Martti Matikainen

Dysphagia and Oesophageal Clearance After Laparoscopic versus Open Nissen Fundoplication. A Randomized, Prospective Trial

Background: An increase in postoperative dysphagia has been reported after laparoscopic fundoplication. Our aim was to compare laparoscopic Nissen-Rossetti fundoplication to open fundoplication regarding oesophageal clearance and dysphagia in a prospective, randomized study. Methods: Twenty-eight consecutive patients with objectively observed gastro-oesophageal reflux disease referred to operative treatment were randomized to laparoscopic (13) or open (15) fundoplication. A standard formula was used in pre- and postoperative interview. Oesophageal clearance was measured by liquid bolus radionuclide transit before and 3 days, 1 month and 1 year after fundoplication. Endoscopy was done preoperatively and 1 year after the operation. Results: Heartburn, regurgitation and ooesophagitis were cured with equal effectiveness (p = 0.001). New-onset dysphagia was observed in nine (69%) of the patients in the laparoscopic group and in nine (60%) in the open group during the first postoperative month. Food impaction occurred in four (31%) cases after laparoscopic and in two (13%) after open surgery (ns). One year after the operation, one patient (8%) in both groups had more than mild symptoms. Oesophageal radionuclide transit remained normal after open fundoplication, but after the laparoscopic procedure oesophageal clearance was disturbed - only one patient did not have a pathologic result during the first postoperative month. One year after the operation, clearance was normal. Conclusions: After laparoscopic operation, a tendency to more severe new-onset dysphagia was observed, and oesophageal clearance was transiently disturbed. Efforts should be made to minimize postoperative swallowing and clearance disturbances after laparoscopic fundoplication in order to get the full value out of otherwise more rapid recovery.BACKGROUND An increase in postoperative dysphagia has been reported after laparoscopic fundoplication. Our aim was to compare laparoscopic Nissen-Rossetti fundoplication to open fundoplication regarding oesophageal clearance and dysphagia in a prospective, randomized study. METHODS Twenty-eight consecutive patients with objectively observed gastro-oesophageal reflux disease referred to operative treatment were randomized to laparoscopic (13) or open (15) fundoplication. A standard formula was used in pre- and postoperative interview. Oesophageal clearance was measured by liquid bolus radionuclide transit before and 3 days, 1 month and 1 year after fundoplication. Endoscopy was done preoperatively and 1 year after the operation. RESULTS Heartburn, regurgitation and ooesophagitis were cured with equal effectiveness (p = 0.001). New-onset dysphagia was observed in nine (69%) of the patients in the laparoscopic group and in nine (60%) in the open group during the first postoperative month. Food impaction occurred in four (31%) cases after laparoscopic and in two (13%) after open surgery (ns). One year after the operation, one patient (8%) in both groups had more than mild symptoms. Oesophageal radionuclide transit remained normal after open fundoplication, but after the laparoscopic procedure oesophageal clearance was disturbed--only one patient did not have a pathologic result during the first postoperative month. One year after the operation, clearance was normal. CONCLUSIONS After laparoscopic operation, a tendency to more severe new-onset dysphagia was observed, and oesophageal clearance was transiently disturbed. Efforts should be made to minimize postoperative swallowing and clearance disturbances after laparoscopic fundoplication in order to get the full value out of otherwise more rapid recovery.

Post-ERCP pancreatitis: reduction by routine antibiotics.

Cholangitis and pancreatitis are severe complications of endoscopic retrograde cholangiopancreatography (ERCP). Antibiotics have been considered important in preventing cholangitis, especially in those with jaundice. Some have suggested that bacteria may play a role in the induction of post-ERCP pancreatitis. It is not clear, however, whether the incidence of post-ERCP pancreatitis could be reduced by antibiotic prophylaxis, as is the case with septic complications. In this prospective study, a total of 321 consecutive patients were randomized to the following two groups: (1) a prophylaxis group (n = 161) that was given 2 g of cephtazidime intravenously 30 minutes before ERCP, and (2) a control group (n = 160) that received no antibiotics. All patients admitted to the hospital for ERCP who had not taken any antibiotics during the preceding week were included. Patients who were allergic to cephalosporins, patients with immune deficiency or any other condition requiring antibiotic prophylaxis, patients with clinical jaundice, and pregnant patients were excluded. In the final analysis six patients were excluded because of a diagnosis of bile duct obstruction but with unsuccessful biliary drainage that required immediate antibiotic treatment. The diagnosis of cholangitis was based on a rising fever, an increase in the C-reactive protein (CRP) level, and increases in leukocyte count and liver function values, which were associated with bacteremia in some. The diagnosis of acute pancreatitis was based on clinical findings, and increases in the serum amylase level (>900 IU/L), CRP level, and leukocyte count with no increase in liver chemical values. The control group had significantly more patients with post-ERCP pancreatitis (15 of 160 in the prophylaxis group vs. 4 of 155 in the control group; P = 0.009) and cholangitis (7 of 160 vs. 0 of 155; P = 0.009) compared to the prophylaxis group. Nine patients in the prophylaxis group (6%) and 15 patients in the control group (9%) had remarkably increased serum amylase levels (>900 III/L) after ERCP, but clinical signs of acute pancreatitis with leukocytosis, CRF’ reaction, and pain developed in four of nine patients in the prophylaxis group compared to 15 of 15 patients with hyperamylasemia in the control group (P = 0.003). In a multivariate analysis, the lack of antibiotic prophylaxis (odds ratio 6.63, P = 0.03) and sphincterotomy (odds ratio 5.60, P = 0.05) were independent risk factors for the development of post-ERCP pancreatitis. We conclude that antibiotic prophylaxis effectively decreases the risk of pancreatitis, in addition to cholangitis after ERCP, and can thus be routinely recommended prior to ERCP These results suggest that bacteria could play a role in the pathogenesis of post-ERCP pancreatitis.

Ileoanal anastomosis without covering ileostomy

Ileoanal anastomosis is usually performed with covering ileostomy. This is primarily done because of fear of pelvic sepsis. Temporary ileostomy may, however, be a source of significant complications. The first 21 patients in the authors clinic were operated upon using covering loop ileostomy in ileoanal operations. These patients had no anastomotic or pouch complications, but there were complications, especially with the closure of the ileostomy. Therefore, a trial of one-stage operations in ileoanal anastomosis was started. Ileoanal anastomosis without ileostomy was performed on 25 consecutive patients. All the patients were operated upon for ulcerative colitis. There was one patient with pelvic abscess who needed diverting ileostomy. Thus, the early failure rate in patients operated upon without ileostomy was 4 percent. There were many other complications among these patients, but no other relaparotomy was needed. The complication rate was not different in patients operated upon without ileostomy compared with the authors first 21 patients operated upon with ileostomy (60 and 52 percent, respectively). Patients with one-stage operation needed a significantly shorter mean hospital stay than patients with two-stage operation (13.6 days and 25.3 days, respectively;P<0.001).The use of corticosteroids appears not to be a contraindication for one-stage operation, because there were significantly more patients using corticosteroids in the one-stage group compared with the two-stage group (92 and 62 percent, respectively;P<0.05).

Clinical and manometric evaluation of anal sphincter function in patients with rectal prolapse

We studied 27 patients with rectal prolapse (7 men and 20 women). Eight patients were continent, 8 were partially incontinent, and 11 were totally incontinent. Perineal descent and an absent anocutaneous reflex were common findings, implying damage to the external anal sphincter and the pelvic floor muscles. Both partially and totally incontinent patients had significantly lower basal and voluntary contraction pressures compared with those of control subjects, which is in accordance with previous reports on the subject. Our continent patients had normal voluntary contraction pressures, but basal pressures were lower than those of the control subjects (p less than 0.02). This suggests that there may be dysfunction of the internal anal sphincter before the development of clinical symptoms of incontinence. The internal anal sphincter reflex was present in 19 patients (70 percent). It was absent in patients with very little tone of the anal canal. It seems that absence of the internal anal sphincter reflex is not invariably connected with rectal prolapse. The results of this study indicate that rectal prolapse is often associated with dysfunction of the anal sphincters, leading to incontinence.

Functional results of operative treatment of rectal prolapse over an 11-year period

PURPOSE: A variety of surgical procedures have been developed to treat rectal prolapse, but there is still no consensus on the operation of choice. The aim of this study was to evaluate the functional results of operative treatment of rectal prolapse during an 11-year period in our department. METHODS: All patients treated for complete rectal prolapse during an 11-year period, from 1985 to 1995, in a single university hospital were included. Of the 123 patients, 22 were men, and the mean age was 59 (range, 15–88) years. The medical records of all patients were reviewed retrospectively, and a questionnaire on bowel symptoms before and after surgery was sent to all 95 living patients. RESULTS: The majority of the procedures (91 percent) were performed by abdominal approach, and the most frequently used open technique was posterior rectopexy with mesh (78 percent). Of the incontinent patients, 35 (63 percent), all those less than 40 years of age and 64 percent of those 40 years or older, were continent postoperatively (P=0.0001) after a median follow-up of five (range, 1–72) months. According to the questionnaire, after a median follow-up of 85 (range, 16–144) months, only 38 percent of the incontinent patients in the mesh or suture group, 78 percent of patients less than 40 years of age (n=18), and 52 percent of those 40 years or older (n=47) claimed to be continent postoperatively. The proportion of patients with constipation was greater after the operation than preoperatively (P=0.02) and more patients used medication for constipation after than before the operation (P=0.0001). The overall complication rate was 15 percent, and the mortality rate was 1 percent (1/123). In the mesh or suture group there were 6 (6 percent) recurrent complete prolapses and 11 (12 percent) mucous prolapses. CONCLUSION: Posterior rectopexy with mesh gave good results in our hands. Older age and longer follow-up seem to have a negative effect on the functional outcome of the operation and on the recurrence rate.

Anal manometric findings in symptomatic hemorrhoids

Anal manometric findings were studied in 50 patients with symptomatic hemorrhoids and an equal number of age- and sex-matched control subjects. Manometry was performed with a continuously perfused catheter by the continuous pull-through technique. Both the control subjects and patients had significant negative collerations between age and basal pressure;i.e., basal pressure was lower with advancing age. Patients with symptomatic hemorrhoids had significantly higher maximal basal pressure (P<0.02) and maximal voluntary contraction pressure (P<0.05) as compared to controls. There was no correlation between the anal manometric findings and the degree of hemorrhoids or duration of symptoms. Those patients who had bleeding as the predominant symptom had higher basal pressures; (P<0.05) than those who had prolapsing hemorrhoids as the predominant symptom.

Chronic inflammatory changes in the pouch mucosa are associated with cholangitis found on peroperative liver biopsy specimens at restorative proctocolectomy for ulcerative colitis.

BACKGROUND The clinical syndrome of primary sclerosing cholangitis (PSC), diagnosed in about 5% of patients with ulcerative colitis (UC), has been shown to be associated with pouchitis after ileal pouch-anal anastomosis. The aim of this study was to ascertain whether UC patients with cholangitis on liver biopsy at proctocolectomy, with or without the clinical syndrome of PSC, have an increased risk of inflammatory changes in the ileal reservoir mucosa and clinical pouchitis. METHODS Of the consecutive 81 UC patients treated with restorative proctocolectomy with ileal J reservoir at Tampere University Hospital between 1985 and 1991, 73 with peroperative liver biopsy were included. A peroperative liver biopsy was obtained during proctocolectomy. After a median follow up of 64 months, pouch biopsy specimens were obtained. Periods of clinical pouchitis were diagnosed by means of clinical criteria alone or by clinical criteria combined with the results of previous pouch endoscopies in all patients. RESULTS Ten patients (14%) showed histologic features consistent with small-duct PSC on liver biopsy. Endoscopic retrograde cholangiography had previously been performed on four of these patients, and all four had large-duct PSC. Patients with cholangitis had significantly more severe chronic, but not acute, inflammation in the pouch mucosa than patients without cholangitis. At least one episode of pouchitis occurred in 30% of the patients without cholangitis as compared with 90% of the patients with cholangitis. Chronic pouchitis was more frequent in the group with cholangitis than in the group without it (70% versus 11%). CONCLUSIONS The only means of detecting all UC patients with cholangitis is a liver biopsy. Cholangitis, either with the clinical syndrome of PSC or found on liver biopsy, seems to be a risk factor for chronic-type inflammatory changes in the pouch mucosa and for the development of pouchitis.

Liver involvement in patients operated for ulcerative colitis, with special reference to the association of cholangitis with colorectal dysplasia and carcinoma.

Abstract This study classified liver changes found in patients undergoing proctocolectomy for ulcerative colitis and examined whether patients with cholangitis have an increased risk of colorectal dysplasia and carcinoma. The patients were 152 who underwent liver biopsy during surgery for ulcerative colitis. Prior surveillance colonoscopy specimens and operative liver and proctocolectomy specimens were examined histologically. Patients with dysplasia or carcinoma in colorectal specimens were pair-matched to patients without such neoplasia. Sixteen (10.5%) patients had histological features consistent with small-duct primary sclerosing cholangitis on liver biopsy, five of them showing normal liver function values. Of the 152 patients 4 were found to have colon carcinoma (2.6%) and another 4 low-grade dysplasia (2.6%) either upon colonoscopy or in colectomy specimens. The median duration of the colitis in the 8 patients with colorectal neoplasia was 12 years (range 2–29) and in the other 142 patients 4 years (0.1–33; P=0.007). The prevalence of primary sclerosing cholangitis (PSC) or cholangitis was 50% in cases with colorectal neoplasia and 13% in pair-matched controls without colorectal neoplasia. In this selected group of patients operated on for ulcerative colitis the prevalence of histological cholangitis was thus higher than that of PSC in previous epidemiological studies. In addition, the prevalence of PSC or cholangitis was much higher in cases with colorectal neoplasia than in pair-matched controls without colorectal neoplasia. Our results support the view that cholangitis constitutes an additional risk factor underlying colorectal dysplasia or carcinoma.

Jejunal Pouch Reconstruction Diminishes Postoperative Symptoms after Total Gastrectomy

Forty-nine gastric carcinoma patients were randomized after total gastrectomy to the Hunt-Lawrence pouch reconstruction (pouch group, 26 patients) or to the Roux-en-Y reconstruction without pouch (con

Histological improvement of oesophagitis after Nissen fundoplication

Nissen fundoplication gives lasting relief from symptoms of gastro-oesophageal reflux and cures endoscopic oesophagitis effectively. The histological effect on the oesophageal mucosa is less clear. We studied the long-term histological effect of Nissen fundoplication on refractory gastro-oesophageal disease with erosive oesophagitis or Barretts metaplasia in 33 patients with biopsy both before and after antireflux surgery. The median postoperative interval to re-examination was 80 (range 37-110) months. Symptoms of reflux were greatly relieved; 31 (94%) of the 33 patients had none or, at the most, mild symptoms. Endoscopic oesophagitis was healed in 26 (79%) of the cases. The histological appearance of the oesophageal mucosa had been abnormal in all the patients preoperatively, but at follow-up it was normal in 22 cases (67%): in 89% of the patients without objectively observed recurrent reflux and in 45% of those with recurrence. Both the pre- and postoperative severity of the histological changes correlated significantly with the endoscopic grade of oesophagitis (r=0.42, P=0.017 and r=0.837, P=0.0001, respectively), but not with the clinical reflux score. In conclusion, Nissen fundoplication resulted in histological healing in the great majority of patients with oesophagitis.