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Biomedical subjects

G V Stiegmann

Publications and source records attributed to G V Stiegmann.

At least 19 recordsLinked to original sources
PubMed1992

Endoscopic sclerotherapy as compared with endoscopic ligation for bleeding esophageal varices.

BACKGROUND: Endoscopic sclerotherapy is an accepted treatment for bleeding esophageal varices, but it is associated with substantial local and systemic complications. Endoscopic ligation, a new form of endoscopic treatment for bleeding varices, may be safer. We compared the effectiveness and safety of the two techniques. METHODS: In this randomized trial we compared endoscopic sclerotherapy and endoscopic ligation in 129 patients with cirrhosis who had proved bleeding from esophageal varices. Sixty-five patients were treated with sclerotherapy, and 64 with ligation. Initial treatment for acute bleeding was followed by elective retreatment to eradicate varices. The patients were followed for a mean of 10 months, during which we determined the incidence of complications and recurrences of bleeding, the number of treatments needed to eradicate varices, and survival. RESULTS: Active bleeding at the first treatment was controlled by sclerotherapy in 10 of 13 patients (77 percent) and by ligation in 12 of 14 patients (86 percent). Slightly more sclerotherapy-treated patients had recurrent hemorrhage during the study (48 percent vs. 36 percent for the ligation-treated patients, P = 0.072). The eradication of varices required a lower mean (+/- SD) number of treatments with ligation (4 +/- 2 vs. 5 +/- 2, P = 0.056) than with sclerotherapy. The mortality rate was significantly higher in the sclerotherapy group (45 percent vs. 28 percent, P = 0.041), as was the rate of complications (22 percent vs. 2 percent, P less than 0.001). The complications of sclerotherapy were predominantly esophageal strictures, pneumonias, and other infections. CONCLUSIONS: Patients with cirrhosis who have bleeding esophageal varices have fewer treatment-related complications and better survival rates when they are treated by esophageal ligation than when they are treated by sclerotherapy.

Esophageal and Gastric Varices↗
PubMed1992

Precholecystectomy endoscopic cholangiography and stone removal is not superior to cholecystectomy, cholangiography, and common duct exploration.

Thirty-four patients with suspected common bile duct stones were randomized to undergo endoscopic cholangiography and stone removal prior to open cholecystectomy or to have open cholecystectomy, operative cholangiography, and common bile duct exploration. Sixteen underwent the first protocol, and 18 the second. Analysis of the ability to clear stones from the common bile duct, morbidity, mortality, hospital stay, length of operation, and hospital cost showed no difference in outcome between patients treated by either method. These data suggest there is neither an advantage nor a disadvantage to treating patients with suspected duct stones by precholecystectomy endoscopic cholangiography and stone removal.

Adult↗
PubMed1992

Three years experience with endoscopic variceal ligation for treatment of bleeding varices.

Endoscopic variceal ligation (EVL) was developed as an alternative to endoscopic variceal sclerosis (ES) because of the high complication rate seen with ES. The new technique involves placement of small elastic bands around the variceal channels in the distal esophagus. The first 146 consecutive patients treated with EVL during the period from August, 1986 to July, 1989 are reported. Portal hypertension was caused by alcoholic liver disease in 93 of these patients. The average age of the patients was 53 years and 66% were males. All of the patients had recently bled from esophageal varices. At the time of treatment, 23% of the patients were actively bleeding. They were all treated acutely with EVL and had repeated treatments with the long-term goal of variceal eradication. The overall survival was 73%. Varices were eradicated or reduced to grade one in 78% of the 125 patients who were followed for more than 30 days. Variceal eradication required a mean of 5.5 sessions. Recurrent bleeding occurred in 44% of the total patient population. There were no major complications from EVL. It is concluded from this non-randomized experience that EVL is an effective treatment for bleeding esophageal varices and that it appears to be as effective as sclerotherapy with fewer complications.

Esophageal and Gastric Varices↗
PubMed1992

Endoscopic ligation of esophageal varices.

Endoscopic variceal ligation was developed to provide a safe alternative to conventional injection sclerotherapy which is known to be associated with a substantial incidence of non-bleeding treatment related complications. Laboratory studies in portal hypertensive dogs have shown the technique results in obliteration of vascular structures in the submucosa by scar tissue formation. The clinical technique of endoscopic ligation is performed in the endoscopy suite or intensive care unit in a fashion similar to endoscopic sclerotherapy except an endoscopic overtube is routinely employed. Initial single arm trials of endoscopic ligation in 146 consecutive patients showed the technique to be effective for control of active bleeding and eradication of varices while being associated with a low incidence of non-bleeding complications. Endoscopic ligation has been investigated in three additional single arm trials and is currently under investigation in three prospective randomized studies comparing the technique with sclerotherapy. Data from these studies have confirmed that endoscopic ligation is at least equal to sclerotherapy for treatment of actively bleeding varices and prevention of recurrent bleeding. The new technique appears to result in a significantly lower risk of non-bleeding treatment related complications than conventional sclerotherapy.

Animals↗
PubMed1991

A prospective study of incisional time, blood loss, pain, and healing with carbon dioxide laser, scalpel, and electrosurgery.

Carbon dioxide laser incisions are reported to be less painful, less bloody, and less prone to seroma formation and to heal better than scalpel or electrosurgical incisions. We compared all three modalities in a prospective randomized study of cholecystectomy incisions. Time required for the incision and incisional blood loss was less with electrosurgery than with the carbon dioxide laser or scalpel. Postoperative pain and wound healing, however, were the same for all three techniques. The carbon dioxide laser appears to offer no advantage over conventional means of making a standard incision.

Adult↗
PubMed1991

Minimal access surgery for gastroesophageal reflux: laparoscopic placement of the Angelchik prosthesis in pigs.

Conventional surgery for gastroesophageal reflux is effective but requires laparotomy. Minimal access surgery for gastroesophageal reflux could provide a decrease in morbidity. The Angelchik antireflux prosthesis is an alternative to fundoplication for the treatment of this ailment. We evaluated the results of laparoscopic placement of the Angelchik prosthesis in 10 pigs. The duration of the procedure averaged 44 min. The mean lower esophageal sphincter pressure increased from 12.2 +/- 2.8 mmHg at baseline to 45.2 +/- 7.8 (P less than 0.05), 32.1 +/- 3.9 (P less than 0.05), and 25.1 +/- 6.5 mmHg (P greater than 0.05) as measured immediately postoperatively, at 1 week, and at 3 weeks, respectively, following placement of the prosthesis. There was no instance of prosthetic migration or esophageal perforation. One postoperative death due to distention and perforation of the colon occurred. Two animals developed distal esophageal impaction of food. We conclude that the antireflux prosthesis can be safely and effectively placed using laparoscopic methods in a porcine model. Further development of this technique is warranted.

Animals↗
PubMed1991

Short intussusception valves prevent reflux after jejunal interposition bilioduodenal anastomosis.

Short whole circumference and semi-circumference intussusception valves were created in interposition cholecysto-jejunal-duodenal conduits in pigs to determine which method best prevented gastrointestinal reflux into the biliary tract. Following intravenous injection of 99 mTc-HIDA the time interval for its excretion from the liver and appearance in the duodenum was not different in either whole or semi-circumference valve animals or in controls without valves. After intragastric administration of 99 mTc-DTPA the relative radioactivity of gallbladder contents (reflux) in the cohort without valves was significantly higher than in both cohorts with valves. Animals with semi-circumferential valves in turn had significantly higher levels of nuclide than those with whole circumference valves. Reflux was observed grossly in 100% of animals without valves, in 20% of those with semi-circumference valves, and in no animals with whole circumference valves. This study indicates that both whole and semi-circumference intussusception valves placed in jejunal biliary conduits allow unimpeded flow of bile into the gastrointestinal tract. Whole circumference valves are more effective for prevention of reflux than semi-circumferential valves.

Animals↗
PubMed1991

The next step.

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Curriculum↗
PubMed1990

Resident training.

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Clinical Competence↗
PubMed1990

Continent ileocolonic urinary reservoirs for filling and lining the post-exenteration pelvis.

Pelvic exenteration has a high complication rate due, in large part, to the extensive raw surfaces and dead space it creates. Numerous techniques have been used to control this space and line these surfaces, but none, to date, has proven to be a reliable solution. We investigated the use of continent ileocolonic urinary reservoirs as a new "flap" to fill and line the pelvis in 17 patients, and found that our historical complication rate of 44% for pelvic exenteration was reduced to 18%. These reservoirs appear to be an improved method of managing the post-exenteration pelvis.

Adult↗
PubMed1989

Extended resection of fixed rectal cancer.

Between 1980 and 1987, we operated on 23 patients (16 men and 7 women) with fixed rectal cancer. Two patients had primary tumours. Twenty-one patients had recurrent disease (anterior resection, 8; abdominoperineal resection, 13). Eighteen patients had prior irradiation (40 Gy to 120 Gy). Resection was possible in 20 patients (16 for cure and 4 for palliation). Operations included extended proctectomy (n = 4), standard pelvic exenteration (n = 4), and sacropelvic exenteration (n = 12). One (5%) patient died postoperatively and five (25%) others had significant postoperative complications. With a follow-up time of 1 to 48+ months (median, 18 months), nine patients are dead of disease (operative death included), four are living with disease, two are dead free of disease, and eight (50% of those undergoing curative resection) are living free of disease. The results suggest that resection of fixed rectal cancer is feasible in many patients and of potential long-term benefit to approximately 50% of those in whom curative resection is possible.

Adenocarcinoma↗
PubMed1989

Technique and early clinical results of endoscopic variceal ligation (EVL).

Endoscopic variceal ligation (EVL) is a new technique designed to be used instead of sclerotherapy. Small elastic "O" rings ligate varices resulting in their strangulation and eradication. During a 12-month period, EVL was employed in 53 consecutive patients, of whom 36 (68%) had alcoholic cirrhosis 17 were Child-Pugh class A, 22 class B, and 14 class C. Varices were graded from I to IV and repeat treatments were given at 1-2 week intervals until the varices were eliminated. At follow-up ranging from 6-18 months (mean 11.5), 217 EVL treatment sessions had been performed. Of the 13 patients (24%) who died during the study, 11 died during the index hospitalization. Active bleeding was controlled in 19 of 21 patients (90%). Of 40 survivors 13 patients (33%) had 1-2 (mean 1.4) recurrent variceal bleeds while 34 patients had repeat EVL treatment. Elimination of distal varices was achieved in 26 and 7 had reduction of varices from grade III-IV to grade I-II or less. Eradication required a mean of 4.4 EVL sessions in Child's A and B patients and 7.0 sessions in Child's C patients (P less than 0.025). No significant treatment-related complications were observed. EVL appears to control active bleeding, is associated with a low incidence of non-bleeding complications, and may be used as an alternative to sclerotherapy.

Child↗
PubMed1989

Endoscopic elastic band ligation for active variceal hemorrhage.

The purpose of this study was to assess the efficacy of EVL for treatment of active variceal hemorrhage. Twenty-three consecutive patients with actively bleeding esophageal varices had EVL with a flexible gastroscope. Treatment was measured by initial control of bleeding, incidence of early and late rebleeding, survival, complications, and size of varices at subsequent endoscopy. Repeat EVL was performed as needed for bleeding and at two week intervals until varices were grade I or eradicated. Follow up of survivors ranged from 90 to 400 days (mean 280). Bleeding varices were initially controlled in 22 (95.6%) patients. Nine (39.1%) died, five from hepatic failure with no recurrent bleeding, four from continued (1) or early recurrent (3) hemorrhage. All deaths occurred within 3 to 24 days (mean = 9.4) of initial treatment for active bleeding. Twelve of 14 surviving patients have achieved variceal eradication or reduction in size to grade I or less with a mean of 5.5 repeat EVL sessions (range, 0-10). One refused further treatment; one is lost to follow up. Excluding rebleeding, there were no treatment-related complications in 80 EVL sessions. Active variceal bleeding requiring endoscopic control is associated with substantial mortality, especially in higher risk patients. EVL is effective for initial and long term control of bleeding. EVL appears to be associated with a low incidence of non-bleeding complications.

Adolescent↗
PubMed1988

Endoscopic esophageal varix ligation: technique and preliminary results in children.

A technique for treating esophageal variceal hemorrhage in children using endoscopically placed rubber ligatures was evaluated in six children. The method offers a major advantage over chemical obliteration of varices by sclerosants in the absence of systemic, local, or distant organ reactions and, perhaps, in the avoidance of esophageal motor dysfunction.

Adolescent↗
PubMed1985

A prospective study of preoperative chemotherapy and split-course irradiation for locally advanced or recurrent oral/pharyngeal squamous carcinoma.

Two courses of preoperative chemotherapy (methotrexate, bleomycin, cisplatin) were combined with split-course irradiation (2,000 rad/10 preop., 4,000 rad/20 postop.) and prospectively compared with standard therapy (surgery and/or irradiation alone) for locally advanced or recurrent oral/pharyngeal squamous cancer. The chemoradiotherapy arm (Ch-XRT) had 31 patients; the standard therapy arm 28 randomized (RC) and 20 concomitantly-treated (CC) patients. Treatment-related mortality was 17% for Ch-XRT; 10% for RC + CC. Number of patients NED at completion of treatment was 74% for Ch-XRT; 83% for RC + CC (NS). Median survival, however, was 17 months for Ch-XRT, 9 months for CC, and 12 months for RC. In addition, survival at 40 + months was 45% for Ch-XRT versus 21-22% for RC and CC (p less than 0.05). Thus, Ch-XRT seems to have promise in advanced oral/pharyngeal cancer, but needs revision to decrease toxicity.

Aged↗
PubMedDate not supplied

Neuroendocrine stress response after minimally invasive surgery in pigs.

Minimally invasive operations such as laparoscopic cholecystectomy appear to result in more rapid recovery of normal function, less physiological disturbance, and presumably less stress to the organism than open operation counterparts. The purpose of this study was to determine the stress response associated with minimally invasive surgery compared to conventional laparotomy. Three groups of pigs underwent general endotracheal anesthesia. The first group had laparoscopic cholecystectomy, the second open cholecystectomy, and the last group (controls) had only general anesthesia. The neuroendocrine serum stress markers adrenocorticotropic hormone (ACTH), cortisol, insulin, and glucagon were measured prior to anesthesia and for the first 3 postoperative days. Analysis of the data showed significant elevations of both ACTH and cortisol for laparoscopic operations as well as for open operation (cortisol only) in the immediate postoperative period. No differences were found for the other serum stress markers. We conclude that minimally invasive surgery in this porcine model confers no advantage, as measured by four neuroendocrine stress hormones, over conventional surgery. Further study is required to determine the clinical implication of these findings.

Adrenocorticotropic Hormone↗