Paraplegia after esophagectomy: who are the patients at risk?
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Adenocarcinoma↗
Biomedical subjects
P E Donahue
Publications and source records attributed to P E Donahue.
Serum amylase and lipase elevation is associated with intracranial events.
Serum amylase and lipase elevation has been observed in trauma patients and patients with traumatic intracranial bleeding. However, the causes of this elevation have not been clearly elucidated. A further question remains as to whether other intracranial events are associated with such enzyme elevation as well. We retrospectively reviewed 75 patients consecutively admitted to Cook County Hospital Neurosurgical Intensive Care Unit over a 3-month period for trauma, infection, tumor, or other space-occupying lesions with an unstable condition or neurological deficit. Eleven patients (15%) had elevated amylase and lipase levels. The patients were divided into two groups: Group I (n = 64) had normal and Group II (n = 11) had raised amylase and lipase levels [amylase 402 +/- 444 U/L with normal < or = 125 U/L and lipase 474 +/- 313 U/L with normal < or = 55 U/L]. All Group II patients suffered an intracranial event. Twenty-four Group I (38%) and 10 Group II (91%) patients required craniotomy (P < 0.01). No patients had clinical or radiographic evidence of pancreatitis. In summary, intracranial events are associated with serum amylase and lipase elevation probably through centrally activated pathways. Because of the lack of diagnostic value, routine pancreatic enzyme monitoring should not be performed in this patient population.
Aged↗
Parietal cell vagotomy versus vagotomy-antrectomy: ulcer surgery in the modern era.
Patients with peptic ulcer occasionally develop complications that require surgical intervention, despite the advances in medical treatment and changes in the natural history of disease. The clinical surgeon must make a decision about performing "selective vagotomy antrectomy versus highly selective vagotomy," based on the information discussed herein. The goals for operative treatment remain safe correction of the presenting problem, avoidance of perioperative morbidity and mortality, and freedom from disabling postoperative side effects. This paper addresses broad aspects of the details of surgical interventions; because most operative procedures are performed in urgent circumstances in patients who often have a variety of conditions, it is not surprising that there is no best operation suited to every complication of ulcer.
Decision Making↗
Ulcer surgery and highly selective vagotomy--Y2K.
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Forecasting↗
Laparoscopic myotomy in achalasia: intraoperative evidence for myotomy of the gastric cardia.
The myotomy performed for achalasia of the esophagus should divide all of the constricting, diseased muscular elements that obstruct the esophagogastric junction (EGJ). Whether the disease process includes proximal gastric as well as esophageal components is as yet unclear, but anatomic evidence complemented by clinical data suggest that the disease process does not end at the evanescent and poorly defined EGJ. Clinical reports from enthusiastic proponents of a particular operative approach for achalasia have not been illuminating in this regard, because all patients are improved to some degree post-operatively, and there are no objective parametric standards for the evaluation of swallowing function. This study reports a series of patients in whom endoscopic viewing was used to judge the adequacy of myotomy after 'esophageal' myotomy. The question posed by this study was, 'Does esophageal myotomy remove all constricting elements at the gastroesophageal junction?' Laparoscopic myotomy was performed in 48 patients with a diagnosis of achalasia; these patients are the most recent in a total cohort of 72 patients operated upon for achalasia during the past 20 years. Myotomy was begun on the esophagus, and extended to the esophagogastric junction; anatomic landmarks, including the appearance of submucosal veins, guided the initial dissection. Intraoperative endoscopy was then performed to determine whether there was residual constriction of the channel between the esophagus and stomach; if so, myotomy was extended onto the gastric cardia until visual evidence of obstruction had disappeared. All patients had either Toupet fundoplication or Dor fundoplication after myotomy. There were obvious constricting elements distal to the gastroesophageal junction in 90% of the patients. These patients required extension of the myotomy onto the stomach for an average of 15 mm. All but one patient had improved swallowing post-operatively. Eight patients required 'stretch' of the distal esophagus/cardia within the first year post-operatively; one patient was reoperated for fibrous scar obstruction of the distal esophagus. Esophageal myotomy limited to the esophageal muscle does not remove all constricting elements at the gastroesophageal junction; as a result, the extended myotomy must be complemented by an antireflux procedure during operations for achalasia.
Cardia↗
Trovafloxacin in the treatment of intra-abdominal infections: results of a double-blind, multicenter comparison with imipenem/cilastatin. Trovafloxacin Surgical Group.
BACKGROUND: Trovafloxacin, a new broad-spectrum fourth-generation quinolone, has in vitro activity against most gram-negative and gram-positive anaerobes and aerobes. Trovafloxacin is available as both an intravenous formulation, alatrofloxacin, and a single daily oral tablet. Excellent tissue pharmacokinetics and oral bioavailability suggest usefulness in the treatment of complicated intra-abdominal infections. Thus, the efficacy of alatrofloxacin followed by oral trovafloxacin was compared with the standard regimen of intravenous imipenem/cilastatin followed by oral amoxicillin/clavulanic acid in this prospective, multicenter, double-blind trial. METHODS: Patients were randomized to receive either 300 mg alatrofloxacin daily followed by 200 mg oral trovafloxacin daily or 1 g imipenem/cilastatin intravenously thrice daily followed by 500 mg oral amoxicillin/clavulanic acid thrice daily for up to 14 days following surgical intervention of a documented intra-abdominal infection. Efficacy was assessed at the end of therapy and at follow-up (day 30). RESULTS: At the end of the study, cure or improvement occurred in 83% (129/156) and 84% (127/152) of clinically evaluable patients in the trovafloxacin and comparative groups, respectively. Pathogen eradication rates, adverse-event profiles, and significant laboratory abnormalities were comparable between groups. CONCLUSION: Intravenous alatrofloxacin with or without oral trovafloxacin was as effective as intravenous imipenem/cilastatin followed by oral amoxicillin/clavulanic acid in complicated intra-abdominal infections.
Abdomen↗
Carcinoma involving the gallbladder in elderly patients presenting with acute cholecystitis.
BACKGROUND: The unexpected intraoperative finding of a cancerous gallbladder has become particularly problematic, because cancer recurs rapidly after laparoscopic cholecystectomy. It would be desirable to identify the patients of greatest risk for gallbladder cancer before operation. After several elderly patients presenting with acute cholecystitis were found to have gallbladder cancer, we performed the following study. METHODS: Records of patients (60 years of age or older, 1987 to 1995) with an admitting diagnosis of acute cholecystitis and symptoms including right upper quadrant pain, nausea, vomiting, fever, and leukocytosis were reviewed. RESULTS: Eighty patients were included in the study. Carcinoma involving the gallbladder was found in seven patients; six had primary and one had metastatic carcinoma. The 73 patients without cancer underwent cholecystectomy. The differences between the noncancer and cancer patients included age (68 +/- 7 versus 74 +/- 8 years, p < 0.05), total bilirubin (mg/dl, 1.5 +/- 1.5 versus 3.7 +/- 3.4, p < 0.01), alkaline phosphatase (IU/L, 179 +/- 132 versus 369 +/- 226, p < 0.01), and aspartate aminotransferase (IU/L, 77 +/- 93 versus 158 +/- 157, p < 0.05). CONCLUSIONS: Additional work-up and open cholecystectomy should be considered in elderly patients presenting with apparent acute cholecystitis, especially when liver functions are abnormal.
Acute Disease↗
Basic considerations in gastroesophageal reflux disease.
The cause of foregut symptoms is often quite uncertain until a comprehensive evaluation has been performed. The critical elements of this evaluation include historic, radiographic, endoscopic, and physiologic data, and most importantly, the insight of a mature diagnostician. Patients who are not evaluated in a comprehensive way are at risk for serious postoperative problems; surgeons who perform interventions without appropriate diagnostic support may have to deal with these unhappy patients. In the long run, a complete workup provides the guidance for treatment and is cost-effective.
Animals↗
Cholestasis in patients with acquired immunodeficiency syndrome: a surgeon's perspective.
Cholestasis is a common finding in patients with acquired immunodeficiency syndrome. The underlying causes may be related to intrahepatic processes, cholecystitis, papillary stenosis, or sclerosing cholangitis. Published reports of hepatobiliary diseases in patients with acquired immunodeficiency syndrome are reviewed. The etiological factors are considered, and available therapeutic approaches are discussed. Hepatic causes of cholestasis indicate poor prognosis, and effective treatments are not yet available. Cholecystitis, often acalculous in origin, remains a surgical disease. Endoscopic sphincterotomy appears to give good results in the treatment of papillary stenosis. Although a standard approach to sclerosing cholangitis has not been established, a trial of appropriate antibiotics may be beneficial. Frequently, the cause of cholestasis is multifactorial in these patients; thus, a coherent therapeutic approach is essential for optimal clinical results.
Acquired Immunodeficiency Syndrome↗
A 50-year perspective upon selective gastric vagotomy.
BACKGROUND: The occurrence of postvagotomy complications was initially considered an unavoidable but acceptable consequence of duodenal ulcer surgery. Following the description of "selective" vagotomy procedures, however, it became apparent that effective ulcer surgery might be accomplished without unpleasant sequellae. METHODS: In 1957 the experimental basis for "highly" selective vagotomy (HSV), which preserved antral innervation, was reported. HSV was performed in several European centers between 1960 and 1968, and was widely accepted there. Surgeons in the United States, in contrast, were largely reluctant to use HSV, an operation which had an excessive ulcer recurrence rate compared to vagotomy-antrectomy. More recently, HSV is recognized as a successful operation, due to more complete division of preganglionic gastric vagal nerves ("extended" HSV) and the liberal use of pyloric reconstruction in patients with juxtapyloric ulcers. RESULTS: HSV is performed with minimal morbidity, with an incidence of recurrent ulcer which is less than 5%. Complications such as dumping, diarrhea, and gastric atony are quite rare. CONCLUSIONS: HSV is an ideal procedure for most patients with duodenal ulcer. Because most operations for ulcer are performed for urgent or life-threatening problems, the most common operation performed in the United States today is truncal vagotomy combined with pyloroplasty or gastric resection. Earlier operation for chronic ulcer has many potential advantages.
Duodenal Ulcer↗
Nyhus' half century of surgery.
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General Surgery↗
Multicentric primary adenocarcinomas of the midgut: the first case report.
Multicentric adenocarcinomas of the midgut have not been described; even multiple adenocarcinomas limited to the small intestine are extremely uncommon, with only 14 cases reported in the literature. We report a case of multicentric synchronous involvement of the entire midgut with adenocarcinoma in a 52-yr-old Polish woman who had more than 30 lesions extending from duodenum to mid-transverse colon. There was no family history of cancer. Preoperative evaluation and intraoperative exploration were negative for primary malignancy of the lungs, breasts, ovaries, pancreas, and other parts of the gastrointestinal tract. Results of histopathological examination, immunohistochemical staining, and ras mutational analysis of the lesions uniformly support the diagnosis of multicentric poorly differentiated adenocarcinoma. The cause for this unusual presentation is unknown, although sporadic genetic alteration(s) of oncogene(s) might have been the precipitating event.
Adenocarcinoma↗
Marked asymmetry of LES: important element of LES barrier in subsets of patients with reflux symptoms.
Computerized axial manometry (CAM) of the lower esophagus measures squeeze pressure at multiple points in each segment of the lower esophageal sphincter (LES), calculates several unique parameters of LES function, and constructs a 3-D display of the LES. Whether parameters derived from CAM, such as the radial mean pressure (LESrmp), Asymmetry (Asym), and Vector Volume (VV), have relevance to function of the LES remains undefined. This study compares the results of CAM in patients with gastroesophageal reflux disease (GERD) and controls. There were 54 patients with GERD and 21 volunteers; all underwent CAM as part of their evaluation; GERD was defined by clinical and endoscopic examinations, and all patients had abnormal 24-hour pH tests. Statistical evaluation was performed. The LESrmp and the Vector Volume were significantly correlated in both groups of patients and differed significantly in both. Asymmetry of the LES was a significant negative factor in LES strength as shown by VV and LESrmp. Asymmetry alone, however, did not show a strong correlation with reflux. Asymmetry is indirectly correlated with the major determinants of LES strength; in patients with low VV, asymmetry might be a critical factor. When a high VV is present, asymmetry has no particular relevance. CAM provides invaluable measurements of the LES.
Analysis of Variance↗
Endoscopically defined treatment strategies in patients with locally advanced esophageal cancer.
Sixty-five consecutive, locally advanced esophageal cancer patients were treated by the West Side Medical Center Esophageal Service at the Cook County and University of Illinois hospitals. Each patient was prospectively evaluated with multiple endoscopies including esophagogastroduodenoscopy, bronchoscopy, nasopharyngoscopy, and laryngoscopy. Twenty-four patients (37%) had endoscopic findings that significantly altered therapeutic regimens. Patients identified as having an obvious or impending esophageal fistula or poor performance status were treated in a palliative fashion. Forty (61.5%) patients were considered candidates for treatment with multimodal therapy which included radiation, chemotherapy, and surgery. There was a response rate of 82.5% and a 1-year disease-free survival of 88.9% which was statistically significant when compared to the other patient treatment groups. These data illustrate the necessity of multiple endoscopic evaluation of locally advanced esophageal cancer patients for stratification into appropriate treatment groups. Aggressive treatment afforded selected patients excellent relief of presenting symptomatology, as well as an improved, more acceptable, disease-free survival.
Adenocarcinoma↗
Esophagocardiomyotomy--floppy Nissen fundoplication effectively treats achalasia without causing esophageal obstruction.
BACKGROUND: Effective surgical treatments for achalasia of the esophagus facilitate swallowing by division of muscles that fail to relax normally during swallowing. If esophagocardiomyotomy is performed, a complementary antireflux procedure is mandatory to prevent postoperative gastroesophageal reflux. We evaluated patients who had undergone a circumferential antireflux procedure after esophagocardiomyotomy to determine the effects of this procedure in patients with an aperistaltic esophagus. METHODS: During the past 15 years we treated 94 patients with achalasia by use of pneumatic dilation (66), esophageal myotomy (19), or esophagocardiomyotomy with floppy Nissen fundoplication (24). Achalasia was defined by radiographic and manometric criteria until 1986 when computerized axial manometry of the esophagus was initiated, providing information about the three-dimensional contour and "volume" of the lower esophageal sphincter in addition to the usual manometric data. RESULTS: Dysphagia was effectively relieved in all, and neither postoperative reflux nor esophageal obstruction was observed after esophagocardiomyotomy followed by floppy Nissen fundoplication. The measured lower esophageal sphincter pressures and sphincter volume were markedly reduced. CONCLUSIONS: Esophagocardiomyotomy with floppy Nissen fundoplication is an effective treatment for achalasia; clinical evidence of obstruction of the esophagus was not seen, and manometric data were typical of a weakened sphincter.
Cardia↗
Early postoperative and postgastrectomy syndromes. Diagnosis, management, and prevention.
The evaluation and treatment of patients after operations on the foregut is a challenge for physicians and surgeons. The early postoperative period is an especially important interval because the very survival of the patient as well as the success of the surgical intervention depends on the correct interpretation of the presenting complaints. In all cases, a thoughtful and systematic approach allows physicians and surgeons to identify the causes and best remedies of these challenging problems.
Esophagus↗
The ipsilateral organization of the afferent nerves to the stomach.
In previous nerve tracing studies we found evidence that the efferent gastric vagus nerves supplying the anterior gastric wall had a regional organization. The first part of this study aimed to determine whether vagus afferent nerve cells supplying the stomach have a regional organization; an ipsilateral pattern of innervation was found. Next, selective blockade of the afferent nerves was performed and verified by axonal tracing. Animals with afferent blockade were stressed to determine the effect of afferent nerve blockade on the gastric stress response. After selective blockade of afferent vagus nerves to the anterior gastric wall in rats, water-immersion stress was then applied. The part of the gastric wall with afferent nerve blockade had fewer acute gastric lesions than control animals or the contralateral side of the stomach after 24 hr of stress. This study supports the hypothesis that afferent as well as efferent vagus nerves have an ipsilateral arrangement. Afferent nerve blockade of the left vagus nerve protected the anterior wall of the stomach against stress ulceration.
Afferent Pathways↗
The vagus nerve and its vagaries.
Without any further comments we advise the surgeon performing open or laparoscopic vagotomy to know the anatomy and the vagaries of the vagus nerve. In view of the demonstration that the nerves of the greater curvature, identified as a concern in achieving a "complete" PGV, are projected from up to 20% of the nerve cell bodies of the dorsal motor nucleus of the vagus nerve in the brain stem, we believe it is appropriate to adopt the technique of EHSV as a means of avoiding the high recurrence rates reported with conventional highly selective vagotomy or proximal gastric vagotomy. When pyloric stenosis or outlet obstruction is present, anterior hemipylorectomy provides a solution. If surgeons adopt a laparoscopic approach to EHSV, they must be cognizant of all sites of preganglionic innervation, and (ideally) attempt to verify the "completeness" of vagotomy by Congo red testing. We look forward, also, to the work of Andrus and Schneider, who are evaluating alternative methods of achieving complete vagotomy.
Humans↗