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Biomedical subjects

M B Orringer

Publications and source records attributed to M B Orringer.

At least 145 records · Page 8Linked to original sources
PubMed1984

Substernal gastric bypass of the excluded esophagus--results of an ill-advised operation.

Substernal gastric bypass of the excluded thoracic esophagus for palliation of esophageal carcinoma was proposed as a method of providing maximum patient comfort with minimum morbidity. Our results with this operation in 37 patients are reviewed and indicate that the procedure carries unacceptable complication and mortality rates. Among our patients, there have been nine (24%) hospital deaths, seven (19%) anastomotic leaks, and six (17%) disruptions of the divided distal thoracic esophagus. Major postoperative complications have occurred in 59% of these patients. Only 15 (54%) of the 28 survivors were discharged swallowing within 3 weeks of operation, and 10 (36%) required hospitalization for 1 month or longer after operation. The average survival time in those leaving the hospital alive has been only 5.9 months. Only seven patients (25% of the survivors) have achieved good palliation with the bypass procedure. It is concluded that substernal gastric bypass of the excluded thoracic esophagus is too much of an operation for patients with unresectable tumors who have a life expectancy of only several months.

Adult↗
PubMed1984

Partial median sternotomy: anterior approach to the upper thoracic esophagus.

Based upon experience with cervicothoracic esophageal carcinomas in which resection of the manubrium, adjacent clavicles, and ribs has facilitated exposure of the tumor, it has been found that a partial upper sternal split (without resection) provides access to the upper thoracic esophagus to the level of the carina. With a knowledge of the anatomic relationships of the esophagus in this area, this direct anterior approach has been used for both benign and selected malignant diseases involving the upper thoracic esophagus. A partial median sternotomy has been used in 11 patients with the following esophageal pathology: upper- and/or middle-third malignancy (six), benign upper-third stricture (three), perforation of upper-third esophagogastric anastomotic stricture (one), and cricopharyngeal achalasia in association with a chronic cervical compression fracture that prevented extension of the neck (one). The following operations were performed: blunt esophagectomy with cervical esophagogastric anastomosis (six), segmental esophageal resection with primary anastomosis (three), drainage of perforation (one), and extended cervical esophagomyotomy (one). A chylothorax developed in one patient with carcinoma, the only major postoperative complication in this group. Transient hoarseness occurred in two patients. Careful evaluation of the patient with upper thoracic esophageal pathology, focusing on the type, extent, and location of the abnormality relative to the level of the carina, as well as the habitus of the patient, often indicates that a partial sternotomy can be utilized to facilitate the operation.

Adult↗
PubMed1984

Clinical, epidemiologic, and morphologic comparison between adenocarcinomas arising in Barrett's esophageal mucosa and in the gastric cardia.

Forty-nine cases of surgically resected adenocarcinomas of the gastric cardia and 23 cases of resected adenocarcinomas arising in Barrett's columnar lined lower esophagus were compared histologically and clinically. Morphologically, the two groups were almost identical in terms of pattern of growth (expansile or infiltrative), degree of differentiation, and extent of spread at the time of operation. These similarities are not surprising, as the two carcinomas arise close to each other from almost identical mucosas. The major histologic difference was the finding of much more frequent dysplasia in the adjacent Barrett's mucosa than in the surrounding cardiac mucosa, probably a reflection of the larger surface area covered by Barrett's than by cardiac mucosa. The groups differed in certain epidemiologic parameters that possibly reflected independent carcinogenetic mechanisms. Thus, although the age ranges and median ages were the same, there was a higher male predisposition among the patients with cardiac carcinoma. In addition, patients with cardiac carcinoma had a significantly higher history of heavy smoking and history of alcohol intake, whereas those with Barrett's carcinoma were much more likely to have hiatal hernias.

Adenocarcinoma↗
PubMed1983

Primary repair of acute traumatic aortic disruption.

A technique that facilitates primary repair of acute traumatic aortic disruption is described. With this technique, primary repair has been possible in 5 of our most recent 9 patients with this injury, whereas all 46 of our previous patients were treated by insertion of a prosthetic graft. Primary repair of traumatic aortic disruption is feasible in many more patients than we initially thought possible and should always be considered, particularly in the young patient with a healthy, elastic aorta that is only partially transected.

Aorta, Thoracic↗
PubMed1983

Evaluation of the pulmonary hilum: comparison of conventional radiography, 55 degrees posterior oblique tomography, and dynamic computed tomography.

In 84 patients with suspected intrathoracic neoplasms we compared the accuracy of conventional radiography, 55 degrees posterior oblique tomography, and contrast-enhanced dynamic incremental computed tomography (CT) in evaluation of the pulmonary hilum. We found dynamic incremental CT to be better than either conventional radiography or oblique tomography in hilar evaluation. In addition, significant information was detected in extrahilar and extramediastinal locations by CT in 21% of patients. This study, unlike earlier reports, indicates a role for CT in hilar evaluation.

Adenocarcinoma↗
PubMed1982

The combined Collis-Nissen operation: early assessment of reflux control.

This report summarizes the clinical experience with 155 patients who underwent the Collis-Nissen operation and have been followed by personal interview, esophageal manometry, barium swallow examination, and acid reflux testing for up to three years (average, 24 months). There has been 1 postoperative death. Major complications have included gastroplasty tube leak (2 patients), stricture perforation during dilation (1 patient), and splenic injury (3 patients). Subjectively, among 135 patients followed for a minimum of 6 months, reflux has been eliminated in 89% (120 patients), remains mild in 6% (8 patients), and is severe in 5% (7 patients). Early satiety ("bloats") of varying degree has occurred in 19% (26 patients), and dysphagia requiring dilation in 15% (20 patients). The overall objective recurrence rate, as documented with the intraesophageal pH probe and the standard acid reflux test, is 13% (18 patients). Among 32 patients with peptic strictures treated with dilation and the Collis-Nissen operation, reflux symptoms have recurred in 3%, and 6% have had abnormal reflux demonstrated with the pH probe. These results substantiate excellent early reflux control with the Collis-Nissen procedure and justify its continued use in appropriately selected patients with gastroesophageal efflux and its complications.

Adolescent↗
PubMed1982

Esophagectomy: definitive treatment for esophageal neuromotor dysfunction.

Twenty-two patients with a history of between one and four (average of two) unsuccessful prior esophageal operations for neuromotor dysfunction were treated with esophageal resection and replacement. Eleven (50%) had recurred reflux esophagitis in association with various disorders of motility: esophageal spasm in 4, achalasia in 3, scleroderma in 2, and esophageal atresia in 2. Eight (36%) had primary esophageal spasm and 3 (14%) had achalasia. Esophageal obstruction, regurgitation, and severe spasm were the most common manifestations of the inability to swallow normally. Transthoracic or transhiatal (blunt) esophagectomies were performed in 5 and 17 patients, respectively. The stomach, with a cervical esophagogastric anastomosis, was used for esophageal substitution in 15 patients. Six patients underwent a long-segment colonic interposition, and 1 patient with achalasia underwent a distal esophagectomy and short-segment colonic interposition. One patient undergoing transthoracic esophagectomy for achalasia died from unrecognized intraoperative bleeding into the opposite chest. There were no other operative deaths. Additional complications included transient hoarseness in 8 patients, chylothorax in 1, and anastomotic leak in 1. After an average follow-up of 25 months for the 21 surviving patients, ability to eat is regarded as good in 18 (85%), fair in 1 (5%), and poor in 2 (10%). In patients with incapacitating esophageal neuromotor disease, a more radical operative approach-esophagectomy--may be safer and more reliable than attempting another procedure and risking another failure. Esophagectomy ensures definitive elimination of the esophageal problem and as optimal an ability to eat as possible. Our experience suggests that the stomach, with a cervical esophagogastric anastomosis, offers a better functional esophageal substitute than does a colonic interposition.

Adult↗
PubMed1981

Scalene node biopsy in pulmonary carcinoma: when is it indicated?

While there is universal agreement that palpable scalene lymph nodes should be biopsied in the preoperative evaluation of patients with carcinoma of the lung, the role of biopsy of nonpalpable scalene nodes remains unclear. This report evaluates the results of biopsy of nonpalpable scalene lymph nodes in 101 consecutive patients with bronchogenic carcinoma otherwise deemed candidates for pulmonary resection. The overall incidence of biopsy positive for metastatic disease was 8.9%. No patient with a peripheral primary lesion, regardless of size or cell type, had metastasis to scalene nodes. Six of 15 patients with centrally located adenocarcinomas showed scalene node metastasis, while only 1 of 40 patients with central squamous cell carcinomas had a positive scalene biopsy. Bilateral biopsy was no more likely to yield positive information than ipsilateral biopsy alone. We now recommend preoperative biopsy of nonpalpable scalene nodes only in patients with central lesions in whom the cell type is adenocarcinoma or unknown.

Adenocarcinoma↗
PubMed1981

Combined Collis gastroplasty--fundoplication operations for scleroderma reflux esophagitis.

Thirty-seven patients with scleroderma and reflux esophagitis, including 16 (43%) with peptic esophageal strictures, have been treated with a combination of the Collis gastroplasty and either a Belsey (240 degree) or Nissen (360 degree) fundoplication. Follow-up data have been obtained through personal interviews, esophageal manometry, and acid reflux testing. There have been no postoperative deaths or wound-healing complications. Five (31%) of the 16 patients with strictures still require intermittent dilatations. In the Collis-Belsey group (17 patients), after an average follow-up of 42 months, reflux symptoms have been eliminated in 11, are mild in three, and moderate or severe in three. Distal esophageal high-pressure zone (HPZ) tone and length have increased from an average of 4.6 mm Hg and 1.6 cm preoperatively to 8.6 mm Hg and 2.3 cm postoperatively. Acid reflux testing with the intraesophageal pH electrode, however, has demonstrated moderate-to-severe reflux in seven patients (41%). In the Collis-Nissen group (20 patients), after an average follow-up of 22 months, reflux symptoms have been eliminated in 17, are mild in two, and severe in one. Average HPZ tone and length have increased from 2.5 mm Hg and 1.2 cm preoperatively to 12 mm Hg and 4.2 cm postoperatively. The acid reflux test has revealed moderate or severe reflux in five patients (25%). Gratifying subjective and objective reflux control can be achieved in scleroderma patients with minimal operative morbidity.

Adult↗
PubMed1980

Intraoperative esophageal manometry: is it valid?

Forty-five patients undergoing a Collis-Nissen antireflux operation had preoperative, several intraoperative, and postoperative distal esophageal high-pressure-zone (HPZ) measurements. In 11 patients (24%), intraoperative manipulation of the esophagus alone, prior to beginning the repair, had a major effect upon the HPZ. The final mean intraoperative HPZ pressure (21.2 mm Hg) differed significantly (p less than 0.01) from that obtained postoperatively at 1 to 3 weeks (15.2 mm Hg), 6 months (11.2 mm Hg), and 12 mm Hg), and 12 months, (12.1 mm Hg). However, there was no significant statistical correlation between the final intraoperative HPZ pressures and those obtained after 6 and 12 months. Irrespective of the final intraoperative HPZ value, no patient undergoing acid reflux testing at 6 to 12 months after operation had any gastroesophageal reflux. It is concluded that esophageal manipulation (mobilization or dilation) results in variable intraoperative Hpz values that are not reliable predictors of HPZ values obtained late postoperatively. The rationale for altering the technique of an operation simply to obtain an "ideal" intraoperative HPZ value must be seriously questioned.

Female↗
PubMed1980

Extended cervical esophagomyotomy for cricopharyngeal dysfunction.

Forty adult patients have undergone a 7 to 10 cm cervical esophagomyotomy (from the superior cornu of the thyroid cartilage to behind the clavicle) for cricopharyngeal dysfunction. A Zenker's diverticulum was present in 12 patients (30%) and in five was recurrent. Preoperative symptoms included cervical dysphagia (85%), expectoration of saliva (40%), and intermittent hoarseness (30%). Four patients were being fed through tubes because of total inability to swallow. "Heartburn" was experienced by one half of the patients, but only 12 had acid or food regurgitation. The duration of symptoms ranged from 1 month to 11 years (average 3.9 years). Weight loss had occurred in 15 patients (38%) and ranged from 5.5 to 40.9 kg (average 16 kg). Barium swallows showed no abnormalities in 10 patients. Abnormal findings included a Zenker's diverticulum (12), prominent cricopharyngeal sphincter (11), nasopharyngeal reflux or incoordinated initiation of deglutition, or both (seven), a sliding hiatal hernia (11), and abnormal esophageal motility (seven). Esophageal manometry revealed abnormalities of upper esophageal sphincter (UES) function in only 16 patients. Of 36 patients undergoing standard acid reflux testing, one third had moderate-to-severe gastroesophageal reflux. Seven patients underwent staple resection of a Zenker's diverticulum at the time of cervical esophagomyotomy. Postoperative complications included transient vocal cord paresis (four), vocal cord paralysis (one), and salivary fistula (one). There were no postoperative deaths. After 2 to 48 months (average 16 months) of follow-up, 34 patients (85%) have had a good to excellent result, and six (15%) have not been benefited by operation.

Adult↗