BACKGROUND Gastric fundoplication with endoscopic technique(GFET)is an innovative approach to managing gastroesophageal reflux disease(GERD).This minimally invasive procedure utilizes the GEN-2 Apollo endosuture devic...BACKGROUND Gastric fundoplication with endoscopic technique(GFET)is an innovative approach to managing gastroesophageal reflux disease(GERD).This minimally invasive procedure utilizes the GEN-2 Apollo endosuture device and Olympus H2T180 gastroscope to perform partial fundoplication by strategically placing Prolene 2-0 sutures at the 11,7,5,1,and 3 o’clock positions around the gastroesophageal junction.AIM To evaluate whether GFET enhances the lower esophageal sphincter function by creating comprehensive plication to improve the barrier against reflux.METHODS This single-center prospective study included patients undergoing GFET.Before beginning GFET,pH metrics and subsequent manometric measurements were obtained.An analysis of variance was performed to determine statistically significant differences between quality of life(QOL)and DeMeester scores at the time of the procedure and 6 and 12 months postoperatively.Pearson’sχ2 test was performed to identify statistically significant differences between categorical variables at the time of the procedure and 6 and 12 months postoperatively.RESULTS Eighteen participants were enrolled(11 males and 7 females;mean age,35 years).More than 70%had an initial Hill grade of IIb.One adverse event was recorded after the procedure.One patient underwent valve reinforcement at 12 months.The mean QOL score was markedly higher at the time of the procedure(39.9±4.0)compared to those at 6 and 12 months postoperatively(P<0.001).Scores at 12 months were slightly higher than those at 6 months.The highest mean QOL score was observed at the time of the procedure,followed by those at 6 and 12 months postoperatively(P<0.001).A similar trend was noted for the mean DeMeester scores(P<0.001).CONCLUSION GFET is a minimally invasive alternative to traditional surgical interventions and endoscopic techniques for managing GERD.Further research is warranted to validate its long-term efficacy and effectiveness over existing treatments.展开更多
AIM:To compare the mid-term outcomes of laparoscopic calibrated Nissen-Rossetti fundoplication with Dor fundoplication performed after Heller myotomy for oesophageal achalasia.METHODS:Fifty-six patients(26 men,30 wome...AIM:To compare the mid-term outcomes of laparoscopic calibrated Nissen-Rossetti fundoplication with Dor fundoplication performed after Heller myotomy for oesophageal achalasia.METHODS:Fifty-six patients(26 men,30 women;mean age 42.8±14.7 years)presenting for minimally invasive surgery for oesophageal achalasia,were enrolled.All patients underwent laparoscopic Heller myotomy followed by a 180°anterior partial fundoplication in 30 cases(group 1)and calibrated NissenRossetti fundoplication in 26(group 2).Intraoperative endoscopy and manometry were used to calibrate the myotomy and fundoplication.A 6-mo follow-up period with symptomatic evaluation and barium swallow was undertaken.One and two years after surgery,the patients underwent symptom questionnaires,endoscopy,oesophageal manometry and 24 h oesophago-gastric pH monitoring.RESULTS:At the 2-year follow-up,no significant difference in the median symptom score was observed between the 2 groups(P=0.66;Mann-WhitneyU-test).The median percentage time with oesophageal pH< 4 was significantly higher in the Dor group compared to the Nissen-Rossetti group(2;range 0.8-10 vs 0.35;range 0-2)(P<0.0001;Mann-WhitneyU-test).CONCLUSION:Laparoscopic Dor and calibrated Nissen-Rossetti fundoplication achieved similar results in the resolution of dysphagia.Nissen-Rossetti fundoplication seems to be more effective in suppressing oesophageal acid exposure.展开更多
Increases in the prevalence of obesity and gastroesophageal reflux disease (GERD) have paralleled one another over the past decade, which suggests the possibility of a linkage between these two processes. In both inst...Increases in the prevalence of obesity and gastroesophageal reflux disease (GERD) have paralleled one another over the past decade, which suggests the possibility of a linkage between these two processes. In both instances, surgical therapy is recognized as the most effective treatment for severe, refractory disease. Current surgical therapies for severe obesity include (in descending frequency) Roux-en-Y gastric bypass, adjustable gastric banding, sleeve gastrectomy, and biliopancreatic diversion with duodenal switch, while fundoplication remains the mainstay for the treatment of severe GERD. In several large series, however, the outcomes and durability of fundoplication in the setting of severe obesity are not as good as those in patients who are not severely obese. As such, bariatric surgery has been suggested as a potential alternative treatment for these patients. This article reviews current concepts in the putative pathophysiological mechanisms by which obesity contributes to gastroesophageal reflux and their implications with regards to surgical therapy for GERD in the setting of severe obesity.展开更多
AIM To compare the outcomes between laparoscopic Nissen fundoplication(LNF)and proton pump inhibitors(PPIs)therapy in patients with laryngopharyngeal reflux(LPR)and typeⅠhiatal hernia diagnosed by oropharyngeal p H-m...AIM To compare the outcomes between laparoscopic Nissen fundoplication(LNF)and proton pump inhibitors(PPIs)therapy in patients with laryngopharyngeal reflux(LPR)and typeⅠhiatal hernia diagnosed by oropharyngeal p H-monitoring and symptom-scale assessment.METHODS From February 2014 to January 2015,70 patients who were diagnosed with LPR and type I hiatal hernia and referred for symptomatic assessment,oropharyngeal p H-monitoring,manometry,and gastrointestinal endoscopy were enrolled in this study.All of the patients met the inclusion criteria.All of the patients underwent LNF or PPIs administration,and completed a2-year follow-up.Patients’baseline characteristics and primary outcome measures,including comprehensive and single symptoms of LPR,PPIs independence,and satisfaction,and postoperative complications were assessed.The outcomes of LNF and PPIs therapy were analyzed and compared. RESULTS There were 31 patients in the LNF group and 39patients in the PPI group.Fifty-three patients(25 in the LNF group and 28 in the PPI group)completed reviews and follow-up.Oropharyngeal p H-monitoring parameters were all abnormal with high acid exposure,a large amount of reflux,and a high Ryan score,associated reflux symptom index(RSI)score.There was a significant improvement in the RSI and LPR symptom scores after the 2-year follow-up in both groups(P<0.05),as well as typical symptoms of gastroesophageal reflux disease.Improvement in the RSI(P<0.005)and symptom scores of cough(P=0.032),mucus(P=0.011),and throat clearing(P=0.022)was significantly superior in the LNF group to that in the PPI group.After LNF and PPIs therapy,13 and 53 patients achieved independence from PPIs therapy(LNF:44.0%vs PPI:7.14%,P<0.001)during follow-up,respectively.Patients in the LNF group were more satisfied with their quality of life than those in the PPI group(LNF:62.49±28.68 vs PPI:44.36±32.77,P=0.004).Body mass index was significantly lower in the LNF group than in the PPI group(LNF:22.2±3.1kg/m^2 vs PPI:25.1±2.9 kg/m^2,P=0.001).CONCLUSION Diagnosis of LPR should be assessed with oropharyngeal p H-monitoring,manometry,and the symptom-scale.LNF achieves better improvement than PPIs for LPR with type I hiatal hernia.展开更多
Gastroesophageal reflux disease (GERD) is a condition that develops when the reflux of gastric contents into the esophagus leads to troublesome symptoms and/or complications. Heartburn is the cardinal symptom, often a...Gastroesophageal reflux disease (GERD) is a condition that develops when the reflux of gastric contents into the esophagus leads to troublesome symptoms and/or complications. Heartburn is the cardinal symptom, often associated with regurgitation. In patients with endoscopy-negative heartburn refractory to proton pump inhibitor (PPI) therapy and when the diagnosis of GERD is in question, direct reflux testing by impedance-pH monitoring is warranted. Laparoscopic fundoplication is the standard surgical treatment for GERD. It is highly effective in curing GERD with a 80% success rate at 20-year follow-up. The Nissen fundoplication, consisting of a total (360°) wrap, is the most commonly performed antireflux operation. To reduce postoperative dysphagia and gas bloating, partial fundoplications are also used, including the posterior (Toupet) fundoplication, and the anterior (Dor) fundoplication. Currently, there is consensus to advise laparoscopic fundoplication in PPI-responsive GERD only for those patients who develop untoward side-effects or complications from PPI therapy. PPI resistance is the real challenge in GERD. There is consensus that carefully selected GERD patients refractory to PPI therapy are eligible for laparoscopic fundoplication, provided that objective evidence of reflux as the cause of ongoing symptoms has been obtained. For this purpose, impedance-pH monitoring is regarded as the diagnostic gold standard.展开更多
AIM: To investigate the quality of life following lapa-roscopic Nissen fundoplication by assessing short-term and long-term outcomes. METHODS: From 1992 to 2005, 249 patients under-went laparoscopic Nissen fundoplicat...AIM: To investigate the quality of life following lapa-roscopic Nissen fundoplication by assessing short-term and long-term outcomes. METHODS: From 1992 to 2005, 249 patients under-went laparoscopic Nissen fundoplication. Short-term outcome data including symptom response, side effects of surgery, endoscopy, and patient's perception of over-all success were collected prospectively. Long-term out-comes were investigated retrospectively in patients witha median follow-up of 10 years by assessment of reflux symptoms, side effects of surgery, durability of antire-flux surgery, need for additional treatment, patient's perception of success, and quality of life. Antireflux sur-gery was considered a failure based on the following criteria: moderate to severe heartburn or regurgitation; moderate to severe dysphagia reported in combination with heartburn or regurgitation; regular proton pump inhibitor medication use; endoscopic evidence of erosive esophagitis Savary-Miller grade 1-4; pathological 24-h pH monitoring; or necessity to undergo an additional surgery. The main outcome measures were short-and long-term cure rates and quality of life, with patient sat-isfaction as a secondary outcome measure. RESULTS: Conversion from laparoscopy to open sur-gery was necessary in 2.4% of patients. Mortality was zero and the 30-d morbidity was 7.6% (95%CI: 4.7%-11.7%). The median postoperative hospital stay was 2 d [interquartile range (IQR) 2-3 d]. Two hundred and forty-seven patients were interviewed for short-term analysis following endoscopy. Gastro-esophageal reflux disease was cured in 98.4% (95%CI: 95.9%-99.6%) of patients three months after surgery. New-onset dysphagia was encountered postoperatively in 13 patients (6.7%); 95% reported that the outcome was better after antireflux surgery than with preopera-tive medical treatment. One hundred and thirty-nine patients with a median follow-up of 10.2 years (IQR 7.2-11.6 years) were available for a long-term evalu-ation. Cumulative long-term cure rates were 87.7% (81.0%-92.2%) at 5 years and 72.9% (64.0%-79.9%) at 10 years. Gastrointestinal symptom rating scores and RAND-36 quality of life scores of patients with treatment success were similar to those of the general population but significantly lower in those with failed antireflux surgery. Of the patients available for long-term follow-up, 83% rated their operation a success. CONCLUSION: For the long-term, our results indicate decreasing effectiveness of laparoscopic antirefluxsurgery, although most of the patients seem to have an overall quality of life similar to that of the general population.展开更多
AIM: To demonstrate the optimal surgical procedure for gastroesophageal reflux disease. METHODS: The electronic databases of Medline, Elsevier, Springerlink and Embase over the last 16 years were searched. All clinica...AIM: To demonstrate the optimal surgical procedure for gastroesophageal reflux disease. METHODS: The electronic databases of Medline, Elsevier, Springerlink and Embase over the last 16 years were searched. All clinical trials involved in the outcomes of laparoscopic Nissen fundoplication (LNF) and laparoscopic Toupet fundoplication (LTF) were identified. The data of assessment in benefits and adverse results of LNF and LTF were extracted and compared using metaanalysis. RESULTS: We ultimately identified a total of 32 references reporting nine randomized controlled trials, eight prospective cohort trials and 15 retrospective trials. These studies reported a total of 6236 patients, of whom 4252 (68.18%) underwent LNF and 1984 (31.82%) underwent LTF. There were no differences between LNF and LTF in patients' satisfaction, perioperative complications, postoperative heartburn, refluxrecurrence and reoperation. Both LNF and LTF enhanced the function of lower esophageal sphincter and improved esophagitis. The postoperative dysphagia, gasbloating syndrome, inability to belch and the need for dilatation after LNF were more common than after LTF. Subgroup analyses showed that dysphagia after LNF and LTF was similar in patients with normal esophageal peristalsis (EP), but occurred more frequently in patients with weak EP after LNF than after LTF. Furthermore, patients with normal EP after LNF still had a higher risk of developing dysphagia than did patients with abnormal EP after LTF.CONCLUSION: Compared with LNF, LTF offers equivalent symptom relief and reduces adverse results.展开更多
Gastro-esophageal reflux disease(GERD)is a verycommon disorder that results primarily from the loss of an effective antireflux barrier,which forms a mechanical obstacle to the retrograde movement of gastric content.GE...Gastro-esophageal reflux disease(GERD)is a verycommon disorder that results primarily from the loss of an effective antireflux barrier,which forms a mechanical obstacle to the retrograde movement of gastric content.GERD can be currently treated by medical therapy,surgical or endoscopic transoral intervention.Medical therapy is the most common approach,though concerns have been increasingly raised in recent years about the potential side effects of continuous longterm medication,drug intolerance or unresponsiveness,and the need for high dosages for long periods to treat symptoms or prevent recurrences.Surgery too may in some cases have consequences such as longlasting dysphagia,flatulence,inability to belch or vomit,diarrhea,or functional dyspepsia related to delayed gastric emptying.In the last few years,transoral incisionless fundoplication(TIF)has proved an effective and promising therapeutic option as an alternative to medical and surgical therapy.This review describes the steps of the TIF technique,using the Esophy X®device and the MUSETM system.Complications and their management are described in detail,and the recent literature regarding the outcomes is reviewed.TIF reconfigures the tissue to obtain a full-thickness gastroesophageal valve from inside the stomach,by serosato-serosa plications which include the muscle layers.To date the procedure has achieved lasting improvement of GERD symptoms(up to six years),cessation or reduction of proton pump inhibitor medication in about 75%of patients,and improvement of functional findings,measured by either p H or impedance monitoring.展开更多
Magnesium deficiency can cause a variety of symptoms,including potentially life-threatening complications such as seizures,cardiac arrhythmias and secondary electrolyte disturbances.Hypomagnesemia can be a serious adv...Magnesium deficiency can cause a variety of symptoms,including potentially life-threatening complications such as seizures,cardiac arrhythmias and secondary electrolyte disturbances.Hypomagnesemia can be a serious adverse effect to proton pump inhibitor(PPI)therapy,which is worrying due to the widespread use of PPIs.Current evidence suggest that the mechanism of PPI induced hypomagnesemia is impaired intestinal magnesium absorption.In this report,we present the case of a long-term PPI user with persistent hypomagnesemia with severe symptoms at presentation.He was unable to stop PPI treatment because of severe reflux symptoms,and was dependent on weekly intravenous magnesium infusions,until his magnesium levels finally normalized without the need for supplementation after a successful laparoscopic fundoplication.展开更多
BACKGROUND Fundoplication, was first introduced as a surgical treatment method of gastroesophageal reflux disease. Consequently, several modifications of this method have been described, whereas laparoscopic fundoplic...BACKGROUND Fundoplication, was first introduced as a surgical treatment method of gastroesophageal reflux disease. Consequently, several modifications of this method have been described, whereas laparoscopic fundoplication was recently introduced. Although single incision(SI) fundoplication was considered as an alternative to the conventional laparoscopic approach, several studies reported an increased operation duration, and high rates of multiport conversion and incisional hernia.AIM To provide a current overview of the technical variations and the postoperative outcomes of patients submitted to SI fundoplication.METHODS The present systematic review of the literature was designed and conducted on the basis of the PRISMA guidelines. A systematic screening of the electronic scholar databases(Medline, Scopus and Web of Science) was performed.RESULTS Literature search resulted in the identification of 19 studies. Overall, 266, 137 and110 SI Nissen, Dor and Toupet fundoplications were reported, respectively. In the majority of the trials, standard laparoscopic instruments were used. The left liver lobe was displayed through the use of forceps, graspers, retractors, drains or even glue. Both intra-corporeal and extracorporeal suturing was described. Mean operative time was 136.3 min. Overall complication rate was 5.2% and the rate of incisional hernia was 0.9%. No mortality was reported.CONCLUSIONDue to the methodological heterogeneity and the lack of high quality studies comparing multi to single access techniques and the several variations, we conclude that further well designed studies are necessary, in order to evaluate the role of SI fundoplication.展开更多
Gastro-oesphageal reflux disease is an increasing health burden.The mainstay of treatment has conventionally been medical therapy but since the introduction of laparoscopic surgery laparoscopic anti-reflux surgery has...Gastro-oesphageal reflux disease is an increasing health burden.The mainstay of treatment has conventionally been medical therapy but since the introduction of laparoscopic surgery laparoscopic anti-reflux surgery has been increasingly used for intractable symptoms or in patients unwilling to take long term medication.The Nissen 360 degree wrap has traditionally been considered the gold standard operation but can be associated with significant complications.These complications include“gas bloat”and dysphagia and can occur relatively frequently.Various modifications have been described to the original operation and some of these have been described.In addition alternative wraps have been described which seem to have a reduced incidence of complications associated with their use.This editorial discusses the various types of wrap that can be performed and the minimum requirements of the surgical technique.The evidence from a recent meta-analysis of the randomised data has suggested that an anterior wrap is associated with a lower rate of complications and gives just as good control of reflux symptoms.The advantages and disadvantages of an anterior wrap are discussed.The lack of long term follow up data concerns some practitioners and at the moment the choice of wrap carried out still rests with the individual surgeon.展开更多
AIM:To compare the outcome of acid reflux prevention by Dor fundoplication after laparoscopic Heller myotomy(LHM)for achalasia.METHODS:Electronic database PubMed,Ovid(Evidence-Based Medicine Reviews,EmBase and Ovid ME...AIM:To compare the outcome of acid reflux prevention by Dor fundoplication after laparoscopic Heller myotomy(LHM)for achalasia.METHODS:Electronic database PubMed,Ovid(Evidence-Based Medicine Reviews,EmBase and Ovid MEDLINE)and Cochrane Library were searched between January 1995 and September 2012.Bibliographic citation management software(EndNote X3)was used for extracted literature management.Quality assessment of random controlled studies(RCTs)and non-RCTs was performed according to the Cochrane Handbook for Systematic Reviews of Interventions 5.1.0and a modification of the Newcastle-Ottawa Scale,respectively.The data were analyzed using Review Manager(Version 5.1),and sensitivity analysis was performed by sequentially omitting each study.RESULTS:Finally,6 studies,including a total of 523achalasia patients,compared Dor fundoplication with other types of fundoplication after LHM(Dor-other group),and 8 studies,including a total of 528 achalasia patients,compared Dor fundoplication with no fundoplication after LHM(Dor-no group).Dor fundoplication was associated with a significantly higher recurrence rate of clinical regurgitation and pathological acid reflux compared with the other fundoplication group(OR=7.16,95%CI:1.25-40.93,P=0.03,and OR=3.79,95%CI:1.23-11.72,P=0.02,respectively).In addition,there were no significant differences between Dor fundoplication and no fundoplication in all subjects.Other outcomes,including complications,dysphagia,postoperative physiologic testing,and operation-related data displayed no significant differences in the two comparison groups.CONCLUSION:Dor fundoplication is not the optimum procedure after LHM for achalasia.We suggest more attention should be paid on quality of life among different fundoplications.展开更多
BACKGROUND Esophagogastric junction outflow obstruction(EGJOO) is a rare syndrome,characterized by an elevation of the integrated relaxation pressure of the lower esophageal sphincter, not accompanied by alterations i...BACKGROUND Esophagogastric junction outflow obstruction(EGJOO) is a rare syndrome,characterized by an elevation of the integrated relaxation pressure of the lower esophageal sphincter, not accompanied by alterations in esophageal motility that may lead to the criteria for achalasia. We were unable to find any prior report of the combination of Heller myotomy with anterior partial fundoplication(Dor) as the treatment for EGJOO. We herein report a case of EGJOO treated with laparoscopic Heller myotomy combined with Dor fundoplication.CASE SUMMARY A 26-year-old man presented with a 3-year history of solid dysphagia and a 30-kg weight loss. He was treated with oral nifedipine, isosorbide, and omeprazole,without resolution of symptoms. An upper gastrointestinal series(barium swallow) revealed a "bird's beak" sign. Esophagogastroduodenoscopy was positive for Los Angeles grade A peptic esophagitis. High-resolution esophageal manometry was compatible with EGJOO. Esophageal pH monitoring showed pathological acid reflux both in orthostatic and decubitus position. An 8-cm laparoscopic Heller myotomy combined with an anterior 220° Dor fundoplication was performed. Solid diet was introduced on postoperative day 2, and the patient was discharged home the same day. At 17-mo follow-up, he reported no symptoms. Barium swallow was compatible with complete radiologic resolution.Both esophageal manometry and upper endoscopy showed normal findings 9 mo after the operation.CONCLUSION Surgical treatment with Heller myotomy and Dor fundoplication is a potential treatment option for EGJOO refractory to medical treatment.展开更多
BACKGROUND Achalasia is a rare benign esophageal motor disorder characterized by incomplete relaxation of the lower esophageal sphincter(LES). The treatment of achalasia is not curative, but rather is aimed at reducin...BACKGROUND Achalasia is a rare benign esophageal motor disorder characterized by incomplete relaxation of the lower esophageal sphincter(LES). The treatment of achalasia is not curative, but rather is aimed at reducing LES pressure. In patients who have failed noninvasive therapy, surgery should be considered. Myotomy with partial fundoplication has been considered the first-line treatment for non-advanced achalasia. Recently, peroral endoscopic myotomy(POEM), a technique that employs the principles of submucosal endoscopy to perform the equivalent of a surgical myotomy,has emerged as a promising minimally invasive technique for the management of this condition.AIM To compare POEM and laparoscopic myotomy and partial fundoplication(LM-PF) regarding their efficacy and outcomes for the treatment of achalasia.METHODS Forty treatment-naive adult patients who had been diagnosed with achalasia based on clinical and manometric criteria(dysphagia score ≥ II and Eckardt score > 3) were randomized to undergo either LM-PF or POEM. The outcome measures were anesthesia time, procedure time, symptom improvement, reflux esophagitis(as determined with the Gastroesophageal Reflux Disease Questionnaire), barium column height at 1 and 5 min(on a barium esophagogram), pressure at the LES, the occurrence of adverse events(AEs), length of stay(LOS), and quality of life(QoL).RESULTS There were no statistically significant differences between the LM-PF and POEM groups regarding symptom improvement at 1, 6, and 12 mo of follow-up(P = 0.192, P = 0.242, and P = 0.242, respectively). However, the rates of reflux esophagitis at 1, 6, and 12 mo of follow-up were significantly higher in the POEM group(P = 0.014, P < 0.001, and P = 0.002, respectively). There were also no statistical differences regarding the manometry values, the occurrence of AEs, or LOS. Anesthesia time and procedure time were significantly shorter in the POEM group than in the LM-PF group(185.00 ± 56.89 and 95.70 ± 30.47 min vs 296.75 ± 56.13 and 218.75 ± 50.88 min,respectively;P = 0.001 for both). In the POEM group, there were improvements in all domains of the QoL questionnaire, whereas there were improvements in only three domains in the LM-PF group.CONCLUSION POEM and LM-PF appear to be equally effective in controlling the symptoms of achalasia,shortening LOS, and minimizing AEs. Nevertheless, POEM has the advantage of improving all domains of QoL, and shortening anesthesia and procedure times but with a significantly higher rate of gastroesophageal reflux.展开更多
Purpose: The purpose of the study was to review a single surgeon, seven-year experience, using the Da Vinci Telerobotic system performing 124 foregut operations. Methods: Data review from 2002-2009 including 71 Nissen...Purpose: The purpose of the study was to review a single surgeon, seven-year experience, using the Da Vinci Telerobotic system performing 124 foregut operations. Methods: Data review from 2002-2009 including 71 Nissen fundoplications, 26 esophagomyotomies, and 27 hiatal hernia repairs was performed. Parameters collected included gender, age, body mass index (BMI), estimated blood loss (EBL), port set up time (PST), robot operating time (ROT), total case time (TCT), length of stay (LOS), complications, conversions, and resident involvement. Statistical analysis was con-ducted. Results: 124 foregut operations: 45 males, 79 females, mean age of 54.8 ± 16.7 (18 - 85) years, mean TCT 174.4 ± 45.0 (102 - 321) min. Nissen fundoplication: mean BMI of 30.8 ± 3.9 (22.4 - 46.8) kg/m2, EBL 30.2 ± 21.8 (5 - 100) ml, PST 32.3 ± 9 (14 - 63) min, ROT 111.4 ± 37.3 (51 - 229) min, TCT 175.0 ± 46.4 (102 - 321) min, median LOS 1 (0 - 9) day, complication rate 7.0% (5/71), conversion rate 5.6%, resident involvement 69.0% (49/71). Esophagomyotomy: mean BMI of 26.5 ± 6.1 (15.4 - 36.6) kg/m2, EBL 39.1 ± 41.7 (10 - 200) ml, PST 28.0 ± 8.6 (16 - 47) min, ROT 122.9 ± 45 (31 - 217) min, and TCT 178.0 ± 40.5 (105 - 262) min, median LOS 1 (0 - 6) day, complication rate 15.4% (4/26), conversion rate 0%, resident involvement 69.2% (18/26). Hiatal hernia repair: mean BMI of 28.4 ± 4.2 (21.9 - 36.8) kg/m2, EBL 38.4 ± 32.7 (10 - 150) ml, PST 28.8 ± 8.0 (17 - 52) min, ROT 109.0 ± 44.5 (49 - 250) min, and TCT 169.2 ± 46.5 (102 - 299) min, median LOS 1 (1 - 14) day, complication rate 11.1% (3/27), conversion rate 3.7%, resident involvement 66.7% (18/27). Conclusion: Robotic-assisted foregut surgery is safe and effective. This series compares favorably with other robotic studies in length of hospital stay, total case time, and complication and conver-sion rates. Foregut surgery is an excellent robotic training ground for residents.展开更多
Gastric necrosis is a rare condition because of the rich blood supply and the extensive submucosal vascular network of the stomach. "Gas-bloat" syndrome is a well known Nissen fundoplication postoperative co...Gastric necrosis is a rare condition because of the rich blood supply and the extensive submucosal vascular network of the stomach. "Gas-bloat" syndrome is a well known Nissen fundoplication postoperative complica-tion. It may cause severe gastric dilatation, but very rarely an ischemic compromise of the organ. Other factors, such as gastric outlet obstruction, may concur to cause an intraluminal pressure enough to blockade venous return and ultimately arterial blood supply and oxygen deliver, leading to ischaemia. We report a case of a 63-year-old women, who presented a total gastric necrosis following laparoscopic Nissen fundoplication and a pyloric phytobezoar which was the trigger event. No preexisting gastric motility disorders were present by the time of surgery, as demonstrated in the preop-erative barium swallow, thus a poor mastication(patient needed no dentures) of a high fiber meal(cabbage) may have been predisposing factors for the develop-ment of a bezoar in an otherwise healthy women at the onset of old age. A total gastrectomy with esophagojejunostomy was performed and patient was discharged home after a 7-d hospital stay with no immediate com-plications. We also discuss some technical aspects of the procedure that might be important to reduce the incidence of this complication.展开更多
We present the first case report known to us of a suspected cerebral arterial gas embolism(CAGE) leading to transient left-sided hemiparesis after a laparoscopic Nissen fundoplication. During the operation there was n...We present the first case report known to us of a suspected cerebral arterial gas embolism(CAGE) leading to transient left-sided hemiparesis after a laparoscopic Nissen fundoplication. During the operation there was no evidence of hemodynamic compromise and the endtidal carbon dioxide level and oxygen saturation had been within normal limits. Radiological studies and transesophageal echocardiography showed no abnormalities. We conclude that CAGE can occur during uncomplicated laparoscopic surgery even in the absence of demonstrable intracardiac shunts.展开更多
Background: With the increasing number of laparoscopic fundoplications, many more patients with a failed primary antireflux operation are being referred for complex redo procedures. The objective of this study was to ...Background: With the increasing number of laparoscopic fundoplications, many more patients with a failed primary antireflux operation are being referred for complex redo procedures. The objective of this study was to evaluate our results of redo antireflux surgery using the Belsey Mark IV (BMIV) Repair. Methods: A retrospective analysis of the patients who underwent BMIV repair following a failed fundoplication was performed. The primary endpoint was failure of the redo procedure and recurrent hiatal hernia. Secondary endpoints were assessment of the functional results of the redo fundoplication and quality of life with a Dysphagia Score, and Gastroesophageal Reflux Disease-Health-Related Quality of Life (GERD-HRQOL) questionnaire. Results: 206 patients underwent surgery for failed primary fundoplication. Most patients had one prior antireflux surgery 148/206 (71.8%). The most common primary failed fundoplication was the Nissen procedure (189/206, 91.7%). The median time from the prior operation to the redo operation was 34 months. Median follow-up was 25.6 months. The Dysphagia score decreased from 3.6 ± 0.5 preoperatively to 1.0 ± 0.4 postoperatively (p < 0.0001). At the time of follow-up, the Median GERD-HRQL score was 4 (range 0 - 9), classified as excellent, compared to a preoperative Median GERD-HRQL score of 43 (range 41 - 50) which was classified as poor. (p < 0.0001). There was no recurrence of the hiatal hernia. Conclusion: Complete takedown and reestablishment of the normal anatomy, recognition of a short esophagus, and proper placement of the wrap are essential components of a redo antireflux procedure. The BMIV repair as the choice of reopertaive procedure results in excellent symptom relief, significant improvement in quality of life, and is associated with excellent medium-term durability in terms of recurrence of the hiatal hernia.展开更多
文摘BACKGROUND Gastric fundoplication with endoscopic technique(GFET)is an innovative approach to managing gastroesophageal reflux disease(GERD).This minimally invasive procedure utilizes the GEN-2 Apollo endosuture device and Olympus H2T180 gastroscope to perform partial fundoplication by strategically placing Prolene 2-0 sutures at the 11,7,5,1,and 3 o’clock positions around the gastroesophageal junction.AIM To evaluate whether GFET enhances the lower esophageal sphincter function by creating comprehensive plication to improve the barrier against reflux.METHODS This single-center prospective study included patients undergoing GFET.Before beginning GFET,pH metrics and subsequent manometric measurements were obtained.An analysis of variance was performed to determine statistically significant differences between quality of life(QOL)and DeMeester scores at the time of the procedure and 6 and 12 months postoperatively.Pearson’sχ2 test was performed to identify statistically significant differences between categorical variables at the time of the procedure and 6 and 12 months postoperatively.RESULTS Eighteen participants were enrolled(11 males and 7 females;mean age,35 years).More than 70%had an initial Hill grade of IIb.One adverse event was recorded after the procedure.One patient underwent valve reinforcement at 12 months.The mean QOL score was markedly higher at the time of the procedure(39.9±4.0)compared to those at 6 and 12 months postoperatively(P<0.001).Scores at 12 months were slightly higher than those at 6 months.The highest mean QOL score was observed at the time of the procedure,followed by those at 6 and 12 months postoperatively(P<0.001).A similar trend was noted for the mean DeMeester scores(P<0.001).CONCLUSION GFET is a minimally invasive alternative to traditional surgical interventions and endoscopic techniques for managing GERD.Further research is warranted to validate its long-term efficacy and effectiveness over existing treatments.
文摘AIM:To compare the mid-term outcomes of laparoscopic calibrated Nissen-Rossetti fundoplication with Dor fundoplication performed after Heller myotomy for oesophageal achalasia.METHODS:Fifty-six patients(26 men,30 women;mean age 42.8±14.7 years)presenting for minimally invasive surgery for oesophageal achalasia,were enrolled.All patients underwent laparoscopic Heller myotomy followed by a 180°anterior partial fundoplication in 30 cases(group 1)and calibrated NissenRossetti fundoplication in 26(group 2).Intraoperative endoscopy and manometry were used to calibrate the myotomy and fundoplication.A 6-mo follow-up period with symptomatic evaluation and barium swallow was undertaken.One and two years after surgery,the patients underwent symptom questionnaires,endoscopy,oesophageal manometry and 24 h oesophago-gastric pH monitoring.RESULTS:At the 2-year follow-up,no significant difference in the median symptom score was observed between the 2 groups(P=0.66;Mann-WhitneyU-test).The median percentage time with oesophageal pH< 4 was significantly higher in the Dor group compared to the Nissen-Rossetti group(2;range 0.8-10 vs 0.35;range 0-2)(P<0.0001;Mann-WhitneyU-test).CONCLUSION:Laparoscopic Dor and calibrated Nissen-Rossetti fundoplication achieved similar results in the resolution of dysphagia.Nissen-Rossetti fundoplication seems to be more effective in suppressing oesophageal acid exposure.
文摘Increases in the prevalence of obesity and gastroesophageal reflux disease (GERD) have paralleled one another over the past decade, which suggests the possibility of a linkage between these two processes. In both instances, surgical therapy is recognized as the most effective treatment for severe, refractory disease. Current surgical therapies for severe obesity include (in descending frequency) Roux-en-Y gastric bypass, adjustable gastric banding, sleeve gastrectomy, and biliopancreatic diversion with duodenal switch, while fundoplication remains the mainstay for the treatment of severe GERD. In several large series, however, the outcomes and durability of fundoplication in the setting of severe obesity are not as good as those in patients who are not severely obese. As such, bariatric surgery has been suggested as a potential alternative treatment for these patients. This article reviews current concepts in the putative pathophysiological mechanisms by which obesity contributes to gastroesophageal reflux and their implications with regards to surgical therapy for GERD in the setting of severe obesity.
文摘AIM To compare the outcomes between laparoscopic Nissen fundoplication(LNF)and proton pump inhibitors(PPIs)therapy in patients with laryngopharyngeal reflux(LPR)and typeⅠhiatal hernia diagnosed by oropharyngeal p H-monitoring and symptom-scale assessment.METHODS From February 2014 to January 2015,70 patients who were diagnosed with LPR and type I hiatal hernia and referred for symptomatic assessment,oropharyngeal p H-monitoring,manometry,and gastrointestinal endoscopy were enrolled in this study.All of the patients met the inclusion criteria.All of the patients underwent LNF or PPIs administration,and completed a2-year follow-up.Patients’baseline characteristics and primary outcome measures,including comprehensive and single symptoms of LPR,PPIs independence,and satisfaction,and postoperative complications were assessed.The outcomes of LNF and PPIs therapy were analyzed and compared. RESULTS There were 31 patients in the LNF group and 39patients in the PPI group.Fifty-three patients(25 in the LNF group and 28 in the PPI group)completed reviews and follow-up.Oropharyngeal p H-monitoring parameters were all abnormal with high acid exposure,a large amount of reflux,and a high Ryan score,associated reflux symptom index(RSI)score.There was a significant improvement in the RSI and LPR symptom scores after the 2-year follow-up in both groups(P<0.05),as well as typical symptoms of gastroesophageal reflux disease.Improvement in the RSI(P<0.005)and symptom scores of cough(P=0.032),mucus(P=0.011),and throat clearing(P=0.022)was significantly superior in the LNF group to that in the PPI group.After LNF and PPIs therapy,13 and 53 patients achieved independence from PPIs therapy(LNF:44.0%vs PPI:7.14%,P<0.001)during follow-up,respectively.Patients in the LNF group were more satisfied with their quality of life than those in the PPI group(LNF:62.49±28.68 vs PPI:44.36±32.77,P=0.004).Body mass index was significantly lower in the LNF group than in the PPI group(LNF:22.2±3.1kg/m^2 vs PPI:25.1±2.9 kg/m^2,P=0.001).CONCLUSION Diagnosis of LPR should be assessed with oropharyngeal p H-monitoring,manometry,and the symptom-scale.LNF achieves better improvement than PPIs for LPR with type I hiatal hernia.
文摘Gastroesophageal reflux disease (GERD) is a condition that develops when the reflux of gastric contents into the esophagus leads to troublesome symptoms and/or complications. Heartburn is the cardinal symptom, often associated with regurgitation. In patients with endoscopy-negative heartburn refractory to proton pump inhibitor (PPI) therapy and when the diagnosis of GERD is in question, direct reflux testing by impedance-pH monitoring is warranted. Laparoscopic fundoplication is the standard surgical treatment for GERD. It is highly effective in curing GERD with a 80% success rate at 20-year follow-up. The Nissen fundoplication, consisting of a total (360°) wrap, is the most commonly performed antireflux operation. To reduce postoperative dysphagia and gas bloating, partial fundoplications are also used, including the posterior (Toupet) fundoplication, and the anterior (Dor) fundoplication. Currently, there is consensus to advise laparoscopic fundoplication in PPI-responsive GERD only for those patients who develop untoward side-effects or complications from PPI therapy. PPI resistance is the real challenge in GERD. There is consensus that carefully selected GERD patients refractory to PPI therapy are eligible for laparoscopic fundoplication, provided that objective evidence of reflux as the cause of ongoing symptoms has been obtained. For this purpose, impedance-pH monitoring is regarded as the diagnostic gold standard.
基金Supported by EVO-funding of the Central Hospital of Central Finland
文摘AIM: To investigate the quality of life following lapa-roscopic Nissen fundoplication by assessing short-term and long-term outcomes. METHODS: From 1992 to 2005, 249 patients under-went laparoscopic Nissen fundoplication. Short-term outcome data including symptom response, side effects of surgery, endoscopy, and patient's perception of over-all success were collected prospectively. Long-term out-comes were investigated retrospectively in patients witha median follow-up of 10 years by assessment of reflux symptoms, side effects of surgery, durability of antire-flux surgery, need for additional treatment, patient's perception of success, and quality of life. Antireflux sur-gery was considered a failure based on the following criteria: moderate to severe heartburn or regurgitation; moderate to severe dysphagia reported in combination with heartburn or regurgitation; regular proton pump inhibitor medication use; endoscopic evidence of erosive esophagitis Savary-Miller grade 1-4; pathological 24-h pH monitoring; or necessity to undergo an additional surgery. The main outcome measures were short-and long-term cure rates and quality of life, with patient sat-isfaction as a secondary outcome measure. RESULTS: Conversion from laparoscopy to open sur-gery was necessary in 2.4% of patients. Mortality was zero and the 30-d morbidity was 7.6% (95%CI: 4.7%-11.7%). The median postoperative hospital stay was 2 d [interquartile range (IQR) 2-3 d]. Two hundred and forty-seven patients were interviewed for short-term analysis following endoscopy. Gastro-esophageal reflux disease was cured in 98.4% (95%CI: 95.9%-99.6%) of patients three months after surgery. New-onset dysphagia was encountered postoperatively in 13 patients (6.7%); 95% reported that the outcome was better after antireflux surgery than with preopera-tive medical treatment. One hundred and thirty-nine patients with a median follow-up of 10.2 years (IQR 7.2-11.6 years) were available for a long-term evalu-ation. Cumulative long-term cure rates were 87.7% (81.0%-92.2%) at 5 years and 72.9% (64.0%-79.9%) at 10 years. Gastrointestinal symptom rating scores and RAND-36 quality of life scores of patients with treatment success were similar to those of the general population but significantly lower in those with failed antireflux surgery. Of the patients available for long-term follow-up, 83% rated their operation a success. CONCLUSION: For the long-term, our results indicate decreasing effectiveness of laparoscopic antirefluxsurgery, although most of the patients seem to have an overall quality of life similar to that of the general population.
文摘AIM: To demonstrate the optimal surgical procedure for gastroesophageal reflux disease. METHODS: The electronic databases of Medline, Elsevier, Springerlink and Embase over the last 16 years were searched. All clinical trials involved in the outcomes of laparoscopic Nissen fundoplication (LNF) and laparoscopic Toupet fundoplication (LTF) were identified. The data of assessment in benefits and adverse results of LNF and LTF were extracted and compared using metaanalysis. RESULTS: We ultimately identified a total of 32 references reporting nine randomized controlled trials, eight prospective cohort trials and 15 retrospective trials. These studies reported a total of 6236 patients, of whom 4252 (68.18%) underwent LNF and 1984 (31.82%) underwent LTF. There were no differences between LNF and LTF in patients' satisfaction, perioperative complications, postoperative heartburn, refluxrecurrence and reoperation. Both LNF and LTF enhanced the function of lower esophageal sphincter and improved esophagitis. The postoperative dysphagia, gasbloating syndrome, inability to belch and the need for dilatation after LNF were more common than after LTF. Subgroup analyses showed that dysphagia after LNF and LTF was similar in patients with normal esophageal peristalsis (EP), but occurred more frequently in patients with weak EP after LNF than after LTF. Furthermore, patients with normal EP after LNF still had a higher risk of developing dysphagia than did patients with abnormal EP after LTF.CONCLUSION: Compared with LNF, LTF offers equivalent symptom relief and reduces adverse results.
文摘Gastro-esophageal reflux disease(GERD)is a verycommon disorder that results primarily from the loss of an effective antireflux barrier,which forms a mechanical obstacle to the retrograde movement of gastric content.GERD can be currently treated by medical therapy,surgical or endoscopic transoral intervention.Medical therapy is the most common approach,though concerns have been increasingly raised in recent years about the potential side effects of continuous longterm medication,drug intolerance or unresponsiveness,and the need for high dosages for long periods to treat symptoms or prevent recurrences.Surgery too may in some cases have consequences such as longlasting dysphagia,flatulence,inability to belch or vomit,diarrhea,or functional dyspepsia related to delayed gastric emptying.In the last few years,transoral incisionless fundoplication(TIF)has proved an effective and promising therapeutic option as an alternative to medical and surgical therapy.This review describes the steps of the TIF technique,using the Esophy X®device and the MUSETM system.Complications and their management are described in detail,and the recent literature regarding the outcomes is reviewed.TIF reconfigures the tissue to obtain a full-thickness gastroesophageal valve from inside the stomach,by serosato-serosa plications which include the muscle layers.To date the procedure has achieved lasting improvement of GERD symptoms(up to six years),cessation or reduction of proton pump inhibitor medication in about 75%of patients,and improvement of functional findings,measured by either p H or impedance monitoring.
文摘Magnesium deficiency can cause a variety of symptoms,including potentially life-threatening complications such as seizures,cardiac arrhythmias and secondary electrolyte disturbances.Hypomagnesemia can be a serious adverse effect to proton pump inhibitor(PPI)therapy,which is worrying due to the widespread use of PPIs.Current evidence suggest that the mechanism of PPI induced hypomagnesemia is impaired intestinal magnesium absorption.In this report,we present the case of a long-term PPI user with persistent hypomagnesemia with severe symptoms at presentation.He was unable to stop PPI treatment because of severe reflux symptoms,and was dependent on weekly intravenous magnesium infusions,until his magnesium levels finally normalized without the need for supplementation after a successful laparoscopic fundoplication.
文摘BACKGROUND Fundoplication, was first introduced as a surgical treatment method of gastroesophageal reflux disease. Consequently, several modifications of this method have been described, whereas laparoscopic fundoplication was recently introduced. Although single incision(SI) fundoplication was considered as an alternative to the conventional laparoscopic approach, several studies reported an increased operation duration, and high rates of multiport conversion and incisional hernia.AIM To provide a current overview of the technical variations and the postoperative outcomes of patients submitted to SI fundoplication.METHODS The present systematic review of the literature was designed and conducted on the basis of the PRISMA guidelines. A systematic screening of the electronic scholar databases(Medline, Scopus and Web of Science) was performed.RESULTS Literature search resulted in the identification of 19 studies. Overall, 266, 137 and110 SI Nissen, Dor and Toupet fundoplications were reported, respectively. In the majority of the trials, standard laparoscopic instruments were used. The left liver lobe was displayed through the use of forceps, graspers, retractors, drains or even glue. Both intra-corporeal and extracorporeal suturing was described. Mean operative time was 136.3 min. Overall complication rate was 5.2% and the rate of incisional hernia was 0.9%. No mortality was reported.CONCLUSIONDue to the methodological heterogeneity and the lack of high quality studies comparing multi to single access techniques and the several variations, we conclude that further well designed studies are necessary, in order to evaluate the role of SI fundoplication.
文摘Gastro-oesphageal reflux disease is an increasing health burden.The mainstay of treatment has conventionally been medical therapy but since the introduction of laparoscopic surgery laparoscopic anti-reflux surgery has been increasingly used for intractable symptoms or in patients unwilling to take long term medication.The Nissen 360 degree wrap has traditionally been considered the gold standard operation but can be associated with significant complications.These complications include“gas bloat”and dysphagia and can occur relatively frequently.Various modifications have been described to the original operation and some of these have been described.In addition alternative wraps have been described which seem to have a reduced incidence of complications associated with their use.This editorial discusses the various types of wrap that can be performed and the minimum requirements of the surgical technique.The evidence from a recent meta-analysis of the randomised data has suggested that an anterior wrap is associated with a lower rate of complications and gives just as good control of reflux symptoms.The advantages and disadvantages of an anterior wrap are discussed.The lack of long term follow up data concerns some practitioners and at the moment the choice of wrap carried out still rests with the individual surgeon.
基金Supported by National Natural Science Foundation of China,Grant 81172373
文摘AIM:To compare the outcome of acid reflux prevention by Dor fundoplication after laparoscopic Heller myotomy(LHM)for achalasia.METHODS:Electronic database PubMed,Ovid(Evidence-Based Medicine Reviews,EmBase and Ovid MEDLINE)and Cochrane Library were searched between January 1995 and September 2012.Bibliographic citation management software(EndNote X3)was used for extracted literature management.Quality assessment of random controlled studies(RCTs)and non-RCTs was performed according to the Cochrane Handbook for Systematic Reviews of Interventions 5.1.0and a modification of the Newcastle-Ottawa Scale,respectively.The data were analyzed using Review Manager(Version 5.1),and sensitivity analysis was performed by sequentially omitting each study.RESULTS:Finally,6 studies,including a total of 523achalasia patients,compared Dor fundoplication with other types of fundoplication after LHM(Dor-other group),and 8 studies,including a total of 528 achalasia patients,compared Dor fundoplication with no fundoplication after LHM(Dor-no group).Dor fundoplication was associated with a significantly higher recurrence rate of clinical regurgitation and pathological acid reflux compared with the other fundoplication group(OR=7.16,95%CI:1.25-40.93,P=0.03,and OR=3.79,95%CI:1.23-11.72,P=0.02,respectively).In addition,there were no significant differences between Dor fundoplication and no fundoplication in all subjects.Other outcomes,including complications,dysphagia,postoperative physiologic testing,and operation-related data displayed no significant differences in the two comparison groups.CONCLUSION:Dor fundoplication is not the optimum procedure after LHM for achalasia.We suggest more attention should be paid on quality of life among different fundoplications.
基金Supported by Research and Events Support Fund at Hospital de Clínicas de Porto Alegre
文摘BACKGROUND Esophagogastric junction outflow obstruction(EGJOO) is a rare syndrome,characterized by an elevation of the integrated relaxation pressure of the lower esophageal sphincter, not accompanied by alterations in esophageal motility that may lead to the criteria for achalasia. We were unable to find any prior report of the combination of Heller myotomy with anterior partial fundoplication(Dor) as the treatment for EGJOO. We herein report a case of EGJOO treated with laparoscopic Heller myotomy combined with Dor fundoplication.CASE SUMMARY A 26-year-old man presented with a 3-year history of solid dysphagia and a 30-kg weight loss. He was treated with oral nifedipine, isosorbide, and omeprazole,without resolution of symptoms. An upper gastrointestinal series(barium swallow) revealed a "bird's beak" sign. Esophagogastroduodenoscopy was positive for Los Angeles grade A peptic esophagitis. High-resolution esophageal manometry was compatible with EGJOO. Esophageal pH monitoring showed pathological acid reflux both in orthostatic and decubitus position. An 8-cm laparoscopic Heller myotomy combined with an anterior 220° Dor fundoplication was performed. Solid diet was introduced on postoperative day 2, and the patient was discharged home the same day. At 17-mo follow-up, he reported no symptoms. Barium swallow was compatible with complete radiologic resolution.Both esophageal manometry and upper endoscopy showed normal findings 9 mo after the operation.CONCLUSION Surgical treatment with Heller myotomy and Dor fundoplication is a potential treatment option for EGJOO refractory to medical treatment.
文摘BACKGROUND Achalasia is a rare benign esophageal motor disorder characterized by incomplete relaxation of the lower esophageal sphincter(LES). The treatment of achalasia is not curative, but rather is aimed at reducing LES pressure. In patients who have failed noninvasive therapy, surgery should be considered. Myotomy with partial fundoplication has been considered the first-line treatment for non-advanced achalasia. Recently, peroral endoscopic myotomy(POEM), a technique that employs the principles of submucosal endoscopy to perform the equivalent of a surgical myotomy,has emerged as a promising minimally invasive technique for the management of this condition.AIM To compare POEM and laparoscopic myotomy and partial fundoplication(LM-PF) regarding their efficacy and outcomes for the treatment of achalasia.METHODS Forty treatment-naive adult patients who had been diagnosed with achalasia based on clinical and manometric criteria(dysphagia score ≥ II and Eckardt score > 3) were randomized to undergo either LM-PF or POEM. The outcome measures were anesthesia time, procedure time, symptom improvement, reflux esophagitis(as determined with the Gastroesophageal Reflux Disease Questionnaire), barium column height at 1 and 5 min(on a barium esophagogram), pressure at the LES, the occurrence of adverse events(AEs), length of stay(LOS), and quality of life(QoL).RESULTS There were no statistically significant differences between the LM-PF and POEM groups regarding symptom improvement at 1, 6, and 12 mo of follow-up(P = 0.192, P = 0.242, and P = 0.242, respectively). However, the rates of reflux esophagitis at 1, 6, and 12 mo of follow-up were significantly higher in the POEM group(P = 0.014, P < 0.001, and P = 0.002, respectively). There were also no statistical differences regarding the manometry values, the occurrence of AEs, or LOS. Anesthesia time and procedure time were significantly shorter in the POEM group than in the LM-PF group(185.00 ± 56.89 and 95.70 ± 30.47 min vs 296.75 ± 56.13 and 218.75 ± 50.88 min,respectively;P = 0.001 for both). In the POEM group, there were improvements in all domains of the QoL questionnaire, whereas there were improvements in only three domains in the LM-PF group.CONCLUSION POEM and LM-PF appear to be equally effective in controlling the symptoms of achalasia,shortening LOS, and minimizing AEs. Nevertheless, POEM has the advantage of improving all domains of QoL, and shortening anesthesia and procedure times but with a significantly higher rate of gastroesophageal reflux.
文摘Purpose: The purpose of the study was to review a single surgeon, seven-year experience, using the Da Vinci Telerobotic system performing 124 foregut operations. Methods: Data review from 2002-2009 including 71 Nissen fundoplications, 26 esophagomyotomies, and 27 hiatal hernia repairs was performed. Parameters collected included gender, age, body mass index (BMI), estimated blood loss (EBL), port set up time (PST), robot operating time (ROT), total case time (TCT), length of stay (LOS), complications, conversions, and resident involvement. Statistical analysis was con-ducted. Results: 124 foregut operations: 45 males, 79 females, mean age of 54.8 ± 16.7 (18 - 85) years, mean TCT 174.4 ± 45.0 (102 - 321) min. Nissen fundoplication: mean BMI of 30.8 ± 3.9 (22.4 - 46.8) kg/m2, EBL 30.2 ± 21.8 (5 - 100) ml, PST 32.3 ± 9 (14 - 63) min, ROT 111.4 ± 37.3 (51 - 229) min, TCT 175.0 ± 46.4 (102 - 321) min, median LOS 1 (0 - 9) day, complication rate 7.0% (5/71), conversion rate 5.6%, resident involvement 69.0% (49/71). Esophagomyotomy: mean BMI of 26.5 ± 6.1 (15.4 - 36.6) kg/m2, EBL 39.1 ± 41.7 (10 - 200) ml, PST 28.0 ± 8.6 (16 - 47) min, ROT 122.9 ± 45 (31 - 217) min, and TCT 178.0 ± 40.5 (105 - 262) min, median LOS 1 (0 - 6) day, complication rate 15.4% (4/26), conversion rate 0%, resident involvement 69.2% (18/26). Hiatal hernia repair: mean BMI of 28.4 ± 4.2 (21.9 - 36.8) kg/m2, EBL 38.4 ± 32.7 (10 - 150) ml, PST 28.8 ± 8.0 (17 - 52) min, ROT 109.0 ± 44.5 (49 - 250) min, and TCT 169.2 ± 46.5 (102 - 299) min, median LOS 1 (1 - 14) day, complication rate 11.1% (3/27), conversion rate 3.7%, resident involvement 66.7% (18/27). Conclusion: Robotic-assisted foregut surgery is safe and effective. This series compares favorably with other robotic studies in length of hospital stay, total case time, and complication and conver-sion rates. Foregut surgery is an excellent robotic training ground for residents.
文摘Gastric necrosis is a rare condition because of the rich blood supply and the extensive submucosal vascular network of the stomach. "Gas-bloat" syndrome is a well known Nissen fundoplication postoperative complica-tion. It may cause severe gastric dilatation, but very rarely an ischemic compromise of the organ. Other factors, such as gastric outlet obstruction, may concur to cause an intraluminal pressure enough to blockade venous return and ultimately arterial blood supply and oxygen deliver, leading to ischaemia. We report a case of a 63-year-old women, who presented a total gastric necrosis following laparoscopic Nissen fundoplication and a pyloric phytobezoar which was the trigger event. No preexisting gastric motility disorders were present by the time of surgery, as demonstrated in the preop-erative barium swallow, thus a poor mastication(patient needed no dentures) of a high fiber meal(cabbage) may have been predisposing factors for the develop-ment of a bezoar in an otherwise healthy women at the onset of old age. A total gastrectomy with esophagojejunostomy was performed and patient was discharged home after a 7-d hospital stay with no immediate com-plications. We also discuss some technical aspects of the procedure that might be important to reduce the incidence of this complication.
文摘We present the first case report known to us of a suspected cerebral arterial gas embolism(CAGE) leading to transient left-sided hemiparesis after a laparoscopic Nissen fundoplication. During the operation there was no evidence of hemodynamic compromise and the endtidal carbon dioxide level and oxygen saturation had been within normal limits. Radiological studies and transesophageal echocardiography showed no abnormalities. We conclude that CAGE can occur during uncomplicated laparoscopic surgery even in the absence of demonstrable intracardiac shunts.
文摘Background: With the increasing number of laparoscopic fundoplications, many more patients with a failed primary antireflux operation are being referred for complex redo procedures. The objective of this study was to evaluate our results of redo antireflux surgery using the Belsey Mark IV (BMIV) Repair. Methods: A retrospective analysis of the patients who underwent BMIV repair following a failed fundoplication was performed. The primary endpoint was failure of the redo procedure and recurrent hiatal hernia. Secondary endpoints were assessment of the functional results of the redo fundoplication and quality of life with a Dysphagia Score, and Gastroesophageal Reflux Disease-Health-Related Quality of Life (GERD-HRQOL) questionnaire. Results: 206 patients underwent surgery for failed primary fundoplication. Most patients had one prior antireflux surgery 148/206 (71.8%). The most common primary failed fundoplication was the Nissen procedure (189/206, 91.7%). The median time from the prior operation to the redo operation was 34 months. Median follow-up was 25.6 months. The Dysphagia score decreased from 3.6 ± 0.5 preoperatively to 1.0 ± 0.4 postoperatively (p < 0.0001). At the time of follow-up, the Median GERD-HRQL score was 4 (range 0 - 9), classified as excellent, compared to a preoperative Median GERD-HRQL score of 43 (range 41 - 50) which was classified as poor. (p < 0.0001). There was no recurrence of the hiatal hernia. Conclusion: Complete takedown and reestablishment of the normal anatomy, recognition of a short esophagus, and proper placement of the wrap are essential components of a redo antireflux procedure. The BMIV repair as the choice of reopertaive procedure results in excellent symptom relief, significant improvement in quality of life, and is associated with excellent medium-term durability in terms of recurrence of the hiatal hernia.
