Laparoscopic Nissen fundoplication versus 90° and 180° fundoplication for gastroesophageal reflux disease

European Surgery - Laparoscopic Nissen fundoplication (LNF) is standard care for surgical treatment of gastroesophageal reflux disease (GERD) in adults. The main disadvantage is the compression of...     

Comparison of two different transection techniques in liver surgery—an experimental study in a porcine model

Aims

Postoperative morbidity and mortality after liver resection is closely related to the degree of intraoperative blood loss; the majority of which occurs during transection of the liver parenchyma. Many approaches and devices have therefore been developed to limit bleeding, but none has yet achieved perfect results up to now. The aim of this standardized chronic animal study was to compare the safety and efficacy of the LigaSure? Vessel Sealing System (LVSS) with the stapler technique, which is one of the modern techniques for transecting the parenchyma in liver surgery.

Methods

Sixteen pigs underwent a left liver resection (LLR). Eight pigs received a LLR by means of an Endo GIA, whereas the other eight pigs underwent liver parenchymal transection followed by simultaneous sealing by the LVSS. The operating time, transection time, blood loss during transection, and time of hemostasis were measured on the day of LLR (postoperative day 0/POD 0). Animals were re-explored on postoperative day 7 (POD 7) and the transection surface of remnant liver was observed for fluid collection (hematoma, biloma, and abscess), necrosis, and other pathologies. A biopsy was taken from the area of transection for histopathological examination.

Results

All animals survived until POD 7. Operating time and transection time of the liver parenchyma on POD 0 was significantly shorter in the stapler group. There was no significant difference between the two groups in terms of blood loss during transection, time of hemostasis and number of sutures for hemostasis on POD 0, morbidity rate, as well as the histopathological examination on POD 7. Furthermore, the material costs were significantly higher in the stapler group than in the LVSS group.

Conclusion

In this standardized chronic animal study concerning transection of the parenchyma in liver surgery, LVSS seems not only to be safe, but also comparable with the stapler technique in terms of morbidity and mortality. Additionally, LVSS significantly reduces material costs. However, the transection time is significantly longer for LVSS than for the stapler resection technique.     

Geometry and reproducibility in 360° fundoplication

Background: In this study, we set out to precisely define two symmetrical points—a on the anterior fundic wall and b on the posterior fundic wall. These points, when advanced around a 60-Fr bougie-filled esophagus, will meet on the right side, to the right of the anterior vagus nerve, to create a reliable, reproducible, loose (i.e., or ``floppy') 360° fundoplication (FP). Methods: For the terms of this study, circumference =c; diameter =d; c/d=π; π= 3.14; and d(cm) = Fr/30. Using a flexible plastic ruler, we measured, in cadavers (n= 5) and intraoperatively (n= 16), esophageal c at the gastroesophageal junction (GEJ) with a 60-Fr bougie in place; d was calculated from c. Results: The smallest measured value for c was 7.5 cm (d= 2.39 cm); the largest value for c was 10.0 cm (d= 3.18 cm). The mean value was 8.35 cm (d= 2.66 cm). Points a and b are established by measuring laterally from a point where the greater curve meets the GEJ in the bougie-filled esophagus. Point a is 6.0 cm laterally and 6.0 cm below the short gastric vessels on the anterior fundus; point b is 6.0 cm laterally in a symmetrical position on the posterior fundus. Connecting these three points as a line defines the inner c of the completed FP and measures 12.0 cm. This gives an internal d of 3.82 cm for the FP. This is >1 cm larger than d for the mean measured external esophageal c of 8.35 cm where d= 2.66 cm. This technique creates a correctly oriented, symmetrical, ``floppy,' true fundoplication. It avoids wrapping or twisting the fundus around the GEJ. The technique is easily taught and reproducible. Conclusions: Two points, measured a horizontal distance of 6.0 cm from the GEJ, symmetrically placed on the anterior (point a) and posterior (point b) fundus can be brought anterior (a) and posterior (b) to the esophagus and sutured to the right of the anterior vagus nerve to reliably and reproducibly create a ``floppy' 360° fundoplication. Received: 20 April 1999/Accepted: 15 February 2000/Online publication: 15 May 2000     

An evaluation of the protective effect of esomeprazole in an experimental model of renal ischemia–reperfusion

Purpose

The ischemia and subsequent reperfusion (IR) which occurs in partial nephrectomy used in the treatment of renal tumors causes loss of parenchyma in the damaged kidney. The aim of this study is to evaluate, both biochemically and histologically, the efficacy of esomeprazole in an ischemia–reperfusion model in rat kidneys.

Methods

The rats were randomized into three groups of seven animals each, referred to as the sham, control, and PPI groups. In the sham group, only a laparotomy was performed. In the control group, following laparotomy the left renal artery was dissected and tied for 30-min ischemia. In the PPI group, a vascular route to the tail vein was opened, and 10 mg/kg esomeprazole was administered. After 1 h, the same procedures described for the control group were performed. All the animals were killed 24 h after the procedure. Biochemical analyses were applied for evaluation of oxidant and antioxidant agents in the blood and left kidney of each subject (oxidative markers: malondialdehyde, myeloperoxidase; antioxidant marker: superoxide dismutase). In the histological examination of the kidney tissues stained with hematoxylin–eosin, the TUNEL method was applied in the evaluation of apoptosis.

Results

No statistically significant biochemical difference was determined in the blood and tissue samples. In the histological and apoptosis evaluations, a statistically significant difference was determined between the sham, control, and PPI groups. The median (IQR) values of the TUNEL-positive cells were counted as 1.50 (4) in the sham group, 11.50 (12) in the control group, and 6.00 (9) in the PPI group (p < 0.001).

Conclusions

A protective effect of esomeprazole was confirmed in renal ischemia–reperfusion damage created in an experimental rat model.

     

Is Toupet fundoplication the procedure of choice for treating gastroesophageal reflux disease? Results of a prospective randomized experimental trial comparing three major antireflux operations in a porcine model

Background  

Gastroesophageal reflux disease (GERD) is among the most common dysfunctions of the upper gastrointestinal tract. It interferes with quality of life and is a risk factor for the development of adenocarcinoma in the lower esophagus. Laparoscopic fundoplication is an effective treatment of GERD, but the physiologic mechanisms of the different available procedures had not been investigated to date.     

Cefuroxime concentrations in the anterior and posterior column of the lumbar spine – an experimental porcine study

BACKGROUND CONTEXTSurgical site infection following spine surgery is associated with increased morbidity and mortality. Perioperative antibiotic prophylaxis is a key factor in lowering the risk of acquiring an infection. Previous studies have assessed perioperative cefuroxime concentrations in the anterior column of the cervical spine with an anterior surgical approach. However, the majority of surgeries are performed in the posterior column and many surgeries involve the lumbar spine.PURPOSEThe objective of this study was to compare the perioperative tissue concentrations of cefuroxime in the anterior and posterior column during lumbar spine surgery with a posterior surgical approach.STUDY DESIGNIn vivo experimental pharmacokinetic study of cefuroxime concentrations in an acute preclinical porcine model.METHODSThe lumbar vertebral column was exposed from L1 to L5 in 8 female pigs. Microdialysis catheters were placed for sampling in the anterior column (vertebral body) and posterior column (posterior arch) within the same vertebra (L5). Cefuroxime (1.5 g) was administered intravenously. Microdialysates and plasma samples were continuously obtained over 8 hours. Cefuroxime concentrations were quantified by Ultra High Performance Liquid Chromatography Tandem Mass Spectrometry. The primary endpoint was the time above the cefuroxime clinical breakpoint minimal inhibitory concentration (T>MIC) for Staphylococcus aureus of 4 µg/mL. The secondary endpoint was tissue penetration (AUC_tissue/AUC_plasma).RESULTSMean T>MIC 4 µg/mL (95% confidence interval) was 123 min (105–141) in plasma, 97 min (79–115) in the anterior column and 93 min (75–111) in the posterior column. Tissue penetration (95% confidence interval) was incomplete for both the anterior column 0.48 (0.40–0.56) and posterior column 0.40 (0.33–0.48).CONCLUSIONST>MIC was comparable between the anterior and posterior column. Mean cefuroxime concentrations decreased below the clinical breakpoint minimal inhibitory concentration for S. aureus of 4 µg/mL after 123 minutes (plasma), 97 minutes (anterior column) and 93 minutes (posterior column). This is shorter than the duration of most lumbar spine surgeries, and therefore alternative dosing regimens should be considered in posterior open lumbar spine surgeries lasting more than 1.5 hours.CLINICAL SIGNIFICANCEOpen lumbar spine surgery often involves extensive soft tissue dissection, stripping and retraction of the paraspinal muscles which may impair the local blood flow exposing the lumbar vertebra to postoperative infections. A single intravenous administration of 1.5 g cefuroxime only provided sufficient prophylactic target tissue concentrations in the vertebra of the lumbar spine for up to 1.5 hours.     

Is there a need for anterior release for 70–90° thoracic curves in adolescent scoliosis?

Large and stiff thoracic scoliotic curves in the adolescent represent a classic indication of anterior release followed by posterior instrumentation. However, third-generation segmental spinal instrumentations have shown increased correction of thoracic curves. Indication for an anterior release may therefore not be required even in large and stiff thoracic curves. The objective of the study was, therefore, to analyze retrospectively the results of third-generation segmental posterior instrumentation in large and stiff thoracic curves and to compare our results with the current literature of anterior release followed by posterior instrumentation. An independent observer, who had not participated in any of the case, reviewed our electronic database of adolescent scoliosis surgery (Scolisoft) with the following query: thoracic curves, Cobb angle between 70° and 90° and posterior surgery only. He was able to identify 19 patients whose thoracic curves were measured between 70° and 90°. Out of these, four had convex-side bending Cobb angle values of less than 45° and were not included in the study, as they were judged too flexible. Fifteen patients (aged 11–18 years, mean 13.6 years) with thoracic scoliosis were left for the study (average Cobb angles 78.5° with a flexibility index of 32.5% (range, 19–42%). The mean follow-up period was 32 months (range 18–64 months). Classic parameters of deformity correction were analysed. The average operative time was 314 min and the mean total blood loss was 1,875 ml. Average level of instrumented vertebrae was 12 (Range, 10–14). Postoperatively, the thoracic Cobb angle was measured at 34.8° (range, 25–45°), which represents a correction rate of 54% (range, 40.0–67.1%) and remained unchanged at the last follow-up (35°). Patients with thoracic hypokyphosis improved from an average 11° to 18°. There were three complications (one excessive bleeding, one early infection and one late infection). One case showed an add-on phenomenon at the last follow-up. Coronal balance was improved from 1.8 cm (Range 0–4cm) down to 0.75 cm (range 0–2.5 cm). Shoulder balance was improved from 1.3 cm (range 0–4cm) down to 0.75 (0–2.5 cm). All patients reported satisfactory results except the patient with an adding-on phenomena. In the literature, most of the results of anterior thoracoscopic release and posterior surgery give a percentage of Cobb angle correction similar or inferior to our series for an average initial Cobb angle of less magnitude. Therefore, with adequate posterior release, and the use of third-generation segmental instrumentation there is no need for anterior release even for curves in the 70 –90° range.     

Efficacy of fleece-bound sealing system (TachoSil®) in delayed anterior tracheal lacerations secondary to ischemic tracheal necrosis after total thyroidectomy

Thyroidectomy is one of the commonest surgical operations performed in endocrine surgery; results are generally excellent and morbidity and mortality usually are negligible. Total thyroidectomy's complication rates are low, with an overall incidence of 4.3% among experienced surgeons: the most frequent complications are vocal cord paresis or paralysis, hypoparathyroidism, hypocalcemia, haematoma and wound infection. Tracheal injury following thyroidectomy is even more rare. As reported from some authors, inadvertent tracheal injury has an incidence of 0-0.6% during thyroidectomy. Tracheal laceration (generally located in the posterolateral surface) is often recognized and repaired immediately, during the same intervention. Rarely, following a total thyroidectomy, a delayed tracheal rupture may occur secondary to an ischemic damage of the trachea. This has been described in few cases reported in literature. In this paper we report of a case in which delayed tracheal lacerations appeared 10 days after the patient underwent total thyroidectomy: a prompt surgical operation was efficient using both direct sutures of tracheal breaches and a patch of fibrinogen-thrombin coated collagen fleece covering the entire surface.     

Electro-physiological parameters of hepatic radiofrequency ablation—a comparison of an in vitro versus an in vivo porcine liver model

Background  Radiofrequency ablation (RFA) is an inherent part of curative treatment within a multimodal therapy concept of malignant liver tumors. The biggest problem is the high rate of local recurrences in tumors with a diameter of more than 3 cm because of the high variability and poor reproducibility of the zone of ablation. No imaging modality facilitates monitoring during neither intraoperativ nor percutaneous RFA. This experimental study describes and compares an in vitro and in vivo porcine model by its electro-physiological parameters with the aim of monitoring RFA procedures. Materials and methods  RFA was performed in a perfused in vitro porcine (one RFA per liver) and in vivo porcine model (24 animals) with three different RFA systems (Rita XL 5 cm, Rita XLi 7 cm, LeVeen 5 cm). In the in vivo model, percutaneous placement of the RFA device was guided by native and contrast-enhanced CT scan. The electro-physical parameters during RFA were online (in real time) recorded by a dedicated software. After the RFA, the livers were explanted, sliced, and measured according to the consensus technique. Results  The delivered energy was in vivo versus in vitro: Rita XL 238 ± 135 kJ versus 135 ± 53 kJ (p = 0.247); Rita XLi 711 ± 180 kJ versus 159 ± 54 (p = 0.016) and with LeVeen 212 ± 71 kJ (in vivo). The LeVeen system was inconsistent in the in vitro model. This correlates to an energy consumption per ml of necrosis in vivo versus in vitro Rita XL of 8 ± 3 kJ/ml versus 6.4 ± 3.9 kJ/ml (p = 0.537), Rita XLi of 10 ± 6 kJ/ml versus 1.8 ± 0.2 kJ/ml (p = 0.016), and LeVeen of 14.0 ± 12 kJ/ml (in vivo). The volume of ablation was in vivo versus in vitro Rita XL 30 ± 10 ml versus 26 ± 17 ml (p = 0.329), Rita XLi 90 ± 58 ml versus 88 ± 21 ml (p = 0.905), and LeVeen 22 ± 11 ml versus 50 ± 12 ml (p = 0.04). The impedance during RFA were in vivo versus in vitro Rita XL 39 ± 4 Ω versus 50 ± 14 Ω (p < 0.247), Rita XLi 33 ± 5 Ω versus 61 ± 16 Ω (p = 0.016) and LeVeen 31 ± 2 Ω (in vivo). Conclusion  The volume of ablation showed analogue data in vivo and in vitro. The delivered energy and energy consumption was in vivo up to five times (Rita XLi) higher than in vitro and the impedance in vivo was always lower than in vitro. These differences observed between in vivo and in vitro were more pronounced than previously described. Thus the use of an in vitro model for research of the RFA technique must be challenged. The large deployment of the Rita XLi was a problem for percutaneous positioning of the device without direct contact to liver surface or major vessels in 80-kg pigs and to a lesser extent in in vitro liver originating from 130- to 140-kg pigs. Modern RFA systems which generate large volume of tissue necrosis can therefore only be adequately tested in a porcine model with a liver weight of at least 1.5–2 kg. Alternatively, a bovine liver model (with a liver weight up to 10 kg) should be developed in the future. Best of Abstracts—Chirurgisches Forum 2009, Deutsche Gesellschaft für Chirurgie.     

Anterior 90° Partial vs Nissen Fundoplication—5?Year Follow-Up of a Single-Centre Randomised Trial

Introduction

Nissen fundoplication can be followed by side effects, and this has driven modifications, including partial fundoplications. We previously reported early outcomes from a randomised trial of Nissen vs anterior 90° partial fundoplication. This paper reports 5-year follow-up outcomes to determine whether anterior 90° fundoplication achieves a satisfactory longer-term outcome.

Methods

From February 1999 to August 2003, 79 patients were randomised to Nissen vs anterior 90° fundoplication. Patients were followed yearly using a standardized clinical questionnaire which included symptom scores to assess heartburn, dysphagia, other post-fundoplication side effects and overall satisfaction with the outcome. Five-year clinical outcomes were analysed.

Results

Seventy-four patients were available for follow-up at 5?years. There were no significant differences for heartburn or satisfaction, although more patients used antisecretory medication after anterior 90° fundoplication (29.7 vs 8.1?%). Dysphagia was greater after Nissen fundoplication when measured by an analogue score for solid food and a composite dysphagia score. Symptoms of bloating were more common following Nissen fundoplication (80.0 vs 32.4?%), and less patients could eat a normal diet (78.4 vs 94.6?%). Re-operation was undertaken in four patients after Nissen fundoplication (dysphagia, three; hiatus hernia, one) vs three after anterior 90° fundoplication (recurrent reflux, three).

Conclusions

At 5?years, anterior 90° partial fundoplication was associated with less side effects, offset by greater use of antisecretory medication. Reflux symptoms and overall satisfaction were similar to Nissen fundoplication. Laparoscopic anterior 90° partial fundoplication is an effective treatment for gastro-esophageal reflux.     

Morbidity and radiographic outcomes of severe scoliosis of 90° or more: a comparison of hybrid with total pedicle screw instrumentation

Objectives

Untreated severe scoliosis is associated with increased mortality and remains a significant surgical challenge. Few studies have reported mortality after the surgical treatment of severe scoliosis beyond a 2-year follow-up. The objectives of this study were to evaluate mortality beyond standard 2-year follow-up and compare radiographic outcomes using hybrid or pedicle screw instrumentation for severe scoliosis.

Methods

We evaluated 32 consecutive patients [11 males, mean age at surgery 15.3 (range 10.7–20.7) years] operated for a scoliosis of 90° or more using either hybrid (n = 15) or pedicle screw (n = 17) instrumentation. The follow-up time averaged 2.9 (2.0–6.6) years for radiographic and quality of life measurements and 5.5 years (2.0–9.0) years for mortality data. Of these patients, one had adolescent idiopathic scoliosis, three secondary scoliosis, and 28 neuromuscular scoliosis. Twelve patients in the hybrid and two patients in the pedicle screw groups underwent anteroposterior surgery (p < 0.001), and three patients in both groups had an apical vertebral column resection.

Results

One (3.1 %) patient died during follow-up for severe pneumonia. Preoperatively, the mean magnitude of the major curve was 109° (90°–127°) in the hybrid and 100° (90°–116°) in the pedicle screw groups (p = 0.015), and was corrected to 45° (19°–69°) in the hybrid and 27° (18°–40°) in the pedicle screw groups at the 2-year follow-up (p < 0.001), with a mean correction of the major curve of 59 % (37–81 %) in the hybrid versus 73 % (60–81 %) in the pedicle screw groups, respectively (p = 0.0023). There were six postoperative complications, including one transient spinal cord deficit necessitating reoperation in the hybrid group as compared with five complications in the pedicle screw group (p = 0.53).

Conclusions

The mid-term mortality rate after the surgical treatment of severe scoliosis was low. Severe scoliosis can be treated safely with significantly better correction of the spinal deformity using pedicle screws than hybrid instrumentation.     

360° laparoscopic fundoplication with tension-free hiatoplasty in the treatment of symptomatic gastroesophageal reflux disease

Background: Since laparoscopic Nissen fundoplication was first described by Cuschieri in 1989 and later by Dallemagne in 1991, this procedure has been widely employed for the treatment of symptomatic gastroesophageal reflux disease (GERD) and/or hiatal hernia. However, a relatively high incidence (7–11%) of intrathoracic Nissen valve migration/paraesophageal hernia following laparoscopic fundoplication has recently been reported. Methods: Between November 1992 and August 1995, 65 consecutive patients with severe GERD and/or hiatal hernia underwent laparoscopic 360° fundoplication. In nine of these 65 (13.8%) patients, an intrathoracic Nissen valve migration had occurred within 4 months. Six of these patients were symptomatic and were again submitted to the laparoscopic intervention. Videotapes of both the first and second operation were reviewed. In all cases, it was apparent that, at the first operation, closure by stitches of the hiatus was under tension, and at the second operation, the muscle fibers of the right crus were disrupted, probably due to the tension between the suture margins during the inspiratory movements of the diaphragm. These findings prompted us to perform an effective tension-free closure of the hiatus. A polypropylene mesh (3 × 4 cm) was placed on the hiatus behind the esophagus and fixed with eight metallic agraphes (2 + 2 on the superior edge and 2 + 2 on the lateral sides of the right and left cruses). Results: Between August 1995 and February 1998, the technique, complete with 360° fundoplication, was used for 67 patients with GERD. At mean follow-up of 22.5 months (range, 1–30), there was no evidence of postoperative paraesophageal hernia or complications related to the use of the mesh. Conclusions: This tension-free hiatoplasty seems to be an effective solution to prevent postoperative paraesophageal hernia in patients undergoing antireflux laparoscopic surgery. However, longer follow-up is still needed. Received: 9 July 1998/Accepted: 19 April 1999     

Is there an advantage in performing a pancreas-preserving total duodenectomy in duodenal adenomatosis?

BACKGROUND: Duodenal adenomatosis is a premalignant condition often not treatable by local resection or endoscopy. An option for treatment is a pylorus-preserving (pp)-Whipple resection. Since the introduction of pancreas-preserving total duodenectomy (PPTD), the question has arisen whether a pp-Whipple resection is still needed to treat duodenal adenomatosis. PATIENTS AND METHODS: In a 5-year period 23 PPTDs were performed for duodenal adenomatosis. In a matched-pairs analysis the outcome following PPTD (16 patients with a follow-up longer than 12 months) was compared with pp-Whipple. RESULTS: Hospital mortality in all 23 patients was 4.3% and total morbidity 30% after PPTD. Operation time, intensive care and hospital stay, morbidity, and mortality were comparable between the matched paired groups (16 patients). Patients with PPTD had significantly lower intraoperative blood loss. No PPTD patient required pancreatic enzyme substitution, compared with 12 patients after pp-Whipple. Quality-of-life analysis in PPTD patients revealed no difference compared to a normal control population and the pp-Whipple group. CONCLUSIONS: PPTD is a safe surgical procedure for duodenal adenomatosis that avoids pancreatic head resection, provides high quality of life, and shows advantages over the pp-Whipple procedure.     

To-and-fro extracorporeal lung assist (ECLA) through a single catheter — in premature goats as an experimental model of infant respiratory insufficiency

A new to-and-fro V-V bypass extracorporeal lung assist (ECLA) through a single catheter as a blood access was investigated for its efficacy on six premature goats delivered by Cesarean section at a gestational age of 118 139 days as an experimental model of infant respiratory insufficiency, then applied to a human premature infant suffering from life threatening barotrauma that had developed from mechanical pulmonary ventilation. The extracorporeal bypass flow and the gas flow to the artificial membrane lung were controlled to keep Pa_{O 2} above 40mmHg and Pa_{CO 2} within normal limits. The neonates own lungs were treated with a continuous positive airway pressure of 5 12cmH₂O, apneic oxygenation or IMV. Two goats weighing 1250g and 700g died 2 2.5 hours after birth from severe circulatory distress. However, the other four neonates which were heavier than 2000g, were successfully weaned from ECLA, and three of these could be weaned from mechanical ventilation as well. A human infant also survived and was weaned from ECLA on the third day.(Tanoue T, Terasaki H, Sadanaga M et al.: To-and-fro extracorporeal lung assist (ECLA) through a single catheter-in premature goats as an experimental model of infant respiratory insufficiency. J Anesth 2: 124–132, 1988)     

Establishment of an animal model of non-transthoracic cardiopulmonary bypass in rats

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