T. C. B. Dehn

Randomized clinical trial of laparoscopic total (Nissen) versus posterior partial (Toupet) fundoplication for gastro-oesophageal reflux disease based on preoperative oesophageal manometry

Laparoscopic fundoplication is an accepted treatment for symptomatic gastro‐oesophageal reflux disease. The aim of this study was to clarify whether total (Nissen) or partial (Toupet) fundoplication is preferable, and whether preoperative oesophageal manometry should be used to determine the degree of fundoplication performed.

Routine day-case laparoscopic cholecystectomy

A prospective study was carried out to assess the feasibility of performing true day‐case laparoscopic surgery in a district general hospital.

Review of open and minimal access approaches to oesophagectomy for cancer

Minimally invasive approaches to oesophagectomy are being used increasingly, but there remain concerns regarding safety and oncological acceptability. This study reviewed the outcomes of totally minimally invasive oesophagectomy (MIO; 41 patients), hybrid procedures (partially minimally invasive; 34) and open oesophagectomy (46) for oesophageal cancer from a single unit.

Laparoscopic management of large paraesophageal hiatal hernia

Background: Large paraesophageal hernias (POHs) predominantly occur in the elderly population. Early repair is recommended to avoid the risks associated with gastric volvulus. Methods: Data were collected prospectively during an 8-year period. Laparoscopic repair of POHs initially included circumcision of the sac and mesh hiatal repair. Sac excision and suture hiatal repair were later adopted. A fundoplication was also included, initially as a selective procedure. Results: Fifty-three patients with large POHs were treated by one surgeon. All had attempted laparoscopic repair, with four conversions to an open procedure. Symptomatic hernia recurrence occurred in five patients (9%). The 21 patients who had sac excision, hiatal repair, and fundoplication have remained free of symptomatic recurrence. The postoperative morbidity rate was 13%, with one death. Conclusions: Laparoscopic repair of large POHs remains feasible. We advocate complete sac excision, hiatal repair, fundoplication, and gastropexy to prevent early recurrence.

Laparoscopic subtotal cholecystectomy without cystic duct ligation.

Cholecystectomy is made hazardous by distortion of the anatomy of Calots triangle by acute or chronic inflammation. Laparoscopic subtotal cholecystectomy (LSTC) without cystic duct ligation is an alternative to conversion to open surgery in difficult cases.

A poor response to proton pump inhibition is not a contraindication for laparoscopic antireflux surgery for gastro esophageal reflux disease

BackgroundWe aimed to determine if a poor response to proton pump inhibitors (PPIs) can predict a poor outcome following laparoscopic antireflux surgery (LARS) in our surgically treated population.MethodsA total of 324 patients undergoing LARS were included in this study. Following standardized assessment, patients recorded the efficacy of their medication on visual analogue scales. Pre- and postoperative symptom scores were recorded, with outcomes measured by modified Visick scores.ResultsThere were 233 good responders (>50% relief) and 91 poor responders (<49% relief). Both groups demonstrated a significant decline in postoperative symptom scores. Ninety-four percent of good responders had an excellent or good outcome, compared to 87% of poor responders. Twenty-seven patients reported a fair or poor outcome, despite improved postoperative symptom scores. Fifteen of these patients reported continuing heartburn; five had positive pH tests.ConclusionOur results do not support the assumption that a poor response to PPIs equates to a poor outcome after LARS.

Does laparoscopic antireflux surgery improve quality of life in patients whose gastro-oesophageal reflux disease is well controlled with medical therapy?

Objective Both medical therapy and laparoscopic antireflux surgery have been shown to improve quality of life in gastro-oesophageal reflux disease. Although patients with poor symptom control or side effects on medical therapy might be expected to have improved quality of life after surgery, our aim was to determine, for the first time, whether patients whose symptoms are well controlled on medical therapy but who decide to undergo surgery (patient preference) would experience improved quality of life. Methods Retrospective analysis of our patient database (1998–2003, n=313) identified 60 patients who underwent laparoscopic antireflux surgery for the indication of patient preference. Two generic quality-of-life questionnaires (Short Form 36 and Psychological General Well-Being index) and a gastrointestinal symptom questionnaire (Gastrointestinal Symptom Rating Scale) were completed preoperatively, while on medical therapy, and 6 months after surgery. Results Thirty-eight patients completed all three questionnaires at both time intervals: 31 males, seven females; mean age 42 (15–66) years. Preoperative scores while on medical therapy were significantly improved after surgery: Short Form 36 median physical composite scores 52.0 and 54.0 (P=0.034) and mental composite scores 51.0 and 56.0 (P=0.020); Psychological General Well-Being median total scores 78.0 and 90.0 (P=0.0001); Gastrointestinal Symptom Rating Scale median total scores 2.13 and 1.73 (P=0.0007) and reflux scores 2.50 and 1.00 (P<0.0001). Conclusion Laparoscopic antireflux surgery significantly improved quality of life in reflux patients whose symptoms were well controlled on medical therapy. Although on the basis of a noncomparative trial with a relatively short follow-up period, we believe such patients should be considered for laparoscopic antireflux surgery.

Twenty-four-hour pH monitoring is required to confirm acid reflux suppression in patients with Barrett's oesophagus undergoing anti-reflux surgery.

Objective To assess whether relief of gastro-oesophageal reflux symptoms in patients with Barretts oesophagus who undergo laparoscopic anti-reflux surgery is a reliable indicator of acid suppression. Design Prospective cohort study. Setting Surgical department of a large district general hospital. Participants Twenty-two patients with Barretts oesophagus and symptomatic gastro-oesophageal reflux who underwent laparoscopic anti-reflux surgery. Interventions Laparoscopic anti-reflux surgery. Main outcome measures Postoperative symptom scores and 24-h pH test results. Results Twenty-one out of 22 patients had no or minimal residual symptoms postoperatively (Visick I or II). DeMeester symptom scores improved from a median of 5 preoperatively to 0 postoperatively (P < 0.001, Mann–Whitney rank sum test). Eighteen out of 22 patients had postoperative pH studies: three had persisting abnormal acid exposure times postoperatively, but all three were asymptomatic. Conclusions In patients with Barretts oesophagus, relief of reflux symptoms following laparoscopic anti-reflux surgery is unreliable as an indicator of acid reflux suppression.

Laparoscopic stapled cardioplasty for failed treatment of achalasia

Treatment of primary achalasia includes injection of botulinum toxin, pneumatic dilatation or surgical myotomy. All of these procedures have an associated failure rate. Laparoscopic stapled cardioplasty (LSC) may be an alternative to failed pneumatic dilatation and laparoscopic Hellers myotomy where oesophagectomy has previously been the only surgical option.

The results of total mesorectal excision for rectal carcinoma in a district general hospital before the era of surgical specialization.

To evaluate the results of rectal cancer surgery performed by a gastrointestinal surgeon in a district general hospital prior to the introduction of specialization, and to compare these to the targets set by the Royal College of Surgeons for specialist units.