Biomedical subjects

T R Eubanks

Publications and source records attributed to T R Eubanks.

12 recordsLinked to original sources

PubMed2002

Symptomatic and physiologic outcomes after operative treatment for extraesophageal reflux.

BACKGROUND: Pharyngeal pH monitoring has recently been used to identify patients with extraesophageal symptoms induced by gastroesophageal reflux. We employed this method of acid detection to evaluate patients with respiratory symptoms prior to and after laparoscopic Nissen fundoplication to further elucidate the relationship between GERD and respiratory symptoms. METHODS: Twenty-one consecutive patients with extraesophageal symptoms thought to be caused by reflux underwent symptomatic and functional evaluation (esophageal manometry and 24-h pH monitoring with a pharyngeal probe) before and after laparoscopic Nissen fundoplication. Episodes of pharyngeal acid exposure were considered abnormal if the pH dropped below 4, occurred simultaneously with esophageal acidification, and occurred outside meal times. RESULTS: All patients had gastroesophageal reflux disease (GERD) and respiratory symptoms; nine of 15 (60%) had evidence of pharyngeal reflux preoperatively. Antireflux procedures resulted in a significant decrease in pharyngeal reflux (7.9 to 1.6 episodes/24h; p <0.05) and esophageal acid exposure (7.5% to 2.1%; p <0.05). In patients with pharyngeal reflux and complete postoperative testing, three (60%) obtained improvement of respiratory symptoms and resolution of pharyngeal reflux. In two patients with recurrent respiratory symptoms after surgery, persistent pharyngeal reflux was detected. CONCLUSION: Operative treatment of GERD is effective in controlling extraesophageal reflux, measured subjectively and objectively. Evidence of pharyngeal reflux on pH testing helps to identify which patients with respiratory symptoms will benefit from an antireflux procedure.

Cough↗

PubMed2002

Total fundoplication is the operation of choice for patients with gastroesophageal reflux and defective peristalsis.

BACKGROUND: Partial fundoplication has traditionally been indicated for patients with gastroesophageal reflux disease (GERD) who have defective peristalsis (DP). Because partial fundoplication had been reported to be a less effective means of controlling acid reflux than total fundoplication, in 1997 we stopped performing partial fundoplication for patients with DP and switched to a floppy total fundoplication. This study analyzes the results of our new strategy and compares it to our former approach. METHODS: We performed a partial fundoplication in 39 patients with DP (distal amplitude >40% of swallows) between 1994 and 1997 and a total fundoplication in 57 patients between 1997 and 2000. Symptoms scores derived from a standard questionnaire with a scale of 0-4 manometry, and 24-h pH monitoring were completed preoperatively in 86 patients and postoperatively in 40 patients. RESULTS: Heartburn scores improved in both groups (preoperative, 2.8; postoperative, 0.65; p<0.05). Dysphagia was 1.1 preoperatively and 0.62 postoperatively (p=NS) in the partial fundoplication group and 1.2 preoperatively and 0.3 postoperatively (p<0.05) in the total fundoplication group. Furthermore, none of the patients in the total fundoplication group developed new dysphagia and none required dilatation. Distal esophageal acid exposure normalized in both groups after operative treatment (median DeMeester score:72.3 vs 11.3, p<0.05, For partial fundoplication; 57.1 vs 6.3, p<0.05, For total fundoplication). Distal esophageal amplitudes averaged 27.8 mmHg preoperatively and 35.6 mmHg (p = NS) in the partial fundoplication group, they averaged 28.2 mmHg preoperatively vs 49.0 mmHg postoperatively (p<0.005) in the total fundoplication group. Two patients with a previous partial fundoplication required a conversion to a total fundoplication. No postoperative dilation was required in either group. CONCLUSIONS: Our study shows that both a partial and a total fundoplication are effective in controlling the symptoms of GERD in patients with defective peristalsis. Dysphagia improves significantly after total fundoplication but not after partial fundoplication. Although both operations brought acid reflux to within normal limits, the effect was more pronounced with total fundoplication. Total, but not partial, fundoplication produced a significant increase in amplitude of esophageal peristalsis, which may explain the subjective improvement during deglutition. Therefore, fundoplication should be the treatment of choice in patients with GERD and defective peristalsis.

Follow-Up Studies↗

PubMed2001

Management and outcome of complications after laparoscopic antireflux operations.

HYPOTHESIS: Perioperative complications of laparoscopic antireflux operations are infrequent and treatable and do not cause permanent disability. DESIGN: Retrospective review of all patients with laparoscopic antireflux operations for the management and outcome of all complications. SETTING: University medical center. PATIENTS: All 538 patients who underwent operation from January 20, 1993, through December 28, 1999. MAIN OUTCOME MEASURES: Complications were defined as any major or minor deviation from the standard postoperative clinical pathway. Minor complications did not require invasive treatment and were not expected to result in permanent disability. Major complications required invasive treatment or could result in permanent disability. The frequency of complications was also stratified into those that occurred during primary antireflux procedures and those that occurred during reoperations for previously failed procedures. RESULTS: Ninety-two complications occurred in 538 operations (17.1%). Sixty-eight patients (12.6%) experienced minor complications. Postoperative ileus was the most common complication (n = 37 [6.9%]), followed by pneumothorax (n = 13 [2.4%]) and urinary retention (n = 10 [1.9%]). Major complications were present in only 24 patients (4.5%) and occurred significantly more frequently after reoperations. Of these, dysphagia was the most frequent complication observed (n = 11 [2.0%]), followed by perforated viscus (n = 4 [0.7%]). Two patients (0.4%) died. All but 4 major complications resulted in full recovery. CONCLUSIONS: Major complications in laparoscopic antireflux surgery are rare, their treatment is straightforward, and permanent disability is uncommon. Complications occur twice as often during reoperations, highlighting the difficulty in performing these procedures. Although primary laparoscopic antireflux operations are performed by many general surgeons routinely, reoperations should be performed by a team experienced in laparoscopic esophageal surgery.

Adult↗

PubMed2001

Pharyngeal pH measurements in patients with respiratory symptoms before and during proton pump inhibitor therapy.

BACKGROUND: Pharyngeal pH monitoring is a diagnostic tool used to identify Gastroesophageal reflux disease (GERD) as an etiology of respiratory symptoms. We performed pharyngeal pH monitoring on 14 patients with respiratory symptoms thought to be induced by GERD. METHODS: Symptoms and pH monitoring (esophageal and pharyngeal) were assessed prior to and 3 months after the initiation of double-dose proton pump inhibitor therapy. RESULTS: Symptoms included cough, hoarseness, and throat clearing. Ten patients had at least one episode of pharyngeal reflux (PR+) and 4 patients had no pharyngeal reflux (PR-). Pharyngeal reflux episodes in PR+ patients decreased from 3.5 to 0.9 (P <0.05) per day with 8 of 10 (80%) patients having elimination or reduction of such episodes. Eight of 9 PR+ patients (89%) with suppressed pharyngeal reflux on medical therapy had resolution of respiratory symptoms. Three of 4 PR- patients (75%) had persistent symptoms on medical therapy. CONCLUSIONS: Proton pump inhibitor therapy improves clinical symptoms and decreases pharyngeal reflux episodes in patients with respiratory symptoms related to GERD. Direct measurement of pharyngeal pH is helpful in the identification of patients likely to respond to antireflux therapy.

Anti-Ulcer Agents↗

PubMed2000

Outcomes of laparoscopic antireflux procedures.

BACKGROUND: Laparoscopy has increased the number of patients undergoing operative correction of gastroesophageal reflux disease (GERD). Symptom improvement has been most commonly reported as the means to assess operative outcome. We compared symptomatic outcome to postoperative pH testing at short-term follow-up to determine the accuracy of clinical assessment at predicting whether acid exposure would be normal or abnormal. METHODS: Of 640 patients who had antireflux surgery between 1993 and 1999, 228 (36%) agreed to repeat manometry and 24-hour pH monitoring 8 to 12 weeks postoperatively and are the subject of this study. Symptom resolution was assumed if the frequency was less than once per week. Normal acid exposure consisted of a distal esophageal pH below 4 less than 4% of the time and a DeMeester composite score less than 14.7. Accuracy of symptom scoring was calculated using acid exposure as the standard. RESULTS: The primary symptom was improved in 93% of the 228 patients. Acid exposure was reduced from a preoperative DeMeester score of 71 to 16 (P <0.05). Eighty percent of patients had normalization of acid exposure postoperatively. Heartburn was the only symptom to have a significant correlation with acid exposure in the postoperative period (P <0.05). Heartburn resolved in 181 patients, 168 of whom had normal acid exposure (true negative). Thirty-eight patients without symptoms had abnormal acid exposure (false negative). Nine patients had persistent heartburn with abnormal acid exposure (true positive) whereas 13 patients had persistent heartburn with normal acid exposure (false positive). Thus, the positive predictive value of heartburn was 43%, the negative predictive value was 82%, and the overall accuracy was 78%. CONCLUSIONS: Operative treatment improves both the symptoms of GERD and the degree of acid exposure as measured by pH monitoring. The most accurate symptom for predicting acid exposure in the postoperative period is heartburn. Although the absence of heartburn postopertively is fairly reliable at predicting normal acid exposure on pH testing, the presence of heartburn warrants postoperative pH monitoring, as more than half of these patients will have normal acid exposure.

Follow-Up Studies↗

PubMed1999

Advances in minimally invasive esophageal surgery.

Advances in minimally invasive techniques have substantially expanded the role of surgery in the treatment of esophageal disease. In many cases this expansion has made more effective treatment available to a larger number of patients. Gastroesophageal reflux disease, paraesophageal hernias, and achalasia are now routinely treated laparoscopically, and laparoscopy is beginning to be used for total esophagectomy as well. The introduction of this technology has created new controversies and revitalized existing ones in the surgical treatment of esophageal disease. The indications, techniques, and outcomes of videoendoscopic approaches to the esophagus, as well as the controversies surrounding them, are discussed in this review.

Esophageal Diseases↗

PubMed1999

Repair of paraesophageal hernias.

BACKGROUND: Three years ago we proposed the use of laparoscopy and systematic addition of an antireflux procedure to repair paraesophageal hernias. We now present an analysis of the outcome on patients and the evolution of the technique proposed. METHODS: Symptoms and esophageal function were prospectively collected and followed in 41 consecutive patients treated over a 4-year period. Indications for repair included chronic anemia in 15 patients, and previous incarceration in 8. Twenty-two patients had symptoms of reflux. RESULTS: All operations were started laparoscopically, two were converted. Mean operating time was 210 minutes, and mean hospital stay was 4 days. Mean follow-up was 3 years. The operation was effective; all symptoms had improved significantly at last follow-up. CONCLUSIONS: Laparoscopic repair of paraesophageal hernia with the addition of an antireflux procedure, although difficult, lengthy, and not totally without risk, improves symptoms substantially, resolves anemia, and prevents incarceration in nearly all patients.

Adult↗

PubMed1999

Minimally invasive treatment of esophageal diverticula.

Minimally invasive approaches are ideally suited to treat diverticula of the mid- and lower esophagus. The most commonly reported procedure is a laparoscopic diverticulectomy and myotomy, particularly when the diverticulum is located within 10 cm of the lower esophageal sphincter. Treatment is the same as for the open approach: Symptomatic patients are offered surgical treatment, the diverticulum is excised without compromise of the esophageal lumen, the proximal extent of the myotomy is dictated by preoperative manometry, and postoperative evaluation is performed to exclude recurrence and gastroesophageal reflux. The results of laparoscopic treatment of esophageal diverticula are similar to the results reported in the open procedure. The laparoscopic technique used to treat esophageal diverticula is described.

Diverticulum, Esophageal↗

PubMed1999

An objective scoring system for laparoscopic cholecystectomy.

BACKGROUND: Direct observation with structured criteria for performance is the most reliable and valid method of assessing technical skill during operative procedures. We developed such a system to evaluate technical performance during a laparoscopic cholecystectomy. The reliability and validity of the system were tested by analyzing the correlation among three observers in a multicenter study and comparing performance with years of surgical experience. STUDY DESIGN: Thirty consecutive cases of laparoscopic cholecystectomy were recorded on videotape, 10 from each of 3 institutions. Independent scores were generated by three observers examining each of the videotapes, providing a total of 90 scores. Points were awarded for successful completion of each of 23 different steps required to perform a laparoscopic cholecystectomy. Error points were tabulated based on the frequency and relative severity of each of 21 potential technical mistakes during the operation. The final score was assumed to be a relative measure of technical skill and was derived by subtracting error points from points awarded for completion of each step of the procedure. Pearson correlation coefficients were used to assess agreement among examiners and correlation with year of surgical experience. RESULTS: Agreement in final scores among the three observers was excellent (r = 0.74-0.96) despite the fact that one observer assigned significantly fewer error points. Correlation between year of experience and two-handed technique scoring was good (r = 0.5, p = 0.057), but the correlation between experience and one-handed technique scores was poor (r = 0.02). CONCLUSIONS: The technical skills required to perform laparoscopic cholecystectomy can reliably be measured using this tool. This method can be used to track the learning curve of surgeons in training, evaluate the efficacy of alternative training tools, and provide a means of self-assessment for the trainee.

Cholecystectomy, Laparoscopic↗

PubMed1999

Minimally invasive surgery for achalasia: an 8-year experience with 168 patients.

BACKGROUND: Seven years ago, the authors reported on the feasibility and short-term results of minimally invasive surgical methods to treat esophageal achalasia. In this report, they describe the evolution of the surgical technique and the clinical results in a large group of patients with long follow-up. PATIENTS AND METHODS: Between January 1991 and October 1998, 168 patients (96 men, 72 women; mean age 45 years, median duration of symptoms 48 months), who fulfilled the clinical, radiographic, endoscopic, and manometric criteria for a diagnosis of achalasia, underwent esophagomyotomy by minimally invasive techniques. Forty-eight patients had marked esophageal dilatation (diameter >6.0 cm). Thirty-five patients had a left thoracoscopic myotomy, and 133 patients had a laparoscopic myotomy plus a partial fundoplication. Follow-up to October 1998 was complete in 145 patients (86%). RESULTS: Median hospital stay was 72 hours for the thoracoscopic group and 48 hours for the laparoscopic group. Eight patients required a second operation for recurrent or persistent dysphagia, and two patients required an esophagectomy. There were no deaths. Good or excellent relief of dysphagia was obtained in 90% of patients (85% after thoracoscopic and 93% after laparoscopic myotomy). Gastroesophageal reflux developed in 60% of tested patients after thoracoscopic myotomy and in 17% after laparoscopic myotomy plus fundoplication. Laparoscopic myotomy plus fundoplication corrected reflux present before surgery in five of seven patients. Patients with a dilated esophagus had excellent relief of dysphagia after laparoscopic myotomy; none required an esophagectomy. CONCLUSIONS: Minimally invasive techniques provided effective and long-lasting relief of dysphagia in patients with achalasia. The authors prefer the laparoscopic approach for three reasons: it more effectively relieved dysphagia, it was associated with a shorter hospital stay, and it was associated with less postoperative reflux. Laparoscopic Heller myotomy and partial fundoplication should be considered the primary treatment for esophageal achalasia.

Adolescent↗

PubMed1997

The effects of different corticosteroids on the healing colon anastomosis and cecum in a rat model.

Corticosteroids are known to adversely affect wound healing in experimental skin models; however, their effect on healing colonic anastomoses is still disputed. Different steroids have not been compared to each other in the same study. We studied the effect of equipotent doses of dexamethasone, hydrocortisone, and methylprednisolone on healing colon anastomoses in a rat model. High-dose steroid therapy was started 2 days prior to the operation and continued until the bursting pressures were measured at 5 and 7 days after the surgery. Anastomotic bursting pressure was not decreased for any of the steroid treatments when compared to the control, but the frequency of anastomotic rupture in the dexamethasone group at day 5 was significantly higher than either of the other steroid groups or the control group (P < 0.01). Bursting pressures of the intact cecum were lower in all the steroid-treated groups compared with the control group. We concluded that dexamethasone slows the rate of wound healing, but short-term high-dose steroid therapy does not decrease the strength of the anastomoses as measured by bursting pressure.

Adrenal Cortex Hormones↗

PubMedDate not supplied

Pharyngeal pH monitoring in 222 patients with suspected laryngeal reflux.

To determine the existence of and characterize gastroesophagopharyngeal reflux in patients with symptoms of airway irritation, we monitored pharyngeal pH over a 24-hour period in 222 consecutive patients. Pharyngeal reflux was defined as a drop in pH to less than 4 at the pharyngeal sensor, which occurred simultaneously with acidification of the distal esophagus. Patients were divided into two groups: those with pharyngeal reflux (PR+) and those without (PR-). The Mann-Whitney U test and Student's t test were used to assess intergroup comparisons. Episodes of pharyngeal reflux (range 1 to 36, average 4.4) were identified in 90 PR+ patients (40%). No pharyngeal reflux was identified in the remaining 132 patients (PR-). Episodes of pharyngeal reflux were rapidly cleared (average duration 1.5 minutes), and occurred while in the upright position in 77 (86%) of 90 patients and while in the supine position in 11 (12%) of 90 patients. Twenty-three patients (25%) experienced symptoms in association with an episode of pharyngeal reflux. In the distal esophagus, the percentage of time the pH was below 4 during the upright position and the total percentage of time the pH was below 4 were greater in PR+ patients (6.4% and 5.8%, respectively) when compared to PR- patients (2.6% and 2.6%, respectively). Laryngoscopic findings did not distinguish PR+ from PR- patients. Pharyngeal reflux occurs most commonly in the upright position and can be identified in more than 40% of patients thought to have acid-induced laryngeal symptoms. Even though these episodes are short lived and rapidly cleared, symptoms occur concomitantly in 25% of patients with proven pharyngeal reflux. Patients with laryngeal symptoms and documented pharyngeal reflux have greater amounts of esophageal reflux when compared to patients with laryngeal symptoms and no demonstrable pharyngeal reflux.

Adult↗