Biomedical subjects

S J Kraemer

Publications and source records attributed to S J Kraemer.

9 recordsLinked to original sources

PubMed1997

[Staging laparoscopy].

The so-called extended diagnostic laparoscopy (EDL) facilitates the comprehensive exploration of the abdominal cavity, thus improving the precision of the pretherapeutic tumor staging in gastrointestinal malignancies. EDL comprises visual inspection with a specific preparation of all relevant sites, laparoscopic sonography and retrieval of samples for biopsy and cytology. Additional relevant therapeutic information was obtained through EDL in 40.5% of gastric cancer patients. EDL could be of similar importance for diagnosing esophageal, hepatobiliary and pancreatic malignancies.

Biopsy↗

PubMed1996

The gastroesophageal flap valve: in vitro and in vivo observations.

BACKGROUND: This study was performed to confirm the presence and significance of a gastroesophageal flap valve. METHODS: The pressure gradient needed to induce reflux across the gastroesophageal junction and the level of a high-pressure zone were determined in 13 cadavers. On inspection in the cadavers, a mucosal flap valve at the entrance of the esophagus into the stomach was seen through a gastrostomy. This valve was deficient or absent in cadavers with a hiatal hernia. The valve was inspected in controls and in patients with reflux with a retroflexed endoscope. RESULTS: In cadavers with no hiatal hernia, a gradient across the gastroesophageal junction was present in nearly all cadavers. The gradient could be increased by surgically accentuating the valve without a concomitant rise in pressure in the high-pressure zone. Reduction of the hiatal hernia in the cadaver and anchoring of the gastroesophageal junction to the normal attachment to the preaortic fascia restored the valve and the gradient as seen through a gastrostomy. Control subjects had a prominent fold of tissue that extended 3 to 4 cm along the lesser curve of the stomach and tightly grasped the shaft of the endoscope. This was diminished or absent in reflux patients. Inspection of the valve in control subjects and subjects with reflux allowed for a grading system with Grades I through IV. This grading system was applied to a cohort of patients with and without reflux. The appearance of the flap valve was a better predictor of the presence or absence of reflux than was lower esophageal sphincter pressure. Endoscopic viewing of the valve during surgery can confirm that a competent valve has been reconstructed. CONCLUSIONS: Grading of the gastroesophageal valve is simple, reproducible, and offers useful information in the evaluation of patients with suspected reflux undergoing endoscopy.

Esophagogastric Junction↗

PubMed1994

[The technique of laparoscopic ultrasound study in diagnostic laparoscopy].

In gastric cancer, retrogastric invasion or enlarged lymph nodes in the hilus of the spleen or at the celiac trunk can readily visualized with laparoscopic ultrasound examination (LUS). Invasion or metastases of the liver can be identified which are "invisible" with the "classic" imaging methods. In our series this led to revision of the TNM staging in 8% of 111 patients with advanced gastric carcinoma. In the staging of early pancreas cancer the standard methods of investigation, including ERCP, are unsatisfactory. Tumor localization, invasion of blood vessels and local or distal lymph node metastases cannot always be evaluated reliably. LUS promises to provide this valuable information. In carcinoma of the distal esophagus or the cardia, LUS can help to exclude small liver metastases, assess invasion of the diaphragm and evaluate the extent of enlarged intraabdominal lymph nodes, especially those at the celiac trunk. A frequent challenge/task for LUS is the exact determination of the benign or malignant nature of liver foci. Quite commonly they are inaccessible to percutaneous CT-guided puncture, but can be easily reached and biopsied under direct vision or LUS-guidance. By virtue of LUS and its information about extrahepatic lymph node infliction, diagnostic laparoscopy is now a less invasive but equally valid substitute for diagnostic laparotomy prior to liver transplantation in oncological diseases. LUS is now well established in diagnostic laparoscopy as a reliable tool for the preoperative staging of distal esophageal and abdominal tumors. It provides additional information which cannot be obtained with conventional imaging procedures.

Esophageal Neoplasms↗

PubMed1994

Early results with the laparoscopic Hill repair.

The open Hill repair is established as a highly effective and durable antireflux procedure. At the present time, we have multi-institutional experience with over 140 laparoscopic Hill repairs. Detailed follow-up on the first 40 patients at our institution is described. All patients had well-documented reflux or esophagitis preoperatively, 7 patients had evidence of peptic stricture or Schatzki's ring, 11 had large hiatal hernia, and 10 weighed more than 200 lb. There were no serious complications and no reoperations. There was 1 death during the follow-up period that was not attributable to the repair. Hospital stay averaged 2.8 days with return to normal activity in 7 to 14 days. Postoperative manometry has been obtained in 24 of the 39 patients available for follow-up (62%) and 24-hour pH studies in 23 of the 39 (59%). Thirty-nine patients were evaluable at a mean follow-up of 10 months and a median follow-up of 8 months (range: 4 to 20 months), with 36 (92%) subjectively rating results as good or excellent. Only one of the three remaining patients has objective evidence of reflux, yielding 97% clinical control of reflux. Mean lower esophageal sphincter pressure (LESP) was raised from 10.7 mm Hg, preoperatively, to 25 mm Hg, postoperatively. Postoperatively, 33 of the 39 patients (85%) are now free of medications referable to the esophagus or upper gastrointestinal tract. This early follow-up experience with the laparoscopic Hill repair leads us to conclude that it is safe, widely applicable, and highly effective as an antireflux operation. Its special features give it certain advantages over the laparoscopic Nissen repair, and we recommend it as the procedure of choice.

Adult↗

PubMed1994

[Quantifying intestino-esophageal reflux with a fiberoptic bilirubin detection probe].

Currently available methods to assess reflux of duodenal contents into the esophagus are cumbersome, unphysiologic, and inaccurate. The role of intestino-esophageal reflux has therefore been controversial. We assessed intestino-esophageal reflux using a new system which allows prolonged intraesophageal measurement of bilirubin, the major pigment of bile. Measurements were made with a newly developed fiber-optic sensor electrode connected to a portable data processing unit (BILITEC 2000, Synectics Medical Inc., Sweden). Light absorption was measured at the absorption peak of bilirubin and a reference point. Studies were performed in 9 subjects without esophagitis, 9 subjects with esophagitis and primary reflux disease and 7 subjects with erosive esophagitis after a total or subtotal gastrectomy. The fiberoptic electrode was placed 5 cm above the lower esophageal sphincter. In vitro studies showed linear correlations between absorbance measurements obtained with the BILITEC-unit and known bilirubin and bile acid concentrations, respectively (p < 0.01). Compared to both other groups, light absorption was markedly increased in the subjects who had esophagitis after a total or subtotal gastrectomy (p < 0.05) indicating severe biliary reflux. An increase in bilirubin absorption occurred particularly during the post-prandial and supine periodes (p < 0.01). A Roux-en-Y biliary diversion procedure completely abolished bile reflux in 2 of these patients. These data indicate that ambulatory 24-hour fiberoptic measurement of bilirubin in the esophagus is feasible and allows quantitation of intestino-esophageal reflux. Intestino-esophageal reflux occurs particularly during the postprandial period and the early morning hours in patients who had a previous subtotal or total gastrectomy.

Adult↗

PubMed1993

Transdiaphragmatic approach to the posterior mediastinum and thoracic esophagus.

OBJECTIVE: Complex operations involving the lower esophagus and posterior mediastinum are frequently compromised by poor exposure, thereby requiring combined thoracic and abdominal incisions. We describe our technique and report our experience with a transdiaphragmatic approach to the posterior mediastinum that improves exposure and eliminates the need for thoracotomies. PATIENTS: The lower thoracic esophagus and posterior mediastinum were exposed through a semicircular incision in the central tendon of the diaphragm. The indications for operation in 14 patients were benign conditions of the lower esophagus (reflux esophagitis, lye stricture, scleroderma, and achalasia) (n = 8), malignant neoplasm of the lower esophagus (n = 3), and revagotomy (n = 3). RESULTS: All indicated procedures, resections, and esophagogastric, esophagojejunal, or esophagocolonic anastomoses were completed through abdominal and/or cervical incisions. There were no thoracotomies performed. CONCLUSIONS: We believe this transdiaphragmatic approach greatly improves exposure to the lower and middle esophagus and posterior mediastinum compared with transhiatal approaches; preserves the integrity of the gastroesophageal junction; allows easy access to the vagus nerves without risking esophageal injury in patients who had undergone surgery previously; shortens operative time; and lessens pulmonary morbidity and decreases patients' pain and recovery time when compared with thoracotomy.

Adult↗

PubMedDate not supplied

Does modern technology belong in gastro-intestinal surgery? A step from subjective perception to objective information.

The intra-operative measurement of lower esophageal sphincter (LES) pressure can aid the surgeon in primary repair of the gastroesophageal junction. We evaluated 1,000 patients undergoing primary repairs; 540 patients underwent surgery before the introduction of LES pressure measurements and 460 patients after LES pressure measurement. The incidence of continued reflux was lower in the group having intraoperative LES pressure measurement (4.5% vs. 1.5%). The incidence of continued reflux in this group has been less than 1%. The measurement of intra-operative LES pressure brings objective technology to our patients and improves their quality of life.

Esophagogastric Junction↗

PubMedDate not supplied

Laparoscopic Hill repair.

Gastroesophageal reflux disease, with its attendant symptoms and complications of heartburn, esophagitis, dysphagia, and upper gastrointestinal bleeding, is the most common disorder of the upper gastrointestinal tract. The open Hill repair, which has been utilized in more than 2000 patients, is best defined as restoration of the anti-reflux barrier. The anti-reflux barrier includes the gastroesophageal valve, lower esophageal sphincter, and diaphragm. The Hill repair has now been done laparoscopically in 17 patients (10 men and 7 women) who have been entered into a detailed protocol, including pre-operative evaluation, intra-operative monitoring, and post-operative evaluation. Results have been excellent, with correction of reflux in all patients. Duration of follow-up ranges from 1 to 18 months, with a mean of 10.5 months. No mortality or serious complications have occurred. Extensive post-operative testing in 13 patients, including complete symptom evaluation, standard acid reflux testing, and 24-hour pH monitoring, has shown no recurrence of reflux; lower esophageal sphincter pressure has been restored to a mean of 28 mm Hg, and gastroesophageal valve status to grade 1. Because the laparoscopic procedure is similar to the open Hill repair, expectations for good long-term results are very high.

Esophagitis, Peptic↗

PubMedDate not supplied

Clinical value of diagnostic laparoscopy with laparoscopic ultrasound in patients with cancer of the esophagus or cardia.

Accurate pretherapeutic tumor staging becomes increasingly important for the selection of therapy in patients with cancer of the upper gastrointestinal tract. We prospectively assessed the clinical value of diagnostic laparoscopy with laparoscopic ultrasound and peritoneal lavage in 127 consecutive patients with cancer of the esophagus or cardia but no evidence of hepatic metastases, peritoneal tumor dissemination, or other systemic tumor manifestations on standard staging techniques. There was no mortality or morbidity associated with diagnostic laparoscopy. Diagnostic laparoscopy with laparoscopic ultrasound showed relevant previously unknown findings, particularly in patients with locally advanced adenocarcinoma of the distal esophagus or cardia (hepatic metastases in 22% and peritoneal tumor spread or free tumor cells in the abdominal cavity in 25%), whereas the diagnostic gain was low in those with squamous cell esophageal cancer. The sensitivity and specificity of laparoscopic ultrasound in predicting positive celiac axis lymph nodes were 67% and 92%, respectively. These data indicate that diagnostic laparoscopy with laparoscopic ultrasound and peritoneal lavage is safe and frequently provides therapeutically relevant new information in patients with locally advanced adenocarcinoma of the distal esophagus or cardia, whereas the clinical value in patients with squamous cell esophageal cancer is limited.

Adenocarcinoma↗