Paul J. Klingler

Five- to eight-year outcome of the first laparoscopic Nissen fundoplications.

The operative mortality and morbidity of laparoscopic fundoplication are lower than for the open procedure. Questions have been raised regarding its long-term durability. One hundred seventy-one patients who had undergone laparoscopic Nissen fundoplication at least 5 years previously answered a questionnaire. During this period, 291 patients underwent a laparoscopic Nissen fundoplication. Surveillance data were available for 171 patients at a mean of 6.4 years after surgery. Overall, 96.5% were satisfied and 3.5% were not satisfied with the result of the procedure. Persistent symptoms included abdominal bloating (20.5%), diarrhea (12.3%), regurgitation (6.4%), heartburn (5.8%) and chest pain (4.1%); 27.5% reported dysphagia, and 7% had required dilatation. Fourteen percent were on continuous proton pump inhibitor therapy, but 79% of these patients were treated for vague abdominal or chest symptoms unrelated to reflux, which calls into question the indications for this therapy. Ninety-three percent of all patients were satisfied with their decision to have surgery. The overall well-being score increased significantly from 2.2 ±1.6 before surgery to 8.8 ±2 (P >0.0001) at more than 5 years after surgery. Twenty-one percent had undergone additional diagnostic procedures after surgery such as endoscopy and/or barium swallow. Laparoscopic Nissen fundoplication is an excellent long-term treatment for gastroesophageal reflux disease with persistent success for more than 5 years. Some patients have continuing symptoms and remain on therapy, but more than 90% of all patients undergoing laparoscopic Nissen fundoplication remain satisfied with their decision to have surgery. These results are at least as good as those achieved with open fundoplication and prove the long-term worth of this procedure.

Angiosarcoma of the aorta: Report of a case and review of the literature

Primary malignant tumors of the thoracic and abdominal aortas are extremely rare. In most cases, a diagnosis is established either postmortem or after an emergency operation for embolic complications. We present the case of a thoracic aortic angiosarcoma in a 71-year-old man who initially was seen with peripheral embolization. The management of these tumors and the world literature are reviewed.

Respiratory symptoms in patients with gastroesophageal reflux disease following medical therapy and following antireflux surgery.

BACKGROUND It is not known whether antireflux surgery is more effective than medical therapy to control respiratory symptoms (RS) in gastroesophageal reflux disease (GERD). METHODS In 21 GERD patients with RS, reflux was assessed by endoscopy, manometry, and pH monitoring. Patients had proton pump inhibitor therapy and cisapride for 6 months. After GERD relapsed following withdrawal of medical therapy, 7 patients with normal esophageal peristalsis had a laparoscopic Nissen fundoplication and 14 with impaired peristalsis a Toupet fundoplication. Respiratory symptoms were scored prior to treatment, at 6 months following medical therapy, and at 6 months after surgery. RESULTS Heartburn and esophagitis were effectively treated by medical and surgical therapy. Only surgery improved regurgitation. Respiratory symptoms improved in 18 patients (85.7%) following surgery and in only 3 patients (14.3%) following medical therapy (P <0.05). Esophageal peristalsis improved following the Toupet fundoplication. CONCLUSION Medical therapy fails to control reflux since it does not inhibit regurgitation. Surgery controls reflux and improves esophageal peristalsis, which contributes to its superiority over medical therapy in the treatment of RS associated with GERD.

The use of ultrasound to differentiate rectus sheath hematoma from other acute abdominal disorders

AbstractBackground: Rectus sheath hematoma (RSH) is a rare entity that can mimic an acute abdomen. Therefore, we designed a study to analyze the etiology, frequency, diagnosis using ultrasound, and treatment of RSH. Methods: A total of 1,257 patients admitted for abdominal ultrasound for acute abdominal pain or unclear acute abdominal disorders were evaluated. Results: In 23 (1.8%) patients, an RSH was diagnosed; three of them were not diagnosed preoperatively by ultrasound. Of 13 men and 10 women (mean age, 57 ± 23 years), 13 developed RSH after local trauma, three after severe coughing, two after defecation, and five spontaneously. Fifteen had nonsurgical therapy, and eight underwent surgery. The use of anticoagulants was accompanied by a larger diameter of the RSH (p < .012), and surgical therapy was more frequently required in these patients. In the surgically treated group, more intraabdominal free fluid could be detected by ultrasound (p < .0005), patients required less analgesics (p < .001), and the mean hospital stay was shorter (p < .001). Conclusions: RSH is a rare condition that is usually associated with abdominal trauma and/or anticoagulation therapy. Ultrasound is a good screening technique. Nonsurgical therapy is appropriate but leads to a greater need for analgesics. Surgery should be restricted to cases with a large hematoma or free intraabdominal rupture.

Ingested foreign bodies within the appendix: A 100-year review of the literature.

Background/Aim: Appendicitis and its complications remain a common problem affecting patients of all age groups. Foreign bodies are a rare cause of appendicitis. We tried to define potentially dangerous foreign bodies that may cause appendicitis and summarize general guidelines for their clinical management. Methods: A 100-year literature review including 256 cases of ingested foreign bodies within the appendix with emphasis on: (1) objects that are more prone to cause appendicitis or appendiceal perforation; (2) foreign bodies that are radiopaque and may be detected during follow-up with plain abdominal films, and (3) guidelines for clinical management. Results: Complications usually occur with sharp, thin, stiff, pointed and long objects. The majority of these objects are radiopaque. An immediate attempt should be made to remove a risky object by gastroscopy. If this fails, clinical follow-up with serial abdominal radiographs should be obtained. If the anatomical position of the object appears not to change and, most commonly, remains in the right lower abdominal quadrant, an attempt at colonoscopic removal is indicated. If this is unsuccessful, laparoscopic exploration with fluoroscopic guidance should be carried out to localize and remove the objects either by ileotomy, colotomy, or by appendectomy. Conclusion: Foreign bodies causing appendicitis are rare. However, if stiff or pointed objects get into the appendiceal lumen they have a high risk for appendicitis or perforation. These foreign bodies are almost always radiopaque.

Efficacy of medical therapy and antireflux surgery to prevent Barrett's metaplasia in patients with gastroesophageal reflux disease.

ObjectiveTo investigate whether Barrett’s metaplasia may develop despite effective medical therapy. Summary Background DataGastroesophageal reflux disease has a multifactorial etiology. Therefore, medical treatment may not prevent complications of reflux disease. MethodsEighty-three patients with reflux disease and mild esophagitis were prospectively studied for the development of Barrett’s metaplasia while receiving long-term therapy with proton pump inhibitors and cisapride. Only patients who had effective control of reflux symptoms and esophagitis were included. The surveillance time was 2 years. The outcome of these 83 patients was compared with that of 42 patients in whom antireflux surgery was performed with a median follow-up of 3.5 years. ResultsTwelve (14.5%) patients developed Barrett’s while receiving medical therapy; this was not seen after surgery. Patients developing Barrett’s had a weaker lower esophageal sphincter and peristalsis before treatment than patients with uncomplicated disease. ConclusionsAntireflux surgery is superior to medical therapy in the prevention of Barrett’s metaplasia. Therefore, patients with reflux disease who have a weak lower esophageal sphincter and poor esophageal peristalsis should undergo antireflux surgery, even if they have only mild esophagitis.

The Surgical Option for Gastroesophageal Reflux Disease

Gastroesophageal reflux disease is a common condition. Most patients can be managed with medications, but patients with refractory disease, particularly those with an incompetent lower esophageal sphincter, should be referred for surgery. The open Nissen fundoplication cures >90% of patients of their symptoms. The laparoscopic approach was first applied for patients with gastroesophageal reflux disease in 1991, and since then numerous reports evaluating the early experience with this technique have been published with results similar to the open procedure. Over the last 5 years, 595 laparoscopic antireflux procedures have been performed by us. There was 1 mortality due to an unrecognized duodenal perforation. Splenic injury did not occur compared to an incidence of up to 8.5% for the open procedure. A total of 9 patients required conversion to the open procedure for perforation, bleeding, or dissection difficulties. However, in the last 350 cases no conversions have been necessary. Most patients are now being discharged from hospital on the day after surgery with some patients being discharged on the same day as surgery. The overall reoperation rate, both for early postoperative morbidity and for late poor outcome, was 3.9% with follow-up ranging from 2 months to 5 years. The laparoscopic Nissen fundoplication achieves the same short-term outcome as the open procedure with significantly less postoperative morbidity and a shorter hospital stay.

Management of the failed antireflux operation.

A further operation is required in a small proportion of patients who have had prior antireflux surgery. This has a surprisingly good chance for success in appropriately evaluated patients. The surgeon must make very specific decisions regarding the surgical approach. The use of laparoscopy for redo surgery is being defined.

Paraesophageal herniation as a complication following laparoscopic antireflux surgery

Paraesophageal herniation of the stomach is a rare complication following laparoscopic Nissen fundoplication. We retrospectively reviewed our experience with 720 patients undergoing laparoscopic Nissen fundoplications. Seven patients were found to have postoperative paraesophageal hernias requiring reoperation. The clinical presentation, diagnostic workup, operative treatment, and outcome were evaluated. There were no deaths or procedure-related complications. Clinical presentation was recurrent dysphagia in four, nonspecific abdominal symptoms in one, and acute abdomen in one. One additional patient was asymptomatic. Preoperatively the correct diagnosis was able to be confirmed in four of six patients by barium esophagogram. Four patients underwent successful laparoscopic repair. Two patients had a thoracotomy including one conversion from laparoscopy to thoracotomy. One patient had a laparotomy to reduce an intrathoracic gastric volvulus. At a mean follow-up of 2.5 months no patient had further complications. Paraesophageal herniation is a rare complication following laparoscopic Nissen fundoplication and a definitive diagnosis is often difficult to establish. Early dysphagia after surgery should alert the surgeon to this complication. Redo laparoscopic surgery is feasible but an open procedure may be necessary.

Esophageal manometry: a comparison of findings in younger and older patients

Objective:We sought to determine the utility of esophageal manometry in an older patient population.Methods:Consecutively performed manometry studies (470) were reviewed and two groups were chosen for the study, those ≥ 75 yr of age (66 patients) and those ≤ 50 years (122 patients). Symptoms, manometric findings (lower esophageal sphincter [LES], esophageal body, upper esophageal sphincter [UES]) and diagnoses were compared between the groups.Results:Dysphagia was more common (60.6%vs 25.4%), and chest pain was less common (17.9 vs 26.2%) in older patients. In the entire group, there were no differences in LES parameters. Older patients with achalasia had lower LES residual pressures after deglutition (2.7 vs 12.0 mm Hg), but had similar resting pressures (31.4 vs 35.2 mm Hg) compared with younger achalasia patients. Duration and amplitude of peristalsis were similar in both groups, whereas peristaltic sequences were more likely to be simultaneous in the older group (15%vs 4%). The UES had a lower resting pressure in the older patients (49.6 vs 77.6 mm Hg) and a higher residual pressure (2.0 vs−2.7 mm Hg). The older patients were less likely to have normal motility (30.3%vs 44.3%) and were more likely to have achalasia (15.2%vs 4.1%) or diffuse esophageal spasm (16.6%vs 5.0%). When only patients with dysphagia were analyzed, achalasia was still more likely in the older group (20.0%vs 12.9%).Conclusions:When older patients present with dysphagia, esophageal manometry frequently yields a diagnosis to help explain their symptoms.