Mesenteric venous thrombosis following laparoscopic antireflux surgery.
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Fundoplication↗
Biomedical subjects
Ronald A Hinder
Publications and source records attributed to Ronald A Hinder.
Use of acid suppressive medications after laparoscopic antireflux surgery: prevalence and clinical indications.
Laparoscopic antireflux surgery (LARS) provides effective control of gastroesophageal reflux (GER) in more than 90% of patients. Despite this high success rate, some patients continue to consume acid suppressive medications after surgical intervention. In this study we evaluate the prevalence, clinical indications, and cause of use of acid reducing drugs in patients after LARS. Consecutive patients undergoing LARS for GERD were surveyed 2-3 years after surgery regarding use of acid suppressive medications, surgical outcome, and GERD specific symptoms. During the study period, 119 patients underwent LARS at our center. Ninety-eight (82%) were available for interview. Two patients died of unrelated causes and two declined to be interviewed. The remaining 94 individuals are the subject of this report. Ninety-four percent were satisfied with the outcome of surgery. Despite this high satisfaction rate, 37 of 94 (39%) were on antireflux medication (ARM; 62% proton pump inhibitors, 22% H2-receptor antagonists, and 16% others), with 70% using continuous medication. Of these patients, 54% took ARM after surgery for GERD-related symptoms, 95% of these patients responded to medical therapy, and yet again, 85% remained satisfied with the surgical outcome. Forty-six percent of patients on ARM after surgery had no GERD symptoms and took ARM for nonappropriate indications such as bloating. Only 47% of these responded to ARM; 82% of this group was satisfied with the surgical outcome. In conclusion, the use of ARM after LARS is a common occurrence despite a high satisfaction rate with this operation. Nearly half of patients consuming ARS after LARS are taking these medications for symptoms not necessarily related to GER. These findings underscore the importance of patient education in the use of these agents.
Adult↗
Jejunopexy for selectively placed fluoroscopically guided percutaneous jejunal feeding tubes.
Prophylactic placement of feeding jejunostomy tubes in patients undergoing esophagectomy or gastrectomy continues to be a common practice. The aim of jejunostomy is to maintain nutrition, especially with an anastomotic leak. Frequently total or supplemental nutrition through a jejunostomy is not required, rendering prophylactic placement unnecessary. In addition, feeding jejunostomy tubes have potentially serious complications.
Esophagectomy↗
Long-term results of laparoscopic Heller myotomy with partial fundoplication for the treatment of achalasia.
BACKGROUND: Treatment options for achalasia include medications, endoscopic balloon dilation, injection of botulinum toxin, or surgery. METHODS: The clinical course of 75 consecutive patients who underwent minimally invasive Heller myotomy and partial fundoplication for achalasia between 1991 and 2001 was reviewed by means of a questionnaire. RESULTS: Mean follow-up was 5.3 (range .8 to 10.9) years. Sixty-four percent of questionnaires were returned. Thirty-seven patients (84%) felt much better and 6 (14%) slightly better; 1 (2%) rated the result as unchanged. Twenty-six patients (59%) experienced weight gain. Seven patients (16%) had persistent swallowing problems and 5 (11%) reported frequent reflux. Twenty-five percent underwent additional therapy, including dilation (n = 8, 18%), repeat surgery (n = 2, 5%), and botulinum toxin injection (n = 2, 5%). Eighteen patients (41%) were using a proton pump inhibitor or H2 blocker, three were on a calcium channel blocker (7%), and 1 was using nitroglycerine (2%). CONCLUSION: Laparoscopic Heller myotomy can achieve short- and long-term results comparable to open surgery and should be considered the treatment of choice for patients suffering from achalasia. Despite the frequent need for further therapy, patient satisfaction is good.
Adolescent↗
Endoscopic treatment of reflux: a quest for the holy grail of reflux?
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Esophagoscopy↗
Abdominal adhesions: to lyse or not to lyse?
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Abdominal Pain↗
Evaluation of vagus nerve function before and after antireflux surgery.
We sought to evaluate vagus nerve integrity before and after antireflux surgery and to compare it with symptomatic outcome. Antireflux surgery patients were recruited. Patients with disorders associated with vagus dysfunction or who took medications with anticholinergic effects were excluded. Each patient underwent a sham-feeding-stimulated pancreatic polypeptide (PP) test before and after surgery. A symptom survey was also administered. Twenty patients completed preoperative testing; their mean age was 57 years, and postoperative testing results were available for 16 of them. Of the 20, 14 (70%) had an appropriate increase in PP level with sham-meal preoperatively. All 4 patients with an abnormal preoperative test remained abnormal, and 5 of 12 (42%) with a normal preoperative test had an abnormal postoperative result; thus 9 of 16 (56%) had an abnormal postoperative PP test. In 15 patients, assessments of bowel function were obtained before and after surgery. Six of 15 (40%) patients developed new or worse symptoms (diarrhea in 4, flatus in 2). The symptoms did not correlate with PP results. This suggests that some patients referred for antireflux surgery have evidence of abnormal vagus function that persists after surgery. Many patients (42%) with normal testing before surgery develop an abnormal test after surgery. There was no correlation between PP tests and the development or worsening of bowel symptoms.
Fundoplication↗
Management of epiphrenic diverticula.
Epiphrenic diverticula are very rarely seen and are often associated with achalasia, esophageal body dysmotility, and a high resting lower esophageal sphincter pressure. The aim of this study was to evaluate the different treatment options for patients with epiphrenic diverticula. Patients with an epiphrenic diverticulum were divided into two treatment groups: surgical and nonsurgical. Retrospective chart review was performed, and a symptom questionnaire was created. There were six patients in the nonsurgical group and 11 patients in the surgical group. The mean follow-up was 26.4 months. Ten patients had a laparoscopic operation performed. One patient was operated on thoracoscopically and had to be converted to a thoracotomy. Two diverticula were inverted with good results. There was one postoperative esophageal leak where no myotomy was added. An empyema developed in another patient at 4 weeks after surgery. One patient, in whom no antireflux procedure was performed, reported postoperative heartburn. Patients in the nonsurgical group had smaller diverticula, were not good candidates for surgery, or were asymptomatic. Esophageal diverticula are very rarely seen. Asymptomatic patients may not require therapy. If surgery is performed and the diverticulum is large, it should be removed. The laparoscopic approach is the surgical treatment of choice. A long myotomy and an antireflux procedure should be added to avoid esophageal leakage at the line of repair and gastroesophageal reflux.
Aged↗
Small bowel transit and gastric emptying after biliodigestive anastomosis using the uncut jejunal loop.
BACKGROUND: The Roux-en-Y loop is an effective procedure for biliodigestive drainage. However, up to 15% of patients suffer from postoperative cholangitis or blind loop syndrome. A new technique to prevent motility abnormalities has been developed. METHODS: Male Lewis rats were used to compare gastric emptying and transit in the small bowel after either a standard Roux-en-Y anastomosis or a new biliodigestive anastomosis technique which involves creating an "uncut" jejunal loop with luminal occlusion. Unoperated rats served as controls. (99)Technetium HIDA and (111)Indium-tagged amberlite were respectively used to investigate small bowel transit and gastric emptying. RESULTS: Histopathology showed distinctive abnormalities only in the liver of conventional Roux-en-Y animals. No recanalization of the obliterated gut lumen occurred in uncut Roux animals. Distribution of (99)Tc-HIDA and (111)In showed were similar in both groups. Gastric emptying is slowed in both groups. CONCLUSIONS: The uncut proximal jejunum loop is a good alternative to the conventional Roux-en-Y loop and showed preserved small bowel motility and adequate jejunal transit. Gastric emptying is slowed in both groups.
Anastomosis, Roux-en-Y↗
Bowel dysfunction after laparoscopic antireflux surgery: incidence, severity, and clinical course.
PURPOSE: To evaluate the incidence, severity, and clinical course of postoperative bowel dysfunction, primarily diarrhea, after laparoscopic antireflux surgery. METHODS: Patients who underwent laparoscopic antireflux surgery during January to December 1998 responded to a questionnaire about pre-existing and postoperative bowel symptoms, which included questions about the type of bowel dysfunction (diarrhea, abdominal pain, bloating, constipation), onset in relation to surgery, frequency, severity, duration, use of medical resources or diagnostic evaluations, and treatment outcome. RESULTS: Of the 109 patients who underwent laparoscopic antireflux surgery at our center during the study, 84 (77%) completed the survey. Thirty-six (43%) had no bowel dysfunction before or after surgery, whereas 29 (35%) had pre-existing bowel dysfunction. New bowel symptoms developed postoperatively in 30 patients (36%), including bloating in 16 (19%) and diarrhea in 15 (18%). Two thirds of the patients with new diarrhea developed it within 6 weeks after surgery. The severity of the diarrhea ranged from mild to debilitating; 4 had fecal incontinence. Most patients (13/15) with diarrhea had symptoms for > or =2 years following surgery. No patient was hospitalized, and only 2 patients reported temporary work loss. CONCLUSION: Postoperative bowel dysfunction, namely diarrhea, is an important adverse effect of antireflux surgery. Awareness of this complication should lead to prompt recognition, effective management, and reduction in anxiety.
Adult↗
Is laparotomy becoming obsolete?
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Humans↗
Postmyotomy dysphagia after laparoscopic surgery for achalasia.
AIM: To determine predictive factors for postoperative dysphagia after laparoscopic myotomy for achalasia. METHODS: Logistic regression was used to investigate the possible association between the response (postoperative dysphagia, with two levels: none/mild and moderate/severe) and several plausible predictive factors. RESULTS: Eight patients experienced severe or moderate postoperative dysphagia. The logistic regression revealed that only the severity of preoperative dysphagia (with four levels: mild, moderate, severe, and liquid) was a marginally significant (P=0.0575) predictive factor for postoperative dysphagia. CONCLUSION: The severity of postoperative dysphagia is strongly associated with preoperative dysphagia. Preoperative symptomatology can significantly impact patient outcome.
Deglutition Disorders↗
Laparoscopic adrenalectomy for pheochromocytoma.
OBJECTIVE: To determine the safety and results of laparoscopic resection of benign pheochromocytomas. PATIENTS AND METHODS: We retrospectively reviewed the medical charts of all patients who underwent laparoscopic adrenalectomy for benign pheochromocytomas at all 3 Mayo Clinic sites between January 1, 1992, and December 31, 2001. Demographics, comorbidities, clinical presentation, imaging studies, biochemical findings, operative intervention, and outcome were examined. Long-term follow-up was obtained via chart review and/or by direct telephone contact with the patient or a relative. RESULTS: Twenty-four women and 23 men with a mean age of 53.1 years (range, 16-81 years) underwent attempted laparoscopic resection of pheochromocytomas. In 5 patients, the procedure was converted to open laparotomy because of bleeding (2), inadequate exposure (2), and adhesions (1). The mean tumor size was 4.3 cm. The mean operative time (181.8 vs 1405 minutes; P = .03), mean hospital stay (6.00 vs 2.64 days; P < .001), and mean blood loss (340 mL vs 80 mL; P < .001) were greater in patients who underwent open laparotomy vs those who underwent laparoscopic resection. All specimens were classified as benign. The mean follow-up was 41 months (range, 10-89 months). No patients experienced a recurrence or developed metastatic disease. CONCLUSIONS: In light of surgical and anesthesia expertise, laparoscopic resection of benign pheochromocytomas is safe and effective with resultant short hospital stays. A low threshold to convert to an open procedure reduces operative times and decreases potentially serious complications. Although there have been no recurrences to date, long-term follow-up is required for all patients, especially those with hereditary forms of pheochromocytomas.
Adolescent↗
Symptom predictability of reflux-induced respiratory disease.
Gastroesophageal reflux disease (GERD) often is associated with pulmonary problems such as asthma as well as recurrent and nocturnal cough. Dual-probe 24-hr pH monitoring may assist in establishing a correlation between these symptoms and GERD-related symptoms. To determine if any specific symptom was predictive of aspiration, this study was undertaken. Ambulatory dual-probe esophageal pH monitoring was performed on 133 patients who had upper airway and additional symptoms for GERD. All patients had esophageal manometric studies of the lower esophageal sphincter (LES), the upper esophageal sphincter (UES), and the esophageal body before dual-probe pH monitoring was performed. Using two assembled glass probes, the distal and the proximal sensors were placed 5 cm above the proximal border of the LES and 1 cm below the lower border of the UES, respectively. Patients were classified into three groups: proximal and distal probe positive (group I), proximal probe negative and distal probe positive (group II) and proximal and distal probe negative (Group III) Upper airway and additional symptoms plus manometry results of the LES, body and UES study were compared between groups. In addition, positive distal probe patients (groups I and II) were compared for distal fraction of time at pH < 4 and number of reflux episodes at each probe position. A positive distal probe result was defined as an abnormal DeMeester score (> 14.8). A proximal probe test result was considered positive if percent time pH < 4.0 was > 1.1 for total, 1.7 for upright, and 0.6 for supine positions. The ages of the subjects ranged from 18 to 83 years (mean age: 50.5 +/- 1.5 years). Groups I, II, and III included 16 patients, 38 patients, and 79 patients, respectively. Group I had a significantly higher incidence of nocturnal cough than the other two groups. (P < 0.05). The manometric data revealed between groups that LES pressure (LESP) for groups I and II was significantly lower than LESP for group III (P = 0.003). Cricoid pressure, pharyngeal pressure, length, and relaxation of UES were not different between groups. Fraction of reflux time for group I was significantly higher than for group II in the supine position and at mealtime (P < 0.05). The number of reflux episodes for group I was significantly higher at meal time (P < 0.01). In conclusion, nocturnal cough is strongly predictive of proximal esophageal reflux. Proximal reflux episodes are significantly more frequent in the supine position and correlate well with the high predictive value of nocturnal cough.
Adolescent↗
Dilation after fundoplication: timing, frequency, indications, and outcome.
BACKGROUND: Dysphagia frequently develops shortly after fundoplication but is usually self-limited. This is an evaluation of the timing, frequency, indications, and outcome of dilation after fundoplication. METHODS: Two hundred thirty-three consecutive patients who underwent fundoplication were included. Preoperative motility, postoperative symptoms, endoscopic and radiographic data, timing and number of dilations, and caliber of the dilator used were evaluated in patients who required dilation. RESULTS: Twenty-nine of 233 (12.4%) patients underwent dilation(s). The mean time to dilation after surgery was 72 days (range 3 to 330 days). Ten of 29 (34.5%) required more than 1 dilation (mean 1.5, range 1 to 5). The mean diameter to which the fundoplication was dilated was 18.6 mm (range 15-20 mm). There were no complications. The indication for dilation was dysphagia in 20, chest pain 4, epigastric pain 1, globus 1, gas bloat 1, belching 1, and vomiting in 1 patient. Two patients were lost to follow-up. Dysphagia resolved with dilation in 12 of 18 (67%) patients. Of the 6 patients whose symptoms did not improve after dilation, 3 noted improvement after further surgery. Two patients with tight fundoplications still require periodic dilation. One patient had a stricture before surgery that persisted after surgery. Symptoms did not improve in any patient who underwent dilation for an indication other than dysphagia. CONCLUSIONS: Dilation after fundoplication was required in 12.4% of patients and was successful in most with dysphagia. Dilation shortly after surgery was safe and only a single dilation was required for most patients. Symptoms other than dysphagia did not respond to dilation.
Deglutition Disorders↗
Incidental cholecystectomy during laparoscopic antireflux surgery.
Cholelithiasis and gastroesophageal reflux are both very common diseases that may occur simultaneously. Management of asymptomatic gallstones is still controversial. Because severe complications due to gallstones may occur incidental cholecystectomy during nonrelated abdominal surgery may be offered to patients with coexisting gallbladder disease. The aim of this study was to assess the clinical outcome of patients after laparoscopic fundoplication and incidental cholecystectomy for cholelithiasis compared with the outcome of patients after fundoplication alone. We conducted a retrospective chart review and prospective analysis using a questionnaire of the clinical outcome of patients who underwent laparoscopic fundoplication and incidental cholecystectomy from June 1991 to January 2000 in comparison with sex- and age-matched patients who had antireflux surgery alone. Sixty-seven (6.3%) of 1065 patients had a laparoscopic cholecystectomy at the time of laparoscopic antireflux surgery; 101 (75%) of 134 answered the questionnaire. The mean follow-up time was 4.6 years. Laparoscopic cholecystectomy did not influence surgical morbidity or mortality. Postoperative symptom score (1-10) did not show a statistically significant difference regarding bloating, diarrhea, abdominal pain, nausea, vomiting, biliary problems, jaundice, pancreatitis, dysphagia for liquids and solid, heartburn, regurgitation, and chest pain when the two groups were compared. We conclude that incidental cholecystectomy during laparoscopic antireflux surgery is safe and does not appear to influence the clinical outcome of the antireflux procedure.
Blood Loss, Surgical↗
Outcome of laparoscopic antireflux surgery in patients with nonerosive reflux disease.
As many as 50% of patients with gastroesophageal reflux disease (GERD) have no endoscopic evidence of esophagitis (EGD negative). Laparoscopic antireflux surgery (LARS) provides effective symptomatic and endoscopic healing in patients with erosive GERD (EGD positive). The surgical outcome of patients undergoing LARS for EGD-negative GERD has not received wide attention. The objective of this study was to compare surgical outcomes between EGD-negative and EGD-positive patients. During the period from June 1996 to September 1998, all patients undergoing LARS for persistent GERD symptoms despite medical therapy, who were EGD-negative, were invited to respond to a questionnaire regarding their clinical status before and after LARS. To perform a comparative analysis, the same questions were posed to a randomly selected equal number of EGD-positive patients who underwent surgery during the same study period. LARS was performed in 255 patients during the study period; 59 patients (23%) had EGD-negative GERD, and 148 (58%) were EGD-positive. Forty-eight patients (19%) did not meet the entry criteria and were excluded from analysis. LARS provided effective symptomatic relief in patients with EGD-negative and EGD-positive GERD. There were no significant differences in patient satisfaction or symptom improvement between the two groups (P = 0.82). The surgical outcome of EGD-negative patients is similar to the outcome for patients with erosive esophagitis. LARS is a valuable treatment option for patients with persistent GERD symptoms regardless of the endoscopic appearance of the esophageal mucosa.
Adult↗
Causes of long-term dysphagia after laparoscopic Nissen fundoplication.
BACKGROUND: Laparoscopic fundoplication has revolutionized the surgical treatment of gastroesophageal reflux disease. Despite improvements in the technique of fundoplication, persistent dysphagia remains a significant cause of postoperative morbidity. METHOD: Causes of persistent postoperative dysphagia were analyzed in a consecutive series of 167 patients after laparoscopic Nissen fundoplication. Short gastric vessel division and its effect on postoperative dysphagia were analyzed. RESULTS: Follow-up was possible in 139 patients (83%). The mean follow-up period was 27 +/- 21 months. Nine patients (6%) had persistent (moderate to severe) dysphagia, and 33 patients (24%) had mild dysphagia. The satisfaction score among patients with persistent dysphagia was significantly lower than that in patients with mild dysphagia (P < 0.0002). On the other hand, the satisfaction rate among patients with mild dysphagia and those who are asymptomatic was similar. Manometry, performed in 7 of 9 persistent dysphagia patients revealed no difference in postoperative lower esophagus sphincter (LES) pressure and relaxation as compared with that in the control group (n = 52). Six of 9 patients with persistent dysphagia underwent a re-do antireflux procedure. Dysphagia as related to fundic mobilization (complete vs. partial) or bougie size (< 58 Fr. vs. > or = 58 Fr.) revealed no difference in the dysphagia ratings. CONCLUSIONS: Laparoscopic short Nissen fundoplication with or without fundic mobilization achieved an acceptable long-term dysphagia rate. Careful patient selection, identification of the short esophagus, and accurate construction of the fundoplication can lead to a decrease in the incidence of persistent postoperative dysphagia.
Adult↗