Search PubMed⌕ Search

Biomedical subjects

M G Patti

Publications and source records attributed to M G Patti.

At least 37 records · Page 2Linked to original sources
PubMed1998

Changing management of gallstone disease during pregnancy.

BACKGROUND: Symptomatic gallstones may be problematic during pregnancy. The advisability of laparoscopic cholecystectomy (LC) is uncertain. The objective of this study is to define the natural history of gallstone disease during pregnancy and evaluate the safety of LC during pregnancy. METHODS: Review of medical records of all pregnant patients with gallstone disease at the University of California, San Francisco, from 1980 to 1996. RESULTS: Of approximately 29,750 deliveries, 47 (0.16%) patients were treated for gallstone disease, including biliary colic in 33, acute cholecystitis in 12, and pancreatitis in two. Conservative treatment was attempted in all patients but failed in 17 (36%) cases. Two patients required combined preterm Cesarean-section cholecystectomy and 10 required surgery in the early postpartum period for persistent symptoms. Seventeen patients required cholecystectomy during pregnancy for biliary colic (10), acute cholecystitis (six), and pancreatitis (one). Three patients were treated with open cholecystectomy. Fourteen patients underwent LC at a mean gestational age of 18.6 weeks, mean OR time of 74 min, and mean length of stay of 1.2 days. Hasson cannulation was utilized in 11 patients. Reduced-pressure pneumoperitoneum (6-10 mmHg) was used in seven patients. Prophylactic tocolytics were used in seven patients, with transient postoperative preterm labor observed in one. There were no open conversions, preterm deliveries, fetal loss, teratogenicity, or maternal morbidity. CONCLUSIONS: In past years, symptomatic gallstones during pregnancy were managed conservatively or with open cholecystectomy. LC is a feasible and safe method for treating severely symptomatic patients.

Adult↗
PubMed1998

Results of laparoscopic antireflux surgery for dysphagia and gastroesophageal reflux disease.

BACKGROUND: Little attention has been paid to nonobstructive dysphagia (dysphagia in the absence of an esophageal stricture) in patients with gastroesophageal reflux disease (GERD). The objectives of this study were to assess (a) the incidence of nonobstructive dysphagia in patients with GERD; and (b) the effects of laparoscopic fundoplication on nonobstructive dysphagia. METHODS: Esophageal manometry and pH monitoring identified 666 patients with GERD. Two hundred and eight patients (31 %) without esophageal strictures complained of dysphagia in addition to heartburn and regurgitation. Forty-nine (24%) of these patients underwent laparoscopic fundoplication. Esophageal function tests were repeated postoperatively in 12 patients (25%). Main outcome measures were effects of laparoscopic fundoplication on symptoms and esophageal motor function. RESULTS: Dysphagia resolved postoperatively in 44 patients (90%), and improved in 2 patients (4%). Postoperative esophageal manometry showed a significant increase in the length and pressure of the lower esophageal sphincter, without changes in its ability to relax in response to swallowing. CONCLUSIONS: About one third of GERD patients without strictures experienced dysphagia; and dysphagia resolved in about 90% of such patients following a laparoscopic fundoplication.

Deglutition↗
PubMed1998

Laparoscopic repair of paraesophageal hiatal hernias.

BACKGROUND: Regardless of symptoms, paraesophageal hiatal hernias should be repaired in order to prevent complications. This study reports the University of California San Francisco experience with laparoscopic repair of paraesophageal hiatal hernias, emphasizing the technical steps essential for good results. PATIENTS AND METHODS: From May 1993 to September 1997, 55 patients, 27 women and 28 men, with a mean age of 67 years (range, 35-102 years) underwent laparoscopic repair of paraesophageal hernias at the University of California San Francisco. Symptoms, which had been present an average of 85 months before surgery, consisted mainly of pain (55%), heartburn (52%), dysphagia (45%), and regurgitation (41%). Of the four patients who presented with acute illness, two had gastric obstruction, one had severe dyspnea, and one had gastric bleeding. Endoscopy demonstrated esophagitis in 25 (69%) of 36 patients, and 24-hour pH-monitoring demonstrated acid reflux in 22 (67%) of 33 patients. Manometry detected severely impaired distal esophageal peristalsis in 17 (52%) of 33 patients. The preferred operation consisted of reduction of the hernia, excision of the sack and the gastric fat pad, closure of the enlarged hiatus without mesh, and construction of a fundoplication anchored by sutures within the abdomen. RESULTS: Of the 55 patients, the operations of 49 were completed laparoscopically using the following reconstructions: Guarner (270-degree) fundoplication (30 patients); Nissen fundoplication (10 patients); and gastropexy (9 patients). Five (9%) operations were converted to laparotomies. The average operating time was 219 minutes; the average blood loss was less than 25 mL; resumption of an unrestricted diet, 27 hours; and mean hospital stay, 58 hours. Intraoperative technical complications occurred in five (9%) patients. One patient died during surgery from a sudden pulmonary embolus. Two (4%) patients required a second operation for recurrent paraesophageal hernias. CONCLUSIONS: Laparoscopic repair of paraesophageal hiatal hernias is safe and effective, but the operation is difficult and good results hinge on details of the operative technique and the surgeon's experience. In this series, the crus could always be closed securely without using mesh. We realized early that a fundoplication should be a routine step, because it corrects reflux and is the best method to secure the gastroesophageal junction in the abdomen.

Adult↗
PubMed1997

Partial fundoplication for gastroesophageal reflux.

BACKGROUND: About 20% of patients with gastroesophageal reflux disease (GERD) have severely impaired esophageal peristalsis in addition to an incompetent lower esophageal sphincter. In these patients a total fundoplication corrects the abnormal reflux, but it is often associated with postoperative dysphagia and gas bloat syndrome. We studied the efficacy of partial fundoplication in such patients. METHODS: A partial fundoplication (240 degrees -270 degrees ) was performed laparoscopically in 26 patients (11 men, 15 women; mean age 50.5 years) with GERD (mean DeMeester score: 92 +/- 16) in whom manometry demonstrated severely abnormal esophageal peristalsis. RESULTS: All operations were completed laparoscopically and the patients were dicharged an average of 39 h after surgery. The preoperative symptoms resolved or improved in all patients, and no patient developed dysphagia or gas bloat syndrome. Postoperative pH monitoring showed complete or nearly complete resolution of the abnormal reflux in every patient. CONCLUSIONS: Partial fundoplication is an excellent treatment for patients with GERD and weak peristalsis, for it corrects the abnormal reflux and avoids postoperative dysphagia.

Endoscopy, Digestive System↗
PubMed1997

Surgery of the esophagus. Anatomy and physiology.

The esophagus can be divided into three parts: cervical, thoracic, and abdominal. Its blood supply, lymphatic drainage, innervation, and architecture of the esophageal wall are described. The topographic relationships of the esophagus and the gastroesophageal junction with neighboring structures are illustrated from the right and left thoroscopic and the laparoscopic viewpoints. Functionally, the esophagus consists of the upper esophageal sphincter; the esophageal body; and the lower esophageal sphincter. Their coordinated muscular activity transports the food bolus into the stomach, while maintaining a barrier against reflux of esophageal contents into the pharynx and gastric juice into the esophagus.

Esophagogastric Junction↗
PubMed1997

Evaluation and treatment of primary esophageal motility disorders.

Achalasia, diffuse esophageal spasm, and nutcracker esophagus constitute the main primary esophageal motility disorders. During the past decade major progress has been made in understanding their pathophysiology and in the ability to establish a precise diagnosis. In addition, minimally invasive surgical intervention has radically changed the therapeutic approach, and thoracoscopic or laparoscopic myotomy is probably the best treatment for most patients.

Diagnosis, Differential↗
PubMed1997

Prognostic factors in esophageal cancer.

Clinical and pathologic factors relevant to the prognosis of esophageal cancer are reviewed in this article. Clinical factors discussed include endoscopic, radiologic, and surgical findings. The importance of Barrett's esophagus and the role of endoscopic screening in the diagnosis of dysplasia and the prevention of adenocarcinoma are evaluated. Pathologic factors include the traditional ones of tumor type, stage, and grade as well as newer tumor markers related to DNA content, rate of cell proliferation, oncogenes, and tumor suppressor genes.

DNA, Neoplasm↗
PubMed1996

Hiatal hernia size affects lower esophageal sphincter function, esophageal acid exposure, and the degree of mucosal injury.

BACKGROUND: Since the role of a hiatal hernia in the pathophysiology of gastroesophageal reflux disease (GERD) has not been fully elucidated, we studied the effects of hiatal hernias on the function of the lower esophageal sphincter (LES) and esophageal acid clearance. PATIENTS AND METHODS: Ninety-five consecutive patients with GERD diagnosed by 24-hour pH monitoring underwent upper gastrointestinal series (UGI), endoscopy, and esophageal manometry. Based on the presence (H+) or absence (H-) of a hiatal hernia on UGI series, they were divided into two groups: H+ (n = 51) and H- (n = 44). Then, using the size of the hiatal hernia, the H+ group was divided into three subgroups: I, H < 3 cm (n = 31); II, H 3.0 to 5 cm (n = 14); and III, H > 5 cm (n = 6). RESULTS: Esophageal manometry showed that patients with larger hiatal hernias (groups II and III) had a weaker and shorter LES and less effective peristalsis compared to patients with a small or no hiatal hernia. Prolonged pH monitoring showed that patients with larger hiatal hernias were exposed to more refluxed acid and had more severely abnormal acid clearance. Endoscopy showed more severe esophagitis among patients with GERD and hiatal hernia compared with GERD patients without hiatal hernia, and the degree of esophagitis was proportionate to the size of the hernia. CONCLUSIONS: Among patients with proven GERD, those with a small hiatal hernia and those with no hiatal hernia had similar abnormalities of LES function and acid clearance. In patients with larger hiatal hernias, however, the LES was shorter and weaker, the amount of reflux was greater, and acid clearance was less efficient. Consequently, the degree of esophagitis was worse in the presence of a large hiatal hernia.

Adolescent↗
PubMed1996

Endoscopic surgical treatment of primary oesophageal motility disorders.

Achalasia, nutcracker oesophagus and diffuse oesophageal spasm are primary oesophageal motility disorders whose treatment has been substantially impacted by the advent and development of minimally invasive surgery. Although several studies had shown that oesophageal myotomy was effective in the treatment of several of these disorders, particularly in the more advanced stages, many of the patients who could have benefited from an operation were instead with medications or balloon dilation, sometimes despite repeated failures of this form of therapy. To a certain extent, this reflected patient and physicians' concerns with the post-operative discomfort and the long recovery time inevitably associated with the performance of a thoracotomy or laparotomy. Today, however, we and others have shown that minimally invasive techniques allow an operation to be performed with the same excellent results provided by open surgery, but with a shorter hospital stay, minimal post-operative discomfort, and faster return to work. We performed our first thoracoscopic myotomy for achalasia in January of 1991, initially using a technique developed by Dr. Cuschieri, which we modified as we gained experience. Subsequently, we extended the same technique to the treatment of diffuse oesophageal spasm and nutcracker oesophagus. This report describes our experience at the University of California at San Francisco and the University of Washington in Seattle for the diagnostic and therapeutic approach to patients with primary oesophageal motility disorders.

Endoscopy↗
PubMed1995

Comparison of medical and minimally invasive surgical therapy for primary esophageal motility disorders.

OBJECTIVE: To compare medical with minimally invasive surgical therapy in the treatment of primary esophageal motility disorders. DESIGN: Prospective study. SETTING: University-based tertiary care center. PATIENTS: Eighty-nine patients (46 men and 43 women) with either achalasia or nutcracker esophagus and diffuse esophageal spasm (DES). Choice of treatment was based not on randomization but on the preference of the referring physician, the patient's choice, and/or the patient's eligibility to access the University of California, San Francisco, for treatment. INTERVENTIONS: Nineteen patients with achalasia and 30 patients with nutcracker esophagus and DES were treated with dilatations and/or medications. Thirty patients with achalasia and 10 with nutcracker esophagus and DES underwent a thoracoscopic myotomy. MAIN OUTCOME MEASURES: Dysphagia, pain, and overall quality of life. RESULTS: In the surgical group, 80% of the patients with nutcracker esophagus and DES and 87% of the patients with achalasia had good or excellent results. In contrast, in the medical group, 26% of the patients with nutcracker esophagus and DES and 26% of the patients with achalasia had good or excellent results. CONCLUSIONS: Surgery by minimally invasive techniques offers a better chance than does medical therapy or dilatation of rendering the patient with achalasia, nutcracker esophagus, and DES asymptomatic.

Adult↗
PubMed1995

Minimally invasive surgery for gastroesophageal reflux disease.

BACKGROUND: The goal of this study was to determine if the outcome of antireflux surgery can be improved by: (1) conducting a careful preoperative workup to characterize gastroesophageal reflux disease (GERD) in the individual patient; and (2) tailoring the operation to the results of the preoperative function tests. PATIENTS AND METHODS: Sixty-eight patients had operations for GERD by minimally invasive techniques. RESULTS: A Rossetti fundoplication was performed in 22 patients. Sixty-eight percent became asymptomatic. Twenty-seven percent developed dysphagia or gas bloat. Thirty-five patients had a Nissen fundoplication. Ninety-one percent are asymptomatic. Eleven patients with severe abnormalities of esophageal peristalsis underwent a Guarner fundoplication with relief of symptoms in 82% of patients. No patients in the Nissen or Guarner group developed postoperative persistent dysphagia or gas bloat. A pyloromyotomy was performed in 3 patients because of severe delayed gastric emptying. CONCLUSIONS: Minimally invasive surgery for GERD gives good-to-excellent results even in patients with abnormal esophageal body function, provided that the operation is tailored to the individual patient based on the results of the preoperative function tests.

Adult↗
PubMed1995

Thoracoscopic and laparoscopic Heller's myotomy in the treatment of esophageal achalasia.

The treatment of esophageal achalasia has been controversial for many years. Even if a myotomy performed through a left thoracotomy gives better results than pneumatic dilatation, the fear of an operation with the associated postoperative pain and disability has kept patients away from this form of treatment. Minimally invasive surgery allows the same results obtained with open surgery, with a short hospital stay, minimal postoperative discomfort, and a fast recovery time. A thoracoscopic or laparoscopic Heller's myotomy should be considered today the primary form of treatment for esophageal achalasia.

Endoscopes↗
PubMed1993

Clinical and functional characterization of high gastroesophageal reflux.

In 70 consecutive patients with symptoms of gastroesophageal reflux (GER), we studied lower esophageal sphincter (LES) and upper esophageal sphincter (UES) pressures, esophageal peristalsis, and esophageal acid exposure 5 and 20 cm above the LES. Based on the percentage of time the pH was below 4 in the proximal esophagus, the patients were divided into 2 groups: (1) group A, less than 3%, 48 patients; (2) group B, greater than 3%, 22 patients. LES was weaker (13.5 +/- 6.0 mm Hg in group A versus 7.8 +/- 4.6 mm Hg in group B) and shorter (2.2 +/- 0.7 cm in group A versus 1.5 +/- 0.5 cm in group B) in group B patients. Group B patients also had lower amplitude of peristalsis in the proximal (59.2 +/- 17.6 mm Hg in group A versus 42.4 +/- 18 mm Hg in group B) and distal esophagus (89.7 +/- 25.2 mm Hg in group A versus 54.7 +/- 27.9 mm Hg in group B) and lower UES pressures (73.7 +/- 30.7 mm Hg in group A versus 54.7 +/- 29.3 mm Hg in group B). Forty-one percent of group B patients had pulmonary aspiration, whereas only 2% of the patients in group A experienced pulmonary aspiration. These data show that, in a subgroup of patients with symptoms of GER, the upper esophagus is exposed to acid for more than 3% of the time. Patients with high GER differ clinically and pathophysiologically from those in whom reflux is limited to the distal part of the esophagus: those with high GER have a panesophageal motor dysfunction and a high risk of aspiration.

Esophagitis, Peptic↗
PubMed1992

Esophageal manometry and 24-hour pH monitoring in the diagnosis of pulmonary aspiration secondary to gastroesophageal reflux.

Twenty-three consecutive patients who had persistent respiratory symptoms of unexplained etiology were evaluated to determine the presence of gastroesophageal reflux (GER) and its relationship to their respiratory complaints. Lower esophageal sphincter (LES) and upper esophageal sphincter (UES) pressures and the characteristics of the peristaltic waves in the proximal and distal esophagus were determined. Esophageal acid exposure 5 cm and 20 cm above the LES was measured using a pH probe with two antimony sensors. Aspiration was diagnosed when respiratory symptoms occurred during or within 3 minutes after a reflux episode, recorded at both levels of the esophagus. Based on these criteria, 12 patients were considered nonaspirators (group A), and 11 were categorized as aspirators (group B). Aspirators had: (1) lower LES pressure (6.1 +/- 3.1 versus 12 +/- 4.8 mm Hg, p less than 0.01); (2) decreased amplitude of peristalsis in the proximal esophagus (34 +/- 16 versus 59 +/- 21 mm Hg, p less than 0.01) and distal esophagus (46 +/- 25 versus 91 +/- 28 mm Hg, p less than 0.01), and higher incidence of simultaneous, nonperistaltic waves (30% versus 4%); and (3) lower UES pressure (44 +/- 23 versus 74 +/- 38 mm Hg). Impaired peristalsis in aspirators caused a higher acid exposure (11.4% +/- 8.0% versus 1.0% +/- 0.7% of time pH less than 4, p less than 0.01) and delayed clearance (5.5 +/- 6.5 versus 0.7 +/- 0.4 min) in the proximal esophagus. Our study shows that, in patients with respiratory symptoms of unexplained etiology, esophageal manometry and 24-hour pH monitoring will identify a subgroup of true aspirators. These patients suffer from a panesophageal motor dysfunction that affects all three barriers to aspiration: the LES, the esophageal "pump mechanism," and the UES.

Adult↗
PubMed1991

Impact of transhiatal esophagectomy on cardiac and respiratory function.

We studied the impact of transhiatal esophagectomy on the cardiac and respiratory function of 44 consecutive patients. Preoperatively, 31 patients had associated medical problems (22 with cardiac disease, 31 with pulmonary disease). Mean forced expiratory volume in 1 second (FEV1) was 2.1 liters, but it was less than 1.2 liters in six patients. Postoperatively, mechanical ventilation was given for a mean of 49 hours. Of the six patients with FEV1 less than 1.2 liters, five were ventilated for an average of 44 hours, and one was ventilated for 221 hours. Intraoperative hypotension, which averaged 8 minutes, was longer in patients with a history of cardiac disease (10 of 14 patients) and in those with a midesophageal tumor (9 of 14 patients). Atrial arrhythmias (14 patients) were more common in patients with a history of cardiac disease and were all successfully treated medically. Nine patients developed congestive heart failure, and they all recovered. Average hospital stay was 15 days. Transhiatal esophagectomy has a greater impact on pulmonary and cardiovascular physiology than previously believed, but the majority of complications can be treated successfully. Transhiatal esophagectomy can be performed safely in patients with poor respiratory function, who constitute about 10% of those who need esophageal resection.

Adult↗
PubMed1990

Gallstone pancreatitis.

Gallstone pancreatitis is caused by transient obstruction of the ampulla of Vater by a migrating gallstone. Intraglandular activation of pancreatic enzymes occurs (by an unclear mechanism), and their entry into the circulation causes most of the local and systemic events of pancreatitis. The diagnosis is based on history and physical examination, an elevation of serum amylase above 1000 IU/L, and ultrasound and CT scans. Endoscopic retrograde cholangiopancreatography can be used in less certain cases to confirm the presence of common bile duct stones. Because of the absence of an agent that can abort progression of the disease, therapy should consist of adequate resuscitation, nutritional support, and careful monitoring to detect early complications. In patients with mild pancreatitis, surgery usually can be performed within 48 or 72 hours of admission or as soon as symptoms and amylase levels return to normal. For patients with severe disease, endoscopic sphincterotomy is emerging as the therapeutic modality of choice. Elective treatment of the associated biliary disease should be performed during the same hospitalization after the acute phase of the disease has subsided.

Acute Disease↗
PubMed1987

Gastric emptying and small bowel transit of solid food after pylorus-preserving pancreaticoduodenectomy.

We examined the gastric emptying and small bowel transit of solid food in ten patients one to 45 months after pylorus-preserving pancreaticoduodenectomy. Gastric emptying and small bowel transit were measured by computer analysis of data from a scintillation camera using technetium Tc 99m-tagged chicken liver mixed with beef stew and were compared with the results in five control subjects. The nutritional status of the patients was also evaluated. Gastric emptying was normal in six patients, rapid in three patients, and delayed in one patient. Small bowel transit was normal in two patients, rapid in seven patients, and delayed in one patient. Most of the patients were asymptomatic, ate three meals a day, and gained weight after the operation. These findings show that after pylorus-preserving pancreaticoduodenectomy, most patients consume a regular diet and achieve an excellent nutritional status. Gastric emptying is normal, not slowed. Small bowel transit is faster than normal but is without clinical sequelae.

Adult↗