Wrap Disruption Research Articles

OC-080 A NOVEL SURGICAL APPROACH, THE DOUBLE TRACT RECONSTRUCTION IN TREATING FAILED RE-DO FUNDOPLICATION

Abstract Aim Recurrence of hiatal hernia may occur in up to 70% of patients. Failure is defined subjectively as recurrence of symptoms and objectively by imaging or pH studies, which can diagnose recurrent hiatal hernia, wrap disruption, and/or reflux disease. Approximately 25% of patients need partial or subtotal esophagectomy - mainly secondarily to scar formation and fibrosis at the hiatus site. Our aim is to report the early results of a novel double tract reconstruction in treating failed re-do fundoplication Materials and methods Retrospective review of prospectively collected data on patients who had undergone salvage operation of failed re-do fundoplication related to demographics, operative details, surgical and clinical outcomes as well as patient satisfaction. Results Conclusion Double tract reconstruction appears a suitable option in treating symptomatic recurrently failed hiatal hernia repair especially after the second or third recurrence with disruption of the anatomy and scarring of gastroesophageal junction.

Innexin-Mediated Adhesion between Glia Is Required for Axon Ensheathment in the Peripheral Nervous System.

Glia are essential to protecting and enabling nervous system function and a key glial function is the formation of the glial sheath around peripheral axons. Each peripheral nerve in the Drosophila larva is ensheathed by three glial layers, which structurally support and insulate the peripheral axons. How peripheral glia communicate with each other and between layers is not well established and we investigated the role of Innexins in mediating glial function in the Drosophila periphery. Of the eight Drosophila Innexins, we found two (Inx1 and Inx2) are important for peripheral glia development. In particular loss of Inx1 and Inx2 resulted in defects in the wrapping glia leading to disruption of the glia wrap. Of interest loss of Inx2 in the subperineurial glia also resulted in defects in the neighboring wrapping glia. Inx plaques were observed between the subperineurial glia and the wrapping glia suggesting that gap junctions link these two glial cell types. We found Inx2 is key to Ca2+ pulses in the peripheral subperineurial glia but not in the wrapping glia, and we found no evidence of gap junction communication between subperineurial and wrapping glia. Rather we have clear evidence that Inx2 plays an adhesive and channel-independent role between the subperineurial and wrapping glia to ensure the integrity of the glial wrap.SIGNIFICANCE STATEMENT Gap junctions are critical for glia communication and formation of myelin in myelinating glia. However, the role of gap junctions in non-myelinating glia is not well studied, yet non-myelinating glia are critical for peripheral nerve function. We found the Innexin gap junction proteins are present between different classes of peripheral glia in Drosophila. Here Innexins form junctions to facilitate adhesion between the different glia but do so in a channel-independent manner. Loss of adhesion leads to disruption of the glial wrap around axons and leads to fragmentation of the wrapping glia membranes. Our work points to an important role for gap junction proteins in mediating insulation by non-myelinating glia.

Real-time MRI for the dynamic assessment of fundoplication failure in patients with gastroesophageal reflux disease.

To assess the diagnostic potential of dynamic real-time MRI for fundoplication failure in patients with persistent or recurrent GERD-like (gastroesophageal reflux disease) complaints. Twenty-two consecutive patients (male n = 11; female n = 11; median age 59years) with recurrent or persistent GERD-like symptom after fundoplication were enrolled between 2015 and 2017. Median duration of GERD-like symptoms was 21months. Real-time MRI (3 Tesla) was performed at 40ms temporal resolution using undersampled radial fast low-angle shot acquisitions with nonlinear inverse image reconstruction. MRI movies dynamically visualized bolus transit of pineapple juice through the gastroesophageal junction, position of the fundoplication wrap and recurring hernia or reflux during Valsalva maneuver. MRI results were compared to endoscopic findings. Real-time MRI was successfully completed in all patients without adverse events (average examination time 15min). Morphological correlates for GERD-like symptoms were evident in 20 patients (90.1%) with gastric reflux in 19 cases. Nine patients (40.1%) had wrap disruption and recurrent gastric hernia. Wrap migration or telescoping hernia was detected in nine patients (40.1%). One patient presented with continued reflux despite intact fundoplication wrap. Esophageal dysmotility with delayed bolus passage was observed in one case. On endoscopy, gastric hernia or wrap disruption was diagnosed in seven cases, and esophagitis or Barret's metaplasia in nine cases. Real-time MRI is a fast and safe modality for dynamic imaging after fundoplication, without radiation exposure or administration of gadolinium-based contrast media. In a relevant number of cases, real-time MRI reveals correlates for GERD-like symptoms. • Real-time MRI reliably visualizes the gastroesophageal junction after fundoplication surgery. • Patients with recurring GERD-like symptoms have a high rate of morphological failure patterns that can be identified by real-time MRI. • Dynamic assessment of gastroesophageal junction by real-time MRI is a perspective diagnostic tool for detection of fundoplication failure.

Swallowing MRI\u2014a reliable method for the evaluation of the postoperative gastroesophageal situs after Nissen fundoplication

PurposeTo evaluate the diagnostic performance of swallowing MRI of the gastroesophageal junction (GEJ) in the postoperative care of patients after laparoscopic antireflux surgery (LARS)Material and methodsIn this institutional review board-approved prospective study, 79 symptomatic patients (mean age, 52.3 years; range, 26–80 years) were evaluated after laparoscopic Nissen fundoplication. MRI findings were correlated with revision surgery, endoscopy, and high-resolution manometry (HRM) as standard of reference. MRI was performed on a 3.0-T unit using T2-weighted half-Fourier acquisition single-shot turbo spin echo (HASTE) sequences for anatomical assessment of the GEJ followed by dynamic MR swallowing (fast low-angle shot sequences). Four independent readers (two radiologists, two surgeons) rated 83 MR scans according to defined criteria, such as wrap disruption, slipping, recurrent hiatal hernia, and esophageal motility disorder.ResultsWrap disruption was correctly diagnosed concordantly with the standard of reference in 87.8%, slipping in 81.5%, and recurrent hiatal hernia in 84.9% of the cases. For esophageal motility disorder, MRI interpretation was consistent with manometry in 66.2% of the subjects. Interobserver analysis showed substantial agreement for recurrent hiatal hernia (k = 0.703), moderate agreement for wrap disruption (k = 0.585), and fair agreement for motility disorder and slipping (k = 0.234 and k = 0.200, respectively).ConclusionMR swallowing readily depicts the major failure mechanisms of LARS and has good reliability even in non-experienced readers.Key Points• MR swallowing accurately readily depicts the major failure mechanisms of laparoscopic antireflux surgery and has good reliability even in non-experienced readers.• It should be included in the preoperative workup for revision surgery after fundoplication.• It will be of great benefit to surgeons in considering and planning a reoperation.

FUNDOPLICATION CONVERSION IN ROUX-EN-Y GASTRIC BYPASS FOR CONTROL OF OBESITY AND GASTROESOPHAGEAL REFLUX: SYSTEMATIC REVIEW.

ABSTRACT Introduction : Obesity is related with higher incidence of gastroesophageal reflux disease. Antireflux surgery has inadequate results when associated with obesity, due to migration and/or subsequent disruption of antireflux wrap. Gastric bypass, meanwhile, provides good control of gastroesophageal reflux. Objective: To evaluate the technical difficulty in performing gastric bypass in patients previously submitted to antireflux surgery, and its effectiveness in controlling gastroesophageal reflux. Methods: Literature review was conducted between July to October 2016 in Medline database, using the following search strategy: (“Gastric bypass” OR “Roux-en-Y”) AND (“Fundoplication” OR “Nissen ‘) AND (“Reoperation” OR “Reoperative” OR “Revisional” OR “Revision” OR “Complications”). Results: Were initially classified 102 articles; from them at the end only six were selected by exclusion criteria. A total of 121 patients were included, 68 women. The mean preoperative body mass index was 37.17 kg/m² and age of 52.60 years. Laparoscopic Nissen fundoplication was the main prior antireflux surgery (70.58%). The most common findings on esophagogastroduodenoscopy were esophagitis (n=7) and Barrett’s esophagus (n=6); the most common early complication was gastric perforation (n=7), and most common late complication was stricture of gastrojejunostomy (n=9). Laparoscopic gastric bypass was performed in 99 patients, with an average time of 331 min. Most patients had complete remission of symptoms and efficient excess weight loss. Conclusion: Although technically more difficult, with higher incidence of complications, gastric bypass is a safe and effective option for controlling gastroesophageal reflux in obese patients previously submitted to antireflux surgery, with the added benefit of excess weight loss.

Mesh hiatal reinforcement in laparoscopic Nissen fundoplication for neurologically impaired children is safe and feasible.

ABSTRACTFundoplication is a standard treatment for gastroesophageal reflux disease (GERD) in neurologically impaired children. However, it has a high recurrence rate due to wrap herniation and disruption resulting from the failure or enlargement of the esophageal hiatus suture site. In adult patients with GERD, reinforcement of the sutured esophageal hiatus with a mesh significantly reduces the recurrence rate after surgery for esophageal hiatus hernia. In children, there are no big series of fundoplication with mesh reinforcement. Therefore, we confirmed the safety and feasibility of an expanded polytetrafluoroethylene mesh hiatal reinforcement with fundoplication as an additional procedure for neurologically impaired children. Neurologically impaired children (age, ≥5 years) who underwent laparoscopic fundoplication and gastrostomy at our institution between 2011 and 2013 were included in this study. The operative time, bleeding amount, complications, and recurrence were retrospectively evaluated. Thirteen patients were included in this study. The mean age at operation was 147.2 ± 37.8 months, and mean body weight was 18.5 ± 7.9 kg. The complication rate of epilepsy and scoliosis was 100% and 84.6%, respectively. The operative time was 265.1 ± 38.1 minutes, and mean blood loss was 26.5 ± 34.7 mL. There were no peri- or postoperative complications. None of the patients showed recurrent symptoms such as repeated vomiting and aspiration pneumonia during the mean follow-up period of 2.5 ± 0.6 years. The mesh hiatal reinforcement with fundoplication for neurologically impaired children is safe and feasible.

The Role of Galectin-3: From Oligodendroglial Differentiation and Myelination to Demyelination and Remyelination Processes in a Cuprizone-Induced Demyelination Model.

The aim of this work was to combine our previously published results with our new data to show how galectin-3 (Gal-3) controls myelin integrity and function, promotes oligodendroglial cell differentiation, and regulates microglial responses to limit cuprizone- (CPZ)-induced demyelination and foster remyelination. In this study, 8-week-old Gal-3-deficient (Lgals3 -/-) and wild type (WT) mice were fed a diet containing 0.2% CPZ w/w for 6weeks, after which CPZ was withdrawn in order to allow remyelination. Our results show that remyelination was less efficient in Lgals3 -/- than in WT mice. Electron microscopic images from remyelinated sections in Lgals3 -/- mice revealed collapsed axons with a defective myelin wrap, while remyelinated WT mice had normal axons without relevant myelin wrap disruption. MMP-3 expression increased during remyelination in WT but not in Lgals3 -/- mice. The number of CD45+, TNFα+ and TREM-2b+ cells decreased only in WT mice only, with no alterations in Lgals3 -/- mice during demyelination and remyelination. Therefore, Gal-3 influences remyelination by mechanisms involving the tuning of microglial cells, modulation of MMP activity, and changes in myelin architecture.

Laparoscopic anti-reflux revision surgery after transoral incisionless fundoplication is safe and effective

Transoral incisionless fundoplication (TIF) treats gastroesophageal reflux disease (GERD) by creating a full-thickness esophagogastric plication using transmural fasteners. If unsuccessful, revision laparoscopic anti-reflux surgery (rLARS) may be performed. This study evaluated operative findings and clinical outcomes of rLARS in 28 patients with prior primary TIF. Intraoperative findings, complications, and symptomatic outcomes with GERD health-related quality of life (GERD-HRQL) were evaluated prospectively in patients having rLARS after TIF. Results are median with interquartile range (IQR). Between 03/2009 and 08/2013, 28 patients underwent rLARS at 14 (13-50) months post-TIF for recurrent symptoms after initial improvement. Pre-rLARS endoscopies found hiatal hernia (9) and wrap disruption (12). All revisions were completed laparoscopically in 88 (70-90) min. Eight patients underwent partial fundoplication, the rest Nissen. No intraoperative or postoperative complications occurred. Operative findings included: No axial hernia in 65%; Dense adhesions in 14%; Fasteners incorporating the lateral crus in 95%; Traction diverticuli from esophagus to crura in 21%. Residual plication was noted anteriorly in 75%, posteriorly in 0%. Operative approaches: (1) Areas where the TIF fundoplication remained were left intact. This necessitated rolling the fundoplication over the fused area to prevent an endoscopic appearance of 'fold'. (2) Fasteners were cut and left to migrate into the lumen, rather than being pulled out. (3) In 8 patients with fusion of the lateral crus to TIF fundoplication and no axial hernia, revision fundoplication was performed without mediastinal mobilization but with posterior hernia repair. One patient required subsequent surgery for small paraesophageal hernia, one for refractory gas-bloat after rLARS. Dysphagia in 2 patients resolved with dilation. GERD-HRQL improved from a median of 20 (8-27) pre-TIF and 10 (1-20) pre-rLARS to 3 (0-4) at 28 months (12-40) post-rLARS (p = 0.020 for pre-rLARS to post-rLARS). rLARS after TIF can be performed safely with excellent clinical outcomes.

Impact of laparoscopic Nissen’s fundoplication on response of disease specific symptoms and quality of life

The aim of this study is to establish responsiveness of gastroesophageal reflux disease (GERD) symptom score, quality of life SF-36 score in GERD with relation to oesophageal manometry and upper gastrointestinal endoscopy following laparoscopic Nissen's fundoplication (LNF). Interventional prospective study was done enrolling 77 patients of GERD who respond to proton pump inhibitor (PPI) and have undergone LNF, strict diagnostic criteria were followed with GERD score, upper gastrointestinal endoscopy, oesophageal manometry, and endoscopically negative patients have further undergone 24-h pH study. Follow-up was done at 12 and 24 months by GERD score, SF-36 score, endoscopy, oesophageal manometry. GERD score shows significant difference in pre-operative and post-operative score with P value <0.001 except dysphagia. Post-LNF improvement in GERD score is consistent with improvement in lower oesophageal sphincter (LES) pressure at 12 months. All dimensions in quality of life SF-36 show significant difference in pre-operative and post-operative score at 12 months with P value <0.001. Results are consistent at 24 months. Oesophagitis was decreased from 40.2 to 11.6 % as well as it showed down grading on endoscopy in post-operative period. Out of three patients of complete disruption of wrap, two patients underwent redo surgery and showed improvement. In properly diagnosed PPI respondent patients by GERD score, LNF has got improvement in GERD score, quality of life in all dimensions of SF-36 score in relation to improvement with LES pressure and oesophagitis.

Nissen Fundoplication in Infants and Children: A Long Term Clinical Study

Methodology: Twenty six neurologically normal children (16 boys and 10 girls between 6 months and 11 years old) underwent Nissen fundoplication for intractable or complicated gastroesophageal reflux between October 1982 and February 2002. Before surgery and at follow up visits, all children were subjected to thorough history, barium meal study and gastroscopy with multiple esophageal biopsies. The mean duration of follow up was 68 ± 64 months (range: 3 months - 19 years).Results: Persistent vomiting or regurgitation since birth was the main symptom (24 patients, 92.3%), chest symptoms occurred in 5 patients (19.2%), malnutrition and retarded growth were found in 4 patients (15.4%), haematemesis and/or melena occurred in 2 patients (7.7%) and dysphagia due to esophageal stricture occurred in 4 patients (15.4%). There was no mortality. The mean hospital stay was 4.1days. Twenty two patients (84.6%) had no recurrent reflux. Reflux symptoms recurred in 4 cases (15.4%). One of these cases had no evidence of recurrent pathological reflux, 2 cases with preoperative stricture developed wrap disruption, recurrent reflux and restricture. Both refused second operation. The fourth case developed melena and reflux esophagitis due to wrap herniation through the hiatus and was successfully managed by second operation.Conclusion: Nissen fundoplication is an effective operation to correct gastroesophageal reflux in infants and children when the drug therapy fails. The operation should be done before occurrence of complications to decrease the recurrence of reflux.

A New Technique for Preventing Wrap Disruption/Migration After Laparoscopic Nissen Fundoplication: An Experimental Study

Laparoscopic Nissen fundoplication (LNF) is associated with a wrap disruption/migration rate of 3-40%. At reoperation, there is usually a lack of adhesions between the wrap, esophagus, and crura. In this paper, we report a new technique for the induction of scarring in the fundic wrap. Eighteen pigs weighing 12-18 kg underwent LNF and were divided into three groups (n = 6 in each). In group A, sandpaper was used to accelerate adhesion formation between the right and left gastric fundi, as well as between the wrap and the crura, by rubbing the surfaces of the gastric fundi and the crura. In group B, fibrin glue was injected between the esophagus and the wrap. Group C received no treatment and acted as controls. All pigs were sacrificed 3 months later, and en bloc specimens consisting of the lower esophagus, fundic wrap, and diaphragmatic crura were examined for evidence of adhesions. There was no wrap disruption or migration in any pig. In group A, there were dense adhesions visible macroscopically between the esophagus and the right and left fundi, and the wrap was adhered tightly to the crura. Microscopically, there were many collagen fibers between the esophagus and the wrap present. In groups B and C, macroscopic adhesions were absent or minimal between the esophagus and the wrap, and the wrap was less adhered to the crura. Histologically, the esophagus and both fundi were distinct with no fibers present between them. Our results do not categorically prove that rubbing with sandpaper prevents wrap disruption or migration, but based on the assumption that denser adhesions hold tissues together more firmly, our technique might act to prevent wrap disruption or migration after LNF.

Nissen fundoplication: three causes of failure (video)

Laparoscopic Nissen fundoplication (LNF) has become the most commonly performed antireflux procedure for gastroesophageal reflux disease. The rate of failure following fundoplication varies from 2% to 30%, and revision is required in many of the patients who have recurrent or new foregut symptoms. Common causes of failure include hiatal hernia, wrap disruption, slipped wrap, and misplaced wrap. This video depicts three different causes of failure of LNF, each demonstrated while performing a redo fundoplication. The first case shows a common cause of failure, a misplaced wrap. Less common causes of failure are seen in the second and third cases: a retained foreign body and fundus herniation through the retroesophageal space. In the first two cases, following the dissection of the original wrap, the proper construction of a Nissen fundoplication is shown. The first patient developed recurrent reflux symptoms that can be explained by the misplaced wrap. In case two, the patient's dysphagia was a result of a retained foreign body from the initial procedure creating a fibrotic reaction and esophageal stricture. The final case shows how chronic failure can sometimes have an acute presentation. We see the patient's gastric fundus has herniated through the retroesophageal space and it has become incarcerated and volvulized, creating a closed loop obstruction and acute distention. The surgeon watching this video can appreciate the identification of various causes of LNF failure, the approach to dissection of the old wraps, and the important steps in the creation of a Nissen fundoplication.

Anatomic findings and outcomes after antireflux procedures in morbidly obese patients undergoing laparoscopic conversion to Roux-en- Y gastric bypass

Background To report the anatomic findings and outcomes in patients undergoing laparoscopic takedown of Nissen fundoplication with conversion to Roux-en- Y gastric bypass. Methods We reviewed the records of patients who underwent laparoscopic Nissen takedown with conversion to Roux-en- Y gastric bypass from January 2001 to April 2006 at the University of Minnesota Medical Center. Results Eleven patients were identified. Nine patients had gastroesophageal reflux disease preoperatively, of whom six underwent 24-hour pH monitoring. In 2 patients, the pH study findings were negative. Eight prior procedures had been performed laparoscopically. Eight patients were women. The mean age was 44 years. The average body mass index preoperatively was 44 kg/m 2 (range 35–61). The mean follow-up was 13.8 months (range 4–39). The body mass index at follow-up was 30.2 kg/m 2. The operative time was 349 minutes (range 222–624). The hospital length of stay was 3.4 days (range 2–6). No conversions to open surgery were required. No major short-term complications developed. Minor complications included wound or drain site infection in 3 patients, with abscess in 2, pressure sore of the lateral aspect of the foot in 1, pneumonia in 2, and marginal ulcer in 2 patients. No strictures were observed. One internal hernia occurred. Of the 9 patients with gastroesophageal reflux disease preoperatively, all had 100% improvement in symptoms, with complete resolution in 7 (78%). Wrap disruption was present in 5 (45%) of 11 patients. Herniation of an intact wrap had occurred in 1 patient. One patient had both herniation and wrap disruption. Conclusion Laparoscopic conversion of Nissen fundoplication to Roux-en- Y gastric bypass is a feasible salvage operation for recurrent gastroesophageal reflux disease in the morbidly obese. The incidence of wrap disruption appears to be relatively high and the incidence of intact wrap herniation low in obese patients after failed Nissen fundoplication, suggesting that the mechanism of failure after primary antireflux surgery in obese patients may be different than that in normal-weight patients.

Recurrent reflux and wrap disruption after Nissen fundoplication: Detection, incidence and timing

One hundred and twenty-five patients with refractory gastro-oesophageal reflux disease underwent floppy Nissen fundoplication. Median follow-up was 52 months, and included endoscopy, manometry and prolonged pH recordings in all cases in addition to clinical assessment. Using objective criteria, 12 patients (9.6 per cent) developed recurrent reflux. In nine of these patients, endoscopy had suggested that the Nissen fundoplication had disrupted; wrap disruption was confirmed in seven patients who underwent reoperation. The median time to endoscopic recognition of wrap disruption was 7 months (range 3-10 months). In contrast, of 115 patients with endoscopic evidence of an intact fundoplication, only 3 (2.6 per cent) had recurrent reflux. Endoscopy allowed reliable differentiation between those with and without reflux control after operation (P less than 0.001). These results suggest that recurrent reflux after Nissen fundoplication is due to wrap disruption. This phenomenon occurs within the first postoperative year and can be recognized by informed endoscopic assessment.

Laparoscopic Nissen fundoplication in children: 2-5-year follow-up.

This study aims to document the current status of a cohort of children who underwent laparoscopic fundoplication at a single centre between 1996 and 1998. Parents were contacted and a questionnaire regarding preoperative and current symptoms completed. Case notes were reviewed for results of postoperative investigations. Forty-five laparoscopic Nissen fundoplications were performed. The median age was 5 years. Twenty-eight children were neurologically impaired. Five died of underlying medical problems during follow-up. Two were lost to follow-up, leaving 38 parents interviewed. Median follow-up was 36 months. Twenty-five children were asymptomatic, and 13 reported upper gastrointestinal symptoms. In ten, symptoms were less severe than preoperatively. Nine of the 13 children were taking acid suppressing drugs. No children reported problems with dysphagia. Twelve of the 13 symptomatic children had investigations for recurrent reflux. In no case was there evidence of reflux or wrap disruption. One of the children who died had been demonstrated to have recurrent reflux on barium swallow. Sixty-six percent of patients reported complete relief, and a further 26% reported considerable improvement of their symptoms. There was a high degree of parental satisfaction with the outcome of the operation. The results suggest that laparoscopic fundoplication is a durable procedure with documented recurrent reflux in only 2% of children at a median follow-up of 3 years.

Frequency of postoperative nausea and vomiting in patients undergoing laparoscopic foregut surgery.

Wrap disruption or intrathoracic herniation of a fundoplication is a dreaded complication of laparoscopic foregut surgery. This problem may often be related to postoperative nausea and vomiting (PONV). This study aimed to investigate the occurrence of PONV and its management in patients undergoing laparoscopic foregut procedures. Between January 31 and May 23, 2000, 104 patients undergoing laparoscopic foregut procedures (fundoplication, myotomy, or paraesophageal hernia repair) were followed prospectively. Their postoperative course was documented along with the occurrence and management of PONV. All laparoscopic foregut surgery patients are managed postoperatively with a uniform clinical pathway, and their care is focused on a nursing unit with skill and experience in postoperative management. Nausea was documented in the postanesthesia care unit (PACU) for 30.1% of the patients, and for 59.6% of the patients during their nursing unit stay. Antiemetics were given to all the patients with documented nausea. Emesis was noted in 1.9% of the patients in the PACU, as compared with 3.8% of the patients on the floor. In one of the patients with nursing unit emesis, an acute wrap herniation into the chest occurred, necessitating a return to the operating room for correction. The patients with a history of postoperative nausea did not have a higher rate of PONV than in those with no history of postoperative nausea. The use of preoperative or intraoperative antiemetics did not appear to alter the occurrence of PONV. Postoperative nausea occurred in 60% of the patients administered preoperative antiemetic, as compared with 64% of the patients who received no preoperative antiemetic. The average length of hospital stay was longer in those with PONV than in those with no PONV (2.6 vs 1.8 days). Nausea after laparoscopic foregut procedures is common, occurring twice as often on the nursing unit as in the PACU. The occurrence of PONV leads to a longer hospital stay, and can result in significant sequelae requiring reoperation. The use of preoperative or intraoperative antiemetics does not alter the frequency of postoperative nausea, suggesting the need to develop effective preemptive regimens for patients undergoing laparoscopic foregut procedures. The high rate of PONV and its potential risk of damage to a fundoplication and hiatal hernia repair should lead surgeons to consider whether laparoscopic foregut procedures should ever be performed on an outpatient basis.

Surgical physiology of esophagogastric junction. Selective testing is effective; some problems remain elusive

When evaluating foregut symptoms which may originate from many sites, accurate diagnosis must be achieved by cost-effective and efficient diagnostic methods. Since all tests cannot be done routinely, invasive tests are mandatory only when the diagnosis is uncertain; testing which confirms the obvious is overly expensive and superfluous. This report describes “selective” preoperative diagnostic testing for patients with heartburn and dysphagia; endoscopy was used always, but radiography, manometry, and pH testing were done selectively. Hiatus hernia remains an elusive entity which resists easy definition. Methods: A total of 273 patients operations (185 with gastroesophageal reflux disease (GERD) and 88 with achalasia (ACHA) of the esophagus) were operated upon during a 15 year period. All heartburn patients had endoscopy; if erosive esophagitis was present and symptoms responded to medical treatment the diagnosis of GERD was made; manometry and pH studies were performed selectively. Esophagrams or other special X-Rays (spiral tomography) were performed often, but selectively, in preoperative patients and less commonly in postoperative patients. When indicated, fundoplication was performed for GERD and transabdominal cardiomyotomy with fundoplication for ACHA. Results (Tables 1, 2): Endoscopy was performed in all patients. Motility examinations (n = 248) and pH studies (n = 175) were helpful in defining operative candidates; 95% of GERD and ACHA operations were effective, and postoperative hiatus hernia or wrap disruption occurred rarely (2%). ACHA patients had minimal reflux, and one had reoperation for extrinsic stricture at the gastoesophageal junction. Unexpected hiatus hernia was found in 8–10% of both groups. Conclusions: Clinical judgment supported by selective diagnostic testing in GERD and ACHA effectively identified operative candidates. The role of hiatus hernia in causing symptoms in individual patients is largely unknown at present; further, there is no reliable noninvasive way of estimating the size of hernia in a single patient.

Patterns of success and failure with laparoscopic Toupet fundoplication.

Advocates of the Toupet partial fundoplication claim that the procedure has a lower rate of the side effects of dysphagia and gas bloat than a complete Nissen fundoplication. However, there is increasing recognition that reflux control is not always as good with the Toupet procedure as with the Nissen. Therefore, we set out to evaluate the factors contributing to success and failure in patients who underwent laparoscopic modified Toupet fundoplication (LTF). A total of 143 patients undergoing LTF for documented gastroesophageal reflux disease (GERD) were evaluated prospectively in regard to their outcomes over a 4-year period. All patients had preoperative esophagogastroduodenoscopy (EGD) and manometry; 24-h pH testing was used selectively. Esophageal manometry was requested of all patients 6 weeks postoperatively. Clinical follow-up was by office visit or questionnaire every 6 months after surgery; patients with significant problems were investigated further. Failure was defined as the development of recurrent reflux documented by endoscopy, 24-h pH test, or wrap disruption on barium swallow, or severe dysphagia persisting >3 months and requiring surgical revision. At a mean follow-up of 30 months (range, 3-51), 21 of 143 patients failed LTF; two had dysphagia and 19 had recurrent reflux. Failure was associated with preoperative findings of a defective lower esophageal sphincter (LES) (14/21), complicated esophagitis (13/21), and failure to divide short gastric vessels (12/19) (chi-square p < 0.05). Defective esophageal body peristalsis, present in 14 patients, resulted in failure in six cases. Presence of either complicated esophagitis or a defective LES was associated with a 3-year 50% success rate, whereas presence of mild esophagitis and a normal LES was reflected in a 96% 3-year success rate. Laparoscopic Toupet fundoplication should be reserved for milder cases of GERD, as assessed by manometry and endoscopy.

Future directions in innovative minimally invasive surgery

Future directions in innovative minimally invasive surgery

Fundoplication wrap disruption: an experimental study in rats.

Antireflux surgery usually gives long lasting control of gastroesophageal reflux disease, but late failures can occur from fundoplication wrap disruption. Disruption presumably occurs when physiological mechanical stresses cause the sutures to pull out of the fundoplication wrap. We hypothesized that complete fundoplications (fundus sutured to fundus) would withstand disruptive forces better than partial fundoplications (fundus sutured to esophagus). Forty-eight rats underwent fundoplication (24 partial and 24 complete). Fundoplication wraps were disrupted by distending the stomach (bursting pressure technique) and by distracting the wrap in a tensiometer (breaking strength technique). Bursting pressures were similar in the partial (103.7 +/- 13.5 mmHg) and complete (100.5 +/- 13.1 mmHg) fundoplication wraps (P = 0.93, not significant). In both groups, all disruptions occurred by sutures tearing through the stomach wall. Breaking strength was also equivalent for the two types of wrap. Partial wraps disrupted at 6.69 +/- 1.49 N and complete wraps disrupted at 6.52 +/- 1.28 N (P = 0.77, not significant). Sutures tore out of the stomach side of the partial wrap in five rats and out of the esophagus in the other seven rats with partial wraps. Disruption occurred by sutures tearing through the stomach in all rats with complete fundoplications. This experimental study in the rat did not show any difference in the ability of partial and complete fundoplication wraps to withstand disruptive forces.