G. G. Jamieson

Postoperative mortality following oesophagectomy and problems in reporting its rate

There have been three previous reviews of the world literature describing postoperative mortality rate following oesophagectomy. The first documented rates in the first half of the last century, the second the period 1960–1979 and the third the interval 1980–1988. The aim of this review was to document the rate for the period 1990–2000.

Systematic review of the safety and effectiveness of methods used to establish pneumoperitoneum in laparoscopic surgery

A systematic review was conducted to determine which of the methods of obtaining peritoneal access and establishing pneumoperitoneum is the safest and most effective.

Totally endoscopic Ivor Lewis esophagectomy

Abstract. Esophagectomy is associated with significant risks of perioperative morbidity and mortality, as well as prolonged convalescence due to effects of the incisions used for conventional surgical access. Because the outcome of this procedure is palliative in the majority of patients, it is possible that laparoscopic techniques could improve initial postoperative outcomes and therefore make surgery more acceptable for patients with esophageal cancer. A new technique is described for Ivor Lewis esophagectomy, which incorporates a hand-assisted laparoscopic approach for gastric mobilization and a thoracoscopic approach for esophageal dissection and anastomosis. Initial experience in two patients has been encouraging, with postoperative hospital stay and convalescence shortened.

Five‐year follow‐up of a randomized clinical trial of laparoscopic total versus anterior 180° fundoplication

Total fundoplication for gastro‐oesophageal reflux disease may be followed by unwanted side‐effects. A randomized trial demonstrated that an anterior 180° partial fundoplication achieved effective reflux control and was associated with fewer side‐effects in the short term than total fundoplication. This paper reports longer‐term (5 year) outcomes from that trial.

Ten‐year clinical outcome of a prospective randomized clinical trial of laparoscopic Nissen versus anterior 180° partial fundoplication

A randomized trial of laparoscopic Nissen fundoplication and anterior 180° partial fundoplication was undertaken to determine whether the anterior procedure might reduce the incidence of dysphagia and other adverse outcomes following surgery for gastro‐oesophageal reflux disease. This study evaluated clinical outcomes after 10 years.

Reflux after oesophagectomy

Reflux of gastric and duodenal content after oesophagectomy with gastric conduit reconstruction is a common problem and largely considered an inevitable consequence of surgery. Cervical burning and regurgitation, often more pronounced when supine, can be troublesome and even disabling, interfering substantially with quality of life. The aim of this study was to identify the factors contributing to reflux after oesophagectomy and evaluate measures to prevent or control it.

Tumor implantation following laparoscopy using different insufflation gases

AbstractBackground: Laparoscopic manipulation of malignancies is associated with an increased incidence of metastasis to port sites in experimental models. This study investigated the effect of different insufflation gases on the implantation of a tumor cell suspension following laparoscopic surgery in an established small animal model. Methods: Forty Dark Agouti rats underwent laparoscopy and the introduction into the peritoneal cavity of a tumor cell suspension. The insufflating gas used for each procedure was one of the following gases (10 rats in each group): carbon dioxide (CO2), nitrous oxide (N2O), helium, and air. The rats were killed 7 days after surgery, and the peritoneal cavity and port sites were examined for the presence of tumor. Results: Although no significant differences were seen between air, CO2, and N2O insufflation groups, tumor involvement of peritoneal surfaces was less likely following helium insufflation. Conclusion: The results of this study suggest that tumor metastasis to port sites following laparoscopic surgery may be influenced by the choice of insufflation gas. In this study, helium was associated with reduced tumor growth.

Laparoscopic repair of large hiatal hernias

The repair of large hiatal hernias can be technically challenging. Most series describing laparoscopic repair report only symptomatic outcomes and the true recurrence rate, including asymptomatic recurrence, is not well documented. This study evaluated the long‐term outcome of laparoscopic repair of large hiatal hernias.

Expandable metallic stents should not be used in the treatment of benign esophageal strictures

Abstract Expandable metallic stents have become popular in recent years for the treatment of esophageal strictures. While they are undoubtedly of great value in the palliation of malignant strictures and tracheo‐esophageal fistulas, there is concern over their use for the treatment of benign diseases. We report three cases, in which such problems were seen following stent insertion for benign esophageal strictures. All three patients developed further strictures above the stents, one was complicated by a tracheo‐esophageal fistula and two stents (in one patient) migrated distally into the stomach. Two of the patients underwent subsequent esophageal surgery. In both cases, this proved extremely difficult and hazardous because of the intense fibrotic reaction induced by the stents. Expandable mesh stents should not be used for the treatment of benign esophageal strictures without careful consideration of the potential problems, which can include rendering the problem inoperable.

Changing strategies in the performance of laparoscopic Nissen fundoplication as a result of experience with 230 operations

From September 1991 to January 1995 we performed 230 Nissen fundoplications by a laparoscopic technique. Whilst a loose 360° fundoplication secured by 3 or 4 sutures was performed in all instances, there was variation between surgeons regarding the performance of hiatal repair and division of short gastric vessels; 207 operations were completed laparoscopically and 23 were converted to an open operation when a satisfactory wrap could not be achieved. Operating time ranged from 30 to 260 min (median 95) and the median postoperative stay was 3 days (1–19).Twenty-three patients (10%) underwent a subsequent operation (14 within 3 months of the original surgery), 2 for recurrent reflux, 10 for para-esophageal herniation, 2 for a misplaced fundoplication resulting in gastric obstruction, 7 for persistent dysphagia (4 due to stenosis of the esophageal hiatus), 1 for bleeding, and 1 for mesenteric thrombosis. (This patient died.) Five other patients were readmitted to hospital subsequent to their discharge—four because of pulmonary emboli and one because of gastric obstruction. Some 226 patients (98%) are free of reflux symptoms with follow-up ranging up to 40 months (median 16). Absence of reflux and the integrity of the fundoplication has been confirmed by postoperative esophageal manometry and pH monitoring in 90 patients, and by barium meal in 126.Postoperative recovery has been quick and wound-related morbidity minimal. Although the rate of surgical revision was significant in this series, the likelihood of complications or further surgery, as well as incidence of conversion to open surgery, decreased in the second half of the experience. Strategies developed to improve the outcome now include routine posterior closure of the hiatus, early postoperative barium-meal examination, and minimization of diathermy dissection. A loose fundoplication is always constructed over a large bougie. The need for division of the short gastric vessels in laparoscopic fundoplication remains controversial and awaits the outcome of a randomized trial.