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Biomedical subjects

J G Hunter

Publications and source records attributed to J G Hunter.

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

Nissen and Toupet fundoplications effectively inhibit gastroesophageal reflux irrespective of natural anatomy and function.

BACKGROUND: The physiology of Nissen fundoplication (NF) and Toupet fundoplication (TF) is controversial. The aim of this study was to determine the contribution of elevated intragastric pressure to the antireflux mechanism after surgically created fundoplication in explanted porcine stomachs. METHODS: The stomachs and 6-8 cm of distal esophagus were removed from 15 pigs and placed in anatomic position. Five NF, 2 cm in length with three interrupted sutures, were performed, taking full-thickness bites of stomach and partial-thickness bites of esophagus around a 60 French dilator. Five 270 degree TF 2 cm in length with six interrupted sutures were performed taking full-thickness bites of stomach and partial-thickness bites of esophagus around a 60 French dilator. Each stomach served as its own control. The pylorus was tied off and the stomach was inflated with Ringer's lactate while the pressure was monitored. RESULTS: Before NF, reflux could be easily induced with a mean intragastric pressure of 5.5 +/- 3.7 mmHg. After NF reflux could not be induced but the sutures pulled out of the stomach at a mean pressure of 36.8 +/- 11.7 mmHg (p<0.01 vs control). Before TF, reflux could easily be induced with a mean intragastric pressure of 3.0 +/- 3.0 mmHg. After TF, reflux could not be induced and the sutures pulled out of the esophagus or stomach with a mean pressure of 30.8 +/- 9.0 mmHg (p<0.01 vs control). Porcine stomachs in vivo are resistant to reflux, but when explanted they reflux easily. NF and TF are so effective at interrupting reflux that the sutures tear out instead of allowing reflux. CONCLUSIONS: While not yet statistically significant, it appears that sutures tear out of the esophagus (TF) more readily than they tear out of the stomach (NF). TF and NF prevent reflux in the absence of anatomic or functional components of the lower esophageal sphincter.

Animals↗
PubMed1997

Endoluminal surgery.

BACKGROUND: Progress in laparoscopic surgery and the employment of minimally invasive techniques have led to the emergence of a new branch in this field, laparoscopic endoluminal surgery (LES). METHODS: LES encompasses all surgical procedures that involve intentional trocar or instrument penetration into the lumen of the gut in order to perform a surgical procedure. The integrity of the organ is preserved except for the small enterotomy sites and the operated area. The procedure is technically demanding and requires sound endoscopic skills. RESULTS: The experience in LES has primarily involved the stomach and right colon for two reasons. First, these organs have a larger volume/surface ratio in the gut; therefore, they are accessible for the endoluminal instruments. Second, even limited resection of the stomach or colon can potentially carry a significant morbidity. LES minimizes the extent of this resection. CONCLUSIONS: In this paper we review recent developments in LES, discuss the technical aspects of the procedure, and recommend its applicability.

Biopsy↗
PubMed1997

Minimally invasive surgery of the esophagus and stomach.

BACKGROUND: Minimally invasive surgery has assumed an ever-expanding role in gastrointestinal surgery since the introduction of laparoscopic cholecystectomy. This review describes some of the more common minimally invasive procedures of the esophagus and stomach, with particular attention to technique. DATA SOURCES: A literature review of minimally invasive surgery of the esophagus and stomach was conducted. CONCLUSIONS: Laparoscopic (and thoracoscopic) approaches for gastroesophageal reflux disease appear to have excellent operative and short-term follow-up results. Long-term follow-up data, however, remain unobtainable for several more years. Limited reports of esophageal cardiomyotomy, paraesophageal hernia repair, and gastric surgery for peptic ulcer disease performed through a minimally invasive approach are encouraging. Experience with resection of esophageal and gastric neoplasia is limited to a few specialized centers. Results should be scrutinized and compared with open operation before proclaiming the benefits of a minimally invasive approach.

Endoscopy↗
PubMed1997

Surgical management of achalasia.

Although achalasia is not a common illness in the United States and Europe, there continues to be a need for surgical therapy for treatment. Laparoscopic Heller myotomy and partial fundoplication has, for the most part, replaced open surgery (abdominal or thoracic) as the surgical treatment of choice. In order to perform this procedure well, one must select patients carefully, evaluate them fully, and adhere to the technical principles required to achieve consistently good results.

Esophageal Achalasia↗
PubMed1997

Dual-channel ambulatory esophageal pH monitoring. A useful diagnostic tool?

Ambulatory pH monitoring of the distal esophagus is the most accurate diagnostic study for patients with suspected gastroesophageal reflux disease (GERD). The measurement of proximal esophageal acid exposure time may be useful in patients with atypical reflux symptoms. The aim of this study is to evaluate if proximal esophageal pH monitoring provides useful information beyond that learned with distal esophageal pH monitoring. We routinely performed dual-channel pH monitoring with pH electrodes positioned at 20 and 5 cm above the manometric lower esophageal sphincter from January 1992 to August 1995. All patients scored their esophageal symptoms from zero (none) to four (severe). We compared proximal esophageal reflux (PR) in patients with typical symptoms (i.e., heartburn, regurgitation) and in patients with atypical symptoms (i.e., chest pain, cough, hoarseness, and asthma). We compared symptom profiles between patients with and without PR. We reviewed our experience in patients with abnormal PR, but with a normal amount of distal esophageal reflux (DR). We studied 441 consecutive patients. There were no significant differences in PR between patients with typical and atypical symptoms. There were no differences in symptom profiles between patients with normal and abnormal PR. There were no differences of PR between the different atypical symptoms. PR did not correlate with the severity of the patient's symptoms. PR correlated well only with DR. Twenty-four patients had isolated abnormal PR, but only six patients improved with antireflux therapy. We conclude that routine ambulatory esophageal pH monitoring of the proximal esophagus appears to be of little value. The decision to offer patients an empiric trial of antireflux therapy for suspected GERD should not be based on the presence or absence of PR.

Adult↗
PubMed1997

Significance of intestinal metaplasia in different areas of esophagus including esophagogastric junction.

Over the past two decades, the incidence of adenocarcinoma of the esophagus and gastric cardia has increased at a rate exceeding that of any other cancer. Barrett's esophagus is the only known risk factor for these malignancies. Recently, emphasis has been placed on the significance of specialized intestinal metaplasia (SIM) on esophageal biopsies. Our aim was to compare the prevalence of SIM at different esophageal locations in patients who are at higher risk of developing esophageal adenocarcinoma (Caucasians) and patients with lower risk of developing esophageal adenocarcinoma (African-Americans). Eighty-seven unselected patients (42 Caucasians and 45 African-Americans) underwent routine upper endoscopy with biopsies from the proximal margin of columnar mucosa. We classified patients into those with a columnar-lined esophagus with SIM (CLE with SIM); CLE without SIM; or SIM with a normal-appearing gastroesophageal junction (SIM-GEJ). The prevalence of CLE with SIM, CLE without SIM, and SIM-GEJ was 28%, 10%, and 10% in Caucasians compared to 0%, 18% and 11% in African-Americans (P = 0.0001, 0.26, and 0.81, respectively). We found CLE with SIM only in patients with reflux symptoms at least twice a week. It is concluded that CLE with SIM is seen most commonly in patients thought to be at risk for esophageal adenocarcinoma (Caucasians with reflux symptoms). It is rarely seen in other groups with lower risk for this malignancy (African-Americans, nonrefluxers). Conversely, SIM-GEJ and CLE without SIM are common in all groups and are of questionable significance.

Adenocarcinoma↗
PubMed1997

Laparoscopic management of gastroesophageal reflux disease.

This monograph provides a review of the contemporary surgical management of gastroesophageal reflux disease (GERD), drawing primarily on the experience at Emory University Hospital. We emphasize the importance of precise anatomic and physiologic preoperative evaluation to confirm the diagnosis of GERD, and stress technical aspects of laparoscopic fundoplication that have improved outcomes.

Fundoplication↗
PubMed1997

Laparoscopic Heller myotomy and fundoplication for achalasia.

OBJECTIVE: The goal of this study was to review the authors' results with laparoscopic cardiomyotomy and partial fundoplication for achalasia. SUMMARY BACKGROUND DATA: Pneumatic dilatation and botulinum toxin (BOTOX) injection of the lower esophageal sphincter largely have replaced cardiomyotomy for treatment of achalasia. After a brief experience with a thoracoscopic approach, the authors elected to perform cardiomyotomy laparoscopically, in combination with a partial fundoplication (anterior or posterior). PATIENTS AND METHODS: Forty patients were treated between July 1992 and November 1996. Thirty patients had previous therapy of achalasia, 21 with pneumatic dilation, 1 with BOTOX, 6 with balloon and BOTOX, and 2 with transthoracic cardiomyotomy. Three patients had previous laparoscopic fundoplication for gastroesophageal reflux. Symptom scores (0 = none to 4 = disabling) were obtained before surgery and after surgery. Barium swallows and esophagogastroduodenoscopy were performed in all patients. Esophageal motility study was performed in 36 patients. Laparoscopic Heller myotomy and fundoplication was performed through five upper abdominal trocars. A 7-cm myotomy extended 6 cm above the GE junction and 1 cm below the GE junction. A posterior fundoplication was performed in 32 patients, anterior fundoplication in 7 patients, and no fundoplication in 1 patient. Statistical inference was performed with a Wilcoxon signed rank test. RESULTS: Mean operative duration was 199 +/- 36.2 minutes. Mean hospital stay was 2.75 days (range, 1-13 days). Dysphagia was alleviated in all but four patients (90%), and regurgitation in all but two patients (95%) (p < 0.001). Chest pain and heartburn improved significantly (p < 0.01) as well. Intraoperative complications included mucosal laceration in six patients and hypercarbia in one. Postoperative pneumonia developed in two patients, and one patient had moderate hemorrhage from an esophageal ulcer 2 weeks after surgery. CONCLUSIONS: Laparoscopic cardiomyotomy and fundoplication appears to provide definitive treatment of achalasia with rapid rehabilitation and few complications.

Adolescent↗
PubMed1997

Laparoscopic antireflux surgery.

The availability of proton pump inhibitors and laparoscopic antireflux surgery has ushered in a new era in the management of chronic gastroesophageal reflux disease. Proton pump inhibitors allow physicians to treat nearly all patients with chronic gastroesophageal reflux with successful medical treatment. Laparoscopic antireflux surgery offers patients an opportunity to abandon their medications with an operation that is well tolerated. The major indication for antireflux surgery is failure of medical therapy. However, many patients with long-term medical therapy requirements are candidates, too. Several factors influence the decision to choose antireflux surgery, including patients' ages, costs of medications, types of symptoms the patients may have (for example, heartburn as opposed to chest pain or asthma), or complications such as Barrett's esophagus, metaplasia, or stricture formation. A through preoperative evaluation of patients being considered for antireflux surgery is essential. All patients should have an upper endoscopy and esophageal manometry. Selected patients, particularly those with nonerosive esophagitis, atypical reflux symptoms, or those in whom the diagnosis is in doubt, should have ambulatory esophageal pH monitoring. Barium swallow is helpful in evaluating patients with Barrett's esophagus, esophageal strictures, and in elderly patients who have a new onset of esophageal symptoms. Gastric testing infrequently identifies patients with significant abnormalities; however, in patients with symptoms of gastric disease it may change the type of surgery that is performed. The results of laparoscopic antireflux surgery are excellent in properly selected patients. Complications are rare and usually easily managed in the postoperative setting. The keys to successful antireflux surgery are a thorough evaluation of the patient, a thorough discussion of the advantages and disadvantages of antireflux surgery with the patient, and a skilled surgeon. Following these principles, antireflux surgery should be very successful in the great majority of patients for whom it is considered.

Gastroesophageal Reflux↗
PubMed1996

Mechanisms and avoidance of esophageal perforation by anesthesia personnel during laparoscopic foregut surgery.

BACKGROUND: This study retrospectively assesses the mechanisms of 13 esophageal or gastric injuries resulting from dilator or nasogastric tube placement during laparoscopic foregut surgery and is intended to assist in determining methods of prevention. METHODS: Information regarding esophageal or gastric injury during laparoscopic foregut surgery was obtained from six experienced laparoscopic surgeons. The specific mechanisms of injury were determined by discussion with the operating surgeon and review of the operative reports. RESULTS: Eleven cases of esophageal or gastric perforation occurred during bougie insertion and two perforations occurred secondary to nasogastric tube placement during Nissen fundoplication or Heller myotomy. Five perforations required conversion to open operation for repair including two delayed thoracotomies. The 13 injuries occurred during the performance of 1,620 laparoscopic foregut operations for an overall incidence of 0.8%. CONCLUSION: Foregut injury resulting from esophagogastric intubation during laparoscopic surgery is more common than expected. Risk factors include esophageal anatomy, intrinsic pathologic changes of the esophagus, and inexperience. Prevention must focus on close communication between the surgeon and anesthesiologist and safe techniques of dilator insertion.

Adult↗
PubMed1996

New technology for the division of short gastric vessels during laparoscopic Nissen fundoplication. A prospective randomized trial.

Division of the short gastric vessels (SGV) is a standard component of laparoscopic Nissen fundoplications (LNF) at our institution. This study compares our original method of vessel control, multifire clip applier (MCA) and sharp division, to the Ultracision Harmonic Scalpel LCS (LCS). Twenty consecutive patients were evaluated in a randomized prospective fashion. Times for SGV division and estimated blood loss (EBL) were recorded. Cost data represent patient charges for use of either the MCA or LCS and the charge for operative time. Use of the LCS produced a significant reduction in the time required for SGV division and in the charges to the patient. [table: see text] We feel it is important to divide the SGV in all LNFs, and LCS use can result in significant savings of time and money.

Adult↗
PubMed1996

Intermediate follow-up of laparoscopic antireflux surgery.

BACKGROUND: Open antireflux surgery is an established long-term treatment for chronic gastroesophageal reflux disease. Short-term results of laparoscopic antireflux surgery are excellent, but long-term follow-up is not yet available. METHODS: Twenty-four-hour ambulatory esophageal pH monitoring and symptom scores were collected prior to laparoscopic antireflux surgery and 6 weeks postoperatively. These studies were repeated in an unselected cohort of patients 1 to 3 years after operation. RESULTS: One hundred patients who were > 1 year from surgery at the time of the present study volunteered for intermediate follow-up symptom assessment, and 35 also completed repeat 24-hour monitoring. The median interval after surgery among these volunteers was 17 months. Thirty-three (94%) had a normal pH study, which correlated with improvements in symptom scores. One patient had an abnormal pH study but no reflux symptoms, and 1 patient with an abnormal study developed recurrent symptoms of reflux after an episode of vomiting 11 months postoperatively. CONCLUSIONS: The intermediate-term results of laparoscopic fundoplication suggest that long-term efficacy of this operation will be equivalent to open fundoplication.

Esophagus↗
PubMed1996

Laparoscopic antireflux surgery.

Gastroesophageal reflux disease is very common, and there continues to be a need for gastroesophageal reflux surgery despite improved medical therapy. With the relatively new option of laparoscopic antireflux surgery, many more of these procedures are now being performed. In order to perform these well, one must select patients carefully, evaluate them fully, and adhere to the technical principles required to achieve consistently good results.

Fundoplication↗
PubMed1996

Late Clostridium perfringens breast implant infection after dental treatment.

Late infection is rare after breast augmentation. Pathogenesis is usually implant seeding caused by bacteremia as a consequence of antecedent distant infections or medical/dental procedures. Reported is the first case of late implant infection, after extensive dental treatment, caused by Clostridium perfringens, an anaerobic pathogen commonly present in the human gastrointestinal tract. Prompt diagnosis and early antibiotic treatment of all bacterial infections, and serious consideration of antibiotic prophylaxis for all bacteremia-producing procedures, is essential for breast implant patients.

Adult↗