, Carbone PP, Vollmer EP: Estrogen Receptors in Human Breast Cancer. New York, Raven Press, 1975. 5. Sasaki GH, Leung BS, Fletcher WS: Levodopa test and estrogen receptor assay in prog3.


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responses of patients with advanced of the breast to endocrine therapy, abstract 31, in Proceedings of the 28th Annual Meeting of the James Ewing Society, 1975, pp 101-102.

nosticating cancer

Feculent, Not Fecund To the Editor.\p=m-\Inthe September issue of the Archives (110:1133, 1975), the following statement caught my attention: "Nonspecific colitis proximal to an obstructing colonic carcinoma has appeared in the surgical literature for



20 years." Maybe that of the surgical literature


why some

HERBERT L. Houston


The Editor is grateful for Dr Fred's grammati¬ cal insight. The literature in the past has been recognized as suffering various maladies, but this is the first time that it has been diagnosed as hav¬ ing colitis.

Needle Aspiration Biopsy for Thyroid Cancer

To the Editor.\p=m-\Thepanel, "Carciof the Thyroid" (Arch Surg


110:783-789, 1975),



and stimulating. But I should like to add an important diagnostic tool not mentioned by the members of the panel. In decision-making for choice of strategy and treatment, I have found it very useful to take a fine\x=req-\ needle aspiration biopsy specimen from the thyroid. The biopsy is performed after the scintigraphy, which is used as guidance in localizing non\x=req-\ active thyroid tissue. With fine-needle biopsy we can identify differentiated thyroid carcinoma and thyroid adenoma. We also can get support for our clinical diagnosis of nodular nontoxic colloid goiter and often can verify the diagnosis of chronic thyroiditis. Our surgical tactics according to the thyroid gland are as follows: thyroid carcinoma (papillary, follicular, medullary), total thyroidectomy; anaplastic carcinoma and sarcoma, cytology makes it possible to start

radiotherapy immediately; thyroid adenoma (microfollicular, oxyphilic, embryonal, trabecular), hemithyroidectomy; nodular nontoxic goiter, levothyroxine sodium (preventing further growth) and, in cases with

mechanical symptoms, subtotal bilat¬ eral thyroidectomy followed by sub¬ stitution with levothyroxine; chronic

thyroiditis, levothyroxine (mostly re¬ ducing the goiter) and, in cases not showing a positive response to this treatment, subtotal thyroidectomy

Letter: More on fundoplication.

More on Fundoplication To the Editor.\p=m-\Wewish to thank Dr Ellis for his comments on our article, "Esophagogastric Fistula" (Arch Surg 110:826-...
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