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At least 1,135 records · Page 63Linked to original sources
PubMed2000

Videoscopic Heller myotomy for achalasia--results beyond short-term follow-up.

BACKGROUND: Heller myotomy has long been utilized for patients failing nonoperative management of achalasia. Videoscopy has been advocated to decrease the morbidity of Heller myotomy; however, few reports document outcome beyond 1 year after videoscopic Heller myotomy. PURPOSE: To determine perioperative morbidity, relief of dysphagia, and the incidence of postoperative reflux symptoms following videoscopic Heller myotomy with follow-up to over 4 years. METHODS: Patients with achalasia documented by barium esophogram and esophageal manometry underwent videoscopic Heller myotomy beginning in 1992. Intraoperative peroral endoscopy was utilized to guide the cephalad and caudad extent of myotomy. A barium esophogram was undertaken in the immediate postoperative period to evaluate for subclinical leak and assess esophageal emptying. RESULTS: Seventy-eight patients underwent videoscopic Heller myotomy. The mean age was 51 years +/- 19 (range 14 to 91). Most (62%) patients had undergone pneumatic dilation prior to surgical consultation and 54% had previous botox injections. All patients complained of dysphagia and 40% had symptoms of heartburn prior to myotomy. After myotomy, 91% of patients stated that their swallowing was improved with myotomy. Thirteen patients (18%) experience heartburn more than once per week after myotomy. The average length of stay was 2 +/- 2 days, with 72% of patients spending 2 days or fewer in the hospital. Six (7.7%) major complications occurred: five esophageal perforations and one enterotomy without long-term sequellae. Three procedures (3.8%) were converted to "open" procedures. No deaths occurred. We conclude that videoscopic Heller myotomy is safe and efficacious, with low morbidity and mortality. Videoscopic myotomy provides relief beyond the short term for dysphagia due to achalasia with minimal reflux symptoms. We advocate videoscopic Heller myotomy in the treatment of severe dysphagia due to achalasia not adequately palliated by or amenable to nonoperative management.

Adolescent↗
PubMed2003

Critical care transesophageal endosonography and guided fine-needle aspiration for diagnosis and management of posterior mediastinitis.

BACKGROUND: Acute mediastinitis is a serious complication; it occurs after esophageal perforation and thoracic surgery and is rarely due to infections. Clinical and computed tomographic scan signs may be nonspecific, especially in postoperative patients. DESIGN: We prospectively evaluated the value of transesophageal endosonography with guided fine-needle aspiration in the diagnosis and identification of etiologic agents in critically ill patients with suspected posterior mediastinitis. SETTING: University hospital. PATIENTS AND METHODS: Transesophageal endosonography/fine-needle aspiration was performed at the bedside in the intensive care unit with a Pentax 34UX echo-endoscope and a portable Hitachi console (EUB 525). Eighteen patients with clinically suspected mediastinitis were examined with intensive care team support. RESULTS: Computed tomography was performed before transesophageal endosonography in all 18 patients and was inconclusive in 9. Transesophageal endosonography detected mediastinal lesions in 16 (89%) of 18 patients and was more accurately diagnostic than computed tomography (p =.0082). Fifteen patients had undergone surgery (11 esophagectomy, 1 other esophageal surgery, 1 head/neck cancer surgery, 1 complication after dilatational tracheostomy, and 1 with intervention after polytrauma). Three patients were suspected to have nonpostoperative mediastinitis. In 16 patients, infectious organisms were detected (bacterial, n = 14; fungal, n = 1; tuberculosis, n = 1). Culture and sensitivity of transesophageal endosonography/fine-needle aspiration specimens led to appropriate drug therapy. In two patients, methicillin-resistant Staphylococcus aureus was detected, leading to isolation care. Twelve patients improved; six died. Of the two patients in whom transesophageal endosonography did not detect a mediastinitis, one was false negative on autopsy. There were no complications. CONCLUSION: Bedside transesophageal endosonography/fine-needle aspiration of posterior mediastinal lesions in critically ill patients was an effective and relatively noninvasive way to detect mediastinitis and provide material to identify the etiologic agent. It was particularly useful in postesophagectomy patients.

Abscess↗
PubMed1986

[Irradiation of recurrent esophageal carcinoma].

81 patients with recurrent esophageal carcinoma after radical radiotherapy were irradiated from Mar. 1958 to Dec. 1973. The results were compared with those of 137 patients with untreated postirradiation recurrences in the same period. Of these 81 patients, 21 failed to complete the second course due to esophageal perforation (8 cases), fatal hemorrhage (4 cases) and deterioration of the general condition (9 cases). The improvement rate of symptoms was 19.75% and that of barium meal was 44.44%. The mean survival of the re-irradiation group was 6.59 +/- 4.66 months in contrast to that of the control group, 4.51 +/- 4.40 months. There was significant difference between these two groups (P less than 0.01). It is shown that the total dose of re-irradiation has no significant effect on the survival. the survival of patients receiving 4,000 rad or less was 5.92 +/- 4.53 months and that of patients receiving more than 4,000 rad was 7.86 +/- 4.72 months (P greater than 0.05). There is no statistical significance in between. We believe that re-irradiation is capable of relieving the symptoms and prolonging survival. It should be selectively used in the patients with recurrent esophageal carcinoma after radical radiotherapy.

Esophageal Neoplasms↗
PubMed1987

Colon interposition for benign esophageal disease.

We reviewed 53 consecutive patients with benign disease who underwent esophageal resection followed by colon interposition to assess operative morbidity and long-term results. Indications were gastroesophageal reflux in 32 patients, advanced motility disorders in eight, esophageal perforation in six, and strictures not related to reflux in seven. There were two operative deaths (3.8%). Fourteen other patients (26.4%) had 18 major complications including three graft infarcts, two graft perforations, and four anastomotic leaks, one of which required surgical treatment. Follow-up was complete in 83% of patients and averaged 5 years. Eight patients required dilations; and 15 underwent late reoperations for stricture, persistent symptoms, or anastomotic leak. Of the 20 patients who did not have pyloroplasty done at the initial resection, five (25%) required a subsequent gastric emptying procedure. Results were rated by patients (subjectively) and physicians (objectively, based on symptoms and the need for further therapy) as 1 = excellent, 2 = good, 3 = fair, and 4 = poor. The patients' ratings averaged 1.89, with 27 patients (75%) claiming good or excellent results despite symptoms of postprandial fullness in 78% and dysphagia in 42%. Objective ratings averaged 2.05, with 28 of 39 patients (72%) rating the results as excellent or good. Despite a 30% major complication rate and a 37% late reoperative rate, colon interposition for benign esophageal disease can be accomplished with low mortality and high patient acceptance and remains our preferred technique for reconstruction of benign esophageal disease.

Adolescent↗
PubMed1982

Intercostal muscle and myo-osseous flaps in difficult pediatric thoracic problems.

Intercostal muscle pedicle flaps have been successfully utilized in the treatment of recurrent tracheoesophageal fistulae and esophageal perforations in the pediatric age group. An intercostal myo-osseous pedicle flap was also created to repair a distal congenital tracheal stenosis at the carina. The viable intercostal flap has the advantage of multiplicity of uses and of considerable mobility. The presence of a blood supply assures healing. The option of retaining periosteum on the flap encourages bone regeneration at the site of tracheal or bronchial repair. The pleura of the flap provides an epithelial surface for intratracheal repair. The rib graft prevents stricture at the site of tracheal repair.

Child, Preschool↗
PubMed1987

Sclerotherapy of esophageal varices by consecutive injection of anhydrous ethanol: 1% polydocanol and thrombin.

In 1978, the first Japanese report of sclerotherapy with the flexible esophagoscope was published. At the Second Meeting of the Japanese Society of Sclerotherapy for Esophageal Varices (August 1986), reports were given on over 4000 cases treated by over 70 groups of endoscopists using various methods and sclerosants. These cases included 15 (about 0.4%) in which esophageal perforation occurred, and other complications, some fatal, were also reported. The main problem is to reduce the frequency of these serious complications. Over 400 cases have been treated by the authors in the past 3 years with a method involving consecutive injections of anhydrous ethanol when it is certain that the needle is in the varices. If there is any possibility of the needle being dislocated, 3-5 ml 1% polydocanol is administered instead. Weekly injections should be repeated until all varices have been sclerosized. No major complications have been observed, and the results are satisfactory [7].

Esophageal and Gastric Varices↗
PubMed1992

Push-through intubation: effective palliation in 409 patients with cancer of the esophagus and cardia.

Between 1980 and 1989, 355 patients with cancer of the esophagus and 54 with cancer of the cardia underwent push-through intubation because of advanced tumor stage or medical contraindications to tumor resection. In 36 other patients (8.1%), the attempt at transtumoral intubation failed. The hospital mortality rate after intubation was 3.4%. The following complications were observed: hemorrhage in 2.0% of the patients, esophageal perforation in 4.9%, tube dislodgment in 12.7%, and tube obstruction in 4.4%. Early resumption of semisolid oral feeding was possible in 80% of the discharged patients. The actuarial 1-year survival rate was 7.7% and the median survival, 3.9 months. In conclusion, push-through intubation represents a valid therapeutic choice, which is indicated mainly for patients with a long, infiltrating, and circumferential stricture of the thoracic esophagus or cardia that is inoperable and for patients with an esophagorespiratory or esophagomediastinal fistula.

Adenocarcinoma↗
PubMedDate not supplied

Witzel pneumatic dilation for achalasia: safety and long-term efficacy.

Forceful dilation of the lower esophageal sphincter is considered primary therapy for achalasia. The Witzel pneumatic balloon dilator, unlike fluoroscopically placed dilators, is placed over a standard gastroscope allowing positioning and dilation under direct vision. We report our experience with the Witzel dilator in 45 patients with achalasia over a 5-year period. All patients had at least one major symptom score of 8 out of 10 for dysphagia and/or regurgitation before dilation. After Witzel dilation, symptomatic response was graded as excellent (score 0 to 2), good (score 3 to 5), fair (score 6 to 8), and poor (no improvement). Symptom response was assessed after 1 week, 1 month, 6 month, 1 year, and present. The mean period of follow-up was 25 months (range, 3 to 85 months). Passage of the balloon across the gastroesophageal junction was technically unsuccessful in three patients. Esophageal perforation occurred in two patients (4%) and transient chest pain greater than 2 days in three patients (7%). There was no bleeding or death. Symptomatic long-term improvement was excellent in 25 patients (63%), good in 6 patients (15%), fair in 4 patients (10%), and poor in 5 patients (12%). A repeat Witzel dilation was performed in five patients but resulted in good/excellent improvement in only one patient. We conclude that pneumatic dilation with the Witzel balloon is a safe, effective procedure for achalasia.

Adolescent↗
PubMed2000

Herpes simplex virus esophagitis in the immunocompetent host: an overview.

OBJECTIVE: The aim of this study was to delineate the characteristics of herpes simplex virus esophagitis (HSVE) in the immunocompetent host. METHODS: The study entailed a case report and a review of relevant literature through a MEDLINE search back to 1966. All cases with documented HSVE in patients without immunosuppression were selected and their characteristics defined. RESULTS: A total of 38 cases were identified. The age range was 1-76 yr and the male/female ratio 3.2/1. Antecedent exposure to HSV disease was described in eight cases (21.1%). A prodrome of systemic manifestations preceded the onset of esophageal symptoms in nine subjects (23.6%). Manifestations included acute odynophagia (76.3%), heartburn (50%), and fever (44.7%). Concurrent oropharyngeal lesions were uncommon (n = 8, 21.1%). Endoscopically, extensive involvement was common, showing friable mucosa (84.2%), numerous ulcers (86.8%), and whitish-exudates (39.5%). The distal esophagus was most commonly affected (63.8%). Microscopic examination showed characteristic viral cytopathology in 26 (68.4%) cases. Virus was recovered from esophageal-brushes or biopsies in 23 of 24 (95.8%) patients and immunocytochemistry was positive in seven of eight (87.5%) cases. Immune status was consistent with primary HSV infection in eight (21.1%) cases. The disease was self-limiting, although esophageal perforation and upper GI bleeding were reported in one case each. CONCLUSIONS: HSVE in the immunocompetent host is a rare but distinct entity, and is significantly more common in male subjects. It represents either primary infection or reactivation, and is characterized by acute onset, systemic manifestations, and extensive erosive-ulcerative involvement of the mid-distal esophagus. Histopathological examination alone may miss the diagnosis; adding tissue-viral culture optimizes the diagnostic sensitivity. It is usually self-limiting; whether antiviral therapy is beneficial remains unknown.

Acyclovir↗
PubMed1985

Lack of iron stores in patients with diseases of the gastrointestinal tract.

Low serum ferritin concentrations indicating empty iron stores are common (30 to 50 per cent of the patients) in patients with carcinomas of the stomach, colon and rectum as well as in patients who have undergone resection of the stomach in addition to proximal selective vagotomy and fundoplication. Malignant diseases of the gastrointestinal tract are also associated with low serum ferritin concentrations and empty iron stores. Abnormal high serum ferritin concentrations are common in patients with polyposis of the stomach, intra-abdominal abscesses, carcinoma of the papilla of Vater, in patients one month after cholecystectomy and patients with benign tumors of the esophagus, esophagitis, perforation of peptic ulcer, diverticulitis of the colon, carcinoma of the esophagus and polyposis of the colon. Patients after proximal selective vagotomy due to duodenal ulcer have frequently lower and higher values than patients with duodenal ulcers who have not undergone operation. Thus, empty iron stores are common in patients with diseases of the gastrointestinal tract, especially ones which are malignant, and after gastric operations, whereas a few neoplasms, malignant diseases and severe infections (intraabdominal abscesses and diverticulitis of the colon) may be associated with high serum ferritin concentrations. It is highly justified to determine serum ferritin concentrations in patients with diseases of the gastrointestinal tract.

Anemia, Hypochromic↗
PubMedDate not supplied

Factors affecting quality of life after minimally invasive Heller myotomy for achalasia.

The effect of prior nonoperative treatment, type of fundoplication, and surgical approach on quality of life after minimally invasive Heller myotomy (MIHM) for achalasia in not known. MIHM for achalasia was performed in 105 patients (primary 102; redo 3). Sixty-five patients had prior nonoperative treatment (dilations in 41; botulinum toxin injections in 13; dilations and botulinum toxin injections in 11). Primary laparoscopic MIHM with fundoplication (Dor in 32; Toupet in 56) was performed in 88 patients and thoracoscopic MIHM without fundoplication in 14. Achalasia and quality-of-life-related symptoms were evaluated prospectively with a visual analogue scoring scale. Median follow-up was 25 months. There was a trend toward a higher incidence of intraoperative esophageal perforation and recurrent dysphagia in patients with prior nonoperative treatment. Patients with prior nonoperative treatment had significant improvement in achalasia-related symptoms postoperatively. Patients with prior botulinum toxin injections with or without dilations had no improvement in quality of life after MIHM. The operative success of MIHM may be compromised if prior nonoperative treatment is used. Botulinum toxin injections may blunt the beneficial effect of MIHM on quality of life. The outcome of MIHM is good regardless of the type of fundoplication or surgical approach.

Botulinum Toxins↗
PubMed1997

Laparoscopic vs conventional Nissen fundoplication. A prospective randomized study.

BACKGROUND: Laparoscopic Nissen fundoplication has gained wide acceptance among surgeons, but the results of the laparoscopic procedure have not been compared to the results of an open fundoplication in a randomized study. METHODS: Some 110 consecutive patients with prolonged symptoms of grade II-IV esophagitis were randomized, 55 to laparoscopic (LAP) and 55 to an open (OPEN) Nissen fundoplication. Postoperative recovery, complications, and outcome at 3- and 12-month follow-up were compared in the two groups. RESULTS: Five LAP operations were converted to open laparotomy due to esophageal perforation (two), technical difficulties (two), and bleeding (one). In the OPEN group (two) patients underwent splenectomy. There was no mortality. The mean hospital stay was 3.2 days in the LAP group and 6.4 in the OPEN group. Dysphagia and gas bloating were the most common complaints 3 months after the operation in both groups. These symptoms had disappeared at the 12-month follow-up examination. All patients in the LAP group and 86% in the OPEN group were satisfied with the result. CONCLUSIONS: Laparoscopic Nissen fundoplication is a safe and feasible procedure. Complications are few and functional results are good if not better than those of conventional open surgery.

Adult↗
PubMed1992

Colonic replacement for the treatment of caustic esophageal strictures in children.

Caustic esophageal stricture is one of the most common indications for esophageal replacement in children. During a 13-year period between 1976 and 1989, colonic replacement was performed in 50 patients for the treatment of caustic esophageal strictures at the Department of Pediatric Surgery of Hacettepe University Children's Hospital. A retrospective clinical study was undertaken to discuss the indications and results of colonic replacement. The 50 children, 34 of whom were male (68%) and 16 of whom were female (32%) with 27 patients (54%) under 6 years of age, were evaluated retrospectively. Indications for operation included 21 (42%) who could not swallow saliva and had total or nearly total obliteration of lumen involving more than 3 cm of an esophageal segment at admittance, and 16 (32%) who had difficulty in swallowing within a 1-month period following the last dilation after completion of a 1-year dilation program. A further 13 (26%) had bleeding and difficulties during dilations, after experiencing an esophageal perforation. The right colon was used in 48 and the left in the remaining 2 patients. Patients were followed for at least 1 year following replacement. Growth was excellent in all but one patient who had redundant colon and showed growth retardation. There was one postoperative late death because of massive bleeding from ulceration of the transplanted colon. The other 49 patients were available for accurate follow-up. The results were good, 46 (92%) were able to eat everything, while occasional dysphagia in 3 (6%) required dilation after operation. Colon conduit provides an excellent substitute for esophagus in pediatric patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Burns, Chemical↗
PubMed1997

Complications and their impact after pneumatic dilation for achalasia: prospective long-term follow-up study.

BACKGROUND: With the exception of esophageal perforations, complications of pneumatic dilation are incompletely defined. This study analyzes the incidence of all complications of this procedure and their impact on the patients' clinical course. METHODS: Sixty-seven consecutive patients with achalasia underwent pneumatic dilation with a Browne-McHardy dilator. Patients were observed for 24 hours after treatment and evaluated 4 weeks later as well as at 2-year intervals for a mean follow-up period of 4.9 +/- 3.8 years. In patients with and without complications, the length of remission was evaluated by Kaplan-Meter life table analysis. RESULTS: Twelve patients (18%) developed morphologic complications consisting in one perforation, two intramural hematomas, and nine diverticula at the gastric cardia. Ten patients (15%) complained of prolonged postdilation chest pain. The 5-year remission rate in the latter patients was 51% compared to 42% for patients without complications and 11% for patients developing traumatic diverticula. Surgery was ultimately performed in one third of all patients, a rate that remained unaffected by the type of complication. CONCLUSIONS: Complications of pneumatic dilation are underestimated and underreported. More than 30% of all patients develop either prolonged pain or morphologic lesions. Although prolonged pain does not indicate an unfavorable prognosis, the appearance of diverticula may be associated with a shorter clinical remission.

Adolescent↗
PubMed1998

Occult Boerhaave's syndrome without vomiting prior to presentation. Report of a case.

Boerhaave's syndrome (spontaneous esophageal perforation) is an uncommon clinical entity that frequently presents with an antecedent history of marked vomiting followed by chest or abdominal pain. We report a case of spontaneous rupture of the esophagus in 53-year-old male who was referred to our hospital with a chest discomfort. A chest radiogram revealed pleural effusion and pneumomediastinum. Nine hours after onset, the diagnosis of Boerhaave's syndrome become evident. She underwent operative repair and, after a prolonged stay, was discharged in relatively good condition 55 days after admission. The absence of vomiting prior to presentation is the distinguishing feature of this particular case. This is the seventh case in the English literature to our knowledge.

Diagnosis, Differential↗
PubMed2004

Schatzki's ring: to cut or break an unresolved problem.

Symptom assessment has been proven to be less reliable than barium pill testing for success of dilation of peptic strictures. Schatzki's ring also has a high recurrence rate. Our aim here was to compare the efficacy of single dilatation with a 54-F Savary dilator and electrosurgical ring incision for symptomatic Schatzki's rings. Schatzki's ring patients who failed to pass a 12.7-mm barium pill were randomized to dilatation with a 54-F Savary dilator or four quadrant incisions with a needle knife. All received lansoprazole (30 mg) for 30 days posttreatment. Follow-up at 1, 3, 6, and 12 months used the pill test and a dysphagia score. Eleven patients (mean age, 62; median, 64) were randomized and received therapy, six with dilatation and five with incision. The ring diameter pretherapy was 9.8 +/- 1.3 mm. One patient with dilatation had a procedure-related esophageal perforation. The dysphagia score decreased (from 2.7 +/- 1.1 predilatation and 3.0 +/- 0.4 preincision) to 0 after treatment, suggesting that both therapies were equally successful. In contrast, using objective measurements with the barium pill showed that the pill failed to pass the ring in 60% at 1 month after therapy. The failure rate by 1 year was 100%. Use of an objective measure of effectiveness of treatment of symptomatic Schatzki's rings showed that neither single large-dilator dilatation nor four quadrant ring incision was a reliable and effective therapy. In the future studies, repeated dilatation may be needed to define success before long-term outcome can be accurately assessed.

2-Pyridinylmethylsulfinylbenzimidazoles↗
PubMed2001

Outcomes of laparoscopic fundoplication for gastroesophageal reflux disease and paraesophageal hernia.

BACKGROUND: Laparoscopic fundoplication has become the standard for operative treatment of gastroesophageal reflux disease (GERD). METHODS: We reviewed our experience with 1,000 consecutive patients receiving laparoscopic fundoplication for GERD (n = 882) or paraesophageal hernia (n = 118) between October 1991 and July 1999. Patients with achalasia and failed fundoplication were excluded from analysis. All the patients were evaluated preoperatively by upper endoscopy, esophageal manometry, and barium swallow. After 1994, 24-h pH monitoring was performed selectively in patients with extraesophageal symptoms and/or those without erosive esophagitis. There were 490 men 510 women in this review. Their mean age was 49 years. Procedures performed were 360 degrees floppy fundoplication (n = 879), 360 degrees fundoplication without fundus mobilization (Rossetti) (n = 22), 270 degrees posterior fundoplication (n = 96), and anterior fundoplication (n = 2). Esophageal lengthening procedure (Collis gastroplasty) was performed in combination with fundoplication in 15 patients. In seven patients the treatment was converted to open fundoplication. OUTCOMES: The average length of hospitalization was 2.2 days, and 136 patients stayed longer than 2 days. Major complications occurred in 21 patients: esophageal perforation (n= 10), acute paraesophageal herniation (n = 4), splenic bleeding (n = 2), cardiac arrest (n = 1), pneumonia (n = 3), and testicular abscess (n = 1). Additional operations were required to manage the complications in 14 patients (70%): Four of these procedures were performed emergently, and 10 patients underwent reoperation between 6 h and 10 days. There were three deaths, all of which involved elderly patients with paraesophageal hernia. There were 35 late failures requiring reoperation for recurrence of GERD or development of new symptoms: The treatment of 32 patients was revised laparoscopically, and 4 patients required laparotomy. Beyond 1 year (median follow-up period, 27 months), 94% of the reviewed patients were satisfied with their surgical outcome.

Aged↗
PubMed1996

High- and low-compliance balloon dilators in patients with achalasia: a randomized prospective comparative trial.

BACKGROUND: Pneumatic dilation is the most effective nonsurgical method for treatment of achalasia. The most serious complication of this procedure is esophageal perforation, which occurs in about 5% of cases. We completed a randomized prospective comparative trial with a high-compliance latex balloon (HCB) mounted on an endoscope (40 mm maximum distension diameter, 6 psi inflation pressure) and a low-compliance balloon (LCB) (35 mm, 20 psi) with respect to efficacy and side effects. METHODS: Twenty-five patients (13 treated with HCB, 12 treated with LCB) were included. The symptom score was assessed both before and after dilation, biannually, for up to 2 years, and complications were graded for severity. All dilations lasted for 3 minutes and were performed under direct endoscopic control. Patients were randomly assigned to the two different balloon types. RESULTS: One perforation was observed in the LCB group (not significant between HCB and LCB). Superficial mucosal tears appeared in 40% of all dilations. Initial dilation treatment was successful in 20 of 25 (80%) patients (10 of 13 HCB, 10 of 12 LCB). There were no significant differences in the median pretreatment and post-treatment symptom scores. Three patients required repeated dilations during the observation period. They were treated with the competing balloon system and showed no difference compared with the initial posttreatment symptom score. CONCLUSIONS: No significant difference could be demonstrated between the HCB and LCB system as far as the complication rate and the clinical outcome are concerned. In consequence, both systems appear equally effective, although the endoscope-mounted system (HCB) can be handled more easily.

Adult↗