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ABSTRACT: Gastroesophageal reflux disease and its complications, such as Barrett's esophagus, are major health problems. In this review, we highlight the critical components of the disease process and surgical considerations relevant to laparoscopic anti-reflux surgery.
Minerva chirurgica 02/2011; 66(1):7-19. · 0.77 Impact Factor
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Journal of Surgical Research 02/2010; 158(2):247. · 2.25 Impact Factor
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Journal of Surgical Research 02/2010; 158(2):246. · 2.25 Impact Factor
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Journal of Surgical Research 02/2010; 158(2):248-9. · 2.25 Impact Factor
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ABSTRACT: It is widely accepted that intestinal anaerobic bacteria do not translocate from the intestinal tract as readily as facultative species. However, to date this hypothesis has not been tested in defined flora animals where the intestinal concentrations of different bacterial species can be closely monitored. Seven different groups of defined flora mice were colonised with from two to seven different species of bacteria representing various mixtures of intestinal facultative and/ or anaerobic species, including Escherichia coli C25 (streptomycin resistant), E. coli M14 (streptomycin sensitive), Proteus mirabilis, enterococcus, Bacteroides vulgatus, B. fragilis, and Clostridium sp. With the exception of the Clostridium sp., each of these species colonised the caeca of defined flora mice at concentrations ≥ 109 per gram. Each of the four facultative species (i.e., E. coli C25, E. coli M14, P. mirabilis, and enterococcus) translocated to the mesenteric lymph nodes of approximately one-half of the defined flora mice associated with each species (n ≥ 42). In contrast, of the remaining three anaerobic species, only B. vulgatus translocated in only three mice (n = 52), despite caecal population levels of each of the Bacteroides species that were comparable to each of the facultative species. These results indicate that, in animals with a limited intestinal flora, intestinal anaerobic bacteria do not translocate as readily as facultative species and that the mechanism responsible for the translocation of facultative bacteria in preference to anaerobic bacteria is independent of the concentration of intestinal bacteria.
07/2009; 1(4):227-235.
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ABSTRACT: The import of the immune system to cancer survival is paramount. Immune effector cells are intimately involved in the patient's response to cancer. People with decreased immune function develop cancer more frequently. In the early stages of solid organ malignancies, surgery can potentially be curative. Surgical intervention, in and of itself, is immunosuppressive. Surgical resections are traditionally performed through large incisions. Technologic advances have allowed minimally invasive surgery (MIS) to evolve to the point it is now being used for cancer treatment. Recent minimally invasive series have reported improved survival and recurrence rates, as compared with historical data. We hypothesized that outcome differences for cancer patients undergoing open surgery vs. MIS are due to differential inhibition of immune effector cell function, in response to the different surgical stimulus. This increased immunosuppression after open surgery could potentially inhibit immune effector cell tumor surveillance as well as inhibit scavenging of any residual or micrometastatic disease or of tumor cells shed at the time of the operation. The less immunosuppressive MIS may leave immune function above a threshold level where remaining tumor is cleared. This difference would lead to less recurrence and to survival advantages. A deeper understanding of the integral components of the immune response to surgery would open the door for immunomodulation strategies and be of great clinical utility in guiding neoadjuvant, surgical, or adjuvant therapeutic decisions.
Medical Hypotheses 02/2007; 68(6):1328-32. · 1.39 Impact Factor
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ABSTRACT: We report the repair of a giant hiatal hernia by laparoscopic Collis gastroplasty and Nissen fundoplication in a patient with situs inversus totalis, highlighting the unique anatomic challenges in this case. The 52-year old female patient had Kartageners syndrome, a giant hiatal hernia, and a history of chronic severe gastroesophageal reflux disease with uncontrolled regurgitation. The laparoscopic procedure was accomplished with five ports placed in a mirror-image configuration, reversed from our standard positions. After visual confirmation of the complete reversal of the intraabdominal anatomy, we performed a modified Collis gastroplasty and Nissen fundoplication. Significant technical challenges were encountered intraoperatively. To the best of our knowledge, this report is the first of its kind in the literature. The use of advanced laparoscopic techniques is highly adaptable to unusual anatomy. Laparoscopic hiatal hernia surgery is feasible in patients with situs inversus.
Surgical Endoscopy 03/2004; 18(2):345-9. · 4.01 Impact Factor
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Journal of Thoracic and Cardiovascular Surgery 06/2001; 121(5):1003-4. · 3.41 Impact Factor
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Journal of Thoracic and Cardiovascular Surgery 06/2001; 121(5):1011-2. · 3.41 Impact Factor
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ABSTRACT: Postpneumonectomy syndrome, a late complication of pneumonectomy, is secondary to shift of the mediastinum and remaining lung toward the pneumonectomy side, leading to tracheobronchial compression between the vertebral body and the aorta or pulmonary artery. Obstructive airway symptoms are usually due to tracheobronchial tree compression, however, secondary airway malacia may develop. We report herein a case of postpneumonectomy syndrome with secondary bronchomalacia after left pneumonectomy in a patient with normal mediastinal vascular anatomy.
The Annals of Thoracic Surgery 03/2001; 71(2):701-3. · 3.74 Impact Factor
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ABSTRACT: A 56-year-old man with primary esophageal lymphoma is presented. Diagnosis of this disease can present a challenge. Clinical characteristics, treatment principles, and a detailed discussion of diagnosis are presented. When primary esophageal lymphoma is diagnosed, combination chemotherapy and radiotherapy afford a significant chance of long-term survival.
The Annals of Thoracic Surgery 11/1998; 66(4):1418-20. · 3.74 Impact Factor
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ABSTRACT: To determine whether measurement of preoperative serum carcinoembryonic antigen concentrations adds useful prognostic data to current preoperative staging of lung cancer by computed tomography, bronchoscopy, and mediastinoscopy.
A prospective cohort study of 130 consecutive patients was evaluated for suspected lung cancer from July 1991 through December 1992 at a university-affiliated Veterans Affairs Medical Center. Serum concentrations of carcinoembryonic antigen were measured before diagnosis, staging, or resection of cancer.
Malignant disease was diagnosed by bronchoscopy, needle biopsy, mediastinoscopy, or resection in 111 of 130 patients. In the 50 patients undergoing resection with curative intent, multivariate analysis indicated that carcinoembryonic antigen was a significant predictor of survival independent of patient age, pathologic stage, histologic type, and tumor size (P=.0357).
Elevated preoperative serum concentrations of carcinoembryonic antigen predict a poor prognosis for lung cancer independent of other conventional staging parameters and have an adjunctive role in the staging of lung cancer.
Journal of Thoracic and Cardiovascular Surgery 10/1998; 116(3):412-6. · 3.41 Impact Factor
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ABSTRACT: The 5-year survival rate following surgical resection of Stage I or Stage II non-small cell lung carcinoma (NSCLC) is 30% to 50%, probably because of undetected occult micrometastases (OMs) at the time of surgery. Other investigators have detected OMs in bone marrow and histologically negative lymph nodes from patients with NSCLC using immunohistochemical staining to cytokeratins and cell surface glycoproteins.
To develop and evaluate an assay based on the reverse transcriptase-polymerase chain reaction (RT-PCR) for the detection of OMs in NSCLC.
Twenty-eight patients with benign or malignant thoracic pathology. Samples of primary tumors and lymph nodes were collected at the time of surgical resection or mediastinoscopic lymph-node biopsy.
Using RT-PCR to detect messenger RNA (mRNA) transcripts for MUC1 (a cell surface glycoprotein present in lung tissue but absent from normal lymph nodes), OMs were identified in 33 of 88 lymph nodes determined to be free of tumor by hematoxylin and eosin staining. Eleven of 11 control mediastinal lymph nodes from patients without malignancy failed to express detectable MUC1 transcripts. Dilutional experiments demonstrate that the assay can detect one MUC1-positive NSCLC cell in 1x10(7) MUC1-negative cells. A comparison of our RT-PCR assay to immunohistochemistry specific for the MUC1 glycoprotein suggests that RT-PCR may be more sensitive than immunohistochemistry for the detection of NSCLC OMs.
This study demonstrates that RT-PCR for MUC1 mRNA can detect the presence of MUC1 mRNA in histologically negative lymph nodes from patients with NSCLC. The prognostic significance of these findings is currently unknown.
Chest 07/1998; 113(6):1526-32. · 5.25 Impact Factor
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ABSTRACT: Medical management for invasive pulmonary aspergillosis (IPA) is often unsatisfactory. Antifungal therapy may be unable to eradicate IPA in the immunocompromised or neutropenic patient.
We retrospectively reviewed the surgical management of IPA in 13 immunocompromised patients at our institution. Twelve patients underwent perioperative bone marrow transplantation (4 autologous, 8 allogenic). All 13 patients received antifungal therapy. Eleven patients were neutropenic at the time of operation.
The mean interval from diagnosis of aspergillosis to operation was 42 days (range, 3 to 135 days). Eighteen operations were performed on the 13 patients. Seven patients had resections from multiple pulmonary sites, whereas 6 had a single lesion resected. The average lesion resected was 3.7 cm in greatest diameter (range, 1 to 9 cm). After a mean follow-up of 21 months (range, 0 to 9 years), 3 patients (23%) are alive with no evidence of aspergillosis, 6 patients (46%) died without evidence of aspergillosis, and 4 patients (31%) died secondary to aspergillus infection. All 4 patients who died of aspergillus infection received an allogenic bone marrow transplantation. Two patients with direct extrapulmonic extension of IPA at time of operation died of recurrent aspergillus infections. Three of 4 patients who died of aspergillus infection had an absolute neutrophil count less than 1,300 cells/microL at time of operation. The mean absolute neutrophil count of the patients who cleared the aspergillus infection was 5,538 cells/microL. The mean survival of allogenic bone marrow transplant recipients was 5.2 months, and for recipients of autografts was 51.4 months.
In this series, surgical resection of IPA cleared the aspergillus infection in 69% of the patients. Neutropenia, extrapulmonic extension of IPA, and allogenic bone marrow transplantation may predict a worse prognosis. Surgical resection of IPA in immunocompromised patients is an effective form of therapy in a properly selected patient population.
The Annals of Thoracic Surgery 06/1998; 65(5):1415-9. · 3.74 Impact Factor
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ABSTRACT: Patients with non-small-cell lung cancer (NSCLC) survive for variable lengths of time, even when adjustment is made for pathological stage. Numerous reports suggest that biological markers predict survival in patients undergoing surgery for NSCLC with curative intent, but many of these claims are unconfirmed or conflicting. We postulated that the use of multiple putative markers might provide greater power in predicting survival. We studied 101 consecutive patients with NSCLC who underwent exploratory thoracotomy and who were followed for at least 2 yr. We assessed mutations in the p53 tumor suppressor gene (exons 5-8) and the K-ras oncogene (codons 12 and 13) by polymerase chain reaction amplification and single strand conformation polymorphism of the product. We identified 19 K-ras mutations (all adenocarcinomas except for two) and 40 p53 mutations among the 101 cases. We also evaluated p53 protein, bcl-2 protein, c-erbB-1 protein, c-erbB-2 protein, and MIA-15-5 antigen by standard immunocytochemical techniques, and we found that all of these antigens were variably expressed. As expected, we found a strong inverse association between surgical tumor stage and survival. Of the molecular markers studied, only MIA-15-5 antigen expression correlated strongly with survival by univariate analysis (p = 0.001) and it remained a significant predictor by multivariate analysis (p = 0.01). However, in this study, overexpression of MIA-15-5 antigen predicted an improved survival, whereas the original report showed a worse prognosis (N. Engl. J. Med. 1992;327:14). We conclude the multiple cell markers are not clinically useful in predicting survival among patients undergoing surgery for NSCLC. Differences between our results and prior reports may be due to chance, to true population differences, or to other factors.
American Journal of Respiratory and Critical Care Medicine 05/1998; 157(4 Pt 1):1093-7. · 11.08 Impact Factor
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ABSTRACT: Inactivation of the cyclin-dependent kinase inhibitor p16INK4a (CDKN2/MTS1) is documented in a wide variety of cancer cell lines and tumors. We have shown that loss of p16INK4a protein expression is a common event in early stage non-small cell lung cancer (NSCLC), correlates with a significantly worse survival, and is more common in higher stage disease. One hundred NSCLC tumors from patients undergoing definitive thoracotomies at a single institution were examined for p16INK4a and retinoblastoma protein (pRB) expression. Abnormal pRB staining was identified in 15% of the tumors, whereas 51% possessed aberrant p16INK4a protein expression. Tumors with aberrant expression of p16INK4a by immunohistochemistry were associated with a significantly worse survival (P=0.04). Additionally, the inverse correlation of pRB and p16INK4a expression previously noted in lung cancer cell lines and tumors was confirmed in this large cohort of patients, with 65% of the tumors demonstrating inverse expression of pRB and p16INK4a (p=0.00019). A statistically significant increase in aberrant p16INK4a expression, as well as inverse expression of p16INK4a and pRB, was seen with increasing pathological stage of disease. These findings establish the prognostic significance (of the absence of p16INK4, in resected NSCLC and confirm the critical importance of disrupting the pathway of cyclin-dependent kinase-mediated phosphorylation of pRB in the molecular oncogenesis and progression of NSCLC.
Cancer Research 09/1996; 56(15):3415-20. · 7.86 Impact Factor
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ABSTRACT: Easy dislodgment and a pneumothorax rate of up to 50% have been reported with the use of mammographic hookwires for radiologic guidance in thoracoscopic surgery. An alternative design is described and preliminary in vitro results are reported.
The new design is based on the T-fastener used in percutaneous gastrostomies and can be deposited with a 20-Fr guidance needle. In vitro measurements of the anchoring capability of this design were compared with the anchoring capability of the Hawkin's III (Meditech/Boston Scientific, Watertown, MA) mammographic hook wire system.
Anchoring capabilities of the alternative anchoring design and the Hawkin's III mammographic hook wire localization system are comparable. Complete dislodgement of both anchors occurs at approximately 350 gm.
Preliminary in vitro investigation demonstrated similar anchoring capabilities of the new design and mammographic hook wires. Potential advantages of this suture-based localization device over hook wires are discussed.
Investigative Radiology 07/1994; 29(6):648-51. · 4.59 Impact Factor
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ABSTRACT: Suppression of the gut luminal aerobic flora to reduce nosocomial infections was tested in a prospective, randomized, double-blind, placebo-controlled clinical trial in patients in a surgical intensive care unit who had persistent hypermetabolism. Forty-six patients were randomized to receive either norfloxacin, 500-mg suspension every 8 hours, together with nystatin, 1 million units every 6 hours, or matching placebo solutions administered through a nasogastric tube within 48 hours of surgical intensive care unit admission. Selective gut decontamination with the experimental therapy or placebo solutions continued for at least 5 days or until the time of surgical intensive care unit discharge. Patients were monitored with routine surveillance cultures for the development of nosocomial infections, as defined by criteria from the Centers for Disease Control. All other therapy was given as clinically indicated, including systemic antibiotics. The selective gut decontamination group experienced a significant reduction in the incidence of nosocomial infections and a reduced length of stay. However, these results were not associated with a concomitant decrease in progressive multiple organ failure syndrome, adult respiratory distress syndrome, or mortality.
Archives of Surgery 03/1992; 127(2):163-7; discussion 167-9. · 4.24 Impact Factor
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ABSTRACT: The intestinal colonization and translocation of enterococci was studied in mice treated intramuscularly with metronidazole or clindamycin, with or without oral streptomycin. Treatment with metronidazole resulted in selective elimination of strictly anaerobic cecal bacteria, with a 100-fold increase in the numbers of aerobic and facultative gram-negative bacilli and a 10,000-fold increase in the numbers of aerobic and facultative gram-positive species. Clindamycin had a similar effect on the cecal flora except that the numbers of aerobic and facultative gram-positive bacteria decreased at least 10-fold. The predominating gram-positive species in the cecal flora or metronidazole-treated mice was an enterococcus, but this organism could not be recovered from the ceca of clindamycin-treated mice. Translocating bacteria (primarily gram-negative enteric bacteria) were recovered from the mesenteric lymph nodes of the majority of mice given metronidazole or clindamycin. Gram-positive bacteria were not recovered from the mesenteric lymph nodes of 20 clindamycin-treated mice, whereas 26% of 19 metronidazole-treated mice had translocating enterococci. With addition of streptomycin to the metronidazole and clindamycin regimens, mice treated with metronidazole-streptomycin became colonized predominantly with an enterococcus, and this was the only translocating species recovered from 13% of 23 mice; however, enterococci could not be detected in the ceca of clindamycin-streptomycin-treated mice, and Bacillus spp. were recovered from the mesenteric lymph nodes of 8% of 24 mice, reflecting the composition of the cecal flora. The apparent elimination of enterococci from the ceca of clindamycin and clindamycin-streptomycin-treated mice was inconsistent with the observation that the average (n=6) peak levels of clindamycin in blood and ceca were 25 and 21 microgram/ml, respectively, whereas the in vitro MIC was 128 microgram/ml. However, this apparent in vivo activity of clindamycin against enterococci was not evident in mice given 10(9) oral enterococci; the concentrations of cecal enterococci in both clindamycin-streptomycin- and metronidazole-streptomycin-treated mice were 10(10) to 10(11) enterococci per g, with translocating enterococci recovered from approximately half of these antibiotic-treated mice. Thus antibiotic therapy with metronidazole, clindamycin, metronidazole-streptomycin, and clindamycin-streptomycin resulted in a wide variation in the cecal population levels and translocation frequencies of enterococci. This variation appeared to be related to the discrepancy between the in vivo and in vitro activities of clindamycin against enterococci.
Antimicrobial Agents and Chemotherapy 01/1989; 32(12):1769-75. · 4.84 Impact Factor
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ABSTRACT: A number of disease states and therapeutic maneuvers common to surgical patients can result in changes in the intestinal flora, permitting bacterial overgrowth and translocation of bacteria to gut lymphoid tissue. It is possible that these changes in gut flora increase portal levels of several factors that are capable of altering macrophage activation state, including endotoxin, lymphokines, and eicosanoids. Since Kupffer cells are directly exposed to gut factors via the portal circulation, changes in intestinal flora may influence Kupffer cell responses. Using germfree rats, it has previously been shown that the presence of gut bacterial flora is important in inducing Kupffer cells to respond to endotoxin, and that an overgrowth of gram-negative bacteria can further augment Kupffer cell responses, supporting the above-mentioned hypothesis. The current set of experiments examines how intestinal gram-negative bacterial overgrowth in normal adult rats effects the response of Kupffer cells to septic stimuli. Kupffer cells were obtained from conventional rats with induced intestinal overgrowth with Escherichia coli C25 for 2 or 7 days. After 2 days of overgrowth, Kupffer cells were only slightly less responsive to lipopolysaccharide (LPS) than control Kupffer cells. However, after 7 days of overgrowth, when placed in coculture with normal hepatocytes, Kupffer cells were significantly more responsive to LPS (p less than 0.001), inducing a greater degree of suppression in hepatocyte protein synthesis at lower LPS concentrations. When cultured alone, Kupffer cells from these animals also produced more interleukin-1 (p less than 0.002) and prostaglandin E2 (PGE2) (p less than 0.009) in response to LPS. These results show that intestinal gram-negative bacterial overgrowth in conventional rats can have direct influences on the response of hepatic macrophages to septic stimuli, and provides further support to the hypothesis that imbalances in the intestinal flora can effect the responses of immune cells in other sites of the body.
Annals of Surgery 11/1988; 208(4):532-40. · 7.49 Impact Factor
