Failed antireflux surgery: quality of life and surgical outcome after laparoscopic refundoplication

BACKGROUND AND AIMS: Laparoscopic antireflux surgery has in recent years become the standard procedure for treating severe gastroesophageal reflux disease. Both laparoscopic antireflux surgery and open surgery cause failures which lead to repeat surgery in 3-6% of cases. We evaluated prospectively quality of life and surgical outcome following laparoscopic refundoplication for failed initial antireflux surgery. PATIENTS AND METHODS: We prospectively studied 51 patients undergoing laparoscopic refundoplication for primary failed antireflux surgery, with complete follow-up 1 year after surgery. In 20 cases the initial surgery used the open technique; four had surgery twice previously. In 31 cases primary procedure was performed laparoscopically. Indication for repeat surgery were recurrent reflux ( n=29), dysphagia ( n=12), and a combination of the two ( n=10). Preoperative and postoperative data including 24-h pH monitoring, esophageal manometry, and quality of life (Gastrointestinal Quality of Life Index) were used to assess outcome. RESULTS: Forty-nine procedures (96%) were completed by the laparoscopic technique. Conversion was necessary in two cases with primary open procedure, in one patient because of injury to the gastric wall and in one severe bleeding of the spleen. Postoperatively two patients (3.9%) suffered from dysphagia and required pneumatic dilatation within the first postoperative year. Average operating time was 245 min after an initial open procedure and 80 min after an initial laparoscopic procedure. The lower esophageal sphincter pressure increased significantly from preoperatively 2.8+/-1.8 mmHg at 3 months (12.8+/-4.1 mmHg) and 1 year (12.3+/-3.9 mmHg) after repeat surgery. In these cases the DeMeester score decreased significantly from preoperative 67.9+/-10.3 to 15.5+/-9.4 at 3 months and 13.1+/-8.1 at 1 year after surgery. Mean Gastrointestinal Quality of Life Index increased from 86.7 points preoperatively to 121.6 points at 3 months and 123.8 points at 1 year and was comparable to that of a healthy population (122.6 points). CONCLUSION: Laparoscopic repeat surgery for recurrent or persistent symptoms of gastroesophageal reflux disease is effective and can be performed safely with excellent postoperative results and a significant improvement in patient's quality of life for a follow-up period of 1 year.     

Internet‐based survey on current practice for evaluation,prevention, and treatment of scars,hypertrophic scars,and keloids

No universally accepted standard for evaluation, prevention, and treatment of scars, hypertrophic scars, and keloids exists. Following development of a questionnaire, we performed a closed Web‐based survey among burn centers. Server‐based data collection was performed over 4 weeks and closed thereafter. The poll revealed emerging new treatment schemes, but the majority of participants adhered to evaluation (Patient and Observer Scar Assessment Scale, Matching Assessment of Scars and Photographs, Vancouver Scar Scale, two‐dimensional photography) and prevention (silicone gel sheets and compression garments) strategies that were in line with the currently available recommendations from the literature. We noted a low penetration for the use of objective evaluation tools in our poll and detected differences in surgical approaches to keloids. Based on the results of our survey and the power of currently available clinical recommendations, we expect future guidelines to gain more evidence‐based power, especially when more high‐quality clinical trials with objective evaluation support, clearly defined disease entities, and therapeutic outcome factors have become available.     

功能性胃肠病的根源——脑肠轴神经系统记忆假说

功能性胃肠病(functionalgastrointestinaldisorders,FGID)以消化道动力与内脏感觉异常为主要病理生理特征并有多种症状重叠、多变或相互转换以及反复发作、较难治愈等特点;其病因和发病机制目前仍未完全清楚.本文将大脑记忆外延提出FGID的根源是脑肠轴神经系统记忆的假说,并用这个假说解释说明FGID的各种特点,以及治疗FGID的思路和方法.     

Danish primary schoolteachers'' knowledge about asthma: results of a questionnaire

We present an anonymous questionnaire inquiry involving 334 primary schoolteachers in the Randers area with the purpose of elucidating teachers' knowledge about asthma. To a series of statements about asthma, the teachers answered yes, no or don't know. A limited knowledge of different aspects of asthma in children was found, although 57% had asthma children in their classes. Specially limited was knowledge about medical treatment. Five percent had received proper instruction about asthma and had a significantly better knowledge of medical treatment (p less than 0.001-0.05). Only 57% knew that wheezing after physical exertion is a strong indicator of asthma and only 33% knew that exertion in cold weather increases the risk of an attack. It is recommended that instruction in children's diseases, especially asthma, is introduced in teacher training colleges.     

Is laparoscopic refundoplication feasible in patients with failed primary open antireflux surgery?

Background: Due to the widespread availability and acceptance of minimal-access surgery, laparoscopic antireflux surgery has become the standard procedure for the treatment of severe gastroesophageal reflux disease (GERD). However, open and laparoscopic antireflux procedures sometimes result in failure, so that redosurgery is required in some cases. The aim of this prospective study was to evaluate the surgical outcome and quality of life of patients who underwent refundoplication after the failure of primary open antireflux surgery. Methods: Twenty patients with a mean age of 52 years (range, 33–69) underwent laparoscopic refundoplication after primary open antireflux surgery. Four of them had undergone surgery twice previously. Preoperative and postoperative data, including esophageal manometry, 24-h pH monitoring, and assessment of quality of life, were reviewed prospectively. Quality of life was evaluated using the Gastrointestinal Quality of Life Index (GIQLI). Results: In 18 patients (90%), the reoperation was completed successfully laparoscopically. Two others (10%) required conversion to an open procedure. One of them had an injury of the gastric wall; in the other case, severe bleeding of the spleen necessitated the conversion. The average operating time was 245 min. Preoperatively, the main symptoms were recurrent reflux in 14 cases and a combination of re-reflux and dysphagia in six cases. The anatomic findings were telescope phenomenon (n = 6), hiatal disruption (n = 10), and wrap breakdown (n = 4). Postoperatively, two patients suffered from dysphagia and required pneumatic dilatation. The lower esophageal sphincter (LES) pressure increased significantly from a preoperative value of 6.08 mmHg to 12.2 mmHg at 3 months and 11.9 mmHg at 1 year after surgery. The DeMeester score decreased from a preoperative value of 69.8 to 17.1 at 3 months and 14.6 at 1 year postoperatively. The GIQLI score increased from a preoperative value of 84.9 points to 119.6 points at 3 months and 120.1 points at 1 year. Conclusion: Laparoscopic refundoplication after the failure of a primary open intervention is an effective procedure that can be performed safely by experienced laparoscopic surgeon. The procedure yields excellent functional results and leads to significant improvement in the patient's quality of life.     

The Viennese culture method: cultured human epithelium obtained on a dermal matrix based on fibroblast containing fibrin glue gels

The aim of this study was to develop a new keratinocyte culture system on a dermal equivalent suitable for skin wound closure. Our dermal matrix is based on a fibrin glue gel containing live human fibroblast (from human foreskin). Keratinocytes obtained from primary culture according to the Rheinwald and Green method, were seeded on to the gel. In all cases, the keratinocytes plated on the dermal equivalent grew to confluence and stratified epithelium was obtained. After 10 days an irregular multilayer could be observed. The cells showed active interaction with the fibrin support, presenting as cell formations projecting into the matrix. After 15 days a regular epithelial sheet consisting of three to four layers of cells was formed. A limiting membrane demarcating the keratinocytes from the fibrin matrix was discernible. Squamous differentiation similar to Strata reticulare and corneum found in vivo could be observed. Nuclei of basal cells were regularly spaced from each other and the chromatin was of homogeneous appearance without prominent nucleoli. The last time point (20 days) showed signs of disintegration of the epithelial sheet. A basement membrane-like structure could not be seen any more. Detachment of the basal cells was associated with subepithelial vacuoles. Basal cells contained irregular nuclei. Therefore, we conclude that 15 days of culture were optimal for the generation of a keratinocyte layers with signs of differentiation; this new culture system could be an important step forward in covering severely burned patients due to a number of advantages, as for example a large expansion factor, the shortening of the optimal culture time to 15 days, the usage of commercially available fibrin glue gels and the versatile manipulation of composite cultures.