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Biomedical subjects

L L Swanstrom

Publications and source records attributed to L L Swanstrom.

At least 19 recordsLinked to original sources
PubMed2002

Laparoscopic radiofrequency ablation and hepatic artery infusion pump placement in the evolving treatment of colorectal hepatic metastases.

BACKGROUND: Laparoscopic radiofrequency ablation (LRFA) and laparoscopic hepatic artery infusion pump (LHAIP) placement are new treatment options for patients with colorectal liver metastases. This study investigates the selection criteria, safety, efficacy, and preliminary outcomes of patients treated with LRFA and LHAIP placement. METHODS: Fourty five patients with colorectal metastases confined to the liver, 37 of whom had failed systemic chemotherapy, were treated with LRFA and/or LHAIP between September 1996 and December 2001. Treatment selection was individualized, based on each patient's general health, liver function, and tumor size, number, location, and distribution. RESULTS: Twenty patients (44%) had LRFA alone, 10 (22%) had LHAIP placement alone, and 15 (33%) patients had combined LRFA and LHAIP therapy. The LRFA group had a significantly shorter mean operative time and blood loss (p <0.05), but hospital stays were similar when compared to patients receiving LRFA + LHAIP or LHAIP alone. Tumor characteristics were worse in both LHAIP groups, with a higher incidence of tumors >or=4 cm, major vascular involvement, diffuse tumor pattern, bilobar distribution, and involvement of more than three segments. During a mean follow-up period of 11.5 +/- 7.8 months (range, 1-38), the actuarial survival was 70%, 67%, and 50% for LRFA, LRFA + LHAIP, and LHAIP, respectively. LHAIP only patients had the shortest estimated mean survival time of the three groups by Kaplan-Meier survival curves (p = 0.001). CONCLUSION: LRFA and/or LHAIP placement are safe and feasible treatment options for the treatment of colorectal hepatic metastases. The choice of treatment for patients should be based primarily on tumor characteristics. Long-term studies, which will elucidate the role of these evolving treatments, are now under way.

Adult↗
PubMed2001

Laparoscopic antireflux surgery in the elderly.

BACKGROUND: Laparoscopic antireflux surgery is frequently denied to older patients with gastroesophageal reflux disease (GERD) because of a perceived higher operative complication rate, a decreased impact of the intervention on quality of life, and decreased cost effectiveness. This study compares disease severity, surgical outcomes, and impact on quality of life between elderly and young patients with GERD. METHODS: Patients were selected from a prospectively maintained database of 1100 patients who underwent various laparoscopic esophageal procedures at our institution. Only patients having chronic intractable GERD and a minimum 6 months' follow-up were included in the study. Thirty elderly patients with a mean age of 71.2 years (SD +/- 5.6) were compared with a group of 30 younger patients (mean age, 43.9 +/- 12.8 years). Comparisons were made between subjective and objective outcomes, operative results, and health-related quality of life (HQRL) scores using SF-36 instruments. RESULTS: The preoperative symptom assessment scores presenting frequency of symptoms on a 0-4 scale), and preoperative pH and manometry data were comparable in the two groups. Elderly patients had significantly higher ASA (American Society of Anesthesiologists) scores. Each group demonstrated a significant improvement in the postoperative symptom assessment scores and the esophageal functional studies (p<0.05). However, no significant differences were found in terms of postoperative complications, postoperative hospital stay, postoperative symptom scores, Demeester scores, or the HRQL data. CONCLUSION: Laparoscopic antireflux surgery in elderly patients improves acid reflux and appears to be safe and effective as measured by postoperative testing in elderly and young patients.

Adult↗
PubMed2001

Cost-effective management of common bile duct stones: a decision analysis of the use of endoscopic retrograde cholangiopancreatography (ERCP), intraoperative cholangiography, and laparoscopic bile duct exploration.

BACKGROUND: There are a variety of approaches to the diagnosis and treatment of common bile duct (CBD) stones in patients undergoing laparoscopic cholecystectomy (LC). METHODS: Decision modeling was used to evaluate the cost-effectiveness of four strategies for managing CBD stones around the time of LC: (a) routine preoperative endoscopic retrograde cholangiopancreatography (ERCP) (preoperative ERCP), (b) LC with intraoperative cholangiography (IOC), followed by laparoscopic common bile duct exploration (LCDE), (c) LC with IOC, followed by ERCP (postoperative ERCP), and (d) expectant management (LC without any tests for CBD stones). Local hospital data were used to estimate costs. Cost-effectiveness was expressed in terms of the cost per case of residual CBD stones prevented (in excess of the cost of LC alone). Diagnostic test characteristics, procedure success rates, and adverse event probabilities were derived from a systematic review of the literature. Sensitivity analysis was used to explore the effect of uncertainty on the results of the model. RESULTS: LC alone was the least costly strategy, but it was also the least effective. Of the more aggressive strategies, LCDE and preoperative ERCP were associated with marginal costs of $5993.60 and $299,259.35, respectively, per case of residual CBD stones prevented. Postoperative ERCP was more costly and less effective than LCDE, but it had a lower cost-effectiveness ratio than preoperative ERCP when the prevalence of CBD stones was <80%. CONCLUSIONS: Compared to other common approaches, laparoscopic CBD exploration is a cost-effective method of managing CBD stones in patients who undergo LC. If expertise in LCDE is unavailable, selective postoperative ERCP is preferred over routine preoperative ERCP, unless the probability of CBD stones is very high (>80%).

Cholangiography↗
PubMed2001

Outcomes of laparoscopic herniorrhaphy without fixation of mesh to the abdominal wall.

BACKGROUND: Recently there has been interest in performing laparoscopic herniorrhaphies without the use of staples or tacks to fix the mesh. Although mesh fixation has been linked to an increased incidence of nerve injury and involves increased operative costs, many surgeons feel that fixation is necessary to reduce the risk of hernia recurrence. This study evaluates the outcomes of laparoscopic herniorrhapies performed with and without mesh fixation at our institution. METHODS: We retrospectively evaluated our last 172 laparoscopic herniorrhaphies, which span a period of conversion from staple fixation to nonfixation of total extraperitoneal herniorrhaphies using systematic chart review and follow-up self-administered questionnaires. The outcomes assessed were the incidences of postoperative neuralgia and hernia recurrence. Adjustment for important prognostic factors was achieved using Cox regression for estimating the risk of recurrence, and multiple logistic regression for estimating the risk of neuropathic complications. RESULTS: Of 172 laparoscopic herniorrhaphies performed in 129 patients since July 1993, 105 were accomplished without mesh fixation, and 67 were performed with fixation of mesh to the abdominal wall. There were no significant differences in demographics between the two groups. A trend toward a higher incidence of neuropathic complications was observed in the mesh-fixation group (risk ratio [RR], 2.2; 95% CI, 0.5-10). A nonsignificant increased risk of hernia recurrence with fixation of mesh was observed (4.2 vs 1.6 per 100 hernia-years at risk; RR, 2.3; 95% CI, 0.4-13.10), but this finding may be associated with a selection bias with regard to giant hernia defects. CONCLUSIONS: Our data suggest that mesh fixation to the abdominal wall may be avoided in total extraperitoneal repairs without increasing the risk of hernia recurrence and neuropathic complications. The increased risk of recurrence observed with mesh fixation possibly results from selection bias. Large randomized controlled studies are needed to determine whether mesh fixation is truly related to neuropathic complications and the incidence of recurrence.

Adult↗
PubMed2001

Preoperative determinants of an esophageal lengthening procedure in laparoscopic antireflux surgery.

BACKGROUND: In a minority of patients undergoing antireflux surgery, an esophageal lengthening procedure is required to reduce the gastroesophageal junction (GEJ) below the esophageal hiatus. We evaluated risk factors associated with an irreducible GEJ to identify clinical features that were predictive of the need for a Collis gastroplasty in patients undergoing laparoscopic antireflux surgery. METHODS: Patients who required a Collis gastroplasty during a laparoscopic antireflux procedure (defined as the inability to reduce the GEJ > 2.5 cm below the esophageal hiatus despite extensive mobilization of the mediastinal esophagus) were compared to a random sample of patients who did not have a Collis gastroplasty. Predictors of the need for an esophageal lengthening procedure were identified using logistic regression modeling. Risks were expressed as odds ratios (OR) and 95% confidence intervals (CI). RESULTS: Twenty patients who had a Collis gastroplasty were compared to 133 patients who had adequate esophageal length. The presence of a stricture (OR 3.0; 95% CI 1.0, 9.7), paraesophageal hernia (OR 3.5; 95% CI 1.3, 9.6), Barrett's esophagus (OR 3.7, 95% CI 1.3, 10.7), and re-do antireflux surgery (OR 6.4; 95% CI 2.0, 20.7) were associated with the need for gastroplasty. Patients with none of these factors were extremely unlikely to require a gastroplasty (OR 0.08; 95% CI 0.02, 0.34). CONCLUSION: Patients undergoing laparoscopic antireflux surgery who are at high risk of needing an esophageal lengthening procedure can be easily identified preoperatively using simple clinical characteristics.

Age Factors↗
PubMed2001

Quality of life before and after laparoscopic Heller myotomy for achalasia.

BACKGROUND: Because the surgical treatment of achalasia is directed at the palliation of chronic symptoms, it is important to assess how surgery affects patients' health-related quality of life (HRQL). METHODS: We evaluated upper gastrointestinal symptoms, satisfaction, and HRQL in 19 patients with achalasia before and after undergoing a laparoscopic Heller myotomy and partial fundoplication. HRQL was assessed using the Medical Outcomes Study 36-item short form health survey (SF-36). RESULTS: The mean age of the patients was 40 years (range 16 to 74), and 58% were men. After a median follow-up of 21 months (range 2 to 35), 12 of 16 patients were satisfied with the results of their surgery. Liquid and solid dysphagia scores were improved after surgery, and the prevalence of heartburn symptoms did not change. Although all the health concepts measured by the SF-36 instrument showed some improvement, statistically significant increases (on a 0 to 100 scale) were detected in physical functioning (11.1, P = 0.02), role-physical (25.0, P = 0.05), bodily pain (12.2, P = 0.01), vitality (13.7, P = 0.02), and social functioning (18.4, P = 0.02). CONCLUSIONS: Most aspects of HRQL improve after a laparoscopic Heller myotomy and partial fundoplication for achalasia.

Activities of Daily Living↗
PubMed2001

Incidence of cancer of the pancreas, extrahepatic bile duct and ampulla of Vater in the United States, before and after the introduction of laparoscopic cholecystectomy.

BACKGROUND: Some epidemiologic studies have identified cholecystectomy as a risk factor for pancreatic and biliary cancer. METHODS: We compared the incidence of cancers of the pancreas, extrahepatic bile duct and ampulla of Vater before and after the widespread adoption of laparoscopic cholecystectomy in the United States in 1991, when the use of cholecystectomy increased dramatically. RESULTS: Compared with 1980 to 1991, there was no increase in the incidence of cancer of the pancreas (adjusted incidence rate ratio [IRR] 0.97, 95% confidence interval [CI] 0.94 to 0.99) or extrahepatic bile duct (IRR 0.80, 95% CI 0.74 to 0.87) during 1992 to 1996. There was a small increase in the incidence of ampullary cancer (IRR 1.14, 95% CI 1.03 to 1.26). CONCLUSIONS: We did not find clear evidence of a short-term increase in the incidence of cancers of the pancreas, bile duct, and ampulla of Vater, that was attributable to the increased use of cholecystectomy.

Adult↗
PubMed2001

Hand-assisted gastroesophageal surgery.

Hand-assisted laparoscopic surgery (HALS) has been shown to be an effective tool when performing advanced laparoscopic procedures. The hand-assist device restores tactile feedback, facilitates retraction and dissection, and can be a successful alternative to open conversion. HALS is a valuable resource when performing complex gastroesophageal operations, including gastrectomy, esophagectomy, and bariatric surgery. The aim of this review is to familiarize the laparoscopic surgeon with the use of HALS when performing these technically demanding procedures.

Dissection↗
PubMed2000

Laparoscopic hernia repairs. The importance of cost as an outcome measurement at the century's end.

At the dawn of this new millennium, surgeons not only must be masters of their craft but also are responsible for identifying and learning new techniques that are being introduced at an ever-increasing rate. Surgeons must overcome the instinctual mistrust of "the new" and, at the same time, avoid over enthusiastic, uncritical adoption of unproven procedures. Today's surgeons must also carefully assess and select the procedures and technologies that they will have time to learn and that will complement their practices and interests. More new things are coming along than any single individual can learn and practice with expertise, which makes general surgery a specialty with relative, as opposed to specifically, defined boundaries. Surgeons also should participate in the process of measuring the outcomes effective and to offer some advantages over open repair, namely less pain and a more rapid recovery period. On the other hand, this surgery has been shown to be difficult to learn and more costly. In a situation such as this, one can delete the procedure from the individual or institutional repertoire or use the modern tools of medical management to attempt to address the "outlier" issues and preserve the good. Laparoscopic hernia repair is a good procedure that can be done in a cost-effective manner if cost-conscious practice guidelines are initiated. It is not yet, however, a technique for all surgeons because of its difficulty to learn and advanced skills needed to perform it well.

Cost-Benefit Analysis↗
PubMed2000

Hand-assisted laparoscopic surgery (HALS) with the HandPort system: initial experience with 68 patients.

OBJECTIVE: To evaluate the feasibility and potential benefits of hand-assisted laparoscopic surgery with the HandPort System, a new device. SUMMARY BACKGROUND DATA: In hand-assisted laparoscopic surgery, the surgeon inserts a hand into the abdomen while pneumoperitoneum is maintained. The hand assists laparoscopic instruments and is helpful in complex laparoscopic cases. METHODS: A prospective nonrandomized study was initiated with the participation of 10 laparoscopic surgical centers. Surgeons were free to test the device in any situation where they expected a potential advantage over conventional laparoscopy. RESULTS: Sixty-eight patients were entered in the study. Operations included colorectal procedures (sigmoidectomy, right colectomy, resection rectopexy), splenectomy for splenomegaly, living-related donor nephrectomy, gastric banding for morbid obesity, partial gastrectomy, and various other procedures. Mean incision size for the HandPort was 7.4 cm. Most surgeons (78%) preferred to insert their nondominant hand into the abdomen. Pneumoperitoneum was generally maintained at 14 mmHg, and only one patient required conversion to open surgery as a result of an unmanageable air leak. Hand fatigue during surgery was noted in 20.6%. CONCLUSIONS: The hand-assisted technique appeared to be useful in minimally invasive colorectal surgery, splenectomy for splenomegaly, living-related donor nephrectomy, and procedures considered too complex for a laparoscopic approach. This approach provides excellent means to explore, to retract safely, and to apply immediate hemostasis when needed. Although the data presented here reflect the authors' initial experience, they compare favorably with series of similar procedures performed purely laparoscopically.

Abdomen↗
PubMed2000

The short esophagus: pathophysiology, incidence, presentation, and treatment in the era of laparoscopic antireflux surgery.

OBJECTIVE: To discuss the pathophysiology and incidence of the short esophagus, to review the history of treatment, and to describe diagnosis and possible treatments in the era of laparoscopic surgery. SUMMARY BACKGROUND DATA: The entity of the short esophagus in antireflux surgery is seldom discussed in the laparoscopic literature, despite its emphasis in the open literature for more than 40 years. This may imply that many laparoscopic patients with short esophagi are unrecognized and perhaps treated inappropriately. Intrinsic shortening of the esophagus most commonly occurs in patients with chronic gastroesophageal reflux disease that involves recurring cycles of inflammation and healing, with subsequent fibrosis. The actual incidence of the short esophagus is estimated to be approximately 10% of patients undergoing antireflux surgery. Of this group, 7% can be appropriately managed with extensive mediastinal mobilization of the esophagus to achieve the required esophageal length. The remaining 3% require an aggressive surgical approach, including the use of gastroplasty procedures, to create an adequate length of intraabdominal esophagus to perform a wrap. Several effective minimally invasive techniques have been developed to deal with the short esophagus. CONCLUSIONS: Because a short esophagus is uncommon, there is a natural concern that many surgeons will not perform enough antireflux procedures to become familiar with its diagnosis and management. A complete understanding of the short esophagus and methods for surgical correction are critical to avoid "slipped" wraps and mediastinal herniation and to achieve the best patient outcome.

Esophagectomy↗
PubMed1999

Radiofrequency ablation lesions in a pig liver model.

BACKGROUND: Radiofrequency (RF) ablation has been reported as a means of liver tumor destruction. This study evaluates the use of ultrasound monitoring of radiofrequency lesion creation and describes the morphology, histologic characteristics, and vascular effects of radiofrequency ablations in a pig liver model. MATERIALS AND METHODS: Hemodynamic monitoring was established and laparotomies were performed in 50-kg pigs. Under ultrasound guidance, radiofrequency needle probes were placed in the liver at predetermined locations. Radiofrequency energy was applied over 15 min to generate lesions 3 cm in diameter. Eighty lesions were generated in 10 animals. At the completion of the experiment, the lesions were examined with ultrasound and then excised for CT, gross, and histologic examination. RESULTS: There were no adverse systemic effects. Ultrasound imaging demonstrated the size, shape, and position of the lesions. Gross examination demonstrated a core of ablated tissue with a surrounding 1- to 2-mm hemorrhagic perimeter. Lesion volumes averaged 12.8 cc(3) (range 5-34 cc(3)). Final lesion shape and size were frequently altered by the cooling effect of local blood flow. Histologic stains demonstrated microvascular thrombosis and coagulative necrosis within the lesions. There appeared to be 100% cellular destruction within the lesion by cytochemical staining. CONCLUSIONS: We demonstrated that RF ablation is capable of killing large volumes of normal liver tissue; however, local vasculature plays a significant a role in defining the ultimate size and shape of the lesion created. This may interfere with the utility of radiofrequency ablation as a modality for local tumor control.

Animals↗
PubMed1999

Totally laparoscopic abdominal aortic aneurysm repair.

On the basis of our previous animal and clinical experience with laparoscopic intra-abdominal vascular reconstructions, and due to the prevalence of abdominal aortic aneurysms (AAA), we have recently broadened our scope to tackle more difficult aortic surgery laparoscopically. We present a case report of our first clinical experience with laparoscopic AAA repair using specialized laparoscopic vascular instrumentation. The patient was an 84-year-old hypertensive male with a 7-cm asymptomatic infrarenal abdominal aortic aneurysm that was discovered incidentally. He presented with postcoronary artery bypass grafting and had moderate chronic obstructive pulmonary disease (COPD). A spiral computed tomograph (CT) angiogram revealed an adequate infrarenal neck and aneurysmal involvement of the proximal iliac arteries. An eight-port transabdominal technique was used with the patient in the supine position. Proximal and distal control was achieved without difficulty. The aneurysm was excluded using endoscopic stapling devices, and an aortobiiliac reconstruction was performed with a 16 x 9-mm bifurcated dacron graft. Estimated blood loss was 1000 ml, and the operative time was approximately 7 hours. The patient was ambulating without assistance on postoperative day 3. Total hospitalization was 7 days (delayed secondarily to postoperative ileus). Minimal quantities of narcotics were required for analgesia. At 6-months follow-up, the patient has palpable peripheral pulses and no complications related to surgery. This case report shows that a completely laparoscopic approach to the abdominal aortic aneurysm is possible using instrumentation specifically designed for laparoscopic vascular surgery. The exact role that laparoscopic techniques will hold in vascular surgery remains to be determined because these procedures are time consuming and technically difficult.

Aged↗
PubMed1999

Laparoscopic management of accessory spleens in immune thrombocytopenic purpura.

BACKGROUND: A disparity exists between the incidence of accessory spleens reported in the open (15-30%) versus the laparoscopic (0-12%) literature. This disparity implies that a percentage of laparoscopic patients will require a reoperation for accessory splenectomy. We present our experience with the laparoscopic management of accessory spleens discovered after primary splenectomy for idiopathic thrombocytopenic purpura (ITP). METHODS: Seventeen patients who underwent primary splenectomy for ITP were reviewed (1 open, 16 laparoscopic). In the laparoscopic group, the incidence of accessory spleens was 3 in 16 (19%). In 1 of these 3 patients, the accessory spleen was found and removed at the initial operation, whereas in 2 of the 16 patients (13%), the accessory spleens were missed. A third patient, whose initial operation was open, presented with recurrent thrombocytopenia after primary splenectomy. After recurrent thrombocytopenia developed, radio nuclide spleen scans were performed showing accessory spleens in all three patients. These three patients underwent accessory splenectomy using a four-port laparoscopic approach. RESULTS: Laparoscopic accessory splenectomy was successfully performed in all three patients. Location of accessory spleens correlated with the spleen scan in each case. Mean operation time was 180 min. There were no conversions to open surgery and no complications. All patients were discharged from the hospital on postoperation day 1. The three patients had a good clinical response and were weaned effectively from their steroid medications. CONCLUSIONS: Patients undergoing a laparoscopic splenectomy for chronic ITP have a higher probability of requiring a reoperation for a missed accessory spleen. To minimize missing an accessory spleen, a systematic search should be made at the beginning of the laparoscopic operation. We have found that preoperation imaging with heat-treated erythrocyte scans is valuable for locating accessory spleens before reoperation. When reoperation for accessory splenectomy is necessary, a laparoscopic approach is safe and effective.

Adolescent↗
PubMed1999

Topical treatments of laparoscopic port sites can decrease the incidence of incision metastasis.

BACKGROUND: Anecdotal reports of port site tumor recurrence have dampened the enthusiasm for laparoscopic colectomy for cancer. We developed a rat model that creates a high incidence of port site metastasis following laparoscopic intervention. Our goal was to assess the feasibility of minimizing implantations using port site irrigation prior to wound closure. METHODS: Colon cancer carcinomatosis was established in 46 female BD9 rats using intraperitoneal injections of 10(6) DHD-K12-TRb rat colon cancer cells. This preparation yielded an 81% incidence of port site metastasis in a control group. Laparoscopic sham surgery was performed using four ports and a CO(2) pneumoperitoneum. Four treatment groups were studied by irrigating each port site as follows: Group I, sterile water; group II, normal saline; group III, heparin; group IV, 5-fluorouracil (5-FU). The animals were killed at 4 weeks, and the port sites were examined for tumors. RESULTS: There were no differences in port site metastasis between controls and groups I, II, and III. The 5-FU group showed a significant decrease (30% vs 81%) in metastasis. CONCLUSIONS: Port site irrigation with 5-FU at the time of laparoscopy reduces the incidence of port site tumor implantation in a rat colon cancer model. This finding may have utility in patients at high risk of such metastasis who undergo laparoscopy for colon cancer.

Administration, Topical↗
PubMed1999

Esophageal motility and outcomes following laparoscopic paraesophageal hernia repair and fundoplication.

BACKGROUND: The addition of an antireflux procedure to all giant paraesophageal hernia (PEH) repairs remains controversial. In addition there are no series evaluating the impact of hernia repair and fundoplication on esophageal physiology. This study examines the outcomes of PEH repair with fundoplication and examines the results of preoperative and postoperative motility and pH testing. METHODS: An analysis of a data base containing all patients undergoing PEH repair between September 1994 and December 1997. Patients underwent laparoscopic sac reduction, hernia repair, and fundoplication. Follow-up was performed under protocol and consisted of a symptoms assessment form, 24 hour pH, and manometry. RESULTS: Fifty-two patients (mean age 63) were treated: 59% complained of heartburn, 50% dysphagia, and 27% chest pain; 26% had a body motility disorder. Complete manometry was not possible in 41%. Mean operative time was 4 hours. There were 48 Nissen, 4 Toupet, and 7 Collis-Nissen procedures. There were 3 (6%) intraoperative and 3 (6%) postoperative complications. There were no operative mortalities. Hospital stay was 3 days (1 to 29). Late follow-up (18 months) was available for 96% of patients and showed dysphagia in 6%, heartburn in 10%, and recurrent herniation in 8%. Objective postoperative testing was available in 61 % of the patients at a mean of 8 months. Twenty-four hour pH tests were abnormal in 4 patients (2 asymptomatic and 2 with a Collis). Lower esophageal sphincter pressures increased 63% and functioned well in 71% of patients; 50% of preoperative motility disorders improved following repair. CONCLUSIONS: Laparoscopic repair of giant PEH is technically difficult but feasible. Routine addition of a fundoplication is advised, as preoperative testing is unreliable for a selective approach and fundoplications are well tolerated in this group of patients.

Adult↗
PubMed1999

Partial fundoplications for gastroesophageal reflux disease: indications and current status.

The Nissen fundoplication, and in particular the laparoscopic Nissen fundoplication, has received widespread acceptance as the most definitive therapy for gastroesophageal reflux disease. There remains, however, certain patients who do better with a less aggressive surgical augmentation of the lower esophageal sphincter. Partial fundoplications originated in the early 1960s as an alternative procedure to the Nissen, which was associated with moderately high rates of postoperative side effects. These "more physiologic" procedures have proved successful in the treatment of reflux disease in patients with poor or no esophageal motility. In particular, the use of partial fundoplications in association with Heller's myotomy for achalasia has been demonstrated to be well tolerated and to reduce the risk of late dysphasia resulting from uncontrolled gastroesophageal reflux (GER). The use of partial fundoplications in GER patients with normal motility, however, has been less successful. High recurrence rates are documented by many centers with the main cause appearing to be related to a less competent neo-lower esophageal sphincter and a higher rate of wrap herniation. This has led to the current practice of a "tailored approach" to reflux disease, in which all patients receive a thorough preoperative physiologic evaluation to determine the best antireflux procedure for the individual. This is generally a Nissen repair for those with normal motility and either an extrashort "floppy" Nissen or a partial wrap for those with impaired peristalsis.

Endoscopy↗