Acute kidney injury due to tubular intraluminal monoclonal light chain crystals mimicking acute pyelonephritis.

Tubular intraluminal inflammatory cells may be seen in kidney biopsies of patients with pyelonephritis, cell-mediated transplant rejection, autoimmune tubulointerstitial nephritis, allergic reactions, or in association with monoclonal light chain casts. When casts in a native kidney are primarily composed of granulocytes, the cause is most commonly acute pyelonephritis due to an ascending bacterial urinary tract infection. We report a 57-year-old man with acute kidney injury and an intense intraluminal neutrophil response to monoclonal lambda light chain crystal containing casts.

A study of intragastric and intravesicular pressure changes during rest, coughing, weight lifting, retching, and vomiting.

BACKGROUND: In patients undergoing a variety of procedures, surgical success is in part dependent on maintaining normal intra-abdominal pressure in the immediate postoperative period. Our objective was to quantify intragastric and intravesicular pressures during activities, through the use of manometry catheters. METHODS: Ten healthy volunteers had a manometry catheter placed transnasally, and a urinary Foley catheter placed. Baseline intragastric and intravesicular pressures were recorded and the catheters were then transduced continuously. Pressures were recorded with activity: coughing, lifting weights, retching (dry heaving), and vomiting. RESULTS: All pressure changes were significant from baseline except for weight lifting. The highest intragastric pressure was 290 mmHg, seen during vomiting. Comparison of intragastric and intravesicular pressures showed no significant difference. There was significantly higher intragastric pressure with vomiting and retching as compared with coughing, whereas coughing applied more pressure than weight lifting. CONCLUSIONS: This is the first report of intragastric pressures during vomiting and retching (dry heaving). We conclude that vomiting and retching (dry heaving) can render significant forces on any tissue apposition within the stomach or the peritoneal cavity.

Repair of 104 failed anti-reflux operations.

OBJECTIVE: To assess whether reoperative surgery for failed Nissen fundoplication is beneficial and to classify all mechanisms of failure recognized. SUMMARY BACKGROUND DATA: Antireflux surgery is often necessary, but a 10% failure rate is commonplace. We report results for patients undergoing reoperative surgery and present a nomenclature of mechanisms of failure. METHODS: A total of 104 patients, who had a previous fundoplication for gastroesophageal reflux disease (GERD), underwent reoperative surgery. Manometry (n = 86), endoscopy (n = 101), pH monitoring (n = 27), upright esophagram (n = 90), gastric emptying (n = 26), and symptom assessment (n = 104) were performed prior to reoperative surgery. Patients were also assessed before and during reoperation for mechanism of failure using a newly proposed classification. The operative approach was laparoscopic in 58 patients, via open laparotomy in 12, and a thoracotomy in 34 patients. Follow-up was conducted by phone interview and was completed in 97 patients (97%; 3 were deceased) with a mean follow-up of 32 months (range, 1-146 months). RESULTS: The conversion rate to laparotomy for laparoscopic patients was 8%. The perioperative complication rate was 32%. One patient died of respiratory insufficiency after a laparotomy. Seven patients required additional surgery for correction of persistent or recurrent symptoms. The short and long-term complication rate was similar for the different operative approachs. Symptom resolution (rare or absent) occurred in 74% of patients with dysphagia, 75% with heartburn, 85% with regurgitation, and 94% with chest pain. The overall post-reoperative patient satisfaction was 7 on a scale of 1 to 10 and 3 on a scale of 1 to 4 when patients were asked to grade the operative result. There was no difference in the symptom resolution for patients operated upon by the laparoscopic approach as compared with laparotomy, but those patients undergoing a Collis gastroplasty had poorer results. The preoperative accuracy of assessment for mechanism of failure was 78%. A nomenclature of mechanisms of failure is included to aide reoperative assessment and new mechanisms of failure are described. CONCLUSION: Reoperative surgery results for GERD are satisfactory. A variety of operative approaches proved equally effective. Poorer results were observed in patients with more advanced disease.

Surgical repair of recurrent hiatal hernia.

The surgical management results of recurrent hiatal hernia repair are unknown in the laparoscopic era. The experience of the senior authors (CJF) and (SKM) is reported herein. From 1993 to 2004, 52 patients underwent re-operative hiatal hernia surgery at our center. Preoperative symptoms were heartburn, chest pain, dysphagia, regurgitation and pulmonary manifestations of gastroesophageal reflux disease. Patients had preoperative evaluation by upper endoscopy, pH-monitoring, esophagogram and manometry to assess the mechanism of failure. Pre- and postoperative symptoms were assessed utilizing a standardized questionnaire. Patients underwent laparoscopic repair (n=18), open laparotomy (n=6) and transthoracic surgery (n=28). Ninety-five percent follow-up was achieved with a mean follow-up of 34 months. Thirty-seven percent of patients encountered para-operative complications one of them died due to respiratory insufficiency. Five patients experienced a re-recurrent hernia. The symptom resolution was 65% for dysphagia, 68% for heartburn, 95% for chest pain and 79% for regurgitation. The overall patient satisfaction was 6.94 on a scale of 1-10. There was no significant difference in patient outcome when comparing the operative approaches or disease process. Surgical repair of recurrent hiatal hernias is safe and effective. Laparoscopic surgery is an appropriate alternative approach for recurrent hiatal hernia repair in selected patients.

Assessment of diaphragmatic stressors as risk factors for symptomatic failure of laparoscopic nissen fundoplication.

An important limitation of antireflux surgery is a 5%-10% failure rate. We investigated the correlation between various diaphragm stressors and failure of antireflux surgery. Forty-one study cases who underwent a reoperative antireflux operation from 1997 to 2001 and 50 control patients who had undergone a successful laparoscopic Nissen fundoplication during the same period without clinical or symptomatic evidence of failure were randomly selected for comparison. A retrospective analysis was conducted utilizing a standardized diaphragm stressor questionnaire, addressing the period between the primary and secondary operation. Stressors considered in the study included height, body mass index (BMI), postoperative gagging, vomiting, weight lifting (greater than 100 pounds), coughing, hiccuping, motion sickness, retching, belching, antidepressant use, smoking, preoperative grade of esophagitis, size of hiatal hernia, lower esophageal sphincter pressure, esophageal body pressures, and preoperative response to proton pump inhibitors. Of the potential stressors investigated, the following were significantly associated with surgical failure after adjusting for other variables through multivariate analysis: gagging (P = 0.005), belching (P = 0.02), and hernia size greater than 3 cm (P = 0.04; Table 1). Other potential risk factors show trends as obvious in Fig. 2. Vomiting was significant (P = 0.01) in the earlier models but lost significance when logistic regression was applied. Patients with postoperative gagging and an intraoperative hiatal hernia (greater than 3 cm) have a poorer outcome, whereas patients with postoperative belching have a better long-term outcome.

A long-term comparison of plication configurations for endoluminal gastroplication: circumferential versus helical.

GOALS: To determine the long-term efficacy of endoluminal gastroplication (ELGP) and the most effective plication configuration. BACKGROUND: Endoluminal gastroplication is an intriguing therapy for gastroesophageal reflux disease. We conducted a retrospective review of a prospective experience of patient cohorts comparing outcomes of the circumferential and helical plication patterns. STUDY: Twenty patients underwent ELGP, with 9 receiving the circumferential (Group 1) and 11 the helical pattern (Group 2). Manometry, endoscopy, and 24-hour pH monitoring were performed at baseline and at 6 months. Symptom scores and medication usage were assessed at baseline, 1, 3, 6, 12, and 18 months. RESULTS: Both groups did not differ significantly from each other with respect to symptom improvement, medication usage, or other variables measured. At 6 months, symptom scores, histamine-2 receptor antagonist (H2RA), proton pump inhibitor usage, and hernia size decreased significantly. No other parameter showed a significant change. At the 18-month follow-up, symptom scores and H2RA usage decreased significantly. CONCLUSION: ELGP improves heartburn and regurgitation scores at 18 months. Our study suggests that there is no benefit to additional plications when using the helical pattern.

Endoluminal gastroplasty: a new treatment for gastroesophageal reflux disease.

Initial studies demonstrate that EndoCinch is safe and may be an effective outpatient procedure. Symptom improvement, reduction in medication requirements, and ultrasound evidence of muscle hypertrophy are encouraging. The durability of these benefits remains in question. Seventeen percent of patients require a repeat gastroplication to achieve a satisfactory result and some elect to undergo laparoscopic Nissen fundoplication. Additional investigations are required to assess the number and location of the plications for optimal patient outcome. Prospective randomized studies comparing ELGP to medical and surgical treatments of GERD may be appropriate after device refinements. Of additional importance is the possibility of a cure with an ELGP. Patients who are self-medicated or noncompliant often are willing to seek consultation if a noninvasive curative procedure is available. One third of these patients have advanced disease and are treated best with surgery rather than an ELGP; thus, surgeons should be involved with ELGP for GERD control.