Endoscopic valvuloplasty for GERD

BACKGROUND: The transoral, endoscopic route has been suggested as a possible approach for the correction of severe gastroesophageal reflux. Such a procedure would involve no mobilization of the cardia or other structures. The optimal placement, number, and configuration of sutures remains undefined. METHODS: With the use of a previously developed endoscopic sewing machine, this study was undertaken in baboons with two suture arrangements immediately below the lower esophageal sphincter. A linear arrangement (group I) and a circular arrangement (group II) were compared. During the 6 months after the procedure, the animals were evaluated using manometry, fluoroscopic barium swallow, upper gastrointestinal endoscopy, and a pressure volume test. RESULTS: A significant increase in lower esophageal sphincter length was demonstrated only in group II (p = 0. 010). A significant increase in lower esophageal sphincter pressure was demonstrated only in group I animals (p = 0.008). The abdominal length increased in group I (p = 0.004) and group II (p = 0.004). The yield pressure and yield volume did not differ significantly from those measured previously in control animals. No evidence of reflux, stricture formation, esophagitis, or other pathology was noted. CONCLUSIONS: Some manometric parameters associated with gastroesophageal reflux are altered by the endoscopic placement of sutures below the gastroesophageal junction, with no associated serious complications.     

Does the duration of gastroesophageal reflux disease and degree of acid reflux correlate with esophageal function? A retrospective analysis of 768 patients

To reconfirm that the duration of symptoms is not associated with esophageal motility in patients with gastroesophageal reflux disease (GERD), esophageal manometric data from 768 patients with GERD were retrospectively analyzed with relation to the duration of symptoms. GERD was defined by positive acid reflux test results monitored by ambulatory 24-hour pH monitoring. Correlation of the duration of symptoms with esophageal body pressures, the presence of dysmotility determined by simultaneous waves, average resting pressure of the lower esophageal sphincter (LES), and abdominal and overall lengths of the LES were statistically analyzed. The median duration of the symptoms was 60 months (range, 1-600). Duration of symptoms was not associated with contraction pressures of the esophageal body at 3 and 8 cm above the LES (r = -0.070 and -0.063, respectively). There was no correlation between LES pressures, LES lengths, or the percentage of simultaneous waves and duration of symptoms. Stricture formation is related to decreased distal esophageal function in GERD patients. In conclusion, the duration of GERD has little influence on esophageal body and LES function.     

Assessment of diaphragmatic stressors as risk factors for symptomatic failure of laparoscopic Nissen fundoplication

An important limitation of antireflux surgery is a 5%–10% failure rate. We investigated the correlation between various diaphragm stressors and failure of antireflux surgery. Forty-one study cases who underwent a reoperative antireflux operation from 1997 to 2001 and 50 control patients who had undergone a successful laparoscopic Nissen fundoplication during the same period without clinical or symptomatic evidence of failure were randomly selected for comparison. A retrospective analysis was conducted utilizing a standardized diaphragm stressor questionnaire, addressing the period between the primary and secondary operation. Stressors considered in the study included height, body mass index (BMI), postoperative gagging, vomiting, weight lifting (greater than 100 pounds), coughing, hiccuping, motion sickness, retching, belching, antidepressant use, smoking, preoperative grade of esophagitis, size of hiatal hernia, lower esophageal sphincter pressure, esophageal body pressures, and preoperative response to proton pump inhibitors. Of the potential stressors investigated, the following were significantly associated with surgical failure after adjusting for other variables through multivariate analysis: gagging (P = 0.005), belching (P = 0.02), and hernia size greater than 3 cm (P = 0.04; Table 1). Other potential risk factors show trends as obvious in Fig. 2. Vomiting was significant (P = 0.01) in the earlier models but lost significance when logistic regression was applied. Patients with postoperative gagging and an intraoperative hiatal hernia (greater than 3 cm) have a poorer outcome, whereas patients with postoperative belching have a better long-term outcome. Presented at the Forty-Sixth Annual Meeting of The Society for Surgery of the Alimentary Tract, Chicago, Illinois, May 14–18, 2005 (poster presentation).     

Is analysis of lower esophageal sphincter vector volumes of valuein diagnosing gastroesophageal reflux disease？

AIM: With successful surgical treatment of gastroesophageal reflux disease (GERD), there is interest in understanding the anti-reflux barrier and its mechanisms of failure. To date, the potential use of vector volumes to predict the DeMeester score has not been adequately explored. METHODS: 627 patients in the referral database received esophageal manometry and ambulatory 24-hour pH monitoring. Study data included LES resting pressure (LESP), overall LES length (OL) and abdominal length (AL), total vector volume (TVV) and intrabdominal vector volume (IVV). RESULTS: In cases where LESP, TVV or IVV were all below normal, there was an 81.4 % probability of a positive DeMeester score. In cases where all three were normal, there was an 86.9 % probability that the DeMeester score would be negative. Receiver-operating characteristics (ROC) for LESP, TVV and IVV were nearly identical and indicated no useful cut-off values. Logistic regression demonstrated that LESP and IVV had the strongest association with a positive DeMeester score; however, the regression formula was only 76.1 % accurate. CONCLUSION: While the indices based on TVV, IVV and LESP are more sensitive and specific, respectively, than any single measurement, the measurement of vector volumes does not add significantly to the diagnosis of GERD.     

Inguinal hernia repair in a developing country

Hernia surgery is typically same-day surgery and can be safely conducted in a developing country. We describe a collaborative effort of the American Hernia Society, the Institute of Latin American Concerns, medical industries, the United States Peace Corps, physicians, surgical residents and nurses from many institutions. During three 5-day periods, we operated on 236 patients and repaired 252 hernias (73% inguinal). In addition, an education day for local physicians was conducted on three occasions and included televised live surgical demonstrations and interactive lectures with question and answer sessions. We suggest this to be a viable public health initiative and demonstrate the role of surgeons in advancing and providing state-of-the-art inguinal hernia surgery to a developing country and its underserved population.     

Is laparoscopic reoperation for failed antireflux surgery feasible?

HYPOTHESIS: Laparoscopic techniques can be used to treat patients whose antireflux surgery has failed. DESIGN: Case series. SETTING: Two academic medical centers. PATIENTS: Forty-six consecutive patients, of whom 21 were male and 25 were female (mean age, 55.6 years; range, 15-80 years). Previous antireflux procedures were laparoscopic (21 patients), laparotomy (21 patients), thoracotomy (3 patients), and thoracoscopy (1 patient). MAIN OUTCOME MEASURES: The cause of failure, operative and postoperative morbidity, and the level of follow-up satisfaction were determined for all patients. RESULTS: The causes of failure were hiatal herniation (31 patients [67%]), fundoplication breakdown (20 patients [43%]), fundoplication slippage (9 patients [20%]), tight fundoplication (5 patients [11%]), misdiagnosed achalasia (2 patients [4%]), and displaced Angelchik prosthesis (2 patients [4%]). Twenty-two patients (48%) had more than 1 cause. Laparoscopic reoperative procedures were Nissen fundoplication (n = 22), Toupet fundoplication (n = 13), paraesophageal hernia repair (n = 4), Dor procedure (n = 2), Angelchik prosthesis removal (n = 2), Heller myotomy (n = 2), and the takedown of a wrap (n = 1). In addition, 18 patients required crural repair and 13 required paraesophageal hernia repair. The mean +/- SEM duration of surgery was 3.5+/-1.1 hours. Operative complications were fundus tear (n = 8), significant bleeding (n = 4), bougie perforation (n = 1), small bowel enterotomy (n = 1), and tension pneumothorax (n = 1). The conversion rate (from laparoscopic to an open procedure) was 20% overall (9 patients) but 0% in the last 10 patients. Mortality was 0%. The mean +/- SEM hospital stay was 2.3+/-0.9 days for operations completed laparoscopically. Follow-up was possible in 35 patients (76%) at 17.2+/-11.8 months. The well-being score (1 best; 10, worst) was 8.6+/-2.1 before and 2.9+/-2.4 after surgery (P<.001). Thirty-one (89%) of 35 patients were satisfied with their decision to have reoperation. CONCLUSIONS: Antireflux surgery failures are most commonly associated with hiatal herniation, followed by the breakdown of the fundoplication. The laparoscopic approach may be used successfully to treat patients with failed antireflux operations. Good results were achieved despite the technical difficulty of the procedures.     

Laparoscopic intracorporeal ultrasound cystic duct length measurement

The incidence of common bile duct injury remains high. Intracorporeal ultrasound mapping of cystic duct anatomy, prior to laparoscopic cholecystectomy (LC), may assist surgeons in avoiding common bile duct injuries. A technique for intraoperative intracorporeal predissection ultrasound imaging (IIPUI) of the cystic duct length was tested. During LC, gallbladder adhesions were lysed, and with the gallbladder retracted by grasping forceps, the ultrasound examination was performed. Using a 7.5-MHz articulating ultrasound probe, visualization of the extrahepatic biliary tree was obtained in five separate planes. Success in visualizing each plane, time for ultrasound examination, and predissection accuracy of cystic duct length measurement were recorded. Intraoperative cholangiography or direct measurement of the dissected cystic duct was used to determine accuracy of the ultrasound cystic duct length estimates. Forty-three patients underwent IIPUI during LC. The time required to perform the examination varied, with a range of 5 to 17 min (mean 9.5 min). Success of visualization in planes 1 through 5 was 44%, 95%, 98%, 98%, and 70%, respectively. The accuracy rate for cystic duct length ultrasound measurement was 87.1%. No complications related to the examination were observed. In this preliminary study, cystic duct length was determined by predissection intracorporeal ultrasound with a high level of accuracy. Predissection imaging may assist in preventing common bile duct injury during LC.