During the past decade, the number of laparoscopic procedures performed in the United States, pri... more During the past decade, the number of laparoscopic procedures performed in the United States, primarily with cholecystectomy, has increased phenomenally. We recently had a patient who developed hypercarbia and cardiovascular compromise during laparoscopic cholecystectomy. The cardiovascular compromise was caused by mechanical factors directly related to increasing intra-abdominal pressures affecting ventilation and venous return as well as the absorption of carbon dioxide (CO2) into the circulation, leading to acidosis and further depression of the cardiopulmonary system. Cardiovascular compromise can be avoided with early recognition of increased end-tidal CO2 concentrations and by preventing intra-abdominal pressures from exceeding 16 mm Hg.
The Stretta procedure is a new, totally endoscopic treatment for GERD, where radiofrequency energ... more The Stretta procedure is a new, totally endoscopic treatment for GERD, where radiofrequency energy is delivered to the smooth muscle of the gastroesophageal junction. Forty-one patients undergoing the Stretta procedure between August 2000 and August 2001 were prospectively evaluated. Under an IRB-approved protocol, patients were studied preoperatively and postoperatively with esophageal manometry, 24-h pH testing, SF12 surveys, and GERD-specific questionnaires (QOLRAD). Results are reported as mean +/- SEM. All procedures were performed on an outpatient basis; 33 were under conscious sedation and 8 were under general anesthesia. Prior to treatment, patients had a mean LES pressure of 25 +/- 2.4 mmHg, Johnson-Demeester score of 32.8 +/- 4.6 mmHg, and % time reflux 8.4 +/- 0.9%. The quality-of-life scores were significantly improved at 6 months: QOLRAD score increased from 3.7 +/- 0.2 to 5.1 +/- 0.2 (p = 0.002), SF12 mental score increased from 44.3 +/- 2.0 to 51.8 +/- 1.7 (p = 0.001), and SF12 physical score increased from 26.2 +/- 2.4 to 33.1 +/- 3.8 (p = 0.001). Eighteen patients returned for esophageal manometry and 24-h pH testing at a mean of 6.8 +/- 0.5 months. There was a significant decrease in esophageal acid exposure time (8.4 +/- 0.9% to 4.4 +/- 1.3%, p = 0.03) and Johnson-Demeester score (32.8 +/- 4.6 to 22.9 +/- 5.3, p = 0.04). There was no significant change in mean LES pressure (25.3 +/- 2.4 mmHg to 26.8 +/- 2.6 mmHg, p = 0.63). Twenty of 31 patients (65%) available for 6 months follow-up were completely off proton pump inhibitors. The only complication related to Stretta was a case of gastroparesis 10 days post-operatively that resolved completely. The Stretta procedure is a promising new endoscopic treatment for GERD. It significantly improves GERD symptoms and quality of life while eliminating the need for proton pump inhibitors in the majority of patients.
While the first laparoscopic ventral hernia repair was reported in 1992, there have been no studi... more While the first laparoscopic ventral hernia repair was reported in 1992, there have been no studies comparing laparoscopic to conventional ventral herniorrhaphy. Twenty-one ventral hernias repaired laparoscopically are compared to a similar group of 16 patients undergoing traditional open repair during a 2-year period. Operative and hospital courses along with outcomes and cost analysis are analyzed. There was no statistical difference between groups in number of previous abdominal operations, prior hernia repairs, and comorbidities. Patients undergoing open repair were older with larger fascial defects. Open repairs had a shorter operative time as compared to the laparoscopic group, but statistically longer postoperative stays and costs. Postoperative complications occurred in 31% of the open group and 23% of the laparoscopic group. There were two recurrences in each group. Laparoscopic herniorrhaphy is as safe and effective as the traditional open technique with shorter length of stay and decreased hospital costs.
Pneumomediastinum can be a sign of esophageal perforation. During laparoscopic esophageal surgery... more Pneumomediastinum can be a sign of esophageal perforation. During laparoscopic esophageal surgery, the mediastinum is exposed to carbon dioxide gas under pressure that can cause pneumomediastinum. Forty-five patients undergoing laparoscopic esophageal procedures had erect, inspiratory, single-view chest radiographs (CXR) performed in the recovery room (RR). Patients with extraabdominal gas underwent daily erect, inspiratory, single-view CXR until resorption of the gas or discharge from the hospital. Insufflation time and pressure were recorded, and morbidity was evaluated. Results are expressed as mean +/- SEM. Twenty-five men (56%)and 20 women (44%) aged 33.0 +/- 2.9 years underwent 10 Heller myotomies (22.2%), 27 Nissen fundoplications (60.0%), six Toupet fundoplications (13.3%), and two paraesophageal hernia repairs (4.4%). Twenty-four patients (53.3%) had normal CXR in RR, and 21 (46.7%) had extraabdominal gas. Eighteen (85.7%) of the 21 had pneumomediastinum, three (14.3%) had pneumothorax, and 12 (57.1%) had subcutaneous emphysema in RR. Sixteen of these 21 remained hospitalized and had repeat CXR on postoperative day 1. Of these 16, five (31.3%) had normal CXR, 11 (68.8%) had pneumomediastinum, and seven (43.8%) had subcutaneous emphysema. There were no esophageal perforations and no chest tube insertions, and there was no morbidity related to pneumomediastinum. Pneumomediastinum is observed frequently following laparoscopic esophageal operations and often persists past 24 h. After these operations, pneumomediastinum is not necessarily indicative of esophageal perforation. In this group, it caused no clinically significant events that altered the course of the patients.
Atrial natriuretic peptides lower arterial pressure, cardiac filling pressure, and cardiac output... more Atrial natriuretic peptides lower arterial pressure, cardiac filling pressure, and cardiac output. In isolated, Langendorff-perfused guinea pig hearts, atriopeptin II, the 23-amino acid atrial natriuretic peptide, is also a potent coronary vasoconstrictor. The median effective dose for atriopeptin II in guinea pig hearts is 26 nanomoles, the threshold constrictor dose is 5 nanomoles, and flow nearly ceases at a dose of 100 nanomoles in perfused hearts at constant pressure. Similar concentrations of atriopeptin II also cause coronary vasoconstriction in rat and dog heart preparations. The disulfide bridge is necessary for vasoconstrictor activity; reduction of this bridge abolishes the activity, as it does the other biological activities of atrial natriuretic peptides.
Gastroesophageal reflux disease (GERD) is a common disorder that may be effectively managed medic... more Gastroesophageal reflux disease (GERD) is a common disorder that may be effectively managed medically or surgically. Direct evaluations of medical resource use are needed to better understand the relative costs of these alternatives. This study compared medical care use for a group of patients receiving surgical treatment for GERD with that for a comparable group of patients receiving medical management. We conducted a retrospective matched cohort study of Tennessee Medicaid (TennCare) patients with GERD undergoing surgical treatment in 1996 and a group of patients who received medical therapy during the same period. Administrative TennCare data provided computerized records that could be used to identify patients and measure healthcare use. There were 7,502 people who met all of the conditions for inclusion in the study, including at least two encounters with a diagnosis of GERD. One hundred thirty-five of these who underwent fundoplication constituted the surgically treated cohort. The 250 persons in the medically treated cohort were selected randomly from the remaining nonsurgical patients and matched to the surgical cohort by age, gender, race, managed care organization, and acid suppression drug use in the baseline year. The principal outcome of interest was total use of medical resources, including prescription medication. The surgical and medical cohorts did not differ significantly by demographic characteristics or by baseline use of pharmaceuticals. During the baseline year the surgically treated patients were prescribed 302 (95% CI: 270-334) days ofGERD treatment and the matched medical patients were prescribed 292 (95% CI: 267-317) days of GERD treatment. Surgically treated patients used more GERD-related outpatient resources (physician visits and diagnostic testing) in the baseline year, particularly in the 3 months before operation, when they had a mean of more than four outpatient encounter-days. In the followup year, use of GERD-related pharmaceuticals decreased markedly in the surgical cohort. These patients were prescribed an average of 123 days (95% CI: 94-153) of therapy, which was only 36% of that for medical patients (339 days [95% CI: 308-370]). More than 29% of surgical patients were prescribed no GERD-related drugs in the followup year compared with 6% of the medically treated group. The mean number of inpatient days for the fundoplication procedure was 3.2 (95% CI: 2.7-3.6), with a range of 0 to 13 days. There were no differences between the two groups in other healthcare use. Our results show that in a 1-year period of followup, surgical treatment of severe gastroesophageal reflux disease led to a 64% postsurgical reduction in GERD medication use, with no increase in use of other medical services.
Purpose: This study was designed to evaluate symptomatic outcomes following laparoscopic antirefl... more Purpose: This study was designed to evaluate symptomatic outcomes following laparoscopic antireflux surgery.Methods: Patients referred for antireflux surgery completed a self-administered 19-question gastrointestinal (GI) survey. The survey evaluates 4 GI symptom complexes: gastroesophageal reflux disease (GERD), abdominal pain, dysphagia and irritable bowel. The GERD symptoms are broken down into GI and respiratory symptoms. Questions are scored on a Likert scale
During the past decade, the number of laparoscopic procedures performed in the United States, pri... more During the past decade, the number of laparoscopic procedures performed in the United States, primarily with cholecystectomy, has increased phenomenally. We recently had a patient who developed hypercarbia and cardiovascular compromise during laparoscopic cholecystectomy. The cardiovascular compromise was caused by mechanical factors directly related to increasing intra-abdominal pressures affecting ventilation and venous return as well as the absorption of carbon dioxide (CO2) into the circulation, leading to acidosis and further depression of the cardiopulmonary system. Cardiovascular compromise can be avoided with early recognition of increased end-tidal CO2 concentrations and by preventing intra-abdominal pressures from exceeding 16 mm Hg.
The Stretta procedure is a new, totally endoscopic treatment for GERD, where radiofrequency energ... more The Stretta procedure is a new, totally endoscopic treatment for GERD, where radiofrequency energy is delivered to the smooth muscle of the gastroesophageal junction. Forty-one patients undergoing the Stretta procedure between August 2000 and August 2001 were prospectively evaluated. Under an IRB-approved protocol, patients were studied preoperatively and postoperatively with esophageal manometry, 24-h pH testing, SF12 surveys, and GERD-specific questionnaires (QOLRAD). Results are reported as mean +/- SEM. All procedures were performed on an outpatient basis; 33 were under conscious sedation and 8 were under general anesthesia. Prior to treatment, patients had a mean LES pressure of 25 +/- 2.4 mmHg, Johnson-Demeester score of 32.8 +/- 4.6 mmHg, and % time reflux 8.4 +/- 0.9%. The quality-of-life scores were significantly improved at 6 months: QOLRAD score increased from 3.7 +/- 0.2 to 5.1 +/- 0.2 (p = 0.002), SF12 mental score increased from 44.3 +/- 2.0 to 51.8 +/- 1.7 (p = 0.001), and SF12 physical score increased from 26.2 +/- 2.4 to 33.1 +/- 3.8 (p = 0.001). Eighteen patients returned for esophageal manometry and 24-h pH testing at a mean of 6.8 +/- 0.5 months. There was a significant decrease in esophageal acid exposure time (8.4 +/- 0.9% to 4.4 +/- 1.3%, p = 0.03) and Johnson-Demeester score (32.8 +/- 4.6 to 22.9 +/- 5.3, p = 0.04). There was no significant change in mean LES pressure (25.3 +/- 2.4 mmHg to 26.8 +/- 2.6 mmHg, p = 0.63). Twenty of 31 patients (65%) available for 6 months follow-up were completely off proton pump inhibitors. The only complication related to Stretta was a case of gastroparesis 10 days post-operatively that resolved completely. The Stretta procedure is a promising new endoscopic treatment for GERD. It significantly improves GERD symptoms and quality of life while eliminating the need for proton pump inhibitors in the majority of patients.
While the first laparoscopic ventral hernia repair was reported in 1992, there have been no studi... more While the first laparoscopic ventral hernia repair was reported in 1992, there have been no studies comparing laparoscopic to conventional ventral herniorrhaphy. Twenty-one ventral hernias repaired laparoscopically are compared to a similar group of 16 patients undergoing traditional open repair during a 2-year period. Operative and hospital courses along with outcomes and cost analysis are analyzed. There was no statistical difference between groups in number of previous abdominal operations, prior hernia repairs, and comorbidities. Patients undergoing open repair were older with larger fascial defects. Open repairs had a shorter operative time as compared to the laparoscopic group, but statistically longer postoperative stays and costs. Postoperative complications occurred in 31% of the open group and 23% of the laparoscopic group. There were two recurrences in each group. Laparoscopic herniorrhaphy is as safe and effective as the traditional open technique with shorter length of stay and decreased hospital costs.
Pneumomediastinum can be a sign of esophageal perforation. During laparoscopic esophageal surgery... more Pneumomediastinum can be a sign of esophageal perforation. During laparoscopic esophageal surgery, the mediastinum is exposed to carbon dioxide gas under pressure that can cause pneumomediastinum. Forty-five patients undergoing laparoscopic esophageal procedures had erect, inspiratory, single-view chest radiographs (CXR) performed in the recovery room (RR). Patients with extraabdominal gas underwent daily erect, inspiratory, single-view CXR until resorption of the gas or discharge from the hospital. Insufflation time and pressure were recorded, and morbidity was evaluated. Results are expressed as mean +/- SEM. Twenty-five men (56%)and 20 women (44%) aged 33.0 +/- 2.9 years underwent 10 Heller myotomies (22.2%), 27 Nissen fundoplications (60.0%), six Toupet fundoplications (13.3%), and two paraesophageal hernia repairs (4.4%). Twenty-four patients (53.3%) had normal CXR in RR, and 21 (46.7%) had extraabdominal gas. Eighteen (85.7%) of the 21 had pneumomediastinum, three (14.3%) had pneumothorax, and 12 (57.1%) had subcutaneous emphysema in RR. Sixteen of these 21 remained hospitalized and had repeat CXR on postoperative day 1. Of these 16, five (31.3%) had normal CXR, 11 (68.8%) had pneumomediastinum, and seven (43.8%) had subcutaneous emphysema. There were no esophageal perforations and no chest tube insertions, and there was no morbidity related to pneumomediastinum. Pneumomediastinum is observed frequently following laparoscopic esophageal operations and often persists past 24 h. After these operations, pneumomediastinum is not necessarily indicative of esophageal perforation. In this group, it caused no clinically significant events that altered the course of the patients.
Atrial natriuretic peptides lower arterial pressure, cardiac filling pressure, and cardiac output... more Atrial natriuretic peptides lower arterial pressure, cardiac filling pressure, and cardiac output. In isolated, Langendorff-perfused guinea pig hearts, atriopeptin II, the 23-amino acid atrial natriuretic peptide, is also a potent coronary vasoconstrictor. The median effective dose for atriopeptin II in guinea pig hearts is 26 nanomoles, the threshold constrictor dose is 5 nanomoles, and flow nearly ceases at a dose of 100 nanomoles in perfused hearts at constant pressure. Similar concentrations of atriopeptin II also cause coronary vasoconstriction in rat and dog heart preparations. The disulfide bridge is necessary for vasoconstrictor activity; reduction of this bridge abolishes the activity, as it does the other biological activities of atrial natriuretic peptides.
Gastroesophageal reflux disease (GERD) is a common disorder that may be effectively managed medic... more Gastroesophageal reflux disease (GERD) is a common disorder that may be effectively managed medically or surgically. Direct evaluations of medical resource use are needed to better understand the relative costs of these alternatives. This study compared medical care use for a group of patients receiving surgical treatment for GERD with that for a comparable group of patients receiving medical management. We conducted a retrospective matched cohort study of Tennessee Medicaid (TennCare) patients with GERD undergoing surgical treatment in 1996 and a group of patients who received medical therapy during the same period. Administrative TennCare data provided computerized records that could be used to identify patients and measure healthcare use. There were 7,502 people who met all of the conditions for inclusion in the study, including at least two encounters with a diagnosis of GERD. One hundred thirty-five of these who underwent fundoplication constituted the surgically treated cohort. The 250 persons in the medically treated cohort were selected randomly from the remaining nonsurgical patients and matched to the surgical cohort by age, gender, race, managed care organization, and acid suppression drug use in the baseline year. The principal outcome of interest was total use of medical resources, including prescription medication. The surgical and medical cohorts did not differ significantly by demographic characteristics or by baseline use of pharmaceuticals. During the baseline year the surgically treated patients were prescribed 302 (95% CI: 270-334) days ofGERD treatment and the matched medical patients were prescribed 292 (95% CI: 267-317) days of GERD treatment. Surgically treated patients used more GERD-related outpatient resources (physician visits and diagnostic testing) in the baseline year, particularly in the 3 months before operation, when they had a mean of more than four outpatient encounter-days. In the followup year, use of GERD-related pharmaceuticals decreased markedly in the surgical cohort. These patients were prescribed an average of 123 days (95% CI: 94-153) of therapy, which was only 36% of that for medical patients (339 days [95% CI: 308-370]). More than 29% of surgical patients were prescribed no GERD-related drugs in the followup year compared with 6% of the medically treated group. The mean number of inpatient days for the fundoplication procedure was 3.2 (95% CI: 2.7-3.6), with a range of 0 to 13 days. There were no differences between the two groups in other healthcare use. Our results show that in a 1-year period of followup, surgical treatment of severe gastroesophageal reflux disease led to a 64% postsurgical reduction in GERD medication use, with no increase in use of other medical services.
Purpose: This study was designed to evaluate symptomatic outcomes following laparoscopic antirefl... more Purpose: This study was designed to evaluate symptomatic outcomes following laparoscopic antireflux surgery.Methods: Patients referred for antireflux surgery completed a self-administered 19-question gastrointestinal (GI) survey. The survey evaluates 4 GI symptom complexes: gastroesophageal reflux disease (GERD), abdominal pain, dysphagia and irritable bowel. The GERD symptoms are broken down into GI and respiratory symptoms. Questions are scored on a Likert scale
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