Long-term symptom control of gastro-oesophageal reflux disease 12 years after laparoscopic Nissen or 180° anterior partial fundoplication in a randomized clinical trial.

BACKGROUND: Laparoscopic 180° anterior fundoplication has been shown to achieve similar reflux control to Nissen fundoplication, with fewer side-effects, up to 5 years. However, there is a paucity of long-term follow-up data on this technique and antireflux surgery in general. This study reports 12-year outcomes of a double-blind RCT comparing laparoscopic Nissen versus 180° laparoscopic anterior fundoplication for gastro-oesophageal reflux disease (GORD). METHODS: Patients with proven GORD were randomized to laparoscopic Nissen or 180° anterior fundoplication. The 12-year outcome measures included reflux control, dysphagia, gas-related symptoms and patient satisfaction. Measures included scores on a visual analogue scale, a validated Dakkak score for dysphagia and Visick scores. RESULTS: Of the initial 163 patients randomized (Nissen 84, anterior 79), 90 (55·2 per cent) completed 12-year follow-up (Nissen 52, anterior 38). There were no differences in heartburn, dysphagia, gas-related symptoms, patient satisfaction or surgical reintervention rate. Use of acid-suppressing drugs was less common after Nissen than after 180° anterior fundoplication: four of 52 (8 per cent) and 11 of 38 (29 per cent) respectively (P = 0·008). The proportion of patients with absent or only mild symptoms was slightly higher after Nissen fundoplication: 45 of 50 (90 per cent) versus 28 of 38 (74 per cent) (P = 0·044). CONCLUSION: The two surgical procedures provided similar control of heartburn and post-fundoplication symptoms, with similar patient satisfaction and reoperation rates on long-term follow-up.

Outcome of laparoscopic inguinal hernia repair in a South African private practice setting.

OBJECTIVE: The aim of this study was to determine the recurrence and complication rates of laparoscopic inguinal hernia repair performed in a private practice in Cape Town. DESIGN AND SUBJECTS: An unselected cohort of 507 patients who underwent laparoscopic totally extraperitoneal (TEP) inguinal hernia repair before September 2005 were included in this study, thus ensuring a minimum 5-year follow-up. Patient demographic data, clinical notes, operating notes and outpatient follow-up notes were studied. Patients were interviewed telephonically regarding hernia recurrence, chronic pain and technique preference if they had previously undergone an open repair. All data collected were recorded on an electronic spreadsheet. The primary outcome parameter was recurrence. The secondary outcome parameters were postoperative and long-term complications. RESULTS: Of the 507 patients, 267 were contactable telephonically. There were 384 hernia repairs with a mean follow-up of 8.8 years. There were 9 recurrences (2.3%). The overall complication rate was 7.9%. Two per cent of patients suffered from chronic groin pain with gradual improvement since surgery. Sixteen per cent of patients had had previous open repair of an inguinal hernia, either on the ipsilateral or the contralateral side, and all judged the open repair to have been more painful. CONCLUSIONS: The recurrence and complication rates for laparoscopic TEP inguinal hernia repair in this practice are low and comparable to the best reported series. There is a low incidence of persistent postoperative pain with the laparoscopic technique, and it is the technique preferred by patients who previously underwent an open repair.

Surgery for colonic cancer in HNPCC: total vs segmental colectomy.

AIM: The high reported risk of metachronous colon cancer (MCC) in hereditary nonpolyposis colorectal cancer (HNPCC) has led some authors to recommend total colectomy (TC) as the preferred operation for primary colon cancer, but this remains controversial. No previous study has compared survival after TC with segmental colectomy (SC) in HNPCC. The aim of this study was to determine the risk of developing MCC in patients with genetically proven HNPCC after SC or TC for cancer, and to compare their long-term survival. METHOD: This is a prospective cohort study of all patients referred to our unit between 1995 and 2009 with a proven germline mismatch repair gene defect, who had undergone a resection for adenocarcinoma of the colon with curative intent. All patients were offered annual endoscopic surveillance. RESULTS: Of 60 patients in the study, 39 had TC as their initial surgery and 21 had SC. After 6 years follow up, MCC occurred in eight (21%) SC patients and in none of the TC patients (P = 0.048). The risk of developing MCC after SC was 20% at 5 years. Colorectal cancer-specific survival was better in TC patients (P = 0.048) but overall survival of the two groups was similar (P = 0.29). CONCLUSION: Patients with HNPCC have a significant risk of MCC after SC. This is eliminated by performing TC as the primary operation for colonic cancer.

Randomized double-blind trial of laparoscopic Nissen fundoplication versus anterior partial fundoplication.

BACKGROUND: This double-blind, randomized study compared outcomes of laparoscopic Nissen total fundoplication and anterior partial fundoplication carried out by a single surgeon in a private practice. METHODS: All patients with proven gastro-oesophageal reflux disease, regardless of motility, presenting for laparoscopic antireflux surgery were randomized to either Nissen total or anterior partial fundoplication. Primary outcome measures were dysphagia and abolition of reflux. Secondary outcome measures were Visick scores, bloating, patient satisfaction and reoperation rate. RESULTS: Complete follow-up was available for 161 (98.8 per cent) of 163 patients (84 Nissen, 79 anterior). There were no differences in mean heartburn scores between groups. Recurrent reflux was observed in ten patients after anterior fundoplication, but none after the Nissen procedure. Dysphagia scores for both liquids and solids were lower after anterior fundoplication. Four patients had persistent troublesome dysphagia after Nissen fundoplication compared with none after anterior fundoplication. There were no differences between groups in postoperative bloating. The overall reoperation rate at 2 years was 7 per cent, all achieved laparoscopically. CONCLUSION: Nissen fundoplication cured reflux in all patients up to 2 years, but 5 per cent required revisional surgery. Recurrent reflux was more common after anterior fundoplication, but dysphagia was rare. Patient satisfaction was excellent in both groups. Revisional laparoscopic surgery was safe and usually successful.

Palliative surgery for acute bowel obstruction caused by Kaposi's sarcoma in a patient with AIDS.

Patients with human immunodeficiency virus (HIV) infection or acquired immune deficiency syndrome (AIDS) can present with acute abdominal surgical problems, either with intra-abdominal opportunistic infection as a result of their immunosuppression, or with associated malignancies. We report a 39-year-old man who developed intermittent nausea and vomiting, which was originally thought to be a side-effect of the chemotherapy he was receiving for facial Kaposi's sarcoma. However, he was found to have intraperitoneal Kaposi's sarcoma causing small bowel obstruction, which was successfully excised at laparotomy. There were no perioperative complications despite AIDS-related respiratory disease. The patient remained free of abdominal symptoms until his death. HIV infections or AIDS alone should not be contraindications to surgery for such problems, as careful patient selection can yield good results and significantly improve quality of life.

Radical excision of multifocal anal intraepithelial neoplasia: report of a case.

PURPOSE: The aim of this study was to describe the technique of radical excision of multifocal anal intraepithelial neoplasia and discuss controversial issues surrounding the management of this condition. METHOD: We describe the case of a 31-year-old female with previous vulval warts, vulval squamous carcinoma, and recent immunosuppression who had widespread anal intraepithelial neoplasia excised, and the resulting defect was split-skin grafted, including the anal canal. RESULTS: Excision and split-skin grafting was successful in removing the disease and left a satisfactory cosmetic and functional result. CONCLUSION: Diffuse, high-grade, anal intraepithelial neoplasia is rare. Excision of these lesions remains controversial but may be the best option.

Efficacy of anterior, posterior and total fundoplication in an experimental model.

BACKGROUND: This study examined the effect of different types of laparoscopic fundoplication on an incompetent lower oesophageal sphincter to test their effectiveness at preventing gastro-oesophageal reflux in the early postoperative period. METHODS: An experimental porcine model was used. Initial oesophageal myotomy ensured an incompetent lower oesophageal sphincter with free reflux of 'intragastric fluid'. Anterior, posterior or total fundoplication was then performed laparoscopically in 15 laboratory pigs (five in each group). Fundoplication competence and efficacy were determined 2 weeks after laparoscopic antireflux surgery by inflating the stomach with liquid through a gastrostomy cannula. Some animals were also studied at 4 and 6 weeks. Lower oesophageal sphincter pressure was determined using a water-perfused oesophageal manometry catheter incorporating a Dent sleeve. RESULTS: All three types of fundoplication produced similar increases in postoperative resting lower oesophageal sphincter pressure and restored adequate competence to the gastro-oesophageal junction. CONCLUSION: All three variants of laparoscopic fundoplication restore gastro-oesophageal competence in the early postoperative period.

Prospective double-blind randomized trial of laparoscopic Nissen fundoplication with division and without division of short gastric vessels.

OBJECTIVE: To determine whether division of the short gastric vessels (SGVs) and full mobilization of the gastric fundus is necessary to reduce the incidence of postoperative dysphagia and other adverse sequelae of laparoscopic Nissen fundoplication. SUMMARY BACKGROUND DATA: Based on historical and uncontrolled studies, division of the SGVs has been advocated during laparoscopic Nissen fundoplication to improve postoperative clinical outcomes. However, this modification has not been evaluated in a large prospective randomized trial. METHODS: One hundred two patients with proven gastroesophageal reflux disease presenting for laparoscopic Nissen fundoplication were prospectively randomized to undergo fundoplication with (52 patients) or without (50 patients) division of the SGVs. Patients with esophageal motility disorders, patients requiring a concurrent abdominal procedure, and patients who had undergone previous antireflux surgery were excluded. Patients were blinded to the postoperative status of their SGVs. Clinical assessment was performed by a blinded independent investigator who used multiple standardized clinical grading systems to assess dysphagia, heartburn, and patient satisfaction 1, 3, and 6 months after surgery. Objective measurement of lower esophageal sphincter pressure, esophageal emptying time, and distal esophageal acid exposure and radiologic assessment of postoperative anatomy were also performed. RESULTS: Operating time was increased by 40 minutes (median 65 vs. 105) by vessel division. Perioperative outcomes and complications, postoperative dysphagia, relief of heartburn, and overall satisfaction were not improved by dividing the SGVs. Lower esophageal sphincter pressure, acid exposure, and esophageal emptying times were similar for the two groups. CONCLUSION: Division of the SGVs during laparoscopic Nissen fundoplication did not improve any clinical or objective postoperative outcome.

Outcome of laparoscopic Nissen fundoplication in patients with disordered preoperative peristalsis.

BACKGROUND: A 360 degrees or Nissen fundoplication remains controversial in patients with disordered peristalsis, some surgeons preferring a partial wrap to minimise postoperative dysphagia. AIM: To evaluate symptoms and manometric outcome in patients with disordered peristalsis after Nissen fundoplication. PATIENTS: In an initial series of 345 patients studied prospectively, 31 patients who had undergone a Nissen fundoplication had disordered peristalsis. Using preoperative manometry, patients were classified as: equivocal primary peristalsis (eight patients); abnormal primary peristalsis (four patients); abnormal maximal contraction pressure (13 patients); abnormal primary peristalsis and maximal contraction pressure (six patients). METHODS: Postoperatively, patients underwent a barium meal, oesophageal manometry and standardised clinical review by a blinded scientific officer. RESULTS: Twenty eight (90%) patients had satisfaction scores of at least 8 out of a maximum of 10 and all would undergo surgery again. Whereas 15 (48%) patients had dysphagia scores greater than 4/10 preoperatively, only two (6%) had these scores at one year. Improved peristalsis was seen in 78% of postoperative manometric studies, and mean preoperative lower oesophageal sphincter pressure increased from 6.6 (range 0-21) mm Hg to 19 (4-50) mm Hg. CONCLUSIONS: These results are similar to the overall group of 345 patients and suggest that disordered peristalsis, and possibly even absent peristalsis, is not a contraindication to Nissen fundoplication as performed in these patients.

Palliation of malignant dysphagia by laser therapy.

The outcome of 211 patients undergoing laser therapy as palliation for inoperable carcinoma of the esophagus is presented. The median age was 73 (range 44-97). The histology was adenocarcinoma for 127 patients and squamous-cell carcinoma for 84 patients. For 133 patients, laser was the only therapy while 56 patients had a combination of laser therapy and radiotherapy/chemotherapy. One patient underwent laser recanalization prior to resection while four patients had recurrence after resection treated by laser. Eleven patients underwent laser therapy for recurrent dysphagia after placement of an esophageal endoprosthesis. Eighteen patients died of procedure-related complications (i.e. 9% of patients and 2% of procedures). Of 32 procedures which perforated the tumour, 10 ended in death and the remaining patients were successfully treated conservatively. Good palliation was achieved for 170 patients (80%), while 19 patients underwent intubation after failure of laser therapy. Laser therapy failed to relieve dysphagia for 22 patients. The median survival was 20 weeks with the 1-year survival 12% and 2-year survival 4%; there were no significant differences in survival dependent on histology or administration of adjuvant radiotherapy or chemotherapy. Laser therapy provides a practical alternative to intubation in the treatment of malignant dysphagia for patients with unresectable esophageal carcinoma.

Colorectal cancer surgery in a district general hospital.

The purpose of our study was to audit colorectal cancer surgery in a large district hospital, compare our results with other series and highlight any areas in patient management where improvements could be made. A comprehensive audit was undertaken of all patients undergoing surgery for colorectal adenocarcinoma over a 2-year period (December 1989 to November 1991). Two hundred and twenty-two patients were studied. General practitioner referrals were seen within 8 weeks in 140 (96%) of 149 cases. Delay to diagnosis was associated with barium enema examination. A consultant or senior registrar was present at 187 (84.2%) of operations, and only two (0.9%) were undertaken between 24.00 and 08.00 hours. For rectal tumours the ratio of anterior resection to abdomino-perineal excision was 2:1. Eight of nine anastomotic leaks followed low anterior resection. All required re-operation and three died. The overall in-hospital mortality was 17 (7.7%). Although our results compare favourably with other published series, several areas for potential improvement in management have been identified.

Enteral versus parenteral nutrition after oesophagogastric surgery: a prospective randomized comparison.

BACKGROUND: There appears to be an emerging consensus that early postoperative nutritional support benefits the high-risk patient by decreasing septic morbidity, maintaining immunocompetence and improving wound healing. Enteral nutrition via a feeding jejunostomy has been associated with serious complications, with a reported mortality rate as high as 10%, while total parenteral nutrition has also been associated with a wide variety of complications. METHODS: Ninety-seven patients undergoing oesophagectomy or gastrectomy underwent pre-operative nutritional assessment and were randomized to receive either total parenteral nutrition (47 patients) or enteral nutrition (50 patients). RESULTS: There was no significant difference in the number of catheter-related complications between the two groups, but 9 (45%) patients in the total parenteral nutrition group had major morbidity (potentially fatal in two patients) requiring active intervention. CONCLUSIONS: This study demonstrates enteral nutrition to be safe and associated with mainly reversible minor complications. It is probable that immediate postoperative enteral feeding conserves the gut's integrity. Whether this leads to a reduction in postoperative septic complications has not been demonstrated by this study although there appears to be a trend in this direction, supporting the concept of enteral feeding as 'primary therapy'. This can be safely, simply and economically achieved using a feeding jejunostomy placed at the time of surgery.

Laparoscopic surgery for gastro-oesophageal reflux: beyond the learning curve.

From September 1991 to October 1995, 320 Nissen fundoplications were undertaken laparoscopically by 12 surgeons at a single institution. To assess the performance of the procedure in the hands of five 'experienced' surgeons, the first 20 procedures performed by each surgeon or surgical trainee were excluded, providing a group of 174 patients for review. A short loose 360 degrees fundoplication was performed in all instances, with short gastric vessel division performed in 35.0 per cent of patients and hiatal repair in 66.7 per cent. Median operating time was 80 (range 30-210) min and median postoperative stay was 3 (range 1-19) days. Sixteen procedures (9.2 per cent) could not be completed laparoscopically and required conversion to open surgery. Some 144 patients were reviewed by a scientific officer 3 months after surgery, 85 at 12 months, and 32 at 2 years, using a standard clinical questionnaire. All but one were free from reflux symptoms, although 20.1 per cent reported some dysphagia at 3 months' follow-up; this figure declined to 11 per cent at 12 months and 6 per cent (two of 34 patients) at 2 years. At each follow-up interval, 91 per cent of patients were satisfied with the outcome of the surgery. Objective testing with oesophageal motility (75 patients) and barium swallow (113) studies 3-6 months after surgery confirmed the clinical outcome. Complications occurred in nine patients (5.2 per cent); four (2.3 per cent) of these required a subsequent operation within 30 days of surgery for bleeding (one patient), paraoesophageal herniation (one) and dysphagia (two). A further procedure was necessary in six other patients (3.4 per cent) for late problems, including paraoesophageal herniation (two), hiatal stenosis (three) and gastric obstruction (one). Revision was performed laparoscopically in two patients. The clinical results of laparoscopic Nissen fundoplication by 'experienced' laparoscopic surgeons were comparable with those of open surgery.

A learning curve for laparoscopic fundoplication. Definable, avoidable, or a waste of time?

OBJECTIVE: The objective of this study was to determine whether a learning curve for laparoscopic fundoplication can be defined, and whether steps can be taken to avoid any difficulties associated with it. SUMMARY BACKGROUND DATA: Although early outcomes after laparoscopic fundoplication have been promising, complications unique to the procedure have been described. Learning curve problems may contribute to these difficulties. Although training recommendations have been published by some professional bodies, there is disagreement about what constitutes adequate supervised experience before the solo performance of laparoscopic antireflux surgery, and the true length of the learning curve. METHODS: The outcome of 280 laparoscopic fundoplications undertaken by 11 surgeons during a 46-month period was assessed prospectively. The experience was analyzed in three different ways: 1) by an assessment of the overall learning experience within chronologically arranged groups, 2) by an assessment of all individual experiences grouped according to the experience of individual surgeons, and 3) by a comparison of early outcomes of operations performed by the surgeons who initiated laparoscopic fundoplication with the early experience of surgeons beginning laparoscopic fundoplication later in the overall institutional experience. RESULTS: The complication, reoperation, and laparoscopic to open conversion rates all were higher in the first 50 cases performed by the overall group, and in the first 20 cases performed by each individual surgeon. These rates were even higher in the initial first 20 cases, and the first 5 individual cases. However, adverse outcomes were less likely when surgeons began fundoplication later in the overall experience, when experienced supervision could be provided. CONCLUSIONS: A learning curve for laparoscopic fundoplication can be defined. Experienced supervision should be sought by surgeons beginning laparoscopic fundoplication during their first 20 procedures. This should minimize adverse outcomes associated with an individual's learning curve.

Peroperative cholangiography through the gallbladder (cholecystocholangiography) during laparoscopic cholecystectomy.

The indications and best technique for peroperative cholangiography during laparoscopic cholecystectomy remain unclear, but the operation has been associated with an increased use of preoperative endoscopic retrograde cholangiography. Cystic duct cholangiography, particularly in the hands of the trainee, can be time consuming, and bile duct injury may be caused by attempts to cannulate the cystic duct. This study analyses 113 consecutive patients undergoing peroperative cholangiography through the gallbladder, or cholecystocholangiography. It was successful in 92 (81.4%) patients, the procedure adding less than 10 min to the operating time. There were no cholangiogram-related complications. Common anatomical variations included both short and particularly wide cystic ducts. This information helps to minimize the risk of damage to the common bile duct. This study demonstrates that cholecystocholangiography is a safe, simple, and effective alternative to cystic duct cholangiography with virtually no "learning curve." It provides a "road-map" of biliary anatomy and identifies common bile duct stones prior to the commencement of dissection. Unsuccessful cholecystocholangiography does not preclude the use of cystic duct cholangiography later in the operation. Difficult anatomy is demonstrated prior to dissection. When unsuspected bile duct calculi necessitate open exploration, further laparoscopic dissection is avoided.

Use of a feeding jejunostomy after oesophagogastric surgery.

Over a 5-year period, 58 patients with oesophageal or gastric malignancy underwent surgical resection with oesophagogastric or oesophagojejunal anastomosis. All were fed temporarily with a catheter feeding jejunostomy placed at the time of surgery. All patients tolerated the feeding well. There were no catheter-related deaths and only one serious complication, formation of an abscess following catheter dislodgement. Experience with this technique suggests that it is safe and cheap method of feeding patients after oesophagogastric surgery. Such patients are particularly suitable for a feeding jejunostomy as they are frequently malnourished, rarely have prolonged postoperative ileus and may develop complications that delay the onset of oral intake.