Ziad T. Awad

The preoperative predictability of the short esophagus in patients with stricture or paraesophageal hernia.

AbstractBackground: Esophageal shortening is a known complication of advanced gastroesophageal reflux disease that may preclude a tension-free antireflux procedure. A retrospective analysis was performed to test the accuracy of preoperative testing. Methods: From September 1993 to December 1998, 39 patients underwent esophageal mobilization with intraoperative length assessment. Patients were selected on the basis of irreducible hiatal hernia, stricture formation, or both. Patients in the upright position with a fixed hiatal hernia larger than 5 cm on an esophagram were considered to have a short esophagus. Manometric length two standard deviations below the mean for height was considered abnormally short. Results: In 31 patients, intraoperative mobilization was sufficient to allow the gastroesophageal junction to lie 2 cm below the diaphragmatic crus, so no esophageal-lengthening procedure was required. Eight patients with a short esophagus required an esophageal-lengthening procedure after complete mobilization. Two patients subsequently underwent intrathoracic migration of the gastroesophageal junction (GEJ), with recurrence of symptoms and required gastroplasty during the second surgery. An esophagram had a sensitivity of 66% and a positive predictive value of 37%, whereas manometric length had a sensitivity of 43% and a positive predictive value of 25% for the diagnosis of short esophagus. The preoperative endoscopic finding of either a stricture or Barretts esophagus was the most sensitive test for predicting the need for a lengthening procedure. Conclusions: Manometry and esophagraphy are not reliable predictors of the short esophagus. Additional tests and/or tests combined with other parameters are needed.

Symptom Predictability of Reflux-Induced Respiratory Disease

Gastroesophageal reflux disease (GERD) often is associated with pulmonary problems such as asthma as well as recurrent and nocturnal cough. Dual-probe 24-hr pH monitoring may assist in establishing a correlation between these symptoms and GERD-related symptoms. To determine if any specific symptom was predictive of aspiration, this study was undertaken. Ambulatory dual-probe esophageal pH monitoring was performed on 133 patients who had upper airway and additional symptoms for GERD. All patients had esophageal manometric studies of the lower esophageal sphincter (LES), the upper esophageal sphincter (UES), and the esophageal body before dual-probe pH monitoring was performed. Using two assembled glass probes, the distal and the proximal sensors were placed 5 cm above the proximal border of the LES and 1 cm below the lower border of the UES, respectively. Patients were classified into three groups: proximal and distal probe positive (group I), proximal probe negative and distal probe positive (group II) and proximal and distal probe negative (Group III) Upper airway and additional symptoms plus manometry results of the LES, body and UES study were compared between groups. In addition, positive distal probe patients (groups I and II) were compared for distal fraction of time at pH < 4 and number of reflux episodes at each probe position. A positive distal probe result was defined as an abnormal DeMeester score (>14.8). A proximal probe test result was considered positive if percent time pH < 4.0 was >1.1 for total, 1.7 for upright, and 0.6 for supine positions. The ages of the subjects ranged from 18 to 83 years (mean age: 50.5 ± 1.5 years). Groups I, II, and III included 16 patients, 38 patients, and 79 patients, respectively. Group I had a significantly higher incidence of nocturnal cough than the other two groups. (P < 0.05). The manometric data revealed between groups that LES pressure (LESP) for groups I and II was significantly lower than LESP for group III (P = 0.003). Cricoid pressure, pharyngeal pressure, length, and relaxation of UES were not different between groups. Fraction of reflux time for group I was significantly higher than for group II in the supine position and at mealtime (P < 0.05). The number of reflux episodes for group I was significantly higher at meal time (P < 0.01). In conclusion, nocturnal cough is strongly predictive of proximal esophageal reflux. Proximal reflux episodes are significantly more frequent in the supine position and correlate well with the high predictive value of nocturnal cough.

Esophageal Shortening during the Era of Laparoscopic Surgery

Abstract. An effective method for determining the presence of a short esophagus preoperatively would be helpful to surgeons. In this study 260 patients underwent primary laparoscopic antireflux surgery; 44 of them were suspected to have esophageal shortening on the basis of: (1) Barretts esophagus or evidence of peptic stricture formation on endoscopy; (2) an irreducible hiatal hernia ≥ 5 cm in length on upright barium esophagram; or (3) a short esophagus on manometric analysis, defined as 2 SD below normal for height. Six patients without preoperative criteria required extensive esophageal mobilization and intraoperative endoscopic/laparoscopic assessment. Preoperative results were then compared with intraoperative esophageal length assessments. Altogether, 13 patients (5% of the whole series) underwent a lengthening procedure: left thoracoscopically assisted laparoscopic Collis gastroplasty (n= 11) or open transthoracic Collis gastroplasty (n= 2) plus antireflux repair (Nissen fundoplication in 9 and Toupet repair in 4). Among the preoperative tests, endoscopy had the highest sensitivity rate (61%); a combination of tests resulted in an increase in the specificity (63–100%) without a corresponding increase in sensitivity (28–42%). Preoperative testing is thus useful for predicting the need for an esophageal lengthening procedure. Endoscopy is the best screening test for the short esophagus. A well planned prospective trial to test the reliability of each test is needed.

Laparoscopic reoperative antireflux surgery

BACKGROUND Antireflux operations for gastroesophageal reflux disease whether performed open or laparoscopically can fail and may require reoperation to control new, recurrent symptoms or operation-related complications. We report our experience with the laparoscopic reoperation for failed antireflux procedures. METHODS Between 1995 and 2000, 37 patients underwent laparoscopic reoperative antireflux procedures. The mean age and weight were 52 years and 181.5 pounds. The main presenting symptoms were heartburn (n = 18), respiratory reflux (n = 4), chest pain (n = 3), regurgitation (n = 1), and dysphagia (n = 10). The mean duration between the first operation and recurrence of symptoms was 18 months, and the duration between the two procedures was 25 months. The operation was completed laparoscopically in 32 patients (86.5%): Nissen fundoplication (n = 27) and Toupet fundoplication (n = 9). RESULTS Intraoperative and postoperative complications occurred in 6 and 14 patients, respectively. Fundoplication disruption was the most common cause of primary surgery failure. The mean hospital stay was 4 days. At a mean follow-up of 26.5 months, results were excellent to good (65%), fair (21.5%), and poor (13.5%). CONCLUSION Laparoscopic reoperative antireflux procedures are technically feasible with acceptable preliminary results.

Left side thoracoscopically assisted gastroplasty: a new technique for managing the shortened esophagus.

Abstract Laparoscopic antireflux surgery is the procedure of choice for gastroesophageal reflux disease (GERD). However, many clinicians have reservations about its application in patients with complicated GERD, notably those with esophageal shortening. In this report, we present our experience with the laparoscopic management of the shortened esophagus. A total of 235 patients with primary GERD underwent laparoscopic antireflux procedures, 38 of whom were suspected preoperatively to have a shortened esophagus. Of the 235 patients, 8 (3.4%) needed a left thoracoscopically assisted gastroplasty in addition to laparoscopic Toupet repair (n= 4) or Nissen fundoplication (n= 4). Complications included pleural effusion (n= 1), pneumothorax (n= 2), and minor atelectasis (n= 1). The average hospital stay was 3 days. Results were satisfactory in 7 of 8 patients, with a mean follow-up of 20.2 months (range, 9–34 months). The surgical management of the shortened esophagus is difficult. However, the role of minimally invasive techniques is justified. Early results are appealing, with less morbidity, satisfactory control of GERD related symptoms, and a shortened hospital stay.

Manometric and radiographic verification of esophageal body decompensation for patients with achalasia

BACKGROUND Although morphologic, radiographic, and manometric features of achalasia have been well defined, it has not been established by careful retrospective analysis whether achalasia is a progressive disorder resulting in complete decompensation. STUDY DESIGN To verify the hypothesis that achalasia is a progressive disease, we retrospectively investigated manometric, radiographic, and symptomatic data in patients with achalasia. Sixty-three patients (36 women and 27 men) with a median age of 44 years (range 11 to 79 years) were evaluated. The duration of symptoms ranged from 1 to 442 months, with a median of 48 months. Patients were divided into four groups according to the duration of symptoms: 36 patients with less than 5 years, 11 with 5 to 10 years, 9 with 10 to 15 years, and 7 with 15 years or more. RESULTS Contraction pressures of the esophageal body decreased significantly at every level when the duration of symptoms increased (p < 0.04). The percentage of simultaneous waves in the esophageal body rose as the duration of symptoms increased. All waves were synchronous in every patient who had had symptoms for more than 15 years. The maximal width of the esophageal body measured on esophagram became greater with an increase in the duration of symptoms, but this measurement did not reach statistical significance (p = 0.063). The tortuosity of the esophagus, measured by the maximal angle of the esophageal axis, was significantly greater in patients with a longer duration of symptoms (p < 0.02). The type of symptoms was not associated with the duration of symptoms. CONCLUSIONS Achalasia is a progressive disease, as verified by manometric and radiographic findings. The classification of esophageal motor function expressed by amplitude of contraction pressure and angle of tortuosity is objective and useful. Classification of achalasia by duration of symptoms may be important in treatment selection and effectiveness.

Surgery for achalasia: 1998.

Technical controversies abound regarding the surgical treatment of aehalasia. To determine the value of a concomitant antireflux procedure, the best antireflux procedure, the correct length for gastric myotomy, the optimal surgical approach (thoracic or abdominal), and the equivalency of minimally invasive surgery, a literature review was carried out. The review is based on 23 articles on open transabdominal or transthoracic myotomy, 14 articles on laparoscopic myotomy, and four articles on thoracoscopic myotomy. Postoperative results of traditional open thoracic or transabdominal myotomy as determined by symptomatology were better with fundoplieation than without fundoplication. The incidence of postoperative reflux as proved by pH monitoring was high in patients who had an open transabdominal myotomy without fundoplication. The type of antireflux procedure used and the length of gastric myotomy had little effect on results. The results of transthoracic Heller myotomy do not require a concomitant fundoplieation. Laparoscopic and thoracoseopic myotomy had excellent results at short-term follow-up. A fundoplication must be added if the myotomy is performed transabdominally. A randomized prospective study is required to determine the best fundoplication and the extent of gastric myotomy. Although minimally invasive surgery for aehalasia has excellent initial results, longer follow-up in a larger population of patients is needed.

Laparoscopic right hemicolectomy with transvaginal colon extraction using a laparoscopic posterior colpotomy: a 2-year series from a single institution.

Background: In laparoscopic-assisted colon surgery, an abdominal incision is needed to remove the specimen and perform an anastomosis. We adopted the technique of totally laparoscopic right hemicolectomy and transvaginal extraction in women who required right colon resection. Methods: Over a 2-year period, 14 women were scheduled for totally laparoscopic right hemicolectomy with intracorporeal anastomosis and transvaginal colon removal. The indications for surgery included malignant (n=9) and benign (n=5) right-side colon pathology. Results: The procedure was accomplished laparoscopically in all patients. In 1 patient, the transvaginal removal was not possible because of a large tumor mass. The American Society of Anesthesiology was III in 13 and II in 1 patient. The mean body mass index was 31.65. Seventy-eight percent of patients had undergone abdominal surgery previously. The mean size of the lesion was 3.75 cm (range, 1.8 to 8.0 cm) and the mean number of lymph nodes was 18.7 (range, 8 to 37). All margins in the resected specimens were macroscopically and microscopically free of any tumor. One patient needed reoperation for intra-abdominal bleeding, whereas 3 patients developed postoperative ileus. Discussion: Laparoscopic right hemicolectomy and transvaginal extraction is a safe and effective procedure that can be added to the armamentarium of surgeons performing laparoscopic colon surgery. This technique may provide both an attractive way to reduce abdominal wall morbidity and a bridge to pure natural orifice transluminal endoscopic surgery for colon surgery.

A combined laparoscopic-endoscopic method of assessment to prevent the complications of short esophagus

Abstract. As antireflux surgery has been used increasingly for gastroesophageal reflux disease (GERD), a need has arisen for an accurate method to assess esophageal length. There are a number of preoperative tests that can help surgeons to establish the presence of a short esophagus, but intraoperative assessment after esophageal mobilization is the standard method. In this era of laparoscopic surgery, the surgeon mobilizes the esophagus extensively from the abdomen and then determines if mobilization is sufficient. We report an intraoperative technique that combines laparoscopic with endoscopic methods to determine the position of the gastroesophageal junction. Because two physicians are required, there is additional operating room time, resulting in increased costs. However, these costs are offset by the assurance that the complications of the short esophagus can be avoided. With experience, modifications were made, resulting in the technique described herein.

Hiatal hernia recurrence: 2004

BackgroundThe incidence of laparoscopic hiatal hernia recurrence is less than ideal. The reasons are more theoretical than objective, as the literature has little data in support of specific mechanisms of recurrence.MethodA recent literature review using all Internet-available, English-language articles on laparoscopic hernia repair was completed.ResultsA multitude of mechanisms of recurrence are suggested, but only surgeon inexperience, postoperative vomiting, heavy lifting, and retention of the hernia sac are supported by data.ConclusionThe incidence of hiatal hernia recurrence has stabilized. The role of an onlay mesh prosthesis for the prevention of hiatal hernia recurrence is under investigation, and long-term results are awaited.