Jennifer C. Myers

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.

Division of Short Gastric Vessels at Laparoscopic Nissen Fundoplication: A Prospective Double-Blind Randomized Trial With 5-Year Follow-Up

ObjectiveTo determine whether division of the short gastric vessels at laparoscopic fundoplication confers long-term clinical benefit to patients. Summary Background DataDividing the short gastric vessels during surgery for gastroesophageal reflux is controversial. This prospective randomized study was designed to determine whether there is a benefit in terms of patient outcome at a minimum of 5 years after primary surgery. MethodsBetween May 1994 and October 1995, 102 patients undergoing a laparoscopic Nissen fundoplication were randomized to have their short gastric vessels either divided or left intact. By September 2000, 99 (50 no division, 49 division) patients were available for follow-up, and they all underwent a detailed telephone interview by an independent and masked investigator. ResultsThere were no significant differences between the groups at 5 years of follow-up in terms of the incidence of epigastric pain, regurgitation, odynophagia, early satiety, inability to belch, anorexia, nausea, vomiting, nocturnal coughing, and nocturnal wheezing. There was also no difference between the groups in the incidence of heartburn when determined by either yes/no questioning or a 0-to-10 visual analog scale. There was no difference between the groups in terms of the incidence and severity of dysphagia determined by yes/no questioning, 0-to-10 visual analog scales, or a composite dysphagia score. There was a significantly increased incidence of flatus production and epigastric bloating and a decreased incidence of ability to relieve bloating in patients who underwent division of the short gastric vessels. ConclusionsDivision of the short gastric vessels during laparoscopic Nissen fundoplication does not improve any measured clinical outcome at 5 years of follow-up and is associated with an increased incidence of “wind-related” problems.

Nasopharyngeal pH Monitoring in Chronic Sinusitis Patients Using a Novel Four Channel Probe

Objective: To determine the prevalence of acid reflux into the nasopharynx in patients with chronic sinusitis.

Impact of ineffective oesophageal motility and wrap type on dysphagia after laparoscopic fundoplication

Laparoscopic 360° fundoplication is the most common operation for gastro‐oesophageal reflux disease, but is associated with postoperative dysphagia in some patients. Patients with ineffective oesophageal motility may have a higher risk of developing postoperative dysphagia, but this remains unclear.

Long‐term outcomes of revisional surgery following laparoscopic fundoplication

A small proportion of patients who have laparoscopic antireflux procedures require revisional surgery. This study investigated long‐term clinical outcomes.

Susceptibility to dysphagia after fundoplication revealed by novel automated impedance manometry analysis

Background  Conventional measures of esophageal pressures or bolus transport fail to identify patients at risk of dysphagia after laparoscopic fundoplication.

Concurrent fluoroscopy and manometry reveal differences in laparoscopic Nissen and anterior fundoplication.

A prospective double-blind randomized trial wasinitiated to examine two types of laparoscopicfundoplication (Nissen and anterior). Thirty-twopatients with proven gastroesophageal reflux diseasepresenting for primary laparoscopic antireflux surgerywere randomized to undergo either Nissen fundoplication(N = 13) or anterior hemifundoplication (N = 19).Postoperative fluoroscopic and manometric examinationwas carried out concomitantly. Nissenfundoplication resulted in significantly greaterelevation of resting (33.5 vs 23 mm Hg) and residuallower esophageal sphincter pressures (17 vs 6.5 mm Hg)and lower esophageal ramp pressure (26 vs 20.5 mm Hg) than theanterior partial fundoplication. A smallerradiologically measured sphincter opening diameter wasseen following Nissen fundoplication (9 mm) comparedwith anterior fundoplication (12 mm). Lower esophageal ramppressure correlated weakly (r = 0.37, P = 0.04) withpostoperative dysphagia. It is concluded that the typeof fundoplication performed significantly influences postoperative manometric and video bariumradiology outcomes. The clinical relevance of thisrequires further investigation.

The influence of esophageal length on outcomes after laparoscopic fundoplication

BACKGROUND It has been suggested that laparoscopic antireflux surgery has been associated with an increased incidence of postoperative paraesophageal hiatus herniation, and that this comes (at least in part) from not performing an esophageal lengthening procedure in patients with preoperative esophageal shortening. This study was undertaken to determine whether patients with esophageal shortening have an increased risk of reoperation after laparoscopic antireflux surgery. STUDY DESIGN All patients who underwent a laparoscopic fundoplication between December 1991 and March 1999, and who had undergone preoperative esophageal manometry in our department were included in this study. Preoperative, operative, and followup data were collected prospectively, and original manometry recordings were reviewed to determine the length of the esophagus (the distance between the midpoints of the upper and lower esophageal sphincters). An index of esophageal length versus height was also calculated by dividing esophageal length by height. Esophageal length and the index were then compared with clinical outcomes. In addition, outcomes for the 50 patients with the shortest index was compared with outcomes of the 50 patients with the longest index. RESULTS This study included 484 patients from an overall experience of 774 laparoscopic antireflux procedures. Postoperative followup ranged from 3 months to 5 years (median 2 years). Mean esophageal length was 23 cm (range 14 to 30 cm). There was a significant correlation between height and esophageal length (r = 0.44, p < 0.0001). Although patients with large hiatus hernias tended to have a shorter esophagus, preoperative endoscopic esophagitis grading did not influence length. Esophageal length did not influence the overall requirement for further surgical reintervention, although an analysis of esophageal length in patients who developed specific complications demonstrated that postoperative paraesophageal herniation was more likely in patients with a shorter esophagus, and reoperation for a tight esophageal hiatus was less likely in patients with a short esophagus. The incidence of paraesophageal hernia in the 50 patients with the shortest index was 8% versus 2% in the 50 patients with the longest index (p = 0.36). CONCLUSIONS Although the overall reoperation rate after laparoscopic fundoplication was not influenced by esophageal length, this study did demonstrate an association between esophageal shortening and postoperative paraesophageal herniation. But the increased risk of this problem is small, and for this reason a case cannot be made for patients with a manometrically short esophagus to routinely undergo an esophageal lengthening procedure.

Gastroesophageal reflux disease and chronic sinusitis: In search of an esophageal-nasal reflex

Background This study was performed to explore whether or not a neural reflex linking the esophagus and the nasal airway exists, as a pathogenic mechanism accounting for the association between gastroesophageal reflux (GER) disease and chronic rhinosinusitis (CRS). A prospective trial of healthy human volunteers was performed. Methods Ten healthy volunteers without GER or sinonasal disease were investigated using an acid infusion challenge test. Normal saline and hydrochloric acid were infused into the lower esophagus through an esophageal manometry catheter. Nasal responses in symptom score, nasal inspiratory peak flow, and mucus production were analyzed after the esophageal challenge. Results A tendency for an increase in nasal mucus production was observed after esophageal stimulation with both normal saline and HCl. This returned to baseline level 45 minutes after the acid infusion. A similar trend was also observed with the measurements of nasal symptom scores and, to a lesser extent, nasal inspiratory peak flow. Conclusion These results support the possibility that a neural reflex exists between the esophagus and the paranasal sinuses via the vagus nerve. If indeed present, the reflex-mediated rhinitis derived from this neuropathic inflammation may contribute to the development of CRS in patients with GER. Further study is required to define the relationship between GER and CRS.

Preoperative gastric emptying and patterns of reflux as predictors of outcome after laparoscopic fundoplication

Some studies have suggested that patients with predominantly upright reflux have a poor outcome after laparoscopic antireflux surgery. It has been proposed that this might be related to gastric emptying. The aim of this study was to evaluate the relationship between preoperative upright reflux pattern, gastric emptying rate and outcome after laparoscopic fundoplication.