Postoperative Dysphagia in laparoscopic paraesophageal hernia repair: the effect of distal esophageal angulation.

BACKGROUND: Dysphagia following laparoscopic paraesophageal hernia repair is an uncommon but difficult problem that may be due to technical factors. We looked for an association between esophageal angulation after posterior crural repair and postoperative dysphagia. MATERIALS AND METHODS: Patients undergoing paraesophageal hiatus hernia repair were identified from a prospectively maintained dedicated database. All patients underwent a standardized laparoscopic repair. Essentially the hernia sac was dissected from the mediastinum, a posterior hiatal repair was carried out with interrupted polyester sutures, and augmented with mesh on lay. A partial posterior fundoplication was then carried out. We used the number of posterior sutures as a proxy for anterior esophageal angulation. Quality-of-life data and dysphagia scores were recorded preoperatively, at 6 weeks postoperatively and 12 months postoperatively using validated instruments. RESULTS: Between November 2004 and September 2010, 114 consecutive patients underwent paraesophageal hiatus hernia repair. There was 1 postoperative death in the series. Median age was 67 years (interquartile range, 59 to 77 y) and 90 (79%) were female. Median hospital stay was 3 days (interquartile range, 2 to 5 y). Follow-up data were available in 87 (76%) of patients at 6 weeks and 94 (82%) of patients at 12 months postoperation. Overall, there was a significant improvement in quality of life that was sustained out to 12 months (P<0.001). Dakkak dysphagia scores were significantly improved postoperatively. Improvement was sustained out to 12 months (P<0.001). Three patients underwent endoscopic esophageal dilation for dysphagia following surgery. There was no significant correlation between the number of posterior sutures used and dysphagia outcome. Specifically there was no association with overall Dakkak scores or change in Dakkak score. CONCLUSIONS: Anterior angulation due to posterior hiatal repair does not result in worsening dysphagia, even in patients with large hiatal defects. A posterior repair should therefore remain the standard approach for hiatal closure.

Use of autopsy in general surgery: a comparison of practice and opinion.

OBJECTIVE: To examine current practice regarding autopsy requests and assess consultant opinion regarding the role of autopsy in a general surgical department. METHODS: One hundred deaths that occurred in a teaching hospital general surgical department, over a 2-year period, were randomly selected. After review of the hospital notes, a brief summary of each admission was distributed to all 13 consultant general surgeons in the department. Surgeons were asked to comment whether each case should have been discussed with the coroner, whether a coroner's autopsy should have been carried out, whether a hospital post-mortem examination should have been carried out and whether it would be appropriate to complete a death certificate without a post-mortem examination. Surgeon responses were compared with actual outcomes, and both were analysed for predictors of variation in practice. RESULTS: The majority of patients were elderly (median age 79 years, 49% >80 years), were admitted acutely (92%) and did not undergo an operation (73%). Thirty-three patients died of cardiac or respiratory causes. Patients who had undergone a recent operation were more likely to be referred to the coroner (P < 0.001) and more likely to undergo coroner's autopsy (P = 0.011). Older patients and those admitted from a rest home were less likely to be referred to the coroner (P < 0.001 and 0.02, respectively) or undergo coroner's autopsy (P = 0.002 and 0.011, respectively). The survey predicted more referrals to the coroner (44 vs 30, P = 0.001) and more hospital autopsies (21 vs 2, P < 0.001) and that the treating doctor would complete the certificate of death less often than actually happened (79 vs 91, P = 0.004). The survey suggested that surgeons were more likely to complete the certificate of death in patients with active malignancy (P = 0.01), but this was not observed in practice. CONCLUSIONS: General surgeons consider autopsy to be necessary more often than that is taking place in practice in our institution. The continued decline in autopsy rates may compromise the safety and quality of the service provided by general surgeons and result in a gap in the education of surgeons and trainees.