Outcome of laparoscopic Nissen fundoplication for gastroesophageal reflux disease in non-responders to proton pump inhibitors.

BACKGROUND: Gastroesophageal reflux disease (GERD) is a common public health problem. Medical treatment remains the first line of treatment of GERD. Failure of medical treatment may occur in up to 45% of GERD patients. This study aims to evaluate the outcome of laparoscopic Nissen fundoplication (LNF) as a means of antireflux surgery in patients with poor response to anti-reflux medication. PATIENTS AND METHODS: This is a prospective study of patients who underwent LNF in the period between January 2000 and December 2010 in the Gastrointestinal Surgical Center, Mansoura University, Egypt. Patients were assessed preoperatively and postoperatively, after 1 year, by clinical examination, esophagogastroscope, barium esophagography, esophageal manometry and 24-h pH monitoring. Patient satisfaction after surgery was also graded through a questionnaire. RESULTS: The study population was 370 patients. 296 patients were good responders to proton pump inhibitors (PPI) while 74 patients were PPI non-responders. Preoperatively, atypical reflux symptoms were significantly more in PPI non-responders (P = 0.006). On follow-up, PPI responders significantly reported relief of heartburn (P = 0.01) and regurgitation (P = 0.04). Patient satisfaction was more in PPI responders (P = 0.04). Both groups were comparable regarding anatomical and functional assessment. Integrity of the wrap was higher in PPI responders (P = 0.04). CONCLUSION: PPI non-responders should not be precluded from LNF. Thorough assessment is mandatory to confirm GERD diagnosis. A substantial proportion of PPI failures show good response to LNF but significantly than clinical response in PPI responders. Increased likelihood of poor outcome after surgery should be discussed with the patient.

Conventional haemorrhoidectomy, stapled haemorrhoidectomy, Doppler guided haemorrhoidectomy artery ligation; post operative pain and anorectal manometric assessment.

BACKGROUND/AIMS: The aim of the present article was to compare stapled haemorrhoidectomy, and haemorrhoidal artery ligation with open haemorrhoidectomy with respect to the postoperative pain, symptom control, and manometric alterations. METHODOLOGY: Forty five patients with third or fourth-degree haemorrhoids were randomly classified into three groups; first group managed by stapled haemorrhoidectomy, second group managed by conventional haemorrhoidectomy and third group managed by Doppler guided haemorrhoidal artery ligation. (15 patients each) Preoperative and 12 weeks postoperative anorectal manometry were done for all patients. RESULTS: There was a significant difference of the operative time between stapled group and Milligan-Morgan group (p < 0.001) while no significant difference between stapled group and Doppler group. The pain scores were significantly higher in open group (p < 0.001) during the first 24 hours at the time of first motion and one week after operation. Postoperative control of prolapsed symptoms was significantly better with open diathermy haemorrhoidectomy than with stapled. The control of other symptoms was similar with regard to bleeding, pain, pruritus, and incontinence scores. Anorectal manometry showed a decrease in the maximum resting pressure and maximum squeeze pressure in all groups, but this decrease was only significant in the stapled haemorrhoidectomy group. CONCLUSIONS: Stapled and Doppler haemorrhoidectomy is as effective as conventional haemorrhoidectomy for the treatment of haemorrhoids, but with the exception of skin tag prolapse. There is a need for long-term follow-up for the changes in manometric parameters after haemorrhoidectomy.