Dennis Blom

Risk factors and the prevalence of trocar site herniation after laparoscopic fundoplication

Background: Although there have been case reports describing trocar site herniation after laparoscopic fundoplication, its overall prevalence and the risk factors for its development are unclear. Methods: The records of 320 patients undergoing primary laparoscopic fundoplication as treatment for gastroesophageal reflex disease (GERD) or hiatal hernia between 1991 and 1999 were reviewed retrospectively. Placement of the initial supraumbilical trocar was by the open Hassan technique in all patients. Results: Nine patients (five male) with a mean age 54 years (range, 37-75) developed trocar site herniation, for an overall prevalence of 3%. The mean interval between surgery and diagnosis was 12 months (range, 4-21). In all patients, the hernia occurred at the supraumbilical camera port site. Patients with trocar hernias tended to have a higher body mass index (BMI) than those without hernias (mean BMI, 29.4 kg/m2 vs 27.2 kg/m2, p = 0.13). None of the patients developed intestinal obstruction as a consequence of herniation. To date, all but one of the hernias have been repaired. Six of them required the insertion of a prosthetic mesh. Conclusions: The prevalence of trocar site herniation after laparoscopic fundoplication was minimal at 3%. All hernias occurred at the midline supraumbilical port, the only site where open trocar insertion was employed. As a consequence of these observations, we have developed a new method of open trocar placement. This method utilizes a paramedian skin incision and separate fascial incisions through anterior and posterior rectus sheathes, with retraction of the rectus abdominis muscle laterally.

Physiologic mechanism and preoperative prediction of new-onset dysphagia after laparoscopic Nissen fundoplication

The aim of this study was to determine whether preoperative physiologic factors can account for and be used to predict the development of postoperative dysphagia after laparoscopic Nissen fundoplication. One hundred sixty-three patients with gastroesophageal reflux disease underwent laparoscopic Nissen fundoplication with a median follow-up of 14 months (range 6 to 81 months). Preoperative dysphagia was present in 37% (60 of 163) and was relieved in all but five patients (92%). Female sex (P = 0.01) and the presence of a stricture (P = 0.02) were the only preoperative variables associated with the presence of preoperative dysphagia. Eight percent (8 of 103) of patients without preoperative dysphagia developed new-onset dysphagia, and of these 63% (5 of 8) had a normal lower esophageal sphincter (LES) (pressure >6 mm Hg; length >2 cm; abdominal length >1 cm). New-onset dysphagia was significantly more common in patients with a normal LES (22% [5 of 23] vs. 4% [3 of 80], P = 001). Patients with a normal LES had almost a sixfold increase in the risk of developing dysphagia as those with an abnormal LES (relative risk = 5.8). Only a preoperative normal LES (P = 0.02) or mean LES pressures (P = 0.04) were positively associated with the development of postoperative dysphagia. The severity of this dysphagia also showed a strong positive trend of increasing with mean preoperative LES pressures (P = 0.07). Finally, preoperative LES pressure significantly correlated with postoperative LES pressure (r = 0.48, P = 0.01) and with mean residual LES (nadir) pressure (r = 0.33, P = 0.05) offering insight into the mechanism of this dysphagia. In conclusion, preoperative LES parameters play a role in the development of dysphagia after laparoscopic Nissen fundoplication. Patients with a normal LES or high mean LES pressures are at increased risk for developing this complication and should be informed of this before laparoscopic Nissen fundoplication.

Redefining gastroesophageal reflux (GER).

Background: The detection of gastroesophageal reflux (GER) has to date been limited to acid exposure observed on 24-h pH monitoring. It is clear, however that nonacid reflux can be a significant clinical problem. Recently, as impedance technology with the capacity to detect all types of reflux (acid, nonacid, liquid, mixed, and air) has been developed. Methods: Seventeen asymptomatic healthy volunteers underwent combined 24-h pH and impedance testing. In all patients, pH was measured at 5 cm above the lower esophageal sphincter (LES), and simultaneous impedance changes were recorded at 3, 5, 7, 9, 15, and 17 cm above the LES. Refluxes were classified as acid (drop in pH <4 for >5 sec), Nonacid, short acid, or nonacid delta based on chemical properties; they were further classified as liquid, mixed, or gas based on the physical refluxate detected by impedance changes. The height of the reflux entering the esophagus was classified as distal (<5 cm), intermediate (5–9 cm), or proximal (9–17 cm). Results: A total of 868 reflux events were characterized. Fifty-nine percent of them were not conventional acid reflux and could only be detected by impedance changes. Less than 2% of the events that were detected by a fall in pH to <4 were not detected by impedance changes. Pure liquid reflux was seen in 35.4%, a mixed pattern in 36.3%, and a gas reflux in 26.7%. Liquid was confined to the distal esophagus in 30%; it reached the midesophagus in 58% and the proximal esophagus in 11%. Conclusions: Over half of GER events are not detected by pH studies. Liquid reflux reaches the mid and proximal esophagus 69% of the time and gas nearly always does (92%). The additional information provided by impedance technology is likely to have a major impact on the understanding and clinical management of patients with gastroesophageal reflux disease (GERD).

Surgery, radiotherapy, and chemotherapy in carcinoma of the esophagus.

Esophageal carcinoma remains a highly lethal disease that has shown a recent profound increase in prevalence and an equally dramatic epidemiologic shift. There is a well recognized causal association between gastroesophageal reflux disease and adenocarcinoma of the esophagus, and the molecular events underlying this progression from mucosal injury, to metaplasia, to dysplasia, to carcinoma are now becoming clear. Current diagnostic modalities and preoperative staging systems all have significant limitations. Fortunately, chemoprevention strategies and the identification of clinically useful molecular biomarkers that may be used to stage disease and select appropriate therapy are on the horizon. The extent of surgical resection for esophageal carcinoma remains an area of great controversy. Disease that is confined to the mucosa is being diagnosed more commonly, and endoscopic ablative techniques have been proposed. To date, however, preoperative discrimination of tumor depth and presence of regional nodal metastases remains inadequate in these very early lesions, and caution is urged before adopting therapies that may compromise cure. For disease penetrating the mucosa, the extent of surgical therapy must be tailored by the objectives of treatment (cure vs palliation) and preoperative stage. Surgical resection is the current standard of care, with combined-modality therapy reserved for prohibitive surgical candidates. No clear survival benefit has been documented for neoadjuvant radiotherapy or chemotherapy alone. The results of preoperative combined-modality therapy, including three prospective, randomized trials, are encouraging but to date have not shown a definite benefit.