Reoperation after gastroesophageal reflux surgery

In a group of 19 patients reoperated after a primary operation on account of gastrooesophageal reflux the authors demonstrate that the reason for reoperation can be either a relapse of the reflux or also other complaints (most frequently dysphagia). The selection of a suitable operation is strictly individual. Cases of a short oesophagus are most difficult to resolve. The decisive factor is a correct surgical approach-laparotomy or thoracotomy.     

Results of antireflux surgery in infants with vesicoureteral reflux

The mechanism underlying the reduced Cu status in rats fed on a high-sulphide diet was investigated. Male rats aged 6 weeks were fed ad libitum on purified diets containing either 0 or 500 mg S2-/kg and demineralized water for a period of 2 weeks. The high-sulphide diet had no effect on feed intake, body-weight gain or weight of liver and kidney but significantly reduced Cu concentrations in plasma and kidney. Biliary Cu excretion was decreased significantly in rats fed on the high-sulphide diet. Apparent Cu absorption (Cu intake-faecal Cu) and true Cu absorption (Cu intake-(faecal Cu-biliary Cu)) were significantly lowered after sulphide feeding for 2 weeks. Rats fed on the high-sulphide diet excreted less Cu in urine than did the controls. We conclude that high sulphide intake reduces Cu status in rats through inhibition of Cu absorption which is reflected by a decrease in biliary Cu excretion as a secondary feature.     

Persistent gastroesophageal reflux disease after antireflux surgery in children: I. immediate postoperative evaluation using extended esophageal pH monitoring

PURPOSE: There is a paucity of quantitative and reproducible follow-up data on childhood operations for gastroesophageal reflux disease (GERD). With the development of minimally invasive techniques for antireflux operations in children, there is a need to quantitatively determine immediate outcomes for such operations performed by laparotomy for comparison. METHODS: A retrospective review of 385 children (age range, 1 week to 15 years) who had a primary antireflux operation in a Children's or University Hospital performed by laparotomy between 1983 and 1997, and who also had an extended esophageal pH study performed within the first 12 postoperative weeks, was conducted. The operations performed included Nissen fundoplication (n = 135), Thal fundoplication (n = 195), and Boerema gastropexy (n = 55). An immediate postoperative failure of the operation to control GERD was defined as an abnormal esophageal pH score persisting up to the twelfth postoperative week. RESULTS: Eleven patients (2.9%) were classified as having an immediate postoperative failure of their operation to control GERD. An additional three patients had an abnormal esophageal pH score 2 weeks postoperatively, which subsequently reverted to a normal esophageal pH score by 12 weeks. The immediate postoperative failure rate was 1.5% (2 of 135) for the Nissen fundoplication, 1.5% (3 of 195) for the Thal fundoplication, and 10.9% (6 of 55) for the Boerema gastropexy. A higher failure rate (five patients, 36%) was seen for the first 14 patients who underwent a Boerema gastropexy during the learning curve period for this operation before 1985, and by excluding these patients the failure rate was 2.4% (1 of 41) after 1985. There was no significantly increased probability of immediate postoperative failure in patients with central nervous system disorders, prematurity, repaired esophageal atresia, or gastric emptying abnormalities. Only 5 (36%) of the 14 children with persisting symptoms suggestive of GERD had immediate postoperative failure of their operation. CONCLUSIONS: Extended esophageal pH monitoring during the first 12 postoperative weeks is a helpful tool to assess the immediate outcome of antireflux operations in children because clinical symptoms alone may be unreliable. The immediate failure rate for an antireflux operation performed in children by laparotomy is very low and seems to be unaffected by comorbid factors.     

Recent advances in surgery for colon and rectal cancer

Surgery is the mainstay of therapy for colon and rectal cancer. Over the past several decades, there have been important advances both in the understanding of the biology of colon and rectal cancer and in the preoperative and operative techniques for treating this disease. Although it appears in some studies that we have made a difference in the survival rates in the treatment of colon and rectal cancer, in actual fact, this phenomenon may only be secondary to better staging and, therefore, a greater ability to prognosticate a particular patient's chance of cure. What has been learned in the past 20 to 30 years is that most colon and rectal carcinomas start as polyps of the colon and rectum. Most often, polyps are sporadic, but there are certain high-risk groups that produce polyps and, consequently, colon and rectal cancer at a much higher rate. The goal of a practicing physician is to identify these high-risk individuals and to recommend frequent screenings so as to intervene before a polyp has had a chance to become a deeply invasive cancer. These high-risk groups are best typified by familial adenomatous polyposis, which if left untreated will, in 100% of cases, lead to the death of a patient from colon or rectal cancer. Other diseases that lead to an increase in colon and rectal cancer but may not go through the usual adenoma-to-carcinoma sequence include inflammatory bowel disease such as Crohn's colitis and ulcerative colitis. Most patients with colorectal carcinoma are asymptomatic at the time of diagnosis. This phenomenon has led to efforts to screen the general population for polyps and for cancer. Screening techniques such as the detection of occult blood in the stool and endoscopic procedures are currently the most popular. It is unclear at this time exactly what the efficacy of these techniques is in improving the survival of the general population from colorectal carcinoma. The surgical techniques to remove colon and rectal carcinomas have recently expanded to include a more aggressive local excision policy for small tumors of the rectum and the application of laparoscopic techniques, new stapling techniques, and new anastomosing techniques for tumors of the colon and rectum. These techniques have become possible in part through advances in surgical instrumentation and also in part from our increasing understanding of the biology of the disease. Both have allowed for more creative approaches to diagnosing and treating colon and rectal cancer.(ABSTRACT TRUNCATED AT 400 WORDS)     

Comprehensive 1-year cost analysis of open antireflux surgery in Nordic countries. Nordic GORD Study Group. Gastro-oesophageal reflux disease

BACKGROUND: Antireflux surgery is a highly effective treatment option in patients with severe gastro-oesophageal reflux disease. However, because of the increasing pressure of cost containment within health care, cost aspects must also be added to the decision-making process. METHODS: The aim of this analysis was to assess the total cost of open antireflux surgery during the first year after operation in 178 patients with chronic reflux, who were recruited into a controlled, prospective clinical trial. The study was carried out in 17 hospitals in the Nordic countries. RESULTS: The cost of the operation represented more than 90 per cent of the direct medical costs which amounted to approximately US $5700. For a patient in the work force the indirect cost, i.e. loss of production, represented 47 per cent of the total cost, which was about US $10800. CONCLUSION: The total cost profile of open antireflux surgery has now been established prospectively and can form a basis for future comparisons.     

The learning curve associated with laparoscopic antireflux surgery in infants and children

Laparoscopic fundoplication is an effective method for treating gastroesophageal reflux in infants and children. Some surgeons prefer the traditional open technique and have concerns regarding complications associated with laparoscopic surgery as well as the time length of operation. This report addresses these concerns in a retrospective review of the first 160 consecutive pediatric patients who underwent laparoscopic fundoplication. "Learning Curves" as a function of surgical experience are presented highlighting some of the lessons learned while developing the laparoscopic fundoplication technique.     

Experience of 143 cases of laparoscopic surgery in urology--clinical outcome in comparison to open surgery

(BACKGROUND). The clinical outcome of laparoscopic surgery performed in 143 patients, including laparoscopic adrenalecotmy, nephrectomy, pelvic lymph node dissection (PLND) and varicocele ligation is reported. (METHODS). In patients who underwent laparoscopic adrenalectomy (32 cases), laparoscopic nephrectomy (7) or PLND (44), the following parameters were evaluated and compared to those obtained in patients undergoing the same surgeries but by conventional open procedure; operation time, hospital stay, pain killer doses and the time necessitated for ambulation. (RESULTS). The operation was successful in 95.8% (137/143). Open laparotomy was necessitated in 4 patients to control bleeding (two in adrenalectomy and two for PLND) and in one nephrectomy case due to massive adhesion with the descending colon. The major complication occurred in 4.2% of the cases, but without mortality. The laparoscopic adrenalectomy, nephrectomy and PLND had an average operating time of 260, 304 and 139 minutes, respectively, while the open surgery for each procedure required 251, 212 and 128 minutes, respectively (p = 0. 24 approximately 0.82). Likewise, the total dose of pain killer was 0.8, 1.8 and 0.9 for the former, whereas it was 3.2, 6.0 and 3.9 for the latter, respectively (p < 0.01). The average hospital stay for laparoscopic surgery was 4.9, 6.4 and 4.7 days in the same order, whereas open adrenalectomy or nephrectomy required about 14 days (p < 0.001). Convalescence was completed within significantly shorter term in patients with laparoscopic surgery. Potential complications of laparoscopic surgery included not only those unique to pneumoperitoneum (8.1%), but also those which may be encountered during any endoscopic operation such as compartment syndrome in the lower extremities. The physiologic changes accompanying increased intra-abdominal pressure affected renal function, characterized by a significant decrease in urinary output (p < 0.02), which, however, resumed to normal range within several hours after the operation without causing permanent renal dysfunction. (CONCLUSION). These results suggest that the laparoscopic surgery in certain area in urology has less morbidity and equal accuracy compared with conventional open surgery.     

Contemporary medical therapy for gastroesophageal reflux disease

Gastroesophageal reflux disease is a chronic disorder that requires long-term therapy in most patients. The appropriate medical therapy should be individualized to the severity of symptoms, the degree of esophagitis and the presence of other acid-reflux complications. Lifestyle changes should form the basis of any therapeutic approach. In patients with mild to moderate disease, initial therapy with histamine H2-receptor antagonists in conventional dosages is suggested. Prokinetic agents are potentially useful in patients with impaired esophageal or gastric motor function, but their efficacy as single agents does not appear to surpass that of standard doses of H2 blockers. Sucralfate, a cytoprotective agent, is an additional therapeutic option. For patients with more severe disease, omeprazole and lansoprazole provide unequaled healing rates and accelerated symptom relief. In most patients, maintenance therapy is vital. Surgery is indicated in patients whose disease is refractory to medical therapy and in those who develop complications not amenable to medical therapy.     

Basic considerations in gastroesophageal reflux disease

The cause of foregut symptoms is often quite uncertain until a comprehensive evaluation has been performed. The critical elements of this evaluation include historic, radiographic, endoscopic, and physiologic data, and most importantly, the insight of a mature diagnostician. Patients who are not evaluated in a comprehensive way are at risk for serious postoperative problems; surgeons who perform interventions without appropriate diagnostic support may have to deal with these unhappy patients. In the long run, a complete workup provides the guidance for treatment and is cost-effective.     

Evaluation of laparoscopic Toupet fundoplication as a primary repair for all patients with medically resistant gastroesophageal reflux

BACKGROUND: This prospective study assesses the outcome results in 100 consecutive patients with gastroesophageal reflux disease (GERD) treated with a laparoscopic Toupet fundoplication. METHODS: GERD was confirmed by 24-h pH study and/or esophagogastroduodenoscopy (EGD). Pre- and postoperative symptoms, operative times, and perioperative complications were recorded on standardized data forms. Early follow-up was at 3 months and late follow-up, including 24-h pH, manometry, and EGD was at 22 months. RESULTS: Preoperative symptoms included heartburn (92%), regurgitation (58%), water brash (39%), and dysphagia (39%). Mean operative time was 3.2 hours. There were no conversions to celiotomy and there were no mortalities. The perioperative complication rate was 14%; 6% (5/83) of patients reported heartburn at 3 months and 20% (15/74) at 22 months. Early and late dysphagia was 20% (17/83) and 9% (7/74), respectively; 24-h pH testing was abnormal in 90% of symptomatic patients (9/10), 39% of asymptomatic patients (12/31), and 51% overall. CONCLUSIONS: Despite early improvement in reflux symptoms following laparoscopic Toupet fundoplications, there is a high incidence of recurrent GERD. Symptomatic follow-up underestimates the true incidence of 24-h pH-documented reflux. Based on these results we cannot recommend the laparoscopic Toupet repair for GERD patients with normal esophageal motility.     

Fundoplication for the treatment of gastroesophageal reflux in hiatal hernia

Blood pressure (BP) levels were recorded in 2223 male and 2205 female children and adolescents ranging in age from 7 to 18 years. In addition, 521 male adults (soldiers) ranging in age from 21 to 25 years were included in the study. Children and adolescents who participated in the survey were selected at random the Elementary and High Schools. The results of the study showed that a gradual increase occurred in the systolic, as well as in the diastolic component of blood pressure from 7 to 18 years of age. By contrast, there was no increase with age in the systolic and diastolic blood pressure in the young male adult subjects, who had BP measurements comparable to those observed in children. A child was characterized as hypertensive according to the criteria outlined by Master et al. Children with BP between the 90th and the 95th percentile were considered as suspect hypertensive, whereas those with BP exceeding the 95th percentile were considered definitely hypertensive. The overall incidence of hypertension in children in this survey was 3.1%.     

Respiratory manifestations of gastroesophageal reflux in children

Gastroesophageal reflux is often overlooked as both a cause and a complication of respiratory disease in children. The manifestations may be protean and may bear little clinical relationship to the gastrointestinal tract. However, a high index of suspicion for its potential role in unexplained respiratory symptoms may yield large benefits for the physician and patient alike.     

Laparoscopic hiatal herniorrhaphy with posterior fundoplication for gastroesophageal reflux

To clarify the underlying mechanism of limb apraxia in corticobasal degeneration (CBD), we investigated somatosensory evoked potentials in 5 patients with CBD, as compared with 12 age-matched control subjects. All patients presented with asymmetric limb apraxia, particularly of limb-kinetic type. N20 latencies were significantly prolonged following median nerve stimulation on the more apraxic side, but not on the less apraxic side. These results suggest that limb apraxia in CBD may, at least in part, be due to a disorder of somatosensory information processing involving the parietal cortex.     

Functional results of the laparoscopic treatment of gastroesophageal reflux (followup greater than 2 years)

Adjuvant immunotherapy with interferons and/or interleukin 2 (IL-2) is widely used for advanced kidney cancer. However, the results are not satisfactory so far. The purpose of this study is to evaluate the inducible activity of lymphokine-activated killer (LAK) cells against autologous human renal cell carcinoma. The effect of interleukin 7 (IL-7) on IL-2-induced LAK activity was assessed by the autologous assay system which we have established. Peripheral blood lymphocytes from patients with renal cell carcinoma were stimulated with IL-2 and/or IL-7, and tested for antitumor activity against autologous renal cell carcinoma. In all 10 cases tested, IL-7 alone induced LAK activity. Moreover, IL-2-induced LAK activity was augmented by the concomitant addition of IL-7. Flow cytometry revealed an increase in IL-2-receptor-positive lymphocytes following incubation with IL-7. These results suggest that combination therapy using IL-2 and IL-7 may be a useful treatment for patients with advanced renal cell carcinoma.     

Wound metastases following laparoscopic and open surgery for abdominal cancer in a rat model

The recent application of laparoscopic resection techniques to malignant disease has raised safety concerns due to metastasis to surgical access wounds. The significance and incidence of this problem are controversial. In the present study a rat model, in which an implanted tumour was lacerated, was used to investigate whether application of laparoscopic techniques for malignant abdominal disease leads to an increased risk of tumour dissemination and implantation within the peritoneal cavity, and abdominal wall wounds. Malignant cells were implanted into the abdominal wall of 42 rats, resulting 7 days later in the growth of a tumour measuring 20-25 mm in diameter. There were three control groups: no surgery (n = 6); blunt manipulation of the tumour laparoscopically (n = 6); and blunt manipulation of the tumour at laparotomy (n = 6). Twenty-four rats underwent surgical laceration of the tumour capsule at either laparoscopy (n = 12) or laparotomy (n = 12). All rats were killed 1 week later, and examined for macroscopic evidence of tumour metastasis. The abdominal surgical wounds were excised for independent microscopic examination by a histopathologist. Growth of the primary tumour was greater in rats that had an operation than in unoperated controls, and was greater after laparotomy. However, wound metastases were five times more likely after laparoscopic tumour laceration than after the same procedure through an open incision (ten of 12 rats versus two of 12, P = 0.0033). Wound metastases following laparoscopic tumour manipulation are an important and real problem, with significant implications for the application of laparoscopic techniques to excise malignant disease in humans.     

Mechanisms of gastroesophageal reflux in healthy premature infants

A seroprevalence study for poliomyelitis was carried out on a sample of sera from a serum bank used for a vitamin A study. Vaccination coverage was satisfactory (80% or more) in five of nine provinces, although a prevalence of antibody to polio of 80% or more was found in all provinces. Serologic immunity (i.e., the prevalence of neutralizing antibodies) exceeded vaccination coverage, suggesting secondary spread of vaccine virus. However, whether or not water was supplied through a piped system was not associated with secondary spread of vaccine virus to nonvaccinated children. Seroprevalence studies are a valuable adjunct to acute flaccid paralysis surveillance, which is the standard surveillance instrument for the poliomyelitis eradication initiative. The use of available and suitable serum banks for seroprevalence investigations is a relatively cheap monitoring option that can yield very valuable information for the eradication initiative.     

Conservative therapy for gastroesophageal reflux in infants with obstructive pulmonary disease

Gastroesophageal reflux (GER) is a commonly recognized problem in infants. However, it is difficult to demonstrate a causal relationship between GER and recurrent obstructive pulmonary disease (ROPD) in infants. In this review, 3 infants with GER and severe ROPD experienced dramatic improvement with conservative GER therapy.