Response of atypical symptoms of GERD to antireflux surgery.

BACKGROUND/AIMS: The results of laparoscopic Nissen's fundoplication (LNF) were compared in patients having typical and atypical symptoms of Gastroesophageal reflux disease (GERD). Atypical symptoms include asthma, chronic cough, non-cardiac chest pain, and ear, nose, and throat symptoms. The effectiveness of antireflux surgery in relief of these symptoms is uncertain. METHODOLOGY: 100 patients with GERD underwent laparoscopic Nissen's fundoplication in El-Mansoura Gastro-enterology center between January, 2002 and March, 2004. Patients were classified according to preoperative symptoms into 3 groups; group 1 (71 cases with severe typical and minimal atypical symptoms), group 2 (18 cases with severe typical and severe atypical symptoms) and group 3 (11 cases with minimal typical and severe atypical symptoms). Patients were reassessed within a mean period of 24 +/- 12 months after surgery. RESULTS: Duration of illness was nearly similar in the three groups (3.2 +/- 2.7:3.3 +/- 2.9:3.7 +/- 3.2 years). In group 1, typical symptoms improved in 66 (92.9%) cases and resolved in 63 (88.7%). In group 2, typical symptoms improved in 17 (94.4%) and resolved in 16 (88.9%), whereas atypical symptoms improved in 15 (83.3%) and resolved in 10 (55.6%). In group 3, atypical symptoms improved in 9 (81.8%) and resolved in 5 (45.5%). Endoscopic, radiologic, esophageal motility and pH metry studies were nearly similar in the 3 groups. CONCLUSIONS: Antireflux surgery improves atypical symptoms of GERD, but symptom resolution occurs in less than half of cases.

Secondary antireflux surgery.

BACKGROUND & AIM: With the introduction of laparoscopy, the number of antireflux surgeries (ARS), and consequently failed fundoplications, had increased. We report the mechanisms of fundoplication failure after ARS, and present our experience in surgical correction of failure. METHODS: Twenty nine patients who had failed fundoplication were reoperated. Pre- and postoperative evaluation of patients included symptom severity score, endoscopy, barium study, esophageal motility and pH metry. RESULTS: The initial procedures were Nissen in 16, Toupet in 10, and Nissen-Rossetti in 3 patients. The causes of failure were transdiaphragmatic migration of fundoplication (n=7), disrupted fundoplication (n=7), tight fundoplication (n=4), slipped fundoplication (n=3), paraesophageal herniation (n=3), tight crural repair (n=3), and migration with disruption (n=2). The secondary ARS performed were Nissen (n=16), Toupet (n=9), paraesophageal hernia repair with crural repair (n=2), widening of crural repair (n=1), and taking down fundoplication (n=1). Per- (n=4) and postoperative (n=5) complications were minor with no mortality. At Follow-up, symptoms were significantly improved. CONCLUSION: Reoperations for failed ARS may be performed safely with excellent results. Proper patient selection and paying attention to some technical details at initial ARS could safe the patient another surgery.

Hepatic resection in cirrhotic liver for treatment of hepatocellular carcinoma in Egyptian patients. Experience with 140 cases in a single center.

BACKGROUND/AIMS: In many centers hepatic resection is still the treatment of choice for hepatocellular carcinoma in cirrhotic liver. Several factors affect the prognosis; one of them is the extent of resection. This study retrospectively evaluates outcome after different types of hepatic resection in cirrhotic liver. METHODOLOGY: Hepatectomy was performed in 245 patients. From them, 140 patients were subjected to hepatic resection for hepatocellular carcinoma in cirrhotic liver. According to the type of resection the patients were divided into three groups (A, B and C), major resection (group A) in 79 (56.3%), segmental resection (group B) 31 (22.1%) and localized resection (group C) in 30 (21.4%). Early postoperative mortality and morbidity as well as long-term survival and recurrence were assessed. RESULTS: The overall hospital mortality rate was (8.6%) with total complications 26%, recurrence rate 32.8% and median survival was 24 months (3-120). Group A showed high incidence rate of hospital mortality, total complications and hepatic cell failure than the other two types (p>0.05). On the other hand, group C patients showed high incidence of wound infection and recurrence rate after hepatic resection than the other two types (p>0.05). At the end of the study, the median survival was 18 months (4-120), 24 months (3-48) and 24 months (3-120) for the three groups respectively without significant difference. The overall 5-year survival rate was 20%, 0% and 15.3% for the three groups respectively (p>0.05). CONCLUSIONS: Although major liver resection in cirrhotic liver has high incidence of early mortality and morbidity, it gives low incidence of recurrence and better survival in comparison with segmental and localized resection. However it has to be reserved for large tumor in good liver and early cirrhosis.

Is resection for large hepatocellular carcinoma in cirrhotic patients beneficial? Study of 38 cases.

BACKGROUND/AIMS: Hepatocellular carcinoma in cirrhotic patients generally carries a poor prognosis either due to recurrence or to postoperative morbidity or both. Several factors affect the prognosis of hepatocellular carcinoma resection as presence of cirrhosis of the liver, tumor diameter and tumor capsulation. METHODOLOGY: Thirty-eight patients with large hepatocellular carcinoma greater than 5 cm with a background of cirrhotic liver were divided into two groups according to tumor diameter. Group A (n = 20) with tumors less than 10 cm in diameter, and group B (n = 18) with tumors larger than 10 cm. All patients underwent preoperative investigations including clinical laboratory tests, sonography, computed tomography, selective angiography and upper gastrointestinal endoscopy. All patients were subjected to different types of hepatic resection. RESULTS: A significant difference in tumor size, capsulation, and operation time were recorded between the two groups, of patients. No significant difference was detected between both groups regarding sex, age, viral markers, pathologic features, and Child classification. Hospital mortality occurred in 5% versus 11.1% of both groups, respectively. Postoperative jaundice and ascitis occurred in 30%, 35% versus 44.4%, 72.0%, respectively (P < 0.005, P < 0.04). Late mortality occurred in 65% of patients in group A and in 77% of group B. Recurrence was detected in 42% of group A and 62% in group B. Recurrence after resection in capsulated tumors was significantly lower than in noncapsulated tumors in group A (P < 0.01), but not significant in group B. Also, survival rate in patients with capsulated tumors was significantly better in both groups (P < 0.01) than that with noncapsulated tumors. CONCLUSIONS: Resection of hepatocellular carcinoma with diameter larger than 10 cm recorded bad prognosis regarding recurrence and mortality rates than tumors less than 10 cm. However, capsulated tumors gave better postoperative prognosis than noncapsulated ones.

Does cholecystectomy affect antral mucosa? Endoscopic, histopathologic and DNA flow cytometric study.

BACKGROUND/AIMS: Although cholecystectomy is still the "gold standard" for treatment of gallstones, this operation may be followed by gastric disorders. The aim of this study is to detect the effects of cholecystectomy on gastric antral mucosa. METHODOLOGY: This prospective study has been carried out on 46 patients (20 M & 26 F) with mean age 41.7 +/- 0.2 years for whom simple cholecystectomy for gallstones was decided. Prior to the operation and 1 year after, patients were subjected to the following: clinical assessment, upper gastrointestinal endoscopy, histopathology of antral mucosa, detection of H. pylori and DNA flow cytometry. RESULTS: There was an increase in the number of patients presenting suggestive symptoms of reflux gastritis: patients experiencing epigastric pain increased from 8 (17.4%) to 11 (23.39%) patients, nausea increased from 6 (13%) to 12 (26.1%) patients and bilious vomiting increased from 3 (6.5%) to 11 (23.9%) patients. Mild antral gastritis increased from 20 (43.5%) to 27 (58.7%) patients. Antral gastritis and antral erosions were detected only after the operation in 8 (17.4%) and 2 (4.3%) patients, respectively. The incidence of active chronic superficial gastritis decreased from 23 (50%) to 13 (28.2%) patients while the inactive form increased from 15 (32.6%) to 23 (50%) patients. Chronic atrophic gastritis, intestinal metaplasia and dysplasia were only detected postoperatively in 2 (4.3%) patients each. There was a decrease in the incidence of H. pylori infection from 32 (69.6) to 19 (41.3%) patients. DNA aneuploid pattern increased from 1 (2.2%) to 4 (8.7%) patients and there was a significant increase of DNA index from 1.01 (+/- 0.03) to 1.03 (+/- 0.05) (P < 0.005). CONCLUSIONS: Changes in clinical, endoscopic and histopathologic findings suggest that cholecystectomy may affect gastric antral mucosa due to duodenogastric reflux. Flow cytometry may be used as an objective method for detection and evaluation of postcholecystectomy reflux gastritis.