Laparoscopic stapled cardioplasty for failed treatment of achalasia.

BACKGROUND: Treatment of primary achalasia includes injection of botulinum toxin, pneumatic dilatation or surgical myotomy. All of these procedures have an associated failure rate. Laparoscopic stapled cardioplasty (LSC) may be an alternative to failed pneumatic dilatation and laparoscopic Heller's myotomy where oesophagectomy has previously been the only surgical option. METHODS: Selected patients with recurrent achalasia following multiple failed medical treatments, including myotomies, were managed by LSC. Patients had postoperative contrast swallows before discharge with clinical follow-up. RESULTS: All seven patients treated with LSC were discharged within 5 days. Rapid oesophageal emptying was noted on all post-LSC contrast swallows. No patient had an anastomotic leak. After 1 year, all but one patient was free from dysphagia, all had gained weight, and four patients had heartburn controlled by a proton pump inhibitor. CONCLUSION: LSC may be a useful procedure for resistant achalasia.

Establishing pneumoperitoneum: Verres or Hasson? The debate continues.

INTRODUCTION: The technique of establishing pneumoperitoneum for laparoscopic surgery remains contentious, with various different techniques available and each having its own advocates. The Verres needle approach has attracted much criticism and is seen to entail more risk, but is this view justified in the era of evidence-based medicine? PATIENTS AND METHODS: Over a 6-year period, a prospective study was undertaken of 3126 patients who underwent laparoscopic surgery performed by two upper gastrointestinal surgeons. One surgeon preferred the Verres needle and the other an open technique. A database was created of all cases and complication rates of the different techniques ascertained. RESULTS: Peri-umbilical Verres needle was used in 1887 cases (60.4%) with two complications encountered, both of which were colonic injuries, with an incidence of 0.1%. Open port insertion was used in 1200 cases (38.4%) with one complication, a small bowel perforation, to give an incidence of 0.08%. The Verres needle was used in alternative positions in 22 cases (0.75%) and, when used in the left upper quadrant (19 cases), there was one complication, a left hepatic lobe puncture, with an incidence of 5.26%. Our overall incidence of intra-abdominal injury was 0.13%, all in patients who had undergone previous abdominal surgery, and in the subgroup of patients with previous surgery the rate was 0.78%. There was no mortality. CONCLUSIONS: Practice varies as to the method chosen to induce pneumoperitoneum, but our results show there is no significant difference between the technique chosen and incidence of complications, and this is supported in the literature.

Review of open and minimal access approaches to oesophagectomy for cancer.

BACKGROUND: Minimally invasive approaches to oesophagectomy are being used increasingly, but there remain concerns regarding safety and oncological acceptability. This study reviewed the outcomes of totally minimally invasive oesophagectomy (MIO; 41 patients), hybrid procedures (partially minimally invasive; 34) and open oesophagectomy (46) for oesophageal cancer from a single unit. METHODS: Demographic and clinical data were entered into a prospective database. MIO was thoracoscopic-laparoscopic-cervical anastomosis, hybrid surgery was thoracoscopic-laparotomy or laparoscopic gastric mobilization-thoracotomy, and open resections were left thoracoabdominal (LTA), Ivor Lewis (IL) or transhiatal oesophagectomy (THO). RESULTS: There were 118 resections for carcinoma (23 squamous cell carcinoma, 95 adenocarcinoma) and three for high-grade dysplasia. MIO took longer than open surgery (median 6·5 h versus 4·8 h for THO, 4·7 h for IL and LTA). MIO required less epidural time (P < 0·001 versus IL and LTA, P = 0·009 versus thorascopic hybrid, P = 0·014 versus laparoscopic IL). Despite a shorter duration of single-lung ventilation with MIO compared with IL and LTA (median 90 versus 150 min; P = 0·013), respiratory complication rates and duration of hospital stay were similar. There were seven anastomotic leaks after MIO, four after hybrid procedures and one following open surgery. Mortality rates were 2, 6 and 2 per cent respectively. Lymph node harvests were similar between all groups, as were rates of complete (R0) resection in patients with locally advanced tumours. CONCLUSION: MIO is technically feasible. It does not reduce pulmonary complications or length of stay. Oncological outcomes appear equivalent.

Anatomical failure following laparoscopic antireflux surgery (LARS): does it really matter?

INTRODUCTION: Failure rates of laparoscopic antireflux surgery (LARS) vary from 2-30%. A degree of anatomical failure is common, and the most common failure is intrathoracic wrap herniation. We have assessed anatomical integrity of the crural repair and wrap using marking Liga clips placed at the time of surgery and compared this with symptomatic outcome. PATIENTS AND METHODS: A prospective study was undertaken on 50 patients who underwent LARS in a single centre over a 3-year period. Each had an X-ray on the first postoperative day and a barium swallow at 6 months at which the distance was measured between the marking Liga clips. An increase in interclip distance of > 25-49% was deemed 'mild separation', and an increase of > 50% 'moderate separation'. Patients completed a standardised symptom questionnaire at 6 months. RESULTS: At 6 months' postoperatively, 22% had mild separation of the crural repair with a mean Visick score of 1.18, and 54% had moderate separation with a mean Visick score of 1.26. Mild separation of the wrap occurred in 28% with a mean Visick score of 1.21 and 22% moderate separation with a mean Visick score of 1.18. Three percent had mild separation of both the crural repair and wrap with a mean Visick score of 1.0, and 16% moderate separation with a mean Visick score of 1.13. Of patients, 14% had evidence of some degree of failure on barium swallow but only one of these was significant intrathoracic migration of the wrap which was symptomatic and required re-do surgery. CONCLUSIONS: The prevalence of some form of anatomical failure, as determined by an increase in the interclip distance, is high at 6 months' postoperatively following LARS. However, this does not seem to correlate with a subjective recurrence of symptoms.

Cost-effective laparoscopic cholecystectomy.

INTRODUCTION: There is wide variation in costs, both theatre and ward, for the same operation performed in different hospitals. The aim of this study was to compare the true costs for a large number of consecutive laparoscopic cholecystectomy (LC) cases using re-usable equipment with those from an adjacent trust in which the policy was to use disposable LC equipment. PATIENTS AND METHODS: Data were collected prospectively between January 2001 and December 2007 inclusive for all consecutive patients undergoing LC by two upper gastrointestinal (UGI) consultants at the Royal Berkshire Hospital. Data were collected for all the instruments used, in particular any additional disposable instruments used at surgeons' preference. Sterilisation costs were calculated for all re-usable instruments. Costs were also obtained from an adjacent NHS trust which adopted a policy of using disposable ports and clip applicators. Disposable equipment such as drapes, insufflation tubing, and camera sheath were not considered as additional costs, since they are common to both trusts and not available in a re-usable form. RESULTS: Over 7 years, a total of 1803 LCs were performed consecutively by two UGI consultants at the Royal Berkshire Hospital. The grand total for 1803 LC cases for the re-usable group, including initial purchasing, was pound89,844.41 (an average of pound49.83 per LC case). The grand total for the disposable group, including sterilisation costs, was pound574,706.25 (an average of pound318.75 per LC case). Thus the saving for the trust using re-usable trocars, ports and clip applicators was pound268.92 per case, pound69,265.98 per annum and pound484,861.84 over 7 years. CONCLUSIONS: This study has demonstrated that considerable savings occur with a policy of minimal use of disposable equipment for LC. Using a disposable set, the instrument costs per procedure is 6.4 times greater than the cost of using re-usable LC sets. It behoves surgeons to be cost-effective and to reduce unnecessary expenditure and wastage. There is no evidence to support use of once-only laparoscopic instruments on grounds of patient safety, ease of use or transmission of infection. If the savings identified in this study of two surgeons' work (savings of pound484,861.84 in a 7-year period) was extended not only across the hospital but across the NHS, large savings could be made for laparoscopic cholecystectomy. Even greater savings would accrue if the results were extrapolated to cover all laparoscopic surgery of whatever discipline.

Randomized clinical trial of laparoscopic total (Nissen) versus posterior partial (Toupet) fundoplication for gastro-oesophageal reflux disease based on preoperative oesophageal manometry.

BACKGROUND: Laparoscopic fundoplication is an accepted treatment for symptomatic gastro-oesophageal reflux disease. The aim of this study was to clarify whether total (Nissen) or partial (Toupet) fundoplication is preferable, and whether preoperative oesophageal manometry should be used to determine the degree of fundoplication performed. METHODS: Preoperative oesophageal manometry was used to stratify 127 patients with established gastro-oesophageal reflux disease into effective (75) and ineffective (52) oesophageal motility groups. Patients in each group were randomized to Nissen (64) or Toupet (63) fundoplication. RESULTS: No significant differences between the operative groups were seen in heartburn, regurgitation or other reflux-related symptoms up to 1 year after surgery. Dysphagia of any degree (27 versus 9 per cent; P = 0.018) and chest pain on eating (22 versus 5 per cent; P = 0.018) were more prevalent at 1 year in the Nissen group. There were no differences in postoperative symptoms between the effective and ineffective motility groups. Surgery failed in eight patients on postoperative pH criteria, three in the Nissen group and five in the Toupet group. CONCLUSION: Any differences in the symptomatic outcome of laparoscopic Nissen and Toupet fundoplication appear minimal. There is no reason to tailor the degree of fundoplication to preoperative oesophageal manometry.

Results of laparoscopic reoperation for failed antireflux surgery: does the indication for redo surgery affect the outcome?

Short and medium term outcomes from laparoscopic antireflux surgery are generally excellent. A small number of patients suffer recurrent reflux or intolerable side-effects and may require reoperation. In this paper we describe our experience of 35 laparoscopic reoperations from a single center. Data on patients undergoing antireflux surgery in our unit has been prospectively collected and includes more than 600 primary laparoscopic antireflux operations since 1993. Laparoscopic reoperations have been performed between 1996 and 2005 for patients suffering recurrent reflux, dysphagia or severe gas bloat symptomatic despite medical treatment. All patients underwent preoperative barium studies and endoscopy with selective manometry and pH studies. Symptomatic outcomes were evaluated at 6 weeks and 12 months with Visick scores. Anatomical results were assessed with barium studies at between 6 and 12 months. Thirty-five laparoscopic reoperations were performed in 20 women and 13 men (median age 56 years). Primary surgery had been performed in our unit in 27 (77%) and elsewhere in eight (23%). Median time from primary surgery was 28.5 months (5-360). Two patients underwent a second reoperation. Indication was recurrent reflux in 28 (80%), dysphagia in five (14%) and gas bloat in two (6%). Thirty-two of the 35 reoperations (91.4%) were completed laparoscopically, median operating time was 120.5 min (65-210) and median hospital stay 2 days. There was no mortality and there were only five minor complications. Twelve-month follow-up was available for 32 reoperations (91%). Overall good symptomatic outcomes were obtained in 26 (74%) Visick I or II at 6 weeks and 24 of 32 (75%) at 12 months. In reoperations for dysphagia/gas bloat there was a relative risk of 4.26 of a poor symptomatic outcome (Visick III or IV) at 12 months compared to those for recurrent reflux (P < 0.05, Fisher's exact test). Laparoscopic reoperation is feasible with low conversion rates and minimal morbidity for patients who have undergone previous abdominal or thoracic hiatal repair. Symptomatic outcomes are generally good, particularly if the indication is recurrent reflux.

The extended learning curve for laparoscopic fundoplication: a cohort analysis of 400 consecutive cases.

Many studies have looked at the learning curve associated with laparoscopic Nissen fundoplication (LNF) in a given institution. This study looks at the learning curve of a single surgeon with a large cohort of patients over a 10-year period. Prospective data were collected on 400 patients undergoing laparoscopic fundoplication for over 10 years. The patients were grouped consecutively into cohorts of 50 patients. The operating time, the length of postoperative hospital stay, the conversion rate to open operation, the postoperative dilatation rate, and the reoperation rate were analyzed. Results showed that the mean length of operative time decreased from 143 min in the first 50 patients to 86 min in the last 50 patients. The mean postoperative length of hospital stay decreased from 3.7 days initially to 1.2 days latterly. There was a 14% conversion to open operation rate in the first cohort compared with a 2% rate in the last cohort. Fourteen percent of patients required reoperation in the first cohort and 6% in the last cohort. Sixteen percent required postoperative dilatation in the first cohort. None of the last 150 patients required dilatation. In conclusion, laparoscopic fundoplication is a safe and effective operation for patients with gastroesophageal reflux disease. New techniques and better instrumentation were introduced in the early era of LNF. The learning curve, however, continues well beyond the first 20 patients.

A poor response to proton pump inhibition is not a contraindication for laparoscopic antireflux surgery for gastro esophageal reflux disease.

BACKGROUND: We aimed to determine if a poor response to proton pump inhibitors (PPIs) can predict a poor outcome following laparoscopic antireflux surgery (LARS) in our surgically treated population. METHODS: A total of 324 patients undergoing LARS were included in this study. Following standardized assessment, patients recorded the efficacy of their medication on visual analogue scales. Pre- and postoperative symptom scores were recorded, with outcomes measured by modified Visick scores. RESULTS: There were 233 good responders (>50% relief) and 91 poor responders (<49% relief). Both groups demonstrated a significant decline in postoperative symptom scores. Ninety-four percent of good responders had an excellent or good outcome, compared to 87% of poor responders. Twenty-seven patients reported a fair or poor outcome, despite improved postoperative symptom scores. Fifteen of these patients reported continuing heartburn; five had positive pH tests. CONCLUSION: Our results do not support the assumption that a poor response to PPIs equates to a poor outcome after LARS.

Results of laparoscopic Nissen fundoplication at 2-8 years after surgery.

BACKGROUND: Although the long-term results of open fundoplication for gastro-oesophageal reflux disease are well documented, there have been few reports of the long-term results of laparoscopic fundoplication. METHODS: Between January 1993 and July 1999, 179 consecutive patients underwent laparoscopic floppy Nissen fundoplication. Of these, 175 were available for long-term follow-up. Structured symptom questionnaires were completed by 140 patients (80 per cent) at 2-5 years (n = 92) or 5-8 years (n = 48) after operation. RESULTS: Patient satisfaction with surgery was 91 per cent at a median follow-up of 48 (range 24-99) months. Visick scores of I or II were recorded by 84 per cent. Ninety per cent of patients remained free from significant reflux symptoms. Side-effects were common (22 per cent) but rarely affected patient satisfaction. Of the 19 patients (14 per cent) taking regular antireflux medication, eight used it for non-reflux symptoms and 12 had normal postoperative pH tests. CONCLUSION: Laparoscopic floppy Nissen fundoplication is an effective and durable treatment for gastro-oesophageal reflux disease. Longer-term follow-up of patients operated on beyond the learning curve can be expected to show further improvements in surgical outcome.

The results of total mesorectal excision for rectal carcinoma in a district general hospital before the era of surgical specialization.

OBJECTIVE: To evaluate the results of rectal cancer surgery performed by a gastrointestinal surgeon in a district general hospital prior to the introduction of specialization, and to compare these to the targets set by the Royal College of Surgeons for specialist units. METHODS: Data collection in 73 consecutive patients (prospective in 53) undergoing elective excisional surgery (sphincter conserving in 77%) for rectal cancer. While adjuvant radio/chemotherapy and pathological assessment evolved over the study period, a standardized surgical technique (total mesorectal excision) was used in all patients. RESULTS: Observed (and recommended) outcome measures were operative mortality 4.1% (<5), anastomotic leak 6.2% (<8), wound infection 2.7% (< 10), pelvic recurrence after curative resection 9.6% (< 10). Temporary defunctioning stomas were used in 32/48 (66.7%) of patients. Other complications, currently without recommended outcomes, were erectile dysfunction (13%), stoma related (7.1%) urinary retention (4.1%), urinary incontinence (2.7%) and benign anastomotic stricture (2.7%). CONCLUSION: All treatment outcome criteria were met. Trained gastrointestinal surgeons outside the setting of a specialist unit can achieve good results with acceptable complication rates.

Twenty-four-hour pH monitoring is required to confirm acid reflux suppression in patients with Barrett's oesophagus undergoing anti-reflux surgery.

OBJECTIVE: To assess whether relief of gastro-oesophageal reflux symptoms in patients with Barrett's oesophagus who undergo laparoscopic anti-reflux surgery is a reliable indicator of acid suppression. DESIGN: Prospective cohort study. SETTING: Surgical department of a large district general hospital. PARTICIPANTS: Twenty-two patients with Barrett's oesophagus and symptomatic gastro-oesophageal reflux who underwent laparoscopic anti-reflux surgery. INTERVENTIONS: Laparoscopic anti-reflux surgery. MAIN OUTCOME MEASURES: Postoperative symptom scores and 24-h pH test results. RESULTS: Twenty-one out of 22 patients had no or minimal residual symptoms postoperatively (Visick I or II). DeMeester symptom scores improved from a median of 5 preoperatively to 0 postoperatively (P < 0.001, Mann-Whitney rank sum test). Eighteen out of 22 patients had postoperative pH studies: three had persisting abnormal acid exposure times postoperatively, but all three were asymptomatic. CONCLUSIONS: In patients with Barrett's oesophagus, relief of reflux symptoms following laparoscopic anti-reflux surgery is unreliable as an indicator of acid reflux suppression.

Patient self-assessment of test-day symptoms in 24-h pH-metry for suspected gastroesophageal reflux disease.

BACKGROUND: Marked daily fluctuations may occur in the pattern and degree of gastroesophageal reflux (GOR) and in patients' symptoms. The aim of this study was to observe how patients' self-assessment of their symptoms on the day of a 24-h pH test correlates with the likely outcome of the test and the potential value in repeating it. METHODS: 367 patients with symptoms suggestive of GOR underwent 24-h pH tests. Fifty-eight patients had repeat studies. Patients assessed the severity of their test-day symptoms as 'better than typical', 'typical' or 'worse than typical'. RESULTS: A 'typical' or 'worse than typical' day was more likely to produce an abnormal test result (P < 0.0001). A normal first test on a 'better than typical' day was more likely to be followed by an abnormal second test than a normal first test on a 'typical' or 'worse than typical' day (55% versus 22%; P = 0.025). The symptom index score, the total acid exposure time on the first test and the presence of oesophagitis were not associated with an abnormal second test (P not significant). CONCLUSIONS: Patients' self-assessment of the severity of their test-day symptoms should be included in the interpretation of 24-h pH tests for suspected GOR. Patients with a normal pH test on a 'better than typical day warrant a repeat test.

Laparoscopic antireflux surgery in the treatment of the acid-sensitive oesophagus.

BACKGROUND: Approximately 10 per cent of patients referred for 24-h oesophageal pH tests with symptoms suggestive of gastro-oesophageal reflux disease will have a normal endoscopic examination and normal distal oesophageal acid exposure times, but a clear temporal correlation between their symptoms and episodes of acid reflux. These patients have an 'acid-sensitive oesophagus', which forms part of the spectrum of reflux-related conditions. Their response to antireflux surgery has not been reported previously. This study represents a prospective cohort analysis of a clearly defined group of patients with acid-sensitive oesophagus who have undergone laparoscopic antireflux surgery. METHODS: Nineteen patients (nine male and ten female; median age 32 years) underwent laparoscopic antireflux surgery for acid-sensitive oesophagus. All had had an incomplete response to medical therapy. RESULTS: Eighteen of 19 patients were graded Visick I or II at 6 months after operation; all 16 patients followed for 1 year were graded Visick I or II. There were significant falls in DeMeester symptom score (4.0 versus 0.5; P < 0.001), symptom events (20 versus none; P < 0.001), number of reflux episodes (17 versus two; P < 0.001) and overall acid exposure times (1.2 versus 0.3 per cent; P < 0.001) after operation. CONCLUSION: Laparoscopic antireflux surgery is a valid and effective treatment for patients with an acid-sensitive oesophagus. Presented in poster form to the British Society of Gastroenterology, Birmingham, March 2000 and the American Gastroenterological Association, San Diego, May 2000