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R F Heitmiller

Publications and source records attributed to R F Heitmiller.

At least 19 recordsLinked to original sources
PubMed1998

Standardized clinical care pathways for major thoracic cases reduce hospital costs.

BACKGROUND: Standardized clinical care pathways have been developed for postoperative management in an attempt to contain costs in an era of rising health care costs and limited resources. The purpose of this study was to assess the effect of these pathways on length of stay, hospital charges, and outcome for major thoracic surgical procedures. METHODS: All anatomic lung (segmentectomy, lobectomy, and pneumonectomy) and partial and complete esophageal resections performed from July 1991 to July 1997 were retrospectively analyzed for length of stay, hospital charges, and outcome. A prospectively developed database was used. Clinical care pathways were introduced in March 1994. Comparisons were made between the procedures performed before (group I) and after (group II) pathway implementation. Common to both pathways are early mobilization and prudent x-ray and laboratory analysis. In addition, the pathway for esophagectomies emphasizes overnight intubation with 24-hour intensive care unit care, and staged diet advancement. The discharge goal was postoperative day 10. For lung resection the emphasis is early postoperative extubation with overnight intensive care unit management. The discharge goal was postoperative day 7. RESULTS: Group I esophagectomies (n = 56) had significantly greater hospital charges compared with group II (n = 96) ($21,977 +/- $13,555 versus $17,919 +/- $5,321; p < 0.04, in actual dollars) and ($29,097 +/- $18,586 versus $19,260 +/- $6,000; p < 0.001, in dollars adjusted for inflation) and greater length of stay (13.6 +/- 6.9 versus 9.5 +/- 2.8 days; p < 0.001). Group I lung resections (n = 185) had a significantly greater length of stay compared with group II (n = 241) (8.0 +/- 6.2 versus 6.4 +/- 3.8 days; p < 0.002); although charges trended downward ($13,113 +/- $10,711 versus $12,404 +/- $7,189; not significant) in actual dollars, charges were significantly less in dollars adjusted for inflation ($17,103 +/- $13,211 versus $13,432 +/- $8,056; p < 0.01). The most significant decreases in charges for esophagectomies were in miscellaneous charges (61% in dollars adjusted for inflation), pharmaceuticals (60%), laboratory (42%) and radiologic (39%) tests, physical therapy charges (35%), and routine charges (34%). For lung resections the greatest savings occurred for pharmaceuticals (38%), supplies (34%), miscellaneous charges (25%), and routine charges (22%). Mortality was similar (esophagectomies: I, 3.6%; II, 0%; lung resections: I, 0.5%; II, 0.8%; not significant). CONCLUSIONS: Introduction of standardized clinical pathways has resulted in a marked reduction of length of stay for all major thoracic surgical procedures. Total charges were reduced for both esophagectomies (34%) and lung resections (21%) with continued quality of outcome.

Aged↗
PubMed1998

The utility of the pectoralis myocutaneous flap in the management of select cervical esophageal anastomotic complications.

OBJECTIVE: The majority of cervical esophageal anastomotic complications can be successfully managed nonoperatively. A small group of patients may have anastomotic strictures or leakage and fistula formation that are chronic and resistant to nonoperative therapy. The purpose of this study was to review our experience with the use of the pectoralis myocutaneous flap to treat these patients. METHODS: Since April 1992, four patients have undergone pectoralis myocutaneous flap repair of cervical esophageal anastomotic complications at our institution. Two patients had chronic strictures, one patient underwent prophylactic repair with a pectoralis myocutaneous flap to prevent stricture formation, and one patient had a chronic anastomotic fistula. The pectoralis myocutaneous flap was harvested in the standard fashion. The technique of anastomotic repair is described. The medical records were retrospectively reviewed to determine patient characteristics and our results. RESULTS: Two suture line leaks developed: one small, contained leak required no intervention, and the other resolved with cervical drainage. Pneumonia, seroma at the site of the pectoralis myocutaneous flap donor, transient hoarseness, and partial skin graft loss occurred in one case each. There were no deaths. Hospital stay ranged from 12 to 22 days. A good functional result was obtained in three patients. CONCLUSION: Our results show that pectoralis myocutaneous flap repair of select cervical anastomotic complications is safe and well tolerated even in patients with complicated problems.

Adult↗
PubMed1998

Strategies to reduce pulmonary complications after transhiatal esophagectomy.

BACKGROUND: By eliminating a thoracotomy, transhiatal esophagectomy (THE) is purported to reduce postoperative pulmonary complications. However, data from many early series do not support this contention, documenting pulmonary complications in up to 50% of patients and pneumonia in 5%-20%. Since 1990, we have implemented a management strategy designed to maximize airway protection in the postoperative period. The purpose of this study was to determine the current incidence of pulmonary complications after transhiatal esophagectomy without thoracotomy. PATIENTS AND METHODS: From 1990 to 1995, 101 consecutive patients underwent THE. Surgical indications were esophageal carcinoma (90 patients) and Barrett mucosa with high-grade epithelial dysplasia (11 patients). Mean age was 60.2 +/- 1.2 years; 89 patients were male. Eighty-two patients were smokers and 26 had chronic obstructive pulmonary disease (COPD). Sixty-five patients were American Society of Anesthesiologists risk score 3 or 4. Postoperatively, all patients were managed according to a standardized clinical pathway that included overnight mechanical ventilation, chest physiotherapy, video pharyngo-esophagram postoperative day 6 or 7, and graduated post-esophagectomy therapeutic diet after acceptable esophagram. RESULTS: Pulmonary complications were classified as major or minor depending upon whether or not a change in therapy was required. Ten patients (10%) had 11 major pulmonary complications. These included pneumonia (3), pleural effusion requiring drainage (4), exacerbation of COPD (2), and mucus plug requiring bronchoscopy or intubation (2). Minor pulmonary complications identified by chest film were atelectasis (97), pleural effusion (85), and pneumothorax (3). Patients with major pulmonary complications were older (69.3 +/- 9.8 vs. 59.2 +/- 12.1 years, p < .02) and more likely to have COPD (70% vs. 21%, p < .005) than those with only minor complications. There were 3 operative deaths; 2 caused by pneumonia and 1 by fungal sepsis in a patient who had exacerbation of COPD. Mean hospital length of stay was 13.1 +/- 1.4 days. CONCLUSIONS: Minor pulmonary complications identified by chest film occur in nearly all patients undergoing THE. Strict adherence to a management protocol designed to maximize airway protection in the postoperative period results in a 10% incidence of major pulmonary complications. Older patient age and COPD are risk factors for major pulmonary complications after THE. Although pneumonia is uncommon, it remains the most frequent cause of death after THE.

Adult↗
PubMed1997

Transhiatal herniation of colon after esophagectomy and gastric pull-up.

Transhiatal herniation of colon is uncommon after transhiatal esophagectomy. Two patients with this complication are presented. Presenting symptoms vary depending on the size and contents of the hernia. Patients may be asymptomatic. The diagnosis is suggested by plain chest radiography, and treatment, in symptomatic patients, is surgical reduction of the hernia via a laparotomy.

Aged↗
PubMed1997

Intramural esophageal dissection.

A case of intramural esophageal dissection is reported and the literature reviewed. Patients with intramural esophageal dissection are usually women in their seventh or eighth decade. The most common presenting symptoms are chest pain, dysphagia, and hematemesis. The diagnosis is made by contrast esophagography, esophagoscopy, or both. Nonoperative therapy has proved to be uniformly successful.

Aged↗
PubMed1997

Multimodality therapy for esophageal cancer.

Over the past decade and a half, several strategies have been developed to improve the survival of patients with esophageal cancer. Two strategies employ either neoadjuvant chemotherapy or chemoradiotherapy followed by surgery to improve local-regional control and decrease the incidence of distant metastases. A third strategy uses nonsurgical therapy as definitive treatment for patients without metastatic disease. Single-institution pilot trials and randomized comparative trials have been conducted evaluating each approach. The rationale for these trials, results, and current recommendations are presented.

Adenocarcinoma↗
PubMed1997

Transthoracic percutaneous endoscopic gastrostomy (PEG) after esophagectomy and gastric pull-up.

The technique of transthoracic percutaneous endoscopic gastrostomy (PEG) tube placement is described as an alternative to standard nasogastric tube drainage and inpatient observation for those patients who require gastric decompression after esophagectomy with gastric pull-up. Indications for transthoracic PEG tube insertion are distention and poor emptying of the intrathoracic stomach conduit with or without contained anastomotic leak, especially when it appears as if the problem will be slow to resolve. This technique is not advocated for patients with free anastomotic leaks. The potential advantages of this technique over standard nasogastric drainage are that it permits stable patients to be treated successfully as outpatients.

Aged↗
PubMed1996

Comparison of prevalence and resection rates in patients with esophageal squamous cell carcinoma and adenocarcinoma.

Since 1987 we have observed a predominance of adenocarcinoma in patients undergoing esophagectomy because of carcinoma at our institution. To discover whether this observation represented an actual change in the prevalence of adenocarcinoma, the Johns Hopkins Hospital pathology records were reviewed for the years 1959 to 1994. Overall, esophageal squamous cell carcinoma was the most common histologic type with 817 cases identified versus 284 cases of adenocarcinoma. The number of patients with squamous cell carcinoma rose slowly from 1959 to 1992 but since 1992 has decreased. Whereas adenocarcinoma was uncommon before 1978, its frequency has since increased markedly, exceeding that of squamous cell carcinoma in 1994. The number of patients with adenocarcinoma who underwent surgical resection has equaled or exceeded the number of those treated nonoperatively for all recorded years. Therefore the predominance of adenocarcinoma in patients undergoing esophageal resection for carcinoma appears to result from two factors: an overall increase in the prevalence of adenocarcinoma since 1978 and an increased likelihood of resection for patients with these tumors.

Adenocarcinoma↗
PubMed1996

Barrett's esophagus with high-grade dysplasia. An indication for prophylactic esophagectomy.

OBJECTIVE: The authors review the results and outcomes of esophagectomy (prophylactic esophagectomy) for patients with Barrett's esophagus and high-grade epithelial dysplasia (HGD). SUMMARY BACKGROUND DATA: The role of prophylactic esophagectomy for Barrett's esophagus with HGD is controversial, with some authors recommending surgery and others favoring endoscopic surveillance until biopsy diagnosis of carcinoma is made. METHODS: Between 1982 and 1994, 30 consecutive patients with HGD underwent esophagectomy and had the pre- and postoperative pathology reviewed at our institution. The medical records were reviewed to determine patient characteristics, preoperative endoscopic data, surgical approach, operative morbidity and mortality, length of hospitalization, and treatment outcome. Patients were divided into two groups based on whether invasive adenocarcinoma was found in the resection specimen (group 1) or not (group 2). RESULTS: The duration of reflux symptoms was 22 +/- 14 years for group 1 and 9 +/- 11 years for group 2 (p = 0.05). There was one operative death (3.3%) and six complications (20%). In 13 patients (43%, group 1), invasive adenocarcinoma was found in the resected esophagus. The American Joint Committee on Cancer stage for these patients was stage I (8 patients), stage II (2 patients), and stage III (3 patients). One stage I patient died of adenocarcinoma (72 months) in an incompletely excised HGD segment. Other stage I and II patients are alive without adenocarcinoma with an 18-and 63-month mean follow-up, respectively. Outcome for stage III patients was one operative death, one noncancer death (6 months), and one patient with metastatic adenocarcinoma (26 months). For group 2 (57%), there were no adenocarcinoma deaths (40 months). CONCLUSIONS: High-grade epithelial dysplasia is an indication for esophagectomy because of the prevalence of occult adenocarcinoma (43%). Esophagectomy can be performed safely, and survival in patients with completely resected Barrett's esophagus and early-stage adenocarcinoma is excellent.

Adenocarcinoma↗
PubMed1996

Cardiopulmonary bypass as an adjunct to pulmonary surgery.

Although performance of concomitant open heart and pulmonary operations has been described, there is general reluctance to perform pulmonary procedures in patients receiving cardiopulmonary bypass (CPB). Reasons for this include fear of excess bleeding caused by systemic heparinization, limited exposure afforded by median sternolomy, and alterations in the immune system caused by CPB that might lead to dissemination of lung cancer or infection. We have used CPB to facilitate operations on the lung in four patients who did not require concomitant cardiac surgery. In each case, lesions involving central pulmonary vessels precluded safe operation by conventional techniques. There were no complications related to the use of CPB. We believe that CPB can be a valuable adjunct in the surgical treatment of selected tumors and vascular malformations that involve large or central pulmonary vessels.

Adult↗
PubMed1996

Esophagectomy for benign disease: trends in surgical results and management.

BACKGROUND: Esophagectomy for benign disease is uncommon. METHODS: From July 1987 to April 1995, 45 consecutive patients (30 men, 15 women; mean age, 50 years) were evaluated in whom the senior author (R.F.H.) performed an esophagectomy, esophageal reconstruction, or both. The study period was divided into two time intervals, July 1987 to January 1992 (time 1) and February 1992 to April 1995 (time 2). RESULTS: Indications for operation included obstruction (23 patients, 51%), benign neoplasia (17.38%), and perforation (5 patients, 11%). A nonthoracotomy approach was used in 19 (42%) patients: 15 transhiatal and 4 substernal. Thoracotomies were performed in 26 (58%) patients through a left thoracoabdominal or multiincisional techniques. Morbidity occurred in 15 (33%) patients, and there was one operative death (2%). CONCLUSIONS: Despite an operative morbidity of 33%, esophagectomy for benign disease may be performed with acceptably low mortality. We observed the following trends: (1) an increase in patients with benign neoplasia and a decline in patients with obstruction, (2) an increased use of transhiatal esophagectomy, (3) a decreased use of colon, an increased use of stomach for esophageal replacement; and (4) a decreased length of hospital stay.

Adolescent↗
PubMed1996

Tracheal release maneuvers.

Tracheal release procedures are specialized surgical techniques designed to permit low tension end-to-end primary reconstruction after tracheal sleeve resection. Therefore, an understanding of the principles and techniques of these tracheal release maneuvers is essential in order to perform tracheal surgery safely. The release procedures include dissection of the pretracheal plane, cervical flexion, and laryngeal and hilar release. Dissection of the pretracheal plane and cervical flexion are the most commonly employed techniques.

Anastomosis, Surgical↗
PubMed1994

Subacute ischemia of the colon esophageal interposition.

The most devastating complication of colon interposition is acute ischemia with colon necrosis. Delayed complications of the interposed colon, including long segment stricturing develop in an occasional patient. Some investigators have speculated that these late complications result from delayed colon ischemia. We believe that these patients represent a small subgroup who have nonnecrotic vascular insufficiency (subacute ischemia) of the interposed colon, which is present from the time of the operation. We reviewed the postoperative contrast radiographic studies of 3 patients with subacute colon ischemia. The radiographic findings are characteristic, and are identical to those seen in ischemic colitis of the nonmobilized colon. They include loss of haustral folds, an ill-defined bowel wall border, and mucosal changes such as "thumbprinting," and "urticaria." Fibrosis and stricturing represent the end-stage of the ischemic process.

Acute Disease↗
PubMed1994

Lung cancer and the left internal mammary artery graft.

A patient with a left upper lobe non-small cell lung cancer involving a previous left internal mammary artery graft is presented to highlight the potential complications associated with resective lung operations in these patients. If left internal mammary artery involvement by tumor is suspected, coronary and left internal mammary artery catheterization should be added to the standard non-small cell lung cancer staging evaluation before considering surgical resection.

Aged↗
PubMed1994

Simplified, standardized technique for cervical esophagogastric anastomosis.

Using transhiatal esophagectomy, the ease of performing the cervical esophagogastric anastomosis varies greatly depending on neck size, length of mobilized stomach, and adhesions from previous neck operations. We therefore have developed a technique, used in 45 consecutive patients undergoing transhiatal esophagectomy, that has simplified the technical performance of cervical esophagogastric anastomosis.

Anastomosis, Surgical↗
PubMed1994

Thoracoscopy for pleural space disease.

We reviewed the results of 40 consecutive patients who underwent thoracoscopy on the general thoracic surgery service at our institution. Pleural space disease was the indication for thoracoscopy in 34 patients (85%). In 18 patients (46%), a malignant tumor accounted for the pleural space disease. In all patients with malignant disease, the diagnosis was established by a single thoracoscopy. For patients with benign pleural space disease, the timing of the thoracoscopic intervention is important. Despite advances in the extended application of thoracoscopy, the diagnosis and management of pleural space disease continues to be the primary indication for the procedure.

Adenocarcinoma↗