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H G Gooszen

Publications and source records attributed to H G Gooszen.

At least 55 records · Page 3Linked to original sources
PubMed2001

The ileo neorectal anastomosis: an experimental study on development of the surgical technique and theoretical background.

OBJECTIVE: The keystones of surgical treatment of ulcerative colitis and familial adenomatous polyposis are resection of the diseased colon with either an ileostomy or restoration of oro-anal continuity with an ileo-anal pouch. The ileo pouch anal anastomosis however, has a 15-35% pouch-related complication rate, 10% failure rate and is accompanied by an unpredictable functional outcome. In order to reduce these unfavourable rates and to improve functional results an alternative surgical technique, the ileo neorectal anastomosis (INRA), was developed experimentally. MATERIALS AND METHODS: In an experimental study 12 Yorkshire-Dutch landpigs had a subtotal colectomy and rectal mucosectomy. Subsequently a vascularized ileal mucosa sling was created and transposed on to the denuded rectal muscular cuff in eight. In another four animals a non-vascularized mucosa sling was transposed. The covering ileostomy was closed after 3 weeks. Repeated endoscopies, histological examinations of mucosal biopsies and rectal compliance measurements were carried out to evaluate the functional result of the neorectum. RESULTS: The surgical procedure of the INRA was technically successful in this animal study. Repeated endoscopy and histology showed complete ileal mucosa ingrowth in the neorectum without severe fibrosis in the group of animals with a vascularized sling. At follow up after 1 year no colonic metaplasia had occurred. Measurements of the neorectal reservoirs in the group of animals with a vascularized INRA procedure showed a median 'maximum tolerated volume' of 338 ml (range 300-410 ml). CONCLUSION: The INRA is technically feasible and reproducible. The histologically proven survival of the vascularized ileal mucosa and development of a compliant neorectal reservoir make the INRA an interesting alternative restorative procedure. Avoidance of the pouch-related complications of the ileo pouch anal anastomosis by this procedure might herald a new era of restorative surgery.

Journal Article↗
PubMed2001

Operative treatment of acute complications of diverticular disease: primary or secondary anastomosis after sigmoid resection.

OBJECTIVE: To assess the comparative effects of two surgical regimens on the outcome of acute complicated diverticular disease. DESIGN: Retrospective study. SETTING: Teaching hospital, The Netherlands. SUBJECTS: 60 patients who presented with acute complicated diverticular disease. INTERVENTIONS: 28 patient were treated by sigmoid resection and a Hartmann operation, and 32 by resection with primary anastomosis and defunctioning stoma. MAIN OUTCOME MEASURES: Morbidity and mortality. RESULTS: The severity of peritonitis and the amount of faecal contamination were similar in the 2 groups. 12 patients died (7 in the Hartmann group and 5 in the primary anastomosis group). There were 3 radiological leaks with no clinical implications in the primary anastomosis group. 6 patients in the Hartmann group and 5 in the primary anastomosis group required reoperations for intra-abdominal abscess or infection. 7 and 3 patients, respectively, developed dysfunction of their stomas, and 9/21 and 3/27, respectively, required a permanent stoma (p = 0.02, 95% confidence interval of difference 0.07 to 0.56). 3 patients in the Hartmann group developed anastomotic leaks after closure of their stomas, 1 of whom required reoperation but died. No patient developed an anastomotic leak after closure of the stoma in the primary anastomosis group. CONCLUSION: Both regimens are accepted treatments for patients with acute complicated diverticular disease, but because of the higher morbidity after the Hartmann procedure we prefer primary anastomosis with covering stoma.

Aged↗
PubMed2001

Impact of delayed gastric emptying on the outcome of antireflux surgery.

OBJECTIVE: To study the effect of Nissen fundoplication on the pattern of gastric emptying and intragastric distribution of symptoms in patients with normal and delayed gastric emptying before surgery, especially in those with delayed emptying before surgery. SUMMARY BACKGROUND DATA: Gastroesophageal reflux disease is associated with delayed gastric emptying and dyspeptic symptoms in approximately 40% of the patients. After Nissen fundoplication, dyspeptic symptoms are also not uncommon. METHODS: Thirty-six patients (26 men, 10 women, mean age 43.1) were studied before and 3 months after Nissen fundoplication. Gastric emptying (dual-isotope, expressed in lag phase, emptying rate, T50, and intragastric distribution) was not included in the decision for surgery. Reflux-related and dyspeptic symptoms were scored before and at 3, 6, and 12 months after surgery. RESULTS: Twenty-six patients had normal and 10 had delayed gastric emptying before surgery. Nissen fundoplication on average enhanced gastric emptying for solids in both subgroups by a combination of a decrease in mean lag phase, emptying rate, and T50. The preoperative difference in intragastric distribution between patients with and without delayed gastric emptying was abolished by fundoplication. Patients with normal gastric emptying before surgery showed an increase in early postprandial satiety; in those with delayed emptying, this was not observed. A correlation was found between preoperative T50 for liquid gastric emptying and postoperative nausea at 3 months in patients with normal gastric emptying. In patients with delayed emptying, preoperative correlations between lag phase for liquids and nausea respectively early satiety were significant, as well as for T50 for liquids and vomiting. CONCLUSIONS: Nissen fundoplication equalizes the preoperative difference in intragastric distribution and accelerates gastric emptying without an effect on symptoms in patients with preexisting delayed gastric emptying, but with an increase in early satiety in patients with normal gastric emptying. Delayed gastric emptying is not a contraindication for antireflux surgery.

Adult↗
PubMed2001

Functional results and visceral perception after ileo neo-rectal anastomosis in patients: a pilot study.

INTRODUCTION: To reduce pouch related complications after restorative proctocolectomy, an alternative procedure was developed, the ileo neo-rectal anastomosis (INRA). This technique consists of rectal mucosa replacement by ileal mucosa and straight ileorectal anastomosis. Our study provides a detailed description of the functional results after INRA. PATIENTS AND METHODS: Eleven patients underwent an INRA procedure with a temporary ileostomy. Anorectal function tests were performed two months prior to and six and 12 months after closure of the ileostomy and comprised: anal manometry, ultrasound examination, rectal balloon distension, and transmucosal electrical nerve stimulation (TENS). Function was subsequently related to the histopathology of rectal biopsy samples. RESULTS: Median stool frequency decreased from 15/24 hours (10-25) to 6/24 hours (4-11) at one year. All patients reported full continence. Anal sensibility, and resting and squeeze pressures did not change after INRA. Rectal compliance decreased (2.1 (0.7-2.8) v 1.5 (0.4-2.2) and 1.4 (0.8-3.7) ml/mm Hg (p=0.03)) but the maximum tolerated volume increased (70 (50-118) v 96 (39-176) (NS) and 122 (56-185) ml (p=0.03)). Decreasing rectal sensitivity was found: the maximum tolerated pressure increased (14 (8-24) v 22 (8-34) (NS) and 26 (14-40) (p=0.02)) and the rectal threshold for TENS displayed a similar tendency. All patients displayed a low grade chronic inflammatory infiltrate in neorectal biopsy samples before closure of the ileostomy, with no change during follow up. CONCLUSIONS: The technique of INRA provides a safe alternative for restorative surgery. Stool frequency after INRA improves with time and seems to be related to decreasing sensitivity and not to histopathological changes in the neorectum. Furthermore, after the INRA procedure, all patients reported full continence.

Adenomatous Polyposis Coli↗
PubMed2000

[Treatment of severely delayed gastric emptying].

For the drug treatment of gastroparesis, domperidone, metoclopramide and cisapride may be prescribed as prokinetics. Positive effects on the rate of emptying of the stomach, dyspeptic symptoms and quality of life are best documented for cisapride. Simultaneous use of cisapride with substances that inhibit the metabolism of cisapride or that may lengthen the QT interval, is contraindicated because of the risk of arrhythmias. Erythromycin is a powerful prokinetic, but because of its antibiotic effects it is usually prescribed only for a brief period. For patients who in spite of drug treatment have persistent unacceptable symptoms and keep losing weight, invasive treatment should be considered. The first step is then insertion of a jejunal tube, followed, if necessary, by antrectomy with Billroth-I reconstruction. The next step is subtotal gastrectomy with Roux-Y reconstruction, this may result in abatement of the symptoms, which, however, rarely disappear altogether.

Cisapride↗
PubMed2000

[Surgical treatment of distal esophageal perforation not due to a malignancy: results in 11 patients, University Medical Center Utrecht, 1994-1998].

OBJECTIVE: To describe the surgical treatment of distal oesophageal perforation and its results. DESIGN: Retrospective. METHODS: From patient records data were collected on 11 patients, 6 men and 5 women (median age: 54 years; range: 21-76) who underwent surgery for distal oesophageal perforation in Utrecht University Medical Centre. There were 7 iatrogenic perforations, 3 after vomiting and 1 perforation was based on an oesophageal stricture. Four patients had a delay < 24 h and 7 > 24 h (range: 6-27 days). Nine presented with sepsis, mediastinitis and empyema. Seven underwent primary repair: 5 in combination with a hemifundoplication, 2 with omentomplasty. In the group of other surgical treatment, 2 had drainage with extension and diversion, 1 had an oesophageal resection and gastric conduit and 1 had only surgical drainage. RESULTS: Primary repair resulted in 7/7 survival. The median period of hospital stay was 24 days (range: 10-62), and the median stay on the ICU was 14 days (range: 0-21). Four patients underwent reoperation. Four patients with primary repair presented no functional complaints, 1 had reflux complaints and 2 dysphagia. Two out of four within other surgery survived the perforation.

Adult↗
PubMed2000

Laparoscopic or conventional Nissen fundoplication for gastro-oesophageal reflux disease: randomised clinical trial. The Netherlands Antireflux Surgery Study Group.

BACKGROUND: For the surgical treatment of gastrooesophageal reflux disease (GORD), laparoscopic Nissen fundoplication has largely replaced the open procedure. Retrospective and prospective non-randomised studies have shown similar results after laparoscopic Nissen fundoplication compared with the open procedure. METHODS: In a multicentre randomised trial candidates for surgical treatment of GORD were randomly assigned to either laparoscopic or open 360 degrees Nissen fundoplication. Primary endpoints were dysphagia, recurrent GORD, and intrathoracic hernia. Secondary endpoints were effectiveness and quality of life. This planned interim analysis focuses on endpoints and complications and in-hospital costs. FINDINGS: At the time of interim analysis, 11 patients in the laparoscopic group and one in the conventional group had reached a primary endpoint (p=0.01; relative risk=8.8, 95% CI 1.2-66.3). This difference was caused mainly by whether or not patients had dysphagia (seven patients in the laparoscopic group and none in the conventional group, p=0.016). INTERPRETATION: Although laparoscopic Nissen fundoplication was as effective as the open procedure in controlling reflux, the significantly higher risk of reaching a primary endpoint in the laparoscopic group led us to stop the study.

Adult↗
PubMed2000

Quality of life with a temporary stoma: ileostomy vs. colostomy.

PURPOSE: The hypothesis is that the impact of a temporary stoma on a patient's daily life is determined by complications and related stoma care problems. METHOD: A prospective clinical trial was performed, studying complications and social well-being of 37 patients with loop ileostomy and 39 patients with a loop colostomy (randomly assigned comparison). Patients were categorized according to degree of social restriction. The association between the degree of social restriction and the presence of stoma care problems and complications was assessed. Follow-up was scheduled every three months until the stoma was closed (94 percent). RESULTS: There is no relation between stoma type (ileostomy or colostomy) and degree of social restriction (chi-squared test, P = 0.42). The more stoma care problems or complications seen, the higher the degree of social restriction: significantly more stoma care problems were seen in the completely isolated group of patients when compared with the patients who were less socially restricted (Spearman correlation coefficient 1 = 0.35, P = 0.003). Especially stoma leakage, peristomal skin irritation, dietary prescriptions, retraction, and prolapse of the stoma have significant impact on the patient's daily life. CONCLUSION: Stoma surgery has a great influence on a patient's daily life. There is a clear relation between the number of stoma care problems and the degree of social restriction. Follow-up of stoma patients under close surveillance of stoma care nurse to minimize stoma care problems and a careful surgical technique are advocated for good stoma care.

Activities of Daily Living↗
PubMed2000

Surgical treatment for recurrent gastro-oesophageal reflux disease after failed antireflux surgery.

BACKGROUND: Recurrent or persistent symptoms occur in 10-15 per cent of patients after antireflux surgery. Failure of surgery is not uniform in its presentation. The cause of failure is not easily detected and even harder to treat. Different approaches have been proposed and few reports are available on the objective and subjective outcome of reoperation. METHODS: This study focuses on 30 patients (16 men and 14 women; age range 20-69 years) with recurrent symptomatic gastro-oesophageal reflux disease (GORD) resistant to medical treatment. In all patients reoperation was by the Belsey Mark IV antireflux operation. A clinical history, endoscopy and oesophageal manometry were obtained in all patients, and 24-h pH monitoring was performed in 27 of 30 before and in most patients after the Belsey procedure. RESULTS: Symptomatic improvement was reported in 24 of 30 patients. Oesophagitis (present before operation in 19 patients) was cured or remained absent in 24 of 30 patients, stabilized in one, improved in four and deteriorated in one. Relief of symptoms combined with absence of oesophagitis was obtained in 21 of 30 patients, with concomitant normalization of the 24-h pH profile in 11 of 22 patients. The median basal lower oesophageal sphincter (LOS) pressure increased significantly from 6. 9 to 9.0 mmHg (P < 0.01). Redo surgery had no effect on oesophageal body motility. CONCLUSION: Reoperation performed for documented recurrent GORD had a good and lasting effect on symptoms, on oesophagitis (both in 24 of 30 patients) and on the combination of both (21 of 30). In these patients reoperation increased basal LOS pressure and decreased reflux time. Overall, the results approximate to those of primary operation.

Adolescent↗
PubMed2000

Obstructive jaundice, bacterial translocation and interdigestive small-bowel motility in rats.

BACKGROUND/AIMS: Translocation of gut bacteria occurs in obstructive jaundice, the underlying mechanisms are unclear. We designed this experimental study to investigate the association between interdigestive motility and the pathogenesis of bacterial translocation during biliary obstruction. METHODS: Rats were fitted with jejunal myoelectrodes for the measurement of the interdigestive migrating motor complex (MMC) and with two cannulas in the proximal common bile duct (CBD) for exteriorization of biliary flow. This allowed measurement of MMCs under control conditions with an intact enterohepatic circulation and during 3 days of CBD obstruction without surgical intervention. Mesenteric lymph nodes, liver, spleen and segments of the duodenum, the jejunum and the caecum were removed for microbial culturing. RESULTS: The MMC cycle length increased from 17.3 min before CBD obstruction to 31.9, 34.1, and 25.3 min on days 1, 2 and 3, respectively, after CBD obstruction (p < 0.05 for all days). Bacterial levels in the jejunum were significantly higher in CBD-obstructed rats than in control rats. The translocation incidence was significantly higher in rats with CBD obstruction (6/8) than in control rats (1/8). The bacterial levels in the jejunum correlated significantly with the MMC cycle length (r = 0.60, p <0.05). CONCLUSION: Experimental biliary obstruction is associated with disturbance of MMCs, small-bowel bacterial overgrowth and increased bacterial translocation.

Animals↗
PubMed1999

[Analysis and treatment of pancreatic cystic diseases].

Owing to the spectacular progress in imaging techniques, cystic lesions of the pancreas are detected more often than previously, and this leads to therapeutic dilemmas. Of the cystic lesions of the pancreas, 80% are found to be pseudocysts and 10-15%, neoplastic cysts. The definition of a pseudocyst is: 'an accumulation of pancreatic juice surrounded by a wall of connective tissue or granulation tissue, developed as the result of acute pancreatitis, pancreatic injury or chronic pancreatitis'. In cases of asymptomatic pseudocyst, an expectative policy suffices; growth and symptomatic pseudocysts justify intervention. In addition to surgical internal drainage (cystojejunostomy) there are new therapeutic techniques: external drainage guided by ultrasonography or CT, and internal drainage guided by endoscopy. Endoscopic drainage is the treatment of choice, but it requires experienced hands. The cystic tumours are subdivided into two groups: serous and mucinous cystadenomas. The group of mucinous tumours is subdivided into mucinous cystadenomas and intraductal papillary mucinous tumours. The mucinous or macrocystic adenoma is potentially malignant and should be treated as a malignancy.

Adenoma↗
PubMed1999

[Surgical treatment of ulcerative colitis and familial adenomatous polyposis: recent developments].

Reconstructive surgery for ulcerative colitis and familial adenomatous polyposis nowadays usually takes the form of an ileoanal pouch, involving making a reservoir of the terminal portion of the ileum which subsequently is anastomosed to the anal canal. This method results in definite cure in many cases, but is associated with a morbidity of 15-30% and fails in 10%. A new surgical treatment includes complete removal of the affected large bowel mucosa, guaranteeing oroanal intestinal continuity, limiting complications and providing good function of the reservoir or of the new rectum. In creation of an ileoneorectal anastomosis, complete removal of the affected mucous membrane is followed by preparing a functional 'neorectum' by means of pedicle grafting of ileal mucous membrane on to the uncovered muscular wall of the rectum. This operation gave good results in a small-scale clinical trial.

Adenomatous Polyposis Coli↗
PubMed1999

Abdominal rectovaginopexy: modified technique to treat constipation.

PURPOSE: We noted the combination of obstructed defecation or constipation and fecal incontinence, the poor results of abdominal rectopexy for constipation, and the well-known risk of postoperative induction of constipation after rectopexy. We developed a new operation to treat patients with constipation or fecal incontinence (with a concomitant rectocele, internal rectal intussusception, enterocele at dynamic defecography, or all three) or both. This new rectopexy technique avoided dorsolateral mobilization of the rectum and did not endanger the hypogastric nerves and pelvic autonomic nerves. A better effect on constipation compared with rectopexies with dorsolateral mobilization was expected. METHODS: The results of this new operation, which was called rectovaginopexy, were studied prospectively in a series of 27 patients. Four-year results were obtained. Preoperative and postoperative questionnaires, dynamic defecograms, and anorectal physiology studies were analyzed. RESULTS: Before the operation 17 patients were constipated, compared with 4 patients one year after rectovaginopexy (76 percent improvement; P = 0.0015) and 5 patients four years after rectovaginopexy (71 percent improvement: P = 0.005), respectively. At one year, fecal incontinence decreased significantly: 15 of 17 patients improved and 9 patients became fully continent (P = 0.0007). Four years after rectovaginopexy the effect on fecal incontinence was no longer significant (P = 0.09). Rectovaginopexy restored anatomy: all (9) enteroceles, all but 1 (17) internal rectal intussusception, and 12 of 20 rectoceles dissolved, and the majority were reduced in size. Rectal sensation for distention was unchanged, and rectal electrosensitivity improved (P = 0.04). CONCLUSIONS: Rectovaginopexy provides significant one-year improvement of both constipation and fecal incontinence. The positive effect on constipation did not deteriorate with time, in contrast to the effect on fecal incontinence.

Adult↗
PubMed1999

The relative contribution of insulin secretory capacity, insulin action, and incretins to metabolic control after islet transplantation in dogs.

Adequate metabolic control is central to the concept of islet transplantation, but has received limited attention. We studied metabolic control in 8 dogs at 6-9 months after intrasplenic autografting of approximately 25% of the normal mass islets--as compared to 30 controls. A similar posttransplant reduction to approximately 25% of the insulin secretory capacity as assessed by intravenous arginine stimulation during 35 mM glucose clamps, mirrored the reduction of the islet mass. Postprandially, in contrast, the insulin response had increased to 140% in the islet recipients--with a concomitant rise of glycemia to approximately 8.5 mM. Posttransplant, the insulin secretory capacity correlated both with the index of insulin action (which averaged 55% of the normal value) as assessed by euglycemic hyperinsulinemic clamps, and--inverse--with the postprandial glucose excursions. Because insulin action did not correlate with postprandial glucose, the insulin secretory capacity appears to be the primary determinant of the impaired glucose tolerance. Marked postprandial hyperglucagonemia, and a virtually absent pancreatic polypeptide response in the grafted animals, may also have contributed to the impaired glucose tolerance. Posttransplant, infusion of a physiological dose of the gut hormone glucagon-like peptide-1 during 8.5 mM glucose clamps--mimicking the postprandial glycemia--potentiated glucose-stimulated insulin 175%. Thus, after transplantation of a suboptimal islet mass, postprandial glucose excursions are restrained by hyperglycemic potentiation of the entero-insular axis, which may account for the difference in the insulin response to the intravenous and oral challenges. Because, the insulin secretory capacity reflects the islet mass and appears to be the major determinant of glucoregulation, transplantation of a larger islet mass may allow near-normal glycemic control.

Animals↗
PubMed1999

The effects of ABT-229 and octreotide on interdigestive small bowel motility, bacterial overgrowth and bacterial translocation in rats.

BACKGROUND: Interdigestive small bowel motility has a regulatory function on the microflora of the upper small bowel. Here we investigate the effects of ABT-229 and octreotide on morphine-induced dysmotility, the accompanying bacterial overgrowth and bacterial translocation. METHODS: Rats were fitted with jejunal myoelectrodes and a subcutaneous cannula for continuous infusion of saline or morphine. Fasting motility was measured for 6 h on four occasions: one control measurement (day 0) and three measurements on consecutive days (days 1-3) while receiving saline alone (group A), morphine alone (group B), saline + ABT-229 (group C), morphine + ABT-229 (group D), saline + octreotide (group E) or morphine + octreotide (group F). Samples from the mesenteric lymph node complex (MLN), liver, spleen, duodenum and ileum were taken for quantitative microbial culturing on day 4. RESULTS: Neither ABT-229 nor octreotide increased the number of propagated activity fronts during saline infusion. During morphine-induced dysmotility, ABT-229 induced more propagated activity fronts in group D (13.4, 9.8 and 8.8 per 6 h) than in group B (7.0, 4.5, 3.8 per 6 h) on days 1, 2 and 3 (P < 0.05 for all days) Octreotide did not induce more propagated activity fronts. Disruption of small bowel motility by morphine led to bacterial overgrowth in the duodenum. ABT-229 and octreotide did not reduce the bacterial growth levels. The total incidence of bacterial translocation was significantly higher in the morphine-treated animals than in the saline-treated animals. Neither ABT-229 nor octreotide reduced the bacterial translocation incidence. The number of propagated activity fronts on day 3 and duodenal bacterial growth correlated significantly in groups A, E and F. CONCLUSIONS: ABT-229, but not octreotide, reduced morphine induced dysmotility. Small bowel bacterial overgrowth and bacterial translocation were not prevented. Fasting small bowel motility has a regulatory function on the intestinal microflora of the upper small bowel.

Animals↗
PubMed1999

Ileoneorectal anastomosis: early clinical results of a restorative procedure for ulcerative colitis and familial adenomatous polyposis without formation of an ileoanal pouch.

OBJECTIVE: To evaluate a new surgical procedure, ileoneorectal anastomosis (INRA), in patients with ulcerative colitis (UC) and familial adenomatous polyposis (FAP). SUMMARY BACKGROUND DATA: Surgical treatment in UC and FAP aims to resect diseased colonic mucosa and restore oroanal continuity. The ileopouch anal anastomosis achieves this but has a 15% to 35% complication rate, a 10% failure rate, and an unpredictable functional outcome. An alternative surgical technique, INRA, has been developed in which the rectal mucosa is replaced by a vascularized ileal mucosa graft. METHODS: Eleven patients underwent an INRA procedure with a temporary diverting ileostomy. Clinical history, repeat endoscopy, histologic examination, and rectal compliance measurements were carried out before and after surgery. RESULTS: The INRA procedure was technically successful in all patients. Endoscopy showed ingrowth of ileal mucosa in the neorectum, with 100% coverage after 6 weeks. No patient had pelvic sepsis, neorectal-anal or -vaginal fistula, autonomic nerve damage, or fecal incontinence. Neorectal function improved with time. The median 24-hour defecation frequency decreased from 15 (range 9 to 25) to 7 (range 4 to 10) at 11 months follow-up, and the median maximum tolerated volume increased to 157 (range 130 to 225) ml. Anal manometry and electrosensitivity were not affected by the surgery. Histologic biopsy samples after 1 year showed a normal small intestinal mucous membrane, without inflammation or fibrosis. CONCLUSION: The combination of a low complication rate and good neorectal function at 1 year is a substantial improvement that justifies extension of the clinical application in patients with UC and FAP.

Adenomatous Polyposis Coli↗
PubMed1998

[Surgical treatment of gastroesophageal reflux disease].

Antireflux surgery is successful in 85-90% of eligible patients, with relief of symptoms, cure of oesophagitis and possibly prevention of progression of the dysplasia in a Barrett's oesophagus. The mortality in the latest publications is given as 0.05%. The morbidity, apart from recurrences, is not yet sufficiently known. Some 250 antireflux operations are performed annually in the Netherlands, fewer than 20% of the estimated requirement of 10 operations per 100,000 of the population per year, and also fewer than in Scandinavia. Nissen fundoplication (folding the fundus of the stomach around the entire circumference (360 degrees) of the oesophagus) is generally accepted as the standard primary operation. Nissen fundoplication during laparoscopy seems to be just as good. Results of randomized clinical trials will have to be awaited to prove this assumption. Belsey's operation (folding the fundus around 270 degrees of the circumference of the oesophagus via thoracotomy) is nowadays performed almost exclusively in recurrent reflux disease and in persistent dysphagia after a primary operation.

Female↗