回肠壁外与腰大肌间隧道抗反流的回肠代输尿管术治疗长段输尿管狭窄(附7例报告)

目的:探讨一种新颖的抗反流技术在回肠代输尿管术治疗长段输尿管严重狭窄中的价值。方法:腹膜后纤维化所致长段输尿管狭窄和肾积水患者7例,其中双侧肾积水5例,单侧肾积水2例,均采用一段回肠替代双侧或单侧输尿管,输尿管与回肠作端侧吻合,并采用回肠壁外与腰大肌间隧道抗反流技术,固定段长3-4cm。结果:7例患者术后均恢复良好,随访8-36个月,术后3个月静脉尿路造影显示肾积水明显减轻,术后半年肾积水基本消失,血生化、电解质正常。结论:回肠替代输尿管时采用回肠壁外隧道抗反流技术是治疗输尿管长段狭窄的较好术式,具有操作简单、抗反流效果良好、术后并发症少等优点。     

Laparoscopic mesh-augmented hiatoplasty as a treatment of gastroesophageal reflux disease and hiatal hernias-preliminary clinical and functional results of a prospective case series

BACKGROUND: Because fundoplication-related side effects are frequent, we evaluated laparoscopic mesh-augemented hiatoplasty (LMAH) as a potential treatment option for gastroesophageal reflux disease and/or symptomatic hiatal herania. LMAH aims to prevent reflux solely by mesh-reinforced narrowing of the hiatus and lengthening of the intra-abdominal esophagus. METHODS: Twenty-two consecutive patients with LMAH were evaluated prospectively using a modified Gastrointestinal Symptom Rating Scale questionnaire, pH measurement, manometry, and endoscopy. Follow-up was scheduled at 3 and 12 months after surgery. RESULTS: Total reflux decreased from 16.3% before surgery to 3.5% 3 months after surgery (P = .001). The reflux score decreased from 3.8 before surgery to 2.1 1 year after surgery (P = .001). The respective values of the indigestion score were 3.4 and 2.0 (P < .001). After surgery, all patients were able to belch. Vomiting was impossible only for 2 patients, and 90% of patients assessed their results as good to excellent. CONCLUSIONS: LMAH seems to be feasible, safe, and has no significant side effects.     

Laparoscopic improves perioperative outcomes of antireflux surgery at US academic centers

Background

Open and laparoscopic antireflux surgeries are standard for the treatment of gastroesophageal reflux disease (GERD). The in-hospital outcomes of laparoscopic and open antireflux procedures were analyzed and compared at US academic medical centers.

Methods

Using International Classification of Diseases, Ninth Revision, Clinical Modification codes for 5,737 patients with GERD that underwent open (n = 1,377) or laparoscopic (n = 4,360) antireflux surgery were identified from the University Health-System Consortium Database over a 3-year period (2004-2007). Demographic and outcome data measured included length of stay, overall complications, in-hospital mortality, observed-to-expected mortality ratio (risk-adjusted mortality), and hospital costs.

Results

Laparoscopic antireflux procedures offered significantly lower mean length of stay, in-hospital morbidity, and hospital costs. Both procedures had a low observed to expected in-hospital mortality. Open surgery was associated with significantly higher procedure-related and pulmonary complications.

Conclusions

In the context of US academic centers, approximately three quarters of antireflux procedures are being performed using the laparoscopic approach. These data suggest that laparoscopy has improved in-hospital outcomes when compared with open surgery and is preferred for the surgical treatment of GERD.     

Prospective Study Examining the Impact of Multichannel Intraluminal Impedance on Antireflux Surgery

Background Reflux monitoring using combined multichannel intraluminal impedance (MII) and pH-metry increases the sensitivity for identifying gastroesophageal reflux episodes. The likelihood of a positive symptom index (SI) for patients with reflux disease (gastroesophageal reflux disease [GERD] or nonerosive reflux disease [NERD]) receiving proton pump inhibitor (PPI) treatment has been used to select candidates for antireflux surgery. Little is known about the advantages of MII-pH monitoring compared with pH monitoring alone for evaluating GERD/NERD patients off PPI treatment considered as candidates for antireflux surgery or for assessing changes in MII-pH-detected reflux episodes after antireflux surgery. This study aimed to determine the additional value of MII over pH-metry alone for patients off PPI treatment before and after antireflux surgery. Methods For this study 12 patients (4 women and 8 men; mean age, 45 years; range, 27–74 years) were evaluated using ambulatory MII-pH monitoring before and 3 months after mesh-augmented hiatoplasty. Reflux events were identified by MII-pH (A) and pH-metry (B) as patients recorded symptoms on a data logger. For each symptom, a symptom index was calculated for reflux events identified by MII-pH and by pH-monitoring alone. Results Preoperatively, MII-pH monitoring identified 71.9 ± 8.4 reflux episodes, whereas pH monitoring identified only 51.0 ± 7.8 (p < 0.05). Postoperatively, MII-pH monitoring identified 35.5 ± 6.6 reflux episodes, whereas pH monitoring identified only 19.6 ± 4.7 (p < 0.05). The pre- and postoperative symptom index for MII-pH monitoring was higher than pH monitoring (preoperative 91.7% vs 25%, p = 0.006; postoperative 50% vs 16.7%, p = 0.012). Conclusion Combined MII-pH-metry improves the pre- and postoperative assessment of GERD patients off PPI and results in a higher symptom-reflux association.     

Laparoscopic Fundoplication in Patients with a Hypertensive Lower Esophageal Sphincter

Background  A small proportion of patients evaluated with manometry prior to a fundoplication have a high-pressure lower esophageal sphincter (LES). This paper examines the outcome of laparoscopic fundoplication for these patients. Material and Methods  Between October 1991 and December 2006, 1,886 patients underwent primary laparoscopic fundoplication. Those with a high-pressure LES on preoperative manometry (LESP ≥30 mm Hg at end expiration) were identified from a prospective database. Long-term outcomes were determined using analogue symptom scores (0–10) for heartburn, dysphagia, and patient satisfaction and compared to those of a matched control group. Results  Thirty patients (1.6%), nine men and 21 women, median age 51 years, had a hypertensive LES (mean, 36 mmHg; range, 30–55). Median follow-up after fundoplication was 99 (12–182) months. These patients had similar mean symptom scores to 30 matched controls for heartburn (2.3 vs. 2.2, P = 0.541), dysphagia (2.7 vs. 3.1, P = 0.539), and satisfaction (7.4 vs. 7.6, P = 0.546). Five patients required revision for dysphagia compared to no control patients (P = 0.005). These patients had a higher preoperative dysphagia score (6.6 vs. 3.1, P = 0.036). Conclusion  Laparoscopic fundoplication can be performed with good long-term results for patients with reflux and a hypertensive LES. However, those with preoperative dysphagia have a higher failure rate.     

Ambulatory pH: monitoring with a wireless system

Background Currently, pH monitoring is the gold standard for assessing esophageal acid exposure in patients with gastroesophageal reflux disease (GERD). The shortcomings of 24-h pH-monitoring wires led to the development of a 48-h, catheter-free pH measurement system using the telemetry technique with the BRAVO capsule. This prospective study aimed to compare conventional 24-h pH monitoring with the BRAVO catheter-free pH-monitoring system in patients with GERD, patients after antireflux surgery, and a healthy control group. Methods A sample of 133 participants were enrolled in the current trial and divided into three subgroups. Group 1 consisted of 10 healthy volunteers. Group 2 consisted of 123 patients with symptomatic gastroesophageal reflux and endoscopic signs of esophagitis. Group 3 consisted of 43 GERD patients (extracted from group 2) who underwent a laparoscopic 360° “floppy” Nissen fundoplication. All the patients underwent both conventional 24-h pH monitoring and BRAVO catheter-free pH monitoring. The data for both methods were recorded and compared in line with the different patient groups regarding their validity and reliability. Additionally, all the patients were interviewed with a standardized questionnaire concerning their subjective perception of the two different methods. Results Both the 24-h pH monitoring and the 48-h BRAVO catheter-free pH monitoring could be successfully performed for all the patients. During measurement, 122 of the patients (92%) continued working or performing daily activities. A significant difference could not be found regarding objective outcome between the two measurement methods in the three patient groups. The two methods showed comparable results in terms of data and measurement reliability. The validity also was comparable, with no significant differences within the groups. Concerning the patients’ subjective estimation of the two methods, the patients reported reduced regular activities and a higher level of discomfort during measurement with the conventional 24-h pH-monitoring system (p < 0.001 and p< 0.0001, respectively). Conclusion Both conventional 24-h pH monitoring and the 48-h catheter-free pH monitoring are valid and reliable recording devices for measuring esophageal acid exposure. However, from the patients’ point of view, the BRAVO capsule affords less discomfort in the throat and allows more normal daily activities.     

Long-term follow up of surgically treated primary vesicorenal reflux

It is well known that the most serious complication of primary vesicoureteric reflux is chronic atrophic pyelonephritis or reflux nephropathy. The main goal in the management of vesicorenal reflux (VRR) is the prevention of progressive renal damage.The elimination of reflux and the eradication of infection are fundamental in order to achieve this goal. The authors performed a retrospective study in 146 pediatric patients operated upon by ureteral reimplantation for primary VRR; 78 operations were unilateral and 68 bilateral, for a total of 214 reimplanted ureters. The mean age at the time of operation was 4.8 years; the mean age at the time of the study was 15.8 years, and the average postoperative observation period was 13.5 years.The study included pre- and postoperative urine analysis and determinations of blood pressure, renal scarring and parenchymal growth, and evolution of renal function.The study showed that: (1) urinary concentrating ability in bilateral high-degree VRR (64 patients) remained reduced in a relatively high percentage of patients; (2) there was significant improvement (from 40.7% to 17.9%) in proteinuria that was related to favorable evolution of renal function (z = 4.152; P <0.01); (3) the frequency of acute pyelonephritis decreased from 41.4 to 3.4%, and only 20% of the patients had episodes of afebrile pathologic bacteriuria in the postoperative period (z = 7.647; P <0.01); (4) more than 15% of the patients were hypertensive (10.3%) or at risk for hypertension, having a high peripheral plasma renin activity (5.2%); (5) some renal scarring developed despite successful antireflux surgery, and usually parenchymal growth resumed; in about 6% of the renal units a further decrease in renal size occurred; and (6) renal function generally improved after successful surgery (z = 4.115; P <0.01). This favorable evolution was much more evident in patients operated upon in the first 2–3 years of life (z = 3.885; P <0.01). However, when the renal function was already severely compromised, an antireflux operation had little or no effect on the inexorable decline in renal function. Correspondence to: G. Belloli     

Radiologic and Endoscopic Characteristics of Laparoscopic Antireflux Wrap: Correlation With Outcome

After antireflux surgery for gastroesophageal reflux disease, 10% to 15% of patients may have unsuccessful results as a result of abnormal restoration of the esophagogastric junction. The purpose of this study was to evaluate the postoperative endoscopic and radiologic characteristics of the antireflux barrier and their correlation with the postoperative results. After surgery, endoscopic and radiologic features of the antireflux wrap were evaluated in 120 consecutive patients. Jobe''s classification of the postoperative valve was used for the definition of a “normal” or “defective” wrap. Patients were evaluated 3 to 5 years later in order to determine the clinical and objective failed fundoplication. A “normal” antireflux wrap was associated with successful results in 81.7% of the patients. On the contrary, defective radiologic or endoscopic antireflux wrap was observed in 19% of cases. Among these patients, hypotensive lower esophageal sphincter was observed in 50% to 65% of patients, abnormal 24-hour pH monitoring in 91%, and recurrent postoperative erosive esophagitis in 50% of patients, respectively (P < 0.001). “Defective” antireflux fundoplication is associated with recurrent reflux symptoms, presence of endoscopic esophagitis, hypotensive lower esophageal sphincter, and abnormal acid reflux.