Mechanisms underlying the antireflux effect of Nissen fundoplication in children

BACKGROUND/PURPOSE: It is reported that the main mechanism responsible for gastroesophageal reflux (GER) is transient lower esophageal sphincter (LES) relaxation in children. However, the effect of Nissen fundoplication on transient LES relaxation has not been investigated in children. This study examined the effect of Nissen fundoplication on motor patterns of the LES in children with pathological GER. METHODS: Esophageal manometry and pH were recorded concurrently for 2 hours after administration of apple juice (10 mL/kg). In seven children documented to have pathological GER by prolonged esophageal pH monitoring (%time pH less than 4.0>5.0), studies were performed preoperatively and 1 to 3 months after surgery. RESULTS: Nissen fundoplication virtually eliminated reflux in all patients. Percentage of time pH was less than 4.0 reduced from 15+/-9 to 0+/-0. Basal LES pressure did not change significantly (pre, 21+/-10 mm Hg v post, 27+/-9 mm Hg). The number of transient LES relaxation reduced significantly from 13+/-4 to 7+/-7, and the mean nadir LES pressures during swallow-induced LES relaxation and transient LES relaxation increased significantly from 1+/-1 mm Hg to 13+/-5 mm Hg and from 0+/-0 mm Hg to 11+/-7 mm Hg, respectively. CONCLUSIONS: Our findings suggest the antireflux effects of Nissen fundoplication may be based on changes of LES motor patterns that result in incomplete LES relaxation and reduction of the number of transient LES relaxation.     

Pitfalls and complications of colon interposition

Colon interposition is a complex operation that requires meticulous technique and attention to detail. In experienced hands, the colon is a valuable conduit for esophageal reconstruction, particularly in patients with benign disease.     

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.     

Pitfalls and complications of esophageal prosthesis, laser therapy, and dilation

Although often diagnosed and treated by gastroenterologists, thoracic surgeons should be skilled partners in the management of esophageal obstruction. Knowledge of pitfalls and complications of any procedure is a prerequisite to success. This article focuses on problems encountered in dilatation, laser ablation, and stenting of esophageal strictures. Dilatation of both benign and malignant strictures requires knowledge of the different types of dilators and the ability to adapt to different stricture characteristics. Although lower morbidity makes laser ablation of malignant obstruction attractive, this author finds its use to be restrictive. The advent of expandable metal stents offers the potential for fewer early complications when compared with plastic protheses but, as discussed, morbidity may be different rather than less.     

Regression of childhood Barrett's esophageal mucosa by antireflux surgery and bipolar electrocoagulation

The authors report a case of a 13-year-old girl with Barrett's esophagus who underwent antireflux surgery and was subsequently treated with endoscopic thermal coagulation using bipolar electrocoagulation. Follow-up endoscopy 15 months after completion of the endoscopic therapy showed normal esophageal mucosa without intestinal metaplasia. Longer follow-up is needed to assess the long-term effects of endoscopic treatment of the Barrett's mucosa with thermal coagulation, and this procedure should still be considered under investigation.     

Laparoscopic antireflux surgery and the thoracic surgeon: what now?

OBJECTIVE: Minimal invasive antireflux surgery is now a well accepted technique gaining a wide spread popularity. Simultaneously there is a growing tendency to fit all surgical candidates into one single type of operation, i.e. laparoscopic Nissen antireflux operation. This study evaluates the impact of this new technology on the strategy and practice of a major referral centre for antireflux surgery. METHODS: An analysis was made of indications for the different types of antireflux techniques performed between July, 1993 and 1995. If on Barium swallow the gastro-oesophageal (GO) junction proved to be reducible, a laparoscopic approach was proposed, if not, an open transthoracic access was preferred. RESULTS: One hundred and fifteen patients were operated. Fifty five patients underwent a minimal invasive approach: 49 Nissen (are the total fundoplication) and 3 Lind (are the partial fundoplication) operations through laparoscopy, 3 Belsey Mark IV through video assisted thoracic surgery (VATS). Sixty patients were treated by open surgery for following reasons: conversion to open surgery in 2 cases, redo surgery in 15 cases, previous other major abdominal surgery in 12, irreducible GO junction in 5, paraoesophageal or mixed type hernia in 12, Barrett and or oesophagitis IV in 4, combined antireflux surgery and feeding gastrostomy in 5, abdominal partial fundoplication by principle in 1, associated motility disorder in 1, combined reflux and gastric ulcer disease in 2, and severe emphysema in 1. In the laparoscopic series reflux control at 1 year post surgery as measured by 24 h pH study in 28 patients was obtained in 89.5%. One patient required a reoperation for symptomatic recurrence. CONCLUSIONS: (1) Laparoscopic antireflux surgery is a feasible and well accepted technique; (2) careful study of each individual patient is of paramount importance to choose the correct type of operation and access as well. Therefore, fitting every patient into a single type of operation, i.e. laparoscopic Nissen, should be avoided; (3) thoracic surgeons with a major interest in GO reflux disease should familiarize themselves with laparoscopic antireflux procedures.     

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.     

Vitreoretinal complications in cataract surgery. I. Retinal detachment

OBJECTIVE: We raise the issue of scanning multifetal pregnancies of higher order as early as possible. A rare case of monochorionic/quadramniotic pregnancy seeking multifetal pregnancy reduction and its clinical management is presented. METHODS: Transabdominal scanning at 16 weeks was performed correctly diagnosing the monochorionic quadruplet pregnancy. RESULTS: Suspecting vascular connections between the placentae, the fetal reduction was declined. The patient was delivered at 31 weeks. The 4 female neonates survived with slight ventilatory assistance. CONCLUSION: Multifetal pregnancies in general, but those of higher order in particular, have to be scanned as early as 8-10 weeks to correctly and easily assign their chorionicity and amnionicity. The case of a monochorionic/quadramniotic pregnancy and its clinical course are presented.     

Urinary tract infections and pregnancy in women who underwent antireflux surgery in childhood

PURPOSE: For several decades ureteroneocystostomy has been performed in children to correct primary vesicoureteral reflux. A purported indication for antireflux surgery is to prevent significant upper urinary tract infection during pregnancy. We performed a long-term followup of women who underwent antireflux surgery during childhood to determine outcome in regard to urinary tract infection history and pregnancy. MATERIALS AND METHODS: We identified 227 women of childbearing age who underwent ureteral reimplantation for primary vesicoureteral reflux from 1964 through 1981. Of the 122 women contacted 41 had been pregnant (77 total pregnancies). Cystitis or asymptomatic bacteriuria and pyelonephritis developed during 18 and 5 pregnancies, respectively. The 77 pregnancies resulted in 57 term births, 7 voluntary pregnancy interruptions and 13 spontaneous abortions. RESULTS: Patients who previously underwent successful antireflux surgery continued to have a significant number of urinary tract infections through the intervening years. Despite a higher than expected incidence of pyelonephritis, they had relatively little hypertension and renal insufficiency. During pregnancy the incidence of pyelonephritis was only slightly higher than that of the general population. However, severe complications of pregnancy, such as preeclampsia, premature birth and acute renal failure, occurred more frequently in women with a history of renal scarring or hypertension (7 of 12) than in those with a history of recurrent infection alone (3 of 10). CONCLUSIONS: When renal scarring is present, reflux should be corrected before pregnancy to minimize maternal and fetal morbidity. When scarring is not present, the literature suggests that women with a history of reflux are at increased risk for pyelonephritis during pregnancy whether or not ureterocystostomy was performed. Pregnant women with a history of reflux may benefit from prophylactic antibiotics and women with reflux nephropathy should be followed throughout life.     

Laparoscopic versus open Nissen fundoplication: outcome of surgery in monozygotic twins

Many clinicians use ultrasonics for root-end preparations. The purpose of this study was to evaluate resected root-end surfaces of bilaterally matched human teeth for cracks before and after ultrasonic root-end preparation. Twenty matched pairs of extracted single rooted teeth were divided into two experimental groups. In group 1, root-end resection was performed on uninstrumented teeth. In group 2, root-end resection was performed after the canals were instrumented and filled with gutta-percha. All teeth in both groups received root-end preparations using ultrasonic instrumentation at low power. Two examiners evaluated the root-ends after root-end resection and again after root-end preparation using zoom magnification of 20x to 63x. The number, types, and location of cracks were mapped. There were no significant differences when gutta-percha filled roots were compared to uninstrumented roots with regard to the number or type of cracks after root-end resection or root-end preparation. In addition, there were no significant differences in the number or type of cracks following root resection and ultrasonic root-end preparation when compared to teeth with root resection alone.     

Management of hysteroscopic surgery complications

Hysteroscopic surgery is considered a safe, routine gynecologic procedure performed in the OR and in office settings. Complications are rare; however, when complications do occur they can be severe and rapid. The surgical team members must understand the significance of patient monitoring and proper equipment operation to ensure positive patient outcomes. This article discusses complications from intravasation of various distending media used during hysteroscopy and the complication of hyponatremia. A physiologic approach to these problems enhances awareness of the significance of patient monitoring during hysteroscopic procedures.     

Iatrogenic complications of endonasal surgery

It has been suggested that the most likely cause of the Testicular Regression Syndrome (TRS) is ante-natal torsion of the testis. As testicular torsion is twice as common on the left this theory cannot explain the incidence of right sided or bilateral cases. From a 5-year retrospective surgical and pathological review, we confirmed that the left testis was the most commonly affected, that boys with TRS tended to be delivered closer to term, and that frequently both testes were present at birth, but one or both subsequently vanished. We also found that direct trauma can produce histological findings indistinguishable from TRS. Close to term, fetal testes are liable to be intrascrotal and therefore susceptible to direct trauma. As the left testis descends into the scrotum at an earlier stage than the right, it is therefore at greater risk of injury. Since the findings of TRS can be produced by direct trauma, we suggest that intra-partum trauma may predispose to the TRS.     

Outcome of open antireflux surgery as assessed in a Nordic multicentre prospective clinical trial. Nordic GORD-Study Group

OBJECTIVE: To evaluate the outcome of antireflux surgery in various hospitals in Scandinavian countries. DESIGN: Partly randomised controlled study, and partly open study. SETTING: Hospitals throughout Norway, Sweden, Denmark and Finland. SUBJECTS: 310 patients with chronic reflux disease and oesophagitis who were initially entered into a randomised controlled study of omeprazole and antireflux surgery. INTERVENTIONS: Total fundic wrap, partial fundoplication, or omeprazole. MAIN OUTCOME MEASURES: Control of symptoms at one year. RESULTS: 154 patients who had their symptoms of reflux completely controlled with omeprazole were initially randomised to have an open operation but 10 refused, leaving 144 for analysis. 34 patients who had only a partial response were also offered operation; 120/178 (68%) had a total fundic wrap, and 53 (30%) partial fundoplication. 6 patients had postoperative complications that required reoperation and 123 made a completely uneventful recovery. Reflux was controlled in most patients, and only 10 (6%) required further treatment with omeprazole. The outcome in those patients who only responded partially to omeprazole was similar to that in patients who had a complete response. CONCLUSION: The outcome of antireflux surgery throughout Norway, Sweden, Denmark, and Finland is good.     

Laparoscopic surgery complications: pneumothorax and pneumomediastinum. Description of two cases

After having illustrated the surgical "advantages" of laparoscopic procedures, the authors discuss the negative aspects of this technique on the anaesthesiological management of the patient. Two cases of pneumothorax during Nissen fundoplicatio are illustrated and the deranged parameters, that allow a precocious diagnosis, are extensively analyzed.     

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.