RESUMEN
Photoinduced deoxygenation of dibenzothiophene S-oxide (DBTO) has been suggested to release atomic oxygen [O((3)P)]. To expand the conditions and applications where O((3)P) could be used, generation of O((3)P) at longer wavelengths was desirable. The sulfoxides benzo[b]naphtho-[1,2,d]thiophene S-oxide, benzo[b]naphtho[2,1,d]thiophene S-oxide, benzo[b]phenanthro[9,10-d]thiophene S-oxide, dinaphtho[2,1-b:1',2'-d]thiophene S-oxide, and dinaphtho[1,2-b:2',1'-d]thiophene S-oxide all absorb light at longer wavelengths than DBTO. To determine if these sulfoxides could be used to generate O((3)P), quantum yield studies, product studies, and computational analysis were performed. Quantum yields for the deoxygenation were up to 3 times larger for these sulfoxides compared to DBTO. However, oxidation of the solvent by these sulfoxides resulted in different ratios of oxidized products compared to DBTO, which suggested a change in deoxygenation mechanism. Density functional calculations revealed a much larger singlet-triplet gap for the larger sulfoxides compared to DBTO. This led to the conclusion that the examined sulfoxides could undergo deoxygenation by two different mechanisms.
Asunto(s)
Oxígeno/química , Procesos Fotoquímicos , Sulfóxidos/química , Tiofenos/química , Benceno/química , Estructura Molecular , Oxidación-Reducción , Solventes/química , Análisis Espectral , Tolueno/química , Rayos UltravioletaRESUMEN
BACKGROUND: It has been reported that the laparoscopic repair of paraesophageal hernias is associated with higher complication and recurrence rates than the open methods of repair. METHODS: We identified 136 consecutive patients who underwent laparoscopic repair of a paraesophageal hernia between 1993 and 1999. Patient demographics and symptom scores for regurgitation, heartburn, chest pain, and dysphagia at presentation and at last follow-up were recorded (0 = none, 1 = mild, 2 = moderate, 3 = severe). The operative records were reviewed, and early and late complications were noted. Only patients with a follow-up of >1 were included in the analysis. RESULTS: The median age was 64 years, and there was a female preponderance (1.8:1). Most patients had some medical comorbidity; the American Society of Anesthesiologists (ASA) scores were <2 in eight patients and ?2 in 117 patients. Three laparoscopic operations were converted to open procedures. There were nine intraoperative complications, five early complications, and three related deaths (morbidity and mortality rates of 10.2% and 2.2%, respectively). Follow-up data were available for 83 patients (66%), and the mean follow-up time was 40 months (range, 12-82). The percentage of patients experiencing chest pain, dysphagia, heartburn, and regurgitation in the moderate to severe range dropped from a range of 34-47% to 5-7% (p <0.05). Three patients underwent repeat laparoscopic repair for symptomatic recurrence. CONCLUSION: The laparoscopic repair of paraesophageal hernias provides excellent long-term symptomatic relief in the majority of patients and has a low rate of symptomatic recurrence. The complication and death rates may be related in part to the higher incidence of comorbidities in this somewhat elderly patient population.
Asunto(s)
Hernia Hiatal/cirugía , Laparoscopía/métodos , Femenino , Hernia Hiatal/patología , Humanos , Masculino , Persona de Mediana Edad , Cuidados Posoperatorios/métodos , Cuidados Preoperatorios/métodos , Estudios Prospectivos , Autoexamen , Índice de Severidad de la Enfermedad , Encuestas y Cuestionarios , Resultado del TratamientoRESUMEN
BACKGROUND: Fundoplication hastens gastric emptying in pediatric patients with gastroesophageal reflux disease (GERD). However, among adult GERD patients with impaired gastric emptying, the degree of improvement offered by fundoplication and the value of pyloroplasty are less well defined. Therefore, we compared outcomes in GERD patients with delayed gastric emptying after fundoplication alone or fundoplication with pyloroplasty. METHODS: Of 616 consecutive GERD patients who submitted to primary fundoplication (601 laparoscopic) between October 1991 and October 1997, 82 underwent preoperative solid-phase nuclear gastric emptying analysis. Of these, 25 had delayed gastric emptying (half-time >100 min). Of 12 patients with emptying half-times between 100 and 150 min, one underwent pyloroplasty at the time of Nissen fundoplication. Of 13 patients with emptying half-times >150 min, 11 had pyloroplasty at the time of Nissen fundoplication. Patients were asked to use a 0 ("none") to 4 ("incapacitating") scale to describe the severity of their symptoms of heartburn, regurgitation, dysphagia, bloating and diarrhea preoperatively and at 6 weeks and 1 year postoperatively. Eight patients consented to a postoperative analysis of gastric emptying. RESULTS: One year after fundoplication, patients with delayed gastric emptying and controls reported a similar improvement in heartburn, regurgitation, and dysphagia, with no increase in undesirable side effects such as bloating and diarrhea. Among the patients with delayed gastric emptying who consented to undergo a repeat gastric emptying study after their operation, fundoplication alone provided a 38% improvement (p < 0.05) in gastric emptying, whereas fundoplication with pyloroplasty resulted in a 70% improvement in gastric emptying (p < 0.05). CONCLUSION: Fundoplication improves gastric emptying. The addition of pyloroplasty results in even greater improvement and may have particular value for patients with severe gastric hypomotility.
Asunto(s)
Fundoplicación/métodos , Vaciamiento Gástrico/fisiología , Reflujo Gastroesofágico/cirugía , Adolescente , Adulto , Factores de Edad , Anciano , Femenino , Reflujo Gastroesofágico/fisiopatología , Estado de Salud , Humanos , Masculino , Persona de Mediana Edad , Píloro/fisiopatología , Píloro/cirugía , Índice de Severidad de la Enfermedad , Resultado del TratamientoRESUMEN
Toupet (270 degrees) fundoplication is commonly recommended for patients with gastroesophageal reflux (GER) and esophageal dysmotility. However, Toupet fundoplication may be less effective at protecting against reflux than Nissen (360 degrees) fundoplication. We therefore compared the effectiveness and durability of both types of fundoplication as a function of preoperative esophageal motility. From January 1992 through January 1998, 669 patients with GER underwent laparoscopic fundoplication (78 Toupet, 591 Nissen). Patients scored heartburn, regurgitation, and dysphagia preoperatively, and at 6 weeks and 1 year postoperatively, using a 0 ("none") to 3 ("severe") scale. We compared symptom scores (Wilcoxon rank sum test) and redo fundoplication rates (Fisher exact test) in Toupet and Nissen patients. We also performed subgroup analyses on 81 patients with impaired esophageal motility (mean peristaltic amplitude, <30 mm Hg or peristalsis <70% of wet swallows) and 588 patients with normal esophageal motility. Toupet and Nissen patients reported similar preoperative heartburn, regurgitation, and dysphagia. At 6 weeks after operation, heartburn and regurgitation were similarly improved in both groups, but dysphagia was more prevalent among Nissen patients. After 1 year, heartburn and regurgitation were re-emerging in Toupet patients, and dysphagia was again similar between groups. Patients with impaired motility who have Nissen fundoplication are no more likely to suffer persistent dysphagia than their counterparts who have Toupet fundoplication. In addition, patients with normal motility are more likely to develop symptom recurrence after Toupet fundoplication than Nissen fundoplication, with no distinction in dysphagia rates. We conclude that since Toupet patients suffer more heartburn recurrence than Nissen patients, with similar dysphagia, selective use of Toupet fundoplication requires further study.
Asunto(s)
Fundoplicación/efectos adversos , Reflujo Gastroesofágico/cirugía , Pirosis/etiología , Trastornos de Deglución/cirugía , Esófago/fisiopatología , Fundoplicación/métodos , Humanos , Peristaltismo , Complicaciones Posoperatorias , RecurrenciaRESUMEN
BACKGROUND: Columnar-lined esophagus with intestinal metaplasia (IM), also called Barrett's esophagus, is a manifestation of severe gastroesophageal reflux (GER) and may predict poor symptom relief and high failure rate after fundoplication. We compared symptom scores and reoperation rates in GER patients with and without Barrett's esophagus. METHODS: Between July 1992 and July 1997, 646 patients underwent fundoplication (626 laparoscopic). Of 150 endoscopic biopsies of suspected columnar-lined esophagus, 80 confirmed IM, 50 identified cardiac or fundic epithelium, and 20 revealed only esophagitis. Typical GER symptoms were scored by patients preoperatively and postoperatively (0 to 4 scale). We compared symptom response (Wilcoxon rank sum test) and failure rates (t test) in patients with IM and GER controls without IM. Preoperative data were available for 74 IM patients and 496 controls. One-year follow-up was available in 45 IM patients and 301 controls. Intermediate follow-up (2 to 5 years) was available in 20 IM patients and 99 controls. RESULTS: Preoperatively and postoperatively, patients with IM reported heartburn, regurgitation, and dysphagia scores similar to controls. Procedure failure, requiring redo fundoplication, appeared more likely in IM patients than controls (6.3% versus 2.5%), but this difference did not reach statistical significance (P = 0.061). CONCLUSION: Fundoplication provides equivalent symptom relief for patients with and without IM.