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Biomedical subjects

R A Hinder

Publications and source records attributed to R A Hinder.

At least 37 records · Page 2Linked to original sources
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

Manometric components of the lower esophageal double hump.

BACKGROUND/AIMS: The lower esophageal sphincter manometry of patients with hiatal hernia often displays a double hump configuration. It seems that this is due to gastric herniation above the high-pressure zone of the crura. This study examines this manometric phenomenon in patients with hiatal hernia and relates it to the lower esophageal antireflux barrier. METHODS: Manometric and 24-hour pH studies of 68 consecutive patients with suspected gastroesophageal reflux disease were analyzed to obtain information regarding the double hump and acid reflux. RESULTS: The findings of a manometric double hump correlated well with the presence of a hiatal hernia of >5 cm. The overall length of the sphincter complex was greater in patients with a double hump, but the length below the respiratory inversion point was constant. Resting pressures at the respiratory inversion point were significantly lower than those measured at either high-pressure zone. The location of the respiratory inversion point was seen most commonly at the superior margin of the distal high-pressure zone. Double hump patients with a negative acid reflux score were found to have higher pressures in the distal high-pressure zone than those patients with acid reflux. CONCLUSIONS: The two high-pressure zones comprising the manometric double hump represent the crural and muscular components of the lower esophageal sphincter. Descriptive information regarding the double hump phenomenon is given, and the importance of the crural component of the lower esophageal sphincter in preventing acid reflux is stressed.

Adult↗
PubMed2000

Surgical therapy for GERD: selection of procedures, short- and long-term results.

Surgical options for the supraesophageal complications of gastroesophageal reflux disease (GERD) should be considered in all patients. Although the majority can be managed successfully with medical therapy, patients with severe complications, refractory disease, or with a severely incompetent lower esophageal sphincter should be referred for surgical evaluation. The laparoscopic Nissen fundoplication achieves the same short-term outcome as the open procedure but has associated significantly less morbidity, shorter hospital stay, and more rapid return to normal function. Patients who respond to medical therapy of supraesophageal GERD complications have a predictably better response than nonresponders to antireflux surgery.

Follow-Up Studies↗
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

A new form of access for endo-organ surgery. The initial experience with percutaneous endoscopic gastrostomy.

BACKGROUND: Intraluminal gastric surgery provides a new treatment option for various disease processes. This study assesses the safety of a new large-diameter percutaneous endoscopic gastrostomy (PEG) for intraluminal surgery. METHODS: Investigators at six institutions were asked to complete a standard questionnaire to assess the difficulties associated with the assembly and introduction of the PEG, plus intraoperative and postoperative problems related to placement of the device. RESULTS: In terms of assembly; 1.9% of respondents reported difficulty obtaining complete vacuum of the balloon tip, and 3.8% had difficulty fitting the graduated dilator to the balloon-tipped cannula. Difficulties associated with introduction of the PEG included disengagement of the dilator from the balloon-tipped cannula (0%), extraction of the dilator-port assembly (0%), difficult PEG pullout (1.9%), abdominal wall bleeding (0%), and difficult PEG dilator separation (7.5%). Intraoperatively, 7.5% of respondents reported inadequate skin bolster fitting, 1.9% had CO(2) leakage into the peritoneal cavity, 0% had inadvertent PEG extraction, and 0% reported injury to the esophagus, colon, or small intestine. Postoperatively, there was a 9.4% rate of wound infection, a 1.9% rate of gastrocutaneous fistula, and a 1.9% rate of esophageal, colon, or small intestine injury. CONCLUSIONS: The large-diameter PEG is safe and effective for endo-organ surgery. Additional preventive measures for PEG site infection should be investigated.

Adult↗
PubMed1999

The use of ultrasound to differentiate rectus sheath hematoma from other acute abdominal disorders.

BACKGROUND: Rectus sheath hematoma (RSH) is a rare entity that can mimic an acute abdomen. Therefore, we designed a study to analyze the etiology, frequency, diagnosis using ultrasound, and treatment of RSH. METHODS: A total of 1,257 patients admitted for abdominal ultrasound for acute abdominal pain or unclear acute abdominal disorders were evaluated. RESULTS: In 23 (1.8%) patients, an RSH was diagnosed; three of them were not diagnosed preoperatively by ultrasound. Of 13 men and 10 women (mean age, 57 +/- 23 years), 13 developed RSH after local trauma, three after severe coughing, two after defecation, and five spontaneously. Fifteen had nonsurgical therapy, and eight underwent surgery. The use of anticoagulants was accompanied by a larger diameter of the RSH (p <.012), and surgical therapy was more frequently required in these patients. In the surgically treated group, more intraabdominal free fluid could be detected by ultrasound (p <.0005), patients required less analgesics (p <.001), and the mean hospital stay was shorter (p <.001). CONCLUSIONS: RSH is a rare condition that is usually associated with abdominal trauma and/or anticoagulation therapy. Ultrasound is a good screening technique. Nonsurgical therapy is appropriate but leads to a greater need for analgesics. Surgery should be restricted to cases with a large hematoma or free intraabdominal rupture.

Abdomen, Acute↗
PubMed1999

The effect of medical therapy and antireflux surgery on dysphagia in patients with gastroesophageal reflux disease without esophageal stricture.

BACKGROUND: Poor esophageal body motility and trapping of the hernial sac by the hiatal crura are the major pathomechanisms of gastroesophageal reflux disease (GERD)-induced dysphagia. There is only little knowledge of the effect of medical therapy or antireflux surgery in reflux-induced dysphagia. METHODS: Fifty-nine consecutive GERD patients with dysphagia were studied by means of a symptom questionnaire, endoscopy, barium swallow, esophageal manometry, and 24-hour pH monitoring of the esophagus. Patients had proton pump inhibitor therapy and cisapride for 6 months. After GERD relapsed following withdrawal of medical therapy, 41 patients decided to have antireflux surgery performed. The laparoscopic Nissen fundoplication was chosen in 12 patients with normal esophageal body motility and the laparoscopic Toupet fundoplication in 29 patients with impaired peristalsis. Dysphagia was assessed prior to treatment, at 6 months of medical therapy, and at 6 months after surgery. RESULTS: Heartburn and esophagitis were effectively treated by medical and surgical therapy. Only surgery improved regurgitation. Dysphagia improved in all patients following surgery but only in 16 patients (27.1%) following medical therapy. Esophageal peristalsis was strengthened following antireflux surgery. CONCLUSIONS: Medical therapy fails to control gastroesophageal reflux as it does not inhibit regurgitation. Thus, it has little effect on reflux-induced dysphagia. Surgery controls reflux and improves esophageal peristalsis. This may contribute to its superiority over medical therapy in the treatment of GERD-induced dysphagia.

2-Pyridinylmethylsulfinylbenzimidazoles↗
PubMed1999

Antireflux surgery. Indications, preoperative evaluation, and outcome.

Gastroesophageal reflux disease (GERD) is an extremely common disorder. Many patients require lifelong medical therapy for symptom control. In patients being considered for antireflux surgery, thorough evaluation is required. Laparoscopic antireflux surgery is a safe and effective method of treating patients who have severe, refractory, or complicated GERD. Excellent long-term results are obtained with minimal morbidity, freeing the patient from the burden of chronic medical therapy.

Gastroesophageal Reflux↗
PubMed1999

Gastric acid blockade with omeprazole promotes gastric carcinogenesis induced by duodenogastric reflux.

Duodenogastric reflux (DGR) in rats causes growth stimulation of the foregut mucosa that is potentiated by gastric acid blockade. It was the aim of this study to investigate if DGR with gastric acid blockade has a higher incidence of carcinomas of the foregut than DGR alone. DGR was induced in 40 Sprague-Dawley rats using a split gastroenterostomy. A cardiomyotomy was performed across the gastroesophageal junction, inducing reflux into the esophagus. Twenty of these rats received omeprazole postoperatively. After one year 18 rats (90%) with DGR + omeprazole treatment and 7 rats (35%) with DGR alone developed adenocarcinoma of the stomach (P < 0.05). None of the rats developed esophageal cancer, but esophageal mucosal hyperplasia was more pronounced in rats receiving omeprazole. Control rats, treated with omeprazole, did not develop carcinomas of the foregut. In conclusion, gastric acid blockade enhanced DGR-induced carcinogenesis of the stomach and promotes growth stimulation of the esophageal mucosa.

Adenocarcinoma↗
PubMed1999

Duodenoesophageal reflux induces apoptosis in rat esophageal epithelium.

The esophageal epithelial damage caused by duodenoesophageal reflux was examined by assessing histology, free radicals, and apoptosis in rats with an end-to-side esophagoduodenostomy (reflux group) or sham operation. Rats were sacrificed at 1, 6, or 12 weeks after surgery. Reflux-associated hyperplasia was noted in the reflux group at 6 and 12 weeks. The reflux group manifested glutathione (GSH) overproduction at one and six weeks. Apoptotic cells were detected by the terminal deoxynucleotidyltransferase-mediated dUTP-biotin nick end-labeling method. Significantly increased numbers of apoptotic cells were seen on the epithelial surface in the reflux group at 6 and 12 weeks. Duodenoesophageal reflux causes esophageal injury with hyperplasia. Early GSH overproduction indicated that reflux esophagitis may be partly mediated by free radicals. Increased apoptosis may counteract increased proliferation and may be a protective mechanism against increased genotoxic events.

Animals↗
PubMed1999

Treatment of achalasia: recent advances in surgery.

Achalasia is an uncommon motility disorder of the esophagus with an uncertain etiology. Considerable debate exists regarding the most effective treatment for long-term relief of symptoms. For decades, pneumatic dilatation has been the primary treatment option, and surgery was reserved for patients who required repeated dilations or for those who were not willing to undergo the risk of perforation associated with dilatation. Recently botulinum toxin injection of the lower esophageal sphincter has been shown to provide substantial short-term relief from dysphagia; however, its effect only lasts for a short period of time. Recently, minimally invasive surgical techniques have been developed to perform a Heller myotomy effectively with an antireflux procedure. This has become a primary treatment option for many patients. We present a review of the outcome of different therapeutic options of achalasia with a special focus on laparoscopic procedures.

Anti-Dyskinesia Agents↗
PubMed1999

Laparoscopic antireflux surgery for the treatment of esophageal strictures refractory to medical therapy.

OBJECTIVE: The response of esophageal strictures to laparoscopic antireflux surgery remains controversial. The aim of this study was to examine the outcome of patients with medically refractory esophageal strictures caused by severe gastroesophageal reflux disease and treated surgically. METHODS: A prospective follow-up analysis was completed using data obtained from detailed specific questioning by an independent observer. Responses were rated for symptoms, dysphagia (range 1-19), satisfaction with treatment, well-being (1 = best, 10 = worst), and need for further therapy. RESULTS: Of 102 patients, 74 (72.5%) responded to follow-up. There were 31 women, mean age 59.6 yr, and 43 men, mean age 55.2 yr. Mean follow-up was 25 months (range 4-68 months). A total of 252 dilations before surgery decreased to 29 after surgery (p < 0.0001) in the mean observation period of 26 months before and 25 months after surgery (mean/patient 5.3 and 1.8, respectively, p < 0.001). The mean dysphagia score was 6.8 +/- 3.6 preoperatively and 3.7 +/- 1.4 postoperatively (p < 0.0001). Nine (12%) patients required continuous postoperative H2-blockers or proton pump inhibitors. Seven of these had gastritis or peptic ulcer disease. Before antireflux surgery, 10 (13.5%) had frequent pneumonia. No pneumonia was observed after surgery. Sixty-eight (91.9%) patients were satisfied with their decision to have surgery. Among these, the well-being score was 1.8 +/- 0.4 postoperatively vs 5.5 +/- 1.2 (p < 0.001) preoperatively. CONCLUSIONS: Laparoscopic surgery in patients with medically refractory esophageal strictures results in a good clinical outcome with minimal complications. Patients are very satisfied with relief of dysphagia, and there is a diminished need for further dilation, with good quality of life.

Deglutition Disorders↗
PubMed1999

Minimally invasive surgical techniques for the treatment of gastroesophageal reflux disease.

Open antireflux surgery produces good long-term control of disease, but new interest in the surgical management of gastroesophageal reflux disease has been stimulated by the introduction of minimally invasive techniques to perform standard antireflux procedures. In the past some scepticism existed among gastroenterologists who quoted the poor surgical results they had seen. These bad results, however, were largely due to inappropriate surgery in poorly worked-up patients or antireflux surgery performed by inexperienced surgeons. Since the introduction of minimally invasive surgery for gastroesophageal reflux disease, excellent results have been reported with over 5 years of follow-up. The most common and successfully used laparoscopically antireflux procedures are reviewed and results analyzed.

Algorithms↗
PubMed1999

Laparoscopic antireflux surgery--It's a wrap!

The surgical management of gastroesophageal reflux disease has been simplified by the availability of minimally invasive techniques to treat this condition. The indications and selection of patients remain the same as for open surgery and initial results with laparoscopic antireflux surgery show long-term results equal to, or better than open procedure. These procedures are technically demanding requiring surgeons skilled in advanced laparoscopy. The evaluation of patients, selection of patients for surgery, surgical techniques and anticipated outcomes are discussed.

Female↗
PubMed1999

Laparoscopic partial posterior fundoplication provides excellent intermediate results in GERD patients with impaired esophageal peristalsis.

BACKGROUND: Gastroesophageal reflux disease (GERD) is frequently associated with impaired esophageal peristalsis, and many authorities consider this condition not suitable for Nissen fundoplication. METHODS: To investigate the outcome of antireflux surgery in the presence of impaired esophageal peristalsis, 78 consecutive GERD patients with poor esophageal contractility who underwent laparoscopic partial posterior fundoplication were studied. A standardized questionnaire, upper gastrointestinal endoscopy, esophageal manometry, and 24-hour pH monitoring were performed preoperatively and at a median of 31 months (range 6-57 months) postoperatively. Esophageal motility was analyzed for contraction amplitudes in the distal two thirds of the esophagus, frequency of peristaltic, simultaneous, and interrupted waves, and the total number of defective propagations. In addition, parameters defining the function of the lower esophageal sphincter were evaluated. RESULTS: After antireflux surgery, 76 patients (97%) were free of heartburn and regurgitation and had no esophagitis on endoscopy. The rate of dysphagia decreased from 49% preoperatively to 10% postoperatively (P < .001). Features defining impaired esophageal body motility improved significantly after antireflux surgery. The median DeMeester score on 24-hour esophageal pH monitoring decreased from 33.3 to 1.1 (P < .001). CONCLUSIONS: Partial posterior fundoplication provides an effective antireflux barrier in patients with impaired esophageal body motility. Postoperative dysphagia is diminished, probably because of improved esophageal body function.

Adolescent↗
PubMed1999

Laparoscopic splenectomy: evolution and current status.

The aim of this review is to assess the indications for, and surgical approach to, laparoscopic splenectomy (LS) and to propose a recommendation for the surgical approach to LS. The reports of LS were reviewed with a detailed analysis of indications, surgical technique, and clinical outcome. Thirty-two articles including a total of 643 patients (549 adults and 94 children) were published between August 1994 and May 1997, with a mean of 20 cases per report. LS is recommended if the spleen has a maximum diameter of 20 cm. Compared to the open procedure, there are fewer perioperative complications, less morbidity, and a shorter hospital stay. The disadvantages of LS are longer operation times and less sensitivity in identifying accessory spleens. LS is not the operation of choice for hypersplenism and traumatic splenic injury.

Adult↗