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BACKGROUND: Gastroesophageal reflux disease (GERD) is a common disease and can successfully be treated by laparoscopic fundoplication. The Nissen and the partial posterior fundoplication (Toupet) are the most widespread documented techniques. METHODS: Detailed description of the operative techniques and results including review of the literature. RESULTS: The Nissen- and partial posterior fundoplication (Toupet) can cure GERD symptoms and improve quality of life, they can cure esophagitis and are able to prevent carcinogenesis. CONCLUSIONS: The laparoscopic Nissen fundoplication represents the gold standard in antireflux surgery, although in some publications, it is challenged by the partial posterior fundoplication (Toupet) regarding postoperative side effects.

In patients with gastroesophageal reflux disease (GERD) it is still controversial as to which type of antireflux procedure—the Nissen or the partial posterior fundoplication—offers the lower rate of side effects in the long term. In this follow-up study the Nissen fundoplication was performed only in GERD patients with normal oesophageal peristalsis. The partial posterior fundoplication was preserved for patients with weak peristalsis. Only patients with effective postoperative control of GERD were included in the study. The study groups consisted of 77 patients who underwent the Nissen fundoplication and 132 patients who underwent partial posterior fundoplication. Clinical assessment of side effects was performed after a median of 52 months following surgery. Manometric assessment of the lower esophageal sphincter (LES) and of esophageal peristalsis was achieved 6 months after surgery. Side effects such as dysphagia, bloating, inability to belch and vomit, epigastric pain and early satiety were significantly more common after the Nissen fundoplication than after partial posterior fundoplication. Improvement of the antireflux barrier was equal in both groups; however, LES relaxation was incomplete following the Nissen fundoplication but normal after partial posterior fundoplication. Partial posterior fundoplication resulted in improved oesophageal peristalsis, whereas the Nissen fundoplication caused slight impairment of peristalsis. Partial posterior fundoplication is a more physiological antireflux procedure than the Nissen fundoplication, and, therefore, this operation has now become our preferred technique for all GERD patients.

Bilateral parathyroid exploration is still the standard therapeutic procedure for primary and recurrent hyperparathyroidism (HPTH). Since a unilateral surgical strategy that reduces surgical complications should not increase the risk of missing enlarged parathyroid glands, reliable preoperative imaging is the first requirement for this approach. This study was conducted to assess the accuracy of preoperative (99m)TcO(4)-(201)T1 pinhole subtraction single photon emission computed tomography (SPECT) compared with sonography.The study population consisted of 15 patients with primary (n = 13) or recurrent (n = 2) HPTH who underwent preoperative (99m)TcO(4)-(201)T1 pinhole subtraction SPECT. Preoperative sonography was also done in 14 of these patients.(99m)TcO(4)-(201)T1 pinhole subtraction SPECT was significantly more accurate than sonography. It had an overall accuracy of 80% in detection of enlarged parathyroid glands. The accuracy of localization increased to 92.3% in patients with solitary adenomas, and to 100% in those with solitary adenomas and no previous parathyroid exploration.The high accuracy of preoperative localization with (99m)TcO(4)-(201)T1 pinhole subtraction SPECT in patients with primary and recurrent HPTH allows for an imaging-guided unilateral operative strategy in most patients, even those with concomitant nodular goiters. This may reduce the risk of surgical complications and expand the use of minimally invasive techniques in parathyroid surgery.

Gastroesophageal reflux disease (GERD) is caused by a mechanically defective lower esophageal sphincter (LES) and may be worsened by impaired esophageal peristalsis. The aim of this study was to evaluate the efficacy of medical treatment depending on the function of the LES and esophageal peristalsis. We studied 128 GERD patients with mild esophagitis. Group 1 (N = 26) consisted of patients with a normal LES and normal esophageal peristalsis. Group 2 (N = 63) comprised patients with a defective LES but normal peristalsis. Patients of group 3 (N = 39) had a defective LES as well as impaired esophageal peristalsis. The patients were continuously treated with omeprazole. Clinical evaluation and endoscopy were repeated after 3, 6, and 12 months. Recurrence of GERD was diagnosed if there was relapse of heartburn and/or esophagitis. The recurrence rate was 7.7% in group 1, 38.1% in group 2 (P < 0.05) and 79.5% in group 3 (P < 0.05). In conclusion, in GERD patients with a mechanically defective LES, especially in those with deteriorated esophageal peristalsis, antireflux surgery should be considered since medical therapy reveals a high recurrence rate.

Background: Gastro-oesophageal reflux disease has a complex pathophysiology. Therefore, therapeutic considerations should not only include the peptic component of the disease. Methods: A variety of studies in rats and in humans demonstrate the consequences of gastro-oesophageal reflux and medical and surgical interventions in terms of inflammation, epithelial growth stimulation, apoptosis and oxidative stress in the epithelium of the oesophagus. Results: Gastro-oesophageal reflux disease consists of a variety of pathophysiologically important factors. These include changes in the anatomy, gastro-oesophageal motility, epithelial growth, inflammation, apoptosis and molecular structure and may lead to carcinogenesis. Surgery restores the antireflux barrier and improves oesophageal and gastric motility, thus preventing the consequences of the disease. Conclusions: Antireflux surgery provides a causative therapy of gastrointestinal reflux disease.

Background: Adjustable gastric banding and esophagogastric banding may affect the function of the lower esophageal sphincter (LES) and esophageal motility in the long-term. Both methods were evaluated in a prospective randomized trial. Materials and Methods: Group 1 comprised 28 patients who underwent laparoscopic adjustable gastric banding and Group 2 consisted of 24 patients in whom adjustable esophagogastric banding was performed. Swedish Adjustable Gastric Bands® were used in all patients. Body mass index (BMI), perioperative complications and reflux symptoms were assessed and upper gastrointestinal endoscopy, esophageal barium studies, esophageal manometry and 24-hour esophageal pH-monitoring were performed pre- and postoperatively. 18 (Group 1) and 14 (Group 2) patients completed the postoperative follow-up procedure after a median of 23 and 24 months, respectively. Results: Postoperatively the median BMI dropped equally in both groups. Perioperative complications requiring re-intervention were significantly more frequent in Group 2 than in Group 1. Heartburn improved equally in both groups following surgery; however, regurgitation and esophagitis were significantly more common in Group 2 than in Group 1.24-hour esophageal pH-monitoring and the LES resting pressure improved equally in both groups, but there was a significant impairment of the LES relaxation and the esophageal peristalsis, which was more pronounced in Group 2 than in Group 1. This caused significant esophageal stasis as shown by barium studies. Conclusions: Both techniques, gastric and esophagogastric banding, provide effective weight loss in morbidly obese patients but affect the esophagogastric junction. Although both procedures strengthen the antireflux-barrier, LES relaxation becomes impaired, thus promoting esophageal dilatation and esophageal stasis. This is more pronounced following esophagogastric banding than following the classic procedure. Since the esophagogastric banding results in more complications requiring re-intervention, we believe that this procedure should not be used any more.

Background: Patients with gastroesophageal reflux disease (GERD) have alterations of gut neuropeptides, such as neurotensin (N) and motilin (M), which are resolved following antireflux surgery. Obesity is associated with GERD. Since the adjustable gastric band prevents gastroesophageal reflux in morbidly obese patients, this study was performed to investigate plasma levels of N and M before and after adjustable gastric banding (AGB). Methods: 47 morbidly obese patients were operated laparoscopically using the Swedish AGB. Preand postoperatively basal plasma levels of N and M were investigated. Symptoms such as heartburn, regurgitation and dysphagia were documented, and esophageal manometry as well as 24-hour pH-monitoring were performed pre- and postoperatively. 11 non-obese, asymptomatic, age-matched volunteers served as controls. Results: After a median postoperative follow-up period of 268 days, a significant weight reduction was observed. Preoperatively, 14 patients suffered from reflux symptoms. An insufficient lower esophageal sphincter (LES) was found in 8 patients, and 2 patients had impaired esophageal body motility. Pathologic pH-testing was found in 6 patients. Postoperatively, reflux symptoms were present in 4 patients; LES findings and pH-testing were normalized in all patients. However, there was significant impairment of esophageal peristalsis. Preoperatively, levels of N were significantly decreased and levels of M increased compared with control subjects. Postoperatively, there was a significant increase of N and levels of M were normalized. Alterations in gut neuropeptides did not correlate with reflux symptoms, impaired gastroesophageal motility, age, gender or BMI. Conclusion: Morbid obesity alters gut neuropeparetides, which are resolved by AGB. This may be caused by reduction of hypercaloric nutrition post-operatively rather than by improvement of gastroesophageal reflux.

LaparoscopicToupet Fundoplication in Patients with Gastroesophageal Reflux Disease and Impaired Esophageal Peristalsis In patients with gastroesophageal reflux disease and impaired

Background: Gastroesophageal reflux disease (GERD) may cause alterations of gut neuropeptides such as motilin and neurotensin that are known to control foregut motility. The aim of this study was to investigate whether these alterations may be resolved following antireflux surgery. Methods: Basal and postprandial plasma levels of motilin and neurotensin were measured in 20 GERD patients preoperatively and 6 months after antireflux surgery. There were 9 patients with normal esophageal peristalsis and 11 with poor esophageal body motility. Eleven healthy subjects served as control group. Results: GERD patients with poor esophageal body motility had low basal plasma levels of motilin and high levels of neurotensin. Postprandial motilin levels were significantly increased in these GERD patients. After antireflux surgery, all observed alterations of gut neuropeptides returned to normal values. Conclusions: Alterations of gut neuropeptides may be implicated in the pathophysiology of impaired esophageal peristalsis in GERD. Antireflux surgery restores normal physiology of gut neuropeptides. This may contribute to improvement of foregut motility in GERD, thus counteracting duodenogastric reflux.

Since the first laparoscopic fundoplication was performed, the frequency of antireflux surgery has increased rapidly with some centers now having an experience of about 1,000 procedures. The question arises whether this increase is due to a change in indications for the surgical treatment of gastrointestinal reflux disease (GERD) despite the simultaneous appearance of powerful antisecretory medications. Adequate knowledge of the pathophysiology of GERD is necessary in order to establish selection criteria for patients suitable for laparoscopic antireflux surgery. In this article, we review the epidemiology and pathophysiology, and provide a rationale for medical and surgical treatment. We also offer an approach to patient selection for antireflux surgery.

Background: Gastroesophageal reflux disease (GERD) is a common condition and may frequently lead to dysphagia and respiratory symptoms. The aim of this study was to investigate the effects of medical and surgical therapy to control these symptoms. Methods: Eighty GERD patients with either dysphagia or respiratory symptoms were studied by means of a detailed symptom questionnaire, upper gastrointestinal endoscopy, esophageal manometry, 24-h esophageal pH monitoring and a barium esophagogram. All patients had been receiving medical therapy with proton-pump inhibitors and cisapride for 6 months. After withdrawal of medical therapy and relapse of GERD, 62 patients decided to undergo anti-reflux surgery (laparoscopic Nissen fundoplication in 19 and laparoscopic partial posterior fundoplication in 43 patients). Symptoms were assessed prior to treatment, at 6 months following medical therapy and 6 months after surgery. Results: Heartburn and esophagitis were effectively treated by medical and surgical therapy. Dysphagia was improved in all patients following surgery but only in 27% of patients following medical therapy. Improvement of respiratory symptoms was found in 86% of patients following surgery but only in 14% following medical therapy. Improvement of regurgitation was registered only following surgical therapy. Conclusions: Since medical treatment is likely to fail in GERD patients with complex symptoms such as dysphagia, regurgitation and respiratory symptoms, the need for surgery arises in these patients and may be the only successful treatment in the long term.

BACKGROUND: Poor esophageal body motility and trapping of the hernial sac by the hiatal crura are the major pathomechanisms of gastroesophageal reflux disease (GERD)-induced dysphagia. There is only little knowledge of the effect of medical therapy or antireflux surgery in reflux-induced dysphagia. METHODS: Fifty-nine consecutive GERD patients with dysphagia were studied by means of a symptom questionnaire, endoscopy, barium swallow, esophageal manometry, and 24-hour pH monitoring of the esophagus. Patients had proton pump inhibitor therapy and cisapride for 6 months. After GERD relapsed following withdrawal of medical therapy, 41 patients decided to have antireflux surgery performed. The laparoscopic Nissen fundoplication was chosen in 12 patients with normal esophageal body motility and the laparoscopic Toupet fundoplication in 29 patients with impaired peristalsis. Dysphagia was assessed prior to treatment, at 6 months of medical therapy, and at 6 months after surgery. RESULTS: Heartburn and esophagitis were effectively treated by medical and surgical therapy. Only surgery improved regurgitation. Dysphagia improved in all patients following surgery but only in 16 patients (27.1%) following medical therapy. Esophageal peristalsis was strengthened following antireflux surgery. CONCLUSIONS: Medical therapy fails to control gastroesophageal reflux as it does not inhibit regurgitation. Thus, it has little effect on reflux-induced dysphagia. Surgery controls reflux and improves esophageal peristalsis. This may contribute to its superiority over medical therapy in the treatment of GERD-induced dysphagia.

Duodenogastric reflux (DGR) in rats causes growth stimulation of the foregut mucosa that is potentiated by gastric acid blockade. It was the aim of this study to investigate if DGR with gastric acid blockade has a higher incidence of carcinomas of the foregut than DGR alone. DGR was induced in 40 Sprague-Dawley rats using a split gastroenterostomy. A cardiomyotomy was performed across the gastroesophageal junction, inducing reflux into the esophagus. Twenty of these rats received omeprazole postoperatively. After one year 18 rats (90%) with DGR + omeprazole treatment and 7 rats (35%) with DGR alone developed adenocarcinoma of the stomach (P < 0.05). None of the rats developed esophageal cancer, but esophageal mucosal hyperplasia was more pronounced in rats receiving omeprazole. Control rats, treated with omeprazole, did not develop carcinomas of the foregut. In conclusion, gastric acid blockade enhanced DGR-induced carcinogenesis of the stomach and promotes growth stimulation of the esophageal mucosa.

Background: Apoptosis maintains cell homeostasis. Altered apoptosis is involved in carcinogenesis. It was our aim to investigate whether reflux esophagitis may alter apoptosis in the esophageal mucosa and whether antireflux surgery may restore normal apoptosis. Methods: Apoptosis was studied preoperatively and postoperatively in esophageal biopsies of 39 patients with various grades of reflux esophagitis and in Barrett’s mucosa using the TUNEL method. Biopsies were also taken from lesions of the squamous epithelium adjacent to the Barrett’s mucosa. Results: Apoptosis increased with the severity of esophagitis. Apoptosis was low in Barrett’s epithelium. Squamous epithelium adjacent to Barrett’s mucosa showed increased apoptosis. After surgery apoptosis decreased in squamous epithelium, and it remained low in Barrett’s epithelium. Conclusions: Apoptosis in reflux esophagitis may be protective against increased proliferation. Low apoptosis following antireflux surgery indicates that surgery is effective to prevent reflux-induced cell proliferation. Inhibition of apoptosis in Barrett’s may promote carcinogenesis. This may not change following surgery.

The Dieulafoy lesion is a rare cause of severe gastrointestinal hemorrhage. The lesion is usually located in the stomach, although it may occur anywhere in the gastrointestinal tract. We describe four patients with extragastric Dieulafoy's disease, in the duodenum (one), the proximal jejunum (two), and the left hemicolon (one). Diagnosis was made by endoscopy in all four and confirmed by histology in three. The pathology of the Dieulafoy lesion is essentially the same throughout the gastrointestinal tract. Endoscopic treatment by sclerotherapy combined with electrocoagulation was successful in the duodenal and colonic Dieulafoy lesions, but not in the jejunal lesions.

Partial posterior fundoplication improvesesophageal peristalsis in patients with gastroesophagealreflux disease (GERD) associated with poor esophagealbody function. The aim of this study was to investigate whether postoperative administration ofcisapride enhances the effect of surgery on esophagealperistalsis. Laparoscopic partial posteriorfundoplication was performed on 34 consecutive GERDpatients with poor esophageal body motility. These patientswere randomized in groups without and with postoperativetreatment with cisapride 20 mg twice daily for sixmonths. Esophageal manometry was performedpreoperatively and six months following surgery. Esophagealbody function improved significantly following partialposterior fundoplication without or with postoperativetreatment with cisapride. However, this effect was more pronounced in the group of patientsreceiving cisapride. Partial posterior fundoplicationcombined with postoperative treatment with cisaprideshould be the therapy of choice in GERD patients with poor esophageal body motility.

Background/Aim: Appendicitis and its complications remain a common problem affecting patients of all age groups. Foreign bodies are a rare cause of appendicitis. We tried to define potentially dangerous foreign bodies that may cause appendicitis and summarize general guidelines for their clinical management. Methods: A 100-year literature review including 256 cases of ingested foreign bodies within the appendix with emphasis on: (1) objects that are more prone to cause appendicitis or appendiceal perforation; (2) foreign bodies that are radiopaque and may be detected during follow-up with plain abdominal films, and (3) guidelines for clinical management. Results: Complications usually occur with sharp, thin, stiff, pointed and long objects. The majority of these objects are radiopaque. An immediate attempt should be made to remove a risky object by gastroscopy. If this fails, clinical follow-up with serial abdominal radiographs should be obtained. If the anatomical position of the object appears not to change and, most commonly, remains in the right lower abdominal quadrant, an attempt at colonoscopic removal is indicated. If this is unsuccessful, laparoscopic exploration with fluoroscopic guidance should be carried out to localize and remove the objects either by ileotomy, colotomy, or by appendectomy. Conclusion: Foreign bodies causing appendicitis are rare. However, if stiff or pointed objects get into the appendiceal lumen they have a high risk for appendicitis or perforation. These foreign bodies are almost always radiopaque.

Die gastroosophageale Refluxkrankheit ist eine Motilitastserkrankung des oberen Gastrointestinaltraktes mit multifaktorieller Genese. Im Vordergrund steht zunachst die mechanische Zerstorung des Antir

Epithelial dysplasia in the gastric remnant is generally considered to have a positive predictive value for malignancy. Whether dysplasia progresses to carcinoma or whether both just have a common origin, is still a matter of controversy. The aim of the present study in rats was to investigate the natural history of epithelial lesions in the gastric remnant. A gastric resection was carried out in 50 male Wistar rats. Postoperatively the animals received N-methyl-N'-nitro-N-nitrosoguanidine orally. Gastroscopy was carried out monthly and biopsies were taken for histologic evaluation. The rats were killed after 12 months or if gastric cancer was found on gastroscopy. Twenty-four rats died postoperatively and were excluded from the study. A total of 228 gastroscopies was performed in the remaining 26 animals; 24 animals developed dysplastic lesions during the follow-up period. The rate of development of gastric cancer within one month increased with the stage of dysplasia at the previous examination (3% for mild, 48% for moderate, 100% for severe dysplasia). There was a strong correlation between the time period following gastric resection and grade of dysplasia and between the grade of dysplasia and development of cancer. Our study demonstrates that gastric stump cancer in rats develops from dysplastic lesions. A dysplasia-carcinoma sequence can therefore be assumed.

The neuropeptides substance P, vasoactive intestinal polypeptide, and the recently discovered peptide secretoneurin are neurotransmitters of the intrinsic nervous system of the gut and effect gut motility. The aim of this study was to investigate whether these neuropeptides are involved in the pathophysiology of large bowel ileus. Five patients underwent colonic resections for obstructive cancer of the colon. Full-thickness specimens of the resected colon were taken 10 cm proximal and 10 cm distal to the site of tumor obstruction. Substance P-, vasoactive intestinal polypeptide-, and secretoneurin-like immunoreactivities were measured in the specimens by radioimmunoassay. In addition immunocytochemistry was performed. Tissue levels of substance P, vasoactive intestinal polypeptide, and secretoneurin were lower in the prestenotic than in the poststenotic bowel segment. In accordance, immunocytochemistry revealed a denser staining of ganglion cells and fibers for all three neuropeptides in the poststenotic bowel. The decreased tissue levels of substance P, vasoactive intestinal polypeptide, and secretoneurin in the prestenotic bowel segment may contribute to the final decompensation of obstructive ileus.

The resting pressure and intraabdominal length are the most important factors which determine competence of the lower esophageal sphincter (LES). The intraabdominal sphincter vector volume (ISVV) is a single value which takes into account both of these measurements. Normal values of ISVV and of the total sphincter vector volume (TSVV) were established in 20 normal subjects. The sensitivity and the specificity of ISVV and TSVV were then evaluated in 81 patients with gastroesophageal reflux disease (GERD) and in 19 normal subjects and were compared with the usual stepwise pullback manometry (SPM) measuring the resting pressure of the LES at the respiratory inversion point. The motorized pullthrough technique was used to perform the vector volume procedure. Normal values of ISVV were 1870–10740 mm Hg2 × mm, and of TSVV 2200–13110 mm Hg2 × mm. The sensitivity of ISVV was 93.8% (p < 0.05), of TSVV 80.2%, and of SPM 81.5%. The specificity of ISVV and TSVV was 89.5% and of SPM 78.9% (not significant). Analysis of the intraabdominal sphincter vector volume is more sensitive than the total sphincter vector volume or standard stationary manometry in establishing a defective LES in patients with GERD. Intraabdominal sphincter vector volume analysis will allow surgeons better to identify patients with a defective LES who may be suitable for antireflux surgery.

Background The Nissen fundoplication, an effective treatment for gastroesophageal reflux disease (GERD), may frequently cause dysphagia in patients with poor esophageal body motility.

Free radical damage in reflux esophagitis of rats induced by 24-hr duodenojejunal ligation was studied. Oxygen free radicals were selectively blocked. Groups were: sham operation, reflux, reflux + superoxide dismutase (SOD), catalase, dimethylthiourea, allopurinol, and inactivated SOD or inactivated catalase alone or in the combination SOD + catalase or SOD + catalase + dimethylthiourea + allopurinol. Macroscopic esophagitis was inhibited only by SOD, alone or in combination with other agents. Esophageal mucosal lipid peroxidation was 10-fold increased in the reflux group compared to the sham group (P0.05). This response was damped by SODcatalase (P0.05) but not by the inactivated enzymes, dimethylthiourea or allopurinol. SOD + catalase showed no significant improvement on SOD alone. Total inhibition of lipid peroxidation was achieved by combining all scavengers. Total glutathione (GSH) in the esophageal mucosa was stimulated by reflux. This response was inhibited by scavengers equivalent to their efficacy in preventing lipid peroxidation. It is concluded that reflux esophagitis is associated with free radical release with O2- being the main source. Free radicals appear to stimulate GSH production in this prolonged oxidative stress.

Free radical-mediated esophagitis was studied during duodenogastroesophageal reflux (mixed reflux) or acid reflux in rats. The influence of reflux on esophageal glutathione levels was also examined. Mixed reflux caused more gross mucosal injury than acid reflux. Gross mucosal injury occurred in the mid-esophagus. Total glutathione (GSH) in the esophageal mucosa of control rats was highest in the distal esophagus. The time course of esophageal GSH in rats treated by mixed reflux showed a significant decrease 4 hr after initiation of reflux, followed by a significant increase from the 12th hour on. Mucosal GSH was increased in both reflux groups after 24 hr but significantly more so in the mixed than in the acid reflux group. The free radical scavenger superoxide dismutase (SOD) prevented esophagitis and was associated with decreased GSH levels. GSH depletion by buthionine sulfoximine (BSO) prevented esophagitis and stimulated SOD production in the esophageal mucosa. It is concluded that gastroesophageal reflux is associated with oxidative stress in the esophageal mucosa. The lower GSH levels in the mid-esophagus may predispose to damage in this area. Duodenogastroesophageal reflux causes more damage than pure acid reflux. Oxidative stress leads to GSH depletion of the esophageal mucosa in the first few hours following damage but then stimulates GSH production. GSH depletion by BSO does not worsen esophagitis since it increases the esophageal SOD concentration.

OBJECTIVE: The open Nissen fundoplication is effective therapy for gastroesophageal reflux disease. In this study, the outcomes in 198 patients treated with the laparoscopic Nissen fundoplication was evaluated for up to 32 months after surgery to ascertain whether similar positive results could be obtained. SUMMARY BACKGROUND DATA: To ensure surgical success, patients were required to have mechanically defective sphincters on manometry and increased esophageal acid exposure on 24-hour pH monitoring. The patients either had severe complications of gastroesophageal reflux disease or had failed medical therapy. These requirements have been found to be necessary to ensure a successful surgical outcome. METHODS: The disease was complicated by ulceration (46), stricture (25) and Barrett's esophagus (33). Patients underwent standard Nissen fundoplications identical in every detail to open procedures except that the procedures were carried out by the laparoscopic route. RESULTS: Perioperative complications included gastric or esophageal perforation (3), pneumothorax (2), bleeding (2), breakdown of crural repair (2) and periesophageal abscess (1). The only mortality occurred from a duodenal perforation. Six patients required conversion to the open procedure. The median hospital stay was 3 days. One hundred patients were observed for follow-up for 6 to 32 months (median 12 months), with outcomes similar to the open Nissen fundoplication. Further surgery was required for two patients who had recurrent gastroesophageal reflux and one who developed an esophageal stricture. Ninety-seven percent are satisfied with their decision to have the operation. CONCLUSIONS: The laparoscopic Nissen fundoplication can be carried out safely and effectively with similar positive results to the open procedure and with all of the advantages of the minimally invasive approach.

Vorliegende Arbeit beschaftigt sich mit der Pathogenese und Diagnostik von Refluxosophagitis und Achalasie. Fur viele dieser tunktionellen Osophaguserkrankungen wird die laparoskopische Operationstechnik nach genauer Indikationsstellung als chirurgische Therapie der Wahl empfohlen. Im Zeitraum zwischen Juli 1991 und November 1992 wurden an der Abteilung fur Allgemein-Chirurgie, Creighton University, Medical School, Omaha, Nebraska 68 Nissen-Fundoplikationen und 10 Kardiomyotomien laparoskopisch durchgefuhrt. Eine umfassende Beschreibung der einzelnen Operationsschritte ist ebenfalls Bestandteil dieser Publikation. Die mittlere Operationsdauer betrug 3,6 Stunden, der Umstieg auf offene Technik 7,6 %. Intra- und postoperative Komplikationen sowie Ergebnisse bezuglich Sphinkterlange, Sphinkterruhedruck und Sphinkterrelaxation bei einer mittleren Beobachtungszeit von 9 Monaten werden detailliert dargestellt und sind mit den Erfolgen nach herkommlichen Techniken vergleichbar bzw. ihnen uberlegen.

This report describes an unusual case of small bowel metastases secondary to carcinoma of the lung in a 60-year-old woman. The patient, who had been operated upon twice for two primary tumors of the lung in May 1985 and March 1990, presented with moderate anemia and a 6-week history of intermittent epigastric pain in October 1990. Esophagogastroduodenoscopy showed a duodenal ulcer without signs of perforation or hemorrhage. Because of the patient's history biopsies were taken and these revealed metastasis of the bronchial tumor. The few previously reported cases of small bowel metastases from lung cancer all presented with severe complications as perforation, hemorrhage or obstruction. In this case early operation prevented severe complications from small bowel metastases secondary to lung cancer.

Primary squamous cell carcinoma (SCC) of the stomach is extremely rare and thought to arise from ectopic squamous epithelium, which in turn could either result from the squamous metaplasia of the gastric mucosa or be congenital in origin. We report herein a case of SCC of the stomach in a 17-year-old male, who died 1 year after undergoing a gastrectomy. To our knowledge, this is the youngest case of primary SCC of the stomach reported in the literature. Further speculative possibilities of the development of primary gastric SCC are discussed following the presentation of this case.

A new method of orotracheal intubation in rats which was developed to prevent apnea during upper gastrointestinal endoscopiy is described. After the anesthetized animals are relaxed with an I. V. injection of Vecuronium, orotracheal intubation was performed with a thin endoscope under complete visual control. After relaxation is achieved the glottis is wide open and intubation can be performed carefully without any medianical irritation of the larynx. After placement of the tube in the trachea, the fiberoptic was removed and pressure–controlled ventilation occurred. This technique can be widely applied in any kind of rat experiment, where controlled ventilation is required.

Background: In patients with primary hyperparathyroidism (HPTH) and previous thyroid operations, complications of parathyroidectomy are more frequent than in patients undergoing initial neck surgery. The aim of this study was to investigate the value of preoperative imaging with regard to its influence on the surgical strategy. Methods: We retrospectively analyzed 17 patients with primary HPTH and previous thyroid surgery. Preoperatively 16 patients underwent sonography and/or scintigraphy. Results: Sonography had an overall accuracy to correctly localize enlarged parathyroid glands of 80%, and scintiscanning had overall accuracy of 78.6%. The accuracy of localization was increased up to 84.6% if both diagnostic procedures were applied. In patients with normal thyroid residues the accuracy of sonography was 85.7%, and it was 100% if scintiscanning was used. Conclusions: Preoperative localization techniques in patients with primary HPTH and previous thyroid surgery have high accuracy. This allows for an imaging-directed operative strategy, thus preventing unnecessary bilateral neck explorations, which carry a high risk of recurrent laryngeal nerve injury.

Although the first laparoscopic Nissen fundoplication was performed almost two decades ago, division of the short gastric vessels is still controversially discussed. The aim of this prospectively randomized trial was to evaluate the clinical and functional outcome following laparoscopic Nissen fundoplication with division versus saving of the short gastric vessels during short- and long-term follow-up. Forty-one consecutive patients (30 men, 11 women) with gastroesophageal reflux disease were allocated to undergo Nissen fundoplication without division (group 1, n = 19) or with division (group 2, n = 22) of short gastric vessels. All patients were evaluated prior to and at 6 months as well as 5 years following fundoplication. Tests included endoscopy, barium swallow, 24-h pH monitoring, and esophageal manometry. Gastroesophageal reflux disease (GERD) symptoms were evaluated and a gastrointestinal quality-of-life index was calculated. Preoperative symptoms such as heartburn (84/86%), regurgitation (79/86%), pulmonary symptoms (47/45%), dysphagia (11/32%), chest pain (16/9%), and globus sensation (21/27%) were seen in groups 1 and 2, respectively. In group 1 regurgitation and mild dysphagia were seen in 7 and 26% of patients, respectively, at 5 years. In group 2 the rate of dysphagia decreased from 32 to 17% during short-term follow-up, but increased thereafter to 18%. Reflux esophagitis (preoperative rates: group 1, 74%; group 2, 59%) disappeared in all patients after fundoplication. Mean operative time (group 1, 109 min versus group 2, 125 min; p

Hypothesis Preexisting gastroesophageal reflux disease (GERD) and esophageal motility disorders may affect the outcome of laparoscopic adjustable gastric banding (AGB). Design Prospective cohort study. Setting Tertiary referral center. Patients Between January 1, 1996, and December 31, 2002, AGB procedures were performed in 587 patients (mean body mass index, 46.7 [calculated as weight in kilograms divided by the square of height in meters]). The study population was composed of patients with preoperative GERD (assessed by a symptom-score questionnaire) and was divided into group 1 (those with preoperative GERD symptoms only) and group 2 (those with preoperative and postoperative GERD symptoms). Interventions Laparoscopic AGB was performed according to the pars-flaccida technique. Main Outcome Measures All patients underwent preoperative and annual postoperative symptom scoring, endoscopy, esophageal barium swallow tests, esophageal manometry, and 24-hour pH monitoring. Results Mean follow-up time was 33 months (range, 12-49 months). A total of 164 patients (27.9%) were diagnosed as having preoperative GERD symptoms. In 112 (68.3%) of these patients GERD symptoms vanished postoperatively (group 1), whereas 52 patients (31.7%) remained symptomatic after undergoing laparoscopic AGB implantation (group 2). Preoperatively, group 2 patients showed significantly poorer esophageal body motility compared with group 1 patients (20.8% vs 12.8% defective propagations; P = .007). In group 2 the mean symptom scores for dysphagia (0.4 vs 0.9) and regurgitation (0.6 vs 1.4) deteriorated significantly following laparoscopic AGB implantation, respectively. Eighteen patients (34.6%) in group 2 developed esophageal dilatation. Conclusions Adjustable gastric banding provides a sufficient antireflux barrier in most of the obese patients with GERD. However, in patients with preoperatively defective esophageal body motility, AGB may aggravate GERD symptoms and esophageal dilatation. Alternative bariatric surgical procedures should be considered in these patients.

Principles The recently introduced robotic surgical systems were developed to overcome the limitations of conventional minimally invasive surgery. We analyse the impact of the da Vinci robotic system on general surgery. Methods The da Vinci operating robot is a telemanipulation system consisting of a surgical arm cart, a master console and a conventional monitor cart. Since its purchase in June 2001, 128 patients have undergone surgery using the da Vinci robot in our department. The mean age of the 78 female and 50 male patients was 52 (range 18-78) years. Results The procedures included 29 cholecystectomies, 16 partial fundoplications, 16 extended thymectomies, 14 colonic interventions, 10 splenectomies, 10 bariatric procedures, 7 hernioplasties, 6 oesophageal interventions, 5 adrenalectomies, 5 lower lobectomies, 4 neurinomectomies and 6 others. 122 of 128 procedures (95%) were completed successfully with the da Vinci robot. Open conversion proved necessary in 4 patients due to surgical problems, and two other procedures were completed by conventional laparoscopy due to robot system technical errors. 30-day mortality was 0%, one redo-operation was necessary and two lower complications not requiring surgical re-intervention occurred. The resection margins of all tumour specimens were histologically tumour free. Conclusions Various general surgical procedures have proved feasible and safe when performed with the da Vinci robot. The advantage of the system is best seen in tiny areas difficult of access and when dissecting delicate, vulnerable anatomical structures. However, in view of longer operating times, higher costs and the lack of adequate instruments, robotic surgery does not at the moment represent a general alternative to conventional minimally invasive surgery.

We report the first robotic resection of an ectopic mediastinal thyroid adenoma in a 72-year-old woman. This intervention was part of staged management for excessive bilateral cervical goiter with intrathoracic dispersion. The robotic resection was found to be feasible and safe. The robotic operating system offers better visual control and operative accuracy than does conventional thoracoscopy.

Background Robotic surgical systems are most effective for operations in areas that are small and difficult to reach. Ideal indications for this new technology have yet to be established. The esophagus possesses attributes that are interesting for general thoracic robotic surgeons. Methods Robotic-assisted thoracoscopic surgery (RATS) using the da Vinci system (Intuitive Surgical, Inc, Mountain View, CA) was performed in six patients with esophageal tumors. This comprised the dissection of the intrathoracic esophagus including lymph node dissection in four patients suffering from esophageal cancer and the extirpation of a benign lesion (one leiomyoma and one foregut cyst) in the remaining two patients. Results All procedures were completed successfully with the robot. The median overall operating time was 173 (160–190) minutes in the oncologic cases and 121 minutes in the benign cases, including the robotic act of 147 (135–160) minutes and 94 minutes, respectively. There were no intraoperative complications. One patient had to undergo a redo thoracoscopy because of a persistent lymph fistula. One cancer patient died after 12 months due to tumor progression and another patient had to be stented due to local tumor recurrence 19 months postoperatively. Conclusions This first small series of various esophageal pathologies treated by robotic-assisted thoracoscopic surgery supports the impression that the esophagus is an ideal organ for a robotic approach. The potential of the da Vinci system, especially for oncologic indications, remains to be proven in future clinical trials.

Gastroesophageal reflux disease (GERD) is the most common foregut disease, with a great impact on quality of life and with intestinal, respiratory and cardiac symptoms and implications of carcinogenesis of the oesophagus. Medical therapy often fails, due to the complex pathophysiology of GERD. Surgery can cure the disease, since it is able to restore the anti-reflux barrier. It improves quality of life and prevents carcinogenesis. Review of the literature and presentation of our own experience and data in a series of more than 4,000 evaluated patients referred for suspected reflux disease, of whom 382 have been operated on. The laparoscopic Nissen fundoplication is the most commonly used operation technique. It provides good long-term results in the majority of patients. However, due to an increase of outflow resistance of the oesophagus this operation is associated with some postoperative side effects. Therefore, alternative anti-reflux procedures may be indicated in selected patients.

Background Successful minimally invasive or imaging-guided operations in patients with primary, recurrent, and persistent hyperparathyroidism are based on the reliability of preoperative parathyroid localization studies. The CT-MIBI image fusion promises a higher diagnostic accuracy than current imaging procedures. The aim of our study was to assess its reliability in correctly detecting enlarged parathyroid glands. Methods In a prospective study 24 consecutive patients underwent CT-MIBI image fusion as preoperative parathyroid localization procedure. The results of technetium 99m sestamibi single photon emission computed tomography (MIBI-SPECT) alone, today the standard method in parathyroid imaging, and CT-MIBI image fusion were analyzed by a blinded reviewer, and the imaging results were compared with the intraoperative findings. Results For CT-MIBI image fusion a sensitivity of 93% and a specificity of 100% in correctly detecting the position of enlarged parathyroid glands was calculated and compared with a sensitivity of MIBI-SPECT of 31% and a specificity of 87% (P

Gastroesophageal reflux disease (GERD) is caused by a mechanically defective lower esophageal sphincter (LES) and may be worsened by impaired esophageal peristalsis. The aim of this study was to evaluate the efficacy of medical treatment depending on the function of the LES and esophageal peristalsis. We studied 128 GERD patients with mild esophagitis. Group 1 (N = 26) consisted of patients with a normal LES and normal esophageal peristalsis. Group 2 (N = 63) comprised patients with a defective LES but normal peristalsis. Patients of group 3 (N = 39) had a defective LES as well as impaired esophageal peristalsis. The patients were continuously treated with omeprazole. Clinical evaluation and endoscopy were repeated after 3, 6, and 12 months. Recurrence of GERD was diagnosed if there was relapse of heartburn and/or esophagitis. The recurrence rate was 7.7% in group 1, 38.1% in group 2 (P0.05) and 79.5% in group 3 (P0.05). In conclusion, in GERD patients with a mechanically defective LES, especially in those with deteriorated esophageal peristalsis, antireflux surgery should be considered since medical therapy reveals a high recurrence rate.

Objectives: The da Vincie surgical robotic system was purchased at our institution in June 2001. The aim of this trial was to evaluate the applicability of the da Vincie operation robot for general thoracic procedures. Methods: The da Vincie surgical system consists of a console connected to a surgical arm cart, a manipulator unit with two instrument arms and a central arm to guide the endoscope. The surgical instruments are introduced via special ports and attached to the arms of the robot. The surgeon, sitting at the console, triggers highly sensitive motion sensors that transfer the surgeon’s movements to the tip of the instruments. The so-called ‘EndoWriste technology’ offers seven degrees of movement, thus exceeding the capacity of a surgeon’s hand in open surgery. We evaluated the role of the robot for several thoracic procedures such as thymectomies, fundoplications, esophageal dissections, resection of mediastinal masses and a pulmonary lobectomy. Results: A total of 10 thymectomies, 16 fundoplications, 4 esophageal dissections, 5 extirpations of benign mediastinal masses and 1 right lower lobectomy was performed with the robot. One resection of a paravertebral neurogenic tumor had to be converted due to surgical problems. A lesion to a left recurrent laryngeal nerve caused transient hoarseness after the extirpation of an ectopic parathyroid in the aortopulmonary window in one patient. The postoperative courses were uneventful and patients were discharged between postoperative days 3 and 8 (with the exception of patients who underwent dissection for esophageal cancer and the patient with conversion to an open access). Conclusions: Advanced general thoracic procedures can be performed safely with the da Vincie robot allowing precise dissection in remote and difficult-to-reach areas. This benefit becomes evident most elegantly in thymectomies, which at our institution have become a routine procedure with the robot. The rigid anatomy of the chest seems to be an ideal condition for robotic surgery. A major limitation for robotic surgery is the lack of more appropriate instruments. This disadvantage becomes most evident in pulmonary lobectomies. q 2004 Elsevier B.V. All rights reserved.

Background: Treatment strategies for idiopathic thrombocytopenic purpura (ITP) are still uncertain and its management is primarily empirical. The aim of this study was to investigate the role of splenectomy in the therapy of ITP and to evaluate whether medical or surgical treatment is superior. Methods Ninety-two patients with ITP were included in the study. All of these patients had medical therapy and 38 of them underwent splenectomy subsequently. Follow-up was completed in 91 patients after a median of 64 months. Results Side effects of medical therapy were noticed in 32 patients (35%), whereas after surgery only 2 patients (5%) had minor complications. A complete or partial remission was achieved in 35 patients (92%) after splenectomy, whereas this was achieved in only 27 patients (30%) after medical therapy. On multivariate analysis splenectomy and age were the only significant independent factors for complete and partial remission. Conclusions Splenectomy is highly effective and safe in the treatment of ITP and is superior over medical therapy. These results should stimulate the discussion about splenectomy for ITP, possibly establishing evidence-based guidelines for surgical treatment in hematology.

This pilot study evaluated the role of the DaVinci operation robot for laparoscopic antireflux surgery.A robot-assisted laparoscopic Toupet-fundoplication was performed on nine consecutive patients with severe gastroesophageal reflux disease using the DaVinci robot system. The operative procedure was performed in the same way as for the conventional laparoscopic procedure. Clinical assessment and endoscopic and manometric follow-up investigations were performed 6 months after surgery in six of the patients.The mean robotic operative time was 173 min (120-235). A mean of 25 min (12-45) was required to establish the pneumoperitoneum, to set the trocars, and to place the robot arms. There were no intraoperative complications. Six months after surgery none of the patients suffered from reflux symptoms and none of the patients had acute esophagitis. Postoperatively one patient complained of mild transient dysphagia. However, persistent dysphagia was not found in any of the patients. One further patient complained of mild bloating. No other side effects occurred. Manometrically there was a significant improvement in the function of the lower esophageal sphincter.The robot-assisted partial posterior fundoplication is a safe procedure and provides a high-quality three-dimensional camera image that is superior to that with the conventional laparoscopic device. The handling of the instruments is precise, and intracorporeal suturing and knot tying is much easier than without the robotic technique. The procedure allows for an accurate approximation of the hiatal crura and for precise construction of the fundic wrap. However, robotic surgery is expensive and the setup of the system is time consuming at present.

Background An imaging-guided unilateral surgical approach in patients with primary hyperparathyroidism (HPTH) requires reliable preoperative localization procedures. Using present imaging techniques, 60% to 80% of patients with primary HPTH can be treated successfully with limited surgery. Thus, further improvement of diagnostic accuracy is required. Computed axial tomography (CAT)–MIBI image fusion was introduced as a new technique for localizing enlarged parathyroid glands. We describe the new method and present its first results. Methods Six consecutive patients with primary HPTH underwent CAT–MIBI image fusion for preoperative parathyroid localization. CAT and technetium-99m–sestamibi scan were performed separately. The patient's head and neck were fixed with the noninvasive Vogele-Bale-Hohner Head Holder (VBH HeadFIX; Medical Intelligence, Schwabmunchen, Germany) and the BodyFIX (Medical Intelligence) vacuum cushion. Radiographic and scintigraphic markers were mounted at the head holder and the patient. CAT and MIBI images were fused by overlaying radiographic markers using a commercial software and workstation. Results In 5 patients, localization and dimension of the solitary adenomas were exactly predicted. In 1 patient with multiglandular disease (3 enlarged glands), CAT–MIBI image fusion was not able to predict multiple gland involvement. However, in a retrospective analysis of the localization study, the other two enlarged parathyroid glands could be correctly identified regarding their site and size. Conclusions First results of CAT–MIBI image fusion are promising. The new technique provides a higher image resolution and better delimitation of enlarged parathyroid glands and adjacent anatomic structures than conventional scintigraphic methods.

Gastroesophageal reflux disease (GERD) is a disease with multifactorial etiology. 1 The impaired lower esophageal sphincter (LES) is the basic anatomic defect that enables reflux of gastric contents into the esophagus. 2 Gastric acid may play an important role in the pathophysiology of acute reflux esophagitis. 1 However, GERD is a general motility disorder of the foregut. It may lead to deterioration of esophageal peristalsis, which impairs esophageal clearance function. 3 This prolongs the presence of the refluxate in the esophagus and may therefore enhance esophageal mucosal damage. 4 Moreover, GERD may result in alteration of gut neuropeptides that are important for the control of antroduodenal motility. 5 Weak antroduodenal motility during the fasting state impairs the clearance function of the stomach and may cause pathologic duodenogastric reflux. 6 Increased concentrations of duodenal contents have been shown in patients with GERD, especially those with Barrett’s metaplasia. 7 Duodenogastroesophageal reflux causes growth stimulation of the foregut mucosa, 8 may enhance production of oxygen-derived free radicals, 9–11 and may alter apoptosis in the esophageal mucosa. 12 These mechanisms may explain the carcinogenic potential of GERD. 13,14 Because of the wide spectrum of pathophysiologic mechanisms in GERD, medical treatment aimed at suppressing gastric acid production does not completely inhibit reflux of all gastroduodenal contents. Therefore, it may be concluded that medical therapy in GERD may not prevent the development of complications such as Barrett’s metaplasia, although patients are free of heartburn and acute esophagitis. 15 It was the aim of this prospective study to investigate whether Barrett’s metaplasia may develop despite effective medical treatment of GERD.

Background: Laparoscopic adjustable gastric banding has become the prefered method for the surgical treatment of morbid obesity in Europe. It is not known whether this procedure may induce gastroesophageal reflux and whether it may impair esophageal peristalsis. Methods: Laparoscopic adjustable gastric banding (Swedish band) was performed in 43 patients (median body mass index [BMI] 42.5 kg/m2). Preoperatively and 6 months postoperatively all patients were assessed for reflux symptoms. In addition all patients underwent preoperative and postoperative endoscopy, esophageal barium studies and manometry, and 24-hour esophageal pH-monitoring. Results: The median BMI dropped significantly to 33.1 kg/m2 (P