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Biomedical subjects

T R DeMeester

Publications and source records attributed to T R DeMeester.

At least 91 records · Page 5Linked to original sources
PubMed1996

The mode of Roux-en-Y reconstruction affects motility in the efferent limb.

OBJECTIVES: To compare motility of a Roux-en-Y esophagojejunostomy after total gastrectomy with normal jejunal motility and to determine the effect on motility of the incorporation of a pouch in the reconstruction. DESIGN: Jejunal motility in normal subjects was compared with jejunal motility in the Roux-en-Y reconstruction with and without a Hunt-Lawrence pouch. SETTING: The case were collected during a 4-year period at a university hospital. The mean time from resection to study was 14 months (range, 4 to 49 months). PATIENTS: Seven control patients were compared with 10 patients with a Roux-en-Y reconstruction and 17 with a Roux-en-Y and Hunt-Lawrence pouch. OUTCOME MEASURE: The fasting-state motility of the jejunum used for reconstruction was measured by a water-perfused manometric system for 2 to 4 hours with the subject in the supine position. RESULTS: Compared with normal subjects, patients with a Roux-en-Y esophagojejunostomy without a pouch had an increased number of phases of the interdigestive motor complex per hour (P < .05). The phases were of shorter duration with a random sequence and increased total time spent in the quiescent phase 1 (P < .05). In patients with a pouch, no differences were detected between the motility in the pouch and the efferent limb. Compared with those without a pouch, there were significantly fewer orthograde interdigestive motor complex phase 3 fronts and more total time spent in phase 1 (P < .05). CONCLUSIONS: Construction of a gastric substitute from jejunum leads to substantial motility changes. The addition of a pouch decreases the overall activity, which may contribute to the storage function of the pouch.

Adult↗
PubMed1996

Outcome of respiratory symptoms after antireflux surgery on patients with gastroesophageal reflux disease.

OBJECTIVE: To investigate factors predictive of relief of respiratory symptoms associated with gastroesophageal reflux disease (GERD). DESIGN: A case series of patients with GERD and respiratory symptoms undergoing fundoplication from 1987 to 1994 at a tertiary care university hospital. PATIENTS: Of 118 patients undergoing fundoplication for cardinal symptoms of GERD, 63 had respiratory symptoms. Postoperative follow-up information was available in 50 patients at a median of 3 years. INTERVENTIONS: The presence of GERD was documented on the basis of barium swallow, esophagoscopy, esophageal manometry, and 24-hour pH studies. A standardized questionnaire was used to score symptoms. A Nissen fundoplication was performed in 39 patients, a Collis-Belsey fundoplication in 3 patients. MAIN OUTCOME MEASURES: A repeat standardized questionnaire was used to evaluate the response to surgery for each symptom experienced. Univariate analysis was performed to evaluate factors influencing outcome. RESULTS: Respiratory symptoms were present in 53% (63/118) of patients with GERD. Fundoplication relieved the respiratory symptoms in 76% (38/50) of the patients. Reflux symptoms were relieved in 86% (43/50) of the patients. Abnormalities of esophageal motility were present in 34% (17/50) of the patients, and these were significantly more common in patients who did not experience relief of their respiratory symptoms (9/12 vs 8/38, chi 2 = 9.54, P = .002). CONCLUSIONS: Respiratory symptoms are common in patients with GERD. Unlike classic reflux symptoms, the beneficial effects of antireflux surgery on respiratory symptoms are less predictable. The probability of relief of these respiratory symptoms with antireflux surgery is directly dependent on esophageal motor function.

Adult↗
PubMed1996

Talc pleurodesis: talc slurry versus thoracoscopic talc insufflation in a porcine model.

BACKGROUND: Pleurodesis using both talc slurry and thoracoscopic talc insufflation has been shown to be clinically effective. This study compares these two modalities of pleural talc instillation in an animal model. METHODS: Eleven immature pigs underwent general endotracheal anesthesia. On one side, a slurry of 5 g sterile United States Pharmacopeia talc in 50 mL of saline solution was instilled through a thoracostomy tube. On the other side, the lung was deflated and 5 g of dry talc was insufflated under thoracoscopic visualization. The animals were sacrificed 30 days later, and the quality of pleural adhesions was graded from 0 to 2 (0 = absent; 1 = light; 2 = dense) in each of six regions of each hemithorax. The distribution of adhesions on each side was graded from 0 to 6, according to the number of areas that contained adhesions. RESULTS: One animal died of anesthetic complications. Among the survivors, adhesions produced by both methods were dense and diffuse in 8 of 10 animals, and light and diffuse in 1 animal. One animal had light or absent adhesions on the talc slurry side, and dense and diffuse adhesions on the thoracoscopic talc insufflation side. There was no difference between the techniques for density of adhesion scores (talc slurry, 9.9 +/- 2.2; thoracoscopic talc insufflation, 10.0 +/- 2.5) or distribution of adhesion scores (talc slurry, 5.5 +/- 1.0; thoracoscopic talc insufflation, 5.8 +/- 0.4) (p > 0.1). CONCLUSIONS: Effective pleurodesis in a porcine model can be obtained with either talc slurry or thoracoscopic talc insufflation.

Animals↗
PubMed1996

The role of fundoplication in the treatment of type II paraesophageal hernia.

OBJECTIVES: The role of fundoplication in patients with pure type II paraesophageal hiatal hernia remains controversial. Conventional thinking suggests that because the lower esophageal sphincter is located within the abdomen, it is competent, and fundoplication is unnecessary. Few studies have used objective evaluation to guide the addition of an antireflux procedure. METHODS: Fifteen consecutive patients with type II paraesophageal hernia were treated between May 1991 and July 1994. All had radiographic criteria of pure type II hernias. Preoperative evaluation included upper intestinal endoscopy, esophageal manometry, and 24-hour ambulatory pH monitoring. The lower esophageal sphincter was considered incompetent if any of the following criteria were present: a resting pressure less than 7 mm Hg, an overall sphincter length less than 2 cm, or an intraabdominal length less than 1 cm. Primary symptoms responsible for surgery were related to the hernia in 73% of patients: dysphagia or postprandial abdominal pain in six patients, abdominal distension or vomiting in four patients, and bleeding in one patient. Symptoms typical of gastroesophageal reflux were present in four patients: heartburn and regurgitation in two each. RESULTS: Objective evidence of gastroesophageal reflux was present in the majority of patients. Five patients (31%) had evidence of esophageal injury: esophagitis in three patients, stricture in one, and esophageal ulcer in one. In 11 of 15 patients (69%), pathologic esophageal acid exposure was detected by 24-hour pH monitoring. Twelve patients (75%) had a defective lower esophageal sphincter, usually the result of an inadequate intraabdominal length (8/12, 66%). Hernia reduction, crural closure, and Nissen fundoplication were performed in 14 patients (one patient awaits surgery). Symptomatic relief was excellent in all cases. No patient has had hernia recurrence at an average of 14 months' follow-up (range 2 to 39 months). CONCLUSION: Objective evaluation reveals that gastroesophageal reflux accompanies type II paraesophageal hernia in a high proportion of patients, usually because of an incompetent lower esophageal sphincter. Appropriate treatment includes reduction of the hernia, crural closure, and fundoplication in most, if not all, patients.

Adult↗
PubMed1996

Gastric juice protects against the development of esophageal adenocarcinoma in the rat.

OBJECTIVE: The authors investigate the effects of gastric juice on tumorigenesis in a rat model of esophageal adenocarcinoma. SUMMARY BACKGROUND DATA: In rats treated with the carcinogen methyl-n-amyl nitrosamine, squamous cancer of the esophagus develops in a time- and dose-dependent manner. When methyl-n-amyl nitrosamine treatment is preceded by an operation to induce reflux of duodenal and gastric juice into the esophagus, there is an increased yield of esophageal tumors, many of which are adenocarcinomas. When only gastric juice refluxes into the esophagus, the tumor yield is less and adenocarcinomas are not found. METHODS: Two hundred seventy 8-week old Sprague-Dawley rats were studied. Twenty unoperated rats served as controls. The remaining rats underwent the following operations: esophagoduodenostomy with gastric and vagal preservation to induce duodenogastroesophageal reflux (n = 48); esophagoduodenostomy with antrectomy and Billroth 1 reconstruction to produce reflux of duodenogastric juice with the exclusion of the antrum (n = 53); esophagoduodenostomy with proximal gastrectomy to induce hypergastrinemia and reflux of duodenogastric juice with exclusion of the body and forestomach (n = 51); esophagoduodenostomy plus total gastrectomy to produce reflux of duodenal juice alone (n = 50); and esophagoduodenostomy with vagal and gastric preservation but with division of the duodenum just beyond the pylorus and reimplantation into the jejunum, 13 cm distal to the esophagoduodenostomy. This produced reflux of duodenal juice with gastric juice diverted downstream, (n = 48). At 10 weeks of age, all rats were given 4 weekly doses of carcinogen (methyl-n-amyl nitrosamine, 25 mg/kg intraperitoneally), and survivors were killed at 36 weeks of age. RESULTS: The prevalence rate of esophageal adenocarcinoma was 30% in rats with duodenogastroesophageal reflux and 87% in rats with reflux of duodenal juice alone. Fifty-six percent of rats with reflux of duodenogastric juice with exclusion of the antrum and 72% of rats with reflux of duodenogastric juice with the exclusion of the body and forestomach developed adenocarcinoma, showing a progression increase in the prevalence of adenocarcinoma as less gastric juice was permitted to reflux with duodenal juice into the esophagus. CONCLUSION: In this rat model, the presence of gastric juice in refluxed duodenal juice against the development of esophageal adenocarcinoma. The protective effect appears to be due to acid secretion from the stomach. Continuous profound acid suppression therapy may be detrimental by encouraging esophageal metaplasia and tumorigenesis in patients with duodenogastroesophageal reflux.

Adenocarcinoma↗
PubMed1996

Intraoperative maintenance of tissue perfusion prevents ARDS. Adult Respiratory Distress Syndrome.

Patients undergoing prolonged, complex oncological surgery are at increased risk of developing the adult respiratory distress syndrome (ARDS) and other organ failures. Our hypothesis is that maintaining adequate tissue perfusion and oxygenation may prevent tissue hypoxia and acidosis in pulmonary, peripheral, and splanchnic microcirculations. Experimental evidence suggests that the hypoxic, acidotic endothelium stimulates the release of cytokines, kinins, and other mediators. We developed and tested an intraoperative protocol for surgical patients likely to develop ARDS and organ dysfunction; the protocol focuses on the intraoperative period but is not limited to this time. Nitroglycerin and fluids were used to maintain tissue perfusion and prevent tissue hypoxia as reflected by transcutaneous oxygen tension values. In 155 high-risk patients, none developed ARDS. We conclude that maintenance of tissue perfusion and oxygenation in high-risk surgical patients decreases the incidence of ARDS.

Adult↗
PubMed1995

The impact of a dedicated trauma program on outcome in severely injured patients.

BACKGROUND: In recent years, many trauma centers have been closing or scaling down their operations because of financial losses and lack of commitment by the relevant authorities. OBJECTIVE: To investigate the effect of commitment to trauma and the establishment of a dedicated trauma program on injury outcome. DESIGN: In 1992, a well-funded dedicated trauma program was implemented at the Los Angeles County--University of Southern California Medical Center, Los Angeles. We analyzed the outcome in severely injured patients (Injury Severity Score [ISS] > 15) before and after implementation of the program (1991 and 1993). SETTING: Large, urban, level 1 trauma center. PATIENTS: Patients with trauma and an ISS higher than 15. RESULTS: There were 737 patients with an ISS higher than 15 in 1991 and 812 patients with an ISS higher than 15 in 1993. The overall mortality rate was 30% in 1991 and 24.5% in 1993 (P = .018), which is a reduction by 18.3%. In patients with blunt trauma and an ISS higher than 15, mortality was reduced by 33% (mortality rate of 31.1% in 1991 vs 20.8% in 1993) (P < .002). Mortality in patients with penetrating trauma and an ISS higher than 30 was reduced by 42.7% (mortality rate of 59.3% in 1991 vs 34% in 1993) (P = .019). There was also a trend toward lower permanent disabilities among survivors with an ISS higher than 15 (14.7% in 1991 vs 11.3% in 1993). CONCLUSION: Commitment of financial and human resources for the establishment of a dedicated trauma program is a sound investment in terms of improved survival and fewer permanent disabilities in critically injured patients.

Accidents, Traffic↗
PubMed1995

Esophageal resection with colon interposition for end-stage achalasia.

OBJECTIVE: To review the potential benefits of esophageal resection with colon interposition in patients with achalasia. DESIGN: Retrospective review. SETTING: University-based tertiary care center. PATIENTS: Nineteen patients (13 men, six women; median age, 44 years; age range, 26 to 77 years) with achalasia and recurrent or persistent dysphagia despite a variety of previous treatments. INTERVENTIONS: Esophageal resection and replacement with colon interposition. MAIN OUTCOME MEASURES: Mortality and morbidity of the procedure, symptomatic outcome, nutritional impact, ability to ingest a meal, and overall patient satisfaction. RESULTS: Follow-up results were available in 15 patients. The procedure accounted for no deaths and complications in four patients. Outcome assessment was done at a median of 6 years (range, 1 to 14 years) after resection. Overall, the symptomatic outcome was excellent to good in 12 patients. Eleven of the 15 patients gained weight (median weight loss, 6.3 kg) after the procedure. Thirteen patients were able to eat three meals daily; seven had the capacity to eat a steak dinner; five, an airline meal; and three, a snack. Nine of the 15 patients enjoyed an unrestricted diet. The speed of ingesting a meal was reduced in that most (11 of 15) were the last to finish when eating in a group. Fourteen of the 15 believed that the operation had cured or improved their preoperative symptoms, and a similar percentage were satisfied with the overall outcome of surgery. Most patients (12 of 15) would have the operation again. CONCLUSIONS: Esophageal replacement for end-stage achalasia can be accomplished with safety and marked improvement of preoperative symptoms. Despite multiple previous therapeutic failures, normal alimentation was restored in the majority of patients, with 93% judging the operation to be highly beneficial, improving their quality of life. Based on this success, guidelines for resection in end-stage achalasia are established.

Adult↗
PubMed1995

Arterial anatomic considerations in colon interposition for esophageal replacement.

BACKGROUND: Little has been written regarding the arterial anatomy predictive of success following esophagectomy and colon interposition. DESIGN: Retrospective review. SETTING: University teaching hospital. PATIENTS: Twenty-five patients undergoing planned left colon interposition. INTERVENTION: Colon interposition was performed via an isoperistaltic left colon graft based on the ascending branch of the left colic artery. MAIN OUTCOME MEASURES: Five angiographic features were considered important to successful use of the left colon: (1) a patient inferior mesenteric artery, (2) a visible ascending branch of the left colic artery, (3) a well-defined anastomosis between the middle colic and left colic systems, (4) a single middle colic trunk prior to its division into right and left branches, and (5) a separate origin of the right colic artery. Venous drainage via a patent marginal vein, inferior mesenteric vein, and superior hemorrhoidal veins was preserved in all patients. RESULTS: Left colon interposition could be performed in 21 (84%) of 25 patients. Eighty percent of the patients (20/25) had at least four of the five criteria thought necessary for optimal graft perfusion. Three or fewer criteria were present in five patients, three of whom underwent gastric interposition. The inferior mesenteric artery was patent in all patients except one who required a right colon interposition. Ninety-two percent (23/25) demonstrated an adequate ascending left colic artery. The superior-inferior mesenteric artery anastomosis was seen in 52% (13/25). A single-trunked middle colic artery was present 80% (20/25) of the time. A single incidence of graft necrosis occurred secondary to venous insufficiency. Ninety-six percent of patients (24/25) were able to swallow without difficulty at the time of discharge from the hospital. CONCLUSIONS: Replacement of the esophagus with colon can be successful in over 80% of patients screened by angiographic criteria. Patients with an occluded or stenotic inferior mesenteric artery or variant middle colic arterial anatomy should undergo an alternate reconstruction.

Anastomosis, Surgical↗
PubMed1995

An intraluminal surgical approach to the management of gastric bezoars.

Trichobezoars are difficult to remove endoscopically, often cause nausea and vomiting, and can result in small-bowel obstruction. A patient with a trichobezoar presented to our clinic with symptoms of partial small-bowel obstruction. Multiple attempts at flexible endoscopic removal were unsuccessful. Two large-diameter percutaneous gastrostomies with an inflatable balloon and distal foam-rubber stent to assure intragastric positioning were introduced under general anesthesia. Visualization was provided by a 0 degree panavision laparoscope placed through one of the gastrostomies. The bezoar was removed through the second gastrostomy using standard laparoscopic instruments. The patient made an uneventful recovery. This is the first reported case of percutaneous removal of a trichobezoar. We conclude large-diameter gastrostomies may serve as a port of access for numerous other intraluminal procedures.

Bezoars↗
PubMed1995

A contemporaneous comparison of hospital charges for laparoscopic and open Nissen fundoplication.

Surgical treatment of gastroesophageal reflux disease is increasingly recognized as a cost-effective alternative to long-term medical therapy. This fact, coupled with the advent of laparoscopic fundoplication as a safe and efficacious alternative to open surgery, underscores the importance of determining the costs associated with laparoscopic treatment. Hospital costs and charges of patients undergoing open (N = 9) and laparoscopic (N = 11) fundoplication were retrospectively analyzed. Both procedures were performed during the same time period (6/91-6/93), at the same hospital, and by the same surgical team. Operative time, and hospital stay, were recorded in addition to total, operating room, anesthesia, sterile supplies, and hospital room charges. Figures are reported as mean values +/- standard error of the mean. The Wilcoxon signed rank test was used for comparison of groups. Operative time (221 +/- 18 vs 165 +/- 12 min, P = 0.033) was longer in the laparoscopic group, while hospital stay (5.8 +/- 02 vs 8.8 +/- 04 days, P < 0.001) was significantly shorter. Total hospital costs were similar for both groups of patients ($14,615 +/- 863 vs $15,891 +/- 921, P = 0.247). Overall hospital charges were nearly identical ($26,634 +/- 1376 vs $27,189 +/- 1753, P = 0.803). A detailed analysis demonstrated cost shifting, with laparoscopic fundoplication resulting in significantly higher charges associated with events in the operating room. Operating room ($6,064 +/- 252 vs $4,283 +/- 380, P = 0.001), sterile supplies ($6,214 +/- 508 vs $5,403 +/- 390), and anesthesia charges ($1,593 +/- 76 vs $1,122 +/- 95, P < 0.001) were all greater in the laparoscopic group.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1995

Carcinoembryonic antigen measurements in the management of esophageal cancer: an indicator of subclinical recurrence.

BACKGROUND: Detection of subclinical recurrence after surgical resection of esophageal cancer would allow earlier treatment of recurrent disease and potentially offer a better outcome for rescue therapy. METHODS: The utility of serum carcinoembryonic antigen (CEA) assay was evaluated in the management of patients with esophageal cancer. RESULTS: Serum carcinoembryonic antigen was measured preoperatively in 74 patients. Elevation of the CEA level (> 5 ng/mL) was present in 14 patients (19%). There was no relationship between preoperative CEA elevation and the stage of the tumor or the patients' survival. Eighty-three patients had CEA assay at regular follow-up intervals after resection. Objective evidence of recurrent disease was determined at similar intervals by chest radiography and abdominal and thoracic computed tomography scans. During follow-up, 53 of 83 patients developed recurrence. Postoperative elevation of CEA levels occurred in 32 patients, resulting in a sensitivity of 55% for detecting recurrent disease. Twenty-nine of the 32 patients who developed CEA elevation had objective evidence of metastatic disease. In 13 patients, the rise in CEA levels predated objective evidence of recurrence by a median of 4 months (range 3 to 35), and in 16 patients, it occurred concomitantly. The specificity with which an elevated postoperative CEA level indicated recurrence was high, 90%, with a positive predictive value of 91%. CONCLUSIONS: Postoperative CEA elevation is highly predictive of recurrent disease. In 16% of patients, elevation of CEA was the earliest objective sign of recurrence; such elevation should prompt consideration of adjuvant therapy.

Adenocarcinoma↗
PubMed1995

A selective therapeutic approach to gastric cancer in a large public hospital.

BACKGROUND: Gastric cancer is a common malignancy with a poor prognosis. The improved survival reported from Japan may be due to earlier detection or to more radical surgery, or both. The relevance of their methods to gastric cancer seen in Western countries is uncertain. PATIENTS AND METHODS: The study involved 204 patients with gastric carcinoma. Preoperative staging by computed tomography scan and endoscopic ultrasound showed that 120 patients (59%) had stage IV disease. RESULTS: Curative resection was performed in 66 patients, palliative resection in 32, bypass/intubation in 39, chemotherapy alone in 41, and supportive treatment in 26. Neoadjuvant chemotherapy was given to 40 of 66 patients treated with curative resection. The mortality of gastrectomy was 3%. Survival was significantly improved after curative resection compared with palliative resection, which in turn was improved over non-resectional or nonsurgical therapy. Postoperative morbidity included four intra-abdominal abscesses, all associated with splenectomy. CONCLUSIONS: Curative surgery for gastric cancer is worthwhile, but the advanced stage of the disease in a public hospital should encourage the establishment of a screening program in high risk populations.

Aged↗
PubMed1995

Does duodenal juice reflux into the esophagus of patients with complicated GERD? Evaluation of a fiberoptic sensor for bilirubin.

BACKGROUND: It is controversial whether duodenal juice can damage esophageal mucosa in patients with gastroesophageal reflux disease (GERD). The issue remains unresolved partly because of difficulties in detecting the presence of duodenal juice in the lower esophagus. OBJECTIVES AND METHODS: This study utilized an in vitro portable spectrophotometer with a fiberoptic probe capable of detecting bile as a marker of duodenal juice. Absorbance/concentration curves were established with known bilirubin concentrations at pH 1.4 and pH 7.7. Esophageal pH and bilirubin absorbance were monitored in vivo over a 24-hour period in 20 healthy volunteers to determine the absorbance threshold for clinical use. The study population consisted of 21 patients with GERD. Four had no mucosal injury, 5 erosive esophagitis, and 12 Barrett's esophagus. RESULTS: The correlation between absorbance and bilirubin concentration was 0.98 and 0.99 for acid and alkaline environments, but bilirubin absorbance was 35% less in an acid environment. Using an absorbance threshold of 0.14, patients with GERD taken in toto had elevated esophageal exposure to bilirubin. No difference was observed in bilirubin exposure between reflux patients without mucosal injury and controls. Highest exposure occurred in patients with Barrett's esophagus. An important observation was that esophageal bilirubin exposure frequently occurred during periods when the esophageal pH was in the normal range. CONCLUSIONS: The fiberoptic probe accurately detects esophageal bilirubin as a marker of duodenal juice. Esophageal exposure to bilirubin is uncommon in normal subjects. Patients with erosive esophagitis and Barrett's metaplasia have increased esophageal exposure to duodenal juice compared to normal subjects. Reflux of duodenal juice into the esophagus can occur when the esophageal pH is within its normal range and is undetectable by pH monitoring alone.

Adult↗