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Biomedical subjects

J G Hunter

Publications and source records attributed to J G Hunter.

At least 73 records · Page 4Linked to original sources
PubMed1996

A physiologic approach to laparoscopic fundoplication for gastroesophageal reflux disease.

OBJECTIVE: The authors examined indications, evaluations, and outcomes after laparoscopic fundoplication in patients with gastroesophageal reflux through this single-institution study. SUMMARY OF BACKGROUND DATA: Laparoscopic fundoplication has been performed for less than 5 years, yet the early and intermediate results suggest that this operation is safe and equivalent in efficacy to open techniques of antireflux surgery. METHODS: Over a 4-year period, 300 patients underwent laparoscopic Nissen fundoplication (252) or laparoscopic Toupet fundoplication (48) for gastroesophageal reflux refractory to medical therapy or requiring daily therapy with omeprazole or high-dose H2 antagonists. Preoperative evaluation included symptom assessment, esophagogastroduodenoscopy, 24-hour pH evaluation, and esophageal motility study. Physiologic follow-up included 24-hour pH study and esophageal motility study performed 6 weeks and 1 to 3 years after operation. RESULTS: The most frequent indication for surgery was the presence of residual typical and atypical gastroesophageal reflux symptoms (64%) despite standard doses of proton pump inhibitors. At preoperative evaluation, 51% of patients had erosive esophagitis, stricture, or Barrett's metaplasia. Ninety-eight percent of patients had an abnormal 24-hour pH study. Seventeen percent had impaired esophageal motility and 2% had aperistalsis. There were four conversions to open fundoplication (adhesions, three; large liver, one). Intraoperative technical difficulties occurred in 19(6%) patients and were dealt with intraoperatively in all but 1 patient (bleeding from enlarged left liver lobe). Minor complications occurred in 6% and major complications in 2%. There was no mortality. Median follow-up was 17 months. One year after operation, heartburn was absent in 93%. Four percent took occasional H2 antagonists, and 3% were back on daily therapy. Atypical reflux symptoms (e.g., asthma, hoarseness, chest pain, or cough) were eliminated or improved in 87% and no better in 13%. Overall patient satisfaction was 97%. Four patients have subsequently undergone laparotomy for repair of gastric perforation (1 year after operation), severe dumping, "slipped" Nissen, and repair of acute paraesophageal herniation. Two patients had laparoscopic revision of herniated fundoplications. Results of follow-up 24-hour pH studies were normal in 91% of patients more than 1 year after operation. In patients with poor esophageal motility, esophageal body pressure improved 1 year after operation in 75% and worsened in 10%. CONCLUSIONS: Although long-term efficacy data are lacking, intermediate follow-up shows laparoscopic fundoplication to be safe and effective. A physiologic approach to evaluation and follow-up of patients with gastroesophageal disease allows the surgeon to tailor antireflux surgery to esophageal body function and follow the function of the fundoplication and esophagus after operation.

Adult↗
PubMed1996

Dysphagia after laparoscopic antireflux surgery. The impact of operative technique.

BACKGROUND: Concerns about laparoscopic antireflux surgery include the frequent appearance of troublesome postoperative dysphagia. This study reviews the frequency of early (less than 6 weeks) and persistent (greater than 6 weeks) solid food dysphagia in patients undergoing Toupet, Rosetti-Nissen, or Nissen fundoplications. METHODS: One hundred eighty-four consecutive patients with normal esophageal peristalsis undergoing laparoscopic antireflux surgery were prospectively studied. Before operation, all patients had endoscopy, 24-hour pH study, and an esophageal motility study. The choice of operation was dependent on anatomy and surgeon preference. Before discharge, all patients were given instructions on a soft diet. Postoperative symptoms were scored by the patients as absent, mild, moderate, or severe 4 weeks and 12 weeks after operation. The option of esophageal dilation was offered to patients with moderate to severe persistent solid food dysphagia. RESULTS: New onset moderate to severe dysphagia to solid foods was present in 30 (54%), 8 (17%), and 13 (16%) patients undergoing Rosetti-Nissen, Nissen, and Toupet fundoplications, respectively, in the first month after operation (p < 0.001). Moderate to severe dysphagia persisted at 3 months in six (11%), one (2%), and two (2%) patients undergoing laparoscopic Rosetti-Hell, Nissen, and Toupet fundoplications, respectively (p < 0.05). Esophageal dilatation was performed in five (4%), zero, and one (1%) patients undergoing laparoscopic Rosetti-Nissen, Nissen, and Toupet fundoplications, respectively (p < 0.05). There was no additional morbidity related to division of short gastric vessels in patients undergoing Nissen fundoplication. CONCLUSIONS: Laparoscopic Rosetti-Nissen fundoplication is associated with a higher rate of early and persistent postoperative dysphagia than either laparoscopic Nissen fundoplication or Toupet fundoplication. Consideration of complete fundus mobilization should be a part of all laparoscopic antireflux procedures.

Adult↗
PubMed1996

Clinical features of type III (mixed) paraesophageal hernia.

OBJECTIVES: The clinical presentation of patients with a paraesophageal hernia is poorly understood. The aim of this study was to evaluate the progression of symptoms in patients with type III paraesophageal hernia. METHODS: We evaluated 25 patients (mean age 66 yr) with a type III paraesophageal hernia, who then had laparoscopic surgical repair. The patients characterized their symptoms as 1) chronic or 2) prompting evaluation (progressive or new). We defined postprandial distress as chest or epigastric pain, shortness of breath, or nausea or vomiting during or shortly after meals. RESULTS: We identified three distinct types of chronic symptoms: heartburn only (36%), heartburn and postprandial distress (32%), and postprandial distress only (32%). Twenty-three patients (92%) reported postprandial distress as the symptom prompting evaluation compared with only 10 patients (40%) reporting heartburn. Eight patients (32%) never had heartburn. Postprandial distress was their only symptom. Laparoscopic repair of the paraesophageal hernia resolved postprandial distress in 74% and improved symptoms in the remaining 26% of patients (mean follow-up 12 months). CONCLUSIONS: Post-prandial distress is the most prominent symptom in patients with a type III paraesophageal hernia. Most patients had chronic symptoms of a sliding hiatal hernia but later featured more pronounced postprandial distress. However, one-third of the patients never experienced significant heartburn. A type III paraesophageal hernia should be suspected in patients, with or without heartburn, who develop new or progressive symptoms of postprandial distress.

Adult↗
PubMed1996

Evaluation and management of postfundoplication dysphagia.

OBJECTIVES: Persistent dysphagia occurs in 3-24% of patients after fundoplication. There are virtually no data on the success or safety of endoscopic dilation to relieve postfundoplication dysphagia. The aim of this study was to review our experience with endoscopic management of patients with dysphagia after fundoplication. MATERIALS AND METHODS: Thirty-five patients (mean age 49 yr; 12 males, 23 females) with dysphagia after fundoplication were referred for endoscopic dilation. Twenty-nine patients had undergone one fundoplication (group A), and six patients had undergone two or more operations (group B). The integrity of the fundoplication was evaluated by barium esophagram and upper endoscopy. Median follow-up after the initial postoperative dilation was 13 months. RESULTS: The 29 patients in group A were dilated to a mean (+/- SD) of 52 +/- 4F during a mean (+/- SD) 1.9 +/- 1.1 dilation sessions per patient. No complications, such as disruption of the fundoplication, resulted from endoscopic dilation, and no one developed new reflux symptoms. Dysphagia resolved in 15 (52%) patients after dilation. The most important prognostic feature was endoscopic or radiological evidence of a slipped fundoplication. Dilation was successful in relieving dysphagia in only three of 11 (27%) patients with a slipped fundoplication, compared with 12 of 18 (67%) patients with an intact fundoplication (p = 0.05). Dysphagia resolved in only one of the six patients in group B. CONCLUSIONS: Endoscopic dilation is safe and often effective in patients with postfundoplication dysphagia. However, patients with a slipped fundoplication or who have undergone multiple fundoplications respond poorly to endoscopic dilation.

Barium Sulfate↗
PubMed1995

Laparoscopic Nissen fundoplication is less expensive than open Belsey Mark IV.

Laparoscopic Nissen fundoplication is a relatively new technique used to treat gastroesophageal reflux disease (GERD). The purpose of this study was to compare the cost to the patient and insurer of a laparoscopic Nissen fundoplication (LN) to an open Belsey Mark IV (B4), the previous standard operation for GERD at Emory University Hospital. A retrospective review of 20 consecutive patients undergoing LN or B4 for GERD was performed. Patients were well matched for age, severity of disease, and comorbid illness. The data were analyzed using an unpaired Student's t-test or Wilcoxon signed rank analysis. The results are as follows (mean +/- SD): [table: see text] We conclude that the charges for laparoscopic Nissen fundoplication are significantly less than the charges for Belsey Mark IV. The majority of the savings resulted from a shortened hospital stay.

Adult↗
PubMed1995

Carbon dioxide pneumoperitoneum induces fetal acidosis in a pregnant ewe model.

The objective of this study was to evaluate the physiologic consequences of a pneumoperitoneum (pneumo) to the midterm fetus in a pregnant sheep model. The performance of laparoscopic cholecystectomy (LC) during pregnancy is controversial. The primary concern regarding the safety of LC during pregnancy is the physiologic consequences of the CO2 pneumo to the fetus. Eight ewes with singlet pregnancies between 100 and 120 days of gestation were anesthetized and intubated. Carotid artery and internal jugular catheters were placed in the ewe and in the fetus. Two trocars were placed through the abdominal wall of the ewe and the abdomen was inflated with CO2 or N2O at 15 mmHg pressure for 90-120 min. Hemodynamic and blood gas data were obtained every 15 min before, during, and after the pneumo. In two ewes attempts were made to keep maternal Pco2 constant with hyperventilation. In two other animals the pneumo was increased stepwise in five mmHg increments to 25 mmHg. One fetus succumbed during the CO2 pneumo, but this animal appeared to be ill during the establishment of invasive monitoring. Fetal respiratory acidosis occurred, reproducibly, after establishment of CO2 pneumo but did not occur before insufflation or under N2O pneumo (P < 0.0001). Hemodynamic changes were minimal with all agents but it appeared that there a was greater prevalence of fetal tachycardia and hypertension during CO2 pneumo than during N2O pneumo. Alterations in ventilator settings based on maternal capnography resulted in late and incomplete correction of respiratory acidosis.(ABSTRACT TRUNCATED AT 250 WORDS)

Acidosis, Respiratory↗
PubMed1995

Biliary tract complications of laparoscopic cholecystectomy are detected more frequently with routine intraoperative cholangiography.

Controversy over whether intraoperative cholangiography (IOC) should be done routinely has intensified since the advent of laparoscopic cholecystectomy (LC). As yet, no study has demonstrated a clear benefit to its use, although their have been suggestions in the literature that routine use may confer an advantage to detection of injuries. One-hundred seventy-seven biliary tract complications occurring secondary to LC were identified from the combined data of seven institutions. The goal of this retrospective study was to examine the impact of IOC on the occurrence, recognition, and correction of such complications. The complications identified include 39 cystic duct leaks, 69 major ductal leaks or strictures, and 69 major ductal transection or excision injuries. Whether IOC was performed was known in 157 (88%) patients with 53 patients definitely having and 104 not having an IOC. Data concerning IOC were unavailable in 20 cases. More injuries were detected intraoperatively in the group having IOC (P < 0.001). Conversion of the LC to a laparotomy, often for repair of the injury, occurred more commonly in the group having a correctly interpreted IOC (P < 0.001). Conversion resulted in detection of injuries sooner, resulting in fewer operative procedures to correct the injury (P < 0.001). A transecting injury was prevented in at least seven patients when no visualization of the proximal biliary tree was documented by IOC. These partial ductal incisions were treated by t-tube placement. Incorrect interpretation of the IOC occurred in at least eight patients, with no identification of the proximal biliary tree in six.(ABSTRACT TRUNCATED AT 250 WORDS)

Bile Ducts↗
PubMed1995

Laparoscopic repair of paraesophageal hernia. New access, old technique.

Large paraesophageal hernias are generally repaired by reduction of the stomach into the abdomen, sac excision, crural closure, and gastropexy or fundoplication. After gaining experience performing laparoscopic repair of sliding hiatal hernias and Nissen fundoplication we combined laparoscopic access with traditional surgical technique in treating patients with complex paraesophageal hernias. Ten adults, six males and four females, with type III paraesophageal hernias underwent laparoscopic repair between February 1993 and April 1994. The average age of the patients was 60.4 years (range 38-81). Using five ports (three 10 mm and two 5 mm), the stomach was reduced into the abdomen, the hernia sac was resected, and the defect was closed with pledgeted horizontal mattress sutures. In addition, nine patients had a Nissen fundoplication performed and one patient had a diaphragmatic gastropexy. The procedure was completed laparoscopically in all ten cases and the median operating time was 282 min (range 165-430). Two complications occurred, an intraoperative gastric laceration, and a postoperative mediastinal seroma. All patients were discharged on the 2nd or 3rd postoperative day. Eight of nine patients were asymptomatic at last follow-up (mean 8.9 months postop). One patient has mild dysphagia and heartburn from partial migration of the fundoplication into the chest. One patient died 3 months postoperatively of unrelated causes. Paraesophageal hernia can be reduced and repaired safely with laparoscopic access using standard surgical techniques.

Adult↗
PubMed1995

Nitrous oxide pneumoperitoneum revisited. Is there a risk of combustion?

Nitrous oxide has been effectively banned from use in therapeutic laparoscopy because of fear of combustion. These fears rest on two case reports, a misunderstanding of the physical chemistry of nitrous oxide, and lack of information on the presence of flammable colonic gases in the pneumoperitoneum mixture. This study aims to identify the presence and quantify the amount of hydrogen and methane found in the peritoneal cavity during laparoscopic GI procedures, and then to compare the gas concentrations detected with known limits of combustion. Gas standards with known concentrations of hydrogen and methane were placed in polypropylene syringes and analyzed on a mass spectrometer after 1, 2, 3, and 4 h. This established the rate at which these gases would be leached through a polypropylene syringe--the amount of gas lost during transport from the patient to the laboratory. Twenty gas samples were drawn, randomly, 30 min to 2 h following the start of laparoscopic gastrointestinal procedures. The samples were analyzed for hydrogen and methane within 30 min of their aspiration from the abdominal cavity. An inconsequential amount of methane was lost from the polypropylene syringe in 4 h. After 1 h, one-half the hydrogen had leached from the polypropylene syringe. Hydrogen was detected in the pneumoperitoneum of four patients at a concentration ranging from 0.016 to 0.075%. No methane was detected in any sample. For combustion to occur in a nitrous oxide environment, hydrogen or methane must occupy 5.5% of the gas volume. The maximum amount of hydrogen we detected was less than 1/50 of the combustion threshold.(ABSTRACT TRUNCATED AT 250 WORDS)

Digestive System↗
PubMed1995

A prospective, randomized comparison of laparoscopic appendectomy with open appendectomy. Laparoscopic Appendectomy Study Group.

BACKGROUND: While the advantages of laparoscopic cholecystectomy are clear, the benefits of laparoscopic appendectomy (LA) are more subtle. We conducted a randomized clinical trial to evaluate whether LA is deserving of more widespread clinical application than it has yet received. MATERIALS AND METHODS: Two hundred fifty-three patients with a preoperative diagnosis of acute appendicitis were randomized into three groups. LA with an endoscopic linear stapler (LAS) (U.S. Surgical Corp., Norwalk, Connecticut) was performed on 78 patients, LA with catgut ligatures (LAL) on 89, and open appendectomy (OA) on 86. LA was performed with a three-trocar technique. OA was accomplished through a right lower-quadrant transverse incision. Data with normal distributions were analyzed by analysis of variance. Nonparametric data were analyzed with either the Kruskal-Wallis H test or Fisher's exact test. RESULTS: The mean operative times for the procedures were 66 +/- 24 minutes (LAS), 68 +/- 25 minutes (LAL), and 58 +/- 27 minutes (OA). The relative brevity of OA compared to LAS and LAL was statistically significant (P < 0.01). Conversion to open procedures was approximately as frequent in the LAS group (n = 5) and the LAL (n = 6). One OA, 2 LAS, and 11 LAL patients experienced vomiting postoperatively (P < 0.05). Two intra-abdominal abscesses occurred in LAS, 4 in LAL, and 0 in OA patients (P = NS). Wound infections were more common following OA (n = 11) than LAL (n = 4) or LAS (n = 0) (P < 0.05, < 0.001). The mean length of postoperative hospital stay was 2.16 +/- 3.2 days (LAS), 2.98 +/- 2.7 days (LAL), and 2.83 +/- 1.6 (OA) (P < 0.05 OA versus LAS). The number of days patients required pain medications overall was not different between groups, but a subgroup analysis of 134 patients who rated their postoperative pain on a visual analogue scale revealed a significantly lower mean level among patients undergoing LA (LAS and LAL) versus OA (P < 0.001). Patients undergoing LA resumed regular activities sooner than those undergoing OA (9 +/- 9 days versus 14 +/- 11 days, P < 0.001). Rates of readmission to the hospital were similar for all procedures. CONCLUSIONS: Laparoscopic appendectomy appears to have distinct advantages over open appendectomy. The laparoscopic procedures produced less pain and allowed more rapid return to full activities, and LAS required shorter hospital stays. The only disadvantages to the laparoscopic approach were slightly increased operative time for both procedures, and increased emesis following LAL.

Adult↗
PubMed1995

The preoperative evaluation of patients considered for laparoscopic antireflux surgery.

Few studies address the proper extent of the preoperative testing in patients referred for consideration of antireflux surgery. Our aim was to perform a thorough gastroesophageal evaluation and determine its influence on the therapeutic decisions of such patients. We evaluated 107 consecutive patients in a combined GI/Surgery clinic for severe or refractory gastroesophageal reflux. The patients had an EGD, esophageal manometry, and 24-h ambulatory esophageal pH monitoring. Only patients with gastric symptoms had gastric testing. Nineteen patients were excluded, 12 refused further evaluation and seven were felt to be unfit for antireflux surgery because of medical or psychological reasons. Eighty-eight patients completed the required studies. Fifty-four patients (61%) had typical reflux symptoms and erosive esophagitis on EGD. All these patients had an abnormal pH study. Five of the 34 patients without esophagitis had a normal pH study and did not have surgery. Ten patients had poor peristalsis by esophageal manometry prompting a subtotal fundoplication. One patient had severe delayed gastric emptying, requiring pyloroplasty in addition to the fundoplication. Eighty of 83 patients had good or excellent surgical results. EGD and esophageal manometry are indispensable in the preoperative evaluation. Manometry may identify abnormalities altering surgical decisions in roughly 10% of patients. Routine ambulatory esophageal pH monitoring is of marginal benefit, except in patients without esophagitis or in those patients where the diagnosis is in doubt. Clinically significant gastric abnormalities are rare, and routine testing of gastric function is not indicated.

Adult↗
PubMed1994

Training in laparoscopic cholecystectomy. Quantifying the learning curve.

There is no clear consensus on the best way to train general surgeons to perform laparoscopic cholecystectomy (LC). We attempted to quantify the "learning curve" for 86 surgeons attending eight consecutive 3-day, three-pig courses in LC. Each step of the operation was scored by the instructor for successful performance: Uncomplicated pneumoperitoneum (p), cystic duct and artery dissection (cd), artery and duct clipping (cc), operative cholangiography (oc), gallbladder dissection without holes (gd), liver bed hemostasis (h), gallbladder removal in one piece (i), and no abdominal organ injury (in). As well, operative time, method of dissection, and contact Nd: YAG or electrocautery were recorded. The percentage of students successfully completing each task for the first and third pigs on which they acted as surgeon was as follows: [table: see text] The operative time for the first and third pigs was 1.3 +/- 0.56 and 0.70 +/- 0.34 (mean +/- SD) h, respectively (P < 0.01). When students were trained with the contact Nd: YAG laser there was more blood loss than with electrosurgery (P < 0.001). Statistically significant improvement could only be demonstrated in the most difficult task, gallbladder dissection without perforation, but that task had not been mastered by the end of 3 days. The flat portion of the laparoscopic cholecystectomy "training curve" had not been reached by the end of the program.

Animals↗
PubMed1993

Laser vs electrosurgery in laparoscopic cholecystectomy. A prospective randomized trial.

While much of the clamor over the optimal instrument for dissection of the gallbladder from the liver bed has died, there remain no prospective comparative data concerning this issue. We undertook a prospective randomized trial comparing the contact neodymium:YAG laser with monopolar electrosurgical dissection in 100 patients undergoing laparoscopic cholecystectomy. Electrosurgical dissection was performed with an "L" hook and spatula electrodes at 25 W coagulation current. Neodymium:YAG laser dissection was performed with a 1200-microns contact tip at 15 W continuous beam. Mean (+/- SD) gallbladder dissection time was 19.2 +/- 8.5 minutes with electrosurgery compared with 23.6 +/- 9.6 minutes with the laser. Estimated blood loss was significantly less in the electrosurgery-treated group. In six instances, laser malfunction or fiber fragmentation necessitated completing the dissection with electrosurgery. We conclude that electrosurgery appears to have significant advantages for dissection of the gallbladder during laparoscopic cholecystectomy.

Aluminum Silicates↗
PubMed1993

Exposure, dissection, and laser versus electrosurgery in laparoscopic cholecystectomy.

The technical complications of laparoscopic cholecystectomy occur while creating the pneumoperitoneum, placing trocars, obtaining exposure, and performing the initial dissection of the cystic duct and artery. The errors most feared are intestinal injury, vascular injury, and common bile duct injury. Bile duct injury usually results from the misinterpretation of the extrahepatic biliary anatomy. Confusion is most likely if the gallbladder infundibulum is pushed superiorly and medially, pulling the common bile duct out from behind the duodenum and into line with the cystic duct and gallbladder. Other dissection errors resulting in bile duct injury include the failure to begin dissection on the gallbladder, routine dissection of the cystic duct all the way to the common bile duct, failure to identify anomalies of the cystic and hepatic ducts, failure to open all folds of the gallbladder infundibulum, and entrapment of a narrow common bile duct by a cystic duct clip "slid" too far proximally. Proper dissection strategy includes posterolateral traction on the gallbladder infundibulum and initiation of dissection at the most medial point where the gallbladder is clearly seen. Pedunculation of the gallbladder will reveal most ductal anomalies but should be supplemented with routine digital fluoroscopic cholangiography. The controversy over optimal sources for thermal dissection of the gallbladder has largely been resolved. Electrosurgical dissection is a more rapid, hemostatic, and economical dissection.

Cholecystectomy, Laparoscopic↗