Raymond J. Joehl

Increased frequency of transient lower esophageal sphincter relaxation induced by gastric distention in reflux patients with hiatal hernia

BACKGROUND & AIMS This study aimed to determine if hiatal hernia influences vulnerability to reflux and transient lower esophageal sphincter relaxation (tLESR) during gastric distention in patients with gastroesophageal reflux disease (GERD). METHODS Eight normal subjects and 15 patients with GERD were studied. A metal clip attached to the squamocolumnar junction (SCJ) was beneath the hiatus in all control subjects. Eight GERD patients with >/=1-cm SCJ-hiatus separation were considered hernia patients, and 7 with <1-cm separation were considered nonhernia patients. Manometry and esophageal pH were recorded for 30 minutes, after which the stomach was loaded with acid dextrose and the recording continued for 2 hours with intragastric air infusion of 15 mL/min. RESULTS Baseline reflux was comparable among groups. Gastric distention increased the frequency of reflux by the tLESR mechanism in all groups. Controls and nonhernia patients had median increases of 4.0 and 4.5 in tLESR frequency, respectively, and hernia patients had a median increase of 9.5/h. tLESR frequency was highly correlated with the SCJ-hiatus separation (r = 0.76; P < 0.001). CONCLUSIONS Gastric air infusion was a potent stimulus for tLESR and reflux. The resultant tLESR frequency was directly proportional to the separation between the SCJ and hiatus, suggesting that the perturbed anatomy associated with hiatal hernia predisposed to eliciting tLESRs in patients with GERD.

Gangrenous cholecystitis: Analysis of risk factors and experience with laparoscopic cholecystectomy

BACKGROUND Gangrenous cholecystitis occurs in up to 30% of patients admitted with acute cholecystitis. Factors predicting gangrenous disease in patients with acute cholecystitis remain poorly defined, making preoperative diagnosis difficult. Identification of these factors and early diagnosis of gangrenous cholecystitis will indicate more aggressive treatment, earlier operation, and a lower threshold for conversion of laparoscopic to open cholecystectomy. METHODS We reviewed our experience with acute cholecystitis during the 2-year period of 1995 to 1996. Admitting history, physical examination, operative report, laboratory and radiology data, and pathology report were analyzed for each patient. Acute cholecystitis and its gangrenous complication were diagnosed by both gross and microscopic examination. RESULTS One hundred fifty-four patients were admitted to the hospital with acute cholecystitis and underwent cholecystectomy; gallbladder gangrene was found in 27 (18%) of these patients. Four patients with gallbladder gangrene underwent open cholecystectomy and 23 patients underwent laparoscopic cholecystectomy, of which 15 (65%) were completed laparoscopically and 8 (35%) had open conversion as a result of severe inflammation. Risk factors for gallbladder gangrene included male gender, age older than 50 years, history of cardiovascular disease, and leukocytosis greater than 17,000 white blood cells/mL. CONCLUSIONS Older male patients (age older than 50 years) with history of cardiovascular disease, leukocytosis greater than 17,000 white blood cells/mL, and acute cholecystitis have increased risk of gallbladder gangrene and conversion of laparoscopic cholecystectomy to open cholecystectomy. Urgent laparoscopic cholecystectomy with low threshold for conversion to open cholecystectomy should be considered in these patients at high risk for gallbladder gangrene.

Laparoscopic live donor nephrectomy: Is it safe? Analysis of 80 consecutive cases and comparison with open nephrectomy

Background. Laparoscopic live donor nephrectomy (LDN) is a less invasive alternative to open nephrectomy (ODN) for living kidney donation. Concerns have been raised regarding the safety of LDN, the short and long term function of kidneys removed by LDN, and a potential higher incidence of urologic complications in LDN transplant recipients. Methods. Between October 1997 and May 1999, 80 LDNs were performed at our center. All patients were followed longitudinally with office visits and telephone interviews. These LDNs were compared with 50 ODN performed from January 1996 to October 1997. Results. LDN procedures took significantly longer than ODN (4.6 vs. 3.1 hr). However, LDN was associated with significant reduction in i.v. narcotic use, a rapid return to diet, and shorter hospital stay. Of the 80 LDN procedures, a total of 75 (94%) were completed laparoscopically. Five patients were converted to laparotomy: three for hemorrhage and two for complex vascular anatomy. ODN conversion was associated with large donor body habitus and/or obesity. Seven LDN patients had minor complications and 4 had major complications. All major complications consisted of vascular injuries (2 lumbar vein injuries, 1 renal artery, and 1 aortic injury). All patients made complete recoveries. All LDN kidneys functioned immediately posttransplant. We have observed 100% patient and 97% 1-year actuarial graft survival in LDN transplant recipients. There have been no short-or long-term urologic complications in this series. Conclusion. With increasing experience and standardization of technique, LDN is a safe and effective procedure. Patients undergoing LDN demonstrate clinically significant, more rapid postoperative recoveries and shorter hospital stays than ODN patients. Excellent initial graft function and long-term graft survival have been observed with LDN kidneys. Urologic complications can be avoided. LDN has become the preferred surgical approach for living kidney donation at our center.

Opioid drugs cause bile duct obstruction during hepatobiliary scans

Hepatobiliary scans using Tc-IDA are reliable in making the diagnosis of acute cholecystitis. Commonly, opioid drugs are administered in patients with acute cholecystitis to relieve pain. Opioid drugs cause biliary sphincter spasm. Whether these drugs adversely affect hepatobiliary scans is unknown. We studied 13 healthy volunteer subjects, performing three hepatobiliary scans in each one. Scans were performed without opioid drugs and 30 minutes after intramuscularly administered meperidine, morphine, hydroxyzine, hydroxyzine plus meperidine, butorphanol, and nalbuphine. Opioid drugs markedly delayed clearance of Tc-IDA from the common bile duct, simulating common bile duct obstruction. Hydroxyzine alone caused an insignificant delay. We have concluded that opioid drugs cause bile duct obstruction in healthy persons. If opioid drugs are administered before a diagnostic hepatobiliary scan, delayed clearance of Tc-IDA from the common bile duct might lead to an erroneous diagnosis and indicate a potentially unnecessary common bile duct exploration. Opioid drugs should not be administered for several hours before a diagnostic hepatobiliary scan.

Exporting a technical skills evaluation technology to other sites

BACKGROUND The Objective Structured Assessment of Technical Skill (OSATS) is a multistation performance-based examination that assesses the technical skills of surgery residents. This study explores the implementation issues involved in remote administration of the OSATS focusing on feasibility and the psychometric properties of the examination. METHODS An eight-station OSATS was administered to surgical residents in Los Angeles and Chicago. The University of Toronto and the local institutions shared responsibility for organization and administration of the examination. RESULTS There was good reliability for both the checklist (alpha = 0.68 for LA, 0.73 for Chicago) and global rating forms (alpha = 0.82 for both sites). Both iterations also showed evidence of construct validity, with a significant effect of training year for the checklist and global rating forms at both sites (analysis of variance: F = 8.66 to 19.93, P <0.01). Despite some challenges, the model of central organization and peripheral delivery was effective for the administration of the examinations. CONCLUSIONS Two iterations of the OSATS at remote sites demonstrated psychometric properties that are highly consistent with previously reported data suggesting that the examination is portable. Both faculty and residents indicated satisfaction with the examination experience. A model of central administration with peripheral delivery was feasible and effective.

Restoration of normal distensive characteristics of the esophagogastric junction after fundoplication.

Objective:To study the mechanical characteristics of the esophagogastric junction (EGJ) of postfundoplication patients and compare them with previously reported data on normal subjects and GERD patients. Methods:Eight normal subjects, 9 GERD patients, and 8 fundoplication patients were studied with concurrent manometry, fluoroscopy, and stepwise controlled barostat distention of the EGJ. The minimal barostat pressure required to open the EGJ during the interswallow period was determined. Thereafter, barium swallows were imaged in 5-mm Hg increments of intrabag pressure. EGJ diameter and length were measured at each pressure during deglutitive relaxation. Results:EGJ opening diameter during deglutitive relaxation was on average 0.5 cm greater in GERD patients compared with normal subjects and fundoplication patients (P < 0.05). EGJ opening pressure and opening diameter were comparable between normal subjects and fundoplication patients; however, the EGJ length was 32% longer in fundoplication patients. Conclusions:Fundoplication restores distensibility of the EGJ to a level similar to normal subjects. Since trans-EGJ flow is related to EGJ length and EGJ diameter, these findings suggest that retrograde flow through the EGJ would be decreased by both a reduction in diameter and an increase in length of the EGJ.

Impact of fundoplication on bolus transit across esophagogastric junction

This study analyzed the effect of fundoplication on the mechanics of liquid and solid bolus transit across the esophagogastric junction (EGJ). The squamocolumnar junction was endoscopically clipped in seven controls, seven hiatal hernia patients, and seven patients after laparoscopic Nissen fundoplication. Concurrent manometry and fluoroscopy were done during swallows of liquid barium and a 13-mm-diameter marshmallow. The EGJ opening, pressure gradients, transit efficacy, and axial motion were measured. The axial motion of the EGJ was reduced in the fundoplication and hiatal hernia patients. The opening dimensions at the squamocolumnar junction were similar among groups, but in each case the constriction limiting flow to the stomach was at the hiatus and this was substantially narrowed with fundoplication. As a result, liquid intrabolus pressure was increased and marshmallow transit frequently required multiple swallows. We conclude that fundoplication limits the axial mobility of the EGJ and leads to a restricted hiatal opening. These alterations decrease the efficacy of solid and liquid transit into the stomach and are potential causes of dysphagia in this population.This study analyzed the effect of fundoplication on the mechanics of liquid and solid bolus transit across the esophagogastric junction (EGJ). The squamocolumnar junction was endoscopically clipped in seven controls, seven hiatal hernia patients, and seven patients after laparoscopic Nissen fundoplication. Concurrent manometry and fluoroscopy were done during swallows of liquid barium and a 13-mm-diameter marshmallow. The EGJ opening, pressure gradients, transit efficacy, and axial motion were measured. The axial motion of the EGJ was reduced in the fundoplication and hiatal hernia patients. The opening dimensions at the squamocolumnar junction were similar among groups, but in each case the constriction limiting flow to the stomach was at the hiatus and this was substantially narrowed with fundoplication. As a result, liquid intrabolus pressure was increased and marshmallow transit frequently required multiple swallows. We conclude that fundoplication limits the axial mobility of the EGJ and leads to a restricted hiatal opening. These alterations decrease the efficacy of solid and liquid transit into the stomach and are potential causes of dysphagia in this population.

One-stage resection and anastomosis in the management of colovesical fistula☆

Thirty-four patients with colovesical fistulas seen over a recent 10 year period were reviewed. Diverticulitis was the most common cause of colovesical fistula, accounting for 71 percent of patients in our series. The majority of patients present electively, and most have urinary tract complaints. In those patients in our study who presented with systemic infection, urinary obstruction was present in 70 percent. Although proctosigmoidoscopy and barium enema examination are essential in the preoperative assessment, cystoscopy is the most useful test in suggesting or confirming the diagnosis of colovesical fistula. Intravenous urography is not necessary in the evaluation of these patients. The surgical treatment depends on the cause of the fistula. For patients with an inflammatory cause of the fistula, one-stage operative treatment is associated with low morbidity and decreased length of stay compared with operative treatment in more than one stage. In the presence of severe inflammation or inadequate bowel preparation, two-stage operative treatment is safe and effective. Operations in three stages for colovesical fistula are not indicated. The primary objectives in the management of colovesical fistulas due to unresectable malignancy are relief of intestinal and urinary obstruction and fecal diversion. Resection of the malignancy should be performed whenever possible.

Symptomatic malignant melanoma of the gastrointestinal tract. Operative treatment and survival.

Malignant melanoma involving the gastrointestinal tract is a common autopsy finding in patients who die with this disease. Melanoma metastatic to bowel infrequently causes symptoms. Some investigators suggest that survival following the onset of gastrointestinal symptoms is very poor and, as a result, surgical intervention to relieve symptoms should be avoided. We reviewed the clinical courses of 15 consecutive patients with symptomatic malignant melanoma of the bowel who underwent resection alone or in combination with bypass of symptomatic intestinal lesions. There were no deaths within 30 days of operation; 14 patients obtained relief of intestinal symptoms; 11 patients survived a mean of 7.9 months; and four patients are alive 2, 7, 22, and 23 months after operation. These results suggest that operations to treat symptomatic intestinal melanoma provide reasonable palliation and survival for patients with this disease.

Distinct patterns of oesophageal shortening during primary peristalsis, secondary peristalsis and transient lower oesophageal sphincter relaxation

Abstract  This study characterized oesophageal shortening during secondary peristalsis and transient lower oesophageal sphincter relaxation (TLOSR) in an attempt to determine its contribution to the opening mechanism. Eight healthy subjects (four males, 26 ± 1 years) had metal clips affixed at 0, +3, and +8 cm relative to the squamocolumnar junction (SCJ), defining two distal oesophageal segments. Axial clip movement was assessed with concurrent videofluoroscopy and manometry during primary peristalsis, secondary peristalsis and TLOSR. Clip‐defined oesophageal segment length change was measured at 0.5‐s intervals. The magnitude of the most distal segment shortening was least with TLOSR, greatest with primary peristalsis and intermediate with secondary peristalsis. Conversely, maximal overall oesophageal shortening during TLOSR, evidenced by SCJ movement, was similar to that during primary peristalsis. In 3/12 TLOSRs, the moment of LOS opening and gas reflux was optimally imaged; SCJ excursion was 0.3 ± 0.1 cm prior to LOS opening and 1.4 ± 0.7 cm immediately after gas reflux. The segmental pattern of oesophageal shortening was distinct during primary peristalsis, secondary peristalsis and TLOSR. During TLOSR, significant elevation of the SCJ occurred only after LOS opening, suggesting that this was a consequence of oesophageal distension induced by gas reflux rather than a component of the opening mechanism.