Immediate and delayed effects of laparoscopic Nissen fundoplication on pulmonary function

Background: An effort was made to assess the respiratory outcomes of laparoscopic Nissen fundoplication (LNF). Methods: Prospective follow-up of 69 patients undergoing LNF for gastroesophageal reflux disease. Outcomes included pulmonary function testing, 24-h pH recording, esophageal manometry, and symptom assessment. Results: There was an improvement (p < 0.0001) in heartburn and cough scores. There was a significant fall in spirometry (p < 0001), diffusing capacity (p < 0.0001), and respiratory muscle strength (p < 0.0001) 36 h after surgery, which had returned to baseline by 1 month. At 6 months, the patients (n= 16) with impaired preoperative diffusing capacity showed improvement (17.8 ± 3.7 to 19.8 ± 4.6 ml/min/mmHg, p= 0.0245). Conclusion: Patients undergoing LNF have impaired gas exchange before surgery which tends to improve 6 months after surgery. There is an early reversible impairment in respiratory function due to diaphragm dysfunction. Patients with a preoperative 1-s forced expired volume > 1.5, or 50% predicted, are unlikely to develop signficant early respiratory complication. Received: 22 April 1996/Accepted: 9 July 1996     

Measuring improved quality of life after laparoscopic Nissen fundoplication

BACKGROUND: While the correction of pathologic gastroesophageal reflux by means of laparoscopic Nissen fundoplication (LNF) has been well documented, the psychological profiles of patients with this disease and the impact on their quality of life are less well understood. We obtained a baseline psychological profile and measured the impact of LNF on patients' quality of life with 2 standardized instruments: the psychological general well-being index (PGWB) and the gastrointestinal symptoms rating scale (GSRS). The study included 34 consecutive patients with typical symptoms of gastroesophageal reflux who underwent LNF in 1995 at a tertiary care university medical center. METHODS: Patients filled out PGWB and GSRS surveys preoperatively and at 2 weeks, 2 months, and 12 months postoperatively. Data were collected in a blinded fashion by a study nurse and analyzed after completion of the study. Data are expressed as mean +/- standard deviation. RESULTS: The mean preoperative PGWB score (69.6 +/- 17.3) of study patients with gastroesophageal reflux disease was lower than that expected for a healthy population. This was primarily attributable to low scores in the general health domain of the questionnaire, although LNF patients also had low scores in the vitality and positive well-being domains of the PGWB scale. LNF improved the PGWB score to a normal level (78.7 +/- 19.3) (P = .05 vs the preoperative PGWB score) at 12 months post surgery. The GSRS also showed improvement from 34.7 +/- 7.8 to 28.1 +/- 10 (P = .008). The improvement in GSRS was attributed to improvement in the heartburn (7.12 +/- 2.4 to 2.72 +/- 1.2, P < .001) and abdominal pain (6.58 +/- 2.5 to 4.92 +/- 1.6, P = .006) domains of the scale. LNF had no impact on the diarrhea, indigestion, and obstipation domains of the GSRS. CONCLUSIONS: Patients with gastroesophageal reflux disease who are candidates for LNF have low psychological and general well-being scores that are restored to normal levels by successful LNF. When compared with baseline measurements, LNF effectively relieved heartburn and did not cause significant new gastrointestinal complaints.     

Randomized clinical trial of laparoscopic Nissen fundoplication compared with proton-pump inhibitors for treatment of chronic gastro-oesophageal reflux

BACKGROUND: Both laparoscopic Nissen fundoplication (LNF) and proton-pump inhibitor (PPI) therapy are established in the treatment of gastro-oesophageal reflux disease (GORD). The aim of this study was to compare these two treatments in a randomized clinical trial. METHODS: Between July 1997 and August 2001, 340 patients with a history of GORD for at least 6 months were investigated by endoscopy, 24-h pH monitoring and manometry. Of these, 217 were randomized, 109 to LNF and 108 to PPI therapy. The two groups were well matched for age, sex, weight and severity of reflux. Twenty-four-hour pH monitoring and manometry were performed 3 months after treatment, and quality of life was assessed in both groups using the Psychological General Well-being Index and the Gastrointestinal Symptom Rating Scale at 3 and 12 months after treatment. RESULTS: At 3 months there was an improvement in lower oesophageal sphincter pressure from 6.3 to 17.2 mmHg in the LNF group but no change in the PPI group (8.1 and 7.9 mmHg before and after treatment respectively) (P < 0.001). The mean DeMeester acid exposure score improved from 42.7 to 8.6 (P < 0.001) in the LNF group and from 36.9 to 17.7 in the PPI group (P < 0.001). The mean gastrointestinal symptom and general well-being scores improved from 31.7 and 95.4 respectively before treatment to 37.0 and 106.2 at 12 months after LNF, compared with changes from 34.3 and 98.5 to 35.0 and 100.4 respectively in the PPI group. The differences in both of these scores were significant between the two groups at 12 months (P = 0.003). CONCLUSION: LNF leads to significantly less acid exposure of the lower oesophagus at 3 months and significantly greater improvements in both gastrointestinal and general well-being after 12 months compared with PPI treatment.     

Gastroesophageal disease and nausea: does fundoplication help or hurt?

HYPOTHESIS: Nausea associated with gastroesophageal reflux disease is cured by laparoscopic Nissen fundoplication (LNF). DESIGN: Prospective cohort study of unselected patients who underwent LNF from January 1, 1995, through March 31, 1999. Patients were followed up by a physician for 6 to 36 months. SETTING: A large community teaching hospital. PATIENTS: One hundred consecutive patients with gastroesophageal reflux disease who underwent LNF; all patients were followed up. Patients were grouped according to the presence (group A, n = 33) or absence (group B, n = 67) of preoperative nausea. Interventions were LNF, esophageal manometry, 24-hour pH monitoring, and nuclear gastric emptying studies. MAIN OUTCOME MEASURES: Resolution of symptoms after LNF. RESULTS: Nausea was the most common atypical symptom of gastroesophageal reflux disease, occurring in 33 patients (33%). There were no differences in esophageal manometry or 24-hour pH results between groups. There was a female preponderance in group A (55% vs 33%; P = .003). Patients in group A had a higher prevalence of preoperative dysphagia (P = .02). Patients with persistent postoperative nausea had a higher prevalence of cough (P = .003) and dysphagia (P = .009). The LNF was more effective in reducing heartburn (95% reduction) and regurgitation (95% reduction) than cough and dysphagia (60% reduction). There was a 79% reduction in the number of patients with nausea (33 to 7; P<.001). CONCLUSION: Laparoscopic Nissen fundoplication is effective in eliminating nausea associated with gastroesophageal reflux disease and is not contraindicated in these patients.     

Preoperative clinical predictors of response to bilateral subthalamic stimulation in patients with Parkinson's disease

BACKGROUND: Younger age and a response to a supra-threshold levodopa challenge have been reported to predict a favorable response to bilateral subthalamic nucleus (STN) stimulation. OBJECTIVE: To identify and evaluate clinical factors which predict a positive outcome after bilateral STN stimulation in patients with Parkinson's disease, using each patient's typical doses of antiparkinsonian medication rather than a supra-threshold levodopa challenge. METHODS: Forty-five Parkinson's disease patients who underwent bilateral STN implantation were included in the study. There were 33 men and 12 women. Mean age and disease duration were 59.4 and 12.7 years, respectively. All patients underwent Unified Parkinson Disease Rating Scale (UPDRS) evaluations in the medication off and on states at baseline and postsurgically with stimulation on at 3, 6 and 12 months. The percentage improvement in UPDRS motor scores at baseline (medication off vs. on) was compared with the percentage improvement after stimulation optimization (baseline medication off vs. follow-up medication off/stimulation on). RESULTS: The preoperative percentage improvement in UPDRS motor scores with antiparkinsonian medications was predictive of the postoperative percentage improvement in the UPDRS motor scores in the medication off/stimulation on state (r = 0.53, p < 0.001). However, preoperative UPDRS motor scores in the medication on state were more strongly correlated with the postsurgical effect of stimulation (r = 0.64, p < 0.001). The postoperative improvement in UPDRS motor scores with stimulation did not correlate with age, disease duration or time to programming optimization. CONCLUSIONS: The preoperative percentage improvement in UPDRS motor scores with antiparkinsonian medications and UPDRS motor score in the medication on state at baseline are the strongest clinical predictors of responsiveness to bilateral STN stimulation.     

Factors contributing to failure of laparoscopic Nissen fundoplication and the predictive value of preoperative assessment

BACKGROUND: Laparoscopic Nissen fundoplication (LNF) has established itself as the procedure of choice in the surgical management of the majority of patients suffering from gastroesophageal reflux disease (GERD). There are, however, few available data on the assessment of long-term failures after LNF. METHODS: We sought to clarify the mechanisms of failure among a group of patients who reported suboptimal results after LNF. In addition, we attempted to identify specific elements in the preoperative evaluation of GERD patients that might herald a predisposition to anatomical or physiological failure. RESULTS: One hundred and thirty-one consecutive patients who underwent LNF by a single surgeon were analyzed to identify reasons for surgical failure. Fourteen patients (10.6%) comprised the failure group. Detailed independent statistical analysis identified a hiatus hernia greater than 3 cm at operation (P = 0.003), abnormal preoperative pH analysis in the upright position (P = 0.039), failure to respond to proton pump inhibition preoperatively (P = 0.015), and a preoperative psychiatric history (P = 0.0012) as predictors of subsequent failure. CONCLUSIONS: In patients who do not respond to proton pump inhibition preoperatively, the evaluating surgeon should be circumspect in advocating antireflux surgery. A detailed assessment of underlying psychiatric or psychological symptoms must also be made. If a large (>3 cm approximately) hiatus hernia is identified or there is abnormal pH analysis in the upright position preoperatively, the surgeon should be guarded about the long-term outcome, and patients should be advised accordingly.     

Short-term cost effectiveness and long-term cost analysis comparing laparoscopic Nissen fundoplication with proton-pump inhibitor maintenance for gastro-oesophageal reflux disease

BACKGROUND: This study examined the short-term cost-effectiveness and long-term cost of laparoscopic Nissen fundoplication (LNF) versus maintenance proton-pump inhibitor (PPI) medication for severe gastro-oesophageal reflux disease (GORD) based on a randomized clinical trial. METHODS: Costs and outcomes for 12 months were obtained from the first 100 patients in the trial. Detailed costing was performed using resource use data from hospital records and general practitioners' notes. Short-term incremental cost-effectiveness ratios, calculated as the cost difference divided by the effectiveness difference between LNF and PPI therapy, were analysed using net benefit and bootstrap approaches. Long-term cost was examined using sensitivity analyses incorporating published data from other large series. RESULTS: The incremental cost of LNF compared with PPI therapy per additional patient returned to a physiologically normal acid score (less than 13.9) at 3 months was pound5515 (95 per cent confidence interval (c.i.) pound3655 to pound13 400) and the incremental cost per point improvement in combined Gastro-Intestinal and Psychological Well-being score at 12 months was pound293 (90 per cent c.i. pound149 to pound5250). On average, LNF cost pound2247 (95 per cent c.i. pound2020 to pound2473) more than PPI therapy in year 1 and broke even in year 8. Break-even was highly sensitive to hospital unit costs but less sensitive to PPI ingestion rate after LNF, LNF reoperation rate, PPI relapse rate, future PPI price, PPI dose escalation and discount rate. CONCLUSION: From a National Health Service perspective, LNF may be cost-saving after 8 years compared with maintenance PPI therapy for the treatment of GORD.     

Laparoscopic Nissen fundoplication: two-year comprehensive follow-up of a technique of minimal paraesophageal dissection.

OBJECTIVE: To provide a comprehensive follow-up of 381 patients after laparoscopic Nissen fundoplication (LNF) using a technique of minimal paraesophageal dissection. METHODS: Patients underwent a 24-hour pH recording, esophageal manometry, and symptom score assessment for six symptoms of gastroesophageal reflux disease preoperatively. To date, 260 patients have undergone repeat studies at 6 months and 108 patients at 2 years. RESULTS: LNF was associated with a significant (p < 0.0001) increase in the lower esophageal sphincter (LES) pressure and a significant (p < 0.0001) drop in duration of acid reflux in 24 hours and symptom score 6 and 24 months after surgery when compared to preoperative values. Twelve patients (3%) have experienced recurrence of reflux symptoms, 8 presenting in the first 6 months and 4 by the second year after surgery, but only 1 has required repeat surgery. The incidence of clinical dysphagia was found to be 1.3% of the patient group. CONCLUSIONS: LNF remains an effective antireflux procedure at 2 years. Most recurrences occur early, and there is no significant deterioration in the high-pressure zone at the LES, the percentage reflux in 24 hours, or symptom control between 6 months and 2 years after surgery, suggesting that the long-term results should be satisfactory.     

Prospective study of laparoscopic nissen fundoplication in a community hospital and its effect on typical, atypical, and nonspecific gastrointestinal symptoms.

BACKGROUND: Laparoscopic Nissen fundoplication (LNF) provides long-term improvement in the typical symptoms of gastroesophageal reflux disease. Few studies have prospectively addressed LNF in the community hospital or the effect of LNF on specific atypical symptoms, other related gastrointestinal symptoms, and weight change. METHODS: Data were collected prospectively on consecutive patients having LNF. Three typical, 6 atypical, and 3 other gastrointestinal symptoms were studied. RESULTS: Short-term data on 91 patients and long-term data on 84 patients were studied. Overall long-term improvement was 98%. Regarding typical symptoms, the greatest improvement occurred in heartburn and regurgitation. Regarding atypical symptoms, the greatest improvement occurred in cough and sore throat, but chest pain, hoarseness, and throat clearing also showed significant durable improvement. Bloating, nausea, and diarrhea showed no significant change from preoperative to postoperative surveys. Mild weight loss was common. CONCLUSION: LNF can be safely performed in a community hospital with results equal to those of university hospitals. Improvement in typical symptoms was greater than improvement in atypical symptoms, but results for both were significant and durable. Nonspecific gastrointestinal symptoms, such as nausea, bloating, and diarrhea, may be unrelated to Nissen fundoplication.     

Outcome of Laparoscopic Nissen Fundoplication for Gastroesophageal Reflux Disease in Non-responders to Proton Pump Inhibitors

Background

Gastroesophageal reflux disease (GERD) is a common public health problem. Medical treatment remains the first line of treatment of GERD. Failure of medical treatment may occur in up to 45 % of GERD patients. This study aims to evaluate the outcome of laparoscopic Nissen fundoplication (LNF) as a means of antireflux surgery in patients with poor response to anti-reflux medication.

Patients and Methods

This is a prospective study of patients who underwent LNF in the period between January 2000 and December 2010 in the Gastrointestinal Surgical Center, Mansoura University, Egypt. Patients were assessed preoperatively and postoperatively, after 1 year, by clinical examination, esophagogastroscope, barium esophagography, esophageal manometry and 24-h pH monitoring. Patient satisfaction after surgery was also graded through a questionnaire.

Results

The study population was 370 patients. 296 patients were good responders to proton pump inhibitors (PPI) while 74 patients were PPI non-responders. Preoperatively, atypical reflux symptoms were significantly more in PPI non-responders (P?=?0.006). On follow-up, PPI responders significantly reported relief of heartburn (P?=?0.01) and regurgitation (P?=?0.04). Patient satisfaction was more in PPI responders (P?=?0.04). Both groups were comparable regarding anatomical and functional assessment. Integrity of the wrap was higher in PPI responders (P?=?0.04).

Conclusion

PPI non-responders should not be precluded from LNF. Thorough assessment is mandatory to confirm GERD diagnosis. A substantial proportion of PPI failures show good response to LNF but significantly than clinical response in PPI responders. Increased likelihood of poor outcome after surgery should be discussed with the patient.     

Outcomes of laparoscopic Toupet compared to laparoscopic Nissen fundoplication

Background: Recent reports suggest that partial fundoplications such as the laparoscopic Toupet (LT) ultimately suffer from a higher recurrence rate compared to complete wraps such as the laparoscopic Nissen fundoplication (LNF). This article summarizes our experience with LT and LNF. Methods: Over a 45-month period (February 1995 to November 1998), 206 patients underwent laparoscopic antireflux operations. The LNF group included 163 patients and the LT group included 43 patients. Global quality of life was measured using the Medical outcomes short form 36 (SF36). Results: There were no differences in disease severity, except that the LT group had a higher incidence of esophageal dysmotility (37.2% 8.6%, p < 0.05). Early outcomes were similar, with no perioperative deaths and morbidity occurring in 15 (9.2%) LNF and 5 (11.6%) LT patients (p = not significant). Long-term follow-up was available in 142 patients at a mean of 19.7 months. A greater number of LT patients required proton pump inhibitors (38 vs 20%) and were dissatisfied (21 vs 7%) with their surgery (p < 0.05). SF36 physical function scores were better in the LNF group (85 vs 74; p < 0.05). Significantly more (p < 0.05) of the LT patients complained of dysphagia (34.5 vs 15%) on follow-up. There were no differences in the incidence of symptoms related to the gas-bloat syndrome. The observed differences between the LT and LNF groups did not appear to be related to differences in esophageal motility. Conclusions: Short-term results were similar for LT and LNF, but with longer follow-up, better results were seen with LNF. Even in the setting of moderate decreases of esophageal motility, complete fundoplication yields superior results.     

Impact of laparoscopic Nissen’s fundoplication on response of disease specific symptoms and quality of life

The aim of this study is to establish responsiveness of gastroesophageal reflux disease (GERD) symptom score, quality of life SF-36 score in GERD with relation to oesophageal manometry and upper gastrointestinal endoscopy following laparoscopic Nissen’s fundoplication (LNF). Interventional prospective study was done enrolling 77 patients of GERD who respond to proton pump inhibitor (PPI) and have undergone LNF, strict diagnostic criteria were followed with GERD score, upper gastrointestinal endoscopy, oesophageal manometry, and endoscopically negative patients have further undergone 24-h pH study. Follow-up was done at 12 and 24 months by GERD score, SF-36 score, endoscopy, oesophageal manometry. GERD score shows significant difference in pre-operative and post-operative score with P value <0.001 except dysphagia. Post-LNF improvement in GERD score is consistent with improvement in lower oesophageal sphincter (LES) pressure at 12 months. All dimensions in quality of life SF-36 show significant difference in pre-operative and post-operative score at 12 months with P value <0.001. Results are consistent at 24 months. Oesophagitis was decreased from 40.2 to 11.6 % as well as it showed down grading on endoscopy in post-operative period. Out of three patients of complete disruption of wrap, two patients underwent redo surgery and showed improvement. In properly diagnosed PPI respondent patients by GERD score, LNF has got improvement in GERD score, quality of life in all dimensions of SF-36 score in relation to improvement with LES pressure and oesophagitis.     

Comparison of patient-centered outcomes after laparoscopic Nissen fundoplication for gastroesophageal reflux disease or paraesophageal hernia

Background Patients undergoing laparoscopic Nissen fundoplication (LNF) with paraesophageal hernias (PEH) are not only older and less healthy than those with gastroesophageal reflux disease (GERD), but in addition the repair is more complicated. We evaluated whether outcomes relating to GERD symptoms and quality of life (QOL) were impacted by the presence of PEH. Methods Prospectively entered data from 149 patients (109 GERD and 40 PEH) were evaluated prior to and one year after LNF with standardized and validated symptoms scores. Scores for heartburn, dysphagia, disease-specific QOL (GERD-HRQL), and general health-related QOL (SF-12 physical and mental component scores) were compared between patients undergoing LNF for PEH or for GERD alone, at baseline and one year after surgery. p < 0.05 was considered statistically significant. Results Preoperative data for GERD-HRQL, heartburn, and dysphagia were available for 134 patients, with 96% one-year follow-up. SF-12 data were collected for 98 patients with 100% follow-up. PEH patients were older and had greater comorbidity. Preoperative GERD-HRQL and heartburn were significantly worse in the GERD group. One year after surgery, both GERD and PEH patients showed significant improvement in GERD-HRQL, heartburn and dysphagia scores, with no difference in any of these disease or symptom measures between the two study groups. Postoperative PCS and MCS scores showed improvement in GERD patients, while PEH patient scores remained at or below the population mean. Conclusions LNF is equally effective as an antireflux procedure in both GERD and PEH patients, prevents symptoms of reflux in PEH patients that have none preoperatively, and does not increase dysphagia in either group. Despite the increased complexity of the procedure, LNF provides an effective control of reflux symptoms in patients undergoing PEH repair. Supported by an unrestricted educational grant from Tyco Healthcare Canada     

Preoperative psychological global well being index (PGWBI) predicts postoperative quality of life for patients with non-small cell lung cancer managed with thoracic surgery.

OBJECTIVE: Non-small cell lung cancer (NSCLC) patients surgically treated often experienced a postoperative disability related to the surgery but did not benefit from a long-term survival advantage (postoperative death and relapse). Therefore, improvement of quality of life (QOL) for all NSCLC patients surgically treated is necessary and the assessment of factors influencing the short-term postoperative QOL is required. Therefore, a prospective study to assess the value of the psychological global well being index (PGWBI) to predict short-term postoperative QOL was conducted. PATIENTS AND METHODS: Prospective study in Academic Hospital's departments of thoracic oncology and surgery. Socio-demographic and clinical characteristics as well as PGWBI scores of 110 NSCLC patients referred for thoracic surgery were prospectively compared to postoperative QOL evaluated by the mean of the EORTC QLQ-C30 and LC13 questionnaires, completed before hospital discharge. RESULTS: Eighty-four patients completed the postoperative QOL questionnaires. In the univariate analysis, most of the PGWBI scores significantly correlated with the postoperative QOL. Also, patients living alone presented with a significantly higher risk of experiencing a poor postoperative QOL. In the multivariate analysis, patients showing a lower preoperative global health status as evaluated through the PGWBI experienced a statistically significant lower postoperative global QOL (hazard ratio (HR) = 1.39, 95% confidence interval (CI) 1.12-1.74, p = 0.003) as well as a reduced physical (HR = 1.32, 95% CI 1.09-1.60, p = 0.004) and emotional (HR = 1.21, 95% CI 1.06-1.39, p = 0.004) functions. CONCLUSIONS: A simple assessment of patients at higher risk of a poor short-term postoperative QOL could be easily performed preoperatively, taking into account certain socio-demographic factors and the results of the QOL assessment using the PGWBI.     

Does laparoscopic fundoplication provide long-term control of gastroesophageal reflux related cough?

Background: Of patients with chronic cough, 21% have GERD. Up to half of these patients may not respond adequately to medical, but the long-term results of antireflux surgery for cough is unknown. Methods: A total of 905 patients (209 with respiratory symptoms, mainly cough) underwent laparoscopic Nissen fundoplication. Preoperatively patients underwent esophageal motility studies, 24-h pH monitoring, and symptom evaluation using a validated scale. Of eligible patients, 81% were followed at 6 months, 73% at 2 years, and 60% at 5 years. Results: Before surgery, 83% of respiratory patients (RP) and 51% of nonrespiratory patients (NRP) had cough. RP had higher cough scores (p < 0.0001), but improvement in cough compared to baseline was similar in the RP and NRP (p = 0.1105 at 6 months, 0.4206 at 2 years, and 0.1348 at 5 years). Cough improved in 83% at 6 months, 74% at 2 years, and 71% at 5 years. Conclusions: Laparoscopic Nissen fundoplication is successful in the long-term control of GERD-related cough, even in patients who fail medical therapy.     

Reversible dementia in patients with chronic subdural hematomas

OBJECT: Neuropsychiatric changes following surgery for chronic subdural hematomas (CSDHs) were analyzed in 26 patients (21 men and five women) by using the Mini-Mental State Examination (MMSE) and the Hasegawa Dementia Scale-Revised (HDS-R) to determine factors that potentially contribute to neuropsychiatric recovery. METHODS: Burr hole irrigation was performed in every patient to treat the CSDH. The patients' profiles, including age and sex, neuroimaging findings (such as hematoma volume and thickness, as well as midline shift), and preoperative and postoperative scores on the MMSE, HDS-R, and activities of daily living (ADL) scale were recorded. According to preoperative MMSE scores, eight patients (30.8%) were classified as mentally healthy and 18 (69.2%) as suffering from dementia before surgery. Nine of the 18 patients with dementia recovered to a normal psychological state following surgery. Surgery improved not only the patients' independence in ADL (p = 0.0026), but also their neuropsychiatric functions such as orientation and calculation, as estimated by scores on the MMSE (p = 0.0002) and the HDS-R (p = 0.0008). Factors affecting neuropsychiatric status on admission were midline shift (p = 0.0398) and ADL score (p = 0.0124); factors that could be used to predict neuropsychiatric recovery after surgery were patient age (p = 0.0027) and ADL score (p = 0.0193). The results of a logistic regression analysis demonstrated that significant predictors of neuropsychiatric recovery after surgery include the following: patient age (p = 0.0049, odds ratio [OR] = 0.842) and preoperative ADL (p = 0.0056, OR = 0.471), MMSE (p < 0.0001, OR = 1.895), and HDS-R (p = 0.0073, OR = 1.303) scores. Results of subgroup analyses demonstrated that patients younger than 74 years of age and those who had preoperative scores lower than 5 on the converted ADL scale, higher than 10 on the MMSE, or higher than 9 on the HDS-R on admission were found to have a significantly better recovery of neuropsychiatric functions after surgery. CONCLUSIONS: Dementia is reversible in many patients with CSDH, and surgery can improve not only independence in ADL, but also neuropsychiatric functions. Patients who are younger and/or those who have lower preoperative ADL scores and/or higher preoperative MMSE or HDS-R scores will achieve a good recovery with regard to neuropsychiatric functions after surgery. Estimations of neuropsychiatric function based on MMSE and HDS-R scores were found to be useful in predicting functional outcomes in patients with CSDH.     

Long-term follow up of bilateral deep brain stimulation of the subthalamic nucleus in patients with advanced Parkinson disease

OBJECT: The use of deep brain stimulation (DBS) of the subthalamic nucleus (STN) has been associated with a marked initial improvement in individuals with advanced Parkinson disease (PD). Few data are available on the long-term outcomes of this procedure, however, or whether the initial benefits are sustained over time. The authors present the long-term results of a cohort of 25 individuals who underwent bilateral DBS of the STN between 1996 and 2001 and were followed up for 1 year or longer after implantation of the stimulator. METHODS: Patients were evaluated at baseline and repeatedly after surgery by using the Unified Parkinson's Disease Rating Scale (UPDRS); the scale was applied to patients during periods in which antiparkinsonian medications were effective and periods when their effects had worn off. Postoperative UPDRS total scores and subscores, dyskinesia scores, and drug dosages were compared with baseline values, and changes in the patients' postoperative scores were evaluated to assess the possibility that the effect of DBS diminished over time. In this cohort the median duration of follow-up review was 24 months (range 12-52 months). The combined (ADL and motor) total UPDRS score during the medication-off period improved after 1 year, decreasing by 42% relative to baseline (95% confidence interval [CI 35-50%], p < 0.001) and the motor score decreased by 48% (95% CI 42-55%, p < 0.001). These gains did diminish over time, although a sustained clinical benefit remained at the time of the last evaluation (41% improvement over baseline, 95% CI 31-50%; p < 0.001). Axial subscores at the time of the last evaluation showed only a trend toward improvement (p = 0.08), in contrast to scores for total tremor (p < 0.001), rigidity (p < 0.001), and bradykinesia (p = 0.003), for which highly significant differences from baseline were still present at the time of the last evaluation. Medication requirements diminished substantially, with total medication doses reduced by 38% (95% CI 27-48%, p < 0.001) at 1 year and 36% (95% CI 25-48%, p < 0.001) at the time of the last evaluation; this decrease may have accounted, at least in part, for the significant decrease of 46.4% (95% CI 20.2-72.5%, p = 0.007) in dyskinesia scores obtained by patients during the medication-on period. No preoperative demographic variable, such as the patient's age at the time of disease onset, age at surgery, sex, duration of disease before surgery, preoperative drug dosage, or preoperative severity of dyskinesia, was predictive of long-term outcome. The only predictor of a better outcome was the patient's preoperative response to levodopa. CONCLUSIONS: In this group of patients with advanced PD who underwent bilateral DBS of the STN, sustained improvement in motor function was present a mean of 2 years after the procedure, and sustained reductions in drug requirements were also achieved. Improvements in tremor, rigidity, and bradykinesia were more marked and better sustained over time than improvements in axial symptoms. A good preoperative response to levodopa predicted a good response to surgery.     

Laparoscopic fundoplication

BACKGROUND: The effectiveness of laparoscopic Nissen fundoplication (LNF) was assessed in patients with chronic gastroesophageal reflux disease (GERD) using pH study and different quality-of-life indexes. We correlated both types of data and hypothesised that improvement in quality of life following LNF does not necessarily correlate with improvement in pH values. METHODS: Seventy patients presenting with typical symptoms of GERD (14 with Barrett's esophagus) underwent LNF between May 1997 and December 2000. All patients were evaluated both prior to and 3 months after surgery using 24-h pH study, endoscopy, and a validated quality-of-life questionnaire. RESULTS: Following LNF, reflux was reduced to normal in all but six patients. Howevers despite persistent reflux, the Gastrointestinal Quality of Life Index (GQLI), of these six patients improved postoperatively from 79.5 +/- 12.2 to 111.7 +/- 8.3. These results correlate with those of patients who had normal postoperative pH studies-namely, 88.5 +/- 19.3 to 112 +/- 16.7. There was no difference in quality-of-life improvement between patients with Barrett's esophagus and those without it. CONCLUSION: There is only a weak correlation between quality-of-life assessment and pH study. Because the patient's quality of life is likely to improve following LNF, an objective means parameter of assessing the effectiveness of antireflux surgery, such as pH study or endoscopy, is recommended.     

Prospective Study Examining the Impact of Multichannel Intraluminal Impedance on Antireflux Surgery

Background Reflux monitoring using combined multichannel intraluminal impedance (MII) and pH-metry increases the sensitivity for identifying gastroesophageal reflux episodes. The likelihood of a positive symptom index (SI) for patients with reflux disease (gastroesophageal reflux disease [GERD] or nonerosive reflux disease [NERD]) receiving proton pump inhibitor (PPI) treatment has been used to select candidates for antireflux surgery. Little is known about the advantages of MII-pH monitoring compared with pH monitoring alone for evaluating GERD/NERD patients off PPI treatment considered as candidates for antireflux surgery or for assessing changes in MII-pH-detected reflux episodes after antireflux surgery. This study aimed to determine the additional value of MII over pH-metry alone for patients off PPI treatment before and after antireflux surgery. Methods For this study 12 patients (4 women and 8 men; mean age, 45 years; range, 27–74 years) were evaluated using ambulatory MII-pH monitoring before and 3 months after mesh-augmented hiatoplasty. Reflux events were identified by MII-pH (A) and pH-metry (B) as patients recorded symptoms on a data logger. For each symptom, a symptom index was calculated for reflux events identified by MII-pH and by pH-monitoring alone. Results Preoperatively, MII-pH monitoring identified 71.9 ± 8.4 reflux episodes, whereas pH monitoring identified only 51.0 ± 7.8 (p < 0.05). Postoperatively, MII-pH monitoring identified 35.5 ± 6.6 reflux episodes, whereas pH monitoring identified only 19.6 ± 4.7 (p < 0.05). The pre- and postoperative symptom index for MII-pH monitoring was higher than pH monitoring (preoperative 91.7% vs 25%, p = 0.006; postoperative 50% vs 16.7%, p = 0.012). Conclusion Combined MII-pH-metry improves the pre- and postoperative assessment of GERD patients off PPI and results in a higher symptom-reflux association.     

The impact of stereotactic pallidal surgery on the dopamine D2 receptor in Parkinson disease: a positron emission tomography study

OBJECT: The aim of this study was to estimate the impact of stereotactic pallidal surgery on the binding potential of dopamine D2 receptors in patients with advanced Parkinson disease (PD). METHODS: Six patients with advanced PD (three men and three women; mean age 56.7 +/- 9.8 years, Hoehn and Yahr stage 3.3 +/- 1.1/3.9 +/- 1.2 [on/off scores], mean +/- standard deviation) underwent stereotactic pallidal surgery. One underwent right posteroventral pallidotomy (PVP), one received left PVP, three were treated with deep brain stimulation (DBS) of the left globus pallidus internus (GPi), and one with bilateral DBS of the GPi. The binding potential of the dopamine D2 receptors of these patients was determined before and after surgery by using positron emission tomography scanning with 11C-nemonapride and it was compared with the value in eight healthy volunteers. The authors also examined whether changes in the D2 receptor binding potential were correlated with the clinical outcome. The clinical symptoms, especially those in the off state, were significantly improved after surgery. Preoperatively, the D2 receptor binding potential in the putamen was elevated by 27% (p < 0.01) and that in the thalamus was 29% lower than that in controls (p < 0.01). The D2 receptor binding potential in the putamen and thalamus returned to control levels after surgery. The preoperative level of the D2 receptor binding potential in the anterior cingulate cortex was comparable to that of controls, but it declined significantly after surgery, whereas the D2 receptor binding potential in other regions of both hemispheres showed no significant changes after surgery. Although the D2 receptor binding potential did not correlate with the Hoehn and Yahr stage, the Schwab and England score, or the Unified PD Rating Scale (UPDRS) score, a positive correlation was seen between the percent improvement rate of the total UPDRS score in the off state and the percentage change of the D2 receptor binding potential in the putamen (r = 0.773, p = 0.0417 according to the Pearson linear correlation). CONCLUSIONS: The altered dopamine D2 receptor binding potential in the putamen might play a crucial role in clinical improvement after PVP or DBS of the GPi in advanced PD.