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The National Cancer Institute of the United States recently sponsored three large-scale, randomized controlled trials of screening for early lung cancer. The trials were conducted at the Johns Hopkins Medical Institutions, the Memorial Sloan-Kettering Cancer Center, and the Mayo Clinic. Participants were middle-aged and older men who were chronic heavy cigarette smokers and thus at high risk of developing lung cancer. Screening procedures were chest radiography and sputum cytology, the only screening tests of established value for detecting early stage, asymptomatic lung cancer. In the Hopkins and Memorial trials the study population was offered yearly chest radiography plus sputum cytology every 4 months. The control population was offered yearly chest radiography only. In these trials the addition of sputum cytology appeared to confer no lung cancer mortality rate advantage. The Mayo Clinic trial compared offering chest radiography and sputum cytology every 4 months to offering advice that the two tests be obtained once a year. This trial demonstrated significantly increased lung cancer detection, resectability, and survivorship in the group offered screening every 4 months compared with the control group. However, there was no significant difference in lung cancer mortality rate between the two groups. The statistical power of these trials was somewhat limited. Nevertheless, results do not justify recommending large-scale radiologic or cytologic screening for early lung cancer at this time.

During a 13-year period, multiple primary lung cancers were diagnosed in 80 consecutive patients. Forty-four patients had metachronous cancers. The initial pulmonary resection was lobectomy in 36 patients, bilobectomy in 3, pneumonectomy in 1, and wedge excision or segmentectomy in 4. The second pulmonary resection was lobectomy in 16 patients, bilobectomy in 2, completion pneumonectomy in 7, and wedge excision or segmentectomy in 19. There were two 30-day operative deaths (mortality rate, 4.5%). Actuarial 5- and 10-year survival rates after the first pulmonary resection for stage I disease were 55.2% and 27.0%, respectively. Five-year and 10-year survival rates for stage I disease after the second pulmonary resection were 41.0% and 31.5%, respectively. The remaining 36 patients had synchronous cancers. The pulmonary resection was lobectomy in 18 patients, bilobectomy in 3, pneumonectomy in 10, and wedge excision or segmentectomy in 8. There were two 30-day operative deaths (mortality rate, 5.6%). Actuarial overall 5- and 10-year survival rates after pulmonary resection were 15.7% and 13.8%, respectively. We conclude that an aggressive surgical approach is safe and warranted in most patients with multiple primary lung cancers and that the presence of synchronous primary cancers is ominous.

In this article, we describe an integrated approach for detection and evaluation of solitary pulmonary nodules. Initial evaluation of the solitary pulmonary nodule includes tomography, fluoroscopy, and comparison with previously obtained roentgenograms. Subsequently, thin-section computed tomography and phantom densitometry can be used for analysis, if indicated. The rationale for the use of computed tomography in the radiologic staging of bronchogenic carcinoma is to expedite and assist in the identification of the subset of patients with resectable tumors. For nonsurgical tissue diagnosis, fiberoptic bronchoscopy is generally the initial procedure for lesions 2.0 cm or larger in diameter, and transthoracic needle biopsy is used for those smaller than 2.0 cm.

The sensitivity of oesophageal mucosa to certain digestive secretions has been implicated in almost all the complications of gastro-oesophageal reflux. Gastro-oesophageal incompetence permits free reflux of the gastroduodenal contents to the oesophagus. The recognized oesophageal consequences of this reflux are directly related to the effects of the secretions on the oesophagus and to the tissue’s response to chemical injury. These consequences are: desquamation; erosion; ulceration; inflammation; pain; bleeding; motility disturbances; oesophageal shortening; stricture formation and Barrett’s disease (columnar epithelial lining of the lower oesophagus). Complications vary from patient to patient, and the pathological processes are often reversed by eliminating the contact between the corrosive secretions and the oesophagus.

Sixty-six patients (54 men and 12 women) with primary bronchogenic carcinoma and documented chest wall invasion underwent en bloc chest wall and pulmonary resection at the Mayo Clinic between January 1, 1960, and January 1, 1980. Ages ranged from 36 to 85 years, with a mean of 62.2. Forty-eight lobectomies, 16 pneumonectomies, and 2 wedge excisions were performed. After operation, 31 patients were classified as T3 N0 M0, 7 as T3 N1 M0, and 12 as T3 N2 M0. In 16 patients, the N classification could not be determined (T3 Nx M0). Operative mortality was 15.2%. Actuarial five-year survival (Kaplan-Meier method) of the 56 patients surviving operation was 32.9%. Five-year survival for patients with T3 N0 M0 neoplasms was 53.7%; five-year survival for patients with N1 and N2 neoplasms was only 7.4% (p = 0.001). The effect of various factors on survival, both singularly and in combination, was assessed by Cox's proportional hazards model. Only age had a significant association with survival. Among patients with T3 N0 M0 neoplasms, five-year survival was 84.6% for those 60 years of age or less and 27.7% for patients who were older than 60 years (p = 0.009). We conclude that en bloc resection for primary bronchogenic carcinoma with chest wall invasion, while associated with a significant mortality, can be performed with a strong likelihood of long-term survival if regional lymph nodes are not metastatically involved and there is no evidence of distant metastasis.

A cytologic examination of pleural fluid was performed on a pleural lavage specimen collected at the completion of operation after pulmonary resection in 135 of 599 patients undergoing curative pulmonary resection for a non-small cell carcinoma of the lung between 1977 and 1982. The cytologic results of lavage was positive for malignant cells in 12 of the 135 patients (8.9%). The incidence of positive results was correlated with lymph node status (N2 > N1 > N0), cell type (adenocarcinoma > other non-small cell lung cancers), stage (III > II > I), and visceral pleural status (invaded > not invaded). No positive cytologic results were noted in 39 patients having a diagnostic excisional pulmonary biopsy prior to more definitive resection. The disease has recurred in nine of the 12 patients with positive cytologic results (only two in the ipsilateral pleural space), and eight have died. The prognostic role of pleural lavage cytology needs more study.

A case of "benign" metastasizing giant cell tumor is presented. Previous experience shows that this is a relatively favorable lesion not having the grave implications of sarcomatous disease, as evidenced by the good long-term results in our previously reported patient [14] and a number of others reported in the literature. An aggressive surgical approach to pulmonary metastasis of giant cell tumors is warranted because long-term control, if not permanent eradication, can be accomplished by that means.

Lobular carcinoma may arise within the epithelial component of fibroadenoma of the breast, as evidenced by 5 cases reported from the files of the Mayo Clinic and 21 cases cited in the literature. The 5 cases reported here occurred in a series of 4000 cases of fibroadenoma during a 43-year period. Lobular carcinoma is the more frequent type to be seen in fibroadenoma (in 22 of 26 cases); it usually develops in situ. Extra-adenomatous carcinoma of the ipsilateral breast was identified in 11 of 26 cases, and 3 cases of contralateral carcinoma were noted in the entire series. Thus, lobular carcinoma arising within the epithelial component of a fibroadenoma has biological features similar to the behavior of lobular carcinoma of the breast in general. The prognosis has been favorable; lesions are usually encountered early; in only 2 of 26 cases were there axillary metastases.

Between 1949 and 1976, 899 patients underwent treatment for achalasia of the esophagus at the Mayo Clinic, 431 by forceful hydrostatic or pneumatic dilation and 468 by a standardized transthoracic esophagomyotomy. Esophageal leak and mediastinal sepsis was an uncommon but major complication of both types of therapy, occurring four times more often with dilation (4%) than with myotomy (1%), although no deaths resulted from this in either group. The 30-day mortality was 0.2% after myotomy and 0.5% after forceful dilation. Although there was minimal morbidity and mortality with either modality, the late results were significantly superior after myotomy. Excellent to good results were obtained by 85% of the group treated with myotomy but only by 65% of those treated with hydrostatic dilation. Late poor results were encountered three times more frequently after dilation (19%) than after myotomy (6%). Analysis of poor results after myotomy indicates that late serious complications of gastroesophageal reflux developed in only 3% of patients operated on.

Twenty-six cases of desmoid tumors of the wall of the chest were reviewed. These are rare lesions, which nonetheless should be considered in the differential diagnosis of all tumors of the chest wall. Although the lesion is most often palpable, several of the tumors were detectable only by means of an x-ray film of the thorax. Definitive diagnosis could not be made clinically but was easily established by pathologic examination of widely excised tumor. Like all desmoid tumors, these were locally aggressive in their growth but nonmetastatic and generally carried a good prognosis. Ideally, treatment consisted of wide local excision, but if there was encroachment of the tumor on vital structures, excision with suboptimal tumor-free margins was required. Even in the latter instance, tumefaction could be well controlled for long periods. Recurrences after an initial attempted removal were common, but most of these responded to reexcision.

During the 27-year period 1949 through 1975, 899 patients underwent treatment for achalasia of the esophagus at the Mayo Clinic: 468 by transthoracic esophagomyotomy and the remaining 431 by one or more forceful hydrostatic or pneumatic dilatations. Comparison of the groups indicates that myotomy is more effective and safer than forceful dilatation. Chronic gastroesophageal reflux as a complication of either form of therapy was rare.

One hundred adult patients underwent Ivor Lewis esophagogastrectomy for documented carcinoma of the esophagus from 1980 through 1982. After operation, 7 patients were classified in Stage I, 11 in Stage II, and 82 in Stage III. Major postoperative complications occurred in 27 patients and included pulmonary problems in 11, suture line leak in 9, wound infection in 5, empyema in 4, renal failure in 4, abdominal abscess in 4, bleeding in 2, myocardial infarction in 2, and chylothorax in 1. There were 3 deaths within 30 days of operation. Five-year survival was 85.7% for patients with Stage I disease, 34.1% for patients with Stage II disease (p = .052), and 15.2% for patients with Stage III disease (p = .001). Late morbidity included weight loss in 60 patients, dysphagia in 40, gastroesophageal reflux in 14, and gastroduodenal dumping in 5. Thirty-one patients required postoperative esophageal dilations (mean, 3.4). Most patients, however, were eating without dysphagia at the time of last follow-up or death. We conclude that the Ivor Lewis esophagogastrectomy can be performed with low mortality, can provide adequate palliation, and does result in satisfactory long-term survival for those patients with more favorable postsurgical stages of cancer. These results support the continued use of the Ivor Lewis esophagogastrectomy for treatment of carcinoma of the esophagus.

The Mayo Clinic surgeons have the largest experience in the world in dealing with pharyngoesophageal diverticulum. This experience has now grown to 888 patients treated between the years 1944 and 1978. In that period, their approach has undergone changes. The reasons behind these changes and their results are discussed.

A patient who had sustained lye burns of the esophagus had undergone reconstruction with a colon interposition. Because of necrosis and stricture of the interposed colon, he was unable to manage salivary secretions and was maintained on gastrostomy feedings. The defect from the pharynx to the midmanubrial level was reconstructed with a free jejunal graft by using microvascular surgical techniques. At 18-month follow-up, barium swallow roentgenography showed flow through the jejunal and colonic segments and into the stomach. The patient gained 15.9 kg postoperatively and was able to consume a normal diet.

During a three-year period, 53 patients with myasthenia gravis underwent transsternal thymectomy by a partial sternum-splitting technique at our institution. This procedure was carried out (1) because an x-ray film or a computed tomography scan had suggested the presence of a thymoma or (2) to manage symptoms of myasthenia gravis. In 41 patients the endotracheal tube was removed in the postanesthesia recovery room. The remaining 12 patients were extubated in the Respiratory Care Unit—in five, after prolonged mechanical ventilation. From our experience, the only factor useful for predicting the probable need for prolonged postoperative mechanical ventilation is the degree of bulbar involvement. Patients in Osserman classification groups 3 and 4 have an extremely high incidence of postoperative respiratory failure. Consideration should be given to the use of preoperative plasmapheresis in myasthenia gravis patients who have significant bulbar symptoms.

During a 6-yr period, 57 children and young adults less than 21 yr of age underwent 111 thoracotomies for pulmonary metastatic osteogenic sarcoma. Follow-up after the initial thoracotomy averaged 36.8 no and ranged from 1 to 78 mo. Twenty-eight patients (49%) underwent more than one thoracotomy--the number of multiple thoracotomies averaged 2.9 and ranged from two to eight. Twenty-six of the 57 patients are currently alive, and 25 of these are free of disease. Median survival was 36 mo. Actuarial survival curves demonstrated a 5-yr survival of approximately 40%. Seventy-one percent of patients who had a tumor-free interval of greater than 1 yr are currently alive, compared with 39% of patients who had a tumor-free interval of less than 1 yr. Patients with disease confined to one lobe at the initial thoracotomy had a better survival (64%) than patients with diffuse or bilateral disease (41%). An aggressive surgical approach toward osteogenic sarcoma with pulmonary metastasis thus appears to be justified.

The cases of 96 patients (55 male and 41 female) with primary chondrosarcoma of the chest wall were reviewed. Ages ranged from 17 to 78 years (median, 53.5 years). The tumor involved the rib in 78 patients and the sternum in 18. Seventy-two patients had treatment at the Mayo Clinic, 28 by wide resection, 25 by local excision, and 19 by palliative excision. There was 1 operative death. Follow-up ranged from 1 to 46 years. Recurrent chondrosarcoma developed in 37 patients. All had local recurrence, and 14 also had metastases. Within 10 years, recurrence had developed in 50% of patients who had local excision and in 17% of patients who had wide resection. Ten-year chondrosarcoma survival (Kaplan-Meier) for patients treated by wide resection was 96%; by local excision, 65%; and by palliative excision, 14% (p less than 0.0001). Tumor grade, tumor diameter, tumor location, and date of operation all had a significant influence on survival. This report documents the natural history of chest wall chondrosarcoma and demonstrates that early wide resection is the treatment of choice.

Ernst Heller's original 1914 report of extramucosal esophagomyotomy for the treatment of "cardiospasm" (achalasia) of the esophagus is reviewed in historical perspective, defining those factors that may have contributed to delay in recognition of its true value as the major contribution to the modern management not only of achalasia but also of many other esophageal motor disorders. Special attention is also given to what Heller actually described, observed, and did in the light of current pathophysiological understanding. Finally emphasis is placed on current management as it has evolved to the present state of technical performance.

En bloc resection of chest wall and lung for primary non-small cell bronchogenic carcinoma with chest wall invasion, although often associated with a significant operative mortality, can be performed with a reasonable expectation of long-term survival if lymph nodes are not metastatically involved. Older age appears to decrease long-term survival, but age alone should not abrogate surgical resection. Non-small cell carcinoma cell type, tumor size, depth of chest wall invasion, and extent of chest wall or lung resection do not significantly influence survival.

Three hundred forty-six patients with post-surgical non-small cell Stage I bronchogenic carcinoma were followed from 5.0 to 10.8 years (median, 7.0 years). Recurrent cancer developed in 135 patients (39%). Seventy-five recurrences were nonregional metastases (55.6%); 35 (25.9%), a subsequent primary lung cancer; and 25 (18.5%), local recurrence only. The rate of recurrent lung cancer decreased from 15.0 patients per 100 patient-years the first postoperative year to 2.3 the seventh and subsequent years. The rate of recurrence varied among the three different types of recurrent cancer. Five years after pulmonary resection, 70.0% of patients with T1 N0 neoplasms had no evidence of recurrence compared with 58.2% of patients with T2 N0 tumors (p = 0.012) and only 31.8% of patients with T1 N1 neoplasms (p less than 0.001). There was no significant difference in overall rate of recurrence among the various cell types. Currently, 174 patients are alive. Lung cancer survival (Kaplan-Meier) was 69.1% at 5 years and 61.9% at 9 years. At 2 years following detection of subsequent lung cancer, 51.8% of patients with subsequent primary lung cancer had survived lung cancer compared with 23.4% for those with local recurrence and only 8.9% for those with nonregional metastases.

This study was undertaken in dogs and monkeys to assess the sequelae of cryosurgery of the lung. In seven animals, a cryoprobe was repeatedly applied to the entire right middle lobe. In no instance was the probe inserted through the pleura into pulmonary parenchyma, but the pulmonary parenchyma was firmly compressed beneath the probe tip during freezing. This permitted through-and-through freezing of the entire right middle lobe and ensured complete cryonecrosis of the entire lobe. In three animals, a portion of the right lower lobe was also frozen by repeatedly applying the probe tip to the midportion of that lobe. All animals survived the procedures, and all resumed normal activity within 24 hours of operation. There were no pleural space complications except for the production of pleural adhesions. All lesions had the features of an acute hemorrhagic infarct, characterized by intense local hemorrhage and complete coagulation necrosis, typical of cryolesions. Subsequently, there was total collapse and fibrosis of underlying pulmonary tissue with areas of hemorrhagic necrosis, hemosiderin in macrocytes, focal calcification, and hyalinization. Serum lactic dehydrogenase values and leukocyte counts promptly increased after cryosurgery; however, all values returned to normal within 14 days, and no significant changes were noted thereafter. Thoracic roentgenograms showed changes consistent with consolidation of the right middle lobe, and by seven weeks, the only roentgeno-graphic evidence of the cryotreated middle lobe was a small density in the hilus. Histologically, this was a small mass of scarified tissue that sealed the bronchial stump and major vessels at the hilus and consisted of organized fibrosis.

Of 97 patients with mediastinal granuloma, 13 had involvement of the esophagus by extension from adjacent lymph nodes or pleura. A knowledge of the anatomic relationships of these structures is important in understanding the distribution and radiologic features of these lesions. The most common manifestation was extrinsic compression, being present in 7 (54%) of the 13 patients. Three patients (31%) had either a fistula or a sinus tract. Esophageal stricture and diverticulum formation also occurred. Mediastinal granuloma should be considered in the differential diagnosis in patients with any of these findings.

Although extirpative surgery is the mainstay of treatment of tumors of the trachea and bronchial tree, other methods for cure or palliation of neoplasms in these structures should be explored. The present study was designed to assess, in dogs, 1. the pathophysiologic effects of complete circumferential cryonecrosis of a segment of trachea, and 2. the feasibility of performing cryosurgery within the distal tracheobronchial tree through a bronchoscope. Eleven mongrel dogs weighing 16 to 20.5 kg were used. Each dog was anesthetized with intravenous pentobarbital. Under clean conditions, a segment of cervical trachea consisting of 10 rings (two through 12) was exposed and completely mobilized through a midline incision in eight dogs. A segment of trachea consisting of five to six tracheal rings was frozen by applying the probe tip to the anterior and lateral surfaces of the trachea and by suspending the posterior wall on the shaft of the cryoprobe tip. Each probe application lasted two minutes. This effected cryonecrosis of the entire circumference of a 15 to 18 mm segment of trachea. The probe was applied to the same site three times (repetitive freezing) and complete thawing was allowed between freezes. Copper constantan needle thermocouples embedded in 25-gauge needles were inserted into the tracheal wall, and recordings of temperature changes within the target areas were made continuously with a penline recorder during freezing and thawing. A probe 0.6 cm in diameter and 55 cm long was developed for transbronchoscopic cryosurgery. In three dogs, several focal areas including the anterior and posterior trachea, carina, main stem, and segmental bronchi were frozen. Each site was frozen repetitively (three times for two minutes each). All 11 dogs survived the procedures and resumed normal activity within 12 hours of operation. Necrosis was localized, reproducible, and followed by prompt regeneration of mucosa. The gross architecture of the trachea and bronchus was not permanently altered, and there was no local or regional infection, except in one dog in which a tracheal stricture developed. This was attributed to persistent infection around a permanent suture placed at operation for the endoscopic identification of the target area. The study indicates that trachea and bronchi may be safely frozen by application of a cryoprobe either to the external surface or to the mucosal surface.

Surgical restoration of gastroesophageal competence is the most desirable means of preventing or treating esophagitis and its complications. Various procedures are evaluated.

Summary The basic cause of symptoms and complications from sliding diaphragmatic hernia is gastroesophageal incompetence with reflux of acid-peptic gastric secretion. The intrinsic physiologic sphincter at the lower end of the esophagus is considered the most important mechanism in preventing reflux of the gastric contents into the esophagus. This sphincter functions best when in its normal anatomic location, and no operative procedure to date imparts sphincter function in the absence of an intrinsic sphincter. Repair of an uncomplicated sliding esophageal hiatal hernia is best achieved by restoring the normal anatomy. Other methods of repair are discussed, but the ultimate role of complicated procedures in the management of hiatal hernia is not known. The successful results of these more complicated operations probably reflect their ability to prevent anatomic recurrence rather than any special effect on sphincter function. Procedures designed to reduce gastric secretions are not required for the effective treatment of uncomplicated sliding hernia but may be required in the presence of associated duodenal ulcer or demonstrable hypersecretion. Irrespective of the methods of repair used, careful selection and follow-up evaluation by modern technics of cinefluoroscopy, esophageal motility and pH studies, and measurement of mucosal potential difference would seem important in clarifying not only the alteration effected by various repairs but also their long-term results. Four years would appear to be an optimal time for evaluation of the effect of any operation, since shorter periods may not include an appreciable percentage of late failures.

Esophageal perforations occurred in 33 (0.4 percent) of 8,038 patients who underwent peroral gastrointestinal endoscopic procedures at the Mayo Clinic from 1961 through 1967. Esophagoscopy was the procedure most often responsible. Perforations of the cervical portion of the esophagus were more common, but less serious than perforations of the thoraco-abdominal portion. Cervical perforations resulted from technical problems related to the endoscopic procedure or from unfavorable physical characteristics of the patient. Thoraco-abdominal perforations occurred at the site of benign or malignant esophageal strictures and were caused by excessive dilation, dilation without a satisfactory guide, or bougienage or biopsy beyond visual range. The most helpful diagnostic tests were roentgenographic examinations of the neck or thorax, including contrast studies of the esophagus. Results were best when treatment was initiated promptly and pursued aggressively, with use of antibiotics, surgical drainage, and elimination of esophageal obstruction.

The surgical management of an unusual case of penetrating chest wall injury with retention of a large foreign body that migrated during a three-year period from the periphery of the lung to a hilar endobronchial locus is reported. Bronchotomy for removal of the foreign body provided safe and effective disposition of the problem, without either loss of functioning lung parenchyma or residual symptoms.

A group of 49 Mayo Clinic patients in whom the original diagnosis of lymphoma was made at splenectomy is reported. Systemic symptoms and pain were the commonest complaints and peripheral blood cytopenias were the major abnormal laboratory findings. The correct diagnosis was suspected in almost half of the patients prior to surgery. The 5-year survival rate for the entire group was 31%. The survival rate of 17 patients with localized lesions that were resected was considerably better than in those with residual tumor left after surgery. Patients of various histologic types of lymphoma with a follicular pattern of distribution tended to have a better prognosis than those with diffuse infiltration. The group with lymphocytic lymphoma had a 5-year survival rate of 60%, considerably higher than that for patients with lesions of other histologic types.

A case is reported of a man who had an acute painless dissecting hematoma of the aorta, which was diagnosed clinically in the absence of hypertension or known precipitating cause. The successful surgical treatment is described and illustrated. The following diagnostic features were stressed in the absence of pain: sudden onset of symptoms, syncope, acute peripheral arterial occlusion, appearance of aortic insufficiency, and finding of bruits over the course of the aorta. The significance of the symptom of pain in the torso and the possible modes of its production in this condition are considered, and it is suggested that pain in dissecting aneurysm may imply a poor prognosis.

Summary Two cases of pulmonary blastoma, or embryoma, and a review of the literature are reported. Clinically, these tumors have many features in common with bronchogenic carcinoma, although their course occasionally is more indolent. The tumor represents a distinct entity which can be differentiated from carcinosarcoma and other tumors of the lung which contain glandular acini.

The case presented, one of corrected transposition of the great vessels with dextrocardia and situs inversus as well as pulmonary stenosis, interatrial communication and persistent “left” superior vena cava, is of interest not only because of the rarity of the condition in situs inversus and the attendant difficulties of surgical orientation but also because the unusual combination of associated defects allowed successful repair. Surgical treatment for patients with congenital corrected transposition of the great vessels is directed at the correction of associated cardiac defects only, since corrected transposition per se does not cause disability. Often the associated defects are multiple and severe, and their repair in the presence of corrected transposition is difficult.

Five cases of verrucous carcinoma of the esophagus have been presented. This is a previously unreported location for this distinct morphologic variant of squamous cell carcinoma, which apparently may occur on any stratified squamous mucosa or modified skin. The tumor in the esophagus is morphologically similar to this tumor in other parts of the body. It is a slowly progressing infiltrating tumor which characteristically becomes large but rarely metastasizes. Early diagnosis of the lesion requires clinical suspicion of this growth, particularly in the presence of cardiospasm or esophageal diverticulum. Diagnosis is more likely when the pathologist is aware of the clinical nature of the lesion and when there is an adequate biopsy specimen to show the characteristic infiltrative growth pattern. Early diagnosis and adequate treatment of verrucous squamous cell carcinoma of the esophagus should produce a better prognosis than that associated with the usual type of carcinoma of the esophagus.

One-stage pharyngo-esophageal diverticulectomy can be performed with minimal morbidity and mortality. The procedure effectively relieves both esophageal symptoms and those related to respiratory aspiration in almost all patients treated. Effective long-term relief can be anticipated.

Following reimplantation of the left lung of dogs, serial bronchospirometric studies of the ventilation and oxygen uptake of both lungs were made. The functional effect noted was a moderate initial depression in both oxygen uptake and tidal volume in the reimplanted lung on the day of operation followed by a continued fall for the next two to three weeks. Tidal volume tended to be depressed less than oxygen uptake. After reaching a nadir during the first three weeks, two different patterns were observed. In 14 animals without structural defects, oxygen uptake gradually rose toward control valves, whereas in the group of 28 animals with structural defects oxygen uptake remained depressed.

It is apparent from this experience that pulsion diverticula of the hypopharynx occur somewhat commonly. Whenever dysphagia occurs it should be investigated promptly. Diagnosis of diverticula of the hypopharynx can be readily established by appropriate roentgenologic investigation. Surgical excision of diverticula of the hypopharynx can be performed as a one-stage operation with few complications and gratifying results.

Summary Rate of fall of brain temperature during the induction of hypothermia is increased by the addition of 10 per cent carbon dioxide to the ventilatory mixture. Under these circumstances brain temperatures approximate those of the esophagus and mixed venous blood.

Most patients with Schatzki's ring have dysphagia that can be relieved by esophageal dilation. We report an unusual case in which dysphagia caused by a Schatzki ring could not be managed conservatively. The obstructing ring was excised through a gastrotomy approached by a left-sided thoracotomy. An antireflux procedure was done after elimination of the ring. Five years later, the patient remained symptom free.