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PubMed1987

Reflux esophagitis.

Reflux esophagitis and its complications are not only common clinical problems but also problems that can be accurately defined by careful history taking and a knowledge of the pathophysiology of the various manifestations. An element of objective assessment, however, is required to define and substantiate fully an individual patient's problem. Only when disabling subjective and intractable objective complications persist after good medical treatment should surgical intervention be considered. Various antireflux procedures are currently available and all can be effective. Surgeons should review their own experiences and make alterations that they perceive will correct the types of problems encountered. In our current technique for the surgical management of gastroesophageal reflux in the common clinical setting, normal esophageal peristalsis is present, the fundus is adequate for plication, and sufficient esophageal mobilization can be effected to permit reduction of the entire stomach and fundoplication below the diaphragm. In addition, the procedure should be restricted to patients who do not have stenosis or have stenosis that can be readily dilated to 50 French.

Esophageal Stenosis↗
PubMed1987

Adenocarcinoma of the esophagus.

Adenocarcinoma involving the distal esophagus usually is far advanced when the patient is first seen. Adenocarcinoma differs from squamous carcinoma of the esophagus since it is relatively unresponsive to radiation therapy or chemotherapy. Adenocarcinoma of the esophagus resembles gastric cancer in its tendency to form a bulky and locally invasive tumor with early regional lymph node metastases. It differs from gastric cancer in its tendency to spread proximally in the esophagus and in the relatively infrequent early involvement of the liver by metastases. From 1979-1986, 37 patients had resection for adenocarcinoma involving the distal esophagus. Thirty-three patients were diagnosed with American Joint Committee for Cancer Stage III or IV adenocarcinoma at the time of operation. Transhiatal esophagectomy in continuity with a proximal gastrectomy was done in 27 patients. Reconstruction was accomplished by cervical esophagogastrostomy using pedicled distal stomach. There were three postoperative deaths (30-day mortality rate: 8%). Anastomotic leak occurred in nine patients and caused significant morbidity in four patients. Eleven patients required dilation of the cervical anastomosis after operation for up to 6 months. Mediastinal recurrence affected three patients treated by transhiatal esophagectomy. The survival rate (Kaplan-Meier) was 44% at 1 year and 31% at 2 years. Resection of adenocarcinoma of the esophagus can be accomplished in most patients with acceptable risks of morbidity and mortality. Resection restores ability to swallow saliva and to consume a normal diet, and is associated with an appreciable improvement in the quality of life.

Adenocarcinoma↗
PubMed2004

Endoscopic management of hypopharyngeal stenosis after organ sparing therapy for head and neck cancer.

OBJECTIVES: The objective of this study was to describe and evaluate the efficacy of an endoscopic technique for the management of postchemoradiation hypopharyngeal stenosis in head and neck cancer patients. STUDY DESIGN: Retrospective review. METHODS: Patients with postchemoradiation hypopharyngeal stenoses were identified from the Dana Farber Cancer Institute head and neck database. Patients who had undergone extirpative surgery and reconstruction were excluded. All patients underwent either anterograde dilatation (AD) by the lead author (C.A.S.) or transgastric retrograde esophagoscopy with anterograde dilatation (TREAD) (C.A.S., M.T.J.). Chemoradiation records, clinic notes, operative reports, and swallowing test data were reviewed. Removal of the gastric feeding tube was considered the endpoint of rehabilitation. RESULTS: Seventeen patients had postcricoid stenoses identified by modified barium swallow. Endoscopy confirmed 15 postcricoid stenoses and 2 proximal esophageal stenoses. Nine (53%) patients had partial stenoses, and eight (47%) had complete stenoses. Eight partial stenosis patients underwent 10 AD procedures and 3 TREAD procedures. Eight complete stenosis patients underwent 9 TREAD procedures and 26 subsequent AD procedures. Fifteen of 16 (93%) patients resumed swallowing after dilatation. Thirteen (81%) patients maintained their weight on an oral diet and had their gastric feeding tubes removed. Complications included hypopharyngeal perforation (13%), abdominal wall infection (6%), stomach wall dehiscence (6%), and chondroradionecrosis of the cricoid cartilage (6%). CONCLUSIONS: Postcricoid hypopharyngeal stenosis may be partial or complete after organ sparing chemoradiation for head and neck cancer. Using the TREAD technique, successful rehabilitation of swallowing can be achieved with a low incidence of complications.

Adult↗
PubMed1998

Video push enteroscopy in the investigation of small bowel disease: defining clinical indications and outcomes.

BACKGROUND: Push enteroscopy is a new technique for investigation of the small intestine. The clinical indications are still being defined. It also offers the potential for therapeutic intervention in suitable cases. AIMS: To evaluate further the role of push enteroscopy in the diagnosis and treatment of patients with suspected or known small bowel disease. METHODS: A prospective record was kept of all patients having enteroscopy at Royal Prince Alfred Hospital between March 1995 and July 1997. The procedure was performed 73 times in 68 patients. Indications and diagnoses were noted. The outcome in patients with obscure gastrointestinal bleeding or anaemia in whom a vascular lesion was treated with a heater probe was also determined. RESULTS: Enteroscopy was performed in 23 patients for gastrointestinal bleeding of obscure origin. An active or possible bleeding source was found in 13 (57%). The commonest of these was jejunal angiodysplasia. In the 21 patients with chronic iron deficiency anaemia a lesion was found in ten (48%). The majority of these were in the stomach, as described by others. The diagnostic yield in the 16 patients having enteroscopy for known or suspected small bowel disease was 56%. One patient underwent balloon dilatation of a postoperative jejunal stricture. Eleven patients with obscure bleeding or anaemia had ablation of a vascular lesion with a heater probe. Transfusion requirements fell after this procedure, particularly in those with active bleeding at the time of the examination. In five of the 11 no further transfusions were required in over six months of follow-up. CONCLUSIONS: The most common indications for enteroscopy are obscure gastrointestinal bleeding, chronic anaemia and known or suspected small bowel disease. A positive result can be expected in over 50% of patients. The treatment of vascular lesions via the enteroscope has a significant impact of subsequent transfusion requirements.

Adolescent↗
PubMed1993

[Thirteen-week repeated dose toxicity by oral administration of trandolapril (RU44570) with 4-week recovery test in beagles].

Trandolapril (RU44570) was orally administered to dogs at a daily dose of 2.5, 25 or 250 mg/kg for 13 weeks. After the administration period, 25 and 250 mg/kg groups were observed for recovery for 4 weeks. The results obtained are as follows: 1. One male in the 250 mg/kg group showed decrease of food consumption and body weight, stomatitis, hematemesis, decumbence, hypothermia, and finally loss of reactivity to stimuli. This animal was killed because of these severe changes on the 39th day of administration. Among the surviving animals, a temporary loss of body weight was observed in a few animals of the 25 and 250 mg/kg groups, and a decreased food consumption was sporadically seen in a few animals of the 250 mg/kg group during the administration period. No abnormal changes were found in the clinical observation and water intake in the surviving animals. 2. The changes attributable to the pharmacological effect of RU44570 were a decreased activity of the angiotensin-converting enzyme, increases in plasma renin activity and urine volume, and decreases in specific gravity and concentrations of Na, K and Cl in the urine of every administration group. A decrease in blood pressure and an increase in the PAS and Bowie positive granules in the juxtaglomerular cells were also found in the 25 and 250 mg/kg groups. In addition, thickening of the afferent arteriolar wall of the glomeruli, a basophilic change of the renal tubular epithelial cells, and localized atrophy and hypertrophy of the renal tubules were observed in the 25 and 250 mg/kg groups, and increases in BUN, ALP and creatinine, and a slight dilation of the renal tubules were seen in the 250 mg/kg group. These observations indicated that RU44570 affected renal structure at a dose of 25 mg/kg or more renal function at a dose of 250 mg/kg. The animal killed in a moribund state showed nephrosis which consisted mainly of a moderate dilation of the renal tubules and vacuolation of the renal tubular epithelial cells, stomatitis, severe hemorrhage and necrosis with neutrophil infiltration in the fundus of the glandular stomach, atrophy of the hemopoietic system, and ectopic calcification in the heart, kidneys, stomach, trachea and alveolar wall. Changes in the kidneys similar to those observed in other animals were also detected. These changes suggested that this animal lapsed into a moribund state due to renal dysfunction and the resultant uremia.(ABSTRACT TRUNCATED AT 400 WORDS)

Administration, Oral↗
PubMed2000

[Neonatal resuscitation: a fascinating story!].

Over the past thousands of years many examples can be found of the treatment given for asphyxia in the apparently dead subject. The resuscitation procedures were applied alike both in adults and in newborn babies. The first reference made to the mouth-to-mouth method was in the Kings'. In the second half of the 1800 many Authors proposed a method to resuscitate the asphyxiated newborn infant, which were still practiced up until the 1930 s. Many other different methods of air and 02 administration to the airway and stomach of an apparently dead newborn were well known and used in the 1800 s and still used in the 1950 s. Other methods used involved the dilatation of the rectum; the immersion in alternating warm and cold water and the use of a larynx tube developed by Chaussier which was then modified by other Authors. The use of tight fitting tracheal tubes and direct tracheal 02 administration after the clearing of the oropharynx using fingers and finally the mouth to mask and mouth to endotracheal tube breathing. All these examples are indicative of the approach taken in the resuscitation of the apparently dead infant. The science of resuscitation and its history continue to evolve....

History, 18th Century↗
PubMed2001

[Consequences of caustic damage of the esophagus].

Following ingestion of a highly concentrated acetic acid solution, three women aged 29, 23 and 25 years old, suffered damage to the oesophagus and the stomach, respiratory and renal insufficiency and haemolysis. After intensive treatment, gastric tube reconstruction was carried out in 2 of these patients, and the third woman required repeated dilatations of the oesophageal stricture from 6 weeks after ingestion onwards. This resulted in a normal passage of solid food in all women. A 58-year-old man who had ingested caustic soda at 4 years of age, presented with increasing problems associated with swallowing food. A squamous cell carcinoma was diagnosed and treated with chemotherapy, oesophagus-cardia resection and gastric tube reconstruction. After 2 years the tumour has not recurred. Ingestion of corrosive substances can lead to serious damage of the gastrointestinal tract. Early endoscopy is important in establishing the extent of the injury. During the acute phase, intensive care admittance is often necessary and resection of the oesophagus is also necessary in some cases. Subsequent treatment can vary from endoscopic dilations to gastric tube reconstruction following resection of the oesophagus.

Acetic Acid↗
PubMed1999

Dilatation and constriction of rat gastric mucosal microvessels through prostaglandin EP2 and EP3 receptors.

BACKGROUND: Prostaglandin (PG)E2 has both a vasodilating action and a protective function in the gastric mucosa. There are four subtypes of PGE2-sensitive, or EP, receptors. AIM: To identify the subtype of EP receptors in the microvessels of the rat gastric mucosa using EP2 and EP3 receptor agonists. METHODS: The posterior wall of the anaesthetized rat stomach was secured in a chamber and superfused with Tyrode's solution, and the gastric microcirculation of the mucosal base was observed through a window with transillumination. PGE2 and its derivatives (20 microL) were applied topically in the window. RESULTS: PGE2 (0.001-10 micromol/L), misoprostol (EP2/EP3 receptor agonist; 0.01-100 micromol/L) and butaprost (EP2 receptor agonist; 1-1000 micromol/L) dilated the arterioles dose-dependently, but M&B 28 767 (EP3 receptor agonist; 0.001-10 micromol/L) did not alter their diameters. M&B 28 767 constricted the venules and collecting venules dose-dependently whereas butaprost dilated them. PGE2 and misoprostol had bell-shaped dose-response curves: constriction by low doses of PGE2 and misoprostol (0.001-0.1 micromol/L and 0.01-1 micromol/L) and dilation by high doses of PGE2 and misoprostol (0.1-100 micromol/L and 1-100 micromol/L). CONCLUSIONS: These results suggest that PGE2 dilated both arterioles and venules in the rat gastric mucosa through the EP2 receptors and constricted the venules through the EP3 receptors.

Alprostadil↗
PubMed1995

Massive gastrointestinal bleeding caused by Dieulafoy's lesion.

Dieulafoy's lesion is an anomaly, difficult to diagnose, consisting of an abnormally dilated submucosal gastric blood vessel that can cause life-threatening gastric hemorrhage. Five patients with Dieulafoy's lesion and massive gastrointestinal bleeding are described. The diagnosis was made by endoscopy in two patients and during operation in the other three. On endoscopy the source of bleeding was localized to the stomach in all patients. This information was important for the operative approach. Conservative treatment failed to prevent rebleeding, and all patients required surgery. In three patients excision of the lesion was performed, and suture only in the other two. The difficulties in diagnosis of the lesion and the surgical options are discussed.

Adult↗
PubMed1989

Relaxatory responses of canine proximal stomach to esophageal and duodenal distension. Importance of vagal pathways.

The viscerovisceral reflex control of gastric tone remains poorly characterized. We have previously demonstrated physiological variations in gastric tone that occur during fasting and after feeding. These variations are neurally regulated. We have now compared the reflex mechanisms modulating gastric tone that are elicited by esophageal or duodenal distension in fasted, conscious dogs. To determine the pathways involved in these reflexes, we combined the technique of vagal blockade (by cooling the supradiaphragmatic vagi isolated within a surgically implanted cooling jacket) with the administration of autonomic drugs. Gastric tone was measured as the air volume within an intragastric bag maintained at a constant, low pressure by an electronic barostat. Standardized distensions were performed by means of an inflatable balloon-catheter positioned either in the mid-esophagus (in three dogs) or in the distal duodenum (in three dogs). A profound and consistent gastric relaxation was induced by distension of either the esophagus (247 +/- 21 ml delta volume, P less than 0.05) or the duodenum (238 +/- 29 ml, P less than 0.05). Supradiaphragmatic vagal cooling abolished the gastric relaxatory response to duodenal distension and significantly reduced, but did not completely suppress, the response to esophageal distension. Neither cholinergic stimulation (intravenous bethanechol) nor adrenergic blockade (combined intravenous phentolamine and propranolol) had any significant effect on either gastric relaxatory response. Combined adrenergic and cholinergic (intravenous atropine) blockade induced gastric relaxation, but failed to suppress the gastric responses. We conclude that both esophageal and duodenal distension elicit gastric relaxation by a noncholinergic vagal mechanism.(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗
PubMed1984

Gastrohepatic ligament: normal and pathologic CT anatomy.

In a review of 200 consecutive CT scans of the upper abdomen, the structures within the gastrohepatic ligament (GHL) were well seen in 182 (91%). In 85% of these 182 patients, the largest structure visible within the GHL was 6 mm or smaller. A total of 27 patients had a structure larger than 6 mm within the GHL; this finding could be explained in 13 by the presence of a normal anatomic variant. Of the 14 others, 12 had known tumor arising in or known to have spread to the upper abdomen. Two patients had no obvious explanation. Fourteen patients with cancers of the stomach (9 patients), pancreas (3 patients), and esophagus (2 patients) had 57 intact nodes that were evaluated pathologically. Of these 40/40 benign nodes and 10/17 malignant nodes were less than or equal to 8 mm in size. When anatomic variants are excluded, the finding of rounded structures greater than 8 mm in the GHL is a reliable indicator of left gastric node involvement by carcinoma or lymphoma or of coronary venous dilatation.

Humans↗
PubMed2003

Distal foregut atresias in consecutive siblings and twins in the same family.

The distal foregut comprises the antrum of the stomach and supra-ampullary region of the duodenum. In this part of the gut, intraluminal mucosal diaphragms, webs, membranes (type I), and rarely solid cord (type II) atresias are occasionally seen in clinical practice. Due to increased awareness, the number of reported cases has increased in recent years. These foregut lesions are known to have a strong genetic association. Both antral (AA) and duodenal atresias (DA) may occur as potentially curable sporadic cases or in combination with lethal malformations such as hereditary multiple gastrointestinal atresias affecting the fore-, mid-, and hindgut. The association of AA and junctional epidermolysis bullosa lethalis is well-known. We describe an unusual occurrence of foregut atresias in two consecutive siblings and a pair of monozygous twins. The involvement of four siblings in a single family is extraordinary and as yet unreported. This cluster of cases not only lends a strong support to a genetic origin, but also the mode of transmission, despite the absence of a history of consanguinity. It indicates that atresia of the gastric antrum and supra-ampullary DA are etiologically closely related. It is also possible that the discordant expression in the twins could be a pleiotropic effect of the same genetic factor. Attempts are made to explain the possible pathogenesis of this unusual atresia and relate it to other associated anomalies.

Dilatation, Pathologic↗
PubMed2001

Gastric dilatation syndrome associated with chronic nephropathy, hypergastrinemia, and gastritis in mice exposed to high levels of environmental antigens.

Gastric dilatation (GD) has been observed in Tac:(SW)fBR surveillance mice, with mean age of 10 months, that are exposed to high levels of environmental antigens during routine exposure to dirty bedding. The aim of the study reported here was to determine whether GD was associated with other systemic conditions affecting mice. Three groups of nine animals including-surveillance mice not exposed to dirty bedding (control), surveillance mice with out GD (NGD), and surveillance mice with GD (group GD)-had mean stomach weight with ingesta of 0.5 +/- 0.02 g, 1.09 +/- 0.07 g (P < 0.0001), and 2.54 +/- 0.4 g (P < 0.0001), respectively. Mean serum creatinine concentration was significantly higher in GD (1.6 +/- 0.25 mg/dl), compared with NGD (0.17 +/- 0.22 mg/dl, P < 0.0001) and control (0.2 +/- 0.16 mg/ dl, P < 0.0001) mice. In addition, lesions consistent with severe chronic nephropathy and mild gastritis were common in GD, compared with NGD and control mice. Finally, serum amidated gastrin concentration was significantly high in GD (179.37 +/- 53.86 pM, P < 0.03) and NGD (264.89 +/- 115.89 pM, P < 0.009), compared with control (60.77 +/- 8.39 pM) mice. Gastric dilatation syndrome is associated with chronic nephropathy, hypergastrinemia, and gastritis in surveillance mice exposed to high levels of environmental antigens.

Animals↗
PubMed1985

Massive upper gastrointestinal hemorrhage from an arteriovenous malformation of the stomach.

Arteriovenous malformations of the stomach are rare; blood loss may be manifested either by chronic anemia or by massive recurrent hemorrhage. We report a patient with massive upper gastrointestinal hemorrhage from a gastric arteriovenous malformation. Emergency operation to control hemorrhage precluded the performance of angiography; diagnosis was made from the appearance of the lesion and dilatation of the veins draining the involved area. Complete operative excision of the lesion was curative.

Angiography↗
PubMed2005

Anesthetic management of a patient with severe dilated cardiomyopathy and an automatic implantable cardioverter-defibrillator (AICD) during total gastrectomy.

We report a case of severe dilated cardiomyopathy with an automatic implantable cardioverter-defibrillator (ICD) undergoing total gastrectomy. During the operation, the defibrillation function of the ICD was suspended and its pacing function was used solely in VOO mode. Electrodes of an external defibrillator were attached on the chest wall, and a pulmonary arterial (PA) catheter with a ventricle pacing port was inserted into the pulmonary artery. Proper perioperative management, including measures that the patient underwent the surgery uneventfully and could attain a rapid and successful discharge from the intensive care unit.

Anesthesia, General↗
PubMed2004

Massive hemorrhage and pseudo-obstruction of the small intestine caused by primary AL amyloidosis associated with gastric cancer: report of a case.

We report a case of AL amyloidosis in a patient diagnosed with early gastric cancer after presenting with massive gastrointestinal hemorrhage and pseudo-obstruction of the small intestine. Primary systemic amyloidosis accounts for 7% of nonhematological malignancies, but very few cases of gastric carcinoma in patients with primary amyloidosis have been described. We performed distal gastrectomy with biopsy of the small intestine in the absence of a diagnosis of systemic amyloidosis associated with early gastric cancer; however, the patient suffered severe postoperative complications secondary to the amyloidosis. Although acute pseudo-obstruction is an uncommon clinical manifestation of AL amyloidosis, the coexistence of both gastrointestinal hemorrhage and pseudo-obstruction of the small intestine should alert the clinician to a diagnosis of gastrointestinal amyloidosis. We discuss the clinical manifestations of primary amyloidosis occurring in association with gastric cancer.

Aged↗
PubMed2006

Electrocautery therapy for refractory anastomotic strictures of the esophagus.

BACKGROUND: Anastomotic esophageal stenoses after esophageal resection are common and sometimes are refractory to Savary bougie dilation. The efficacy of electrocautery needle-knife treatment in these patients is described. METHODS: Twenty patients with a refractory anastomotic stricture of the esophagus were treated with electrocautery and were followed for 12 months. All patients had recurrence of dysphagia despite repeated bougienage. OBSERVATIONS: All 12 patients with a stricture shorter than 1 cm remained without dysphagia after a single treatment. In all 8 patients with a long-segment stenosis of 1.5 to 5 cm, dysphagia recurred, and a mean of 3 treatments were necessary. The interval between electrocautery treatments was significantly longer compared with bougienage. There were no complications. The body weight of all patients increased. CONCLUSIONS: Electrocautery seems to be a good single-treatment modality for refractory short-segment anastomotic strictures, whereas longer-segment stenoses appear to require repeated treatment sessions before similar results are obtained.

Adult↗