Open Nissen fundoplication and highly selective vagotomy as a treatment for gastro-oesophageal reflux disease

BACKGROUND

Open Nissen fundoplication has been the most common surgical treatment of gastro-oesophageal reflux disease (GORD). The present paper describes the symptomatic result, and quantifies the acid reduction achieved by open Nissen fundoplication combined with highly selective vagotomy (HSV) in a consecutive case series.

METHODS

A study of 106 patients undergoing open Nissen fundoplication and HSV for GORD was performed between 1988 and 1996. A history consistent with reflux was obtained and the diagnosis confirmed with ambulatory oesophageal pH studies and endoscopy. Postoperative pH studies were performed, and peri-operative and late complications were recorded. A standard questionnaire was sent out to patients postoperatively to assess the efficacy of surgery.

RESULTS

Pre-operative pH studies were performed on 104 (98%) patients, and on 97 (91.5%) following surgery. There was a highly significant improvement in all parameters of the pH study postoperatively. All symptoms, including bloating and dysphagia, improved significantly postoperatively, except flatulence, which was exacerbated. The majority of patients were very satisfied with their outcome, 82% rating the operation from 80 to 100% successful. Complications were rare and there was no mortality.

CONCLUSIONS

Open Nissen fundoplication and HSV is an effective method of treating GORD, producing an improvement in symptoms and in ambulatory pH studies.

A survey of antimicrobial prophylaxis in elective colorectal surgery in New Zealand

In 1988 a survey of New Zealand general surgeons was conducted, by post, on the subject of routine antimicrobial prophylaxis for elective colorectal surgery. Surgeons who gave routine prophylaxis were asked for details of their regimens; those who did not were asked for their reasons. One hundred and seventy-five questionnaires were distributed and 167 were returned. Of these, 124 came from surgeons with a colorectal practice, and 118 of the 124 surgeons satisfactorily completed the questionnaire. Routine antimicrobial prophylaxis was given by 96.6% (114 of 118). Of the 114 surgeons prescribing prophylaxis, one antimicrobial agent was used by 36.8%, two were employed by 53.5% and three or five were used by the remainder. The most commonly used (74.6%) antimicrobial agents were cephalosporins which were prescribed, alone or in combination with a nitroimidazole. The most frequent duration (46.4%) of antimicrobial administration was a combination of both the peri- and postoperative periods. When antimicrobial spectrum, route and duration of administration were all taken into account, 49.1% (56 of 114) were considered to give satisfactory regimens. Excessively protracted administration was the most frequent reason for unsatisfactory classification. The results of this survey demonstrate serious deficiencies in the practice of antimicrobial prophylaxis in elective colorectal surgery. These should be addressed through a programme of continuing education.

Effect of opiate, general anaesthesia and surgery on plasma atrial natriuretic peptide levels in man

1. Animal data suggest that opiates, halothane anaesthesia and activation of the sympathetic system stimulates release of atrial natriuretic peptide (ANP). To examine whether this is so in man, venous ANP levels were measured in five patients undergoing elective cholecystectomy. 2. Plasma levels of cortisol, aldosterone, norepinephrine and epinephrine increased 3-6 fold during the study. Cortisol-aldosterone relationships were close in all patients (r = 0.73-0.97), whereas plasma renin activity and aldosterone correlations were strong in only two subjects. 3. Baseline plasma ANP concentrations were within the normal range and were not altered by opiate injection, anaesthesia, or surgery. 4. Unlike experimental animals, man exhibits little or no ANP response to opiates, halothane, or surgical stimulation of the sympathetic nervous system.

Effect of cimetidine and omeprazole on aspirin- and taurocholate-induced gastric mucosal damage in the rat

The effect of varying doses of cimetidine and omeprazole, on acute gastric mucosal lesions produced by topical aspirin (200 mg/kg; 1 ml/100 g) in 0.175 M HCl or topical sodium taurocholate (40 mM; 1 ml/100 g) in 0.175 M HCl was studied in the pylorus ligated rat. Preliminary studies revealed dose dependent inhibition of acid secretion with both cimetidine and omeprazole. Intraperitoneal cimetidine 50 mg/kg and 100 mg/kg given before topical acidified aspirin reduced mucosal lesions from a control score of 23.7 +/- 3.5 (mean +/- SEM) in which 83% of stomachs contained lesions, to 6.9 +/- 2.2 and 3.5 +/- 2.1 respectively (p less than 0.05), 36% and 27% of stomachs containing lesions. A dose of 250 mg/kg failed to reduce lesion score significantly (17.8 +/- 4.9) and 64% of stomachs contained lesions. Taurocholate-induced lesion score was reduced from a control value of 32.7 +/- 4.3 in which 97% of stomachs contained lesions to 10.8 +/- 3.3 and 15.5 +/- 3.8 by cimetidine 10 mg/kg and 25 mg/kg respectively (p less than 0.05), 62% and 68% of stomachs containing lesions. Cimetidine 50 mg/kg and 100 mg/kg failed to significantly reduce mucosal damage. Intraduodenal omeprazole (1.25 to 50 mumol/kg) given before topical acidified aspirin or taurocholate failed to reduce mucosal lesions, as did intragastric omeprazole 5 mumol/kg and 50 mumol/kg given before acidified aspirin. Cimetidine showed cytoprotective properties over a specific dose range beyond which the effect was lost despite continuing suppression of acid secretion. Omeprazole exhibited no cytoprotective activity.

The prevention of recurrent variceal haemorrhage by chronic injection sclerotherapy

Forty eight patients who have survived admission with acute variceal haemorrhage have been readmitted and entered into a programme of chronic injection sclerotherapy to prevent recurrent variceal haemorrhage. Two hundred and nineteen elective courses of injections were performed at fibreoptic endoscopy with minor complications occurring in six patients. Twenty three patients rebled on 33 occasions but in only five instances did haemorrhage occur following variceal obliteration. With 67 per cent of patients surviving one year, this treatment option offers a satisfactory means of preventing recurrent haemorrhage when variceal obliteration is achieved.

The effect of omeprazole on insulin induced gastric secretion in man

The effect of oral omeprazole on insulin induced gastric secretion was studied in 12 healthy subjects. Each subject participated in two secretory tests receiving an intravenous infusion of insulin (0.03 units/kg/h) and being randomly allocated to receive 30mg or 60mg omeprazole suspended in 100ml water containing 16 mmol NaHCO3 on the second study day. Peak plasma concentrations of omeprazole were achieved within 30 minutes of administration in all but one subject and plasma half life was 30 minutes. Mean peak stimulated acid output in the six subjects receiving 30mg omeprazole was reduced to 4.3 +/- S.E. 1.8 mmol/h from a control value of 16.8 +/- 2.2 mmol/h (p less than 0.05) and in six subjects receiving 60mg omeprazole, mean peak output fell to 3.4 +/- 2.1 mmol/h from a control value of 12.3 +/- 2.6 mmol/h (p less than 0.05). The two doses of omeprazole produced similar reduction in acid secretion (74% and 73% respectively) but neither dose affected pepsin secretion. Both doses of omeprazole were associated with a small statistically insignificant increase in the plasma gastrin response to insulin infusion.

Prediction of outcome following acute variceal haemorrhage

In order to identify factors predicting survival following acute variceal haemorrhage, data were collected prospectively from 100 admissions in 70 patients managed by a standard policy employing oesophageal tamponade, injection sclerotherapy and, if necessary, oesophageal transection. Of the ten predictive factors identified by univariate analysis, only prothrombin ratio, serum creatinine and the presence of encephalopathy on admission were shown by stepwise logistic regression to have independent significance. The derived regression equation allowed clearer identification than conventional scoring systems of high and low risk groups and successfully predicted outcome in 90 per cent of admissions.

Primary sclerosing cholangitis

Six patients with primary sclerosing cholangitis are described. It is an uncommon disease of uncertain aetiology following an unpredictable course but often progresses to secondary biliary cirrhosis, portal hypertension, and premature death from liver failure. Ulcerative colitis is commonly associated with primary sclerosing cholangitis. Endoscopic retrograde cholangiography is the investigation of choice. Liver biopsy may support the diagnosis but is not pathognomonic. There is no effective treatment but symptoms may be controlled.