Biomedical subjects

Joshua Felsher

Publications and source records attributed to Joshua Felsher.

13 recordsLinked to original sources

PubMed2005

Gastric electrical stimulation significantly increases canine lower esophageal sphincter pressure.

This study determined the effect of low-frequency and high-frequency gastric electrical stimulation (GES) on canine lower esophageal sphincter (LES) pressure and also evaluated the effect of such stimulation on neurohumoral factors that modulate LES pressure. Eight dogs were fitted with stimulation wires along the greater curvature of the stomach. A sleeve device measured LES pressure before, during, and after GES, and regulatory peptides were measured during fasting and after a meal. A consistent and significant rise in LES pressure was observed during GES, and it was sustained after GES was discontinued. Plasma concentration and area under the curve of pancreatic polypeptide, motilin, gastrin and neurotensin were not affected by GES. We conclude that acute low- and high-frequency GES significantly increases LES pressure. This effect may not be modulated by efferent vagal activity or release of regulatory peptides.

Animals↗

PubMed2004

Predictive factors for successful laparoscopic splenectomy in patients with immune thrombocytopenic purpura.

HYPOTHESIS: Younger patients with immune thrombocytopenic purpura (ITP) and high preoperative platelet counts successfully respond to laparoscopic splenectomy (LS). DESIGN: Case series. SETTING: Private, tertiary care referral center. PATIENTS: Sixty-seven consecutive patients undergoing LS for ITP between 1995 and 2001. INTERVENTIONS: Laparoscopic splenectomy. MAIN OUTCOME MEASURES: A successful response to LS was defined as a postoperative platelet count greater than 100 x 10(3)/microL without medical therapy. Failures were classified as recurrent or refractory. Patients considered refractory to surgery did not achieve a platelet count greater than 100 x 10(3)/microL without medical therapy. Patients with recurrent ITP initially achieved a platelet count greater than 100 x 10(3)/microL, but thrombocytopenia subsequently recurred. RESULTS: Both univariate and multivariate analyses were performed for 13 preoperative variables to identify factors predictive of success following LS. At a mean follow up of 22 months, 43 patients (64%) had a successful response to LS, 14 (21%) were refractory, and 10 (15%) developed recurrent ITP. By univariate analysis, patients responding to laparoscopic splenectomy were younger (P =.005) and had a higher preoperative platelet count (P =.005). In multivariate analysis, younger age (P =.005) and a higher preoperative platelet count (P =.007) again predicted a successful response to LS. CONCLUSIONS: A successful response to LS for ITP is expected in patients younger than 50 years and in those with preoperative platelet counts greater than 70 x 10(3)/microL. These factors can be incorporated into an equation that yields a splenectomy prediction score, which predicts the success of LS for ITP.

Adult↗

PubMed2004

Decompressive percutaneous endoscopic gastrostomy in nonmalignant disease.

BACKGROUND: Percutaneous endoscopic gastrostomy is the standard for long-term enteral access. It can provide enteral nutrition or gastrointestinal decompression. Utilization of the gastrostomy for decompression has traditionally been reported in the setting of malignant obstruction. However, decompressive gastrostomy can play a role in the treatment of nonmalignant bowel dysfunction as well. METHODS: Over a 2-year period, 20 of 121 percutaneous endoscopic gastrostomies attempted by this surgical endoscopist were for gastrointestinal decompression. RESULTS: Eleven of 18 gastrostomies successfully placed for decompression were for benign conditions. In 5 patients with fistulous disease, the purpose of decompression was to divert the gastrointestinal tract until operative repair. Four of these patients have since undergone definitive surgery. CONCLUSIONS: This series presents the successful use of the percutaneous endoscopic gastrostomy for decompression of nonmalignant conditions. In such scenarios, the drainage gastrostomy can be employed as a bridge to future surgery, or as a means of long-term decompression for bowel dysfunction.

Adult↗

PubMed2004

Laparoscopic adrenalectomy: a cost analysis of three approaches.

Laparoscopic adrenalectomy (LA) is the current standard for treatment of benign adrenal disease and is performed more often now in the setting of malignant disease. Three surgical approaches, the lateral transperitoneal technique, the lateral retroperitoneal technique, and the posterior technique are utilized commonly. While advantages of each approach are advocated, a cost analysis is not available. This article analyzes the operating costs of the three approaches. The operative costs of 51 unilateral LA at the Cleveland Clinic Foundation from 1998 to 2002 were analyzed for comparison. Patients were grouped according to one of the three laparoscopic approaches--transperitoneal (group A), lateral retroperitoneal (group B), and posterior (group C). For each group, n=17. Perioperative characteristics and operative cost were analyzed. The groups were compared using single factor ANOVA analysis. Significance was assigned for P<0.05. The average costs of unilateral LA were $2,885, $3,219, and $2,850 for groups A, B, and C, respectively (P=0.20). Differences were not statistically significant. Six bilateral procedures were performed. There were no significant differences for these six cases. However, the cohort was too small for an appropriate power analysis. LA is commonly performed utilizing one of three surgical approaches. Our data demonstrates no significant difference in operative cost between the respective techniques. Operative costs should not be a factor in choosing a laparoscopic approach for unilateral adrenal disease.

Adrenal Gland Diseases↗

PubMed2004

Management of splenic abscess in a critically ill patient.

Because of the increased number of immunocompromised patients within the general population, the incidence of splenic abscesses has increased over the last decade. This cohort of immune-deficient patients with splenic abscesses engenders a distinct evolution in the pathogenesis and microbiology of the disease process. Moreover, the morbidity and mortality rates for splenic abscesses are increased in this unique population. Clinically, these patients do not have a characteristic presentation. Diagnostically, computed tomography of the abdomen is the test of choice. Antibiotics and splenectomy remain the standard of care in most clinical settings. However, percutaneous drainage is reported with solitary and unilocular abscesses and in poor operative candidates. An unusual case of a patient with a splenic abscess awaiting heart transplantation is presented. This patient was successfully treated with percutaneous drainage and antibiotics. The literature regarding the presentation, diagnosis, pathogenesis, and treatment of splenic abscesses is reviewed as well.

Abscess↗

PubMed2004

A novel endolaparoscopic intragastric partitioning for treatment of morbid obesity.

Morbid obesity is a burgeoning health crisis. Significant morbidity is associated with the current gastric bypass, and, therefore, alternative surgical modalities are desired. A novel minimally invasive surgical technique, endoluminal gastric partitioning, is presented. Ten mongrel dogs underwent endolaparoscopic placement of intragastric mesh. Each circular prosthesis (Surgisis or prolene mesh) was 8 cm in diameter with a 1.5 cm central aperture. The mesh was passed transorally into the gastric lumen and secured with a laparoscopic, intragastric suturing resulting in a 30 to 50 mL proximal gastric reservoir. The operation was successfully completed in all 10 animals. Nine of 10 animals were healthy at the scheduled sacrifice date. In 2 dogs, the intragastric mesh was 100% adherent to the gastric mucosa after 7 days. Four of the final 5 dogs demonstrated some degree of mucosal adherence after 1 week. Endoluminal placement of intragastric mesh appears feasible and safe. Long-term studies are necessary to demonstrate the efficacy and long-term weight loss of this, or alternate intraluminal gastric partitioning techniques.

Animals↗

PubMed2003

Mucosal apposition in endoscopic suturing.

BACKGROUND: The proliferation of minimally invasive surgery has led to the development of numerous entirely intracorporeal endoscopic suturing techniques. These techniques allow for simple apposition of the GI mucosa. It is yet to be determined whether this results in long-term mucosal apposition. This study was designed to determine whether the current techniques of endoscopic suturing necessitate preliminary mucosal manipulation. METHODS: Seven dogs underwent laparotomy and gastrotomy to expose the proximal gastric mucosa. Three different suturing techniques were used to appose adjacent tissue folds: simple mucosal apposition, electrosurgical mucosal ablation before closure, and mucosal resection before closure. Apposition sites were scored histologically, based on tissue healing after 2 weeks. RESULTS: Mucosal ablation before tissue apposition resulted in significantly greater healing compared with simple apposition and resulted in histologic scoring similar to that for mucosal resection. The mean histologic score after ablation was 1.5, vs. 1.25 after mucosal resection, and 0.9 for sites closed simply (p=0.02). CONCLUSIONS: Endoscopic suturing techniques may one day offer an alternative to surgical treatment in the management of numerous GI conditions. As this modality evolves, the incorporation of target tissue ablation or mucosal resection before tissue apposition requires consideration. Human studies evaluating the safety and long-term efficacy of these modifications are necessary.

Animals↗

PubMed2003

Small bowel obstruction after laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: Despite the proliferation of laparoscopic Roux-en-Y gastric bypass (LRYGBP), postoperative bowel obstructions still occur from mesocolonic constrictions, internal hernias, and anastomotic strictures. Obstructed patients do not present with a characteristic history and physical. Therefore, radiographic studies including upper gastrointestinal films and computed tomography are essential for diagnosing these unique obstructive etiologies after LRYGBP. METHODS: From February 2000 to December 2000, 115 patients underwent standard LRYGBP at the Cleveland Clinic Foundation. Retrocolic anastomoses were performed on all patients. Defects at the mesocolon and mesomesentery were closed with interrupted, nonabsorbable sutures. All patients underwent upper gastrointestinal study on the first postoperative day. RESULTS: Six patients developed small bowel obstructions postoperatively. Five of these patients required reexploration. The obstructive etiologies were two mesocolonic constrictions, three internal herniations, and one massive clot at the gastrojejunostomy. Repair of the mesocolonic constrictions involved incising the transverse mesocolon vertically to create a larger window for the Roux limb. Internal herniations were reduced, and defects were reclosed with nonabsorbable sutures. The patient with an obstructive clot was treated endoscopically. CONCLUSIONS: Based on these 6 patients, we have altered our technique to antecolic placement of the Roux limb. This technique requires division of the omentum and additional mobilization of the Roux limb mesentery in order to decrease tension at the gastrojejunostomy. Since initiating these changes and closing all iatrogenic defects, we have not experienced further early small bowel obstructions.

Adult↗

PubMed2003

Laparoscopic small bowel resection of metastatic pulmonary carcinosarcoma.

Carcinosarcoma of the lung is a rare malignancy consisting of both epithelial and mesenchymal components. Although metastatic disease is common, metastatic disease to the small intestine is rare and has been reported only once in the literature. An unusual case of pulmonary carcinosarcoma with metastasis to the small bowel is presented. At the time of laparoscopic exploration, a 4 x 4 cm mass was seen in the jejunum involving the adjacent mesentery. The affected small bowel and mesentery were resected laparoscopically and bowel continuity was restored through an entirely intracorporeal technique. Laparoscopic small bowel resection can be performed safely in the setting of malignant disease and imparts many of the benefits of minimally invasive surgery.

Carcinosarcoma↗

PubMed2003

Isolated trans-hiatal colonic herniation.

Isolated herniation of the colon through congenital or traumatic diaphragmatic defects are well documented. However, trans-hiatal herniation of the colon in the absence of an intrathoracic stomach has been reported only once. A 67-year-old man presented with intragastric abdominal pain and a chest x-ray film documenting a posterior mediastinal air-fluid level. Computed tomography showed gastrointestinal contents within the thorax. The findings on an upper gastrointestinal film with small bowel follow-through were normal. Finally, a barium enema identified transverse colon within the thoracic cavity. At laparoscopy, the entire transverse colon was reduced with the hernia sac. The crural defect was repaired, and a Toupet fundoplication was performed. A gastropexy was also added. The patient was discharged on postoperative day 2 able to tolerate a regular diet, and he has been asymptomatic for 5 months. This defect most likely represents a congenital deformity of the diaphragm with intact posterior gastric attachments, including the posterior phrenoesophageal ligament. An intact gastric mesentery enabled isolated colonic herniation with retention of the stomach its normal anatomic position. An antireflux procedure was performed in addition to the crural repair because of the circumferential dissection of the esophagus. This article is the second report of an isolated trans-hiatal herniation of the colon and the first report of laparoscopic repair of this entity.

Aged↗

PubMed2003

Laparoscopic splenectomy for Evans syndrome.

Evans syndrome is a rare, chronic, sometimes fatal immunologic disorder defined as Coombs' positive hemolytic anemia and immune thrombocytopenia without an underlying etiology. This syndrome has a variable clinical course, and the benefit of splenectomy is unknown. This report reviews the clinical outcome of laparoscopic splenectomy for Evans syndrome. A retrospective review was conducted of patients undergoing laparoscopic splenectomy for autoimmune hemolytic anemia and concomitant immune thrombocytopenic purpura at the Cleveland Clinic Foundation from August 1995 through August 2001. Data were collected in a prospective database and included demographic characteristics of the patients, surgical indications, operative details, and postoperative follow-up information. Five patients underwent laparoscopic splenectomy for Evans syndrome. At mean follow-up of 18 months (range, 1-31) after laparoscopic splenectomy, two patients had normal platelet counts (>100,000/microL) and required no further medical therapy. Two patients did not respond to laparoscopic splenectomy and are still undergoing medical therapy. One patient initially responded to laparoscopic splenectomy but became thrombocytopenic at 18 months and required further medical therapy. After 2 months of further medical treatment, this patient is currently (at month 10) in remission. Laparoscopic splenectomy for Evans syndrome is safe and technically feasible. The clinical outcome of splenectomy for patients with Evans syndrome is unpredictable. This select cohort of patients requires extensive long-term follow-up to determine the merits of splenectomy.

Adolescent↗

PubMed2003

Laparoscopic resection of focal nodular hyperplasia.

Focal nodular hyperplasia (FNH) is a benign liver lesion incidentally discovered with increasing frequency because of the proliferation of imaging studies. Radiographic characterization can diagnose this pathologic lesion and nonoperative therapy is the standard of care. However, if radiographic studies and fine needle biopsy are inconclusive, operative intervention may be required. Depending on the anatomic location of the lesion, biopsy and/or resection can be performed laparoscopically. A patient with biliary dyskinesia and focal nodular hyperplasia is presented. She underwent laparoscopic cholecystectomy with excision of the FNH. This paper reviews the case as well as the diagnosis and treatment of FNH.

Adult↗

PubMed2003

Future trends in flexible endoscopy.

Over the past 20 years, flexible endoscopy has evolved from a primarily diagnostic endeavor to one of the most rapidly growing fields of therapeutic surgery. Multitudes of techniques and technologies have been developed to treat a wide spectrum of gastrointestinal diseases. Endoscopic suturing, radiofrequency energy delivery, mucosal resection, and thermal ablative techniques are among the most promising modalities in the field. Furthermore, the development of endoscopic transgastric surgery opens the door to a variety of novel intraluminal procedures. Though the ultimate role of these innovations is yet to be determined, the future of feasible surgical endoscopy holds great potential.

Endoscopes↗