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BACKGROUND: While injuries to the esophagus, stomach, spleen and pleura are well-known, cardiac lesions resulting from complications of surgery at the esophagogastric junction are rarely reported in the literature. METHODS: We report on two of our own patients with cardiac tamponade after surgery at the esophagogastric junction and present a review of the literature. RESULTS: We overview seven patients (including our own). In five cases a stitch to the diaphragm was the cause. The lesions became apparent during and up to fourteen days after the operation. In three cases the complication led to death. CONCLUSIONS: It is essential to consider the risk of cardiac lesions with surgery at the esophagogastric junction, especially if sutures or staples are placed in this region. Only with an appropriate alertness and management can this complication be prevented and its potentially fatal issue averted. 相似文献
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Introduction The approach to paraesophageal hernias has changed radically over the last 15 years, both in terms of indications for the
repair and of surgical technique.
Discussion Today we operate mostly on patients who are symptomatic and the laparoscopic repair has replaced in most cases the open approach
through either a laparotomy or a thoracotomy. The following describes a step by step approach to the laparoscopic repair of
paraesophageal hernia.
Presented at the 49th Annual Meeting of the Society for Surgery of the Alimentary Tract, San Diego, California, May 17–21,
2008 相似文献
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Although esophageal lengthening procedures (Collis gastroplasty) have been recommended as an adjunct to antireflux surgery
in patients with shortened esophagus, there are few data on physiologic outcomes in these patients. This study details the
long-term outcomes in patients who underwent antireflux surgery with Collis gastroplasty. All patients undergoing esophagogastric
fundoplication (EGF) with a Collis gastroplasty for the management of gastroesophageal reflux disease or paraesophageal hernia
were identified from a prospectively maintained database. Symptom questionnaires were used during followup to assess symptomatic
outcomes. Barium esophogram, upper endoscopy with biopsy, and catheterless esophageal acid monitoring (BRAVO system) were
recommended for all patients. Patients with abnormal results of physiologic studies underwent further treatment based on a
standardized algorithm. Between 1996 and 2002, a total of 68 patients underwent EGF with Collis gastroplasty. Twenty-seven
(40%) had a large paraesophageal hernia, and 20 (30%) had undergone a prior EGF. Fifty-six (82%) of the procedures were performed
laparoscopically. Mean follow-up time was 30 months, with 10 (15%) patients lost to latest follow-up. Symptomatic outcome
data were available for 85% of patients, with significant improvements reported for heartburn (86%), chest pain (90%), dysphagia
(89%), and regurgitation (91%). Most patients (84%) were off medications. Physiologic data were completed in 37% of the patients.
Of those undergoing physiologic follow-up studies, 17% had recurrent hiatal hernia, and 80% had endoscopically identified
esophagitis and pathologic esophageal acid exposure on pH testing. Despite this, 65% of the patients with objectively identified
abnormalities reported significant symptomatic improvement compared to their preoperative symptoms. Two patients developed
changes associated with Barrett’s esophagus that were not present preoperatively. Distal esophageal injury can persist after
EGF with Collis gastroplasty, despite significant symptomatic improvements. Appropriate follow-up in these patients requires
objective surveillance, which should eventuate in further treatment if esophageal acid is not completely controlled. Although
the Collis gastroplasty is conceptually appealing, these results call into question the liberal application of this technique
during EGF.
Presented at the Forty-Fourth Annual Meeting of The Society for Surgery of the Alimentary Tract, Orlando, Florida, May 18–21,
2003 (oral presentation). 相似文献
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Anirban Gupta David Chang Kimberley E. Steele Michael A. Schweitzer Jerome Lyn-Sue Anne O. Lidor 《Journal of gastrointestinal surgery》2008,12(12):2119-2124
Introduction Paraesophageal hernia (PEH) repair is a technically challenging operation. These patients are typically older and have more
co-morbidities than patients undergoing anti-reflux operations for gastroesophageal reflux disease (GERD), and these factors
are usually cited as the reason for worse outcomes for PEH patients. Clinically, it would be useful to identify potentially
modifiable variables leading to improved outcomes.
Methods We performed a retrospective analysis of a representative sample from 37 states, using the Nationwide Inpatient Sample database
over a 5-year period (2001–2005). Patients undergoing any anti-reflux operation with or without hiatal hernia repair were
included, and comparison was made based on primary diagnoses of PEH or GERD. Exclusion criteria were diagnosis codes not associated
with reflux disease or diaphragmatic hernia, emergency admissions, and age <18. Primary outcome was in-hospital mortality.
Two sets of multivariate analyses were performed; one set adjusting for pre-treatment variables (age, gender, race, Charlson
Comorbidity Index, hospital teaching status, hospital volume of anti-reflux surgery, calendar year) and a second set adjusting
further for post-operative complications (splenectomy, esophageal laceration, pneumothorax, hemorrhage, cardiac, pulmonary,
and thromboembolic events, (VTE)).
Results Of the 23,458 patients, 6,706 patients had PEH. PEH patients are older (60.4 vs. 49.1, p < 0.001) and have significantly more co-morbidities than GERD patients. On multivariate analysis, adjusting for pre-treatment
variables, PEH patients are more likely to die and have significantly worse outcomes than GERD patients. However, further
adjustment for pulmonary complications, VTE, and hemorrhage eliminates the mortality difference between PEH and GERD patients,
while adjustment for cardiac complications or pneumothorax did not eliminate the difference.
Conclusions While PEH patients have worse post-operative outcomes than GERD patients, we note that differences in mortality are explained
by pulmonary complications, VTE, and hemorrhage. The impact of hemorrhagic complications on this group underscores the importance
of careful dissection. Additionally, age and co-morbidities alone should not preclude a patient from PEH repair; rather, attention
should be focused on peri-operative optimization of pulmonary status and prophylaxis of thromboembolic events. 相似文献
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目的 探讨使用腹腔镜行食管裂孔疝修补术的疗效和安全性.方法 对61例食管裂孔疝患者使用腹腔镜行食管裂孔疝修补术,做胃底270°部分折叠术(Toupet术),19例应用补片修补疝缺口,42例采用直接线缝合.结果 61例腹腔镜食管裂孔疝修补术全部获得成功.手术时间30~190 rain,平均手术时间110 min,失血10~50 mL;术后24~48 h进流质饮食,无术后并发症;术后平均住院5.7 d.结论 61例患者的反酸症状均在24 h内缓解,术后停用抗酸药物,修补术具有疗效确定、安全和创伤小的优点,值得进一步推广应用. 相似文献
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Go Watanabe Jun-ichi Tanaka Satoshi Odashima Michihiko Kitamura Kenji Koyama 《Surgery today》1997,27(11):1093-1096
We treated a case of paraesophageal hiatus hernia by laparoscopic repair. The procedure included a reduction of the gastric
fundus and duodenal bulbus, closure of the diaphragmatic defect, mesh wrapping of the closure, gastropexy to the diaphragm,
and a gastrostomy. Preoperative monitoring of the pH for 24h showed no reflux. Intraoperative intraluminal manometry of the
esophagus after hernia reduction showed the pressure of the lower esophageal sphincter to be normal, and thus an antireflux
procedure was not deemed to be necessary. The patient was put on a soft diet from postoperative day 2. A postoperative upper
gastrointestinal series showed no gastroesophageal reflux. No complications or recurrence of the hiatus hernia have been observed
in the 12 months since the operation. Laparoscopic repair of a paraesophageal hiatus hernia with normal pressure of the lower
esophageal sphincter, so that fundoplication is not needed, is thus considered to be possible. 相似文献
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Computer-enhanced vs. standard laparoscopic antireflux surgery 总被引:5,自引:0,他引:5
W. Scott Melvin M.D. Bradley J. Needleman M.D. Kevin R. Krause M.D. Carol Schneider B.S.N. E. Christopher Ellison M.D. 《Journal of gastrointestinal surgery》2002,6(1):11-16
Computer-assisted telesurgical devices have recently been approved in the United States for general surgery. To determine
the safety and efficacy of these procedures, we performed a prospective trial of computer-enhanced “robotic” fundoplication
compared to standard laparoscopic control procedures. Consecutive patients undergoing surgical treatment for gastroesophageal
reflux were included. The operating surgeon worked at a console using a three-dimensional image and manipulated hand controls.
Operative times, complications, and length of hospital stay were recorded. A standardized questionnaire was administered to
evaluate symptoms. Twenty patients were entered into each group. There were no differences in age, preoperative weight, or
sex. Operative times were significantly longer in the robot group (97 vs. 141 minutes). There were no complications and most
patients went home the first postoperative day. At follow-up, symptoms were similar in both groups; however, there was a significant
difference in the number of patients taking antisecretory medication—none in the robotic group but six in the laparoscopic
group reported regular use. Computer-assisted laparoscopic antireflux surgery is safe. However, operative times are longer,
with little difference in outcomes. At the current level of technology and experience, robotic antireflux surgery appears
to offer little advantage over standard laparoscopic approaches.
Presented at the Forty-Second Annual Meeting of The Society for Surgery of the Alimentary Tract, Atlanta, Ga., May 20–23,
2001.
Supported in part by a grant from United States Surgical, a Division of Tyco Healthcare. 相似文献
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Laparoscopic fundoplication has emerged as an effective treatment for gastro-oesophageal reflux disease. The majority of patients who have undergone antireflux surgery report an improvement in reflux symptoms and in quality of life. However, some patients are dissatisfied with the outcome of antireflux surgery, and attempts have been made by surgeons to improve the results of this surgery. Careful case selection based on objective evidence of acid reflux, refinement of the surgical technique and 'tailoring' the wrap to suit the patient by selective use of a partial fundoplication may help to optimize the outcome from laparoscopic antireflux surgery. 相似文献
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St Peter SD Valusek PA Calkins CM Shew SB Ostlie DJ Holcomb GW 《Journal of pediatric surgery》2007,42(1):25-30
Objectives
Herniation of the fundoplication wrap through the esophageal hiatus is a common reason for surgical failure in children who have undergone laparoscopic Nissen fundoplication. Extensive mobilization of the gastroesophageal junction in combination with decreased adhesions after laparoscopy may contribute to the development of this complication. In an attempt to decrease the incidence of wrap migration, we changed our technique to minimal mobilization of the intraabdominal esophagus and to placement of esophageal-crural sutures. In this study, we investigate the impact of these modifications on outcome.Methods
A retrospective analysis was performed on all patients undergoing laparoscopic fundoplication by the senior author (GWH) from January 2000 through December 2004. Those undergoing operation with extensive esophageal mobilization and without esophagocrural sutures (January 2000 to March 2002) (group I) were compared with those in whom there was minimal esophageal dissection with placement of these esophagocrural sutures (April 2002 to December 2004) (group II).Results
Two hundred forty-nine patients underwent laparoscopic Nissen fundoplication during the study period. One hundred thirty patients were in group I, and 119 patients were in group II. The rate of transmigration decreased from 12% in group I to 5% in group II (P = .072). The relative risk of transmigration with extensive esophageal mobilization and without the esophagocrural sutures was 2.29.Conclusions
This retrospective study has shown that placement of esophagocrural sutures and minimization of the dissection around the esophagus results in a more than 2-fold reduction in the risk of wrap transmigration after laparoscopic Nissen fundoplication. 相似文献15.
IntroductionObesity is a risk factor for hiatal hernia. In addition, much higher recurrence rates are reported after standard surgical treatment of hiatal hernia in morbidly obese patients. Laparoscopic Roux-en-Y gastric bypass (LRYGB) is an effective surgical treatment for morbid obesity and is known to effectively control symptoms of gastroesophageal reflux (GERD).Case presentationTwo patients suffering from giant hiatal hernias where a combined LRYGB and hiatal hernia repair (HHR) with mesh was performed are presented in this paper. There were no postoperative complications and at 1 year follow-up, there was no sign of recurrence of the hernia.DiscussionThe gold standard for all symptomatic reflux patients is still surgical correction of the paraesophageal hernia, including complete reduction of the hernia sac, resection of the sac, hiatal closure and fundoplication. However, HHR outcome is adversely affected by higher BMI levels, leading to increased HH recurrence rates in the obese.ConclusionConcomitant giant hiatal hernia repair with LRYGB appears to be safe and feasible. Moreover, LRYGB plus HHR appears to be a good alternative for HH patients suffering from morbid obesity as well than antireflux surgery alone because of the additional benefit of significant weight loss and improvement of obesity related co-morbidity. 相似文献
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PURPOSE: To assess the outcome for patients undergoing early reoperation following laparoscopic antireflux surgery. METHODS: The outcome was prospectively determined for 28 patients who underwent 30 reoperative procedures within 4 weeks of their initial laparoscopic fundoplication between 1992 and 1998. Follow-up ranged from 3 months to 4 years (median 2 years). Before mid 1994, patients were assessed and managed based on clinical findings (first 192 patients in overall series), whereas subsequently (for the most recent 530 patients) all patients underwent routine early postoperative barium swallow radiography, and laparoscopic exploration during the first postoperative week if problems were suspected. RESULTS: The reoperations were performed for acute paraoesophageal hiatus hernia (8 patients), tight oesophageal hiatus (7), postoperative haemorrhage (3), tight Nissen fundoplication (8), early recurrent reflux (1), and coeliac/superior mesenteric artery thrombosis (1). Two patients required a second operation for persistent dysphagia due to a tight hiatus. Both patients initially underwent loosening of their fundoplication. Before mid 1994, reoperations were usually undertaken by an open approach, whereas subsequently a laparoscopic approach has usually been successful. Laparoscopic reintervention was easily achieved within 7 days of the first procedure whereas subsequent surgery was more difficult and often required open surgery. The change in protocol was associated with an improvement in overall patient satisfaction and dysphagia in the latter part of this experience. CONCLUSIONS: Routine early contrast radiology following laparoscopic fundoplication and a low threshold for laparoscopic reexploration facilitates early identification of postoperative problems at a time when laparoscopic correction is easily achieved. This may result in an improved overall outcome for patients requiring early reintervention following laparoscopic antireflux surgery. 相似文献
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N T Nguyen J D Luketich D M Friedman S Ikramuddin P R Schauer 《JSLS, Journal of the Society of Laparoendoscopic Surgeons》1999,3(2):149-153
Deep venous thrombosis and pulmonary embolism are concerning causes of morbidity and mortality in patients undergoing general surgical procedures. Laparoscopic surgery has gained rapid acceptance in the past several years and is now a commonly performed procedure by most general surgeons. Multiple anecdotal reports of pulmonary embolism following laparoscopic cholecystectomy have been reported, but the true incidence of deep venous thrombosis and pulmonary embolism in patients undergoing laparoscopic surgery is not known. We present a case of pulmonary embolism following laparoscopic repair of paraesophageal hernia. The literature is then reviewed regarding the incidence of pulmonary embolism following laparoscopic surgery, the mechanism of deep venous thrombosis formation, and the recommendations for deep venous thrombosis prophylaxis in patients undergoing laparoscopic procedures. 相似文献
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Laparoscopic antireflux surgery at an outpatient surgery center 总被引:2,自引:2,他引:0
BACKGROUND: Laparoscopic fundoplication (LF) procedures have been shown to be safe and effective for the control of gastroesophageal reflux disease (GERD). Preliminary reports suggest that LF can be performed safely in an ambulatory surgery center. We report on our extensive experience with outpatient LF. METHODS: Since May 1995, we have performed laparoscopic antireflux procedures in 557 consecutive patients at a freestanding outpatient surgery center. All patients had esophageal manometrics and esophagogastroduodenoscopy (EGD) within 1 year of their surgical procedure. This series included 16 patients with large paraesophageal hernias (mostly type III) and 22 patients with prior antireflux procedures. Most patients (n = 494) underwent Nissen fundoplication. RESULTS: Patients were typically given clear liquids 6 hs postoperatively and discharged home in 相似文献
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