Paraesophageal hernia.

The laparoscopic repair of paraesophageal hernia has proven to be safe and effective, with relatively low morbidity and mortality rates. The laparoscopic approach is feasible in patients with paraesophageal hernia because these patients are usually past middle age and commonly have multiple other medical problems. The procedure is technically demanding, but skilled laparoscopic surgeons should be able to perform the standard repair, that is, sac excision, crural closure, and fundoplication or gastropexy.

Gastric cancer in Iceland. What is the current status? Survival of 193 patients operated on for cure, 1980-1995.

OBJECTIVE: The incidence of gastric cancer has been decreasing in the last decades. Nevertheless, gastric cancer is still a substantial health problem in Iceland. The aim of this study was to analyze the survival of patients with gastric cancer operated on for cure. MATERIAL AND METHODS: We reviewed all medical files for above-mentioned patients, operated on at the National University Hospital in Reykjavik and the Quarter District Hospital of Akureyri during 1980-1995. The study was divided into three periods: 1980-1985, 1986-1990 and 1991-1995. The five-year survival for each study period and for the whole group was evaluated. RESULTS: The study group included 193 patients between the ages of 21-96 (median 71). The five-year survival for the whole group was 28% (26% 1980-1985, 22% 1986-1990, 35% 1991-1995). Despite longer survival during the last period, it was not statistically significant (p = 0.16). The major survival factor of gastric cancer was the stage of the disease at diagnosis. A greater number of patients were at stage IA during 1991-1995. The complication rate was rather high or 31% and the hospital mortality was 6.7%. CONCLUSION: The survival of patients with gastric cancer operated on for cure was low in Iceland but comparable to that in other countries. During the last years, the survival has been rising, and fortunately, more were diagnosed at a lower stage of the disease. These operations have a considerable risk and the hospital mortality was substantial.

Laparoscopic Collis gastroplasty and Nissen fundoplication. A new technique for the management of esophageal foreshortening.

BACKGROUND: The short esophagus increases the difficulty and limits the effectiveness of laparoscopic Nissen fundoplication. In out experience, approximately 20-25% of esophagi judged by preoperative criteria to be foreshortened will, after dissection, be insufficiently long to allow 2 cm of esophagus to reside below the diaphragm without inferior distraction (i.e., tension free). Collis gastroplasty combined with Nissen fundoplication has become the standard approach for the creation of an intraabdominal neoesophagus and fundic wrap. METHODS: After developing methods of performing totally laparoscopic stapled gastroplasty in the cadaver lab in 1994, we started applying the technique clinically in 1966. We performed 220 laparoscopic antireflux procedures between January 1966 and July 1997. Of these 220 patients, 26% were suspected to have esophageal foreshortening based on preoperative barium studies and/or endoscopy. RESULTS: After hiatal dissection, nine patients, or 16% of those suspected to have esophageal foreshortening and 4% of the entire population, required the laparoscopic Collis-Nissen procedure. There was symptomatic improvement in all patients as assessed by patient-initiated symptom scores. CONCLUSIONS: The management of patients with esophageal foreshortening is a complex problem. We believe that our technique of laparoscopic Collis-Nissen provides an effective means of achieving intraabdominal placement of the fundic wrap while maintaining the benefits of minimally invasive approach.

[Laparoscopic Cholecystectomy at Landspítalinn, University Hospital of Iceland. The first 353 cases.].

OBJECTIVE: Since the first laparoscopic cholecystectomy done at the Department of Surgery in November 1991, our aim has been to operate on all presenting patients by this method. MATERIAL AND METHODS: From November 17th 1991 until September 30th 1994, 384 cholecystectomies were performed. Open cholecystectomy was performed in 31 patients. The most frequent causes for open operation were; suspected stones in the choledochus, acute cholecystitis or biliary sepsis. The objective of this study was to determine the frequency of procedure-related complications and the frequency of conversion to open surgery. Furthermore, the operation time, the length of post-operative hospital stay, mortality and morbidity were studied. RESULTS: A retrospective analysis of patients undergoing cholecystectomy during this period was performed. Post-operatively patients were also contacted by telephone. There were 121 males and 263 females, ranging between three and 91 year of age. Mean age was 53.2 years. Urgent operations (operation performed after emergency admission) were 43.9%, being highest in the last period of the study. Conversion to open surgery was needed in 63 cases (17.8%). The reasons were; adhesions (39.7%), unclear anatomy (17%) and bleeding (15.9%). Conversion rate was 13% for elective operations but 24% for acute cases. Reoperation was needed in 11 cases (3.8%). Seven patients were reoperated during the same hospital admission but four later on. The reasons were; bleeding (four), bile leakage (three), common duct stone (two), subphrenic abscess (one) and injury to the common bile duct (one). One patient (83 years old male) died of pulmonary embolus after a converted operation. The mean operation time for laparoscopic cholecystectomy was 94.9 minutes (30-210 minutes). For the first 100 operations the mean operative time was 99.3 minutes but 85.5 minutes for the last 100. The mean hospital stay after laparoscopic cholecystectomy was 3.1 days (ranging from just few hours to 60 days). Data on 257 patients after laparoscopic cholecystectomy showed that the mean loss of work or preoperative activity level was 17.6 days (2-87 days). There was a statistically significant difference between preoperative activity level in the emergency versus the elective group (21.4 or 15 days, p<0.05). CONCLUSIONS: We conclude that laparoscopic cholecystectomy is a safe procedure and its safety will increase as surgeons gain more experience. Furthermore, this technique may be recommended for elective and emergency cases. Shorter hospital stay and fewer working days lost, followed by decreased expenses both for the patient as well as the community as a whole, must also be considered as a major advantage.

[Peptic ulcer perforations, University Hospital of Iceland 1989-1995.].

OBJECTIVE: In this audit we looked at patients who came in to the University Hospital of Iceland, diagnosed to have perforated peptic ulcer, with the aim to gain information about the patients and the treatment. MATERIAL AND METHODS: Information was from patients' notes, of 72 patients presenting with perforated peptic ulcer, from 1 January 1989 to 31 December 1995. Mean age of patients was 59 years. Male: female 1:1. RESULTS: Twenty nine persent of the patients had history of previous peptic ulcer. One third of the patients were receiving NSAID at the time of perforation, 54% had gastric perforation and 45% duodenal perforation. Fourty four (64%) did undergo laparotomy and 25 (36%) laparoscopy. Of the 25, 11 operations were converted to laparotomy. Mortality was 13%. Patients, that had laparoscopic treatment, were discharged 2.3 days earlier on average, compared to those undergoing laparotomy. Thirty one (45%) patients had concomitant disease(s). CONCLUSIONS: A large proportion of patients coming to hospital with perforated peptic ulcers are older people, many with serious concomitant diseases. Laparoscopic treatment of perforated ulcers are equal to lapotomy, altough laporoscopic treatment shows a trent towards shortening of postoperative treatment in hospital.

[Subcutaneous metastasis after laparoscopic cholecystectomy in a patient with unsuspected adenocarcinoma of the pancreas.].

A 63 year old patient underwent uneventful laparoscopic cholecystectomy in 1994. The patient had a long history of biliary colic after fatty meals. The chief presenting symptom was pain localized in the epigastrium radiating to the back and later distributing to the whole abdomen. The patient also had a history of constipation, but no other symptoms were noted. An ultrasonogram of the liver, gall bladder and pancreas was reported to show calculi in the gall bladder but otherwise normal findings. The laparascopic cholecystectomy was uneventful with discharge the following day. The symptoms however did not disappear, changing in character, locating at the center of the abdomen. The patient began to lose appetite with bouts of diarrhea. The symptoms gradually increased and the patient was admitted to the hospital. Upon arrival the patient was found to have diffuse abdominal pain with a painful swelling of the umbilical trocar site. Incarcerated hernia was suspected, but proved to be a mass at exploration. Pathologic examination disclosed a metastatic adenocarcinoma. A similar but smaller mass was also discovered in the epigastric trocar site. CT scan showed a pancreatic carcinoma of the corpus with infiltration. The patient deteriorated rapidly and died four months after the diagnosis of pancreatic cancer.

Laparoscopic management of achalasia.

Cardiomyotomy for achalasia is one of the ideal procedures for the video endoscopic approach. Magnification of the operative field during laparoscopic surgery allows precise division of the muscle fibers with excellent results. The number of reports on cardiomyotomy performed with laparoscopic (and thoracoscopic) access is growing. They all show the same excellent results as for conventional (open) myotomy, with minimal morbidity, short hospital stay, and early return to routine activity.

Biliary tract complications of laparoscopic cholecystectomy are detected more frequently with routine intraoperative cholangiography.

Controversy over whether intraoperative cholangiography (IOC) should be done routinely has intensified since the advent of laparoscopic cholecystectomy (LC). As yet, no study has demonstrated a clear benefit to its use, although their have been suggestions in the literature that routine use may confer an advantage to detection of injuries. One-hundred seventy-seven biliary tract complications occurring secondary to LC were identified from the combined data of seven institutions. The goal of this retrospective study was to examine the impact of IOC on the occurrence, recognition, and correction of such complications. The complications identified include 39 cystic duct leaks, 69 major ductal leaks or strictures, and 69 major ductal transection or excision injuries. Whether IOC was performed was known in 157 (88%) patients with 53 patients definitely having and 104 not having an IOC. Data concerning IOC were unavailable in 20 cases. More injuries were detected intraoperatively in the group having IOC (P < 0.001). Conversion of the LC to a laparotomy, often for repair of the injury, occurred more commonly in the group having a correctly interpreted IOC (P < 0.001). Conversion resulted in detection of injuries sooner, resulting in fewer operative procedures to correct the injury (P < 0.001). A transecting injury was prevented in at least seven patients when no visualization of the proximal biliary tree was documented by IOC. These partial ductal incisions were treated by t-tube placement. Incorrect interpretation of the IOC occurred in at least eight patients, with no identification of the proximal biliary tree in six.(ABSTRACT TRUNCATED AT 250 WORDS)

Nitrous oxide pneumoperitoneum revisited. Is there a risk of combustion?

Nitrous oxide has been effectively banned from use in therapeutic laparoscopy because of fear of combustion. These fears rest on two case reports, a misunderstanding of the physical chemistry of nitrous oxide, and lack of information on the presence of flammable colonic gases in the pneumoperitoneum mixture. This study aims to identify the presence and quantify the amount of hydrogen and methane found in the peritoneal cavity during laparoscopic GI procedures, and then to compare the gas concentrations detected with known limits of combustion. Gas standards with known concentrations of hydrogen and methane were placed in polypropylene syringes and analyzed on a mass spectrometer after 1, 2, 3, and 4 h. This established the rate at which these gases would be leached through a polypropylene syringe--the amount of gas lost during transport from the patient to the laboratory. Twenty gas samples were drawn, randomly, 30 min to 2 h following the start of laparoscopic gastrointestinal procedures. The samples were analyzed for hydrogen and methane within 30 min of their aspiration from the abdominal cavity. An inconsequential amount of methane was lost from the polypropylene syringe in 4 h. After 1 h, one-half the hydrogen had leached from the polypropylene syringe. Hydrogen was detected in the pneumoperitoneum of four patients at a concentration ranging from 0.016 to 0.075%. No methane was detected in any sample. For combustion to occur in a nitrous oxide environment, hydrogen or methane must occupy 5.5% of the gas volume. The maximum amount of hydrogen we detected was less than 1/50 of the combustion threshold.(ABSTRACT TRUNCATED AT 250 WORDS)

Laparoscopic Nissen fundoplication is less expensive than open Belsey Mark IV.

Laparoscopic Nissen fundoplication is a relatively new technique used to treat gastroesophageal reflux disease (GERD). The purpose of this study was to compare the cost to the patient and insurer of a laparoscopic Nissen fundoplication (LN) to an open Belsey Mark IV (B4), the previous standard operation for GERD at Emory University Hospital. A retrospective review of 20 consecutive patients undergoing LN or B4 for GERD was performed. Patients were well matched for age, severity of disease, and comorbid illness. The data were analyzed using an unpaired Student's t-test or Wilcoxon signed rank analysis. The results are as follows (mean +/- SD): [table: see text] We conclude that the charges for laparoscopic Nissen fundoplication are significantly less than the charges for Belsey Mark IV. The majority of the savings resulted from a shortened hospital stay.

Laparoscopic repair of paraesophageal hernia. New access, old technique.

Large paraesophageal hernias are generally repaired by reduction of the stomach into the abdomen, sac excision, crural closure, and gastropexy or fundoplication. After gaining experience performing laparoscopic repair of sliding hiatal hernias and Nissen fundoplication we combined laparoscopic access with traditional surgical technique in treating patients with complex paraesophageal hernias. Ten adults, six males and four females, with type III paraesophageal hernias underwent laparoscopic repair between February 1993 and April 1994. The average age of the patients was 60.4 years (range 38-81). Using five ports (three 10 mm and two 5 mm), the stomach was reduced into the abdomen, the hernia sac was resected, and the defect was closed with pledgeted horizontal mattress sutures. In addition, nine patients had a Nissen fundoplication performed and one patient had a diaphragmatic gastropexy. The procedure was completed laparoscopically in all ten cases and the median operating time was 282 min (range 165-430). Two complications occurred, an intraoperative gastric laceration, and a postoperative mediastinal seroma. All patients were discharged on the 2nd or 3rd postoperative day. Eight of nine patients were asymptomatic at last follow-up (mean 8.9 months postop). One patient has mild dysphagia and heartburn from partial migration of the fundoplication into the chest. One patient died 3 months postoperatively of unrelated causes. Paraesophageal hernia can be reduced and repaired safely with laparoscopic access using standard surgical techniques.

The preoperative evaluation of patients considered for laparoscopic antireflux surgery.

Few studies address the proper extent of the preoperative testing in patients referred for consideration of antireflux surgery. Our aim was to perform a thorough gastroesophageal evaluation and determine its influence on the therapeutic decisions of such patients. We evaluated 107 consecutive patients in a combined GI/Surgery clinic for severe or refractory gastroesophageal reflux. The patients had an EGD, esophageal manometry, and 24-h ambulatory esophageal pH monitoring. Only patients with gastric symptoms had gastric testing. Nineteen patients were excluded, 12 refused further evaluation and seven were felt to be unfit for antireflux surgery because of medical or psychological reasons. Eighty-eight patients completed the required studies. Fifty-four patients (61%) had typical reflux symptoms and erosive esophagitis on EGD. All these patients had an abnormal pH study. Five of the 34 patients without esophagitis had a normal pH study and did not have surgery. Ten patients had poor peristalsis by esophageal manometry prompting a subtotal fundoplication. One patient had severe delayed gastric emptying, requiring pyloroplasty in addition to the fundoplication. Eighty of 83 patients had good or excellent surgical results. EGD and esophageal manometry are indispensable in the preoperative evaluation. Manometry may identify abnormalities altering surgical decisions in roughly 10% of patients. Routine ambulatory esophageal pH monitoring is of marginal benefit, except in patients without esophagitis or in those patients where the diagnosis is in doubt. Clinically significant gastric abnormalities are rare, and routine testing of gastric function is not indicated.

A micromethod for the assay of cellular secretory physiology: application to rabbit parietal cells.

A micromethod for investigating secretory physiology in isolated cells was evaluated. The method utilized a specially designed polycarbonate incubation chamber to provide constant oxygenation to cells incubating in a 96-well microtiter plate. Cells were rapidly separated from media by vacuum filtration. Isolated parietal cells were utilized to demonstrate the versatility of the method for assay of intracellular accumulation of [14C]-aminopyrine, secretion of intrinsic factor into the medium, and assay of intracellular cAMP. Histamine stimulated the uptake of [14C]aminopyrine and intrinsic factor secretion in a sustained and linear fashion. At the end of the 2-h period uptake of aminopyrine and secretion of intrinsic factor were increased 17- and 5-fold, respectively. This response to histamine was accompanied by a rapid and sustained 3-fold rise in intracellular cyclic AMP. In contrast, carbamylcholine caused a transient increase in [14C]aminopyrine accumulation and intrinsic factor secretion which was most pronounced during the first 10 min and had almost ceased by 30 min. Carbamylcholine had no effect on intracellular cAMP levels. This new method, which can handle 400 replicates using parietal cells from the fundic mucosa of a single rabbit, is suitable for studying the time course of intracellular events which accompany general secretory processes.

Identification and characterization of a cytosolic 30 kDa histamine stimulated phosphoprotein in parietal cell cytosol.

Histamine stimulated acid secretion is mediated by an increase in intracellular cAMP. Cytosolic protein phosphorylation stimulated by histamine was investigated in isolated rabbit parietal cells. Histamine stimulated the phosphorylation of a 30 kDa phosphoprotein with an isoelectric point of 5.6. Cimetidine completely inhibited histamine-stimulated pp30 phosphorylation. However, omeprazole had no effect on the phosphorylation of pp30. Forskolin and 8-bromo-cAMP also stimulated the phosphorylation of pp30. The results suggest that pp30 is a histamine-stimulated, cAMP-dependently phosphorylated protein substrate in parietal cell cytosol.

A calmodulin dependent protein kinase in parietal cells.

An enriched population of isolated rabbit gastric parietal cells, from the fundic mucosa of New Zealand White rabbit, contained an active cytosolic calmodulin-dependent protein kinase activity with a prominent 100 kDa substrate (pp100). The latter focused as a doublet with isoelectric point of 6.8-7.0. The pp100 protein was phosphorylated only on threonine residues on a single tryptic peptide. Trifluoperazine inhibited the pp100 kinase activity with a KI of 10-15 microM. Addition of exogenous calmodulin was able to restore activity to uninhibited levels. A protein band with a molecular weight and phosphopeptide map identical to pp100, phosphorylated by calcium-dependent kinase, was also observed in rabbit pancreatic cytosol. The data suggest that a type III calmodulin-dependent kinase is present in parietal cell cytosol.

A specific histamine-stimulated phosphoprotein in isolated parietal cells.

Histamine-stimulated phosphorylation was studied in isolated rabbit parietal cells. Secretion of acid, as assessed by aminopyrine uptake, was linear at 15 min of stimulation with histamine. By utilizing two dimensional gels, a specific 30,000-Da protein (pp30) was identified whose phosphorylation was prominently stimulated by histamine after 15 min of incubation. The pp30 protein displayed an isoelectric point of 6.0. Furthermore, cAMP-dependent pp30 phosphorylation could also be demonstrated in vitro in a preparation of parietal cell cytosol. The results suggest that pp30 may represent an important histamine-stimulated cAMP-dependent phosphoprotein involved in the initiation or maintenance of parietal cell secretion.

Somatostatin inhibition of intrinsic factor secretion from isolated guinea pig gastric glands.

The aim of our study was to examine the direct effect of somatostatin on histamine- and pentagastrin-stimulated intrinsic factor (IF) release in collagenase-dispersed guinea pig gastric glands. The effect of somatostatin (10(-11) M to 10(-6) M) on half-maximal doses of histamine (10(-6) M), pentagastrin (10(-6) M), and both histamine and pentagastrin together was tested. All tested concentrations of histamine significantly stimulated IF release. Pentagastrin (10(-10) M to 10(-6) M) inconsistently stimulated IF release. The quantity of IF release stimulated by histamine and pentagastrin together was approximately the additive sum of that produced by either agent alone. Somatostatin (10(-6) M) inhibited histamine-stimulated (10(-6) M) IF release by 69.9 +/- 7.2% and the combination of histamine (10(-6) M) and pentagastrin (10(-6) M) by 64.2 +/- 9.1%. This is the first in vitro demonstration that somatostatin inhibits IF release.

A novel protein kinase activity in rabbit gastric gland cytosol.

A novel protein kinase activity was characterized from the cytosolic fraction of isolated rabbit gastric glands. The kinase phosphorylated a major 33,000 Da endogenous protein (pp33) and was stimulated by Zn2+ and Mn2+ with Kact of 1.0 and 7.5 mM, respectively. Mg2+ and Ca2+ failed to stimulate any pp33 kinase activity. The kinase utilized both ATP and GTP as phosphate donors with a Km of 10 microM for both. The pp33 protein displayed an isoelectric point of 7.5 to 7.8 and was phosphorylated predominantly on threonine residues. The kinase activity is clearly differentiable from all reported kinase activities and appeared to be enriched in rabbit gastric fundic mucosa. The results indicate that gastric fundic mucosa contains a novel protein kinase activity.