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Biomedical subjects

Carlos A Pellegrini

Publications and source records attributed to Carlos A Pellegrini.

At least 19 recordsLinked to original sources
PubMed2006

Long-term outcome of esophagectomy for high-grade dysplasia or cancer found during surveillance for Barrett's esophagus.

Endoscopic surveillance is recommended for patients with Barrett's esophagus to detect high-grade dysplasia (HGD) or cancer. We studied the outcome of esophagectomy in a cohort of patients who developed HGD or cancer between 1995 and 2003 while under surveillance for Barrett's. Outcomes were measured by analysis of clinical records, symptom questionnaire, and SF-36 (version 2). In 34 patients, mean surveillance time was 48 months (range, 4-132); the mean number of endoscopies was 10 (range, 3-30). Preoperative diagnosis was HGD in 9 patients (26.5%), carcinoma in situ in 16 (47%), and adenocarcinoma in 9 (26.5%). There was no esophagectomy-related mortality; 10 patients (29%) had complications. At mean follow-up of 46 months (range, 13-108), SF-36 (version 2) results showed quality of life scores equal to or better than those of healthy individuals. Incidence and severity scores (VAS 1-10) for postoperative symptoms were reflux, 59% (2.8); dysphagia, 28% (3.7); bloating, 45% (2.6); nausea, 28% (2.1); and diarrhea, 55% (2.5). Twenty-nine patients (85%) have no clinical, radiographic, or endoscopic evidence of recurrent esophageal cancer or metastasis. One patient has metastatic disease. Endoscopic surveillance in Barrett's patients yields malignant lesions at an early, generally curable, stage. Esophagectomy is curative in the great majority and can be accomplished with minimal mortality and excellent quality of life.

Adenocarcinoma↗
PubMed2006

Biologic prosthesis reduces recurrence after laparoscopic paraesophageal hernia repair: a multicenter, prospective, randomized trial.

OBJECTIVE: Laparoscopic paraesophageal hernia repair (LPEHR) is associated with a high recurrence rate. Repair with synthetic mesh lowers recurrence but can cause dysphagia and visceral erosions. This trial was designed to study the value of a biologic prosthesis, small intestinal submucosa (SIS), in LPEHR. METHODS: Patients undergoing LPEHR (n = 108) at 4 institutions were randomized to primary repair -1 degrees (n = 57) or primary repair buttressed with SIS (n = 51) using a standardized technique. The primary outcome measure was evidence of recurrent hernia (> or =2 cm) on UGI, read by a study radiologist blinded to the randomization status, 6 months after operation. RESULTS: At 6 months, 99 (93%) patients completed clinical symptomatic follow-up and 95 (90%) patients had an UGI. The groups had similar clinical presentations (symptom profile, quality of life, type and size of hernia, esophageal length, and BMI). Operative times (SIS 202 minutes vs. 1 degrees 183 minutes, P = 0.15) and perioperative complications did not differ. There were no operations for recurrent hernia nor mesh-related complications. At 6 months, 4 patients (9%) developed a recurrent hernia >2 cm in the SIS group and 12 patients (24%) in the 1 degrees group (P = 0.04). Both groups experienced a significant reduction in all measured symptoms (heartburn, regurgitation, dysphagia, chest pain, early satiety, and postprandial pain) and improved QOL (SF-36) after operation. There was no difference between groups in either pre or postoperative symptom severity. Patients with a recurrent hernia had more chest pain (2.7 vs. 1.0, P = 0.03) and early satiety (2.8 vs. 1.3, P = 0.02) and worse physical functioning (63 vs. 72, P = 0.03 per SF-36). CONCLUSIONS: Adding a biologic prosthesis during LPEHR reduces the likelihood of recurrence at 6 months, without mesh-related complications or side effects.

Aged↗
PubMed2006

Sole treatment of acid gastroesophageal reflux in idiopathic pulmonary fibrosis: a case series.

RATIONALE: Idiopathic pulmonary fibrosis (IPF) is a progressive and fatal disease despite the available treatment regimes. Increased acid gastroesophageal reflux (GER) occurs in IPF patients. OBJECTIVES: To follow the course of IPF in patients while being treated for acid GER alone. METHODS: A retrospective review of the clinical outcomes of four patients with newly diagnosed IPF and increased acid GER who chose to be treated solely with anti-acid GER therapy were followed up regularly with pulmonary function tests (PFTs) [measuring FVC and the diffusing capacity of the lung for carbon monoxide] over a period of 2 to 6 years. Anti-acid GER therapy was administered using proton-pump inhibitors and fundoplication, if needed. Adequate suppression of acid GER was ascertained by 24-h esophageal pH monitoring. MAIN RESULTS: PFT results in all four patients stabilized or improved while their conditions were maintained with adequate treatment for acid GER. All patients were alive at the last follow-up, and none manifested an acute exacerbation of IPF or needed treatment for respiratory problems during this period. After maintaining 4 years of improved status (based on PFT and exercise testing findings) while adhering to treatment for acid GER, one patient's deterioration correlated with poor compliance to daily treatment during the fifth year, although the PFT results at the sixth year showed stabilization compared to baseline values. The condition of another patient was stabilized by adhering to anti-acid GER treatment after an initial period of deterioration that was associated with nonadherence CONCLUSIONS: Future clinical studies are indicated to clarify the role of acid GER in IPF and to determine whether adequate treatment for increased acid GER in part improves the outcome of patients with IPF.

Aged↗
PubMed2005

Typical GERD symptoms and esophageal pH monitoring are not enough to diagnose pharyngeal reflux.

BACKGROUND: Abnormal pharyngeal reflux of acid (PR) (as measured by pH monitoring) is associated with microaspiration, and is a good predictor of airway symptom response to medical and surgical anti-reflux therapy. However, in clinical practice the link between airway disease and Gastroesophageal reflux disease (GERD) is still based on the presence of typical symptoms (e.g., heartburn) and/or standard esophageal function testing (manometry and 24-pH monitoring). PR is rarely measured directly. We undertook this study to determine if typical symptoms and standard testing could reliably predict the presence of PR. METHODS: The study group consisted of 518 patients with suspected reflux induced airway disease evaluated from December 1998 through January 2002. Each patient completed a standardized symptom questionnaire, underwent esophageal manometry, and 24-h esophageal and pharyngeal pH monitoring. Patients were classified having abnormal pharyngeal reflux (PR+) if they had >1 episode of PR detected during pH monitoring. RESULTS: One hundred eighty-one patients were PR+ and 337 were PR-. The most common symptoms, namely cough (PR +73%, PR- 68%), hoarseness (PR +64%, PR- 66%), and dyspnea (PR +59%, PR- 59%) were present with similar incidence in PR+ and PR- patients. The incidence of heartburn was 54% in the PR+ and 52% in the PR- patients. Logistic regression analysis revealed that abnormal esophageal acid exposure was a predictor of PR+ (P < 0.001). Neither the presence of heartburn or specific respiratory symptoms, the pressure of the lower esophageal sphincter (LES) or upper esophageal sphincter (UES), or amplitude of esophageal contractions predicted PR+. There was substantial variability in esophageal length (UES to LES), thus the placement of the distal pH probe from the LES varied considerably (median = 13 cm, 2-20 cm). Using established normal values of acid exposure at multiple levels of the esophagus, 24% of PR+ patients had normal amounts of esophageal acid exposure. CONCLUSIONS: Typical GERD symptoms, such as heartburn, and typical symptoms of aspiration such as hoarseness, cough, or dyspnea are not enough to positively identify PR. While patients with abnormal esophageal acid exposure are three times more likely than those with normal values to have PR, abnormal esophageal acid exposure alone does not identify all patients with PR. Therefore, relying on symptoms and standard diagnostic testing may fail to identify patients with extraesophageal reflux. Pharyngeal pH monitoring should be considered for patients with suspected reflux-induced airway disease.

Diagnostic Techniques, Digestive System↗
PubMed2005

Gastric mass.

Explore the source record for details and available documents.

Aged↗
PubMed2005

A randomized, controlled trial evaluating the impact of a computerized rounding and sign-out system on continuity of care and resident work hours.

BACKGROUND: Adoption of limits on resident work hours prompted us to develop a centralized, Web-based computerized rounding and sign-out system (UWCores) that securely stores sign-out information; automatically downloads patient data (vital signs, laboratories); and prints them to rounding, sign-out, and progress note templates. We tested the hypothesis that this tool would positively impact continuity of care and resident workflow by improving team communication involving patient handovers and streamlining inefficiencies, such as hand-copying patient data during work before rounds ("prerounds"). STUDY DESIGN: Fourteen inpatient resident teams (6 general surgery, 8 internal medicine) at two teaching hospitals participated in a 5-month, prospective, randomized, crossover study. Data collected included number of patients missed on resident rounds, subjective continuity of care quality and workflow efficiency with and without UWCores, and daily self-reported prerounding and rounding times and tasks. RESULTS: UWCores halved the number of patients missed on resident rounds (2.5 versus 5 patients/team/month, p = 0.0001); residents spent 40% more of their prerounds time seeing patients (p = 0.36); residents reported better sign-out quality (69.6% agree or strongly agree); and improved continuity of care (66.1% agree or strongly agree). UWCores halved the portion of prerounding time spent hand-copying basic data (p < 0.0001); it shortened team rounds by 1.5 minutes/patient (p = 0.0006); and residents reported finishing their work sooner using UWCores (82.1% agree or strongly agree). CONCLUSIONS: This system enhances patient care by decreasing patients missed on resident rounds and improving resident-reported quality of sign-out and continuity of care. It decreases by up to 3 hours per week (range 1.5 to 3) the time used by residents to complete rounds; it diverts prerounding time from recopying data to more productive tasks; and it facilitates meeting the 80-hour work week requirement by helping residents finish their work sooner.

Continuity of Patient Care↗
PubMed2005

Laparoscopic repair of paraesophageal hernia.

Laparoscopic repair of paraesophageal hernias is rapidly replacing the traditional open approach. Regardless of the approach, certain aspects of repairing paraesophageal hernias have proven to be beneficial and others remain controversial. This article addresses the effectiveness of the laparoscopic approach, the accepted and controversial technical aspects of repair, and which patients should undergo surgical correction of the hernia.

Fundoplication↗
PubMed2005

Achalasia.

Surgical therapy (Heller myotomy) is the most effective treatment to relieve dysphagia associated with achalasia. The advent of minimally invasive techniques, specifically the laparoscopic approach, significantly reduced the morbidity of surgical therapy, making it the procedure of choice for most patients who have achalasia. Pneumatic dilatation is a viable alternative, though is associated with inferior results and a higher risk of esophageal perforation than surgical therapy. Pharmacotherapy and Botox provide inferior results and should be reserved for temporizing therapy, or for patients who are deemed too frail for surgical intervention. For best results, a laparoscopic myotomy should be carried at least 3 cm onto the stomach, and a partial fundoplication should be performed to reduce the incidence of postoperative GE reflux.

Barium Radioisotopes↗
PubMed2005

Laparoscopic Heller myotomy and Roux-en-Y gastric bypass: a novel operation for the obese patient with achalasia.

Morbid obesity is a disease encompassing multiple, significant comorbidities. The only current, reliable, durable treatment of obesity is surgical intervention, most commonly gastric bypass. Achalasia, a swallowing disorder of esophageal motility and failure of the lower esophageal sphincter (LES) to relax, is rarely seen in the morbidly obese patient. Treatment is directed at disruption of the LES to allow passage of food. As medical management usually fails in both disease processes, surgical treatment is often chosen. The patient with both morbid obesity and achalasia presents an unusual challenge for surgical treatment. The standard surgical approach for each disease does not address the other, and may have deleterious consequences on the other condition if approached unilaterally. We present the first case of a patient treated with a concomitant laparoscopic esophagogastric myotomy (LEM) and laparoscopic Roux-en-Y gastric bypass (LRYGBP).

Adult↗
PubMed2004

Organizing the transfer of patient care information: the development of a computerized resident sign-out system.

BACKGROUND: The problem of safe and efficient transfer of care has increased over the years as new and complex diagnostic tools and more complex treatment options became available. Traditionally, residents ensured continuity of care by working long hours and minimizing the transfer of significant diagnostic or therapeutic responsibilities to other providers. The new 80-hour workweek has curtailed that practice and increased the pressure on trainees for workflow efficiency. We report on a study of information-handling routines among residents for the separate tasks of transfer of care ("sign-out") and daily patient care work (ward work). Using these results, an institution-wide computerized system was developed to centralize information-handling tasks and facilitate the management and transfer of patient care information. STUDY DESIGN: House staff from 31 resident-run inpatient and consult services at 2 teaching hospitals described current methods of maintaining patient information used during ward rounds and during sign-out. A subgroup of 28 residents then participated in the design of a computerized resident sign-out system to centralize patient information and produce lists for rounding and transferring care duties. Accuracy, flexibility, and portability were identified as key elements by the design team. RESULTS: Analysis of the type of information handled by residents caring for inpatients at our institution demonstrated common elements across many services. Most services used a paper patient list to manage both nightly sign-out and daily ward work, which required repeated recopying of patient data during the day. Utilizing medical information systems tools and rapid application development concepts, we constructed a computerized resident sign-out system ("UWCores"). This system combines the patient sign-out and daily ward work information in one central location. We believed this would improve the quality of information transferred during sign-out and enhance resident efficiency. During the design process, we identified rules that govern the type of clinical information that should be automatically versus manually updated. We observed an immediate acceptance by all residents and services that tried the system. CONCLUSIONS: This study shows that by combining downloaded patient data from hospital systems with resident-entered patient details, a computerized resident sign-out system can be a feasible, powerful, and popular tool. While its effect on patient safety and resident efficiency await the results of further studies, our study shows that this tool rapidly captured the attention of resident physicians and became widely used as a valuable means to centralize and organize sign-out and daily ward work information.

Continuity of Patient Care↗