Elias Athanasakis

Laparoscopic vs open approach for Nissen fundoplication

Background: Several studies, most of them nonrandomized, have shown similar functional results for both laparoscopic and open Nissen fundoplication, the operation of choice for the treatment of gastroesophageal reflux disease (GERD). Methods: A total of 106 patients with documented GERD were randomized to receive either a laparoscopic or an open Nissen fundoplication. Preoperative and postoperative investigations included clinical assessment, esophagogram, upper gastrointestinal endoscopy, esophageal manometry, and 24-h ambulatory pHmetry. Results: Both approaches were successful in controlling reflux. There was an overall improvement in esophageal peristalsis and an increase in lower esophageal sphincter (LES) pressure in both groups. Open Nissen fundoplication was associated with a significantly increased rate of wound (p <0.001) and respiratory (p <0.05) complications. Hospitalization was also longer after the open technique (p <0.001). At 3-month follow-up, although the rate of postoperative dysphagia was similar for the two approaches, the open approach was associated with a significantly higher incidence of postprandial epigastric fullness (p <0.05) and bloating syndrome (p <0.01). Conclusions: The open and laparoscopic approaches for the Nissen fundoplication are equally effective in controlling GERD. The open approach is associated with a significantly higher rate of wound and respiratory complications and, at early stages, an increased rate of postprandial epigastric fullness and abdominal bloating. The dysphagia rate is similar with both methods.

Laparoscopic surgery for gastroesophageal reflux disease patients with impaired esophageal peristalsis: Total or partial fundoplication?

BACKGROUND It has been proposed that partial fundoplication is associated with less incidence of postoperative dysphagia and consequently is more suitable for patients with gastroesophageal reflux disease (GERD) and impaired esophageal body motility. The aim of this study was to assess whether outcomes of Toupet fundoplication (TF) are better than those of Nissen-Rossetti fundoplication (NF) in patients with GERD and low-amplitude esophageal peristalsis. STUDY DESIGN Thirty-three consecutive patients with proved GERD and amplitude of peristalsis at 5 cm proximal to lower esophageal sphincter (LES) less than 30 mmHg were randomly allocated to undergo either TF (19 patients: 11 men, 8 women; mean age: 61.7 +/- 8.7 SD years) or NF (14 patients: 7 men, 7 women; mean age: 59.2 +/- 11.5 years), both by the laparoscopic approach. Pre- and postoperative assessment included clinical questionnaires, esophageal radiology, esophageal transit time study, endoscopy, stationary manometry, and 24-hour ambulatory esophageal pH testing. RESULTS Duration of operation was significantly prolonged in the TF arm (TF: 90 +/- 12 minutes versus NF: 67 +/- 15 minutes; p < 0.001). At 3 months postoperatively, the incidences of dysphagia (grades I, II, III) and gas-bloat syndrome were higher after NF than after TF (NF: 57% versus TF: 16%; p < 0.01 and NF: 50% versus TF: 21%; p = 0.02, respectively), but decreased to the same level in both groups at the 1-year followup (NF: 14% versus TF: 16% and NF: 21% versus TF: 16%, respectively). At 3 months postoperatively, patients with NF presented with significantly increased LES pressure than those with TF (p = 0.02), although LES pressure significantly increased after surgery in both groups, as compared with preoperative values. Amplitude of esophageal peristalsis at 5 cm proximal to LES increased postoperatively to the same extent in both groups (TF, preoperatively: 21 +/- 6 mmHg versus postoperatively: 39 +/- 12 mmHg; p < 0.001, and NF, preoperatively: 20 +/- 8 mmHg versus postoperatively: 38 +/- 12 mmHg; p < 0.001). Reflux was abolished in all patients of both groups. CONCLUSIONS Both TF and NF efficiently control reflux in patients with GERD and low amplitude of esophageal peristalsis. Early in the postoperative period, TF is associated with fewer functional symptoms, although at 1 year after surgery those symptoms are reported at similar frequencies after either procedure.

Stapled Transanal Rectal Resection (Starr) to Reverse the Anatomic Disorders of Pelvic Floor Dyssynergia

Anterior rectocele and rectoanal intussusception are anatomic disorders related to excessive straining during defecation that usually manifest with symptoms of obstructive defecation. Stapled transanal rectal resection (STARR), a newly described surgical method for correcting these disorders, is considered a good alternative to the traditional transrectal approaches. The aim of the present study was to assess the early postoperative functional results of STARR. A total of 16 patients (13 female) were subjected to the STARR procedure during a period of 12 months. The presence of anatomic disorders of the anorectum was verified by dynamic defecography. Preoperative assessment also included colonic transit time, anal sphincter ultrasonography, and anorectal stationary manometry. Postoperative assessment included the same battery of tests. Altogether, 12 patients had rectoanal intussusception of > 2 cm and rectocele. In eight of them the anterior component of the rectocele was 2 to 4 cm, and in four it was > 4 cm. Four patients had a 1- to 2-cm internal intussusception and a rectocele of < 2 cm. All of them reported evacuation difficulties, but none had significant incontinence. Preoperative endoscopy did not reveal the presence of a solitary ulcer in any of the patients. All females had had normal vaginal deliveries, and four of them were multiparous. No complications were encountered postoperatively, and the need for analgesics was minimal. At defecography, rectoanal anatomy was seen to be restored in all patients. Obstructive defecation symptoms remained rather unaffected in seven, disappeared in three, and improved significantly in the remaining six patients. The seven failures showed anismus at manometry and had biofeedback treatment with satisfactory results in five of them. Failure of the operation and biofeedback sessions to treat symptoms in those two cases was attributed to coexisting enterocele, which had been missed preoperatively. Immediately after surgery, most of the patients complained of urgency and frequent small motions that resolved spontaneously within 3 to 5 weeks in all but two cases. STARR is a safe, well tolerated surgical procedure that effectively restores anatomy and function of the anorectum in patients with anterior mucosal prolapse and rectoanal intussusception. Additional biofeedback treatment is usually necessary for further functional improvement. Failure may be the result of other coexisting anatomic and functional abnormalities of the pelvic floor.

Rectoanal Intussusception: Presentation of the Disorder and Late Results of Resection Rectopexy

BACKGROUNDRectoanal intussusception may cause symptoms of obstructed defecation, and functional results of prosthesis rectopexy are usually not satisfactory. The aim of this study was to assess several parameters of the disorder and to evaluate the outcome of resection rectopexy.METHODSDuring a 10-year period, 27 female patients with symptomatic large rectoanal intussusception had resection rectopexy (23 laparoscopy; 4 laparotomy). Conservative treatment, including biofeedback treatment in 22 patients, had failed in all cases. Preoperative and postoperative evaluation included clinical assessment, anorectal manometry, evacuation defecography, and colon transit studies. Follow-up ranged between one and five years.RESULTSLength of intussusception was 2 to 4.9 cm and was significantly related to pelvic floor descent (P = 0.003) and inversely related to resting anal pressures (P < 0.001). Eleven patients had undergone a previous hysterectomy, 9 had enterocele-sigmoidocele, 7 had incontinence of varying severity, and 8 had a solitary rectal ulcer. Colon transit was abnormal in all but five cases. Immediate functional results were bad in two-thirds of the cases; tenesmus, urge to defecate, and frequent stools were the main complaints. By the time these symptoms had subsided, and one year after surgery, all but two patients were satisfied with the outcome. Intussusception was reduced in all cases, anal sphincter tone recovered (P = 0.002), perineal descent decreased (P < 0.001), and colonic transit was accelerated (P < 0.001). Patients available at five-year follow-up had no or only minor defecatory problems.CONCLUSIONResection rectopexy improves symptoms of obstructed defecation attributed to large rectoanal intussusception.

Pancreatic trauma in the adult: current knowledge in diagnosis and management.

Background/Aims: Although pancreatic trauma, isolated or not, is uncommon, it carries significant morbidity and mortality because of the delay in recognition and consequent treatment. Methods: The current knowledge of pancreatic injury, concerning the incidence, mechanism of induction, diagnosis, treatment, complications and outcome, is herein presented based on a literature review and our limited experience. Results: The diagnosis of pancreatic trauma entails a high index of suspicion because neither clinical nor laboratory evaluation provide pathognomonic elements. Patients with penetrating injuries are usually evaluated during laparotomy, while those with a blunt trauma can be managed conservatively, provided they are in a stable condition, there is no pancreatic duct involvement and care is intensive. At laparotomy, minor pancreatic injuries are best managed by drainage. Distal pancreatectomy is best suited for distal pancreatic trauma with ductal involvement. For severe trauma, Roux-en-Y pancreaticojejunostomy, pancreaticogastrostomy, duodenal diversion operations and Whipple’s procedure are all indicated according to the preoperative evaluation and intraoperative findings. Independent of the procedure to be performed, drainage is mandatory. Conclusion: Because pancreatic injury is rare, most general surgeons lack experience and ability to deal with such injured patients. Therefore, an experienced and skilled surgeon should govern the management of pancreatic trauma in order to minimize the incidence of morbidity and mortality.

Metastatic liver disease and fulminant hepatic failure: presentation of a case and review of the literature.

Although liver metastases are commonly found in cancer patients, fulminant hepatic failure (FHF) secondary to diffuse liver infiltration is rare. Furthermore, clinical presentation and laboratory findings are obscure and far from being pathognomonic for the disease. We report a case of a patient who died in the intensive care unit of our hospital from multiple organ failure syndrome secondary to FHF, as a result of liver infiltration from poorly differentiated small cell lung carcinoma. We also present the current knowledge about the clinical picture, laboratory findings and physical history of neoplastic liver-metastasis-induced FHF.

Rectoanal motility in Crohn's disease patients.

PURPOSE: It has been documented that Crohns disease affects anorectal function when anorectal manifestations of the disease are present. The aim of this study was to investigate whether the presence of histologic lesions in rectal biopsy affected anorectal motility in patients with Crohns disease but no evidence of macroscopic anorectal involvement. METHODS: Forty-one patients with documented Crohns disease were included in the study. Twenty-one of them had no endoscopic or histologic lesions in the rectum, and 20 patients had a positive histology for Crohns disease on rectal biopsy, with or without macroscopic or endoscopic involvement of the anorectum. All patients underwent a standard anorectal manometry, with an eight-channel, water-perfused catheter. RESULTS: Patients with positive rectal biopsy but no evidence of endoscopic rectal involvement had lower anal resting and squeeze pressures (76±16 standard deviationvs. 86±19 standard deviationP=0.002; 152±56 standard deviationvs. 192±52 standard deviationP<0.001, respectively), and a lower sphincter and high-pressure zone length (2.8±0.8 standard deviationvs. 3.2±0.8 standard deviationP=0.006; 1.7±0.6 standard deviationvs. 2±0.6 standard deviationP=0.005, respectively) compared with patients with negative rectal histology. Also, slow and ultra slow wave amplitude and ultra slow wave frequency were significantly lower (10±6 standard deviationvs. 13±7 standard deviationP=0.04; 17±16 standard deviationvs. 34±24 SDP=0.004; 0.9±0.8 standard deviationvs. 1.3±0.6 standard deviationP=0.05, respectively), rectal sensation more affected, and rectal compliance significantly reduced (7.4±1 standard deviationvs. 11.1±2.2 standard deviationP<0.001) in the former group of patients. Simultaneous presence of endoscopic and histologic lesions in the rectum was associated with further impairment of the anorectal function. CONCLUSION: Microscopic presence alone of Crohns disease in the rectum appears to induce anorectal motility disorders. The synchronous presence of endoscopic rectal and macroscopic anal involvement is associated with further deterioration of anorectal function.

Molecular pathways and genetic factors in the pathogenesis of laryngopharyngeal reflux

The prevalence of laryngopharyngeal reflux (LPR) has been constantly rising in the western world and affects today an alarmingly high percentage of the general population. Even though LPR and gastroesophageal reflux disease (GERD) are both the product of gastroesophageal reflux and seem to be sibling disorders, they constitute largely different pathological entities. While GERD has been for a long time identified as a source of esophageal disease, LPR has only recently been associated with head and neck disorders. Despite the high incidence of LPR and its great impact on patients’ quality of life, little is known regarding its pathogenesis. On the other hand, studying the molecular and genetic basis of a disease is of fundamental importance in medicine as it offers better insight into the pathogenesis and opens new, disease-specific therapeutic trends. The aim of this study is to enlighten any known or suspected molecular mechanisms that contribute to the pathogenesis of LPR, and to suggest new trends for future research.

Internal-mesocolic hernia after laparoscopic left colectomy report of case with late manifestation

Introduction In contrast to right colectomy, closure of the mesocolic gap after laparoscopic left colectomy is not practiced, and reports of small gut herniation through this gap are scarce. Presentation of case A 73 year old male was admitted as an emergency with symptoms and clinical signs, suggesting obstruction of the small bowel. Abdominal imaging, including computed tomography confirmed the diagnosis. The patient had undergone laparoscopic left colectomy for cancer, three years ago. At laparotomy small bowel loops were found to herniate through the mesocolic defect at the level of the colonic anastomosis. The small bowel loops were reduced and their viability was ascertained. Because of an iatrogenic perforation of the colon at the anastomosis during small bowel loops mobilization, the colon was temporarily exteriorized in the form of a double barrel colostomy. The postoperative course was uneventful. Discussion Very few cases have been reported in the liteature indicating the need of sutuing the mesenterium. Despite the limited numbe of the reported cases, there is clearly a risk of intenal hernia after laparoscopic left colectomy. Conclusion Although rare internal hernia after laparoscopic left colectomy may occur, and this brings forward the question of mesocolic gap closure.

Is There Any Mediterranean Diet Not Affecting Bilitec Assessment of Bile Reflux

Background: Colored food substances may interfere with Bilitec system that uses bilirubin as a marker for the detection of duodeno-gastro-esophageal reflux, causing false positive results. Therefore, diets have been suggested for consumption during Bilitec studies that contain minimal amounts of pigments. Aim: To enrich the list of suitable foods for Bilitec measurements with dishes common in Mediterranean diets, and improve subject’s compliance. Methods: Ninety substances were in vivo tested for ‘bilirubin absorbance’. ‘Dry’ substances were blended after being diluted in water, while ‘floppy’ substances and cooked foods were blended undiluted. Blended mixtures and ‘liquids’ were tested for bilirubin without further dilution and after being mixed with hydrochloric acid. The procedure was repeated to assess reproducibility of the measurements. Results: Measurements are highly reproducible. Thirty five foods exhibited ‘bilirubin absorbance’ values safely below the threshold, and are considered to be suitable for Bilitec studies. On the contrary some vegetables and fruits, legumes, tomato sauce preparations, red wine, coffee, tea and jams showed high absorbance values, and are not recommended. Conclusion: Menus containing part of the variety of Mediterranean food preparations are safely recommended for consumption during Bilitec studies, enriching food lists available at present.