[Show abstract][Hide abstract] ABSTRACT: Preoperative esophageal manometry and 24-hour pH monitoring commonly are used in preoperative evaluation of patients undergoing fundoplication. Here we review our experience with the selective preoperative workup of patients undergoing fundoplication to treat gastroesophageal reflux disease.
A series of 628 consecutive antireflux procedures was reviewed. History and physical examination, upper endoscopy, and upper gastrointestinal videofluoroscopy were obtained preoperatively on all patients; the first 30 patients also underwent esophageal manometry and pH monitoring (routine evaluation group). Thereafter, pH monitoring only was performed for atypical reflux symptoms, and manometry only was performed for a history of dysphagia, odynophagia, or for abnormal motility on videofluoroscopy (selective evaluation group). All patients underwent a laparoscopic floppy Nissen fundoplication, and then endoscopy and fluoroscopy at 3 months and 12 months postoperatively.
Eighty-five of the patients in the selective evaluation group (14%) required manometry, and 88 (15%) underwent pH monitoring. Eighteen of the 115 patients who underwent manometry (16%) had evidence of dysmotility. None of these 18 patients had increased dysphagia postoperatively; 8 of 18 reported improvement with swallowing. Five patients in the selective group (0.8%) had persistent postoperative dysphagia caused by technical error (four patients) or with no identifiable cause (one patient). The estimated charge or collection reduction with use of the selective evaluation was 1,253,100 US dollars or 395,000 US dollars, respectively.
Selective use of manometry and pH monitoring was cost effective and safe in this series. Although esophageal manometry and 24-hour pH monitoring might be necessary with abnormal findings on videofluoroscopy or atypical symptoms, in our experience, their routine use is not essential in preoperative evaluation of patients undergoing fundoplication for gastroesophageal reflux disease.
Journal of the American College of Surgeons 10/2003; 197(3):358-63; discussion 363-4. DOI:10.1016/S1072-7515(03)00591-X · 4.45 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Small bowel calcification is a rare finding, often associated with chronic infection or small intestinal neoplasms. The authors report a patient who developed dystrophic ileal calcification in the setting of medically refractory Crohn's disease. The patient had longstanding, obstructive ileal Crohn's disease, treated with corticosteroids for a 10-year period. Diffuse terminal ileal calcification was evident on radiographic studies, including plain films as well as abdominal CT scan. The patient underwent successful resection of the diseased segment of small bowel and has done well over the ensuing 3-year period. Dystrophic calcification is a rare complication of long-standing chronic inflammation in Crohn's disease that may occur in the absence of adenocarcinoma or chronic infection.
[Show abstract][Hide abstract] ABSTRACT: Dysphagia for solids usually indicates a structural esophageal abnormality. This article is a description of a group of 5 young men referred with chronic dysphagia for solids. Esophagoscopy and barium esophagogram failed to show a cause. Our evaluation showed that these patients had eosinophilic esophagitis and a "small-caliber esophagus." This article describes the clinical features, diagnosis, and management of the small-caliber esophagus.
Patients were evaluated by barium esophagogram with marshmallow challenge, esophageal manometry, Bernstein test, and EGD with biopsies. All patients underwent empiric esophageal dilation with wire-guided dilators.
A diffusely narrow esophagus was appreciated in 3 of 5 patients radiographically, endoscopically, or both. However, the latter studies showed normal findings in 2 patients. Eosinophilic esophagitis was found in all 4 patients in whom biopsy specimens were obtained. Esophageal manometry was performed in 4 patients and showed normal findings in all. The feature that most confirmed the diagnosis of small-caliber esophagus in all patients was the unusually long rents (8 to 17 cm) in the esophageal wall after empiric dilation. Dilation relieved the symptoms in all cases.
The small-caliber esophagus is a cause of dysphagia for solids in young men with eosinophilic esophagitis. It frequently defies detection by routine diagnostic studies. The clue to diagnosis lies in endoscopic reinspection after dilation and the finding of unusually long rents in the esophageal wall.
[Show abstract][Hide abstract] ABSTRACT: To study the effect of barium sulfate on wound healing in the gastrointestinal tract of the rat.
Sixty rats weighing approximately 320 g were divided into four groups: Fifteen control rats had gastric, small-bowel, and colonic incisions; 15 rats had gastric incision; 15 rats had small-bowel incision; and 15 rats had colonic incision. Barium sulfate was placed into the incision before closure in all rats except those in the control group, and the effects were documented clinically and histopathologically for 3 months. Autopsy was performed in five rats from each group at 1, 4, and 12 weeks. The incisions in the rats receiving barium sulfate were compared with those in the control rats.
There was no difference in the clinical course (weight gain, activity, and viability) between the control and experimental groups. Early and late autopsy findings and histopathologic grading of healing and inflammatory response were similar for both the control and experimental groups.
Under the conditions of this study, the effect of barium sulfate on visceral transmural wound healing in the gastrointestinal tract of the rat was minimal.
[Show abstract][Hide abstract] ABSTRACT: Filling defects in the pancreatic duct are a frequent finding during endoscopic retrograde pancreatography (ERP) and have a variety of causes. Some filling defects may be artifactual or related to technical factors and, once their origin is recognized, can be disregarded. Others may be due to acute changes of pancreatitis and should prompt more careful injection of contrast material into the duct. Intraluminal masses may represent calculi or a neoplasm, either of which may require surgery or endoscopic intervention. The exact nature of these filling defects may not be apparent on radiographs, and other studies may be needed. This article reviews our approach to the evaluation of filling defects in the pancreatic duct.
American Journal of Roentgenology 01/1993; 159(6):1203-8. DOI:10.2214/ajr.159.6.1442383 · 2.74 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Imaging considerations and features when assessing acquired abnormalities of the spleen with CT are described. Indexes of normal size and the implications of splenomegaly are discussed, as well as the CT appearances and types of neoplasia, cysts, traumatic injuries, infarction, and inflammatory changes.
American Journal of Roentgenology 01/1992; 157(6):1213-9. DOI:10.2214/ajr.157.6.1950868 · 2.74 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The utility of oblique views for augmenting standard posteroanterior and lateral double-contrast radiography of the pharynx was examined. Over an 8-month period, two oblique views were added to the standard posteroanterior and lateral views of the pharynx during routine upper gastrointestinal studies in 102 patients divided into two groups. Group 1 consisted of 81 patients without suspected pharyngeal or esophageal disease who demonstrated what was considered to be normal anatomy on all radiographic views. Group 2 consisted of 21 patients who were known or suspected to have pathologic abnormality of the pharynx. The members of this latter group each demonstrated various abnormal pharyngeal anatomy on the standard views. In just over half of these cases the oblique projection contributed significant information not obtained with conventional views. Therefore, the authors conclude that oblique images are a beneficial addition to the diagnostic evaluation of patients highly suspected of having pharyngeal disease.
[Show abstract][Hide abstract] ABSTRACT: Lipomas of the gastrointestinal tract are an infrequent finding on radiologic examination; however, they occur often enough to warrant consideration in the differential diagnosis of mass lesions of the gut. In many instances, their morphologic characteristics allow the specific diagnosis of a lipoma. In this report, we review gastrointestinal lipomas with an emphasis on their radiologic and pathologic correlation.
American Journal of Roentgenology 01/1991; 155(6):1205-10. DOI:10.2214/ajr.155.6.2122666 · 2.74 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Knowledge of the anatomy, embryology, and congenital anomalies of the spleen is needed in order to avoid pitfalls in the interpretation of abdominal imaging studies such as CT and sonography. For this reason, this pictorial essay illustrates the anatomy, embryology, and radiologic images of congenital anomalies of the spleen.
American Journal of Roentgenology 11/1990; 155(4):805-10. DOI:10.2214/ajr.155.4.2119113 · 2.74 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Prototype electronic workstations incorporated in networks linking computed tomographic (CT) and magnetic resonance imaging systems are being developed. The authors compared observer efficiency and sensitivity in reading body CT studies from a two-screen workstation (1,000-line monitors and 12-bit dynamic range in image memory) and conventional film panel alternator. The two-screen workstation displayed 32 images at a matrix resolution of 256 x 256 or eight images at a matrix resolution of 512 x 512 simultaneously. Ninety-six images with a matrix resolution of 512 x 512 could be displayed simultaneously at the film panel alternator. Four observers read images from 20 cases, 10 with repeat examinations, in a randomized viewing sequence. There was an average of 32 images per case. Reporting time was less with the film panel alternator (average, 5.08 minutes) than with the workstation (average, 6.66 minutes). There was improved sensitivity for all observers in reading from the film panel alternator (range, 1%-12%) (P less than .05). In complex cases evaluated by means of body CT, the current prototype two-screen electronic workstation is limited by display capabilities.
[Show abstract][Hide abstract] ABSTRACT: We characterized the normal patterns relating to the onset of the oral-swallowing phase in patients with normal oral motor function. The main pattern of swallowing was of the tipper type, in which swallowing is initiated with the tip of the tongue against the incisors and the bolus is in a supralingual position. However, a second pattern of a dipper-type swallow occurred, in which part of the bolus initially is positioned beneath the anterior part of the tongue. This circumstance requires that the tongue dip beneath the bolus in order to elevate the bolus above the tongue. Dipper swallows occurred in all age groups, but were more prevalent in subjects 60 years or older. Recognition of this component in normal swallowing patterns is essential for optimal evaluation of normal subjects and patients with an abnormal oral phase of swallowing.
American Journal of Roentgenology 01/1990; 153(6):1197-9. DOI:10.2214/ajr.153.6.1197 · 2.74 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Choledochal cyst is a congenital malformation of the biliary tree that is unusual but by no means rare. During a 13-year period, we encountered eight patients with choledochal cysts who were evaluated with cholangiopancreatography. All of our cases showed an anomalous union of the pancreatic duct and common bile duct, resulting in a long common channel. Review of cholangiopancreatograms also showed ectasia of the common channel in six of the eight patients. Mean length of the common channel, corrected for magnification, was 26 mm (normal, less than 15 mm). The mean corrected diameter of the common channel was 7 mm (normal, 3-5 mm). We conclude that ectasia of the common channel is an important additional radiographic observation in the diagnosis of choledochal cyst. This observation has not been emphasized before.
American Journal of Roentgenology 12/1989; 153(5):969-72. DOI:10.2214/ajr.153.5.969 · 2.74 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Cowden's disease was first recognized by its striking dermatological manifestations and subsequently by the increased incidence of neoplastic involvement of the thyroid and breast. Two cases of Cowden's disease with gastrointestinal polyps are presented to illustrate the alimentary tract involvement in this syndrome, gastrointestinal tract involvement with polyposis being seen in at least 50% of cases. As opposed to the more serious potential of neoplasia in the thyroid and breast, involvement of the alimentary tract has negligible clinical impact to the patient.
British Journal of Radiology 11/1989; 62(742):890-2. DOI:10.1259/0007-1285-62-742-890 · 2.02 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We evaluated the efficacy of fatty-meal sonography for identifying patients with partial common duct obstruction. The test consisted of initial control measurements of common duct diameter followed by repeated measurements every 15 min for 60 min after a fatty meal consisting of Lipomul (1.5 ml/lb). The rationale proposed for the fatty-meal test is that in the presence of partial common duct obstruction, fat-induced increases in bile flow related to increased circulating levels of cholecystokinin are associated with an increase in the diameter of the common duct. Initial analysis of our data indicated that a change in diameter of +/- 1 mm was within the range of measurement error or possibly physiologic variation. In 44 control subjects (24 without a gallbladder), the common duct diameter either remained unchanged, showed an insignificant change of +/- 1 mm, or decreased (greater than or equal to 2 mm). The common duct diameter never showed an increase of more than 1 mm. The results of fatty-meal sonography in 47 patients with suspected partial common duct obstruction were negative in all 28 true-negative cases (specificity, 100%) and were positive (common duct increased by greater than or equal to 2 mm) in 14 of 19 true-positive cases (sensitivity, 74%). Thus, in this study a positive test finding always indicated partial common duct obstruction. Of the true-positive cases, fatty-meal sonography correctly identified seven of eight patients with cryptic obstructive sphincter-of-Oddi dysfunction (stenosis or dyskinesia) and five of nine patients with commun duct stones. We conclude that fatty-meal sonography is a useful noninvasive screening test for evaluating patients with suspected partial common duct obstruction.
American Journal of Roentgenology 08/1988; 151(1):63-8. DOI:10.2214/ajr.151.1.63 · 2.74 Impact Factor