RESUMEN
BACKGROUND: The Bravo catheter-free pH monitoring system uses a capsule attached to the esophageal mucosa to detect acid exposure. Placement of the Bravo capsule is associated with intermittent chest pain in 50% of normal volunteers. The authors hypothesized that chest pain in this setting may be attributable to hypertensive esophageal contractions induced by the Bravo capsule. METHODS: The study population consisted of 40 consecutive patients with reflux symptoms who had stationary esophageal manometry within 1 h after Bravo capsule placement. The control group consisted of 40 patients with symptomatic gastroesophageal reflux disease (GERD) from a population of patients with foregut symptoms who were computer matched to the study group for age, sex, lower esophageal sphincter (LES) pressure, LES length, and 24-h pH composite score. The patients in the control group had manometry before Bravo capsule placement. The occurrence of chest pain was assessed before and during the monitoring period by interview and review of the patient's diary. Mean contraction amplitudes in the distal third of the esophagus after 10 wet swallows were averaged. The prevalence of patients with esophageal contraction amplitudes in the distal third that exceeded the 95th percentile of normal (180 mmHg) and the mean amplitude of distal third esophageal contractions in the study and control populations were compared. In the study group, the incidence of chest pain among the patients with hypercontractility of the esophagus was compared with the incidence among those without hypercontractility. RESULTS: The mean contraction amplitude was higher in the study group (144.7 vs 105.5 mmHg; p = 0.002). The number of patients with a mean distal esophageal contraction amplitude exceeding the 95th percentile of normal also was significantly higher in the study group (13/40 vs 5/40; p = 0.03). A total of 10 patients experienced new onset of chest pain with the Bravo capsule in place, and 6 patients experienced hypertensive esophageal contractions. CONCLUSIONS: The intraesophageal Bravo capsule can cause hypertensive esophageal contractions, which may lead to chest pain.
Asunto(s)
Dolor en el Pecho/etiología , Enfermedades del Esófago/etiología , Enfermedades del Esófago/fisiopatología , Reflujo Gastroesofágico/metabolismo , Monitoreo Fisiológico/efectos adversos , Monitoreo Fisiológico/instrumentación , Contracción Muscular , Protones , Adulto , Anciano , Anciano de 80 o más Años , Estudios de Casos y Controles , Diseño de Equipo , Humanos , Concentración de Iones de Hidrógeno , Persona de Mediana Edad , Músculo Liso/fisiopatologíaRESUMEN
BACKGROUND: Identification of high-grade dysplasia (HGD) in Barrett's esophagus has been considered an indication for esophagectomy because of the high risk for coexisting cancer. However, rigorous endoscopic surveillance programs recently have been recommended, reserving esophagectomy for patients whose cancer is identified on biopsy. This approach risks continued surveillance for patients who already have cancer unless reliable markers for the presence of occult cancer are identified. This study aimed to determine the endoscopic, histologic, and demographic features associated with the presence of occult cancer in patients with HGD. METHODS: Endoscopic, histologic, and demographic findings for 31 patients who underwent esophagectomy for HGD were reviewed. The presence of an ulcer, nodule, stricture, or raised area on preoperative endoscopy was noted. The results of endoscopic biopsies taken before resection every 1 to 2 cm along the Barrett's segment were reviewed. The HGD was categorized as unilevel if the dysplasia was limited to one level of biopsy and as multilevel if more than one level was involved. Patients were divided into two groups according to the presence or absence of cancer in the resected specimens, and these variables were compared. RESULTS: The prevalence of coexisting cancer in patients with HGD was 45% (14/31). Of the 31 patients in this study, 9 had a visible lesion. Cancer was found in the resected specimens from 7 (78%) of 9 patients with a visible lesion and 7 (32%) of 22 patients without a visible lesion (p = 0.019). Of 22 patients without a visible lesion, 10 had multilevel and 12 had unilevel HGD. The findings showed that 6 (60%) of 10 patients with multilevel HGD and 1 (8.3%) of 12 patients with unilevel HGD had cancer in the resected esophagus (p = 0.009). CONCLUSION: For patients with HGD, a lesion visible on endoscopy and/or HGD at multiple biopsy levels is associated with an increased risk for coexisting cancer. These patients should be considered for early esophagectomy.
Asunto(s)
Adenocarcinoma/epidemiología , Esófago de Barrett/epidemiología , Neoplasias Esofágicas/epidemiología , Adenocarcinoma/diagnóstico , Adenocarcinoma/patología , Adenocarcinoma/cirugía , Anciano , Anciano de 80 o más Años , Esófago de Barrett/patología , Esófago de Barrett/cirugía , Biopsia , Comorbilidad , Neoplasias Esofágicas/diagnóstico , Neoplasias Esofágicas/patología , Neoplasias Esofágicas/cirugía , Esofagectomía , Esofagoscopía , Femenino , Humanos , Masculino , Persona de Mediana Edad , Prevalencia , Estudios Retrospectivos , Medición de RiesgoRESUMEN
Selective management was offered in 57 patients who had penetrating injury to the anterior neck. During the study period, decision making in patient management at our institution depended largely on clinical presentations. Indications for neck explorations were unstable hemodynamics, airway obstruction, active bleeding from the wound, and evidence of aerodigestive tract injuries. Some patients with deep wounds of zone II also underwent neck explorations. Investigations were performed in selected cases. With this selective policy, there were two unnecessary operations among 40 patients (70.2%) who underwent neck exploration. Both of them were operated because of deep wounds of zone II. The remaining 17 patients (29.8%) had uneventful conservative treatment. There was no mortality in this study. The authors concluded that selective management of penetrating neck injuries based on clinical presentations is safe and practical.
Asunto(s)
Traumatismos del Cuello/cirugía , Heridas Penetrantes/cirugía , Femenino , Humanos , Masculino , Estudios Retrospectivos , Resultado del Tratamiento , Procedimientos InnecesariosRESUMEN
One hundred and thirty two patients who underwent aortic surgery at King Chulalongkorn Memorial Hospital, Bangkok, Thailand from January 1991 to December 2000 were studied. Twenty three patients (17.4%) were aged less than 60 years, 102 (77.3%) aged 60-80 years, and 7 (5.3%) were older than 80 years. Ninety eight patients (74.2%) underwent elective operations and 34 (25.8%) underwent emergency operations. Elective abdominal aortic aneurysms (AAA) repair was the most common indication for abdominal aortic surgery (56.0%). Eighteen patients (13.6%) underwent surgery for infected AAA. The incidence of infected AAA was 16.1 per cent among patients with AAA. Fifteen patients (11.4%) had ruptured AAA and 19 patients (14.4%) had aortoiliac occlusive disease. The overall mortality rate was 15.2 per cent. The mortality of elective aortic surgery was 5.1 per cent and of emergency aortic surgery was 44.1 per cent. The mortality of elective AAA repair was 4 per cent. Multiple system organ failure was the most common cause of death (80%), followed by acute myocardial infarction (10%) and exsanguination (10%). The authors conclude that elective surgery on the abdominal aorta is safe and should be performed when indicated to prevent the development of complications requiring emergency surgery which carries a much higher risk.