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Biomedical subjects

D B Skinner

Publications and source records attributed to D B Skinner.

At least 19 recordsLinked to original sources
PubMed1998

Massive hiatal hernias: the anatomic basis of repair.

OBJECTIVES: In the repair of giant hiatal hernias, controversy persists as to whether an antireflux repair is required and whether a Collis gastroplasty is necessary. This study was undertaken to determine the location of the gastroesophageal junction in giant hiatal hernias with an intrathoracic stomach, as well as the outcome after repair without a Collis gastroplasty. METHODS: Fifty-two patients were evaluated for a giant hiatal hernia, of whom 47 underwent surgical correction. Preoperative evaluation included esophagoscopy (n = 45), gastrointestinal series (n = 40), esophageal manometry (n = 20), and 24-hour pH testing (n = 13). The dominant clinical features were acute chest or abdominal pain (72%), heartburn (53%), and gastrointestinal bleeding (49%). The gastroesophageal junction was located in the mediastinum in 77% of patients, in the abdomen in 17%, and was not determined in 6%. Twenty-eight patients (59%) had clinical or objective evidence of reflux. Reduction with an antireflux repair without a gastroplasty was done in 47 (Belsey, n = 28; Nissen, n = 19). An excellent or good result was achieved in 38 patients (90%) with a median follow-up of 45 months. CONCLUSIONS: These results, obtained without a Collis gastroplasty, are equivalent to those obtained by an antireflux repair with an esophageal lengthening procedure. The frequent location of the gastroesophageal junction in the mediastinum suggests that these massive hernias often are the result of progressive enlargement of a sliding component. An antireflux repair is therefore necessary in the majority of patients.

Aged↗
PubMed1997

En bloc esophagectomy improves survival for stage III esophageal cancer.

OBJECTIVE: The role of en bloc esophagectomy in the surgical treatment of patients with locally advanced esophageal cancer is not well defined. This report attempts to elucidate its impact on survival, in comparison with less extensive resection, among patients with stage III disease. METHODS: A prospectively established database was retrospectively analyzed. RESULTS: One hundred twenty-eight patients underwent esophagectomy for carcinoma of the thoracic esophagus between 1988 and 1996 (78 underwent en bloc resection and 50 underwent standard resection). The 30-day and hospital mortality rates were 3.9% and 5.4%, respectively, comparable for the two procedures. Fifty-four patients had stage III disease. Overall 4-year survival was 34.5% after en bloc resection, with a median survival of 27 months (n = 33), and 11% after standard resection (n = 21), with a median survival of 12 months (p = 0.007). Among patients with stage III disease undergoing a complete resection, 4-year survivals were 36.7% and 0% after en bloc and standard resections, respectively (p = 0.001). Eighty-six of 128 patients had nodal metastasis. Three-year survivals for patients with NI disease were 33.9% and 13% after en bloc and standard resections, respectively (p = 0.02). CONCLUSION: Among patients with stage III esophageal cancer, en bloc resection appears to significantly improve survival compared with lesser resections. This improvement in survival may be attributable to resection of nodal disease.

Actuarial Analysis↗
PubMed1997

Occult cervical nodal metastasis in esophageal cancer: preliminary results of three-field lymphadenectomy.

The extent of lymphadenectomy for carcinoma of the thoracic esophagus remains debatable. A prospective study was initiated in August 1994 to evaluate the patterns of nodal spread after esophagectomy with three-field lymph node dissection. The hospital mortality rate was 3.3%. Nodal metastases occurred in 73% (22/30) of patients. The most commonly affected nodal groups were the lesser curvature nodes (57%), parahiatal nodes (42%), and the right recurrent nodes (35%). Cervical nodal metastasis occurred in 10 patients (35%) irrespective of tumor location or T status. The cervical field of dissection was as likely as the mediastinum to be a site of nodal disease. These findings should be considered when the operative strategy for esophageal carcinoma is planned.

Adult↗
PubMed1995

A continuing medical education strategy for care of the elderly by the surgical specialties.

As the absolute numbers and percentage of older people rises in Canada, surgeons are required to treat an increasing number of elderly patients. Recognizing the need to enhance the quality of health care for these people by continuing medical education of health care professionals, the Canadian Medical Association sponsored an invitational workshop in May 1992. The workshop group addressing surgery and its specialties identified three essential underprinnings: knowledge of the aging process (altered physiology and response to illness); decision analysis for interventions (risks, benefits and ethical dimensions); and communication skills. Three priorities for continuing education were recommended: improving knowledge of the physiologic changes that impact on the recovery of elderly patients from surgery; management of postoperative care; and improved knowledge and skills in prescribing medications for older surgical patients. Strategies to implement these priorities are outlined.

Aged↗
PubMed1994

Esophageal carcinoma with airway invasion. Evolution and choices of therapy.

In order to define the evolution of airway invasion by esophageal cancer, we reviewed 53 patients presenting with (group A) or without (group B) tracheoesophageal fistulae. Patients in group A were treated by esophageal bypass (4), esophageal diversion (4), expectant therapy (4), or esophageal prosthesis (1). The median survival was 4 months. Group B patients were treated by esophageal resection (18), esophageal bypass (4), or radiation therapy (13), depending on the extent of local disease. Bronchoscopy was a valuable tool for predicting resectability. Surgical resection, when possible, yielded better palliation. There were 4 long-term survivors in group B.

Adenocarcinoma↗
PubMed1993

Thoracic esophageal diverticula. Why is operation necessary?

Diverticula of the thoracic esophagus are uncommon disorders. The indications for surgical intervention in asymptomatic or minimally symptomatic patients are unclear. Among 20 patients referred during a 20-year period, 6 were male and 14 female, with a median age of 65 years. Two had had previous diverticulectomies. Dysphagia was present in 9 (45%) and regurgitation in 11 (55%). Nine patients had severe nocturnal cough with symptoms of aspiration. In two of these nine and in three other patients (25%), pulmonary symptoms were the only manifestation of disease, with no or minimal esophageal symptoms. In one patient the diagnosis of the presence of bronchial asthma for several years was incorrect; one patient had massive aspiration before hernia repair, in one a bronchoesophageal fistula and lung abscess developed, and two had severe persistent cough. All patients had a diagnostic barium esophagogram and endoscopy. Operation was performed in 17 patients, whereas three others declined operation. There was one hospital death. Follow-up is complete on 17 of 19 patients until June 1991. All operative survivors but one are free of symptoms. Of three patients refusing operation, one died of aspiration pneumonia, another died of myocardial infarction, and one with severe dysphagia is living. Because of the prevalence of aspiration (45%) and the potential for life-threatening pulmonary complications in some patients (15%), we conclude that operative intervention should be undertaken in all patients with thoracic esophageal diverticula regardless of the presence or absence of symptoms.

Adolescent↗
PubMed1991

High-grade dysplasia in the columnar-lined esophagus.

Abnormal columnar lining of the esophagus is a well-recognized premalignant condition. The management of patients with high-grade dysplasia without evidence of carcinoma remains controversial. Esophagectomy is proposed by some investigators, whereas others favor follow-up endoscopy and biopsy until microinvasive malignancy is documented. We reviewed our experience with nine patients referred with high-grade dysplasia on endoscopic biopsies without evidence of carcinoma. Eight patients had the columnar lining extending orad from the cardia, and one patient had heterotopic columnar epithelium in the cervical esophagus. All were white men ranging in age from 19 to 76 years (median: 47 years). Eight patients underwent esophagectomy with colon interposition. A sleeve resection of the cervical esophagus was done in one patient. Multifocal carcinoma was found in three patients, all of whom had severe dysplastic changes throughout the columnar lining. The patient with heterotopic columnar epithelium had microinvasive carcinoma. All four patients with carcinoma had negative nodes and are long-term survivors. No carcinoma was found in the resected specimens of the remaining five patients. High-grade dysplasia is an important marker of malignancy in patients with a columnar-lined esophagus. Esophagectomy is indicated in suitable candidates since carcinoma was found in 45% of our patients.

Adult↗