John Sophocles Vassilakis

Laparoscopic vs open approach for Nissen fundoplication

Background: Several studies, most of them nonrandomized, have shown similar functional results for both laparoscopic and open Nissen fundoplication, the operation of choice for the treatment of gastroesophageal reflux disease (GERD). Methods: A total of 106 patients with documented GERD were randomized to receive either a laparoscopic or an open Nissen fundoplication. Preoperative and postoperative investigations included clinical assessment, esophagogram, upper gastrointestinal endoscopy, esophageal manometry, and 24-h ambulatory pHmetry. Results: Both approaches were successful in controlling reflux. There was an overall improvement in esophageal peristalsis and an increase in lower esophageal sphincter (LES) pressure in both groups. Open Nissen fundoplication was associated with a significantly increased rate of wound (p <0.001) and respiratory (p <0.05) complications. Hospitalization was also longer after the open technique (p <0.001). At 3-month follow-up, although the rate of postoperative dysphagia was similar for the two approaches, the open approach was associated with a significantly higher incidence of postprandial epigastric fullness (p <0.05) and bloating syndrome (p <0.01). Conclusions: The open and laparoscopic approaches for the Nissen fundoplication are equally effective in controlling GERD. The open approach is associated with a significantly higher rate of wound and respiratory complications and, at early stages, an increased rate of postprandial epigastric fullness and abdominal bloating. The dysphagia rate is similar with both methods.

Resection rectopexy for rectal prolapse. The laparoscopic approach.

AbstractBackground: Resection rectopexy through open laparotomy is an established procedure for the treatment of rectal prolapse. Methods: Resection rectopexy was successfully performed in 10 multiparous women by the laparoscopic approach (LAP), and the results were compared to those of eight women with laparotomy resection rectopexy (OPEN). Preoperative and postoperative assessment included anorectal manometry, defecography, and measurement of large-bowel transit. Results: The duration of the operation was longer in the LAP than in the OPEN group (p < 0.01). Morbidity was lower (p < 0.01) and hospital stay was shorter (p < 0.001) after the LAP than in the OPEN group. Prolapse was cured in all cases. Postoperatively, anal resting and squeeze pressures and rectal compliance increased significantly in both groups of patients (p= 0.007, p= 0.003, and p < 0.001, respectively). In all patients, the operation resulted in acceleration of large-bowel transit (p < 0.001) and in more obtuse anorectal angles at rest (p= 0.007). In addition, sampling events were observed more commonly (p= 0.008) postoperatively. Preoperatively, incontinence was present in 13 patients (seven LAP and six OPEN) and persisted in four of them after rectopexy (two LAP and two OPEN). Conclusions: Resection rectopexy for rectal prolapse can be performed safely via the laparoscopic route. Recovery is uneventful and of shorter duration after the laparoscopic than after the open approach. Similarly satisfactory functional results are obtained with both procedures.

Effect of Hiatal Hernia on Esophageal Manometry and pH-Metry in Gastroesophageal Reflux Disease

An increased frequency of reflux events and a prolonged acid clearance have been shown in gastroesophageal reflux (GER) patients with a hiatal hernia as compared to those without. The objective of the present study was to further investigate esophageal motility and patterns of reflux in GER patients, in relation to the presence or absence of hiatal hernia. Esophageal manometry and ambulatory 24-hr esophageal pH-metry were used in 42 patients with GER and 18 controls. Eighteen of the patients were considered to have a nonreducing hiatal hernia on endoscopy. Hiatal hernia patients showed a higher extent of reflux (total composite score,P=0.016; total reflux time,P=0.008, reflux time in supine position,P=0.024; reflux time in upright position,P=0.008), a lower frequency of reflux events (P=0.005), a more severe esophagitis on endoscopy (P<0.01) and a lower amplitude of peristalsis at 5 cm proximal to LES (P=0.0009) as compared to patients without hiatal hernia. The amplitude of peristalsis at the distal esophagus was inversely related to the extent of reflux (P=0.024). Acid clearance was also significantly prolonged in the hernia subgroup (P=0.011). Although LES resting pressure did not differ significantly between the two subgroups of patients, it was inversely related to the extent of reflux in the patients with hiatal hernia (P=0.0005). It is concluded, that GER patients with hiatal hernia present with an increased amount of reflux and more severe esophagitis, which results in more severely impaired esophageal peristalsis as compared to patients without hernia. Prolonged acid clearance and impaired esophageal emptying observed in patients with hiatal hernia could be the result of both the presence of the hernia itself and the reduced peristaltic activity of the esophagus.

The effect of erythromycin on human esophageal motility is mediated by serotonin receptors

OBJECTIVE:Erythromycin exhibits prokinetic properties. The drug enhances esophageal and gastric motility by acting as a motilin agonist and promoting acetylocholine release. 5-HT3 receptors are involved in the spontaneously occurring migrating motor complex and the effect of erythromycin on antral motility in dogs. The aim of the study was to investigate the hypothesis that 5-HT3 receptors are also involved in the action of erythromycin on the human esophagus.METHODS:A total of 18 healthy volunteers underwent standard esophageal manometry on three different occasions in a double-blind, placebo-controlled, randomized manner, as follows: 1) after placebo, 2) after 200 mg of erythromycin i.v., and 3) after 200 mg of i.v. erythromycin subsequent to pretreatment with either 4 mg of i.v. ondansetron (serotonin receptor antagonist) (10 subjects) or 12 μg/kg of i.v. atropine (8 subjects).RESULTS:Erythromycin significantly increased a) the amplitude of peristalsis at 5 cm (from 87 ± 19 mm Hg to 108 ± 26 mm Hg; p= 0.0007), 10 cm (from 72 ± 24 mm Hg to 81 ± 26 mm Hg; p= 0.016), and 15 cm (from 47 ± 15 mm Hg to 55 ± 17 mm Hg; p= 0.014) proximal to LES, b) the duration of peristalsis at 5 cm (from 4.5 ± 0.9 s to 5.7 ± 1.2 s; p < 0.0001) and 10 cm (from 4.1 ± 1 s to 4.9 ± 1 s; p < 0.0001) proximal to the LES and c) the strength of peristalsis at 5 cm proximal to the LES (from 180 ± 49 mm Hg · s to 276 ± 100 mm Hg · s; p < 0.0001), and decreased the velocity of peristalsis at distal esophagus (from 4.1 ± 1 cm/s to 3.8 ± 0.9 cm/s; p= 0.03). In addition, erythromycin significantly increased the resting pressure of the LES (from 36 ± 10 mm Hg to 44 ± 12 mm Hg; p= 0.002). Pretreatment with ondansetron totally reversed all of the effects of erythromycin to the placebo state. Pretreatment with atropine not only prevented the effects of erythromycin, but it reduced the amplitude and strength of peristalsis at the distal esophagus at significantly lower levels than after placebo.CONCLUSIONS:Erythromycin exerts its prokinetic action on the lower esophagus by stimulating cholinergic pathways. This action includes not only an increase in LES pressure, but significant increases in the amplitude and duration of esophageal peristalsis, as well. 5-HT3 receptors are also involved in this process.

Impairment of anorectal function in diabetes mellitus parallels duration of disease.

PURPOSE: The aim of this study was to investigate any possible relation between the severity of anorectal dysfunction in diabetes mellitus and duration of disease and presence of microangiopathy or neuropathy or both. METHODS: Standard multiport anorectal manometry was performed in 25 healthy control subjects (10 males; age (mean±1 standard deviation), 62±14 years) and 38 patients with diabetes mellitus. Patients were divided into two groups according to the duration of the disease: Group A (19 patients) with a duration less than 10 years (7.2±2.5; 8 males; age, 57±18) and Group B (19 patients) with a duration longer than 10 years (19.8±5.6; 6 males; age, 62±15). RESULTS: Results are reported as mean ± one standard deviation. Patients showed lower resting and squeeze anal pressures (P<0.01), impaired rectoanal inhibitory and anocutaneous reflexes, and reduced sensitivity in rectal distention (P=0.004) as compared with controls. In addition, Group B showed a significantly increased incidence of microangiopathy (P=0.04) and autonomic and peripheral neuropathy (P=0.002), significantly reduced basal and squeeze anal pressures (52±16vs. 64±24 mmHg;P=0.03 and 98±39vs. 124±54 mmHg;P=0.04, respectively), reduced amplitude of slow waves (7.3±3vs. 9.5±3.7 mmHg;P=0.03), anal leak in smaller rectal volumes (P=0.003), and reduced response of the anal sphincter at the anocutaneous reflexes (29±14vs. 39±14 mmHg;P=0.05) compared with Group A. The former group of patients exhibited a significantly higher incidence of fecal incontinence (P=0.008). CONCLUSION: Patients with long-standing diabetes mellitus have increased incidence of fecal incontinence and severely impaired function of both the anal sphincters and the rectum. These findings could be attributed to the increased incidence of microangiopathy and autonomic and peripheral neuropathy observed in this subset of diabetic patients.

Erythromycin enhances oesophageal motility in patients with gastro-oesophageal reflux

Background: Intravenous (i.v.) erythromycin enhances gastric emptying and oesophageal motility in both healthy and disease situations, acting either as a motilin or acetylcholine agonist. The purpose of the present paper was to investigate any possible effect of i.v. erythromycin on oesophageal motility in patients with gastro‐oesophageal reflux (GOR).

The effect of intravenous erythromycin on esophageal motility in healthy subjects

BACKGROUND It has been confirmed that erythromycin has gastrokinetic properties of enhancing gastric emptying both in health and disease. The objective of the present study was to investigate any possible effect of erythromycin on esophageal motility. METHODS In 14 healthy subjects, standard esophageal manometry was performed before and after the intravenous administration of 200 mg of erythromycin. The calculated manometric parameters of esophageal motility were the lower esophageal sphincter (LES) pressure; the amplitude and duration of peristalsis at 5, 10, and 15 cm proximal to the LES; and the velocity and strength of peristalsis at 5 cm proximal to the LES. RESULTS Erythromycin significantly increased the LES pressure (P<0.001), and the amplitude (P=0.002), duration (P=0.003), strength (P=0.014) and velocity (P=0.008) of peristalsis at 5 cm proximal to LES. Erythromycin also increased the amplitude of peristalsis at 10 cm proximal to the LES (P=0.035). CONCLUSION Erythromycin affects the motility of the distal esophagus.

Rectoanal motility in Crohn's disease patients.

PURPOSE: It has been documented that Crohns disease affects anorectal function when anorectal manifestations of the disease are present. The aim of this study was to investigate whether the presence of histologic lesions in rectal biopsy affected anorectal motility in patients with Crohns disease but no evidence of macroscopic anorectal involvement. METHODS: Forty-one patients with documented Crohns disease were included in the study. Twenty-one of them had no endoscopic or histologic lesions in the rectum, and 20 patients had a positive histology for Crohns disease on rectal biopsy, with or without macroscopic or endoscopic involvement of the anorectum. All patients underwent a standard anorectal manometry, with an eight-channel, water-perfused catheter. RESULTS: Patients with positive rectal biopsy but no evidence of endoscopic rectal involvement had lower anal resting and squeeze pressures (76±16 standard deviationvs. 86±19 standard deviationP=0.002; 152±56 standard deviationvs. 192±52 standard deviationP<0.001, respectively), and a lower sphincter and high-pressure zone length (2.8±0.8 standard deviationvs. 3.2±0.8 standard deviationP=0.006; 1.7±0.6 standard deviationvs. 2±0.6 standard deviationP=0.005, respectively) compared with patients with negative rectal histology. Also, slow and ultra slow wave amplitude and ultra slow wave frequency were significantly lower (10±6 standard deviationvs. 13±7 standard deviationP=0.04; 17±16 standard deviationvs. 34±24 SDP=0.004; 0.9±0.8 standard deviationvs. 1.3±0.6 standard deviationP=0.05, respectively), rectal sensation more affected, and rectal compliance significantly reduced (7.4±1 standard deviationvs. 11.1±2.2 standard deviationP<0.001) in the former group of patients. Simultaneous presence of endoscopic and histologic lesions in the rectum was associated with further impairment of the anorectal function. CONCLUSION: Microscopic presence alone of Crohns disease in the rectum appears to induce anorectal motility disorders. The synchronous presence of endoscopic rectal and macroscopic anal involvement is associated with further deterioration of anorectal function.

Roux-Y choledochojejunostomy and duodenojejunostomy for the complicated duodenal diverticulum

BACKGROUND Exclusion of the duodenum by means of transection and Roux-Y duodenojejunostomy has been practiced for the treatment of complicated duodenal diverticulum. However, this method does not divert bile away from the diverticulum, hence the possibility of pancreaticobiliary complications is not eliminated. METHODS Roux-Y choledochojejunostomy and duodenojejunostomy, for the diversion of bile and food, has been applied for the treatment of pancreaticobiliary complications of duodenal diverticulum in 4 patients. Postoperatively, all patients had endoscopy, HIDA-scintigraphy for the measurement of enterogastric reflux, and assessment of gastric emptying. RESULTS One year postoperatively, there were no recurrent symptoms of cholangitis or pancreatitis, no anastomotic ulceration was found on endoscopy, there were no complaints of gastric stasis, and enterogastric reflux was not significant. CONCLUSIONS Roux-Y choledochojejunostomy and duodenojejunostomy for the treatment of the complicated duodenal diverticulum is associated with satisfactory results. Postoperative symptoms attributed to anastomotic ulceration, bile reflux, or gastric stasis are also absent.

VARICOSIS COLI TOTALIS : REPORT OF A CASE OF IDIOPATHIC AETIOLOGY

A case of colonic varices manifesting with rectal bleeding in a young patient is presented. There was no evidence of portal hypertension or any other cause. Familial history was also negative. Diagnosis was established by barium enema, colonoscopy and angiography. On colonoscopy, varices involved the entire colon. At operation, dilatation of the subserosal small veins of the entire small and large bowel was confirmed. The patient underwent a subtotal colectomy with ileorectal anastomosis with satisfactory result.