Search

Background: The aim of this study was to determine the long-term symptom control after laparoscopic fundoplication for gastroesophageal reflux disease (GERD), and possible prognostic factors., Methods: A cohort of 271 patients, operated on at a university hospital from 1996 through 2002, was eligible for evaluation after a median interval of 102 months (range = 12-158). The time between surgery and recurrence of reflux symptoms (i.e., time to treatment failure) served as the end point for statistical analysis. Putative risk factors for symptom recurrence were analyzed by univariate analysis and by using Cox's multiple-hazards regression., Results: According to Kaplan-Meier estimates, the rate of reflux symptom recurrence was 15 % after 108 months, 11 % in cases without intestinal metaplasia, but 43 % in patients with long-segment (≥ 3 cm) Barrett's esophagus (BE; p < 0.0001). Reflux symptoms recurred in 22 % of cases with a hiatal hernia (HH) ≥ 3 cm before operation, but only in 7 % with smaller or absent HH (p = 0.005). Multivariate analysis revealed a relative risk of 6.6 (CI = 3.0-13.0) for long-segment BE and 3.0 (CI = 1.7-10.1) for HH ≥ 3 cm. A strong statistical interaction was found between HH ≥ 3 cm and long-segment BE: the small group (n = 18) of cases exhibiting both risk factors had an exaggerated recurrence rate of 72 % at 108 months., Conclusions: Laparoscopic fundoplication for symptomatic GERD provided a long-lasting abolition of reflux symptoms in 231 of 271 (85 %) patients. HH ≥ 3 cm and long-segment BE were shown as independent prognostic factors favoring recurrence.

Background: The impact from the mode of operation (partial vs total fundoplication) on long-term outcome after fundoplication still is unknown, although short-term randomized studies have not shown significant differences in the efficacy of reflux control. To obtain some insight concerning the long-term results, the data of a nonrandomized cohort were analyzed using propensity score statistics., Methods: For 134 patients who underwent laparoscopic fundoplication for gastroesophageal reflux disease (GERD), the time until recurrence of reflux symptoms was assessed. The impact of putative prognostic factors and the mode of operation (partial vs total fundoplication) on outcome were tested for significance using univariate and multivariate statistics, including the propensity score, correcting for nonrandomized treatment groups. The follow-up period was 60 to 123 months (median, 93 months). In this study, 45 patients had a partial (Toupet) fundoplication, and 89 patients underwent a total (Nissen) fundoplication., Results: The rate of recurrence after 93 months (the median follow-up interval) was 14% after Nissen and 9% after Toupet fundoplication (nonsignificant difference) as estimated according to Kaplan and Meier. Massive acid exposure to the esophagus was associated with an increased risk of recurrence for 23% of the patients with a DeMeester score of 50 or higher, but only for 9% of the patients with less severe reflux (DeMeester score <50; p < 0.05). Multiple proportional hazard regression using the propensity score did not show additional significance for the variables of age, gender, presence of a Barrett esophagus, and mode of operation., Conclusion: The operation method did not have a significant impact on the efficacy of laparoscopic fundoplication in a cohort during a follow-up period of 60 to 123 months (median, 93 months).

Background: This study was designed to assess the relationship between gastric emptying of glucose solution and the ensuing plasma concentrations of glucagon-like peptide-1 (GLP-1), peptide YY (PYY), and glucose-dependent insulinotropic polypeptide (GIP) in patients having undergone fundoplication for gastroesophageal reflux (GERD)., Subjects and Methods: In 10 male patients the emptying of 50% glucose solution was determined scintigraphically and its relationship with plasma glucose, GLP-1, PYY, and GIP concentrations was studied before and 3 months after fundoplication., Results: In the first 30 min after glucose ingestion, emptying was significantly (p = 0.048) faster after fundoplication than before. Emptying and GLP-1 and GIP correlated: the faster the emptying during the first 30 min the greater the concentrations integrated over that period (p = 0.04; p = 0.01; p = 0.02). Emptying and PYY concentrations were unrelated. In the 120-180 min. period, blood glucose concentrations were lower the faster the emptying in the initial 30 min (p = 0.06) and the entire 50-min recording period (p = 0.03) had been. The GLP-1 concentrations integrated over the first 30 min correlated inversely with the integrated plasma glucose during the third hour after ingestion (p = 0.004)., Conclusions: After fundoplication, gastric emptying may, if accelerated in its initial phases, give rise to greater and earlier increases in plasma glucose, GLP-1, and GIP concentrations and thus to reactive hypoglycemia.

In comparison with the older technique of ligation of the anomalous coronary artery in Bland-White-Garland syndrome, the various methods of revascularisation have in common the concept of a two coronary artery system. Between 1980 and 1992, 10 children from 6 weeks to 11 years of age (mean 2 years) underwent revascularisation: direct reimplantation of the coronary ostium from the pulmonary artery to the aorta (n = 7), modified implantation with coronary artery elongation (n = 1), bypasses using subclavian artery (n = 1) or the mammary artery (n = 1). Postoperatively, 2 infants died, both following direct reimplantation, resulting in an overall mortality of 20%. There was no late death. All children but one are asymptomatic and do not require medication on follow up for between 3 months and 12 years (mean 5 years) after the procedure. Echocardiography, cardiac catheterisation, and scintigraphy show a significant improvement of left ventricular function and, as a direct consequence, a decrease in preexisting mitral insufficiency. Hence any surgical manipulation at the mitral valve should be avoided at the initial operation. As a principle, the revascularisation procedure should be performed at the earliest possible time to avoid further ischemic myocardial damage. On long-term follow-up, ventricular function and prognosis of the residual low-degree mitral insufficiency remain unclear and require regular control examinations.

Body composition and energy expenditure were investigated before and 10-14 days after surgery in 44 patients with upper gastrointestinal cancer (23 esophageal and 21 gastric cancer) in order to assess the impact of preoperative weight loss on metabolic adaptation to the surgical trauma and on postoperative complications. Patients were divided in three groups with I: 0-5%, II: 5-10% and III: greater than 10% preoperative weight loss related to the usual body weight. 50% of the patients presented with no or just minor weight loss. Even in case of weight loss greater than 10% no decrease below the ideal body weight was observed. Body cell mass and fat mass were significantly (p less than 0.05) reduced in group III when compared with I. Since energy expenditure and substrate oxidation rates were rather normal in most patients weight loss was considered to be due to tumor related stenosis and dysphagia. More than 50% of the energy requirements were gained from fat oxidation. General criteria of malnutrition were not fulfilled. Perioperative weight loss was lowest (1.6 +/- 4.9 kg) in patients of group III related to group I (2.9 +/- 1.7 kg) and II (5.0 +/- 6.9 kg). Similar elevation of energy expenditure and lipid oxidation with concomitant reduction in glucose oxidation was observed in all groups of patients. This led to a similar decrease of body cell mass. Independent of preoperative weight loss major complications occurred in 8 cases--pneumonia in 6 and leakage of the anastomosis in 2 patients; no patient died. From this study can be concluded that with regard to perioperative weight loss the metabolic response to surgical trauma is adequate even in patients with marked preoperative weight loss. These patients remain compensated and preoperative weight loss is without major effect on postoperative complication rate.

The impact of distal resection margins and the mode of operation on pelvic recurrence rate was assessed in 331 cases following abdomino-perineal resection (APR; n = 134), and anterior resection (AR; n = 197) for rectal cancer. Local recurrence was observed in 55 cases (16.6%) after a median interval of 16 months. Only 20 of 212 patients (9.4%) without positive lymph nodes developed a local recurrence, but 35 of 119 (29.4%) with nodal involvement. The recurrence rate was 33% (10/30) in cases with local spread to adjacent structures (T4), and 15% in cases with less extensive penetration. Of 59 poorly differentiated cancers 15 developed pelvic failure (25%), as opposed to 40 of 272 (14.7%) well or moderately differentiated tumours. 17.7% developed local recurrence after AR, and 14.9% after APR. The recurrence rate following AR was 30% in 33 cases with resection margins less than or equal to 10 mm and 17.4% in 115 cases with margins from 11 to 40 mm, and 10% in 49 cases with wider margins. Cox's multiple proportional hazards regression revealed that nodal involvement (p = 0.0003), local invasion (p = 0.0055), poor differentiation (p = 0.066), and AR vs. APR (p = 0.099) were independent risk factors for pelvic failure. For the AR cases the factors were nodal involvement (p less than 0.0001), local invasion (p = 0.0043), and a resection margin less than or equal to 25 mm on the fixed specimen (p = 0.0039). For patients with negative lymph nodes local invasion was the only independent risk factor, whereas the variables "anterior resection" and narrow resection margin were significant only in node positive cases.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of thermic and laser energy applied onto human in vivo gastric wall has not yet been reported in literature. In our study we evaluated the maximum amount of energy not harming the patient as well as principles for secure and sufficient therapy. In 8 patients hospitalized for gastric resection we applied vaporization by laser- and hydrothermosounds in this part of the stomach which should be resected. Endoscopic pictures were taken. We used a NdYAG laser (maximum performance 70 W, time of application 1-3 s) and hydrothermosounds (maximum performance 170 W, time of application 1-3 s). The stomach was resected 3-8 days following application. Comparing laser- and hydrothermosounds marks we observed a bigger area of necrosis at hydrothermosounds marks using the same amount of energy. In histological investigation correlation between depth and diameter of necrosis was found. After the same application time both depth and diameter of necrosis were bigger by hydrothermosounds than by laser. Lesions reached serosa at the maximum time of application of 3 s. Serosal lesion itself did not appear. Endoscopic treatment of tissue lesion by laser and thermic irradiation (vaporization of bleeding polyp pedicles, treatment of tumors) is secure using the maximum energy mentioned above. Serosal lesion did not appear. Bleeding lesions must be treated by higher energy because of absorption of energy by escaped blood.

The case report is presented of a newborn that developed pseudomembranous colitis and intestinal obstruction after antibiotic therapy with cefoxitin and gentamicin in the first week of life. At laparotomy on the fifth day a complete obliteration of the descending colon by pseudomembranes was encountered. After resection of the diseased segment the recovery was uneventful. We believe this case is the first to be published of antibiotic-associated pseudomembranous colitis causing intestinal obstruction.

A horizontal submammary skin incision was chosen as approach route to median sternotomy in 36 patients undergoing cardiac operations. The low complication rate in conjunction with a cosmetically acceptable result makes this procedure the method of choice for selected patients. The potentially higher risk of infection should not be overlooked when planning the operation.

Between 1971 and 1988 74 operations for intestinal complications following radiotherapy were performed on 67 patients at the Second Surgical Department, University of Vienna. The lesions were located in the small bowel (n = 41) and in the sigmoid colon/rectum (n = 33). 98.5% of the patients were females, the most frequent cause for irradiation being ovarian cancer. Bowel stenosis with resultant chronic or acute ileus was the most frequent indication for operation, occurring in 31 cases (76%) of the small bowel lesions and in 15 cases (46%) of the colon lesions. Percutaneous irradiation resulted in a significantly higher proportion of small bowel lesions (77%, p = 0.001), whilst endocavitary irradiation was followed in 67% of cases by colorectal lesions. Different application modality of irradiation also resulted in completely different symptoms for small and large bowel lesions. The operative mortality was 9.5%. Peritonitis following anastomotic leakage was the cause of death in 6 of 7 cases. In the treatment of small bowel ileus mortality following bowel resection (9%, one of 11 cases) was comparable to that of the bypass operation (6%, one of 18 cases). Both operation methods seem to be justified. Single-layer anastomosis resulted in zero mortality in 21 cases of ileus operated on by this technique, compared with 19% mortality in 16 cases treated by double-layer anastomosis and should be preferred for operations on the irradiated bowel.

Antibiotic prophylaxis with 2 g Cefamandole at induction of anaesthesia was performed in 12 male patients undergoing aortocoronary bypass surgery. Caused by hemodilution, there was a marked decrease of serum concentration at the beginning of extracorporeal circulation, from 110.96 +/- 40.29 mcg/ml to 70.89 +/- 34.65 mcg/ml within 10 min. During extracorporeal circulation, elimination was as fast as before and after perfusion. 240 min after application, mean serum concentrations of 16.80 +/- 9.32 mcg/ml were measured. Failure of antibiotic prophylaxis in operations exceeding 4 h might be due to unadaequate antibiotic concentrations, beyond the minimal inhibitory concentration for the pathogens, reported to cause infections after cardiac operations.

Reaccumulation of ascitic fluid after peritoneovenous shunt implantation demands accurate diagnostic procedure. Between 1973 and 1985 81 peritoneovenous shunts have been implanted at the IInd Surgical Department of the University of Vienna. In the same time 34 reoperations in 17 patients have been performed for reasons of shunt-dysfunction. Besides thorax x-ray, diagnosis was established in 11 cases by means of Doppler ultrasound investigation, in 26 cases by technetium scan and in 15 cases by shunt angiography. Shuntography proved to be the method of choice, with no false results. Doppler ultrasound results were unclear in a high percentage, thus this method is not used any more.