[Reflux and hiatus hernia in the controversy between conservative and operative therapy]

Approximately 20 % of the population are affected by gastroesophageal reflux disease (GERD). The subjective clinical and objective pathological extent of the disease is highly variable and the underlying pathophysiological mechanisms extraordinarily diverse. The importance of hiatus hernia for GERD has been intensively debated for decades. Hiatus hernia was initially considered to be at the center of the pathophysiology but later the function of the lower esophageal sphincter was increasingly considered to be of importance. Currently, additional relevant pathophysiological cofactors are being detected with the continuous improvement in diagnostic methods and used for therapeutic decision-making. Despite standardization of the operative technique and increasing criticism on long-term proton pump inhibitor (PPI) therapy, antireflux surgery still requires a very critical assessment of indications based on a comprehensive diagnostic evaluation.

[Angioinvasion by neuroendocrine jejunal tumor. Demonstration of a malignancy sign by acetone compression]

Neuroendocrine neoplasms of the digestive system are classified by current World Health Organization (WHO) guidelines as G1 and G2 neuroendocrine tumors (NET) as well as neuroendocrine carcinoma (NEC) based on proliferation and differentiation. The G1 NET tumors are highly differentiated, low proliferating and usually exhibit a favorable course of the disease without the development of metastases. In the case presented here, angioinvasion by a pT3 NET G1 was demonstrated after complete work-up of the mesenterial fat by acetone compression. The findings indicate an unfavorable course of disease requiring intensive surveillance.

[Less reflux recurrence following Nissen fundoplication : results of laparoscopic antireflux surgery after 10 years]

BACKGROUND

Reflux recurrence is the most common long-term complication following fundoplication. Results for different techniques of laparoscopic antireflux surgery were retrospectively compared after 10 years.

METHODS

From 1992 to 1997, the 120 patients studied had laparoscopic fundoplication with 'tailored' approaches: 88 Nissen, 22 anterior, and ten Toupet fundoplications. Follow-up of 87% of these patients included disease-related questions and the gastrointestinal quality of life index (GIQLI).

RESULTS

Of the patients, 89% would select surgery again. Regurgitations after fundoplication were noted from 15% of patients after Nissen, 44% after anterior, and 10% after Toupet types (P=0.04). Twenty-eight percent were on acid suppression therapy. Proton pump inhibitors were used less frequently following Nissen fundoplication (P=0.01). The GIQLI score was 110+/-24 without significant differences for type of fundoplication.

DISCUSSION

Overall results are satisfactory after 10 years of experience with fundoplication. Total fundoplication appears to control reflux better than partial fundoplication.

Ten-year outcome of laparoscopic antireflux surgery

BACKGROUND

Reflux recurrence is the most common long-term complication of fundoplication. Its frequency was independent from the type of fundoplication in randomized studies. Results for different techniques of laparoscopic antireflux surgery were retrospectively evaluated after 10 years.

METHODS

From 1992 to 1997, 120 patients had primary laparoscopic fundoplication with a "tailored approach" (type of wrap chosen according to esophageal peristalsis): 88 received a Nissen, 22 an anterior, and 10 a Toupet fundoplication. Follow-up of 87% of the patients included disease-related questions and the gastrointestinal quality-of-life index (GIQLI).

RESULTS

Of the patients, 89% would select surgery again. Heartburn was reported by 30% of the patients. Regurgitations were noted from 15% of patients after a Nissen, 44% after anterior fundoplication, and 10% after a Toupet (p = 0.04). Twenty-eight percent were on acid-suppressive drugs again. Following Nissen fundoplication, proton pump inhibitors were less frequently used (p = 0.01) and on postoperative pH-metry reflux recurrence rate was lower (p = 0.04). The GIQLI was 110 +/- 24 without significant differences for the type of fundoplication.

DISCUSSION

Ten years after laparoscopic fundoplication, overall outcome is good. A quarter of the patients are on acid-suppressive drugs. Nissen fundoplication appears to control reflux better than a partial fundoplication.

Quality of life following laparoscopic gastric banding in patients with morbid obesity

In a prospective study of 188 patients with morbid obesity, the time-dependent changes in the quality of life of individual patients were analyzed following laparoscopic gastric banding (LGB). These 188 patients (148 females and 40 males; age 19 to 59 years; body mass index 33 to 72 kg/m(2)) underwent evaluation of the LGB according to a strict protocol that included psychological testing using standardized instruments, detailed medical evaluation, upper gastrointestinal function studies, and evaluation of quality of life using the Gastrointestinal Quality of Life Index (GIQLI). Following this evaluation, 73 patients (57 females and 16 males; age 37 years [range 19 to 59 years]; body mass index 48 kg/m(2) [range 37 to 72 kg/m(2)]) underwent LGB and were followed up for 2 years focusing on weight loss, postoperative morbidity, weight-related comorbidity, and quality of life. The results demonstrate that LGB is well able to allow for a significant loss of excess weight and a significant improvement in patients' quality of life, both after a rather short period of time after surgery and at a continuous rate throughout the follow-up. The price for this success that was found in approximately 90% of patients is a complication rate of 38%; 85% of these patients, almost one third of all patients, must undergo some type of revision surgery. However, once the complications are resolved, these patients achieve the same level of weight loss and improvement in quality of life as patients with an uncomplicated postoperative course.

[Nocturnal gastroesophageal reflux as a cause of refractory chronic laryngitis--pathophysiology and management]

Chronic laryngitis is a common disease with a multifactoral genesis. One of the known causal factors is gastrolaryngeal acid reflux as a consequence of gastroesophageal reflux disease (GERD). 10 to 30% of the patients do not show an adequate response to the standard treatment with proton pump inhibitors, which could not be well explained in the past. Our own observations indicate, that sleep related gastroesophageal reflux may play an important role. The special physiological conditions in sleep can impair the reflux, and an increased nocturnal breathing effort in snoring or sleep apnea induces an intensive gastrolaryngeal reflux. This paper explains the pathophysiological background and the diagnostics and differential treatment.

[Epidemiology and pathophysiology of Barrett esophagus]

The pathophysiology of Barrett's esophagus appears to be a sequential process; the squamous epithelium of the esophagus is replaced by multipotent undifferentiated cells; secondary to cellular damage in the course of gastroesophageal reflux disease these undifferentiated cells further differentiate under the ongoing influence of mucosal damage, thus forming the typical morphology of Barrett mucosa. While the prevalence of gastroesophageal reflux disease amounts to 10% to 30%, the prevalence of Barrett's esophagus is estimated to be 1% in the general population. The epidemiologic data of Barrett's esophagus gain special attention with regard to the fact that the specialized columnar epithelium with intestinal metaplasia represents the only recognized risk factor for the development of adenocarcinoma in the esophagus. Currently it is estimated that the risk of the development of an adenocarcinoma on the basis of Barrett's esophagus is about 30-50 fold higher than that in the general population.

Sonography for selecting candidates for laparoscopic cholecystectomy: a prospective study

OBJECTIVE

We assessed the value of sonography in predicting intraoperative difficulties for patients undergoing laparoscopic cholecystectomy and in identifying indicators for conversion to conventional cholecystectomy.

SUBJECTS AND METHODS

Upper abdominal sonography was performed (according to a checklist) in 75 consecutive patients before laparoscopic cholecystectomy. Sonographic findings were verified by the surgeon in the operating room.

RESULTS

Conversion from laparoscopic surgery to laparotomy was performed in five patients (6.7%). Of 75 patients, 19 had sonograms revealing gallbladder wall thickening (>4 mm); surgical preparation difficulties in 16 of these patients led to laparotomy in four patients. Sensitivity, specificity, positive predictive value, and accuracy of wall thickening as an indicator of technical difficulties were 66.7%, 94.1%, 84.2%, and 85.3%, respectively. Sensitivity, specificity, positive predictive value, and accuracy of wall thickening as an indicator of surgical conversion were 80.0%, 78.6%, 21.1%, and 78.7%, respectively. Technical difficulties at laparoscopy occurred in all five patients with pericholecystic fluid on sonography (sensitivity, 20.8%; specificity, 100%; positive predictive value, 100%; accuracy, 74.7%) and led to laparotomy in three patients (sensitivity 60.0%, specificity 97.1%, positive predictive value 60%, accuracy 94.7%). The accuracy of sonography for cholecystolithiasis was 100%.

CONCLUSION

On sonography, gallbladder wall thickening is the most sensitive indicator and pericholecystic fluid is the most specific indicator of technical difficulties during laparoscopic cholecystectomy. Such difficulties may require conversion to laparotomy.

[Functional diagnosis of pelvic floor insufficiency--consequences for surgery]

Functional tests allow for the qualification and quantification of underlying function defects in the diagnosis of pelvic floor incompetence. However, the results of these instrumental investigations alone do not suffice for a therapeutic decision. The decision for a surgical therapy should therefore always be based on the clinical presentation, the extent of subjective impairment, and the degree of the causative pathophysiologic defect detected in the function tests.

Variability in the composition of physiologic duodenogastric reflux

Duodenogastric reflux has long been associated with various diseases of the foregut. Even though bile is often used as a marker, duodenogastric reflux consists of other components such as pancreatic juice and duodenal secretions. The aim of this study was to investigate the occurrence of duodenogastric reflux, its components, and the variability of its composition in normal subjects. Twenty healthy volunteers (7 men and 13 women) whose median age was 24 years underwent combined 24-hour bilirubin and gastric pH monitoring and intraluminal gastric aspiration. All probes were placed at 5 cm below the lower border of the lower esophageal sphincter. Aspiration was performed hourly and at any time when bilirubin and/or pH monitoring showed signs of duodenogastric reflux. Elastase and amylase were measured in the aspirate. All volunteers had episodes of physiologic duodenogastric reflux. A total of 70 episodes of duodenogastric reflux were registered with a median of three episodes (range 1 to 8) per subject. Most bile reflux occurred separately from pancreatic enzyme reflux. Pancreatic enzyme aspirate was significantly more often associated with a rise in pH in comparison to bile reflux (P <0.01). Duodenogastric reflux is a physiologic event with varying composition. Both bile and pancreatic enzyme reflux frequently occur separately. These findings could explain the disagreement regarding assessment and interpretation of duodenogastric reflux in the past. Thus monitoring of duodenogastric reflux requires more than the detection of just one component.

[Patient selection for laparoscopic gastric banding operation]

This study presents methods and results of a systematic selection of patients for laparoscopic gastric banding. A seven-step selection process considering anamnestic data, comprehensive counseling of patients and relatives, standardized psychological evaluation, specific medical work-up, including functional foregut testing, and economic issues was performed to select 50 of 163 referred patients (30.1%) for surgery. Long-term follow-up is needed to assess the value of this selection process.

The role of 24-hr gastric pH-monitoring in the interpretation of 24-hr gastric bile monitoring for duodenogastric reflux

BACKGROUND/AIMS

Duodenogastric reflux is a physiologic phenomenon. For a number of years, alkalinization of the acidic intragastric pH environment, as assessed by 24-hour gastric pH-monitoring, was thought to be caused by duodenogastric reflux. The recent introduction of the fotooptic Bilitec system for intraluminal bilirubin measurement has created the possibility to directly quantify a component of duodenal juice.

METHODOLOGY

In this study, 24-hour gastric pH-monitoring and 24-hour bilirubin monitoring were performed in healthy subjects. The upper limits for physiologic bile reflux are the percentage of total time of bile reflux of 28.2% and an average absorbance during a reflux episode of 0.62 (95th percentile with threshold 0.25).

RESULTS

Comparing bile with pH-monitoring (absorbance > 0.25 and/or pH > 4), an increase of bilirubin was found most frequently with constant pH (43%) or an increase of pH with constant bilirubin (37%).

CONCLUSIONS

The hypothesis was drawn that the composition of duodenogastric refluxate can vary. Bile and pancreatic juice may separately contribute to duodenogastric reflux.

[Laparoscopic anti-reflux surgery--report of experiences from Germany]

This is a report on a questionnaire in Germany reflecting the activity in antireflux surgery, both in open and laparoscopic modifications in the time period of 1990 through 1995. It serves as an overview of the acceptance of diagnostic workup, indication, applied techniques, and different antireflux procedures. In a total of 104 representative hospitals, 2,036 patients were operated during this time. Almost 80% of the hospitals provide antireflux surgery in the open technique and only 1/3 of the hospitals have experience in the laparoscopic technique. There is a total rise in antireflux surgery during the last 5 years, since the number of laparoscopic antireflux operations rises constantly with a total amount of open operations of about 250 cases per year. In open surgery the most favourite technique is the Nissen-Rossetti procedure, while in laparoscopic technique the choice for the original Nissen, the Nissen-Rossetti, or the floppy Nissen technique is divided in almost equal parts.

Inter- and intraindividual reproducibility of anorectal manometry

BACKGROUND

This study investigates the inter- and intraindividual variability of normal values and, thus, the reproducibility of anorectal manometry.

MATERIALS AND METHODS

Following a standardized protocol, three anorectal manometries were performed 4 h apart on 2 days of investigation, with an interval of 4 weeks, in ten healthy volunteers. Measured parameters in all 60 manometries were: sphincter length (SL), resting pressure (RP), maximum squeeze pressure (MSP), relaxation of the internal anal sphincter (RIAS), and rectal compliance (RC). Interindividual variability was expressed as standard deviation from calculated mean values and intraindividual variability was tested with Wilcoxon's test for tied samples and Spearman's rank correlation test.

RESULTS

A large interindividual variability was found for all measured parameters, except for SL, reflecting the extensive absolute range of measured values. Median intraindividual variability among the six individual measurements and between both measurement days revealed that MSP, RIAS and RC are parameters which were not reproducible in this volunteer study. A significant correlation between the results of the repetitive measurements and, thus, a good reproducibility was only found for the parameters SL and RP.

CONCLUSIONS

Anorectal manometry has only limited diagnostic value; although rather exact quantifications of individual parameters can be achieved, the impact of these measurements should be regarded rather critically, since only SL and RP appeared to be reproducible parameters.

Application of the new classification for cancer of the cardia

BACKGROUND

Cancer of the cardia is now topographically classified into three types: type I, with the tumor center in the distal esophagus treated with subtotal esophagectomy; type II, arising at the gastroesophageal junction and treated with distal esophagectomy and either proximal or total gastrectomy; and type III, subcardial cancer treated with extended total gastrectomy. Our objective was to review the new classifications and compare the outcomes in patients grouped and treated according to these classifications.

METHODS

Seventy-four patients with cancer of the cardia--15 with type I, 30 with type II, and 29 with type III cancer--underwent surgical resection at our institution between 1992 and 1997. Postoperative complications, UICC stages, and survival (Kaplan-Meier) were compared.

RESULTS

The majority of patients with type I (73%) or type II (53%) cancer had stage I or II tumors, but only 27% of patients with type III cancer had this tumor stage (P < .05). Overall 30-day mortality was 4% and morbidity was 31%. Curative resections were performed in 73% (54 of 74) of the patients with 3-year survival rates of 72% (type I), 68% (type II), and 61% (type III).

CONCLUSION

The recommended therapy for the different types of cancer of the cardia results in acceptable morbidity, mortality, and survival rates.

[How expensive is treatment of reflux disease?]

In a prospective documented series of reflux patients, a retroelective analysis of medication cost and duration of conservative therapy as well as the costs for surgical therapy including preoperative diagnostic workup, cost during hospitalization, and costs for complications with necessary additional treatment and readmissions is assessed. Cost-relevant factors are in conservative treatment cost-relevant factors are those patients who need increasing dosages, while in surgical treatment the cost-relevant patients are those with complications who need additional treatment.

[Laparoscopic interventions in gastroesophageal reflux--a cost-benefit analysis]

On the basis of a cost analysis of conservative and surgical therapy of gastroesophageal reflux disease in 70 patients health economic aspects are discussed. In a prospective documented series of reflux patients a retrolective analysis of medication cost and duration of conservative therapy is performed. In addition, the costs for surgical therapy including preoperative diagnostic workup, cost during hospitalization as well as costs for complications with necessary additional treatment and readmissions are assessed. For the conservative treatment of 70 reflux patients a total of more than DM < 700,000 had to be spent during preoperative 5 years. A major part of this sum was spent for patients who needed to increase the initial 20 mg dosage of Omeprazol within 5 years. A mean of approximately DM 2,000 per patient was spent for conservative treatment. Surgical treatment without complications was calculated with DM 5,425 per case. However, in 7 patients complications occurred causing prolonged or even rehospitalization with necessary further treatment summing up to about DM 486,000 for surgical therapy in 70 patients including complications. Cost relevant factors are therefore in conservative treatment patients who need increasing dosages, while, in surgical treatment, the cost relevant patients are those with complications and necessary additional treatment.

[Antroduodenal motility in patients with gastroesophageal reflux disease]

Beside the defective lower esophageal sphincter different mechanisms may be involved pathophysiology of GERD. This study shows antroduodenal motility disorders including a lower incidence of IMC's and lower frequencies of contractions in some study periods as possible pathophysiologic feature in selected patients with atypical symptoms and increased duodenogastric reflux.

Tailored augmentation of the lower esophageal sphincter in experimental antireflux operations

BACKGROUND

Modern upper GI function studies allow for the detection of several pathophysiological factors that contribute to gastroesophageal reflux disease. The information obtained can lead to therapeutic consequences in patients with an indication for a surgical intervention, i.e., an individualized choice of antireflux procedure according to the existing pathophysiologic defect.

METHODS

In an experimental study on mini-pigs the mechanical effect of four standardized antireflux operations (anterior and posterior 180 degrees hemifundoplication, Nissen-DeMeester and Nissen-Rossetti 360 degrees fundoplication) on the lower esophageal sphincter (LES) was investigated. It was the aim of the study to objectively determine the extent of changes in pressure and length parameters at the LES according to the performed antireflux procedure.

RESULTS

It could be demonstrated that different degrees of fundic wrap formation lead to a proportional mechanical effect at the LES according to the size of this wrap.

CONCLUSION

Choosing a distinct type of fundoplication will allow for a tailored augmentation of the LES according to the individual functional defect.

[Practical and theoretical aspects of cost-benefit relations in viscerosynthesis]

The necessity of limiting health care costs requires adequate service recording and quality control even in visceral surgery. In this field, the safety of the anastomoses is of greatest importance. Anastomoses at risk are esophageal connections to jejunum or colon and deep rectal anastomoses. At these locations expensive suture devices, such as stapling instruments, can be used in a cost saving aspect, if they help to increase anastomotic safety, time saving and expansion of surgical indication. Manual sutures thus represent the cheapest anastomotic technique as continuous sutures would cost between DM 10.- to 20.- and single stitch sutures between DM 60.- and 100.-. A surgical school should prevalently aim at training manual anastomoses, while special anastomotic techniques should only complete the skill for selected indications. The overall staff expenditure for extended operations amounts around DM 600.- per hour respectively DM 10.- per minute. Time for surgery might be shortened by auxiliary tools as much as to perform an additional operation. However, a circular stapler anastomosis that costs between DM 650.- to 850.- is twice as expensive as manual sutures notwithstanding the double time needed. In the past years, the necessity for a rational use of different anastomotic techniques has shown to be mandatory since, increasingly, financial aspects of health economy require cost benefit calculations in visceral surgery.

The mode of Roux-en-Y reconstruction affects motility in the efferent limb

OBJECTIVES

To compare motility of a Roux-en-Y esophagojejunostomy after total gastrectomy with normal jejunal motility and to determine the effect on motility of the incorporation of a pouch in the reconstruction.

DESIGN

Jejunal motility in normal subjects was compared with jejunal motility in the Roux-en-Y reconstruction with and without a Hunt-Lawrence pouch.

SETTING

The case were collected during a 4-year period at a university hospital. The mean time from resection to study was 14 months (range, 4 to 49 months).

PATIENTS

Seven control patients were compared with 10 patients with a Roux-en-Y reconstruction and 17 with a Roux-en-Y and Hunt-Lawrence pouch.

OUTCOME MEASURE

The fasting-state motility of the jejunum used for reconstruction was measured by a water-perfused manometric system for 2 to 4 hours with the subject in the supine position.

RESULTS

Compared with normal subjects, patients with a Roux-en-Y esophagojejunostomy without a pouch had an increased number of phases of the interdigestive motor complex per hour (P < .05). The phases were of shorter duration with a random sequence and increased total time spent in the quiescent phase 1 (P < .05). In patients with a pouch, no differences were detected between the motility in the pouch and the efferent limb. Compared with those without a pouch, there were significantly fewer orthograde interdigestive motor complex phase 3 fronts and more total time spent in phase 1 (P < .05).

CONCLUSIONS

Construction of a gastric substitute from jejunum leads to substantial motility changes. The addition of a pouch decreases the overall activity, which may contribute to the storage function of the pouch.

A tailored approach to antireflux surgery

Tailored surgical antireflux procedures were done in 104 patients during a 7-year period. Presenting symptoms included heartburn in 95 patients (91%), regurgitation in 83 patients (80%), and dysphagia in 61 patients (60%). Evaluation before operation included video barium esophagography, endoscopy, 24-hour esophageal pH monitoring, and esophageal motility studies. On the basis of anatomic and functional findings, the following procedures were performed: 15 laparoscopic and 49 open transabdominal Nissen fundoplications, 23 transthoracic Nissen fundoplications, seven Belsey partial fundoplications, and 10 Collis gastroplasty and Belsey partial fundoplications. The severity of symptoms was assessed before and after operation according to a previously published grading score. Eighty-five of the 104 patients (82%) were able to be contacted for a follow-up evaluation by means of a standardized questionnaire. Median length of follow-up was 4 years, with 40 patients having follow-up beyond 5 years. The tailored operation cured the symptoms of heartburn in 97%, regurgitation in 91%, and dysphagia in 92%. Ninety-eight percent of the patients reported that operation had cured their preoperative symptoms and 93% were satisfied with the outcome of the operation. To obtain optimal results, surgical treatment of gastroesophageal reflux disease should be tailored to the patient's anatomic and functional assessments. For early, uncomplicated disease a transabdominal Nissen fundoplication is done, laparoscopically when expertise exists. Patients with complicated disease should undergo an open antireflux procedure tailored to specific anatomic or functional abnormalities.

Clinical and physiologic comparison of laparoscopic and open Nissen fundoplication

BACKGROUND

Although recent reports have documented the safety and efficacy of laparoscopic fundoplication, none have compared outcomes to that of open Nissen fundoplication.

STUDY DESIGN

Eighty-one patients had either open (n = 47) or laparoscopic (n = 34) Nissen fundoplication. Relief of symptoms was measured by a standardized questionnaire and scored by a modified Visick-Index. Physiologic outcome was assessed by postoperative pH monitoring and manometry in a subset of both groups.

RESULTS

Primary symptoms were heartburn in 55 percent of the patients, regurgitation in 9 percent, dysphagia in 11 percent, and atypical in 25 percent of patients. Twenty-seven (84 percent) of 32 patients in the laparoscopic group and 31 (84 percent) of 37 patients in the open group were cured or improved. Operative time was significantly longer in the laparoscopic group (218 compared to 168 minutes). The period of hospitalization was shorter for the laparoscopic group (4.7 compared to 9.2 days, p < 0.0001). Postoperative pressures in the lower esophageal sphincter (LES) were significantly higher in the laparoscopic group (20.9 compared to 12.1, p = 0.006). Augmentation of sphincter length was similar for both groups. More patients in the laparoscopic group failed to relax their LES completely after fundoplication (32 compared to 71 percent, p = 0.1).

CONCLUSIONS

Symptomatic outcome after laparoscopic fundoplication is similar to that of open surgery. Physiologic studies reveal a greater augmentation of LES pressure and a low prevalence of sphincter relaxation after laparoscopic fundoplication.

A contemporaneous comparison of hospital charges for laparoscopic and open Nissen fundoplication

Surgical treatment of gastroesophageal reflux disease is increasingly recognized as a cost-effective alternative to long-term medical therapy. This fact, coupled with the advent of laparoscopic fundoplication as a safe and efficacious alternative to open surgery, underscores the importance of determining the costs associated with laparoscopic treatment. Hospital costs and charges of patients undergoing open (N = 9) and laparoscopic (N = 11) fundoplication were retrospectively analyzed. Both procedures were performed during the same time period (6/91-6/93), at the same hospital, and by the same surgical team. Operative time, and hospital stay, were recorded in addition to total, operating room, anesthesia, sterile supplies, and hospital room charges. Figures are reported as mean values +/- standard error of the mean. The Wilcoxon signed rank test was used for comparison of groups. Operative time (221 +/- 18 vs 165 +/- 12 min, P = 0.033) was longer in the laparoscopic group, while hospital stay (5.8 +/- 02 vs 8.8 +/- 04 days, P < 0.001) was significantly shorter. Total hospital costs were similar for both groups of patients ($14,615 +/- 863 vs $15,891 +/- 921, P = 0.247). Overall hospital charges were nearly identical ($26,634 +/- 1376 vs $27,189 +/- 1753, P = 0.803). A detailed analysis demonstrated cost shifting, with laparoscopic fundoplication resulting in significantly higher charges associated with events in the operating room. Operating room ($6,064 +/- 252 vs $4,283 +/- 380, P = 0.001), sterile supplies ($6,214 +/- 508 vs $5,403 +/- 390), and anesthesia charges ($1,593 +/- 76 vs $1,122 +/- 95, P < 0.001) were all greater in the laparoscopic group.(ABSTRACT TRUNCATED AT 250 WORDS)

Teaching upper gastrointestinal endoscopy: the pig stomach

An easily applicable teaching and training technique for flexible endoscopy in the upper gastrointestinal tract is presented. Using a fresh, flushed-out pig stomach with adherent esophagus and duodenum, the trainee endoscopist can practice all the essential endoscopic diagnostic and interventional techniques. The teaching model proposed requires little preparation, represents a cheap and easy technique with widespread applicability, offers a high degree of learning efficiency, and is appropriate for specialized teaching courses.

Motility in the Hunt-Lawrence pouch after total gastrectomy

PURPOSE

The aim of this study was to evaluate motility patterns of the Hunt-Lawrence pouch and the jejunal limb of patients reconstructed with a pouch after total gastrectomy, and to compare the findings in symptomatic patients to those without symptoms after the operation.

PATIENTS AND METHODS

Thirty-three patients who had undergone post-gastrectomy pouch reconstruction were studied using a water-perfused motility system. In 21, the pouch was connected by a Roux-en-Y, and, in 12, by a jejunal interposition. Twenty-eight patients were asymptomatic, including 17 connected by a Roux-en-Y and 11 by a jejunal interposition. Five patients were by a jejunal interposition. Five patients were symptomatic, including 4 connected by Roux-en-Y Y and 1 by jejunal interposition. A control group consisted of 5 healthy volunteers who had not undergone operation.

RESULTS

The motility phases in the pouch and jejunal limb of asymptomatic patients were of shorter duration than those of controls, and they followed a random sequence instead of a normal progression from phase I to II to III. Motility features were similar in the pouch and the jejunal limb. Orthograde propagation of phase III-like activity was reduced and may contribute to the pouch storage function. Four of the 5 symptomatic patients showed highly abnormal motility with hypomotile or obstructive patterns. The technique of connecting the pouch--jejunal interposition of Roux-en-Y--did not affect the motility findings.

CONCLUSIONS

The altered motility occurs after a Hunt-Lawrence pouch reconstruction in asymptomatic patients. Symptoms after gastrectomy are associated with further disturbed motility that can be differentiated from the motility changes in asymptomatic patients.

Laparoscopic adhesiolysis

The aim of this study was the detection of criteria that support the indication for laparoscopic adhesiolysis in patients presenting with unspecific symptoms. A prospective analysis investigates the value of laparoscopic adhesiolysis in patients with chronic abdominal pain after exclusion of other pathologic findings; 58 consecutive patients were followed after laparoscopic adhesiolysis. Endpoints of investigation were extent of adhesions, complications, postoperative hospitalization, and postoperative quality of life. A comparison was drawn to patients following laparoscopic cholecystectomy, laparoscopic cholecystectomy plus adhesiolysis, and conventional cholecystectomy. The results showed that major complications occurred in 10% of cases. In 45% of patients we found a complete remission, in 35% a substantial improvement, and in 20% a persistence of complaints. In a correlation between the preoperative complaints and the extent of adhesions we found small adhesions to cause recurrent abdominal pain without other symptoms while large adhesions produce recurrent abdominal pain in combination with symptoms indicative of intermittent bowel obstruction. Finally, the results of this study indicate a certain "ideal constellation" for an enduring successful adhesiolysis per laparoscopy: it is the subjective complaint of recurrent abdominal pain with a localized and reproducible punctum maximum in combination with a circumscribed area of adhesions at that site.

[Laparoscopic interventions in previously operated patients]

This prospective study investigates the technical feasibility and the potential advantage of laparoscopic operative techniques in patients following previous surgery. Data were obtained from a group of patients following previous surgery who underwent laparoscopic cholecystectomy, explorative laparoscopy, laparoscopic adhesiolysis, or laparoscopic procedures on the intestinal tract; all of these patients presented intraabdominal adhesions leading to a change of the originally intended operative procedure. 240 patients who underwent laparoscopic cholecystectomy without previous surgery or with previous surgery but without relevant adhesions represented the control group. Endpoints of investigation were duration of operation, post-operative hospitalization, intra- and postoperative complications, and postoperative quality of life. A total of 370 patients was followed after laparoscopic procedures. With an equal distribution of complications in both groups a higher percentage of calculated and emergency conversions was found in the group of patients following previous surgery; these conversions did not lead to a larger ratio of complications. The patients' postoperative quality of life, recorded by means of a complaint score, was equal in both groups. These results show that "previous abdominal surgery" does not represent a contraindication for laparoscopic surgery and that patients following previous surgery will profit from laparoscopic operations to the same extent as already proven for patients undergoing laparoscopic procedures without previous surgery.

Selection of patients for curative or palliative resection of esophageal cancer based on preoperative endoscopic ultrasonography

OBJECTIVE

To assess the accuracy of pretreatment staging and the potential of using endosonographic findings to select patients for curative or palliative resection by comparing the preoperative endosonographic and computed tomographic (CT) findings with the histology of the surgical specimen.

METHODS

Forty-two patients referred to our clinic with esophageal carcinoma underwent preoperative upper endoscopy with biopsy, endosonography, thoracic CT, and abdominal CT. Based on endoscopic ultrasonographic findings, patients with early-stage disease underwent en-bloc esophagogastrectomy, whereas those with advanced disease had a palliative transhiatal esophagectomy. Exceptions included patients with poor physiologic reserve who were treated by the transhiatal route.

RESULTS

In eight patients, we were unable to pass the ultrasonographic endoscope. Seven of these eight had transmural tumors with nodal involvement on histologic study. Tumor length, based on endosonographic measurements, was correctly predicted in 34 patients (85%). Extent of wall penetration was accurately predicted in 26 (76%) of the 34, and regional lymph node status was accurately predicted in 28 (82%) of the 34. Of the patients with sonographic wall penetration, 80% had histologic evidence of one or more positive nodes. Using the WNM staging system, endoscopic ultrasonography correctly staged the cancer in 68% of the patients. Three patients were treated with an inappropriate procedure.

CONCLUSION

Endosonography is a reliable method for the preoperative staging and selection of patients for curative or palliative resection. Endosonographic wall penetration appears to be a critical factor in determining tumor spread.

Laparoscopic posterior vagotomy and anterior seromyotomy

Laparoscopic truncal vagotomy with anterior seromyotomy, as described by Taylor, is our operation of choice in open surgery for elective treatment of chronic duodenal ulcer because it is a rapid, reliable and efficacious procedure. This procedure also does not have the variability of highly selective vagotomy in relation to the surgeon who is performing the operation. The technique is standardised and the results on 90 patients showed minimal morbidity and no mortality with a recurrence rate of 4.2% after a follow-up of 2-41 months. These results are very similar to those obtained in open surgery and compare favorably with the recurrence results after medical treatment. The procedure is therefore effective and safe and should be included in the armamentarium of treatment of chronic duodenal ulcer resistant to a thorough medical treatment.

[Experiences with laparoscopic technique in anti-reflux surgery]

The introduction of the laparoscopic techniques in antireflux surgery has created hopes for an improvement in the patients' outcome. Initial experience with minimally invasive procedures show that the application in antireflux surgery is possible without major problems. However, the functional result of antireflux surgery rather depends more on a differentiated indication for operation and an operative procedure designed to remove or compensate the underlying pathophysiologic functional defect. The method of access is of lesser priority. The promising results of this series may encourage to continue the demonstrated protocol and operative technique. However, generalized application of laparoscopic antireflux surgery should not be performed until further data of its advantages are available.

[Laparoscopic cholecystectomy--what is the value of laparoscopic technique in "difficult" cases?]

This prospective study with an external control group of patients investigates the technical aspects of laparoscopic cholecystectomy in patients with difficult intraabdominal situations as well as the postoperative quality of life of these persons. Difficult concomitant circumstances were defined when those patients had multiple adhesions after previous abdominal surgery in the middle and upper quadrants, acute cholecystitis, and severe obesity. 100 patients after classic cholecystectomy represented the external control group. 170 patients were followed after laparoscopic cholecystectomy. Endpoints of investigation were duration of operation, complications, postoperative hospitalization, and postoperative quality of life. Major complications occurred in 1.2%. Although in patients after laparoscopy minor complications were registered at a higher incidence than in classic cholecystectomy, the patients' postoperative quality of life improved significantly faster after laparoscopy in all patients groups. These results show that even patients with severe adhesions, with acute cholecystitis and with prolonged duration of operation still profit from the laparoscopic technique in comparison to laparotomy.

[Subcutaneous Dirofilaria (Nochtiella) repens infection in man--report of the first case in Austria and review of the literature (author's transl)]

A 39-year-old female patient developed migratory skin nodules 4 months after a vacation in Greece. The patient observed a total of 17 nodules moving over the trunk to the left thigh, where a subcutaneous lesion was excised, yielding a parasite measuring 0.5 mm X 7 cm. It was classified as Dirofilaria (Nochtiella) repens. Since this is the first case observed in Austria, an exact description of subcutaneous dirofilariasis, its geographical distribution and a review of the literature is presented.