PubMed Health⌕ Search

Biomedical subjects

D B Skinner

Publications and source records attributed to D B Skinner.

At least 91 records · Page 5Linked to original sources
PubMed1982

Potentially curable cancer of the esophagus.

This study assesses factors in staging which may define potentially curable esophageal cancer, and reports experience with exfoliative cytology for diagnosis of asymptomatic cases. The extent of neoplasm in 91 esophagectomy specimens is reviewed and compared to two-year survival rates of patients without evident disease. Metastases to lymph nodes, and muscular penetration by the cancer, but not tumor size, cell type differentiation, or location independently and significantly influenced prognosis. A technique for inexpensive brush cytology of the esophagus and preliminary results demonstrating capability of this method to detect asymptomatic esophageal cancer are described. Early diagnosis of esophageal neoplasm before wall penetration and lymph node spread can lead to improved survival rates from surgical treatment.

Adenocarcinoma↗
PubMed1982

Interaction of lower esophageal sphincter pressure and length of sphincter in the abdomen as determinants of gastroesophageal competence.

This study defines the components of distal esophageal sphincter function which predict gastroesophageal competence and examines the mechanisms by which three antireflux procedures restore competence to the cardia. In a prospective study, the reflux status of 391 patients was determined by 24 hour pH monitoring. Distal esophageal sphincter pressure and length of sphincter exposed to the positive pressure environment of the abdomen was measured by esophageal infusion manometry. Similar pre- and postoperative studies were performed in 45 patients who were randomized to three equal groups for the Hill, Belsey and Nissen antireflux procedures. Two hundred sixty-seven (68 percent) of the 391 patients had a positive 24 hour pH test. Competence of the cardia was related to pressure in the distal esophageal sphincter, to the length of sphincter in the abdomen and to an interaction between both (all p less than 0.05). Thus, competence of the cardia requires an adequate pressure and length of sphincter in the abdomen. In determining competence, the pressure and length effects are not additive, but have an interacting relationship. Sphincter pressure and abdominal length are independently corrected by surgery. Restoration of competence requires increases in both. The gastric fundic wrap best augments distal esophageal sphincter pressure by application of normal functioning smooth muscle to the lower esophagus. Sphincter dynamics are normal after a wrap as the gastric fundus and distal esophageal sphincter share the functions of synchronous contractions and simultaneous relaxation on deglutition.

Esophagogastric Junction↗
PubMed1982

The role of the esophageal body in the antireflux mechanism.

The competency of the cardia depends on the interaction of the distal esophageal sphincter (DES) pressure and the length of the DES exposed to the positive-pressure environment of the abdomen. These two components were measured in 20 normal control volunteers and 126 patients with objectively proved gastroesophageal reflux. The results, when plotted on a grid with the horizontal bar representing the length of the abdominal esophagus and the vertical bar representing the DES pressure, indicated that factors in addition to the mechanical components of the cardia were important in the antireflux mechanism. The 24-hour esophageal pH records from the patients and the antireflux mechanism. The 24-hour esophageal pH records from the patients and normal subjects were analyzed as to the number of reflux episodes that occurred per hour while the patients were in the supine position and the ability to clear the refluxed acid by the propulsive "P"pump" of the body of the esophagus. It was concluded that the antireflux mechanism of the esophagus consists of a valvular cardia and a propulsive "pump" action of the body of the esophagus. The failure of either may lead to abnormal acid exposure but can be compensated by one or the other in normal subjects. Failure of both invariably leads to abnormal acid exposure. The cardia can fail either mechanically (i.e., having inadequate valvular components) or functionally (i.e., having normal valvular component but abnormal number of reflux episodes per hour). The latter suggests gastric pathology. Precise diagnosis of the reason for abnormal acid exposure is needed to develop a rational basis for therapy.

Cardia↗
PubMed1981

Twenty-four-hour pH monitoring of esophageal function. Its use in evaluation in symptomatic patients after truncal vagotomy and gastric resection or drainage.

The incidence and character of gastrointestinal reflux after truncal vagotomy and gastric resection or drainage were studied prospectively in 42 symptomatic patients. Gastroesophageal reflux, proven by 24-hour pH monitoring, occurred in 31 patients. Initial symptoms of heartburn, regurgitation, or dysphagia were similar in patients with and without reflux. Eighteen patients had pure acid, nine had acid-alkaline, and four had pure alkaline reflux. Reflux occurred predominantly in the supine position. Esophagitis occurred only in patients with reflux and was not dependent on the pH of refluxed material. Reflux was eventually controlled by antireflux repair in 19 and by colon interposition in three patients. Twenty-four-hour esophageal pH monitoring is beneficial in evaluating symptoms after gastric surgery. It quantifies both acid and alkaline reflux, provides an objective assessment of the patient's subjective complaints, and gives a rational basis for management.

Drainage↗
PubMed1981

Recent advances in the management of thoracic surgical infections.

Current management of infections in thoracic surgery is reviewed. The selection of patients for the use of antibiotics prophylactically, the diagnosis and treatment of pulmonary infection in immunosuppressed patients, indications for operation in patients with fungal infections, bronchiectasis, lung abscess, and empyema, and the management of mediastinitis after sternotomy and of postpneumonectomy space infections is described.

Amphotericin B↗
PubMed1981

Relationship of a hiatal hernia to the function of the body of the esophagus and the gastroesophageal junction.

One hundred two patients referred to our Esophageal Function Laboratory without endoscopic evidence of esophagitis were divided into two groups on the basis of the presence of a hiatal hernia on endoscopic examination. Fifty-three patients had a hiatal hernia and 49 did not. Both groups and 30 normal volunteer subjects had esophageal manometry and 24 hour esophageal pH monitoring. The incompetency of the cardia in patients with a hiatal hernia was dependent upon loss of components responsible for the antireflux mechanism, mainly a decrease in distal esophageal sphincter pressure and a decrease in the length of the sphincter exposed to the positive-pressure environment of the abdomen. These deficiencies were not related to the presence of a hiatal hernia and were similar to those of patients with an incompetent cardia without a hiatal hernia. Patients with a hiatal hernia and an incompetent cardia had significantly more esophageal exposure to refluxed acid than without a hiatal hernia. On the basis of the number of reflux episodes that lasted 5 minutes or longer and radioisotope transit studies, this increased acid exposure was due to both a loss of competency of the cardia and poor esophageal clearance secondary to the presence of a hiatal hernia. Reduction of the hernia and anchoring the distal esophagus into the abdomen not only may improve the antireflux mechanism, but corrects the clearance abnormality as well. The presence of a hiatal hernia has a detrimental effect on the clearance function of the body of the esophagus and may aggravate the effects of gastroesophageal reflux due to an incompetent cardia.

Adolescent↗
PubMed1980

Intra-abdominal pressure and manometric data of the distal esophageal sphincter. Their relationship to gastroesophageal reflux.

Nineteen patients with abnormal gastroesophageal reflux (13 with and six without hiatal hernia) had esophageal manometry and simultaneous 24-hour monitoring of esophageal pH and intra-abdominal pressure (IAP). Only 8% of all IAP challenges induced a reflux episode. This incidence increased to 13% in patients with a distal esophageal sphincter (DES) pressure of less than 5 mm Hg and an abdominal esophageal length of less than 1 cm, whereas it was only 6% in patients with a greater DES pressure and a longer abdominal esophagus. At the same time, there was an average of 2.7 reflux episodes per hour, of which 38.7% were caused by a challenge of IAP indicating that other mechanisms, besides changes in abdominal pressure, can cause reflux. There was no difference in DES pressure, length of abdominal esophagus, and the effect of IAP challenges in patients with and those without a hiatal hernia.

Abdomen↗
PubMed1980

Management of esophageal perforation.

Early diagnosis of esophageal perforation is critical. The importance of performing sufficient surgery at the first procedure whenever possible is emphasized. If early primary closure cannot be achieved, then the initial therapeutic method of choice is resection or diversion followed by reconstruction. Drainage of the perforated esophagus alone does not appear to be satisfactory treatment. Our experience indicates that later elective surgery for the management of patients undergoing successful initial resuscitation from esophageal perforation may be accomplished with an acceptable mortality rate.

Adult↗
PubMed1980

Esophageal reconstruction.

Experience with 112 esophageal reconstructions in 108 patients employing an overall philosophy for this problem is summarized. In patients with malignant disease, the reconstruction should be the quickest and simplest possible, and a higher long-term complication rate caused by the reconstruction may be acceptable. Experience with the use of the stomach demonstrates that the mortality and complication rates are acceptable but that the stomach has the clear disadvantage of a higher incidence of postoperative aspiration pneumonia, which adds to mortality, and an incidence of serious complications from reflux esophagitis. These late specific complications after esophagogastrostomy are not acceptable in the treatment of patients with benign disease, so the use of intestinal segments, descending colon or jejunum is advocated. Both have the hazard of venous infarction, although the risk of anastomotic leakage, aspiration and late esophagitis is diminished or eliminated. In desperate circumstances, an extracorporeal tube to restore alimentation may be useful in reconstructing the esophagus.

Adult↗
PubMed1980

Technique, indications, and clinical use of 24 hour esophageal pH monitoring.

The technique of 24 hour esophageal pH monitoring (24 hour pH test) is described. Experience with the 24 hour pH test in 393 patients with suspected esophageal disease has shown the clinical usefulness of the test in objectively determining the presence of gastroesophageal reflux. The test was effective in evaluating atypical symptoms of gastroesophageal reflux such as respiratory symptoms and chest pain and, in children, failure to thrive and recurrent pneumonia. The 24 hour pH test was particularly useful in evaluating patients who were referred with other abdominal or thoracic disease and had, in addition, symptoms suggestive of gastroesophageal reflux on history. The test helped to unsnarl the cause of recurrent symptoms after an esophageal myotomy for achalasia or an antireflux procedure. Of 179 patients with typical symptoms of gastroesophageal reflux, 27% had normal 24 hour test results and were subsequently diagnosed as having another cause for their symptoms. Of 146 patients who had normal findings on esophagoscopy, 54% were shown to have abnormal gastroesophageal reflux on 24 hour pH monitoring, indicating lack of sensitivity of endoscopy to detect reflux. In addition, the 24 hour pH test identified patterns of abnormal reflux and indicated those patients most at risk for development of stricture. The test is well tolerated by the patients, simple to use, and dependable when performed and read as described. The clinical use of the 24 hour pH test brings objectivity to the evaluation of exophageal disease that has hitherto not been available.

Aged↗
PubMed1980

Pathogenesis of esophagitis in patients with gastroesophageal reflux.

Endoscopic examination of 50 patients with gastroesophageal reflux showed 26 with and 24 without esophagitis. Distal esophageal sphincter (DES) characteristics of the two groups were similar. All patients had abnormal acid gastroesophageal reflux (GER) on 24-hour pH monitoring of the distal esophagus compared to normal subjects. Patients with esophagitis did not have significantly greater acid exposure than those without esophagitis. Abnormal alkaline GER occurred in only five patients, two with and three without esophagitis. Esophageal clearance was impaired in patients with esophagitis compared to patients without esophagitis as determined by the acid clearance test and the number of reflux episodes of 5 minutes' duration or longer during 24-hour esophageal pH monitoring. Patients with esophagitis also had more frequent reflux episodes than those without esophagitis. Gastric emptying was significantly delayed in patients with esophagitis compared to those without esophagitis who were similar to normal subjects. When patients were analyzed in terms of position of reflux, combined refluxers had the highest, supine refluxers intermediate, and upright refluxers the lowest incidence of esophagitis. Gastric emptying in combined and supine refluxers was similar to the group of patients with esophagitis. Upright refluxers were distinguished by rapid gastric emptying compared to normal subjects and, as such, are a unique entity. We conclude that the development of esophagitis in a patient with an incompetent cardia is related to impaired esophageal clearance and delayed gastric emptying.

Acids↗
PubMed1979

A reappraisal of the value of carcinoembryonic antigen in the management of patients with various neoplasms.

Eight hundred and eight patients with histologically proved malignant disease had carcinoembryonic antigen (CEA) estimations performed at the time of tissue diagnosis. An elevated level was found in 384 of 518 patients with gastrointestinal neoplasms (74 per cent) and in 162 of 290 patients with other neoplasms (56 per cent). No correlation was found between CEA elevations and tumour differentiation. There was a good correlation between tumour staging and CEA levels for patients with colorectal cancer; the more advanced the tumour, the higher the CEA. Several illustrative cases are presented and the role of CEA assay in the diagnosis and management of neoplasia is discussed. CEA assay is a poor screening test for neoplastic disease, but serial CEA monitoring is valuable in the detection of residual or recurrent cancer.

Adult↗