Michael Gadenstätter

Treatment of morbid obesity with laparoscopic adjustable gastric banding affects esophageal motility.

BACKGROUND Laparoscopic adjustable gastric banding has become the prefered method for the surgical treatment of morbid obesity in Europe. It is not known whether this procedure may induce gastroesophageal reflux and whether it may impair esophageal peristalsis. METHODS Laparoscopic adjustable gastric banding (Swedish band) was performed in 43 patients (median body mass index [BMI] 42.5 kg/m(2)). Preoperatively and 6 months postoperatively all patients were assessed for reflux symptoms. In addition all patients underwent preoperative and postoperative endoscopy, esophageal barium studies and manometry, and 24-hour esophageal pH-monitoring. RESULTS The median BMI dropped significantly to 33.1 kg/m(2) (P <0.05). Preoperatively 12 patients complained of reflux symptoms. Mild esophagitis was detected in 10 patients. Postoperatively only 1 patient complained of heartburn and mild esophagitis was diagnosed in another patient. None of the patients had dysphagia. Preoperatively a defective LES and pathologic pH-testing were found in 9 and 15 patients, respectively. These parameters were normal in all of the patients postoperatively. Postoperatively there was significant impairment of LES relaxation and deterioration of esophageal peristalsis with dilatation of the esophagus in some of the patients. CONCLUSION Laparoscopic adjustable gastric banding provides a sufficient antireflux barrier and therefore prevents pathologic gastroesophageal reflux. However, it impairs relaxation of the LES, leading to weak esophageal peristalsis.

Laparoscopic toupet fundoplication for gastroesophageal reflux disease with poor esophageal body motility

Impaired esophageal body motility is a complication of chronic gastroesophageal reflux disease (GERD). In patients with this disease, a 360-degree fundoplication may result in severe postoperative dysphagia. Forty-six patients with GERD who had a weak lower esophageal sphincter pressure and a positive acid reflux score associated with impaired esophageal body peristalsis in the distal esophagus (amplitude <30 mm Hg and >10% simultaneous or interrupted waves) were selected to undergo laparoscopic Toupet fundoplication. They were compared with 16 similar patients with poor esophageal body function who underwent Nissen fundoplication. The patients who underwent Toupet fundoplication had less dysphagia than those who had the Nissen procedure (9% vs. 44%;P=0.0041). Twenty-four-hour ambulatory pH monitoring and esophageal manometry were repeated in 31 Toupet patients 6 months after surgery. Percentage of time of esophageal exposure to pH <4.0, DeMeester reflux score, lower esophageal pressure, intra-abdominal length, vector volume, and distal esophageal amplitude all improved significantly after surgery. Ninety-one percent of patients were free of reflux symptoms. The laparoscopic Toupet fundoplication provides an effective antireflux barrier according to manometric, pH, and symptom criteria. It avoids potential postoperative dysphagia in patients with weak esophageal peristalsis and results teria. It avoids potential postoperative dysphagia in patients with weak esophageal peristalsis and results in improved esophageal body function 6 months after, surgery.

Laparoscopic partial posterior fundoplication provides excellent intermediate results in GERD patients with impaired esophageal peristalsis.

BACKGROUND Gastroesophageal reflux disease (GERD) is frequently associated with impaired esophageal peristalsis, and many authorities consider this condition not suitable for Nissen fundoplication. METHODS To investigate the outcome of antireflux surgery in the presence of impaired esophageal peristalsis, 78 consecutive GERD patients with poor esophageal contractility who underwent laparoscopic partial posterior fundoplication were studied. A standardized questionnaire, upper gastrointestinal endoscopy, esophageal manometry, and 24-hour pH monitoring were performed preoperatively and at a median of 31 months (range 6-57 months) postoperatively. Esophageal motility was analyzed for contraction amplitudes in the distal two thirds of the esophagus, frequency of peristaltic, simultaneous, and interrupted waves, and the total number of defective propagations. In addition, parameters defining the function of the lower esophageal sphincter were evaluated. RESULTS After antireflux surgery, 76 patients (97%) were free of heartburn and regurgitation and had no esophagitis on endoscopy. The rate of dysphagia decreased from 49% preoperatively to 10% postoperatively (P < .001). Features defining impaired esophageal body motility improved significantly after antireflux surgery. The median DeMeester score on 24-hour esophageal pH monitoring decreased from 33.3 to 1.1 (P < .001). CONCLUSIONS Partial posterior fundoplication provides an effective antireflux barrier in patients with impaired esophageal body motility. Postoperative dysphagia is diminished, probably because of improved esophageal body function.

Dieulafoy's disease of the large and small bowel.

The Dieulafoy lesion is a rare cause of severe gastrointestinal hemorrhage. The lesion is usually located in the stomach, although it may occur anywhere in the gastrointestinal tract. We describe four patients with extragastric Dieulafoys disease, in the duodenum (one), the proximal jejunum (two), and the left hemicolon (one). Diagnosis was made by endoscopy in all four and confirmed by histology in three. The pathology of the Dieulafoy lesion is essentially the same throughout the gastrointestinal tract. Endoscopic treatment by sclerotherapy combined with electrocoagulation was successful in the duodenal and colonic Dieulafoy lesions, but not in the jejunal lesions.

Quality of life in GERD patients: Medical treatment versus antireflux surgery

Medical and surgical treatments are able to improve symptoms in patients with gastroesophageal reflux disease (GERD). The aim of this study was to evaluate the outcome in GERD patients without therapy, under continuous medical treatment, and after laparoscopic antireflux surgery. Five hundred seventy-nine consecutive patients underwent medical or surgical treatment for GERD-induced symptoms. Patients were studied in detail before and after treatment by means of a symptom questionnaire, endoscopy, esophageal manometry, 24-hour esophageal pH monitoring, and a barium esophagogram. In addition, quality of life was measured by the means of the Gastrointestinal Quality of Life Index (GIQLI) and the Health-Related Quality of Life (HRQL) questionnaire. Surgery was indicated and performed in 351 patients with persistent or recurrent GERD symptoms and/or complications, and in patients preferring surgery to medical treatment, despite the use of an adequate medication. The remaining 228 patients were treated with proton pump inhibitors (PPI) in the standard dose, or if required, the double dose. The outcome was assessed 3 and 12 months after treatment. While symptoms and quality of life were highly impaired in GERD patients without therapy compared with normal people, a significant improvement was obtained by PPI therapy. Following surgery, quality of life was normalized in all subsections and was significantly higher compared with the medically treated group. These results stayed constant in short-term and intermediate follow-up. Medical and surgical therapies are both able to improve symptoms and quality of life in GERD patients. Nevertheless, the outcome is significantly better following surgery. It can be suggested that surgical treatment may be the more successful therapy in the long-term.

Medical treatment of gastroesophageal reflux disease does not prevent the development of Barrett's metaplasia and poor esophageal body motility

ZusammenfassungZie: Duodenalinhaltsstoffe, die aufgrund eines Reflux in den ösophagus gelangen, sind möglicherweise in die Pathophysiologie der gastroösophagealen Refluxkrankheit (GERD) involviert. Ziel dieser Studie war, zu untersuchenk ob die medikamentöse Behandlung von GERD mit dem Ziel die Magensäureproduktion zu unterdrücken, das Auftreten von Komplikationen, wie z.B. Barrett-Metaplasie oder schwache Ösophagusmotilität, verhindern kann. Studiendesign: Retrospektive Untersuchung,. Ort: Universitätsklinik. Patienten: 138 GERD-Patienten wurden bezüglich des Auftretens von Barrett-Metaplasie oder beeinträchtigter Ösophagusmotilität bei intermittierender oder ständiger Behandlung mit H2-Blockern oder Omeprazol untersucht. Hauptuntersuchungspunkte: Rate der Patienten mit Barrett-Metaplasie oder beeinträchtigter Ösophagusmotilität mit und ohne effektive medikamentöse Behandlung. Ergebnisse: Eine Barrett-Metaplasie, die bei Beginn der Behandlung nicht nachweisbar war, wurde bei 33,8% der Patienten mit medikamentöser Behandlung bzw. bei 21,9% ohne Therapie gefunden (nicht signifikant). 41,9% der Patienten mit Medikation hatten eine beeinträchtigte Ösophagusmotilität im Vergleich zu 59,3% der Patienten ohne Behandlung (p<0,05), aber diese Patienten wiesen eine signifikant kürzere Verlaufszeit von GERD auf. Schlußfolgerungen: Die medikamentöse Behandlung mit H2-Blockern oder Omeprazol verhindert nicht das Auftreten einer Barrett-Metaplasie oder beeinträchtigten Ösophagusmotilität.AbstractObjective: Duodenal contents refluxing into the esophagus may be involved in the pathophysiology of gastroesophageal reflux disease (GERD). This study was performed to investigate whether medical treatment of GERD aimed at suppression of gastric acid production can prevent the development of complications, such as Barretts metaplasia or poor esophageal body motility.Design: Retrospective study.Setting: University hospital.Patients: 138 GERD patients were analyzed regarding the development of Barretts metaplasia or poor esophageal body motility, despite intermittent or continuous treatment with H2 blockers or omeprazole.Main outcome measures: The rate of patients with Barretts metaplasia or poor esophageal body motility with or without effective medical treatment.Results: Barretts metaplasia was found in 33.8% of patients receiving medical treatment, although it was not present when treatment was induced. This rate was 21.9% among patients who were not receiving therapy (not significant). In all, 41.9% of patients with medication had impaired esophageal body motility compared with 59.3% of patients not receiving treatment (P<0.05), but these patients had a significantly shorter history of GERD.Conclusions: Medical treatment with H2 blockers or omeprazole does not prevent the development of Barretts metaplasia or poor esophageal body motility.

Pathophysiology of gastro-oesophageal reflux disease (GERD) with respect to reflux-induced carcinogenesis

SummaryBackground: Gastro-oesophageal reflux disease has a complex pathophysiology. Therefore, therapeutic considerations should not only include the peptic component of the disease.Methods: A variety of studies in rats and in humans demonstrate the consequences of gastro-oesophageal reflux and medical and surgical interventions in terms of inflammation, epithelial growth stimulation, apoptosis and oxidative stress in the epithelium of the oesophagus.Results: Gastro-oesophageal reflux disease consists of a variety of pathophysiologically important factors. These include changes in the anatomy, gastro-oesophageal motility, epithelial growth, inflammation, apoptosis and molecular structure and may lead to carcinogenesis. Surgery restores the antireflux barrier and improves oesophageal and gastric motility, thus preventing the consequences of the disease.Conclusions: Antireflux surgery provides a causative therapy of gastrointestinal reflux disease.ZusammenfassungGrundlagen: Die gastroösophageale Refluxkrankheit hat einen breiten pathophysiologischen Hintergrund und läßt sich somit auch in bezug auf die Therapie nicht auf die peptische Komponente reduzieren.Methodik: In mehreren Untersuchungen sowohl an der Ratte als auch am Menschen werden die Auswirkungen des gastroösophagealen Refluxes und die Effekte medikamentöser und chirurgischer Maßnahmen in Hinblick auf Entzündung, Wachstumsstimulation, Apoptose und Auftreten von freien Sauerstoffradikalen am Ösophagusepithel demonstriert.Ergebnisse: Die gastroösophageale Refluxkrankheit umspannt eine breite Palette von Veränderungen in bezug auf Anatomie, Motilität, Entzündung mit Freisetzung von Sauerstoffradikalen, Apoptose und DNA-Struktur bis hin zur Karzinogenese im distalen Ösophagus. Die chirurgische Therapie der Refluxkrankheit vermag eine ausreichende Barriere am Hiatus wiederherzustellen, verbessert die Magenmotilität und die Ösophagusperistaltik und ist in der Lage, dem gastroösophagealen Reflux mit all seinen Auswirkungen entgegenzuwirken.Schlußfolgerungen: Die Antirefluxchirurgie stellt somit eine kausale Therapie der Refluxkrankheit dar.

Significant weight loss after laparoscopic Nissen fundoplication

BackgroundLaparoscopic Nissen fundoplication (LNF) has evolved as a gold standard in antireflux surgery. However, the association between body weight and gastroesophageal reflux disease (GERD) is still unclear, and no data are available concerning the effect of fundoplication on body weight. We present the first report elucidating the impact of LNF on body weight in GERD patients with special emphasis on patients’ quality of life.MethodsFrom July 2000 to March 2003, LNF was carried out in 213 patients (85 women and 128 men) after thorough preoperative examination including clinical interview with standardized assessment of symptoms and quality of life (QoL), endosocopy, barium swallow, 24-h pH-metry, and manometry. Follow-up investigations were performed 3 and 12 months after LNF obtainable from 209 patients (98.1%) and 154 patients (72.3%), respectively.ResultsThe mean body mass index (BMI) decreased significantly after LNF (27.6 ± 5.6 kg/m2 before LNF vs 26.0 ± 3.8 kg/m2 after LNF, p < 0.001). Twelve months after LNF, neither a tendency toward a renewed increase nor a further decrease in BMI was observable. The average body weight loss was 3.9 kg. BMI reduction was higher in women than in men (p < 0.002), and obese patients lost more weight than lean patients (p < 0.001). There was no association between BMI reduction and dysphagia. Plasma cholesterol and triglyceride levels did not change after LNF. The mean general score of the Gastrointestinal Quality of Life Index markedly improved (90.1 ± 21.3 before LNF vs 118.0 ± 16.2 after LNF, p < 0.01), as did the GERD-Health Related Quality of Life Index (21.9 ± 6.4 before LNF vs 3.5 ± 2.7 after LNF, p < 0.001). However, there was no association between changes in BMI and QoL.ConclusionLNF leads to significant and persistent body weight loss.

Laparoscopic antireflux surgery provides excellent results and quality of life in gastroesophageal reflux disease patients with respiratory symptoms.

Medical and surgical treatment are able to improve symptoms in patients with gastroesophageal refiux disease(GERD).Theaim of this study was to evaluate the outcomefollowing laparoscopic antirefiux surgery in GERD patients with primary respiratory-related symptoms and to investigate the quality of life index before and after therapy. Three hundred thirty-eight consecutive patients underwent surgical treatment for GERD-induced symptoms. Of this group 126 patients had primary respiratory symptoms related to GERD. All patients were studied by means of a symptom questionnaire, endoscopy, esophageal manometry, 24-hour esophageal pH monitoring, and a barium esophagogram. In addition, the quality of life was measured by the means of the Gastrointestinal Quality of Life Index (GIQLI). All patients had medical therapy with proton pump inhibitors preoperatively. A laparoscopic fundoplication was performed in all patients. The outcome was assessed 3 and 12 months postoperatively. Following surgery, all respiratory symptoms were significantly improved. While GIQLI was highly impaired before surgical therapy, a significant improvement of quality of life was obtained. Because medical treatment is likely to fail in GERD patients with respiratory symptoms, the need for surgery arises and may be the only successful treatment in the long term. Quality of life was significantly improved by surgical treatment.

Laparoscopic partial posterior fundoplication improves poor oesophageal contractility in patients with gastrooesophageal reflux disease.

OBJECTIVE To investigate the effect of partial posterior fundoplication on oesophageal contractility in patients with gastrooesophageal reflux disease (GORD). DESIGN Follow-up study with 6 months of survey. SETTING University hospital, Austria. SUBJECTS 24 consecutive patients with GORD and poor oesophageal contractility. INTERVENTIONS Laparoscopic partial posterior fundoplication. Oesophageal contractility was assessed manometrically. MAIN OUTCOME MEASURES Changes in measurements of mean contraction amplitudes in the distal oesophagus, the number of contractions with amplitudes of less than 30 mmHg, the number of interrupted and simultaneous contractions, and the total number of defective contractions. RESULTS 16 of the patients (67%) complained of dysphagia preoperatively, and none postoperatively. The mean (SEM) amplitudes in the distal oesophagus improved significantly (level 442.4 mmHg (3.5) compared with 31.8 mmHg (3.3), p = 0.03, and level 5-45.7 mmHg (3.8) compared with 32.6 mmHg (3.7), p = 0.02), the number of contractions with amplitudes below 30 mmHg decreased (18.0% (5.7) compared with 38.3% (6.2), p = 0.02), as did the number of interrupted or defected contractions (11.5% (3.6) compared with 26.3% (5.5), p = 0.03, and 29.5% (6.5) compared with 66.6% (5.1), p < 0.0001 respectively). There was no significant effect on the number of simultaneous waves (p = 0.11). CONCLUSIONS Partial posterior fundoplication improves poor oesophageal body motility. This results in improvement of preoperative dysphagia.