Kathy D. Galloway

Long-term outcome of laparoscopic repair of paraesophageal hernia

BackgroundIt has been reported that the laparoscopic repair of paraesophageal hernias is associated with higher complication and recurrence rates than the open methods of repair.MethodsWe identified 136 consecutive patients who underwent laparoscopic repair of a paraesophageal hernia between 1993 and 1999. Patient demographics and symptom scores for regurgitation, heartburn, chest pain, and dysphagia at presentation and at last follow-up were recorded (0=none, 1=mild, 2=moderate, 3=severe). The operative records were reviewed, and early and late complications were noted. Only patients with a follow-up of 1 were included in the analysis.ResultsThe median age was 64 years, and there was a female preponderance (1.8∶1). Most patients had some medical comorbidity; the American Society of Anesthesiologists (ASA) scores were <2 in eight patients and ≥2 in 117 patients. Three laparoscopic operations were converted to open procedures. There were nine intraoperative complications, five early complications, and three related deaths (morbidity and mortality rates of 10.2% and 2.2%, respectively). Follow-up data were available for 83 patients (66%), and the mean follow-up time was 40 months (range, 12–82). The percentage of patients experiencing chest pain, dysphagia, heartburn, and regurgitation in the moderate to severe range dropped from a range of 34–47% to 5–7% (p<0.05). Three patients underwent repeat laparoscopic repair for symptomatic recurrence.ConclusionThe laparoscopic repair of paraesophageal hernias provides excellent long-term symptomatic relief in the majority of patients and has a low rate of symptomatic recurrence. The complication and death rates may be related in part to the higher incidence of comorbidities in this somewhat elderly patient population.

Outcomes of laparoscopic fundoplication for gastroesophageal reflux disease and paraesophageal hernia.

Background: Laparoscopic fundoplication has become the standard for operative treatment of gastroesophageal reflux disease (GERD). Methods: We reviewed our experience with 1,000 consecutive patients receiving laparoscopic fundoplication for GERD (n = 882) or paraesophageal hernia (n = 118) between October 1991 and July 1999. Patients with achalasia and failed fundoplication were excluded from analysis. All the patients were evaluated preoperatively by upper endoscopy, esophageal manometry, and barium swallow. After 1994, 24-h pH monitoring was performed selectively in patients with extraesophageal symptoms and/or those without erosive esophagitis. There were 490 men 510 women in this review. Their mean age was 49 years. Procedures performed were 360° floppy fundoplication (n = 879), 360° fundoplication without fundus mobilization (Rossetti) (n = 22), 270° posterior fundoplication (n = 96), and anterior fundoplication (n = 2). Esophageal lengthening procedure (Collis gastroplasty) was performed in combination with fundoplication in 15 patients. In seven patients the treatment was converted to open fundoplication. Outcomes: The average length of hospitalization was 2.2 days, and 136 patients stayed longer than 2 days. Major complications occurred in 21 patients: esophageal perforation (n= 10), acute paraesophageal herniation (n = 4), splenic bleeding (n = 2), cardiac arrest (n = 1), pneumonia (n = 3), and testicular abscess (n = 1). Additional operations were required to manage the complications in 14 patients (70%): Four of these procedures were performed emergently, and 10 patients underwent reoperation between 6 h and 10 days. There were three deaths, all of which involved elderly patients with paraesophageal hernia. There were 35 late failures requiring reoperation for recurrence of GERD or development of new symptoms: The treatment of 32 patients was revised laparoscopically, and 4 patients required laparotomy. Beyond 1 year (median follow-up period, 27 months), 94% of the reviewed patients were satisfied with their surgical outcome.

Fundoplication provides effective and durable symptom relief in patients with Barrett's esophagus.

BACKGROUND Columnar-lined esophagus with intestinal metaplasia (IM), also called Barretts esophagus, is a manifestation of severe gastroesophageal reflux (GER) and may predict poor symptom relief and high failure rate after fundoplication. We compared symptom scores and reoperation rates in GER patients with and without Barretts esophagus. METHODS Between July 1992 and July 1997, 646 patients underwent fundoplication (626 laparoscopic). Of 150 endoscopic biopsies of suspected columnar-lined esophagus, 80 confirmed IM, 50 identified cardiac or fundic epithelium, and 20 revealed only esophagitis. Typical GER symptoms were scored by patients preoperatively and postoperatively (0 to 4 scale). We compared symptom response (Wilcoxon rank sum test) and failure rates (t test) in patients with IM and GER controls without IM. Preoperative data were available for 74 IM patients and 496 controls. One-year follow-up was available in 45 IM patients and 301 controls. Intermediate follow-up (2 to 5 years) was available in 20 IM patients and 99 controls. RESULTS Preoperatively and postoperatively, patients with IM reported heartburn, regurgitation, and dysphagia scores similar to controls. Procedure failure, requiring redo fundoplication, appeared more likely in IM patients than controls (6.3% versus 2.5%), but this difference did not reach statistical significance (P = 0.061). CONCLUSION Fundoplication provides equivalent symptom relief for patients with and without IM.

Prospective randomized clinical trial comparing nitrous oxide and carbon dioxide pneumoperitoneum for laparoscopic surgery.

BACKGROUND Recent publications demonstrating the safety and advantages of N2O for pneumoperitoneum (PP) prompted us to reconsider N2O as an agent for PP in general surgical laparoscopy. The purpose of this prospective, double-blind, randomized clinical trial was to determine whether N2O PP has any benefits over CO2 PP. STUDY DESIGN One hundred three patients received N2O (group I, n = 52) or CO2 (group II, n = 51) PP for elective laparoscopic surgery. Heart rate, mean arterial blood pressure, end-tidal CO2, minute ventilation, and O2 saturation were recorded before PP, during PP, and in the recovery room. Postoperative pain medication use was recorded. Pain was assessed by means of visual analog scale (VAS) at postoperative hours 2 and 4, and on day 1. RESULTS There were no differences between groups I and II in patient age, gender, weight, anesthesia risk (American Society of Anesthesiologists Score > 2), operative time, duration of PP, or length of hospital stay. Mean end-tidal CO2 increase under anesthesia was greater in group II than group I (3.0 versus 0.5 mmHg, p < 0.001) despite a greater mean intraoperative increase in minute ventilation in group II than group I (0.7 versus -0.2 L/min p < 0.001). The patients who had N2O PP had less pain 2 hours postoperatively (VAS: 4.9 versus 5.7, p <0.05), 4 hours postoperatively (VAS: 3.3 versus 5.1, p < 0.01), and 1 day postoperatively (VAS: 1.7 versus 3.5, p < 0.01) than patients who had CO2 PP. Postoperative narcotic or ketorolac use was not statistically different between groups. There were no adverse events related to either N2O or CO2 pneumoperitoneum. CONCLUSIONS These results suggest that the use of N2O PP has sufficient advantages over CO2 that it should be considered as the standard agent for therapeutic PP.

Asthma and gastroesophageal reflux: fundoplication decreases need for systemic corticosteroids☆

An association between gastroesophageal reflux (GER) and asthma has been suggested for many decades. Although antireflux therapy (medical and surgical) has been shown to be beneficial in patients with asthma, response to therapy has not been well quantified. The aim of this study was to evaluate long-term outcome in patients with asthma and associated GER undergoing fundoplication. From a database of more than 600 patients with GER treated surgically between 1991 and 1996, 39 patients with asthma as their primary indication for surgery were identified. Asthma symptom scores were determined using the National Asthma Education Program classification, and medication frequency scores were determined preoperatively and at latest follow-up (median follow-up 2.7 years). Comparisons were made using the Wilcoxon rank-sum test. Asthma symptom scores decreased significantly after antireflux surgery. More important, the medication scores for use of systemic corticosteroids decreased significantly postoperatively (2.2 preoperatively vs. 0.7 postoperatively; P = 0.0001). Of the nine patients who required daily oral corticosteroids, seven have discontinued treatment entirely (78%). In patients with asthma associated with GER, symptoms of asthma are improved following fundoplication. Especially important has been the ability to wean patients from systemic corticosteroids postoperatively. Fundoplication should be offered to those patients with GER-associated asthma, especially those who are steroid dependent.

Asthma and gastroesophageal reflux: Fundoplication decreases need for systemic corticosteroids

An association between gastroesophageal reflux (GER) and asthma has been suggested for many decades. Although antireflux therapy (medical and surgical) has been shown to be beneficial in patients with asthma, response to therapy has not been well quantified. The aim of this study was to evaluate long-term outcome in patients with asthma and associated GER undergoing fundoplication. From a database of more than 600 patients with GER treated surgically between 1991 and 1996, 39 patients with asthma as their primary indication for surgery were identified. Asthma symptom scores were determined using the National Asthma Education Program classification, and medication frequency scores were determined preoperatively and at latest follow-up (median follow-up 2.7 years). Comparisons were made using the Wilcoxon rank-sum test. Asthma symptom scores decreased significantly after antireflux surgery. More important, the medication scores for use of systemic corticosteroids decreased significantly postoperatively (2.2 preoperatively vs. 0.7 postoperatively; P = 0.0001). Of the nine patients who required daily oral corticosteroids, seven have discontinued treatment entirely (78%). In patients with asthma associated with GER, symptoms of asthma are improved following fundoplication. Especially important has been the ability to wean patients from systemic corticosteroids postoperatively. Fundoplication should be offered to those patients with GER-associated asthma, especially those who are steroid dependent.