Do patients with gastroesophageal reflux disease and somatoform tendencies benefit from antireflux surgery?

BACKGROUND: The clinical presentation of gastroesophageal reflux disease (GERD) shows a large symptom variation also in different intensities among patients. As several studies have shown, there is a large overlap in the symptomatic spectrum between proven GERD and other disorders such as dyspepsia, functional heartburn and/or somatoform disorders. AIM: To prospectively evaluate the GERD patients with and without somatoform disorders before and after laparoscopic antireflux surgery. METHODS: In a tertiary referral center for foregut surgery over a period of 3 years patients with GERD, qualifying for the indication of laparoscopic antireflux surgery, were investigated prospectively regarding their symptomatic spectrum in order to identify GERD and associated somatoform disorders. Assessment of symptoms was performed by an instrument for the evaluation of somatoform disorders [Somatoform Symptom Index (SSI) > 17]. Quality of life was evaluated by Gastrointestinal Quality of Life Index (GIQLI). RESULTS: In 123 patients an indication for laparoscopic antireflux surgery was established and in 43 patients further medical therapy was suggested. The portion of somatoform tendencies in the total patient population was 20.48% (34 patients). Patients with a positive SSI had a preoperative GIQLI of 77 (32-111). Patients with a normal SSI had a GIQLI of 105 (29-140) (P < 0.0001). In patients with GERD the quality of life could be normalized from preoperative reduced values of GIQLI 102 (47-140) to postoperative values of 117 (44-144). In patients with GERD and somatoform disorders, the GIQLI was improved from preoperative GIQLI 75 (47-111) to postoperative 95 (44-122) (P < 0.0043). CONCLUSION: Patients with GERD and associated somatoform disorders have significantly worse levels of quality of life. The latter patients can also benefit from laparoscopic fundoplication, however they will not reach a normal level.

Post-epilepsy surgery psychogenic nonepileptic seizures.

OBJECTIVES: We investigated the prevalence of post-epilepsy surgery psychogenic nonepileptic seizures (PNES) in patients with drug-resistant epilepsy and the possible influence of risk factors on these seizures. METHODS: In this retrospective study, we examined data from all patients with a clinical diagnosis of drug-resistant epilepsy who underwent epilepsy surgery at Graduate Hospital and the Jefferson Comprehensive Epilepsy Center between 1986 and 2016. Postsurgical outcome was identified for up to 15 years after surgery. Diagnosis of PNES was verified in the epilepsy monitoring unit with video-electroencephalography (EEG) ictal recording. Potential associated factors were assessed by comparing patients with or without postoperative PNES. RESULTS: A total of 1,105 patients were studied; 697 patients had postoperative seizures, and, of these, 27 patients (3.9%) had documented PNES after surgery. A full-scale intelligence quotient (IQ) <80 was significantly associated with post-epilepsy surgery PNES (odds ratio [OR] 2.89, p = 0.007, 95% confidence interval [CI] 1.33-6.29). A history of a preoperative psychiatric diagnosis was also significantly associated with post-epilepsy surgery PNES (OR 4.67, p = 0.0001, 95% CI 2.01-10.82). Other factors were not significantly associated with post-epilepsy surgery PNES. SIGNIFICANCE: Post-epilepsy surgery PNES should be considered when patients report recurrent seizures after epilepsy surgery. Although these seizures probably occur relatively infrequently, attention to factors such as appearance of new ictal behaviors, a preoperative history of a psychiatric disorder, and a low full-scale IQ should raise suspicion and lead to appropriate diagnostic measures.

Impact of psychogenic nonepileptic seizures on epilepsy presurgical investigation and surgical outcomes.

INTRODUCTION: We sought to determine the percentage of patients undergoing presurgical assessment that had both psychogenic nonepileptic seizures (PNESs) and epileptic seizures (ESs) captured within our telemetry unit and how this affected progression to surgery and describe eventual outcomes in patients with a history of mixed PNESs/ESs who underwent surgery. MATERIAL AND METHODS: To determine what happened to patients who had PNESs recorded during a presurgical workup, we reviewed the records of 725 patients admitted to our telemetry unit for presurgical assessment between 2007 and 2013 and identified those with PNESs and ESs recorded. To determine outcomes postsurgery in operated patients who had mixed PNESs/ESs, we also reviewed the records of 519 patients who had had epilepsy surgery between 1999 and 2012 and identified those within this group who also had PNESs prior to surgery. RESULTS: Nineteen of the 725 patients had PNESs captured during their presurgical telemetry along with ESs captured on either this or a previous study. Four of these patients were ultimately offered surgery. Nine of the 519 patients with a history of PNESs underwent epilepsy surgery. At 1 to 5years of follow-up (mean: 4.1years) of those nine patients, five were still having ESs and three patients had worsening or new-onset PNESs. At the last follow-up, four had had a worthwhile improvement. DISCUSSION: This study suggests that recent outcomes for people with mixed PNESs/ESs are not as promising as previously described and that PNESs should remain a relative contraindication for surgery.

Nonpsychiatric medical treatment of body dysmorphic disorder.

Many individuals with body dysmorphic disorder seek nonpsychiatric medical and surgical treatment to improve perceived defects in their physical appearance. However, the types of treatments sought and received, as well as the treatment outcome, have received little investigation. This study describes the frequency, types, and outcomes of treatments sought and received by 200 individuals with body dysmorphic disorder. Treatment was sought by 71.0% and received by 64.0%. Dermatological treatment was most frequently sought and received (most often, topical acne agents), followed by surgery (most often, rhinoplasty). Twelve percent of the subjects received isotretinoin. Such treatment rarely improved body dysmorphic disorder. Thus, nonpsychiatric medical treatments do not appear effective in its treatment.

Augmentation phalloplasty surgery for penile dysmorphophobia in young adults: considerations regarding patient selection, outcome evaluation and techniques applied.

OBJECTIVES: To report on the efficacy and safety of augmentation phalloplasty procedures in physically normal young men, to introduce a patient selection and outcome evaluation questionnaire as well as, to propose a surgical technique modification. METHODS: Eleven (11) out of 28 psychosomatically normal men (25-35 years) who presented complaining of penile dysmorphophobia (subjective perception of small penis), were subjected to: (a) penile lengthening (suprapubic skin advancement--ligamentolysis): n=5, (b) penile lengthening and shaft thickening (free dermal-fat graft shaft coverage): n=3 and (c) panniculectomy--suprapubic lipectomy and penile lengthening: n=2. A self administered questionnaire was employed in order to facilitate selection of the patients qualifying for the operation as well as to evaluate the outcome. In addition, a technical modification regarding dermal-fat graft handling was applied. RESULTS: The postoperative course was uneventful with minor complications. The mean penile length gain (flaccid--stretched penis) was 1.6 cm (1-2.3 cm) [p=0.0014], the mean circumference gain was 2.3 cm [p=0.003] at the base and 2.6 cm [p=0.0012] subcoronaly. Significant (20%-53%) [p<0.0001] sexual self-esteem and functioning improvement was reported by the majority (91%) of patients. CONCLUSIONS: Although penile size alteration was not spectacular or satisfying the patients' "great" expectations, the substantially uneventful clinical course coupled with the significant improvement in sexual self-esteem and function and the highly accepted outcome by the patients, render augmentation phalloplasty reasonable treatment modality for the management of strictly selected and thoroughly informed young adults who suffer from penile dysmorphophobia.

Posterior decompression and stabilization for metastatic spine diseases.

BACKGROUND: The purpose of this study was to investigate the clinical results of posterior decompression and stabilization for metastatic diseases of the thoracolumbar spine. METHODS: From 1980 to 2001, 70 consecutive patients with spinal metastases underwent palliative surgery by posterior decompression of spinal cord and subsequent stabilization with instrumentation. There were 38 women and 32 men. Their ages ranged from 24 to 75 years (mean 58 years). We retrospectively reviewed medical records to analyze their survival, clinical presentations, image findings and surgical outcomes. RESULTS: Sixty-one patients (87%) survived longer than 3 months. Forty-nine patients (70%) survived longer than 6 months, of whom 35 patients were still alive at an average of 24 months (range 13-40 months) after surgery. All maintained spinal stability postoperatively. Forty-seven of 60 patients (78.3%) with severe pain obtained significant symptomatic relief for 3 months or more, and 38 of 54 (70.1%) paralyzed patients gained neural improvement. Of the 60 patients bedridden before surgery due to pain or paresis, 36 patients (60%) experienced an increase in activity tolerance. CONCLUSIONS: The results of this study shows that neurological recovery, pain relief and mobility can be enhanced by posterior decompression and stabilization in highly selective patients with spinal metastases.

Psychological issues in patient outcomes.

This article provides an overview of the psychological issues of facial plastic surgery patients. It begins with a review of the research on the preoperative psychological characteristics of cosmetic surgery patients. Results from the studies assessing postoperative changes in psychological status are reviewed. The psychological issues of specific patient groups, including adolescents and male patients, are discussed. Individuals who undergo plastic surgical procedures as a result of craniofacial anomalies or facial injuries often face a myriad of psychosocial challenges. These issues are outlined in brief. The article concludes with a discussion of two psychiatric conditions, body dysmorphic disorder and posttraumatic stress disorder, that may be frequently encountered by facial plastic surgeons.

Does cosmetic surgery improve psychosocial wellbeing?

Both men and women are becoming increasingly concerned about their physical appearance and are seeking cosmetic enhancement. Most studies report that people are generally happy with the outcome of cosmetic procedures, but little rigorous evaluation has been done. More extensive ("type change") procedures (eg, rhinoplasty) appear to require greater psychological adjustment by the patient than "restorative" procedures (eg, face-lift). Patients who have unrealistic expectations of outcome are more likely to be dissatisfied with cosmetic procedures. Some people are never satisfied with cosmetic interventions, despite good procedural outcomes. Some of these have a psychiatric disorder called "body dysmorphic disorder".

Surgical and nonpsychiatric medical treatment of patients with body dysmorphic disorder.

It appears that many individuals with body dysmorphic disorder (BDD) receive nonpsychiatric medical treatment and surgery; however, this topic has had little systematic investigation. This study assessed the nonpsychiatric treatment sought and received by 289 individuals (250 adults and 39 children/adolescents) with DSM-IV BDD. Such treatment was sought by 76.4% and received by 66.0% of adults. Dermatologic treatment was most often received (by 45.2% of adults), followed by surgery (by 23.2%). These treatments rarely improved BDD symptoms. Results were similar in children/adolescents. These findings indicate that a majority of patients with BDD receive nonpsychiatric treatment but tend to respond poorly.

Cross-cultural understanding of aesthetic surgery: the male cosmetic surgery patient in japan and the USA.

This review describes the historical development of aesthetic surgery in Japan and parallels with the development of the specialty in the United States. The focus is on the consequences of aesthetic surgery in the male patient when collaboration between mental health clinicians and surgeons lags. The cultural, social, and psychological issues raised are relevant to the diverse cultural groups now seeking aesthetic surgery in the United States. Case illustrations are a reminder to aesthetic surgeons of the potential need for more comprehensive evaluation in the group of male patients who may be at added risk for negative outcomes in terms of satisfaction.

Body image dissatisfaction and body dysmorphic disorder in 100 cosmetic surgery patients.

This study was the first empirical investigation of body image dissatisfaction and body dysmorphic disorder in cosmetic surgery patients. Of 132 women, 100 women (response rate, 76 percent) completed two body image measures prior to surgery, the Multidimensional Body-Self Relations Questionnaire and the Body Dysmorphic Disorder Examination Self-Report. Cosmetic surgery patients did not demonstrate greater dissatisfaction with their overall appearance compared with the reported normal values of the measures. However, when asked about the specific bodily feature they were considering for cosmetic surgery, they reported significantly greater dissatisfaction than a normative sample. In addition, 7 percent of the sample met diagnostic criteria for body dysmorphic disorder, a potential psychiatric contraindication to cosmetic surgery. Implications of these findings are discussed with respect to the nature of body image dissatisfaction and the prevalence of body dysmorphic disorder in cosmetic surgery populations.

The "obsessive" cosmetic surgery patient: a consideration of body image dissatisfaction and body dysmorphic disorder.

"Obsessive" cosmetic surgery patients often present as "hyper-focused" on their appearance. We may best be able to understand these patients through examining their thoughts and feelings about their body image. This paper reviews the relationship between physical appearance, body image dissatisfaction, and the pursuit of cosmetic surgery. An extreme form of body image dissatisfaction, Body Dysmorphic Disorder (BDD), which may characterize many "obsessive" patients, is also discussed. Recommendations for assessing patients' body image concerns include a comprehensive history as well as specific questions about appearance-related concerns.

Somatoform pain disorder in a case of Klinefelter's syndrome with multiply operated lower back.

We report a case of Klinefelter's syndrome with multiply operated low back (MOB). Psychological and/or psychosocial problems related to MOB have been of recent interest in the field of orthopedic surgery. Based on psychiatric interviews, this case was diagnosed as a somatoform pain disorder of the DSM-III-R somatoform disorders. In addition to psychological problems, the pain was partly explicable by severe osteoporosis, which was prematurely caused by endocrinological disturbances associated with Klinefelter's syndrome. Patients with this syndrome are more likely to develop severe osteoporosis. In the presenile period of Klinefelter's syndrome with severe osteoporosis, liaison psychiatrists may pay attention to somatoform disorders (e.g. somatoform pain disorder and conversion disorder) linked with the MO.

Surgery and medical treatment in persistent somatizing patients.

This study describes the utilization of surgical operations, frequency and outcome of medical and surgical treatment in a group of persistent somatizers compared with a control group of non-somatizers. The study was carried out using the Danish national medical register to identify persons in the general population (age range 17-49 yr) with at least 10 general admissions during an 8-yr period. Persistent somatizers were defined as persons with more than six medically unexplained general hospital admissions in their lifetimes before 1985. Conversely, non-somatizers were patients whose admissions could mainly be ascribed to well-defined somatic disorders. The findings show that persistent somatizers had been exposed to extensive surgery, outnumbering the non-somatizers. Surgical operations were of several categories, with gastrointestinal and gynaecological operations being the most frequent. The physicians used medical and surgical treatment nearly as often for treating persistent somatizers as in the treatment of the non-somatizers. Surgical or medical treatment was used in nearly half of the medically unexplained admissions. The outcome of the surgical treatment of the persistent somatizers was, however, generally unsuccessful in that the effect was unsatisfactory in three quarters of cases. Similarly, two thirds of the medical treatments were judged to be unsuccessful in persistent somatizers. The findings suggest that the costs of somatic diagnostic procedures and fruitless surgical and medical treatment attempts on persistent somatizers are enormous, and only exceeded by the risk of iatrogenic harm. This emphasizes the need for an early diagnosis of somatization and of treating it properly.

Medical problems of adults who were sexually abused in childhood.

The aim of the study was to see whether adults who had been sexually abused in childhood were vulnerable to physical symptoms and therefore investigation and intervention. The case histories of seven patients who were aged 22-39, were under the care of three consultant psychiatrists, had experienced childhood sexual abuse, and had a history of medical or surgical intervention were surveyed. The patients had had a mean of 18 contacts with non-psychiatric consultant teams and a mean of eight operations, with a high rate (66-70%) of normal findings. They had experienced many somatic symptoms, which led to investigations and interventions in the specialties of gynaecology, obstetrics, gastroenterology, urology, rheumatology, haematology, orthopaedics, neurology, and neuropsychiatry. The history of childhood sexual abuse was recognised only in the later stages of this medical and surgical intervention. The possibility of childhood sexual abuse should be considered earlier in such cases to prevent further unnecessary intervention.