The evolution and long-term results of laparoscopic antireflux surgery for the treatment of gastroesophageal reflux disease.

BACKGROUND: For nearly 2 decades, the laparoscopic correction of gastroesophageal reflux disease (GERD) has demonstrated its utility. However, the surgical technique has evolved over time, with mixed long-term results. We briefly review the evolution of antireflux surgery for the treatment of GERD, provide an update specific to the long-term efficacy of laparoscopic antireflux surgery (LARS), and analyze the factors predictive of a desirable outcome. MATERIALS AND METHODS: PubMed and Medline database searches were performed to identify articles regarding the laparoscopic treatment of GERD. Emphasis was placed on randomized control trials (RCTs) and reports with follow-up >1 year. Specific parameters addressed included operative technique, resolution of symptoms, complications, quality of life, division of short gastric vessels (SGVs), mesh repair, and approximation of the crura. Those studies specifically addressing follow-up of <1 year, the pediatric or elderly population, redo fundoplication, and repair of paraesophageal hernia and short esophagus were excluded. RESULTS: LARS has varied in technical approach through the years. Not until recently have more long-term, objective studies become available to allow for evidenced-based appraisals. Our review of the literature found no long-term difference in the rates of heartburn, gas-bloat, antacid use, or patient satisfaction between laparoscopic Nissen and Toupet fundoplication. In addition, several studies have shown that more patients had an abnormal pH profile following laparoscopic partial as opposed to total fundoplication. Conversely, dysphagia was more common following laparoscopic total versus partial fundoplication in 50% of RCTs at 12-month follow-up, though this resolved over time, being present in only 20% with follow-up >24 months. We confirmed that preoperative factors, such as hiatal hernia, atypical symptoms, poor antacid response, body mass index (BMI), and postoperative vomiting, are potential predictors of an unsatisfactory long-term outcome. Last, no trial disfavored division of the short gastric vessels (SGVs), closure of the crura, or mesh repair for hiatal defects. CONCLUSION: LARS has significantly evolved over time. The laparoscopic total fundoplication appears to provide more durable long-term results than the partial approach, as long as the technical elements of the operation are respected. Division of the SGVs, closure of the crura, and the use of mesh for large hiatal defects positively impacts long-term outcome. Hiatal hernia, atypical symptoms, poor antacid response, body mass index (BMI), and postoperative vomiting are potential predictors of failure in LARS.

Reduced tLESR elicitation in response to gastric distension in fundoplication patients.

Transient lower esophageal sphincter relaxations (tLESRs) are vagally mediated in response to gastric cardiac distension. Nine volunteers, eight gastroesophageal reflux disease (GERD) patients, and eight fundoplication patients were studied. Manometry with an assembly that included a barostat bag was done for 1 h with and 1 h without barostat distension to 8 mmHg. Recordings were scored for tLESRs and barostat bag volume. Fundoplication patients had fewer tLESRs (0.4 +/- 0.3/h) than either normal subjects (2.4 +/- 0.5/h) or GERD patients (2.0 +/- 0.3/h). The tLESRs rate increased significantly in normal subjects (5.8 +/- 0.9/h) and GERD patients (5.4 +/- 0.8/h) during distension but not in the fundoplication group. All groups exhibited similar gastric accommodation (change in volume/change in pressure) in response to distension. Fundoplication patients exhibit a lower tLESR rate at rest and a marked attenuation of the response to gastric distension compared with either controls or GERD patients. Gastric accommodation was not impaired with fundoplication. This suggests that the receptive field for triggering tLESRs is contained within a wider field for elicitation of gastric receptive relaxation and that only the first is affected by fundoplication.

The effect of glucagon-induced gastric relaxation on TLOSR frequency.

This study aimed to determine the effect of glucagon-induced gastric relaxation on the frequency of transient lower oesophageal sphincter relaxations (TLOSRs). Eight normal subjects (four male, age 18-52 y) were studied after a 6-h fast using a combined manometric barostat assembly. The recording was divided into two 1-h sessions: (1) a baseline period with the barostat set at minimal distending pressure (MDP) + 2 mmHg and (2) a period with continuous glucagon or placebo infusion with barostat set at MDP + 2 mmHg. Patients were studied on two different days and randomly received glucagon (4.8 microg kg(-1) bolus followed by 9.6 microg kg(-1) h(-1) infusion) on 1 day and placebo (saline) on another. Lower oesophageal sphincter (LOS) pressure, frequency of TLOSRs, and barostat bag volumes were determined for both placebo and glucagon infusion. Glucagon induced significant fundal relaxation compared with placebo (P < 0.05) and significantly decreased baseline LEOS pressure (P < 0.05). The frequency of TLOSRs was not altered by glucagon infusion compared with placebo. Despite causing substantial proximal stomach relaxation, glucagon did not increase TLOSR frequency. This suggests that the relevant gastric mechanoreceptors responsible for triggering TLOSRs do not respond to passive elongation.

Distinct patterns of oesophageal shortening during primary peristalsis, secondary peristalsis and transient lower oesophageal sphincter relaxation.

This study characterized oesophageal shortening during secondary peristalsis and transient lower oesophageal sphincter relaxation (TLOSR) in an attempt to determine its contribution to the opening mechanism. Eight healthy subjects (four males, 26 +/- 1 years) had metal clips affixed at 0, +3, and +8 cm relative to the squamocolumnar junction (SCJ), defining two distal oesophageal segments. Axial clip movement was assessed with concurrent videofluoroscopy and manometry during primary peristalsis, secondary peristalsis and TLOSR. Clip-defined oesophageal segment length change was measured at 0.5-s intervals. The magnitude of the most distal segment shortening was least with TLOSR, greatest with primary peristalsis and intermediate with secondary peristalsis. Conversely, maximal overall oesophageal shortening during TLOSR, evidenced by SCJ movement, was similar to that during primary peristalsis. In 3/12 TLOSRs, the moment of LOS opening and gas reflux was optimally imaged; SCJ excursion was 0.3 +/- 0.1 cm prior to LOS opening and 1.4 +/- 0.7 cm immediately after gas reflux. The segmental pattern of oesophageal shortening was distinct during primary peristalsis, secondary peristalsis and TLOSR. During TLOSR, significant elevation of the SCJ occurred only after LOS opening, suggesting that this was a consequence of oesophageal distension induced by gas reflux rather than a component of the opening mechanism.

Indications and results of liver resection and hepatic chemoembolization for metastatic gastrointestinal neuroendocrine tumors.

BACKGROUND: We reviewed 36 patients with liver metastases from islet cell tumors of the pancreas (n = 18) and carcinoid tumors (n = 18) who were treated with surgical resection (n = 16) or hepatic chemoembolization (n = 20). METHODS: All resections were complete and included 4 lobectomies, 6 segmental resections, and 6 wedge resections. There were no operative deaths. RESULTS: Median survival has not yet been reached, and the actuarial 5-year survival rate is 70%. Prognostic variables associated with improved disease-free survival included prior resection of the primary tumor and 4 or fewer metastases resected (P <.05). With an average of 3 chemoembolization procedures per patient, 17 of 20 patients (90%) demonstrated either a significant radiographic response (n = 5), stabilization of tumor mass (n = 2), or improvement of clinical symptoms (n = 10). Factors related to a sustained response (more then 1 year) included surgical resection of the primary tumor, 4 or more chemoembolization procedures, and liver metastases of 5 cm or smaller. Median survival after treatment was 32 months (range, 7-63 months), and the actuarial 5-year survival rate was 40%. CONCLUSIONS: Surgical resection of metastatic neuroendocrine tumors provides the best chance for extended survival. Chemoembolization effectively improves clinical symptoms and, in selected patients, may provide sustained tumor control.

Manometric heterogeneity in patients with idiopathic achalasia.

BACKGROUND & AIMS: In certain cases of achalasia, particularly those in early stages with minimal endoscopic or radiographic abnormalities, the diagnosis may rely on manometry, which is the most sensitive test for the disease. The aim of this study was to critically evaluate the manometric criteria in a population of patients with idiopathic achalasia. METHODS: Clinical histories and manometric recordings of 58 patients with idiopathic achalasia and 43 control subjects were analyzed with regard to esophageal body contraction amplitude, peristaltic effectiveness in terms of both completeness and propagation velocity, lower esophageal sphincter (LES) resting pressure, LES relaxation pressure, and intraesophageal-intragastric pressure gradient. Variants of achalasia were defined by finding manometric features that significantly differed from the remainder of achalasia patients, such that the diagnosis might be questioned. RESULTS: Four manometrically distinct variants were identified. These variants were characterized by (1) the presence of high amplitude esophageal body contractions, (2) a short segment of esophageal body aperistalsis, (3) retained complete deglutitive LES relaxation, and (4) intact transient LES relaxation. In each instance, the most extreme variant is discussed and compared with the remainder of the achalasia population and with controls. CONCLUSIONS: The significance in defining these variants of achalasia lies in the recognition that these sometimes confusing manometric findings are consistent with achalasia when combined with additional clinical data supportive of the diagnosis. Furthermore, such variants provide important clues into the pathophysiology of this rare disorder.

Decreased type IV collagenase activity in experimental pancreatic fibrosis.

BACKGROUND: Severe hyperstimulation and duct obstruction pancreatitis (SHOP) is characterized by pancreatic fibrosis and loss of acinar cell mass. MMP-2 and MMP-9 are type IV collagenases and gelatinases. We hypothesized that fibrosis results from disruption of the normal collagen homeostasis and that altered activity of the type IV collagenases may contribute to pancreatic fibrosis in SHOP. METHODS: SHOP rats (n = 15) were prepared with pancreatic duct obstruction and cerulein (50 microg/kg/d, ip) hyperstimulation. Pancreas from unoperated control (n = 8), 48 h SHOP (n = 8), and 96 h SHOP (n = 7) rats was harvested, homogenized, and assayed for protein concentration (BCA method). Type IV collagenase (MMP-2 and MMP-9) expression was measured by zymography using gelatin as substrate. Type IV collagenase activity was quantified with a fluorescence assay. RESULTS: Expression of the active form of MMP-9 decreased while latent MMP-9 and active and latent MMP-2 increased on gelatin zymography. Activity of type IV collagenases (MMP-2 and MMP-9) progressively decreases with SHOP injury. The differences between expression and activity are likely due to posttranslational regulators such as MT-MMPs and TIMPs. CONCLUSIONS: Collagenase expression and activity are decreased in the SHOP model of pancreatitis, suggesting a decrease in the homeostatic mechanisms for type IV collagen in the extracellular matrix. Therefore, early fibrosis in the SHOP model is, at least in part, due to alterations in collagen homeostasis and not simply increased collagen production.

Primary gastrointestinal sarcomas: analysis of prognostic factors and results of surgical management.

BACKGROUND: This study was done to review the clinical presentation, surgical management, and prognostic factors for primary gastrointestinal sarcomas. METHODS: We reviewed medical records of 55 patients who were treated for primary gastrointestinal sarcomas from 1981 through 1996. Mean follow-up time was 32 months. RESULTS: Clinical findings included gastrointestinal bleeding (51%), palpable mass (36%), and abdominal pain (33%). The stomach was the most common site of disease (53%), followed by the small intestine (33%). Tumors were high grade in 76% of patients and low-grade in 24% of patients. Complete resection of all gross disease was accomplished in 35 patients (64%), incomplete resection in 17 patients (31%), and biopsy only in 3 patients (5%). Adjacent organ resection was required in 19 patients (35%). Overall actuarial survival was 22% (median survival, 32 months). Unfavorable prognostic factors were incomplete resection, high-grade histologic features, and tumor size of 5 cm or more (P<.05). En bloc resection of contiguous organs did not adversely effect survival. In patients with complete resections, tumor grade was the most important prognostic factor (median survival, 55 months vs 19 months for low-grade vs high-grade tumors; P<.05). CONCLUSIONS: Aggressive surgical resection, including en bloc resection of locally advanced tumors, appears warranted. Despite complete resections, patients with high-grade tumors remain at risk for recurrence.

Laparoscopic live donor nephrectomy--is it safe?

BACKGROUND: Laparoscopic live donor nephrectomy (LDN) is a less invasive alternative to open nephrectomy (ODN) for living kidney donation. Concerns have been raised regarding the safety of LDN, the short and long term function of kidneys removed by LDN, and a potential higher incidence of urologic complications in LDN transplant recipients. METHODS: Between October 1997 and May 1999, 80 LDNs were performed at our center. All patients were followed longitudinally with office visits and telephone interviews. These LDNs were compared with 50 ODN performed from January 1996 to October 1997. RESULTS: LDN procedures took significantly longer than ODN (4.6 vs. 3.1 hr). However, LDN was associated with significant reduction in i.v. narcotic use, a rapid return to diet, and shorter hospital stay. Of the 80 LDN procedures, a total of 75 (94%) were completed laparoscopically. Five patients were converted to laparotomy: three for hemorrhage and two for complex vascular anatomy. ODN conversion was associated with large donor body habitus and/or obesity. Seven LDN patients had minor complications and 4 had major complications. All major complications consisted of vascular injuries (2 lumbar vein injuries, 1 renal artery, and 1 aortic injury). All patients made complete recoveries. All LDN kidneys functioned immediately posttransplant. We have observed 100% patient and 97% 1-year actuarial graft survival in LDN transplant recipients. There have been no short-or long-term urologic complications in this series. CONCLUSION: With increasing experience and standardization of technique, LDN is a safe and effective procedure. Patients undergoing LDN demonstrate clinically significant, more rapid postoperative recoveries and shorter hospital stays than ODN patients. Excellent initial graft function and long-term graft survival have been observed with LDN kidneys. Urologic complications can be avoided. LDN has become the preferred surgical approach for living kidney donation at our center.

Bolus transit assessed by an esophageal stress test in postfundoplication dysphagia.

INTRODUCTION: Dysphagia is common after Nissen fundoplication but the relationship between dysphagia and bolus transit is poorly defined. This study compared bolus transit of fundoplication patients to normal individuals. METHODS: Twelve fundoplication patients and 20 healthy volunteers rated their ability to swallow eight bolus consistencies from no difficulty (0) to extreme difficulty (3) to compute a dysphagia score (range = 0-24). A 16-lumen manometric assembly was positioned across the esophagogastric junction (EGJ) and subjects were imaged fluoroscopically in a supine posture while swallowing 5 cc liquid barium and a 5-cc marshmallow-like viscoelastic barium bolus. Videofluoroscopic images were analyzed for total esophageal transit time and the fraction of time required to cross the EGJ. Manometric tracings were analyzed for the intrabolus pressure proximal to the EGJ, intragastric pressure, and distal peristaltic amplitude for each bolus. RESULTS: Dysphagia scores for fundoplication patients were significantly higher (7.3 +/- 5.1, range = 1-17) than for normals (0.5 +/- 0.6, range = 0-2). This correlated with longer total transit times for liquids and solids (r = 0.60, P < 0.01) and a greater percentage of transit time attributable to the EGJ transit. Retrograde flow at the EGJ (escape of bolus proximally up the esophagus) and peristaltic dysfunction were more frequent in fundoplication patients. However, no differences existed in manometric parameters between groups. CONCLUSIONS: Fundoplication impairs both liquid and solid esophageal bolus transit. Dysphagia perceived by fundoplication patients correlated with increased transit time, particularly across the EGJ. Combined quantitative evaluation with manometry and fluoroscopy reveals functional defects in fundoplication subjects, which are not evident by either modality alone.

Increased frequency of transient lower esophageal sphincter relaxation induced by gastric distention in reflux patients with hiatal hernia.

BACKGROUND & AIMS: This study aimed to determine if hiatal hernia influences vulnerability to reflux and transient lower esophageal sphincter relaxation (tLESR) during gastric distention in patients with gastroesophageal reflux disease (GERD). METHODS: Eight normal subjects and 15 patients with GERD were studied. A metal clip attached to the squamocolumnar junction (SCJ) was beneath the hiatus in all control subjects. Eight GERD patients with >/=1-cm SCJ-hiatus separation were considered hernia patients, and 7 with <1-cm separation were considered nonhernia patients. Manometry and esophageal pH were recorded for 30 minutes, after which the stomach was loaded with acid dextrose and the recording continued for 2 hours with intragastric air infusion of 15 mL/min. RESULTS: Baseline reflux was comparable among groups. Gastric distention increased the frequency of reflux by the tLESR mechanism in all groups. Controls and nonhernia patients had median increases of 4.0 and 4.5 in tLESR frequency, respectively, and hernia patients had a median increase of 9.5/h. tLESR frequency was highly correlated with the SCJ-hiatus separation (r = 0.76; P < 0.001). CONCLUSIONS: Gastric air infusion was a potent stimulus for tLESR and reflux. The resultant tLESR frequency was directly proportional to the separation between the SCJ and hiatus, suggesting that the perturbed anatomy associated with hiatal hernia predisposed to eliciting tLESRs in patients with GERD.

Esophagogastric junction pressure topography after fundoplication.

OBJECTIVES: This study compared the pressure topography after laparoscopic Nissen fundoplication to that of normal subjects and patients with hiatal hernia and reflux disease. METHODS: Seven patients with fundoplication, 7 normal subjects and 7 patients with hiatal hernia, were studied. The squamocolumnar junction and intragastric margin of the esophagogastric junction (EGJ) were marked with metal clips. Axial and radial characteristics of EGJ pressure were mapped relative to the hernia and clipped during concurrent fluoroscopy and manometry. Responses to inspiration and abdominal compression were also analyzed. RESULTS: Fundoplication modifies the EGJ by restoration of the hiatal component of EGJ pressure and elongation of the subdiaphragmatic component. Maximal EGJ pressure after fundoplication is mainly dependent on the extrinsic effect of the hiatal canal that compresses the esophagus; the resultant length of the EGJ reflects the length of the fundic wrap. Integrity of the EGJ after fundoplication is independent of the intrinsic lower esophageal sphincter itself. CONCLUSIONS: Fundoplication alters the pressure topography of the EGJ by reducing the hiatal hernia, tightening the hiatal orifice, and constructing a subdiaphragmatic wrap of variable length. Each effect depends on different technical aspects of the surgery with the potential of substantial variability in the resultant pressure topography.

Operative manometry and endoscopy during laparoscopic Heller myotomy. An initial experience.

BACKGROUND: We report our initial experience using operative esophageal manometry as an adjunct to endoscopy to determine the completeness of esophagogastric high-pressure zone (HPZ) obliteration during laparoscopic Heller myotomy. METHODS: Between July 1997 and October 1998, we performed laparoscopic Heller myotomies in 20 patients (eight male, 12 female; median age, 41 years). Mean duration of symptoms was 3.2 +/- 2.6 years (r = 0.5-11), and 45% of the patients had received prior dilation or toxin injection. A 16-channel esophageal manometry catheter was placed prior to anesthesia, with sites crossing the lower esophageal sphincter (LES). An endoscope was passed intraoperatively to localize the squamocolumnar junction, and the myotomy was performed. While the translucency was imaged in the area of the incision, we determined the adequacy of myotomy by visual assessment of LES and gastric cardia opening in response to endoscopic air insufflation. Manometry was then performed to detect any potential residual high pressure at the myotomized esophagogastric junction (EGJ). If it was found, the locus of persistent pressure was identified by probing along the myotomy, and residual muscle fibers were cut to yield a minimum pressure at the EGJ. RESULTS: A persistent HPZ was identified after the initial myotomy in 10 of 20 patients (50%). A Dor fundoplasty completed the operation. The mean operating time was 2.6 +/- 0.5 h (median, 2.5; r = 2-3.5 h), and the mean hospital stay was 1.6 +/- 1 days (median, 1, r = 1-5 days). The mean LES pressure was 2 +/- 3 mmHg immediately postmyotomy (p < 0.001 compared with preoperative value). Of 20 patients, only two have reported recurrence of dysphagia (10%). One had a recurrent HPZ on manometry, and one developed esophagitis, which resolved with omeprazole. CONCLUSIONS: Our initial experience suggests that operative esophageal manometry is a useful adjunct to upper endoscopy during laparoscopic Heller myotomy, quantitatively assuring obliteration of the nonrelaxing LES and HPZ.

Results of gastric interposition for reconstruction of the pharyngoesophagus.

BACKGROUND: Free jejunal transfer has become the standard technique for reconstruction of the proximal pharynx and hypopharynx. Gastric tube interposition is an effective alternative when resection extends below the thoracic inlet. This study was done to determine current indications, review morbidity and mortality rates, and to define clinical and pathologic determinants of survival associated with this procedure. METHODS: We reviewed the records of 32 patients who underwent gastric tube interposition for reconstruction of the pharyngoesophagus from 1987 to 1997. RESULTS: The overall complication rate was 50%. Complications were more frequent in the reoperative group (22% vs 66%, P < .05). The overall fistula rate was 31%. The overall mortality rate was 12%. Ultimately, 71% of patients resumed oral feedings. The 5-year actuarial survival rate was 22%. Unfavorable prognostic factors associated with significantly reduced survival (P < . 05) included margin positive resection, positive lymph node involvement, and operations done for recurrent tumor CONCLUSIONS: Reconstruction of the pharyngoesophagus with gastric tube interposition is indicated for primary tumors of the hypopharynx and cervical esophagus with inferior extension below the thoracic inlet and recurrent tumors or benign strictures in which free jejunal transfer is not feasible or has failed. It can be done with acceptable morbidity and mortality and provides reasonable expectations for long-term survival and resumption of oral intake.

Gangrenous cholecystitis: analysis of risk factors and experience with laparoscopic cholecystectomy.

BACKGROUND: Gangrenous cholecystitis occurs in up to 30% of patients admitted with acute cholecystitis. Factors predicting gangrenous disease in patients with acute cholecystitis remain poorly defined, making preoperative diagnosis difficult. Identification of these factors and early diagnosis of gangrenous cholecystitis will indicate more aggressive treatment, earlier operation, and a lower threshold for conversion of laparoscopic to open cholecystectomy. METHODS: We reviewed our experience with acute cholecystitis during the 2-year period of 1995 to 1996. Admitting history, physical examination, operative report, laboratory and radiology data, and pathology report were analyzed for each patient. Acute cholecystitis and its gangrenous complication were diagnosed by both gross and microscopic examination. RESULTS: One hundred fifty-four patients were admitted to the hospital with acute cholecystitis and underwent cholecystectomy; gallbladder gangrene was found in 27 (18%) of these patients. Four patients with gallbladder gangrene underwent open cholecystectomy and 23 patients underwent laparoscopic cholecystectomy, of which 15 (65%) were completed laparoscopically and 8 (35%) had open conversion as a result of severe inflammation. Risk factors for gallbladder gangrene included male gender, age older than 50 years, history of cardiovascular disease, and leukocytosis greater than 17,000 white blood cells/mL. CONCLUSIONS: Older male patients (age older than 50 years) with history of cardiovascular disease, leukocytosis greater than 17,000 white blood cells/mL, and acute cholecystitis have increased risk of gallbladder gangrene and conversion of laparoscopic cholecystectomy to open cholecystectomy. Urgent laparoscopic cholecystectomy with low threshold for conversion to open cholecystectomy should be considered in these patients at high risk for gallbladder gangrene.

Altered gallbladder bile acidification with long-term total parenteral nutrition.

BACKGROUND: An important function of the gallbladder is to acidify and concentrate bile. Acidification helps protect against the precipitation of calcium salts, which promote gallstone formation. Altered acidification may result in pigment gallstones. We investigated gallbladder composition in a model of TPN-associated pigment gallstones to test whether changes in acidification may be important in this gallstone model. MATERIALS AND METHODS: Ten miniswine were intravenously fed for 21 to 27 days (mean 23 days). Ten fed pig chow with intravenous infusion of saline served as controls. Gallbladder and hepatic bile electrolytes, lipids, pH, and pCO2 were measured. RESULTS: All animals remained healthy and gained weight. Hepatic bile electrolytes and pH were similar among all animals. Pigs on TPN had a higher gallbladder pH and the [H+] was half the value of controls [8.1 +/- 1.6 x 10(-8) meq/liter (control) versus 3.9 +/- 0.7 x 10(-8) meq/liter (TPN)]. Gallbladder bile pCO2, sodium (Na), and potassium were higher in controls. Biliary lipids [bile salts (BS), phospholipids, and cholesterol] with TPN were decreased in both hepatic and gallbladder bile. CONCLUSIONS: Unlike short-term TPN where gallbladder pH and [BS] are similar, with long-term TPN pH is higher with lower [H+], [Na], and [BS]. Despite a presumed longer residence time in the gallbladder, intravenous feeding without oral intake results in gallbladder bile that is less concentrated and acidified. Enteral stimulation may be an important stimulus for gallbladder acidification and periods without feeding may promote gallstone formation by increasing the pH of gallbladder bile.

A learning curve for laparoscopic splenectomy at an academic institution.

BACKGROUND: Laparoscopic splenectomy is emerging as the standard for treatment of benign splenic disorders. Since splenectomy is indicated relatively infrequently, issues arise concerning training of surgeons to perform laparoscopic splenectomy. Our experience with 50 laparoscopic splenic procedures is reported with emphasis on the learning curve at an academic institution. MATERIALS AND METHODS: Data were prospectively collected on 50 consecutive patients undergoing attempted or successful laparoscopic surgical procedures on the spleen at Northwestern Memorial Hospital or The Chicago Health Care System, Lakeside Division, from April 1993 to April 1998, and on 5 patients undergoing open splenectomy from April 1993 to October 1995. Outcomes including conversion rate, operative time, day feedings were tolerated, and length of hospital stay was examined and correlated with the number of attempted cases. RESULTS: Laparoscopic splenectomy progressed from an operation requiring two advanced laparoscopic surgeons to one performed by carefully supervised senior residents. Success rates increased from 60% initially to greater than 95% recently. Likewise, operative time decreased significantly from 195 to 97 min, while length of stay declined from 2.5 to 1.5 days. High success rates, low operative times, and short length of stays were achieved during the last 20 patients while surgical residents were taught to perform the procedures. The reasons for improvement are multifactorial including use of the harmonic scalpel, a change to the lateral position, and increasing experience with the procedure. CONCLUSIONS: Laparoscopic splenectomy is a safe and effective procedure that reduces postoperative length of hospital stay. It can be performed successfully in most patients with operative times comparable to those of open splenectomy. Moreover, the procedure can (and should) be taught to residents once they master basic and advanced laparoscopic skills.

Esophageal sensitivity and symptom perception in gastroesophageal reflux disease.

Patients with gastroesophageal reflux disease (GERD) experience a wide spectrum of symptoms, varying both in quality and severity. This review summarizes clinical observations of esophageal sensitivity and symptom perception in GERD patients. The Bernstein test, although lacking standardization, remains a useful tool in determining esophageal sensitivity to acid stimuli. Ambulatory 24-hour pH monitoring with symptom event marking and subsequent symptom-reflux correlation between acid reflux events and esophageal symptomatology now provides an alternative method for establishing esophageal acid sensitivity. The intraesophageal balloon distention test (IEBD) was developed to assess esophageal sensitivity to mechanical stimuli. Variants of each of these tests have been applied to the evaluation of uncomplicated GERD patients and patients with esophagitis and Barrett's metaplasia, who generally demonstrate less esophageal sensitivity than the former group. Studies using these methods have demonstrated increased esophageal sensitivity in patients with esophageal chest pain and have also identified a subset of patients with esophageal symptoms yet normal esophageal acid exposure, a condition referred to as "hypersensitive esophagus." The Bernstein test, 24-hour pH monitoring with symptom assessment, and IEBD have each contributed to our understanding of esophageal pain syndromes; it is hoped that future work in this area will lead to improved and more specific therapy for these patients.

Impact of fundoplication on bolus transit across esophagogastric junction.

This study analyzed the effect of fundoplication on the mechanics of liquid and solid bolus transit across the esophagogastric junction (EGJ). The squamocolumnar junction was endoscopically clipped in seven controls, seven hiatal hernia patients, and seven patients after laparoscopic Nissen fundoplication. Concurrent manometry and fluoroscopy were done during swallows of liquid barium and a 13-mm-diameter marshmallow. The EGJ opening, pressure gradients, transit efficacy, and axial motion were measured. The axial motion of the EGJ was reduced in the fundoplication and hiatal hernia patients. The opening dimensions at the squamocolumnar junction were similar among groups, but in each case the constriction limiting flow to the stomach was at the hiatus and this was substantially narrowed with fundoplication. As a result, liquid intrabolus pressure was increased and marshmallow transit frequently required multiple swallows. We conclude that fundoplication limits the axial mobility of the EGJ and leads to a restricted hiatal opening. These alterations decrease the efficacy of solid and liquid transit into the stomach and are potential causes of dysphagia in this population.

Bilateral adrenal cortical adenomas in primary hyperaldosteronism.

Bilateral adrenal cortical adenomas in the presence of primary hyperaldosteronism is an extremely rare condition. We present a case of primary hyperaldosteronism in which a unilateral hypersecreting aldosterone-producing adenoma coexisted with a large, contralateral adrenal mass ultimately found to be consistent with cortical adenoma. Management consisted of total adrenalectomy and enucleation of adenoma from the opposite adrenal. The patient is normotensive 3 years after surgery. Enucleation as a successful approach to hyperfunctioning cortical adenomas is proposed.