Susan A. Branton

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.

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.

Laparoscopic antireflux surgery for the treatment of esophageal strictures refractory to medical therapy.

OBJECTIVE:The response of esophageal strictures to laparoscopic antireflux surgery remains controversial. The aim of this study was to examine the outcome of patients with medically refractory esophageal strictures caused by severe gastroesophageal reflux disease and treated surgically.METHODS:A prospective follow-up analysis was completed using data obtained from detailed specific questioning by an independent observer. Responses were rated for symptoms, dysphagia (range 1–19), satisfaction with treatment, well-being (1 = best, 10 = worst), and need for further therapy.RESULTS:Of 102 patients, 74 (72.5%) responded to follow-up. There were 31 women, mean age 59.6 yr, and 43 men, mean age 55.2 yr. Mean follow-up was 25 months (range 4–68 months). A total of 252 dilations before surgery decreased to 29 after surgery (p < 0.0001) in the mean observation period of 26 months before and 25 months after surgery (mean/patient 5.3 and 1.8, respectively, p < 0.001). The mean dysphagia score was 6.8 ± 3.6 preoperatively and 3.7 ± 1.4 postoperatively (p < 0.0001). Nine (12%) patients required continuous postoperative H2-blockers or proton pump inhibitors. Seven of these had gastritis or peptic ulcer disease. Before antireflux surgery, 10 (13.5%) had frequent pneumonia. No pneumonia was observed after surgery. Sixty-eight (91.9%) patients were satisfied with their decision to have surgery. Among these, the well-being score was 1.8 ± 0.4 postoperatively vs 5.5 ± 1.2 (p < 0.001) preoperatively.CONCLUSIONS:Laparoscopic surgery in patients with medically refractory esophageal strictures results in a good clinical outcome with minimal complications. Patients are very satisfied with relief of dysphagia, and there is a diminished need for further dilation, with good quality of life.

Treatment of achalasia: recent advances in surgery.

Achalasia is an uncommon motility disorder of the esophagus with an uncertain etiology. Considerable debate exists regarding the most effective treatment for long-term relief of symptoms. For decades, pneumatic dilatation has been the primary treatment option, and surgery was reserved for patients who required repeated dilations or for those who were not willing to undergo the risk of perforation associated with dilatation. Recently botulinum toxin injection of the lower esophageal sphincter has been shown to provide substantial short-term relief from dysphagia; however, its effect only lasts for a short period of time. Recently, minimally invasive surgical techniques have been developed to perform a Heller myotomy effectively with an antireflux procedure. This has become a primary treatment option for many patients. We present a review of the outcome of different therapeutic options of achalasia with a special focus on laparoscopic procedures.

Small-intestinal enteroliths—Unusual cause of small-intestinal obstruction

PurposePurpose The aim of this study was to report on a rare cause of small-intestinal obstruction caused by small-intestinal enteroliths. METHODS: We present three different cases of enterolith formation in the small intestine. One occurred after nontropical sprue, one patient had multiple jejunal diverticula, and another patient had enterolith formation in a blind loop after a small-bowel side-to-side anastomosis. RESULTS: After initial conservative therapeutic approach all patients underwent surgery. In two patients the enteroliths were removed by ileotomy or jejunostomy. In the third patient the bowel anastomosis had to be revised after removal of the enterolith. CONCLUSION: Small-intestinal enteroliths may cause small-bowel obstruction. The first therapeutic approach is nonsurgical; however, if obstruction proceeds, surgical removal with or without revision of underlying pathology is necessary. We discuss the causes and therapeutic management of enteroliths and give a review of related literature.

Surgical therapy for supraesophageal reflux complications of gastroesophageal reflux disease

Supraesophageal complications of gastroesophageal reflux can be successfully treated by antireflux surgery. Careful preoperative testing, including 24-hour esophageal pH, manometry, and endoscopy, will help to identify appropriate patients who will benefit from surgery. The best results are achieved in patients with nocturnal asthma, the onset of reflux before pulmonary symptoms, laryngeal inflammation, and a good response to medical therapy. Cough is more responsive to surgical therapy than is asthma. The benefits of minimally-invasive surgery are evident in patients with pulmonary disease, who have a faster recovery with fewer complications than after open surgery.

Endo-organ and laparoscopic management of gastric leiomyomas.

Various techniques have been reported for the laparoscopic treatment of benign gastric lesions, depending on the site of the lesion. Recently, a new technique of endo-organ gastric surgery has been developed that is particular useful for the treatment of lesions on the posterior gastric wall. We report on two patients with submucosal gastric tumors. A 79-year-old man was found to have a submucosal tumor near the esophagogastric junction in the posterior wall of the stomach. Endosonography suggested that the tumor was a gastric leiomyoma. Under endoscopic guidance, three ports were inserted into the stomach and the tumor could be successfully enucleated. A 78-year-old woman was found to have a 2 x 1-cm submucosal tumor at the anterior wall of the antrum. The tumor was successfully removed by laparoscopic gastrotomy and resection. The various laparoscopic techniques for the treatment of gastric lesions are discussed.

Laparoscopic Antireflux Surgery –It’s a Wrap!

The surgical management of gastroesophageal reflux disease has been simplified by the availability of minimally invasive techniques to treat this condition. The indications and selection of patients remain the same as for open surgery and initial results with laparoscopic antireflux surgery show long-term results equal to, or better than open procedure. These procedures are technically demanding requiring surgeons skilled in advanced laparoscopy. The evaluation of patients, selection of patients for surgery, surgical techniques and anticipated outcomes are discussed.

Minimally Invasive Surgical Techniques for the Treatment of Gastroesophageal Reflux Disease

Open antireflux surgery produces good long-term control of disease, but new interest in the surgical management of gastroesophageal reflux disease has been stimulated by the introduction of minimally invasive techniques to perform standard antireflux procedures. In the past some scepticism existed among gastroenterologists who quoted the poor surgical results they had seen. These bad results, however, were largely due to inappropriate surgery in poorly worked-up patients or antireflux surgery performed by inexperienced surgeons. Since the introduction of minimally invasive surgery for gastroesophageal reflux disease, excellent results have been reported with over 5 years of follow-up. The most common and successfully used laparoscopically antireflux procedures are reviewed and results analyzed.

Surgical management of a long efferent loop after J-pouch ileoanal reconstruction

PURPOSE: To demonstrate a simple and effective repair of a poorly constructed ileal J-pouch with an extensive long efferent limb. METHOD: A retrospective case review was performed. RESULTS: The surgical procedure described preserves additional ileum and enlarges the ileal reservoir. The procedure succeeded in resolving the patients complaints of partial obstruction, weight loss, and increased stool frequency. At five-month follow-up, the patient was doing well with three to six stools daily. Evaluation of the new ileal J-pouch showed no signs of inflammation, and the pouch size measured more than 20 cm compared with 12 cm preoperatively. CONCLUSIONS: Repair of a long efferent limb by this simple stapling technique is feasible, simple, and effective, with an excellent clinical result. It preserves valuable small intestine and enlarges the capacity of the reservoir, leading to better functional outcome.