Laparoscopic repair of paraesophageal hernia with anterior gastropexy: a multicenter study.

BACKGROUND: The approach to repair of paraesophageal hernias (PEHs) is controversial. Recent data suggest that mesh repair leads to recurrence rates similar to non-mesh approaches, while subjecting patients to mesh-associated complications. Routine fundoplication during PEH repair has been favored despite significant dysphagia rates. We present our multicenter prospective data on laparoscopic PEH repairs using a modified Boerema anterior gastropexy without fundoplication. METHODS: We prospectively followed patients after modified Boerema PEH repair at three institutions. Patient demographics, perioperative data, and postoperative outcomes were evaluated. Subjective and objective outcomes were assessed via clinical assessment, follow-up questioning, endoscopy, and radiographic swallow studies. RESULTS: A total of 101 patients were followed a mean of 10.8 (median, 12) months. We encountered 9 (8.9%) intraoperative complications and 13 (12.9%) postoperative complications. There was no mortality. Reflux symptoms were absent in 71 patients (70.3%) postoperatively. Of the remaining subjects, 8 (7.9%) had mild intermittent reflux without the need for proton pump inhibitors (PPI), 12 (11.9%) had moderate reflux necessitating PPI as needed, and 10 (9.9%) had reflux requiring daily PPI. Our recurrence rate, assessed at postoperative endoscopy/barium swallow, was 16.8%. Of these, 10 (9.9%) were small segmental recurrences and 7 (6.9%) were large recurrences. CONCLUSION: Herein, we demonstrate a favorable recurrence rate while avoiding the potential major complications associated with mesh hiatoplasty. Our data tend to support a tailored approach to incorporation of fundoplication during PEH repair. Postoperative acid reflux was absent in most of our patients, and pharmacotherapy alone was sufficient for those experiencing reflux symptoms.

One million years of glaciation and denudation history in west Greenland.

The influence of major Quaternary climatic changes on growth and decay of the Greenland Ice Sheet, and associated erosional impact on the landscapes, is virtually unknown beyond the last deglaciation. Here we quantify exposure and denudation histories in west Greenland by applying a novel Markov-Chain Monte Carlo modelling approach to all available paired cosmogenic 10Be-26Al bedrock data from Greenland. We find that long-term denudation rates in west Greenland range from >50 m Myr-1 in low-lying areas to ∼2 m Myr-1 at high elevations, hereby quantifying systematic variations in denudation rate among different glacial landforms caused by variations in ice thickness across the landscape. We furthermore show that the present day ice-free areas only were ice covered ca. 45% of the past 1 million years, and even less at high-elevation sites, implying that the Greenland Ice Sheet for much of the time was of similar size or even smaller than today.

Chronic pain and recurrence after laparoscopic inguinal herniorrhaphy.

Chronic pain after open inguinal herniorrhaphy is a complication with an incidence of 10-20% and recurrence in 2-5% of the patients. We here present our experience with the laparoscopic technique. Patients who had undergone laparoscopic inguinal herniorrhaphy (TAPP) in our department from 1995 to 2002 received a questionnaire (N = 161). Patients were asked whether they had chronic pain or recurrence; if so, they were seen in the outpatient clinic. A total of 146 patients responded to the questionnaire (91%). Chronic pain was found in 6 patients (4%) and recurrence in 2 patients (1.4%); 134 patients (92%) had previously had inguinal herniorrhaphy with an open procedure (all Lichtenstein) on the same side. Of these, 105 (78%) preferred the laparoscopic procedure. Laparoscopic inguinal herniorrhaphy led to a very low incidence of chronic pain and recurrence compared with previous reports in open surgery. The majority of our patients were operated on for recurrent hernias, after which an even lower incidence of chronic pain and fewer recurrences in laparoscopic primary herniorrhaphies could be expected.

Evidence for external forcing of the Atlantic Multidecadal Oscillation since termination of the Little Ice Age.

The Atlantic Multidecadal Oscillation (AMO) represents a significant driver of Northern Hemisphere climate, but the forcing mechanisms pacing the AMO remain poorly understood. Here we use the available proxy records to investigate the influence of solar and volcanic forcing on the AMO over the last ~450 years. The evidence suggests that external forcing played a dominant role in pacing the AMO after termination of the Little Ice Age (LIA; ca. 1400-1800), with an instantaneous impact on mid-latitude sea-surface temperatures that spread across the North Atlantic over the ensuing ~5 years. In contrast, the role of external forcing was more ambiguous during the LIA. Our study further suggests that the Atlantic Meridional Overturning Circulation is important for linking external forcing with North Atlantic sea-surface temperatures, a conjecture that reconciles two opposing theories concerning the origin of the AMO.

Tracking the Atlantic Multidecadal Oscillation through the last 8,000 years.

Understanding the internal ocean variability and its influence on climate is imperative for society. A key aspect concerns the enigmatic Atlantic Multidecadal Oscillation (AMO), a feature defined by a 60- to 90-year variability in North Atlantic sea-surface temperatures. The nature and origin of the AMO is uncertain, and it remains unknown whether it represents a persistent periodic driver in the climate system, or merely a transient feature. Here, we show that distinct, ∼55- to 70-year oscillations characterized the North Atlantic ocean-atmosphere variability over the past 8,000 years. We test and reject the hypothesis that this climate oscillation was directly forced by periodic changes in solar activity. We therefore conjecture that a quasi-persistent ∼55- to 70-year AMO, linked to internal ocean-atmosphere variability, existed during large parts of the Holocene. Our analyses further suggest that the coupling from the AMO to regional climate conditions was modulated by orbitally induced shifts in large-scale ocean-atmosphere circulation.

Dysphagia after laparoscopic Nissen fundoplication.

OBJECTIVE: To investigate the frequency and severity of dysphagia during the first 8 weeks after laparoscopic Nissen fundoplication for gastro-oesophageal reflux disease. So far, there have been no studies reporting data on day-to-day occurrence of dysphagia after laparoscopic fundoplication in a consecutive series of patients. This may explain why the frequency of dysphagia varies greatly in the literature (4-100%). MATERIAL AND METHODS: Forty consecutive patients, undergoing elective laparoscopic Nissen fundoplication, completed a standard dysphagia registration diary each day during the first 8 weeks after surgery. Patients who preoperatively had suffered from dysphagia were excluded. Thus, none of the patients had dysphagia in the 2-month period before surgery. Ten patients undergoing elective cholecystectomy served as controls. Data were quantified, and a score value of 4 or more was considered bothersome. RESULTS: Thirty-seven patients (93%) experienced some degree of dysphagia during the observation period. Sixteen patients (44%) had at least one day with annoying dysphagia. The dysphagia started 1-2 days after surgery, was most prominent during the first few weeks, and subsided in nearly all cases after 5-6 weeks. Two patients with persistent dysphagia were treated once with balloon dilatation. None of the patients in the control group had dysphagia. CONCLUSIONS: Nearly all patients experience some degree of dysphagia after laparoscopic Nissen fundoplication, and in nearly half of the patients it is considered annoying. However, even severe dysphagia usually disappears within 5-6 weeks. These results suggest a conservative attitude for the first 1-2 months after surgery. The data may also serve as a background for preoperative information to the patients.

Fast-track giant paraoesophageal hernia repair using a simplified laparoscopic technique.

BACKGROUND AND AIMS: Operation for paraoesophageal hernia may be associated with severe complications, especially when performed as an open technique. Furthermore, it is not settled whether the procedure should be performed in combination with an antireflux procedure. Fast-track rehabilitation programs in other operations have been associated with shortened hospital stay and reduced complications compared with conventional care programs. The aim of the present study was to combine a simplified surgical technique with a fast-track rehabilitation program for repair of giant paraoesophageal hernia. METHODS: During a 2-year period, 21 patients underwent laparoscopic paraoesophageal hernia repair with a fast-track rehabilitation program. We did not use an antireflux procedure or repaired the enlarged hiatus in any of the patients. All patients had the hernia sac dissected and a gastropexy to the anterior abdominal wall. RESULTS: Median operation time was 75 min (range 65-120), and the median postoperative hospital stay was 2 days (1-20), where 10 patients stayed for only 1 day. Two patients received postoperative blood transfusions, and the same 2 patients also developed postoperative pneumonia treated with penicillin. Before operation, 4 patients were treated with proton pump inhibitors for reflux symptoms, but after operation, only 1 patient continued treatment with omeprazol 20 mg daily. At barium x-ray follow-up after 3 months, 3 patients had a partial recurrence of a paraoesophageal hernia, but none of them had any symptoms and therefore did not undergo further treatment. CONCLUSION: Using a fast-track rehabilitation program and a simplified laparoscopic surgical technique, repair of giant paraoesophageal hernias can be performed with a short hospital stay and minimal complications.

[Laparoscopic cholecystectomy as an outpatient procedure]. / Laparoskopisk kolecystektomi i dagkirurgisk regi.

INTRODUCTION: The aim of this study was to describe our experience with laparoscopic cholecystectomy as an outpatient procedure in terms of complications, same-day discharge, and a registration of patient' postoperative pain, convalescence and contact with general practitioners. MATERIALS AND METHODS: A prospective evaluation was done of the first 231 patients undergoing laparoscopic cholecystectomy in an outpatient clinic. RESULTS: Ninety per cent of the patients were discharged directly from the outpatient clinic, and a total of 93% of the patients were discharged within 24 hours of the operation. The readmission rate was 1%. Leakage from the cystic duct occurred in one case (0.4%), and no other injuries to the bile ducts were observed. The conversion rate was 1%. Within a week 54% of the patients had no pain and 55% of the patients had resumed normal activity. Postoperatively, 25% of the patients had contact with a general practitioner due to wound and other complaints that required no intervention. DISCUSSION: Laparoscopic cholecystectomy is very suitable as an outpatient procedure due to its high same-day discharge rate and high patient satisfaction combined with low readmission and complication rates. Our study did expose, however, a high number of postoperative contacts with general practitioners due to non-surgical problems, which emphasizes the need for better patient information and cooperation with general practitioners to optimize the outpatient procedure further.