Current management of esophageal perforation after pneumatic dilation for achalasia is thoracotomy and repair with myotomy. This study aims to assess the outcome of patients managed by laparotomy, and the role of laparoscopic repair. The study was carried out by means of retrospective case review and prospective follow-up with a symptom questionnaire. Results were compared with results in patients undergoing elective Heller myotomy. Over a 20-year period, 445 dilations for achalasia were performed in 371 patients. There were 10 esophageal perforations. Nine patients were referred for surgery and were successfully managed with a transabdominal repair. Laparoscopic repair was attempted in four patients but was successful in only one because of the perforation site. After a mean follow-up of 5.4 years, grade 1 or 2 Visick scores were recorded in all patients. Residual symptoms of dysphagia occurred in 67% in the emergency group and 88% in the elective group. There was an increased incidence of heart-burn compared to elective myotomy. Early operation after perforation provides good results for treatment of achalasia. Mild dysphagia persists and there is an increasing sensation of heartburn. The site of perforation is typically posterolateral, which makes laparoscopic repair difficult.

Catheterization↗

PubMedDate not supplied

Functional outcome after Heller myotomy and fundoplication for achalasia.

This study aims to provide longitudinal prospective data on symptomatic outcome following Heller myotomy with fundoplication and to examine variables that might predict a poor outcome. Patients were prospectively followed by means of a biannual mailed questionnaire that assessed symptoms, satisfaction with the procedure, medication, and need for further intervention. Patients were classified as achieving a good or poor outcome based on predetermined criteria. Duration of clinical remission was determined using Kaplan-Meier curves. Between 1992 and 1999, 62 patients with at least 12 months' follow-up were categorized as having either a good outcome (41 patients) or a poor outcome (21 patients). The cumulative probability of a good outcome at 7 years was 37%. Dysphagia significantly increased over the follow-up period despite initial resolution. Patient variables (age, sex, symptom duration, esophageal dilatation, manometric findings) and operative factors (myotomy length, wrap type, case number mucosal perforation, primary therapy) were not demonstrated to influence outcome at 3 years. A comparison of Nissen fundoplication with partial fundoplication suggested increased dysphagia and chest pain in the Nissen group. Despite initial symptomatic relief, patients with achalasia suffer a progressive decline with recurrent dysphagia and regurgitation. The type of fundoplication used may contribute to these poor results.

Deglutition Disorders↗

PubMedDate not supplied

Preoperative esophageal transit studies are a useful predictor of dysphagia after fundoplication.

Fundoplication performed for gastroesophageal reflux disease may be complicated by postoperative dysphagia despite successful reduction in reflux symptoms. This is more likely in those patients with reflux who have concurrent esophageal dysmotility. The aim of this study was to establish whether esophageal transit studies using a technetium-99m jello bolus (jello esophageal transit) could detect the presence of motility disorders preoperatively and hence predict surgical outcome. Transit studies in 33 healthy volunteers yielded a normal range of 2 to 24 seconds using ninety-fifth percentile distribution. In the second phase of the study, 26 patients accepted for laparoscopic fundoplication were enrolled: jello esophageal transit, manometry, and endoscopy were attempted preoperatively in all subjects. A clinical dysphagia score was assigned from a questionnaire. Six months after surgery, five patients had dysphagia and of these four were found to have abnormal preoperative jello esophageal transit, for a sensitivity of 80%. Of the 21 patients who had no dysphagia after surgery, 20 patients had normal preoperative jello esophageal transit, showing a specificity of 95%. This esophageal transit study is noninvasive, reliable, and sensitive. When performed prior to fundoplication, it appears to be of significant value in detecting a subtle functional motility disorder that predisposes to postoperative dysphagia. Jello esophageal transit may assist the surgeon in planning treatment of gastroesophageal reflux disease.

Adult↗

PubMedDate not supplied

The influence of sex chromosomes on finger dermatoglyphic patterns.

Finger pattern frequencies for patients exhibiting various sex chromosome aneuploidies were obtained from literature sources. The sample consisted of 141 XO, 500 XX, 68 XXX, 9 XXXX, 500 XY, 93 XYY, 30 XXYY and 6 XXXXY. Pattern frequencies were converted to radial and ulnar loop frequencies, and these in turn were used to construct four variables; pattern intensity; radial-ulnar difference; radial loop asymmetry; and ulnar loop asymmetry. The relationship between the dermatoglyphic variables on to the sex chromosomes was examined by regressing the dermatoglyphic variables on to the number of X and Y chromosomes. Radial-ulnar difference and radial loop asymmetry showed the strongest relationship with the number of X and Y chromosomes. The X and Y chromosomes had about equal influence on radial-ulnar difference, but the Y had a stronger effect on radial loop asymmetry. It is postulated that sex chromosomes influence dermatoglyphic development by controlling tissue sensitivity to fetal sex steroids.

Aneuploidy↗

PubMedDate not supplied

Selenium depletion in burn patients.

Victims of major burns may be at risk for selenium (Se) depletion because increased postinjury nutrient needs are often met by total parental nutrition and tube feedings which contain little Se. This study compared Se status of 17 burn patients and 191 healthy control subjects. Se intake of burn patients was lower than the intake of control subjects when total parenteral nutrition or tube feedings were used as primary nutrient sources but was comparable to the control intake when burn patients consumed oral diets. Serial determinations each 10 days during recovery showed that burn patients had lower plasma Se, erythrocyte Se, and erythrocyte glutathione peroxidase levels, and lower 24-hr urine Se excretion. These results provide biochemical evidence of Se depletion despite exogenous Se intake within the range recommended for healthy adults. Further studies are indicated to determine if Se depletion in burn patients can be prevented by Se supplementation of total parenteral nutrition and tube feeding solutions.

Adult↗

PubMedDate not supplied

Hand grip strength--a simple prognostic indicator in surgical patients.

This study evaluates hand grip strength as an indicator of nutritional status and a predictor of postoperative complications. Hand grip strength and other parameters of nutritional status, namely, midarm muscle circumference, forearm muscle circumference, triceps skinfold, percentage ideal body weight, serum albumin, and percent usual weight were determined preoperatively in 205 patients. Complications occurred in 28 patients (14%). Patients with at least one abnormal nutritional parameter had a higher incidence of postoperative complications. Their length of total and postoperative hospitalization was greater by 6.2 and 4.6 days, respectively (p less than 0.01). Grip strength was the most sensitive single parameter, but forearm muscle circumference and percentage ideal body weight were the most specific indices. Hand grip strength is a simple measure of nutritional status and an accurate prognostic indicator that requires further clinical evaluation.

Adult↗

PubMedDate not supplied

The role of brushing cytology in the diagnosis of gastric malignancy.

The results of endoscopic biopsy and brushing cytology in 234 consecutive patients with established histologic diagnoses of discrete gastric lesions were analyzed. A histopathologic diagnosis of malignancy, established by independent means, was made in 74 patients. Brushing cytology was positive for malignancy in 63, a diagnostic sensitivity of 85%. Endoscopic biopsy was positive in 64, a diagnostic sensitivity of 86%. The sensitivity for combined cytology and biopsy was 91%, which was not significantly greater than for biopsy alone (P = .6). Cytology yielded false-positive results in 5 of 160 patients (3.1%) with confirmed benign disease. There were no false-positive biopsy reports. Although both brushing cytology and biopsy have high diagnostic sensitivities, based on the findings of this study, the routine addition of cytology to biopsy in the endoscopic evaluation of gastric lesions is not recommended. Cytology could be reserved for situations in which difficulty is encountered in obtaining adequate tissue for histologic examination and for cases with a high suspicion of malignancy that have yielded negative biopsies.

Adenocarcinoma↗