John E. Meilahn

Laparoscopic Esophagomyotomy for Achalasia: Does Anterior Hemifundoplication Affect Clinical Outcome?

Objective:To determine whether the addition of anterior hemifundoplication to laparoscopic esophagomyotomy for achalasia yields better clinical outcomes than laparoscopic esophagomyotomy alone. Summary Background Data:Although hemifundoplication may prevent gastroesophageal reflux after esophagomyotomy for achalasia, it may also lead to persistent dysphagia in these patients with esophageal aperistalsis. Methods:This is a retrospective study of 51 consecutive patients (mean age 47.5 ± 12.6 years) who had laparoscopic esophagomyotomy for achalasia by our group between August 1995 and January 2001. In 29 patients (57%) an anterior hemifundoplication was added to the esophagomyotomy. In 22 patients (43%), no wrap was added. Patients scored (0 = none; 1 = mild; 2 = moderate; 3 = severe) symptom severity (dysphagia, regurgitation, heartburn, chest pain) preoperatively and postoperatively. Weight gain, use of gastrointestinal (GI) medication, tolerance to food, and patient satisfaction were also assessed. Results:Mean patient follow-up was 33 months, and there were no operative deaths. Four patients were converted to open operation (8%). The wrap and no wrap groups were similar in terms of esophageal dilation, preoperative symptom severity and duration (5.7 ± 7.1 versus 6.1 ± 7.0 years), and preoperative weight loss (18 ± 15 versus 20 ± 20 pounds). Both groups had similar improvement in symptom grade postoperatively and equivalent satisfaction rates (86%). Postoperative weight gain, GI medication use, and food intolerance was also similar. Postoperatively, patients in the wrap group did not have higher dysphagia scores or lower heartburn scores than the no wrap group. Conclusion:The addition of anterior hemifundoplication to esophagomyotomy for achalasia does not improve or worsen clinical results.

Effect of prolonged selective intramesenteric arterial vasodilator therapy on intestinal viability after acute segmental mesenteric vascular occlusion.

ObjectiveTo evaluate the effect of selective intramesenteric artery vasodilator infusion on intestinal viability in a rat model of acute segmental mesenteric vascular occlusion. Summary Background DataAlthough intramesenteric arterial vasodilator infusion may be an effective treatment for nonocclusive mesenteric ischemia, it has also been advocated to increase collateral blood flow after mesenteric vascular occlusion. However, the authors have previously found that intraarterial vasodilators actually reduce collateral blood flow acutely, by preferentially dilating the vasculature of adjacent, nonischemic mesenteric vascular beds, a phenomenon well established in other organs. MethodsA segment of rat ileum was acutely devascularized, with blood flow provided only by collateral arterial vessels from adjacent, nonischemic bowel. Papaverine (30 or 40 &mgr;g/kg/min), isoproterenol (0.06 &mgr;g/kg/min), norepinephrine (0.1 or 0.2 &mgr;g/kg/min), or vehicle saline was continuously infused into the cranial (superior) mesenteric artery for 48 hours. Viability was then assessed using previously established, objective gross and microscopic criteria. ResultsAlthough papaverine increased total mesenteric blood flow in normally vascularized rats, it not only failed to improve but actually significantly reduced the length of the devascularized segment maintained viable by collateral blood flow after 48 hours. Isoproterenol had a similar effect. Norepinephrine infusion decreased both normal mesenteric blood flow and viable segment length. ConclusionsThese findings suggest that intraarterial vasodilator therapy fails to improve intestinal viability after segmental mesenteric vascular occlusion.

Intussusception after Laparoscopic Gastric Bypass Surgery: An Underrecognized Complication

Introduction. Intussusception after bariatric surgery is an uncommon complication that is now being frequently reported. Most people consider dysmotility to be the causative mechanism in the absence of obvious etiology. Material and Methods. A worldwide search identified literature describing intussusception after bariatric surgery. We also included our own patients and analyzed information regarding demographic profile, risk factors, presentation, diagnosis, and post treatment course. Results. Seventy one patients were identified between 1991 and 2011. Majority of the affected patients were females (n = 70, 98.6%); median time to presentation after gastric bypass surgery was 36 months. Most patients presented with abdominal pain, nausea and vomiting, but without obvious peritonitis. Sixty eight patients (96%) required surgery; 48 (70.6%) underwent revision of anastomosis, 16 (23.5%) had reduction without resection, while 4 patients (5.9%) had plication only. Amongst these, most patients (n = 51, 75%) were found to have retrograde intussusception. Post-operatively, 9 patients presented with recurrence (range, 0.5–32 months). Five patients, who had earlier been treated without resection, eventually required revision of the anastomosis. There was no mortality noted. Conclusion. Intussusception after bariatric surgery is uncommon and its diagnosis is based on a combination of physicial, radiological and operative findings. An early surgical intervention reduces morbidity and prevents recurrence.

Bleeding gastric or duodenal ulcer

Of the estimated 4 000 000 people in the USA with peptic ulcer disease, about 100 000 bleed each year. The attendant mortality rate has remained relatively constant at 6–10% during the past 30 years, despite numerous advances in therapy. Predictors of increased chance of death from an episode of ulcer haemorrhage include an age of over 60 years, multiple organ system disease, transfusion of 5 or more units of whole blood or its equivalent, the recent stress of operation, trauma or sepsis, and the performance of emergency surgery to control haemorrhage (in these patients mortality rates range from 15 to 25%). The mortality rate in patients undergoing emergency surgery is twice as high for bleeding gastric ulcer as it is for bleeding duodenal ulcer.