Search

Background: The surgical treatment of gastroesophageal reflux-induced reflux laryngitis remains controversial. The aim of this study was to determine both long-term objective endoscopic findings and subjective symptomatic outcomes after laparoscopic Nissen fundoplication in patients operated on for reflux laryngitis. Methods: 40 consecutive patients with pH-proven reflux laryngitis underwent laparoscopic Nissen fundoplication between 1998 and 2002. 68% (n = 27) of these patients underwent an endoscopic evaluation and 90% (n = 36) were available for the subjective long-term outcome (personal interviews). Results: At a median follow-up of 91 months there were no disrupted plications, none of the patients had esophagitis but 3 recurrent hiatal hernias were detected. 61% of the patients reported no or only mild reflux laryngitis symptoms postoperatively and 69% of the patients evaluated their voice quality improved after surgery. 94% of the patients were satisfied with their surgical result. With benefit of hindsight, 11% of the patients would not choose surgical treatment and 42% had reinitiated antireflux medications postoperatively. Conclusion: The majority of pH-proven gastroesophageal reflux-induced reflux laryngitis patients attain long-term symptomatic benefit and satisfaction on the surgical outcome, and with proper patient selection laparoscopic Nissen fundoplication provides a feasible long-term treatment option for reflux laryngitis. Copyright © 2010 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Late results after colonic anastomoses performed with the biofragmentable anastomosis ring (BAR; Valtrac®; Davis & Geck, Wayne, NJ) were evaluated in 30 patients who had undergone a left-sided colonic or rectosigmoid anastomosis a mean of 24.5 (range, 12-38) months earlier. Patients were asked about their late postoperative recovery and their bowel habits. A barium enema was performed, and then a flexible endoscopy was done, during which the anastomotic area was evaluated both in macroscopic terms and histologically. One of the patients had died, and three refused to participate in the investigation. Of the remaining 26 patients, one had been reoperated on 22 months after the primary sigmoid resection. The reason for reoperation was an anastomotic stricture. One of the patients was admitted to the hospital during the study and was operated on for reasons not related to the anastomosis. Twenty-four patients underwent the study scheme. All had recovered uneventfully. Sixteen anastomoses could not be identified radiologically and seven not even during endoscopy. Histologically, there was mild-to-moderate fibrosis and scarring in 17 anastomoses, and, in the seven that could not be identified, only normal colonic mucosa was found. The late results of BAR anastomoses are satisfying, and the rate of complications is acceptable. [ABSTRACT FROM AUTHOR]

Importance: Long-term results from randomized clinical trials comparing laparoscopic sleeve gastrectomy (LSG) with laparoscopic Roux-en-Y-gastric bypass (LRYGB) are limited., Objective: To compare long-term outcomes of weight loss and remission of obesity-related comorbidities and the prevalence of gastroesophageal reflux symptoms (GERD), endoscopic esophagitis, and Barrett esophagus (BE) after LSG and LRYGB at 10 years., Design, Setting, and Participants: This 10-year observational follow-up evaluated patients in the Sleeve vs Bypass (SLEEVEPASS) multicenter equivalence randomized clinical trial comparing LSG and LRYGB in the treatment of severe obesity in which 240 patients aged 18 to 60 years with median body mass index of 44.6 were randomized to LSG (n = 121) or LRYGB (n = 119). The initial trial was conducted from April 2008 to June 2010 in Finland, with last follow-up on January 27, 2021., Interventions: LSG or LRYGB., Main Outcomes and Measures: The primary end point was 5-year percentage excess weight loss (%EWL). This current analysis focused on 10-year outcomes with special reference to reflux and BE., Results: At 10 years, of 240 randomized patients (121 randomized to LSG and 119 to LRYGB; 167 women [69.6%]; mean [SD] age, 48.4 [9.4] years; mean [SD] baseline BMI, 45.9 [6.0]), 2 never underwent surgery and there were 10 unrelated deaths; 193 of the remaining 228 patients (85%) completed follow-up on weight loss and comorbidities, and 176 of 228 (77%) underwent gastroscopy. Median (range) %EWL was 43.5% (2.1%-109.2%) after LSG and 50.7% (1.7%-111.7%) after LRYGB. Mean estimate %EWL was not equivalent between the procedures; %EWL was 8.4 (95% CI, 3.1-13.6) higher in LRYGB. After LSG and LRYGB, there was no statistically significant difference in type 2 diabetes remission (26% and 33%, respectively; P = .63), dyslipidemia (19% and 35%, respectively; P = .23), or obstructive sleep apnea (16% and 31%, respectively; P = .30). Hypertension remission was superior after LRYGB (8% vs 24%; P = .04). Esophagitis was more prevalent after LSG (31% vs 7%; P < .001) with no statistically significant difference in BE (4% vs 4%; P = .29). The overall reoperation rate was 15.7% for LSG and 18.5% for LRYGB (P = .57)., Conclusions and Relevance: At 10 years, %EWL was greater after LRYGB and the procedures were not equivalent for weight loss, but both LSG and LRYGB resulted in good and sustainable weight loss. Esophagitis was more prevalent after LSG, but the cumulative incidence of BE was markedly lower than in previous trials and similar after both procedures., Trial Registration: ClinicalTrials.gov Identifier: NCT00793143.

Importance: Laparoscopic sleeve gastrectomy (LSG) is currently the predominant bariatric procedure, although long-term weight loss and quality-of-life (QoL) outcomes compared with laparoscopic Roux-en-Y gastric bypass (LRYGB) are lacking., Objective: To determine weight loss equivalence of LSG and LRYGB at 7 years in patients with morbid obesity, with special reference to long-term QoL., Design, Setting, and Participants: The SLEEVE vs byPASS (SLEEVEPASS) multicenter, multisurgeon, open-label, randomized clinical equivalence trial was conducted between March 10, 2008, and June 2, 2010, in Finland. The trial enrolled 240 patients with morbid obesity aged 18 to 60 years who were randomized to undergo either LSG or LRYGB with a 7-year follow-up (last follow-up, September 26, 2017). Analysis was conducted on an intention-to-treat basis. Statistical analysis was performed from June 4, 2018, to November 8, 2019., Interventions: Laparoscopic sleeve gastrectomy (n = 121) or LRYGB (n = 119)., Main Outcomes and Measures: The primary end point was percentage excess weight loss (%EWL) at 5 years. Secondary predefined follow-up time points were 7, 10, 15, and 20 years, with included 7-year secondary end points of QoL and morbidity. Disease-specific QoL (DSQoL; Moorehead-Ardelt Quality of Life questionnaire [range of scores, -3 to 3 points, where a higher score indicates better QoL]) and general health-related QoL (HRQoL; 15D questionnaire [0-1 scale for all 15 dimensions, with 1 indicating full health and 0 indicating death]) were measured preoperatively and at 1, 3, 5, and 7 years postoperatively concurrently with weight loss., Results: Of 240 patients (167 women [69.6%]; mean [SD] age, 48.4 [9.4] years; mean [SD] baseline body mass index, 45.9 [6.0]), 182 (75.8%) completed the 7-year follow-up. The mean %EWL was 47% (95% CI, 43%-50%) after LSG and 55% (95% CI, 52%-59%) after LRYGB (difference, 8.7 percentage units [95% CI, 3.5-13.9 percentage units]). The mean (SD) DSQoL total score at 7 years was 0.50 (1.14) after LSG and 0.49 (1.06) after LRYGB (P = .63), and the median HRQoL total score was 0.88 (interquartile range [IQR], 0.78-0.95) after LSG and 0.87 (IQR, 0.78-0.95) after LRYGB (P = .37). Greater weight loss was associated with better DSQoL (r = 0.26; P < .001). At 7 years, mean (SD) DSQoL scores improved significantly compared with baseline (LSG, 0.50 [1.14] vs 0.10 [0.94]; and LRYGB, 0.49 [1.06] vs 0.12 [1.12]; P < .001), unlike median HRQoL scores (LSG, 0.88 [IQR, 0.78-0.95] vs 0.87 [IQR, 0.78-0.90]; and LRYGB, 0.87 [IQR, 0.78-0.92] vs 0.85 [IQR, 0.77-0.91]; P = .07). The overall morbidity rate was 24.0% (29 of 121) for LSG and 28.6% (34 of 119) for LRYGB (P = .42)., Conclusions and Relevance: This study found that LSG and LRYGB were not equivalent in %EWL at 7 years. Laparoscopic Roux-en-Y gastric bypass resulted in greater weight loss than LSG, but the difference was not clinically relevant based on the prespecified equivalence margins. There was no difference in long-term QoL between the procedures. Bariatric surgery was associated with significant long-term DSQoL improvement, and greater weight loss was associated with better DSQoL., Trial Registration: ClinicalTrials.gov Identifier: NCT00793143.

Purpose: Bariatric surgery is considered as an effective therapeutic strategy for weight loss in severe obesity. Remission of type 2 diabetes is often achieved after the surgery. We investigated whether increase in self-reported habitual physical activity associates with improved skeletal muscle insulin sensitivity and reduction of fat depots after bariatric surgery., Methods: We assessed self-reported habitual physical activity using Baecke questionnaire in 18 diabetic and 28 nondiabetic patients with morbid obesity (median age, 46 yr; body mass index, 42.0 kg·m) before and 6 months after bariatric surgery operation. Insulin-stimulated femoral muscle glucose uptake was measured using fluorodeoxyglucose positron emission tomography method during hyperinsulinemia. In addition, abdominal subcutaneous and visceral fat masses were quantified using magnetic resonance imaging and liver fat content using magnetic resonance spectroscopy. Also, serum proinflammatory cytokines were measured., Results: Patients lost on average 22.9% of weight during the follow-up period of 6 months (P < 0.001). Self-reported habitual physical activity level increased (P = 0.017). Improvement in skeletal muscle insulin sensitivity was observed only in those patients who reported increase in their physical activity postoperatively (P = 0.018). The increase in self-reported physical activity associated with the loss of visceral fat mass (P = 0.029). Postoperative self-reported physical activity correlated also positively with postoperative hepatic insulin clearance (P = 0.02) and tended to correlate negatively with liver fat content (P = 0.076). Postoperative self-reported physical activity also correlated negatively with serum TNFα, methyl-accepting chemotaxis protein and interleukin 6 levels., Conclusions: Self-reported physical activity is associated with reversal of skeletal muscle insulin resistance after bariatric surgery as well as with the loss of visceral fat content and improved postoperative metabolism in bariatric surgery patients., Trial Registration: Clinicaltrials.gov, NCT00793143 (SLEEVEPASS), NCT01373892 (SLEEVEPET2).

Importance: Laparoscopic sleeve gastrectomy for treatment of morbid obesity has increased substantially despite the lack of long-term results compared with laparoscopic Roux-en-Y gastric bypass., Objective: To determine whether laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass are equivalent for weight loss at 5 years in patients with morbid obesity., Design, Setting, and Participants: The Sleeve vs Bypass (SLEEVEPASS) multicenter, multisurgeon, open-label, randomized clinical equivalence trial was conducted from March 2008 until June 2010 in Finland. The trial enrolled 240 morbidly obese patients aged 18 to 60 years, who were randomly assigned to sleeve gastrectomy or gastric bypass with a 5-year follow-up period (last follow-up, October 14, 2015)., Interventions: Laparoscopic sleeve gastrectomy (n = 121) or laparoscopic Roux-en-Y gastric bypass (n = 119)., Main Outcomes and Measures: The primary end point was weight loss evaluated by percentage excess weight loss. Prespecified equivalence margins for the clinical significance of weight loss differences between gastric bypass and sleeve gastrectomy were -9% to +9% excess weight loss. Secondary end points included resolution of comorbidities, improvement of quality of life (QOL), all adverse events (overall morbidity), and mortality., Results: Among 240 patients randomized (mean age, 48 [SD, 9] years; mean baseline body mass index, 45.9, [SD, 6.0]; 69.6% women), 80.4% completed the 5-year follow-up. At baseline, 42.1% had type 2 diabetes, 34.6% dyslipidemia, and 70.8% hypertension. The estimated mean percentage excess weight loss at 5 years was 49% (95% CI, 45%-52%) after sleeve gastrectomy and 57% (95% CI, 53%-61%) after gastric bypass (difference, 8.2 percentage units [95% CI, 3.2%-13.2%], higher in the gastric bypass group) and did not meet criteria for equivalence. Complete or partial remission of type 2 diabetes was seen in 37% (n = 15/41) after sleeve gastrectomy and in 45% (n = 18/40) after gastric bypass (P > .99). Medication for dyslipidemia was discontinued in 47% (n = 14/30) after sleeve gastrectomy and 60% (n = 24/40) after gastric bypass (P = .15) and for hypertension in 29% (n = 20/68) and 51% (n = 37/73) (P = .02), respectively. There was no statistically significant difference in QOL between groups (P = .85) and no treatment-related mortality. At 5 years the overall morbidity rate was 19% (n = 23) for sleeve gastrectomy and 26% (n = 31) for gastric bypass (P = .19)., Conclusions and Relevance: Among patients with morbid obesity, use of laparoscopic sleeve gastrectomy compared with use of laparoscopic Roux-en-Y gastric bypass did not meet criteria for equivalence in terms of percentage excess weight loss at 5 years. Although gastric bypass compared with sleeve gastrectomy was associated with greater percentage excess weight loss at 5 years, the difference was not statistically significant, based on the prespecified equivalence margins., Trial Registration: clinicaltrials.gov Identifier: NCT00793143.

Unlabelled: Accurate diagnosis of the nature of pancreatic cysts is challenging but more important than ever, in part because of the increasing number of incidental cystic findings in the pancreas. Preliminary data suggest that (18)F-FDG PET/CT may have a significant influence on clinical decision making, although its role is still evolving. Our aim was to prospectively compare the accuracy of combined (18)F-FDG PET and contrast-enhanced CT ((18)F-FDG PET/CT), multidetector CT (MDCT), and MR imaging in differentiating malignant from benign pancreatic cysts., Methods: Thirty-one consecutive patients with pancreatic cysts were enrolled in the study. They underwent a protocol including (18)F-FDG PET/CT, MDCT, and MR imaging combined with MR cholangiopancreatography, all of which were evaluated in a masked manner. The findings were confirmed macroscopically at surgery or histopathologic analysis (n = 22) or at follow-up (n = 9)., Results: Of the 31 patients, 6 had malignant and 25 had benign lesions. The diagnostic accuracy was 94% for (18)F-FDG PET/CT, compared with 77% and 87% for MDCT (P < 0.05) and MR imaging, respectively. (18)F-FDG PET/CT had a negative predictive value of 100% and a positive predictive value of 75% for pancreatic cysts. The maximum standardized uptake value was significantly higher in malignant (7.4 ± 2.6) than in benign lesions (2.4 ± 0.8) (P < 0.05). When the maximum standardized uptake value was set at 3.6, the sensitivity and specificity were 100% and 88%, respectively. Furthermore, when compared with MDCT and MR imaging, respectively, (18)F-FDG PET/CT altered the clinical management of 5 and 3 patients, respectively., Conclusion: (18)F-FDG PET/CT is an accurate imaging modality for differentiating between benign and malignant pancreatic cysts. We recommend the use of (18)F-FDG PET/CT in the evaluation of diagnostically challenging pancreatic cysts., (© 2015 by the Society of Nuclear Medicine and Molecular Imaging, Inc.)

Aims/hypothesis: The intestine is the main site for glucose absorption and it has been suggested that it exhibits insulin resistance. Bariatric surgery has been shown to reverse insulin resistance and type 2 diabetes, but its effects on human intestinal metabolism are unknown. Our aim was to evaluate the effects of insulin on intestinal glucose metabolism before and after bariatric surgery., Methods: Twenty-one morbidly obese individuals undergoing bariatric surgery and ten age-matched healthy individuals were recruited and intestinal and skeletal muscle glucose uptake (GU) was measured using [(18)F]fluoro-2-deoxyglucose and positron emission tomography at fast and during hyperinsulinaemia. MRI was used as anatomical reference. Obese participants were studied again 6 months postoperatively., Results: In contrast to healthy individuals, insulin had no effect on intestinal GU in obese participants with or without diabetes, suggesting that intestinal insulin resistance is present early in morbid obesity. Postoperatively, jejunal GU increased in line with whole-body and muscle GU. Postoperative GU values in the intestine correlated with whole-body insulin sensitivity, indicating that the intestinal mucosa may reflect the overall glycaemic state and potentially mediate obesity-associated insulin resistance., Conclusions/interpretation: This study shows that insulin is a potent stimulator of GU in the healthy intestine and that intestinal insulin resistance is ameliorated after bariatric surgery. In our study, obese individuals had intestinal insulin resistance regardless of their glycaemic status. Persistent changes in intestinal glucose metabolism are likely to influence both local processes in the gut and systemic glucose homeostasis.

Obesity and insulin resistance are associated with altered brain glucose metabolism. Here, we studied brain glucose metabolism in 22 morbidly obese patients before and 6 months after bariatric surgery. Seven healthy subjects served as control subjects. Brain glucose metabolism was measured twice per imaging session: with and without insulin stimulation (hyperinsulinemic-euglycemic clamp) using [18F]fluorodeoxyglucose scanning. We found that during fasting, brain glucose metabolism was not different between groups. However, the hyperinsulinemic clamp increased brain glucose metabolism in a widespread manner in the obese but not control subjects, and brain glucose metabolism was significantly higher during clamp in obese than in control subjects. After follow-up, 6 months postoperatively, the increase in glucose metabolism was no longer observed, and this attenuation was coupled with improved peripheral insulin sensitivity after weight loss. We conclude that obesity is associated with increased insulin-stimulated glucose metabolism in the brain and that this abnormality can be reversed by bariatric surgery.

Background: Using positron emission tomography (PET), we compared two tracers, [11C]metomidate ([11C]MTO) and [11C]acetate ([11C]ACE), for the characterization of hepatic tumors., Methods: Thirty-three patients underwent PET with [11C]MTO and [11C]ACE and magnetic resonance imaging (MRI). Based on the histology of the tumor biopsy, 14 patients had hepatocellular carcinoma (HCC), 9 patients had focal nodular hyperplasia (FNH), and 10 patients had other types of hepatic tumors. Tumor uptake was evaluated by calculating the maximum and mean standardized uptake value and tumor-to-liver ratio., Results: Altogether, 120 hepatic lesions (59 HCC, 18 FNH, 30 metastases of different primaries, 9 adenomas, and 4 regenerating nodules of liver cirrhosis) were detected by MRI. The overall tumor detection rate was slightly higher for [11C]MTO (39%) than for [11C]ACE (33%). [11C]ACE was more sensitive for HCC detection (50% versus 43%, respectively), whereas [11C]MTO was more sensitive for FNH detection (78% versus 44%, respectively). In HCC patients, the tumor grade correlated with [11C]ACE, but not with [11C]MTO. All of the patients with liver metastases, from various primary tumors (n = 10), were negative for both tracers., Conclusions: Due to low sensitivity, [11C]MTO and [11C]ACE PET have only limited value in diagnosing hepatic tumors.

Background: The long-term efficacy of laparoscopic Roux-en-Y gastric bypass (RYGB) in the treatment of morbid obesity has been demonstrated. Laparoscopic sleeve gastrectomy (SG) as a single procedure has shown promising short-term results, but the long-term efficacy of SG has not yet been demonstrated. The aim of this study was to determine the preliminary 30-day morbidity and mortality of RYGB and SG in a prospective multicenter randomized setting., Methods: A total of 240 morbidly obese (BMI = 35-66 kg/m²) patients evaluated by a multidisciplinary team were randomized to undergo either RYGB or SG. There were 117 patients in the RYGB group and 121 in the SG group; two patients had to be excluded after randomization. Both study groups were comparable regarding age, gender, BMI, and comorbidities., Results: There was no 30-day mortality. The median operating time was significantly shorter in the SG group (66 min vs. 94 min, p < 0.001). All complications were recorded thoroughly. There were 7 (5.8 %) major complications following SG and 11 (9.4 %) after RYGB (p = 0.292). Nine (7.4 %) SG patients and 20 (17.1 %) RYGB patients had minor complications (p = 0.023). The overall morbidity was 13.2 % after SG and 26.5 % after RYGB (p = 0.010). There were three (2.5 %) early reoperations after SG and four (3.3 %) after RYGB (p = 0.719)., Conclusions: At 30-day analysis SG is associated with a shorter operating time and fewer early minor complications compared to RYGB. There were no significant differences in major complications or early reoperations. Long-term follow-up is required to determine the effect on weight loss, resolution of obesity-related comorbidities, and improvement of quality of life.

Background: Laparoscopic Nissen fundoplication (LNF) has become the method of choice in the surgical treatment of gastroesophageal reflux disease (GERD), replacing its open counterpart without confirmation by the long-term results of controlled clinical studies. The goal of the present study was to compare the 15-year outcome of a randomized controlled comparison study of LNF versus open Nissen fundoplication (ONF)., Methods: From 1992 to 1995, 110 consecutive patients were randomized to undergo LNF or ONF. The 15-year objective results were evaluated by endoscopy, and the subjective symptomatic outcome was assessed by interviews., Results: A total of 86 patients (48 in the LNF [LAP] and 38 in the ONF [OPEN] group) participated in the study. The late long-term symptomatic outcome was similar in the two patient groups. In the LAP group, 91.7% of the patients gave a positive evaluation of their surgical result, as compared with 76.3% of the patients in the OPEN group (p=0.0484). A significantly greater number of disrupted plications (p=0.0115) and incisional hernias (p<0.001) occurred in the OPEN than in the LAP group. Both the subjective outcome and the objective endoscopic and clinical findings in the present study were in accord with our previously reported outcomes at 11-years after laparoscopic versus open fundoplication. The study found a trend toward (p=0.0851) an increasing need for the regular use of a proton pump inhibitor with the passage of time after Nissen fundoplication., Conclusions: The 15-year results obtained in the present study define laparoscopic Nissen fundoplication as the procedure of choice in the surgical management of GERD. The long-term symptomatic outcomes of open and laparoscopic Nissen fundoplication appear to remain unaltered after the first 10 postoperative years., (Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: In addition to actual weight loss and the possible resolution of obesity-related co-morbidities following bariatric surgery, another widely recognized important outcome measure is the improvement of quality of life (QOL)., Methods: Disease-specific quality of life (DSQOL) and general health-related quality of life (HRQOL) were measured preoperatively and at 1 and 5 years postoperatively following laparoscopic adjustable gastric banding (LAGB) for morbid obesity. The Moorehead-Ardelt questionnaire was used for DSQOL assessments and a generic 15-dimensional questionnaire (15D) was used for HRQOL measurements. In addition, HRQOL was compared with that of the age- and gender-standardized general population., Results: DSQOL scores were significantly improved on all domains after 1 year from the operation and this improvement was maintained at 5 years. This improvement was also seen in the total HRQOL scores. Despite this improvement, the HRQOL after LAGB remained worse compared to the age- and gender-standardized general population., Conclusions: DSQOL and HRQOL improve both significantly after LAGB. This QOL improvement is maintained at 5-year follow-up although QOL does not reach the level of the general population.

Purpose: To study blood flow (BF) and metabolism in normal pancreas and in different pancreatic lesions. We then determined the effect of these biomarkers on outcome in patients with pancreatic cancer., Experimental Design: Oxygen-15-labeled water and fluorodeoxyglucose positron emission tomography/computed tomography scans were used in 26 patients with a suspicion of pancreatic cancer to measure pancreatic BF and metabolism. In addition, the ratio of standardized uptake value to BF (SUV/BF) was calculated. Patients were divided into three groups: patients with a finding of normal pancreas (n = 7), benign lesions (n = 8), and malignant tumors (n = 11)., Results: Patients with benign and malignant pancreatic tumors had decreased BF of the lesion by 48% and 60%, respectively, compared with patients with normal pancreatic tissue. SUV(max) was 3-fold higher in malignant tumors compared with both benign lesions and normal pancreas (P < 0.05). In contrast, the SUV(max) of patients with benign lesions and normal pancreas did not differ. The SUV/BF ratio was significantly higher in malignant lesions than in benign lesions or in patients with normal pancreas (P < 0.05). In patients with cancer, high SUV/BF ratio was a stronger predictor of poor survival compared with high metabolism or lower-than-normal pancreatic BF., Conclusions: BF in pancreatic cancer is significantly reduced compared with the normal pancreas, which may in part explain the poor success of both radiotherapy and chemotherapy. We suggest that the composite measurement of BF and metabolism in pancreatic cancer could serve as a novel tool in the planning of treatments targeting vasculature.

The study was set up to determine the clinical value of dihydroxyphenylalanine positron emission tomography-computed tomography ([(18)F]DOPA PET-CT) in patients with neuroendocrine tumors (NETs). Eighty-two patients with suspected/known NET were imaged with PET(-CT) using [(18)F]DOPA. Patients were divided into two groups: primary diagnosis/staging and restaging of disease. All patients without previous diagnosis of NET had biochemical proof of disease. The diagnostic accuracy of PET was assessed by comparing the histopathology and clinical follow-up. The overall accuracy of [(18)F]DOPA PET was 90%. In patients having PET for primary diagnosis/staging (n=32), the accuracy of PET was 88%, and for restaging 92% (n=61). The mean s.d. sizes of primary and metastatic lesions detected by PET were 26+/-11 and 16+/-9 mm respectively. In organ-region-specific analysis, the sensitivity and specificity were 100% in the primary diagnosis of pheochromocytoma (n=16) and metastases were found in all cases with recurrent disease (n=5). The accuracy for NET of gastrointestinal tract was 92% in restaging (n=24). For the NETs located in the head-neck-thoracic region (n=19), the overall accuracy of PET was 89% including 12 cases of recurrent medullary thyroid cancer with a sensitivity of 90%. In analysis of patients with biochemical proof of disease combined with negative conventional imaging methods, PET had positive and negative predictive value of 92% and 95% respectively. [(18)F]DOPA PET-CT provided important additional information in the diagnosis of pheochromocytoma and restaging of known NET. Both in primary diagnosis and in patients with formerly known NET and increasing tumor markers, [(18)F]DOPA PET-CT is a sensitive first-line imaging method.

The objective of this clinical prospective study was to find out if laparoscopic Nissen fundoplication is an effective treatment in laryngopharyngeal reflux disease. Twenty-two consecutive patients, 16 female and 6 male, who were referred to laparoscopic fundoplication and operated by a senior gastroenterology surgeon were included in this study. Their mean age was 41 years (SD 13), and ranged from 18 to 64. The patients selected for surgical treatment had LPRD with several vocal and laryngeal symptoms. The status findings were typical for laryngopharyngeal reflux and the symptoms and signs had responded to antireflux medication. Vocal symptoms were interviewed and patients underwent laryngoscopy, esophagogastroscopy, and 24-h esophageal pH monitoring. The follow-up of symptoms and signs were 3 months after beginning of medication, before surgery, 3 months, and 1 year after surgery. The number of patients experiencing vocal symptoms decreased during the medical treatment, from the situation before medical treatment to the situation before surgery (P < 0.001), from the situation before surgery to the situation 3 months (P < 0.001) and 1 year post operation (P < 0.001), but no significant changes were found from the situation 3 months to 1 year post operation. Voice quality improved significantly only from the time point before surgery to 3 months post operation. Three months after medical treatment, laryngeal and pharyngeal findings did not decrease significantly, but several findings decreased significantly (P < 0.001) from the time point before surgery compared to 3 months and to 1 year post operation. Based on this study, the laparoscopic fundoplication is an effective and safe treatment of LPRD.

Objective: In a small proportion of patients, fundoplication fails and a reoperation is required. However, there are few reports on the symptomatic outcome after reoperative antireflux surgery. The aim of this study was to evaluate the results after fundoplication revision., Material and Methods: All patients (n=71) undergoing fundoplication revision between 1997 and 2005 were included in this study. The follow-up data were collected both from the hospital records and during postoperative control visits, including a personal interview using a structured questionnaire; follow-up was completed by 61 patients (88.4%)., Results: The primary fundoplications included both open (n=21) and laparoscopic (n=40) approaches; 92% (n=56) of the reoperations were open procedures. The morbidity rate was 21% and the reoperation rate 16%. Fifty-six percent (n=34) of the patients regarded the result of their reoperative surgery as excellent, good or satisfactory at a mean follow-up of 51 months; 66% of the patients had no significant reflux symptoms after re-fundoplication. With the benefit of hindsight, 77% of the patients would again choose to undergo re-fundoplication, but only 48% of the patients would again primarily choose surgical treatment. Mortality rate was 1.4% (n=1) and in three patients the reoperative treatment required total gastrectomy., Conclusions: These suboptimal results show that surgical treatment for gastro-oesophageal reflux disease in general is far from being perfect and this is even more marked after reoperative antireflux surgery, as fundoplication revision can result in severe complications. This emphasizes the importance of proper patient selection for both initial and reoperative antireflux surgery.

Background: For all surgical procedures, a surgeons' learning curve can be anticipated during which complication rates are increased. The aims of this study were to evaluate individual learning curves for a group of surgeons performing laparoscopic fundoplication and to evaluate if the Procedicus MIST-simulator (Mentice Inc., Göteborg, Sweden) accurately predicts surgical performance., Methods: Twelve Nordic centers participated, each contributing with a "master" and a "pupil" surgeon. The pupils were tested in the simulator and thereafter performed their first 20 supervised operations. All procedures were videotaped and evaluated by 3 independent reviewers., Results: A significant decrease in operative time (P <0.001) and a trend (P = 0.12) toward improved score were seen during the series. The master significantly affected the pupil's score (P =0.0137). The simulator-test showed no correlation with the operative score., Conclusions: Individual learning curves varied, and the teacher was shown to be the most important factor influencing the pupil's performance score. The correlation between assessed performance and patient outcome will be further investigated.

Their adhesion to the intestinal mucosa is considered one of the main reasons for the beneficial health effects of specific lactic acid bacteria (LAB). However, the influence of disease on the mucosal adhesion is largely unknown. Adhesion of selected LAB to resected colonic tissue and mucus was determined in patients with three major intestinal diseases (i.e., diverticulitis, rectal carcinoma, and inflammatory bowel disease) and compared to healthy control tissue. All strains were observed to adhere better to immobilized mucus than to whole intestinal tissue. Two strains (Lactobacillus rhamnosus strain GG and L. reuteri) were found to exhibit disease-specific adhesion to intestinal tissue. All tested strains, with the exception of L. rhamnosus strain GG, displayed disease-specific adhesion to intestinal mucus. These results suggest that strains with optimal binding characteristics for a particular intestinal disease can be selected.

Several studies have found genetic variation in plant resistance to herbivory. One of the explanations suggested for the observed intermediate levels of resistance are the costs of resistance, i.e., negative genetic correlations between resistance and other fitness components that may constrain the evolution of resistance. We studied the cost of herbivore resistance by investigating the genetic correlations between resistance traits and plant growth traits, and between resistance to insect and mammalian herbivores in cloned saplings of silver birch, Betula pendula. We used the performance of a geometrid moth, Epirrita autumnata, as an indicator of insect resistance. The numbers of resin droplets at the base and at the tip of the saplings correlate with mammalian resistance, and were thus used here as indicators of vole and hare resistance, respectively. We have previously observed genetic variation in these resistance traits. Further, we examined the correlations between several groups of secondary chemicals and plant growth traits. Finally, to reveal the effect of environmental factors on the trade-offs mentioned above, we investigated the correlations in saplings that were grown at two nutrient levels. We found significant negative correlations between indices of constitutive insect resistance and relative height growth in non-fertilized saplings, indicating cost of constitutive insect resistance. The two groups of secondary chemicals that have been shown to correlate strongly with constitutive insect resistance, i.e., condensed tannins and flavonol glycosides (especially myricetin glycosides), had different genetic correlations with plant traits; the concentration of condensed tannins did not correlate negatively with any of the plant traits, whereas the concentration of flavonol glycosides correlated negatively with plant height. Insect and mammalian resistance did not correlate negatively, indicating no ecological trade-offs.

Background: A causal relationship between gastroesophageal reflux (GER) and asthma has been suggested. Should this be the case, one could expect treatment of GER to diminish bronchial sensitivity. There has been a lack of trials evaluating the efficacy of antireflux surgery on airway reactivity., Objectives: To investigate the correlation between GER and bronchial responsiveness, and to determine the efficacy of Nissen fundoplication on bronchial responsiveness and pulmonary function., Methods: A methacholine inhalation challenge was performed on 15 consecutive GER patients preoperatively and approximately 5 months after Nissen fundoplication. Airway responsiveness was quantified with a dose-response slope (DRS), calculated by dividing the decrease in FEV(1) (%) with the dose of methacholine administered (micromoles)., Results: A positive correlation between the severity of distal esophageal reflux and bronchial responsiveness was found (r = 0.83, p < 0.001). There was an improvement in FEV(1) after fundoplication (p = 0.03). All 3 asthmatic patients participating in the study presented with bronchial hyperresponsiveness (BHR) which improved clearly in all of these patients after fundoplication. This resulted in an apparent trend for DRS to improve when the entire study population was considered (p = 0.12)., Conclusions: According to the current study there seems to be a positive correlation between the severity of distal esophageal reflux and bronchial responsiveness. These data suggest that operative treatment of GER may ameliorate BHR in asthmatic patients. Moreover, the results of the present study suggest that fundoplication may improve pulmonary function in patients with GER., (Copyright 2002 S. Karger AG, Basel)

Adhesion to the intestinal mucosa is one of the main selection criteria for probiotic strains. The adhesion of commonly used probiotic strains to human intestinal tissue pieces and mucus was assessed. The strains tested adhered to the intestinal tissue at low levels and adhered to the intestinal mucus at higher levels.