Laparoscopic treatment of gastroesophageal reflux disease.

Laparoscopic fundoplication is technically feasible in treating gastroesophageal reflux disease (GERD). Although medication is the primary treatment for GERD, not all patients respond completely or are able to adhere to a medical regimen. In the present series, 59 patients were laparoscopically treated for GERD at three centers using a standardized technique. All patients had been medically treated prior to referral, although 84 per cent had heartburn and 2 per cent had laryngitis despite 20 to 40 mg/day of omeprazole. Fifteen per cent of patients were intolerant of or would no longer take omeprazole. Patients were evaluated by esophageal manometry (in 100%) and 24-hour pH studies (in 66%). Seventy-six per cent of patients had lower-esophageal sphincter pressure <15 mm Hg. Five patients had low esophageal body peristaltic pressures (<35 mm Hg). These patients underwent Toupet partial fundoplication, whereas 54 patients underwent Nissen fundoplication. Mean operative time was 158 +/- 7 minutes, and three patients (5%) were converted to an open procedure. Operative complications were minor and occurred in 13 per cent. In 45 patients evaluated 1 year after surgery, heartburn had resolved in 98 per cent. Thirty-nine of 56 patients (70%) had mild early (<1 month postoperatively) dysphagia, and 9 (19%) had severe early dysphagia, which improved in 7 after nonoperative dilatation. Two of these had continued mild dysphagia. Two patients had severe dysphagia and were laparoscopically converted from Nissen to Toupet fundoplications, which resulted in marked improvement. Early gas bloat symptoms occurred in 45 per cent and dropped to 5 per cent at 1 year. Laparoscopic treatment of GERD is safe and effective in preventing reflux symptoms. Although mild dysphagia occurs after the procedure, this is transient in most patients. Patients with severe dysphagia can be treated with nonoperative dilatation or laparoscopic partial fundoplication and maintain the antireflux characteristics of the wrap.

Laparoscopic reoperation on failed antireflux procedures: report of two patients.

Two cases are presented that demonstrate the feasibility of using the laparoscopic transabdominal approach for failed antireflux procedures. The first patient had two previous Belsey hemifundoplications that had both failed and had intractable reflux unresponsive to conservative treatment. The Belsey operation was taken down and a floppy Nissen fundoplication performed; the patient had only transient postoperative dysphagia. The second patient had a standard floppy Nissen fundoplication performed over a large bougie and developed a postoperative motility problem that failed to respond to medication and dilation. The Nissen was taken down laparoscopically and converted to a Toupet procedure; the patient had total relief of the dysphagia. Neither patient had intra-abdominal complications, and both have had total relief of their heartburn and regurgitation.

Pathogenesis of fecal incontinence in diabetes mellitus: evidence for internal-anal-sphincter dysfunction.

We studied 16 patients with diabetes and fecal incontinence. The onset of incontinence coincided with the onset of chronic diarrhea in most patients. Episodes of incontinence occurred when stools were frequent and loose; however, 24-hour stool weights were usually within normal limits. All patients had evidence of autonomic neuropathy, and one third had steatorrhea. Incontinent diabetics had a lower mean basal anal-sphincter pressure than 35 normal subjects (63 +/- 4 vs. 37 +/- 4 mm Hg; P less than 0.001), reflecting abnormal internal-anal-sphincter function. The increment in sphincter pressure with voluntary contraction (external-sphincter function) was not significantly different from normal. Incontinent diabetics also had impaired continence for a solid sphere and for rectally infused saline. In contrast, 14 diabetics without diarrhea or incontinence had normal sphincter pressures and normal results on tests of continence, even though 79 per cent had evidence of autonomic neuropathy and nearly half had steatorrhea. We conclude that incontinence in diabetic patients is related to abnormal internal-anal-sphincter function, and that as a group, diabetics without diarrhea do not have latent defects in continence.

A report of five patients with large-volume secretory diarrhea but no evidence of endocrine tumor or laxative abuse.

The purpose of this paper is to report five patients with chronic secretory diarrhea (maximum stool volume greater than 1 liter per day, duration 6 weeks to 8 years) in whom we could find no evidence of an endocrine tumor or of surreptitious laxative ingestion. All except one had severe hypokalemia. There was apparent improvement after treatment with prednisone in two patients and loperamide in one. The diarrhea resolved spontaneously in three patients and has undergone several temporary remissions in one patient. The last patient died after a severe unremitting illness. Extensive investigations failed to establish the etiology, but intestinal perfusion (carried out in four of the five patients) revealed secretion or abnormally low absorption of water and electrolytes in the jejunum and abnormally low absorption in the colon. The management of patients with chronic watery diarrhea is discussed.

Acute meningoencephalitis after withdrawal of antibiotics in Whipple's disease.

A man with Whipple's disease was treated with oral penicillin (500 mg twice a day) for 2 years with eradication of bacillary organisms from the jejunum and a return of jejunal histologic findings to normal. While he was on this regimen, however, intermittent vertigo and tinnitus and decreased auditory acuity developed. Two days after penicillin was withdrawn, the patient developed acute meningoencephalitis that responded to parenteral penicillin and chloramphenicol therapy. Subsequently, central nervous system signs and symptoms and cerebrospinal fluid pleocytosis have been controlled with chronic chloramphenicol therapy. Penicillin may suppress, but not prevent, central nervous system disease in patients with otherwise successfully treated Whipple's disease.