Heinz Wykypiel

Efficacy of medical therapy and antireflux surgery to prevent Barrett's metaplasia in patients with gastroesophageal reflux disease.

ObjectiveTo investigate whether Barrett’s metaplasia may develop despite effective medical therapy. Summary Background DataGastroesophageal reflux disease has a multifactorial etiology. Therefore, medical treatment may not prevent complications of reflux disease. MethodsEighty-three patients with reflux disease and mild esophagitis were prospectively studied for the development of Barrett’s metaplasia while receiving long-term therapy with proton pump inhibitors and cisapride. Only patients who had effective control of reflux symptoms and esophagitis were included. The surveillance time was 2 years. The outcome of these 83 patients was compared with that of 42 patients in whom antireflux surgery was performed with a median follow-up of 3.5 years. ResultsTwelve (14.5%) patients developed Barrett’s while receiving medical therapy; this was not seen after surgery. Patients developing Barrett’s had a weaker lower esophageal sphincter and peristalsis before treatment than patients with uncomplicated disease. ConclusionsAntireflux surgery is superior to medical therapy in the prevention of Barrett’s metaplasia. Therefore, patients with reflux disease who have a weak lower esophageal sphincter and poor esophageal peristalsis should undergo antireflux surgery, even if they have only mild esophagitis.

Austrian experiences with redo antireflux surgery

BackgroundFrom 1996, the entire number of fundoplications performed in Austria increased dramatically, favoring the laparoscopic technique. Despite good results, some patients experience failure of antireflux surgery and therefore require redo surgery if medical therapy fails to control symptoms. The aim of the study was to describe the refundoplication policy in Austria with evaluation of the postoperative results.MethodsA questionnaire was sent to all Austrian surgical departments at the beginning of 2003 with questions about redo fundoplications (number, techniques, intraoperative complications, history, migration of patients, preoperative workup, mortality, and postoperative long-term complaints). It also included questions about primary fundoplications (number, technique, postoperative symptoms).ResultsOut of 4,504 primary fundoplications performed in Austria since 1990, 3,952 have been carried out laparoscopically. In a median of 31 months after the primary operation, 225 refundoplications have been performed, laparoscopically in the majority of patients. The Nissen and the partial posterior fundoplication were the preferred techniques. The conversion rate in these was 10.8%, mainly because of adhesions and lacerations of the spleen, the stomach, and the esophagus. The mortality rate after primary fundoplications was 0.04%, whereas the rate after refundoplications was 0.4%, all resulting from an open approach.ConclusionLaparoscopic refundoplications are widely accepted as a treatment option after failed primary antireflux surgery in Austria. However, the conversion rate is 6 times higher and the mortality rate is 10 times higher than for primary antireflux surgery. Therefore, redo fundoplications should be performed only in departments with large experience.

Listeria meningitis in transplant recipients.

SummaryINTRODUCTION: Meningitis is a rare complication following organ and stem-cell transplantation and can be caused by a variety of microorganisms. AIM: To retrospectively review the clinical course and outcome of five cases of listeriosis in four organ recipients and one stem-cell recipient during a seven-year period. PATIENTS AND METHODS: Patient records for more than 3500 patients undergoing organ or stem-cell transplantation at the university hospital of Innsbruck during a 27-year period were evaluated. Standard immunosuppression consisted of calcineurin inhibitor-based triple drug therapy with or without ATG or IL2 receptor antagonist induction. RESULTS: The first case affected a 35-year-old woman who received an allogenic bone marrow transplant for advanced breast cancer. Cases two and three related to two male heart recipients. Cases four and five were diagnosed in one male and one female renal recipient. Listeria monocytogenes was isolated from blood in two cases and from cerebrospinal fluid in three. Treatment consisted of ampicillin in all cases with the addition of tobramycin (1), TMPS (1), meropenem (2) or imipenem/cilastatin (1). The deaths of two patients were directly related to L. monocytogenes. CONCLUSIONS: Although listeriosis is a rare complication following transplantation, this infection should be ruled out in individuals presenting with neurological symptoms and fever.ZusammenfassungEINLEITUNG: Meningitis ist eine seltene Komplikation nach Organ- bzw. Stammzelltransplantation und kann durch eine Vielzahl von Mikroorganismen verursacht werden. Ziel dieser Studie war eine retrospektive Analyse über klinischen Verlauf und Outcome bei fünf Transplantationspatienten, die an einer Listerienmeningits erkrankt sind. PATIENTEN UND METHODEN: Die Studienpopulation dieser Arbeit umfasst mehr als 3500 Organ- bzw. Stammzelltransplantationen, die an der Universiätsklinik in Innsbruck während eines Zeitraumes von 26 Jahren durchgeführt wurden. Die Standardimmunosuppression umfasste eine Calcineurininhibitor-basierte Dreifachtherapie, zum Teil unter Verwendung einer Induktionstherapie mit ATG oder eines IL2-Rezeptor-Antagonisten. ERGEBNISSE: Alle Patienten zeigten Zeichen der Meningitis und hatten hohes Fieber sowie eine Erhöhung der Entzündungsparameter. Bei zwei Fällen handelte es sich um eine nosokomiale Erkrankung innerhalb der ersten beiden Wochen nach Transplantation. Beim ersten Fall handelte es sich um eine 35-jährige Frau, die sich aufgrund eines fortgeschrittenen Mamma-Karzinoms einer allogenen Stammzelltransplantation unterziehen musste. Die übrigen vier Betroffenen waren zwei Herz- und zwei Nierenempfänger. Listeria monocytogenes wurde bei zwei Patienten im Blut und bei drei Patienten im Liquor nachgewiesen. Die Behandlung erfolgte in allen Fällen mit Ampicillin. Zusätzlich wurden Tobramycin (n = 1), Meropenem (n = 2) und Imipenem/Cilastatin (n = 1) verabreicht. Zwei Patienten verstarben unmittelbar an den Folgen der Listeriose. SCHLUSSFOLGERUNG: Obwohl die Listerienmeningitis eine seltene Komplikation nach Transplantation darstellt, sollte sie doch bei allen Organempfängern mit hohem Fieber in Erwägung gezogen werden, die eine neurologische Symptomatik entwickeln.

The laparoscopic fundoplications: Nissen and partial posterior (Toupet) fundoplication

ZusammenfassungGRUNDLAGEN: Die gastroösophageale Refluxkrankheit ist weit verbreitet und kann mit einer laparoskopischen Fundoplikation kausal behandelt werden. Die Nissen-Fundoplikation und die partielle posteriore Fundoplikation (nach Toupet) sind die gängigsten Operationen. METHODIK: Detaillierte Beschreibung der Operationstechnik und der Ergebnisse mit Übersicht über die Literatur. ERGEBNISSE: Die Nissen- und die partielle posteriore Fundoplikation können GERD-Symptome heilen und die Lebensqualität verbessern, sie können eine Ösophagitis zur Abheilung bringen und der Karzinogenese entgegenwirken. SCHLUSSFOLGERUNGEN: Die laparoskopische Nissen-Fundoplikation stellt quasi den Goldstandard in der operativen Behandlung von GERD dar, obwohl sie in einigen Publikationen von der partiellen posterioren Fundoplikation ernsthaft konkurriert wird.SummaryBACKGROUND: Gastroesophageal reflux disease (GERD) is a common disease and can successfully be treated by laparoscopic fundoplication. The Nissen and the partial posterior fundoplication (Toupet) are the most widespread documented techniques. METHODS: Detailed description of the operative techniques and results including review of the literature. RESULTS: The Nissen- and partial posterior fundoplication (Toupet) can cure GERD symptoms and improve quality of life, they can cure esophagitis and are able to prevent carcinogenesis. CONCLUSIONS: The laparoscopic Nissen fundoplication represents the gold standard in antireflux surgery, although in some publications, it is challenged by the partial posterior fundoplication (Toupet) regarding postoperative side effects.

Routine upper gastrointestinal swallow studies after laparoscopic sleeve gastrectomy are unnecessary.

BACKGROUND Laparoscopic sleeve gastrectomy has gained popularity among bariatric surgeons. The purpose of this study was to evaluate the usefulness of early upper gastrointestinal (UGI) contrast studies in the detection of postoperative complications. METHODS Radiographic reports were reviewed from April 2006 to January 2013. During that time, 161 patients underwent laparoscopic sleeve gastrectomy. All patients were submitted to UGI examination on postoperative day (POD) 1. RESULTS Among the 161 patients who underwent UGI, no contrast leaks were found on POD 1. Three patients (1.9%) developed stapler line leaks near the gastroesophageal junction, which were diagnosed on PODs 3, 4, and 10. Gastroesophageal reflux in 5 patients (3.1%) and delayed gastroesophageal transit in 10 patients (6.2%) were detected. CONCLUSIONS The results of this study show that UGI series on POD 1 cannot assess the integrity of the gastric remnant. Early UGI series are not required as routine procedures in all operated patients. Computed tomographic swallow studies should be performed in patients who postoperatively develop clinical signs and symptoms of complications such as tachycardia, pain, or fever.

The Nissen fundoplication: indication, technical aspects and postoperative outcome

IntroductionGastroesophageal reflux disease (GERD) is the most common foregut disease, with a great impact on quality of life and with intestinal, respiratory and cardiac symptoms and implications of carcinogenesis of the oesophagus. Medical therapy often fails, due to the complex pathophysiology of GERD. Surgery can cure the disease, since it is able to restore the anti-reflux barrier. It improves quality of life and prevents carcinogenesis.MethodsReview of the literature and presentation of our own experience and data in a series of more than 4,000 evaluated patients referred for suspected reflux disease, of whom 382 have been operated on.ConclusionThe laparoscopic Nissen fundoplication is the most commonly used operation technique. It provides good long-term results in the majority of patients. However, due to an increase of outflow resistance of the oesophagus this operation is associated with some postoperative side effects. Therefore, alternative anti-reflux procedures may be indicated in selected patients.

Perioperative results of robotic lung lobectomy: summary of literature

Dear Editor, We appreciate the interest in our manuscript [1] by Takagi and colleagues, resulting in a detailed analysis of the current literature [2]. After its introduction in cardiac surgery, thoracic surgeons were eager to adopt the robotic technique for minimally invasive thoracic surgery. While the technique offers benefits in mediastinal tumor resections [3] and has become the standard technique for minimally invasive thymectomies in many centers [4], studies comparing robotic and conventional minimally invasive lung resections do not show any clear advantage for a robotic approach, as shown by Takagi and colleagues. Reports on larger series of robotic lung lobectomy and oncologic longterm outcomes are still missing. Only a few centers perform robotic lobectomy regularly; fellowships in robotic thoracic surgery are rare. Furthermore, high acquisition and maintenance costs of the robotic system hinder its broad availability. In contrast, video-assisted thoracoscopic surgery (VATS) lobectomies have been performed since the early 1990s in numerous institutions, and fellowships in minimally invasive thoracic surgery are offered in many of them. Various case series and randomized and nonrandomized trials have been published documenting its feasibility and oncologic safety [5]. Takagi and colleagues conclude that median length of stay (LOS) of robotic patients is only half of that of VATS lobectomies (and open lobectomies), when compared to results of a meta-analysis of Yan and colleagues [6]. However, LOS is not only affected by recovery of patients, but also by different social systems. The results on median LOS in this meta-analysis are based on seven Japanese papers with median LOS of 15.4 days and six manuscripts from other countries (USA: 4; France 1; China: 1) with median LOS of 6.9 days. This highlights the regional differences in LOS. In our opinion, results of a comparison of median LOS with the meta-analysis from Yan et al. should be interpreted with caution, since none of the robotic lobectomies included in the pooled data of Takagi et al. were performed in Japan. Ideally, comparative studies should be performed within a single center to overcome regional differences in patient management. We recently performed a retrospective analysis of our own VATS lobectomy patients and compared them with the robotic group; the manuscript summarizing this study is currently in progress. We agree with Takagi et al. that randomized studies are needed to finally answer the question of whether a robotic approach is superior to conventional minimally invasive lobectomy. We share the authors’ enthusiasm for robotic thoracic surgery; however, it needs to be proven that superior perioperative and oncologic outcome warrant the higher procedural costs of a robotic approach.

Laparoscopic sleeve gastrectomy: gateway to kidney transplantation

BACKGROUND The prevalence of obesity and obesity-related morbidity in end-stage renal disease patients is rising. Although it is established that obesity does not abrogate the transplant benefit with respect to lower long-term mortality and cardiovascular risk, it is associated with increased graft failure, delayed graft function, surgical complications, prolonged hospital stay, and costs. OBJECTIVES To examine the safety and efficacy of LSG (laparoscopic sleeve gastrectomy) in renal transplant candidates and evaluate transplant outcomes. SETTING Single-center prospective nonrandomized trial METHODS: We here report on a prospective single-center trial establishing a 2-step approach for obese renal transplant candidates. Patients with end-stage renal disease and a BMI (body mass index) of 35 kg/m2 or higher underwent laparoscopic sleeve gastrectomy. After reaching a BMI of<35 kg/m2, patients were waitlisted for kidney transplantation. Age, gender, body mass index (BMI), associated co-morbidities, cause of end-stage renal disease, surgical complications, and outcome after kidney transplantation (graft survival, incidence of delayed graft function, incidence of rejection, serum creatinine) were collected. RESULTS LSG was performed in 8 renal transplant candidates with a mean BMI of 38.8 kg/m2 each. BMI dropped to below 35 kg/m2 within a median of 3 months. Percent excess body mass index loss (%EBMIL) was 62.7% at 1 year after LSG. Within 17 months (mean) after metabolic surgery, 7 patients underwent kidney transplantation. All transplants were successful with a serum creatinine of 1.9±.8 mg/dL at discharge and stable allograft function thereafter. Mean follow-up was 3.2±1.4 years; no patient was lost to follow-up. CONCLUSION LSG is safe and efficacious for treatment of obesity in renal transplant candidates. Rapid and sustained weight loss and subsequent waitlisting for kidney transplantation may reduce overall and in particular posttransplant patient morbidity.

Robot-assisted versus conventional laparoscopic fundoplication: short-term outcome of a pilot randomized controlled study

We read with great interest the recent Surgical Endoscopy publication entitled ‘‘Robot assisted versus conventional laparoscopic fundoplication: short-term outcome of a pilot randomized controlled study’’. The authors come to the conclusion that—besides shortened operation time—the application of the operation robot does not reveal a further benefit in laparoscopic fundoplication. In 2002 we were able to perform a pilot study on robot-assisted laparoscopic Toupet fundoplication with the DaVinci surgical system (Intuitive Surgical, Mountain View, Calif., USA) with a 6month follow-up and came to the same conclusion except for an even longer set-up and operating time in our series [1]. Despite demanding experience of the surgeon in order to obtain a good functional outcome the performance of a laparoscopic fundoplication does not require the four main advantages of robot assisted laparoscopic surgery: it is not an operation that cannot be performed laparoscopically without the robot [2]; it does not require microscopic view and movements of the arms; anatomically it is not an operation in a remote or narrow operating field [3, 4]; and in a normal laparoscopic fundoplication no complex manoeuvres such as creation of an intracorporeal anastomosis or complex suturing [5] are needed. Improved ergonomics for the surgeon and a shorter set-up and operation time as a matter of training (as demonstrated in the above mentioned paper) do not outweigh higher operative costs as long as no further clear advantage is proven. Laparoscopic redo fundoplications [6] often consist of an even more demanding intraoperative situation where the operation robot could allow for a more precise dissection, avoiding inadvertent lacerations (e.g., lacerations of the vagus nerve), and therefore lead to a better outcome. For training purposes in order to be prepared for such more demanding applications the performance of robot-assisted laparoscopic fundoplications seems justified.