Clinical results of laparoscopic fundoplication at ten years after surgery

BACKGROUND: Several studies have demonstrated laparoscopic antireflux surgery (LAS) for the treatment of gastroesophageal reflux disease (GERD) to be efficient at short- and midterm follow-up evaluations. The aim of this study was to evaluate the results for LAS 10 years after surgery. METHODS: The 100 consecutive patients who underwent LAS by a single surgeon in 1993 were entered into a prospective database. Nissen fundoplication was performed for 68 patients, and partial posterior fundoplication (modified Toupet procedure) was performed for 32 patients. Evaluations of the outcome were made 5 and 10 years after surgery. A structured symptom questionnaire and upper gastrointestinal barium series were used at 5 years. The same questionnaire and an added quality-of-life questionnaire (the Gastrointestinal Quality of Life Index [GIQLI]) were used at 10 years. RESULTS: Seven patients died of unrelated causes during the 10-year period. Four patients underwent revision surgery: one patient for persistent dysphagia and three patients for recurrent reflux symptoms. Three patients were lost to any follow-up study. At 5 years, 93% of the patients were free of significant reflux symptoms. At 10 years, 89.5% of the patients still were free of significant reflux (93.3% after Nissen, 81.8% after Toupet). Major side effects (flatulence and abdominal distension) were related to "wind" problems. The GIQLI scores at 10 years were significantly better than the preoperative scores of the patients under medical therapy with proton pump inhibitors. CONCLUSIONS: Elimination of GERD symptoms improved quality of life and eliminated the need for daily acid suppression in most patients. These results, apparent 5 years after the operation, still were valid at 10 years.     

Postoperative joint symptoms: a risk factor for pouchitis in ulcerative colitis patients

BACKGROUND: The prevalence and significance of joint symptoms appearing in patients with ulcerative colitis (UC) following a colectomy are unclear. AIM: We investigated the relationship between joint symptoms during steroid tapering following an ileal pouch-anal anastomosis (IPAA) and the cumulative risk for developing pouchitis. PATIENTS AND METHODS: The medical records of 571 patients who underwent an IPAA with a mucosectomy were retrospectively reviewed to evaluate their joint symptoms. A diagnosis of pouchitis was obtained using the Pouchitis Disease Activity Index (PDAI) and the cumulative risk of pouchitis was estimated using a Kaplan-Meier life table analysis. RESULTS: Joint symptoms during steroid tapering were reported by 126 (22.0%) of the UC patients and each of those had involvement of the small joints of the hand. The main symptoms were pain and stiffness, especially in the morning. The cumulative risk for developing pouchitis after 10 years was found to be 20% in patients who experienced joint symptoms during steroid tapering and 10% in those without those symptoms (p = 0.001). CONCLUSION: The presence of joint symptoms during steroid tapering is a significant risk factor for the development of pouchitis in patients who have undergone an IPAA for UC.     

Risk Factors for Ileoanal J Pouch-Related Septic Complications in Ulcerative Colitis and Familial Adenomatous Polyposis

OBJECTIVE: To analyze the association between pre- and perioperative factors and pouch-related septic complications (PRSC) in ulcerative colitis (UC) and in familial adenomatous polyposis (FAP) after ileal pouch-anal anastomosis (IPAA). SUMMARY BACKGROUND DATA: For patients with UC and FAP, IPAA is the surgical therapy of choice, but in some patients the outcome is compromised by PRSC. METHODS: A total of 706 consecutive patients (494 UC, 212 FAP) were assessed in a study aimed at identifying subgroups of patients who were at high risk for PRSC. The rate of PRSC was analyzed as a time-dependent function (Kaplan-Meier estimation). Patients with UC and FAP were stratified separately according to associated factors (age, sex, surgeon's experience, temporary ileostomy, colectomy before IPAA, anastomotic tension, and several factors specific for UC). RESULTS: In all, 131 (19.2%) patients had PRSC (23.4% UC, 9.4% FAP). In patients with UC, the estimated 1-year PRSC rate was 15.6% and the estimated 3-year PRSC rate was 24.2%. In patients with FAP, the estimated 1-year and 3-year PRSC rates were 9.2%. The difference between the estimated rates of PRSC was significant (P <.001). In the univariate analysis, patients with UC younger than 50 years, with severe proctitis, with preoperative hemoglobin levels less than 10 g/L, or receiving corticoid medication had a significantly higher risk for PRSC (P =.039, P =.037, P =.047, P =.003, respectively). Multivariate analysis showed that patients with UC receiving a systemic prednisolone-equivalent corticoid medication of more than 40 mg/day had a significantly greater risk of developing pouch-related complications than patients with UC receiving 1 to 40 mg/day and patients with UC who were not receiving corticoid medication (RR: 3.78, 2.25, 1, respectively, P <.001). Patients with FAP proved to have a significantly higher risk for PRSC in the univariate and multivariate analyses if anastomotic tension had occurred (RR 3.60, P =.0086). CONCLUSIONS: Pouch-related septic complications occur as late complications and should therefore be considered in regular, specific long-term follow-up examinations. The authors identified significant risk factors for PRSC specific to patients with UC and FAP; these must be considered for each individual surgical strategy.     

Cancer in ulcerative colitis: what failed in follow-up?

In a 16-year series of 235 patients operated on for ulcerative colitis (UC), 16 patients had altogether 21 colorectal malignancies: 15 patients adenocarcinomas and 1 a lymphoma. These patients were analyzed to find the typical features of colitic cancer and to evaluate the chance for early detection of cancer. The mean age of the patients was 35 years (19-86), and the mean duration of UC 14 years (5-26). All patients had total colitis, and 13 of 21 tumours (62%) were located proximal to the splenic flexure. Three patients under regular surveillance had Dukes' stage A cancers, while those with only initial or no follow-up had more advanced tumours (1 Dukes' A, B, 1C, 10D). Early cancer was symptomless or indistinguishable from colitic symptoms. The reasons for inadequate surveillance were few symptoms of UC (n = 9), an unsatisfactory follow-up system (n = 3) and patient refusal (n = 1). Our survey indicates that only regular follow-up can disclose early tumours and, thus, improve the prognosis of colitic carcinoma. The necessity of establishing colonoscopic surveillance of UC patients soon after the diagnosis, and regardless of the degree of symptoms is emphasized, because 7 (44%) of our patients developed cancer within 10 years of the onset of UC.     

Self-management of asthma in general practice,asthma control and quality of life: a randomised controlled trial

BACKGROUND: A study was undertaken to determine the effectiveness of asthma self-management in general practice. METHODS: Nineteen general practices were randomly allocated to usual care (UC) or self-management (SM). Asthma patients were included after confirmation of the GP diagnosis. Follow up was 2 years. Patients kept diary cards and visited the lung function laboratory every 6 months. Outcomes were number of successfully treated weeks, limited activity days, asthma specific quality of life, forced expiratory volume in 1 second (FEV(1)), FEV(1) reversibility, concentration of histamine provoking a fall in FEV(1) of 20% or more (PC(20) histamine), and amount of inhaled steroids. RESULTS: A total of 214 patients were included in the study (104 UC/110 SM; one third of the total asthma population in general practice); 62% were female. The mean percentage of successfully treated weeks per patient in the UC group was 72% (74/103 weeks) compared with 78% (81/105 weeks) in the SM group (p=0.003). The mean number of limited activity days was 1.2 (95% CI 0.5 to 1.9) in the SM group and 3.9 (95% CI 2.5 to 5.4) in the UC group. The estimated increase in asthma quality of life score was 0.10 points per visit in the UC group and 0.21 points per visit in the SM group (p=0.055). FEV(1), FEV(1) reversibility, and PC(20) histamine did not change. There was a saving of 217 puffs of inhaled steroid per patient in favour of the SM group (p<0.05). CONCLUSION: Self-management lowers the burden of illness as perceived by patients with asthma and is at least as effective as the treatment usually provided in Dutch primary care. Self-management is a safe basis for intermittent treatment with inhaled corticosteroids.     

Elevated platelet count before ileal pouch-anal anastomosis for ulcerative colitis is associated with the development of chronic pouchitis

Acute pouchitis (AP) after ileal pouch-anal anastomosis (IPAA) is common and easily treated. However, chronic pouchitis (CP) remains a difficult management problem and may represent a form of Crohn disease (CD) of the ileal pouch. Because CD patients have higher platelet counts than ulcerative colotis (UC) patients, we prospectively evaluated the association between preoperative platelet count and pouchitis development in 159 patients undergoing IPAA. Reactive thrombocytosis (RT) was defined as a platelet count > 450 x 10(9)/L. Median preoperative platelet count was 312 x 10(9)/L (range, 103 x 10(9)/L to 886 x 10(9)/L). One hundred twenty-five patients (79%) had a normal (150 x 10(9)/L to 450 x 10(9)/L) platelet count (-RT patient group). Twenty-eight patients (18%) had RT. Six patients (3%) had a platelet count below 150 x 10(9)/L. After a median follow-up of 13 months, 45 patients (28%) developed pouchitis. Pouchitis developed in 33 +RT patients (26%) versus 9 -RT patients (32%) (P = NS). UC patients who had +RT had a 25 per cent incidence of CP compared to only 7 per cent of those UC patients who had -RT (P = 0.03). The incidence of CP was significantly higher after IPAA in UC patients having thrombocytosis before surgery compared to UC patients having a normal platelet count before surgery.     

Incidence and therapeutic outcome of pouchitis for ulcerative colitis in Japanese patients

AIM: The aim of this study was to examine the cumulative risk of pouchitis following restorative proctocolectomy for UC and FAP in Japanese patients, and to assess the response to medical treatment and its outcome. PATIENTS AND METHODS: 521 patients with UC and 117 FAP patients underwent proctocolectomy and received a J-shaped IPAA at our department of surgery. We investigated these patients using PDAI for the diagnostic criteria of pouchitis. RESULTS: Pouchitis occurred in only 32 UC patients (6.1%). The cumulative risk of developing pouchitis for a UC patient was 7% at 5 years after and 12% at 10 years after surgery. The medical treatment of acute pouchitis was usually oral metronidazole (250 mg twice daily) for 2 weeks or oral ciprofloxacin (200 mg thrice daily) in patients who could not tolerate metronidazole. Single episodes of pouchitis occurred in 21 patients (65.6%) and chronic or frequent relapses of pouchitis in 11 patients (34.4%). Three patients (9.4%) required re-ileostomy. Two patients (6.3%) required pouch excision. There were no patients with complicated dysplasia. CONCLUSION: The cumulative risk of pouchitis in Japanese UC patients is lower than that of western countries.     

Predictors of residual symptoms in lower extremities after decompression surgery on lumbar spinal stenosis

Leg pain/numbness and gait disturbance, two major symptoms in the lower extremities of lumbar spinal stenosis (LSS), are generally expected to be alleviated by decompression surgery. However, the paucity of information available to patients before surgery about specific predictors has resulted in some of them being dissatisfied with the surgical outcome when the major symptoms remain after the procedure. This prospective, observational study sought to identify the predictors of the outcome of a decompression surgery: modified fenestration with restorative spinoplasty. Of 109 consecutive LSS patients who underwent the decompression surgery, 89 (56 males and 33 females) completed the 2 year follow-up. Both leg pain/numbness and gait disturbance determined by the Japanese Orthopedic Association scoring system were significantly improved at 2 years after surgery compared to those preoperative, regardless of potential predictors including gender, preoperative presence of resting numbness in the leg, drop foot, cauda equina syndrome, degenerative spinal deformity or myelographic filling defect, or the number of decompressed levels. However, 27 (30.3%) and 13 (14.6%) patients showed residual leg pain/numbness and gait disturbance, respectively. Among the variables examined, the preoperative resting numbness was associated with residual leg pain/numbness and gait disturbance, and the preoperative drop foot was associated with residual gait disturbance, which was confirmed by logistic regression analysis after adjustment for age and gender. This is the first study to identify specific predictors for these two remaining major symptoms of LSS after decompression surgery, and consideration could be given to including this in the informed consent.     

Neutrophil priming as a surgery-related risk factor for postoperative infectious complications in patients with ulcerative colitis

AIMS: The present study was designed to assess whether preoperative neutrophil priming under surgical stress has causal effects on the postoperative clinical outcomes of ulcerative colitis (UC) patients. PATIENTS AND METHODS: In 63 consecutive UC patients, perioperative changes in cytokines and neutrophil elastase (NE) were quantified and their relationships to postoperative infectious complications (PICs) were evaluated. RESULTS: A preoperative increase in NE (high group: Group H) was associated with longer disease duration and greater preoperative total amount of steroids administered. Patients in Group H developed more PICs than those in the low NE group when they underwent surgery >240 min. In Group H, the NE level remained high after longer duration surgery, but decreased rapidly after shorter duration surgery. Multivariate analyses revealed that the total amount of steroids used and preoperative NE level were independent risk factors for predicting PICs in the longer operation group. CONCLUSION: Preoperative neutrophil activation may become a risk factor for postoperative morbidity when the patients undergo intense surgical stress. The most important procedures for preventing postoperative morbidity in high-risk UC patients may be reducing surgical stress and/or controlling neutrophil activation perioperatively.     

Patterns of disease and surgical treatment among United States veterans more than 50 years of age with ulcerative colitis

BACKGROUND: Ulcerative colitis (UC) is a clinical entity that predominantly affects young adults yet large series of middle age or elderly patients with UC are infrequently reported. The aim of this study is to identify patterns of disease, indications for operation, surgical treatment, and outcome of patients more than 50 years of age who required surgery for UC in Department of Veterans Affairs (DVA) Medical Centers. METHODS: A population-based study on all patients in 159 hospitals of the DVA from 1997 to 2001 was carried out. Data were compiled from several national computerized VA data sets. Supplementary information including demographic information, discharge summaries, operative reports and pathology reports were obtained from local medical records. Patient variables were entered into a computerized database and analyzed using the Pearson chi-square and Fisher's exact tests. Statistical significance is designated as P < 0.05. RESULTS: One hundred fifty-eight patients were evaluable. The mean age was 59 years (range 51-81); 99% were male. The mean duration of UC was 23 years (range 2 to 50). One hundred of the 158 patients had proctocolitis; 58 had either left-sided colitis or proctosigmoiditis. The mean dose of prednisone prior to surgery was 20 mg; the mean duration of steroid use was 8 years. The indications for elective surgery were intractability (59%), mass or stricture (27%), and dysplasia (14%). Twenty of the 158 patients (12%) were operated on emergently for either toxic colitis, perforation, or hemorrhage. One hundred three of the 158 underwent proctocolectomy and permanent ileostomy, 55 underwent a restorative proctocolectomy, and underwent a segmental colectomy. Twenty of the 158 patients were found to have dysplasia in their colectomy specimens; an additional 10 (7%) were found to have invasive cancer. Surgical morbidity was 22%. Overall mortality was 4% (7 of 158); all but 1 death occurred after emergent surgery. Mean hospitalization was 36 days (range 2 to 297). CONCLUSIONS: Restorative proctocolectomy was performed in 36% of veterans more than 50 years of age requiring surgery for UC. The majority required surgery for intractable symptoms. Dysplasia and invasive cancer was found in 18% of patients. Mortality after surgery for acute surgical emergencies remains high.     

Vertebral reconstruction with biodegradable calcium phosphate cement in the treatment of osteoporotic vertebral compression fracture using instrumentation

OBJECTIVE: To assess the efficacy of posterior instrumentation and vertebral reconstruction with biodegradable calcium phosphate cement (CPC) in the treatment of osteoporotic vertebral compression fracture with neurologic deficit. BACKGROUND: Vertebroplasty consists of the injection of polymethylmethacrylate (PMMA) cement into the vertebral body. While PMMA has high mechanical strength, it cures fast and thus allows only a short handling time. Other potential problems of using PMMA injection may include damage to surrounding tissues due to the high polymerization temperature or by the toxic unreacted monomer and the lack of long-term biocompatibility. Bone mineral cements such as calcium carbonate and CPCs have a longer working time and low thermal effect. They are also biodegradable while providing good mechanical strength. However, the viscosity of injectable mineral cements is high, and the infiltration of these cements into the vertebral body has been questioned. Recently, the infiltration properties of CPC have been significantly improved, making it more suitable for injection into the vertebral bodies for vertebral reconstruction. METHODS: Five patients were included in this open prospective study. Inclusion criteria were delayed collapsed vertebral compression fractures responsible for severe pain and neurologic dysfunction necessitating posterior decompression surgery. Of five patients, two were male and three were female with an average age at surgery of 80.4 years (71-85 years) and an average duration of follow-up of 2.5 years (2-3.5 years). Evaluation of clinical data was based on x-ray, Japanese Orthopaedic Association (JOA) score for low back pain (full score is 29 points), and Visual Analog Scale (VAS). RESULTS: The levels of the delayed collapsed vertebrae were T10, L1, and L2 (for one patient each) and L4 (two patients). All patients were in poor condition, for example, renal failure, heart failure, and chronic hepatitis. The average operative time was 2 hours (1 hour 36 minutes to 2 hours 16 minutes), and intraoperative bleeding was 181 mL (85-236 mL). As for clinical symptoms, preoperative JOA score averaged 17.8 points and was improved to 26 points postoperatively, while the preoperative VAS score of 8.6 points improved to 2 points postoperatively. Morphologic evaluation showed preoperative vertebral compression ratio averaged 41% and improved to 74% immediately after the operation and finally settled at 68%. Just one of five cases experienced late vertebral collapse 3 months after the operation. CONCLUSION: Vertebral reconstruction with biodegradable CPC in the treatment of osteoporotic vertebral compression fracture using instrumentation was a safe and useful surgical treatment.     

Colorectal cancer complicating inflammatory bowel disease: a comparative study of Crohn’s disease vs ulcerative colitis in 34 patients

Aim Colorectal cancer (CRC) complicating inflammatory bowel disease (IBD) accounts for 10–15% of all IBD deaths. Survival of patients with IBD‐related CRC was reviewed to analyse differences between ulcerative colitis (UC) and Crohn’s disease (CD). Method We analysed (24 men and 10 women) patients with CD (n = 14) or UC (n = 20) with CRC, who presented between 1990 and 2007, and were followed to October, 2009. Results The mean age of patients was 56 ± 12 years for patients with UC and 49 ± 17 years for patients with CD, and the mean duration of symptoms was 22 ± 11 and 16 ± 8 years, respectively. The median duration of follow up after the diagnosis of CRC was 49 (1–157) months. Recurrence occurred in five patients with UC and in nine with CD (P = 0.02). The overall and disease free five year survivals were significantly higher in patients with UC than CD [70%vs 43% (P = 0.01) and 63%vs 31% (P = 0.01), respectively]. Conclusion The results showed a poorer prognosis of CRC in patients with CD than with UC.     

A lecithinized superoxide dismutase (PC‐SOD) improves ulcerative colitis

Objective To assess the safety and efficacy of lecithinized superoxide dismutase (PC‐SOD) in patients with ulcerative colitis (UC). Method PC‐SOD was injected once daily at doses of 40 mg (n = 22) and 80 mg (n = 20) for a total treatment period of 4 weeks. Efficacy was assessed by UC‐Disease Activity Index (DAI) total score. All side effects were recorded and investigated. Results At 4 weeks, the UC‐DAI total score was significantly decreased vs baseline in both the 40 mg and 80 mg groups. It was confirmed that PC‐SOD 80 mg was, at least, not significantly superior to PC‐SOD 40 mg. Twenty incidences of side effects were noted in 12 (54.55%) of 22 patients in the 40 mg group, while there were three incidences of side effects in two (10.00%) of 20 patients in the 80 mg group. None of these side effects was severe. Thus it was concluded that the test drug is safe when given at daily dosages of 40 mg and 80 mg. Conclusion In this pilot study PC‐SOD improved UC more rapidly than previously existing drugs. A double blind, placebo‐controlled clinical trial of PC‐SOD 40 mg/day is required to confirm the efficacy of this agent against UC.     

Prediction of postoperative gas bloating after laparoscopic antireflux procedures based on 24-h pH acid reflux pattern

Background:Postoperative gas/bloating (G/B) is a common sequelae after laparoscopic fundoplication. Patients with "upright" reflux are thought to have more aerophagic tendencies contributing to their GERD symptoms than patients with significant "supine" patterns of reflux. The risk of postoperative G/B developing was analyzed in relation to patient preoperative patterns of upright, mixed, or supine 24-h pH scores. Methods: In this study, 339 patients undergoing fundoplication (278 Nissen and 61 Toupet) were evaluated for preoperative G/B symptoms using a 0 to 10 severity visual analogue scale. Reflux patterns were classified as upright, supine, or mixed according to 24-h pH studies. Results: As compared with preoperative values, 46% of the patients with a preoperative G/B score less than 3 and an upright or mixed reflux pattern had a significant increase in their average G/B score at 2 years (upright, from 0.9 to 4.2; mixed, from 1.1 to 4.1). However, the patients with a supine reflux pattern did not have a statistically significant change (from 2.0 to 2.2; p > 0.05). The patients with established aerophagic tendencies preoperatively (G/B score > 3) showed significant improvement in these symptoms at 2 years across all three reflux patterns (average G/B score, from 7.7 preoperatively to 4.8 at 2 years). There was no gender predisposition, nor was there any difference in the incidence of G/B between complete and partial fundoplication. Conclusions: The pattern of 24-h acid reflux can be predictive of G/B after antireflux surgery. Patients with mild preoperative G/B symptoms (score <3) and upright or mixed patterns of 24-h acid reflux appear to have an increased postoperative risk for chronic G/B as compared with patients who have supine reflux and mild preoperative G/B. Patients with moderate to severe preoperative G/B symptoms (score, 3–10) appear to have a general improvement in G/B symptoms at 2 years after fundoplication.     

Peripheral nerve vein wrapping for intractable lower extremity pain

HYPOTHESIS/PURPOSE: The purpose of this study was to determine the effectiveness of lower extremity peripheral nerve vein wrapping procedures in the management of patients with intractable lower extremity pain. The hypothesis was that nerve insulation through vein wrapping is effective in treating symptoms related to adhesive neuralgia, but not those secondary to intraneural damage. METHODS: We retrospectively reviewed 25 consecutive patients whose intractable chronic lower extremity peripheral neuralgia had been treated with revision neurolysis and vein wrapping. The 14 women and 11 men had an average age of 39 years (range, 21 to 53 years). Vein wrapping was performed using a saphenous vein autograft in 19 patients and a fetal umbilical vein in six patients. The average length of follow-up after vein wrapping was 24 months (range, 12 to 63 months). Assessment of pain and dysfunction was on a scale of 0 (no pain/dysfunction) to 10 (severe enough to prompt request for amputation and required use of a wheelchair). RESULTS: Pain scores improved from a preoperative average of 8.7 points (range, 6 to 10 points) to a postoperative average of 4.6 points (range, 0 to 10 points); dysfunction improved from a preoperative average of 7.3 points (range, 3 to 10 points) to a postoperative average of 4.4 points (range, 0 to 9 points). Although 17/25 patients were satisfied with the procedure, only 14/25 stated they would undergo the surgery again. All eight patients who exhibited no improvement had preoperative and intraoperative evidence of an idiopathic etiology and/or intraneural damage. Preoperatively, 18/25 patients could not work; postoperatively, that number improved to 8/25. Conclusions: Vein wrapping of lower extremity peripheral nerves is most effective in relieving symptoms related to adhesive neuralgia and less beneficial in the presence of intraneural damage. Although symptoms are rarely relieved completely, vein wrapping typically results in a substantial improvement in symptoms related to scar entrapment of peripheral nerves.     

Results of laparoscopic fundoplication where atypical symptoms coexist with oesophageal reflux

BACKGROUND: Laparoscopic Nissen fundoplication (LNF) has been increasingly performed for gastro-oesophageal reflux disease. The outcomes of LNF for patients with concurrent symptoms other than heartburn are unclear. The purpose of the present paper was to review the outcomes of LNF performed by one surgeon over 4 years and compare the outcomes of patients with reflux symptoms with those of patients having reflux symptoms plus atypical symptoms. METHODS: The records of a consecutive series of 90 patients were reviewed. Preoperative symptoms were defined as typical (heartburn and reflux) or atypical (other symptoms, e.g. cough, atypical chest pain, choking). At the time of follow up an independent observer interviewed patients, and collected data on current symptoms and patient satisfaction. A questionnaire of current symptoms and patient satisfaction was completed. A satisfaction score from 1 to 10 was given by patients, with 1 being very unsatisfied and 10 being very satisfied. RESULTS: Of the 90 patients, 97% had typical symptoms and 56% had concurrent atypical symptoms. Eighty-three of 90 patients were contacted; typical reflux symptoms improved in 95% of patients whereas atypical symptoms improved in only 54%. Overall, the mean satisfaction score was 8.7. Patients with atypical symptoms had a lower satisfaction score of 8.0 versus a satisfaction score of 9.0 for patients with only typical symptoms (P < 0.05). Patients with a satisfaction score < 8.0 had a higher rate of atypical symptoms (75%) than patients with a satisfaction score > or = 8 (50%). CONCLUSION: Laparoscopic Nissen fundoplication controlled typical reflux symptoms very well but atypical symptoms were improved in only approximately 50%. A lower satisfaction score was associated with preoperative atypical symptoms.     

Results of a longer than 10-year follow-Up of patients with rheumatoid arthritis treated by occipitocervical fusion

STUDY DESIGN: Evaluation of results a longer than 10-year follow-up of patients with upper cervical lesions due to rheumatoid arthritis who underwent occipitocervical fusion. OBJECTIVE: To determine the final outcome of patients with upper cervical lesions due to rheumatoid arthritis treated by occipitocervical fusion. SUMMARY OF BACKGROUND DATA: There are few studies reporting the final outcome of patients with rheumatoid arthritis treated by occipitocervical fusion and observed for longer than 10 years. METHODS: The subjects were 16 patients with rheumatoid arthritis with myelopathy who underwent occipitocervical fusion with a rectangular rod more than 10 years ago. All 16 patients had irreducible atlantoaxial dislocation, and 11 also had vertical dislocation of the axis. All patients had preoperative nuchal pain, and were classified into Class II (two patients), Class IIIA (nine patients), and class IIIB (five patients) according to Ranawat's preoperative neurologic classification. RESULTS: The atlas-dens interval remained the same as immediately after surgery. Vertical dislocation returned to the preoperative condition, despite successful surgical correction. Preoperative occipital pain disappeared or was reduced in all cases. Myelopathy improved in 12 of the 16 patients (75%) by more than one class in the Ranawat preoperative neurologic classification. Survival rate at 10 years after surgery was 38%; mean age at death was 70.7 years. The postoperative periods during which patients could walk by themselves ranged from 6 months to 13 years (mean, 7.5 years). CONCLUSIONS: Occipitocervical fusion for patients with rheumatoid arthritis is useful for decreasing nuchal pain, reducing myelopathy, and improving prognosis.     

Postmyotomy recollection of premyotomy symptoms of achalasia is very accurate,supporting longitudinal studies of symptom improvement

Background Recollection of preoperative symptom frequency and severity may change postoperatively, thus invalidating longitudinal studies. This study was undertaken to compare symptoms of achalasia before myotomy to patients’ postoperative recollection of premyotomy symptoms. Methods A total of 173 patients, 54% male, of median age 48 years, have undergone laparoscopic Heller myotomy and have been followed through a prospectively maintained registry. Preoperatively, patients scored the frequency and severity of their symptoms on a Likert scale: 0 (never/very bothersome) to 10 (always/very bothersome). Similarly, after laparoscopic Heller myotomy, patients scored the frequency and severity of their symptoms, and re-scored their preoperative symptoms. Data are presented as median, mean ± SD. Results Before myotomy, dysphagia, regurgitation, choking, chest pain, vomiting, and heartburn were particularly notable; symptom scores nearly globally improved after myotomy (p < 0.05 for all, Wilcoxon matched pairs test), especially obstructive symptoms. Postmyotomy recollection of premyotomy symptom frequency and severity was neither substantively nor consistently different from premyotomy scoring. Conclusions Before myotomy, patient symptom scores reflected the deleterious impact of achalasia. After myotomy, patient symptom scores dramatically improved, reflecting the favorable impact of laparoscopic Heller myotomy. Even years after myotomy, patient recollection of premyotomy symptom severity and frequency is very accurate and supports longitudinal studies of symptom improvement after myotomy. Presented at the 25th Annual Meeting of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), Dallas, Texas, 26–29 May 2006     

Predictors of airway complications after thyroidectomy for substernal goiter

HYPOTHESIS: Airway complications after thyroidectomy for substernal goiter can be predicted by preoperative symptom profiles, radiologic findings, or other factors. DESIGN: Retrospective review.Settings A university tertiary care center and a veterans' hospital. PATIENTS: Sixty patients with substernal goiter who underwent thyroidectomy between 1993 and 2002. MAIN OUTCOME MEASURES: Symptoms, preoperative radiologic findings, extent of thyroid resection, tumor size, and postoperative complications. RESULTS: Dysphagia was the most common preoperative symptom (n = 26), followed by dyspnea (n = 21), orthopnea (n = 13), and hoarseness (n = 6); 18 patients (30%) had superior vena caval obstruction. Thirteen patients (22%) were asymptomatic. Preoperative imaging identified tracheal deviation or compression in 45 patients (75%). Substernal goiter was resected via a cervical approach in 59 patients (98%). Of 47 patients with preoperative symptoms, 41 (87%) reported improvement postoperatively. Seven patients (12%) had postoperative airway complications: 1 developed a neck hematoma requiring reoperation, and 6 could not be immediately extubated; all 6 were successfully extubated after 1 to 10 days. Patients with airway complications were older (mean +/- SEM, 70.3 +/- 3.6 years vs 61.5 +/- 2.2 years), had larger goiters (mean +/- SEM, 210.7 +/- 37.0 g vs 112.2 +/- 7.7 g), and were more likely to have tracheal compression on preoperative imaging than those who did not have complications (P<.05). CONCLUSIONS: Most patients with substernal goiters underwent thyroid resection via a cervical approach with an improvement in symptoms. The few patients who developed postoperative airway complications were older, had larger goiters, and were more likely to have tracheal compression on preoperative imaging than those without airway complications.     

Durability of Success after Rectocele Repair

The purpose of the study was to determine the durability of success after rectocele repair and to evaluate parameters that might influence long-term results. Twenty-five patients with rectocele were prospectively evaluated both clinically and physiologically. Follow-up was performed twice, at 1 and 5.1 years postoperatively. Twenty-four patients had a long-term follow-up; 21/23 patients (91%) with preoperative symptoms of rectal emptying difficulty reported improvement of their symptoms and 9 of 12 (75%) with preoperative symptoms of pelvic heaviness reported relief at long-term follow-up. All 5 patients with preoperative pathologic transit study had various degrees of rectal emptying difficulty at long-term follow-up. Three of 5 patients with preoperative paradoxical sphincter reaction (PSR) at electromyography (EMG) reported improvement of the symptoms of rectal emptying difficulty at long-term follow-up. Surgery for rectocele is associated with improved symptoms in a majority of patients which are sustained long term. Patients with pathologic transit study may have a less favorable symptomatic outcome. The clinical significance of PSR needs further study.