Search

OBJECTIVE: To determine the safety and results of laparoscopic resection of benign pheochromocytomas. PATIENTS AND METHODS: We retrospectively reviewed the medical charts of all patients who underwent laparoscopic adrenalectomy for benign pheochromocytomas at all 3 Mayo Clinic sites between January 1, 1992, and December 31, 2001. Demographics, comorbidities, clinical presentation, imaging studies, biochemical findings, operative intervention, and outcome were examined. Long-term follow-up was obtained via chart review and/or by direct telephone contact with the patient or a relative. RESULTS: Twenty-four women and 23 men with a mean age of 53.1 years (range, 16-81 years) underwent attempted laparoscopic resection of pheochromocytomas. In 5 patients, the procedure was converted to open laparotomy because of bleeding (2), inadequate exposure (2), and adhesions (1). The mean tumor size was 4.3 cm. The mean operative time (181.8 vs 1405 minutes; P = .03), mean hospital stay (6.00 vs 2.64 days; P < .001), and mean blood loss (340 mL vs 80 mL; P < .001) were greater in patients who underwent open laparotomy vs those who underwent laparoscopic resection. All specimens were classified as benign. The mean follow-up was 41 months (range, 10-89 months). No patients experienced a recurrence or developed metastatic disease. CONCLUSIONS: In light of surgical and anesthesia expertise, laparoscopic resection of benign pheochromocytomas is safe and effective with resultant short hospital stays. A low threshold to convert to an open procedure reduces operative times and decreases potentially serious complications. Although there have been no recurrences to date, long-term follow-up is required for all patients, especially those with hereditary forms of pheochromocytomas. [ABSTRACT FROM AUTHOR]

Background: Treatment failure with recurrent dysphagia after Heller myotomy occurs in fewer than 10 % of patients, most of whom will seek repeat surgical intervention. These reoperations are technically challenging, and as such, there exist only limited reports of reoperation with esophageal preservation., Methods: We retrospectively reviewed the records of patients who sought operative intervention from March 1998 to December 2014 for obstructed swallowing after esophagogastric myotomy. All patients underwent a systematic approach, including complete hiatal dissection, takedown of prior fundoplication, and endoscopic assessment of myotomy. Patterns of failure were categorized as: fundoplication failure, inadequate myotomy, fibrosis, and mucosal stricture., Results: A total of 58 patients underwent 65 elective reoperations. Four patients underwent esophagectomy as their initial reoperation, while three patients ultimately required esophagectomy. The remainder underwent reoperations with the goal of esophageal preservation. Of these 58, 46 were first-time reoperations; ten were second time; and two were third-time reoperations. Forty-one had prior operations via a trans-abdominal approach, 11 via thoracic approach, and 6 via combined approaches. All reoperations at our institution were performed laparoscopically (with two conversions to open). Inadequate myotomy was identified in 53 % of patients, fundoplication failure in 26 %, extensive fibrosis in 19 %, and mucosal stricture in 2 %. Intraoperative esophagogastric perforation occurred in 19 % of patients and was repaired. Our postoperative leak rate was 5 %. Esophageal preservation was possible in 55 of the 58 operations in which it was attempted. At median follow-up of 34 months, recurrent dysphagia after reoperation was seen in 63 % of those with a significant fibrosis versus 28 % with inadequate myotomy, 25 % with failed wrap, and 100 % with mucosal stricture (p = 0.10)., Conclusions: Laparoscopic reoperation with esophageal preservation is successful in the majority of patients with recurrent dysphagia after Heller myotomy. The pattern of failure has implications for relief of dysphagia with reoperative intervention.

Objective: High-resolution manometry of the esophagus has gained worldwide acceptance, using different solid-state catheters. Thus, normal values for lower esophageal sphincter (LES) resting pressure in suspected gastroesophageal reflux disease patients have been established using water-perfused manometry. These standard values are commonly applied using also solid-state techniques, although they have never been compared before. The aim of the study was to compare LES measurements obtained with water-perfused manometry with a solid-state technique., Methods: Thirty healthy subjects were studied twice on the same day: Technique 1: Station pull through using a water-perfused catheter with ports arranged at 0°, 90°, 180° and 270° which were averaged to give a mean LES pressure. Technique 2: Solid-state circumferential probe with a single station pull through. Data were collected using the same computer system and program. The LES pressures were randomly and blindly analyzed., Results: Twenty-seven subjects out of 30 were analyzed. Using the solid-state system, the mean LES pressure was higher (15.0 vs. 23.3 mmHg, p = 0.003) and 19 of 27 (70%) individual measurements were higher. Two subjects had a hypertensive LES by solid state (58.6 resp. 47.5 mmHg), while their pressures were normal with water-perfused manometry (21.0 resp. 23.4 mmHg). The distal esophageal pressures (mean of pressure at 3 and 8 cm above LES) were the same with the two techniques., Conclusion: In normal control subjects, LES measurement using circumferential solid-state transducers yields higher pressures than standard water-perfused manometry. Which system yields the "true" resting pressure of the physiologic LES remains to be determined.

Background/aims: Achalasia (Ach), diffuse esophageal spasm (DES), nutcracker esophagus (NE), and nonspecific motility disorder (NSMD) are described primary esophageal body motility disorders; however, their clinical symptom correlation is poorly understood. The aim of this study is to examine the association between a patient's presenting symptoms and their manometric diagnosis., Methods: Manometric findings and reported symptoms of all patients undergoing esophageal manometry at the Creighton University Medical Center were prospectively entered in a database. Twenty-four-year data from 1984 through 2008 were accessed and analyzed., Results: Of the 4,215 patients, 130 (3.1%) had Ach, 192 (4.6%) had DES, 290 (6.9%) had NE, 508 (12.1%) had NSMD, and 3,095 (73.4%) had normal esophageal body motility. There was significant symptom overlap between the groups. Ach and DES had a similar symptom distribution, with dysphagia being the predominant symptom. Patients with NE, normal body motility, and NSMD presented predominantly with reflux symptoms. There was an increasing prevalence of esophageal dysmotility (DES and NSMD) with age, and women were found to be more likely to have NE than men., Conclusion: In an individual, reported symptoms do not correlate with their manometric diagnosis in a predictable fashion, and a thorough physiological assessment should be obtained to understand and diagnose the disease process. Esophageal motility deteriorates with age., (Copyright © 2012 S. Karger AG, Basel.)

Organ shortage continues to be a major challenge in transplantation. Recent experience with controlled non-heart-beating or donation after cardiac death (DCD) are encouraging. However, long-term outcomes of DCD liver allografts are limited. In this study, we present outcomes of 19 DCD liver allografts with follow-up >4.5 years. During 1998-2001, 19 (4.1%) liver transplants (LT) with DCD allografts were performed at our center. Conventional heart-beating donors included 234 standard criteria donors (SCD) and 214 extended criteria donors (ECD). We found that DCD allografts had equivalent rates of primary non-function and biliary complications as compared with SCD and ECD. The overall one-, two-, and five-yr DCD graft and patient survival was 73.7%, 68.4%, and 63.2%, and 89.5%, 89.5%, and 89.5%, respectively. DCD graft survival was similar to graft survival of SCD and ECD in non hepatitis C virus (HCV) recipients (p > 0.370). In contrast, DCD graft survival was significantly reduced in HCV recipients (p = 0.007). In conclusion, DCD liver allografts are durable and have acceptable long-term outcomes. Further research is required to assess the impact of HCV on DCD allograft survival.

Hypothesis: Laparoscopic resection of gastric gastrointestinal stromal tumors (GISTs) is safe and effective., Design: Retrospective medical record review., Setting: Tertiary referral center., Patients: Patients undergoing laparoscopic resection of gastric GISTs from April 1, 2000, to April 1, 2006., Main Outcome Measures: Demographic data, diagnostic workup, operative technique, tumor characteristics, morbidity, mortality, and follow-up., Results: Thirty-three patients underwent attempted laparoscopic resection of gastric GISTs, with 31 operations completed laparoscopically. The mean patient age was 68 years (age range, 35-86 years). The female to male ratio was 18:15. Sixteen patients (49%) were asymptomatic, and their tumors were found incidentally. Of 24 patients (73%) who underwent preoperative endoscopic ultrasonography, the results of fine-needle aspiration verified the diagnosis in 13 patients (54%). The mean operative time was 124 minutes (range, 30-253 minutes). A combined endoscopic-laparoscopic approach was used in 11 patients (33%). The mean tumor size was 3.9 cm (range, 0.5-10.5 cm). Two patients (6%) underwent conversion to an open procedure. The median hospital stay duration was 3 days. The mean follow-up was 13 months (range, 3-64 months). There were no local recurrences. Three patients (9%) experienced complications, including 1 wound infection and 2 episodes of upper gastrointestinal tract bleeding. There were no mortalities., Conclusion: Although technically demanding, the laparoscopic approach to gastric GISTs is safe and effective, resulting in a short hospital stay duration and low morbidity.

Diffuse esophageal spasm is a motility disorder of undetermined cause. The optimal treatment remains controversial, and evidence-based data are lacking. Several medical treatment modalities have been proposed, but none has emerged as the treatment of choice. Patients who do not respond to medical therapy may be considered for surgical treatment. The surgical treatment of diffuse esophageal spasm is based on similar principles to the treatment of achalasia. A long esophageal myotomy is done to divide the hypertrophied circular muscle that is frequently noted in diffuse esophageal spasm. To protect against postoperative reflux, an antireflux procedure may be added. However, the surgical treatment of diffuse esophageal spasm has not been subjected to randomized clinical trials. The purpose of this article is to provide a review of the available literature regarding the surgical management of the diffuse esophageal spasm. In particular, we offer an appraisal of surgical outcomes, the effects of surgery on manometric and radiologic parameters (when available), complications, and mortality.

Gastroesophageal reflux disease (GERD) has emerged as one of the most common diseases in modern civilization. This article reviews selected changes in epidemiology of GERD during the past decade and provides information on treatment options with a focus on the impact of GERD and potential role of laparoscopic antireflux surgery in patients with diabetes mellitus, obesity, liver cirrhosis, at the extremes of life age and in immunocompromised individuals such as liver and lung transplant recipients.

Background: Late complications are rarely encountered after laparoscopic Nissen fundoplication. These complications include acute gastric herniation through the esophageal hiatus, port-site herniation, recurrent reflux, and anatomic failure of the fundoplication. Only three cases of late gastric perforation after laparoscopic Nissen fundoplication have been reported, all associated with intrathoracic wrap herniation., Methods: We retrospectively reviewed all cases of gastric perforation after laparoscopic antireflux procedures performed between July 1991 and March 2002 by a single surgeon., Results: In this series of 1,600 laparoscopic antireflux procedures, we found six delayed gastric fundal perforations occurring in three patients at 1, 41, 48, 51, 68, and 72 months after surgery. All the perforations were on the anterior wall of the fundus of the stomach and were distant from the stitches of the fundoplication. None of the perforations was associated with severe peritoneal contamination., Conclusions: This series of late gastric fundal perforations in 0.2% of our patients after laparoscopic fundoplication may have been caused by medications, gastric stasis, ischemia, or a foreign body such as a stitch or Teflon pledget.

Background: Ureteral stent placement to localize the ureters during operations is an invasive procedure. The aim of this study was to evaluate the feasibility of using the gamma probe to intraoperatively identify the ureters after intravenous injection of a radiopharmaceutical agent., Study Design: Ten patients undergoing elective abdominal operations were prospectively enrolled in this study. An average dose of 4.5 mCi (range 2.8 to 5.3 mCi) of technetium Tc 99m-labeled diethylenetriamine pentaacetic acid ((99m)Tc-DTPA) was administered intravenously before localization of the ureters. The gamma probe was used to localize the ureters. Correct identification of the ureters was confirmed when gentle manipulation induced a typical ureteral peristaltic pattern., Results: Gamma counts were significantly elevated in all ureters examined. Compared with background counts, gamma counts were increased over the ureter in all patients, with an average increase of 465%. The technique was modified after use in the first 3 patients and standardized for patients 4 through 10. Data from those seven patients were analyzed. Both ureters were correctly identified using the gamma probe at a mean of 15 minutes (median, 10 minutes) after a single (99m)Tc-DTPA injection (range 4 to 41 minutes). The mean background count was 80 counts per second (cps, range 50 to 130 cps). The mean ureter count was 393 cps (range 128 to 700 cps). The average percent increase of each ureter count compared with its specific background count was 465% (range 256% to 1,077%). The difference was statistically significant for all values (p < 0.001)., Conclusions: This novel technique of gamma probe localization of the ureters may offer a noninvasive approach for ureteral identification.

Gastroesophageal reflux disease (GERD) is a common disease and can be successfully treated by laparoscopic fundoplication. This article describes the technique of laparoscopic surgery for GERD with a focus on operative pitfalls.

Laparoscopic antireflux surgery (LARS) provides effective control of gastroesophageal reflux (GER) in more than 90% of patients. Despite this high success rate, some patients continue to consume acid suppressive medications after surgical intervention. In this study we evaluate the prevalence, clinical indications, and cause of use of acid reducing drugs in patients after LARS. Consecutive patients undergoing LARS for GERD were surveyed 2-3 years after surgery regarding use of acid suppressive medications, surgical outcome, and GERD specific symptoms. During the study period, 119 patients underwent LARS at our center. Ninety-eight (82%) were available for interview. Two patients died of unrelated causes and two declined to be interviewed. The remaining 94 individuals are the subject of this report. Ninety-four percent were satisfied with the outcome of surgery. Despite this high satisfaction rate, 37 of 94 (39%) were on antireflux medication (ARM; 62% proton pump inhibitors, 22% H2-receptor antagonists, and 16% others), with 70% using continuous medication. Of these patients, 54% took ARM after surgery for GERD-related symptoms, 95% of these patients responded to medical therapy, and yet again, 85% remained satisfied with the surgical outcome. Forty-six percent of patients on ARM after surgery had no GERD symptoms and took ARM for nonappropriate indications such as bloating. Only 47% of these responded to ARM; 82% of this group was satisfied with the surgical outcome. In conclusion, the use of ARM after LARS is a common occurrence despite a high satisfaction rate with this operation. Nearly half of patients consuming ARS after LARS are taking these medications for symptoms not necessarily related to GER. These findings underscore the importance of patient education in the use of these agents.

Prophylactic placement of feeding jejunostomy tubes in patients undergoing esophagectomy or gastrectomy continues to be a common practice. The aim of jejunostomy is to maintain nutrition, especially with an anastomotic leak. Frequently total or supplemental nutrition through a jejunostomy is not required, rendering prophylactic placement unnecessary. In addition, feeding jejunostomy tubes have potentially serious complications.

Background: Treatment options for achalasia include medications, endoscopic balloon dilation, injection of botulinum toxin, or surgery., Methods: The clinical course of 75 consecutive patients who underwent minimally invasive Heller myotomy and partial fundoplication for achalasia between 1991 and 2001 was reviewed by means of a questionnaire., Results: Mean follow-up was 5.3 (range .8 to 10.9) years. Sixty-four percent of questionnaires were returned. Thirty-seven patients (84%) felt much better and 6 (14%) slightly better; 1 (2%) rated the result as unchanged. Twenty-six patients (59%) experienced weight gain. Seven patients (16%) had persistent swallowing problems and 5 (11%) reported frequent reflux. Twenty-five percent underwent additional therapy, including dilation (n = 8, 18%), repeat surgery (n = 2, 5%), and botulinum toxin injection (n = 2, 5%). Eighteen patients (41%) were using a proton pump inhibitor or H2 blocker, three were on a calcium channel blocker (7%), and 1 was using nitroglycerine (2%)., Conclusion: Laparoscopic Heller myotomy can achieve short- and long-term results comparable to open surgery and should be considered the treatment of choice for patients suffering from achalasia. Despite the frequent need for further therapy, patient satisfaction is good.

We sought to evaluate vagus nerve integrity before and after antireflux surgery and to compare it with symptomatic outcome. Antireflux surgery patients were recruited. Patients with disorders associated with vagus dysfunction or who took medications with anticholinergic effects were excluded. Each patient underwent a sham-feeding-stimulated pancreatic polypeptide (PP) test before and after surgery. A symptom survey was also administered. Twenty patients completed preoperative testing; their mean age was 57 years, and postoperative testing results were available for 16 of them. Of the 20, 14 (70%) had an appropriate increase in PP level with sham-meal preoperatively. All 4 patients with an abnormal preoperative test remained abnormal, and 5 of 12 (42%) with a normal preoperative test had an abnormal postoperative result; thus 9 of 16 (56%) had an abnormal postoperative PP test. In 15 patients, assessments of bowel function were obtained before and after surgery. Six of 15 (40%) patients developed new or worse symptoms (diarrhea in 4, flatus in 2). The symptoms did not correlate with PP results. This suggests that some patients referred for antireflux surgery have evidence of abnormal vagus function that persists after surgery. Many patients (42%) with normal testing before surgery develop an abnormal test after surgery. There was no correlation between PP tests and the development or worsening of bowel symptoms.

Background: The aberrant left hepatic artery (ALHA) is an anatomic variation that may present an obstacle in laparoscopic antireflux procedures. Based on our experience, we addressed the following questions: How frequent is ALHA? When or why is it divided? What is the outcome in patients after division of the ALHA?, Methods: From a prospective collected database of 720 patients undergoing laparoscopic antireflux surgery, we collected the following information: presence of an ALHA, clinical data, diagnostic workup, operative reports, laboratory data, and follow-up data., Results: In 57 patients (7.9%) (37 men and 20 women; mean age, 51 +/- 15.7 years), an ALHA was reported. Hiatal dissection was impaired in 17 patients (29.8%), requiring division of the ALHA. In three patients (5.3%), the artery was injured during dissection; in one case (1.8%), it was divided because of ongoing bleeding. Ten of the divided ALHA (55.5%) were either of intermediate size or large. Mean operating time was 2.2 +/- 0.8 h; mean blood loss was 63 +/- 49 ml. Postoperative morbidity was 5.3% and mortality was 0%. None of the patients with divided hepatic arteries had postoperative symptoms related to impaired liver function. Postoperatively, two patients (11.7%) had transient elevated liver enzymes. At a mean follow-up of 28.5 +/- 12.8 months, no specific complaints could be identified., Conclusions: ALHA is not an uncommon finding in laparoscopic antireflux surgery and may be found in > or =8% of patients. Division may be required due to impaired view of the operating field or bleeding. Patients do not experience clinical complaints after division, but liver enzymes may be temporarily elevated.

Background: The Roux-en-Y loop is an effective procedure for biliodigestive drainage. However, up to 15% of patients suffer from postoperative cholangitis or blind loop syndrome. A new technique to prevent motility abnormalities has been developed., Methods: Male Lewis rats were used to compare gastric emptying and transit in the small bowel after either a standard Roux-en-Y anastomosis or a new biliodigestive anastomosis technique which involves creating an "uncut" jejunal loop with luminal occlusion. Unoperated rats served as controls. (99)Technetium HIDA and (111)Indium-tagged amberlite were respectively used to investigate small bowel transit and gastric emptying., Results: Histopathology showed distinctive abnormalities only in the liver of conventional Roux-en-Y animals. No recanalization of the obliterated gut lumen occurred in uncut Roux animals. Distribution of (99)Tc-HIDA and (111)In showed were similar in both groups. Gastric emptying is slowed in both groups., Conclusions: The uncut proximal jejunum loop is a good alternative to the conventional Roux-en-Y loop and showed preserved small bowel motility and adequate jejunal transit. Gastric emptying is slowed in both groups.

Epiphrenic diverticula are very rarely seen and are often associated with achalasia, esophageal body dysmotility, and a high resting lower esophageal sphincter pressure. The aim of this study was to evaluate the different treatment options for patients with epiphrenic diverticula. Patients with an epiphrenic diverticulum were divided into two treatment groups: surgical and nonsurgical. Retrospective chart review was performed, and a symptom questionnaire was created. There were six patients in the nonsurgical group and 11 patients in the surgical group. The mean follow-up was 26.4 months. Ten patients had a laparoscopic operation performed. One patient was operated on thoracoscopically and had to be converted to a thoracotomy. Two diverticula were inverted with good results. There was one postoperative esophageal leak where no myotomy was added. An empyema developed in another patient at 4 weeks after surgery. One patient, in whom no antireflux procedure was performed, reported postoperative heartburn. Patients in the nonsurgical group had smaller diverticula, were not good candidates for surgery, or were asymptomatic. Esophageal diverticula are very rarely seen. Asymptomatic patients may not require therapy. If surgery is performed and the diverticulum is large, it should be removed. The laparoscopic approach is the surgical treatment of choice. A long myotomy and an antireflux procedure should be added to avoid esophageal leakage at the line of repair and gastroesophageal reflux.

Gastroesophageal reflux disease (GERD) is a very common disorder. Therapeutic options include lifestyle modifications, medical therapy, laparoscopic antireflux surgery, and three more recent options-injection therapy to the lower esophageal sphincter, endoscopic sewing procedures, and radio frequency ablation therapy. Medical therapy is effective in most patients but not always successful with advanced disease. Up to 70% of subjects do not have adequate nocturnal control of gastric acid secretion with 20 mg of omeprazole given twice per day. Patients who do not tolerate medical therapy, who respond inadequately, or who want to avoid life-long drug therapy are candidates for alternate treatments. Studies on endoscopic procedures such as polymethylmethacrylate (PMMA) injection, the Stretta procedure,and endoscopic suturing techniques all suffer from having small study groups for each procedure,unknown durability, short follow-up, and the absence of randomized, controlled procedures. Limitations on endoscopic techniques are esophageal motility disorders, severe esophagitis, and larger hiatal hernias. Laparoscopic antireflux surgery remains a well-established, durable alternative to long-term medical therapy. It has the benefits of convenience, safety, minimal complications, improved quality of life, and low cost. Alternative methods will have to earn their place against this gold standard.

Aim: To determine predictive factors for postoperative dysphagia after laparoscopic myotomy for achalasia., Methods: Logistic regression was used to investigate the possible association between the response (postoperative dysphagia, with two levels: none/mild and moderate/severe) and several plausible predictive factors., Results: Eight patients experienced severe or moderate postoperative dysphagia. The logistic regression revealed that only the severity of preoperative dysphagia (with four levels: mild, moderate, severe, and liquid) was a marginally significant (P=0.0575) predictive factor for postoperative dysphagia., Conclusion: The severity of postoperative dysphagia is strongly associated with preoperative dysphagia. Preoperative symptomatology can significantly impact patient outcome.

Purpose: To evaluate the incidence, severity, and clinical course of postoperative bowel dysfunction, primarily diarrhea, after laparoscopic antireflux surgery., Methods: Patients who underwent laparoscopic antireflux surgery during January to December 1998 responded to a questionnaire about pre-existing and postoperative bowel symptoms, which included questions about the type of bowel dysfunction (diarrhea, abdominal pain, bloating, constipation), onset in relation to surgery, frequency, severity, duration, use of medical resources or diagnostic evaluations, and treatment outcome., Results: Of the 109 patients who underwent laparoscopic antireflux surgery at our center during the study, 84 (77%) completed the survey. Thirty-six (43%) had no bowel dysfunction before or after surgery, whereas 29 (35%) had pre-existing bowel dysfunction. New bowel symptoms developed postoperatively in 30 patients (36%), including bloating in 16 (19%) and diarrhea in 15 (18%). Two thirds of the patients with new diarrhea developed it within 6 weeks after surgery. The severity of the diarrhea ranged from mild to debilitating; 4 had fecal incontinence. Most patients (13/15) with diarrhea had symptoms for > or =2 years following surgery. No patient was hospitalized, and only 2 patients reported temporary work loss., Conclusion: Postoperative bowel dysfunction, namely diarrhea, is an important adverse effect of antireflux surgery. Awareness of this complication should lead to prompt recognition, effective management, and reduction in anxiety.

As many as 50% of patients with gastroesophageal reflux disease (GERD) have no endoscopic evidence of esophagitis (EGD negative). Laparoscopic antireflux surgery (LARS) provides effective symptomatic and endoscopic healing in patients with erosive GERD (EGD positive). The surgical outcome of patients undergoing LARS for EGD-negative GERD has not received wide attention. The objective of this study was to compare surgical outcomes between EGD-negative and EGD-positive patients. During the period from June 1996 to September 1998, all patients undergoing LARS for persistent GERD symptoms despite medical therapy, who were EGD-negative, were invited to respond to a questionnaire regarding their clinical status before and after LARS. To perform a comparative analysis, the same questions were posed to a randomly selected equal number of EGD-positive patients who underwent surgery during the same study period. LARS was performed in 255 patients during the study period; 59 patients (23%) had EGD-negative GERD, and 148 (58%) were EGD-positive. Forty-eight patients (19%) did not meet the entry criteria and were excluded from analysis. LARS provided effective symptomatic relief in patients with EGD-negative and EGD-positive GERD. There were no significant differences in patient satisfaction or symptom improvement between the two groups (P = 0.82). The surgical outcome of EGD-negative patients is similar to the outcome for patients with erosive esophagitis. LARS is a valuable treatment option for patients with persistent GERD symptoms regardless of the endoscopic appearance of the esophageal mucosa., (Copyright 2002 The Society for Surgery of the Alimentary Tract, Inc.)

Cholelithiasis and gastroesophageal reflux are both very common diseases that may occur simultaneously. Management of asymptomatic gallstones is still controversial. Because severe complications due to gallstones may occur incidental cholecystectomy during nonrelated abdominal surgery may be offered to patients with coexisting gallbladder disease. The aim of this study was to assess the clinical outcome of patients after laparoscopic fundoplication and incidental cholecystectomy for cholelithiasis compared with the outcome of patients after fundoplication alone. We conducted a retrospective chart review and prospective analysis using a questionnaire of the clinical outcome of patients who underwent laparoscopic fundoplication and incidental cholecystectomy from June 1991 to January 2000 in comparison with sex- and age-matched patients who had antireflux surgery alone. Sixty-seven (6.3%) of 1065 patients had a laparoscopic cholecystectomy at the time of laparoscopic antireflux surgery; 101 (75%) of 134 answered the questionnaire. The mean follow-up time was 4.6 years. Laparoscopic cholecystectomy did not influence surgical morbidity or mortality. Postoperative symptom score (1-10) did not show a statistically significant difference regarding bloating, diarrhea, abdominal pain, nausea, vomiting, biliary problems, jaundice, pancreatitis, dysphagia for liquids and solid, heartburn, regurgitation, and chest pain when the two groups were compared. We conclude that incidental cholecystectomy during laparoscopic antireflux surgery is safe and does not appear to influence the clinical outcome of the antireflux procedure.

Background: Operative treatment of achalasia can fail in 10% to 15% of patients. No information is available on the outcome of laparoscopic reoperation for achalasia., Methods: Data from patients undergoing redo surgery for achalasia were prospectively collected. The data were analyzed, and a questionnaire was sent to all the patients., Results: Eight patients underwent redo procedures at our institution between 1994 and 1998. The reasons for failure of the initial operations were incomplete myotomy (n = 5), incorrect diagnosis (n = 2), and new onset of reflux symptoms (n = 1). All the redo procedures were performed laparoscopically. All the patients except one had excellent or good results. The average symptom severity score for dysphagia, regurgitation, chest pain, cough, and heartburn all improved after redo procedures. The average quality of life score improved from poor to good., Conclusions: Laparoscopic reoperation for achalasia is safe and feasible. It results in symptom improvement for most patients. Surgeon experience and recognition of the cause for failure of the original operation are most important in predicting the outcome.

Background: Dysphagia frequently develops shortly after fundoplication but is usually self-limited. This is an evaluation of the timing, frequency, indications, and outcome of dilation after fundoplication., Methods: Two hundred thirty-three consecutive patients who underwent fundoplication were included. Preoperative motility, postoperative symptoms, endoscopic and radiographic data, timing and number of dilations, and caliber of the dilator used were evaluated in patients who required dilation., Results: Twenty-nine of 233 (12.4%) patients underwent dilation(s). The mean time to dilation after surgery was 72 days (range 3 to 330 days). Ten of 29 (34.5%) required more than 1 dilation (mean 1.5, range 1 to 5). The mean diameter to which the fundoplication was dilated was 18.6 mm (range 15-20 mm). There were no complications. The indication for dilation was dysphagia in 20, chest pain 4, epigastric pain 1, globus 1, gas bloat 1, belching 1, and vomiting in 1 patient. Two patients were lost to follow-up. Dysphagia resolved with dilation in 12 of 18 (67%) patients. Of the 6 patients whose symptoms did not improve after dilation, 3 noted improvement after further surgery. Two patients with tight fundoplications still require periodic dilation. One patient had a stricture before surgery that persisted after surgery. Symptoms did not improve in any patient who underwent dilation for an indication other than dysphagia., Conclusions: Dilation after fundoplication was required in 12.4% of patients and was successful in most with dysphagia. Dilation shortly after surgery was safe and only a single dilation was required for most patients. Symptoms other than dysphagia did not respond to dilation.

Background: The elderly have more severe reflux disease and paraesophageal hernias than younger patients, leading to a high failure rate of medical therapy. Laparoscopic antireflux surgery has an overall mortality of 0.1% and a low morbidity, making it a safe and beneficial procedure for the elderly., Methods: We performed a retrospective study of octo- and nonogenerians with a mean follow-up of 3.1 years after laparoscopic fundoplication. Thirty (3.5%) patients who were in their eighties or older are reported. Preoperative symptoms, esophageal testing, postoperative symptoms, and satisfaction rate were analyzed., Results: Fifty-seven percent of patients had paraesophageal hernias. Mean duration of procedures was 146 +/- 49 min, blood loss was 76 +/- 101 ml, and hospitalization was 2.2 +/- 1.0 days. There was one conversion to laparotomy, two intraoperative complications, and no deaths. Follow-up data were available in 93% of patients. Mean follow-up time was 3.1 years. Two died of unrelated causes. At follow-up 96% stated that their surgical outcome was satisfactory. Two patients were suffering from severe symptoms. Overall well-being at follow-up was 7.5 (range 3-10) on a 10-point scale in comparison to 2.2 (range 1-5) before surgery (p = 0.03)., Conclusion: Laparoscopic surgery is a good option for the treatment of severe gastroesophageal reflux disease in octo- and nonagenarians.

Gastroesophageal reflux disease (GERD) often is associated with pulmonary problems such as asthma as well as recurrent and nocturnal cough. Dual-probe 24-hr pH monitoring may assist in establishing a correlation between these symptoms and GERD-related symptoms. To determine if any specific symptom was predictive of aspiration, this study was undertaken. Ambulatory dual-probe esophageal pH monitoring was performed on 133 patients who had upper airway and additional symptoms for GERD. All patients had esophageal manometric studies of the lower esophageal sphincter (LES), the upper esophageal sphincter (UES), and the esophageal body before dual-probe pH monitoring was performed. Using two assembled glass probes, the distal and the proximal sensors were placed 5 cm above the proximal border of the LES and 1 cm below the lower border of the UES, respectively. Patients were classified into three groups: proximal and distal probe positive (group I), proximal probe negative and distal probe positive (group II) and proximal and distal probe negative (Group III) Upper airway and additional symptoms plus manometry results of the LES, body and UES study were compared between groups. In addition, positive distal probe patients (groups I and II) were compared for distal fraction of time at pH < 4 and number of reflux episodes at each probe position. A positive distal probe result was defined as an abnormal DeMeester score (> 14.8). A proximal probe test result was considered positive if percent time pH < 4.0 was > 1.1 for total, 1.7 for upright, and 0.6 for supine positions. The ages of the subjects ranged from 18 to 83 years (mean age: 50.5 +/- 1.5 years). Groups I, II, and III included 16 patients, 38 patients, and 79 patients, respectively. Group I had a significantly higher incidence of nocturnal cough than the other two groups. (P < 0.05). The manometric data revealed between groups that LES pressure (LESP) for groups I and II was significantly lower than LESP for group III (P = 0.003). Cricoid pressure, pharyngeal pressure, length, and relaxation of UES were not different between groups. Fraction of reflux time for group I was significantly higher than for group II in the supine position and at mealtime (P < 0.05). The number of reflux episodes for group I was significantly higher at meal time (P < 0.01). In conclusion, nocturnal cough is strongly predictive of proximal esophageal reflux. Proximal reflux episodes are significantly more frequent in the supine position and correlate well with the high predictive value of nocturnal cough.

Background: Laparoscopic fundoplication has revolutionized the surgical treatment of gastroesophageal reflux disease. Despite improvements in the technique of fundoplication, persistent dysphagia remains a significant cause of postoperative morbidity., Method: Causes of persistent postoperative dysphagia were analyzed in a consecutive series of 167 patients after laparoscopic Nissen fundoplication. Short gastric vessel division and its effect on postoperative dysphagia were analyzed., Results: Follow-up was possible in 139 patients (83%). The mean follow-up period was 27 +/- 21 months. Nine patients (6%) had persistent (moderate to severe) dysphagia, and 33 patients (24%) had mild dysphagia. The satisfaction score among patients with persistent dysphagia was significantly lower than that in patients with mild dysphagia (P < 0.0002). On the other hand, the satisfaction rate among patients with mild dysphagia and those who are asymptomatic was similar. Manometry, performed in 7 of 9 persistent dysphagia patients revealed no difference in postoperative lower esophagus sphincter (LES) pressure and relaxation as compared with that in the control group (n = 52). Six of 9 patients with persistent dysphagia underwent a re-do antireflux procedure. Dysphagia as related to fundic mobilization (complete vs. partial) or bougie size (< 58 Fr. vs. > or = 58 Fr.) revealed no difference in the dysphagia ratings., Conclusions: Laparoscopic short Nissen fundoplication with or without fundic mobilization achieved an acceptable long-term dysphagia rate. Careful patient selection, identification of the short esophagus, and accurate construction of the fundoplication can lead to a decrease in the incidence of persistent postoperative dysphagia.

Gastroesophageal reflux disease can result in such supraesophageal complications as hoarseness, sore throat, cough, bronchitis, asthma, recurrent pneumonia, intermittent choking, chest pain, and ear pain. Appropriate patient care involves careful evaluation to decide on medical or surgical therapy. Preoperative testing must include endoscopy, 24-hour esophageal pH monitoring, and esophageal manometry. Additional evaluations, such as barium swallow, chest x-ray, bronchoscopy, and sinus radiographs, may be required. Medical treatment improves gastroesophageal reflux and supraesophageal symptoms. However, surgical therapy seems to provide better long-term results. A profile that predicts the best response to medical therapy has not been identified, although the best results with surgery are achieved in patients with nocturnal asthma, onset of reflux before pulmonary symptoms, laryngeal inflammation, and a good response to medical treatment.

The term paraesophageal hernia is described as a herniation of the gastric fundus through the open hiatus into the thoracic cavity while the lower esophageal sphincter (LES) remains in its normal anatomic position. This is considered a rolling esophageal hernia (Type II), and it is the least commonly encountered hiatal hernia. A more commonly encountered herniation of the fundus of the stomach is the Type III hernia, in which both the LES and the fundus herniate into the chest. This has also been classified as a paraesophageal hernia. The most common hiatal hernia is a sliding hiatal hernia (Type I), which consists of herniation of the stomach through the esophageal hiatus, causing the LES and gastric cardia to lie in the thoracic cavity. There are several controversial issues involved in paraesophageal hernia repair, including indications for surgery, the most appropriate surgical approach, and the need for a concomitant antireflux procedure. The increasing popularity of laparoscopic paraesophageal hernia repair has dramatically altered the approach to these patients and has allowed patients at higher risk to better tolerate this procedure with a decrease in morbidity and mortality. However, they remain difficult surgical procedures., (Copyright 2001 by W.B. Saunders Company.)

Congenital diaphragmatic hernia is rarely seen in adults. A review of the literature is presented, and 2 additional cases of Morgagni and Bochdalek hernias are presented. They were both repaired with the laparoscopic approach., (Copyright 2001 by W.B. Saunders Company.)

Introduction: Laparoscopic surgery for the treatment of gastroesophageal reflux disease has been established as being safe, effective, and the best alternative to continuous life-long medical therapy. Antireflux surgery is not, however, devoid of complications and failures. Treatment of these patients represents a major challenge, especially when reoperation is indicated., Patients: One-hundred consecutive patients had a reoperation in our clinic. Previous antireflux procedures were laparoscopic (52 patients), laparotomy (39 patients), and thoracotomy (9 patients)., Results: Peri- or postoperative complications occurred in 30 patients (30%). Operative complications were stomach perforation (14), significant bleeding (6), esophageal mucosal perforation (4), gastrocutaneous fistula (2), small bowel enterotomy followed by fistula (1), and tension pneumothorax (1). Reoperation was required in only 2 patients because of a missed stomach perforation or persistent chest leak. The conversion rate (from laparoscopic to open procedure) was 17% overall., Conclusion: Laparoscopic reoperation after a failed antireflux procedure is a major surgical challenge, and it is not devoid of morbidity. The surgeon must have extensive experience in laparoscopic surgery and should be able to perform reoperative open surgery through the abdomen and chest. Laparoscopic redo surgery is feasible with good results. Many patients in whom previous open surgery has failed enjoy the advantages of a laparoscopic redo procedure., (Copyright 2001 by W.B. Saunders Company.)

One of the most common complications of gastroesophageal reflux disease is Barrett's esophagus. Medical therapy for this condition is not very effective and does not seem to be able to control the occurence and progression of the disease. In contrast, there is some evidence that effective antireflux surgery does have a slowing effect on the occurence and the progression of Barrett's esophagus. There is also some evidence that the progression of Barrett's to high-grade dysplasia and carcinoma is less after antireflux surgery than during medical therapy. Antireflux surgery should be considered in patients with Barrett's who have a large hiatal hernia, dysplasia, a weak lower esophageal sphincter pressure, failed medical therapy, noncompliance to medications, and young age., (Copyright 2001 by W.B. Saunders Company.)

Background: Patients with head and neck cancer often need a percutaneous endoscopic gastrostomy to provide adequate nutrition because of inability to swallow after tumor radiation therapy. However, metastasis of the original tumor to the gastrostomy exit site may occur., Methods: We describe the case of a 61-year-old man with stage III (T2 N1) squamous cell carcinoma of the tongue in whom a PEG tube was placed to circumvent anticipated difficulties in swallowing after radiation therapy. We also compare this case with similar cases in the literature., Results: Soreness and erythema near the gastrostomy site reported by the patient were diagnosed as cellulitis, and two courses of antibiotic treatment were prescribed. However, a biopsy showed that the original squamous cell carcinoma had metastasized to the gastrostomy exit site. The "pull" method of tube placement had been used in this patient and in all 19 cases of metastasis reported in the literature., Conclusions: Metastatic cancer should be considered in patients with head and neck cancer who have unexplained skin changes at the gastrostomy site. Our experience with this case and review of the literature indicate that, in patients with head and neck cancer, "pull" procedures for placement of gastrostomy tubes may induce metastasis by direct implantation of tumor cells because of contact between the gastrostomy tube and tumor cells. Methods of tube insertion that avoid such contact are preferred.

Barrett esophagus has malignant potential and seems to be an acquired abnormality. It is associated with chronic gastroesophageal reflux disease and represents its severest form. The literature comparing medical treatment with antireflux surgery was reviewed. Questions regarding the advantages of surgery, who should undergo surgery, whether surgery can change the course of Barrett esophagus, the change in cancer risk, who needs surveillance, and cost-effectiveness were addressed. The incidence of developing Barrett cancer was 1 in 145 patient-years in reviewing 2032 patient-years of medical therapy compared with 1 in 294 patient-years in reviewing 4122 patient-years after surgery. Median follow-up time in the 2 groups was 2.7 years in the medically treated patients and 4.0 years in the surgically treated patients. Surveillance of Barrett esophagus is required irrespective of treatment. Laparoscopic antireflux surgery was found to be cost-effective after 7 years. Although these data do not prove that surgery is superior to medical treatment in the prevention of cancer related to Barrett esophagus, we found a tendency for surgery to be better than medical therapy to prevent the development and progression of Barrett carcinoma.

The operative mortality and morbidity of laparoscopic fundoplication are lower than for the open procedure. Questions have been raised regarding its long-term durability. One hundred seventy-one patients who had undergone laparoscopic Nissen fundoplication at least 5 years previously answered a questionnaire. During this period, 291 patients underwent a laparoscopic Nissen fundoplication. Surveillance data were available for 171 patients at a mean of 6.4 years after surgery. Overall, 96.5% were satisfied and 3.5% were not satisfied with the result of the procedure. Persistent symptoms included abdominal bloating (20.5%), diarrhea (12.3%), regurgitation (6.4%), heartburn (5.8%) and chest pain (4.1%); 27.5% reported dysphagia, and 7% had required dilatation. Fourteen percent were on continuous proton pump inhibitor therapy, but 79% of these patients were treated for vague abdominal or chest symptoms unrelated to reflux, which calls into question the indications for this therapy. Ninety-three percent of all patients were satisfied with their decision to have surgery. The overall well-being score increased significantly from 2.2 +/- 1.6 before surgery to 8.8 +/- 2 (P > 0.0001) at more than 5 years after surgery. Twenty-one percent had undergone additional diagnostic procedures after surgery such as endoscopy and/or barium swallow. Laparoscopic Nissen fundoplication is an excellent long-term treatment for gastroesophageal reflux disease with persistent success for more than 5 years. Some patients have continuing symptoms and remain on therapy, but more than 90% of all patients undergoing laparoscopic Nissen fundoplication remain satisfied with their decision to have surgery. These results are at least as good as those achieved with open fundoplication and prove the long-term worth of this procedure.