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Biomedical subjects

L Lundell

Publications and source records attributed to L Lundell.

At least 91 records · Page 5Linked to original sources
PubMed1996

Long-term results of a prospective randomized comparison of total fundic wrap (Nissen-Rossetti) or semifundoplication (Toupet) for gastro-oesophageal reflux.

The importance of the extent of the fundic wrap that encircles the distal oesophagus for the establishment of long-term control of gastro-oesophageal reflux disease (GORD) and for the risk of symptoms after fundoplication was evaluated in a prospective, randomized clinical trial. Of 137 consecutive patients with GORD, 72 were allocated to a semifundoplication (180-200 degrees, Toupet) and 65 to a total fundoplication (360 degrees, Nissen-Rossetti). Dysphagia was more common in the early postoperative period after a total fundic wrap, a difference which disappeared with time. This corresponded to a higher resting tone in the lower oesophageal sphincter area. Seven patients (5 per cent) experienced relapse of GORD during follow-up of more than 3 years. Although no difference in the cumulative relapse rate (5 per cent for Nissen-Rossetti versus 6 per cent for Toupet) was found between the two study groups, the total failure rate was higher (P < 0.05) among patients who had a Nissen-Rossetti procedure because of a procedure-specific complication: intrathoracic herniation of the fundoplication in five patients caused obstructive symptoms without reflux (four had no posterior crural repair). In addition, symptoms in the form of flatulence were more frequently seen after Nissen-Rossetti fundoplication (P < 0.05 at 2 years and P < 0.01 at 3 years). Both Nissen-Rossetti and Toupet fundoplication equally well and durably controlled GORD. Fewer symptoms occurred in those having a semifundoplication, both in the early and late postoperative period.

Adult↗
PubMed1996

Food intake after gastrectomy for gastric carcinoma: the role of a gastric reservoir.

Patients with carcinoma of the stomach who underwent curative resection were randomized to total gastrectomy (n = 49), total gastrectomy and an S-shaped gastric substitute (n = 28) or subtotal gastrectomy (n = 12); all had a Roux-en-Y reconstruction. The gastric substitute and gastric remnant allowed a volume of 400-500 ml to be installed without increments in basal pressures. The corresponding volume in the Roux limb was 100 ml. Energy intake was approximately 120 kJ/kg preoperative weight per day 3 months after operation, and then remained constant. Patients who had subtotal gastrectomy ate less (91.7 kJ/kg preoperative weight) 3 months after operation, but thereafter increased their intake. Patients allocated to have a gastric pouch or subtotal gastrectomy complained more frequently of adverse postprandial symptoms (P < 0.03) as a major cause of reduced calorie intake. The construction of a gastric reservoir did not improve nutritional adaptation after surgery for gastric carcinoma.

Adult↗
PubMed1996

Quality of life in gastric cancer prior to gastrectomy.

A growing number of surgical trials include quality of life variables in the overall assessment of outcomes. This is believed to broaden the criteria for choice of treatment and the evaluation of treatment regimens. The present study is a baseline evaluation of the health-related quality of life in patients with gastric cancer facing surgery. The quality of life in these patients was related to that of other patient groups referred for surgical interventions and general population groups. Our study included 103 consecutive patients with carcinoma of the stomach considered amenable to a curative major surgical procedure. The quality of life evaluation was based on a battery of questionnaires, covering general body symptoms, mood level and functional limitations. Patients with gastric cancer reported more neurasthenic complaints such as reduced sexual interest, insomnia and poor appetite as well as a lower mood level than the general population. The gastric cancer group also showed a markedly lower mood level in comparison with a group of cancer survivors 2-3 years after diagnosis and patients with intermittent claudication. The mental well-being of gastric cancer patients matched that of cancer survivors with one or more recurrences. Overall, 25% of the gastric cancer patients reported functional limitations regarded as clinically significant. Patients with intermittent claudication reported more and patients with small cell lung cancer markedly more limitations. We conclude that although patients with gastric cancer showed a low level of limitations on average, problems in the areas of sleep/rest, home management and, especially, eating were frequently reported.

Adult↗
PubMed1996

The endoscopic assessment of esophagitis: a progress report on observer agreement.

BACKGROUND & AIMS: The study and management of reflux esophagitis require an endoscopic classification system founded on esophageal lesions that can be reproducibly identified. The aim of this study was to investigate interobserver agreement for the identification of endoscopic lesions typical of reflux esophagitis. METHODS: Paired comparisons of observers' descriptions were obtained. Seventeen endoscopists assessed 100 still images, and 42 endoscopists, including 13 endoscopists in training, assessed 23 endoscopic video recordings. In a third, ancillary study, using a simpler evaluation sheet, 219 gastroenterologists recorded their assessments of 20 still images. RESULTS: The agreement between endoscopists was similar for still images and video recordings. Agreement between experienced endoscopists was acceptable to good for recognition of minimal changes (erythema, friability, mucosal edema; kappa = 0.46 to kappa = 0.8), mucosal breaks (discretely, demarcated areas of slough or erythema; kappa = 0.84), and complications (ulceration, kappa = 0.92; stricturing, kappa = 0.80; columnar metaplasia, kappa = 0.81), although there was poor agreement when the circumferential extent and number of mucosal breaks were assessed. However, total circumferential extent of the mucosal break had a kappa value of 0.59. Agreement between inexperienced endoscopists was poor for recognition of minimal changes but was good for recognition of complications (kappa, 0.70-0.90). CONCLUSIONS: Endoscopists can identify mucosal breaks confined to a mucosal fold and lesions that extend throughout the esophageal circumference. Complications of reflux disease can be reproducibly recorded. Criteria for assessing the number of mucosal breaks and their radial extent must be defined more clearly, as must the features of minimal change esophagitis.

Esophagitis↗
PubMed1996

Is motility impaired in the entire upper gastrointestinal tract in patients with gastro-oesophageal reflux disease?

BACKGROUND: Although the pathogenesis of gastro-oesophageal reflux disease is multifactorial, abnormal function of the lower oesophageal sphincter has been established, and in some cases motility defects in the oesophageal body has been described. In some patients with gastro-oesophageal reflux disease delayed gastric emptying has also been observed. METHODS: Oesophageal and gastric motor function, as evaluated by use of scintigraphy and manometry, were studied concomitantly in 105 patients with chronic, gastro-oesophageal reflux disease before and after antireflux surgery. In a subgroup of these patients (n = 29) similar data were retrieved also at 2.7 years after antireflux surgery. RESULTS: Impaired oesophageal motor function expressed as delayed transit of a labelled bolus was closely associated with motor dysfunction also recorded in the stomach as determined by delayed emptying of labelled solid food items. A similar relationship was found when oesophageal motor dysfunction was characterized as the frequency of failed primary peristalses after water swallows during manometry. When the 105 patients were studied half a year after an antireflux operation, noncorrelation between oesophageal and gastric motor function could be recorded. CONCLUSIONS: These data further substantiate the view that gastro-oesophageal reflux disease is associated with a disturbed motor function within the entire upper gastrointestinal tract.

Adult↗
PubMed1996

Quality of life assessment after laparoscopic and open fundoplications. Results of a prospective, clinical study.

BACKGROUND: In the evaluation of different treatment alternatives, assessment of the patients' own perceived situation can give important clinical information in addition to the conventional efficacy variables used. METHODS: Fifty patients with chronic gastroesophageal reflux disease (GERD) were operated on with either an open fundoplication (n = 25; 17 men; mean age, 51.5 years) or with a fundoplication through the laparoscope (n = 25; 16 men; mean age, 49.8 years). In each case adequate control of the GERD was achieved with the operation, also when objectively assessed. Twelve months after surgery the quality of life was studied by using a battery of self-administered questionnaires (the Psychological General Well-being (PGWB) index and the Gastrointestinal Symptom Rating Scale (GSRS), and a visual analogue scale, depicting specific reflux-related symptoms (RVAS). RESULTS: After antireflux surgery the overall PGWB scores were normalized with no obvious difference between the two procedures. In the GSRS scale, however, differences were shown between the two procedures, with more dyspeptic and indigestion symptoms in patients having a laparoscopic total fundic wrap. CONCLUSION: These data emphasize the clinical efficacy of antireflux surgery, with normalization of the quality of life in terms of well-being after these procedures. It should be noted that these instruments are sensitive enough to pick up significant differences between different antireflux procedures and should therefore be frequently used in the attempt to refine and optimize long-term therapeutic alternatives in reflux disease.

Female↗
PubMed1996

Laparoscopic gastric bypass. Another option in bariatric surgery.

BACKGROUND: The present report describes the technical details of laparoscopic bypass for morbid obesity. METHODS: The laparoscopic approach was attempted in eight patients and completed in six. In these latter patients the stomach was divided with an endoscopic linear cutter (ETC 60 Ethicon), and a antecolic jejunal loop was brought to the proximal pouch and anastomosed by use of manual suture technique supported with locking clips for knotting substitutes [Lapra-Ty (Ethicon)]. Distal to the gastrojejunostomy a side-to-side enteroanastomosis was also performed. RESULTS: Five patients in whom the laparoscopic procedure was completed had an uneventful postoperative period and a rapid recovery. However, one patient had a postoperative left-sided pleuropneumonia that required prolonged hospital stay. Of those who were converted, one was because of a large steatotic left liver lobe and another was due to a perforation of the small intestine. CONCLUSIONS: These early results indicate that gastric bypass for the treatment of morbid obesity can be safely performed with laparoscopic techniques. Further development in this field should be encouraged.

Adult↗
PubMed1996

Vertical banded gastroplasty by laparoscopic technique in the treatment of morbid obesity.

From October 1993 through May 1994, 38 consecutive morbidly obese patients underwent a laparoscopic vertical banded gastroplasty (VBG). During the operation a gastric window was made by a 25-mm circular stapler; and the vertical staple line, establishing the gastric pouch, was constructed by using a 60-mm, four-row linear stapler. The outflow stoma was reinforced by a Gore-Tex band and calibrated to have an internal diameter of 9 mm. Three patients had to be converted to open surgery during the initial laparoscopic procedure because of insufficient operative access. Another three patients had to be reoperated during subsequent postoperative courses, one laparoscopically to reinforce a vertical staple line defect caused by a transected nasogastric tube, another because of an open reoperation during the first postoperative day for a rupture in the vertical staple line, and, finally, a patient was reexplored because of the present of postoperative fever with a left-sided pleuropneumonia and subphrenic accumulation of fluid. However, during the operation no leakage or any other local complications were detected. The subsequent postoperative courses were uneventful in all these patients. Compared with the reference group comprising the latest consecutive 17 obese patients operated with open VBG before the introduction of the laparoscopic technique, the laparoscopy group had less postoperative pain and had mobilization sooner. In the latter group, we recorded an improved respiratory status during the early postoperative period, as reflected by increased oxygen saturation and peak exspiratory flow rates as well as a lower body temperature. In conclusion, laparoscopic VBG is technically feasible and can be safely performed. Our early postoperative experiences suggest that these patients have a shorter and less cumbersome postoperative recovery period compared with conventionally operated obese patients. The long-term follow-up of these patients will determine whether these initial advantages of the laparoscopic approach are corroborated by comparable effects on weight control.

Adult↗
PubMed1995

Does massive obesity promote abnormal gastroesophageal reflux?

Fifty consecutive massively obese patients referred for gastroplasty operations were prospectively studied to determine the existence of gastroesophageal reflux disease by means of a standardized questionnaire, 24-hr ambulatory pH-metry, and endoscopy (27 females, mean age 48 years, range 38-57 years). These patients had a body mass index (BMI) of 42.5 +/- 5.2 kg/m2 and an actual weight of 125.5 +/- 17 kg. Heartburn and acid regurgitation was reported by 37% and 28%, respectively, mostly of a mild degree (22% and 20%). Dysphagia was reported by 2%, but none had odynophagia. No patient had any macroscopic esophagitis. The pH data were compared with those obtained in 29 age- and sex-matched, symptom-free, healthy controls (15 females, mean age 47.6 years, range 30-63 years). During ambulatory pH-metry, we recorded a predominance of daytime reflux (7.2 +/- 8.2% and total acid exposure of 5.3 +/- 6.4%) in the obese patients, but neither the weight, BMI, nor the waist-hip ratio were significantly correlated with any of the reflux variables. The pH data obtained from these patients did not, however, differ significantly from those recorded in the control population, although a somewhat lower daytime acid reflux was found in the latter group. These results suggest that massive overweight is not associated with an increased prevalence of gastroesophageal reflux disease.

Adult↗
PubMed1994

Role of acid secretory response to sham feeding in predicting recurrent ulceration after proximal gastric vagotomy.

The completeness of vagal denervation in determining the long-term outcome of patients with duodenal ulcer disease after proximal gastric vagotomy (PGV) was studied by examining the relationship between the postoperative acid secretory response to sham feeding ('chew and spit' technique) and the subsequent ulcer recurrence rate during a mean follow-up of 7.5 (range 5-15) years. The cumulative recurrence rate of 98 patients analysed prospectively was 11 per cent. Of 22 patients who had incomplete vagotomy as suggested by the sham feeding response, five had a later relapse. This compares with only an 8 per cent relapse rate among those with a secretory response suggesting complete vagotomy. Four patients suffered from a relapse more than 5 years after operation but none had undergone incomplete vagotomy. However, in seven patients with an early postoperative relapse (within 5 years) five had had incomplete vagal denervation (P < 0.05). In this latter group the median time elapsed from surgery until the first recurrence was only 1 year. It is concluded that the early postoperative acid secretory response to a sham feeding stimulus is clinically useful as it allows prediction of the risk of early relapse after PGV. This test may be helpful for the validation of new techniques of vagotomy.

Adult↗
PubMed1994

Clinical management of gastric carcinoid tumors.

Four types of gastric carcinoids have been identified: (1) multiple small body-fundus carcinoids associated with chronic atrophic gastritis type A (A-CAG); (2) sporadic solitary lesions without specific pathogenetic background (non-A-CAG); (3) carcinoidosis associated with Zollinger-Ellison/MEN 1 syndrome, and (4) rare tumors, e.g. gastrin cell tumors, neuroendocrine carcinomas and mixed endocrine-exocrine tumors. In a retrospective study of 15 patients with gastric carcinoids (11 A-CAG, 3 non-A-CAG and 1 gastrin cell tumor) over a 10-year period, the histopathological and clinical features were assessed. The A-CAG-type carcinoids were clinically silent with lymph node metastases in 2/11 cases but no hepatic metastases. The non-A-CAG-type carcinoids were malignant with disseminated disease, hormonal symptoms and increased urinary excretion of the main histamine metabolite, MeImAA. Five patients with A-CAG tumors were subjected to antrectomy to remove hypergastrinemia, which is thought to be of pathogenetic importance for these tumors. During the observation period (1.5-8 years) 1 patient developed recurrent tumors, while the other 4 showed persistent argyrophil cell hyperplasia. A prospective treatment protocol of these tumors is suggested with endoscopic removal of less numerous, small lesions as first-step therapy, followed by antrectomy at recurrence. Larger lesions should be excised in combination with antrectomy. Gastrectomy is reserved for the rare cases of invasive tumors with lymph node metastases. As evident from the outcome of patients with non-A-CAG tumors radical surgery should be performed whenever practicable.

Carcinoid Tumor↗
PubMed1994

Long-term treatment of gastro-oesophageal reflux disease with omeprazole.

Reflux oesophagitis is a chronic disorder with frequent relapses on cessation of initial successful treatment. In patients with reflux oesophagitis, treatment with the acid pump inhibitor, omeprazole, has repeatedly been demonstrated to prevent the recurrence of symptoms and of erosive and/or ulcerative lesions in the oesophagus. Comparative trials have shown that an average of 82% of oesophagitis patients were maintained in endoscopic and symptomatic remission over a period of 12 months when treated with omeprazole, 20 mg once daily. This compares with only 36% of patients in remission when given 'full-dose' H2-receptor antagonist therapy (ranitidine, 300 mg daily). It is interesting to note that, in a recent trial, 62% of reflux oesophagitis patients were in remission after 12 months of treatment with omeprazole, 10 mg once daily, compared with the corresponding figure of 72% among those on 20 mg once daily. In patients poorly responsive to control of oesophagitis with H2-receptor antagonists, omeprazole at a dose of at least 20 mg daily is required to achieve symptom resolution and endoscopic healing--and remission can be maintained for years with continued omeprazole treatment. Omeprazole has been shown to have a good long-term safety profile, as evaluated in these trials.

Chronic Disease↗
PubMed1993

The effect of antireflux operations on lower oesophageal sphincter tone and postprandial symptoms.

To elucidate potential mechanism(s) behind the mode of action of antireflux operations, the basal tone of the lower oesophageal sphincter and the relaxation after water swallows were studied before and after either a total fundic wrap (n = 25), highly selective vagotomy combined with fundoplication (n = 38), or insertion of an Angelchik prosthesis (n = 9). The basal tone preoperatively was similar in the three study groups, as was the relaxation that ensued on water swallows (nadir pressure). The fundic wrap increased the basal pressure in the lower oesophageal region from 13.0 +/- 2.3 (SE) to 21.2 +/- 2.4 mm Hg (p = 0.01), and insertion of the prosthesis around the sphincter had a similar effect (from 10.2 to 19.3 mm Hg). However, the combined vagotomy and fundic wrap procedure did not significantly change the basal pressure recordings (13.9 to 14.3 mm Hg). The mean nadir pressure after water swallows increased significantly postoperatively in all study groups. Patients with fundoplication and highly selective vagotomy relaxed their lower oesophageal sphincter less than patients with fundoplication only (p < 0.05). Similar results were obtained in patients who had an Angelchik insertion, although this did not reach statistical significance. These results suggest that the fundic wrap functions in part as a mechanical external compression and that the vagus nerve contributes to the ability of the postoperative high-pressure zone to relax on swallowing.(ABSTRACT TRUNCATED AT 250 WORDS)

Deglutition↗
PubMed1992

Defective inhibition of gastrin release by antral distension in duodenal ulcer patients.

The gastrin response to a low and a high dose of gastrin-releasing peptide infusion was studied in healthy volunteers and in patients with duodenal ulcer disease. In duodenal ulcer patients, the gastrin response was exaggerated. Cholinergic blockade did not change the gastrin release in healthy volunteers. Antrum distension during neutralization of the gastric lumen was unable to stimulate gastrin release, also under cholinergic blockade. However, in healthy volunteers distension of the antrum significantly inhibited the gastrin response to gastrin-releasing peptide infusion. This inhibitory influence was most pronounced in patients given the lower dose of the neuropeptide. Cholinergic blockade counteracted the inhibitory effect exerted by antral distension. On the other hand, antral distension did not alter the gastrin response to gastrin-releasing peptide in patients with duodenal ulcer disease. These results suggest an additional defective inhibitory mechanism in duodenal ulcer patients.

Adult↗
PubMed1992

Nervous control of distension-induced relaxation of the porcine lower oesophageal sphincter.

The mechanisms involved in the relaxation of the lower oesophageal sphincter induced by distension of the oesophagus and different parts of the stomach, were studied in an anaesthetized porcine model. A computer technique was developed allowing on-line digitizing of lower oesophageal sphincter (sleeve device) and intragastric pressures. Basal sphincter tone was slightly reduced by truncal vagotomy, an effect which seemed to be reversed by sectioning of the vagosympathetic trunks in the neck. Balloon distension of the body of the oesophagus, relaxed the sphincter irrespective of the denervation procedures carried out. Distension of the whole stomach with increasing amounts of air induced a dose-dependent relaxatory lower oesophageal sphincter response, which was also closely associated with the subsequent increases in intragastric pressure. Denervation procedures did not alter this dose-response relationship. The importance of intramural mechanisms was illustrated by the abolition of distension-induced effects in most animals studied after transection of the gastro-oesophageal junction distal to the sphincter. Balloon distension of the antrum elicited a smaller but significant sphincter relaxation, but the mechanisms behind this response seemed to be more complex than after insufflation of air.

Animals↗