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Biomedical subjects

J G Hunter

Publications and source records attributed to J G Hunter.

At least 19 recordsLinked to original sources
PubMed1999

Laparoscopic surgery of the gastroesophageal junction.

Incompetence of the lower esophageal sphincter mechanism leads to gastroesophageal reflux (GER), which is the most common indication for surgery of the gastroesophageal junction. Evaluation, diagnosis, and the modern surgical treatment of GER are discussed. Evaluation of patients with severe heartburn include upper endoscopy to evaluate the general condition of the esophagus, stomach, and duodenum; an upper gastrointestinal contrast study for a complete anatomic view of the esophagus and stomach; esophageal manometry to evaluate the function of the esophagus; 24-hour pH monitoring to determine esophageal acid exposure; and a gastric emptying study selectively to determine the presence of a motility disorder. These studies most often prove the diagnosis of gastroesophageal reflux, hiatal hernia, Barrett's esophagus, peptic esophageal stricture, paraesophageal hernia, or achalasia. The laparoscopic approach to treatments for these include Nissen fundoplication, Toupet fundoplication, Collis gastroplasty with fundoplication, modified Heller myotomy, esophageal diverticulectomy, and revisional operations. These procedures are described in detail. The results of these operations indicate that they are safe and effective and should be considered the new gold standard for correction of gastroesophageal pathology. Laparoscopic surgery has revolutionized many procedures traditionally performed through a laparotomy. Although they are technically more difficult and require a significant amount of time and practice for the surgeon to become proficient, it is becoming apparent that for functional surgery of the gastroesophageal junction laparoscopy is the access of choice.

Endoscopy, Digestive System↗
PubMed1999

The "floppy" Nissen fundoplication is a completely competent antireflux valve.

BACKGROUND: The antireflux capacity of various gastric fundoplications combines the creation of a valve (flapper or nipple) with recreation of a sharp cardioesophageal angle. Experimental comparison of valve competency and appropriate valve geometry is incomplete despite wide application of these techniques. Our primary aim was to compare the competency of several antireflux valves in explanted cadaver stomachs. Our secondary aim was to understand better the geometry of the gastric fundus in empty and full stomachs. METHODS: Stomachs with 6-8 cm of distal esophagus were harvested from 18 fresh cadavers. With the stomach empty, the greater and lesser curvature length and the transverse dimensions of the anterior and posterior surface of the stomach in the fundus, body, and antrum were measured. The pylorus was tied off over a catheter; the stomachs were inflated with water; and reflux occurred. Intragastric pressure was measured during inflation with a needle inserted in the side of the stomach. A clamp was then placed on the esophagus, and the stomach was inflated to a pressure of 10 mmHg. Gastric measurements were recalculated in the distended stomach. The stomachs were deflated, the clamp removed, and a 2-cm Nissen fundoplication as well as 270 degrees and 180 degrees posterior fundoplications were performed over a 60 Fr dilator. The stomachs were reinflated while the pressure was transduced. The inflation was stopped when reflux occurred or when the fundoplication disrupted. RESULTS: The stomachs expanded symmetrically when filled with water except for the fundus in which the anterior gastric wall lengthened by more than 100% and the posterior gastric wall lengthened by about 50%. In the untreated stomachs, reflux occurred at a pressure of 3.0 +/- 1.0 mmHg. After fundoplication, reflux never occurred, but the sutures pulled out of the stomach or esophagus at 28.6 +/- 16.8 mmHg. Posterior fundoplications refluxed water in several stomachs. CONCLUSIONS: When filled, the anterior fundus expands to a greater degree than the posterior fundus, offering more tissue for creation of floppy fundoplication. The "floppy" Nissen fundoplication is completely competent, suffering a degradation before allowing reflux. The posterior partial fundoplication is unpredictable in its competency.

Cadaver↗
PubMed1999

Complete clinical outcomes audit. Resource requirements and validation of the instrument.

BACKGROUND: Clinically relevant surgical outcomes are usually monitored by surgeons only for new and/or high-volume procedures. Prospective outcomes audit studies are rarely done on 100% of procedures performed by a single surgeon, a surgical practice, or an institution. Therefore, we set out to determine the resource utilization and accuracy of a well-validated system at its introduction into a North American university surgical practice. METHODS: The Otago Surgical Audit, which has been validated in a wide spectrum of surgical practices in Australasia, was applied to a university practice in general and laparoscopic surgery. Data were recorded by the surgeon on the day of operation, at discharge, and during any subsequent readmission. Resource utilization was determined by timing the important steps in data acquisition and computer entry. Data accuracy was assessed by an independent chart review of 22% of all records. Case capture was audited by reviewing operating room case logs. RESULTS: Over 1 year, from October 1, 1996 to September 30, 1997, 338 procedures were performed. Data recording and coding by the surgeon required 2 min per form, or a total of 676 min (11.3 h) annually. Data entry required 2.11 min per form, or a total of 713 min (11.9 h) for the year. Eight percent of cases were returned to the surgeon for additional information. In the medical record audit, no additional mortality or readmissions were discovered, and one minor complication was recorded in the hospital record but not the outcomes audit. One complication and three operations recorded in the audit database were omitted from operating room records. Two minor procedures on the operating room log were omitted from the audit database. Operating time reported by the surgeon averaged 19 min less than recorded in the operative log. Data accuracy and coding accuracy improved significantly between the 1st month (month 4) and the 2nd month audited (month 12), (p <.01). CONCLUSIONS: It is possible to perform a 100% clinical outcome audit with the use of minimal resources. When the surgeon is involved with data acquisition and coding, the accuracy and completeness of the log may outstrip the medical record, but a learning curve of 4-6 months may be required to achieve this goal.

Humans↗
PubMed1999

Fundoplications resist reflux independent of in vivo anatomic relationships.

BACKGROUND: Antireflux operations restore lower esophageal sphincter (LES) function and hiatal anatomy; however, the relative contributions are unclear. METHODS: We measured the competency of fundoplications, exclusive of in vivo variables, in gastroesophageal explants from 8 cadavers. Using a multichannel manometer, esophageal, LES, and intragastric pressures were recorded during transpyloric distension. Data were compared at baseline, and after Nissen (360 degrees) and Toupet (270 degrees) fundoplications. RESULTS: Before fundoplication, stomachs refluxed immediately upon distension. Nissen fundoplications never refluxed before gastric rupture (46.8 +/- 15.0 mm Hg). LES pressure averaged 2.0 +/- 0.5 times intragastric pressure during distension. Toupet fundoplications refluxed at intragastric pressure <2 mm Hg, then became competent until gastric rupture (49.9 +/- 15.0 mm Hg). LES pressure averaged 2.4 +/- 1.0 times intragastric pressure during distension. CONCLUSIONS: Nissen and Toupet fundoplications increase LES pressure linearly at 2 to 2.5 times intragastric pressure, independent of in vivo variables. Toupet fundoplication lacks the competency of Nissen fundoplication at low intragastric pressures.

Aged↗
PubMed1999

Laparoscopic floppy Nissen fundoplication.

Good results for antireflux surgery are obtained when proper patients are selected, trained surgeons perform the operation, and proper techniques are used. As our prior results showed higher rates of dysphagia without fundus mobilization (Nissen-Rossetti fundoplication), we now perform complete mobilization on all patients. Full fundus mobilization requires take-down of the short gastric vessels to reveal the base of the left crus, take-down of all posterior gastropancreatic adhesions and the peritoneal fold that is cauded to the crus and superior to the pancreas. Proper division of these attachments will allow an untethered fundoplication and may reduce the risk of dysphagia and slip of the fundoplication onto the stomach.

Fundoplication↗
PubMed1999

Fundoplication provides effective and durable symptom relief in patients with Barrett's esophagus.

BACKGROUND: Columnar-lined esophagus with intestinal metaplasia (IM), also called Barrett's esophagus, is a manifestation of severe gastroesophageal reflux (GER) and may predict poor symptom relief and high failure rate after fundoplication. We compared symptom scores and reoperation rates in GER patients with and without Barrett's esophagus. METHODS: Between July 1992 and July 1997, 646 patients underwent fundoplication (626 laparoscopic). Of 150 endoscopic biopsies of suspected columnar-lined esophagus, 80 confirmed IM, 50 identified cardiac or fundic epithelium, and 20 revealed only esophagitis. Typical GER symptoms were scored by patients preoperatively and postoperatively (0 to 4 scale). We compared symptom response (Wilcoxon rank sum test) and failure rates (t test) in patients with IM and GER controls without IM. Preoperative data were available for 74 IM patients and 496 controls. One-year follow-up was available in 45 IM patients and 301 controls. Intermediate follow-up (2 to 5 years) was available in 20 IM patients and 99 controls. RESULTS: Preoperatively and postoperatively, patients with IM reported heartburn, regurgitation, and dysphagia scores similar to controls. Procedure failure, requiring redo fundoplication, appeared more likely in IM patients than controls (6.3% versus 2.5%), but this difference did not reach statistical significance (P = 0.061). CONCLUSION: Fundoplication provides equivalent symptom relief for patients with and without IM.

Barrett Esophagus↗
PubMed1999

Improvement in quality of life measures after laparoscopic antireflux surgery.

OBJECTIVE: To determine if patients with gastroesophageal reflux "well controlled medically" had a different quality of life from those with residual symptoms receiving aggressive medical therapy, and to determine whether laparoscopic antireflux surgery significantly altered quality of life in patients with gastroesophageal reflux. SUMMARY BACKGROUND DATA: Clinical determinants of outcome may not adequately reflect the full impact of therapy. The medical outcomes study short form (SF-36) is a well-validated questionnaire that assays eight specific health concepts in three general fields. It may provide a more sensitive tool for judging the success of antireflux therapy. METHODS: A total of 345 patients undergoing laparoscopic antireflux surgery completed at least one questionnaire during the study period. Preoperative questionnaires were completed by 290 patients, 223 completed a questionnaire 6 weeks after surgery, and 50 completed the same questionnaire 1 year after surgery. A subgroup of 70 patients was divided before surgery into two groups on the basis of their response to standard medical therapy. RESULTS: Preoperative scores were extremely low. All eight SF-36 health categories improved significantly 6 weeks and 1 year after surgery. In the 70-patient subgroup, 53 patients (76%) underwent laparoscopic antireflux surgery because of symptoms refractory to medical therapy and 17 patients (24%) reported that their symptoms were well controlled but elected to have surgery because they wished to be medication-free. The preoperative quality of life scores of these two patient groups were equivalent in all but one category. Postoperative scores were significantly improved in all categories and indistinguishable between the two groups. CONCLUSIONS: Laparoscopic antireflux surgery is an effective therapy for patients with gastroesophageal reflux and may be more effective than medical therapy at improving quality of life.

Female↗
PubMed1999

Laparoscopic fundoplication failures: patterns of failure and response to fundoplication revision.

OBJECTIVE: To determine rates and mechanisms of failure in 857 consecutive patients undergoing laparoscopic fundoplication for gastroesophageal reflux disease or paraesophageal hernia (1991-1998), and compare this population with 100 consecutive patients undergoing fundoplication revision (laparoscopic and open) at the authors' institution during the same period. SUMMARY BACKGROUND DATA: Gastroesophageal fundoplication performed through a laparotomy or thoracotomy has a failure rate of 9% to 30% and requires revision in most of the patients who have recurrent or new foregut symptoms. The frequency and patterns of failure of laparoscopic fundoplication have not been well studied. METHODS: All patients undergoing fundoplication revision were included in this study. Symptom severity was scored before and after surgery by patients on a 4-point scale. Evaluation of patients included esophagogastroscopy, barium swallow, esophageal motility, 24-hour ambulatory pH, and gastric emptying studies. Statistical analysis was performed with multiple chi-square analyses, Fisher exact test, and analysis of variance. RESULTS: Laparoscopic fundoplication was performed in 758 patients for gastroesophageal reflux disease and in 99 for paraesophageal hernia. Median follow-up was 2.5 years. Thirty-one patients (3.5%) have undergone revision for fundoplication failure. The mechanism of failure was transdiaphragmatic herniation of the fundoplication in 26 patients (84%). In 40 patients referred from other institutions, after laparoscopic fundoplication, only 10 (25%) had transdiaphragmatic migration (p < 0.01); a slipped or misplaced fundoplication occurred in 13 patients (32%), and a twisted fundoplication in 12 patients (30%). The failure mechanisms of open fundoplication (29 patients) followed patterns previously described. Fundoplication revision procedures were initiated laparoscopically in 65 patients, with six conversions (8%). The morbidity rate was 4% in laparoscopic procedures and 9% in open ones. There was one death, from aspiration and adult respiratory distress syndrome after open fundoplication. A year or more after revision operation, heartburn, chest pain, and dysphagia were rare or absent in 88%, 78%, and 91%, respectively, after laparoscopic revision, and were rare or absent in 91%, 83%, and 70%, respectively, after open revision, but 11 patients ultimately required additional operations for continued or recurrent symptoms, 3 after open revision (17%), and 8 after laparoscopic fundoplication (11%). CONCLUSIONS: Laparoscopic fundoplication failure is infrequent in experienced hands; the rate may be further reduced by extensive esophageal mobilization, secure diaphragmatic closure, esophageal lengthening (applied selectively), and avoidance of events leading to increased intraabdominal pressure. When revision is required, laparoscopic access may be used successfully by the laparoscopically experienced esophageal surgeon.

Fundoplication↗
PubMed1999

NSAIDs, aspirin, and esophageal strictures: are over-the-counter medications harmful to the esophagus?

There are several studies that suggest that aspirin (acetylsalicylic acid [ASA]) and nonsteroidal anti-inflammatory drugs (NSAIDs) are associated with esophagitis or esophageal stricture formation. There are limited data on the potential of low-dose ASA and over-the-counter (OTC) NSAIDs to cause esophageal injury. The goal of this study was to determine whether there is an association between esophageal strictures and ASA/NSAID use, including low-dose ASA and OTC NSAIDs. A total of 79 consecutive patients (mean age, 52.8 years; 38 men, 41 women) referred for endoscopy from 4/1/96 to 11/15/96 for chronic gastroesophageal reflux disease symptoms were evaluated. Data collected include gender, race, and age, NSAID or ASA use, as well as an assessment of dysphagia, heartburn duration, and heartburn frequency. Patients taking NSAIDs or ASA at least twice a week were considered ASA/NSAID users. There were 46 patients without strictures and 33 patients with peptic strictures. Patients with strictures were older than patients without strictures (mean age, 58.7 versus 48.6 years; p < 0.01), had longer duration of heartburn symptoms (8.6 versus 6.4 years, p < 0.05), and were more likely to have mucosal injury (50% versus 26.1%). Stricture patients were more likely to use ASA/NSAIDs (63.6% versus 26.1%; p < 0.01). In particular, stricture patients were more likely to use low-dose ASA than patients without strictures (30.3% versus 2.2%; p < 0.01). Otherwise, there were no significant differences with regard to gender, race, or heartburn duration or frequency. Linear regression analysis showed that ASA/NSAID use had a greater influence on the incidence of peptic strictures than age. There is an association between esophageal stricture and ASA/NSAID use, which includes OTC NSAIDs and low-dose ASA.

Age Factors↗
PubMed1999

Two-point, timesaving method for measurement of gastric emptying with diagnostic accuracy comparable to that of the conventional method.

Solid-phase gastric emptying is linear. Therefore, the authors calculated gastric-emptying half-time, the time for half of the ingested solids or liquids to leave the stomach, with the conventional multiple-point method and the proposed two-point method (at 0 and 120 minutes) in retrospective and prospective studies of 50 patients each. The results showed excellent correlation. Results with the two-point method were comparable to those with the multiple-point method, and the two-point method substantially reduced technologist and camera times.

Adult↗
PubMed1998

The use of bipolar cautery, laparosonic coagulating shears, and vascular clips for hemostasis of small and medium-sized vessels.

Advanced laparoscopic surgery requires a reliable method of hemostasis. In order to determine the efficacy of common hemostatic devices, we tested bipolar electrosurgery (BPES), laparosonic coagulating shears (LCS), and vascular clips (VC) on arteries of various sizes to compare the strength of hemostasis against elevated intraarterial pressure. The procedures were performed on a porcine model through a laparotomy. Segments of visceral arteries were isolated and cannulated with an angiocatheter that was linked to a pressure monitor. After hemostasis with the tested instrument and division of the vessel, the intraarterial pressure was elevated by infusion of saline solution through the angiocatheter. The pressure was recorded when bleeding occurred through the cut end of the vessel or when the pressure reached 300 mm Hg. All three devices were effective in maintaining hemostasis on small (diameter, 0.25-0.5 mm) and medium-sized arteries (diameter, 2-3.5 mm) with a success rate ranging between 75% and 100% (p = n.s.). Practice and technical finesse were required with the use of the LCS and BPES before excellent results could be obtained. The LCS has an advantage over BPES because it allows the surgeon to perform hemostasis and division simultaneously, thus keeping the operating field clean and avoiding instrument adhesion to the tissue.

Animals↗
PubMed1998

Laparoscopic Collis gastroplasty and Nissen fundoplication. A new technique for the management of esophageal foreshortening.

BACKGROUND: The short esophagus increases the difficulty and limits the effectiveness of laparoscopic Nissen fundoplication. In out experience, approximately 20-25% of esophagi judged by preoperative criteria to be foreshortened will, after dissection, be insufficiently long to allow 2 cm of esophagus to reside below the diaphragm without inferior distraction (i.e., tension free). Collis gastroplasty combined with Nissen fundoplication has become the standard approach for the creation of an intraabdominal neoesophagus and fundic wrap. METHODS: After developing methods of performing totally laparoscopic stapled gastroplasty in the cadaver lab in 1994, we started applying the technique clinically in 1966. We performed 220 laparoscopic antireflux procedures between January 1966 and July 1997. Of these 220 patients, 26% were suspected to have esophageal foreshortening based on preoperative barium studies and/or endoscopy. RESULTS: After hiatal dissection, nine patients, or 16% of those suspected to have esophageal foreshortening and 4% of the entire population, required the laparoscopic Collis-Nissen procedure. There was symptomatic improvement in all patients as assessed by patient-initiated symptom scores. CONCLUSIONS: The management of patients with esophageal foreshortening is a complex problem. We believe that our technique of laparoscopic Collis-Nissen provides an effective means of achieving intraabdominal placement of the fundic wrap while maintaining the benefits of minimally invasive approach.

Adult↗
PubMed1998

Management of pancreatic pseudocysts.

BACKGROUND: Operative internal drainage has been standard treatment for chronic unresolved pancreatic pseudocysts (PPs). Recently, percutaneous external drainage (PED) has become the primary mode of treatment at many medical centers. STUDY DESIGN: A retrospective chart review was performed of 96 patients with PPs who were managed between 1987 and 1996. Longterm followup information was obtained by telephone and mail questionnaire. RESULTS: Twenty-seven patients underwent computed tomographic (CT)-guided PED. PP resolution occurred in 17 patients. Clinical deterioration or secondary infection mandated urgent pancreatic debridement in 7 (26%) patients and cystgastrostomy in 2 (7%) patients. There was one hospital death in this group. Thirty-two patients underwent cystgastrostomy or cystjejunostomy (n = 21), distal pancreatectomy (n = 8), pancreatic debridement and external drainage (n = 2), or cystectomy (n = 1). Two (6%) patients required postoperative pancreatic debridement for failure of resolution and peritonitis and two patients underwent PED of abscess. There was one hospital death in the expectantly managed group of 37 patients. Median followup of 3 years (range, 0.5-9.3 years) in 66 patients revealed that 6, 3, and 4 patients of PED, surgery, and expectantly managed groups, respectively, had radiologic evidence of recurrent PPs. CONCLUSIONS: Operative management for PPs appears to be superior to CT-guided PED. Although the later was often successful, it required major salvage procedures in one third of the patients. An expectant management protocol may be suitable for selected patients.

Abscess↗
PubMed1998

Laparoscopic antireflux surgery in the elderly.

OBJECTIVE: Laparoscopic antireflux surgery is indicated in young patients with medication-dependent gastroesophageal reflux disease (GERD), both because of their need for lifelong medical treatment and the need to prevent the complications of GERD. Many elderly patients with GERD have similar concerns. We compared the safety and efficacy of laparoscopic antireflux surgery in the elderly with the results achieved in patients <65 yr. METHODS: A total of 359 patients have had laparoscopic antireflux surgery in our hospital, 42 of whom were > or = 65 yr of age. Symptoms were scored from 0 (none) to 4 (severe) before and after surgery. Ambulatory pH monitoring was also performed before and after surgery. Results were compared between age groups with the Mann-Whitney U test. RESULTS: Elderly patients had significantly higher preoperative American Society of Anesthesiologists (ASA) scores (mean 2.4 vs 2.0) (p = 0.0024), but otherwise there were no significant differences in preoperative symptom scores or pH results. Both groups demonstrated equivalent postoperative improvement in symptoms and 24-h pH study. There was no mortality in either group, and there was no significant difference in morbidity or hospital stay between the two groups. CONCLUSION: Laparoscopic antireflux surgery is a safe and effective treatment of GERD in the elderly and should not be refused solely on the basis of age.

Adolescent↗
PubMed1998

The prevalence of intestinal metaplasia in patients with and without peptic strictures.

OBJECTIVE: Several studies suggest that patients with esophageal peptic strictures have a high prevalence of Barrett's esophagus. However, these studies did not include appropriate control groups, were retrospective in nature, or did not strictly define Barrett's esophagus. Our aim was to compare the prevalence of Barrett's esophagus in patients with and without gastroesophageal reflux disease strictures in a prospective study. METHODS: Seventy-nine patients referred for endoscopy for gastroesophageal reflux disease symptoms were evaluated. We collected demographic information and an esophageal symptom assessment. Biopsy specimens were obtained from peptic strictures, Schatzki rings, or from any areas of columnar-lined esophagus or mucosal injury. Barrett's esophagus was strictly defined as the presence of intestinal metaplasia from tubular esophagus. RESULTS: There were 46 patients without strictures and 28 patients with peptic strictures. Five patients had Schatzki's rings. The prevalence of intestinal metaplasia was 23.9% in patients without strictures, and 25% in patients with peptic strictures (p = NS). There was no difference in prevalence of short- or long-segment Barrett's esophagus between the groups. Patients with strictures were older than patients without strictures (mean age 58.9 vs 48.6 yr), and more likely to have mucosal injury (50% vs 26.1%). Otherwise, there were no significant differences with regards to gender, race, heartburn duration or frequency. CONCLUSIONS: Barrett's esophagus, as defined by the presence of intestinal metaplasia in the tubular esophagus, is equally common in patients with and without peptic strictures. There does not appear to be an association between Barrett's esophagus and peptic strictures.

Age Factors↗