An Anterior or Posterior Approach to Partial Fundoplication? Long-term Results of a Randomized Trial

Background

Partial fundoplications have been popularized by their lower risk of mechanical side effects. The question then emerges whether a similar partial wrap should be done posterior or anterior to the distal esophagus? We therefore conducted a study to compare the long-term outcome of laparoscopic partial fundoplications constructed either as anterior (AF) or posterior (PF) repairs.

Patients and Methods

Ninety-five patients were enrolled in a randomized clinical trial. After a mean follow up of 65 months, 43 AF and 45 PF patients remained in the study. The levels of reflux control and postfundoplication complaints were assessed by use of validated instruments.

Results

A posterior fundoplication was found to provide significantly better control of reflux related symptoms (heartburn p < 0.0001, acid regurgitation p < 0.0001). This was also reflected in a significantly lower number of reoperations and need for antisecretory drug therapy. The earlier postoperative difference in postfundoplication symptoms had disappeared.

Conclusions

A laparoscopic posterior partial fundoplication offers a high and durable level of disease control with few side effects. The current anterior type of repair cannot be recommended due to insufficient reflux control.

     

Comparison Between Billroth-II with Braun and Roux-en-Y Reconstruction After Laparoscopic Distal Gastrectomy

Purpose

This study aims to compare the effectiveness of Billroth-II with Braun and Roux-en-Y reconstruction after laparoscopic distal gastrectomy.

Methods

From April 2010 to August 2012, 66 patients underwent laparoscopic distal gastrectomy (Billroth-II with Braun reconstruction, 26; Roux-en-Y, 40). The patients’ data were collected prospectively and reviewed retrospectively.

Results

The mean operation and reconstruction times were statistically shorter for Billroth-II with Braun reconstruction than Roux-en-Y (198.1?±?33.0 vs. 242.3?±?58.1 min, p?=?0.001). One case of postoperative stricture was observed in each group. One case each of intra-abdominal abscess and delayed gastric emptying occurred in the Billroth-II with Braun group. At 1 year postoperatively, gastric residue and reflux esophagitis were not significantly different between the groups. Gastritis and bile reflux were more frequently observed in the Billroth-II with Braun group (p?=?0.004 and p?<?0.001, respectively). At 2 years postoperatively, gastric residue was not significantly different, but gastritis, bile reflux, and esophagitis were more frequent in the Billroth-II with Braun group (p?=?0.029, p?<?0.001, and p?=?0.036, respectively).

Conclusion

The postoperative effectiveness of Roux-en-Y reconstruction may be superior to Billroth-II with Braun reconstruction after laparoscopic distal gastrectomy.

     

Reflux and Belching after Laparoscopic 270 degree Posterior Versus 180 degree Anterior Partial Fundoplication

Background

Laparoscopic 270 degree posterior, or Toupet (LTF), and 180 degree anterior partial fundoplication (LAF) ensure equal reflux control and reduce the risk of gas-related symptoms compared to 360 degree (Nissen) fundoplication. It is unclear which type of partial fundoplication is superior in preventing gas-related side-effects. The aim of this study was to determine differences in effect of LTF and LAF on reflux characteristics and belching patterns.

Methods

Upper gastrointestinal endoscopy, esophageal manometry, and 24-h combined pH-impedance monitoring were performed before and 6 months after fundoplication (n?=?10, LTF vs. n?=?10, LAF). Observed changes after surgery (?) were compared between the two procedures.

Results

Symptomatic reflux control as well as the reduction in the mean number of acid (? ??58.5 vs. ??66.5; P?= 0.912), liquid (? ??17.0 vs. ??43.5; P?=?0.247), and mixed liquid gas reflux episodes (? ??38.0 vs. ??40.0; P?=?0.579) were comparable following LTF and LAF. There were no differences in the mean number of weakly acidic reflux episodes after LTF and LAF (1.0 (0.8–4) vs. 1.0 (0–3), P?= 0.436). The reduction in proximal (P?=?1.000), mid-esophageal (P?=?0.063), and distal reflux episodes (P?=?0.315) was comparable. Both procedures equally reduced the number of gastric belches (P?=?0.278) and supragastric belches (P?=?0.123), with no significant reduction in the number of air swallows after either procedure (P?=?0.278).

Conclusion

LTF and LAF provide similar reflux control, with a comparable effect on acidic, liquid, and gas reflux. Both procedures equally reduced the number of belches and supragastric belches. This study provides the physiological evidence for the published randomized trials reporting similar symptomatic outcome after both types of partial fundoplication.

     

Laparoscopic Nissen Fundoplication Plus Mid-gastric Plication for Treatment of Obese Patients with Gastroesophageal Reflux Disease

Background

Gastroesophageal reflux disease (GERD) is commonly associated with obesity, and its surgical management is debatable.

Objective

The objective of this study was to prove the safety and feasibility of laparoscopic Nissen’s fundoplication (LNF) combined with mid-gastric plication (MGP) for treatment of obese patients with GERD.

Methods

LNF combined with MGP was done for 18 patients. All interventions were performed under general anesthesia. The follow-up protocol included body mass index (BMI), percentage of excess weight loss (%EWL), percentage of excess BMI loss (%EBMIL), and clinical assessment using the Gastro-esophageal Reflux Health-Related Quality-of-Life (GERD-HRQOL) scale at 6 and 12 months.

Results

The period of follow-up ranged from 12 to 33 months with a mean of 17.74 ± 3.73 months. The operation time was 1.40 ± 0.27 h. No serious procedure-related complications occurred. GERD-related symptoms resolved in all patients (p < 0.001). There was a significant improvment in endoscopic findings at 6 months compared to properatively (p = 0.001). There was a significant patient satisfaction score using GERD-HRQOL at 6 and 12 months (p = 0.000). The 1-year follow-up excess weight was significantly less than the baseline excess weight (p < 0.001). The average BMI decreased from 37.59 ± 1.89 kg/m² at baseline to 30.61 ± 1.57 kg/m² at 1 year (p < 0.001).

Conclusions

LNF combined with MGP for treatment of obese patients with GERD is technically safe, feasible, and promising with no serious procedure-related complications. The technique is effective in terms of weight loss and cure of GERD. However, future larger studies are required to demonstrate the safety, effectiveness, and long-term durability of the procedure.

     

A Matched Comparison of Per Oral Endoscopic Myotomy to Laparoscopic Heller Myotomy in the Treatment of Achalasia

Background

Per oral endoscopic myotomy (POEM) is increasingly utilized to treat patients with achalasia. Early results have demonstrated significant improvement of symptoms, but there are concerns about postoperative reflux. With only limited comparative data available, we sought to compare POEM to laparoscopic Heller myotomy (LHM) with partial fundoplication.

Methods

This is a retrospective review of 42 POEM and 84 LHM patients undergoing primary myotomy for achalasia. Patients were matched by achalasia type, by Eckardt and dysphagia scores, and by quality of life (QOL) metrics. Analysis at 6–12-month follow-up evaluated these metrics, PPI use, pH, manometric, and endoscopic data.

Results

We matched 25 patients with achalasia types I (6), II (13), and III (6). Follow-up was longer for LHM at 158.1 (36.5–272.9) weeks versus 36.2 (22.2–41.2) weeks (p?=?0.001). Eckardt scores, QOL metrics, and dysphagia significantly improved in both groups. DeMeester scores and total percent time less than 4 were abnormal in both groups and comparable (p?=?0.925 and p?=?0.838). Esophagitis was seen in 53.4 % (POEM) and 31.6 % (LHM) (Yates’ p?=?0.91), and PPI use was equivalent at 36 %.

Conclusion

Early clinical outcomes are excellent with POEM and comparable to the standard of care LHM. Long-term follow-up is required as concerns for reflux persist.

     

Surgical techniques to prevent reflux esophagitis in proximal gastrectomy reconstructed by esophagogastrostomy with preservation of the lower esophageal sphincter,pyloric and celiac branches of the vagal nerve,and reconstruction of the new His angle for early proximal gastric cancer

Purpose

This article describes the surgical techniques to prevent reflux esophagitis (RE) after proximal gastrectomy reconstructed by esophagogastrostomy (PGE) preservation of the lower esophageal sphincter (LES) and both pyloric and celiac branches of the vagal nerve (PCVN), and reconstruction of the new His angle (HA) for early proximal gastric cancer (PGC).

Methods

Twenty patients after PGE were divided into 2 groups (group A: 10 patients without preserved LES and PCVN for advanced PGC; group B: 10 patients with preserved LES and PCNV and the addition of a new HA for early PGC). A postoperative interview on gastroesophageal reflux disease (GERD) and satisfaction with this procedure and the collection of endoscopic findings for RE and stasis of the remnant stomach (SRS) were conducted 1 year after PGE in groups A and B.

Results

The rates of proton pump inhibitor administration and the symptoms of GERD, RE and SRS in group A were significantly higher than those in group B (p = 0.0433, p = 0.0190, p = 0.0253, p = 0.0190, respectively). Seven out of 10 patients in group A voiced dissatisfaction. Patients in group B were significantly more satisfied with this procedure than those in group A (p = 0.0010).

Conclusion

This method is useful for preventing postoperative GERD including RE in early PGC patients.

     

Nationwide variation in outcomes and cost of laparoscopic procedures

Introduction

Healthcare systems and surgeons are under increasing pressure to provide high-quality care for the lowest possible cost. This study utilizes national data to examine the outcomes and costs of common laparoscopic procedures based on hospital type and location.

Methods

The National Inpatient Sample was queried from 2008 to 2011 for five laparoscopic procedures: colectomy (LC), inguinal hernia repair, ventral hernia repair (LVHR), Nissen fundoplication (NF), and cholecystectomy (LCh). Outcomes, including complication rate and inpatient mortality, were stratified by region and hospital type. Both univariate and multivariate regression analyses were performed using regression-based survey methods; risk-adjusted mean costs for hospital were calculated after adjusting for patient characteristics.

Results

In univariate analysis, the rates of minor complications varied significantly between geographic regions for LCh, LC, NF, and LVHR (p < 0.05). Though LCh and LVHR had statistical variation between regions for rates of major complications (p < 0.05), all regions were equivalent in rates of inpatient mortality for the procedures (p > 0.05). Rural and urban centers had similar rates of complications (p > 0.05), except for higher rates of major complications following IHR and LC in rural centers (p < 0.02) and following Nissen fundoplication in urban facilities(p < 0.0003). Though urban centers were more expensive for all procedures (p < 0.0001), mortality was similar between groups (p > 0.05). For hospital ownership, private investor-owned facilities were substantially more expensive (p < 0.0001), but had no significant differences in complications compared to other hospital types (p > 0.05). In multivariate analysis, while patient factors helped explain differences between outcome differences in different hospital types and locations, in general, the difference in cost remained statistically significant between hospitals.

Conclusion

Though patient demographics and characteristics accounted for some differences in postoperative outcomes after common laparoscopic procedures, higher cost of care was not associated with better outcomes or more complex patients.

     

Risk of anastomotic leak after laparoscopic versus open colectomy

Background

Anastomotic leak following colorectal surgery is associated with significant morbidity and mortality. With the widespread adoption of laparoscopy, data from initial clinical trials evaluating the efficacy of laparoscopic when compared to open surgery may not currently be generalizable. We assess the risk of anastomotic leak after laparoscopic versus open colorectal resection using a nationwide database with standardized definitions.

Methods

The 2012–2013 ACS-NSQIP targeted colectomy data were queried for all elective colorectal resections. Characteristics were compared for those patients undergoing laparoscopic versus open operations. Univariable and multivariable analyses, followed by a propensity score-matched analysis, were performed to assess the impact of laparoscopy on the development of an anastomotic leak.

Results

Of 23,568 patients, 3.4 % developed an anastomotic leak. Laparoscopic surgery was associated with a leak rate of 2.8 % (n = 425) and open surgery, 4.5 % (n = 378, p < 0.0001). Patients who developed a leak were more likely to die within 30 days of surgery (5.7 vs. 0.6 %, p < 0.0001). Patients who underwent laparoscopic surgery compared to open were younger (61 vs. 63 years, p = 0, p = 0.045) and with fewer comorbidities. On univariable analysis laparoscopic surgery was associated with reduced odds of developing an anastomotic leak (OR 0.60, p < 0.0001), and this remained after adjusting for all significant preoperative and disease-related confounders (OR 0.69, 95 % CI 0.58–0.82). A propensity score-matched analysis confirmed benefit of laparoscopic surgery over open surgery for anastomotic leak.

Conclusion

Laparoscopic colectomy is safe and associated with reduced odds of developing an anastomotic leak following colectomy when controlling for patient-, disease- and procedure-related factors.

     

Robotic versus laparoscopic left lateral sectionectomy of liver

Background

A few studies have reported only short-term outcomes of various robotic and laparoscopic liver resection types; however, published data in left lateral sectionectomy (LLS) have been limited. The aim of this study was to compare the long- and short-term outcomes of robotic and laparoscopic LLS.

Methods

We retrospectively compared demographic and perioperative data as well as postoperative outcomes of robotic (n = 12) and laparoscopic (n = 31) LLS performed between May 2007 and July 2013. Resection indications included malignant tumors (n = 31) and benign lesions (n = 12) including intrahepatic duct (IHD) stones (n = 9).

Results

There were no significant differences in perioperative outcomes of estimated blood loss, major complications, or lengths of stay, but operating time was longer in robotic than in laparoscopic LLS (391 vs. 196 min, respectively) and the operation time for IHD stones did not differ between groups (435 vs. 405 min, respectively; p = 0.190). Disease-free (p = 0.463) and overall (p = 0.484) survival of patients with malignancy did not differ between groups. The 2- and 5-year disease-free survival rates were 63.2 and 36.5 %, respectively. However, robotic LLS costs were significantly higher than laparoscopic LLS costs ($8183 vs. $5190, respectively; p = 0.009).

Conclusions

Robotic LLS was comparable to laparoscopic LLS in surgical outcomes and oncologic integrity during the learning curve. Although robotic LLS was more expensive and time intensive, it might be a good option for difficult indications such as IHD stones.

     

Is There a Role for Anything Other Than a Nissen’s Operation?

Background

The Nissen fundoplication is the most frequently applied antireflux operation worldwide. The aim of this review was to compare laparoscopic Nissen with partial fundoplication.

Methods

Nine randomized trials comparing several types of wraps were analyzed, four for the comparison Nissen vs. Toupet and five for the comparison Toupet or Nissen vs. anterior fundoplication. Similar comparisons in nonrandomized studies were also included.

Results

Dysphagia rates and reflux recurrence were not related to preoperative esophageal persistalsis independent of the selected procedure. Overall, Nissen fundoplication revealed slightly better reflux control, but was associated with more side effects, such as early dysphagia and gas bloat. Advantages of an anterior approach were only reported by one group. A significantly higher reflux recurrence rate for anterior fundoplication was observed in all other comparisons.

Conclusion

Tailoring antireflux surgery according to esophageal motility is not indicated. At present, the relevant factor for selection of a Nissen or Toupet fundoplication is personal experience. Anterior fundoplication offers less effective long-term reflux control.

     

Dor Vs Toupet Fundoplication After Laparoscopic Heller Myotomy: Long-Term Randomized Controlled Trial Evaluated by High-Resolution Manometry

Background

Laparoscopic Heller myotomy (LHM) with partial fundoplication is an effective treatment for achalasia. However, the type of fundoplication is still a subject of debate.

Aim

The aim of the study is to identify which partial fundoplication leads to better control of acid exposure, manometric parameters, and symptoms scores.

Methods

A randomized controlled trial was performed to compare Dor vs Toupet fundoplication after LHM. The preoperative diagnosis was made by high-resolution manometry (HRM), upper endoscopy, and barium esophagogram. Preoperative and postoperative symptoms were evaluated with Eckardt, GERD-HRQL, and EAT-10 questionnaires.

Results

Seventy-three patients were randomized, 38 underwent Dor and 35 Toupet. Baseline characteristics were similar between groups. Postoperative HRM showed that the integrated relaxation pressure (IRP) and basal lower esophageal sphincter (LES) pressure were similar at 6 and 24 months. The number of patients with abnormal acid exposure was significantly lower for Dor (6.9%) than that of Toupet (34.0%) at 6 months, but it was not different at 12 or 24 months. No differences were found in postoperative symptom scores at 1, 6, or 24 months.

Conclusion

There were no differences in symptom scores or HRM between fundoplications in the long term. A higher percentage of abnormal 24-h pH test were found for the Toupet group, with no difference in the long term.

     

Emergent laparoscopic cholecystectomy for acute acalculous cholecystitis revisited

Purpose

To compare the safety of emergent laparoscopic cholecystectomy for acute acalculous cholecystitis (AAC) with surgery for acute calculous cholecystitis (ACC).

Methods

We retrospectively reviewed the perioperative records of 111 patients who underwent emergent laparoscopic cholecystectomy for acute cholecystitis under the care of the Department of Digestive Surgery, Kawasaki Medical School, Kurashiki, between January 2010 and April 2014. Patients were divided into the AAC group (27 patients) and the ACC group (84 patients), and their perioperative outcomes were compared.

Results

Patients in the AAC group had significantly higher disease severity and American Society of Anesthesiologists physical status scores (p = 0.001 and 0.037, respectively), lower blood hemoglobin and albumin concentrations (p = 0.0005 and 0.017, respectively), and lower hematocrit and platelet count (p < 0.0001 and 0.040, respectively) than those in the ACC group. When we compared perioperative outcomes, we also found that patients in the AAC group were more likely to have received a blood transfusion (p = 0.002) and to have required conversion to open surgery (p = 0.008). There were no significant differences in morbidity, mortality or length of hospital stay.

Conclusions

Early laparoscopic cholecystectomy is safe in acute acalculous as well as acute calculous cholecystitis.

     

Laparoscopic-assisted abdominoperineal resection for low rectal cancer provides a shorter length of hospital stay while not affecting the recurrence or survival: a propensity score-matched analysis

Purpose

To compare the short- and intermediate-term outcomes of open versus laparoscopic abdominoperineal resection (APR) for low rectal cancer.

Methods

Elective open and laparoscopic APRs were identified in a prospective database and were 1:1 propensity score-matched for age, ASA grade, tumour stage and type of neoadjuvant therapy. The short- and intermediate-term outcomes were compared.

Results

From January 2003 until June 2013, a total of 135 APRs (87 open, 48 laparoscopic) were identified and matched (n = 96, standardised mean difference of covariates <0.25). The thirty-day mortality, R0 rate, lymph nodes harvested and reoperations were similar. The length of the hospital stay was shorter in the laparoscopic group [10 versus 14 days, p = 0.004 (Mann–Whitney U test), Bonferroni-corrected significance level = 0.0083]. The median follow-up was 4.6 (IQR: 2.0–6.0) years. The overall and recurrence-free 3-year survival rate estimates (Kaplan–Meier method; 95 % CI in brackets) were 71 % (59–86) and 57 % (44–73) in the open group versus 78 % (66–92) and 72 % (60–87) in the laparoscopic group, respectively [p = 0.167 and p = 0.186 (log-rank test), respectively]. The 3-year cumulative incidence of recurrence was 27 % (15–40) in the open group and 16 % (8–29) in the laparoscopic group [p = 0.359 (Gray’s test)].

Conclusions

Compared to open APR, laparoscopic APR provided a shorter length of hospital stay while showing no intermediate-term differences in the survival or cumulative incidence of recurrence.

     

Evaluating the impact of a minimally invasive pediatric surgeon on hospital practice: comparison of two children’s hospitals

Purpose

Widespread adoption of minimally invasive surgery (MIS) techniques in pediatric surgery has progressed slowly, and the shift in practice patterns has been variable among surgeons. We hypothesized that a pediatric surgeon committed to MIS could effectively change surgical practice by creating an emphasis on MIS.

Methods

Annual case volumes from 2000 to 2009 at two tertiary care pediatric hospitals, one with a dedicated minimally invasive pediatric surgeon, were evaluated for trends in MIS for ten different operations. Univariate analyses of the differences between hospitals in the use of the open versus laparoscopic approach were performed. The Breslow–Day test was used to examine differences in use of laparoscopic procedures across hospitals in early versus middle and middle versus late time periods.

Results

Between the two hospitals, for 9 of the 10 types of surgery, the number of laparoscopic and open procedures differed significantly (p values ranged from <0.0001 to 0.003). Over the 10-year period, the hospital with a dedicated MIS surgeon had a larger proportion of procedures done laparoscopically for all years. This difference reached statistical significance for appendectomy (p < 0.0001), congenital diaphragmatic hernia (p < 0.0002), chest wall reconstruction (p < 0.0001), cholecystectomy (p = <0.0001), gastrostomy (p < 0.0001), nissen fundoplication (p < 0.0001) oophorectomy (p < 0.0001), pyloromyotomy (p < 0.0001) and splenectomy (p = 0.0006). After grouping the years into early (2000–2003), middle (2004–2006) and late (2007–2009) categories, the hospital with a dedicated MIS surgeon had a significantly higher rate of increase in use of laparoscopic surgery between the early and middle years for four procedures: diaphragmatic hernia repair (p = 0.003), chest wall reconstruction (p = 0.0086), cholecystectomy (0.0083) and endorectal pull-through (p = 0.025).

Conclusion

The presence of a dedicated minimally invasive pediatric surgeon led to a significant change in surgical practice with an overall trend of increasing MIS several years in advance of a hospital that did not have a dedicated MIS surgeon. This has implications for resident training in academic medical centers and potential patient care outcomes.

     

Heller myotomy with esophageal diverticulectomy: an operation in need of improvement

Background

This study was undertaken to evaluate the outcomes after laparoscopic Heller myotomy with anterior fundoplication and diverticulectomy for patients with achalasia and esophageal diverticula.

Methods

634 patients undergoing laparoscopic Heller myotomy and anterior fundoplication from 1992 to 2015 are prospectively followed up; patients were stratified for those undergoing concomitant diverticulectomy. Patients graded symptom frequency and severity before and after myotomy, using a Likert scale (0 = never/not bothersome to 10 = always/very bothersome). Median data are presented (mean ± SD).

Results

Forty-four patients, age 70 years (65 ± 14.2), underwent laparoscopic Heller myotomy, anterior fundoplication, and diverticulectomy. Operative time was 182 min (183 ± 54.6). Fifty percentage of patients had a postoperative complication: Most notable were leaks at the diverticulectomy site (n = 8) and pulmonary complications (n = 11; 10 effusion, 1 empyema). Length of stay (LOS) was 3 days (5 ± 8.3). All leaks occurred after discharge and resolved without sequelae using transthoracic catheter drainage and parenteral nutrition; two patients received endoscopic esophageal stents. Median follow-up is 39 months. Symptoms amelioration was significant postoperatively, including severity of dysphagia [6 (6 ± 3.9) to 2(4 ± 3.6)]. Seventy-six percentage of patients rated their symptoms at last follow-up as satisfying/very satisfying. Seventy-seven percentage of patients had symptoms once per week or less. Eighty-one percentage would have the operation again knowing what they know now.

Conclusions

Laparoscopic Heller myotomy, anterior fundoplication, and diverticulectomy well palliate the symptoms of achalasia with accompanying esophageal diverticulum. The operations are generally longer than those without diverticulectomy and are accompanied by a relatively longer LOS. Complications are relatively frequent and severe (e.g., leaks and pneumonia). In particular, leaks at the diverticulectomy site are unpredictable, occur after discharge, and remain vexing. Nevertheless, for this advanced form of achalasia, long-term symptom relief and patient satisfaction are high after anterior fundoplication with concomitant diverticulectomy. New and innovative techniques are needed to decrease the frequency of leaks at the diverticulectomy site.

     

Gastroesophageal reflux symptoms do not correlate with objective pH testing after peroral endoscopic myotomy

Introduction

Peroral endoscopic myotomy (POEM) is an emerging treatment for esophageal achalasia. Postoperative reflux has been found in a significant number of patients, but it is unknown whether subjective reports of reflux correlate with objective pH testing. The purpose of this study was to compare the objective rate of reflux with standardized reflux symptom scales after POEM. Our hypothesis was that subjective symptoms would not correlate with objective measurement of reflux.

Methods and procedures

Data on all patients undergoing POEM were collected prospectively between August 2012 and June 2014 and included demographics, objective testing (48-h pH probe, manometry, endoscopy), as well as gastroesophageal reflux disease health-related quality of life (GERD-HRQL), GERD symptom scale (GERSS), and antacid use.

Results

Forty-three patients underwent POEM during the study period. The mean age was 53.5 ± 17.4 years with a BMI of 29.6 ± 8.4 kg/m², and 27 (63%) were male. Forty-two patients (98%) completed at least 6 months of follow-up, and 26 (60%) underwent repeat pH measurement. Dysphagia scores improved from 4 (0–5) at baseline to 0 (0–3) (p < 0.001). On follow-up pH testing, 11 (42%) were normal and 15 (58%) had elevated DeMeester scores. Postoperative GERSS or GERD-HRQL scores did not correlate with DeMeester scores on Spearman’s rank-order tests (r = 0.02, p = 0.93 and r = 0.04, p = 0.50, respectively). Postoperative PPI use was not significantly associated with normal or abnormal pH testing: 5 of 7 (71%) patients who were taking PPIs postoperatively had abnormal DeMeester scores compared to 9 of 18 (50%) of patients who were not taking PPIs (p = 0.332).

Conclusions

Peroral endoscopic myotomy provides excellent dysphagia relief for patients with achalasia, but is associated with a high rate of reflux on pH testing postoperatively. Subjective symptoms are not a reliable indicator of postoperative reflux. Routine pH testing should be considered in all patients following POEM.

     

Comparison of pain management after laparoscopic distal gastrectomy with and without epidural analgesia

Purpose

The optimal analgesia following laparoscopic distal gastrectomy (LDG) has not been determined; moreover, it has been unclear whether epidural anesthesia has benefits for laparoscopic surgery. In this study, we evaluated the effectiveness of epidural analgesia after LDG.

Methods

This retrospective study included 84 patients who underwent LDG for gastric cancer. Patients received either combined thoracic epidural and general anesthesia (Epidural group, n = 34) or general anesthesia alone (No epidural group, n = 50). We recorded data on the patients, surgery, postoperative outcomes and anesthesia-related complications.

Results

In the Epidural group, the first day of flatus was significantly earlier (2.21 vs. 2.44 days, p = 0.045) and the number of additional doses of analgesics was significantly lower (2.85 vs. 4.86 doses, p = 0.007) than in the No epidural group. Postoperative urinary retention occurred at a significantly higher rate in the Epidural group (n = 7; 20.6 %) than in the No epidural group (p < 0.001).

Conclusion

Epidural anesthesia may reduce the need for additional analgesics after LDG, but increases the risk of urinary retention.

     

Robotic or laparoscopic sacrohysteropexy versus open sacrohysteropexy for uterus preservation in pelvic organ prolapse

Introduction and hypothesis

The aim of this study was to compare robotic or laparoscopic sacrohysteropexy (RLSH) and open sacrohysteropexy (OSH) as a surgical treatment for pelvic organ prolapse (POP).

Methods

Among 111 consecutive patients who had undergone sacrohysteropexy for POP, surgical outcomes and postoperative symptoms were compared between the RLSH (n?=?54; robotic 14 cases and laparoscopic 40 cases) and OSH (n?=?57). groups The medical records of enrolled patients were reviewed retrospectively.

Results

Compared with the OSH group, the RLSH group had shorter operating time (120.2 vs 187.5 min, p?<?0.0001), less operative bleeding (median estimated blood loss 50 vs 150 ml; p?<?0.0001; mean hemoglobin drop 1.4 vs 2.0 g/dl; p?<?0.0001), and fewer postoperative symptoms (13 vs 45.6 %; p?<?0.0001). Patients’ overall satisfaction (94.4 vs 91.2 %; p?=?0.717) and required reoperation due to postoperative complications (3.7 vs 1.8 %; p?=?0.611) did not differ between groups.

Conclusions

RLSH could be a feasible and safe procedure in patients with POP and should be considered as a surgical option that allows preservation of the uterus. Prospective randomized trials will permit the evaluation of potential benefits of RLSH as a minimally invasive surgical approach.

     

The Long-Term Effects of the Adjustable Gastric Band on Esophageal Motility in Patients Who Present for Band Removal

Background

During the past decade, laparoscopic adjustable gastric banding (LAGB) was one of the most popular surgical procedures in treating morbid obesity. Long-term effects, specifically on esophageal motility, of LAGB have not been well described in the literature despite the high prevalence of reoperations and post-operative dysphagia. We aimed to characterize esophageal dysmotility after long-term follow-up using data of high-resolution esophageal manometry (HRM) performed in patients who presented for LAGB removal. The research was conducted in Academic Hospital Center in the USA.

Methods

Research was conducted with approval from the institution’s Institutional Review Board. We included 25 consecutive patients who were requesting removal of the band or revisional bariatric surgery. All patients underwent HRM between 2011 and 2015.

Results

A Fisher’s exact test two-sided p value 0.41 shows no statistically significant difference in proportions of normal motility or impaired motility between asymptomatic and symptomatic patients.

Conclusions

Patients with a history of LABG can have esophageal dysmotility whether they are symptomatic or asymptomatic. Based on existing literature, we recommend pre-operative manometry in these patients requesting revisional surgery.