Eelco B. Wassenaar

Bulging of the mesh after laparoscopic repair of ventral and incisional hernias.

Although not a hernia recurrence, symptomatic bulging after laparoscopic ventral hernia repair requires a new repair.BACKGROUND AND OBJECTIVES Now nearly 2 decades into the laparoscopic era, nationwide laparoscopic cholecystectomy conversion rates remain around 5% to 10%. We analyzed patient- and surgeon-specific factors that may impact the decision to convert to open. METHODS We retrospectively analyzed 2205 LCs performed at a large tertiary community hospital over a 52 month period (May 2004 through October 2008). RESULTS The overall conversion rate was 4.9%. The most common reason for conversion was adhesions, and the majority of these patients had prior abdominal surgery. Males and patients >50 years old had a significantly higher likelihood of open conversion. The conversion rate of high-volume surgeons (≥100 total cases) in comparison to low-volume surgeons (40 to 99 total cases) was significantly lower. Conversion rates were lower among surgeons with fellowship training and those who completed residency training after 1990. Interestingly, the percentage of conversions due to technical difficulty was lower among those with fellowship training but higher among those who completed training after 1990. CONCLUSION Conversion occurred in ∼5% of all laparoscopic cholecystectomies. Males, patients >50 years old, and cases performed by low-volume surgeons had a higher likelihood of conversion. Other surgeon-specific factors did not have a significant impact on conversion rate.

Pepsin detection in patients with laryngopharyngeal reflux before and after fundoplication

BackgroundSome patients with gastroesophageal reflux disease (GERD) suffer from laryngopharyngeal reflux (LPR). There is no reliable diagnostic test for LPR as there is for GERD. We hypothesized that detection of pepsin (a molecule only made in the stomach) in laryngeal epithelium or sputum should provide evidence for reflux of gastric contents to the larynx, and be diagnostic of LPR. We tested this hypothesis in a prospective study in patients with LPR symptoms undergoing antireflux surgery (ARS).MethodsNine patients undergoing ARS for LPR symptoms were studied pre- and postoperatively using a clinical symptom questionnaire, laryngoscopy, 24-h pH monitoring, biopsy of posterior laryngeal mucosa, and sputum collection for pepsin Western blot assay.ResultsThe primary presenting LPR symptom was hoarseness in six, cough in two, and globus sensation in one patient. Pepsin was detected in the laryngeal mucosa in eight of nine patients preoperatively. There was correlation between biopsy and sputum (+/+ or −/−) in four of five patients, both analyzed preoperatively. Postoperatively, pH monitoring improved in all but one patient and normalized in five of eight patients. Eight of nine patients reported improvement in their primary LPR symptom (six good, two mild). Only one patient (who had negative preoperative pepsin) reported no response to treatment of the primary LPR symptom. Postoperatively, pepsin was detected in only one patient.ConclusionsPepsin is often found on laryngeal epithelial biopsy and in sputum of patients with pH-test-proven GERD and symptoms of LPR. ARS improves symptoms and clears pepsin from the upper airway. Detection of pepsin improves diagnostic accuracy in patients with LPR.

Causes and treatments of achalasia, and primary disorders of the esophageal body

The following on achalasia and disorders of the esophageal body includes commentaries on controversies regarding whether patients with complete lower esophageal sphincter (LES) relaxation can be considered to exhibit early achalasia; the roles of different mucle components of the LES in achalasia; sensory neural pathways impaired in achalasia; indications for peroral endoscopic myotomy and advantages of the technique over laparoscopic and thorascopic myotomy; factors contributing to the success of surgical therapy for achalasia; modifications to the classification of esophageal body primary motility disorders in the advent of high‐resolution manometry (HRM); analysis of the LES in differentiating between achalasia and diffuse esophageal spasm (DES); and appropriate treatment for DES, nutcracker esophagus (NE), and hypertensive LES (HTLES).

Barrett's esophagus: surgical treatments

The following on surgical treatments for Barretts esophagus includes commentaries on the indications for antireflux surgery after medical treatment; the effects of the various procedures on the lower esophageal sphincter; the role of impaired esophageal motility and delayed gastric emptying in the choice of the surgical procedure; indications for associated highly selective vagotomy, duodenal switch, and gastric electrical stimulation; therapeutic strategies for detection and treatment of shortened esophagus; the role of antireflux surgery on the regression of metaplastic mucosa and the risk of malignant progression; the detection of asymptomatic reflux brfore bariatric surgery; the role of non‐GERD symptoms on the results of surgery; and the indications of Collis gastroplasty and choice of the type of fundoplication.

Outcomes of esophageal surgery, especially of the lower esophageal sphincter

This paper includes commentaries on outcomes of esophageal surgery, including the mechanisms by which fundoduplication improves lower esophageal sphincter (LES) pressure; the efficacy of the Linx™ management system in improving LES function; the utility of radiologic characterization of antireflux valves following surgery; the correlation between endoscopic findings and reported symptoms following antireflux surgery; the links between laparoscopic sleeve gastrectomy and decreased LES pressure, endoscopic esophagitis, and gastroesophageal reflux disease (GERD); the less favorable outcomes following fundoduplication among obese patients; the application of bioprosthetic meshes to reinforce hiatal repair and decrease the incidence of paraesophageal hernia; the efficacy of endoluminal antireflux procedures, and the limited efficacy of revisional antireflux operations, underscoring the importance of good primary surgery and diligent work‐up to prevent the necessity of revisional procedures.

Synthetic Reinforcement of Diaphragm Closure for Large Hiatal Hernia Repair

Repair of large hiatal hernias has traditionally been a difficult procedure and is associated with significant morbidity and mortality. Repair via thoracotomy or laparotomy leads to morbidity and mortality rates of 20% and 2% respectively.1,2 With more modern perioperative care and minimally invasive techniques, morbidity and mortality have improved. Perhaps for this reason and also the increased life expectancy of patients, attention has focused more on longer term outcomes, including recurrence.