Laparoscopic Nissen fundoplication decreases gastroesophageal junction distensibility in patients with gastroesophageal reflux disease

Laparoscopic Nissen fundoplication (LNF) is the surgical treatment of choice for gastroesophageal reflux disease (GERD). Post-LNF complications, such as gas bloat syndrome, inability to belch and vomit, and dysphagia, remain too common and prevent LNF from being more highly recommended. It remains controversial as to whether preoperative assessment can predict the development of post-LNF complications. Some authors have shown a correlation between pre-LNF manometry characteristics and post-LNF dysphagia, and others have not. We hypothesize that many post-LNF complications are caused by a decrease in the distensibility of the GEJ and that standard manometry is at best an indirect measure of this. The aim of this study is to directly measure the effect of LNF on gastroesophageal junction (GEJ) distensibility (GEJD).The lower esophageal sphincter (LES) of 15 patients undergoing LNF was characterized using standard manometry. The GEJD before and after a standardized LNF was measured using a specialized catheter, containing an infinitely compliant bag, placed within the LES. GEJD was measured, as dV/dP over volumes 5 to 25 mL distended at a rate of 20 mL/min. Mean dP ± standard error of the mean for each volume was calculated, and distensibility curves were generated and compared. Measurements were also taken after abolishing LES tone by mid-esophageal balloon distension. Patient symptoms were recorded before and after surgery. Statistical analysis was performed by two-way repeated-measures analysis of variance, paired t test, and the Tukey test. Laparoscopic Nissen fundoplication led to a statistically significant increase in Dpressure over each volume tested and therefore a significant decrease in the distensibility of the GEJ. Abolition of LES tone had no statistical effect on GEJD after fundoplication. There were no complications, and none of the patients developed the symptom of dysphagia postoperatively. These are the first direct measurements to show that LNF significantly reduces the distensibility of the GEJ. We hypothesize that the magnitude of this reduction may be the vital variable in the development of post-LNF complications and specifically post-LNF dysphagia. The intraoperative measurement of LES distensibility may provide a means for avoiding this feared and other post-LNF complications in the future. Presented at the Forty-Sixth Annual Meeting of The Society for Surgery of the Alimentary Tract, Chicago, Illinois, May 14–18, 2005 (poster presentation).     

Short-term effect of complementary feeding frequency on total ad libitum consumption in 6- to 10-month-old breast fed Indian infants

OBJECTIVE: To evaluate the short-term effect of frequency of complementary feeding on total ad libitum consumption in breast fed infants. METHODS: Twenty infants between 6 to 10 months of age were studied in a tertiary hospital in New Delhi for 48 hours. A traditional gruel made of rice and pulses (mean (SD) caloric density 54.22 (7.08) kcal/100 g) was offered in a randomized manner three (n = 10) or four (n = 10) times per day to the subjects over the first 24 hours with the subjects crossing over in the next 24 hours. They were allowed ad libitum breast feeding with no other food or fluid during the study period. Total caloric intake from breast milk and semisolids was computed for each day. RESULTS: There was no difference in the total caloric consumption with a semisolid feeding frequency of three or four times per day. The frequency of breast feeding and the breast feeding duration were also comparable (P > 0.05). However, breast milk intake was lower with a semisolid feeding frequency of 4 times/day (mean difference -61.2 g/d [95% confidence interval (CI) -122.2-0.32]; P = 0.051). The time required for feeding was higher (mean difference 14.75 min; P < 0.001), whereas the per meal intake of semisolids was lower with four semisolid feeds per day (mean difference -5.5 kcal/meal; [95% CI -10.19 to -0.81]; P = 0.024). CONCLUSION: In the short term, a change in semisolid feeding frequency from three to four times per day does not result in enhanced energy consumption because of lower breast milk intake.     

Tuberculosis verrucosa cutis: antitubercular therapy, a well-conceived diagnostic criterion

A 39-year-old housewife sustained inadvertent trauma to the right index finger about 6 years ago, whilst stitching clothes. A couple of weeks later, the site of trauma became hard and gritty. Ever since, it has progressed slowly, without any appreciable outward sign. It was not associated with any discomfort/pain. Consequent on an opinion from a surgeon, it was decided to operate on the right index finger. During the operation, under local anesthesia, a hard and gritty material was removed. The material was subjected to histopathologic study. Several stitches were applied to the wound. It failed to respond to antimicrobial therapy over a 4-week period, prompting the patient to seek another opinion. Examination of the skin surface revealed a plaque with an irregular configuration on and around the distal interphalangeal joint of the right index finger. It was erythematous and pigmented. The top of the plaque was irregular and had alternating elevations and depressions ( Fig. 1 ). Diascopy was negative for apple jelly nodule. A bacillus Calmette–Guérin (BCG) vaccination scar was identified on the left deltoid. There was no regional lymphadenopathy or systemic abnormality. Mantoux test with intradermal injection of 0.1 mL SPAN's tuberculin (purified protein derivative/5 tuberculin units/0.1 mL) (Span Diagnostic Ltd., Murat, India) was negative after 72 h. Investigations, including total and differential leukocyte count, erythrocyte sedimentation rate, serum biochemistry, and renal and liver function tests, were within the normal range, as was a chest X-ray.

Figure 1 Open in figure viewer PowerPoint Tuberculosis verrucosa cutis before (a) and after (b) antitubercular therapy (ATT)     

The enigma of pain

The unusual subject of pain in all its forms is explored at a recently opened Wellcome Trust exhibition at the Science Museum in London. Arveen Bajaj speaks to the exhibition's curator, Javier Moscoso, about the themes, ideas and insights behind the exhibition.     

Bilateral, multifocal orbital cysticercosis

Orbital cysticercosis is a benign infection with a variety of clinical presentations. Awareness of all of the possible clinical manifestations could aid early diagnosis and prevention of late sequelae. We report a case of bilateral, multifocal, intraconal orbital cysticercosis, which is an extremely rare presentation.     

Supracondylar Femoral Nail in the management of non-union of humeral shaft fractures

We reviewed seven patients with established non-union of a shaft of humerus fracture, treated by locked intramedullary nailing using the Intramedullary Supracondylar Nail (IMSC Nail; Smith & Nephew Richards, Memphis TN). The mean age of the patients was 65 years (range 48-78 years). Three of the fractures involved the proximal third of the diaphysis while the remaining four involved the middle third. Six of the original fractures were closed and one was an open fracture. The time interval between the original injury and final surgery averaged 9.3 months. All the nailings were done by the ante-grade approach with static locking. Six of the patients had closed nailing and one had open nailing with bone grafting. The mean follow-up was 8 months and osseous union was achieved in all seven cases at a mean of 5.6 months. We conclude that the Supracondylar Femoral Nail is a useful alternative implant in the management of non-union of fractures of the humeral shaft with wide medullary canals.