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Biomedical subjects

C G Bremner

Publications and source records attributed to C G Bremner.

At least 55 records · Page 3Linked to original sources
PubMed1997

Barrett's esophagus.

The columnar replacement of squamous epithelium in the lower esophagus is the result of gastroesophageal reflux. Whether the squamous cells are replaced or undergo metaplasia is still conjectural. This neoepithelium is unstable in the presence of continued reflux and prone to complications of stricture, ulceration, and adenocarcinoma. Considerable evidence supports the hypothesis that duodenal contents play a role in the development of Barrett's esophagus and its complications. The increasing incidence of adenocarcinoma in Barrett's esophagus is of concern in the Western World. Surveillance programs in some centers have been successful in early diagnosis, and excellent survival periods have been reported following resection in these cases. Both medical and surgical antireflux treatment is successful in symptom relief, but even in the absence of symptoms, reflux may continue. Surgery offers better overall results than proton pump inhibition of gastric acid and has been more popular since less aggressive (minimally invasive) techniques have been popularized. Mucosal ablation and antireflux measures by medicine or surgery are still in the experimental stages but hold considerable promise for the future.

Barrett Esophagus↗
PubMed1997

Invasive carcinoma in juvenile polyposis--report of a case in an African patient.

Since the 1980s it has been recognized that the polyps of juvenile polyposis have malignant potential. Since the introduction of colonoscopy this syndrome has been redefined and the hamartoma-adenoma-carcinoma sequence recognized. We believe this case is the first report of an invasive carcinoma associated with juvenile polyposis to be described in an African patient.

Adenocarcinoma, Mucinous↗
PubMed1997

Zinc toxicity following massive coin ingestion.

This is the first reported case of human fatality associated with zinc intoxication following a massive ingestion of coins. Four hundred and sixty-one coins were removed form the gastrointestinal tract of a schizophrenic patient during the course of hospitalization. Many of the post-1981 pennies, which consist primarily of zinc, showed severe corrosion due to their prolonged contact with acidic gastric juice. The patient presented with clinical manifestations consistent with the local corrosive as well as systemic effects of zinc intoxication and died 40 days after admission with multi-system organ failure. Tissue samples of the kidneys, pancreas, and liver obtained at autopsy revealed acute tubular necrosis, mild fibrosis, and acute massive necrosis, respectively, and contained high levels of zinc. The overall effects of zinc intoxication on the various organ systems, possible hematological derangement, and the impairment of copper absorption as well as the outcome with treatment are discussed.

Bilirubin↗
PubMed1997

Inflammation and specialized intestinal metaplasia of cardiac mucosa is a manifestation of gastroesophageal reflux disease.

OBJECTIVE: The purpose of the study was to test the hypothesis that cardiac mucosa, carditis, and specialized intestinal metaplasia at an endoscopically normal-appearing cardia are manifestations of gastroesophageal reflux disease. SUMMARY BACKGROUND DATA: In the absence of esophageal mucosal injury, the diagnosis of gastroesophageal reflux disease currently rests on 24-hour pH monitoring. Histologic examination of the esophagus is not useful. The recent identification of specialized intestinal metaplasia at the cardia, along with the observation that it occurs in inflamed cardiac mucosa, led the authors to focus on the type and condition of the mucosa at the gastroesophageal junction and its relation to gastroesophageal reflux disease. METHODS: Three hundred thirty-four consecutive patients with symptoms of foregut disease, no evidence of columnar-lined esophagus, and no history of gastric or esophageal surgery were evaluated by 1) endoscopic biopsies above, at, and below the gastroesophageal junction; 2) esophageal motility; and 3) 24-hour esophageal pH monitoring. The patients were divided into groups depending on the histologic presence of cardiac epithelium with and without inflammation or associated intestinal metaplasia. Markers of gastroesophageal reflux disease were compared between groups (i.e., lower esophageal sphincter characteristics, esophageal acid exposure, the presence of endoscopic erosive esophagitis, and hiatal hernia). RESULTS: When cardiac epithelium was found, it was inflamed in 96% of the patients. The presence of cardiac epithelium and carditis was associated with deterioration of lower esophageal sphincter characteristics and increased esophageal acid exposure. Esophagitis occurred more commonly in patients with carditis whose sphincter, on manometry, was structurally defective. Specialized intestinal metaplasia at the cardia was only seen in inflamed cardiac mucosa, and its prevalence increased both with increasing acid exposure and with the presence of esophagitis. CONCLUSION: The findings of cardiac mucosa, carditis, and intestinal metaplasia in an endoscopically normal-appearing gastroesophageal junction are histologic indicators of gastroesophageal reflux disease. These findings may be among the earliest signs of gastroesophageal reflux and contribute to the authors understanding of the pathophysiology of the disease process.

Adolescent↗
PubMed1997

Can the combination of symptoms and endoscopy confirm the presence of gastroesophageal reflux disease?

The aim of this study was to evaluate the accuracy of symptomatology and esophagogastroduodenoscopy (EGD) in the diagnosis of proven gastroesophageal reflux disease (GERD). We evaluated the symptoms and EGD findings of 100 consecutive patients presenting with symptoms suggestive of GERD. Patients' symptoms were scored at their first visit with a standardized symptom scoring system (grades 0-3). Grade 3 symptoms were the most severe. EGD findings were classified according to the modified Savary-Miller scale. Esophageal acid exposure was quantified using 24-hour esophageal pH monitoring; a positive composite score was considered evidence of GERD. Fifty-seven patients had positive pH scores, and 43 were negative. The combination of grade 2 or 3 heartburn and/or regurgitation with erosive esophagitis or Barrett's esophagus on EGD had a 97 per cent specificity and 64 per cent sensitivity for accurately diagnosing GERD. It is concluded that, in the presence of moderate to severe symptoms and endoscopic injury, the diagnosis of GERD can be made without further studies. However, 24-hour esophageal pH monitoring is still indicated in patients with mild typical symptoms, atypical symptoms, or when the combination of heartburn and regurgitation, regardless of their severity, occurs in the absence of severe mucosal damage.

Adolescent↗
PubMed1996

The mode of Roux-en-Y reconstruction affects motility in the efferent limb.

OBJECTIVES: To compare motility of a Roux-en-Y esophagojejunostomy after total gastrectomy with normal jejunal motility and to determine the effect on motility of the incorporation of a pouch in the reconstruction. DESIGN: Jejunal motility in normal subjects was compared with jejunal motility in the Roux-en-Y reconstruction with and without a Hunt-Lawrence pouch. SETTING: The case were collected during a 4-year period at a university hospital. The mean time from resection to study was 14 months (range, 4 to 49 months). PATIENTS: Seven control patients were compared with 10 patients with a Roux-en-Y reconstruction and 17 with a Roux-en-Y and Hunt-Lawrence pouch. OUTCOME MEASURE: The fasting-state motility of the jejunum used for reconstruction was measured by a water-perfused manometric system for 2 to 4 hours with the subject in the supine position. RESULTS: Compared with normal subjects, patients with a Roux-en-Y esophagojejunostomy without a pouch had an increased number of phases of the interdigestive motor complex per hour (P < .05). The phases were of shorter duration with a random sequence and increased total time spent in the quiescent phase 1 (P < .05). In patients with a pouch, no differences were detected between the motility in the pouch and the efferent limb. Compared with those without a pouch, there were significantly fewer orthograde interdigestive motor complex phase 3 fronts and more total time spent in phase 1 (P < .05). CONCLUSIONS: Construction of a gastric substitute from jejunum leads to substantial motility changes. The addition of a pouch decreases the overall activity, which may contribute to the storage function of the pouch.

Adult↗
PubMed1996

Outcome of respiratory symptoms after antireflux surgery on patients with gastroesophageal reflux disease.

OBJECTIVE: To investigate factors predictive of relief of respiratory symptoms associated with gastroesophageal reflux disease (GERD). DESIGN: A case series of patients with GERD and respiratory symptoms undergoing fundoplication from 1987 to 1994 at a tertiary care university hospital. PATIENTS: Of 118 patients undergoing fundoplication for cardinal symptoms of GERD, 63 had respiratory symptoms. Postoperative follow-up information was available in 50 patients at a median of 3 years. INTERVENTIONS: The presence of GERD was documented on the basis of barium swallow, esophagoscopy, esophageal manometry, and 24-hour pH studies. A standardized questionnaire was used to score symptoms. A Nissen fundoplication was performed in 39 patients, a Collis-Belsey fundoplication in 3 patients. MAIN OUTCOME MEASURES: A repeat standardized questionnaire was used to evaluate the response to surgery for each symptom experienced. Univariate analysis was performed to evaluate factors influencing outcome. RESULTS: Respiratory symptoms were present in 53% (63/118) of patients with GERD. Fundoplication relieved the respiratory symptoms in 76% (38/50) of the patients. Reflux symptoms were relieved in 86% (43/50) of the patients. Abnormalities of esophageal motility were present in 34% (17/50) of the patients, and these were significantly more common in patients who did not experience relief of their respiratory symptoms (9/12 vs 8/38, chi 2 = 9.54, P = .002). CONCLUSIONS: Respiratory symptoms are common in patients with GERD. Unlike classic reflux symptoms, the beneficial effects of antireflux surgery on respiratory symptoms are less predictable. The probability of relief of these respiratory symptoms with antireflux surgery is directly dependent on esophageal motor function.

Adult↗
PubMed1995

Esophageal resection with colon interposition for end-stage achalasia.

OBJECTIVE: To review the potential benefits of esophageal resection with colon interposition in patients with achalasia. DESIGN: Retrospective review. SETTING: University-based tertiary care center. PATIENTS: Nineteen patients (13 men, six women; median age, 44 years; age range, 26 to 77 years) with achalasia and recurrent or persistent dysphagia despite a variety of previous treatments. INTERVENTIONS: Esophageal resection and replacement with colon interposition. MAIN OUTCOME MEASURES: Mortality and morbidity of the procedure, symptomatic outcome, nutritional impact, ability to ingest a meal, and overall patient satisfaction. RESULTS: Follow-up results were available in 15 patients. The procedure accounted for no deaths and complications in four patients. Outcome assessment was done at a median of 6 years (range, 1 to 14 years) after resection. Overall, the symptomatic outcome was excellent to good in 12 patients. Eleven of the 15 patients gained weight (median weight loss, 6.3 kg) after the procedure. Thirteen patients were able to eat three meals daily; seven had the capacity to eat a steak dinner; five, an airline meal; and three, a snack. Nine of the 15 patients enjoyed an unrestricted diet. The speed of ingesting a meal was reduced in that most (11 of 15) were the last to finish when eating in a group. Fourteen of the 15 believed that the operation had cured or improved their preoperative symptoms, and a similar percentage were satisfied with the overall outcome of surgery. Most patients (12 of 15) would have the operation again. CONCLUSIONS: Esophageal replacement for end-stage achalasia can be accomplished with safety and marked improvement of preoperative symptoms. Despite multiple previous therapeutic failures, normal alimentation was restored in the majority of patients, with 93% judging the operation to be highly beneficial, improving their quality of life. Based on this success, guidelines for resection in end-stage achalasia are established.

Adult↗
PubMed1995

A contemporaneous comparison of hospital charges for laparoscopic and open Nissen fundoplication.

Surgical treatment of gastroesophageal reflux disease is increasingly recognized as a cost-effective alternative to long-term medical therapy. This fact, coupled with the advent of laparoscopic fundoplication as a safe and efficacious alternative to open surgery, underscores the importance of determining the costs associated with laparoscopic treatment. Hospital costs and charges of patients undergoing open (N = 9) and laparoscopic (N = 11) fundoplication were retrospectively analyzed. Both procedures were performed during the same time period (6/91-6/93), at the same hospital, and by the same surgical team. Operative time, and hospital stay, were recorded in addition to total, operating room, anesthesia, sterile supplies, and hospital room charges. Figures are reported as mean values +/- standard error of the mean. The Wilcoxon signed rank test was used for comparison of groups. Operative time (221 +/- 18 vs 165 +/- 12 min, P = 0.033) was longer in the laparoscopic group, while hospital stay (5.8 +/- 02 vs 8.8 +/- 04 days, P < 0.001) was significantly shorter. Total hospital costs were similar for both groups of patients ($14,615 +/- 863 vs $15,891 +/- 921, P = 0.247). Overall hospital charges were nearly identical ($26,634 +/- 1376 vs $27,189 +/- 1753, P = 0.803). A detailed analysis demonstrated cost shifting, with laparoscopic fundoplication resulting in significantly higher charges associated with events in the operating room. Operating room ($6,064 +/- 252 vs $4,283 +/- 380, P = 0.001), sterile supplies ($6,214 +/- 508 vs $5,403 +/- 390), and anesthesia charges ($1,593 +/- 76 vs $1,122 +/- 95, P < 0.001) were all greater in the laparoscopic group.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1995

A selective therapeutic approach to gastric cancer in a large public hospital.

BACKGROUND: Gastric cancer is a common malignancy with a poor prognosis. The improved survival reported from Japan may be due to earlier detection or to more radical surgery, or both. The relevance of their methods to gastric cancer seen in Western countries is uncertain. PATIENTS AND METHODS: The study involved 204 patients with gastric carcinoma. Preoperative staging by computed tomography scan and endoscopic ultrasound showed that 120 patients (59%) had stage IV disease. RESULTS: Curative resection was performed in 66 patients, palliative resection in 32, bypass/intubation in 39, chemotherapy alone in 41, and supportive treatment in 26. Neoadjuvant chemotherapy was given to 40 of 66 patients treated with curative resection. The mortality of gastrectomy was 3%. Survival was significantly improved after curative resection compared with palliative resection, which in turn was improved over non-resectional or nonsurgical therapy. Postoperative morbidity included four intra-abdominal abscesses, all associated with splenectomy. CONCLUSIONS: Curative surgery for gastric cancer is worthwhile, but the advanced stage of the disease in a public hospital should encourage the establishment of a screening program in high risk populations.

Aged↗
PubMed1995

Does duodenal juice reflux into the esophagus of patients with complicated GERD? Evaluation of a fiberoptic sensor for bilirubin.

BACKGROUND: It is controversial whether duodenal juice can damage esophageal mucosa in patients with gastroesophageal reflux disease (GERD). The issue remains unresolved partly because of difficulties in detecting the presence of duodenal juice in the lower esophagus. OBJECTIVES AND METHODS: This study utilized an in vitro portable spectrophotometer with a fiberoptic probe capable of detecting bile as a marker of duodenal juice. Absorbance/concentration curves were established with known bilirubin concentrations at pH 1.4 and pH 7.7. Esophageal pH and bilirubin absorbance were monitored in vivo over a 24-hour period in 20 healthy volunteers to determine the absorbance threshold for clinical use. The study population consisted of 21 patients with GERD. Four had no mucosal injury, 5 erosive esophagitis, and 12 Barrett's esophagus. RESULTS: The correlation between absorbance and bilirubin concentration was 0.98 and 0.99 for acid and alkaline environments, but bilirubin absorbance was 35% less in an acid environment. Using an absorbance threshold of 0.14, patients with GERD taken in toto had elevated esophageal exposure to bilirubin. No difference was observed in bilirubin exposure between reflux patients without mucosal injury and controls. Highest exposure occurred in patients with Barrett's esophagus. An important observation was that esophageal bilirubin exposure frequently occurred during periods when the esophageal pH was in the normal range. CONCLUSIONS: The fiberoptic probe accurately detects esophageal bilirubin as a marker of duodenal juice. Esophageal exposure to bilirubin is uncommon in normal subjects. Patients with erosive esophagitis and Barrett's metaplasia have increased esophageal exposure to duodenal juice compared to normal subjects. Reflux of duodenal juice into the esophagus can occur when the esophageal pH is within its normal range and is undetectable by pH monitoring alone.

Adult↗
PubMed1995

A tailored approach to antireflux surgery.

Tailored surgical antireflux procedures were done in 104 patients during a 7-year period. Presenting symptoms included heartburn in 95 patients (91%), regurgitation in 83 patients (80%), and dysphagia in 61 patients (60%). Evaluation before operation included video barium esophagography, endoscopy, 24-hour esophageal pH monitoring, and esophageal motility studies. On the basis of anatomic and functional findings, the following procedures were performed: 15 laparoscopic and 49 open transabdominal Nissen fundoplications, 23 transthoracic Nissen fundoplications, seven Belsey partial fundoplications, and 10 Collis gastroplasty and Belsey partial fundoplications. The severity of symptoms was assessed before and after operation according to a previously published grading score. Eighty-five of the 104 patients (82%) were able to be contacted for a follow-up evaluation by means of a standardized questionnaire. Median length of follow-up was 4 years, with 40 patients having follow-up beyond 5 years. The tailored operation cured the symptoms of heartburn in 97%, regurgitation in 91%, and dysphagia in 92%. Ninety-eight percent of the patients reported that operation had cured their preoperative symptoms and 93% were satisfied with the outcome of the operation. To obtain optimal results, surgical treatment of gastroesophageal reflux disease should be tailored to the patient's anatomic and functional assessments. For early, uncomplicated disease a transabdominal Nissen fundoplication is done, laparoscopically when expertise exists. Patients with complicated disease should undergo an open antireflux procedure tailored to specific anatomic or functional abnormalities.

Adolescent↗
PubMed1995

Mixed reflux of gastric and duodenal juices is more harmful to the esophagus than gastric juice alone. The need for surgical therapy re-emphasized.

OBJECTIVE: The author's goal was to determine the role of duodenal components in the development of complications of gastroesophageal reflux disease. SUMMARY AND BACKGROUND DATA: There is a disturbing increase in the prevalence of complications, specifically the development of Barrett's esophagus among patients with gastroesophageal reflux disease. Earlier studies using pH monitoring and aspiration techniques have shown that increased esophageal exposure to fluid with a pH above 7, that is, of potential duodenal origin, may be an important factor in this phenomenon. METHODS: The presence of duodenal content in the esophagus was studied in 53 patients with gastroesophageal reflux disease confirmed by 24-hour pH monitoring. A portable spectrophotometer (Bilitec 2000, Synectics, Inc.) with a fiberoptic probe was used to measure intraluminal bilirubin as a marker for duodenal juice in the esophagus. Normal values for bilirubin monitoring were established for 25 healthy subjects. In a subgroup of 22 patients, a custom-made program was used to correlate simultaneous pH and bilirubin absorbance readings. RESULTS: Fifty-eight percent of patients were found to have increased esophageal exposure to gastric and duodenal juices. The degree of mucosal damage increased when duodenal juice was refluxed into the esophagus, in that patients with Barrett's metaplasia (n = 27) had a significantly higher prevalence of abnormal esophageal bilirubin exposure than did those with erosive esophagitis (n = 10) or with no injury (n = 16). They also had a greater esophageal bilirubin exposure compared with patients without Barrett's changes, with or without esophagitis. The correlation of pH and bilirubin monitoring showed that the majority (87%) of esophageal bilirubin exposure occurred when the pH of the esophagus was between 4 and 7. CONCLUSIONS: Reflux of duodenal juice in gastroesophageal reflux disease is more common than pH studies alone would suggest. The combined reflux of gastric and duodenal juices causes severe esophageal mucosal damage. The vast majority of duodenal reflux occurs at a pH range of 4 to 7, at which bile acids, the major component of duodenal juice, are capable of damaging the esophageal mucosa.

Adult↗
PubMed1995

Clinical and physiologic comparison of laparoscopic and open Nissen fundoplication.

BACKGROUND: Although recent reports have documented the safety and efficacy of laparoscopic fundoplication, none have compared outcomes to that of open Nissen fundoplication. STUDY DESIGN: Eighty-one patients had either open (n = 47) or laparoscopic (n = 34) Nissen fundoplication. Relief of symptoms was measured by a standardized questionnaire and scored by a modified Visick-Index. Physiologic outcome was assessed by postoperative pH monitoring and manometry in a subset of both groups. RESULTS: Primary symptoms were heartburn in 55 percent of the patients, regurgitation in 9 percent, dysphagia in 11 percent, and atypical in 25 percent of patients. Twenty-seven (84 percent) of 32 patients in the laparoscopic group and 31 (84 percent) of 37 patients in the open group were cured or improved. Operative time was significantly longer in the laparoscopic group (218 compared to 168 minutes). The period of hospitalization was shorter for the laparoscopic group (4.7 compared to 9.2 days, p < 0.0001). Postoperative pressures in the lower esophageal sphincter (LES) were significantly higher in the laparoscopic group (20.9 compared to 12.1, p = 0.006). Augmentation of sphincter length was similar for both groups. More patients in the laparoscopic group failed to relax their LES completely after fundoplication (32 compared to 71 percent, p = 0.1). CONCLUSIONS: Symptomatic outcome after laparoscopic fundoplication is similar to that of open surgery. Physiologic studies reveal a greater augmentation of LES pressure and a low prevalence of sphincter relaxation after laparoscopic fundoplication.

Adolescent↗
PubMed1994

Selection of patients for curative or palliative resection of esophageal cancer based on preoperative endoscopic ultrasonography.

OBJECTIVE: To assess the accuracy of pretreatment staging and the potential of using endosonographic findings to select patients for curative or palliative resection by comparing the preoperative endosonographic and computed tomographic (CT) findings with the histology of the surgical specimen. METHODS: Forty-two patients referred to our clinic with esophageal carcinoma underwent preoperative upper endoscopy with biopsy, endosonography, thoracic CT, and abdominal CT. Based on endoscopic ultrasonographic findings, patients with early-stage disease underwent en-bloc esophagogastrectomy, whereas those with advanced disease had a palliative transhiatal esophagectomy. Exceptions included patients with poor physiologic reserve who were treated by the transhiatal route. RESULTS: In eight patients, we were unable to pass the ultrasonographic endoscope. Seven of these eight had transmural tumors with nodal involvement on histologic study. Tumor length, based on endosonographic measurements, was correctly predicted in 34 patients (85%). Extent of wall penetration was accurately predicted in 26 (76%) of the 34, and regional lymph node status was accurately predicted in 28 (82%) of the 34. Of the patients with sonographic wall penetration, 80% had histologic evidence of one or more positive nodes. Using the WNM staging system, endoscopic ultrasonography correctly staged the cancer in 68% of the patients. Three patients were treated with an inappropriate procedure. CONCLUSION: Endosonography is a reliable method for the preoperative staging and selection of patients for curative or palliative resection. Endosonographic wall penetration appears to be a critical factor in determining tumor spread.

Adult↗
PubMed1994

Is Barrett's metaplasia the source of adenocarcinomas of the cardia?

OBJECTIVE: To investigate the prevalence of Barrett's esophagus in patients with adenocarcinomas located at the gastroesophageal junction. DESIGN: A case series of patients who underwent esophagogastrectomy for adenocarcinoma was retrospectively reviewed. Tumors were grouped by location as esophageal, cardiac, and subcardiac, and the prevalence of specialized intestinal metaplasia in the histological specimens was determined. SETTING: A university department of surgery that specializes in esophageal diseases. PATIENTS: One hundred patients with adenocarcinoma of the esophagus, cardia, or proximal stomach. MAIN OUTCOME: Cardiac adenocarcinomas were associated with Barrett's esophagus in 42% of the patients. RESULTS: Specialized intestinal metaplasia was identified in the histological sections from the resected specimen in 42% (13/31) of cardiac adenocarcinomas and in 79% (38/48) of esophageal adenocarcinomas but in only 5% (1/21) of subcardiac adenocarcinomas. The preoperative endoscopic biopsy results concurred with the final diagnosis of Barrett's esophagus in 33 of the 38 esophageal tumors, six of the 13 cardiac tumors, and the one subcardiac tumor but failed to detect specialized intestinal metaplasia in 54% (7/13) of cardiac tumors. Cardiac tumors were associated with shorter lengths of Barrett's mucosa than esophageal tumors (2.7 +/- 1.8 cm vs 7.4 +/- 3.4 cm, P < .01). The Barrett's metaplasia was dysplastic in 36 of the 38 esophageal tumors, 10 of the 13 cardiac tumors, but not in the subcardiac tumor. CONCLUSIONS: Adenocarcinomas located at the gastroesophageal junction were associated with Barrett's metaplasia in nearly one half of the patients. The length of the Barrett segment tends to be short and may be missed during endoscopy. The presence of high-grade dysplasia within Barrett's mucosa supports a barrett's origin for half of the adenocarcinomas arising at this location.

Adenocarcinoma↗