Biomedical subjects
Publications and source records attributed to D M Sataloff.
Percutaneous endoscopic gastrostomy is commonly utilized in patients with head and neck cancer. Tumor at the PEG exit site is a rare occurrence, likely due to direct implantation. We present a case report, review of the relevant literature, discussion of the mechanism of spread, and management.
BACKGROUND: Complicated gastroesophageal reflux disease (GERD) requires long-term medical therapy, which in some instances is incompletely effective or poorly tolerated. Additionally, there is concern about the consequences of prolonged acid suppression therapy. Surgical correction of GERD has been a therapeutic option for decades. With the advent of video-assisted laparoscopic surgery, antireflux surgery has had a resurgence in popularity. PATIENTS AND METHODS: Between October 1992 and June 1995, 20 patients who underwent laparoscopic antireflux surgery were completely studied preoperatively and 3 months postoperatively with 24-hour pH monitoring and esophageal manometry. Follow-up averaged 18 months. The indication for surgery was medically refractory disease in 75%, intolerance to medication in 10%, and concern regarding the consequences of long-term medical therapy in 15%. Two thirds of these patients had complicated GERD. RESULTS: Operative time averaged 4 hours. There was no conversion to an open procedure. There was no mortality. Two patients had recurrent reflux, for a failure rate of 10%. Overall, postoperative reflux episodes and percent of time pH was less than 4 dropped significantly. Lower esophageal sphincter function showed a statistically significant increase in mean postoperative resting pressure and residual sphincter pressure during swallowing. There was no change in motility postoperatively. CONCLUSIONS: Laparoscopic antireflux surgery is a safe, effective, therapeutic alternative in the management of gastroesophageal reflux disease.
BACKGROUND: Laparoscopic Nissen fundoplication is an effective procedure for the treatment of gastro-oesophageal reflux disease (GORD), but the underlying motility mechanisms that explain the success of this operation remain unclear. METHODS: Twenty patients with a history of GORD underwent stationary oesophageal manometry and prolonged ambulatory pH monitoring, both before and 3 months after fundoplication. RESULTS: Eighteen patients were completely cured of reflux symptoms and stopped all antireflux medication after operation. After fundoplication there was a significant increase (P < 0.01) in median resting lower oesophageal sphincter (LOS) pressure and length. Median residual LOS pressure during swallow-induced LOS relaxation also increased significantly after operation (P < 0.01). The number of reflux episodes decreased from a median of 48 to 3 after fundoplication (P < 0.01). The time at pH less than 4 decreased from 5.7 to 0 per cent in the supine position (P < 0.01), and from 9.8 to 0.2 per cent while upright (P < 0.001). CONCLUSION: Early subjective results at 3 months following laparoscopic antireflux surgery show improved symptoms. One of the mechanisms underlying the antireflux action of fundoplication is an increase in median residual LOS pressure at the gastro-oesophageal junction. This may be a purely mechanical effect of the fundic wrap extrinsic to the LOS.
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BACKGROUND: The prognosis for patients with locally advanced carcinoma of the breast remains poor. This study examines the pathologic evidence of response of the mammary tumor and axillary nodes after preoperative chemotherapy. We sought to determine if there was a relationship between the histologic response and clinical outcome. STUDY DESIGN: Between 1987 and 1992, 36 patients with locally advanced carcinoma of the breast received three cycles of chemotherapy after incisional biopsy. Modified radical mastectomy was then performed. The breast and axillary nodes were examined pathologically for therapeutic effect and a grading scale was assigned. Postoperatively, patients received completion chemotherapy with the same agents used preoperatively followed by radiation therapy to the chest wall. RESULTS: Fourteen tumors (39 percent) showed near total therapeutic effect, five (14 percent) showed greater than 50 percent but less than total effect, 12 (33 percent) showed less than 50 percent effect, and five (14 percent) showed no effect. Nodal positivity was seen in 61 percent of the patients. Overall clinical response to induction chemotherapy was seen in 86 percent of the patients. There was poor correlation between clinical and pathologic response. Only 50 percent of the patients with complete clinical response were pathologically free of disease. Patients with excellent pathologic therapeutic response had a 79 percent overall five-year survival rate compared with 34 percent for tumors with a lesser response. This was irrespective of nodal status. While pathologic response was critical in determining outcome, clinical response was not. CONCLUSIONS: These results indicate that patients whose tumors have the best pathologic response to induction chemotherapy experience the best outcome.
The elderly population in the United States has been subjected to a massive experiment in mandatory outpatient surgery. Fortunately, this experiment has proven successful. Outpatient surgery of the elderly is feasible and routinely safe if common sense is used and appropriate precautions are undertaken.
Gastric-restrictive operations for the treatment of morbid obesity are well established. Postoperative stricture is one complication of this procedure. In a large obesity practice, 40 patients presented with this complication. The authors reviewed retrospectively the management of these strictures, using endoscopic dilatation. All patients were morbidly obese, defined as greater than 100 pounds more than ideal weight. The original gastric-restrictive procedure included vertical-banded gastroplasty (35 patients); revision vertical-banded gastroplasty (2 patients); and revision of gastric bypass to vertical-banded gastroplasty (3 patients). Three methods were used: dilatation with endoscope, balloon dilatation, and Savary-Guilliard dilatation. Twenty-seven patients became asymptomatic after dilatation (68%). Occasionally, multiple dilatations were necessary. In 13 patients (32%), dilatation was unsuccessful and revision surgery was needed. In early postoperative (6 to 12 weeks) stricture, dilatation with the endoscope was often successful. When strictures were associated with an angulated channel, dilatation was almost uniformly unsuccessful. In summary, endoscopic dilatation for postgastroplasty strictures is a useful and effective technique, obviating the need for operative revision in the majority of patients; however, when the stenosis is associated with channel angulation, dilatation is almost uniformly unsuccessful. Such patients should not be subjected to repeated dilatation but rather proceed promptly to revision surgery.
Endometriosis is a common gynecologic diagnosis. Typical complaints of patients with pelvic endometriosis include dysmenorrhea, menstrual irregularities, dyspareunia, and infertility. Endometriosis may also occur in extrapelvic sites and cause unusual symptoms and diagnostic dilemmas. Endometriosis has been described in the inguinal region, and this is illustrated in the first case history. The tender inguinal masses often fluctuate with the menstrual cycle but the condition initially may be confused with an inguinal hernia. Treatment is surgical. Abdominal wall scar endometriosis, seen in the second case, has been described in patients after a wide variety of gynecologic procedures. This also is initially noted as a tender mass, usually fluctuating with menstruation, and is often confused with an incisional hernia. Again, surgery is the treatment of choice. Pathologic features of endometriosis are constant, regardless of location. Microscopically, endometrial glands and stroma, fibrosis, chronic inflammation, and old hemorrhage are seen. Familiarity with the unusual types of endometriosis is important to the general surgeon.
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Morbid obesity is a significant health problem in the United States today. This has resulted in an intensive investigation into temporary interventions for weight control. Dental splinting does not result in long-term weight loss because patients rapidly regain weight following release of jaw fixation. The Garren-Edwards intragastric bubble was equally ineffective in achieving weight loss and was fraught with numerous complications.
Indications for tracheotomy in patients with respiratory burns have been unclear. Much of the literature is inconclusive or misleading. A thorough understanding of the pathogenesis, diagnosis, and therapy of inhalation injury is necessary to understand the role of tracheotomy. A critical review reveals relatively clearcut indications for the use of tracheotomy in inhalation injury, but many unanswered questions. Increased participation by otolaryngologists in burn management is recommended.