Laparoscopic fundoplication and new aspects of neural anatomy at the oesophagogastric junction.

BACKGROUND: In fundoplication, mobilization of the distal oesophagus and proximal stomach is essential to obtain a sufficient tension-free intra-abdominal oesophageal length for creation of an efficient antireflux barrier. Most surgical literature and anatomical illustrations do not describe nerve branches running from the diaphragm to the stomach. After observing small nerve branches at laparoscopic fundoplication, penetrating the left crus of the diaphragm lateral to the hiatus and apparently running into the stomach, an anatomical cadaver study was undertaken to identify the origin and target organ of these nerves. METHODS: Fifty-three human cadavers (23 men, 30 women; age range 35-103 years) were dissected with special attention to the nerves that penetrate the left crus of the diaphragm. The entire course of these nerves was documented with standardized drawings and photos. RESULTS: Small nerve branches penetrating the diaphragm lateral to the left crus of the hiatus were found in 17 (32 per cent) of the 53 cadavers. In 14 of these 17 cadavers, one or two splanchnic nerve branches were identified, and in ten of the 17 the nerve branches were found to be phrenic nerves. In seven of these 17 cadavers, two different nerve branches were found and assigned to both splanchnic and phrenic nerves. CONCLUSION: Nerves penetrating the left crus with splanchnic origin or phrenic origin have been identified. Their function remains unclear and their relationship to postfundoplication symptoms remains to be determined.

ANTECEDENTES: A la hora de realizar una fundoplicatura, la movilización del esófago distal y del estómago proximal es esencial para obtener una longitud de esófago intraabdominal suficiente y sin tensión para crear una barrera antirreflujo eficiente. La mayoría de la literatura quirúrgica y de las ilustraciones anatómicas no describen unas ramas nerviosas que discurren desde el diafragma al estómago. Tras observar pequeñas ramas nerviosas durante la realización de una fundoplicatura laparoscópica que penetran la crura izquierda del diafragma lateral al hiato y que aparentemente discurren hacia el estómago, se llevó a cabo un estudio anatómico en cadáver para identificar el origen y el órgano diana de estos nervios. MÉTODOS: Se diseccionaron 53 cadáveres humanos (23 varones, 30 mujeres, rango de edad: 35-103 años) con especial atención hacia los nervios que penetran la crura izquierda del diafragma. Se documentó el recorrido completo de estos nervios con fotos y dibujos de una forma estandarizada. RESULTADOS: En 17 (32%) de 53 cadáveres se hallaron pequeñas ramas nerviosas que penetraban el diafragma lateral a la crura izquierda del hiato. En 14 cadáveres (de los 17) se identificaron una o dos ramas nerviosas esplácnicas, y en 10 de los 17 cadáveres las ramas nerviosas que se hallaron resultaron ser nervios frénicos. En 7 de estos 17 cadáveres, se hallaron dos ramas nerviosas diferentes y se asignaron a ambos nervios, esplácnicos y frénicos. CONCLUSIÓN: Se han identificado los nervios que penetran la crura izquierda con un origen esplácnico y frénico. Sus funciones están por aclarar, así como su relación con los síntomas que aparecen tras la fundoplicatura.

Revisional Gastric Bypass After Failed Adjustable Gastric Banding-One-Stage or Two-Stage Procedure?

BACKGROUND: Revisional laparoscopic Roux-en-Y gastric bypass (R-LRYGB) is the preferred procedure after failed adjustable gastric banding. Little is known about whether a one-stage procedure (one surgery for band removal and R-LRYGB) or a two-stage procedure (first band removal and later R-LRYGB) is superior. Aim of this study is to compare early- and long-term results of both methods at our institution. METHODS: Retrospective analysis of 165 (m 26/f 139) consecutive patients (98 one-stage, 67 two-stage) with R-LRYGB. Mean follow-up time was 50.1 ± 38.8 months. Indications for one-stage vs. two-stage procedures, operating time, peri- and postoperative complications, morbidity, mortality, and length of stay (LOS) were analyzed. Data are reported as total numbers (%) and mean ± standard deviation. RESULTS: Mean age at R-LRYGB was 43.9 ± 10.7 vs. 44.3 ± 10.7 years with a BMI of 37.1 ± 6.8 vs. 39.8 ± 7.1 (one-stage vs. two-stage). In the one-stage group, the main indication for revisional surgery was weight regain (57.1%), followed by dilatation of the esophagus or pouch (37.7%) and gastroesophageal reflux disease (GERD) (36.7%), whereas in the two-stage group, it was band erosion (52.2%) and dilatation of the esophagus or pouch (17.9%) and GERD (11.9%). There was no significant difference in operative time (208.5 ± 61.2 vs. 206.3 ± 73.5 min), LOS (8.6 ± 3.4 vs. 9.3 ± 5.7 days) or mortality (0% overall). Major complications (Clavien-Dindo ≥ IIIa) occurred similarly often in both groups: 15.3% vs. 16.9% (one-stage vs. two-stage). CONCLUSION: Both approaches achieve good results. However, the one-stage R-LRYGB is the preferable procedure because it reduces costs and LOS by doing without an additional surgical procedure.

Laparoscopic partial posterior (Toupet) fundoplication improves esophageal bolus propagation on scintigraphy.

BACKGROUND: Impaired esophageal clearance is important in the pathogenesis of gastroesophageal reflux disease (GERD). It is unknown whether esophageal clearance improves following antireflux surgery. The aim of this study was to investigate the effect of laparoscopic Nissen fundoplication (NF), laparoscopic partial posterior (Toupet) fundoplication (PPF) or medical therapy on esophageal clearance. METHODS: This was a prospective nonrandomized crossover study. Sixty patients were evaluated with endoscopy, esophageal manometry, radionuclide scanning of esophageal emptying, and assessment of symptoms prior to surgery or medical therapy and 6 months after treatment. In 20 GERD patients with normal esophageal peristalsis an NF was performed, in 20 patients with impaired esophageal peristalsis a PPF was chosen, and 20 patients received proton-pump inhibitor (PPI) treatment. RESULTS: On endoscopy, esophagitis had resolved in all patients after surgery; two patients with medical therapy still had esophagitis. On manometry, a significant improvement of lower esophageal sphincter competence was seen in both surgical groups. LES relaxation was complete after PPF, but incomplete after NF. Esophageal peristalsis did not improve after medical therapy, was significantly improved after PPF, but had worsened after NF. On scintigraphic esophageal emptying for solid meals, there was no improvement after medical therapy but a significant improvement after PPF. A significant deterioration of esophageal emptying was observed after NF. There was a strong correlation between scintigraphic and manometric evaluation of peristalsis preoperatively (r(s) = -0.87, p < 0.05) and postoperatively (r(s) = -0.82, p < 0.05). There was no change in dysphagia after medical therapy and after NF but a significant improvement after PPF. Globus sensation was significantly improved after PPF but did not change after medical therapy or NF. Postprandial bloating and inability to belch were significantly more common after NF than after PPF. CONCLUSION: Laparoscopic partial posterior (Toupet) fundoplication can restore a preoperatively defective esophageal bolus propagation on scintigraphy with the same antireflux effect as the laparoscopic Nissen fundoplication, but with lower side-effects.

Austrian experiences with redo antireflux surgery.

BACKGROUND: From 1996, the entire number of fundoplications performed in Austria increased dramatically, favoring the laparoscopic technique. Despite good results, some patients experience failure of antireflux surgery and therefore require redo surgery if medical therapy fails to control symptoms. The aim of the study was to describe the refundoplication policy in Austria with evaluation of the postoperative results. METHODS: A questionnaire was sent to all Austrian surgical departments at the beginning of 2003 with questions about redo fundoplications (number, techniques, intraoperative complications, history, migration of patients, preoperative workup, mortality, and postoperative long-term complaints). It also included questions about primary fundoplications (number, technique, postoperative symptoms). RESULTS: Out of 4,504 primary fundoplications performed in Austria since 1990, 3,952 have been carried out laparoscopically. In a median of 31 months after the primary operation, 225 refundoplications have been performed, laparoscopically in the majority of patients. The Nissen and the partial posterior fundoplication were the preferred techniques. The conversion rate in these was 10.8%, mainly because of adhesions and lacerations of the spleen, the stomach, and the esophagus. The mortality rate after primary fundoplications was 0.04%, whereas the rate after refundoplications was 0.4%, all resulting from an open approach. CONCLUSION: Laparoscopic refundoplications are widely accepted as a treatment option after failed primary antireflux surgery in Austria. However, the conversion rate is 6 times higher and the mortality rate is 10 times higher than for primary antireflux surgery. Therefore, redo fundoplications should be performed only in departments with large experience.

A cluster of rotavirus enteritis in adult transplant recipients.

Diarrhea following solid organ transplantation is a common side effect of some immunosuppressive agents but can also be caused by many pathogens. An outbreak of rotavirus (RV) enteritis presenting with severe diarrhea in four solid organ recipients was analyzed. The first case was diagnosed in a 6-month-old liver recipient who was prehospitalized on a pediatric ward. Within 1 month, three adult patients (two liver, one renal recipient) presented with enteritis. During diarrhea a significant rise in tacrolimus levels was observed. One patient developed toxic megacolon with ulcerative colitis. Infections were self-limiting but led to secondary infectious complications and prolonged hospitalization. This is the first reported outbreak of RV enteritis in a multiorgan transplant unit involving adult patients. Although no fingerprinting or subtyping of the virus was performed we assume the child was the primary source. In transplant recipients presenting with diarrhea RV infection should be considered.

The Nissen fundoplication: indication, technical aspects and postoperative outcome.

INTRODUCTION: Gastroesophageal reflux disease (GERD) is the most common foregut disease, with a great impact on quality of life and with intestinal, respiratory and cardiac symptoms and implications of carcinogenesis of the oesophagus. Medical therapy often fails, due to the complex pathophysiology of GERD. Surgery can cure the disease, since it is able to restore the anti-reflux barrier. It improves quality of life and prevents carcinogenesis. METHODS: Review of the literature and presentation of our own experience and data in a series of more than 4,000 evaluated patients referred for suspected reflux disease, of whom 382 have been operated on. CONCLUSION: The laparoscopic Nissen fundoplication is the most commonly used operation technique. It provides good long-term results in the majority of patients. However, due to an increase of outflow resistance of the oesophagus this operation is associated with some postoperative side effects. Therefore, alternative anti-reflux procedures may be indicated in selected patients.

First experiences with the da Vinci operating robot in thoracic surgery.

OBJECTIVES: The da Vinci surgical robotic system was purchased at our institution in June 2001. The aim of this trial was to evaluate the applicability of the da Vinci operation robot for general thoracic procedures. METHODS: The da Vinci surgical system consists of a console connected to a surgical arm cart, a manipulator unit with two instrument arms and a central arm to guide the endoscope. The surgical instruments are introduced via special ports and attached to the arms of the robot. The surgeon, sitting at the console, triggers highly sensitive motion sensors that transfer the surgeon's movements to the tip of the instruments. The so-called 'EndoWrist technology' offers seven degrees of movement, thus exceeding the capacity of a surgeon's hand in open surgery. We evaluated the role of the robot for several thoracic procedures such as thymectomies, fundoplications, esophageal dissections, resection of mediastinal masses and a pulmonary lobectomy. RESULTS: A total of 10 thymectomies, 16 fundoplications, 4 esophageal dissections, 5 extirpations of benign mediastinal masses and 1 right lower lobectomy was performed with the robot. One resection of a paravertebral neurogenic tumor had to be converted due to surgical problems. A lesion to a left recurrent laryngeal nerve caused transient hoarseness after the extirpation of an ectopic parathyroid in the aortopulmonary window in one patient. The postoperative courses were uneventful and patients were discharged between postoperative days 3 and 8 (with the exception of patients who underwent dissection for esophageal cancer and the patient with conversion to an open access). CONCLUSIONS: Advanced general thoracic procedures can be performed safely with the da Vinci robot allowing precise dissection in remote and difficult-to-reach areas. This benefit becomes evident most elegantly in thymectomies, which at our institution have become a routine procedure with the robot. The rigid anatomy of the chest seems to be an ideal condition for robotic surgery. A major limitation for robotic surgery is the lack of more appropriate instruments. This disadvantage becomes most evident in pulmonary lobectomies.

Robot-assisted laparoscopic partial posterior fundoplication with the DaVinci system: initial experiences and technical aspects.

BACKGROUND: This pilot study evaluated the role of the DaVinci operation robot for laparoscopic antireflux surgery. PATIENTS AND METHODS: A robot-assisted laparoscopic Toupet-fundoplication was performed on nine consecutive patients with severe gastroesophageal reflux disease using the DaVinci robot system. The operative procedure was performed in the same way as for the conventional laparoscopic procedure. Clinical assessment and endoscopic and manometric follow-up investigations were performed 6 months after surgery in six of the patients. RESULTS: The mean robotic operative time was 173 min (120-235). A mean of 25 min (12-45) was required to establish the pneumoperitoneum, to set the trocars, and to place the robot arms. There were no intraoperative complications. Six months after surgery none of the patients suffered from reflux symptoms and none of the patients had acute esophagitis. Postoperatively one patient complained of mild transient dysphagia. However, persistent dysphagia was not found in any of the patients. One further patient complained of mild bloating. No other side effects occurred. Manometrically there was a significant improvement in the function of the lower esophageal sphincter. CONCLUSIONS: The robot-assisted partial posterior fundoplication is a safe procedure and provides a high-quality three-dimensional camera image that is superior to that with the conventional laparoscopic device. The handling of the instruments is precise, and intracorporeal suturing and knot tying is much easier than without the robotic technique. The procedure allows for an accurate approximation of the hiatal crura and for precise construction of the fundic wrap. However, robotic surgery is expensive and the setup of the system is time consuming at present.

"Floppy" Nissen vs. Toupet laparoscopic fundoplication: quality of life assessment in a 5-year follow-up (part 2).

BACKGROUND AND STUDY AIMS: Quality of life as an outcome variable has become an important measure in clinical research. This study is the second part of a prospective assessment of the quality of life outcome, in a 5-year follow-up of patients who underwent laparoscopic Nissen fundoplication or Toupet fundoplication. Data from a 1-year follow-up have been previously published (part I). PATIENTS AND METHODS: Using the Gastrointestinal Quality of Life Index (GIQLI), the quality of life data of 169 consecutive patients who had undergone a laparoscopic Nissen fundoplication (LNF; n = 104) or a laparoscopic Toupet fundoplication (LTF; n = 65), were evaluated 3 years and 5 years postoperatively. Six patients out of the initial study group (n = 175), including three from each group, were excluded from the main analysis because they had undergone laparoscopic re-fundoplication during the 1-year follow-up. Data from patients with repeat surgery have been analysed separately. In addition to administering the GIQLI, we evaluated patient satisfaction with surgery, possible surgical side effects or recurrent disease-related symptoms, the use of antireflux medication, and also surgical interventions in relation to initial antireflux surgery. In those patients, who were willing (n = 111) we also performed esophageal manometry and 24-hour pH monitoring 5 years postoperatively. RESULTS: At 3 years and 5 years postoperatively, the analysis of quality of life data showed that the GIQLI score remained stable in comparison with the 1-year follow-up data, with mean scores of 121 +/- 8.7 points in the LNF-group and 119.8 +/- 9 points in the LTF-group, at 5 years after surgery. Laparoscopic re-fundoplication was necessary in four patients due to a "slipping" Nissen (LNF group n = 1) or recurrent symptoms (LTF group, n = 3). In two patients in the LTF group herniation of a trocar incision was found. No patient suffered from severe surgical side effects. Patient satisfaction with surgery was rated as "excellent" or "good" in 97.9 % of patients. There were no significant differences between the groups concerning these data. The results of esophageal manometry and 24-hour pH monitoring also remained stable and showed normal values in all but two patients (in the LTF group), who suffered from mild and infrequent symptoms of recurrent heartburn without endoscopic signs of esophagitis. The outcome in patients who underwent laparoscopic re-fundoplication is comparable to the outcomes for those with a successful primary intervention. CONCLUSIONS: Both Nissen and Toupet laparoscopic fundoplication can significantly improve patients' quality of life during the 5 years following surgical intervention. Quality of life scores for both surgical groups were almost equal and postoperative outcomes were comparable to values in healthy controls. Patient satisfaction with surgical treatment was very high, even though repeat laparoscopic surgery was necessary in some cases. Patients who had a repeat procedure experienced nearly identical outcomes.

Mid- and long-term quality of life assessments after laparoscopic fundoplication and refundoplication: a single unit review of more than 500 antireflux procedures.

BACKGROUND: For the evaluation of surgical interventions, quality of life data are being increasingly used as an efficacy endpoint. AIMS: To evaluate impact of laparoscopic fundoplication and laparoscopic refundoplication on quality of life as well as on patient satisfaction with the procedure for at least 5 years after surgical intervention. PATIENTS: After more than 500 laparoscopic antireflux procedures, quality of life data have been prospectively reviewed and data compared with healthy individuals, untreated gastro-oesophageal reflux disease patients (n = 150) and successfully treated patients (n = B4) under adequate omeprazole therapy. METHODS: Gastrointestinal Quality of Life Index has been used in all patients and evaluated the day before surgery and 5 times after surgery. Moreover, the SF-36 questionnaire has been used up to 2 years after surgical intervention, but only in patients who underwent laparoscopic redo-surgery (n = 49). RESULTS: In both surgical groups, mean preoperative Gastrointestinal Quality of Life Index showed a significant (p < 0.01) impairment (before laparoscopic antireflux surgery: 90.4 +/- 10.3 points; before redo-surgery: 84.3 +/- 8.1 points) when compared with healthy individuals (mean: 122.6 +/- 8.5 points) and successfully treated patients with acid-suppressive therapy (mean: 121.4 +/- 9.2 points). After surgery, the mean Gastrointestinal Quality of Life Index increased significantly and remained stable for at least 5 years after laparoscopic antireflux surgery (120.8 +/- 8.6 points) or for at least 2 years after redo-proce-dure (120.9 +/- 7.2 points). Before laparoscopic refundoplication, 6 out of 8 SF-36 scores were significantly p < 0.05) decreased. Redo-surgery influenced these 6 scores significantly (p < 0.05-0.01), resulting in values comparable to those of general population. Patients' satisfaction with surgery was excellent or good in 95%. CONCLUSION: Both, laparoscopic fundoplication as well as laparoscopic refundoplication are able to improve patients' quality of life significantly for at least 5 years. Therefore, quality of life data provide useful information to discuss different treatment options with patients.

Long-term results of laparoscopic antireflux surgery.

BACKGROUND: It is estimated that laparoscopic antireflux surgery has replaced the open approach in centers worldwide. Findings show it to be an established treatment option for chronic gastroesophageal reflux disease with an excellent clinical outcome and success rates between 85% and 95%. This prospective study aimed to evaluate surgical outcome and analysis of failure after 500 laparoscopic antireflux procedures followed up for as long as 5 years. METHODS: Between September 1993 and May 2000, 500 laparoscopic antireflux procedures were performed in our surgical unit. In 345 patients, a laparoscopic "floppy" Nissen fundoplication was performed, and in 155 patients, a Toupet fundoplication was carried out with standard mobilization of the upper part of the gastric fundus and with division of the short gastric vessels. Preoperative and postoperative data including 24-h pH monitoring, esophageal manometry, and analysis of failure were prospectively reviewed. RESULTS: Conversion to open surgery was necessary in two patients (0.4%). Morbidity was 7%, including 24 patients (4.8%) for whom a laparoscopic redoprocedure was necessary because of failed primary intervention. There was no mortality. During a follow-up period of 3 months to 5 years, 24-h pH monitoring and esophageal manometry showed normal values in 95% of the patients including patients who had undergone redosurgery. CONCLUSION: The results of the current study demonstrate that laparoscopic antireflux surgery is feasible and effective, and that it can be performed safely without mortality and with low morbidity, yielding good to excellent results over a follow-up period up to 5 years.

Is laparoscopic refundoplication feasible in patients with failed primary open antireflux surgery?

BACKGROUND: Due to the widespread availability and acceptance of minimal-access surgery, laparoscopic antireflux surgery has become the standard procedure for the treatment of severe gastroesophageal reflux disease (GERD). However, open and laparoscopic antireflux procedures sometimes result in failure, so that redosurgery is required in some cases. The aim of this prospective study was to evaluate the surgical outcome and quality of life of patients who underwent refundoplication after the failure of primary open antireflux surgery. METHODS: Twenty patients with a mean age of 52 years (range, 33-69) underwent laparoscopic refundoplication after primary open antireflux surgery. Four of them had undergone surgery twice previously. Preoperative and postoperative data, including esophageal manometry, 24-h pH monitoring, and assessment of quality of life, were reviewed prospectively. Quality of life was evaluated using the Gastrointestinal Quality of Life Index (GIQLI). RESULTS: In 18 patients (90%), the reoperation was completed successfully laparoscopically. Two others (10%) required conversion to an open procedure. One of them had an injury of the gastric wall; in the other case, severe bleeding of the spleen necessitated the conversion. The average operating time was 245 min. Preoperatively, the main symptoms were recurrent reflux in 14 cases and a combination of re-reflux and dysphagia in six cases. The anatomic findings were telescope phenomenon (n = 6), hiatal disruption (n = 10), and wrap breakdown (n = 4). Postoperatively, two patients suffered from dysphagia and required pneumatic dilatation. The lower esophageal sphincter (LES) pressure increased significantly from a preoperative value of 6.08 mmHg to 12.2 mmHg at 3 months and 11.9 mmHg at 1 year after surgery. The DeMeester score decreased from a preoperative value of 69.8 to 17.1 at 3 months and 14.6 at 1 year postoperatively. The GIQLI score increased from a preoperative value of 84.9 points to 119.6 points at 3 months and 120.1 points at 1 year. CONCLUSION: Laparoscopic refundoplication after the failure of a primary open intervention is an effective procedure that can be performed safely by experienced laparoscopic surgeon. The procedure yields excellent functional results and leads to significant improvement in the patient's quality of life.

Efficacy of medical therapy and antireflux surgery to prevent Barrett's metaplasia in patients with gastroesophageal reflux disease.

OBJECTIVE: To investigate whether Barrett's metaplasia may develop despite effective medical therapy. SUMMARY BACKGROUND DATA: Gastroesophageal reflux disease has a multifactorial etiology. Therefore, medical treatment may not prevent complications of reflux disease. METHODS: Eighty-three patients with reflux disease and mild esophagitis were prospectively studied for the development of Barrett's metaplasia while receiving long-term therapy with proton pump inhibitors and cisapride. Only patients who had effective control of reflux symptoms and esophagitis were included. The surveillance time was 2 years. The outcome of these 83 patients was compared with that of 42 patients in whom antireflux surgery was performed with a median follow-up of 3.5 years. RESULTS: Twelve (14.5%) patients developed Barrett's while receiving medical therapy; this was not seen after surgery. Patients developing Barrett's had a weaker lower esophageal sphincter and peristalsis before treatment than patients with uncomplicated disease. CONCLUSIONS: Antireflux surgery is superior to medical therapy in the prevention of Barrett's metaplasia. Therefore, patients with reflux disease who have a weak lower esophageal sphincter and poor esophageal peristalsis should undergo antireflux surgery, even if they have only mild esophagitis.

Quality of life and surgical outcome after laparoscopic Nissen and Toupet fundoplication: one-year follow-up.

BACKGROUND AND STUDY AIMS: Quality of life data are becoming widely accepted as a measure of surgical outcome, but the multifaceted symptoms in patients with gastrointestinal disorders are a challenge for this type of evaluation. The aim of the present study was to determine any potential differences in quality of life, specifically in patients undergoing either laparoscopic "floppy" Nissen fundoplication or Toupet fundoplication. PATIENTS AND METHODS: Using the Gastrointestinal Quality of Life Index (GIQLI), the quality of life data for 175 consecutive patients undergoing laparoscopic "floppy" Nissen (n=107) or Toupet (n=68) fundoplication at our department of surgery over a period of 30 months were evaluated prospectively. The patients included 97 men and 78 women, with a mean age of 52 years. The GIQLI creates a general score for quality of life by classifying five different subscales: gastrointestinal symptoms, emotional status, physical and social functions, and stress of medical treatment. This questionnaire was given to the patients preoperatively, and on three occasions after surgery -- at six weeks, three months, and one year. RESULTS: The analysis showed that the patients had a low GIQLI preoperatively in comparison with healthy individuals (mean 90.4 vs. 122.6 points), with all subscales being affected. The general score improved significantly six weeks postoperatively (mean: 118.2 points; P<0.05), showed further improvement at three months (mean: 124.2 points), and remained stable at one year (mean: 123.1 points; P<0.01) postoperatively. There were no differences in the quality of life or side effects between patients with a Nissen or Toupet fundoplication, except regarding the frequency of mild, transient dysphagia. CONCLUSIONS: Patients with gastroesophageal reflux disease suffer from a poor quality of life. After laparoscopic fundoplication, the quality of life improves and becomes comparable to that of healthy individuals. In our view, quality of life data should be evaluated as a major factor in determining the role of surgical interventions. Patients should receive consultation and advice regarding quality of life questions prior to surgery.

Colostomy vs tube cecostomy for protection of a low anastomosis in rectal cancer.

BACKGROUND: Symptomatic anastomotic leakage is the most important surgical complication following rectal resection with intestinal anastomosis. Therefore, the routine use of a protective stoma is suggested by several authors. In our department 2 different techniques are performed to protect the anastomosis. Patients receive either a loop colostomy/ileostomy (C/I) or a tube cecostomy (TC). HYPOTHESIS: No significant difference is noted between C/I and TC for protection of a low anastomosis regarding clinical anastomotic leakage rate, reoperation rate for anastomotic leaks/fistulas, postoperative mortality, and permanent colostomy rate. By avoiding a second operation (for colostomy closure), median hospital stay should be significantly reduced. DESIGN: A retrospective review during 1985 to 1997. SETTING: Tertiary care center PATIENTS: One hundred fifty-eight patients who had undergone anterior resections for rectal cancer were studied. Protective C/Is were used in 19 patients; a TC was fashioned in 30 patients. MAIN OUTCOME MEASURES: Clinical anastomotic leakage rate, reoperation rate for anastomotic leaks/fistulas, postoperative mortality, permanent colostomy rate, and median hospital stay. RESULTS: The rate of anastomotic leaks (C/I, 16%; TC, 17%), fecal peritonitis (C/I, 0%; TC, 10%), reoperation for anastomotic leaks/fistulas (C/I, 0%; TC, 13%), permanent colostomies (C/I, 0%; TC, 7%), and postoperative mortality (C/I, 5%; TC, 0%) did not differ significantly in both groups. Median hospital stay was significantly reduced in patients with TC (C/I, 28 days; TC, 15 days). CONCLUSION: In our patients with low resections for rectal cancer, a C/I for protection of the anastomosis did not improve outcome significantly as compared with a TC. With a properly fashioned TC and adequate postoperative management a second operation (for colostomy closure) can be avoided and the overall hospital stay is significantly reduced.

[Coping with stress and personality structure in patients with and without stress-associated symptoms of gastroesophageal reflux]. / Stressverarbeitung und Persönlichkeitsstruktur bei Patienten mit und ohne stressassoziierter Symptomatik der gastroösophagealen Refluxkrankheit.

BACKGROUND: Psychological aspects like stress, emotions or personality are known to affect the severity of symptoms of gastroesophageal reflux disease (GERD). The aim of the present study was to evaluate differences in coping with stress, structure of personality and also objective and subjective parameters of patients with or without a stress-related perception of symptoms in GERD. METHODS: 100 patients which underwent laparoscopic antireflux surgery at our department of surgery were included in this study. All patients answered questionnaires to evaluate their coping with stress (SVF), structure of personality (FPI-R) and quality of life (GILQI) pre- and postoperatively. Also data of physiological parameters like manometry, 24-hours pH monitoring, endoscopy and clinical history were included. Patients were divided into two groups: one with and one without a stress-related perception of symptoms. RESULTS: 46 out of 100 patients declared stress-related symptoms of reflux (group 1) and 54 out of 100 had no influence of stress to their reflux disease (group two). Those two groups showed significant differences (p < .05) in some coping strategies and their personality: Coping with stress (SVF): Trial to control the situations (18.3 vs. 13.1), trial to control reactions (18.2 vs. 13.3), requirement of social support (9.7 vs. 14.8), tendency to escape (7.7 vs. 13.9) and aggression (13.1 vs. 7.6); structure of personality (FPI-R): Standard of performance (10.8 vs. 7.2), stress (9.8 vs. 4.7) and physical discomfort (7.6 vs. 4.6). We also found significant (p < .05) differences in pre- and postoperative quality of life (GILQI: preoperative 86.3 vs. 98.5 points; postoperative 117.9 vs. 128.2 points) and the day-time of reflux perception. There were no differences in physiological parameters. CONCLUSION: These findings point out that there are no physiological differences between the two groups with or without stress-related symptoms in GERD. But we found significant differences in psychological factors. Therefore we suggest that preoperative psychological interventions may optimize the subjective outcome after antireflux surgery in patients with a stress-related perception of symptoms.

Respiratory symptoms and dysphagia in patients with gastroesophageal reflux disease: a comparison of medical and surgical therapy.

BACKGROUND: Gastroesophageal reflux disease (GERD) is a common condition and may frequently lead to dysphagia and respiratory symptoms. The aim of this study was to investigate the effects of medical and surgical therapy to control these symptoms. METHODS: Eighty GERD patients with either dysphagia or respiratory symptoms were studied by means of a detailed symptom questionnaire, upper gastrointestinal endoscopy, esophageal manometry, 24-h esophageal pH monitoring and a barium esophagogram. All patients had been receiving medical therapy with proton-pump inhibitors and cisapride for 6 months. After withdrawal of medical therapy and relapse of GERD, 62 patients decided to undergo anti-reflux surgery (laparoscopic Nissen fundoplication in 19 and laparoscopic partial posterior fundoplication in 43 patients). Symptoms were assessed prior to treatment, at 6 months following medical therapy and 6 months after surgery. RESULTS: Heartburn and esophagitis were effectively treated by medical and surgical therapy. Dysphagia was improved in all patients following surgery but only in 27% of patients following medical therapy. Improvement of respiratory symptoms was found in 86% of patients following surgery but only in 14% following medical therapy. Improvement of regurgitation was registered only following surgical therapy. CONCLUSIONS: Since medical treatment is likely to fail in GERD patients with complex symptoms such as dysphagia, regurgitation and respiratory symptoms, the need for surgery arises in these patients and may be the only successful treatment in the long term.