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P J Klingler

Publications and source records attributed to P J Klingler.

At least 19 recordsLinked to original sources
PubMed2004

Aberrant left hepatic artery in laparoscopic antireflux procedures.

BACKGROUND: The aberrant left hepatic artery (ALHA) is an anatomic variation that may present an obstacle in laparoscopic antireflux procedures. Based on our experience, we addressed the following questions: How frequent is ALHA? When or why is it divided? What is the outcome in patients after division of the ALHA? METHODS: From a prospective collected database of 720 patients undergoing laparoscopic antireflux surgery, we collected the following information: presence of an ALHA, clinical data, diagnostic workup, operative reports, laboratory data, and follow-up data. RESULTS: In 57 patients (7.9%) (37 men and 20 women; mean age, 51 +/- 15.7 years), an ALHA was reported. Hiatal dissection was impaired in 17 patients (29.8%), requiring division of the ALHA. In three patients (5.3%), the artery was injured during dissection; in one case (1.8%), it was divided because of ongoing bleeding. Ten of the divided ALHA (55.5%) were either of intermediate size or large. Mean operating time was 2.2 +/- 0.8 h; mean blood loss was 63 +/- 49 ml. Postoperative morbidity was 5.3% and mortality was 0%. None of the patients with divided hepatic arteries had postoperative symptoms related to impaired liver function. Postoperatively, two patients (11.7%) had transient elevated liver enzymes. At a mean follow-up of 28.5 +/- 12.8 months, no specific complaints could be identified. CONCLUSIONS: ALHA is not an uncommon finding in laparoscopic antireflux surgery and may be found in > or =8% of patients. Division may be required due to impaired view of the operating field or bleeding. Patients do not experience clinical complaints after division, but liver enzymes may be temporarily elevated.

Adult↗
PubMed2001

Nipple complication caused by a mesenteric GORE-TEX sling reinforcement in a Kock ileal reservoir: report of a case.

INTRODUCTION: The surgical trend after proctocolectomy at present is to perform a pelvic pouch reservoir with an ileoanal anastomosis. Before that a continent ileal Kock pouch was the procedure of choice, which enabled the patient to collect the intestinal discharge for several hours and avoid involuntary escape of reservoir contents, thus making the wearing of plastic bags unnecessary. Although in the majority of patients an increased life quality can be observed, different complications with a Kock pouch may occur. METHODS: We present a case of a young female with signs of outlet obstruction several years after a Kock reservoir was performed because of complicated ulcerative colitis. The obstruction was caused by a fecal-coated GORE-TEX sling that had penetrated through the nipple-valve base into the pouch. The mesenteric sling was introduced as a modification of the original Kock procedure to reinforce the efferent ileal segment, thus preventing nipple prolapse. The perforation site was closed with interrupted sutures and an ileostomy was performed. RESULTS: Three months thereafter, the ileostomy was closed and at a follow-up visit one year later the patient had no complaints and a well-functioning reservoir. CONCLUSION: If continence is desired after definitive ileostomy or if failure of the ileoanal reservoir occurs, a Kock pouch procedure still has a place in the surgical armamentarium of colorectal surgery. Many experts today do not use sling reinforcement maneuvers, and most of these procedures seem to work well without it.

Adult↗
PubMed2001

Pheochromocytoma.

Explore the source record for details and available documents.

Adrenal Gland Neoplasms↗
PubMed2001

Efficacy of medical therapy and antireflux surgery to prevent Barrett's metaplasia in patients with gastroesophageal reflux disease.

OBJECTIVE: To investigate whether Barrett's metaplasia may develop despite effective medical therapy. SUMMARY BACKGROUND DATA: Gastroesophageal reflux disease has a multifactorial etiology. Therefore, medical treatment may not prevent complications of reflux disease. METHODS: Eighty-three patients with reflux disease and mild esophagitis were prospectively studied for the development of Barrett's metaplasia while receiving long-term therapy with proton pump inhibitors and cisapride. Only patients who had effective control of reflux symptoms and esophagitis were included. The surveillance time was 2 years. The outcome of these 83 patients was compared with that of 42 patients in whom antireflux surgery was performed with a median follow-up of 3.5 years. RESULTS: Twelve (14.5%) patients developed Barrett's while receiving medical therapy; this was not seen after surgery. Patients developing Barrett's had a weaker lower esophageal sphincter and peristalsis before treatment than patients with uncomplicated disease. CONCLUSIONS: Antireflux surgery is superior to medical therapy in the prevention of Barrett's metaplasia. Therefore, patients with reflux disease who have a weak lower esophageal sphincter and poor esophageal peristalsis should undergo antireflux surgery, even if they have only mild esophagitis.

2-Pyridinylmethylsulfinylbenzimidazoles↗
PubMed2001

Clinical and objective data on spinal cord stimulation for the treatment of severe Raynaud's phenomenon.

Ischemic vascular disease of the upper extremity represents a difficult therapeutic problem wherein medical treatment often fails. Epidural spinal cord stimulation has been shown to be an effective alternative in severe peripheral arterial disease. Although this method has been used for nearly two decades only limited experience exists in Raynaud's phenomenon of the upper limbs. In addition objective parameters to prove therapeutic success are not well defined. Herein we describe a patient with severe primary Raynaud's phenomenon over several years who had significant pain relief and complete healing of ischemic digital ulcerations after spinal cord stimulation. Pain level was evaluated using a visual rating scale before and after surgery. Microcirculatory parameters were assessed before and after spinal cord stimulation by capillary microscopy and laser Doppler anemometry. Significant improvement of red blood cell velocity, capillary density, and capillary permeability was demonstrated. At follow-up 18 months after surgery the patient had no complaints and all ulcerations of her fingertips had healed. Spinal cord stimulation appears to be an effective treatment in severe cases of Raynaud's phenomenon and we recommend its use in the case of failed medical therapy. Pain rating and capillary microscopy enable one to assess and visualize the effects of spinal cord stimulation.

Aged↗
PubMed2000

Capnocytophaga pleural empyema following laparoscopic Nissen fundoplication. A rare complication, a rare pathogen.

Empyema complicating laparoscopic fundoplication is exceedingly rare, as is Capnocytophaga infection in the immunocompetent host, with the exception of gingivitis. We report a 29-year-old healthy man who presented with Capnocytophaga empyema 10 days after uneventful elective, laparoscopic Nissen fundoplication for gastroesophageal reflux disease. The exact mechanism of this complication is not known, but hypotheses, including a mini-Boerrhave's syndrome, can be drawn based on knowledge of the operation, the involvement of Capnocytophaga sp., and a patient history that included severe gingivitis. Because of prompt operative evacuation of the empyema and expedient identification of Capnocytophaga in the empyema fluid, appropriate antibiotic therapy was initiated. The infection was adequately treated, and the patient recovered fully. To the best of our knowledge, this is the first report of such a complication.

Adult↗
PubMed2000

[Spontaneous rupture and embolization: a rare complication of port catheter implantation].

HISTORY AND CLINICAL FINDINGS: A 70-year-old male patient had a venous port catheter implanted into his right subclavian vein for neoadjuvant radio-chemotherapy of a rectal carcinoma (T3N0N0). Due to the patient's difficult venous access the catheter was left in situ after treatment. 31 weeks later he was admitted to the hospital because of parasternal and subclavicular pain. INVESTIGATIONS: Physical examination and an electrocardiogram revealed no abnormalities. A chest x-ray was performed. DIAGNOSIS, TREATMENT AND COURSE: The chest x-ray showed a normal location of the port-system but the tip of the catheter had embolized into the right atrium. The embolized fragment was extracted with a loop-snare technique and the reservoir of the system was removed under local anaesthesia without any complications. CONCLUSIONS: Despite its frequent use intravascular embolization of catheter fragments from implantable venous port-catheter systems present a rare but potentially life-threatening complication. Any implanted catheters should therefore be removed after completion of treatment or the system's integrity should be monitored on a regular basis.

Aged↗
PubMed2000

Clinical utility of routine screening for abdominal aortic aneurysm during echocardiography.

BACKGROUND: The aim of this study was to determine the clinical utility of transthoracic echocardiography (TTE) as a screening method for the detection of abdominal aortic aneurysms (AAA). PATIENTS AND METHODS: Each patient who was referred to the echocardiography laboratory TTE was included into the study. After complete cardiac assessment the abdominal aorta was evaluated. Patients with a known, a clinically suspected, or a previously operated AAA were excluded. RESULTS: During the study period, 14,876 patients underwent TTE. 13,166 (88.5%) of the patients were 50 years and older. Of these 6953 (52.8%) were men and 6213 (47.2%) were women. A total of 108 (0.82%; 95% confidence interval (CI) 0.67-0.99) clinically unsuspected AAA of at least 3 cm in diameter (range 3 cm-6.8 cm) were detected. There were 93 (86.1%) men and 15 (13.9%) women with a mean age of 73.8 years (range 59-90). In 7 patients an AAA was suspected by TTE but not verified on subsequent abdominal ultrasound, as the diameter of the abdominal aorta was less than 3 cm. The prevalence of an AAA in patients 50 years and older was 1.34% (95% CI 1.08-1.64) for men and 0.24% (95% CI 0.14-0.40) for women. In patients less than 50 years old no aneurysm was detected. Seventeen patients who were found to have an AAA with a mean diameter of 4.4 cm (range 3-6 cm) underwent successful elective conventional AAA repair after a mean interval of 13.9 months (range 0.2-49 months) following the initial diagnosis. CONCLUSIONS: TTE performed in a highly selected cardiac patient group in a tertiary referral center is not a useful tool to screen for clinically unsuspected abdominal aortic aneurysms due to the low prevalence. The detection of an aneurysm should be confirmed by conventional abdominal ultrasound.

Aged↗
PubMed2000

Simultaneous aortic surgery and malnutrition increase morbidity after revascularisation of the mesenteric arteries.

OBJECTIVE: To evaluate the early and late outcome of mesenteric revascularisation in patients who had had elective mesenteric revascularisation for chronic intestinal ischaemia. DESIGN: Retrospective review. SETTING: Academic clinic, United States. SUBJECT: 19 consecutive patients (7 men, 12 women; mean age 70 years, range 53-83). RESULTS: Angiography showed that 2 mesenteric vessels were affected in 7 patients and 3 in 12. Four patients had coexisting symptomatic aortoiliac occlusive disease and 1 patient had bilateral renal artery stenosis. A total of 36 visceral arteries were revascularised. One patient died postoperatively, and 8 developed serious complications. Morbidity and mortality were significantly higher in patients who had simultaneous infrarenal aortic or renal artery reconstructions (p = 0.01). Patients whose body weight before operation was less than 90% of ideal had more complications (8/11) than patients who were within 10% of their ideal body weight (1/8) (p = 0.02). Cumulative survival was 89% at 1 year, 72% at 3 years, and 57% at 5 years. The cumulative graft patency rate was 92% at 3 years and 66% at 5 years. CONCLUSIONS: Mesenteric bypass procedures for chronic mesenteric ischaemia are durable. Long-term survival and graft patency rates are excellent even in older patients. Simultaneous aortic surgery should be avoided because of the associated morbidity. More than 10% below ideal body weight was associated with higher morbidity. For these patients, early total parenteral nutrition postoperatively, or a period of total parenteral nutrition preoperatively may reduce postoperative morbidity and mortality.

Aged↗
PubMed2000

Accurate placement of the esophageal pH electrode for 24-hour pH monitoring using a combined pH/manometry probe.

OBJECTIVE: Accurate placement of a pH electrode requires manometric localization of the lower esophageal sphincter (LES). Combined manometry/pH devices using water-perfused tubes attached to pH catheters and the use of an electronic "LES locator" have been reported. We investigated whether accurate placement of pH probes can be achieved using such a probe, and whether this may reduce the need for the performance of the usual stepwise pull-back manometry. METHODS: Thirty consecutive patients (15 men, 15 women; median age, 56 yr; interquartile range, 42-68 yr) referred for manometry and pH testing were included in the study. The localization of the LES was determined with standard esophageal manometry. After that, a second 3-mm pH electrode with an internal perfusion port was passed into the stomach. Using this catheter, a single stepwise pull-through manometry was performed and the LES position was noted. LES location, mean pressure, and length obtained with standard manometry were compared to data from the combined pH/manometry catheter. Additionally the time necessary to perform each of the procedures was noted and the patient's discomfort caused by the catheter was evaluated using a standardized questionnaire. RESULTS: The LES location with the pH/manometry probe was proximal to that with standard manometry in 19 patients (63%), the same in nine patients (30%), and distal in two patients (7%). The differences were <2 cm in 29 of 30 (97%) patients. The LES location with the pH/manometry probe required a median of 6.5 min (interquartile range: 3.5-8.5 min) versus a median of 21.5 min (interquartile range: 14.5-26.5 min) for standard manometry (p < 0.0001). In addition, LES evaluation using the combined pH/manometry probe provided accurate data on the resting pressure, as well as overall and intraabdominal length of the LES. All patients tolerated the combination probe better than the standard manometry probe (p < 0.001). CONCLUSIONS: Placement of the esophageal electrode for 24-h esophageal pH monitoring using a combined pH/manometry probe is accurate. The technique is simple, time-saving, and convenient for the patients. Because it is possible to accurately evaluate the LES using this technique, it may even replace conventional manometry before pH probe placement.

Adult↗
PubMed2000

Selection of patients for laparoscopic antireflux surgery.

Since the first laparoscopic fundoplication was performed, the frequency of antireflux surgery has increased rapidly with some centers now having an experience of about 1,000 procedures. The question arises whether this increase is due to a change in indications for the surgical treatment of gastrointestinal reflux disease (GERD) despite the simultaneous appearance of powerful antisecretory medications. Adequate knowledge of the pathophysiology of GERD is necessary in order to establish selection criteria for patients suitable for laparoscopic antireflux surgery. In this article, we review the epidemiology and pathophysiology, and provide a rationale for medical and surgical treatment. We also offer an approach to patient selection for antireflux surgery.

Animals↗
PubMed2000

Clostridium difficile infection: risk factors, medical and surgical management.

BACKGROUND: Clostridium difficile has become recognized as a cause of nosocomial infection which may progress to a fulminant disease. METHODS: Literature review using electronic literature research back to 1966 utilizing Medline and Current Contents. All publications on antibiotic-associated diarrhea, antibiotic-associated colitis, and pseudomembranous colitis as well as C. difficile infection were included. We addressed established and potential risk factors for C. difficile disease such as an impaired immune system and cost benefits of different diagnostic tests. An algorithm is outlined for diagnosis and both medical and surgical management of mild, moderate and severe C. difficile disease. RESULTS: Diagnosis of C. difficile infection should be suspected in patients with diarrhea, who have received antibiotics within 2 months or whose symptoms started after hospitalization. A stool specimen should be tested for the presence of leukocytes and C. difficile toxins. If this is negative and symptoms persist, stool should be tested with 'rapid' enzyme immunoabsorbent and stool cytotoxin assays, which are the most cost-effective tests. Endoscopy and other imaging studies are reserved for severe and rapidly progressive courses. Oral metronidazole or vancomycin are the antibiotics of choice. Surgery is rarely required for selected patients refractory to medical treatment. The threshold for surgery in severe cases with risk factors including an impaired immune system should be low. CONCLUSION: C. difficile infection has been recognized with increased frequency as a nosocomial infection. Early diagnosis with immunoassays of the stool and prompt medical therapy have a high cure rate. Metronidazole has supplanted oral vancomycin as the drug of first choice for treating C. difficile infections.

Bacterial Toxins↗
PubMed2000

Aberrant left hepatic artery in laparoscopic gastric banding.

BACKGROUND: The aberrant left hepatic artery (ALHA) is an anatomic variation which may be an obstacle in the laparoscopic gastric banding operation. Based on our experience, our mission was to answer the questions: How frequently is an ALHA encountered? Is division necessary? Are there any additional complications in cases where the ALHA is preserved? METHODS: In a prospectively collected database of 270 patients undergoing laparoscopic gastric banding in our unit, information including presence of an ALHA, clinical data, diagnostic work-up, operative reports, laboratory data, and follow-up data were collected. RESULTS: In 48 patients (17.7%) (39 women, 9 men, mean age 39.2 years) an ALHA was observed. Hiatal dissection was not impaired in any of these patients, and none required division of the ALHA. In all but two cases, the band was placed above the ALHA, offering additional stability to the band positioning. In 2 patients (4.1%), the artery was injured during dissection and was divided due to ongoing bleeding. Twenty-two (45.8%) of the ALHAs were of intermediate or large size. Neither pouch dilatation nor band slippage occurred in the above-mentioned group. The two patients with divided hepatic arteries had no postoperative symptoms related to impaired liver function. CONCLUSIONS: ALHA is not an uncommon finding during laparoscopic gastric banding and may be found in approximately 18% of patients. Division can nearly always be avoided and may be required only in selected cases due to bleeding. Patients do not experience clinical complications after division, although liver enzymes may be temporarily elevated, and no monitoring is necessary.

Adolescent↗
PubMed2000

Pheochromocytoma in an incidentally discovered asymptomatic cystic adrenal mass.

Cystic adrenal lesions can be either cortical or medullary, and distinguishing between these 2 types of lesions may be important in patient management. Pheochromocytomas, which are adrenal medullary neoplasms, typically manifest with hypertension, headaches, palpitations, tachycardia, sweating, and anxiety symptoms; however, 10% to 17% of patients with pheochromocytomas are asymptomatic. We describe a 67-year-old woman with lifelong headaches and recent persistent cough in whom a left cystic adrenal mass was incidentally discovered by computed tomography of the chest. A moderate increase in normetanephrine and total metanephrine values in two 24-hour urine samples suggested a pheochromocytoma. Computed tomography with use of contrast medium revealed ring enhancement of the cyst wall, a finding consistent with an adrenal medullary tumor. This report demonstrates the importance of repeated 24-hour urine samples to determine the metanephrine values together with contrast-enhanced computed tomography in a patient with nonspecific symptoms.

Adrenal Cortex Function Tests↗
PubMed1999

Is laparoscopic reoperation for failed antireflux surgery feasible?

HYPOTHESIS: Laparoscopic techniques can be used to treat patients whose antireflux surgery has failed. DESIGN: Case series. SETTING: Two academic medical centers. PATIENTS: Forty-six consecutive patients, of whom 21 were male and 25 were female (mean age, 55.6 years; range, 15-80 years). Previous antireflux procedures were laparoscopic (21 patients), laparotomy (21 patients), thoracotomy (3 patients), and thoracoscopy (1 patient). MAIN OUTCOME MEASURES: The cause of failure, operative and postoperative morbidity, and the level of follow-up satisfaction were determined for all patients. RESULTS: The causes of failure were hiatal herniation (31 patients [67%]), fundoplication breakdown (20 patients [43%]), fundoplication slippage (9 patients [20%]), tight fundoplication (5 patients [11%]), misdiagnosed achalasia (2 patients [4%]), and displaced Angelchik prosthesis (2 patients [4%]). Twenty-two patients (48%) had more than 1 cause. Laparoscopic reoperative procedures were Nissen fundoplication (n = 22), Toupet fundoplication (n = 13), paraesophageal hernia repair (n = 4), Dor procedure (n = 2), Angelchik prosthesis removal (n = 2), Heller myotomy (n = 2), and the takedown of a wrap (n = 1). In addition, 18 patients required crural repair and 13 required paraesophageal hernia repair. The mean +/- SEM duration of surgery was 3.5+/-1.1 hours. Operative complications were fundus tear (n = 8), significant bleeding (n = 4), bougie perforation (n = 1), small bowel enterotomy (n = 1), and tension pneumothorax (n = 1). The conversion rate (from laparoscopic to an open procedure) was 20% overall (9 patients) but 0% in the last 10 patients. Mortality was 0%. The mean +/- SEM hospital stay was 2.3+/-0.9 days for operations completed laparoscopically. Follow-up was possible in 35 patients (76%) at 17.2+/-11.8 months. The well-being score (1 best; 10, worst) was 8.6+/-2.1 before and 2.9+/-2.4 after surgery (P<.001). Thirty-one (89%) of 35 patients were satisfied with their decision to have reoperation. CONCLUSIONS: Antireflux surgery failures are most commonly associated with hiatal herniation, followed by the breakdown of the fundoplication. The laparoscopic approach may be used successfully to treat patients with failed antireflux operations. Good results were achieved despite the technical difficulty of the procedures.

Adolescent↗
PubMed1999

DNA-ploidy analysis correlates with the histogenetic classification of thymic epithelial tumours.

The ploidy values of the epithelial component were determined in a series of thymomas and organotypic thymic carcinomas using image cytometry and the results were compared with the histological tumour subtypes according to the histogenetic classification introduced by Marino, Müller Hermelink, and Kirchner (MMHK). Forty-six cases of thymic epithelial tumours were included in the study. After reclassification according to the MMHK classification, the distribution among the subtypes was as follows: three medullary, nine mixed type, five predominantly cortical (organoid), 16 cortical thymomas, and 13 well-differentiated thymic carcinomas. Single cell preparations were made from paraffin-embedded tumour tissue and stained according to Feulgen. Ploidy analysis was performed using an automated image analysis system. In five cases, DNA cytometry could not be performed, for technical reasons. The remaining 41 cases consisted of 11 diploid and 30 non-diploid tumours. The percentage of aneuploid tumours in the different subtypes increased from medullary (0 per cent) through mixed type (44.4 per cent), predominantly cortical (75 per cent), cortical (83.3 per cent) to well-differentiated thymic carcinomas (100 per cent). DNA-ploidy determination using image cytometry correlates with the concept of the MMHK classification of thymomas.

Humans↗