William L. Campbell

Laparoscopic repair of giant paraesophageal hernia: 100 Consecutive cases

ObjectiveTo summarize the authors’ laparoscopic experience for paraesophageal hernia (PEH). Summary Background DataLaparoscopic antireflux surgery and repair of small hiatal hernias are now routinely performed. Repair of a giant PEH is more complex and requires conventional surgery in most centers. Giant PEH accounts for approximately 5% of all hiatal hernias. Medical management may be associated with a 50% progression of symptoms and a significant death rate. Conventional open surgery has a low death rate, but complications are significant and return to routine activities is delayed in this frequently elderly population. Recently, short-term outcome studies have reported that minimally invasive approaches to PEH may be associated with a lower complication rate, a shorter hospital stay, and faster recovery. MethodsFrom July 1995 to February 2000, 100 patients (median age 68) underwent laparoscopic repair of a giant PEH. Follow-up included heartburn scores and quality of life measurements using the SF-12 physical component and mental component summary scores. ResultsThere were 8 type II hernias, 85 type III, and 7 type IV. Sac removal, crural repair, and antireflux procedures were performed (72 Nissen, 27 Collis-Nissen). The 30-day death rate was zero; there was one surgery-related death at 5 months from a perioperative stroke. Intraoperative complications included pneumothorax, esophageal perforation, and gastric perforation. There were three conversions to open surgery. Major postoperative complications included stroke, myocardial infarction, pulmonary emboli, adult respiratory distress syndrome, and repeat operations (two for abscess and one each for hematoma, repair leak, and recurrent hernia). Median length of stay was 2 days. Median follow-up at 12 months revealed resumption of proton pump inhibitors in 10 patients and one repeat operation for recurrence. The mean heartburn score was 2.3 (0, best; 45, worst); the satisfaction score was 91%; physical and mental component summary scores were 49 and 54, respectively (normal, 50). ConclusionThis report represents the largest series to date of laparoscopic repair of giant PEH. In the authors’ center with extensive experience in minimally invasive surgery, laparoscopic repair of giant PEH was successfully performed in 97% of patients, with a minimal complication rate, a 2-day length of stay, and good intermediate results.

The clinical significance of cervical esophageal and hypopharyngeal webs.

One thousand consecutive cinefluorographic examinations of the hypopharynx and cervical esophagus were reviewed to determine the incidence of webs in a population routinely referred for upper gastrointestinal examination. The age, sex, and incidence of iron deficiency anemia in patients with webs were compared with those of the controls, and dysphagia and associated diseases were noted. 5.5% of the patients had one or more webs; these patients had a similar sex distribution to the control group but were generally older. Both groups had the same incidence of iron deficiency anemia. None of the patients with webs met the criteria for Plummer-Vinson syndrome. The authors believe that most cervical esophageal and hypopharyngeal webs are of no clinical significance.

Systemic sclerosis (scleroderma) and esophageal adenocarcinoma: Is increased patient screening necessary?

An increased risk of esophageal carcinoma has been reported in systemic sclerosis (scleroderma). Periodic endoscopic or radiologic surveillance, or both, of systemic sclerosis patients with gastroesophageal reflux symptoms has been recommended for early detection of Barretts mucosa and esophageal adenocarcinoma. A review of 680 closely followed systemic sclerosis patients for esophageal carcinoma of all types, and of a 22-yr experience with esophageal and esophagogastric junction adenocarcinoma and undifferentiated carcinoma, did not reveal a significant increase in the frequency of esophageal carcinoma in systemic sclerosis. Regular surveillance for Barretts esophagus and esophageal adenocarcinoma would not appear to be cost-effective because of the rarity of carcinoma, increased patient discomfort and expense, and the questionable benefit for long-term survival.

Comparative studies of esophageal function in systemic sclerosis

Three modalities for assessing esophageal dysfunction in patients with systemic sclerosis were prospectively compared. Seventeen patients underwent (a) esophageal manometry with measurement of distal esophageal peak contraction pressure amplitude, percentage of peristaltic waves, and lower esophageal sphincter pressure; (b) cine-esophagography with scoring based on residual contrast and the character of visualized waves; and (c) esophageal transit scintigraphy with quantification of residual swallowed tracer. Highly significant correlations were found between scintigraphic residual and cine-esophagography score, between scintigraphic residual and manometric amplitude, and indeed between all pairs of measured esophageal function parameters except those involving lower esophageal sphincter pressure. In addition, scintigraphy and cine-esophagography showed comparable ability to discriminate between patients with abnormal and normal esophageal motor function. Symptoms did not significantly correlate with quantitative parameters, nor did they have diagnostic discriminating ability. Induction of Raynauds phenomenon in a subgroup of patients had no detectable effect on esophageal function. It was concluded that these three diagnostic modalities are approximately equivalent in their ability to detect esophageal dysmotility in systemic sclerosis and measure its severity.

Percutaneous Transhepatic Cholangiography and Biliary Drainage After Liver Transplantation: A Five-Year Experience

Evaluation of the biliary tract by percutaneous transhepatic cholangiography (PTC) is often required in liver transplant patients with an abnormal postoperative course. Indications for PTC include failure of liver enzyme levels to return to normal postoperatively, an elevation of serum bilirubin or liver enzyme levels, suspected bile leak, biliary obstructive symptoms, cholangitis, and sepsis.Over a 5-year period 625 liver transplants in 477 patients were performed at the University Health Center of Pittsburgh. Fifty-three patients (56 transplants) underwent 70 PTCs. Complications diagnosed by PTC included biliary strictures, bile leaks, bilomas, liver abscesses, stones, and problems associated with internal biliary stents.Thirty-two percutaneous transhepatic biliary drainage procedures were performed. Ten transplantation patients underwent balloon dilatation of postoperative biliary strictures. Interventional radiologic techniques were important in treating other complications and avoiding additional surgery in many of these patients.

Empiric assessment of parameters that affect the design of multireader receiver operating characteristic studies

RATIONALE AND OBJECTIVES The authors attempted to assess experimentally the magnitude of reader variability and the correlations and interactions among cases, readers, and modalities during observer performance studies and their possible effects on study design and sample size. MATERIALS AND METHODS Published data from 32 selected receiver operating characteristic (ROC) studies were reviewed to compare the magnitude of the variance component from readers with the variance component from modality. Estimates of correlation and interactions among cases, readers, and modalities were also computed directly from ROC data ascertained during two large studies performed in our laboratory. Each of these two studies included 529 cases and six readers, but one study used eight modalities and the other nine. RESULTS Published results indicate that reader variability is task dependent and larger (P < .05) than modality variability in detection of interstitial disease. Measured correlations between modalities for the same reader were task dependent and ranged from 0.35 to 0.59. Modality-by-reader and modality-by-case interactions often are not important factors. The random error term was greater than the modality-by-reader interaction in 11 of 20 comparisons and greater than the modality-by-case interaction in eight of 20 comparisons. CONCLUSION Use of the same cases interpreted with different modes is justifiable in many situations because of the high variability from readers. This comprehensive review of existing ROC studies resulted in parameter assessments that can be used to better estimate sample-size requirements in multireader ROC studies.

Amelioration of intestinal dysmotility and stasis by octreotide early after small-bowel autotransplantation in dogs.

BACKGROUND Intestinal dysmotility and stasis after intestinal transplantation are considered to promote bacterial overgrowth and translocation. Two prokinetic agents, KW5139 (13-leu-motilin) and the somatostatin analogue octreotide acetate, were studied to determine whether they can ameliorate intestinal dysmotility during the early postoperative period. MATERIALS AND METHODS Motility was recorded by multiple extraluminal strain-gauge transducers in 6 dogs on postoperative days 1, 3, 7, and 14. A barium meal study was performed with a separate group of 8 dogs on postoperative days 3 and 7. RESULTS The agent KW5139 induced brief, weak contractions in the graft and had little effect on the dilated bowel; however, octreotide induced motor activity that propelled accumulated intestinal contents into the colon and reduced dilation of the transplanted bowel. CONCLUSION Octreotide, but not KW5139, ameliorates intestinal dysmotility associated with bowel autotransplantation during the early postoperative period. Short-term administration of octreotide may be useful for the treatment of dysmotility following intestinal transplantation.

The Autonomous Thyroid Nodule: Correlation of Scan Appearance and Histopathology1

Abstract Histopathology and scan findings were correlated in patients with autonomous and nonfunctioning thyroid nodules. Autonomous nodules showed significantly more cellular hyperplasia and atrophy of extranodular tissue than nonfunctioning nodules did. Histologically, most autonomous nodules were “nontoxic” nodular goiter. The histopathology of the nodules did not correlate with antithyroid drugs, metabolic state, nodule size, or duration of symptoms. Only autonomous nodules measuring ≥ 3 cm in diameter caused hyperthyroidism. It was concluded that the histology of thyroid nodules correlates with their functional status as determined by scanning. Autonomous nodules may be differentiated histologically from nonfunctioning nodules in most cases.

Bile leakage as a complication of liver biopsy in liver transplants

Four liver transplant recipients with intrahepatic bile duct leakage following liver biopsy are described. Two patients were clinically suspected of having a bile leak, one of whom had bile peritonitis. All four patients had elevated liver enzyme levels. In three patients, cholangiography showed contrast media leakage into the peritoneum through the needle biopsy tract; one leak was totally intraparenchymal. All patients had varying degrees of biliary obstruction. The differential diagnosis of bile leakage posttransplantation should include recent liver biopsy.

Specificity and Sensitivity of Esophageal Motor Abnormality in Systemic Sclerosis (Scleroderma) and Related Diseases: A Cineradiographic Study

Using cineradiography, we studied esophageal peristalsis in patients with suspected systemic sclerosis and related diseases, and in patients without known esophageal disease who had been referred for upper gastrointestinal series. Patterns of peristaltic abnormality were identified, and specificity and sensitivity values calculated. Esophageal aperistalsis was 100% specific, and consistently weak peristalsis after all, swallows was 88% specific for systemic sclerosis. Specificity decreased to 70% in patients over age 60. Abnormal peristalsis after some, but not all, swallows had only 52% specificity. Consistently abnormal peristalsis (absent or diminished) was 67% sensitive for scleroderma. Although a high sensitivity value (87%) for cineradiography can be obtained by considering any peristaltic abnormality as a sign of scleroderma, this is achieved at the price of an undesirably high number of false positives (specificity 40%).