Laparoscopic reoperative antireflux surgery.

BACKGROUND: Antireflux operations for gastroesophageal reflux disease whether performed open or laparoscopically can fail and may require reoperation to control new, recurrent symptoms or operation-related complications. We report our experience with the laparoscopic reoperation for failed antireflux procedures. METHODS: Between 1995 and 2000, 37 patients underwent laparoscopic reoperative antireflux procedures. The mean age and weight were 52 years and 181.5 pounds. The main presenting symptoms were heartburn (n = 18), respiratory reflux (n = 4), chest pain (n = 3), regurgitation (n = 1), and dysphagia (n = 10). The mean duration between the first operation and recurrence of symptoms was 18 months, and the duration between the two procedures was 25 months. The operation was completed laparoscopically in 32 patients (86.5%): Nissen fundoplication (n = 27) and Toupet fundoplication (n = 9). RESULTS: Intraoperative and postoperative complications occurred in 6 and 14 patients, respectively. Fundoplication disruption was the most common cause of primary surgery failure. The mean hospital stay was 4 days. At a mean follow-up of 26.5 months, results were excellent to good (65%), fair (21.5%), and poor (13.5%). CONCLUSION: Laparoscopic reoperative antireflux procedures are technically feasible with acceptable preliminary results.

Patient satisfaction. The survey says....

Health care organizations and providers compete in a marketplace where loyal consumers are essential to a successful business. Contemporary consumers have health care knowledge and power. As employers negotiate benefits with providers, most will consider input from employees receiving care. Negative feedback from dissatisfied recipients of care can affect employers' selection of facilities and providers. This is significant leverage that health care organizations should consider when providing services to customers. Information obtained through patient satisfaction programs has proven to be a valuable source for quality improvement marketing, risk management, strategic planning, and finance initiatives. In this article, the authors describe variables associated with a patient satisfaction survey, identify key elements of a patient satisfaction survey program, and offer workable solutions to maximize patient satisfaction programs.

Left side thoracoscopically assisted gastroplasty: a new technique for managing the shortened esophagus.

Laparoscopic antireflux surgery is the procedure of choice for gastroesophageal reflux disease (GERD). However, many clinicians have reservations about its application in patients with complicated GERD, notably those with esophageal shortening. In this report, we present our experience with the laparoscopic management of the shortened esophagus. A total of 235 patients with primary GERD underwent laparoscopic antireflux procedures, 38 of whom were suspected preoperatively to have a shortened esophagus. Of the 235 patients, 8 (3.4%) needed a left thoracoscopically assisted gastroplasty in addition to laparoscopic Toupet repair (n = 4) or Nissen fundoplication (n = 4). Complications included pleural effusion (n = 1), pneumothorax (n = 2), and minor atelectasis (n = 1). The average hospital stay was 3 days. Results were satisfactory in 7 of 8 patients, with a mean follow-up of 20.2 months (range, 9-34 months). The surgical management of the shortened esophagus is difficult. However, the role of minimally invasive techniques is justified. Early results are appealing, with less morbidity, satisfactory control of GERD related symptoms, and a shortened hospital stay.

Esophageal shortening during the era of laparoscopic surgery.

An effective method for determining the presence of a short esophagus preoperatively would be helpful to surgeons. In this study 260 patients underwent primary laparoscopic antireflux surgery; 44 of them were suspected to have esophageal shortening on the basis of: (1) Barrett's esophagus or evidence of peptic stricture formation on endoscopy; (2) an irreducible hiatal hernia > or = 5 cm in length on upright barium esophagram; or (3) a short esophagus on manometric analysis, defined as 2 SD below normal for height. Six patients without preoperative criteria required extensive esophageal mobilization and intraoperative endoscopic/laparoscopic assessment. Preoperative results were then compared with intraoperative esophageal length assessments. Altogether, 13 patients (5% of the whole series) underwent a lengthening procedure: left thoracoscopically assisted laparoscopic Collis gastroplasty (n = 11) or open transthoracic Collis gastroplasty (n = 2) plus antireflux repair (Nissen fundoplication in 9 and Toupet repair in 4). Among the preoperative tests, endoscopy had the highest sensitivity rate (61%); a combination of tests resulted in an increase in the specificity (63-100%) without a corresponding increase in sensitivity (28-42%). Preoperative testing is thus useful for predicting the need for an esophageal lengthening procedure. Endoscopy is the best screening test for the short esophagus. A well planned prospective trial to test the reliability of each test is needed.