Short and long-term results of laparoscopic total fundic wrap (Nissen) or semifundoplication (Toupet) for gastroesophageal reflux disease.

INTRODUCTION: Gastroesophageal reflux disease (GERD) is a common upper GIT disorder. The choice of surgical management options is debatable between laparoscopic Nissen fundoplication (LNF) and Toupet fundoplication (LTF) especially in cases with esophageal dysmotility. PATIENTS AND METHODS/AIMS: 102 patients with chronic GERD divided into 2 groups. Group (1): Patients with good peristalsis (n=70) done LNF. Group (2): Patients with poor peristalsis (n=32) patients done LTF to compare the outcome. They were included in this study. They subjected to clinical, radiological and esophageal motility investigations. RESULTS: In postoperative period, Recurrent of heartburn, dysphagia and abdominal distension were found in 5.71% , 14.28% and 27.14% post LNF and in 9.37%, 15.62% and 15.62% post LTF respectively. Pre operative LESP was 10.16±5.4 mmHg in LNF & 9.56±3.51 mmHg in LTF group increased to 20.7±7.84 mmHg early after LNF (p<0.0001) & 15.26±6.47 early after LTF (p = 0.0002). Esophageal 24hrs pH metry in early and late post operative showed a significant improvement of % reflux (p < 0.001) in both groups. CONCLUSION: Toupet fundoplication became the procedure of choice of cases with esophageal dysmotility due to its ease of application, patient satisfaction, low dysphagia rate and low levels of abdominal distension.

Short gastric vessels division in Laparoscopic Nissen Fundoplication.

BACKGROUND/AIMS: To divide or not the short gastric vessels during Laparoscopic Fundoplication (LF) is still controversial. This retrospective study is based on short gastric vessels division (SGVsD), if necessary, during LF to construct a satisfactory loose wrap and to evaluate its effect upon the symptomatic and physiologic outcome in patients with proven GERD. METHODOLOGY: 150 patients (90 males, 60 females) with a mean age of 37 +/- 9 with typical symptoms of GERD, adequate motility study and positive 24-hour pH studies underwent LF; 100 (66.7%) were feasible after careful and complete fundal dissection without SGVsD while, 50 (33.3%) were not possible except with SGVsD. Outcome measures included assessment of the relief of the primary symptom responsible for surgery; repeated upper endoscopy and barium study. Postoperative 24-hour esophageal pH and LES manometry were performed in 110 patients. RESULTS: The mean operative time was prolonged with short gastric division (130 +/- 60 vs. 90 +/- 40 minutes). At a mean period of follow-up of 35 +/- 12 months, relief of the primary symptom responsible for surgery was achieved in 92.2% of patients with division and 87.5% of patients without. Recurrent attacks of abdominal distension were documented in 2 patients (5.6%) with division and 12 patients (16%) without division. Occasional dysphagia not present before surgery occurred in 27 patients at 3 months; 11 (31.4%) with division and 16 (21.3%) without, and decreased to 11 patients by 12 months after surgery; 2 (5.7%) with division and 9 (12%) without; only one case of those without division required 5 sets of endoscopic dilatation. Endoscopic esophagitis healed in all patients with division and 71 of 75 patients (94.7%) without. LES pressures had returned to normal in all patients except one case without division (1.3%) with a higher mean pressure among those without division (22.3 mmHg vs. 18.5 mmHg) and a better relaxation with division (89.9% vs. 80.5%). 24-hour esophageal acid exposure had returned to normal in 33 of 35 patients (94.3%) with division and 66 of 75 patients (88%) without. CONCLUSIONS: Construction of a satisfactory loose Nissen Fundoplication was feasible in two thirds of patients without SGVsD. Despite prolongation of the operative time, SGVsD provides a better symptomatic and physiologic outcome.

Outcome after resection of central cholangiocarcinoma: preliminary experience with 46 patients in a single center.

BACKGROUND/AIMS: Despite the enormous progress in surgery the management of cholangiocarcinoma remains a problem. In this study we present our preliminary experience in the surgical treatment of central cholangiocarcinoma. METHODOLOGY: Between May 1997 and December 2001, 175 patients with central cholangiocarcinoma were admitted to our center. Of the 175 patients, 54 cases subjected to surgery, the remaining 131 patients did not undergo surgery because of advanced disease, advanced liver cirrhosis and poor general condition. Forty-six patients underwent surgical excision, their mean age was 53 +/- 3 years, and male to female ratio was 74-26%. All patients presented with jaundice associated with pain (30%) or biliary stones (32%). Surgical resection of the bile duct with or without part of segment IV were done in fourteen patients and bile duct resection together with major hepatectomy had been done in the remaining 28 patients. RESULTS: Hospital mortality occurred in 10.8%; the main cause of mortality was hepatic cell failure. The most common complications were hepatic cell failure that occurred in 7 cases (15%), biliary leakage in 8 cases (17%), gastrointestinal bleeding in 3 cases (6.5%) and wound infection in 3 cases (6.5%). Late complication in the form of recurrence occurred in 12 cases (29.5%). cholangitis in 8 cases (19.5%), hepatic cell failure in 5 (12%) and gastrointestinal bleeding in 2 (4.8%). At the end of the study, 19 patients (46%) were alive with mean follow-up of 16.6 +/- 9 months. The survival rate at 6, 12, 18, 24 months was 92, 82, 52, 25, 18%, respectively. Recurrence and cholangitis were found significantly higher in the group without hepatectomy than the group after hepatectomy (p < 0.0001, p < 0.0016, respectively). CONCLUSIONS: From our results we can conclude that major hepatectomy with excision of the extrahepatic bile duct system and caudate lobe resection may be recommended for the surgical treatment of central cholangiocarcinoma in selected cases.

Gastric myoelectrical activity in diabetics with and without diabetic autonomic neuropathy.

BACKGROUND/AIMS: The effects of diabetes mellitus on gastric myoelectrical activity has not been fully investigated. The aim of the present study was to investigate the pattern of gastric myoelectrical activity in noninsulin dependent diabetics, detected by electrogastrography in an attempt to clarify the relation between diabetic autonomic neuropathy and gastric myoelectrical abnormalities, if any. METHODOLOGY: The study was carried out on 34 noninsulin dependent diabetes (7 males, 27 females). Their age ranged from 35-60 years with mean age of 51.5 +/- 3.5 years. The EGG was recorded for 30 min in both the fasting and postprandial states, using an ambulatory EGG recording device (Digitrapper EGG, Synectics Medical). The adaptive spectral analysis method was used to assess the normality of the EGG. The EGG was defined as abnormal if: the percentage of normal slow waves (2.5-3.7 cycles/min) was below 70% during either the baseline or postprandial recording or there was a decrease in EGG peak power after the meal, or both. RESULTS: EGG abnormalities were detected in 13 patients (38.2%); 1 had tachygastria, 1 had bradygastria, 7 had dysrhythmias, and 4 had decreased EGG peak power after the meal. All diabetic patients with abnormal EGG suffer autonomic neuropathy. CONCLUSIONS: These results suggest that gastric myoelectrical abnormalities occur in a high proportion of noninsulin dependent diabetics and these abnormalities predominate in those patients with autonomic neuropathy.

Chronic liver disease and hepatitis C virus in Egyptian patients.

BACKGROUND/AIMS: This study was designed to evaluate anti-HCV and anti-GOR in chronic liver disease (CLD) caused by HCV alone or with bilharzia. METHODOLOGY: The parameters of hepatitis C virus (HCV) infection among 45 chronic liver disease (CLD) patients are the subject of this study. The samples that were collected included serum, saliva and liver biopsy. For comparison, 44 serum, saliva and liver biopsies were also collected from non liver disease (NLD) patients undergoing surgery at the Gastroenterology Surgical Center, Mansoura University. RESULTS: Screening of antihepatitis C (anti-HCV) with a second generation ELISA test showed that 37/45 (82.2%) sera and 17/45 (37.7%) saliva samples from CLD patients were positive for the presence of anti-HCV (IgG), while, anti-HCV (IgG) was detected among 32/44 (72.7%) sera and 6/44 (13.6%) saliva samples from NLD patients. HCV antigen was detected by immunostaining in the liver biopsy sections of 11/45 (24.4%) CLD and in 6/44 (13.6%) NLD patients. HCV antigen was detected in hepatocyte cytoplasm and nuclei, in some endothelial cells lining the hepatic cell cords, and in some bile duct cells. The serum and saliva samples from both CLD and NLD patients were also tested by ELISA for the presence of anti-GOR to determine the prevalence of autoantibody in HCV infected and non-infected patients. Anti-GOR was detected in 19/45 (42.2%) sera and in 1/45 (2.21%) saliva samples from CLD patients, while in the case of NLD patients, anti-GOR antibodies were found in 7/44 (15.9%) sera and in 4/44 (9%) saliva samples. GOR antigen was detected by an indirect immunoperoxidase stain of liver biopsies. Positive GOR antigen signals were found in hepatocytes but granular cytoplasmic, and extrahepatic localization was also noticed. A correlation between the detection of anti-GOR and anti-HCV revealed that, out of 37 anti-HCV positive CLD patients, there were 19 (51.3%) positive for anti-GOR, while 7/32 (21.8%) NLD patients were positive for anti-HCV and for anti-GOR. CONCLUSIONS: The results of the present study confirm the published anti-HCV high seropositivity among Egyptian CLD patients and point to an autoimmune processes in CLD. The liver biopsy findings stress the presence of HCV antigen in extra hepatic cells as well as in hepatocytes in CLD. Our data confirm that anti-GOR is commonly present in sera from CLD patients and show that anti-GOR are secreted in saliva. Our results showed that saliva can not be used reliably, instead of serum, for the diagnosis of HCV infection or auto-antibodies related to HCV infection, but can be used as a parameter for the evaluation of CLD activity, when repeated sampling is necessary.

Fundal varices: problem and management.

BACKGROUND/AIMS: The pathophysiology of gastric varices may be due to generalized or segmental portal hypertension. A considerable debate has arisen regarding the role of injection sclerotherapy in the pathogenesis of gastric varices. METHODOLOGY: During the period from 1987 to 1997, a total of 1686 cases with bleeding varices were presented to our center and 225 cases (13.3%) with bleeding gastric varices were diagnosed. There were 198 males and 27 females with a total mean age of 45.7 years (+/- 7.6). Primary fundal varices (FV) were found in 121 (54%) cases and secondary FV were found in 104 (46%) cases. All patients with isolated FV presented with repeated attacks of upper gastrointestinal bleeding. RESULTS: The pathological diagnosis was studied in 120 cases; it was schistosomal in 8.3% of cases, non-schistosomal in 33.3% of cases, and mixed (Schistosomal with post viral cirrhosis) in 58.3% of cases. Seventy-five cases were subjected to splenectomy and gastroesophageal decongestion (SGED), 64 cases were subjected to distal splenorenal shunt (DSRS), and 86 cases were subjected to sclerotherapy. Mortality after DSRS was 7.8%, after SGED it was 12%, and after sclerotherapy it was 21%. Rebleeding was the major complication and occurred in 3% after DSRS, in 13% after SGED, and in 18% of cases after sclerotherapy. CONCLUSIONS: Gastric varices are not an uncommon condition as a cause of upper gastrointestinal bleeding. Our findings support the hypothesis that gastric varices may be considered a late sequel of injection sclerotherapy, though they may also be considered as one of the pathophysiologies of generalized portal hypertension. Finally, DSRS was found to be the treatment of choice in the management of fundal varices.

The potential site of disordered gallbladder contractility during the early stage of cholesterol gallstone formation.

BACKGROUND/AIMS: Feeding a high cholesterol diet to dogs causes a reduction in gallbladder smooth muscle contractility with a consequent stasis. Gallbladder stasis is an important link between the hepatic secretion of cholesterol saturated bile and the formation of cholesterol gallstones. METHODOLOGY: In this study we tried to localize the probable site of gallbladder smooth muscle dysfunction in a well established animal model of cholesterol gallstone disease. Adult male dogs were fed either a high or low cholesterol diet (control group). Strips of gallbladder smooth muscle for tension development were stimulated with two groups of agonists and dose response curves were plotted for all agonists used. RESULTS: The forces developed in response to the first group of agonists, the cell membrane-active agonists, e.g. acetylcholine, cholecystokinin, and potassium chloride were decreased in high cholesterol fed dogs with an increased cholesterol saturation of bile when compared to the control group. On the other hand, the contractile response showed non-significant differences between the test and the control group on using the second group of agonists that bypass the intact sarcolemmal membrane and stimulate directly either the contractile mechanism, e.g. barium, or the intracellular signal transduction pathways e.g. aluminum fluoride. CONCLUSION: We conclude that the smooth muscle defect responsible for disordered gallbladder contractility in high cholesterol fed dogs most probably involves the sarcolemmal membrane.

Surgical treatment of hepatic hydatid cysts.

BACKGROUND/AIMS: The purpose of this study was to evaluate open surgery as a treatment for hydatid liver cysts in our locality. METHODOLOGY: Between February 1987 and September 1996, 20 patients with hepatic hydatid cysts were surgically treated. The patients were assessed by clinical examination, serologic tests, abdominal ultrasound, and computed tomography. RESULTS: Right hypochondrial pain was the most common presenting symptom (95%). The most common pathology was a solitary right lobe cyst (40%), and involvement of both the right and left liver lobes occurred in 35% of the patients. Associated visceral (splenic) cysts were diagnosed in 2 patients (10%). Intraoperatively, a cystobiliary fistula was found in 2 patients (10%). An endocystectomy was performed on 12 patients, a pericystectomy on 6 patients, and a segmental hepatic resection on 2 patients. No operative mortality was reported. The mean hospital stay was 10 +/- 5 days. Biliary leakage occurred in 2 patients (10%), a liver abscess occurred in one patient (5%), and right subphrenic collection occurred in 1 patient (5%). Recurrence was detected in 2 patients (10%). CONCLUSIONS: Surgery is still the treatment of choice for hydatid liver cysts. However, advances in pre- and intraoperative imaging techniques, together with pre- and postoperative chemotherapy (benzimidazole compounds) may offer a prospect of reducing or preventing recurrence.

Postcholecystectomy bile duct injuries: experience with 49 cases managed by different therapeutic modalities.

BACKGROUND/AIMS: In this study we present our experience in the management of iatrogenic biliary injuries. Forty-nine cases with iatrogenic biliary injuries were managed in our center during the period from 1984 to 1995. MATERIAL AND METHODS: Forty patients were referred from other hospitals after cholecystectomy, and 9 cases underwent the original operation in our center. Four (0.3%) of our patients after 1300 conventional cholecystectomy, and 5 (0.9%) cases after 550 laparoscopic cholecystectomy. RESULTS: The injuries were recognized intraoperatively in 5 (10%) cases and were immediately repaired, 3 cases by axial anastomosis and T-tube drainage, 2 cases by hepatico-jejunostomy (Roux-en-Y). The injuries were detected in the remaining 44 patients postoperatively from one week up to 2 months, the mode of presentation was jaundice in 39 (89%) cases, biliary fistula with or without jaundice and biliary peritonitis were detected in 13 (30%) and in 4 (9%) cases respectively. Eleven (25%) cases were treated endoscopically by sphincterotomy, stent in 8 cases, dilatation and double stent in two cases, and dilatation using rigid dilators and stent in one case. The remaining 33 (75%) cases were treated surgically by hepatico-jejunostomy in 21 (64%) cases, and hepatico-duodenostomy in 12 (36%) cases. No hospital mortality occurred, but late mortality occurred in two (5%) patients after surgery due to biliary restricture with progressive cirrhosis in one case, and due to advanced colon cancer in the other case, an din one (9%) case after endoscopic treatment. We achieved 87% excellent surgical results during the period of follow-up (36 months), while 80% excellent results were achieved after endoscopic treatment. Good final results (95%, 83%) were achieved after hepatico-jejunostomy and after hepatico-duodenostomy respectively. CONCLUSION: Postcholecystectomy biliary injuries present a surgical problem needing extra efforts and careful management. Hepatico-jejunostomy appears to be the procedure of choice in repairing these injuries. Immediate surgical repair of bile duct injury offers excellent results with lower morbidity rates. Endoscopic treatment may be a less invasive technique and have a role in some types of injuries, but needs more time for accurate evaluation.

Correlation between endoscopy, histopathology, and DNA flow cytometry in patients with gastric dyspepsia.

BACKGROUND/AIMS: Gastric cancer has a poor prognosis, this is partly due to the advanced stage in which the tumor is diagnosed. The objective of this study is to elucidate the clinical significance of DNA flow cytometry and study its impact on monitoring the progression of gastric precancerous lesions in patients with gastric dyspepsia, and to correlate between endoscopic and histopathological findings with results of DNA flow cytometry. MATERIAL AND METHODS: A total of 92 cases underwent upper gastrointestinal endoscopy, 69 males with mean age 44.0 years and 23 females with mean age 38.7 years. Based on the endoscopic appearance, patients under study were classified into: 15 cases with endoscopic normal mucosa (EN), 26 cases with endoscopic gastritis (EG), 43 cases with duodenal ulcer (DU), and 8 cases with gastric ulcer (GU). Two antral biopsies were taken for histopathology and DNA flow cytometry. RESULTS: Chronic gastritis (CG) was present in 12 (80%) of EN cases. In DU patients, CG was present in 42 (97.7%) of cases, and it was associated with intestinal metaplasia (IM) in 11 (25.6%), and with dysplasia in 9 (20.9%) of these cases. While in GU patients, CG was present in all cases. Two (13.3%) of endoscopic normal cases revealed DNA aneuploidy in specimens with CG. The incidence of aneuploidy increases as the endoscopic findings changes from EG (15.4%), DU (16.3%) to GU (37.5%), and as the histopathological changes progresses from chronic atrophic gastritis (CAG) (18.2%), IM (21.7%) to dysplasia (33.3%). CONCLUSION: DNA aneuploidy is a useful marker for recognizing the presence of abnormal cells in epithelial lesions of the stomach, and for monitoring the progression of gastric lesions. Patients with gastric dyspepsia should not only be subjected to endoscopy but also to biopsy and DNA flow cytometry to allow the early detection of malignant transformations in gastric precancerous lesions.