Surgery for gastroesophageal reflux disease: a comparative study between the open and laparoscopic approaches.

OBJECTIVE: Given the demonstrated effectiveness of medical treatment together with the eminent acceptance of the laparoscopic approach, the indications of surgery in the treatment of gastroesophageal reflux disease (GERD) are currently subject to continuous controversy. To participate in this debate, we have the following work hypothesis: "The results of the 360 masculine short and floppy laparoscopic fundoplication are superior to those of open surgery". CLINICAL DESIGN: Prospective, clinical, non-randomized study. PATIENTS: Our work was developed between November 1991 and December 1998 by means of a prospective, non-randomized clinical rehearsal with two groups of patients: Group I (n = 75): 360 degree short and floppy laparoscopic fundoplication in Hospital Dr. Peset, Valencia (Spain). Group II (n = 28): 360 degree short and floppy, open fundoplication in Hospital General, Valencia (Spain). We evaluated the preoperative parameters and found no differences, which allows us to know that both groups were comparable. RESULTS: The analysis of peroperative results (morbidity and surgical time) and of clinical follow-up (every three months and later annually) and instrumental follow-up (TEGD, upper digestive endoscopy, pHmetry and manometry) show no differences, while the postoperative analysis shows statistically significant (s.s.) differences regarding recovery (pain, oral intake, hospital stay and return to previous activities). CONCLUSIONS: The results of the 360 degree short and floppy laparoscopic fundoplication are similar to those of the open approach, but favor the former approach with a better postoperative tolerance.

Cirugía de la enfermedad por reflujo gastroesofágico: estudio comparativo entre los abordajes abierto y laparoscópico / Surgery for gastroesophageal reflux disease: a comparative study between the open and laparoscopic approaches

Objetivo: en la actualidad, dada la efectividad demostrada del tratamiento médico junto con la eminente aceptación del abordaje laparoscópico, las indicaciones de la cirugía en el tratamiento de la enfermedad por reflujo gastroesofágico son causa de continua controversia. Para participar en este debate, nos planteamos la siguiente hipótesis de trabajo: "Los resultados de la funduplicatura de 360° corta y holgada por vía laparoscópica son superiores a los de la vía abierta". Diseño clínico: estudio clínico prospectivo no aleatorizado. Pacientes: el trabajo se desarrolló entre noviembre de 1991 y diciembre de 1998, mediante un ensayo clínico prospectivo no aleatorio de dos grupos de pacientes: -Grupo I (n = 75): funduplicatura de 360°, corta y holgada por laparoscopia en el Hospital Universitario Dr. Peset de Valencia. -Grupo II (n = 28): funduplicatura 360°, corta y holgada por vía abierta en el Hospital General Universitario de Valencia. Comparamos, sin hallar diferencias, los parámetros preoperatorios lo que nos permite conocer que los dos grupos son homologables. Resultados: el análisis de los resultados peroperatorios (morbilidad y tiempo quirúrgico) y del seguimiento clínico (a los tres meses y posteriormente de forma anual) e instrumental (TEGD, endoscopia digestiva alta, pHmetría y manometría) no demuestran diferencias; mientras que en el postoperatorio inmediato existen diferencias estadísticamente significativas (e.s.) en lo referente a la recuperación (dolor, tolerancia, estancia y reincorporación a las actividades previas). Conclusiones: los resultados de la funduplicatura de 360° corta y holgada por vía laparoscópica son similares a los de la vía abierta, beneficiándose la primera de una mejor tolerancia postoperatoria

Objective: given the demonstrated effectiveness of medical treatment together with the eminent acceptance of the laparoscopic approach, the indications of surgery in the treatment of gastroesophageal reflux disease (GERD) are currently subject to continuous controversy. To participate in this debate, we have the following work hypothesis: "The results of the 360º short and floppy laparoscopic fundoplication are superior to those of open surgery". Clinical design: prospective, clinical, non-randomized study. Patients: our work was developed between November 1991 and December 1998 by means of a prospective, non-randomized clinical rehearsal with two groups of patients: -Group I (n = 75): 360° short and floppy laparoscopic fundoplication in Hospital Dr. Peset, Valencia (Spain). -Group II (n = 28): 360° short and floppy, open fundoplication in Hospital General, Valencia (Spain). We evaluated the preoperative parameters and found no differences, which allows us to know that both groups were comparable. Results: the analysis of peroperative results (morbidity and surgical time) and of clinical follow-up (every three months and later annually) and instrumental follow-up (TEGD, upper digestive endoscopy, pHmetry and manometry) show no differences, while the postoperative analysis shows statistically significant (s.s.) differences regarding recovery (pain, oral intake, hospital stay and return to previous activities). Conclusions: the results of the 360° short and floppy laparoscopic fundoplication are similar to those of the open approach, but favor the former approach with a better postoperative tolerance

Isolated human colon strips as a pharmacological tool.

The spontaneous activity of isolated human colon strips was studied to obtain homogeneous results with a reproducible model. The strips of macroscopically normal appearance were mounted in an organ bath containing Krebs solution at 32 degrees C or Tyrode solution at 37 degrees C. Mechanical activity was recorded by an isometric transducer. Spontaneous motility did not occur in all preparations. Moreover, when observed, it could not always be evaluated. The percentage of strips with spontaneous activity was lower with Tyrode solution than with Krebs solution (65 vs. 81%). KC1 did not induce a plateau contraction. Acetylcholine induced concentration-dependent contractions, with a significantly different pD2: 4.43 +/- 0.39 and 5.59 +/- 0.16 for Krebs and Tyrode, respectively. Isoprenaline abolished spontaneous motility in Krebs solution. Only 20% of specimens presented evaluable motility. Krebs solution may be the best conditions for studying the effects of drugs on spontaneous motility, while Tyrode solution can be used to investigate the effects of contractile agents.

Laparoscopic treatment of esophageal achalasia.

An observational cohort study evaluated the initial results of using laparoscopic-approach cardioesophageal myotomy with Dor-type anterior fundoplicature for esophageal achalasia. The study involved our first 12 patients: five men and seven women whose median age was 51 years. Esophageal motility was vigorous in four patients; the other eight had aperistalsis. Conversion to laparotomy was required in one case. No postoperative mortality occurred. Postoperative complications included one left subdiaphragmatic abscess secondary to perforation of the esophageal mucosa, which was sutured. Median postoperative hospital stay was 5 days (confidence interval, 4.7-6.7 days). Symptom relief (disappearance of dysphagia) was recorded in 10 cases; relief with partial persistence of dysphagia was observed in the remaining two patients, who were treated by postoperative dilatation. As to the postoperative manometric results, the median basal pressure of the lower esophageal sphincter was reduced from 26.3 mm Hg preoperatively to 15.5 mm Hg postoperatively, with a tendency toward statistical significance (p = 0.08); the median esophageal isotopic retention after 15 min decreased from 60% preoperatively to 24.5% after surgery, with a tendency toward statistical significance (p = 0.07). Cardiomyotomy with Dor fundoplicature through a laparoscopic approach seems effective in treating esophageal achalasia.

Injury in laparoscopic surgery.

A prospective study was made to evaluate injury caused by laparoscopic surgery, in terms of physiological response. Two groups of patients were established: Group 1 (laparoscopic surgery, n = 26) and Group 2 (open surgery, n = 18). The groups were homogeneous in terms of age, sex, body mass index (BMI), duration of surgery, and anesthetic technique. Both groups exhibited significant postoperative increases in plasma adrenocorticotropic hormone (ACTH), growth hormone (GH), insulin, and cortisol (p < 0.05), with a significant decrease in follicle-stimulating hormone (FSH) and T3 (p < 0.05). Significant increases were noted in 24-h urine cortisol and catecholamine levels in Group 2 (p < 0.05). No correlation was noted between the duration of surgery and the intensity of neuroendocrine response. Acute-phase postoperative metabolic response was greater in Group 2 and was correlated to the duration of surgery. No postoperative hydrosaline or acid-base alterations were recorded in either group. Injury was graded in terms of neuroendocrine and metabolic response and proved highest in Group 2. Complex laparoscopic surgery (e.g., sigmoid colon and esophageal hiatus) exhibited the least neuroendocrine response, whereas laparoscopic inguinal hernioplasty involved the least metabolic response. To conclude, laparoscopic surgery globally involves less neuroendocrine and metabolic response than does open surgery.

[Surgical trauma from laparoscopic cholecystectomy]. / Traumatismo quirúrgico de la colecistectomía laparoscópica.

UNLABELLED: The authors present a prospective study whose objective is to estimate the degree of injury from laparoscopic cholecystectomy, by means of the determination of the neuroendocrine response to the surgical aggression. By means of a simple randomization, two study groups are established: group A, consisting of 17 patients subjected to laparoscopic cholecystectomy, and group B, consisting of 18 patients subjected to different techniques of open surgery. EXCLUSION CRITERIA: transfusion of blood derivatives or therapy with corticosteroids. The groups are homogeneous with regard to age, sex, Quetelet index, duration of the intervention, and anaesthetic drugs. A postoperative increase of plasma ACTH, growth hormone, insulin, cortisol and T3 was found in both groups (p < 0.05), and a significant postoperative increase of cortisol and catecholamines in 24 hour urine was found especially in group B. It can be concluded that even though there is an increase of the contraregulatory hormones in the postoperative phase of both groups, the neuroendocrine response is lower after laparoscopic cholecystectomy.

120-hour 5-fluorouracil (5-FU) continuous infusion (CI) plus BCNU in advanced colorectal cancer.

Seventy-five previously untreated patients with measurable advanced colorectal cancer were treated with 5 fluorouracil 1,000 mg/m2 as a 24-hour intravenous (i.v.) continuous infusion during days 1-5 and 28-32 every cycle, plus 1,3-bis(2-chloroethyl)-1-nitrosourea (BCNU), 200 mg/m2 i.v. bolus on day 1, all given every 8 weeks up to 6 cycles. Median Karnofsky performance status (KPS) was 100. Sites of disease at entry were mainly the abdomen (45%) and liver (33%). All patients were evaluable for response and survival. There were two complete responses and seven partial responses (PR) for an overall response rate of 12% (95% confidence limits: 5-20%). Four out of 25 patients with liver metastases alone had PR. Stabilization was seen in 40 patients (53%). Median time to progression was 9.3 months and overall median survival was 12.5 months, whereas median survival for patients with liver metastases alone was 16 months. Toxicity was mild except for 8% with WHO grade 4 mucositis. Only KPS had statistical significance in the multivariate analysis of prognostic factors. It is concluded that this regimen is relatively active and well tolerated in patients with advanced colorectal cancer.

[Surgical treatment of cancer of the colon: a review of 175 cases]. / Tratamiento quirúrgico del cáncer de colon: revisión de 175 casos.

We present a review of 175 cases of carcinoma of the colon out of 270 cases of colorectal cancer operated in our service during the period 1980-1986. It is noteworthy that 46.8% of the patients underwent emergency surgery for occlusion and/or diastasic tumoral perforation, and that they presented an advanced average age (48.5% were over 70 years). In emergency surgery there was a predominance of bypass operations (73%) versus tumoral resection (27%). In programmed surgery the index of resectability was 83%. The global operative mortality was 12.5%, but separately it was greater for emergency surgery (18%) than for elective surgery (7.5%). Wound infection occurred in 35% of emergency operations and in 11.8% of programmed operations. An anastomotic fistula appeared in 6.9% of cases, with a similar incidence for mechanical and manual anastomoses. It is concluded that early detection of the disease is necessary to reduce the percentage of urgent operations, and consequently the rates of operative morbi-mortality, and improve long-term survival.