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1.
Background: Advocates of the Toupet partial fundoplication claim that the procedure has a lower rate of the side effects of dysphagia
and gas bloat than a complete Nissen fundoplication. However, there is increasing recognition that reflux control is not always
as good with the Toupet procedure as with the Nissen. Therefore, we set out to evaluate the factors contributing to success
and failure in patients who underwent laparoscopic modified Toupet fundoplication (LTF).
Methods: A total of 143 patients undergoing LTF for documented gastroesophageal reflux disease (GERD) were evaluated prospectively
in regard to their outcomes over a 4-year period. All patients had preoperative esophagogastroduodenoscopy (EGD) and manometry;
24-h pH testing was used selectively. Esophageal manometry was requested of all patients 6 weeks postoperatively. Clinical
follow-up was by office visit or questionnaire every 6 months after surgery; patients with significant problems were investigated
further. Failure was defined as the development of recurrent reflux documented by endoscopy, 24-h pH test, or wrap disruption
on barium swallow, or severe dysphagia persisting >3 months and requiring surgical revision.
Results: At a mean follow-up of 30 months (range, 3–51), 21 of 143 patients failed LTF; two had dysphagia and 19 had recurrent reflux.
Failure was associated with preoperative findings of a defective lower esophageal sphincter (LES) (14/21), complicated esophagitis
(13/21), and failure to divide short gastric vessels (12/19) (chi-square p < 0.05). Defective esophageal body peristalsis, present in 14 patients, resulted in failure in six cases. Presence of either
complicated esophagitis or a defective LES was associated with a 3-year 50% success rate, whereas presence of mild esophagitis
and a normal LES was reflected in a 96% 3-year success rate.
Conclusion: Laparoscopic Toupet fundoplication should be reserved for milder cases of GERD, as assessed by manometry and endoscopy.
Received: 29 June 1998/Accepted: 2 July 1999 相似文献
2.
Background: This study was designed to determine the feasibility and outcome of laparoscopic cardiomyotomy in patients with achalasia
who have persistent or recurrent dysphagia following balloon dilatation.
Methods: Ten patients who had undergone a minimum of two (range, two to seven) previous balloon dilatations underwent a single anterior
cardiomyotomy extending from the gastroesophageal junction onto the esophagus proximally for 6 cm. Four patients had a Toupet
fundoplication. Patients were analyzed using pre- and postoperative DeMeester symptom scores for dysphagia, regurgitation,
and heartburn (0 = none–3 = maximal) and esophageal manometry.
Results: Mean operating time was 90 min. Periesophagitis was noted in some patients but was rarely troublesome. Submucosal fibrosis
was present in all patients and made dissection more difficult particularly around the cardioesophageal junction. As a result,
three patients had mucosal perforations that required repair by laparoscopic suturing. There were no subsequent postoperative
complications. Median (IQR) postoperative stay was 3 (2–4) days. At 3-month reassessment, there was a reduction in the median
dysphagia score from 3 to 0, and also in the regurgitation score from 3 to 0. At last follow-up (median, 22 months), one patient
had developed recurrent dysphagia (grade 2), which improved with dilatation. Overall success of the laparoscopic procedure
was therefore 90%. Only one patient developed new symptoms of reflux (mild, grade 1) after surgery.
Conclusions: Laparoscopic cardiomyotomy provides good control of the symptoms of dysphagia and regurgitation without the morbidity of
a laparotomy or thoracotomy incision. Although technically more difficult, the technique can be extended to those who have
had previous balloon dilatation with complication and success rates similar to published results in patients who have not
undergone previous dilatation.
Received: 7 January 1998/Accepted: 22 June 1998 相似文献
3.
Awad ZT Filipi CJ Mittal SK Roth TA Marsh RE Shiino Y Tomonaga T 《Surgical endoscopy》2000,14(5):508-512
Laparoscopic antireflux surgery is the procedure of choice for gastroesophageal reflux disease (GERD). However, many clinicians
have reservations about its application in patients with complicated GERD, notably those with esophageal shortening. In this
report, we present our experience with the laparoscopic management of the shortened esophagus. A total of 235 patients with
primary GERD underwent laparoscopic antireflux procedures, 38 of whom were suspected preoperatively to have a shortened esophagus.
Of the 235 patients, 8 (3.4%) needed a left thoracoscopically assisted gastroplasty in addition to laparoscopic Toupet repair
(n= 4) or Nissen fundoplication (n= 4). Complications included pleural effusion (n= 1), pneumothorax (n= 2), and minor atelectasis (n= 1). The average hospital stay was 3 days. Results were satisfactory in 7 of 8 patients, with a mean follow-up of 20.2 months
(range, 9–34 months). The surgical management of the shortened esophagus is difficult. However, the role of minimally invasive
techniques is justified. Early results are appealing, with less morbidity, satisfactory control of GERD related symptoms,
and a shortened hospital stay.
Received: 3 August 1999/Accepted: 10 November 1999/Online publication: 17 April 2000 相似文献
4.
Evaluation of laparoscopic Toupet fundoplication as a primary repair for all patients with medically resistant gastroesophageal reflux 总被引:5,自引:2,他引:3
Background: This prospective study assesses the outcome results in 100 consecutive patients with gastroesophageal reflux disease (GERD)
treated with a laparoscopic Toupet fundoplication.
Methods: GERD was confirmed by 24-h pH study and/or esophagogastroduodenoscopy (EGD). Pre- and postoperative symptoms, operative times,
and perioperative complications were recorded on standardized data forms. Early follow-up was at 3 months and late follow-up,
including 24-h pH, manometry, and EGD was at 22 months.
Results: Preoperative symptoms included heartburn (92%), regurgitation (58%), water brash (39%), and dysphagia (39%). Mean operative
time was 3.2 hours. There were no conversions to celiotomy and there were no mortalities. The perioperative complication rate
was 14%; 6% (5/83) of patients reported heartburn at 3 months and 20% (15/74) at 22 months. Early and late dysphagia was 20%
(17/83) and 9% (7/74), respectively; 24-h pH testing was abnormal in 90% of symptomatic patients (9/10), 39% of asymptomatic
patients (12/31), and 51% overall.
Conclusions: Despite early improvement in reflux symptoms following laparoscopic Toupet fundoplications, there is a high incidence of
recurrent GERD. Symptomatic follow-up underestimates the true incidence of 24-h pH-documented reflux. Based on these results
we cannot recommend the laparoscopic Toupet repair for GERD patients with normal esophageal motility.
Received: 24 March 1997/Accepted: 28 May 1997 相似文献
5.
Background: It has been suggested that antireflux surgery may cause an improvement in esophageal motor function (EMF) and lead to reduced
postoperative dysphagia.
Methods: We evaluated the changes in dysphagia symptom scores and esophageal and lower esophageal sphincter (LES) pressures in patients
before (n= 381), at 6 months (n= 260), and at 24 months (n= 97) after laparoscopic fundoplication.
Results: There was a significant increase in LES basal and nadir pressure following surgery in all patients and an improvement in
EMF only in patients with poor preoperative esophageal motor function. A total of 76% of the patients reported no dysphagia
or an improved dysphagia score 6 and 24 months after surgery. This improvement was more marked in patients with poor EMF.
An improvement in EMF did not correlate with the improvement in dysphagia score reported by other patients. Patients with
increased dysphagia scores 2 years after surgery had significantly higher LES basal and nadir pressures as compared to other
patients.
Conclusions: Laparoscopic Nissen fundoplication is associated with an overall reduction in dysphagia scores and leads to an improvement
in esophageal motor function in patients with poor preoperative esophageal motility. Tightness and inadequate relaxation of
the wrap during swallowing may be a determinant of long-term dysphagia.
Received: 5 May 1997/Accepted: 19 August 1997 相似文献
6.
W. O. Richards R. H. Clements P. C. Wang C. D. Lind H. Mertz J. K. Ladipo M. D. Holzman K. W. Sharp 《Surgical endoscopy》1999,13(10):1010-1014
Background: There is still some controversy over the need for antireflux procedures with Heller myotomy in the treatment of achalasia.
This study was undertaken in an effort to clarify this question.
Methods: To determine whether Heller myotomy alone would cause significant gastroesophageal reflux (GER), we studied 16 patients who
had undergone laparoscopic Heller myotomy without concomitant antireflux procedures. Patients were asked to return for esophageal
manometry and 24-h pH studies after giving informed consent for the Institutional Review Board (IRB)-approved study at a median
follow-up time of 8.3 months (range, 3–51). Results are expressed as the mean ± SEM.
Results: Fourteen of the 16 patients reported good to excellent relief of dysphagia after myotomy. They were subsequently studied
with a 24-h pH probe and esophageal manometry. These 14 patients had a significant fall in lower esophageal sphincter (LES)
pressure from 41.4 ± 4.2 mmHg to 14.2 ± 1.3 mmHg, after the myotomy (p < 0.01, Student's t-test). The two patients who reported more dysphagia postoperatively had LES pressures of 20 and 25 mmHg, respectively. Two
of 14 patients had DeMeester scores of >22 (scores = 61.8, 29.4), while only one patient had a pathologic total time of reflux
(percent time of reflux, 8%). The mean percent time of reflux in the other 13 patients was 1.9 ± 0.6% (range, 0.1–4%), and
the mean DeMeester score was 11.7 ± 4.6 (range, 0.48–19.7).
Conclusions: Laparoscopic Heller myotomy is effective for the relief of dysphagia in achalasia if the myotomy lowers the LES pressure
to <17 mmHg. If performed without dissection of the entire esophagus, the laparoscopic Heller myotomy does not create significant
GER in the postoperative period. Clearance of acid refluxate from the aperistaltic esophagus is an important component of
the pathologic gastroesophageal reflux disease (GERD) seen after Heller myotomy for achalasia. Furthermore, GERD symptoms
do not correlate with objective measurement of GE reflux in patients with achalasia. Objective measurement of GERD with 24
h pH probes may be indicated to identify those patients with pathologic acid reflux who need additional medical treatment.
Received: 12 May 1998/Accepted: 15 December 1998 相似文献
7.
M. Anselmino G. Zaninotto M. Costantini M. Rossi C. Boccu' D. Molena E. Ancona 《Surgical endoscopy》1997,11(1):3-7
Background: The Heller-Dor operation has recently been proposed for the treatment of esophageal achalasia even via a laparoscopic approach.
Methods: To measure the medium-term effectiveness of this new minimally invasive technique, an evaluation of pre- and postoperative
symptoms, esophagogram, endoscopic findings, esophageal manometry, and pH monitoring was prospectively designed in 43 patients
with primary esophageal achalasia. The mean clinical follow-up for all the patients is 12 months (range 3–43), while the mean
radiological follow-up is 11 months (range 1–23). Endoscopic data 1 year after surgery are currently available for 27 patients
(63%), whereas a 12-month (range 1–26) functional follow-up (including manometric and pH-monitoring studies of the esophagus)
is currently available for 35 patients (81.4%).
Results: No dysphagia was reported in 38 cases (88.4%); two (4.6%) complained of occasional swallowing discomfort which regressed
spontaneously; two (4.6%) had persistent dysphagia which regressed with pneumatic dilatation. One patient (2.8%) reported
mild occasional dysphagia after a 1-year asymptomatic period. Preoperatively, esophagograms showed an average maximum diameter
of 40.6 ± 9.1 mm which decreased to 24.1 ± 6.0 mm after operation. Mean lower esophageal sphincter (LES) resting and residual
pressures decreased significantly from 28.6 ± 10.7 mmHg to 8.8 ± 4.1 mmHg and from 17.0 ± 9.7 mmHg to 4.7 ± 4.0 mmHg, respectively
(p < 0.0001). These effects on esophageal diameter and LES function seem to persist over time. The complete absence of any peristaltic
contractions recorded preoperatively in all cases remained unchanged after surgery in all but four patients. However, this
rare recovery of peristalsis proved to be transient, and patients revealed a manometric impairment of their esophageal body
function, but without complaining of dysphagia. Twenty-four-hour pH monitoring showed abnormal gastroesophageal reflux episodes
in two (5.7%) of the 35 patients who were monitored: one was asymptomatic; the other had heartburn and endoscopically demonstrated
grade II esophagitis.
Conclusions: Laparoscopic Heller-Dor operation achieves excellent medium-term results which, together with the already-demonstrated advantages
of a minimal surgical trauma and rapid convalescence, validate the use of such a minimally invasive approach to treat patients
with primary achalasia of the esophagus.
Received: 19 March 1996/Accepted: 15 May 1996 相似文献
8.
The value of 24-h pH study in evaluating the results of laparoscopic antireflux surgery in children 总被引:4,自引:0,他引:4
Background: The performance of laparoscopic antireflux surgery is steadily increasing among pediatric surgeons. Different techniques
are being used. However, due to a lack of standardized follow-up methods, postoperative results are difficult to compare.
In this study, we describe the results of postoperative 24-h pH study as an objective criterion for evaluating the results
of laparoscopic Thal antireflux surgery.
Methods: In a prospective study, 53 patients underwent a laparoscopic Thal procedure. Preoperatively, all patients were subjected
to 24-h pH monitoring, an upper GI series, and esophagogastroscopy. pH monitoring was performed 3 months postoperatively to
evaluate the effect of the fundoplication. Esophagogastroscopy was repeated in case of preoperative esophagitis.
Results: In one patient, the laparoscopy was converted to an open procedure. Feeding was commenced on day 1 in 49 of the 53 children.
Mean hospitalization time was 4.4 days. One patient was reoperated for a too-tight fundoplication, and two patients died of
unrelated causes. Ultimately, 44 of 50 children (88%) were free of symptoms; however, 11 of 41 children (25%) still displayed
pathological reflux on pH monitoring.
Conclusions: The Thal fundoplication can be performed laparoscopically in children. Children have a quick recovery, and hospitalization
is short (4.4 days). At follow-up, nearly 90% of the children are free of symptoms. However, 25% still have pathological reflux
as measured with pH monitoring. Therefore, questionnaires alone are not a sufficient means of measuring outcome postoperative.
pH monitoring is a valuable additional tool for the objective postoperative evaluation of the results of (laparoscopic) antireflux
procedures.
Received: 9 July 1998/Accepted: 6 October 1998 相似文献
9.
Endoscopic photodynamic therapy for obstructing esophageal cancer: 77 cases over a 2-year period 总被引:14,自引:0,他引:14
Luketich JD Christie NA Buenaventura PO Weigel TL Keenan RJ Nguyen NT 《Surgical endoscopy》2000,14(7):653-657
rid="id="<e5>Correspondence to:</e5> J. D. Luketich, 200 Lothrop Street, C-800, Presbyterian Hospital, Pittsburgh, PA 15213,
USA
Background: Photodynamic therapy (PDT) is an alternative treatment option for the palliation of obstructive esophageal cancer. We report
our experience with PDT for patients presenting with inoperable, obstructing, or bleeding esophageal cancer.
Methods: Seventy-seven patients with inoperable, obstructing esophageal cancer were treated with PDT from November 1996 to July 1998.
Photofrin (1.5–2.0 mg/kg) was administered, followed by endoscopic light treatment (630 nm red dye laser) at 48 h. Dysphagia
score (1 for no dysphagia to 5 for complete obstruction), dysphagia-free interval, and patient survival were assessed.
Results: Seventy-seven patients underwent 125 PDT courses. The mean dysphagia score at 4 weeks after PDT in 90.8% of the patients
improved from 3.2 ± 0.7 to 1.9 ± 0.8 (p < 0.05). PDT adequately controlled bleeding in all six patients who had bleeding. The most common complications after the
125 PDT courses were esophageal stricture (4.8%), Candida esophagitis (3.2%), symptomatic pleural effusion (3.2%), and sunburn (10.0%). Twenty-nine patients (38%) required more than
one PDT course, and seven patients required placement of an expandable metal stent for recurrent dysphagia. The mean dysphagia-free
interval was 80.3 ± 58.2 days. The median survival was 5.9 months.
Conclusions: Photodynamic therapy is a safe and effective treatment for the palliation of obstructing and bleeding esophagus cancer.
Received: 8 May 1999/Accepted: 24 September 1999/Online publication: 15 May 2000 相似文献
10.
Laparoscopic toupet fundoplication for gastroesophageal reflux disease with poor esophageal body motility 总被引:5,自引:2,他引:5
Richard J. Lund M.D. Gerold J. Wetcher M.D. Frank Raiser M.D. Karl Glaser M.D. Galen Perdikis M.D. Michael Gadenstätter M.D. Natsuya Katada M.D. Charles J. Filipi M.D. Ronald A. Hinder M.D. Ph.D. 《Journal of gastrointestinal surgery》1997,1(4):301-308
Impaired esophageal body motility is a complication of chronic gastroesophageal reflux disease (GERD). In patients with this
disease, a 360-degree fundoplication may result in severe postoperative dysphagia. Forty-six patients with GERD who had a
weak lower esophageal sphincter pressure and a positive acid reflux score associated with impaired esophageal body peristalsis
in the distal esophagus (amplitude <30 mm Hg and >10% simultaneous or interrupted waves) were selected to undergo laparoscopic
Toupet fundoplication. They were compared with 16 similar patients with poor esophageal body function who underwent Nissen
fundoplication. The patients who underwent Toupet fundoplication had less dysphagia than those who had the Nissen procedure
(9% vs. 44%;P=0.0041). Twenty-four-hour ambulatory pH monitoring and esophageal manometry were repeated in 31 Toupet patients 6 months
after surgery. Percentage of time of esophageal exposure to pH <4.0, DeMeester reflux score, lower esophageal pressure, intra-abdominal
length, vector volume, and distal esophageal amplitude all improved significantly after surgery. Ninety-one percent of patients
were free of reflux symptoms. The laparoscopic Toupet fundoplication provides an effective antireflux barrier according to
manometric, pH, and symptom criteria. It avoids potential postoperative dysphagia in patients with weak esophageal peristalsis
and results teria. It avoids potential postoperative dysphagia in patients with weak esophageal peristalsis and results in
improved esophageal body function 6 months after, surgery.
Presented at the Thirty-Seventh Annual Meeting of The Society for Surgery of the Alimentary Tract, San Francisco, Calif.,
May 19–22, 1996. 相似文献
11.
A comparison of laparoscopic Nissen fundoplication and Rossetti's modification in 239 patients 总被引:4,自引:0,他引:4
Background: Laparoscopic Nissen fundoplication and the Rossetti modification represent two different surgical approaches to resolving
gastroesophageal reflux disease (GERD). Concerns have arisen that the Rossetti modification results in increased postoperative
dysphagia. In this study, we compared a group of patients who underwent a laparoscopic Nissen fundoplication with a group
who had undergone the Rossetti modification to determine if there was a significant difference in postoperative dysphagia.
Additionally, we wanted to confirm that the Nissen procedure performed laparoscopically could resolve GERD as successfully
as the Rossetti modification, with no difference in operative complications.
Methods: We prospectively collected data on 101 patients who underwent laparoscopic Nissen fundoplication and compared outcomes with
those of 138 patients who had undergone the laparoscopic Rossetti modification in a previous series.
Results: All patients experienced resolution of reflux symptoms. No statistically significant differences were found between the groups
in terms of intraoperative or postoperative complications, conversions to open procedure, or length of hospitalization. Paradoxically,
there was a significant difference in operating time between the Rossetti and the Nissen groups (70.6 min vs 45.6 min, p= 0.006). Postoperative dysphagia requiring dilation was significantly higher in the Rossetti group (21.7% vs 8.9%, p= 0.008). However, there was a significantly higher percentage of patients in the Rossetti group who had had esophagitis preoperatively
(95.7% vs 86.1%, p= 0.009), although the proportion of patients having Barrett's esophagus was higher in the Nissen group (9.4% vs 24.8%, p= 0.001).
Conclusions: Both approaches resolved reflux symptoms without significant differences in complications, conversions, or length of stay.
Preoperative differences between groups, as well as the method of sequentially comparing the two different procedures, prevent
us from attributing greater postoperative dysphagia in the Rossetti group solely to the choice of surgical approach. Prospective
randomized studies are needed to control for variables, such as surgical team experience and patient differences.
Online publication: 17 April 2000 相似文献
12.
Laparoscopic Heller myotomy relieves dysphagia in achalasia when the esophagus is dilated 总被引:4,自引:1,他引:3
M. G. Patti C. V. Feo U. Diener A. Tamburini M. Arcerito B. Safadi L. W. Way 《Surgical endoscopy》1999,13(9):843-847
Background: It has been said that a Heller myotomy cannot improve dysphagia in achalasia when the esophagus is markedly dilated or sigmoid
shaped. Those who hold this belief recommend esophagectomy as the primary treatment in such cases. This study aimed to compare
the results of laparoscopic Heller myotomy combined with Dor fundoplication in 66 patients with and without esophageal dilatation,
all of whom had achalasia.
Methods: On the basis of the maximal diameter of the esophageal lumen and the shape of the esophagus, the patients were placed into
four groups: group A (esophageal diameter <4.0 cm; 26 patients), group B (diameter 4.0–6.0 cm; 21 patients), group C1 (diameter
>6.0 cm and straight esophageal axis; 12 patients), and group C2 (diameter >6.0 cm and sigmoid-shaped esophagus; 7 patients).
All patients underwent a laparoscopic Heller myotomy and Dor fundoplication.
Results: The duration of the operation and the length of hospital stay were similar among the four groups. Excellent or good results
were obtained in 88% of group A, 100% of group B, 83% of group C1, and 100% of group C2. No patient in this consecutive series
ultimately required an esophagectomy.
Conclusions: In patients with achalasia who have esophageal dilation, a laparoscopic Heller myotomy and Dor fundoplication (a) took no
longer and was no more difficult, (b) was associated with no more postoperative complications, and (c) gave just as good relief
of dysphagia. We conclude that esophageal dilation by itself should rarely serve as an indication for esophagectomy rather
than myotomy as the initial surgical treatment.
Received: 1 March 1999/Accepted: 21 June 1999 相似文献
13.
Iatrogenic thoracic migration of the stomach complicating laparoscopic Nissen fundoplication 总被引:1,自引:0,他引:1
Background: Intrathoracic gastric herniation after laparoscopic Nissen fundoplication is an uncommon but potentially life-threatening
complication that may present in the early or late postoperative period.
Methods: A retrospective analysis was performed on all patients undergoing antireflux surgery from December 1991 to June 1999.
Results: Nine cases of gastric herniation occurred after 511 operations (0.17%). Patients presented with the condition 4 days to 29
months after surgery. Eight of these nine patients (89%) had reported vomiting in the immediate postoperative period. Seven
patients (78%) reported persistent odynophagia. A factor common to all patients was that posterior crural repair had not been
performed.
Conclusions: Measures should be undertaken to prevent postoperative vomiting after laparoscopic Nissen fundoplication. Posterior crural
repair is essential after surgery in all cases.
Received: 12 July 1999/Accepted: 22 November 1999/Online publication: 8 May 2000 相似文献
14.
R. Rosati U. Fumagalli S. Bona L. Bonavina M. Pagani A. Peracchia 《Surgical endoscopy》1998,12(3):270-273
Background: Extramucosal myotomy of the lower esophagus and cardia, combined with anterior fundoplication, is, in our opinion, the procedure
of choice to treat stage I–III esophageal achalasia.
Methods: After a successful experience with open surgery in over 280 patients, from January 1992 through February 1997, 61 patients
underwent laparoscopic Heller-Dor for stage I–III achalasia. Conversion to laparotomy was done in three cases. All procedures
were performed under intraoperative endoscopic control. Intraoperative complications were seven mucosal tears, which were
sutured laparoscopically in five cases. The sole postoperative complication was bleeding from an acute gastric ulcer (conservative
treatment).
Results: Follow-up consisted of clinical and radiographic study 1 month after surgery, and endoscopy and manometry within 1 year.
After a mean follow-up (F.U.) of 21 months (1–62), clinical results range from excellent to good in 98.2%. One patient (1.7%)
complaining of recurrent dysphagia improved after endoscopic dilation. Esophageal diameter reduced from 52 to 27 mm. LES pressure
reduced from 30.3 ± 12.4 to 10.7 ± 3.5 mmHg (basal) and from 14.8 ± 9.3 to 2.9 ± 2.1 mmHg (residual).
Conclusions: Laparoscopic Heller-Dor operation is feasible, safe, and effective. Special care should be taken in patients with previous
endoscopic dilations.
Received: 3 April 1997/Accepted: 28 July 1997 相似文献
15.
Background: There is a certain amount of controversy regarding the need to divide the short gastric vessels (SGV) in laparoscopic fundoplication
for treatment of gastroesophageal reflux disease (GERD). In addition, there is often difficulty in identifying the crural
fibers when encircling the lower esophagus.
Methods: We determine whether it is necessary to divide the SGV by trying to appose the gastric fundus to the anterior abdominal wall
intraoperatively. If this could be done easily, the SGV are preserved. When their division is required, a posterior gastric
approach is employed. We have also found that the injection of methylene blue into the left crural fibers anterior to the
esophagus is helpful in identifying the left side when dissection posterior to the gastroesophageal junction is difficult.
Results: Between 1992 and 1995 we performed 20 laparoscopic fundoplications for GERD. All patients had at least grade 3 esophagitis
(Savary-Miller scale), increased esophageal exposure to acid (median DeMeester score of 195), and decreased lower esophageal
sphincter (LES) pressure. The median operative time was 175 min. There were no conversions to open surgery, and there was
no mortality. Three patients developed transient postoperative dysphagia and one patient had pneumonia. The median hospital
stay was 3 days; all patients were free of reflux symptoms at follow-up ranging from 7 to 42 months.
Conclusion: We conclude that the techniques described by us aid in intraoperative decision making and allow laparoscopic fundoplication
to be both simple and effective.
Received: 29 March 1996/Accepted: 28 May 1996 相似文献
16.
The effect of medical therapy and antireflux surgery on dysphagia in patients with gastroesophageal reflux disease without esophageal stricture 总被引:11,自引:0,他引:11
Wetscher GJ Glaser K Gadenstaetter M Profanter C Hinder RA 《American journal of surgery》1999,177(3):189-192
BACKGROUND: Poor esophageal body motility and trapping of the hernial sac by the hiatal crura are the major pathomechanisms of gastroesophageal reflux disease (GERD)-induced dysphagia. There is only little knowledge of the effect of medical therapy or antireflux surgery in reflux-induced dysphagia. METHODS: Fifty-nine consecutive GERD patients with dysphagia were studied by means of a symptom questionnaire, endoscopy, barium swallow, esophageal manometry, and 24-hour pH monitoring of the esophagus. Patients had proton pump inhibitor therapy and cisapride for 6 months. After GERD relapsed following withdrawal of medical therapy, 41 patients decided to have antireflux surgery performed. The laparoscopic Nissen fundoplication was chosen in 12 patients with normal esophageal body motility and the laparoscopic Toupet fundoplication in 29 patients with impaired peristalsis. Dysphagia was assessed prior to treatment, at 6 months of medical therapy, and at 6 months after surgery. RESULTS: Heartburn and esophagitis were effectively treated by medical and surgical therapy. Only surgery improved regurgitation. Dysphagia improved in all patients following surgery but only in 16 patients (27.1%) following medical therapy. Esophageal peristalsis was strengthened following antireflux surgery. CONCLUSIONS: Medical therapy fails to control gastroesophageal reflux as it does not inhibit regurgitation. Thus, it has little effect on reflux-induced dysphagia. Surgery controls reflux and improves esophageal peristalsis. This may contribute to its superiority over medical therapy in the treatment of GERD-induced dysphagia. 相似文献
17.
Background: Laparoscopy is used increasingly for the management of acute abdominal conditions. For many years, previous abdominal surgery
and intestinal obstruction have been regarded as contraindications to laparoscopy because there is an increased risk of iatrogenic
bowel perforation. The role of laparoscopy in acute small bowel obstruction remains unclear.
Methods: Since 1995, data from patients undergoing laparoscopic surgery have been entered prospectively into a database. Patients
who underwent surgery before 1995 were added retrospectively to the same database. The charts of all patients treated surgically
for mechanical small bowel obstruction were reviewed. Univariate analysis was performed to identify factors associated with
success or failure, especially intraoperative complications, conversion, and postoperative morbidity. Stepwise logistic regression
was used to assess for independent variables.
Results: This study included 83 patients (56 women and 27 men) with a mean age of 56 years (range, 17–91 years). Conversion was necessary
in 36 cases (43%). Laparoscopy alone was successful in 47 patients (57%). Intraoperative complications were noted in 16% and
postoperative complications in 31% of the patients. Eight reoperations (9%) were necessary. Mortality was 2.4%. Duration of
surgery (p < 0.001) and a bowel diameter exceeding 4 cm (p= 0.02) were predictors of conversion. No risk factor for intraoperative complication was identified. Accidental bowel perforation
(p= 0.008) and the need for conversion (p= 0.009) were the only independent factors associated with an increased risk of postoperative complications.
Conclusions: Laparoscopic management of small bowel obstruction is possible in roughly 60% of the patients selected for this approach.
Morbidity is lower, resumption of a normal diet is faster, and hospital stay is shorter than with patients requiring conversion.
No clear predictor of success or failure was identified, but intraoperative complications must be avoided. If the surgeon
is widely experienced in advanced laparoscopic surgery and there is a liberal conversion policy, laparoscopy is a valuable
alternative to conventional surgery in the management of acute small bowel obstruction.
Received: 20 July 1999/Accepted: 22 November 1999/Online publication: 17 April 2000 相似文献
18.
The preoperative predictability of the short esophagus in patients with stricture or paraesophageal hernia 总被引:4,自引:2,他引:2
Mittal SK Awad ZT Tasset M Filipi CJ Dickason TJ Shinno Y Marsh RE Tomonaga TJ Lerner C 《Surgical endoscopy》2000,14(5):464-468
Background: Esophageal shortening is a known complication of advanced gastroesophageal reflux disease that may preclude a tension-free
antireflux procedure. A retrospective analysis was performed to test the accuracy of preoperative testing.
Methods: From September 1993 to December 1998, 39 patients underwent esophageal mobilization with intraoperative length assessment.
Patients were selected on the basis of irreducible hiatal hernia, stricture formation, or both. Patients in the upright position
with a fixed hiatal hernia larger than 5 cm on an esophagram were considered to have a short esophagus. Manometric length
two standard deviations below the mean for height was considered abnormally short.
Results: In 31 patients, intraoperative mobilization was sufficient to allow the gastroesophageal junction to lie 2 cm below the diaphragmatic
crus, so no esophageal-lengthening procedure was required. Eight patients with a short esophagus required an esophageal-lengthening
procedure after complete mobilization. Two patients subsequently underwent intrathoracic migration of the gastroesophageal
junction (GEJ), with recurrence of symptoms and required gastroplasty during the second surgery. An esophagram had a sensitivity
of 66% and a positive predictive value of 37%, whereas manometric length had a sensitivity of 43% and a positive predictive
value of 25% for the diagnosis of short esophagus. The preoperative endoscopic finding of either a stricture or Barrett's
esophagus was the most sensitive test for predicting the need for a lengthening procedure.
Conclusions: Manometry and esophagraphy are not reliable predictors of the short esophagus. Additional tests and/or tests combined with
other parameters are needed.
Received: 1 April 1999/Accepted: 10 August 1999/Online publication: 17 May 2000 相似文献
19.
Laparoscopic Nissen fundoplication for the treatment of gastroesophageal reflux disease (GERD) 总被引:1,自引:0,他引:1
D. L. van der Peet E. C. Klinkenberg-Knol Q. A. J. Eijsbouts M. van den Berg L. M. de Brauw M. A. Cuesta 《Surgical endoscopy》1998,12(9):1159-1163
Background: A prospective study was conducted to evaluate the physiologic and clinical consequences of laparoscopic Nissen fundoplication
(LNF), using strict indications for surgery.
Methods: From 1992 to 1997, 50 patients underwent LNF. Indications for operative treatment were either failure of conservative treatment
or foresight to see long-term use of strong acid suppressive therapy. Patients were evaluated by barium esophagogastric study
(BES), esophagoscopy, 24-h pH monitoring (pHM), stationary esophageal manometry, gastric-emptying studies (GES), pancreatic
polypeptide stimulation test (PPT) and clinical evaluation using questionnaires.
Results: Perioperative complications necessitated conversion to laparatomy in two cases, and there was no mortality. Severe dysphagia
resulted in reoperation in two patients. The average maximum lower esophageal sphincter pressure (MLESP) increased from 6.1
mmHg to 12.7 mmHg. Endoscopy showed improved grading of the esophagitis, and the total percentage of pH less than 4 during
24 h decreased from a mean of 9.2 to 0.95. Three patients demonstrated impaired PPTs postoperatively; two had (mild) diarrhea.
The overall success rate after the operation was 90%.
Conclusions: The results of LNF in a limited number of patients with severe and/or resistant gastroesophageal reflux disease (GERD) receiving
continuous medical treatment with proton pump inhibitors (PPIs) on a maintenance base are comparable with LNF results in centers
with a more liberal policy concerning indications for LNF surgery.
Received: 15 September 1997/Accepted: 12 October 1997 相似文献
20.
Objective To determine the influence of preoperative esophageal motility on clinical and objective outcome of the Toupet or Nissen fundoplication
and to evaluate the success rate of these procedures.
Summary background data Nissen fundoplication (360°) is the standard operation in the surgical management of gastroesophageal reflux disease (GERD).
In order to avoid postoperative dysphagia it has been proposed to tailor antireflux surgery according to pre-existing esophageal
motility. Postoperative dysphagia is thought to occur more commonly in patients with esophageal dysmotility and it has been
recommended to use the Toupet procedure (270°) in these patients. We performed a randomized trial to evaluate this tailored
concept and to compare the two operative techniques concerning reflux control and complication rate (dysphagia).
Methods 200 patients with GERD were included in a prospective, randomized study. After preoperative examinations (clinical interview,
endoscopy, 24-hour pH-metry and esophageal manometry) 100 patients underwent either a laparoscopic Nissen procedure (50 with
and 50 without motility disorders), or Toupet (50 with and 50 without motility disorders). Postoperative follow-up after two
years included clinical interview, endoscopy, 24-hour pH-metry, and esophageal manometry.
Results After two years 85% (Nissen) and 85% (Toupet) of patients were satisfied with the operative result. Dysphagia was more frequent
following a Nissen fundoplication compared to Toupet (19 vs. 8, p < 0.05) and did not correlate with preoperative motility. Concerning reflux control the Toupet proved to be as good as the
Nissen procedure.
Conclusion Tailoring antireflux surgery according to the esophageal motility is not indicated, as motility disorders are not correlated
with postoperative dysphagia. The Toupet procedure is the better operation as it has a lower rate of dysphagia and is as good
as the Nissen fundoplication in controlling reflux. 相似文献