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Surgical Endoscopy 12/2011; · 4.01 Impact Factor
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Surgery 06/2011; 149(6):825-9. · 3.10 Impact Factor
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Surgical Endoscopy 02/2011; 25(2):515-20. · 4.01 Impact Factor
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ABSTRACT: In patients undergoing a variety of procedures, surgical success is in part dependent on maintaining normal intra-abdominal pressure in the immediate postoperative period. Our objective was to quantify intragastric and intravesicular pressures during activities, through the use of manometry catheters.
Ten healthy volunteers had a manometry catheter placed transnasally, and a urinary Foley catheter placed. Baseline intragastric and intravesicular pressures were recorded and the catheters were then transduced continuously. Pressures were recorded with activity: coughing, lifting weights, retching (dry heaving), and vomiting.
All pressure changes were significant from baseline except for weight lifting. The highest intragastric pressure was 290 mmHg, seen during vomiting. Comparison of intragastric and intravesicular pressures showed no significant difference. There was significantly higher intragastric pressure with vomiting and retching as compared with coughing, whereas coughing applied more pressure than weight lifting.
This is the first report of intragastric pressures during vomiting and retching (dry heaving). We conclude that vomiting and retching (dry heaving) can render significant forces on any tissue apposition within the stomach or the peritoneal cavity.
Surgical Endoscopy 10/2008; 22(12):2571-5. · 4.01 Impact Factor
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ABSTRACT: The creation of a floppy and symmetric fundoplication over a bougie has been the standard of care in laparoscopic surgery. The use of a bougie carries a risk of esophageal perforation but lowers the risk of postoperative dysphagia. Intraoperative esophagogastroduodenoscopy (IEGD) can be used to assess the orientation and position of a properly constructed Nissen. The aim of this study was to determine if IEGD can replace the routine use of a bougie in the creation of a fundoplication.
One hundred consecutive patients undergoing laparoscopic Nissen fundoplication from 2003 to 2005 were entered into a prospective database. IEGD was used in all patients instead of a bougie. Preoperative and postoperative data, including symptom scores, pH studies, manometry, and upper gastrointestinal studies, were analyzed.
All 100 patients completed the study for a mean follow-up period of 18 months. The mean surgical time was 102 minutes. The mean intraoperative endoscopy time was 14 minutes. There were a total of 24 (24%) alterations of the fundoplication performed according to endoscopic wrap creation. The most common alteration was removal of a fundoplication stitch in 15 patients with a tight appearance of wrap. There were no major complications. Two patients required esophageal dilatation for mild to moderate dysphagia.
IEGD is a valuable tool for laparoscopic Nissen fundoplication. IEGD helps to appreciate the true location of the gastroesophageal junction and allows for fundoplication adjustment based on additional visualization. The creation of a symmetric and floppy wrap during Nissen fundoplication can be facilitated greatly by intraoperative endoscopy and may lead to improved clinical outcomes without the risk of esophageal perforation.
American journal of surgery 01/2008; 194(6):866-70; discussion 870-1. · 2.36 Impact Factor
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ABSTRACT: Ambulatory wireless 48-h esophageal pH monitoring (Bravo Medtronic, Shoreview, MN, USA) has been shown to be more sensitive in detecting abnormal esophageal acid exposure compared with transnasal 24-h pH probes. However, accurate interpretation of the wireless monitoring data is paramount when contemplating surgical intervention for those with gastroesophageal reflux disease. The aim of this study is to evaluate the incidence of false-positive interpretations of this wireless monitoring data secondary to premature transit of the Bravo capsule into the stomach and subsequently into the duodenum prior to the completion of the 48-h study period. We reviewed 100 consecutive Bravo pH studies at our University Esophageal Motility Center. There were 58 women and 42 men included in our evaluation. Premature transit of the Bravo capsule into the stomach and subsequently into the small bowel was defined by a prolonged gastric pH phase with either evidence of alkalinization and no further reflux episodes or loss of communication with the Bravo capsule prior to the end of the 48-h data collection period. Of the 100 patients reviewed, 11% manifested evidence of early passage of the Bravo capsule resulting in a misinterpretation of the data as abnormal acid exposure. The mean time of inaccurate data after transit of the Bravo capsule was 18 h and 42 min. The mean length of time that the capsule was retained in the stomach prior to duodenal passage was 4 h. If the aforementioned data were included in the final interpretation of the study, it yielded a mean DeMeester score of 44.25 with a mean total time of pH <4 of 14.7% per case. Exclusion of the prolonged gastric phase from the final interpretation of each case resulted in a statistically significant reduction in the mean total time the pH <4 (4.33 vs. 14.7%, p < 0.05) and the mean DeMeester score (12.81 vs. 44.25 p < 0.05). The mean time from the initiation of esophageal pH data to the passage of the Bravo capsule into the stomach was 15 h and 22 min. The observation mandates meticulous inspection of the pH tracing by the interpreting physician throughout the entirety of a 48-h study to identify premature transit of the capsule. Tracings that show prolonged acid exposure or loss of communication with the Bravo capsule should be screened for the capsule's possible early dislodgement and premature advancement into the stomach.
Journal of Gastrointestinal Surgery 06/2007; 11(5):638-41. · 2.83 Impact Factor
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ABSTRACT: To assess whether reoperative surgery for failed Nissen fundoplication is beneficial and to classify all mechanisms of failure recognized.
Antireflux surgery is often necessary, but a 10% failure rate is commonplace. We report results for patients undergoing reoperative surgery and present a nomenclature of mechanisms of failure.
A total of 104 patients, who had a previous fundoplication for gastroesophageal reflux disease (GERD), underwent reoperative surgery. Manometry (n = 86), endoscopy (n = 101), pH monitoring (n = 27), upright esophagram (n = 90), gastric emptying (n = 26), and symptom assessment (n = 104) were performed prior to reoperative surgery. Patients were also assessed before and during reoperation for mechanism of failure using a newly proposed classification. The operative approach was laparoscopic in 58 patients, via open laparotomy in 12, and a thoracotomy in 34 patients. Follow-up was conducted by phone interview and was completed in 97 patients (97%; 3 were deceased) with a mean follow-up of 32 months (range, 1-146 months).
The conversion rate to laparotomy for laparoscopic patients was 8%. The perioperative complication rate was 32%. One patient died of respiratory insufficiency after a laparotomy. Seven patients required additional surgery for correction of persistent or recurrent symptoms. The short and long-term complication rate was similar for the different operative approachs. Symptom resolution (rare or absent) occurred in 74% of patients with dysphagia, 75% with heartburn, 85% with regurgitation, and 94% with chest pain. The overall post-reoperative patient satisfaction was 7 on a scale of 1 to 10 and 3 on a scale of 1 to 4 when patients were asked to grade the operative result. There was no difference in the symptom resolution for patients operated upon by the laparoscopic approach as compared with laparotomy, but those patients undergoing a Collis gastroplasty had poorer results. The preoperative accuracy of assessment for mechanism of failure was 78%. A nomenclature of mechanisms of failure is included to aide reoperative assessment and new mechanisms of failure are described.
Reoperative surgery results for GERD are satisfactory. A variety of operative approaches proved equally effective. Poorer results were observed in patients with more advanced disease.
Annals of Surgery 08/2006; 244(1):42-51. · 7.49 Impact Factor
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ABSTRACT: The high prevalence of gastroesophageal reflux disease (GERD) in Western societies has accelerated the need for new modalities of treatment. Currently, medical and surgical therapies are widely accepted among patients and physicians. New potent antisecretory drugs and the development of minimally invasive surgery for the management of GERD are at present the pivotal and largely accepted approaches to treatment. The minimally invasive treatment revolution, however, has stimulated several new endoscopic techniques for GERD. Up to now, the data is limited and further studies are necessary to compare the advantages and disadvantages of the various endoscopic techniques to medical and laparoscopic management of GERD. New journal articles and abstracts are continuously being published. The Food and Drug Administration has approved 3 modalities, thus gastroenterologists and surgeons are beginning to apply these techniques. Further trials and device refinements will assist clinicians. This article will present an overview of the various techniques that are currently on study. This review will report the efficacy and durability of various endoscopic therapies for gastroesophageal reflux disease (GERD). The potential for widespread use of these techniques will also be discussed. Articles and abstracts published in English on this topic were retrieved from Pubmed. Due to limited number of studies and remarkable differences between various trials, strict criteria were not used for the pooled data presented, however, an effort was made to avoid bias by including only studies that used off-PPI scoring as baseline and intent to treat.
World Journal of Gastroenterology 06/2006; 12(17):2641-55. · 2.47 Impact Factor
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ABSTRACT: The surgical management results of recurrent hiatal hernia repair are unknown in the laparoscopic era. The experience of the senior authors (CJF) and (SKM) is reported herein. From 1993 to 2004, 52 patients underwent re-operative hiatal hernia surgery at our center. Preoperative symptoms were heartburn, chest pain, dysphagia, regurgitation and pulmonary manifestations of gastroesophageal reflux disease. Patients had preoperative evaluation by upper endoscopy, pH-monitoring, esophagogram and manometry to assess the mechanism of failure. Pre- and postoperative symptoms were assessed utilizing a standardized questionnaire. Patients underwent laparoscopic repair (n=18), open laparotomy (n=6) and transthoracic surgery (n=28). Ninety-five percent follow-up was achieved with a mean follow-up of 34 months. Thirty-seven percent of patients encountered para-operative complications one of them died due to respiratory insufficiency. Five patients experienced a re-recurrent hernia. The symptom resolution was 65% for dysphagia, 68% for heartburn, 95% for chest pain and 79% for regurgitation. The overall patient satisfaction was 6.94 on a scale of 1-10. There was no significant difference in patient outcome when comparing the operative approaches or disease process. Surgical repair of recurrent hiatal hernias is safe and effective. Laparoscopic surgery is an appropriate alternative approach for recurrent hiatal hernia repair in selected patients.
Hernia 04/2006; 10(1):13-9. · 1.84 Impact Factor
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ABSTRACT: An important limitation of antireflux surgery is a 5%-10% failure rate. We investigated the correlation between various diaphragm stressors and failure of antireflux surgery. Forty-one study cases who underwent a reoperative antireflux operation from 1997 to 2001 and 50 control patients who had undergone a successful laparoscopic Nissen fundoplication during the same period without clinical or symptomatic evidence of failure were randomly selected for comparison. A retrospective analysis was conducted utilizing a standardized diaphragm stressor questionnaire, addressing the period between the primary and secondary operation. Stressors considered in the study included height, body mass index (BMI), postoperative gagging, vomiting, weight lifting (greater than 100 pounds), coughing, hiccuping, motion sickness, retching, belching, antidepressant use, smoking, preoperative grade of esophagitis, size of hiatal hernia, lower esophageal sphincter pressure, esophageal body pressures, and preoperative response to proton pump inhibitors. Of the potential stressors investigated, the following were significantly associated with surgical failure after adjusting for other variables through multivariate analysis: gagging (P = 0.005), belching (P = 0.02), and hernia size greater than 3 cm (P = 0.04; Table 1). Other potential risk factors show trends as obvious in Fig. 2. Vomiting was significant (P = 0.01) in the earlier models but lost significance when logistic regression was applied. Patients with postoperative gagging and an intraoperative hiatal hernia (greater than 3 cm) have a poorer outcome, whereas patients with postoperative belching have a better long-term outcome.
Journal of Gastrointestinal Surgery 02/2006; 10(1):12-21. · 2.83 Impact Factor
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ABSTRACT: Initial studies demonstrate that EndoCinch is safe and may be an effective outpatient procedure. Symptom improvement, reduction in medication requirements, and ultrasound evidence of muscle hypertrophy are encouraging. The durability of these benefits remains in question. Seventeen percent of patients require a repeat gastroplication to achieve a satisfactory result and some elect to undergo laparoscopic Nissen fundoplication. Additional investigations are required to assess the number and location of the plications for optimal patient outcome. Prospective randomized studies comparing ELGP to medical and surgical treatments of GERD may be appropriate after device refinements. Of additional importance is the possibility of a cure with an ELGP. Patients who are self-medicated or noncompliant often are willing to seek consultation if a noninvasive curative procedure is available. One third of these patients have advanced disease and are treated best with surgery rather than an ELGP; thus, surgeons should be involved with ELGP for GERD control.
Thoracic Surgery Clinics 09/2005; 15(3):385-94.
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Journal of the American College of Surgeons 08/2005; 201(1):132-40. · 4.55 Impact Factor
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ABSTRACT: To determine the long-term efficacy of endoluminal gastroplication (ELGP) and the most effective plication configuration.
Endoluminal gastroplication is an intriguing therapy for gastroesophageal reflux disease. We conducted a retrospective review of a prospective experience of patient cohorts comparing outcomes of the circumferential and helical plication patterns.
Twenty patients underwent ELGP, with 9 receiving the circumferential (Group 1) and 11 the helical pattern (Group 2). Manometry, endoscopy, and 24-hour pH monitoring were performed at baseline and at 6 months. Symptom scores and medication usage were assessed at baseline, 1, 3, 6, 12, and 18 months.
Both groups did not differ significantly from each other with respect to symptom improvement, medication usage, or other variables measured. At 6 months, symptom scores, histamine-2 receptor antagonist (H2RA), proton pump inhibitor usage, and hernia size decreased significantly. No other parameter showed a significant change. At the 18-month follow-up, symptom scores and H2RA usage decreased significantly.
ELGP improves heartburn and regurgitation scores at 18 months. Our study suggests that there is no benefit to additional plications when using the helical pattern.
Journal of Clinical Gastroenterology 39(10):869-76. · 3.16 Impact Factor
