[Innovative Techniques in Reflux Surgery - State of the Art]. / Innovative Techniken in der Refluxchirurgie.

There is renewed interested in novel surgical procedures for GERD, as there are potential undesirable effects of PPI therapy and the results of the current surgical methods are not always satisfactory. The technique and results of magnetic enhancement (LINX®) and electrical stimulation (EndoStim®) of the lower oesophageal sphincter are presented and discussed. Both methods are less invasive, principally reversible and associated with encouraging mid-term results. It may therefore be an extended indication for the surgical treatment of gastroesophageal reflux disease. However, this, in combination with the technical simplicity of the procedures, carries the risk of inadequate indications. In order to obtain reliable long-term results, the establishment of a mandatory register is proposed.

Mentorship Programs in Bariatric Surgery Reduce Perioperative Complication Rate at Equal Short-Term Outcome-Results from the OPTIMIZE Trial.

OBJECTIVES: The aim of this study was to determine the efficacy of coaching on outcome in low volume centers of excellence and to evaluate the influence of mentorship programs on the center development. BACKGROUND: The number of bariatric procedures has increased steadily in the last years. Providing nationwide bariatric care on a high professional level needs structures to train and guide upcoming centers and ensure high quality in patient care. METHODS: A prospective multicentered, observational study including laparoscopic sleeve gastrectomies (SG) and Roux-en-Y gastric bypass (RYGB) procedures was performed. Twelve emerging bariatric centers were coached by five experienced bariatric centers. Surgeons of the mentor centers gave guidance on pre- and postsurgical management of their patients including complications and proctored the first interventions. The results were compared regarding operative outcomes, percentage of excess weight loss, complications, and resolution of comorbidities. RESULTS: A total of 214 of 293 patients (73.0%) completed the study. The most frequently reported complications were wound infection (4.4%), disorder of emptying stomach/new reflux (2.4%), anastomotic leaks, intra-abdominal secondary hemorrhage, and dumping syndrome (2.0% each). The mortality rate was zero. We found no difference in overall complication rates or resolution of obesity-related comorbidities when comparing experienced surgeons with less experienced surgeons. CONCLUSIONS: Our results suggest that under the conditions of the practices of this study, coaching and mentoring were associated with comparable outcomes both in experienced and emerging centers. In addition, mentorship programs ensure equal outcome quality in terms of improvement of obesity-associated comorbidities. TRIAL REGISTRATION: NCT Number: NCT01754194 .

Long-term benefits of Roux-en-Y pouch reconstruction after total gastrectomy: a randomized trial.

OBJECTIVE: Roux-en-Y reconstruction with and without jejunal pouch was compared in a randomized controlled trial to identify the optimal reconstruction procedure in terms of quality of life. BACKGROUND DATA: Randomized trials comparing techniques of reconstruction after total gastrectomy have shown controversial results. METHODS: One hundred and thirty-eight patients with gastric cancer were intraoperatively randomized for Roux-en-Y reconstruction with pouch (n = 71) or without pouch (n = 67) after gastrectomy and stratified into curative or palliative resection. Intra- and postoperative complications were recorded. Body weight and quality of life were determined every 6 months with a follow-up of up to 12 years. RESULTS: Both groups were comparable for age, sex, incidence of concomitant disease, and staging. There were no differences in operative time, postoperative complications, and mortality. Short- and long-term weight loss was similar in both groups. In the first postoperative year, there were no benefits of pouch reconstruction in terms of quality of life, independent of the resection status. In the third, fourth, and fifth year after surgery quality of life was significantly improved for patients with a pouch. CONCLUSIONS: Roux-en-Y pouch reconstruction after gastrectomy is simple to perform and safe. Long-term survivors benefit from pouch reconstruction. Therefore, a pouch is recommended for patients with a good prognosis.

Changes in depression following gastric banding: a 5- to 7-year prospective study.

BACKGROUND: Long-term outcomes of gastric banding regarding depression and predictors of change in depression are still unclear. This prospective, controlled study investigated depression and self-acceptance in morbidly obese patients before and after gastric banding. METHODS: A total of 248 morbidly obese patients (mean body mass index [BMI] = 46.4, SD = 6.9) seeking gastric banding completed questionnaires for symptoms of depression (Beck Depression Inventory) and self-acceptance. One hundred twenty-eight patients were treated with gastric banding and 120 patients were not. After 5 to 7 years, patients who either had (n = 40) or had not (n = 42) received gastric banding were reassessed. RESULTS: In the preoperative assessment, 35% of all obese patients suffered from clinically relevant depressive symptoms (BDI score > or =18). The mean depression score was higher and the mean self-acceptance score was lower than those of the normal population. Higher preoperative depression scores were observed among patients living alone and who had obtained low levels of education. After 5 to 7 years, patients with gastric banding had lost significantly more weight than patients without gastric banding (mean BMI loss 10.0 vs. 3.3). Gastric banding patients improved significantly in depression and self-acceptance, whereas no change was found in patients without gastric banding. Symptoms of depression were more reduced in patients who lost more weight, lived together with a partner, and had a high preoperative depression score. CONCLUSION: Morbid obesity is associated with depressive symptoms and low self-acceptance. Gastric banding results in both long-term weight loss and improvement in depression and self-acceptance.

Short- and long-term results of laparoscopic gastric banding for morbid obesity.

BACKGROUND: Today, gastric banding has become a common bariatric procedure. Weight loss can be excellent, but is not sufficient in a significant proportion of patients. Few long-term studies have been published. We present our results after up to 9 years of follow-up. MATERIALS AND METHODS: One hundred twenty-seven patients (1997-2004) were analyzed retrospectively after laparoscopic gastric banding (perigastric technique: n = 60; pars flaccida technique: n = 67) in terms of preoperative characteristics, weight loss, comorbidities, short- and long-term complications, and quality of life. RESULTS: Median follow-up was 63 months (range 2-104). Incidence of postoperative complications were: gastric perforation in 3.1%, band erosion in 3.1%, band or port leak in 2.3%, port infection in 5.3%, port dislocation in 6.9%, and pouch dilatation in 16.9%. Total number of patients requiring reoperation was 34 (26.7%) [perigastric technique n = 23 (38.8%) versus pars flaccida technique n = 11 (16%), p = 0.039]. Mean excess body weight loss (%) was 50.6%. Most patients reported an increase in quality of life after surgery. CONCLUSIONS: Gastric banding is effective for achieving weight loss and improving comorbidity in obese patients. Obviously, gastric banding can be performed more safely with the pars flaccida technique, although the complication rate remains relatively high. Nevertheless, based on adequate patient selection, gastric banding should still be considered a valuable therapeutic option in bariatric surgery.

[Antroduodenal motility and pH changes after partial gastrectomy including the pacemaker region of the dog's stomach]. / Alterações da motilidade antroduodenal e do pH gástrico após ressec o gástrica parcial incluindo a rea correspondente ao marca-passo do estômago de cães.

BACKGROUND: Functional alterations of antroduodenal motility are not well defined at present. The gastric pacemaker is located at the greater curvature, next to the fundus. PURPOSE: The aim was to evaluate the influence of the gastric pacemaker on the gastroduodenal motility in dogs. METHODS: The study was designed in three steps and performed with 20 dogs: first, construction of a cervical esophagostomy to measure the antroduodenal motility and gastric pH-metry as validation step. The manometry was performed by means of a six point electronic manometry probe and both manometry and pH-metry were recorded during 4 hours. Second, the stomach's pacemaker region and gastric reservoir were resected by videolaparoscopy. Third, the antroduodenal motility and gastric pH-metry were measured again. RESULTS: In the validation step, there was established a typical dogs' antroduodenal motility pattern, with a three-shaped interdigestive motility complex (IMC) (phases 1 to 3); the gastric pH-metry showed a baseline at pH 1,15. After partial gastric resection, overall there was an increase in contractions' frequency, an increase in phase 2 and a decrease in phase 3 participation on the IMC's. Regarding the gastric pH measurements, there was an increase in pH intervals 0-1 and 1-2 and a decrease in pH intervals 6-7; overall, there was a decrease in the stomach's pH and a decrease in the prandial time. CONCLUSION: The resection of the stomach's pacemaker region and gastric reservoir correlated with alterations in antroduodenal motility, maintaining however the typical IMC pattern.

Alterações da motilidade antroduodenal e do pH gástrico após ressecçäo gástrica parcial incluindo a área correspondente ao marca-passo do estômago de cäes / Antroduodenal motility and pH changes after partial gastrectomy including the pacemaker region of the dog's stomach

As alterações funcionais da motilidade antroduodenal ainda näo foram bem caracterizadas até a presente data. O marca-passo gástrico, possivelmente localiza-se junto à grande curvatura, próximo ao fundo gástrico. A partir dele, ondas de despolarizaçäo dirigem-se ao estômago, duodeno e às demais partes do intestino delgado. OBJETIVO: Avaliar a influência do marca-passo gástrico sobre a motilidade gastroduodenal em cäes. MÉTODOS: O protocolo experimental constou de três etapas. Na primeira, realizou-se esofagostomia cervical seguida de manometria antroduodenal eletrônica e pH-metria em 20 cäes (grupo controle), durante 4 horas. Na segunda etapa, realizou-se a ressecçäo de parte do fundo gástrico e da área do marca-passo gástrico, com técnica videolaparoscópica. Na terceira, decorridos três meses, repetiu-se a manometria antroduodenal e a pH-metria gástrica. RESULTADOS: No grupo controle observou-se traçado típico de motilidade antroduodenal, com complexo interdigestivo de motilidade (IMC) com fases 1, 2 e 3; na pH-metria, observou-se padräo de acidez com linha de base em pH de 1,15. Após a ressecçäo gástrica parcial, a manometria apresentou, no geral, aumento na freqüência de contrações, aumento da participaçäo relativa da fase 2 e diminuiçäo da participaçäo relativa da fase 3. No pH gástrico, observou-se aumento no percentual de pH 0 - 1 e pH 1 - 2, bem como diminuiçäo na porcentagem de pH 6 - 7, com conseqüente diminuiçäo do pH gástrico e reduçäo no tempo prandial. CONCLUSÄO: Pela retirada da área do marca-passo gástrico ocorreram alterações de motilidade antroduodenal, permanecendo porém a ocorrência de IMC's completos

Interaction of sleep disturbances and gastroesophageal reflux in chronic laryngitis.

BACKGROUND: A considerable percentage of patients with reflux laryngitis do not respond to conventional treatment with proton pump inhibitors or prokinetics. At the present time, the reasons for this are not well known. PURPOSE: To investigate whether nocturnal reflux associated with sleep-related respiratory disorders is the cause of refractory laryngitis. METHOD: The data from 227 patients (133 women, ages 18 to 75 years, body mass index 17.4 to 38.3, mean 32.1 kg/m(2)) with LG were analyzed retrospectively. All received laryngoscopy and gastroscopy. All patients initially received 40- to 80 mg omeprazole and underwent a follow-up laryngoscopy after 6 weeks. Of the patients, 202 showed a clear improvement, whereas 25 (11.1%) did not. All underwent 24-hour pH monitoring and cardiorespiratory polysomnography. RESULTS: All of the patients showed laryngoscopic signs of LG. Of the patients, 102 (45%) had a hiatal hernia and 53 (28%) suffered from reflux esophagitis. Forty-two patients (19%) were found to have Helicobacter pylori in the stomach. Among the 25 patients who failed to respond to omeprazole, pH monitoring showed nocturnal acid reflux in 15 (60%). Twenty-four patients (96%) showed a sleep-related respiratory disturbance manifesting as pathologic snoring (16 patients) or obstructive sleep apnea (8 patients, respiratory disturbance index [RDI] 11 to 33, mean 16.3/h). All received nasal continuous positive airway pressure (nCPAP) treatment, 16 with constant mask pressure (4 to 12, mean, 5.6 mbar) and 8 with autoadjusting pressure. One patient abandoned treatment; the other 23 showed clear subjective and objective improvement after 3 months of treatment. CONCLUSIONS: Even without pH monitoring evidence of nocturnal reflux, refractory LG is very often associated with sleep-related respiratory disorders and responds well to nCPAP treatment. Prospective studies are needed to clarify the details of this association.

Role of gastric functional disorders in gastroesophageal reflux disease

A doença do refluxo gastroesofagico e uma doença multifatorial que pode comprometer todos os segmentos do trato gastrointestinal superior. Durante muito tempo as causas gástricas de refluxo gastroesofagico näo foram consideradas, pois o estudo de alteraçöes gástricas näo era passível de ser realizado nos moldes atuais. Num estudo prospectivo de 365 pacientes com doença do refluxo...