Reintervenciones por fallo de la cirugía antirreflujo / Reinterventions for Failed Antireflux Surgery

RESUMEN Introducción: En la actualidad, la fundoplicatura laparoscópica se considera el tratamiento de elección para la enfermedad por reflujo gastroesofágico con resultados excelentes en más del 90 por ciento de los pacientes. Sin embargo, a pesar de estos resultados, el 30 % de los pacientes presentan persistencia de los síntomas y del 3 por ciento al 10 por ciento requieren reintervención por fallo de la cirugía antirreflujo. Objetivo: Describir las causas del fracaso de la cirugía antirreflujo y las técnicas realizadas en la reintervención. Método: Se realizó un estudio descriptivo, retrospectivo y longitudinal, de una serie de pacientes a los cuales se les realizo cirugía antirreflujo en el Centro Nacional de Cirugía de Mínimo Acceso desde enero de 1994 hasta diciembre de 2016. Las variables analizadas fueron: reintervenciones y sus causas, tratamiento quirúrgico, morbilidad y el índice de conversión. Resultados: De un total de 1 550 pacientes operados, 37 (2,3 por ciento) fueron reintervenidos. Las causas más frecuentes de reintervención fueron la recidiva de los síntomas y la presencia de disfagia. La herniación de la fundoplicatura fue el hallazgo transoperatorio más frecuente. El índice de conversión fue bajo y no hubo fallecidos en las reintervenciones. La morbilidad triplicó la del total de la serie, así como la estadía hospitalaria. Conclusiones: Las reintervenciones por fallo de la cirugía antirreflujo resultan de gran complejidad pues aumentan considerablemente la morbilidad y la estadía hospitalaria. Debe realizarse en centros que acumulen una alta experiencia en estas técnicas(AU)

ABSTRACT Introduction: Nowadays, laparoscopic fundoplication is considered the treatment of choice for gastroesophageal reflux disease, showing excellent results in more than 90 percent of patients. However, despite these results, 30 percent of patients present with persistent symptoms, while 3 percent to 10 percent require reintervention for failed antireflux surgery. Objective: To describe the causes of failed antireflux surgery and the techniques performed in the reintervention. Method: A descriptive, retrospective and longitudinal study was conducted with a series of patients who underwent antireflux surgery at the National Center for Minimally Access Surgery, from January 1994 to December 2016. The variables analyzed were reinterventions and their causes, surgical treatment, morbidity and the conversion rate. Results: From among 1550 patients operated on, 37 (2.3 percent) were reintervened. The most frequent causes of reintervention were the recurrence of symptoms and the occurrence of dysphagia. The fundoplication herniation was the most frequent transoperative finding. The conversion rate was low and there were no deaths in the reinterventions. The morbidity tripled that of the total of the series, as well as hospital stay. Conclusions: Reinterventions for failed antireflux surgery are very complex, since they increase morbidity and hospital stay considerably. It must be performed in centers that accumulate a high experience in these techniques(AU)

Antireflux surgery is equally beneficial in nonerosive and erosive gastroesophageal reflux disease

PURPOSE: Although nonerosive and erosive gastroesophageal reflux disease (GERD) have similar symptom severity, nonerosive reflux disease (NERD) is considered a milder type of GERD and gastroenterologists have hesitated to refer these patients for antireflux surgery. The aim of this study was to compare surgical outcomes of antireflux surgery between patients with NERD and erosive reflux disease (ERD). METHODS: Seventy patients met the inclusion criteria of this study among a total of 117 patients who underwent antireflux surgery from November 2012 to October 2017. According to preoperative endoscopy, patients were classified into NERD group (minimal changes or no esophagitis) and ERD group. Clinical characteristics and surgical outcomes were compared between NERD and ERD. RESULTS: There were 26 patients in NERD group and 44 patients in ERD group. The male:female ratio was higher in the ERD group than in the NERD group (P = 0.044). Preoperative symptoms, response to acid suppressive medication, acid exposure on pH monitoring study, and esophageal manometry results were similar in the 2 groups. Reflux on barium esophagography was more frequently observed in ERD (77.3%) than in NERD (50.0%, P = 0.019). At 6 months after surgery, complete resolution and partial improvement of GERD symptoms were similar in the 2 groups (80.8% and 15.4%, respectively, in NERD vs. 88.6% and 2.3%, respectively, in ERD; P = 0.363). CONCLUSION: Laparoscopic Nissen fundoplication is equally beneficial to patients with NERD and ERD. Antireflux surgery should not be avoided for GERD patients without mucosal breaks on endoscopy as the evidence of erosive esophagitis.

Incidental splenic injury and splenectomy: an overview based on available evidence / Lesión esplénica incidental y esplenectomía: una visión general basada en la evidencia disponible

Splenectomy indications are hematologic disease, traumatic damage and iatrogenic injury. The aim of this study was to present an evidence-based overview of some clinical aspects of interest related with iatrogenic splenic injury and subsequent splenectomy. An overview of the available evidence was conducted. Articles that evaluated clinical aspects of interest related with iatrogenic splenic injury and subsequent splenectomy, without language limits, publication date and designs. BVS, PubMed, SciELO and TRIP databases were reviewed. Evaluated variables were: Frequency and etiology of surgical spleen injuries, treatment options, frequency of splenectomy, associated postoperative morbidity (POM) and mortality, recommendation for splenectomy. Classification of the available evidence was made using the classification proposed by Oxford Centre of Evidence-based Medicine. 1144 records were obtained. 1109 were discarded for not meeting eligibility criteria, or were not relevant for the purpose of this research. Finally, the study consisted of 35 articles, 3 of evidence level type 3a, 31 of evidence level type 4 and 1 of evidence level type 5. Splenectomy is a complication of common abdominal procedures, prevalence and incidence of iatrogenic splenic injury is underestimated because of lack of information, there is evidence of risk factors of surgical spleen injuries, the etiology of surgical spleen injuries are bariatric, esophago-gastric, antireflux, colorectal, abdominal vascular and urological procedures. POM in patients undergoing splenectomy is more frequent in emergency splenectomy secondary to trauma. There was no significant risk reduction of infectious complications after implementation of routine vaccination. Available evidence is based on few and heterogeneous articles, which make a meaningful conclusions difficult. Studies with better evidence levels, methodological quality and population size are needed for conclusions and recommendations.

Las indicaciones de esplenectomía son enfermedades hematológicas, daño por trauma y por lesiones iatrogénicas. El objetivo de este estudio es presentar una visión general basada en la evidencia actualmente disponible, respecto de algunos aspectos clínicos de interés relacionados con la lesión esplénica iatrogénica y posterior esplenectomía. Revisión global de la evidencia disponible. Se incluyeron artículos que evaluaron aspectos clínicos de interés relacionados con lesión esplénica iatrogénica y posterior esplenectomía; sin límites de lenguaje, fecha de publicación y diseño. Se revisaron las bases de datos BVS, PubMed, SciELO y Trip Database. Las variables evaluadas fueron: frecuencia y etiología de las lesiones, opciones de tratamiento, frecuencia de esplenectomía, morbimortalidad postoperatoria, recomendación de esplenectomía. La clasificación de la evidencia se realizó con la propuesta del Centro de Medicina Basada en la Evidencia de Oxford. Se obtuvieron 1144 registros. 1109 fueron descartados por no cumplir criterios de elegibilidad, o ser no relevantes para el objetivo de la investigación. La población en estudio quedó compuesta por 35 artículos, 3 de nivel de evidencia 3a, 31 de nivel de evidencia 4 y 1 de nivel de evidencia 5. La esplenectomía es una complicación propia de la cirugía abdominal. La prevalencia e incidencia de lesión esplénica iatrogénica es subestimada por falta de información. Hay evidencia de factores de riesgo de lesiones del bazo. La etiología de estas es: procedimientos bariátricos, esófago-gástricos, colorrectales, vasculares abdominales y urológicos. La morbilidad es más frecuente en esplenectomía de emergencia secundaria a trauma. No se ha registrado disminución significativa del riesgo de complicaciones infecciosas con la vacunación rutinaria. La evidencia disponible se basa en pocos artículos y heterogéneos, lo que impide sacar conclusiones. Se necesitan estudios de mejor nivel de evidencia, calidad metodológica y tamaño de muestra para obtener conclusiones válidas y recomendaciones adecuadas.

Late evaluation of patients operated for gastroesophageal reflux disease by nissen fundoplication / Avaliação tardia de pacientes operados por doença do refluxo gastroesofágico pela técnica de nissen

ABSTRACT Background: Surgical treatment of GERD by Nissen fundoplication is effective and safe, providing good results in the control of the disease. However, some authors have questioned the efficacy of this procedure and few studies on the long-term outcomes are available in the literature, especially in Brazil. Aim: To evaluate patients operated for gastro-esophageal reflux disease, for at least 10 years, by Nissen fundoplication. Methods: Thirty-two patients were interviewed and underwent upper digestive endoscopy, esophageal manometry, 24 h pH monitoring and barium esophagogram, before and after Nissen fundoplication. Results: Most patients were asymptomatic, satisfied with the result of surgery (87.5%) 10 years after operation, due to better symptom control compared with preoperative and, would do it again (84.38%). However, 62.5% were in use of some type of anti-reflux drugs. The manometry revealed lower esophageal sphincter with a mean pressure of 11.7 cm H2O and an average length of 2.85 cm. The average DeMeester index in pH monitoring was 11.47. The endoscopy revealed that most patients had a normal result (58.06%) or mild esophagitis (35.48%). Barium swallow revealed mild esophageal dilatation in 25,80% and hiatal hernia in 12.9% of cases. Conclusion: After at least a decade, most patients were satisfied with the operation, asymptomatic or had milder symptoms of GERD, being better and with easier control, compared to the preoperative period. Nevertheless, a considerable percentage still employed anti-reflux medications.

RESUMO Racional: O tratamento cirúrgico para DRGE empregando a fundoplicatura à Nissen é eficaz e seguro, oferecendo bons resultados no controle da doença. Entretanto, alguns autores têm questionado quanto a sua eficácia, e poucos estudos com avaliação tardia destes doentes são encontrados na literatura, sobretudo no Brasil. Objetivo: Avaliar pacientes operados por doença do refluxo gastroesofágico há pelo menos 10 anos, pela técnica de Nissen. Métodos: Trinta e dois pacientes foram entrevistados e submetidos à endoscopia digestiva alta, manometria esofágica, pHmetria prolongada de 24h e esofagograma baritado, antes e após a fundoplicatura à Nissen. Resultados: A maioria estava assintomático 10 anos após a operação e satisfeitos com o resultado dela (87,5%) e a fariam novamente (84,38%), devido melhor controle sintomático com medicação, em comparação com o período pré-operatório. Entretanto, 62,5% empregavam algum tipo de medicação anti-refluxo. Quanto aos exames, a manometria revelou extensão média de 2,85 cm de esfíncter esofágico inferior, com pressão média de 11,7 cm de H2O. O índice médio de DeMeester na pHmetria foi de 11,47. Na endoscopia a maior parte dos pacientes apresentou exame normal (58,06%), ou esofagite leve (35,48%). O esofagograma revelou discreta dilatação esofágica em 25,80% e hérnia hiatal em 12,9% dos casos. Conclusão: Após no mínimo uma década, a maioria dos doentes estava satisfeita com a operação, assintomática ou apresentava sintomatologia mais branda da DRGE que era de melhor e mais fácil controle, comparado ao período pré-operatório. Porcentagem não desprezível ainda empregava medicações para refluxo.

Evaluación intraoperatoria de la distensibilidad de la unión gastroesofágica en fundoplicatura antireflujo / Intraoperative assessment of the distensibility of the gastroesophageal junction in antireflux fundoplication

Introducción: La alteración de la distensibilidad de la unión gastro esofágica (UGE) es un factor etiológico para la enfermedad de reflujo gastroesofágico. El incremento de la distensibilidad permite el reflujo de contenido gástrico incrementa las relajaciones transitorias del esfínter, el número de reflujos y la exposición al ácido. Ha sido descrito que la UGE puede ser calibrada en el acto operatorio utilizando sonda balón, que permite una medida en tiempo real de la capacidad, diámetro y presión de la UGE. Objetivos: evaluar la utilidad de la medida de la distensibilidad de la UGE como predictor de éxito en fundoplicatura laparoscópica (FPL) mediante el uso de la sonda Endoflip ® (Crospon) utilizada intra operatoriamente en pacientes sometidos a FPL como tratamiento anti reflujo practicando mediciones antes y después de la plicatura. Materiales y métodos: La FP se realizó según técnica de Toupet. Se tomaron medidas de distensión del balón con llenado de 40 ml de solución salina 0,2% a) después de la inducción de la anestesia b) después de la reparación de la crura y c) al finalizar el arropado. Los datos fueron analizados por t students. P<0,05 fue considerado significativo. Resultados: Fueron evaluados 9 pacientes, el promedio de edad fue de 45,2; en todos los pacientes existía indicación de cirugía, todos presentaban hernia hiatal. La FPL redujo el promedio de distensibilidad de la UGE de 52,8 mm2/mmHg a 29,8 mm2/mmHg (p=0,0021, (43,5%). Conclusión: Este método permite tomar decisiones en cirugía de la UGE donde el valor objetivo de la distensibilidad puede definir el éxito de la cirugía y evitar eventos adversos post operatorios.

Introduction: The altered distensibility of the gastro esophageal junction (GEJ) is recognized as a primary pathophysiologic factor in the development of gastro esophageal reflux disease (GERD). The increase in GEJ distensibility allows reflux of large volumes of gastric contents into the esophagus, increases transient relaxations of the lower esophageal sphincter and increases the number of reflux and esophageal exposure to acid. Moreover, other pathologies with functional obstruction of the GEJ as achalasia have very little distensibility. Recently was reported that GEJ can be calibrated during surgery using balloon catheter, allowing real-time measurement of capacity, diameter and GEJ pressure during surgery. Objectives: To review the usefulness of the measurement of the distensibility of the GEJ as a predictor of success in laparoscopic fundoplication (LP) using Endoflip® commercial catheter, used intra-operatively in patients undergoing LP anti reflux surgery practicing measurements before and after plication. Material and Methods: The Toupet Fundoplication (TFP) was performed under standard technique, balloon distension measurements were taken, filling with 40 ml of 0.2% saline solution as specified by the manufacturer: a) after induction of anesthesia and once the pneumo peritoneum was stabilized b) After repairing the crura of the diaphragm and c) after the wrapping. Data was analyzed by students t P <0.05 and was considered significant. Results: A total of 9 patients (6 men), age average was 45.2 (32-72), all patients had previous functional and endoscopic studies and surgical indication existed, they all had a diagnosis of hiatal hernia, they all signed informed consent. No patient had postoperative complications. The Toupet Fundoplication (TFP) significantly reduced average GEJ distensibility to 40 ml of 52.8 to 29.8 mm2/mmHg mm2/mmHg (p = 0.0021, which represents a reduction of 43.5%). Conclusion: This method allows the gastro surgical team to make decisions on GEJ surgery in which the target value of distensibility can define the success of the surgery and avoid postoperative adverse events.

Identificação de fatores de risco pré-operatórios para disfagia pós-operatória persistente após cirurgia laparoscópica para doença do refluxo gastroesofágico / Identification of preoperative risk factors for persistent postoperative dysphagia after laparoscopic antireflux surgery

RACIONAL: Disfagia no pós-operatório é comum após a operação anti-refluxo. No entanto, uma parte dos pacientes relatam disfagia persistente, e técnica cirúrgica inadequada é uma causa bem documentada deste resultado. OBJETIVO: Este estudo retrospectivo avaliou os fatores de risco no pré-operatório para a disfagia persistente após operação anti-refluxo por via laparoscópica. MÉTODOS: Pacientes submetidos à operação anti-refluxo por via laparoscópica pela técnica de Nissen modificada foram avaliados no pré-operatório de forma retrospectiva. A severidade da disfagia pós-operatória foi avaliada prospectivamente usando uma escala estabelecida. A disfagia após seis semanas foi definida como persistente. Os testes estatísticos de associação e regressão logística foram utilizados para identificar os fatores de risco associados à disfagia persistente. RESULTADOS: Um total de 55 pacientes foram submetidos ao procedimento por via laparoscópica por uma única equipe de cirurgiões. Destes, 25 doentes referiam disfagia pré-operatório (45,45%). A disfagia pós-operatória persistente foi relatada por 20 (36,36%) pacientes. Dez (18,18%) necessitaram de dilatações por endoscopia digestiva. Houve associação estatística entre a satisfação com a operação e disfagia no pós-operatório e exigindo o uso de medicação anti-refluxo após o procedimento, e entre disfagia no pré-operatório e disfagia no pós-operatório. A regressão logística identificou a disfagia no pré-operatório, como fator de risco para a disfagia pós-operatória persistente. Não foram observadas correlações com manometria pré-operatória. CONCLUSÕES: Os pacientes com disfagia no pré-operatório foram mais propensos a relatar disfagia pós-operatória persistente. Os critérios manométricos atuais utilizados para definir dismotilidade esofágica não identificaram pacientes com risco de disfagia persistente pós-fundoplicatura. Análise minuciosa da história clínica sobre a presença e intensidade da disfagia no pré-operatório é muito importante na seleção de candidatos à operação anti-refluxo.

BACKGROUND: Postoperative dysphagia is common after antireflux surgery and generally runs a self-limiting course. Nevertheless, part of these patients report long-term dysphagia. Inadequate surgical technique is a well documented cause of this result. AIM: This retrospective study evaluated the preoperative risk factors not surgery-related for persistent dysphagia after primary laparoscopic antireflux surgery. METHODS: Patients who underwent laparoscopic antireflux surgery by the modified technique of Nissen were evaluated in the preoperative period retrospectively. Postoperative severity of dysphagia was evaluated prospectively using a stantardized scale. Dysphagia after six weeks were defined as persistent. Statistical tests of association and logistic regression were used to identify risk factors associated with persistent dysphagia. RESULTS: A total of 55 patients underwent primary antireflux surgery by a single surgeon team. Of these, 25 patients had preoperative dysphagia (45,45%). Persistent postoperaive dysphagia was reported by 20 (36,36%). Ten patients (18,18%) required postoperative endoscopic dilatation for dysphagia. There was statistical association between satisfaction with surgery and postoperative dysphagia and requiring the use of antireflux medication after the procedure; and between preoperative dysphagia and postoperative dysphagia. Logistic regression identified significant preopertive dysphagia as risk factor for persistent postoperative dysphagia. No correlations were found with preoperative manometry. CONCLUSIONS: Patients with significant preoperative dysphagia were more likely to report persistent postoperative dysphagia. This study confirms that the current manometric criteria used to define esophageal dysmotility are not reliable to identify patients at risk for post-fundoplication dysphagia. Minucious review of the clinical history about the presence and intensity of preoperative dysphagia is important in the selection of candidates for antireflux surgery.

Early experiences of minimally invasive surgery to treat gastroesophageal reflux disease / 대한외과학회지

PURPOSE: There are fewer patients with gastroesophageal reflux disease (GERD) in Korea compared with Western countries. The incidence of GERD has increased in recent years however, concerning many physicians. Here, we report our early experiences of using a recently introduced method of laparoscopic antireflux surgery for the treatment of GERD in Korean patients. METHODS: Fifteen patients with GERD were treated using antireflux surgery between May 2009 and February 2012 at the University of Ulsan College of Medicine and Asan Medical Center. Laparoscopic Nissen fundoplication with 360degrees wrapping was performed on all patients. RESULTS: Eleven male and four female patients were evaluated and treated with an average age of 58.1 +/- 14.1 years. The average surgical time was 118.9 +/- 45.1 minutes, and no complications presented during surgery. After surgery, the reflux symptoms of each patient were resolved; only two patients developed transient dysphagia, which resolved within one month. One patient developed a 6-cm hiatal hernia that had to be repaired and reinforced using mesh. CONCLUSION: The use of laparoscopic surgery for the treatment of GERD is safe and feasible. It is also an efficacious method for controlling the symptoms of GERD in Korean patients. However, the use of this surgery still needs to be standardized (e.g., type of surgery, bougienage size, wrap length) and the long-term outcomes need to be evaluated.

Laparoscopic Gastric Wedge Resection and Prophylactic Antireflux Surgery for a Submucosal Tumor of Gastroesophageal Junction

A laparoscopic wedge resection for a submucosal tumor, which is close to the gastroesophageal junction, is technically challenging. This can be a dilemma to both patients and surgeons when the tumor margin involves the gastroesophageal junction because a wedge resection in this situation might result in a deformity of the gastroesophageal junction or an injury to the lower esophageal sphincter, which ultimately results in lifelong gastroesophageal reflux disease. The patient was a 42 year-old male, whose preoperative endoscopic ultrasonographic finding did not rule out a gastrointestinal stromal tumor. He underwent a laparoscopic gastric wedge resection and prophylactic anterior partial fundoplication (Dor) and was discharged from hospital on the fifth postoperative day without any complications. There were no symptoms of reflux 5 months after surgery. A laparoscopic wedge resection and prophylactic anti-reflux surgery might be a good surgical option for a submucosal tumor at the gastroesophageal junction.

Minimally Invasive Surgery for Gastroesophageal Reflux Disease / 대한소화기학회지

Gastroesophageal reflux disease (GERD) is a chronic disease deteriorating patient's quality of life. With the advent of proton pump inhibitors, treatment failures have decreased considerably. However, surgical therapy offers the potential for cure in more than 90% of patients with GERD. Specific indications for antireflux surgery are: incomplete response to medical therapy, frequent recurrences despite the medical treatment, laryngopharyngeal, and/or respiratory symptoms, and complications of GERD, such as esophageal stricture, erosive esophagitis, esophageal ulcer, and/or Barrett's esophagus. The introduction of laparoscopic surgery in early ninties had a profound impact on many surgical fields, including the treatment of GERD. In this review, laparoscopic Nissen fundoplication is described and controversial topics, such as total vs. partial fundoplication, and the natural history of Barrett's esophagus after antireflux surgery are addressed.

Síntomas respiratorios asociados a la enfermedad por reflujo gastroesofágico: diagnóstico y tratamiento / GERD related respiratory symptoms: diagnosis and treatment

La enfermedad por reflujo gastroesofágico puede generarsíntomas respiratorios. Éstos se desencadenan cuandoel contenido esofágico refluye a la vía aérea, generandouna microaspiracion; o a través de un reflejo vago-vagal. Los síntomas respiratorios pueden ser vagos ycoexistir con la enfermedad por reflujo, sin una verdaderarelación causa-efecto. Para tratar estos pacientes,es fundamental realizar un diagnóstico preciso que asocielas dos entidades. El algoritmo debe incluir estudiosque detecten reflujo gastroesofágico, microaspiración y,de corresponder, lesión laríngea. A continuación, se debeaplicar la terapéutica más efectiva. El tratamientomédico posee menor tasa de éxito si lo comparamos conla obtenida en pacientes con síntomas típicos. Esto puededeberse a que episodios de reflujo no-ácido son losgeneradores de síntomas, a la existencia de un dañoirreversible en la vía aérea o a dosis insuficientes demedicación para neutralizar el ácido. La fundoplicaturaes un tratamiento efectivo que frena todo tipo dereflujo patológico (ácido y no-ácido). Este artículo describela utilidad de los tests diagnósticos y menciona losresultados obtenidos con las diversas formas de tratamiento.Adicionalmente, comenta acerca de la potencialaplicación de la impedancia esófago-faringea enesta población.

Gastroesophageal reflux disease can cause respiratory symptoms. These symptoms are triggered by reflux events that reach the pharynx, causing microaspiration or through vagal reflex. Respiratory symptoms can be vague and coexist with gastroesophageal reflux disease, without a real link between the two entities. To effectively treat these patients, it is important tofind an association between the two diseases. Work up should include the diagnosis of reflux disease, the diagnosis of pharyngeal reflux events -microaspiration - and, if possible, of laryngeal injury. Once the diagnosis has been established, an effective therapy must be offered to the patient. In these patients, medical treatment is less effective when compared to the results in the population with typical symptoms. This may be due to the fact that non-acid reflux episodes are causing the respiratory symptoms or as a result of an irreversible damage generated in the airway. Antireflux surgery is an effective therapy that reduces both acid and non-acid reflux events. This article describes the different diagnostic tests as well as the results obtained with surgical treatment in this population. Additionally, it describes potential applications of esophageal and pharyngeal impedance monitoring in these patients.

99mTc-DMSA Renal Scan after Anti-reflux Surgery in Children with Primary Vesicoureteral Reflux / 대한비뇨기과학회지

PURPOSE: 99mTc-dimercaptosuccinic acid(DMSA) renal scintigraphy is recognized as the most effective imaging modality for demonstrating renal scarring In children with vesicoureteral reflux. We determined if significant numbers of new scar develop and progression of scarring occur after antireflux surgery. MATERIALS AND METHODS: Retrospective study was undertaken In a series of 102 reflux renal units out of 60 children(male 35, female 25) with vesicoureteral reflux as documented by voiding cystourethrography, whose age was 28(median, range:1-150) months. We carefully examined DMSA renal scans taken in 2(median, range:0.3-58) months before operation and 18(median, range:3-62) months after operation in each patients. Twenty two children(37 renal units) were further followed up by additional scans up to 50(median, range:25-120) months postoperatively. Each scan was blindly reviewed twice in terms of the size, number and zonal location of the cortical defects based on morphology. The Interval changes were categorized into 3 patterns(improved, no change, progressed) based on the review findings RESULTS: There were no patients with postoperative pyelonephritis but asymptomatic bacteriuria were found in 19 patients(31.5%). Most(57 patients, 109 renal units) of the antireflux operation were done by Cohen method and refluxes were still found in 8 renal units(7.8%) in immediately postoperative periods and were ultimately disappeared. No postoperative urethral obstruction was found on intravenous pyelogram. On follow-up renal scintigraphy most of renal units(89, 87.3%) showed no change while 11(10.7%) showed improvement and progression was observed In 2(2.0%). No correlation was established between scintigraphic change and several clinical factors such as sex, age of first pyelonephritis presentation, presence or frequency of pyelonephritis before initial renal scan , nor postoperative episodes of urinary tract infection. CONCLUSIONS: Our results show that on the contrary to the most of the previous reports, no further development of renal scar was found after successful surgery. There was no significant morphologic change in the postoperative follow-up renal scan in most of reflux and if any, most were disappearance or diminution of renal scars.

Cohen Ureteral Reimplantation: Outcome of 58 Ureters in 34 Children / 대한비뇨기과학회지

Surgical results of 34 children (68 ureters) who underwent Cohen ureteral reimplantation in the last 6 years were evaluated. All children were followed at least 4 months after the operation. Indication for the repair consisted of vesicoureteral reflux in 22 children, obstructive megaureter in 8 children and ureterocele in 4 children. The underlying problems in 55 ureters ( 94.8% ) were successfully corrected. Surgical failures were persistent reflux in 2 ureters, new ipsilateral reflux in 1 ureter and contralateral reflux in 1 ureter. However, no ureteral obstruction was noticed in this series. In conclusion, the Cohen cross trigonal technique was a safe and effective method of ureteral reimplantation in children.

Experience of Gil Vernet Antireflux Surgery / 대한비뇨기과학회지

A new antireflux surgical technique was introduced by Gil Vernet in 1984, which is simple and rapidly accomplished without mobilization of the distal ureter. The technique involves a single stitch that implicates the trigone, effectively lengthening the intramural segment of terminal ureter, which is particularly effective in patients with megatrigone. We applied this new technique in 2 children with vesicoureteral reflux, of whom one had unilateral grade III reflux and the other bilateral grade II and grade IV reflux. Vesicoureteral reflux and urinary tract infection were lost at follow up voiding cystourethrogram and urinalysis 4 months after operation. We think that this new technique is excellent method in surgical treatment of vesicoureteral reflux.

Primary Vesicoureteral Reflux - Extravesical Antireflux Plasty - / 대한비뇨기과학회지

The vesicoureteral reflux is closely related to urinary tract infection in children and persistent vesicoureteral reflux with recurrent urinary tract infection is the common indication for antireflux plasty But it has been known that the vesicoureteral reflux was rare in Korea. From March 1979 to June 1984, author observed 13 patients with vesicoureteral reflux in the absence of any lower urinary tract obstruction, neuropathic disorder, inflammatory lesion at the base of the bladder, which were confirmed with IVP, VCUG and cystoscopy. The results were as follows 1. Age distribution was from 1 yr to 10 yr 2. Sex ratio of male to female was 1.1:1 3. Chief complaints at admission were fever 7 cases (53.9 %), flank pain 3 cases (23%), abdominal mass 2 cases (15.3%), incontinence 1 cases (7.6%). 4. Urinary culture at abmission revealed E. Coli in 9 patients (69%) and both E. Coli and Staphylococci in a patient. 5. 9 of 13 patients showed normal findings in IVP before treatment 6. 13 of 19 ureters showed one more than grade III in VCUG; before treatment. 7. In cystoscopy, shapes of 19 ureteral orifices with vesicoureteral reflux were golf-hole type 9 cases (47.4 %), horse-shoe type 2 cases (10.5 %), stadium type 1 case (5.2%), cone type 6 cases (31.6%) and in one case, it couldn`t be detected due to severe trabeculation. 8. Gregoir-Lich extravesical antireflux plasty were obtained in 13 of 19 ureters with vesicoureteral reflux without failure during four to seven follow-up months.