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Biomedical subjects

P R Schauer

Publications and source records attributed to P R Schauer.

At least 19 recordsLinked to original sources
PubMed2000

Minimally invasive surgical staging for esophageal cancer.

BACKGROUND: The incidence of esophageal adenocarcinoma is increasing in the United States, and the 5-year survival rate is dismal. Preliminary data suggest that conventional imaging is inaccurate in staging esophageal cancer and could limit accurate assessment of new treatments. The objective of this study was to compare minimally invasive surgical staging (MIS) with conventional imaging for staging esophageal cancer. METHODS: Patients with potentially resectable esophageal cancer were eligible. Staging by conventional methods used computed tomography (CT) scan of the chest and abdomen, and endoscopic ultrasound (EUS), whereas MIS used laparoscopy and videothoracoscopy. Conventional staging results were compared to those from MIS. RESULTS: In 53 patients, the following stages were assigned by CT scan and EUS: carcinoma in situ (CIS; n = 1), I (n = 1), II (n = 23), III (n = 20), IV (n = 8). In 17 patients (32.1%), MIS demonstrated inaccuracies in the conventional imaging, reassigning a lower stage in 10 patients and a more advanced stage in 7 patients. CONCLUSIONS: In 32.1% of patients with esophageal cancer, MIS changed the stage originally assigned by CT scan and EUS. Therefore, MIS should be applied to evaluate the accuracy of new noninvasive imaging methods and to assess new therapies for esophageal cancer.

Adenocarcinoma↗
PubMed2000

Minimally invasive esophagectomy.

BACKGROUND: Open esophagectomy can be associated with significant morbidity and delay return to routine activities. Minimally invasive surgery may lower the morbidity of esophagectomy but only a few small series have been published. METHODS: From August 1996 to September 1999, 77 patients underwent minimally invasive esophagectomy. Initially, esophagectomy was approached totally laparoscopically or with mini-thoracotomy; thoracoscopy subsequently replaced thoracotomy. RESULTS: Indications included esophageal carcinoma (n = 54), Barrett's high-grade dysplasia or carcinoma in situ (n = 17), and benign miscellaneous (n = 6). There were 50 men and 27 women with an average age of 66 years (range 30 to 94 years). Median operative time was 7.5 hours (4.5 hours with > 20 case experience). Median intensive care unit stay was 1 day (range 0 to 60 days); median length of stay was 7 days (range 4 to 73 days) with no operative or hospital mortalities. There were four nonemergent conversions to open esophagectomy; major and minor complication rates were 27% and 55%, respectively. CONCLUSIONS: Minimally invasive esophagectomy is technically feasible and safe in our center, which has extensive minimally invasive and open esophageal experience. Open surgery should remain the standard until future studies conclusively demonstrate advantages of minimally invasive approaches.

Adult↗
PubMed2000

Laparoscopic repair of giant paraesophageal hernia.

Giant paraesophageal hernias (PEHs) account for less than 5% of all hiatal hernias. In contrast to the small type I hiatal hernia, nonsurgical management of giant PEHs may be associated with progression of symptoms and life-threatening complications including hemorrhage, strangulation, and death. Most giant PEHs are associated with a current or previous history of gastroesophageal reflux disease and represent progression of the typical type I hernia to a type III hernia. Conventional open repair is associated with good results and low mortality but also with a significant morbidity and a delay in return to routine activities in this frequently elderly population. Recently, short-term outcome studies have reported that minimally invasive approaches to PEH may be associated with less morbidity, shorter hospital stay, faster recovery, and excellent clinical results.

Adult↗
PubMed2000

Outcomes after laparoscopic Roux-en-Y gastric bypass for morbid obesity.

OBJECTIVE: To evaluate the short-term outcomes for laparoscopic Roux-en-Y gastric bypass in 275 patients with a follow-up of 1 to 31 months. SUMMARY BACKGROUND DATA: The Roux-en-Y gastric bypass is a highly successful approach to morbid obesity but results in significant perioperative complications. A laparoscopic approach has significant potential to reduce perioperative complications and recovery time. METHODS: Consecutive patients (n = 275) who met NIH criteria for bariatric surgery were offered laparoscopic Roux-en-Y gastric bypass between July 1997 and March 2000. A 15-mL gastric pouch and a 75-cm Roux limb (150 cm for superobese) was created using five or six trocar incisions. RESULTS: The conversion rate to open gastric bypass was 1%. The start of an oral diet began a mean of 1.58 days after surgery, with a median hospital stay of 2 days and return to work at 21 days. The incidence of early major and minor complications was 3.3% and 27%, respectively. One death occurred related to a pulmonary embolus (0.4%). The hernia rate was 0.7%, and wound infections requiring outpatient drainage only were uncommon (5%). Excess weight loss at 24 and 30 months was 83% and 77%, respectively. In patients with more than 1 year of follow-up, most of the comorbidities were improved or resolved, and 95% reported significant improvement in quality of life. CONCLUSION: Laparoscopic Roux-en-Y gastric bypass is effective in achieving weight loss and in improving comorbidities and quality of life while reducing recovery time and perioperative complications.

Adult↗
PubMed2000

Laparoscopic repair of giant paraesophageal hernia: 100 consecutive cases.

OBJECTIVE: To summarize the authors' laparoscopic experience for paraesophageal hernia (PEH). SUMMARY BACKGROUND DATA: Laparoscopic antireflux surgery and repair of small hiatal hernias are now routinely performed. Repair of a giant PEH is more complex and requires conventional surgery in most centers. Giant PEH accounts for approximately 5% of all hiatal hernias. Medical management may be associated with a 50% progression of symptoms and a significant death rate. Conventional open surgery has a low death rate, but complications are significant and return to routine activities is delayed in this frequently elderly population. Recently, short-term outcome studies have reported that minimally invasive approaches to PEH may be associated with a lower complication rate, a shorter hospital stay, and faster recovery. METHODS: From July 1995 to February 2000, 100 patients (median age 68) underwent laparoscopic repair of a giant PEH. Follow-up included heartburn scores and quality of life measurements using the SF-12 physical component and mental component summary scores. RESULTS: There were 8 type II hernias, 85 type III, and 7 type IV. Sac removal, crural repair, and antireflux procedures were performed (72 Nissen, 27 Collis-Nissen). The 30-day death rate was zero; there was one surgery-related death at 5 months from a perioperative stroke. Intraoperative complications included pneumothorax, esophageal perforation, and gastric perforation. There were three conversions to open surgery. Major postoperative complications included stroke, myocardial infarction, pulmonary emboli, adult respiratory distress syndrome, and repeat operations (two for abscess and one each for hematoma, repair leak, and recurrent hernia). Median length of stay was 2 days. Median follow-up at 12 months revealed resumption of proton pump inhibitors in 10 patients and one repeat operation for recurrence. The mean heartburn score was 2.3 (0, best; 45, worst); the satisfaction score was 91%; physical and mental component summary scores were 49 and 54, respectively (normal, 50). CONCLUSION: This report represents the largest series to date of laparoscopic repair of giant PEH. In the authors' center with extensive experience in minimally invasive surgery, laparoscopic repair of giant PEH was successfully performed in 97% of patients, with a minimal complication rate, a 2-day length of stay, and good intermediate results.

Aged↗
PubMed1999

Laparoscopic Roux-en-Y gastric bypass: a case report at one-year follow-up.

Surgery is the only treatment for morbid obesity that has been proven to achieve a significant long-term weight loss. The Roux-en-Y gastric bypass procedure has been performed for the treatment of morbid obesity over the past two decades with excellent results. Wound complications and perioperative morbidity remain unresolved problems of the procedure. A laparoscopic approach to this procedure has great potential to minimize the complications of this highly effective technique. We describe a laparoscopically performed Roux-en-Y gastric bypass in a 28-year-old woman with morbid obesity. The technique described here preserves the anatomic construct of the operation but introduces the benefit of the laparoscopic approach.

Adult↗
PubMed1999

Minilaparoscopy.

Minilaparoscopy is an emerging aspect of laparoscopic surgery involving the use of miniaturized scopes and instruments to further reduce perioperative morbidity and enhance cosmesis. Recent improvements in optical technology and instrument design have enabled relatively broad applications of minilaparoscopy to include diagnostic and therapeutic procedures in both inpatient and outpatient settings. Early results suggest that minilaparoscopic procedures in the hands of experienced laparoscopic surgeons appear to be similarly safe and effective with minimally perceptive scarring. Although promising, clear advantages in reducing perioperative pain and morbidity have yet to be determined.

Humans↗
PubMed1999

Effect of open and laparoscopic surgery on cellular immunity in a swine model.

Immune suppression associated with trauma has been demonstrated to be proportional to the magnitude of injury. Laparoscopic surgery has been shown to produce a diminished stress response compared to open surgery. Postoperative immune function, specifically cellular immunity, may be better preserved after laparoscopic surgery compared to open surgery. The aim of this study was to examine the effect of open versus laparoscopic surgery on cellular immunity in a swine model. Twenty domestic female pigs were randomly selected for laparoscopic cholecystectomy (LC) or open cholecystectomy (OC). Cellular immune functions were evaluated with delayed-type hypersensitivity (DTH) skin test and serial phytohemoagglutinin (PHA)-induced T-cell proliferation of the peripheral blood. There was a significant reduction in PHA-induced T-cell proliferation in both LC and OC groups on days 1 and 3 compared to preoperative values (p < 0.05). The reduction of mitogen-induced T-cell proliferation after LC was significantly less than after OC on day 1 (p = 0.03). The mean DTH reaction was 29.7 +/- 3.7 mm2 in the LC group compared to 13.9 +/- 1.2 mm2 in the OC group (p < 0.001). There was no difference in postoperative white blood count values between the two groups. Suppression of cellular immunity occurred after both LC and OC. The magnitude and duration of impaired cellular immunity after laparoscopic surgery was less than after open surgery as measured by T-cell proliferation and DTH response.

Animals↗
PubMed1998

Coagulation modifications after laparoscopic and open cholecystectomy in a swine model.

BACKGROUND: The stress response to surgical trauma precipitates a state of transient hypercoagulation. Studies have demonstrated that laparoscopic surgery results in a diminished stress response compared to open surgery. The aim of this study was to determine the extent of postoperative hypercoagulability following laparoscopic cholecystectomy (LC) compared to open cholecystectomy (OC). METHODS: Twenty-one pigs were randomly selected to undergo LC (N = 10) or OC (N = 11). Whole blood was collected preoperatively and on postoperative days (PODs) 1, 2, and 3 for determination of viscoelastic changes using a thromboelastography (TEG) coagulation analyzer. Four parameters were calculated from the TEG: R (reaction time), K (coagulation time), alpha (rate of clot formation), and MA (maximal amplitude). Antithrombin III (AT III) level was measured preoperatively and on POD 1. RESULTS: After OC, three of four TEG parameters changed to reflect a state of hypercoagulation. Only MA values were significantly changed after LC. Comparison between OC and LC showed no difference in the TEG parameter. There was no significant change in AT III levels after LC or OC. CONCLUSIONS: OC results in postoperative hypercoagulation typically encountered in open abdominal surgery. Although there were no differences in TEG or AT III between the two groups, after the laparoscopic approach all but one TEG parameter remained unchanged, suggesting a diminished hypercoagulable state. By reducing postoperative hypercoagulation, laparoscopic surgery may reduce the risk of developing postoperative venous thrombosis.

Animals↗
PubMed1998

Comparison of laparoscopic versus open repair of paraesophageal hernia.

BACKGROUND: Recent reports suggest that laparoscopic paraesophageal hernia repair (LPHR) is feasible, but no direct comparisons with the standard open paraesophageal hernia repair (OPHR) have been reported. The purpose of this study was to compare the short-term outcome of LPHR versus OPHR at a single institution. METHODS: The operative and postoperative courses of 95 consecutive patients undergoing open or laparoscopic repair of a paraesophageal hernia (PEH) were retrospectively reviewed, and outcomes of LPHR versus OPHR were compared. RESULTS: PEH was associated with advanced age and significant comorbidity. Although the operative time was increased for LPHR, there was a significant reduction in blood loss, intensive care unit stay, ileus, hospital stay, and overall morbidity associated with LPHR compared with OPHR. CONCLUSIONS: PEH is associated with significant comorbidity that increases the operative risk. Short-term outcomes for LPHR are superior to OPHR, suggesting that the laparoscopic approach is the preferred approach to paraesophageal hernia repair.

Adult↗
PubMed1998

Detection of micrometastases in histologically negative lymph nodes in esophageal cancer.

BACKGROUND: New molecular techniques may identify micrometastases in histologically negative lymph nodes and have an impact on the staging of esophageal cancer. We investigated the role of the reverse transcriptase-polymerase chain reaction (RT-PCR) assay to identify micrometastases in esophageal cancer. METHODS: The RT-PCR assay to detect carcinoembryonic antigen (CEA) messenger ribonucleic acid (mRNA) was performed on lymph nodes from patients with esophageal cancer and benign esophageal disorders. The presence of CEA mRNA in lymph nodes was considered evidence of metastases. RESULTS: Histopathologic study revealed metastases in 50 (41%) of 123 lymph nodes from 30 patients with esophageal cancer. All histologically positive lymph nodes contained CEA mRNA by RT-PCR. Of 73 histologically negative lymph nodes, 36 (49%) contained CEA mRNA, a significant increase compared with the histopathologic diagnosis (p < 0.001). Lymph nodes in patients with benign disease contained no CEA mRNA. In 10 patients, histologic stage was NO. Five of them were also negative by RT-PCR, and all are alive with only one recurrence. In the remaining 5 patients, RT-PCR was positive for occult lymph node metastases; 2 have died of disease, and 1 is alive with recurrent disease. CONCLUSIONS: In patients with esophageal cancer, RT-PCR detects more lymph node metastases than does histopathology. Initial follow-up suggests a positive RT-PCR with negative histologic findings may have poor prognostic implications. Further studies will be needed to confirm any clinical implications.

Carcinoembryonic Antigen↗
PubMed1998

Preliminary results of thoracoscopic Belsey Mark IV antireflux procedure.

Laparoscopic Nissen fundoplication has replaced open approaches for refractory gastroesophageal reflux disease (GERD) in many major medical centers. Here we report our preliminary results of the Belsey Mark IV antireflux procedure performed by video-assisted thoracoscopy (VATS-Belsey). Fifteen patients underwent VATS-Belsey. The indications for surgery included GERD refractory to medical therapy (n=10), achalasia (n=2), diffuse esophageal spasms (n=1), epiphrenic esophageal diverticulum (n=1), and paraesophageal hernia (n=1). The median operative time was 235 min. There were three conversions to open minithoracotomy (8-10 cm) necessitated by severe adhesions (n=2) and repair of a gastric perforation (n=1). The median hospital stay was 4 days. Postoperative complications included persistent air leaks, requiring discharge with a Heimlich valve in one patient. There were no perioperative deaths. At a median follow-up of 19 months, ten patients (66%) were asymptomatic and were not taking any antacids. One patient who had taken proton pump inhibitors preoperatively required postoperative H2 blockers for mild heartburn. In three patients, recurrent GERD symptoms (mean follow-up 6 months) led to laparoscopic takedown of the Belsey and Nissen fundoplication. One patient with achalasia, who had recurrent dysphagia after 1 year of relief following VATS myotomy and Belsey, underwent esophagectomy. The Belsey Mark IV antireflux procedure is technically feasible by VATS with minimal morbidity. However, our preliminary results suggest that open thoracotomy for Belsey Mark IV should remain the standard operation for GERD with poor esophageal motility when a thoracic approach is desired. We have modified our approach to laparoscopic partial fundoplications (Toupet or Dor) for severe GERD and poor esophageal motility when an abdominal approach is possible.

Adult↗
PubMed1997

Complications of surgical endoscopy. A decade of experience from a surgical residency training program.

BACKGROUND: This study examines the notion that gastrointestinal endoscopy performed by supervised surgical residents is safe. METHODS: We reviewed all gastrointestinal endoscopic procedures performed by surgical residents with faculty supervision for complications and deaths occurring up to 30 days following the procedures. RESULTS: The overall complication rate for 9,201 upper and lower endoscopy procedures was 1.4% and 0.42%, respectively. Overall mortality rate was 0.76% for upper endoscopy and 0.6% for lower endoscopy. No mortality was a direct result of a procedure-related complication. Intestinal perforation, drug overdose, bleeding, and aspiration were the most common procedure-related complications. Each resident completed an average of 75 upper endoscopies and 79 lower endoscopies during their training period. CONCLUSIONS: Gastrointestinal endoscopy can be performed safely by surgical residents with appropriate supervision. The higher morbidity and mortality of upper endoscopy are most likely related to the underlying disease rather than the procedure. Awareness of common complications and application of appropriate precautions and instruction are critical for minimizing complications.

Adult↗
PubMed1997

Role of positron emission tomography in staging esophageal cancer.

BACKGROUND: Conventional noninvasive staging of esophageal cancer is inaccurate. This study investigated the role of positron emission tomography (PET) in staging esophageal cancer. METHODS: Patients with potentially resectable esophageal cancer were included. A whole-body PET scan was acquired after injection of 18F-fluorodeoxyglucose and was evaluated for areas of increased focal uptake. Accuracy was determined by comparing PET with surgical staging. RESULTS: Potentially resectable esophageal cancer was identified in 35 patients. Positron emission tomography detected nine sites of distant metastases missed by conventional scanning, but one false-negative PET scan occurred in a patient with a 2-mm liver lesion. There were 11 false-negative PET scans for small, intracapsular local-regional nodal metastases (mean diameter 5.2 mm; range 2 to 10 mm). For distant metastases, the sensitivity was 88%, the specificity was 93%, and the accuracy was 91%. For local-regional nodal metastases, the sensitivity was 45%, the specificity was 100%, and the accuracy was 48%. CONCLUSIONS: Positron emission tomography improved our ability to detect distant metastases missed by conventional noninvasive staging of esophageal cancer. Small local-regional nodal metastases are not identified by current PET technology. Early use of PET in the staging of patients with esophageal cancer could facilitate treatment planning and identifying unsuspected distant metastases in up to 20% of patients with a negative metastatic survey by conventional staging.

Adenocarcinoma↗
PubMed1997

Incidence and significance of subdiaphragmatic air following laparoscopic cholecystectomy.

Subdiaphragmatic free-air may be indicative of a perforated viscus; however, it is normally present after open abdominal surgery. The objective of this study was to determine the significance and incidence of subdiaphragmatic free air following laparoscopic cholecystectomy (LC). Cases of intestinal perforation following laparoscopic cholecystectomy from 1991 to 1995 at The University of Texas Health Science Center at San Antonio were reviewed and their association with subdiaphragmatic free air was determined. Twenty-five patients undergoing LC and 20 patients undergoing open cholecystectomy (OC) were prospectively evaluated with chest radiographs to determine the incidence and quantity of nonpathologic postoperative free air. Four cases of intestinal perforation resulting from trocar injuries or electrocautery burns occurred among 1603 LCs during this study period, for an incidence of 0.2 per cent. Three of the four patients with perforations were diagnosed postoperatively (2-5 days), and two patients had a moderate volume of subdiaphragmatic free air that aided the diagnosis. The incidence of subdiaphragmatic air following LC was 24 per cent, compared to 60 per cent for OC (P < 0.05). Eighty-three per cent of patients with retained air after LC had a minimal volume, compared to 67 per cent of patients after OC (P < 0.05). Nonpathologic subdiaphragmatic free air may normally be present following laparoscopic cholecystectomy but is uncommon 24 hours after the operation. When present, only a small volume is usually detectable. In the rare situation of intestinal perforation resulting from LC, subdiaphragmatic free air may be an important diagnostic finding.

Adult↗
PubMed1996

Upper gastrointestinal bleeding following major surgical procedures: prevalence, etiology, and outcome.

With continuing improvements in the medical therapy of peptic ulcer disease, the incidence of primary upper gastrointestinal bleeding (UGIB) has markedly declined. Nonetheless, in a subset of surgical patients, secondary UGIB following a major operation may still be a source of substantial morbidity. To further elucidate this problem, we reviewed 103 cases of overt UGIB following all major surgical procedures conducted in two hospitals between July 1982 and June 1994. The prevalence of postoperative UGIB during this period was 0.39%. The mean interval between initial operation and UGIB was 16 days (range 1-55 days) and there was a high incidence of associated sepsis (26%). The source of bleeding was defined endoscopically in all cases and included gastritis (69.9%), solitary ulcers (17.5%), and other causes (12.6%). Postoperative UGIB (nonvariceal) was most commonly seen following portacaval shunting operations but mortality rates were highest in patients who developed UGIB after cardiovascular operations. We conclude that: (1) postoperative UGIB has become a relatively uncommon but still formidable clinical problem; (2) erosive gastritis continues to be the major source of UGIB but acute ulcers, varices, and other causes contribute to the total; and (3) postoperative UGIB is most likely to be fatal in cardiovascular patients and those who develop concurrent sepsis and/or multiorgan failure.

Adult↗