The myth of the short esophagus.
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Congenital Abnormalities↗
Biomedical subjects
Z T Awad
Publications and source records attributed to Z T Awad.
Hiatal hernia recurrence: 2004.
BACKGROUND: The incidence of laparoscopic hiatal hernia recurrence is less than ideal. The reasons are more theoretical than objective, as the literature has little data in support of specific mechanisms of recurrence. METHOD: A recent literature review using all Internet-available, English-language articles on laparoscopic hernia repair was completed. RESULTS: A multitude of mechanisms of recurrence are suggested, but only surgeon inexperience, postoperative vomiting, heavy lifting, and retention of the hernia sac are supported by data. CONCLUSION: The incidence of hiatal hernia recurrence has stabilized. The role of an onlay mesh prosthesis for the prevention of hiatal hernia recurrence is under investigation, and long-term results are awaited.
Digestive System Surgical Procedures↗
Esophageal papillomatosis complicated by squamous cell carcinoma in situ.
We present a case of esophageal papillomatosis with underlying squamous cell carcinoma in situ. An esophageal lesion resected from a 74-year-old woman demonstrated histological findings characteristic of squamous cell papilloma (fibrovascular core and numerous finger-like projections covered with hyperplastic squamous epithelium) and severe dysplasia characteristic of squamous cell carcinoma. The relation of squamous papilloma and squamous cell carcinoma is discussed. It is suggested that esophageal squamous cell papilloma is a premalignant lesion.
Aged↗
The laparoscopic reoperation of failed Heller myotomy.
BACKGROUND: Laparoscopic Heller myotomy for achalasia has a 10-20% failure rate and may require reoperation to control persistent, or recurrent symptoms of dysphagia. We report our experience with laparoscopic reoperation for failed Heller myotomy. METHODS: Between 1996 and 2001, 5 patients underwent reoperative laparoscopic Heller myotomy. The mean age was 39 years. The presenting symptoms were persistent dysphagia ( n = 3), recurrent dysphagia ( n = 1), and weight loss ( n = 1). The mean duration between 1st surgery and recurrence of symptoms was 2 months and the mean duration between surgeries was 27.5 months. All operations were completed laparoscopically. RESULTS: There were no intraoperative or postoperative complications. Incomplete gastric myotomy was the cause of all 5 primary surgical failures. The mean hospital stay was 2 days. Mean follow-up was 12.8 months. Results were excellent in 2 patients who reported no dysphagia postoperatively (dysphagia grade 0) and good in 3 patients (60%) who all reported improvement in swallowing (dysphagia grade I-II). CONCLUSION: Laparoscopic reoperation for failed Heller myotomy is feasible with encouraging preliminary results.
Adult↗
Cystosarcoma phyllodes of the breast: a clinicopathological study of 11 cases.
Eleven cases of phyllodes tumour were managed at a single institute over 12 years period. All patients were females, the mean age was 48 years, painless breast lump was the commonest presentation, the left breast was affected in (55%), the upper outer quadrant was the most commonly involved site (60%). Four cases were malignant and the remaining 7 were benign. The diagnostic accuracy rate of fine needle aspiration cytology and intraoperative frozen section was 17% and 37.5% respectively. Adequate treatment was wide local excision in benign cases and simple mastectomy in malignant tumour. At a mean follow-up of 37 months the local recurrence and distant metastasis rate was 27% and 9% respectively.
Biopsy, Needle↗
The effect of diaphragmatic stressors on recurrent hiatal hernia.
Hiatal disruption is one of the common mechanisms of failure after Nissen fundoplication. We investigated the correlation between various diaphragm stressors and disruption of the diaphragmatic closure. Thirty-seven patients with a hiatal hernia recurrence of 2 cm or greater, as proven by esophagram, endoscopy, or operative findings, were included. A retrospective analysis was conducted utilizing a standardized diaphragm stressor questionnaire for the study group and a control group of 50 patients without hiatal hernia recurrence. Logistic regression was used to determine the significant predictors of hiatal hernia recurrence. Three predictors emerged in the final model: weight lifting (P < 0.0174), vomiting (P < 0.0313) and hiccoughing (P < 0.2472). Of these, only vomiting and weight lifting were significant. The odds ratio for weight lifting is OR = 3.662 (95% CI: 1.256-10.676), and for vomiting it is OR = 4.938 (95% CI: 1.154-21.126). Vomiting or heavy weight lifting is a significant predictor of hiatal hernia recurrence.
Abdominal Cavity↗
An unusual case of gastric volvulus after laparoscopic paraesophageal hernia repair.
Laparoscopic surgery for paraesophageal hernia is well accepted. However, the complications of this relatively new procedure have not been thoroughly investigated. Only four cases of recurrent volvulus after paraesophageal hernia repair have been reported. A 52-year-old man presented with a large right-side paraesophageal hernia. He experienced a retroperitoneal midgastric volvulus despite correct orientation of the stomach distally and proximally. We report an unusual complication that seems congenital in origin. Diagnostic and corrective measures are suggested.
Hernia, Hiatal↗
The short esophagus: pathogenesis, diagnosis, and current surgical options.
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Esophageal Stenosis↗
Esophageal shortening during the era of laparoscopic surgery.
An effective method for determining the presence of a short esophagus preoperatively would be helpful to surgeons. In this study 260 patients underwent primary laparoscopic antireflux surgery; 44 of them were suspected to have esophageal shortening on the basis of: (1) Barrett's esophagus or evidence of peptic stricture formation on endoscopy; (2) an irreducible hiatal hernia > or = 5 cm in length on upright barium esophagram; or (3) a short esophagus on manometric analysis, defined as 2 SD below normal for height. Six patients without preoperative criteria required extensive esophageal mobilization and intraoperative endoscopic/laparoscopic assessment. Preoperative results were then compared with intraoperative esophageal length assessments. Altogether, 13 patients (5% of the whole series) underwent a lengthening procedure: left thoracoscopically assisted laparoscopic Collis gastroplasty (n = 11) or open transthoracic Collis gastroplasty (n = 2) plus antireflux repair (Nissen fundoplication in 9 and Toupet repair in 4). Among the preoperative tests, endoscopy had the highest sensitivity rate (61%); a combination of tests resulted in an increase in the specificity (63-100%) without a corresponding increase in sensitivity (28-42%). Preoperative testing is thus useful for predicting the need for an esophageal lengthening procedure. Endoscopy is the best screening test for the short esophagus. A well planned prospective trial to test the reliability of each test is needed.
Adult↗
Cecal herniation through the foramen of Winslow after laparoscopic Nissen fundoplication.
Laparoscopic Nissen fundoplication is the treatment of choice for medically refractive gastroesophageal reflux disease. Cecal herniation is an exceedingly rare complication of this procedure. We report the case of a 51-year-old woman who presented 2 months after a successful laparoscopic Nissen fundoplication with heartburn and epigastric pain that radiated to her back. Abdominal films showed an air-filled loop in the left upper quadrant. At surgery, the patient had a redundant loop of cecum, which had herniated through the foramen of Winslow over the stomach and was positioned beneath the left hemidiaphragm. The cecum was not ischemic. A right hemicolectomy was performed to prevent recurrence. The patient recovered fully and has had no further problems. This is the first report of such a case.
Cecal Diseases↗
Laparoscopic reoperative antireflux surgery.
BACKGROUND: Antireflux operations for gastroesophageal reflux disease whether performed open or laparoscopically can fail and may require reoperation to control new, recurrent symptoms or operation-related complications. We report our experience with the laparoscopic reoperation for failed antireflux procedures. METHODS: Between 1995 and 2000, 37 patients underwent laparoscopic reoperative antireflux procedures. The mean age and weight were 52 years and 181.5 pounds. The main presenting symptoms were heartburn (n = 18), respiratory reflux (n = 4), chest pain (n = 3), regurgitation (n = 1), and dysphagia (n = 10). The mean duration between the first operation and recurrence of symptoms was 18 months, and the duration between the two procedures was 25 months. The operation was completed laparoscopically in 32 patients (86.5%): Nissen fundoplication (n = 27) and Toupet fundoplication (n = 9). RESULTS: Intraoperative and postoperative complications occurred in 6 and 14 patients, respectively. Fundoplication disruption was the most common cause of primary surgery failure. The mean hospital stay was 4 days. At a mean follow-up of 26.5 months, results were excellent to good (65%), fair (21.5%), and poor (13.5%). CONCLUSION: Laparoscopic reoperative antireflux procedures are technically feasible with acceptable preliminary results.
Adult↗
Type IV hiatal hernia post laparoscopic Nissen fundoplication: report of a case.
A postoperative hiatal hernia is a rare but serious complication of fundoplication. We report herein a 62-year-old female who presented with abdominal pain and vomiting 2 years following laparoscopic Nissen fundoplication. At laparotomy, the stomach and the transverse colon were intrathoracic (type IV hiatal hernia); the esophageal hiatus was markedly dilated with no evidence that they had been approximated. At 18 months follow-up, she is doing very well apart from occasional heartburn. A high index of suspicion is needed to diagnose postoperative hiatal hernias. A routine closure of the crura with nonabsorbable suture material and an avoidance of iatrogenic pneumothorax may help to reduce the occurrence of this problem.
Abdominal Pain↗
Bilateral choroidal metastases as the initial presentation of breast carcinoma.
A 64 year old female presented with a right eye visual impairment. On examination, the visual acuity was decreased on the right side. Slit lamp examination showed bilateral non-pigmented choroidal lesions. Physical examination was unremarkable; bilateral mammogram, however, showed a mass in the left breast, the biopsy from which confirmed the lesion as infiltrative carcinoma. Other tests were normal apart from the isotope bone scan which showed evidence of metastatic disease. She received a short course of radiotherapy to both eyes as well as a 6-month course of chemotherapy. At 6 months follow-up, the choroidal lesions were no longer present and the visual acuity had stabilized. Choroidal metastasis as the initial presentation of breast carcinoma is unusual. Any patient with an ocular tumour should undergo a systemic check-up to rule out an underlying malignancy.
Breast Neoplasms↗
Left side thoracoscopically assisted gastroplasty: a new technique for managing the shortened esophagus.
Laparoscopic antireflux surgery is the procedure of choice for gastroesophageal reflux disease (GERD). However, many clinicians have reservations about its application in patients with complicated GERD, notably those with esophageal shortening. In this report, we present our experience with the laparoscopic management of the shortened esophagus. A total of 235 patients with primary GERD underwent laparoscopic antireflux procedures, 38 of whom were suspected preoperatively to have a shortened esophagus. Of the 235 patients, 8 (3.4%) needed a left thoracoscopically assisted gastroplasty in addition to laparoscopic Toupet repair (n = 4) or Nissen fundoplication (n = 4). Complications included pleural effusion (n = 1), pneumothorax (n = 2), and minor atelectasis (n = 1). The average hospital stay was 3 days. Results were satisfactory in 7 of 8 patients, with a mean follow-up of 20.2 months (range, 9-34 months). The surgical management of the shortened esophagus is difficult. However, the role of minimally invasive techniques is justified. Early results are appealing, with less morbidity, satisfactory control of GERD related symptoms, and a shortened hospital stay.
Esophagus↗
The preoperative predictability of the short esophagus in patients with stricture or paraesophageal hernia.
BACKGROUND: Esophageal shortening is a known complication of advanced gastroesophageal reflux disease that may preclude a tension-free antireflux procedure. A retrospective analysis was performed to test the accuracy of preoperative testing. METHODS: From September 1993 to December 1998, 39 patients underwent esophageal mobilization with intraoperative length assessment. Patients were selected on the basis of irreducible hiatal hernia, stricture formation, or both. Patients in the upright position with a fixed hiatal hernia larger than 5 cm on an esophagram were considered to have a short esophagus. Manometric length two standard deviations below the mean for height was considered abnormally short. RESULTS: In 31 patients, intraoperative mobilization was sufficient to allow the gastroesophageal junction to lie 2 cm below the diaphragmatic crus, so no esophageal-lengthening procedure was required. Eight patients with a short esophagus required an esophageal-lengthening procedure after complete mobilization. Two patients subsequently underwent intrathoracic migration of the gastroesophageal junction (GEJ), with recurrence of symptoms and required gastroplasty during the second surgery. An esophagram had a sensitivity of 66% and a positive predictive value of 37%, whereas manometric length had a sensitivity of 43% and a positive predictive value of 25% for the diagnosis of short esophagus. The preoperative endoscopic finding of either a stricture or Barrett's esophagus was the most sensitive test for predicting the need for a lengthening procedure. CONCLUSIONS: Manometry and esophagraphy are not reliable predictors of the short esophagus. Additional tests and/or tests combined with other parameters are needed.
Esophageal Stenosis↗
Persistent dysphagia after laparoscopic vagotomy.
BACKGROUND: Laparoscopic vagotomy represents a new and less invasive treatment for peptic ulcer disease, but the problem of postvagotomy dysphagia has not been solved. The aim of this study was to determine the etiologic factors related to long-term laparoscopic postvagotomy dysphagia. METHODS: Two female and 11 male patients with a mean age of 48.5 years who underwent laparoscopic vagotomy were investigated retrospectively. Preoperative diagnosis included duodenal ulcer resistant to medical treatment, gastric hypersecretion, gastric outlet obstruction, cholelithiasis, and gastroesophageal reflux disease (GERD). Ten patients underwent laparoscopic highly selective vagotomy, and three patients had laparoscopic truncal vagotomy with gastrojejunostomy or pyloroplasty. Nine of these patients had a Nissen fundoplication in conjunction with the vagotomy. RESULTS: The median long-term follow-up period was 47 months. Two patients complained of severe dysphagia, one of moderate dysphagia, and two of mild dysphagia. Neither type of vagotomy nor an additional fundoplication was correlated with the severity of postoperative long-term dysphagia. Severity of postoperative dysphagia was associated with severity of preoperative dysphagia (r = 0.752, p = 0.003) but not with heartburn (r = 0.358, p = 0.531) or regurgitation (r = 0.024, p = 0.938). The cause of preoperative dysphagia varied; however, all of these patients had GERD and consequent esophageal lesions. CONCLUSION: Preexisting dysphagia appears to play an integral role in persistent postoperative dysphagia. Care must be taken to construct a loose fundoplication in patients with dysphagia.
Cholelithiasis↗
Does the duration of gastroesophageal reflux disease and degree of acid reflux correlate with esophageal function? A retrospective analysis of 768 patients.
To reconfirm that the duration of symptoms is not associated with esophageal motility in patients with gastroesophageal reflux disease (GERD), esophageal manometric data from 768 patients with GERD were retrospectively analyzed with relation to the duration of symptoms. GERD was defined by positive acid reflux test results monitored by ambulatory 24-hour pH monitoring. Correlation of the duration of symptoms with esophageal body pressures, the presence of dysmotility determined by simultaneous waves, average resting pressure of the lower esophageal sphincter (LES), and abdominal and overall lengths of the LES were statistically analyzed. The median duration of the symptoms was 60 months (range, 1-600). Duration of symptoms was not associated with contraction pressures of the esophageal body at 3 and 8 cm above the LES (r = -0.070 and -0.063, respectively). There was no correlation between LES pressures, LES lengths, or the percentage of simultaneous waves and duration of symptoms. Stricture formation is related to decreased distal esophageal function in GERD patients. In conclusion, the duration of GERD has little influence on esophageal body and LES function.
Adolescent↗
Spontaneous rectus sheath hematoma and an anterior pelvic hematoma as a complication of anticoagulation.
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Aged↗