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
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
CAPT J. T. MULLEN, MD, USN
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
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.
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
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
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
treatment; and diffuse nontoxic goi¬ ter, treatment—if necessary—with
If it is difficult to differentiate be¬
thyroid carcinoma and a thy¬
roid adenoma on the basis of material obtained for cytology by fine-needle biopsy, we treat the case as adenoma (hemithyroidectomy). If the definite histological diagnosis shows carcino¬ ma we perform total thyroidectomy (hemithyroidectomy on the other side) in a second seance. I think it is important to mention that the combination of scintigraphy and cytology makes it possible to ob¬ tain an informative and guiding pre¬
HEIMANN, MD, PHD Bergen, Norway
established by him correlate well with values based on 28 patients (aged 45 to 82) with normal carotid arterio¬ our
Hypertension and cardiac arrhyth¬ mias are serious limitations to the use of OAP determinations by this meth¬ od. Pulse amplitude in a calibrated system is a diagnostic modality. Pulse delay of the nonintegrated pulse is the most sensitive indicator of carotid blood flow. Both modalities will com¬ plement the determination of OAP and enhance the application of the in¬ strument.
ANDREW L. CARNEY, MD La Grange, Ill 1. Borras A, et al: Ophthalmodynametric artery pressure. Am J Ophthalmol 67:681-683,1969.
Reply.\p=m-\DrCarney has manifested of the same "exaggeration and oversight" of which he unfairly accuses our investigative team. A care-
Ophthalmodynamometry To the Editor.\p=m-\Thearticle by Sand et al (Arch Surg 110:813-818, 1975) conveys the enthusiasm often associated with exaggeration and oversight. The oversight is the failure to recognize that the Gee ocular plethysmodynamography unit cannot determine the systolic pressure of the ophthalmic
artery greater than 110
their Fig 6), which is often present in the hypertensive patient. Our experience in 261 studies performed since February 1974 is that this represents a serious limitation of the instrument. To offset this limitation, we have employed measurement of the pulse amplitude and pulse
In 16 cases of total occlusion of the internal carotid artery, eight patients
had ophthalmic artery pressure (OAP) on the side of occlusion greater than 110 mm Hg. When upright, asymmetry was demonstrated in an additional two patients (success rate, 10 of 16). Asymmetry of pulse amplitude was present in 12 of 16 patients. Pulse delay utilizing the nonintegrated signal was present in all 16
It would be an exaggeration to as¬ that 30 patients, only one of whom has a blood pressure greater than 155 mm Hg systolic, can estab¬ lish normal values for an aging hy¬ pertensive population. Borras et al1 studied an elderly population by can¬ nulation of the brachial and supraorbital arteries. The normal ranges sume
ful review of our article will disclose the information that our "preliminary evaluation of a new technique for [suction ophthalmodynamometry] ODM, identified as ocular plethysmodynamography (OPDG)" was directed "to an assessment of the instrument package and the technique involved in its use." Anyone who has had experience with classical ODM will immediately appreciate the advantages of OPDG. We do not suggest the ophthalmic artery pressure (OAP) alone is an important predictive measurement, but we do suggest that this method for OAP determination "deserve[s] notice and merit[s] corroboration." On a positive note, our experience with the analysis of ocular pulse-wave morphology and pulse delay in several hundred patients indicates that this additional modality would be a valuable adjunct to OPDG in the early detection of extracranial obstructive disease. We will be reporting these data in the near future. BRUCE J. SAND, MD Beverly Hills, Calif In Reply.\p=m-\DrCarney is correct in his observation that the Gee unit cannot determine the systolic pressure of the ophthalmic artery greater than 110 mm Hg. I disagree with his assumption that this represents a serious limitation of the instrument. In over 700 studies performed since July 1971, fifty-nine patients with documented
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unilateral carotid occlusion have been encountered. In 57 of the 59 patients, the ophthalmic systolic pressure on the side of the occlusion was below 110 mm Hg. In the two patients in whom the ophthalmic systolic pressures from both eyes exceeded 110 mm Hg, the calibrated pulse amplitude from the eye distal to the occluded artery was distinctly lower than that from the contralateral eye. Both of these patients had systemic systolic pressures in excess of 200 mm
Hg. High speed recording, as suggested by Dr Carney, is not necessary for clinical application. The design and performance of this
instrument rests on six years of extensive animal and clinical testing. Of prime importance to me was the development of a useful clinical tool rather than an interesting research gadget. I am confident that the in¬ strument fulfills its intended role.
GEE, MD Bethesda, Md WILLIAM
as Cause of "Colon Cutoff"
To the Editor.\p=m-\Adams, in his article entitled "Adynamic Ileus of the Colon" (Arch Surg 109:503-507, 1974), found that the plain film of the abdomen often showed an apparent cutoff in the distended colon at the splenic flexure. In a subsequent letter to the editor, Euphrat (Arch Surg 110:224\x=req-\ 225,1975) suggested that this was due to kinking of the colon. Actually, this apparent cutoff is easily explained by gravity. When the patient is in the supine position, the transverse colon is elevated and tends to fill with gas, while the descending colon, which is in a dependent position, may be collapsed or filled with fluid. In either case, there will be an apparent cutoff in the gas-distended colon at the splenic flexure. In such cases, the patient may be turned into the prone position and air will outline the descending colon. An additional maneuver that we have found particularly useful is to obtain a recumbent left lateral view of the abdomen. In pa¬ tients with adynamic ileus, we often see a gas-filled rectum, which con¬ firms that the distention is due to ileus and not to obstruction. IGOR LAUFER, MD Hamilton, Ontario