Management of pancreatic pseudocysts.

BACKGROUND: Operative internal drainage has been standard treatment for chronic unresolved pancreatic pseudocysts (PPs). Recently, percutaneous external drainage (PED) has become the primary mode of treatment at many medical centers. STUDY DESIGN: A retrospective chart review was performed of 96 patients with PPs who were managed between 1987 and 1996. Longterm followup information was obtained by telephone and mail questionnaire. RESULTS: Twenty-seven patients underwent computed tomographic (CT)-guided PED. PP resolution occurred in 17 patients. Clinical deterioration or secondary infection mandated urgent pancreatic debridement in 7 (26%) patients and cystgastrostomy in 2 (7%) patients. There was one hospital death in this group. Thirty-two patients underwent cystgastrostomy or cystjejunostomy (n = 21), distal pancreatectomy (n = 8), pancreatic debridement and external drainage (n = 2), or cystectomy (n = 1). Two (6%) patients required postoperative pancreatic debridement for failure of resolution and peritonitis and two patients underwent PED of abscess. There was one hospital death in the expectantly managed group of 37 patients. Median followup of 3 years (range, 0.5-9.3 years) in 66 patients revealed that 6, 3, and 4 patients of PED, surgery, and expectantly managed groups, respectively, had radiologic evidence of recurrent PPs. CONCLUSIONS: Operative management for PPs appears to be superior to CT-guided PED. Although the later was often successful, it required major salvage procedures in one third of the patients. An expectant management protocol may be suitable for selected patients.

Laparoscopic antireflux surgery in the elderly.

OBJECTIVE: Laparoscopic antireflux surgery is indicated in young patients with medication-dependent gastroesophageal reflux disease (GERD), both because of their need for lifelong medical treatment and the need to prevent the complications of GERD. Many elderly patients with GERD have similar concerns. We compared the safety and efficacy of laparoscopic antireflux surgery in the elderly with the results achieved in patients <65 yr. METHODS: A total of 359 patients have had laparoscopic antireflux surgery in our hospital, 42 of whom were > or = 65 yr of age. Symptoms were scored from 0 (none) to 4 (severe) before and after surgery. Ambulatory pH monitoring was also performed before and after surgery. Results were compared between age groups with the Mann-Whitney U test. RESULTS: Elderly patients had significantly higher preoperative American Society of Anesthesiologists (ASA) scores (mean 2.4 vs 2.0) (p = 0.0024), but otherwise there were no significant differences in preoperative symptom scores or pH results. Both groups demonstrated equivalent postoperative improvement in symptoms and 24-h pH study. There was no mortality in either group, and there was no significant difference in morbidity or hospital stay between the two groups. CONCLUSION: Laparoscopic antireflux surgery is a safe and effective treatment of GERD in the elderly and should not be refused solely on the basis of age.

Complications of laparoscopic paraesophageal hernia repair.

The complications of laparoscopic paraesophageal hernia repair at two institutions were reviewed to determine the rate and type of complications. A total of 76 patients underwent laparoscopic paraesophageal hernia repair between December 1992 and April 1996. Seventy-one of them had fundoplication (6 required a Collis-Nissen procedure). Five patients underwent hernia reduction and gastropexy only. There was one conversion to laparotomy. Traumatic visceral injury occurred in eight patients (11%) (gastric lacerations in 3, esophageal lacerations in 2, and bougie dilator perforations in 3). All lacerations were repaired intraoperatively except for one that was not recognized until postoperative day 2. Vagus nerve injuries occurred in at least three patients. Three delayed perforations occurred in the postoperative period (4%) (2 gastric and 1 esophageal). Two patients had pulmonary complications, two had gastroparesis, and one had fever of unknown origin. Seven patients required reoperation for gastroparesis (n = 2), dysphagia after mesh hiatal closure of the hiatus (n = 1), or recurrent herniation (n = 4). There were two deaths (3%): one from septic complications and one from myocardial infarction. Paraesophageal hernia repair took significantly longer (3.7 hours) than standard fundoplication (2.5 hours) in a concurrent series (P <0.05). Laparoscopic paraesophageal hernia repair is feasible but challenging. The overall complication rate, although significant, is lower than that for nonsurgically managed paraesophageal hernia.

Evaluation and management of postfundoplication dysphagia.

OBJECTIVES: Persistent dysphagia occurs in 3-24% of patients after fundoplication. There are virtually no data on the success or safety of endoscopic dilation to relieve postfundoplication dysphagia. The aim of this study was to review our experience with endoscopic management of patients with dysphagia after fundoplication. MATERIALS AND METHODS: Thirty-five patients (mean age 49 yr; 12 males, 23 females) with dysphagia after fundoplication were referred for endoscopic dilation. Twenty-nine patients had undergone one fundoplication (group A), and six patients had undergone two or more operations (group B). The integrity of the fundoplication was evaluated by barium esophagram and upper endoscopy. Median follow-up after the initial postoperative dilation was 13 months. RESULTS: The 29 patients in group A were dilated to a mean (+/- SD) of 52 +/- 4F during a mean (+/- SD) 1.9 +/- 1.1 dilation sessions per patient. No complications, such as disruption of the fundoplication, resulted from endoscopic dilation, and no one developed new reflux symptoms. Dysphagia resolved in 15 (52%) patients after dilation. The most important prognostic feature was endoscopic or radiological evidence of a slipped fundoplication. Dilation was successful in relieving dysphagia in only three of 11 (27%) patients with a slipped fundoplication, compared with 12 of 18 (67%) patients with an intact fundoplication (p = 0.05). Dysphagia resolved in only one of the six patients in group B. CONCLUSIONS: Endoscopic dilation is safe and often effective in patients with postfundoplication dysphagia. However, patients with a slipped fundoplication or who have undergone multiple fundoplications respond poorly to endoscopic dilation.

Clinical features of type III (mixed) paraesophageal hernia.

OBJECTIVES: The clinical presentation of patients with a paraesophageal hernia is poorly understood. The aim of this study was to evaluate the progression of symptoms in patients with type III paraesophageal hernia. METHODS: We evaluated 25 patients (mean age 66 yr) with a type III paraesophageal hernia, who then had laparoscopic surgical repair. The patients characterized their symptoms as 1) chronic or 2) prompting evaluation (progressive or new). We defined postprandial distress as chest or epigastric pain, shortness of breath, or nausea or vomiting during or shortly after meals. RESULTS: We identified three distinct types of chronic symptoms: heartburn only (36%), heartburn and postprandial distress (32%), and postprandial distress only (32%). Twenty-three patients (92%) reported postprandial distress as the symptom prompting evaluation compared with only 10 patients (40%) reporting heartburn. Eight patients (32%) never had heartburn. Postprandial distress was their only symptom. Laparoscopic repair of the paraesophageal hernia resolved postprandial distress in 74% and improved symptoms in the remaining 26% of patients (mean follow-up 12 months). CONCLUSIONS: Post-prandial distress is the most prominent symptom in patients with a type III paraesophageal hernia. Most patients had chronic symptoms of a sliding hiatal hernia but later featured more pronounced postprandial distress. However, one-third of the patients never experienced significant heartburn. A type III paraesophageal hernia should be suspected in patients, with or without heartburn, who develop new or progressive symptoms of postprandial distress.

Intermediate follow-up of laparoscopic antireflux surgery.

BACKGROUND: Open antireflux surgery is an established long-term treatment for chronic gastroesophageal reflux disease. Short-term results of laparoscopic antireflux surgery are excellent, but long-term follow-up is not yet available. METHODS: Twenty-four-hour ambulatory esophageal pH monitoring and symptom scores were collected prior to laparoscopic antireflux surgery and 6 weeks postoperatively. These studies were repeated in an unselected cohort of patients 1 to 3 years after operation. RESULTS: One hundred patients who were > 1 year from surgery at the time of the present study volunteered for intermediate follow-up symptom assessment, and 35 also completed repeat 24-hour monitoring. The median interval after surgery among these volunteers was 17 months. Thirty-three (94%) had a normal pH study, which correlated with improvements in symptom scores. One patient had an abnormal pH study but no reflux symptoms, and 1 patient with an abnormal study developed recurrent symptoms of reflux after an episode of vomiting 11 months postoperatively. CONCLUSIONS: The intermediate-term results of laparoscopic fundoplication suggest that long-term efficacy of this operation will be equivalent to open fundoplication.