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Biomedical subjects

R E Crozier

Publications and source records attributed to R E Crozier.

14 recordsLinked to original sources
PubMed1991

Acid-provoked esophageal spasm as a cause of noncardiac chest pain.

A total of 394 patients with noncardiac chest pain underwent both basal esophageal manometry and combined esophageal motility and acid perfusion studies between 1986 and 1988. On basal esophageal manometry, 275 patients had a normal response, 64 patients had findings of high-amplitude peristalsis or "nut-cracker" esophagus, and 11 patients exhibited changes of diffuse esophageal spasm. Of the 275 patients who had normal findings on basal esophageal manometry, 90 patients (33%) had a positive response on combined esophageal motility and acid perfusion studies, that is, reproduction of chest pain with associated abnormal motility changes. The present study focuses on the 90 patients with acid-provoked esophageal spasm. On acid perfusion study, these 90 patients had a 46.2% rise in deglutition response and a 95% increase in duration compared with a 3.2% and a 4.3% change in values for the control group of healthy volunteers. Of the group with acid-induced spasm, 90.1% had excessive dysmotility changes (repetitive waves, multiple peaks, spontaneous or simultaneous contractions) compared with an incidence of 12.5% in the control group.

Adult↗
PubMed1986

Paraesophageal hiatus hernia.

Fifty-five operations for paraesophageal hiatus hernia were performed at the Lahey Clinic, Burlington, Mass, between January 1970 and October 1985. Pain was present in 35 of 51 patients. Other less common symptoms were anemia and vomiting. Reflux symptoms were rare. Esophageal manometry disclosed a mean lower esophageal sphincter pressure of 18.2 mm Hg and a length of 3.5 cm. An anterior crural repair (Collis procedure) was employed in all patients. In 22 patients Stamm gastrostomies were also performed. In two patients, a Nissen fundoplication was also carried out because of coexisting gastroesophageal reflux. One patient died postoperatively of a pulmonary embolus. Of the patients, 88.4% benefited from the operation. Of the five poor results, four were due to hernial recurrence and only one was due to severe reflux symptoms. Gastroesophageal reflux is rare in patients with paraesophageal hiatus hernia. An antireflux procedure should be added to surgical correction of the anatomic defect only if evidence of a hypotensive lower esophageal sphincter is clearly present preoperatively or intraoperatively. The addition of gastrostomy to the procedure protects against recurrence of hernia.

Adult↗
PubMed1986

Reoperative achalasia surgery.

Forty-six patients with esophageal achalasia required reoperation between January 1970 and January 1986. Three of these patients required a second reoperative procedure, for a total of 49 reoperations. Indications for reoperation were inadequate myotomy, 17; gastroesophageal reflux, 14; concomitant antireflux operation, six; incorrect diagnosis, four; carcinoma of the esophagus, four; megaesophagus, three; and paraesophageal hernia, one. Various procedures were employed at the time of reoperation, including revision of the myotomy, takedown or revision of a previously performed wrap, fundoplication, and resection. Of the 48 patients available for follow-up study over an average postoperative period of 5 years, the condition of 38 (79%) was considered to have been improved by reoperation. The best results were obtained by revision or takedown of a previous wrap (an improvement rate of 88.9%) and radical resective procedures (89% to 100%). We conclude that for good results to be achieved after reoperative achalasia procedures, the preoperative diagnosis must be accurate, the operation should be performed early before the development of megaesophagus, and a short but complete esophagomyotomy must be performed, preferably without the addition of an antireflux procedure. Elimination or revision of a previously performed fundoplication can be expected to be followed by good results. The precise indications for radical resective procedures have yet to be defined clearly, but their wider application to carefully selected patients with postoperative achalasia seems justified.

Adult↗
PubMed1984

Reflux control by fundoplication: a clinical and manometric assessment of the Nissen operation.

Ninety-two Nissen fundoplications were performed for relief of symptoms of reflux in patients without stricture and in whom the wrap was left in the abdomen. Of these, 25 were reoperations. Reflux secondary to a hypotensive lower esophageal sphincter was associated with a sliding esophageal hiatus hernia in 61 patients, and surgical or other manipulative maneuvers were responsible for a hypotensive lower esophageal sphincter in 5 patients. No obvious cause could be determined in the remaining patients. The operation was transabdominal in 74 patients and by thoracotomy in 18 patients. Fifteen patients required ancillary operative procedures. Follow-up studies averaged 5 3/4 years in 82 patients and revealed permanent control of reflux in 74 of them (90.2%). Eighty percent of the patients were able to belch after operation. Overall patient satisfaction was achieved in 67 patients (81.7%). Among those who underwent operation for the first time, 84.5% achieved satisfactory results, whereas only 75% of those who underwent reoperation were benefited. Poorest results were caused by too tight a wrap, a complication that became rare after the size of the indwelling stent was increased to 42F. Esophageal manometry documented effective and significant augmentation of the amplitude and length of the lower esophageal sphincter from preoperative values of 7.2 +/- 0.5 mm Hg and 2.4 +/- 0.1 cm to postoperative values of 15.6 +/- 0.6 mm Hg and 4.1 +/- 0.1 cm (p less than 0.001). We conclude that if patients are properly selected and the wrap loosely fashioned, permanent control of reflux can be achieved by the classic Nissen fundoplication in 90% of patients with relatively few complications and a high degree of patient satisfaction.

Esophagus↗
PubMed1984

Operation for esophageal achalasia. Results of esophagomyotomy without an antireflux operation.

Between January, 1970, and January, 1984, 113 patients with esophageal achalasia underwent 115 esophagomyotomies at the Lahey Clinic. Twenty-nine patients had been treated on one or more occasions by forceful dilation, and 18 had been operated upon before. Results are based on follow-up studies of 103 patients operated on 1 to 13.5 years ago (average follow-up period, 6.75 years). Six patients were lost to follow-up study, and six were operated upon less than a year ago. The condition of 94 patients (91%) was improved by operation. The improvement rate was 94% for those who underwent a primary operation and 76% for those who underwent reoperation. Only four of the nine poor results were caused by reflux esophagitis, and these patients are satisfactorily managed medically. Multiple regression analysis of risk factors including age, sex, duration of symptoms, severity of disease, length of follow-up, previous operation, and forceful dilations revealed that only previous operation correlated significantly with poor results (p = 0.0004). Preoperative and postoperative manometric assessment of the lower esophageal sphincter was made on some of these patients. The amplitude of lower esophageal sphincter pressure dropped from 32.5 +/- 1.6 (SEM) to 14.5 +/- 1.4 mm Hg, and the length of the lower esophageal sphincter decreased from 3.7 +/- 0.1 to 2.2 +/- 0.1 cm. These differences were highly significant (p = 0.001). After myotomy a short subhiatal remnant of the lower esophageal sphincter remains with pressure within the normal range, which minimizes the risk of postoperative gastroesophageal reflux. Because of the high success rate of limited esophagomyotomy and the low incidence of significant reflux symptoms after its use, we recommend that it be performed without an associated antireflux procedure.

Adolescent↗
PubMed1981

Cervical esophageal dysphagia: indications for and results of cricopharyngeal myotomy.

Twenty patients with cervical esophageal dysphagia were treated by cricopharyngeal myotomy. Of these 20 patients, ten had pharyngoesophageal diverticula, four had a hypertensive upper esophageal sphincter (UES), four had bulbar palsy, and two has miscellaneous forms of cricopharyngeal dysfunction. Preoperative esophageal manometric examination revealed mean UES pressures of 37.2 mmHg +/- 4.8 SEM in patients with diverticula-markedly lower (p = 0.01) than in normal patients (55.9 mmHg +/- 5.0 SEM). In patients with hypertensive UES the mean pressure was 166.2 mmHg +/- 13.4, significantly higher (p less than 0.001) than normal. Incoordination of the deglutitive response of the UES characterised by premature relaxation and contraction was present in all patients with diverticula and in one other patient. Another patient exhibited incomplete sphincteric relaxation (achalasia). A 4-5 cm myotomy of the cricopharyngeus muscle and adjacent esophageal muscle was performed in all patients. On the patients with diverticula two also had diverticulectomy. No patient with bulbar palsy was benefited. All other patients were relieved of dysphagia by the operation, with the exception of one patient with a diverticulum. A subsequent diverticulectomy was required in this patient. Postoperative manometric examination revealed an average decrease in UES pressure of 63% and an average decreased in length of the high pressure zone of 1.4 cm.

Adult↗
PubMed1981

Reoperation for complications of the Nissen fundoplication.

Case histories of 25 patients are reported in whom complications after a Nissen fundoplication were sufficiently severe to require reoperation. Patients were classified by complications as having postoperative dysphagia (14), recurrent reflux (seven), "gas bloat" syndrome (two), and paraesophageal hernia (two). Six of the 14 patients with dysphagia had no esophageal peristalsis, one had a panmural fibrous stricture, and had a "slipped" Nissen, and in six the wrap was presumed to have been fashioned too tightly. Too tight a wrap was also responsible for the seven instances of recurrent reflux and the two of "gas bloat" syndrome. Revision of the fundoplication relieved the symptoms in the 15 patients in whom it was done. A variety of surgical procedures were performed on the other 10, all but one of whom experienced a good result. Proper selection of patients for operation coupled with attention to certain technical surgical details will ensure good results in 90% of patients after a Nissen fundoplication.

Deglutition Disorders↗
PubMed1980

Parietal cell vagotomy: its effect on lower exophageal sphincter function.

Lower esophageal sphincter (LES) function was studied before and after parietal cell vagotomy in 11 patients with duodenal ulcer, none of whom experienced postoperative symptoms of gastroesophageal reflux. No changes were noted in any of the following variables measured: amplitude of LES pressure (before operation, 12.7 +/- 1.18 mm Hg; after operation, 13.7 +/- 0.73 mm Hg), length of LES (before, 3.85 +/- 0.15 cm; after, 3.73 +/- 0.17 cm), and adaptive response of LES (before, 1.26 +/- 0.23; after 1.31 +/- 0.16). In man, LES possesses intrinsic tone, presumably related to tonic, myogenic activity independent of an extrinsic nerve supply.

Duodenal Ulcer↗
PubMed1980

Esophagomyotomy for achalasia of the esophagus.

Currently conflicting opinions regarding the efficacy of esophagomyotomy alone as the preferred treatment for esophageal achalasia prompted this review of the results in 69 patients treated at the Lahey Clinic between January 1970 and January 1980. Preoperative symptoms were alleviated completely or partially in 92% of the 60 patients operated on more than 12 months ago and who were available for follow-up study (average: 42 months). Excellent or good results were achieved in 84% of patients. Only one of the poor results was due to reflux esophagitis. It is concluded that an antireflux procedure is not routinely necessary to prevent postoperative reflux esophagitis if the technique of esophagomyotomy follows certain specific guidelines.

Adolescent↗
PubMed1978

Surgery for short esophagus with stricture: an experimental and clinical manometric study.

The surgical management of short esophagus with stricture has been simplified in recent years by the introduction of an esophageal lengthening procedure (Collis gastroplasty) combined with antireflux maneuvers, such as the Belsey and Nissen operations. This report compares the experimental and clinical manometric findings after these procedures. After myectomy of the lower esophageal sphincter (LES) in the cat, three experimental groups were developed including Collis gastroplasty, Collis-Belsey and Collis-Nissen. formation of a gastric tube did not provide protection against reflux while the Collis-Nissen procedure was more effective than the Collis-Belsey in raising pressures at the high pressure zone (HPZ) (26.0 +/- 3.5 cm H2O vs 15.0 +/- 2.7) and in preventing reflux (pH 6.3 +/- 0.5 vs 2.9 +/- 0.04). Of 20 patients with short esophagus and stricture, 11 underwent a Collis-Belsey procedure and nine a Collis-Nissen procedure. The latter procedure resulted in an HPZ of greater amplitude and length than the Collis-Belsey (18.7 +/- 2.3 mm Hg vs 11.6 +/- 1.7 and 3.9 +/- 0.4 cm vs 2.4 +/- 0.2). It also proved to be a more effective antireflux procedure, for no patient so treated had a positive pH reflux test after operation whereas after the Collis-Belsey procedure all but one patient had a positive pH reflux test. Short-term clinical results also support the superiority of the Collis-Nissen operation.

Animals↗
PubMed1977

Diffuse spasm of the esophagus. Clinical manometric, and surgical considerations.

Extended esophagomyotomy was performed on 11 patients with diffuse spasm of the esophagus (DSE). Preoperative and postoperative clinical, manometric, and roentgenographic findings are reviewed. Preoperative manometry performed in all patients disclosed a mean deglutitive pressure of 70 mm. Hg in the diseases areas and indicated the required length of myotomy. The lower esophageal sphincter (LES) was within normal limits in most instances, with a mean amplitude of 20 mm. Hg, and its exclusion from the myotomy eliminated the need for additional antireflux procedures. Postoperative manometry in 10 patients disclosed a 70 percent reduction in deglutitive pressures in the myotomized segments, and the mean LES amplitude of 13 mm. Hg remained within the normal range (10 to 20 mm. Hg). Ten of the 11 patients were clinically improved, and postoperative reflux developed in only one patient. These results support the continued use of extended esophagomyotomy in selected patients with DSE and suggest that exclusion of the LES from the myotomy affords satisfactory antireflux protection without ancillary sphincter-enhancing maneuvers.

Adult↗