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Biomedical subjects

K R DeVault

Publications and source records attributed to K R DeVault.

At least 37 records · Page 2Linked to original sources
PubMed1999

Laparoscopic antireflux surgery for the treatment of esophageal strictures refractory to medical therapy.

OBJECTIVE: The response of esophageal strictures to laparoscopic antireflux surgery remains controversial. The aim of this study was to examine the outcome of patients with medically refractory esophageal strictures caused by severe gastroesophageal reflux disease and treated surgically. METHODS: A prospective follow-up analysis was completed using data obtained from detailed specific questioning by an independent observer. Responses were rated for symptoms, dysphagia (range 1-19), satisfaction with treatment, well-being (1 = best, 10 = worst), and need for further therapy. RESULTS: Of 102 patients, 74 (72.5%) responded to follow-up. There were 31 women, mean age 59.6 yr, and 43 men, mean age 55.2 yr. Mean follow-up was 25 months (range 4-68 months). A total of 252 dilations before surgery decreased to 29 after surgery (p < 0.0001) in the mean observation period of 26 months before and 25 months after surgery (mean/patient 5.3 and 1.8, respectively, p < 0.001). The mean dysphagia score was 6.8 +/- 3.6 preoperatively and 3.7 +/- 1.4 postoperatively (p < 0.0001). Nine (12%) patients required continuous postoperative H2-blockers or proton pump inhibitors. Seven of these had gastritis or peptic ulcer disease. Before antireflux surgery, 10 (13.5%) had frequent pneumonia. No pneumonia was observed after surgery. Sixty-eight (91.9%) patients were satisfied with their decision to have surgery. Among these, the well-being score was 1.8 +/- 0.4 postoperatively vs 5.5 +/- 1.2 (p < 0.001) preoperatively. CONCLUSIONS: Laparoscopic surgery in patients with medically refractory esophageal strictures results in a good clinical outcome with minimal complications. Patients are very satisfied with relief of dysphagia, and there is a diminished need for further dilation, with good quality of life.

Deglutition Disorders↗
PubMed1998

Proposed catheter standards for pharyngeal manofluorography (videomanometry)

With the recent introduction of commercially available pharyngeal manofluorography systems, catheter design should be standardized. Catheters of different designs can produce different data because of their design characteristics. A standard catheter design should make results between investigators comparable and facilitate acceptable normal values. The authors' combined laboratory experience with many catheter designs was reviewed and the literature consulted. For pharyngeal manofluorography, the proposed standard catheter should be 2 x 4 mm in diameter, ovoid, and 100 cm long. The catheter should be marked in centimeters with an anterior and posterior orientation. There should be a slightly malleable, 3- to 4-cm length without sensors beyond the most distal sensor. Solid state transducer sensors should be three or four in number and placed in the pharyngoesophageal segment, midhypopharynx, and tongue base (esophagus for fourth sensor). Sensor spacing should be 3 cm, except 2 cm between the midhypopharynx and tongue base. Unidirectional, in-line, posteriorly oriented sensors with the option of a single circumferential sensor in the cricopharyngeus are currently preferred over circumferential sensors because of their small diameter (patient comfort).

Adult↗
PubMed1997

The surgical option for gastroesophageal reflux disease.

Gastroesophageal reflux disease is a common condition. Most patients can be managed with medications, but patients with refractory disease, particularly those with an incompetent lower esophageal sphincter, should be referred for surgery. The open Nissen fundoplication cures >90% of patients of their symptoms. The laparoscopic approach was first applied for patients with gastroesophageal reflux disease in 1991, and since then numerous reports evaluating the early experience with this technique have been published with results similar to the open procedure. Over the last 5 years, 595 laparoscopic antireflux procedures have been performed by us. There was 1 mortality due to an unrecognized duodenal perforation. Splenic injury did not occur compared to an incidence of up to 8.5% for the open procedure. A total of 9 patients required conversion to the open procedure for perforation, bleeding, or dissection difficulties. However, in the last 350 cases no conversions have been necessary. Most patients are now being discharged from hospital on the day after surgery with some patients being discharged on the same day as surgery. The overall reoperation rate, both for early postoperative morbidity and for late poor outcome, was 3.9% with follow-up ranging from 2 months to 5 years. The laparoscopic Nissen fundoplication achieves the same short-term outcome as the open procedure with significantly less postoperative morbidity and a shorter hospital stay.

Fundoplication↗
PubMed1997

Incomplete upper esophageal sphincter relaxation: association with achalasia but not other esophageal motility disorders.

Incomplete upper esophageal sphincter (UES) relaxation is not well understood. We compared clinical and manometric characteristics of patients with normal and abnormal UES relaxation. Consecutive patients (n = 208) underwent manometric evaluation of the lower esophageal sphincter (LES), esophageal body, and UES/pharynx. The patients were divided into those with abnormal UES relaxation (residual pressure > 6.7 mmHg) (n = 21) and normal relaxation (n = 187). Clinical and manometric profiles were compared. Sex, age, and presenting complaint did not correlate with UES relaxation. Normal esophageal peristaltic sequences were more frequently present in the normal UES group (73.6%) compared with the abnormal (55.8%) (p < 0.01). The UES relaxation was shorter in the group with abnormal relaxation (410.0 ms vs. 510.2 ms, p < 0.001). All other manometric parameters were not different between the two groups. When individual manometric diagnoses were analyzed, only achalasia was noted to be more common in the abnormal UES group (23.8% vs. 9.1%, p < 0.05), and a trend was noted toward diffuse esophageal spasm being more common (14.3% vs. 9.6%, not significant). We conclude that incomplete UES relaxation is a rare manometric finding, associated with achalasia and not specifically associated with any other motility disturbance. This finding may represent a secondary response to the poor esophageal emptying seen in achalasia.

Deglutition Disorders↗
PubMed1997

Acid infusion does not affect intraesophageal balloon distention-induced sensory and pain thresholds.

OBJECTIVE: We sought to evaluate the potential interaction between acid-sensitive chemoreceptors and pressure-sensitive mechanoreceptors. METHODS: Twenty-one normal control subjects underwent esophageal balloon distention with a commercially produced combined-manometry, acid-infusion, balloon-distention catheter. The intraesophageal balloon was localized 10 cm above the lower esophageal sphincter. With a mechanical pump, sensory and pain thresholds were determined by using sequentially increasing balloon volumes (range 0-23 cc, increment 1 cc). A 15-min acid infusion (0.1 N HCl at 6-8 cc/min) or a 0.9 N saline infusion was then applied just proximal to the distending balloon, followed by a second determination of sensory and pain thresholds. The results of the trials before and after acid and placebo were compared. RESULTS: All subjects tolerated the procedure. The initial mean volume-to-sensory threshold was 9.1 ml (range 5-16), decreasing to 6.2 (range 4-11) after acid infusion (p < 0.005). The sensory threshold also decreased from 9.8 ml (range 6-16) to 6.8 ml (range 4-14) after saline infusion (p = 0.06). The mean volume-to-pain threshold was 16.0 (range 14-21) before and 15.2 (range 11-23) after acid infusion and 15.8 (range 12-20) before and 14.0 (range 10-20) after saline infusion (NS). CONCLUSION: We conclude that infused acid has no effect on pain threshold and has a nonspecific effect on sensory threshold induced by esophageal balloon distention.

Adolescent↗
PubMed1996

Esophageal sensation in spinal cord-injured patients: balloon distension and cerebral evoked potential recording.

We sought to determine the esophageal sensory function in patients with a C6 or C7 spinal cord injury. A balloon was repetitively distended 10 cm above the lower esophageal sphincter in five patients and nine normal control subjects. Sensation was reported on a scale from 0 to 2 with progressive distension to pain threshold (level 2). Cortical responses were recorded from midline scalp electrodes. Blinded determinations of quality and reproducibility of the potentials were performed. All subjects experienced sensation with esophageal balloon distension. Volumes to sensation showed a trend toward a higher sensory threshold in patients but were significant only for first sensation, not pain. In all subjects, a triphasic evoked potential response consisting of a negative-positive-negative complex was noted with distension but not with sham distension. Characteristics (amplitude, latency, reproducibility, and quality) of the evoked potentials were not different in patient and control groups. These data suggest sensory pathways from the distal esophagus are intact in patients with a C6 or C7 spinal cord injury.

Adult↗
PubMed1996

Current management of gastroesophageal reflux disease.

Gastroesophageal reflux disease (GERD) is a chronic condition that is very common, and may result in considerable morbidity as well as mortality (from complications). I present data on the therapy of patients with GERD and offer a practical approach to their management. The goals of management of GERD are relief of symptoms, healing of esophagitis, prevention of complications, and maintenance of remission. Simple lifestyle changes may control GERD in up to 20% of patients. Promotility therapy addresses the pathophysiology of this disorder, but the best results are only 50 to 60% control using cisapride, whereas the older agents (metoclopramide and bethanechol) are limited by side effects. Acid suppression using histamine receptor antagonists controls GERD in 50 to 60% of patients, whereas proton pump inhibitors offer the most effective control (80-100%). A surgical approach (especially using newer laparoscopic techniques) will provide effective therapy of GERD in a high percentage of patients, but further careful comparisons are needed to define the long-term efficacy and cost issues associated with both surgical and chronic medical therapy of GERD. Despite this lack of long-term data, we know that GERD is a chronic, often lifelong illness, and maintenance therapy should be offered to most patients. This therapy may include aggressive medical therapy (up to and including chronic proton pump inhibitor therapy) or antireflux surgery in selected patients.

Antacids↗
PubMed1995

Guidelines for the diagnosis and treatment of gastroesophageal reflux disease. Practice Parameters Committee of the American College of Gastroenterology.

Gastroesophageal reflux disease (GERD) is a common disorder that affects all segments of the population. These guidelines have been prepared to suggest the preferable, but not only, approaches to the management of a patient with GERD. The physician must be free to choose the course best suited to the individual patient. The world literature was reviewed and the guidelines were developed under the auspices of the American College of Gastroenterology, and approved by other gastroenterology societies. Diagnostic recommendations include the following: (1) general approach to GERD, including empiric therapy, (2) appropriate mucosal evaluation (ie, endoscopy and radiology), (3) use of pH and provocative testing, and (4) indications for manometric evaluation. Therapeutic recommendations include the following: (1) general approach to therapy including lifestyle changes, (2) use of acid suppression, (3) use of promotility drugs, (4) maintenance treatment of GERD, and (5) indications for antireflux surgery.

Gastroesophageal Reflux↗
PubMed1994

Current diagnosis and treatment of gastroesophageal reflux disease.

OBJECTIVE: To review recent advances in the diagnosis and treatment of gastroesophageal reflux disease (GERD). MATERIAL AND METHODS: Original English language reports were obtained through a Medline search of the National Library of Medicine up to and including 1993. The reference lists of all original reports and review articles were searched to locate any further material. In the evaluation of therapeutic efficacy, randomized studies were preferentially considered; greatest priority was given to double-blind, placebo-controlled trials. Abstracts, nonrandomized trials, and non-English language publications were considered only when other data were unavailable. RESULTS: Information obtained from histories and physical examinations suggests that GERD occurs in many patients. Evaluation of mucosal injury with use of either endoscopy or air contrast barium radiography is an important early step in the diagnosis of GERD. Endoscopy obtains tissue for histologic study, especially in Barrett's esophagus. Prolonged esophageal pH monitoring is the most useful determinant of the presence and amount of reflux of acid. Patients with GERD should be counseled on lifestyle modification and the use of antacids and antirefluxants. Histamine type 2 receptor antagonists provide symptomatic relief in 32 to 82% of patients with GERD and resolution of verified esophagitis in 0 to 82%. Responses with omeprazole therapy are higher; symptomatic responses were noted in 62 to 94% of patients, and healing of esophagitis occurred in 71 to 96%. Promotility agents and surgical therapy have a role in selected patients. CONCLUSION: GERD is a chronic disorder that often necessitates individualized lifelong therapy. Many questions remain to be answered about the cost-effectiveness of both diagnostic tests and therapy for GERD.

Gastroesophageal Reflux↗
PubMed1994

Hepatitis C in sickle cell anemia.

We evaluated the contribution of hepatitis C virus infection to liver disease in patients with sickle cell anemia. Antibody to hepatitis C virus (anti-HCV) by commercial enzyme immunoassay and a second confirmatory assay were assayed in 121 consecutive patients with sickle cell anemia. Anti-HCV was detected in 25 of 121 patients (20.7%). Of patients transfused > 10 units of blood products, 30.3% were anti-HCV seropositive, whereas 8.6% of those patients who transfused < 10 units were seropositive. In 11 of the 121 patients, serum alanine aminotransferase levels were repeatedly elevated. Nine of these 11 patients were anti-HCV seropositive, one was positive for hepatitis B surface antigen, and one was negative for all viral markers. In contrast, of 110 patients with normal serum alanine aminotransferase levels, only 14% were anti-HCV seropositive. In patients with sickle cell anemia, exposure to hepatitis C is common, related to the number of previous transfusions, and the most likely cause of persistently elevated aminotransferase levels.

Adolescent↗