Fundoplication combined with mediogastric plication

BackgroundThe purpose of this pilot study was to demonstrate the feasibility and procedural safety of laparoscopic fundoplication combined with mediogastric plication in patients with a body mass index of 32–35 kg/m².MethodsSixteen patients underwent laparoscopic fundoplication combined with mediogastric plication. All procedures were performed with the patient under general anesthesia. The 1-year follow-up results encompassed gastroesophageal reflux disease recovery and excess weight loss.ResultsThe procedure time varied from 65 to 95 minutes. No serious procedure-related complications occurred. Gastroesophageal reflux disease-related symptoms resolved in all patients (P = .000). The excess weight loss was 10 ± 4 kg (58%) 1 year after the procedure. The 1-year follow-up excess weight was significantly less than the baseline excess weight (P = .000). The average body mass index decreased from 33.8 ± 1.9 kg/m² at baseline to 27.2 ± 1.7 kg/m² at 1 year (P = .02). Of the 16 patients, 14 had an excess weight loss of 62%, and 2 sweet-eaters had an excess weight loss of 33%. At 1 year of follow-up, the excess weight in those who smoked (n = 10) was greater than that of nonsmokers (n = 6; P = .02). However, smoking did not seem to significantly affect excess weight loss (P = .065).ConclusionFundoplication combined with mediogastric plication produced a total recovery from gastroesophageal reflux disease and an excess weight loss of 62% in 87.5% of patients after 1 year of follow-up. This procedure is technically feasible, and no serious procedure-related complications occurred. The follow-up is ongoing to investigate the efficacy and long-term durability of the procedure.     

Esophageal pH Profile Following Laparoscopic Total Fundoplication Compared to Anterior Fundoplication

In Barrett’s esophagus, total abolition of reflux may give maximum protection against the development of malignancy. To determine whether laparoscopic anterior fundoplication gives the same degree of antireflux control as a total fundoplication, we analyzed a prospectively followed cohort of patients from randomized controlled trials of laparoscopic antireflux surgery. There were 167 patients who returned for routine esophageal pH studies within 6 months of surgery (123 laparoscopic total fundoplications and 44 anterior fundoplications). There was no difference in percentage time pH <4 between fundoplication groups, but the total number of reflux episodes was significantly different (total fundoplication, four reflux events vs. partial fundoplication, six reflux events; p = 0.03). It is difficult to believe that this difference is either biologically or clinically important. In patients with a second esophageal pH study more than 5 years later, both the percentage time pH <4 (0.1% total fundoplication vs. 2.7% partial fundoplication; p = 0.004) and total number of reflux episodes (three total fundoplication vs. 24 partial fundoplication; p = 0.002) were significantly different. However, the postoperative esophageal acid exposure was within the normal range for both total and partial fundoplication, so whether the statistical difference is clinically important, remains a moot point. Each author’s contribution to the article: 1. Conception & design, data acquisition, analysis and interpretation: ASYW, JCM, GGJ. 2. Drafting and critically revising the article: ASYW, JCM, GGJ. 3. Final approval of version to be published: ASYW, JCM, GGJ. This paper was presented at the 76th Annual Scientific Congress of the Royal Australasian College of Surgeons, May 10, 2007, Christchurch, New Zealand.     

Nissen Fundoplication after Failure of Endoluminal Fundoplication: Short-Term Results

Background  

Endoluminal fundoplcation (ELF) with EsophyX™ is a new attractive investigational procedure for the control of gastroesophageal reflux disease (GERD). The aim of this work is to evaluate the short-term results of Nissen fundoplication (NF) after failure of ELF.     

Abdominoplasty: modified plication

The authors present an addition to standard abdominoplasty techniques. Transverse plication of the aponeurotic layer in the epigastrium corrects the prominence in this area and helps the flap to reach the pubic region.     

Left atrial plication combined with mitral valve surgery in patients with a giant left atrium

The benefits of performing left atrial plication during mitral valve surgery for patients with a giant left atrium were evaluated by analyzing the short- and long-term surgical results and changes in the left atrial dimension (LAD) and respiratory function of 30 patients. Of the 30 patients, 2 (7%) died of multiple organ failure on postoperative days 26 and 117, but no other deaths occurred during the mean follow-up of 5.9±2.1 years. Valve thrombosis was observed in one patient and cerebral complications with no residual deficit were observed in two patients, with a 9-year event-free rate of 87±7%. The LAD decreased significantly from 69.0±8.5 mm to 53.7±9.1 mm (P<0.01) shortly after surgery, and this decrease was maintained even 5 years after surgery (53.3±11.4 mm). The cardiothoracic ratio decreased from 74.8±8.3% to 62.8±9.0% (P<0.01) and the vital capacity of the lungs increased from 71.1±18.0% to 82.9±22.2% (P<0.01). Thus, we conclude that performing left atrial plication during mitral valve surgery is safe and effective for patients with a giant left atrium.     

Leaflet folding plasty combined with annular plication for mitral valve repair

We describe a new technique of mitral valve repair based on two reconstructive techniques: (1) the folding leaflet method, and (2) the classic annular plication. This combination appears to be useful in cases with a large prolapsing posterior mitral leaflet with excessive leaflet height or in cases with commissural prolapse involving both the anterior and posterior leaflets.     

Penoscrotal plication as a uniform approach to reconstruction of penile curvature

Study Type – Therapy (case series)
Level of Evidence 4

OBJECTIVE

To present our 4‐year experience of using a minimally invasive technique, penoscrotal plication (PSP), as a uniform treatment for men with debilitating penile curvature resulting from Peyronie’s disease.

PATIENTS AND METHODS

In 48 men (median age 58.7 years) with penile curvature the penis was reconstructed by imbricating the tunica albuginea opposite the curvature with multiple nonabsorbable sutures. All patients, regardless of the degree or direction of curvature, were approached through a small penoscrotal incision made without degloving the penis. Detailed measurements of penile shaft angle and stretched penile length were recorded and analysed before and after reconstruction, and the numbers of sutures required for correction were documented.

RESULTS

Nearly all patients had dorsal and/or lateral deformities that were easily corrected via a ventral penoscrotal incision. The median (range) degree of correction was 28 (18–55)° and number of sutures used was 6 (4–17). Stretched penile length measurements before and after plication showed no significant difference. A single PSP procedure was successful in 45/48 (93%) patients; two were dissatisfied with the correction, one having repeat plication and the other a penile prosthesis; one other required a suture release for pain.

CONCLUSIONS

PSP is safe and effective and should be considered even for cases with severe or biplanar curvature.     

Dorsal tunica albuginea plication to correct congenital and acquired penile curvature: a long-term follow-up

OBJECTIVE: To evaluate the long-term efficacy of a tunica albuginea dorsal plication technique for treating congenital and acquired penile curvature. PATIENTS AND METHODS: We retrospectively evaluated 83 patients (median age 1.8 years) who had their penile curvature corrected surgically using dorsal tunica albuginea plication between 1992 and 2002. The results were evaluated objectively using a pharmacological erection test or subsequently based either on the parents' reports or patients' self-assessment. The median (range) follow-up was 6 (0.7-10) years. RESULTS: Seventy (84%) patients had penile plication as an integral part of hypospadias repair, while the remaining 13 (16%) with a normal urethra had dorsal plication only. Twenty-eight (34%) of the 83 patients had an erection test during a repeat hypospadias repair or closure of a urethrocutaneous fistula; 22 of these had a straight penis, while the remaining six required additional plication for a satisfactory cosmetic outcome. Parents of 45 (54%) children reported that their child had a normal erection with no chordee during the follow-up. Ten (12%) adult patients reported straight erections enabling satisfactory penetration and sensation during sexual intercourse. None of the patients reported penile shortening or erectile dysfunction after surgery, and none had recurrent curvature during the follow-up. There was no difference in the results between patients with congenital or acquired penile curvature. CONCLUSIONS: Dorsal plication of the tunica albuginea is a simple and effective method in the long term for correcting congenital and acquired penile curvature.     

Peyronie disease: plication or grafting

Peyronie disease (PD) is an incurable, sexually debilitating disease resulting in penile deformity, coital failure, and significant psychological stress for patients and their partners. Appropriate treatment should be individualized and tailored to the patient's goals and expectations, disease history, physical examination findings, and erectile function. After medical therapy is considered and the disease has stabilized, surgical correction, including tunical shortening or lengthening procedures, is an excellent option for patients with functional impairment caused by PD. Outcomes are satisfactory when proper treatment decisions are made, with the goal being expected return to normal sexual function following PD treatment.     

Gastrectomy as a Remedial Operation for Failed Fundoplication

The decision for, and choice of, a remedial antireflux procedure after a failed fundoplication is a challenging clinical problem. Success depends upon many factors including the primary symptom responsible for failure, the severity of underlying anatomic and physiologic defects, and the number and type of previous remedial attempts. Satisfactory outcomes after reoperative fundoplication have been reported to be as low as 50%. Consequently, the ideal treatment option is not clear. The purpose of this study was to evaluate the outcome of gastrectomy as a remedial antireflux procedure for patients with a failed fundoplication. The study population consisted of 37 patients who underwent either gastrectomy (n = 12) with Roux-en-Y reconstruction or refundoplication (n = 25) between 1997–2005. Average age, M/F ratio, and preoperative BMI were not significantly different between the two groups. Outcome measures included perioperative morbidity, relief of primary and secondary symptoms, and the patients’ overall assessment of outcome. Mean follow up was 3.5 and 3.3 years in the gastrectomy and refundoplication groups, respectively (p = 0.43). Gastrectomy patients had a higher prevalence of endoscopic complications of GERD (58% vs 4%, p = 0.006) and of multiple prior fundoplications than those having refundoplication (75% vs 24%, p = 0.004). Mean symptom severity scores were improved significantly by both gastrectomy and refundoplication, but were not significantly different from each other. Complete relief of the primary symptom was significantly greater after gastrectomy (89% vs 50%, p = 0.044). Overall patient satisfaction was similar in both groups (p = 0.22). In-hospital morbidity was higher after gastrectomy than after refundoplication (67% vs 20%, p = 0.007) and new onset dumping developed in two gastrectomy patients. In select patients with severe gastroesophageal reflux disease (GERD) and multiple previous fundoplications, primary symptom resolution occurs significantly more often after gastrectomy than after repeat fundoplication. Gastrectomy, however, is associated with higher morbidity. Gastrectomy is an acceptable treatment option for recurrent symptoms particularly when another attempt at fundoplication is ill advised, such as in the setting of multiple prior fundoplications or failed Collis gastroplasty. Presented at the 47th Annual Meeting of the Society for Surgery of the Alimentary Tract, Los Angeles, California, May 20–24, 2006.     

Laparoscopic gastric plication: Technical report

BackgroundLaparoscopic gastric plication is an emerging restrictive bariatric procedure but still lacks standardization of the technique. The aim of this study was to apply a standardized, modified 3-port approach to laparoscopic gastric plication to improve outcomes.MethodsThe modified laparoscopic gastric plication technique was applied for 63 morbidly obese patients between March 2010 and January 2013. There were 9 men and 54 women, with a mean age of 34.2 years (range 20–48 years) and a mean body mass index of 38.9 kg/m² (range 32–65 kg/m²).ResultsThere were no deaths, no conversion to laparotomy, no reoperation, and no readmission. Percent excess weight loss was 41%, 52%, and 60% at 3, 6, and 12 months, respectively. There were no major complications reported in our study, but prolonged early postoperative nausea and vomiting occurred in 3 of 63 (4.8%) patients who had been successfully treated with proton pump inhibitors and antiemetics.ConclusionsOur initial experience showed that the 4-bite technique starting 2 cm below the angle of His with tight calibration of the gastric tube for obese patients is feasible, effective, and well tolerated, with a low frequency of major problems.     

Fundoplication: a model for immunologic aspects of laparoscopic and conventional surgery

BACKGROUND AND PURPOSE: Immunologic investigations of laparoscopic and conventional procedures have recently been performed during cholecystectomy or colon resection, but the results might have been influenced by the amount of dissection or the presence of malignant tumor. Because fundoplication is characterized by moderate dissection and no resection, we supposed it to be an appropriate procedure for comparing immunologic changes during laparoscopic and conventional surgery. PATIENTS AND METHODS: Immunologic analysis (interleukin [IL]-6, IL-10, leukocytes, HLA-DR monocytes) was carried out on the peripheral blood of 34 patients who underwent elective Nissen fundoplication by the laparoscopic (LAP; N = 26) or conventional (OPEN; N = 8) technique for gastroesophageal reflux disease. Blood samples were obtained before and 1 and 4 hours after the beginning of the operation and on days 1, 2, 4, 7 after the procedure. RESULTS: A very fast and significant (P < 0.01) increase of the proinflammatory cytokines (IL-6, IL-10) and leukocytes and a decrease of cell-mediated functions (HLR-DR monocytes) were detected. Most of the analyzed measures had returned to preoperative values by 2 days after the procedure. All of the changes were similar in the two groups with the exception of IL-6. Throughout the post-operative study period, IL-6 concentrations were higher in the OPEN group, being significant 4 hours, 1 day, 2 days, and 4 days after the operation. CONCLUSION: The investigation measures do not give evidence that laparoscopic fundoplication is superior to conventional fundoplication in its immunologic effects.