Should adjuvant or neoadjuvant treatment be administered in esophageal cancer?

The Nissen fundoplication is not the proper antireflux procedure for patients with poor esophageal peristalsis as it does not strengthen impaired esophageal peristalsis. The aim of this study was to investigate if tailoring of antireflux surgery according to esophageal contractility is an effective treatment of gastroesophageal reflux disease (GERD) with a low incidence of postoperative dysphagia. The Toupet fundoplication was laparoscopically performed on 32 patients with poor esophageal peristalsis and the Nissen fundoplication on 17 patients with normal peristalsis. After a median follow-up of 15 months, only 1 of the 49 patients (2.04%) complained of heartburn. Acute esophagitis was found in none of them on endoscopy. Of 40 patients tested postoperatively, 2 (5%) underwent pathologic esophageal pH monitoring. Postoperative dysphagia was found in two patients (4.1%) compared with 25 (51%) preoperatively (p < 0.05). There was a significant reduction of dysphagia following the Toupet fundoplication. Both procedures increased the resting pressure of the lower esophageal sphincter (LES) significantly, which was more pronounced following the Nissen fundoplication. Relaxation of the LES was significantly better following the Toupet than after the Nissen fundoplication. There was significant improvement of esophageal peristalsis following the Toupet fundoplication. Tailored antireflux surgery is an effective strategy for treatment of GERD. The incidence of postoperative dysphagia is low owing to improvement of impaired esophageal peristalsis following the Toupet fundoplication. It may be due to the fact that the Toupet fundoplication causes less esophageal outflow resistance than the Nissen fundoplication.     

Examination of contact lens surfaces by Atomic Force Microscope (AFM)

BACKGROUND: Reduction of acid secretion is an important aspect of medical treatment of reflux esophagitis. Truncal vagotomy and drainage procedures used in conjunction with antireflux procedures to reduce acid secretion in patients with gastroesophageal reflux were unsatisfactory. This study reviews the results of parietal cell vagotomy used in conjunction with a 360-degree fundoplication to determine if reduction of acid by this form of vagotomy was beneficial to patients with gastroesophageal reflux. METHODS: Between March 1973 and May 1993, 94 private and 64 Veterans Administration patients underwent parietal cell vagotomy and Nissen type fundoplication for esophageal reflux. Esophagogastroduodenoscopy (EGD), gastric analysis, cine-esophagogram, and 24-hour esophageal pH and motility studies were performed preoperatively on VA patients. Private patients underwent EGD, cine-esophagogram, and sometimes pH and motility studies. Similar studies were performed postoperatively if the patient permitted. The major technical alteration made during the study was the addition of posterior gastropexy to the operations performed between March 1978 and January 1987. Patients were considered failures if dysphagia and reflux symptoms were moderate but operation not contemplated (Visick III) or symptoms were severe and reoperation had been performed or was contemplated (Visick IV). RESULTS: There were no operative deaths. There were 25 operative failures; dysphagia contributed to failure in 4, reflux in 11, and dysphagia and reflux in 10 patients. Reoperation was required in 6 patients. There was no statistical difference in acid secretion inhibition for patients with or without postoperative reflux symptoms. The cumulative probability for operative failure was 9.3 +/- SE 4.2% for patients who underwent posterior gastropexy and 22.9 +/- SE 4.6% (P <0.02) for those who did not. CONCLUSIONS: Parietal cell vagotomy with Nissen fundoplication is a safe operation. The exposure created by PCV protected the vagi from injury. The study design made it impossible to determine whether PCV improved the results of fundoplication but the failure rate was significantly (P <0.02) reduced by the addition of posterior gastropexy. This may have lessened the risk of disintegration of the wrap that might be more likely to occur after PCV.     

Laparoscopic Toupet fundoplication for gastroesophageal reflux disease with poor esophageal body motility

Impaired esophageal body motility is a complication of chronic gastroesophageal reflux disease (GERD). In patients with this disease, a 360-degree fundoplication may result in severe postoperative dysphagia. Forty-six patients with GERD who had a weak lower esophageal sphincter pressure and a positive acid reflux score associated with impaired esophageal body peristalsis in the distal esophagus (amplitude <30 mm Hg and >10% simultaneous or interrupted waves) were selected to undergo laparoscopic Toupet fundoplication. They were compared with 16 similar patients with poor esophageal body function who underwent Nissen fundoplication. The patients who underwent Toupet fundoplication had less dysphagia than those who had the Nissen procedure (9% vs.44%; P=0.0041). Twenty-four-hour ambulatory pH monitoring and esophageal manometry were repeated in 31 Toupet patients 6 months after surgery. Percentage of time of esophageal exposure to pH <4.0, DeMeester reflux score, lower esophageal pressure, intra-abdominal length, vector volume, and distal esophageal amplitude all improved significantly after surgery. Ninety-one percent of patients were free of reflux symptoms. The laparoscopic Toupet fundoplication provides an effective antireflux barrier according to manometric, pH, and symptom criteria. It avoids potential postoperative dysphagia in patients with weak esophageal peristalsis and results in improved esophageal body function 6 months after surgery.     

Long-term results after reoperation for failed antireflux procedures

From January 1960 to June 1995, 185 patients underwent reoperation without esophageal resection for symptoms of recurrent gastroesophageal reflux disease. There were 102 men and 83 women. Median age was 58 years (range 20 to 84 years). A single previous antireflux operation had been performed in 147 patients, two in 33, and three in 5. The median interval between the reoperation and the previous operation was 36 months (range 1 to 291 months). Indications for reoperation were symptoms in 184 patients and a large paraesophageal hernia in one patients. The surgical approach was by means of a thoracotomy in 133 patients (71.9%), laparotomy in 27 (14.6%), and a thoracoabdominal incision in 25 (13.5%). A Nissen fundoplication was performed in 107 patients (57.8%), Belsey fundoplication in 47 (25.4%), truncal vagotomy and antrectomy with Roux-en-Y reconstruction in 17 (9.2%), anatomic hernia repair in 12 (6.5%), and Hill gastropexy in 2 (1.1%). A Collis gastroplasty was added to the fundoplication in 116 patients (62.7%), and a pyloroplasty was performed in 17 (9.2%). There was one operative death (0.5%). Complications occurred in 47 patients (25.4%). Median postoperative hospitalization was 9 days (range 5 to 58 days). Follow-up was complete in 156 patients (84.3%) and ranged from 3 to 283 months (median 44 months). Improvement occurred in 137 patients (87.8%). Functional results were classified as excellent in 65 patients (41.6%), good in 29 (18.6%), fair in 43 (27.6%), and poor in 19 (12.2%). No single operative approach or procedure proved to be functionally superior. We conclude that reoperation with esophageal preservation after a failed antireflux procedure will result in significant functional benefit and can be performed with low mortality and acceptable morbidity. The type of repair should be tailored to the individual patient.     

Results of laparoscopic Nissen fundoplication

BACKGROUND/AIMS: Laparoscopic surgery for treatment of gastroesophageal reflux disease was first described 5 years ago. The more widespread technique is the Nissen fundoplication with its different modifications. The early results suggest that this operation is equivalent in efficacy to the open antireflux operations. METHODOLOGY: Over a 5 year period, 622 patients underwent laparoscopic fundoplication for gastroesophageal reflux disease. Five hundred and fifty patients underwent Nissen fundoplication. Preoperative, operative and postoperative data were prospectively reviewed. One hundred twenty seven patients were evaluated 1 to 4 years after the operation. RESULTS: Laparoscopic Nissen fundoplication with standard gastric mobilisation and without division of the SGV was performed during the first three years of the laparoscopic approach. Since early 1994, we applied division of the SGV with complete mobilisation of the upper part of the gastric fundus in all the patients. The mean operative time was 86 minutes (range 30-180 minutes). Conversion to open surgery was necessary in 5 patients (0.9%). There was neither incidence of splenic trauma nor esophageal perforation. There was no mortality. Morbidity was 2.3%. Mean hospital stay was 3.1 days (range 1-13 days). Postoperative dysphagia was observed in all the patients and resolved after 2 to 6 weeks in all but 12 patients (2.1%) who were submitted to endoscopic dilatation with success in 9 patients. At a median follow-up period of 2 years (16-44 months), 127 consecutive patients from the initial experience (series 1991-1992) volunteerd for mid term follow-up evaluation. We obtained Visick I and II grading in 92% of the patients. Reoperation for failure has been necessary in 6 patients (1.0%). CONCLUSIONS: The long term results of laparoscopic Nissen fundoplication are not yet available. The incidence of poor long term outcome or recurrence of symptoms cannot be assessed. At present, we feel that, in experienced hands, the laparoscopic operation is as good as the open procedure if all the surgical principles of antireflux surgery are respected. One of our complications is related to the choice of the operative technique and that highlights the absolute necessity of strict preoperative assessment and selection of the patient but also selection of the type of operation, tailored to the patient.     

Pyloric muscle in asymptomatic infants: sonographic evaluation and discrimination from idiopathic hypertrophic pyloric stenosis

Nissen fundoplication is now the most common antireflux operation for gastroesophageal reflux disease. This study is a report on the laparoscopically performed floppy Nissen procedure. Two hundred consecutive patients were analyzed (84 women, 116 men, mean age 49 years, mean duration of symptoms 5 years) after laparoscopic Nissen fundoplication between 1992 and 1996. The main indications for surgery were daily heartburn, retrosternal pain, and regurgitation demanding continuous medical therapy. Eight patients (4%) had esophageal stricture, and 21 (11%) had Barrett's esophagus with intestinal metaplasia. All patients underwent upper gastrointestinal endoscopy, 24-h esophageal pH monitoring, and esophageal manometry before and 3 months after the operation. In addition, a questionnaire was completed an average of 2.2 years (range 1.0-4.6) after the operation. The results of the study were as follows: mortality was zero, and the morbidity rate was 5%. The mean hospital stay was 3.8 +/- 2.8 days, and sick leave was 14.3 +/- 10.4 days. Postoperatively, esophagitis was healed or significantly improved in all but 4 patients (98%), and 24-h pH and lower esophageal sphincter pressure were normal. After 2 years, 87% of the patients had Visick scores of I-II. It is concluded that laparoscopic floppy Nissen fundoplication provides an efficient and safe alternative for surgical treatment of gastroesophageal reflux disease.     

Vitamin E dose-response studies in humans with use of deuterated RRR-alpha-tocopherol

A prospective double-blind randomized trial was initiated to examine two types of laparoscopic fundoplication (Nissen and anterior). Thirty-two patients with proven gastroesophageal reflux disease presenting for primary laparoscopic antireflux surgery were randomized to undergo either Nissen fundoplication (N = 13) or anterior hemifundoplication (N = 19). Postoperative fluoroscopic and manometric examination was carried out concomitantly. Nissen fundoplication resulted in significantly greater elevation of resting (33.5 vs 23 mm Hg) and residual lower esophageal sphincter pressures (17 vs 6.5 mm Hg) and lower esophageal ramp pressure (26 vs 20.5 mm Hg) than the anterior partial fundoplication. A smaller radiologically measured sphincter opening diameter was seen following Nissen fundoplication (9 mm) compared with anterior fundoplication (12 mm). Lower esophageal ramp pressure correlated weakly (r = 0.37, P = 0.04) with postoperative dysphagia. It is concluded that the type of fundoplication performed significantly influences postoperative manometric and video barium radiology outcomes. The clinical relevance of this requires further investigation.     

Laparoscopic hiatal reconstruction and use of harmonic scalpel instrument

The method of laparoscopic repair of hiatal hernia is accepted in surgery. Usually associated with Nissen fundoplication which is the most commonly performed antireflux operation. Within a ten-year period authors have done 90 antireflux operations, 52 was laparoscopic procedures. (30 operations for GERD, 10 for hiatal hernia, 12 for the combination of both.) A patient was submitted to operation with large hiatal hernia. He was treated laparoscopic way with success and good results. The Ultracision Harmonic Scalpel instrument helped their operation in many ways, and provided correct bloodless preparation of cardiac region. The authors demonstrate our procedure and the use of the Harmonic Scalpel. Their patient were completely pleased with the results after discharge, they are still under regular control.     

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.     

Design and synthesis of small semi-mimetic peptides with immunomodulatory activity based on myelin basic protein (MBP)

Bile reflux has been implicated in the pathogenesis and malignant degeneration of Barrett's esophagus, but clinical studies in patients with adenocarcinoma arising in Barrett's esophagus are lacking. Ambulatory esophageal measurement of acid and bile reflux was performed with the previously validated fiberoptic bilirubin monitoring system (Bilitec) combined with a pH probe in 20 asymptomatic volunteers, 19 patients with gastroesophageal reflux disease (GERD) but no mucosal injury, 45 patients with GERD and erosive esophagitis, 33 patients with GERD and Barrett's esophagus, and 14 patients with early adenocarcinoma arising in Barrett's esophagus. Repeat studies were done in 15 patients under medical acid suppression and 16 patients after laparoscopic Nissen fundoplication. The mean esophageal bile exposure time showed an exponential increase from GERD patients without esophagitis to those with erosive esophagitis and benign Barrett's esophagus and was highest in patients with early carcinoma in Barrett's esophagus (P <0.01). Pathologic esophageal bile exposure was documented in 18 (54.5%) of 33 patients with benign Barrett's esophagus and 11 (78.6%) of 14 patients with early adenocarcinoma in Barrett's esophagus. Nissen fundoplication but not medical acid suppression resulted in complete suppression of bile reflux. Bile reflux into the esophagus is particularly prevalent in patients with Barrett's esophagus and early cancer. Bile reflux into the esophagus can be completely suppressed by Nissen fundoplication but not medical acid suppression alone.     

Recent advances in antireflux surgery for gastroesophageal reflux diseases--from open surgery to laparoscopic surgery

Gastroesophageal reflux diseases (GERD) are common in the western countries and have been well studied about diagnosis and treatment. Nissen technique (a complete wrap) and Toupet technique (a partial wrap) are usually transabdominal fundoplication. Hill technique is a transabdominal posterior gastropexy. Allison technique is a transthoracic reduction method of the herniated cardia back into the abdomen, but is not frequently employed today. Belsey Mark VI technique is a transthroacic anterior plication. Collis gastroplasty is an esophageal lenghening technique and is used with standard repairs (Nissen, Belsey, and Hill). Good result rate of above mentioned surgery are about 90%. Recently, laparoscopic Nissen/Toupet technique are a standard antireflex surgery because of minimal invasiveness and more than 90% of good results. After introducing laparoscopic surgery the indication of antireflex surgery for GERD can be changed because of quality of life of patients and medicoeconomical reasons.     

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.     

Systemic clotting activation by low-grade endotoxaemia in liver cirrhosis: a potential role for endothelial procoagulant activation

Laparoscopic fundoplication is technically feasible in treating gastroesophageal reflux disease (GERD). Although medication is the primary treatment for GERD, not all patients respond completely or are able to adhere to a medical regimen. In the present series, 59 patients were laparoscopically treated for GERD at three centers using a standardized technique. All patients had been medically treated prior to referral, although 84 per cent had heartburn and 2 per cent had laryngitis despite 20 to 40 mg/day of omeprazole. Fifteen per cent of patients were intolerant of or would no longer take omeprazole. Patients were evaluated by esophageal manometry (in 100%) and 24-hour pH studies (in 66%). Seventy-six per cent of patients had lower-esophageal sphincter pressure <15 mm Hg. Five patients had low esophageal body peristaltic pressures (<35 mm Hg). These patients underwent Toupet partial fundoplication, whereas 54 patients underwent Nissen fundoplication. Mean operative time was 158 +/- 7 minutes, and three patients (5%) were converted to an open procedure. Operative complications were minor and occurred in 13 per cent. In 45 patients evaluated 1 year after surgery, heartburn had resolved in 98 per cent. Thirty-nine of 56 patients (70%) had mild early (<1 month postoperatively) dysphagia, and 9 (19%) had severe early dysphagia, which improved in 7 after nonoperative dilatation. Two of these had continued mild dysphagia. Two patients had severe dysphagia and were laparoscopically converted from Nissen to Toupet fundoplications, which resulted in marked improvement. Early gas bloat symptoms occurred in 45 per cent and dropped to 5 per cent at 1 year. Laparoscopic treatment of GERD is safe and effective in preventing reflux symptoms. Although mild dysphagia occurs after the procedure, this is transient in most patients. Patients with severe dysphagia can be treated with nonoperative dilatation or laparoscopic partial fundoplication and maintain the antireflux characteristics of the wrap.     

Transcript map of the chromosome 2-linked autosomal dominant spastic paraplegia (SPG4) critical region and identification of a highly informative STRP

A fit young man sustained a ruptured diaphragm during a recreational scuba dive three months after undergoing an uncomplicated laparoscopic Nissen fundoplication for gastro-oesophageal reflux disease. It is proposed that this rare occurrence was attributable to gastrointestinal barotrauma. The injury was treated by laparotomy, mobilisation of herniated abdominal viscera back into the abdomen, repair of the crura and gastropexy. He made a full postoperative recovery. It is concluded that scuba diving should be avoided in patients who have undergone fundoplication.     

Nissen fundoplication by laparoscopy

Short term results following laparoscopic Nissen fundoplication were evaluated in 31 patients with symptomatic gastroesophageal reflux. 6 were females and 26 males, and they ranged in age from 5 months to 64 years (mean: 4.9 years in 19 younger than 18 years, and 39.3 years in 12 adults). Most of the adults who complained of pain and heartburn underwent pH monitoring, endoscopy, and manometry as needed. Milk scan was the most useful diagnostic tool for the evaluation of the children, who suffered mainly from gastroesophageal-related pulmonary disease. Indications for laparoscopic operation were identical with those for conventional open Nissen fundoplication. 1 case of dysautonomia died postoperatively; the rate of complications, mostly minor, was 22.5%. 3 patients required conversion to open Nissen fundoplication due to cardiorespiratory instability secondary to pneumothorax in 2, and to esophageal perforation in the third. 5 adults developed temporary dysphagia. 3 children had only partial improvement in their pulmonary disease following the operation, while the other 15 had complete relief. The total time for the laparoscopic operation averaged 245 minutes in adults, and 228 in children. Discharge was usually on the fourth postoperative day in adults (mean: 6.0 days). Regurgitation and heartburn were cured in 10 out of 11 adults (91%). All parents of children were satisfied. Symptomatic outcomes following laparoscopic Nissen fundoplication compare favorably with those of open surgery with respect to mortality, complications, and outcome.     

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.     

Clinical and manometric results of laparoscopic partial (Toupet) and complete (Rosetti-Nissen) fundoplication

It is unclear whether a partial or complete gastric fundoplication done laparoscopically will offer the best control of reflux with the fewest side effects. Prospective evaluation of laparoscopic Rosetti-Nissen (360) and Toupet (180) fundoplication was performed with assessment of clinical and manometric data. METHODS: Patients with severe gastroesophageal reflux referred for surgical correction underwent preoperative motility and upper endoscopy. A Rosetti-Nissen or Toupet fundoplication was then performed laparoscopically. Short gastrics were not divided. No bougie was used in the Toupet, which was sutured intracorporeally. A 2-cm, loose, floppy wrap about a 50-Fr bougie was performed in the Nissen. Eleven patients underwent Rosetti-Nissen and 11 Toupet fundoplication. Mean ages, duration symptoms, weight, and baseline LES, were not different. Preop esophagitis grades were similar, as were Visick Scores and presence of dysphagia. RESULTS: Visick scores at 6 months were better in the Toupet group than the Rosetti-Nissen (P = 0.07). Persistent Dysphagia in four, Gas-Bloat in two, and Odynophagia in one within the Rosetti-Nissen group accounted for the difference, and were not seen in Toupets. LES pressures differed significantly pre and postop (P < 0.001). The change in LES pressure was significantly different between Toupet and Rosetti-Nissen (chart). Seven patients had postop 24-h pH tests; all had no reflux. Three Rosettis have required revision to Toupet, with resolution of their symptoms. CONCLUSIONS: In patients with severe GERD, laparoscopic Toupet and Rosetti-Nissen control symptoms and esophageal pH similarly. LES pressures are higher postop in the Rosetti-Nissen. Dysphagia and gas-bloat are more prevalent in the Nissen group. Laparoscopic Toupet fundoplication may be superior to Rosetti-Nissen in reducing the frequency of side effects frequently associated with antireflux surgery, yet with equal control of reflux.     

Laparoscopic Nissen fundoplication for gastroesophageal reflux disease: clinical experience and outcome in first 100 patients

Using retrospective chart review, the authors evaluated the results of laparoscopic Nissen fundoplication in their first 100 patients. All patients were diagnosed with gastroesophageal reflux disease. More than 90% of the patients in this series were symptomatically improved, and 92% of those studied endoscopically had healed esophagitis and intact fundoplication. No deaths, esophageal injuries, or splenic injuries occurred. Laparoscopic fundoplication can be performed safely and efficiently. Using a linear stapler enables rapid and safe fundi mobilization. Selective manometrics and ambulatory pH monitoring provide excellent results. Laparoscopic Nissen is safe and as effective as the open procedure. Research centers have noted some differences in postoperative function of the lower esophageal sphincter, but symptomatically patient satisfaction is comparable.     

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.     

Selecting the surgical procedure for simple and complicated esophageal achalasia in children

BACKGROUND/PURPOSE: Surgical experience in children who have achalasia is limited. Surgical treatment requires esophagocardiomyotomy and an antireflux procedure. However, when these operations fail, other procedures are needed. To summarize the experience treating children who have this condition, the authors reviewed retrospectively all case histories of patients treated from 1971 to 1996 at their hospital. METHODS: Three boys and a girl, ranging in age from 18 months to 11 years, were treated. All had multiple previous dilatations. Two then underwent operation using an abdominal approach for a Heller procedure and a posterior fundoplasty (Guarner operation). Two children were previously treated in another hospital. One underwent a Heller operation complicated by perforation of the anterior mucosa. The other had undergone three previous abdominal approaches for esophagocardiomyotomy and a Nissen fundoplication. Symptoms persisted and imaging and endoscopy showed stenosis in both patients. In the first patient an esophagocardioplasty with transverse closure (Wendel procedure) and a posterior fundoplasty was performed. In the second child, the three previous abdominal surgical approaches mandated a transthoracic approach with transdiaphragmatic latero-lateral esophagogastric anastomosis (Heyrowsky operation) and a modified Guarner operation using the remaining fundus and gastric body. RESULTS: There were no intraoperative or postoperative complications. Follow-up time ranged from 3 months to 17 years. All patients experienced dramatic relief of symptoms and satisfactory weight gain. No recurrence of symptomatology has occurred. CONCLUSIONS: Esophagocardiotomy associated with an antireflux procedure may be the first option in the surgical treatment of children who have achalasia. However, if this fails, esophagocardioplasty and the latero-lateral esophagogastric anastomosis associated with antireflux procedure may be successful alternatives.