Evaluation and treatment of laryngopharyngeal reflux symptoms

Gastroesophageal reflux disease (GERD) is a well-defined disease characterized by symptoms or complications caused by an abnormal amount of GER, which is a retrograde movement of gastric contents into the esophagus. Laryngopharyngeal reflux (LPR) is a subset of GERD and given its own identity, because the main symptomatic regions are the larynx and pharynx. Accurate diagnosis and effective treatment of LPR has been challenging. Much research has been dedicated to the elucidation of its complex pathophysiology and the development of accurate diagnostic modalities and effective treatment. Considerable advancements have been made in the evaluation and treatment of LPR.     

Impact of concurrent hiatal hernia repair during laparoscopic sleeve gastrectomy on patient-reported gastroesophageal reflux symptoms: a state-wide analysis

BackgroundConcurrent hiatal hernia repair (HHR) during laparoscopic sleeve gastrectomy (LSG) may improve gastroesophageal reflux disease (GERD) symptoms. However, patient-reported outcomes are limited, and the influence of surgeon technique remains unclear.ObjectivesTo assess patient-reported GERD severity before and after LSG with and without concomitant HHR.SettingTeaching and non-teaching hospitals participating in a state-wide quality improvement collaborative.MethodsUsing a state-wide bariatric-specific data registry, all patients who underwent a primary LSG between 2015 and 2019 who completed a baseline and 1 year validated GERD health related quality of life (GERD-HRQL) survey were identified (n = 11,742). GERD severity at 1 year as well as 30-day risk-adjusted adverse events was compared between patients who underwent LSG with or without HHR. Results were also stratified by anterior versus posterior HHR.ResultsA total of 4015 patients underwent a LSG-HHR (34%). Compared to patients who underwent LSG without HHR, LSG-HHR patients were older (47.8 yr versus 44.6 yr; P < .0001), had a lower preoperative body mass index (BMI) (45.8 kg/m² versus 48 kg/m²; P < .0001) and more likely to be female (85.2% versus 77.6%, P < .0001). Patients who underwent a posterior HHR (n = 3205) experienced higher rates of symptom improvement (69.5% versus 64.0%, P = .0014) and lower rates of new onset symptoms at 1 year (28.2% versus 30.2%, P = .0500). Patients who underwent an anterior HHR (n = 496) experienced higher rates of hemorrhage and readmissions with no significant difference in symptom improvement.ConclusionsConcurrent posterior hiatal HHR at the time of sleeve gastrectomy can improve reflux symptoms. Patients undergoing anterior repair derive no benefit and should be avoided.     

Mid term analysis of safety and quality of life after the laparoscopic repair of paraesophageal hiatal hernia

Background Initial experience with the laparoscopic repair of paraesophageal and type III mixed hiatal hernias showed that it is safe and feasible, with excellent immediate and short-term results. However, after a longer follow-up, a recurrence rate of 40% has been demonstrated. Data related to the outcome of paraesophageal hernia repair and the recurrence rate are still lacking. Quality-of-life scores may offer a better means of assessing the impact of surgical treatment on the overall health status of patients. Therefore, we performed prospective evaluation of anatomic and/or symptomatic recurrences after paraesophageal or large hiatal hernia repair. In addition, we investigated the correlation between recurrence and the patients quality of life.Methods All patients after who had undergone repair of paraesophageal of mixed hiatal hernia were identified prospectively from a database consisting of all patients who had had laparoscopic operations for gastroesophageal pathology at our hospital between February 1998 and December 2002. The preoperative symptoms were taken from patients clinical files. In March 2003, all patients with 6 months of follow-up had a barium swallow and were examined for radiological and clinical signs of recurrence. Thereafter, the patients quality of life after surgery was evaluated using three standard questionnaires (Short Form 36 [SF-36], Glasgow Dyspepsia Severity Score [GDSS], and Gastrointestinal Quality of Life Index [GIQLI].Result During the study period, 46 patients had been operated on. The mean age was 63 years (range, 28–93). Thirty seven of them had a follow-up of 6 months. Eight patients (21%) had postoperative gastrointestinal symptoms. Barium swallow was performed in 30 patients (81%) and showed a recurrence in six of them (20%). According to SF-36 and GDSS, the patients postoperative quality of life reached normal values and did not differ significantly from the standard values for the Spanish population of similar age and with similar comorbidities. Successfully operated patients reached a GIQLI value comparable to the standard population. However, symptomatic patients had significantly lower GIQLI scores than the asymptomatic or the Rx-recurrent group.Conclusion The laparoscopic treatment of large paraesophageal and mixed hiatal hernias is not only feasible and safe but also offers a good quality of life on a midterm basis. However, the anatomic and functional recurrence rate is high. The next step is to identify the subset of patients who are at risk of failure and to establish technical alternatives that would ensure the durability of the repair.Presented in foster format at the 2003 scientific meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Los Angeles, CA, USA, March 2003, and as a free paper at the 10th congress of the European Association for Endoscopic Surgery (EASES), Glasgow, Scotland, United Kingdom, June 2003     

Laparoscopic hiatal hernia repair

Background The recurrence rate after laparoscopic repair of hiatal hernias with paraesophageal involvement (LRHP) is reported to be high. Mesh reinforcement has been proposed with the objective of solving this problem. This study aimed to compare the outcome of LRHP before and after the introduction of mesh reinforcement. Methods Between 1992 and 2003, 56 consecutive patients received LRHP including posterior crurorrhaphy and additional fundoplication. Of these 56 patients, 17 underwent a mesh-reinforced hiatoplasty. Perioperative outcome was assessed retrospectively, and follow-up assessment was performed according to protocol including a barium contrast swallow. Results The follow-up period averaged 52 ± 31 months (range, 9–117 months). The recurrence rate for hiatal hernia without mesh reinforcement was 19% (7/36). No recurrence (0/16) was observed in patients with mesh reinforcement. The intraoperative complication rate was 9%, and the perioperative morbidity rate was 14%. There were neither mesh-related complications nor operation-related deaths. Conclusions Although challenging, LRPH is a successful procedure. The high recurrence rate reported in the literature can be reduced by additional mesh reinforcement.     

The effect of laparoscopic sleeve gastrectomy with or without hiatal hernia repair on gastroesophageal reflux disease in obese patients

BackgroundObesity is an independent risk factor for gastroesophageal reflux disease (GERD), which is often associated with the presence of a hiatal hernia (HH). Despite increasing popularity of laparoscopic sleeve gastrectomy (LSG) in bariatric surgery, its effect on GERD is still unclear. The objective of this study was to evaluate the effect of LSG with or without hiatal hernia repair (HHR) on GERD in obese patients.MethodsSeventy-eight patients with HH underwent LSG with concomitant HHR (LSG+HHR group). Their data were compared with that of 102 patients without HH, who underwent only LSG (LSG-group). All patients underwent a standardized questionnaire, a double-contrast barium swallow, and an upper-gastrointestinal endoscopy before the surgical procedure and at least 6 months later.ResultsAt baseline, the prevalence of GERD symptoms and their frequency-intensity scores did not differ between groups. At follow up, there was a significant decrease in the prevalence of typical GERD symptoms only in the LSG-group (P = .003). LSG+HHR patients showed a significantly higher heartburn frequency-intensity score compared with LSG patients (P = .009).ConclusionThis finding confirms that LSG has a beneficial effect on relieving GERD symptoms, although the underlying mechanisms are still unclear; conversely, the procedure of HHR did not produce any improvement in GERD symptoms.     

腹腔镜治疗食管裂孔疝的初步临床经验

目的总结腹腔镜手术治疗食管裂孔疝的初步经验。方法2004年5月~2005年4月,食管裂孔疝15例行腹腔镜食管裂孔疝修补加抗反流手术。Ⅰ型4例均伴有严重的胃食管反流,Ⅱ型10例,Ⅲ型1例。在缝合缩小食管裂孔的同时,行N issen术9例,Toupet术4例,Dor术2例。采用视觉模拟积分(visual analogue scales,VAS)评价术前及术后1、6个月胃食管反流症状,包括烧心、吞咽梗阻、反酸、胸痛、嗳气等。结果全组无中转开腹。手术时间100~187 m in,平均125 m in。术后住院2~5 d,平均2.8 d。术后随访1~12个月,平均8.5月,无疝复发。胃食管反流综合症状VAS评分术前5.0±3.9,术后1个月降至0.9±1.3(t=3.823,P<0.05),术后6个月降至0.8±1.6(t=3.549,P<0.05)。术后并发胃潴留2例,吞咽梗阻1例,3个月后缓解。结论采用腹腔镜技术手术治疗食管裂孔疝具有创伤小、恢复快的特点,其短期临床效果满意。     

Simultaneous laparoscopic paraesophageal hernia repair and sleeve gastrectomy in the morbidly obese

BackgroundMorbid obesity is associated with increased rates of hiatal and paraesophageal hernias. Although laparoscopic sleeve gastrectomy is gaining popularity as the procedure of choice for morbid obesity, there is little data regarding the management of paraesophageal hernias found intraoperatively. The aim of this study was to evaluate the feasibility and benefits of a combined sleeve gastrectomy and paraesophageal hernia repair in morbidly obese patients.MethodsFrom May 2011 to February 2013, 23 patients underwent laparoscopic sleeve gastrectomy combined with the repair of a paraesophageal hernia. Only 4 patients had a large hiatal hernia documented preoperatively on esophagogastroduodenoscopy (EGD). The body mass index (BMI), operative time, length of stay, and complications were evaluated.ResultsThe average operative time was 165 minutes (115–240 minutes) and length of stay was 2.83 days (2–6 days). All patients were female except for one, with an average age of 53.4 years and a BMI of 41.9 kg/m². There were no complications during the procedures. Mean follow-up was 6.16 months (1–19 months), and mean excess weight loss was 39%. The average cost of admission for a combined procedure ($10,056), was slightly higher than a laparoscopic sleeve gastrectomy ($8905) or laparoscopic paraesophageal hernia repair ($8954) done separately.ConclusionsLaparoscopic sleeve gastrectomy combined with a paraesophageal hernia repair is well-tolerated and feasible in morbidly obese patients. Surgeons should be aware that preoperative EGD is not effective at diagnosing large hiatal or paraesophageal hernias. Surgeons with the skill set to repair paraesophageal hernias should do a combined procedure because it is well-tolerated, feasible, and can reduce the cost of multiple hospital admissions.     

Evolution and advances in laparoscopic ventral and incisional hernia repair

Primary ventral hernias and ventral incisional hernias have been a challenge for surgeons throughout the ages. In the current era, incisional hernias have increased in prevalence due to the very high number of laparotomies performed in the 20 th century. Even though minimally invasive surgery and hernia repair have evolved rapidly, general surgeons have yet to develop the ideal, standardized method that adequately decreases common postoperative complications, such as wound failure, hernia recurrence and pain. The evolution of laparoscopy and ventral hernia repair will be reviewed, from the rectoscopy of the 4th century to the advent of laparoscopy, from suture repair to the evolution of mesh reinforcement. The nuances of minimally invasive ventral and incisional hernia repair will be summarized, from preoperative considerations to variations in intraoperative practice. New techniques have become increasingly popular, such as primary defect closure, retrorectus mesh placement, and concomitant component separation. The advent of robotics has made some of these repairs more feasible, but only time and well-designed clinical studies will tell if this will be a durable modality for ventral and incisional hernia repair.     

腹腔镜食管裂孔疝修补术的初步探讨

目的探讨腹腔镜食管裂孔疝修补和胃底折叠术（Toupet手术）治疗食管裂孔疝的临床效果。方法 2009年1月～2010年5月,21例患者行腹腔镜食管裂孔疝（Ⅰ型9例,Ⅱ型4例,Ⅲ型6例,Ⅳ型2例）修补,采用单纯缝合膈肌脚,补片完全缝合,补片缝合加钉合等方法修补食管裂孔疝,并同期行部分胃底折叠术。结果本组患者手术均获成功,手术时间85～170min。无中转开腹及死亡病例。术后平均住院7d。术后随访1～16个月,20例临床症状完全消失,1例改善不明显,无明确复发病例。结论腹腔镜食管裂孔疝修补和胃底折叠术安全有效,应根据患者情况采用个体化的修补方式。     

超声引导下聚桂醇注射在腹腔镜腹股沟疝修补术后血清肿中的应用

目的 观察超声引导下聚桂醇注射治疗腹腔镜腹股沟疝修补术后血清肿的效果.方法 选取徐州医科大学附属医院普外科2016年5月至2019年11月腹腔镜腹股沟疝修补术后并发血清肿、术后1个月仍未消退(Ⅱ型及以上血清肿)病人15例,彩超引导下抽空液体后注入聚桂醇后疝气带局部加压包扎.结果 15例病人中13例1次注射后治愈,2例1...     

Technical refinements in laparoscopic repair of childhood inguinal hernias

Background This study aimed to evaluate the laparoscopic repair of childhood hernias and to identify technical refinements for improvements.Methods The records of 49 boys and 13 girls who underwent laparoscopic hernia repair in the authors institution between July 2002 and July 2003 were reviewed. Their mean age was 4.5 years (range, 3 months to 15 years). No hernia opening was found in two patients, whereas 17 bilateral hernias (28%, 17/60) were found laparoscopically. Two bilateral hernias were diagnosed preoperatively. Four patients had the operation for recurrent hernias after open procedures.Results Over a mean follow-up period of 7.5 months (range, 3–15 months), there was one recurrence (1%, 1/79), but no other complication. With saline injection administered extraperitoneally, laparoscopic hernia repair can be performed safely for boys. Use of the needle sign avoided damage to the testicular vessel and vas. Placement of the needle medial to a prominent inferior epigastric artery and the presence of a complete ring sign prevented recurrence. The use of reusable 3-mm ports and round polypropylene stitches lowered the cost of the operation and improved the cosmesis for the patients. For recurrent hernias after open repair, the laparoscopic method was as simple as fresh hernia repair.Conclusions Laparoscopic hernia repair allows detection and repair of contralateral hernias during the same operation. With refinements in technique, the procedure can be safely performed for boys, with the added advantages of lower costs, fewer recurrences, and improved cosmesis.     

To repair or not to repair incidental defects found on laparoscopic repair of groin hernia

Background: During laparoscpic transabdominal preperitoneal (TAPP) repair of unilateral groin hernias, a significant proportion of patients are found to have unsuspected hernias (incidental defects) on the contralateral side without any clinically demonstrable signs. The reported incidence is 10% to 25%, and controversy exists about the routine repair of these hernias. We present the early results of a prospective randomized study designed to follow the clinical behavior of incidental defects. Methods: For this study, 32 consecutive men found to have incidental defects on the contralateral side during laparoscopic TAPP repair of groin hernias were prospectively randomized into two categories. In 16 patients (control group), the defects were repaired simultaneously, and in another 16 patients (trial group), surgical repair was not performed. Subsequently, five consecutive patients found to have incidental defects were included in the trial group. Hence, the total number of patients with unrepaired defects was 21. All the patients subsequently were followed up in the clinic and examined by an independent clinician to detect any clinically demonstrable hernias. Results: The median follow-up was 15 months for the control patients and 12 months for the trial patients. During this time, demonstrable hernias developed in 6 patients of the trial group (28.6%). Conclusions: This study demonstrated that despite a short follow-up period, a significant proportion of incidental defects will progress to a symptomatic hernia if left untreated. Hence, their simultaneous repair is justifiable on the grounds that it reduces the number of operations and hospital visits, and thus the cost to the National Health Service. It also is of major benefit to the patient.     

腹腔镜修补治疗耻骨上疝的经验

目的 探讨腹腔镜修补治疗耻骨上疝的合理性、安全性和有效性。方法 回顾性分析 2004年7月至2016年 12 月我科接受腹腔镜耻骨上疝修补术的90例病人临床资料,观察其临床疗效及并发症发生情况。结果 90例病人中89例完成腹腔镜耻骨上疝修补术,1例因严重粘连中转为开放Onlay修补。其中经腹腹膜前修补术（TAPP）7例,腹腔内补片修补术（IPOM）6例,经腹部分腹膜前修补术（TAPE）76例。疝缺损平均长径为(12.54±5.72)（2~30） cm,疝缺损平均面积为(92.98±62.09)（4~360） cm²。补片平均面积为(311.24±112.89)（80~600） cm²。平均手术时间为(54.04±16.60)（25~110） min。平均住院时间为(5.53±3.61)（1~33） d。术后使用镇痛药比例为8.99%（8/89）。术后复发4例,复发率为4.49%（4/89）。89例病人的中位随访时间为72（13~161）个月。结论 TAPP适用于治疗原发性耻骨上疝和腹膜较完整的小切口疝。TAPE是腹腔镜修补耻骨上疝的合理、安全且有效的术式。     

Amyand's hernia: a case report describing laparoscopic repair in a pediatric patient

Amyand's hernia is a rare hernia in which an incarcerated or perforated appendix is found in the right inguinal canal. This case report looks at the clinical presentation, the modalities for preoperative evaluation, and finally a combined approach of laparoscopic appendectomy and open repair of the hernia. To our knowledge, this is the first report of this type of management, and we feel that it is a safe and effective option.     

Recurrences after laparoscopic ventral hernia repair: Results and critical review

We describe the whole cohort of patients operated on laparoscopically for ventral hernias at our institution. Information on early results, complications, and long-term follow-up was collected prospectively. Of 90 operations attempted, five (5.8%) required conversion. Of the remaining 85 patients, 65 (76%) had an incisional hernia, while 20 (24%) had primary defects. Three trocars were routinely employed (Hasson and two 5-mm). The prosthetic mesh used was ePTFE inserted through the first trocar and fixed using helicoidal staplers. Patients were periodically followed in the outpatient clinic for at least 12 months postoperatively and contacted at the time of this review. Mean operative time was 101 min. We had three small bowel injuries repaired laparoscopically. Postoperative pain was limited. Bowel movements, deambulation, and discharge were prompt. We had six (7%) urinary retentions, eight (9%) seromas, three (3.5%) cases of pneumonia, two (2%) cases of postoperative vomiting, and one (1%) prolonged ileus, which resolved spontaneously on postoperative day 2. Mean postoperative stay was 4 days. One patient was readmitted after 4 weeks with incomplete obstruction, resolved conservatively. There were three recurrences (3.5%), which developed within 1 year of the operation, and a trocar-site herniation (1%). The technique appears safe and efficacious.     

Postoperative pain after laparoscopic ventral hernia repair: a prospective comparison of sutures versus tacks.

BACKGROUND AND OBJECTIVES: Mesh fixation in laparoscopic ventral hernia repair typically involves the use of tacks, transabdominal permanent sutures, or both of these. We compared postoperative pain after repair with either of these 2 methods. METHODS: Patients undergoing laparoscopic ventral hernia repair at the Mount Sinai Medical Center were prospectively enrolled in the study. They were sorted into 2 groups (1) those undergoing hernia repairs consisting primarily of transabdominal suture fixation and (2) those undergoing hernia repairs consisting primarily of tack fixation. The patients were not randomized. The technique of surgical repair was based on surgeon preference. A telephone survey was used to follow-up at 1 week, 1 month, and 2 months postoperatively. RESULTS: From 2004 through 2005, 50 patients were enrolled in the study. Twenty-nine had hernia repair primarily with transabdominal sutures, and 21 had repair primarily with tacks. Both groups had similar average age, BMI, hernia defect size, operative time, and postoperative length of stay. Pain scores at 1 week, 1 month, and 2 months were similar. Both groups also had similar times to return to work and need for narcotic pain medication. CONCLUSIONS: Patients undergoing laparoscopic ventral hernia repair with primarily transabdominal sutures or tacks experience similar postoperative pain. The choice of either of these fixation methods during surgery should not be based on risk of postoperative pain.     

Metabolic responses after laparoscopic or open hernia repair

Background: The purpose of a prospective randomized study was to compare the surgical trauma in patients undergoing laparoscopic or open hernia repair. Methods: Postoperative pain, analgesic consumption, and metabolic response to surgery were assessed in 30 patients undergoing laparoscopic (group 1; n=15) or open (group II; n=15; Shouldice repair) unilateral inguinal hernia repair. Both groups were comparable with respect to age, sex, and type and size of inguinal hernia. Results: Postoperative visual analogue scales (VAS) for pain were reduced on mobilization for patients of group I with a significant difference (P=0.02) on the operative day, whereas pain scores at rest and analgesic requirements were similar for both groups. No differences between groups I and II were found in postoperative levels of interleukin-1, interleukin-6, tumor necrosis factor alpha, Creactive protein, fibrinogen, transferrin, alpha-1-antitrypsin, and white blood cells. Postoperative polymorphonuclear (PMN) elastase concentrations remained within normal range in group II but showed a significant increase in patients operated laparoscopically for postoperative days 1 and 2. Conclusions: No major surgical trauma was found after herniorraphy compared to open hernia repair.     

地市级医院初期开展腹腔镜下食管裂孔疝修补及胃底折叠术的经验

目的探讨地市级医院初期开展腹腔镜下食管裂孔疝修补及胃底折叠术的技术要点及临床疗效。 方法回顾分析咸阳市中心医院2016年3月至2019年3月,行腹腔镜下食管裂孔疝修补、胃底折叠术31例患者的临床资料。按胃底折叠术的术式不同,分为Dor术式组、Toupet术式组、Nissen术式组。观察并记录各术式组患者的手术时间、术中出血量、住院时间。随访3~36个月时的并发症及复发率。 结果31例均行腹腔镜下食管裂孔疝修补联合胃底折叠术。其中Dor折叠4例、Toupe折叠3例、Nissen折叠24例;各术式手术时间分别为（60±4.5）、（68±6.3）、（70±9.2）min;各术式术中出血量分别为（21±4.8）、（24±5.4）、（30±9.1）ml;术后出院时间（7±2.1）、（8±2.8）、（9±2.4）d。31例患者术后不适症状均得到缓解,4例患者术后出现吞咽困难并发症,其中1例患者因保守对症治疗效果不理想,行二次手术拆除胃底折叠后好转,其余3例患者经对症治疗后缓解。31例患者术后随访,失访患者1例,随访3~36个月,中位时间28个月。经胃镜、上消化道造影检查,未复发且无其他并发症发生。 结论腹腔镜下食管裂孔疝修补、胃底折叠术安全、有效,微创优势明显,值得临床推广。     

Polyester composite versus PTFE in laparoscopic ventral hernia repair

Introduction:

Both polyester composite (POC) and polytetrafluoroethylene (PTFE) mesh are commonly used for laparoscopic ventral hernia repair. However, sparse information exists comparing perioperative and long-term outcome by mesh repair.

Methods:

A prospective database was utilized to identify 116 consecutive patients who underwent laparoscopic ventral hernia repair at The Mount Sinai Hospital from 2004-2009. Patients were grouped by type of mesh used, PTFE versus POC, and retrospectively compared. Follow-up at a mean of 12 months was achieved by telephone interview and office visit.

Results:

Of the 116 patients, 66 underwent ventral hernia repair with PTFE and 50 with POC mesh. Patients were well matched by patient demographics. No difference in mean body mass index (BMI) was demonstrated between the PTFE and POC group (31.8 vs. 32.5, respectively; P=NS). Operative time was significantly longer in the PTFE group (136 vs.106 minutes, P<.002). Two perioperative wound infections occurred in the PTFE group and none in the POC group (P=NS). No other major complications occurred in the immediate postoperative period (30 days). At a mean follow-up of 12 months, no significant difference was demonstrated between the PTFE and POC groups in hernia recurrence (3% vs. 2%), wound complications (1% vs. 0%), mesh infection, requiring removal (3% vs. 0%), bowel obstruction (3% vs. 2%), or persistent pain or discomfort (28% vs. 32%), respectively (P=NS).

Conclusion:

Our study demonstrated no significant association between types of mesh used and postoperative complications. In the 12-month follow-up, no differences were noted in hernia recurrence.