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Wood M, Lazo C, Hassid V, Awad ZT. Replaced common hepatic artery from superior mesenteric artery during pancreaticoduodenectomy. Gulf J Oncolog 2012:60-62. [PMID: 22227547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/15/2011] [Indexed: 05/31/2023]
Abstract
The hepatic arterial anatomy is highly variable. A 67 year female with pancreatic mass and replaced common hepatic artery originating from the superior mesenteric artery underwent pancreaticoduodenectomy (PD). The anomalous vessel was discovered on preoperative CT scan and MRI. The vessel was dissected and preserved as it passed dorsal to the pancreas. Preservation of the blood supply to the liver and biliary tree is important after PD to prevent biliary fistula and hepatic ischaemia.
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Affiliation(s)
- M Wood
- Department of Surgery, University of Florida College of Medicine, Jacksonville, FL, USA
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Affiliation(s)
- J C Munoz
- Division of Gastroenterology, University of Florida College of Medicine/Jacksonville, Jacksonville, Florida 32207, USA
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3
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Abstract
BACKGROUND The incidence of laparoscopic hiatal hernia recurrence is less than ideal. The reasons are more theoretical than objective, as the literature has little data in support of specific mechanisms of recurrence. METHOD A recent literature review using all Internet-available, English-language articles on laparoscopic hernia repair was completed. RESULTS A multitude of mechanisms of recurrence are suggested, but only surgeon inexperience, postoperative vomiting, heavy lifting, and retention of the hernia sac are supported by data. CONCLUSION The incidence of hiatal hernia recurrence has stabilized. The role of an onlay mesh prosthesis for the prevention of hiatal hernia recurrence is under investigation, and long-term results are awaited.
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Affiliation(s)
- V Puri
- Department of Surgery, Creighton University, Suite 3700 601 N. 30th St, Omaha, NE 68131, USA
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4
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Awad ZT. The myth of the short esophagus. Surg Endosc 2005; 18:1819; author reply 1820. [PMID: 15809798 DOI: 10.1007/s00464-004-8103-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Abstract
We present a case of esophageal papillomatosis with underlying squamous cell carcinoma in situ. An esophageal lesion resected from a 74-year-old woman demonstrated histological findings characteristic of squamous cell papilloma (fibrovascular core and numerous finger-like projections covered with hyperplastic squamous epithelium) and severe dysplasia characteristic of squamous cell carcinoma. The relation of squamous papilloma and squamous cell carcinoma is discussed. It is suggested that esophageal squamous cell papilloma is a premalignant lesion.
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Affiliation(s)
- J Reynoso
- Department of Surgery, Creighton University School of Medicine, Omaha, Nebraska 68131, USA
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Abstract
BACKGROUND Laparoscopic Heller myotomy for achalasia has a 10-20% failure rate and may require reoperation to control persistent, or recurrent symptoms of dysphagia. We report our experience with laparoscopic reoperation for failed Heller myotomy. METHODS Between 1996 and 2001, 5 patients underwent reoperative laparoscopic Heller myotomy. The mean age was 39 years. The presenting symptoms were persistent dysphagia ( n = 3), recurrent dysphagia ( n = 1), and weight loss ( n = 1). The mean duration between 1st surgery and recurrence of symptoms was 2 months and the mean duration between surgeries was 27.5 months. All operations were completed laparoscopically. RESULTS There were no intraoperative or postoperative complications. Incomplete gastric myotomy was the cause of all 5 primary surgical failures. The mean hospital stay was 2 days. Mean follow-up was 12.8 months. Results were excellent in 2 patients who reported no dysphagia postoperatively (dysphagia grade 0) and good in 3 patients (60%) who all reported improvement in swallowing (dysphagia grade I-II). CONCLUSION Laparoscopic reoperation for failed Heller myotomy is feasible with encouraging preliminary results.
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Affiliation(s)
- P E Duffy
- Department of Surgery, Suite 3740, Creighton University Medical Center, 601 North 30th Street, Omaha, NE 68131, USA
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7
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Alam I, Awad ZT, Given HF. Cystosarcoma phyllodes of the breast: a clinicopathological study of 11 cases. Ir Med J 2003; 96:179-80. [PMID: 12926760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
Eleven cases of phyllodes tumour were managed at a single institute over 12 years period. All patients were females, the mean age was 48 years, painless breast lump was the commonest presentation, the left breast was affected in (55%), the upper outer quadrant was the most commonly involved site (60%). Four cases were malignant and the remaining 7 were benign. The diagnostic accuracy rate of fine needle aspiration cytology and intraoperative frozen section was 17% and 37.5% respectively. Adequate treatment was wide local excision in benign cases and simple mastectomy in malignant tumour. At a mean follow-up of 37 months the local recurrence and distant metastasis rate was 27% and 9% respectively.
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Affiliation(s)
- I Alam
- Department of Surgery, Academic Surgical Unit, University College Hospital Galway, National University of Ireland, Ireland.
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8
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Abstract
AIM To determine the usefulness of endoscopically-delivered small intestinal submucosa (SIS) as a scaffold in enhancing the lower oesophageal sphincter (LOS) pressures. METHODS Six dogs were endoscopically injected--four with the SIS and two with its glycerin carrier. Manometry was performed prior to injection and every four weeks post-op. RESULTS Adequate and site correct injections were made in four dogs. In one dog, significant augmentation of pressures were obtained at four weeks. None had significant changes in pressure at eight weeks, differences in length at either four or eight weeks or significant differences in the thickness of the examined layers. Four of the six had capillary cushions on pathological examination. The dog injected with the carrier had a loose and disorganise collection, while the others were well organised. CONCLUSION SIS is a biologically compatible material. Lack of an animal model for gastro-oesophageal reflux disease (GORD) makes determining the ability of injections of SIS to combat reflux problematic.
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Affiliation(s)
- R E Marsh
- Department of Surgery, Creighton University, NE, Omaha 68131, USA
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Kakarlapudi GV, Awad ZT, Haynatzki G, Sampson T, Stroup G, Filipi CJ. The effect of diaphragmatic stressors on recurrent hiatal hernia. Hernia 2002; 6:163-6. [PMID: 12424593 DOI: 10.1007/s10029-002-0081-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2002] [Accepted: 06/19/2002] [Indexed: 11/24/2022]
Abstract
Hiatal disruption is one of the common mechanisms of failure after Nissen fundoplication. We investigated the correlation between various diaphragm stressors and disruption of the diaphragmatic closure. Thirty-seven patients with a hiatal hernia recurrence of 2 cm or greater, as proven by esophagram, endoscopy, or operative findings, were included. A retrospective analysis was conducted utilizing a standardized diaphragm stressor questionnaire for the study group and a control group of 50 patients without hiatal hernia recurrence. Logistic regression was used to determine the significant predictors of hiatal hernia recurrence. Three predictors emerged in the final model: weight lifting (P < 0.0174), vomiting (P < 0.0313) and hiccoughing (P < 0.2472). Of these, only vomiting and weight lifting were significant. The odds ratio for weight lifting is OR = 3.662 (95% CI: 1.256-10.676), and for vomiting it is OR = 4.938 (95% CI: 1.154-21.126). Vomiting or heavy weight lifting is a significant predictor of hiatal hernia recurrence.
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Affiliation(s)
- G V Kakarlapudi
- Department of Surgery, Suite 3740, Creighton University School of Medicine, 601 N 30th Street, Omaha, NE 68131-2197, USA
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Samson TD, Tercero FM, Sato K, Awad ZT, Filipi CJ. Cecal herniation through the foramen of Winslow after laparoscopic Nissen fundoplication. Surg Endosc 2001; 15:1490. [PMID: 11965478 DOI: 10.1007/s004640041027] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2000] [Accepted: 02/27/2001] [Indexed: 12/16/2022]
Abstract
Laparoscopic Nissen fundoplication is the treatment of choice for medically refractive gastroesophageal reflux disease. Cecal herniation is an exceedingly rare complication of this procedure. We report the case of a 51-year-old woman who presented 2 months after a successful laparoscopic Nissen fundoplication with heartburn and epigastric pain that radiated to her back. Abdominal films showed an air-filled loop in the left upper quadrant. At surgery, the patient had a redundant loop of cecum, which had herniated through the foramen of Winslow over the stomach and was positioned beneath the left hemidiaphragm. The cecum was not ischemic. A right hemicolectomy was performed to prevent recurrence. The patient recovered fully and has had no further problems. This is the first report of such a case.
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Affiliation(s)
- T D Samson
- Department of Surgery, Creighton University School of Medicine, St. Joseph Hospital, 601 N. 30th Street, Suite 3740, Omaha, Nebraska 68131-2197, USA
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Awad ZT, Anderson PI, Sato K, Roth TA, Gerhardt J, Filipi CJ. Laparoscopic reoperative antireflux surgery. Surg Endosc 2001; 15:1401-7. [PMID: 11965454 DOI: 10.1007/s004640080206] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2000] [Accepted: 05/15/2001] [Indexed: 11/25/2022]
Abstract
BACKGROUND Antireflux operations for gastroesophageal reflux disease whether performed open or laparoscopically can fail and may require reoperation to control new, recurrent symptoms or operation-related complications. We report our experience with the laparoscopic reoperation for failed antireflux procedures. METHODS Between 1995 and 2000, 37 patients underwent laparoscopic reoperative antireflux procedures. The mean age and weight were 52 years and 181.5 pounds. The main presenting symptoms were heartburn (n = 18), respiratory reflux (n = 4), chest pain (n = 3), regurgitation (n = 1), and dysphagia (n = 10). The mean duration between the first operation and recurrence of symptoms was 18 months, and the duration between the two procedures was 25 months. The operation was completed laparoscopically in 32 patients (86.5%): Nissen fundoplication (n = 27) and Toupet fundoplication (n = 9). RESULTS Intraoperative and postoperative complications occurred in 6 and 14 patients, respectively. Fundoplication disruption was the most common cause of primary surgery failure. The mean hospital stay was 4 days. At a mean follow-up of 26.5 months, results were excellent to good (65%), fair (21.5%), and poor (13.5%). CONCLUSION Laparoscopic reoperative antireflux procedures are technically feasible with acceptable preliminary results.
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Affiliation(s)
- Z T Awad
- Department of Surgery, Suite 3740, Creighton University School of Medicine, 601 N. 30th Street, Omaha, NE 68131, USA
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Awad ZT. Direct inguinal hernia strangulating through the superficial inguinal ring. Ir Med J 2001; 94:313. [PMID: 11837633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
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Abstract
An effective method for determining the presence of a short esophagus preoperatively would be helpful to surgeons. In this study 260 patients underwent primary laparoscopic antireflux surgery; 44 of them were suspected to have esophageal shortening on the basis of: (1) Barrett's esophagus or evidence of peptic stricture formation on endoscopy; (2) an irreducible hiatal hernia > or = 5 cm in length on upright barium esophagram; or (3) a short esophagus on manometric analysis, defined as 2 SD below normal for height. Six patients without preoperative criteria required extensive esophageal mobilization and intraoperative endoscopic/laparoscopic assessment. Preoperative results were then compared with intraoperative esophageal length assessments. Altogether, 13 patients (5% of the whole series) underwent a lengthening procedure: left thoracoscopically assisted laparoscopic Collis gastroplasty (n = 11) or open transthoracic Collis gastroplasty (n = 2) plus antireflux repair (Nissen fundoplication in 9 and Toupet repair in 4). Among the preoperative tests, endoscopy had the highest sensitivity rate (61%); a combination of tests resulted in an increase in the specificity (63-100%) without a corresponding increase in sensitivity (28-42%). Preoperative testing is thus useful for predicting the need for an esophageal lengthening procedure. Endoscopy is the best screening test for the short esophagus. A well planned prospective trial to test the reliability of each test is needed.
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Affiliation(s)
- Z T Awad
- Department of Surgery, Creighton University School of Medicine, 601 N. 30th Street, Suite 3740, Omaha, Nebraska 68131, USA
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Sato K, Filipi CJ, Shiino Y, Mittal SK, Zacher K, Gardner GC, Awad ZT. An unusual case of gastric volvulus after laparoscopic paraesophageal hernia repair. Surg Endosc 2001; 15:757. [PMID: 11591985 DOI: 10.1007/s004640020031] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/1999] [Accepted: 11/10/1999] [Indexed: 11/29/2022]
Abstract
Laparoscopic surgery for paraesophageal hernia is well accepted. However, the complications of this relatively new procedure have not been thoroughly investigated. Only four cases of recurrent volvulus after paraesophageal hernia repair have been reported. A 52-year-old man presented with a large right-side paraesophageal hernia. He experienced a retroperitoneal midgastric volvulus despite correct orientation of the stomach distally and proximally. We report an unusual complication that seems congenital in origin. Diagnostic and corrective measures are suggested.
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Affiliation(s)
- K Sato
- Department of Surgery, Creighton University, St. Joseph Hospital, 601 N 30th Street, Suite 3740, Omaha, NE 68131-2197, USA
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Abstract
A postoperative hiatal hernia is a rare but serious complication of fundoplication. We report herein a 62-year-old female who presented with abdominal pain and vomiting 2 years following laparoscopic Nissen fundoplication. At laparotomy, the stomach and the transverse colon were intrathoracic (type IV hiatal hernia); the esophageal hiatus was markedly dilated with no evidence that they had been approximated. At 18 months follow-up, she is doing very well apart from occasional heartburn. A high index of suspicion is needed to diagnose postoperative hiatal hernias. A routine closure of the crura with nonabsorbable suture material and an avoidance of iatrogenic pneumothorax may help to reduce the occurrence of this problem.
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Affiliation(s)
- Z T Awad
- St. Columcilles Hospital, Loughlinstown, Co. Dublin, Republic of Ireland
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O'Gorman CS, Awad ZT, Given HF. Bilateral choroidal metastases as the initial presentation of breast carcinoma. Ir Med J 2001; 94:85-6. [PMID: 11354691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/16/2023]
Abstract
A 64 year old female presented with a right eye visual impairment. On examination, the visual acuity was decreased on the right side. Slit lamp examination showed bilateral non-pigmented choroidal lesions. Physical examination was unremarkable; bilateral mammogram, however, showed a mass in the left breast, the biopsy from which confirmed the lesion as infiltrative carcinoma. Other tests were normal apart from the isotope bone scan which showed evidence of metastatic disease. She received a short course of radiotherapy to both eyes as well as a 6-month course of chemotherapy. At 6 months follow-up, the choroidal lesions were no longer present and the visual acuity had stabilized. Choroidal metastasis as the initial presentation of breast carcinoma is unusual. Any patient with an ocular tumour should undergo a systemic check-up to rule out an underlying malignancy.
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Affiliation(s)
- C S O'Gorman
- Department of Surgery, Clinical Science Institute, University College Hospital, Galway, Republic of Ireland
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Affiliation(s)
- Z T Awad
- Department of Surgery, School of Medicine, Creighton University, 601 N 30th St, Suite 3740, Omaha, NE 68131, USA
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Joyce MR, Awad ZT, Saleem T, Salmo EN, Gormley M, Given HF. The parotid gland: an unusual site of metastasis from carcinoma of breast. Ir J Med Sci 2000; 169:230. [PMID: 11245139 DOI: 10.1007/bf03167708] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Awad ZT, Filipi CJ, Mittal SK, Roth TA, Marsh RE, Shiino Y, Tomonaga T. Left side thoracoscopically assisted gastroplasty: a new technique for managing the shortened esophagus. Surg Endosc 2000; 14:508-12. [PMID: 10858484 DOI: 10.1007/s004640000091] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Laparoscopic antireflux surgery is the procedure of choice for gastroesophageal reflux disease (GERD). However, many clinicians have reservations about its application in patients with complicated GERD, notably those with esophageal shortening. In this report, we present our experience with the laparoscopic management of the shortened esophagus. A total of 235 patients with primary GERD underwent laparoscopic antireflux procedures, 38 of whom were suspected preoperatively to have a shortened esophagus. Of the 235 patients, 8 (3.4%) needed a left thoracoscopically assisted gastroplasty in addition to laparoscopic Toupet repair (n = 4) or Nissen fundoplication (n = 4). Complications included pleural effusion (n = 1), pneumothorax (n = 2), and minor atelectasis (n = 1). The average hospital stay was 3 days. Results were satisfactory in 7 of 8 patients, with a mean follow-up of 20.2 months (range, 9-34 months). The surgical management of the shortened esophagus is difficult. However, the role of minimally invasive techniques is justified. Early results are appealing, with less morbidity, satisfactory control of GERD related symptoms, and a shortened hospital stay.
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Affiliation(s)
- Z T Awad
- Department of Surgery, Creighton University School of Medicine, Suite 3740, 601 N. 30th Street, Omaha, NE 68131, USA
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Mittal SK, Awad ZT, Tasset M, Filipi CJ, Dickason TJ, Shinno Y, Marsh RE, Tomonaga TJ, Lerner C. The preoperative predictability of the short esophagus in patients with stricture or paraesophageal hernia. Surg Endosc 2000; 14:464-8. [PMID: 10858473 DOI: 10.1007/s004640020023] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Esophageal shortening is a known complication of advanced gastroesophageal reflux disease that may preclude a tension-free antireflux procedure. A retrospective analysis was performed to test the accuracy of preoperative testing. METHODS From September 1993 to December 1998, 39 patients underwent esophageal mobilization with intraoperative length assessment. Patients were selected on the basis of irreducible hiatal hernia, stricture formation, or both. Patients in the upright position with a fixed hiatal hernia larger than 5 cm on an esophagram were considered to have a short esophagus. Manometric length two standard deviations below the mean for height was considered abnormally short. RESULTS In 31 patients, intraoperative mobilization was sufficient to allow the gastroesophageal junction to lie 2 cm below the diaphragmatic crus, so no esophageal-lengthening procedure was required. Eight patients with a short esophagus required an esophageal-lengthening procedure after complete mobilization. Two patients subsequently underwent intrathoracic migration of the gastroesophageal junction (GEJ), with recurrence of symptoms and required gastroplasty during the second surgery. An esophagram had a sensitivity of 66% and a positive predictive value of 37%, whereas manometric length had a sensitivity of 43% and a positive predictive value of 25% for the diagnosis of short esophagus. The preoperative endoscopic finding of either a stricture or Barrett's esophagus was the most sensitive test for predicting the need for a lengthening procedure. CONCLUSIONS Manometry and esophagraphy are not reliable predictors of the short esophagus. Additional tests and/or tests combined with other parameters are needed.
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Affiliation(s)
- S K Mittal
- Department of Surgery, Creighton University School of Medicine, Suite #3740, 601 North 30th Street, Omaha, NE 68131, USA
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Abstract
BACKGROUND Laparoscopic vagotomy represents a new and less invasive treatment for peptic ulcer disease, but the problem of postvagotomy dysphagia has not been solved. The aim of this study was to determine the etiologic factors related to long-term laparoscopic postvagotomy dysphagia. METHODS Two female and 11 male patients with a mean age of 48.5 years who underwent laparoscopic vagotomy were investigated retrospectively. Preoperative diagnosis included duodenal ulcer resistant to medical treatment, gastric hypersecretion, gastric outlet obstruction, cholelithiasis, and gastroesophageal reflux disease (GERD). Ten patients underwent laparoscopic highly selective vagotomy, and three patients had laparoscopic truncal vagotomy with gastrojejunostomy or pyloroplasty. Nine of these patients had a Nissen fundoplication in conjunction with the vagotomy. RESULTS The median long-term follow-up period was 47 months. Two patients complained of severe dysphagia, one of moderate dysphagia, and two of mild dysphagia. Neither type of vagotomy nor an additional fundoplication was correlated with the severity of postoperative long-term dysphagia. Severity of postoperative dysphagia was associated with severity of preoperative dysphagia (r = 0.752, p = 0.003) but not with heartburn (r = 0.358, p = 0.531) or regurgitation (r = 0.024, p = 0.938). The cause of preoperative dysphagia varied; however, all of these patients had GERD and consequent esophageal lesions. CONCLUSION Preexisting dysphagia appears to play an integral role in persistent postoperative dysphagia. Care must be taken to construct a loose fundoplication in patients with dysphagia.
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Affiliation(s)
- Y Shiino
- Department of Surgery, Creighton University, 601 North 30th Street, Omaha, NE 68131, USA
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Abstract
We performed endo-organ full thickness gastric excision to treat a high-risk patient with T2 gastric cancer. The patient, a 75-year-old white man with a gastric adenocarcinoma located just below the gastroesophageal junction, had a history of chronic obstructive pulmonary disease and cor pulmonale, and developed markedly elevated pulmonary artery pressures under general anesthesia. The less invasive endo-organ approach was utilized because of these severe morbidities. The carcinoma was staged laparoscopically, then removed utilizing the full-thickness endo-organ excision technique. This case report serves to demonstrate that full thickness endo-organ gastric excision may be indicated not only for certain early gastric cancers, but also for high-risk patients who cannot tolerate open surgery due to advanced age or serious illness.
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Affiliation(s)
- T Tomonaga
- Department of Surgery, Creighton University School of Medicine, St. Joseph Hospital, Omaha, NE 68131-2194, USA
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Shiino Y, Filipi CJ, Tomonaga T, Awad ZT, Marsh RE. Does the duration of gastroesophageal reflux disease and degree of acid reflux correlate with esophageal function? A retrospective analysis of 768 patients. J Clin Gastroenterol 2000; 30:56-60. [PMID: 10636211 DOI: 10.1097/00004836-200001000-00010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
To reconfirm that the duration of symptoms is not associated with esophageal motility in patients with gastroesophageal reflux disease (GERD), esophageal manometric data from 768 patients with GERD were retrospectively analyzed with relation to the duration of symptoms. GERD was defined by positive acid reflux test results monitored by ambulatory 24-hour pH monitoring. Correlation of the duration of symptoms with esophageal body pressures, the presence of dysmotility determined by simultaneous waves, average resting pressure of the lower esophageal sphincter (LES), and abdominal and overall lengths of the LES were statistically analyzed. The median duration of the symptoms was 60 months (range, 1-600). Duration of symptoms was not associated with contraction pressures of the esophageal body at 3 and 8 cm above the LES (r = -0.070 and -0.063, respectively). There was no correlation between LES pressures, LES lengths, or the percentage of simultaneous waves and duration of symptoms. Stricture formation is related to decreased distal esophageal function in GERD patients. In conclusion, the duration of GERD has little influence on esophageal body and LES function.
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Affiliation(s)
- Y Shiino
- Department of Surgery, Creighton University School of Medicine, Omaha, Nebraska 68131, USA
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26
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Abstract
Technical controversies abound regarding the surgical treatment of achalasia. To determine the value of a concomitant antireflux procedure, the best antireflux procedure, the correct length for gastric myotomy, the optimal surgical approach (thoracic or abdominal), and the equivalency of minimally invasive surgery, a literature review was carried out. The review is based on 23 articles on open transabdominal or transthoracic myotomy, 14 articles on laparoscopic myotomy, and four articles on thoracoscopic myotomy. Postoperative results of traditional open thoracic or transabdominal myotomy as determined by symptomatology were better with fundoplication than without fundoplication. The incidence of postoperative reflux as proved by pH monitoring was high in patients who had an open transabdominal myotomy without fundoplication. The type of antireflux procedure used and the length of gastric myotomy had little effect on results. The results of transthoracic Heller myotomy do not require a concomitant fundoplication. Laparoscopic and thoracoscopic myotomy had excellent results at short-term follow-up. A fundoplication must be added if the myotomy is performed transabdominally. A randomized prospective study is required to determine the best fundoplication and the extent of gastric myotomy. Although minimally invasive surgery for achalasia has excellent initial results, longer follow-up in a larger population of patients is needed.
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Affiliation(s)
- Y Shiino
- Department of Surgery, Creighton University School of Medicine, Omaha, Nebraska 63131, USA
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Awad ZT, Watson P, Filipi CJ, Marsh RE, Tomonaga T, Shiino Y, Bhatia S, Boedefeld W. Correlations between esophageal diseases and manometric length: a study of 617 patients. J Gastrointest Surg 1999; 3:483-8. [PMID: 10482704 DOI: 10.1016/s1091-255x(99)80101-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The purpose of this study was to measure the length of the esophagus and assess its relationship to sex, weight, age, height, and various esophageal disorders. A retrospective analysis was undertaken of 617 esophageal manometric studies, which included 51 normal control subjects (27 males and 24 females) and 566 patients (297 males and 269 females) with esophageal disorders (50 with achalasia, 6 with diffuse esophageal spasm, 64 with strictures, 38 with nutcracker esophagus, 398 with gastroesophageal reflux disease [GERD] with positive 24-hour pH monitoring, and 66 with possible GERD but negative 24-hour pH monitoring). Manometry was performed in all of them by the station pull-through technique. The length of the esophagus was defined as the distance between the proximal end of the upper esophageal sphincter and the distal end of the lower esophageal sphincter. In the control group the mean (+/- standard deviation) length of the esophagus was 28.3 +/- 2.41 cm. In patients with esophageal disorders the mean length of the esophagus was 28.0 +/- 2.87 cm. Length of the esophagus is related to height but not to weight, sex, age, diffuse esophageal spasm, or nutcracker esophagus. Achalasia is associated with a longer esophagus, and GERD is associated with a shorter esophagus. Stricture is associated with a shorter esophagus, but this is in part due to the association between stricture and GERD. Patients with possible GERD but negative 24-hour pH monitoring have an esophageal length similar to that of GERD patients with positive 24-hour pH monitoring. Patients with GERD and stricture formation showed esophageal shortening in shorter patients. Achalasia, GERD, and GERD with stricture formation influence esophageal length. GERD-related strictures shorten the esophagus more significantly in short patients.
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Affiliation(s)
- Z T Awad
- Department of Surgery, Creighton University School of Medicine, Omaha, Nebraska 68131, USA
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Tomonaga T, Houghton SG, Filipi CJ, Hinder RA, Hunter J, Dallemagne B, Katkhouda N, Kozarek R, DeMeester TR, Deeik R, Shiino Y, Awad ZT, Marsh RE. A new form of access for endo-organ surgery. The initial experience with percutaneous endoscopic gastrostomy. Surg Endosc 1999; 13:738-41. [PMID: 10430675 DOI: 10.1007/s004649901089] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
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.
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Affiliation(s)
- T Tomonaga
- Department of Surgery, Creighton University, 601 N. 30th Street, Suite 3740, Omaha, NE 68131, USA
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Shiino Y, Houghton SG, Filipi CJ, Awad ZT, Tomonaga T, Marsh RE. Manometric and radiographic verification of esophageal body decompensation for patients with achalasia. J Am Coll Surg 1999; 189:158-63. [PMID: 10437837 DOI: 10.1016/s1072-7515(99)00091-5] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND Although morphologic, radiographic, and manometric features of achalasia have been well defined, it has not been established by careful retrospective analysis whether achalasia is a progressive disorder resulting in complete decompensation. STUDY DESIGN To verify the hypothesis that achalasia is a progressive disease, we retrospectively investigated manometric, radiographic, and symptomatic data in patients with achalasia. Sixty-three patients (36 women and 27 men) with a median age of 44 years (range 11 to 79 years) were evaluated. The duration of symptoms ranged from 1 to 442 months, with a median of 48 months. Patients were divided into four groups according to the duration of symptoms: 36 patients with less than 5 years, 11 with 5 to 10 years, 9 with 10 to 15 years, and 7 with 15 years or more. RESULTS Contraction pressures of the esophageal body decreased significantly at every level when the duration of symptoms increased (p < 0.04). The percentage of simultaneous waves in the esophageal body rose as the duration of symptoms increased. All waves were synchronous in every patient who had had symptoms for more than 15 years. The maximal width of the esophageal body measured on esophagram became greater with an increase in the duration of symptoms, but this measurement did not reach statistical significance (p = 0.063). The tortuosity of the esophagus, measured by the maximal angle of the esophageal axis, was significantly greater in patients with a longer duration of symptoms (p < 0.02). The type of symptoms was not associated with the duration of symptoms. CONCLUSIONS Achalasia is a progressive disease, as verified by manometric and radiographic findings. The classification of esophageal motor function expressed by amplitude of contraction pressure and angle of tortuosity is objective and useful. Classification of achalasia by duration of symptoms may be important in treatment selection and effectiveness.
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Affiliation(s)
- Y Shiino
- Department of Surgery, Creighton University School of Medicine, Omaha, NE 68131, USA
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Awad ZT, Dickason TJ, Filipi CJ, Shiino Y, Marsh RE, Tomonaga T, Tasset MR, Mittal S. A combined laparoscopic-endoscopic method of assessment to prevent the complications of short esophagus. Surg Endosc 1999; 13:626-7. [PMID: 10347306 DOI: 10.1007/s004649901056] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
As antireflux surgery has been used increasingly for gastroesophageal reflux disease (GERD), a need has arisen for an accurate method to assess esophageal length. There are a number of preoperative tests that can help surgeons to establish the presence of a short esophagus, but intraoperative assessment after esophageal mobilization is the standard method. In this era of laparoscopic surgery, the surgeon mobilizes the esophagus extensively from the abdomen and then determines if mobilization is sufficient. We report an intraoperative technique that combines laparoscopic with endoscopic methods to determine the position of the gastroesophageal junction. Because two physicians are required, there is additional operating room time, resulting in increased costs. However, these costs are offset by the assurance that the complications of the short esophagus can be avoided. With experience, modifications were made, resulting in the technique described herein.
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Affiliation(s)
- Z T Awad
- Department of Surgery, Suite 3740, Creighton University School of Medicine, 601 North 30th Street, Omaha, NE 68131, USA
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