Is laparoscopic antireflux surgery for gastroesophageal reflux disease in the elderly safe and effective?

Background: The elderly have prevalence rates and clinical features of gastroesophageal reflux disease (GERD) similar to those in younger individuals, but the role of laparoscopic antireflux surgery (LARS) in the elderly has not been clearly established. The purpose of this study was to determine if the results of LARS in the elderly are comparable with those in younger patients. Methods: All patients undergoing LARS for GERD at the Washington University Medical Center were entered prospectively into a computerized database. Between May 1992 and June 1998, 339 patients underwent LARS and were divided into two groups based on age: nonelderly (ages, 18–64 years; n= 303) and elderly (age, ≥65 years; n = 36). Data were expressed as mean ± standard deviation (SD) and statistical analysis was performed. Results: Elderly patients had a higher American Society of Anesthesiology (ASA) score (2.3 ± 1.5) and a longer hospital stay (2.1 ± 0.2 days) than the younger group (ASA, 1.9 ± 0.5; hospital stay, 1.6 ± 0.9 days; p < 0.001). Operation times averaged 154 ± 68 min in the elderly compared with 134 ± 49 min in the nonelderly (p= NS). Grade I complications occurred significantly more frequently in the elderly (13.9%) than in the nonelderly (2.6%), but the incidence of grade II complications was similar between the groups (elderly 2.8% vs nonelderly 2.7%). There were no grade III complications in either group, but there was one death in the nonelderly group. At follow-up ranging to 81 months (median, 27 months), the two groups had similar low incidences of heartburn and dysphagia. Anatomic failures of LARS developed in 19 nonelderly patients (6.2%) compared with 2 elderly patients (5.5%; p= NS). Conclusions: As shown in this study, LARS is safe and effective in elderly patients with GERD. Age older than 65 years should not be a contraindication to laparoscopic antireflux surgery in properly selected patients. Received: 3 March 1999/Accepted: 2 April 1999     

Laparoscopic antireflux surgery in the elderly

Background: Laparoscopic antireflux surgery is frequently denied to older patients with gastroesophageal reflux disease (GERD) because of a perceived higher operative complication rate, a decreased impact of the intervention on quality of life, and decreased cost effectiveness. This study compares disease severity, surgical outcomes, and impact on quality of life between elderly and young patients with GERD. Methods: Patients were selected from a prospectively maintained database of 1100 patients who underwent various laparoscopic esophageal procedures at our institution. Only patients having chronic intractable GERD and a minimum 6 months' follow-up were included in the study. Thirty elderly patients with a mean age of 71.2 years (SD ± 5.6) were compared with a group of 30 younger patients (mean age, 43.9 ± 12.8 years). Comparisons were made between subjective and objective outcomes, operative results, and health-related quality of life (HQRL) scores using SF-36 instruments. Results: The preoperative symptom assessment scores (representing frequency of symptoms on a 0-4 scale), and preoperative pH and manometry data were comparable in the two groups. Elderly patients had significantly higher ASA (American Society of Anesthesiologists) scores. Each group demonstrated a significant improvement in the postoperative symptom assessment scores and the esophageal functional studies (p<0.05). However, no significant differences were found in terms of postoperative complications, postoperative hospital stay, postoperative symptom scores, Demeester scores, or the HRQL data. Conclusion: Laparoscopic antireflux surgery in elderly patients improves acid reflux and appears to be safe and effective as measured by postoperative testing in elderly and young patients.     

Clinical outcomes after laparoscopic antireflux surgery in patients with and without preoperative endoscopic esophagitis

A wide spectrum of endoscopic findings exists in patients with gastroesophageal reflux disease (GERD). This study compared clinical outcomes after laparoscopic antireflux surgery (LARS) in patients who had GERD with and without preoperative endoscopic esophagitis. From 1992 to 2001, a total of 414 patients who underwent LARS with 6 months or more of follow-up were prospectively entered into a database. Among these patients, 84 (20%) had no endoscopic evidence of esophagitis on preoperative endoscopy (group 1), whereas 330 (80%) did have esophagitis (group 2). Perioperative outcomes, GERD symptom relief, and the use of acid-reducing medication were assessed. Preoperative DeMeester scores in groups 1 and 2 were 44 ± 29 and 61 ± 62 (P < 0.05) and mean esophageal peristaltic amplitude was 86 ± 32 mm Hg vs. 60 ± 42 mm Hg, respectively (P < 0.05). Although procedure time was significantly shorter in group 1, other perioperative outcomes were similar. At postoperative follow-up, the use of proton pump inhibitors was reduced in both groups (86% to ≤14%). With the exception of postoperative dysphagia, there was no difference in GERD symptom relief between groups 1 and 2. The presence or absence of preoperative esophagitis has minimal effect on favorable symptomatic outcomes after LARS. Thus LARS is an effective treatment option for patients, irrespective of endoscopic evidence of esophagitis, leading to excellent symptom relief and a marked reduction in the use of proton pump inhibitors. Presented at the Forty-Third Annual Meeting of The Society for Surgery of the Alimentary Tract, San Francisco, California, May 19–22, 2002 (oral presentation). Supported by the Washington University Institute for Minimally Invasive Surgery.     

Age and body mass index: significant predictive factors for successful laparoscopic antireflux surgery

Purpose

Laparoscopic antireflux surgery (LARS) is a feasible treatment for gastroesophageal reflux disease (GERD) patients, but it is unclear who will benefit from the surgery. This study investigated patients’ GERDspecific quality of life (GsQOL) and analyzed the factors leading to the performance of successful LARS.

Methods

Twenty-six (57.8%) of 45 consecutive patients who underwent LARS for GERD during the last decade were enrolled. All patients were evaluated by 24-h pH monitoring, esophageal manometry, esophagogastro-duodenoscopy and physical examinations. GsQOL was assessed by a visual analog scale, and the difference between the pre- and postoperative scores was defined as the visual analog scale improvement score (VASIS). The patients were classified into three groups based on the VASIS, and their clinical factors and surgical outcomes were compared.

Results

The high VASIS group patients (>70 VASIS; Excellent group) patients were significantly younger and obese in comparison to low the VASIS group (<30 VASIS; Poor group) consisting of older nonobese patients (P < 0.05). A multiple regression analysis revealed that age <60 years and body mass index (BMI) >25 kg/m² were significant factors that affected postoperative GsQOL. No other clinical or surgical factors had any influence on the postoperative GsQOL.

Conclusion

These results suggest that age and BMI can be predictive factors for the performance of successful LARS.     

Preoperative Lower Esophageal Sphincter Manometry Data Neither Impact Manifestations of GERD nor Outcome After Laparoscopic Nissen Fundoplication

Background  Experience with laparoscopic antireflux surgery (LARS) in patients with gastroesophageal reflux disease (GERD) and manometrically intact lower esophageal sphincter (LES) is limited. The disease pattern may be different and LARS may fail to control reflux or result in higher rates of dysphagia. This is the first study investigating the impact of preoperative LES manometry data not only on manifestations of GERD and subjective outcome alone but also on objective outcomes 1 year after LARS. Methods  Three hundred fifty-one GERD patients underwent LARS and had subjective symptom and quality of life assessment, upper gastrointestinal endoscopy, barium swallow esophagogram, 24-h esophageal pH monitoring, and manometry pre- and 1 year postoperatively. Patients were divided into those with a preoperatively intact versus defective LES based on intraabdominal length and resting pressure. Baseline and 1-year postoperative follow-up data were compared. Results  Preoperative manifestations of GERD were similar in each group. Postoperatively, all symptoms except flatulence, quality of life scores, and objective manifestations improved significantly in each group. Conclusions  The preoperative manometric character of the LES neither impacts the manifestations of GERD nor subjective and objective outcomes after LARS. Patients with GERD and manometrically intact LES have no higher risk for postoperative dysphagia.     

Laparoscopic fundoplication in elderly patients with gastroesophageal reflux disease

HYPOTHESIS: It is unclear if age should be considered a factor in the choice of treatment for gastroesophageal reflux disease (GERD) and if fundoplication in elderly patients is as safe and effective as it is in younger patients. We hypothesized that the outcome of laparoscopic antireflux operations in patients younger than 65 years is similar to that of patients 65 years and older. DESIGN: Retrospective review of findings from a prospectively acquired database. SETTING: University-based tertiary care center. PATIENTS: Three hundred four consecutive patients underwent laparoscopic fundoplication for GERD. Two hundred forty-one patients were younger than 65 years (group A; median age, 46 years), and 63 patients were 65 years or older (group B; median age, 69 years). MAIN OUTCOME MEASURES: Presence, duration, and severity of GERD symptoms; presence of a hiatal hernia or esophageal stricture; duration of operation; incidence of complications; and length of hospital stay. RESULTS: Elderly patients more often had regurgitation and respiratory symptoms in addition to heartburn. Hiatal hernias were more common among elderly patients (77% vs 51%). The duration of the operation was similar for the 2 groups. The incidence of intraoperative and postoperative complications was low and similar in the 2 groups. The median hospital stay was 24 hours for each group. Heartburn resolved in approximately 90% of patients in each group. CONCLUSIONS: Elderly patients more often had hiatal hernias and respiratory symptoms. Laparoscopic antireflux surgery was as safe in elderly patients as it was in younger patients, and clinical outcomes were as good.     

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??Laparoscopic antireflux surgery for gastroesophageal reflux disease: A clinical analysis of 185 patients SHAN Cheng-xiang, ZHANG Wei, JIANG Dao-zhen, et al. Department of General Surgery, Chang Zheng Hospital Affiliated to Second Military Medical University, Shanghai 200003, China
Corresponding author: QIU Ming, E-mail: Qiuming2006@yahoo.cn
Abstract Objective To summarize the technical practice of laparoscopic antireflux surgery (LARS) for gastroesophageal reflux disease (GERD). Methods The clinical data, high-definition LARS videos, and postoperative diet scheme of 185 GERD patients from 2000 to 2013 in Department of General Surgery, Chang Zheng Hospital Affiliated to Second Military Medical University were reviewed retrospectively. Results Laparoscopic antireflux surgery (hiatal herniorrhaphy plus fundoplication) was all successfully performed in 185 patients with none death and conversion operation. The procedure of LARS was divided into 7 steps according to our experience and HD video, standard surgical rules were followed and specific anatomic landmarks were found in each step, such as diaphragmatic crura and esophageal hiatus. The patients were deprived of food 24 hours after surgery and recovered to normal diet from clear liquid gradually and slowly. Conclusion Identification of anatomic landmarks and surgical planes, and adherence of technical key points are important to perform LARS successfully. Effective postoperative dietary guidance is helpful to increase satisfaction rate of patients.     

Long-term outcome of laparoscopic antireflux surgery in the elderly

The aim of this retrospective study was to compare results and five-year surgical outcome of laparoscopic antireflux surgery (LARS) in patients younger than 65 years and elderly patients aged 65 years or older. From January 1992 to December 1998, 2684 patients underwent LARS in 31 surgical units; 369 elderly patients (group 1) were compared with 2315 younger patients (group 2). Elderly patients have a higher American Society of Anesthesiologists score (mean, 2.38 versus 1.98). The conversion rate was higher in group 1 (10.2%, n = 38 versus 6.1%, n = 142), as was the morbidity rate (7.6% in group 1 versus 4.5% in group 2). Mean hospital stay was longer for group 1 (7.6 ± 5.6 days versus 5.9 ± 2.8 days). Functional evaluation was excellent in both groups (91-93%) at 3 months and 2 and 5 years. LARS in the elderly is a safe and efficient procedure. Good results appear to be sustainable in the long term. The study participants are listed at the end of the article.     

Outcome of laparoscopic antireflux surgery in patients with nonerosive reflux disease

As many as 50% of patients with gastroesophageal reflux disease (GERD) have no endoscopic evidence of esophagitis (EGD negative). Laparoscopic antireflux surgery (LARS) provides effective symptomatic and endoscopic healing in patients with erosive GERD (EGD positive). The surgical outcome of patients undergoing LARS for EGD-negative GERD has not received wide attention. The objective of this study was to compare surgical outcomes between EGD-negative and EGD-positive patients. During the period from June 1996 to September 1998, all patients undergoing LARS for persistent GERD symptoms despite medical therapy, who were EGD-negative, were invited to respond to a questionnaire regarding their clinical status before and after LARS. To perform a comparative analysis, the same questions were posed to a randomly selected equal number of EGD-positive patients who underwent surgery during the same study period. LARS was performed in 255 patients during the study period; 59 patients (23%) had EGD-negative GERD, and 148 (58%) were EGD-positive. Forty-eight patients (19%) did not meet the entry criteria and were excluded from analysis. LARS provided effective symptomatic relief in patients with EGD-negative and EGD-positive GERD. There were no significant differences in patient satisfaction or symptom improvement between the two groups (P = 0.82). The surgical outcome of EGD-negative patients is similar to the outcome for patients with erosive esophagitis. LARS is a valuable treatment option for patients with persistent GERD symptoms regardless of the endoscopic appearance of the esophageal mucosa. Presented in abstract form at the Annual Meeting of the American Gastroenterology Association, Orlando, Florida, May 15, 1999.     

The efficacy and safety of totally laparoscopic hepatectomy for non-cirrhotic hepatocellular carcinoma in the elderly

Background

Laparoscopic hepatectomy (LH) has been identified to be effective and safe for elderly patients (≥70?years). This study aims to assess the short-and long-term outcome of totally laparoscopic liver resection for elderly patients with Hepatocellular carcinoma (HCC).

Methods

We retrospectively reviewed 93 patients with HCC who underwent LH from August, 2003 to July, 2013 in a single center. Short-term operative and postoperative outcomes together with long-term outcomes, including disease free survival (DFS) and overall survival (OS) were analyzed.

Results

A total of 81 patients was finally reviewed, of which 23 patients (28.40%) were grouped to elderly (≥70?years) and 58 patients (71.60%) were divided into younger group (<?70?years). The mean ages of patients in the elderly and younger cohorts were 74.9?±?3.4 and 50.9?±?12.7?years old, respectively. The median follow-up durations in elderly cohort and young cohort were 30?months and 24?months. The mean postoperative hospital stay was nearly 4?days longer in the elderly cohort than that in younger group (13.4 vs 9.5; p?=?0.003). The elderly cohort has a higher rate of non-surgical complications than that in the younger cohort (P?=?0.045), while the risks of surgical complications were comparable between the two groups. For the postoperative complications, elderly patients were more easily to develop grade III or more of Clavien-Dindo classification than that in the younger patients (P?=?0.008). The median OS in the elderly group and younger group was 44.09?months and 42.49?months, respectively, with p?=?0.089. The median DFS in the elderly group and the younger group was 39.87?months and 37.86?months, respectively, with p?=?0.0616.

Conclusions

Elderly patients could obtain comparable operative and survival benefits from LH for HCC as younger counterparts. Age may not be a contraindication to laparoscopic liver resection for elderly patients.

     

Does major depression in patients with gastroesophageal reflux disease affect the outcome of laparoscopic antireflux surgery?

Background: It is known that psychological factors can affect end points of surgical treatment. The current study aimed to evaluate the outcome of laparoscopic antireflux surgery (LARS) in patients with gastroesophageal reflux disease (GERD) who experience concomitant major depression in comparison with GERD patients who have no known comorbidity. Methods: Among a sample of more than 550 patients who underwent LARS, a group of 38 GERD patients with concomitant major depression (MD) were included in this study. The patients included 24 women and 14 men, with a mean age of 51 years. A group of 38 control patients (non-MD) matched in terms of age, gender, and esophageal manometry findings was selected from the database for comparison of surgical outcomes between patients with GERD accompanied by concomitant major depression and GERD patients with no known comorbidity. In each group, 23 patients received a Toupet fundoplication and 15 patients underwent a "floppy" Nissen fundoplication. The following factors were evaluated before surgery, 3 months afterward, and 1 year after LARS: symptoms (heartburn, regurgitation, chest pain, bloating, and dysphagia), quality of life (Gastrointestinal Quality of Life Index [GIQLI]), lower esophageal sphincter pressure (LESP), and 24-h pH monitoring (DeMeester score). Results: Before and after surgery, there were no significant differences between the two groups in terms of LESP and DeMeester score. Preoperative GIQLI showed significant differences (p < 0.05) between the two groups (MD group, 71.8 ± 8.6 vs non-MD group, 91.1 ± 9.8), and significant differences (p < 0.01–0.001) between the mean data and that for healthy individuals (122.6 ± 8.5). The GIQLI scores had improved significantly at 3 months and at 1 year after surgery (p < 0.05–0.001) in all the patients (1 year postoperatively: MD group, 99.3 ± 8.6 vs non-MD group, 121.9 ± 9.7). Before surgery, when symptoms were compared between the two groups, significant differences (p < 0.001) were found in the percentage of chest pain (81.6% vs 37.4%) and bloating (92.2% vs 37.4%), showing that these symptoms were more predominant and graded as much more severe among patients with MD. In both groups, all the symptoms but dysphagia showed a significant improvement in severity (p < 0.05–0.0001). A comparison of both groups postoperatively showed that significant differences were still present in chest pain (44.7% vs 2.6%), bloating (68.4% vs 18.4), and dysphagia (50.1% vs 2.6%). A significant difference (p < 0.001) was observed only in patients with major depression and depending on the kind of wrap procedure (Nissen vs Toupet), showing that dysphagia (78.9% vs 21.1%) and chest pain (82.4% vs 17.6%) were much more predominant in patients who underwent "floppy" Nissen fundoplication. Conclusions: Even if they are good surgical candidates from a physiologic point of view, GERD patients with concomitant major depression should be selected carefully. In these patients, LARS can normalize physiologic data, but some patients have demonstrated less symptomatic relief, suffered from postoperative dysphagia, and showed less quality-of-life improvement. Eventually, laparoscopic Toupet fundoplication used with these patients could result in a better subjective outcome.     

腹腔镜胆总管切开取石在老年胆道结石患者中的应用

目的探讨腹腔镜胆总管切开取石治疗老年胆道结石患者的有效性,安全性。方法从2007年4月至2011年12月本院共行86例腹腔镜胆总管切开取石术。将这些患者按年龄分为两组,并进行回顾性分析。老年组(≥70岁)40例,年轻组(<70岁)46例。对比两组临床特点,手术时间,住院时间,中转开放手术率,术后累计并发症发生率,残石率和死亡率。结果老年组表现出较高的麻醉评分(P=0.003)及基础疾病患病率(P<0.01),而平均手术时间,术后住院时间,中转开放手术率,残石率,并发症的发生率、死亡率,两组无显著性差异(P>0.05)。结论腹腔镜胆总管切开取石不仅对年轻胆总管结石患者安全有效,对老年患者也是一种安全有效的治疗方式。     

The use of medication after laparoscopic antireflux surgery

Background  Laparoscopic antireflux surgery (LARS) significantly improves symptoms of gastro-esophageal reflux disease (GERD) and quality of life. Nevertheless, 14–62% of patients report using antisecretory medication after surgery, although only a tiny percentage has proven recurrence of GERD. We sought to determine symptoms of GERD, quality of life, and use of medication before and after LARS, and to compare our findings with those from previous studies. Methods  Five hundred fifty-three patients with GERD who underwent LARS were evaluated before and at 1 year after surgery. After surgery, multidisciplinary follow-up care was provided for all patients by surgeons, psychologists, dieticians, and speech therapists. Results  Symptoms of GERD and quality of life improved significantly and only 4.2% of patients still required medication after surgery [proton pump inhibitors (PPI) (98.4 vs. 2.2%; p < 0.01), prokinetics (9.6 vs. 1.1%; p < 0.01), and psychiatric medication (8 vs. 1.6%; p < 0.01)]. Conclusion  LARS significantly reduced medication use at 1-year follow-up. However, these effects might be attributed, in part, to the multidisciplinary follow-up care. Further studies are therefore required to investigate which patients may benefit from multidisciplinary follow-up care and whether its selective application may reduce the need for medication after LARS.     

Outcome of Surgery for Lung Cancer in Young and Elderly Patients

Purpose It has been suggested that lung cancer follows a more aggressive course and has a poorer prognosis in young patients than in elderly patients. We conducted this study to determine whether the basal characteristics and survival of young patients undergoing surgical resection of lung cancer differ from those of elderly patients.Methods Eighty patients who underwent surgery for lung cancer at our hospital between 1989 and 2004 were divided into two groups according to age. Group 1 comprised 50 patients aged 45 years or younger and group 2 comprised 30 patients aged 70 years or older. The patients’ medical records were reviewed with respect to age, gender, histological diagnosis, coexisting diseases, smoking history, postoperative staging, type of operation, and postoperative morbidity, mortality, and survival results.Results The average ages were 40.2 ± 3.77 years (range, 29–45 years) in group 1 and 72.2 ± 2.53 years (range, 70–80 years) in group 2. The incidence of postoperative complications was significantly higher in group 2 (P = 0.02). However, the 5-year survival rates for patients who underwent surgery for non-small cell lung cancer did not differ between groups 1 and 2, at 33.3% versus 21.3%, respectively (P = 0.09).Conclusions The incidence of adenocarcinoma was higher in the young patients, whose prognosis was slightly better than that of the elderly patients. Coexisting diseases and postoperative complications were the major factors that adversely affected the prognosis of the elderly patients.     

Laparoscopic Nissen fundoplication after failure of Enteryx injection into the lower esophageal sphincter

Background We investigated the feasibility, safety, and efficacy of laparoscopic antireflux surgery (LARS) after failure of Enteryx injection in the lower esophageal sphincter for the treatment of gastroesophageal reflux disease (GERD).Methods Four patients underwent LARS after failure of Enteryx injection. Particular care was taken during the procedure to identify unusual material or fibrosis.Results All patients underwent LARS successfully. In three patients, tight adhesions with fibrous tissues and black foreign material were observed around the esophagus. No complications occurred during the procedures. The postoperative period was uneventful and functional results were excellent.Conclusion LARS following Enteryx injection is feasible. Careful dissection is mandatory to avoid operative complications. Both techniques may be considered as options for treating GERD.     

Long term quality of life after laparoscopic antireflux surgery for the elderly

Background

Studies have previously shown laparoscopic antireflux surgery is a safe and effective treatment for GERD even in elderly patients. The aim of the current study was to evaluate patients receiving laparoscopic antireflux surgery before and after 65 years of age and to assess their surgical outcomes and improvements in long term quality of life.

Methods

Patients were given a standardized symptoms questionnaire and the Short-Form 36 Health Survey for quality-of-life evaluation before and after laparoscopic total fundoplication.

Results

Forty-nine patients older than 65 years of age were defined as the elderly group (EG) whereas the remaining 262 younger than 65 years of age were defined as the young group (YG).There were 114 (36.6%) patients who filled out the SF36 questionnaire (98 in the younger group, rate: 37.4%; 16 in the elderly group, rate: 32.6%) pre- and post-operatively. There was no significant difference between the two age groups regarding preoperative PCS ( 45.6 ± 7.8 in YG vs. 44.2 ± 8.2 in EG; P = 0.51) and MCS ( 48.1 ± 10.7 in YG vs. 46.9 ± 9.2 in EG; P = 0.67). There was no significant difference between the two age groups regarding postoperative PCS (49.8 ± 11.9 in YG and 48.2 ± 9.5 in EG ; P = 0.61 and MCS (48.4 ± 10.7 in YG vs. 50.1 ± 6.9 in EG; P = 0.54).

Conclusions

In conclusion, laparoscopic total fundoplication is a safe and effective surgical treatment for gastroesophageal reflux disease generally warranting low morbidity and mortality rates and a significant improvement of symptoms comparable. An improved long-term quality of life is warranted even in the elderly.

     

Pathophysiological Measurement and Results After Laparoscopic Fundoplication for Gastroesophageal Reflux Disease

Purpose: Both surgical and conservative treatments for gastroesophageal reflux disorder (GERD) are controversial. The aim of this prosepective study was to examine outcomes after laparoscopic antireflux surgery. Methods: The subjects were 143 patients who underwent laparoscopic antireflux surgery. Following diagnostic procedures 126 patients were allocated to a total fundoplication group (360°C, Nissen-DeMeester) and 17, to a posterior semifundoplication group (250–270°, Toupet). All complications were registered, and pathophysiological and outcome data were examined 3, 6, and 9 months after surgery. Results: By 6 months after surgery the mean lower esophageal sphincter (LES) pressure had improved significantly, to 14.8 mmHg in the Nissen-DeMeester group, and to 12.1 mmHg in the Toupet group, corresponding to successful prevention of esophageal reflux in both groups. Dysphagia was more common in the early postoperative period after total fundic wrap (17% vs 12%), but this difference disappeared in time. All patients reported complete relief of reflux symptoms, although two of those who underwent the Nissen-DeMeester fundoplication experienced relapse of GERD and required open reconstruction (1.4%). The laparoscopic procedure was converted to open surgery in three patients (2%). There were no associated deaths and the perioperative complication rate was 4.2%. Conclusion: Laparoscopic antireflux surgery is an effective treatment for GERD. More than 93% of the patients in this series rated their outcome as good to excellent following the operation. Received: December 10, 2001 / Accepted: May 7, 2002 Reprint requests to: K. Ludwig     

Outcomes of Surgery for Mid and Distal Rectal Cancer in the Elderly

Background This study aimed to evaluate the surgical strategies, operative results, and oncological outcomes of elderly patients who underwent curative resection for mid and distal rectal cancer. Comparison was made with patients of younger age. Study Design Of the 612 patients who underwent curative resection for rectal cancer, 133 were older than 75 years of age. Comparisons were made between the young and elderly patients in the aspects of operative strategies, operative results, and long-term outcomes. Results Resection resulting in a permanent end colostomy was performed in 96 patients (15.7%), and there was no difference between young and elderly patients. There was a female predominance in the elderly group. Elderly patients also had a higher incidence of comorbid medical diseases, especially cardiovascular and neurological diseases. The operative time, blood loss, and incidence of intraoperative complications did not differ in the two groups. However, significantly fewer elderly patients underwent adjuvant radiation and/or chemotherapy. The overall 30-day mortality was 1.14%. There was no difference between the elderly patients and younger patients in hospital mortality (P = 0.178). The complication rates of the elderly and young patients were 36.8% and 30.1%, respectively (P = 0.141). Comparison between the individual complications in the elderly and young patients revealed significantly more cardiovascular complications in the elderly patients. With the median follow up of the surviving patients of 45.1 months, the overall 5-year survival of the elderly and younger groups was 47.7% and 70.1%, respectively (P < 0.001). The 5-year cancer-specific survival was 75.4% and 67.5% in the young and elderly patients, respectively (P = 0.061). Conclusions Curative resection for mid and distal rectal cancer for the elderly can be performed safely with the same strategies of sphincter preservation used for younger patients. The postoperative complications and the 5-year cancer-specific survival rates were similar to those of younger patients.     

Efficacy of laparoscopic antireflux surgery in patients with Barrett's esophagus

BACKGROUND: Laparoscopic antireflux surgery (LARS) corrects significant physiologic and anatomic abnormalities in patients with gastroesophageal reflux disease (GERD); however, debate exists whether LARS prevents recurrent symptoms and malignant transformation in patients with Barrett's esophagus (BE). This study compared clinical outcomes after LARS in patients with and without BE. METHODS: From 1994 to 2001, 448 patients who underwent LARS were studied. Of these, 68 (15%) had preoperative evidence of BE with low-grade dysplasia in 3 (4%), and 380 (85%) were without BE. Mean postoperative follow-up was more than 30 months in each group. RESULTS: After LARS, there was equivalent reduction in acid reduction medication use and typical GERD symptoms in both groups. Anatomic failures developed in 12% of patients with BE and in 5% of those without BE (P = 0.05). Upper endoscopy with biopsies was obtained in 50 of 68 patients (74%) with BE at 37 +/- 22 months postoperatively. Intestinal metaplasia was no longer present in 7 of 50 (14%) BE patients, and low-grade dysplasia regressed to nondysplastic Barrett's in 2 of 3 patients. New low-grade dysplasia developed in 1 BE patient (2%) at postoperative endoscopic surveillance. No BE patients developed high-grade dysplasia or adenocarcinoma. CONCLUSIONS: After LARS, patients with BE have symptomatic relief and reduction in medication use equivalent to non-BE patients. Regression of intestinal metaplasia and the absence of progression to high-grade dysplasia or adenocarcinoma suggest that LARS is an effective approach for the management of patients with Barrett's esophagus. The higher failure rate of LARS in BE is of concern and mandates ongoing follow-up of these patients.     

Laparoscopic Gastric Bypass after Antireflux Surgery for the Treatment of Gastroesophageal Reflux in Morbidly Obese Patients: Initial Experience

Background: Laparoscopic Roux-en-Y gastric bypass (LRYGBP) has been proven effective against gastroesophageal reflux disease (GERD) in morbidly obese patients. We present our experience with revision of antireflux procedures to LRYGBP in obese patients with recurrent GERD, weight gain or a combination of both and discuss the indications and technical considerations involved. Methods: Between June 2000 and December 2003, 7 morbidly obese patients with a mean BMI of 37.5 kg/m² underwent revision of an antireflux procedure to LRYGBP by our group. Important steps of the revision include dissection of the diaphragmatic crura and gastroesophageal fat pad, reduction and repair of hiatal hernia, and complete take-down of the wrap to avoid stapling over the fundoplication which can create an obstructed, septated pouch. Results: Mean operative time was 6 hr 12 min and length of stay was 4.8 days. There were 3 major complications postoperatively and no deaths. During follow-up, 5 patients developed anastomotic strictures and 2 patients were re-explored for gastric remnant herniation and intestinal obstruction. At a mean follow-up of 24 (3-44) months, mean excess weight loss was 70.7% and 14/20 (70%) co-morbid conditions were improved or resolved. GERD evaluation with the GERD-HRQL scale showed a significant reduction of GERD scores postoperatively (P =0.006). Conclusions: Although LRYGBP after antireflux surgery is a technically more difficult procedure with a higher morbidity, it is feasible and effective for the treatment of recurrent GERD and worsening obesity with the additional advantage of weight loss and improvement of co-morbidities.