Is a bougie required for the performance of the fundal wrap during laparoscopic Nissen fundoplication?

BACKGROUND: It has been claimed that oesophageal intubation with a bougie during laparoscopic Nissen fundoplication (LNF) reduces the risk of a tight crural repair and wrap, and thereby decreases the prevalence of post-operative dysphagia. The aim of this study is to assess the benefit of routinely inserting a bougie during LNF, in relation to post-operative dysphagia. METHODS: All patients who underwent LNF by a single surgeon between March 2005 and March 2007 were reviewed. Oesophageal intubation during surgery was routinely performed in all patients who underwent LNF during the first 11 months of the study period, whilst during the second phase, routine oesophageal intubation was not performed. The main outcome measures were the prevalence of post-operative dysphagia and complication rates. Dysphagia severity was assessed clinically by a scoring system at discharge, and again at 6 weeks, 3 months, 6 months and 1 year. RESULTS: Forty patients had a bougie inserted (group 1) and 42 had no bougie (group 2). The mean age was 49.1 (SD, standard deviation +/- 8.1) years in group 1 and 49.4 (SD +/- 8.4) years in group 2 (p = 0.88). There were no major complications. When assessed at 12 weeks, 60% of group 1 and 51% of group 2 patients still had some degree of dysphagia (p = 0.635) but by 1 year dysphagia had resolved in all patients (p = 1.00). There was no significant difference in the median dysphagia scores between the two groups at: discharge (p = 0.181), 6 weeks (p = 0.234), 12 weeks (p = 0.504), 24 weeks (p = 0.182) or 1 year (p = 0.530). Analysis of the progression of dysphagia over the first post-operative year using Cox regression analysis did not show any significant difference between the two groups (p = 0.375). CONCLUSIONS: LNF can be safely performed without the routine use of an oesophageal bougie and this practice does not result in increased post-operative dysphagia rates.

The effect of laryngeal mask airway insertion on intraocular pressure measurement in children receiving general anesthesia.

PURPOSE: To study changes in intraocular pressure (IOP) in children while under general anesthesia before and after laryngeal mask airway (LMA) insertion. DESIGN: Prospective, comparative study. METHOD: IOP was measured in children after induction and one minute after LMA insertion. Children younger than 16 years who were scheduled to undergo elective ophthalmic surgery while receiving a general anesthetic were included. Children with a history of glaucoma or previous intraocular surgery were excluded. Data were collected on the age of the child, IOP, heart rate (HR), end tidal CO2, and blood pressure (BP) before and after LMA insertion. RESULTS: Sixty-six children with a mean age of 5.5 +/- 3.6 years (range, four months to 16 years) were included in the study. The mean IOP was 13.6 +/- 3.9 mm Hg and 13.6 +/- 3.6 mm Hg in right and left eyes, respectively, before LMA insertion and 15.5 +/- 3.8 mm Hg and 15.2 +/- 3.8 mm Hg in right and left eyes, respectively, after LMA insertion (P = .001). A decrease in BP was significantly associated with an increase in IOP (P = .008), and the interaction between the change in the BP, HR, and CO2 affected the change in IOP measured after insertion of the LMA (P = .04). There was no correlation between the age of the child and the change in IOP measured after insertion of the LMA. CONCLUSIONS: In our study, a small but significantly higher IOP was found after LMA insertion than before. It is recommended that the measurement of IOP in children receiving a general anesthetic is carried out before the insertion of the LMA.

Impact of retinopathy of prematurity screening examination on cardiorespiratory indices: a comparison of indirect ophthalmoscopy and retcam imaging.

PURPOSE: To compare the impact of retinopathy of prematurity (ROP) screening examination between a digital fundus camera and conventional binocular indirect ophthalmoscopy (BIO) using cardiorespiratory indices as a measure of distress. DESIGN: Prospective comparative (nonrandomized) interventional study. PARTICIPANTS: Eighty-six preterm infants with a birth weight of < or =1500 g or gestational age of < or =32 weeks and undergoing ROP screening were included. METHODS: Retinopathy of prematurity screening examination with BIO or the digital fundus camera was performed. Cardiovascular indices were recorded before, during, and 1 hour after examination. Race, birth weight, gender, twin status, duration of the examination, gestational age, and postconceptual age were recorded. MAIN OUTCOME MEASURES: Heart rate (HR), oxygen saturation, respiratory rate (RR), and mean blood pressure (BP). RESULTS: Thirty-four infants underwent indirect ophthalmoscopy, whereas 52 underwent digital fundus camera examination. The increase in HR and RR was significantly higher in the indirect ophthalmoscopy group than in the digital fundus camera group (P<0.05). There was a significant increase in HR and mean BP during examination in both groups (P<0.05). No clinically significant response persisted at 1 hour. Digital fundus camera examination took significantly longer (P<0.001). CONCLUSIONS: Screening for ROP with a digital fundus camera is associated with a significantly lower stress-related response than conventional indirect ophthalmoscopy.

Intermittent exotropia, overcorrecting minus lenses, and the Newcastle scoring system.

PURPOSE: We sought to determine whether the Newcastle Control Score (NCS) could be used to indicate a successful outcome in patients with intermittent exotropia that were treated with minus lenses. METHODS: We studied patients with an intermittent exotropia who were prescribed minus lens therapy in an effort to manage their strabismus conservatively. The NCS, which quantitatively estimates the control of an intermittent exotropia, was applied before treatment and 4 months after treatment. The results of minus lens therapy with a pretreatment NCS of > or =5 (group 1) were compared with those with a NCS of < or =4 (group 2). RESULTS: There were 24 patients (13 girls, 11 boys) treated with minus lenses. The mean age of the patients was 6.8 +/- 3.8 years (range, 2-17 years; median, 5). The mean pretreatment distance angle was 28.5 +/- 10 prism diopters (range, 6-45; median, 30) and the mean post-treatment distance angle was 18.3 +/- 8.9 prism diopters (range, 0-35; median, 18) P = 0.001. Using the NCS minus lenses significantly (P = 0.041) improved control of exotropia. In group 2 (n = 16) 75% had improved scores post-treatment compared with 62.5% in group 1 (n = 8), P = 0.68. CONCLUSIONS: These data suggest that the NCS is a useful method to indicate the success in the control of intermittent exotropia with conservative treatment with minus lens therapy.

Validity and ease of use of a computerized Hess chart.

PURPOSE: To investigate agreement between computerized and conventional methods for obtaining Hess charts and to compare relative ease of use of both methods. METHODS: Hess charts of 65 patients were obtained by the use of the computerized Assaf Ocular Motility Analyzer (OMA) and the conventional Lees screen method. The Hess charts produced by each method were compared with a previously described scoring system. Patients compared the ease of testing by using a 5-point Likert scale. RESULTS: For horizontal deviations of the right eye, the OMA provided a significantly larger (P = 0.0001) deviation (301° ± 267°) than the Lees screen (204° ± 306°). The Lees screen gave a significantly larger score for vertical deviations of the left eye (117° ± 158° vs 96° ± 129°; P = 0.003). Vertical deviations of the right eye and horizontal deviations of the left eye did not differ significantly between tests. Patients required the same amount of time to complete both tests, but the OMA was slightly easier to perform than the Lees screen (Likert score, 1.2 ± 0.5 vs 1.3 ± 0.4; P = 0.046). CONCLUSIONS: The scores measured were larger with OMA in the horizontal and smaller in the vertical direction than with the Lees screen in some directions. Although the OMA did not save time, patients found it easier to perform than the Lees screen. The OMA may be considered a useful alternative to the Lees screen.