G. J. Wetscher

Treatment of morbid obesity with laparoscopic adjustable gastric banding affects esophageal motility.

BACKGROUND Laparoscopic adjustable gastric banding has become the prefered method for the surgical treatment of morbid obesity in Europe. It is not known whether this procedure may induce gastroesophageal reflux and whether it may impair esophageal peristalsis. METHODS Laparoscopic adjustable gastric banding (Swedish band) was performed in 43 patients (median body mass index [BMI] 42.5 kg/m(2)). Preoperatively and 6 months postoperatively all patients were assessed for reflux symptoms. In addition all patients underwent preoperative and postoperative endoscopy, esophageal barium studies and manometry, and 24-hour esophageal pH-monitoring. RESULTS The median BMI dropped significantly to 33.1 kg/m(2) (P <0.05). Preoperatively 12 patients complained of reflux symptoms. Mild esophagitis was detected in 10 patients. Postoperatively only 1 patient complained of heartburn and mild esophagitis was diagnosed in another patient. None of the patients had dysphagia. Preoperatively a defective LES and pathologic pH-testing were found in 9 and 15 patients, respectively. These parameters were normal in all of the patients postoperatively. Postoperatively there was significant impairment of LES relaxation and deterioration of esophageal peristalsis with dilatation of the esophagus in some of the patients. CONCLUSION Laparoscopic adjustable gastric banding provides a sufficient antireflux barrier and therefore prevents pathologic gastroesophageal reflux. However, it impairs relaxation of the LES, leading to weak esophageal peristalsis.

Tailored Antireflux Surgery for Gastroesophageal Reflux Disease: Effectiveness and Risk of Postoperative Dysphagia

Abstract 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.

Adjustable Gastric and Esophagogastric Banding: A Randomized Clinical Trial

Background: Adjustable gastric banding and esophagogastric banding may affect the function of the lower esophageal sphincter (LES) and esophageal motility in the long-term. Both methods were evaluated in a prospective randomized trial. Materials and Methods: Group 1 comprised 28 patients who underwent laparoscopic adjustable gastric banding and Group 2 consisted of 24 patients in whom adjustable esophagogastric banding was performed. Swedish Adjustable Gastric Bands® were used in all patients. Body mass index (BMI), perioperative complications and reflux symptoms were assessed and upper gastrointestinal endoscopy, esophageal barium studies, esophageal manometry and 24-hour esophageal pH-monitoring were performed pre- and postoperatively. 18 (Group 1) and 14 (Group 2) patients completed the postoperative follow-up procedure after a median of 23 and 24 months, respectively. Results: Postoperatively the median BMI dropped equally in both groups. Perioperative complications requiring re-intervention were significantly more frequent in Group 2 than in Group 1. Heartburn improved equally in both groups following surgery; however, regurgitation and esophagitis were significantly more common in Group 2 than in Group 1.24-hour esophageal pH-monitoring and the LES resting pressure improved equally in both groups, but there was a significant impairment of the LES relaxation and the esophageal peristalsis, which was more pronounced in Group 2 than in Group 1. This caused significant esophageal stasis as shown by barium studies. Conclusions: Both techniques, gastric and esophagogastric banding, provide effective weight loss in morbidly obese patients but affect the esophagogastric junction. Although both procedures strengthen the antireflux-barrier, LES relaxation becomes impaired, thus promoting esophageal dilatation and esophageal stasis. This is more pronounced following esophagogastric banding than following the classic procedure. Since the esophagogastric banding results in more complications requiring re-intervention, we believe that this procedure should not be used any more.

Respiratory symptoms in patients with gastroesophageal reflux disease following medical therapy and following antireflux surgery.

BACKGROUND It is not known whether antireflux surgery is more effective than medical therapy to control respiratory symptoms (RS) in gastroesophageal reflux disease (GERD). METHODS In 21 GERD patients with RS, reflux was assessed by endoscopy, manometry, and pH monitoring. Patients had proton pump inhibitor therapy and cisapride for 6 months. After GERD relapsed following withdrawal of medical therapy, 7 patients with normal esophageal peristalsis had a laparoscopic Nissen fundoplication and 14 with impaired peristalsis a Toupet fundoplication. Respiratory symptoms were scored prior to treatment, at 6 months following medical therapy, and at 6 months after surgery. RESULTS Heartburn and esophagitis were effectively treated by medical and surgical therapy. Only surgery improved regurgitation. Respiratory symptoms improved in 18 patients (85.7%) following surgery and in only 3 patients (14.3%) following medical therapy (P <0.05). Esophageal peristalsis improved following the Toupet fundoplication. CONCLUSION Medical therapy fails to control reflux since it does not inhibit regurgitation. Surgery controls reflux and improves esophageal peristalsis, which contributes to its superiority over medical therapy in the treatment of RS associated with GERD.

CT-MIBI image fusion: a new preoperative localization technique for primary, recurrent, and persistent hyperparathyroidism.

BACKGROUND Successful minimally invasive or imaging-guided operations in patients with primary, recurrent, and persistent hyperparathyroidism are based on the reliability of preoperative parathyroid localization studies. The CT-MIBI image fusion promises a higher diagnostic accuracy than current imaging procedures. The aim of our study was to assess its reliability in correctly detecting enlarged parathyroid glands. METHODS In a prospective study 24 consecutive patients underwent CT-MIBI image fusion as preoperative parathyroid localization procedure. The results of technetium 99m sestamibi single photon emission computed tomography (MIBI-SPECT) alone, today the standard method in parathyroid imaging, and CT-MIBI image fusion were analyzed by a blinded reviewer, and the imaging results were compared with the intraoperative findings. RESULTS For CT-MIBI image fusion a sensitivity of 93% and a specificity of 100% in correctly detecting the position of enlarged parathyroid glands was calculated and compared with a sensitivity of MIBI-SPECT of 31% and a specificity of 87% (P<.001). This new imaging technique enabled us to successfully treat 22 of our patients (92%) with imaging-guided surgery. Twenty (83%) underwent unilateral or minimally invasive operations. CONCLUSIONS CT-MIBI image fusion appears to be superior to MIBI-SPECT in preoperative parathyroid imaging. CT-MIBI image fusion can be performed on existing CT- and MIBI-SPECT units. We recommend this method for preoperative localization in patients with primary, recurrent and persistent hyperparathyroidism.

The use of ultrasound to differentiate rectus sheath hematoma from other acute abdominal disorders

AbstractBackground: Rectus sheath hematoma (RSH) is a rare entity that can mimic an acute abdomen. Therefore, we designed a study to analyze the etiology, frequency, diagnosis using ultrasound, and treatment of RSH. Methods: A total of 1,257 patients admitted for abdominal ultrasound for acute abdominal pain or unclear acute abdominal disorders were evaluated. Results: In 23 (1.8%) patients, an RSH was diagnosed; three of them were not diagnosed preoperatively by ultrasound. Of 13 men and 10 women (mean age, 57 ± 23 years), 13 developed RSH after local trauma, three after severe coughing, two after defecation, and five spontaneously. Fifteen had nonsurgical therapy, and eight underwent surgery. The use of anticoagulants was accompanied by a larger diameter of the RSH (p < .012), and surgical therapy was more frequently required in these patients. In the surgically treated group, more intraabdominal free fluid could be detected by ultrasound (p < .0005), patients required less analgesics (p < .001), and the mean hospital stay was shorter (p < .001). Conclusions: RSH is a rare condition that is usually associated with abdominal trauma and/or anticoagulation therapy. Ultrasound is a good screening technique. Nonsurgical therapy is appropriate but leads to a greater need for analgesics. Surgery should be restricted to cases with a large hematoma or free intraabdominal rupture.

Ingested foreign bodies within the appendix: A 100-year review of the literature.

Background/Aim: Appendicitis and its complications remain a common problem affecting patients of all age groups. Foreign bodies are a rare cause of appendicitis. We tried to define potentially dangerous foreign bodies that may cause appendicitis and summarize general guidelines for their clinical management. Methods: A 100-year literature review including 256 cases of ingested foreign bodies within the appendix with emphasis on: (1) objects that are more prone to cause appendicitis or appendiceal perforation; (2) foreign bodies that are radiopaque and may be detected during follow-up with plain abdominal films, and (3) guidelines for clinical management. Results: Complications usually occur with sharp, thin, stiff, pointed and long objects. The majority of these objects are radiopaque. An immediate attempt should be made to remove a risky object by gastroscopy. If this fails, clinical follow-up with serial abdominal radiographs should be obtained. If the anatomical position of the object appears not to change and, most commonly, remains in the right lower abdominal quadrant, an attempt at colonoscopic removal is indicated. If this is unsuccessful, laparoscopic exploration with fluoroscopic guidance should be carried out to localize and remove the objects either by ileotomy, colotomy, or by appendectomy. Conclusion: Foreign bodies causing appendicitis are rare. However, if stiff or pointed objects get into the appendiceal lumen they have a high risk for appendicitis or perforation. These foreign bodies are almost always radiopaque.

Laparoscopic Appendectomy Does Not Change the Incidence of Postoperative Infectious Complications

BACKGROUND It is not clear whether the laparoscopic approach does decrease the incidence of postoperative infectious complications after appendectomy. METHODS One hundred sixty-nine patients were randomized, 87 with laparoscopic (LA) and 82 with open appendectomy (OA). Patients in the OA group had a McBurney incision; LA was performed in the lithotomy position. RESULTS Acute appendicitis was confirmed in 75% of patients. The appendix was perforated in 5 patients of the LA versus 2 patients of the OA group. No conversion to the open procedure was necessary. The median operating time was 35 minutes in the LA group and 31 minutes in the open group (P = 0.58). The median postoperative hospital stay was shorter after laparoscopic than after open surgery (3 days versus 4 days, P = 0.026), whereas the time required for return to work was not significantly different (14 versus 15 days). There were 5 (6%) patients with superficial wound infection following LA and 6 (7%) after OA (P = 0.67). Intra-abdominal fluid collections were found in 2 (2%) patients following LA and 3 (4%) patients following OA (P = 0.60). In the LA group, 3 patients presented with intra-abdominal hemorrhage and another 3 developed a paralytic ileus that was treated conservatively. CONCLUSIONS Laparoscopic appendectomy is as safe and as effective as the open procedure; however, it does not decrease the rate of postoperative infectious complications.

The effect of medical therapy and antireflux surgery on dysphagia in patients with gastroesophageal reflux disease without esophageal stricture.

BACKGROUND Poor esophageal body motility and trapping of the hernial sac by the hiatal crura are the major pathomechanisms of gastroesophageal reflux disease (GERD)-induced dysphagia. There is only little knowledge of the effect of medical therapy or antireflux surgery in reflux-induced dysphagia. METHODS Fifty-nine consecutive GERD patients with dysphagia were studied by means of a symptom questionnaire, endoscopy, barium swallow, esophageal manometry, and 24-hour pH monitoring of the esophagus. Patients had proton pump inhibitor therapy and cisapride for 6 months. After GERD relapsed following withdrawal of medical therapy, 41 patients decided to have antireflux surgery performed. The laparoscopic Nissen fundoplication was chosen in 12 patients with normal esophageal body motility and the laparoscopic Toupet fundoplication in 29 patients with impaired peristalsis. Dysphagia was assessed prior to treatment, at 6 months of medical therapy, and at 6 months after surgery. RESULTS Heartburn and esophagitis were effectively treated by medical and surgical therapy. Only surgery improved regurgitation. Dysphagia improved in all patients following surgery but only in 16 patients (27.1%) following medical therapy. Esophageal peristalsis was strengthened following antireflux surgery. CONCLUSIONS Medical therapy fails to control gastroesophageal reflux as it does not inhibit regurgitation. Thus, it has little effect on reflux-induced dysphagia. Surgery controls reflux and improves esophageal peristalsis. This may contribute to its superiority over medical therapy in the treatment of GERD-induced dysphagia.

Laparoscopic partial posterior fundoplication provides excellent intermediate results in GERD patients with impaired esophageal peristalsis.

BACKGROUND Gastroesophageal reflux disease (GERD) is frequently associated with impaired esophageal peristalsis, and many authorities consider this condition not suitable for Nissen fundoplication. METHODS To investigate the outcome of antireflux surgery in the presence of impaired esophageal peristalsis, 78 consecutive GERD patients with poor esophageal contractility who underwent laparoscopic partial posterior fundoplication were studied. A standardized questionnaire, upper gastrointestinal endoscopy, esophageal manometry, and 24-hour pH monitoring were performed preoperatively and at a median of 31 months (range 6-57 months) postoperatively. Esophageal motility was analyzed for contraction amplitudes in the distal two thirds of the esophagus, frequency of peristaltic, simultaneous, and interrupted waves, and the total number of defective propagations. In addition, parameters defining the function of the lower esophageal sphincter were evaluated. RESULTS After antireflux surgery, 76 patients (97%) were free of heartburn and regurgitation and had no esophagitis on endoscopy. The rate of dysphagia decreased from 49% preoperatively to 10% postoperatively (P < .001). Features defining impaired esophageal body motility improved significantly after antireflux surgery. The median DeMeester score on 24-hour esophageal pH monitoring decreased from 33.3 to 1.1 (P < .001). CONCLUSIONS Partial posterior fundoplication provides an effective antireflux barrier in patients with impaired esophageal body motility. Postoperative dysphagia is diminished, probably because of improved esophageal body function.