Revision of failed transoral incisionless fundoplication by subsequent laparoscopic Nissen fundoplication

AIM:To evaluate the feasibility and outcomes of laparoscopic Nissen fundoplication after failed transoral incisionless fundoplication(TIF).METHODS:TIF is a new endoscopic approach for treating gastroesophageal reflux disease(GERD).In cases of TIF failure,subsequent laparoscopic fundoplication may be required.All patients from 2010 to 2013 who had persistence and objective evidence of recurrent GERD after TIF underwent laparoscopic Nissen fundoplication.Primary outcome measures included operative time,blood loss,length of hospital stay and complications encountered.RESULTS:A total of 5 patients underwent revisional laparoscopic Nissen fundoplication(LNF)or gastrojejunostomy for recurrent GERD at a median interval of 24mo(range:16-34 mo)after TIF.Patients had recurrent reflux symptoms at an average of 1 mo following TIF(range:1-9 mo).Average operative time for revisionalsurgical intervention was 127 min(range:65-240 min)and all surgeries were performed with a minimal blood loss(<50 m L).There were no cases of gastric or esophageal perforation.Three patients had additional finding of a significant hiatal hernia that was fixed simultaneously.Median length of hospitalization was 2 d(range:1-3 d).All patients had resolution of symptoms at the last follow up.CONCLUSION:LNF is a feasible and safe option in a patient who has persistent GERD after a TIF.Previous TIF did not result in additional operative morbidity.     

Development of achalasia secondary to laparoscopic Nissen fundoplication

Dysphagia after laparoscopic Nissen fundoplication (LNF) is commonly attributed to edema and/or improperly constructed wraps, and in some instances the cause can be difficult to identify. We report, for the first time, the development of secondary achalasia after LNF as a cause of late-onset postoperative dysphagia. A total of 250 consecutive patients undergoing LNF were analyzed for the development of postoperative dysphagia at a university hospital. Patients were considered to have secondary achalasia if they met the following four criteria: (1) preoperative manometry demonstrating normal peristalsis and normal lower esophageal sphincter (LES) relaxation; (2) lack of esophageal peristalsis on postoperative manometry or fluoroscopy with or without incomplete LES relaxation; (3) no mucosal lesions seen on endoscopy; and (4) dysphagia refractory to dilatation. The following three groups of patients were identified: patients who developed secondary achalasia (group A, n = 7); patients with persistent dysphagia requiring and responding to postoperative dilatation (group B, n = 12 patients); and patients whose postoperative recovery was not complicated by dysphagia (group C, n = 231). The groups were comparable in terms of all preoperative variables except for age. Patients in group A were older than those in group B (57 years [range 27 to 66 years] vs. 36.5 years [range 27 to 63 years], P = 0.028) but were not significantly older than patients in group C (45 years [range 20 to 84 years], P = 0.42). The onset of severe dysphagia was later in group Athan in group B (135 days [range 15 to 300 days] vs. 20 days [range 9 to 70 days],P = 0.002). The median weight loss in group A was also significantly greater than in Group B (15 pounds [range 11 to 44 pounds] vs. 4 pounds [range 0 to 15 pounds], P = 0.0007). Two patients in group A who underwent reoperation failed to improve. Botulinum toxin injections were tried in two patients and Heller myotomy in one with good results. Nine patients in group B improved promptly after one dilatation, and three improved after two dilatations. Secondary achalasia should be considered as one of the causes of persistent dysphagia after an apparently successful antireflux operation. Secondary achalasia tends to occur in older patients and is characterized by a delayed onset of symptoms. Imaging studies are a reliable means of excluding mechanical obstruction as a cause of secondary achalasia, and a negative result should raise the suspicion of secondary achalasia. Esophageal motility studies are necessary to confirm the diagnosis. Failure to consider the diagnosis of secondary achalasia can lead to multiple fruitless attempts at dilatation or even inappropriate reoperations. Presented at the Forty-Second Annual Meeting of The Society for Surgery of the Alimentary Tract, Atlanta, Georgia, May 20–23, 2001 (oral presentation).     

3D腹腔镜疝修补术联合胃底折叠术治疗食管裂孔疝53例临床分析

目的 探究3D腹腔镜疝修补术联合胃底折叠术治疗食管裂孔疝的可行性及疗效.方法 回顾性分析2012年3月至2016年5月于潍坊市人民医院普外科行3D腹腔镜疝修补术联合胃底折叠术治疗食管裂孔疝53例患者的临床资料,总结其治疗情况.结果 53例手术均顺利完成,手术时间(121.6 ±17.5)min,术中出血量(51.7 ±6.7)mL,术后住院时间(4.3 ± 1.6)d,无胃食管穿孔、气胸等并发症,术后3例出现吞咽困难(Nissen法2例,Toupet法1例),53例患者随访时间为24个月,随访率100%,49例患者临床症状完全消失,4例偶伴有反酸、烧心(Dor法2例,Toupet法2例),无复发病例.结论 3D腹腔镜疝修补术联合胃底折叠术治疗食管裂孔疝是安全、有效、可行的,可取得较好的治疗效果.     

Cardiorespiratory changes during laparoscopic fundoplication in children

The results of a prospective assessment of cardiorespiratory changes related to anaesthesia and laparoscopic Nissen fundoplication are described in 25 children aged 1.2 to 14.3 years, weighing 9.0 to 64.0 kg. Respiratory disease or oesophagitis were present in 68% cases. During balanced inhalational anaesthesia, hypotension or bradycardia occurred prior to peritoneal insufflation in three cases of reverse Trendelenburg position. During surgery, intra-abdominal pressure was in the 6–10 mmHg range. Transiently, two patients were hypotensive while ten were hypertensive. PETCO₂ gradually increased but only two patients required increased minute ventilation. One bronchial intubation episode developed. Airway complications were related to isoflurane administration. Postoperatively, transient hypoxia (25% cases) was observed during the first 3 h. Analgesia duration was in the 40–1440 min range. Hospital stay was 5.6 ± 1.5 days (mean ± SD). Laparoscopic paediatric fundoplication is safe when hypovolaemia and postoperative hypoxia are prevented.     

Dumping syndrome after combined pyloroplasty and fundoplication

Dumping syndrome in infancy is a rare complication following gastric surgery. We describe an 11-monthold infant affected by recurrent peptic oesophagitis who underwent a combined Nissen fundoplication and pyloroplasty. Early dumping symptoms such as irritability, pallor, sweating, abdominal distension and watery diarrhoea were observed postoperatively after bolus feeding. Gastric emptying, measured after the administration of 150 ml of regular cow milk mixed with 200 Ci (8 MBq) of technetrum-99m sulfur colloid (^99mTc-SC), demonstrated an early rapid and massive emptying of the isotopes into the small intestine, followed by duodenogastric reflux and a second wave of emptying and reflux at 9 min. The initial pattern of gastric emptying and duodenogastric reflux was followed by a slow emptying phase with half-emptying time of 81 min. Isotope studies should be used to investigate motility disorders caused by this type of anti-reflux operation.     

Esophageal achalasia: current diagnosis and treatment

Introduction: Esophageal achalasia is a primary esophageal motility disorder of unknown origin, characterized by lack of peristalsis and by incomplete or absent relaxation of the lower esophageal sphincter in response to swallowing. The goal of treatment is to eliminate the functional obstruction at the level of the gastroesophageal junction.

Areas covered: This comprehensive review will evaluate the current literature, illustrating the diagnostic evaluation and providing an evidence-based treatment algorithm for this disease.

Expert commentary: Today, we have three very effective therapeutic modalities to treat patients with achalasia – pneumatic dilatation, peroral endoscopic myotomy, and laparoscopic Heller myotomy with fundoplication. Treatment should be tailored to the individual patient, in centers where a multidisciplinary approach is available. Esophageal resection should be considered as a last resort for patients who have failed prior therapeutic attempts.     

Laparoscopic fundoplication in children: anaesthetic experience of 51 cases

We report the anaesthetic management and outcomes of our first 51 laparoscopic fundoplications. Case records of the 50 patients (one redo), median age 6 years (5 months to 20 years), were reviewed. Median duration of anaesthesia was 120 (60-300) min. During the procedure, the heart rate and blood pressure increased by more than 20% over baseline in 18% and 12% cases, respectively. Median increase in PECO2 was 1.0 (0.3-2.3) kPa [7.6 (2.3-18) mmHg]. After surgery, all but one of the patients were managed on a normal surgical ward. Postoperative analgesia requirement was oral or rectal analgesics in 89% of patients and ceased within 48 h of surgery in 95% patients. Median time to discharge home from day of operation was 2 (1-9) days. We conclude that laparoscopic fundoplication in children is well tolerated, there is no requirement for routine postoperative high dependency care and analgesic requirements are minimal.     

Anti‐reflux surgery for patients with esophageal atresia

Gastroesophageal reflux (GER) is almost constant in esophageal atresia and tracheoesophageal fistula (EA/TEF). These patients resist medical treatment and require antireflux surgery quite often. The present review examines why this happens, the long‐term consequences of GER and the main indications and results of fundoplication in this particular group of patients. The esophagus of EA/TEF patients is malformed and has abnormal extrinsic and intrinsic innervation and, consequently, deficient sphincter function and dysmotility. These anomalies are permanent. Fifty percent of patients overall have GER, and one‐fifth have Barrett's metaplasia. Close to 100%, GER of pure and long‐gap cases require fundoplication. In the long run, these patients have 50‐fold higher risk of carcinoma than the control population. GER in EA/TEF does not respond well to dietary, antacid, or prokinetic medication. Surgery is necessary in protracted anastomotic stenoses, in pure and long‐gap cases, and when there is an associated duodenal atresia. It should be indicated as well in other symptomatic cases when conservative treatment fails. However, confection of a suitable wrap is anatomically difficult in this condition as shown by a failure rate of 30% that is also explained by the persistence for life of the conditions facilitating GER.     

Modified Dor fundoplication technique following diverticulectomy and myotomy for epiphrenic diverticulum combined with esophageal motility disorders: prevention of esophageal leak at the diverticulectomy staple line

Surgery is the standard treatment for patients with pulmonary or incapacitating symptoms related to an epiphrenic diverticulum combined with esophageal motility disorders. Leakage from the staple line at the diverticulectomy site is a severe complication because of the lack of proper esophageal muscle. When the staple line that lacks the proper muscle is wider than expected, interrupted suturing may cause the muscle to tear because of the lack of adventitia of the esophagus, or esophageal stenosis may occur as the result of a tight suture. We propose that an antireflux wrap should be used to cover over the staple line to prevent esophageal leaks. Even if a staple line leak occurred, a major leak and mediastinitis can be avoided when the muscle defect is completely covered by a fundus.