No association between obesity and post-tonsillectomy haemorrhage.

BACKGROUND: The prevalence of overweight and obesity is increasing worldwide. The impact of overweight on post-tonsillectomy haemorrhage rates in children and adults is unclear. METHODS: Body mass index and post-tonsillectomy haemorrhage were evaluated in all patients treated with tonsillectomy within one year in a tertiary referral centre. Bleeding episodes were categorised according to the Austrian Tonsil Study. RESULTS: Between June 2011 and June 2012, 300 adults and children underwent tonsillectomy. Post-tonsillectomy haemorrhage occurred in 55 patients. Of those, 29 were type A (history of blood in saliva only, no active bleeding), 15 were type B (active bleeding, treatment under local anaesthesia) and 11 were type C (active bleeding, treatment under general anaesthesia). The return to operating theatre rate was 3.7 per cent. Post-tonsillectomy haemorrhage was more frequent in adolescents and adults than in children. Overweight or obesity was positively correlated with age. Post-tonsillectomy bleeding was recorded in 11.1 per cent of underweight patients, 18.9 per cent of normal weight patients and 18.7 per cent of overweight patients (p = 0.7). Data stratification (according to age and weight) did not alter the post-tonsillectomy bleeding risk (p = 0.8). CONCLUSION: Overweight or obesity did not increase the risk of post-tonsillectomy haemorrhage in either children or adults.

99mTc-EDDA/HYNIC-Tyr(3)-octreotide for staging and follow-up of patients with neuroendocrine gastro-entero-pancreatic tumors.

AIM: To evaluate the use of 99mTc-EDDA-hydrazinonicotinyl-Tyr3-octreotide (Tc-TOC) for staging and follow-up of neuroendocrine gastro-entero-pancreatic (GEP) tumors with special focus on the acquisition protocol including single photon emission computed tomography (SPECT). METHODS: Eighty-eight patients (37 female, 51 male; age range: 16 to 81 years; mean age: 56.3 years) were studied: 42 patients for staging after initial histological confirmation and 46 patients during post-therapy follow-up. An average activity of 400 MBq of the radiopharmaceutical was injected. All tumors originated from neuroendocrine tissue of the gastroenteropancreatic tract. Whole body scintigrams at 4 h postinjection and SPECT of the abdomen were obtained in all patients. Additional planar images of the abdomen were acquired at 2 h after injection in 68 patients. RESULTS: The Tc-TOC scan result was true-positive in 56 patients, true-negative in 17, false-negative in 14, and false-positive in 1 patient. The false-positive finding was caused by a colonic adenoma. Overall, a scan sensitivity of 80% (56/70 patients), specificity of 94.4% (17/18 patients) and accuracy of 82.9% (73/88 patients) were calculated on patient basis. In total, Tc-TOC detected 357 foci in 69 patients. In 7 patients equivocal findings were observed in the bowel at 4 h postinjection without corresponding tracer uptake in the scan 2 h earlier, meaning that these abnormal findings were correctly classified as non-malignant. In addition to planar views, SPECT revealed further 62 lesions. CONCLUSIONS: Tc-TOC with one-day, dual-time acquisition protocol is an accurate staging procedure in patients with neuroendocrine GEP tumors. SPECT shows high sensitivity for detection of abdominal lesions, while earlier images improve the reliability of abnormal abdominal findings.

Videobronchoscopic guidance makes percutaneous dilational tracheostomy safer.

BACKGROUND: Percutaneous dilational tracheostomy (PDT) can be performed under either conventional bronchoscopic or videobronchoscopic guidance. Only the latter procedure provides the surgeon with direct visual information. This study prospectively assessed procedural parameters and complications of PDT guided by conventional bronchoscopy (CB) or videobronchoscopy (VB). METHODS: Consecutive intensive care unit (ICU) patients who underwent PDT were enrolled in this study. Videobronchoscopy was available in two ICUs, whereas CB was available in three ICUs. Demographic data, procedural variables, and complications were recorded. RESULTS: In this study, 36 patients underwent PDT guided by VB (group V), and 38 patients underwent PDT guided by CB (group C). The two groups were well matched in terms of gender, anatomic aspects, and positioning of the patient. Operating time, procedural difficulty, and extent of tracheal bleeding were not different between the two groups. Group V showed a tendency to younger age (p = 0.055). Surgeons significantly more often considered PTD to be "completely safe" in group V (92% vs 61% in group C). The skin incisions were smaller (p = 0.003), and the extent of stomal bleeding was less (p = 0.001). Complications were tendentiously less frequent in group V (5.5%) than in group C (23.7%; p = 0.062). CONCLUSIONS: The surgeon performing PDT guided by VB has a higher degree of safety, resulting in less bleeding than with PDT guided by CB.

Robot-assisted mediastinal parathyroidectomy.

We report the first case of robot-assisted thoracoscopic resection of a mediastinal parathyroid adenoma in the aorto-pulmonary window. Intervention planning was based on preoperative CT-MIBI image fusion, a new imaging modality that enabled reliable and precise localization of the parathyroid. The technique consists of taking MIBI-SPECT and CT separately, using a fixation unit that provides reproducible positioning of the patients head and neck. The data sets are then superimposed upon each other using special software. After the localization process, a minimally invasive operation was performed using the DaVinci operating robot. The procedure proved not only to be feasible but also safe and not time-consuming. The postoperative course was uneventful, and the patient was discharged 4 days postoperatively. Compared to conventional thoracoscopic surgery, the robotic operating system provides better visualization of the operating field and facilitates the movement of the instruments. Precise preoperative imaging enables the careful planning of robot-assisted surgery for ectopic parathyroids located at relatively inaccessible regions such as the anterior mediastinum.

Efficacy of medical therapy and antireflux surgery to prevent Barrett's metaplasia in patients with gastroesophageal reflux disease.

OBJECTIVE: To investigate whether Barrett's metaplasia may develop despite effective medical therapy. SUMMARY BACKGROUND DATA: Gastroesophageal reflux disease has a multifactorial etiology. Therefore, medical treatment may not prevent complications of reflux disease. METHODS: Eighty-three patients with reflux disease and mild esophagitis were prospectively studied for the development of Barrett's metaplasia while receiving long-term therapy with proton pump inhibitors and cisapride. Only patients who had effective control of reflux symptoms and esophagitis were included. The surveillance time was 2 years. The outcome of these 83 patients was compared with that of 42 patients in whom antireflux surgery was performed with a median follow-up of 3.5 years. RESULTS: Twelve (14.5%) patients developed Barrett's while receiving medical therapy; this was not seen after surgery. Patients developing Barrett's had a weaker lower esophageal sphincter and peristalsis before treatment than patients with uncomplicated disease. CONCLUSIONS: Antireflux surgery is superior to medical therapy in the prevention of Barrett's metaplasia. Therefore, patients with reflux disease who have a weak lower esophageal sphincter and poor esophageal peristalsis should undergo antireflux surgery, even if they have only mild esophagitis.

Surgical therapy for primary hyperparathyroidism in patients with previous thyroid surgery.

BACKGROUND: In patients with primary hyperparathyroidism (HPTH) and previous thyroid operations, complications of parathyroidectomy are more frequent than in patients undergoing initial neck surgery. The aim of this study was to investigate the value of preoperative imaging with regard to its influence on the surgical strategy. METHODS: We retrospectively analyzed 17 patients with primary HPTH and previous thyroid surgery. Preoperatively 16 patients underwent sonography and/or scintigraphy. RESULTS: Sonography had an overall accuracy to correctly localize enlarged parathyroid glands of 80%, and scintiscanning had overall accuracy of 78.6%. The accuracy of localization was increased up to 84.6% if both diagnostic procedures were applied. In patients with normal thyroid residues the accuracy of sonography was 85.7%, and it was 100% if scintiscanning was used. CONCLUSIONS: Preoperative localization techniques in patients with primary HPTH and previous thyroid surgery have high accuracy. This allows for an imaging-directed operative strategy, thus preventing unnecessary bilateral neck explorations, which carry a high risk of recurrent laryngeal nerve injury.

Gastric acid blockade with omeprazole promotes gastric carcinogenesis induced by duodenogastric reflux.

Duodenogastric reflux (DGR) in rats causes growth stimulation of the foregut mucosa that is potentiated by gastric acid blockade. It was the aim of this study to investigate if DGR with gastric acid blockade has a higher incidence of carcinomas of the foregut than DGR alone. DGR was induced in 40 Sprague-Dawley rats using a split gastroenterostomy. A cardiomyotomy was performed across the gastroesophageal junction, inducing reflux into the esophagus. Twenty of these rats received omeprazole postoperatively. After one year 18 rats (90%) with DGR + omeprazole treatment and 7 rats (35%) with DGR alone developed adenocarcinoma of the stomach (P < 0.05). None of the rats developed esophageal cancer, but esophageal mucosal hyperplasia was more pronounced in rats receiving omeprazole. Control rats, treated with omeprazole, did not develop carcinomas of the foregut. In conclusion, gastric acid blockade enhanced DGR-induced carcinogenesis of the stomach and promotes growth stimulation of the esophageal mucosa.

The effect of medical therapy and antireflux surgery on dysphagia in patients with gastroesophageal reflux disease without esophageal stricture.

BACKGROUND: Poor esophageal body motility and trapping of the hernial sac by the hiatal crura are the major pathomechanisms of gastroesophageal reflux disease (GERD)-induced dysphagia. There is only little knowledge of the effect of medical therapy or antireflux surgery in reflux-induced dysphagia. METHODS: Fifty-nine consecutive GERD patients with dysphagia were studied by means of a symptom questionnaire, endoscopy, barium swallow, esophageal manometry, and 24-hour pH monitoring of the esophagus. Patients had proton pump inhibitor therapy and cisapride for 6 months. After GERD relapsed following withdrawal of medical therapy, 41 patients decided to have antireflux surgery performed. The laparoscopic Nissen fundoplication was chosen in 12 patients with normal esophageal body motility and the laparoscopic Toupet fundoplication in 29 patients with impaired peristalsis. Dysphagia was assessed prior to treatment, at 6 months of medical therapy, and at 6 months after surgery. RESULTS: Heartburn and esophagitis were effectively treated by medical and surgical therapy. Only surgery improved regurgitation. Dysphagia improved in all patients following surgery but only in 16 patients (27.1%) following medical therapy. Esophageal peristalsis was strengthened following antireflux surgery. CONCLUSIONS: Medical therapy fails to control gastroesophageal reflux as it does not inhibit regurgitation. Thus, it has little effect on reflux-induced dysphagia. Surgery controls reflux and improves esophageal peristalsis. This may contribute to its superiority over medical therapy in the treatment of GERD-induced dysphagia.

Respiratory symptoms and dysphagia in patients with gastroesophageal reflux disease: a comparison of medical and surgical therapy.

BACKGROUND: Gastroesophageal reflux disease (GERD) is a common condition and may frequently lead to dysphagia and respiratory symptoms. The aim of this study was to investigate the effects of medical and surgical therapy to control these symptoms. METHODS: Eighty GERD patients with either dysphagia or respiratory symptoms were studied by means of a detailed symptom questionnaire, upper gastrointestinal endoscopy, esophageal manometry, 24-h esophageal pH monitoring and a barium esophagogram. All patients had been receiving medical therapy with proton-pump inhibitors and cisapride for 6 months. After withdrawal of medical therapy and relapse of GERD, 62 patients decided to undergo anti-reflux surgery (laparoscopic Nissen fundoplication in 19 and laparoscopic partial posterior fundoplication in 43 patients). Symptoms were assessed prior to treatment, at 6 months following medical therapy and 6 months after surgery. RESULTS: Heartburn and esophagitis were effectively treated by medical and surgical therapy. Dysphagia was improved in all patients following surgery but only in 27% of patients following medical therapy. Improvement of respiratory symptoms was found in 86% of patients following surgery but only in 14% following medical therapy. Improvement of regurgitation was registered only following surgical therapy. CONCLUSIONS: Since medical treatment is likely to fail in GERD patients with complex symptoms such as dysphagia, regurgitation and respiratory symptoms, the need for surgery arises in these patients and may be the only successful treatment in the long term.

Laparoscopic partial posterior fundoplication improves poor oesophageal contractility in patients with gastrooesophageal reflux disease.

OBJECTIVE: To investigate the effect of partial posterior fundoplication on oesophageal contractility in patients with gastrooesophageal reflux disease (GORD). DESIGN: Follow-up study with 6 months of survey. SETTING: University hospital, Austria. SUBJECTS: 24 consecutive patients with GORD and poor oesophageal contractility. INTERVENTIONS: Laparoscopic partial posterior fundoplication. Oesophageal contractility was assessed manometrically. MAIN OUTCOME MEASURES: Changes in measurements of mean contraction amplitudes in the distal oesophagus, the number of contractions with amplitudes of less than 30 mmHg, the number of interrupted and simultaneous contractions, and the total number of defective contractions. RESULTS: 16 of the patients (67%) complained of dysphagia preoperatively, and none postoperatively. The mean (SEM) amplitudes in the distal oesophagus improved significantly (level 442.4 mmHg (3.5) compared with 31.8 mmHg (3.3), p = 0.03, and level 5-45.7 mmHg (3.8) compared with 32.6 mmHg (3.7), p = 0.02), the number of contractions with amplitudes below 30 mmHg decreased (18.0% (5.7) compared with 38.3% (6.2), p = 0.02), as did the number of interrupted or defected contractions (11.5% (3.6) compared with 26.3% (5.5), p = 0.03, and 29.5% (6.5) compared with 66.6% (5.1), p < 0.0001 respectively). There was no significant effect on the number of simultaneous waves (p = 0.11). CONCLUSIONS: Partial posterior fundoplication improves poor oesophageal body motility. This results in improvement of preoperative dysphagia.

Management of hyperparathyroidism in an endemic goiter area.

In an endemic goiter area patients with hyperparathyroidism (HPTH) frequently also have thyroid abnormalities. In a retrospective study of 95 patients with HPTH we assessed the diagnostic accuracy of imaging techniques (ultrasonography or radionuclide scanning) for preoperative localization of parathyroid adenomas. Altogether 86% of our patients had goiter, requiring thyroid resections in 37%. For 19 patients the parathyroid exploration was the second or third cervical operation, most of them due to goiter. We found that the overall rate of transient and permanent recurrent nerve paralysis is considerably increased in patients with previous neck surgery (26% vs. 7%). The combination of ultrasonography and radionuclide scanning can lead surgeons to the site of parathyroid lesions responsible for HPTH in 85% of cases, although frequent nodular goiters can produce pitfalls for correct imaging in iodine-deficient countries. In endemic goiter areas preoperative localization studies can be recommended in patients with primary HPTH--for evaluation of thyroid pathology possibly leading to resection or its accuracy in localizing parathyroid adenomas. These studies also seem justified in patients with previously unsuccessful neck explorations for HPTH.

Reflux-induced apoptosis of the esophageal mucosa is inhibited in Barrett's epithelium.

BACKGROUND: Apoptosis maintains cell homeostasis. Altered apoptosis is involved in carcinogenesis. It was our aim to investigate whether reflux esophagitis may alter apoptosis in the esophageal mucosa and whether antireflux surgery may restore normal apoptosis. METHODS: Apoptosis was studied preoperatively and postoperatively in esophageal biopsies of 39 patients with various grades of reflux esophagitis and in Barrett's mucosa using the TUNEL method. Biopsies were also taken from lesions of the squamous epithelium adjacent to the Barrett's mucosa. RESULTS: Apoptosis increased with the severity of esophagitis. Apoptosis was low in Barrett's epithelium. Squamous epithelium adjacent to Barrett's mucosa showed increased apoptosis. After surgery apoptosis decreased in squamous epithelium, and it remained low in Barrett's epithelium. CONCLUSIONS: Apoptosis in reflux esophagitis may be protective against increased proliferation. Low apoptosis following antireflux surgery indicates that surgery is effective to prevent reflux-induced cell proliferation. Inhibition of apoptosis in Barrett's may promote carcinogenesis. This may not change following surgery.

Tailored antireflux surgery for gastroesophageal reflux disease: effectiveness and risk of postoperative dysphagia.

The Nissen fundoplication is not the proper antireflux procedure for patients with poor esophageal peristalsis as it does not strengthen impaired esophageal peristalsis. The aim of this study was to investigate if tailoring of antireflux surgery according to esophageal contractility is an effective treatment of gastroesophageal reflux disease (GERD) with a low incidence of postoperative dysphagia. The Toupet fundoplication was laparoscopically performed on 32 patients with poor esophageal peristalsis and the Nissen fundoplication on 17 patients with normal peristalsis. After a median follow-up of 15 months, only 1 of the 49 patients (2.04%) complained of heartburn. Acute esophagitis was found in none of them on endoscopy. Of 40 patients tested postoperatively, 2 (5%) underwent pathologic esophageal pH monitoring. Postoperative dysphagia was found in two patients (4.1%) compared with 25 (51%) preoperatively (p < 0.05). There was a significant reduction of dysphagia following the Toupet fundoplication. Both procedures increased the resting pressure of the lower esophageal sphincter (LES) significantly, which was more pronounced following the Nissen fundoplication. Relaxation of the LES was significantly better following the Toupet than after the Nissen fundoplication. There was significant improvement of esophageal peristalsis following the Toupet fundoplication. Tailored antireflux surgery is an effective strategy for treatment of GERD. The incidence of postoperative dysphagia is low owing to improvement of impaired esophageal peristalsis following the Toupet fundoplication. It may be due to the fact that the Toupet fundoplication causes less esophageal outflow resistance than the Nissen fundoplication.

Medical treatment of gastroesophageal reflux disease does not prevent the development of Barrett's metaplasia and poor esophageal body motility.

OBJECTIVE: Duodenal contents refluxing into the esophagus may be involved in the pathophysiology of gastroesophageal reflux disease (GERD). This study was performed to investigate whether medical treatment of GERD aimed at suppression of gastric acid production can prevent the development of complications, such as Barrett's metaplasia or poor esophageal body motility. DESIGN: Retrospective study. SETTING: University hospital. PATIENTS: 138 GERD patients were analyzed regarding the development of Barrett's metaplasia or poor esophageal body motility, despite intermittent or continuous treatment with H2 blockers or omeprazole. MAIN OUTCOME MEASURES: The rate of patients with Barrett's metaplasia or poor esophageal body motility with or without effective medical treatment. RESULTS: Barrett's metaplasia was found in 33.8% of patients receiving medical treatment, although it was not present when treatment was induced. This rate was 21.9% among patients who were not receiving therapy (not significant). In all, 41.9% of patients with medication had impaired esophageal body motility compared with 59.3% of patients not receiving treatment (P < 0.05), but these patients had a significantly shorter history of GERD. CONCLUSIONS: Medical treatment with H2 blockers or omeprazole does not prevent the development of Barrett's metaplasia or poor esophageal body motility.

Laparoscopic technique of proximal selective vagotomy.

Proximal selective vagotomy (PSV) is an effective, definitive therapy for peptic ulcer disease of the duodenum. Long-term studies have shown that ulcer recurrence occurs in less than 10% of patients if the operation is performed by an experienced surgeon. Since PSV does not influence gastric emptying, side effects such as diarrhea, gastric stasis or the dumping syndrome are rare. Due to this favorable experience, PSV is our preferred technique for the laparoscopic approach to peptic ulcer disease. We have performed this operation in 13 patients. Indications were chronic duodenal ulceration unresponsive to medical therapy, chronic duodenal ulceration combined with reflux esophagitis, and reflux esophagitis due to gastric acid hypersecretion. In patients with reflux esophagitis PSV was performed in addition to an antireflux procedure. Laparoscopic PSV can be performed more accurately than the open procedure since it allows for better visualization with less possibility of missing small vagal connections to the parietal cells such as the 'criminal nerve'. The median duration of operation was 3 hours. There were no serious peri- or postoperative complications. The median time of postoperative hospital stay was 3 days. During the median follow-up of 27 months no recurrence of duodenal or esophageal ulceration was encountered and none of the patients complained of epigastric pain, diarrhea or dumping symptoms.

[Bioprosthesis degeneration and reoperation in the aortic and mitral position]. / Bioprothesendegeneration und Reoperation in Aorten- und Mitralposition.

In agreement with our experiences from our first study 15 patients (8 men, 7 women) underwent reoperation because of degeneration of bioprosthetic valves implanted in aortic or mitral position during the last 24 months. At reoperation 4 patients had a more complex cardiac procedure (double valve replacement, double valve replacement with bypass grafting, valve replacement with enlargement of the valvular area). There was no acute operation and only 1 patient was serious symptomatic preoperatively (NYHA IV). We revealed a mean implantation time of 126.4 months +/- 32.2 (median 130) for all bioprostheses without a significant difference in implant time regarding to aortic or mitral position. At reoperation bypass time (p = 0.001) and aortic clamp time (p = 0.011) was significantly longer compared to the first operation. There was no perioperative death, all patients are still alive and in good condition (8 of them NYHA I, 7 NYHA II). The early change of tissue degenerated bioprostheses can be carried out under elective conditions with improved postoperative outcome: mortality and morbidity remains acceptable low. In our group incremental risk factors for early mortality are severely affected patients with low functional status (NYHA IV) and acute operation. Preoperative coronary angiography remains essential for evaluation of concomitant coronary artery disease.