Surgical treatment of gastroesophageal reflux disease

Antireflux surgery is successful in 85-90% of eligible patients, with relief of symptoms, cure of oesophagitis and possibly prevention of progression of the dysplasia in a Barrett's oesophagus. The mortality in the latest publications is given as 0.05%. The morbidity, apart from recurrences, is not yet sufficiently known. Some 250 antireflux operations are performed annually in the Netherlands, fewer than 20% of the estimated requirement of 10 operations per 100,000 of the population per year, and also fewer than in Scandinavia. Nissen fundoplication (folding the fundus of the stomach around the entire circumference (360 degrees) of the oesophagus) is generally accepted as the standard primary operation. Nissen fundoplication during laparoscopy seems to be just as good. Results of randomized clinical trials will have to be awaited to prove this assumption. Belsey's operation (folding the fundus around 270 degrees of the circumference of the oesophagus via thoracotomy) is nowadays performed almost exclusively in recurrent reflux disease and in persistent dysphagia after a primary operation.     

Surgical treatment of gastroesophageal reflux disease

Modern techniques have substantially improved the outcome of surgical therapy for reflux. Surgery, therefore, should not be considered a method of last resort but instead a reasonable alternative to treat patients with abnormal reflux. Adequate preoperative staging of the disease helps design the most appropriate operation. Minimally invasive techniques improve exposure and enhance recovery. Control of symptoms is achieved in the great majority of patients, and complications are minimal if the operation is performed following basic principles of sound operative technique.     

Modern diagnosis of gastroesophageal reflux disease (GERD)

Typical dominant symptoms such as heartburn and regurgitation are very specific for the diagnosis of GERD. Unfortunately they are relatively insensitive. The diagnosis can be made reliably if mucosal breaks are present at endoscopy. In endoscopy-negative patients with atypical symtoms, the most accurate investigation is 24-hour pH-monitoring with symptom analysis. Another alternative which may prove more cost-effective is to start with a PPI-test (e.g. omeprazole 20 or 40 mg bid for one or two weeks) and to use the symptomatic response as a diagnostic test.     

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%.     

Laparoscopic Nissen fundoplication for the treatment of gastroesophageal reflux disease

The Nissen fundoplication is the most common operative approach to the correction of gastroesophageal reflux disease (GERD) in the United States. This report describes our success in performing this anti-reflux procedure laparoscopically in 28 patients with symptomatic GERD refractory to conventional medical therapy. Our laparoscopic technique does not differ significantly from the traditional, open Nissen fundoplication. After surgery, all patients reported symptomatic relief, and none required medication for the control of reflux symptoms. Oral feedings were begun on the first postoperative day, and patients were typically discharged on the second day after surgery. All but two patients resumed normal eating within an average of 26 days. Two patients experienced longer term postoperative dysphagia, including one who had undergone a highly selective vagotomy concurrent with the antireflux surgery.     

The retention of large particles (greater than 2mum) in fibrous filters

A simple method of testing fibrous filters to obtain the grade efficiency curve in the particle size range 2-22 mum is described. Dust collected by the method has been used to measure the retention efficency of model filters and it is shown that there is a maximun in the grade efficency curve. The influence of relative humidity on filter behaviour has been investigated. It is shown that the efficiency of filtration in high particle inertia systems increases with increasing relative humidity. It is considered that the reason for this is an increase in particle-fiber adhesion force.     

Duodenogastric reflux potentiates the injurious effects of gastroesophageal reflux

Experimental studies have shown that the severity of esophageal mucosal injury in gastroesophageal reflux disease is related to the reflux of both gastric and duodenal juice. The purpose of this study was to determine whether duodenal juice potentiates esophageal injury in patients with reflux disease or, in fact, causes no harm allowing acid and pepsin to do the damage. A total of 148 consecutive patients who had no previous gastric or esophageal surgery underwent endoscopy and biopsy, manometry, and 24-hour esophageal pH and bilirubin monitoring. Esophageal injury was defined by the presence of erosive esophagitis, stricture, or biopsy-proved Barrett's esophagus. Exposure to duodenal juice, identified by the absorbance of bilirubin, was defined as an exposure time exceeding the ninety-fifth percentile measured in 35 volunteers. To separate the effects of gastric and duodenal juice, patients were stratified according to their acid exposure time. One hundred patients had documented acid reflux on pH monitoring, and in 63 of them it was combined with reflux of duodenal juice. Patients with combined reflux (50 of 63) were more likely to have injury than patients without combined reflux (22 of 37; P < 0.05). When the acid exposure time was greater than 10%, patients with injury (n = 40) had a greater exposure to duodenal juice (median exposure time 17.2% vs. 1.1%, P = 0.006) than patients without injury (n = 5), but there was no difference in their acid exposure (16.9% vs. 13.4%). Patients with dysplasia of Barrett's epithelium (n = 9) had a greater exposure to duodenal juice (median exposure time 30.2% vs. 7.2%, P = 0.04) compared to patients without complications (n = 25), whereas acid exposure was the same (16.4% vs. 15%). Duodenal juice adds a noxious component to the refluxed gastric juice and potentiates the injurious effects of gastric juice on the esophageal mucosa.     

Laryngeal manifestations of gastroesophageal reflux before and after treatment with omeprazole

BACKGROUND: Laryngeal manifestations of gastroesophageal reflux disease are thought to be prevalent in our society. In general, diagnosis has been primarily based on symptoms. Historically, additional testing has included laryngoscopy, barium swallow, manometry, and single and double probe pH monitoring. METHODS: We assessed 96 patients who had symptoms suggestive of reflux laryngitis. We administered surveys grading their symptoms. All patients had standardized videolaryngostroboscopic evaluation and computerized acoustic analysis. Patients then received a uniform regimen of dietary restrictions and omeprazole (a proton pump inhibitor) for 12 weeks, after which they were retested. RESULTS: Using the new laryngoscopic grading system, we found that this regimen produced statistically significant improvement in all symptoms except granulomas. In patients with the pretherapy complaint of hoarseness, acoustic measurements of jitter, shimmer, habitual frequency, and frequency range all showed significant improvement. CONCLUSIONS: We conclude that in patients with symptomatic reflux laryngitis, standardized videolaryngoscopy and, if the patient is hoarse, acoustic analysis are useful techniques to aid diagnosis and monitor therapy. Antireflux therapy with omeprazole is effective, and improvement can be objectively shown with the techniques described.     

Comparison of the effect of lansoprazole and omeprazole on intragastric acidity and gastroesophageal reflux in patients with gastroesophageal reflux disease

A prospective study of the pharmacokinetics of itraconazole solution was performed in 11 patients who underwent allogeneic BMT (day of BMT = day 0) after a conditioning regimen including total body irradiation (TBI). Itraconazole solution (400 mg once a day) was given 7 days before BMT and continued up to the end of neutropenia unless another antifungal treatment was necessary. Blood samples were collected before itraconazole intake (Cmin) and 4 h later (Cmax) every other day for assays of itraconazole (ITRA) and its active metabolite hydroxy-itraconazole (OH-ITRA). The mean values of Cmin ITRA and OH-ITRA, respectively, were 287 +/- 109 ng/ml and 629 +/- 227 ng/ml at day -1 and 378 +/- 147 ng/ml and 725 +/- 242 ng/ml at day +1. The maximum Cmin values were observed at day +3. Six patients at day -1 (54%) and 8 at day +1 (72%) had satisfactory residual plasma concentrations of at least 250 ng/ml of unchanged ITRA. From day +1 to day +9, eight patients discontinued the itraconazole treatment, five of them had satisfactory plasma residual concentrations at this time. This work shows a good bioavailability of itraconazole oral solution during the early phase after allogeneic BMT, but more data are needed for the late phases.     

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.     

Function of the esophagus and stomach in gastroesophageal reflux

The recognition of abnormal DNA structure by proteins is fundamentally different from sequence-specific DNA binding. Recent crystal structures of uracil-DNA glycosylases show a novel uracil-binding pocket that explains the enzyme's selectivity for uracil-containing DNA and provide a structural basis for exploring the catalytic mechanism of amino-glycosylic bond cleavage.     

The ileal neobladder: complications and functional results in 363 patients after 11 years of followup

PURPOSE: Since 1986 orthotopic lower urinary tract reconstruction using the ileal neobladder has been our diversion of choice in patients of both sexes undergoing cystectomy. We report on experience and functional results of the first 363 men 11 years after this procedure. MATERIALS AND METHODS: Complications were assessed, tabulated, subdivided into early (3 months or less postoperatively) and late types, and further categorized with respect to relationship to neobladder construction. Continence and voiding pattern were individually evaluated via a detailed patient questionnaire. RESULTS: Perioperative death occurred in 11 patients (3%). Neobladder related early and late complications occurred in 56 (15.4%) and 85 (23.4%) of the 363 patients, respectively. Neobladder related early and late abdominal reoperation rates were 0.3 and 4.4%, respectively. Perioperative neobladder unrelated early complications were observed in 122 patients (33.6%) and 44 (12.1%) required operative treatment. Late postoperative complications unrelated to the neobladder occurred in 45 patients (12.4%) and 19 required open surgical revision. Of 290 evaluable patients 96.1% void spontaneously, 3.9% perform clean intermittent catheterization in some form and 1.7% perform regular intermittent catheterization. Daytime and nighttime continence was reported as good by 95.9% and satisfactory by 95% of the patients. Unacceptable daytime continence requiring more than 1 pad per day occurred in only 4.1% of the patients and only 5% are wetting more than 1 pad a night. CONCLUSIONS: The ileal neobladder produces good functional results and can be constructed with acceptable complications. Our data suggest that although it is not a complication-free procedure, we advocate its use when possible.     

Has laparoscopy changed the surgical approach in gastroesophageal reflux? Apropos of an experience with 63 cases of gastroesophageal reflux treated by laparoscopy

INTRODUCTION: Indications for surgery in gastrooesophageal reflux disease (GERD) have decreased significantly since the introduction of proton pump inhibitors. At the same time there has been renewed surgical interest in this disease triggered by the development of laparoscopy. We present our results with laparoscopic treatment of GERD and the change in our surgical approach to the condition during the past few years. METHODS: All patients admitted to the surgical department underwent prior evaluation by a gastroenterologist. Indications for surgery were resistance to medical therapy in 30 cases, recurrence of GERD after cessation of treatment in 25 cases and personal preference of the patient when maintenance therapy was necessary in 6 cases. The data were reviewed and the patients contacted during the first trimester of 1998 to evaluate long-term results. RESULTS: 63 patients were operated on between 1991 and July 1997. Rossetti-Nissen fundoplication was performed routinely until March 1995. Thereafter, the type of antireflux surgery has been chosen according to the preoperative evaluation of the patients, including endoscopy, oesophageal manometry and gastric emptying studies. There was no mortality and, except for one case, only minor morbidity. Four patients required reoperation, two for severe gas bloat syndrome and two for recurrence of GERD. Overall, the long-term follow-up shows that 93 patients are satisfied or very satisfied with their outcome (Visick 1 or 2). 5% of the patients need daily medication for heartburn, 5% complain of occasionally disturbing dysphagia, and 12% of sometimes distressing gas bloat. More patients have gas bloat after the Rossetti-Nissen procedure than after the Nissen or Toupet fundoplications. CONCLUSIONS: The enthusiasm of surgeons for the laparoscopic approach to GERD has prompted renewed interest in the pathophysiology of the disease. Consequently, indications for surgery are better defined, surgical technique is chosen according to the individual patient based on objective preoperative studies and follow-up has improved. In this setting, laparoscopic fundoplication represents an effective treatment for GERD. It is associated with lower postoperative morbidity than open surgery and represents the first choice when surgery is indicated.     

Favorable results of implantable cardioverter-defibrillator implantation in patients older than 70 years

BACKGROUND: The clinical results of implantable cardioverter-defibrillator (ICD) implantation in the elderly have received limited documentation. As the longevity of the U.S. population has increased, so has the need for ICD implantation in the elderly. We evaluated the efficacy and outcome of ICD implantation in elderly patients (>70 years) compared with younger patients. METHODS: The case records of all consecutive patients who underwent ICD implantation at our institution between 1986 and 1994 were reviewed. Of a total of 238 patients, 78 patients were 70 years of age or older and 160 patients were younger than 70 years of age. RESULTS: The mean age of the younger group was 58 years and that of the elderly group was 74 years. There were no statistical differences in the presence of coronary artery disease, left ventricular systolic function, the inducibility of arrhythmias, or the history of sudden cardiac death. The hospital morbidity rate was similar in both groups (6.9% in the younger group and 7.7% in the elderly group; p = not significant). The operative mortality rate was 1.9% for the younger group and 1.3% for the elderly group (p = not significant). At a mean follow-up of 33 +/- 26 months, Kaplan-Meier survival curves demonstrated similar survival rates, with 93%, 82%, and 65% of the patients alive at 1, 3, and 6 years, respectively. CONCLUSIONS: Implantable cardioverter-defibrillator implantation was equally effective in the treatment of patients older than 70 years as in younger patients. No differences in theoretic survival or morbidity were observed.