Prospective evaluation of a new through-the-scope nasoduodenalenteral feeding tube

L. J. Damore, II, C. H. Andrus, V. M. Herrmann, T. P. Wade, D. L. Kaminski, G. C. Kaiser

Department of Surgery, Saint Louis University Health Sciences Center, 3635 Vista Avenue, Saint Louis, MO 63110, USA

Received: 18 March 1996/Accepted: 5 August 1996

AbstractBackground: With present techniques, transpyloric feedingtube placement is unreliable. This study evaluated a newnasoduodenal tube placed through a gastroscope.Methods: A therapeutic gastroscope was advanced into thedistal duodenum, and through the 3.7-mm channel this feed-ing tube was advanced under direct vision into the smallbowel. The tube/guidewire combination was then advancedwith the concomitant equidistant retraction of the scope un-til the wire could be grasped at the lips and exchanged to thenose using a nasal transfer tube. The guidewire was re-moved, and a Y connector was then attached to the endof the tube.Results: Successful tube placement in all 21 patients (14M/7F) required an endoscopy time of 31 3.3 min and thetubes were utilized for 9.24 0.94 days. Tube tips wereconfirmed in the distal duodenum (10) or proximal jejunum(11) by radiographic contrast injection.Conclusion: This new through-the-scope tube can be placedin the distal duodenum quickly, safely, and consistently.

Key words: Enteral feeding tube Gastroscopy Duo-denum

The need for nutritional support in chronically ill, trauma,burn, or surgical patients has been well known. In thosepatients who are unable to ingest nutrition by natural oralmethods of mastication, deglutition, and swallowing, someother form of nutritional supplementation must be em-ployed. Options for supplementation include either the en-teral or parenteral route (TPN). Unlike TPN, enteral tubenutrition is much less expensive and has a very low inci-dence of sepsis and metabolic complications. Enteral feed-

ing also avoids or minimizes bacterial translocation and thesubsequent potential sepsis. In addition, enteral tubes can besafely placed for indefinite periods of time.

Currently, there exist two major forms of enteral routesfor nutritional supplementation: nasal or oral enteral tubesand operatively or endoscopically placed gastrostomy orjejunostomy tubes. Although more permanent, operativegastrostomies and percutaneous endoscopic gastrostomies(PEG) [3] and operative jejunostomies and percutaneousendoscopic jejunostomies (PEJ) [14] require a surgical in-cision for placement and carry added risks for wound in-fection, peritonitis, hemorrhage, and injury to other organsduring placement [2]. These more permanent enteral tubesare indicated for long-term nutritional supplementation. Re-garding short-term nutritional supplementation, the place-ment of oral or nasal enteral tubes is preferred [1]. Thesimplest method, blind placement of orogastric or nasogas-tric tubes, is associated with elevated risk of gastroesopha-geal reflux and subsequent enteral feeding aspiration [9]. Inat least one study, the optimal tube position for minimizingreflux through the pylorus was found to be just distal to theligament of Treitz [5]. Thus, the placement of transpyloricenteral feeding tubes can be advocated for the temporaryenteral alimentation of critically ill patients who have afunctioning intestinal system [15].

There now exist a great variety of methods for nasoen-teral feeding tube insertion. One method involves blindplacement of a nasoenteral tube into the stomach [15]. Blindpassage also can result in the inadvertent intubation of thetrachea and possible bronchopleural injuries [6]. Althoughnasoduodenal tube placement under fluoroscopic guidanceis more reproducible and accurate, the procedure requires acumbersome C-arm at the bedside or transportation of thepatient to the Radiology Department with subsequent radia-tion exposure to the patient and staff. With the advent offiberoptic flexible endoscopy, guidance of feeding tubesinto the upper intestinal tract under direct vision has becomepossible. At present time, nasoduodenal tubes can be placedby endoscopic direction alongside the endoscope [11] or byseveral other methods described in the literature [1, 4, 7, 8,

Correspondence to: C. H. Andrus, Fifth Avenue and Roosevelt Streets,P.O. Box 5000, Hines, IL 60141, USA

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10, 13]. These previous methods have all had technicalshortcomings that this newest study attempts to circumventby using a newly designed through-the-endoscope nasoduo-denal feeding tube.

Materials and methods

Under an approved Institutional Review Board study, all patients who hadfailed placement of nasoduodenal tubes by more traditional methods suchas blind placement, placement under fluoroscopy, or alongside the endo-scope were offered attempted placement of a newly designed through-the-scope nasoduodenal tube (Fig. 1) (Kangaroo endoscopically-placed clearfeeding tube a with a radiopaque stripe [KTE], 9 French or 10 French 140cm with a 280 cm guidewire, tungsten-weighted tip, Sherwood Medical, St.Louis, MO, 63103). (Commercially available nasoduodenal tubes at pre-sent have a nominal outer diameter of 8 or 10 French. Unfortunately, thesecannot be placed through the endoscope due to larger outer diameter of theweight tips, the relative shorter length of the tube and wire, and the per-manent fixation of the Y-connector to the proximal end of the tube.)

Therapeutic gastroscopes (GIF2T10 [12.6 mm O.D], GIF1T100 [11.0mm O.D.], GIF2T100 [12.6 mm O.D.]; Olympus, America Corporation,Lombard, IL 60148) with working channels of at least a nominal insidediameter of 3.7 mm were utilized for the placement of the KTE. The biopsychannel was initially irrigated with water mixed with silicone spray, whilethe full length of the feeding tube was moistened with tap water to activatethe prelubricated surface coating. With its guidewire in place, the KTE wasthen inserted through the therapeutic channel to the endoscopes tip. Afterappropriate intravenous conscious sedation of the patient with a narcoticand a benzodiazepine, the gastroscope was then passed through the oral

cavity and upper gastrointestinal tract as far as possible into the distalduodenum (Fig. 2). Once the most distal duodenum was reached, thefeeding tube was advanced through the endoscopic port under direct visionas far as possible into the small bowel. With continued KTE advancementthrough the biopsy port, the gastroscope was then methodically removedcontinuously an equivalent distance with regard to KTE advancement.Once the tip of the gastroscope had reached the patients lips, the KTEsposition was secured by an assistants grasp. A lubricated nasal transfertube (NTT) was inserted through the nose and grasped in the hypopharynxby the operators fingers; the tip of the NTT was brought out the mouth.The guidewire was then threaded through the NTT. The NTT with the wirewas removed out the nose, thus transforming the external portion of theKTE out a nostril. The guidewire was then pulled out from the feedingtube, the end of the tube was cut, the tube was taped in place, and a Yconnector was next attached to the end of the tube. Distal bowel placementwas then confirmed by injection of 2030 ml of a radiopaque dye throughthe feeding tube followed immediately by an abdominal radiograph (Fig 3).

Data regarding the sex, age, and diagnosis of the patient; size of thefeeding tube and time required for placement; radiographic position of thefeeding tube tip; patient tolerance to tube feedings; number of days offeeding tube utilization; and reason for removal of the feeding tube werecollected concomitantly. The statistical analysis of the data (mean; standarderror of the mean; and the appropriately indicated comparison tests: t-test,chi-square analysis, or ANOVA) is subsequently reported.

Results

Twenty-one patients, 14 males (mean age 54.4 5.2 years)and seven females (mean age 62.4 5.8 years), underwentplacement of either a 10-French (n 4 15) or 9-French (n 46) feeding tube through the therapeutic endoscopic biopsyport of the gastroscope. Of the 21 patients, 20 had failedfluoroscopic placement and one had failed endoscopicplacement.

There was no increased difficulty in the gastroscopiccannulation of the upper gastrointestinal tract even thoughtherapeutic scopes have a slightly larger outer diameter(11.2-mm to 12.6-mm O.D. for a therapeutic scope vs 11.0

Fig. 1. Kangaroo 9-French through-the-endoscope (KTE) nasoduodenaltube with guidewire in place. Y connector is included.

Fig. 2. Sequential frames of the advancement of the KTE tube into thedistal duodenum and jejunum.

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mm for a standard adult gastroscope). The mean proceduretime was 31 3.3 min (range 1070 min), which was in-dependent of the size of the tube used (9 French: 27.5 4.8min; 10 French: 32.3 4.3 min; p 4 0.53); but the pro-longed placement time in several individuals was associatedwith the 10-French version of the tube because of the in-creased friction between the 10-French tube (O.D. ~3.2mm) and the channel of the therapeutic gastroscope (nomi-nal I.D. 3.7 mm but may decrease in size with scope angu-lation in older models). The only complication associatedwith the placement of any of the nasoenteral feeding tubeswas nasal mucosa excoriation requiring packing in one co-agulopathic patient.

Confirmation of the position of the feeding tube wasobtained by abdominal radiograph after injection of 2030ml of a radiopaque dye through the feeding tube. The tip ofthe tube was confirmed to be in the jejunum in 11 patients,while in the remaining ten patients the tip of the KTE wasnoted to be in the distal duodenum. The distal tip positionwas independent of the tube size (p 4 0.73).

After tube placement, all feeding tubes initially func-tioned without difficulty. While the mean number of daysthe tubes were used for enteral feeding was 9.24 0.94 days(range 222 days), the feeding tubes were removed for avariety of reasons: inadvertent tube extubation (eight); tubeobstruction (three); a more permanent feeding tube (i.e.,

PEG) was eventually placed (3); tolerating oral feedings(four); one undocumented case; a death; and the unrelateddevelopment of an enteric fistula for which the patient wasplaced on long-term TPN. The length of utilization of theKTE tubes was similar (9 French: 7.33 1.43 days, 10French: 10 1.16 days; p 4 0.21).

Discussion

The importance for nutritional support in the critically illpatient is well documented. Unlike TPN, enteral nutritionhas much less risk of septic and/or metabolic complications.For short-term enteral nutritional support, placement of anasoenteral feeding tube is preferred. These tubes avoid thecomplications of wound infections and peritonitis involvedin the placement of the PEG or PEJ.

The placement of the through-the-endoscope feedingtube (KTE) was simple, precise, and consistently reproduc-ible. Since the tube is advanced in an equidistant fashionwith the concomitant withdrawal of the endoscope, thetubes do not back out during the process and no tube place-ments had to be redone. In all patients in which these feed-ing tubes were placed, the tips of the tubes were transpyloricand located in the distal duodenum or proximal jejunum.

Feeding was initiated immediately after proper place-ment was confirmed by an abdominal radiograph with ra-diopaque contrast injection. This clinical trial shows that thethrough-the-endoscope feeding tube is an adequate substi-tute for the placement of feeding tubes along the side of theendoscope and is at least equal if not superior to any pre-viously described endoscopic nasoenteral feeding tubeplacement method. Through this study, the KTE tube hasbeen shown to be an excellent method for placement oftemporary transpyloric feeding tubes in critically ill patientsfor those who favor transpyloric enteral nutrition. Sincethese tubes were placed only after prior failure of attemptedplacement of nasoduodenal tubes by fluoroscopic or otherendoscopic techniques, the Kangaroo through-the-endoscope nasoduodenal tube and this placement techniquewas consistently reproducible (100% of the time) and defi-nitely more successful than other attempted methods ofplacement in the patients studied.

Acknowledgment. Our thanks to the technical assistance of Mr. RaymondBodicky, Sherwood Medical, St. Louis, MO.

References

1. Bosco JJ, Gordon F, Zelig MP, Heiss F, Horst DA, Howell DA (1994)A reliable method for the endoscopic placement of a nasogastric feed-ing tube. Gastrointest Endosc 40: 740743

2. Gauderer MWL, Stellato TA (1986) Gastrostomies: evolution, tech-niques, indications, and complications. Curr Probl Surg 23: 661719

3. Gauderer MWL, Ponsky JL, Izant J (1980) Gastrostomy without lap-arotomy: a percutaneous endoscopic technique. J Pediatr Surg 15:872875

4. Ginsberg GG, Lipman TO, Fleischer DE (1994) Endoscopic clip-assisted placement of enteral feeding tubes. Gastrointest Endosc 40:220222

5. Gustke RF, Varma RR, Soergel KH (1970) Gastric reflux during per-fusion of the small bowel. Gastroenterology 59: 890

6. Hedry PJ, Akyurekl Y, McIntyre R, Quarrington A, Keon W (1986)

Fig. 3. Confirmation of the distal tube placement utilizing a water-solublecontrast injection through the tube and a supine abdominal radiograph.

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Bronchopleural complications of nasogastric feeding tubes. Crit CareMed 14: 892894

7. Hudspeth DA, Thorne MT, Meredith JW (1995) A simple endoscopictechnique for nasoenteric feeding tube placement. J Am Coll Surg 180:229230

8. Kuipers EJ, van Mourik-van Steyn G, Rijsberman W, KlinkenbergKnol EC, Meuwissen SGM (1994) Direct endoscopic placement ofnasoenteral feeding tubes. Endoscopy 26: 371

9. Metheny NA, Eisenberg P, Spies M (1986) Aspiration pneumonia inpatients fed through nasoenteral tubes. Heart Lung 15: 256261

10. Mitchell RG, Kerr RM, Ott DJ, Chen M (1992) Transnasal endoscopictechnique for feeding tube placement. Gastrointest Endosc 38: 596597

11. Pleatman MA, Naunheim KS (1987) Endoscopic placement of feedingtubes in the critically ill patient. Surg Gynecol Obstet 165: 6970

12. Rombeau JL, Barot LR (1981) Enteral nutrition therapy. Surg ClinNorth Am 61: 605620

13. Stark SP, Sharpe JN, Larson GM (1991) Endoscopically placed naso-enteral feeding tubes: indications and techniques. Am Surg 57: 203205

14. Westfall SH, Andrus CH, Naunheim KS (1990) A reproducible, safejejunostomy replacement technique by a percutaneous endoscopicmethod. Am Surg 5: 141143

15. Whatley K, Turner W, Day M, Meier D (1983) Transpyloric passageof feeding tubes. Nutr Suppl Serv 3: 1821

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Laparoscopic vs conventional Nissen fundoplication

A prospective randomized study

S. Laine, A. Rantala, R. Gullichsen, J. Ovaska

Department of Surgery, Turku University Central Hospital, Kiinamyllynkatu 48, FIN-20520 Turku, Finland

Received: 15 May 1996/Accepted: 10 September 1996

AbstractBackground: Laparoscopic Nissen fundoplication hasgained wide acceptance among surgeons, but the results ofthe laparoscopic procedure have not been compared to theresults of an open fundoplication in a randomized study.Methods:Some 110 consecutive patients with prolongedsymptoms of grade IIIV esophagitis were randomized, 55to laparoscopic (LAP) and 55 to an open (OPEN) Nissenfundoplication. Postoperative recovery, complications, andoutcome at 3- and 12-month follow-up were compared inthe two groups.Results:Five LAP operations were converted to open lap-arotomy due to esophageal perforation (two), technical dif-ficulties (two), and bleeding (one). In the OPEN group(two) patients underwent splenectomy. There was no mor-tality. The mean hospital stay was 3.2 days in the LAPgroup and 6.4 in the OPEN group. Dysphagia and gas bloat-ing were the most common complaints 3 months after theoperation in both groups. These symptoms had disappearedat the 12-month follow-up examination. All patients in theLAP group and 86% in the OPEN group were satisfied withthe result.Conclusions:Laparoscopic Nissen fundoplication is a safeand feasible procedure. Complications are few and func-tional results are good if not better than those of conven-tional open surgery.

Key words: Gastroesophageal reflux disease Laparos-copy Fundoplication Antireflux surgery Laparo-scopic surgery

Since Nissens original description of fundoplication nearly40 years ago [12] this procedure has undoubtedly been themost commonly used operation for the treatment of gastro-esophageal reflux disease (GERD). The long-term resultsafter this procedure have been very successful, with excel-

lent control of reflux symptoms in 91% of patients 10 yearsafter the operation [5]. Very soon after the laparoscopicrevolution in biliary surgery other intraabdominal diseaseswere treated with this new technique. In 1991 Dallemagne[4] described the operative technique and reported the earlyresults of a laparoscopic Nissen fundoplication. Since then,several studies have demonstrated the safety and effective-ness of this procedure [7, 9, 10]. However, no randomizedseries comparing an open and a laparoscopic fundoplicationhave been published and many general surgeons have beensuspicious about this technique. In this study we compareda laparoscopic and an open Nissen fundoplication in a ran-domized manner.

Patients and methods

Between April 1992 and June 1995, 110 consecutive patients, 65 males and45 females, were randomized to either laparoscopic (LAP) or conventional(OPEN) Nissen fundoplication. The age of the patients ranged from 21 to75 years, with a mean age of 47 years in the LAP group and 51 years in theOPEN group. All patients had a long history of chronic reflux esophagitisand every patient had been treated conservatively for more than 24 monthswith H2-blockers or proton-pump inhibitors. Preoperative clinical symp-toms were assessed with a questionnaire and esophagogastroscopy wasperformed on all patients. Esophagitis was graded according to the Savary-Miller classification [15] (Table 1). Ambulatory 24-h pH measurement(Synetics Medical) and esophageal manometry (Lectromed) were per-formed at the Department of Clinical Physiology. The preoperative valuesof the pH recordings were available in 46 patients in the LAP group and in41 patients in the OPEN group. Seven patients in LAP group and nine inOPEN group refused pH recording and esophageal manometry. In addition,these tests failed for technical reasons in seven cases. The pH electrode wasplaced 5 cm superior to the lower esophageal sphineter (LES); the positionof the electrode was checked by advancing the electrode into the stomachand by pulling it slowly upward. The location of the LES was taken to thepoint where the pH change occurred. If positioning was uncertain, thelocation of the electrode was checked using X-rays. The proportion ofepisodes with pH below 4, the number of episodes lasting over 5 min, andthe duration of the longest episode with pH below 4 were used to measurethe severity of acid reflux. Esophageal manometry was performed using thepull-through technique to determine the LES pressure. The normal valuesof LES pressure used in our laboratory range from 9 to 32 mmHg, with amean of 19.2 6.9 mmHg [6]. Preoperative manometry was carried out in43 patients in the LAP group and in 39 patients in the OPEN group. Themean LES pressure was 13.7 mmHg in the LAP group and 15.1 in theCorrespondence to:J. Ovaska

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OPEN group. The motor function of the tubular esophagus was normal inall cases that were included in the study.

The laparoscopic operation was performed according to the same prin-ciples as the conventional Nissen fundoplication [13]. The laparoscopictechnique used in this study is described in our preliminary report [14].Ligation of the short gastric vessels was done in five operations in bothgroups. Hiatoplasty was done in four patients in the LAP group and in onepatient in the OPEN group. All laparoscopically operated patients receiveda single-dose perioperative antibiotic prophylaxis (cefuroxime 1.5 g) at theinduction of anesthesia. Antithromboembolic prophylaxis consisted of sub-cutaneous low molecular weight heparin (Fragmin, Pharmacia, Sweden),2,500 units daily, and antithromboembolic stockings during the operation.

The follow-up was carried out on an outpatient basis 3 and 12 monthsafter the operation. The evaluation included a careful patient history,esophagogastroscopy, ambulatory 24-h pH recording, and esophageal ma-nometry. Informed consent was obtained from all the patients. The datawas analyzed using the Fishers test.

Results

Of the operations on the patients randomized to the LAPgroup, (91%) could be completed laparoscopically. Five

conversions to open laparotomy were necessarytwo foresophageal perforation, two for technical difficulties, andone for bleeding. Further recovery was uneventful in all fivepatients. In the OPEN group two patients underwent sple-nectomy due to iatrogenic splenic bleeding and five patientshad postoperative infectious complications (Table 2).

Five patients complained of severe dysphagia in theLAP group, as did three patients in the OPEN group. Fundicdilatation with a pneumatic balloon was necessary in threepatients in the LAP group and in one patient in the OPENgroup 2, 4, 10, and 12 weeks after the operation to relievethe troublesome symptom. Postoperative morbidity was14.5% in the LAP group and 18.2% in the OPEN group.There was no mortality in either group.

The mean duration of the operation was 88 min (range42180) in the LAP group and 57 min (30190) in theOPEN group.

The average hospital stay was 3.2 days (25) in the LAPand 6.4 (415) in the OPEN group and the mean sick leavewas 15.3 (327) and 37.2 (2060) days, respectively.

Fig. 1. Mean pH-% before and after surgery. Fig. 2. Mean LES pressure before and after surgery.

Table 1.Severity of the esophagitis before surgery in the laparoscopic andconventional fundoplication groups (Savary-Miller classification)

Grade ofesophagitis

Type of procedure

Laparoscopic Conventional

I 4 7II 31 32III 19 12IV 1 4Total 55 55

Table 2. Complications during and after laparoscopic and conventionalfundoplication

Complication Laparoscopic Conventional

Esophageal perforation 2 0Intraoperative bleeding 1 0Splenic bleedingand splenectomy 0 2Pneumonia 0 1Subphrenic abscess 0 1Wound infection 0 3

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Follow-up

Ninety-four patients (90%) kept the 3-month follow-up ap-pointment, including 45 patients in the LAP group and 49 inthe OPEN group. Esophagogastroscopy was performed on85 patients. Four patients in the LAP group and five in theOPEN group refused the endoscopy because they werecompletely symptom-free. The endoscopy results were nor-mal in all patients (100%) in the LAP group and in 39patients (89%) in the OPEN group. Likewise, the 24-h pHtracing was normal in 97% (33/34 patients) in the LAPgroup and in 68% (23/34 patients) in the OPEN group (Fig.1). The mean LES pressure increased from 13.7 mmHg to24.7 mmHg (80%) in the LAP group and from 15.1 mmHgto 21.0 mmHg (39%) in the OPEN group (Fig. 2).

During the first 3 months after the operation 18% (8/45patients) of the patients in the LAP group and 16% (8/49patients) in the OPEN group had had dysphagia and 22% ofthe patients in both groups (10/45 patients vs 11/49 patients)had suffered from increased bloating. Two patients in theOPEN group suffered from heartburn and one from upperabdominal pain (Fig. 3). Two patients in the LAP groupsuffered from upper abdominal pain of unknown origin;95% of the patients in the LAP group and 89% in the OPENgroup were subjectively satisfied with the operative result.

One-year follow-up was completed in 48 patients, 18from the LAP group and 30 from the OPEN group. Theresults of endoscopy were normal in all patients (100%) inthe LAP group and in 24/27 patients (88%) in the OPENgroup. The 24-h pH tracing was normal in 16/18 (89%)patients in the LAP group and in 12/16 (75%) patients in theOPEN group (Fig. 1). The results of esophageal manometrywere available for 30 patients, 13 patients in the LAP groupand 17 patients in the OPEN group (Fig. 2). The mean LESpressure in the LAP group was 25.1 mmHg and 20.8 mmHgin the OPEN group.

Four patients in the OPEN group suffered from milddysphagia and two patients experienced bloating; three pa-tients in the LAP group also complained of bloating (Fig. 4).Two patients required continuous medication and one pa-tient had been reoperated later on, all after OPEN proce-

dure. Subjectively all patients in the LAP group and 86% inthe OPEN group were satisfied with the operative result.

Discussion

It is now generally accepted that laparoscopic operationsoffer a good cosmetic result, a short hospital stay, and arapid return to the normal activities. However, in manyintraabdominal operations it still remains to be seen whetherthe postoperative results of a procedure done laparoscopi-cally are as good as the results of open surgery. In the caseof cholecystectomy the benefits of the laparoscopic tech-nique are obvious [3, 17], but when we consider laparo-scopic antireflux surgery the situation is different becausethe question arises as to whether we are really doing thesame operation as in open surgery. We started to performlaparoscopic fundoplications in 1992 and in principle weused the same technique that we used in open surgery. Ourinitial experience [14] with a laparoscopic Nissen fundopli-cation was good and encouraged us to start this randomizedstudy.

The main technical goals of both operations were tocreate a loose and short fundic wrap around the lowermostpart of the esophagus and to anchor it to the esophagocardialjunction with a suture. In the LAP group five patients had tobe converted to open operations, two due to esophagealperforation, which was the most serious technical compli-cation in this group. Both of these patients had severe peri-esophagitis, which made the dissection of the paraesopha-geal space difficult. In both cases the perforation site wasretroesophageal, which is the most common place for thiscomplication [16]. Fortunately the perforations were imme-diately recognized and after conversion the perforationswere sutured and covered with the fundic wrap. The recov-ery period was uneventful in both cases. In open surgeryesophageal perforation is a rare complication [16], butsplenic injury which requires splenectomy occurs in about2% [18]. In this series splenic injury occurred in 3.6% (twopatients).

One of the most common postoperative problems after

Fig. 3. Symptoms 3 months after surgery. Fig. 4. Symptoms 12 months after surgery.

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fundoplication is dysphagia, which is reported to occur in21% of patients after open surgery [5] and is said to be evenhigher after a laparoscopic procedure [2]. Many authorsrecommend routine division of the short gastric vessels inorder to abolish the lateral pull of the esophagus [1]. On theother hand, if one uses the anterior wall of the fundus toconstruct the wrap as described by Gaegea [8], only seldomthere will be tension on the wrap. This is our experiencealso, and division of the short gastrics was necessary in onlyfive patients in both groups. Actually, the question of fundalmobilization is still controversial, as has been shown byLuostarinen et al. [11], who in a randomized study could notfind any advantage from fundal mobilization in reducingpostoperative dysphagia when compared to patients withoutfundal mobilization. In our series during the early postop-erative period there was no difference in the amount ofdysphagia and bloating between the two groups, althoughthe LES pressure was higher after the lapararoscopic opera-tion. The higher LES pressure may be the reason for thebetter results in gastroscopy and pH monitoring in the LAPgroup. These objective differences in the results between thetwo groups mean that the laparoscopic and the open fundo-plication are probably not functionally the same procedure,and the wrap after a laparoscopic operation tends to betighter than after an open procedure, although both opera-tions are performed in principle in the same way.

The results 1 year after the operation were still verygood; all the patients in the LAP group and 86% in theOPEN group were satisfied with the result. Dysphagia andbloating had disappeared in almost all patients, but twopatients in the OPEN group had reflux symptoms andneeded continuous medication. In addition, one patient inthe OPEN group had been reoperated for reflux symptoms.In both groups there was a tendency for the LES pressure todiminish when compared to the result 3 months after theoperation, but this did not have any influence on the symp-toms of the patients or on the results in gastroscopy and pHmonitoring.

The real benefit of laparoscopic fundoplication over theopen procedure was seen in the recovery period. There werefive patients with infectious complications after the OPENoperation but none after the laparoscopic procedure. Themean hospital stay was 3.2 days vs 6.4 days and the meansick leave 15.3 vs 37.2 days, favoring the LAP group. Be-cause most of the patients operated on for gastroesophagealreflux disease are still at work, a rapid recovery period is notonly beneficial to the patient but also to the whole commu-nity.

In conclusion, we feel that a laparoscopic Nissen fun-doplication is a safe and feasible procedure. There are fewcomplications, and the functional results are as good if noteven better than after conventional open surgery, and webelieve that laparoscopic fundoplication is the procedure ofchoice in the treatment of patients offered surgery for gas-troesophageal reflux disease.

References

1. Cadiere CB, Houben JJ, Bruyns J, et al. (1994) Laparoscopic Nissenfundoplication: technique and preliminary results. Br J Surg 81: 400403

2. Collard JM, Gheldere CA, De Kock M, et al. (1994) Laparoscopicantireflux surgery. What is real progress? Ann Surg 220: 146154

3. Cuschieri A, Dubois F, Mouiel J, et al. (1991) The European experi-ence with laparoscopic cholecystectomy. Am J Surg 161: 385387

4. Dallemagne B, Weerts JM, Jehaes C, et al. (1991) Laparoscopic Nis-sen fundoplication: preliminary report. Surg Laparosc Endosc 1: 138143

5. DeMeester TR, Bonavina L, Albertucci M (1986) Nissen fundoplica-tion for gastroesophageal reflux disease. Evaluation of primary repairin 100 consecutive patients. Ann Surg 204: 920

6. Drossman DA (1993) Manual of gastroenterologic procedures. RavenPress, New York

7. Fontaumard E, Espalieu P, Boulez J (1995) Laparoscopic Nissen-Rossetti fundoplication. Surg Endosc 9: 869873

8. Gaegea T (1994) Laparoscopic Nissen-Rossetti fundoplication. SurgEndosc 8: 10801084

9. Hinder RA, Filipi CJ, Wetscher G, et al. (1994) Laparoscopic Nissenfundoplication is an effective treatment for gastroesophageal refluxdisease. Ann Surg 220: 472483

10. Jamieson GG, Watson DI, Britten-Jones R, et al. (1994) LaparoscopicNissen fundoplication. Ann Surg 220: 137145

11. Luostarinen M, Koskinen M, Isolauri J (1996) Effect of fundal mo-bilisation in Nissen-Rossetti fundoplication on oesophageal transit anddysphagia. Eur J Surg 162: 3742

12. Nissen R (1956) Eine einfache Operation zur Beeinflussung de Re-fluxosophagitis. Schweiz Med Wochenschr 86: 590592

13. Nissen R (1961) Gastropexy and fundoplication in the surgical treat-ment of hiatal hernia. Am J Dig Dis 6: 954961

14. Ovaska J, Rantala A, Laine S, Gullichsen R, Hietanen E (1995) Lap-aroscopic Nissen fundoplication. Initial experience. Ann Chir Gynae-col 84: 385389

15. Savary M, Miller G (1977) Der OesophagusLehrbuch und endosko-pischer Atlas. Verlag Gassman Ag, Solothurn, Schwitzerland

16. Schauer PR, Meyers WC, Eubanks S, et al. (1996) Mechanisms ofgastric and esophageal perforations during laparoscopic Nissen fun-doplication. Ann Surg 223: 4352

17. Schirmer BD, Edge SB, Dix J, et al. (1990) Laparoscopic cholecys-tectomy. Treatment of choice for symptomatic cholelithiasis. Ann Surg213: 665677

18. Urschel JD (1993) Complications of antireflux surgery. Am J Surg166: 6870

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Case reports

Laparoscopic removal of a swallowed toothbrush

J. D. Wishner, A. M. Rogers

Department of Surgery, St. Lukes-Roosevelt Hospital Center, 1000 Tenth Avenue, Suite 2B, New York, NY 10019, USA

Received: 20 December 1995/Accepted: 1 March 1996

Abstract. Toothbrush swallowing is an uncommon occur-rence. Unlike most cases of foreign-body ingestion, therehave been no cases of spontaneous passage reported. Con-sequently, prompt removal is recommended before compli-cations develop. We report a case of toothbrush ingestionwhich failed attempted endoscopic removal. This patientwas managed successfully with laparoscopic assisted re-moval via gastrotomy. We recommend this approach for theremoval of any ingested foreign bodies when surgical in-tervention is indicated.

Key words: Foreign body Gastric Toothbrush Laparoscopic

Foreign-body ingestion is a well-recognized problem thatconfronts physicians. Many foreign bodies will pass un-eventfully. Endoscopy or laparotomy may be required tofacilitate removal. In situations which require surgery, thelaparoscopic approach should provide many advantages.We report a case of laparoscopic removal of a swallowedtoothbrush and review the available literature on the curioushistory of toothbrush swallowing.

Case report

A 20-year-old Asian female presented to the emergency room complainingof having swallowed her toothbrush. She stated that she had been attempt-ing to scratch her pharynx with the handle of her toothbrush when aspontaneous gag reflex caused her to swallow the toothbrush. She deniedany pain or other symptoms. She had no known psychiatric history orhistory of bulimia.

A lateral neck and chest X-ray were obtained. No foreign body or otherabnormality was noted. Upper endoscopy was performed immediately fol-lowing the X-ray studies. The toothbrush was easily identified; however,the ends were wedged between the gastric mucosal folds, preventing itsremoval.

Due to the low likelihood of spontaneous passage, the patient was taken

to the operating room for laparoscopic assisted removal of the toothbrush.A pneumoperitoneum was created using a Veress needle and a 10-mmtrocar was placed in the umbilicus. Three additional 10-mm trocars wereplacedone in the right upper quadrant in the midclavicular line, one inthe right upper quadrant in the anterior axillary line, and one in the leftupper quadrant in the midclavicular line. The stomach was grasped with aBabcock clamp and the end of the toothbrush was easily identified as ittented the gastric wall (Fig. 1). Prior to opening the stomach, the nasogas-tric tube was pulled back above the gastroesophageal junction to enable thelower esophageal sphincter to close and facilitate maintenance of the pneu-moperitoneum. A small gastrotomy was made on the anterior wall of thebody of the stomach in this region using the cautery scissors. A Babcockclamp was passed into the stomach and opened to dilate the gastrotomy.The laparoscope was passed into the stomach and the toothbrush wasvisualized. A second Babcock clamp was passed into the stomach, and thetoothbrush was grasped and withdrawn through the trocar (Fig. 2). Thegastrotomy was closed using interrupted 2-0 Vicryl sutures and the proce-dure was completed. The patient was discharged 36 h after the procedureand has recovered uneventfully.

Discussion

Foreign-body ingestion is a common occurrence. Episodeshave been reported as early as 1200B.C. [2]. Although in-gestion may be accidental, as in our patient, associated fac-tors are frequently identified. Alcohol consumption, psychi-atric disorders, and seizure disorders have all been reportedas contributory factors. Bulimia is a recent addition to thelist [7]. A wide variety of objects may be swallowed, butcoins, pins, bones, and razor blades predominate [1, 6].Single or multiple objects may be ingested. In 1928 Chalkand Foucar reported the removal of 2,533 foreign bodiesfrom the stomach of a single patient [1]. The majority ofthese objects were pins, wire, and pieces of glass.

Treatment options for ingested foreign bodies continueto evolve. At the turn of the century, patients were subjectedto emergent laparotomy to remove the objects and preventperforation [4]. This approach can no longer be recom-mended. Recent reports suggest that the majority (80%) offoreign bodies will pass spontaneously if they have reachedthe stomach [6]. In addition, endoscopic techniques can of-ten facilitate removal without surgical intervention. Conse-quently, most patients can be managed without surgery.

The first case of toothbrush ingestion was reported inCorrespondence to:J. D. Wishner, 30 W. 60th Street[ 1H, New York, NY10023, USA

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1882 [4]. This patient did well after successful surgicalremoval via laparotomy and gastrotomy. The first reporteddeath from a toothbrush occurred in 1889 as the result ofgastric perforation 3 days after ingestion [4]. In a recentreview, Kirk and colleagues identified 31 cases of tooth-brush ingestion [5]. No episodes of spontaneous passagewere reported.

In 1983 the first case of successful endoscopic tooth-brush removal was reported [3]. In our case, we found theendoscopic approach unsuccessful due to the size and shapeof the toothbrush. Wilcox and colleagues reported unsuc-cessful attempts at endoscopic removal in two patients forsimilar reasons [7]. In addition, there has been a report ofesophageal perforation during endoscopic toothbrush ex-traction [6].

This is the first reported case of laparoscopic assistedtoothbrush extraction. We proceeded with prompt surgicalintervention after an unsuccessful attempt at endoscopic re-moval. The patient was discharged 36 h after surgery andrecovered uneventfully.

Most gastric foreign bodies pass spontaneously and canbe managed by observation with serial examinations andabdominal radiographs. If these measures fail or are felt tobe inappropriate in a specific ethical situation, endoscopicremoval may be attempted. An ingested toothbrush will not

pass spontaneously, and prompt removal is advised to mini-mize morbidity and avoid a prolonged hospital course. Cau-tious endoscopic removal may be attempted by a skilledendoscopist. It this is not possible, or is unsuccessful, werecommend a laparoscopic approach as an alternative tolaparotomy.

Acknowledgment.The authors would like to thank Jeovanni Rivas for histechnical expertise and assistance in producing the photographs.

References

1. Chalk SG, Foucar HO (1928) Foreign bodies in the stomach. Arch Surg16: 494500

2. Deslypere JP, Praet M, Verdonk G (1984) An unusual case of thetrichobezoar: the Rapunzel syndrome. Am J Gastroenterol 77: 467470

3. Ertan A, Kedia SM, Agrawal NM, et al (1983) Endoscopic removal ofa toothbrush. Gastrointest Endosc 29: 144145

4. Friedenwald AM, Rosenthal LJ (1903) A statistical report of gastroto-mies for removal of foreign bodies from the stomach. NY Med J PhilaMed J: 110123

5. Kirk AD, Bowers BA, Moylan JA, Meyers WC (1988) Toothbrushswallowing. Arch Surg 123: 382384

6. Selivanov V, Sheldon GF, Cello JP, Crass RA (1984) Management offoreign body ingestion. Ann Surg 199: 187191

7. Wilcox DT, Karamanoukian HL, Glick PL (1994) Toothbrush ingestionby bulimics may require laparotomy. J Pediatr Surg 29: 1596

Fig. 1. Toothbrush identified with Babcock clamp. Fig. 2. Toothbrush extraction.

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Technique

A simplified approach to laparoscopic fundoplication

G. S. Ferzli, J. B. Hurwitz, A. Hallak, M. A. Fiorillo, T. Kiel

Department of Laparoendoscopic Surgery, Staten Island University Hospital, 78 Cromwell Ave., Staten Island, NY 10304, USA

Received: 29 March 1996/Accepted: 28 May 1996

AbstractBackground:There is a certain amount of controversy re-garding the need to divide the short gastric vessels (SGV) inlaparoscopic fundoplication for treatment of gastroesopha-geal reflux disease (GERD). In addition, there is often dif-ficulty in identifying the crural fibers when encircling thelower esophagus.Methods:We determine whether it is necessary to divide theSGV by trying to appose the gastric fundus to the anteriorabdominal wall intraoperatively. If this could be done eas-ily, the SGV are preserved. When their division is required,a posterior gastric approach is employed. We have alsofound that the injection of methylene blue into the left cruralfibers anterior to the esophagus is helpful in identifying theleft side when dissection posterior to the gastroesophagealjunction is difficult.Results:Between 1992 and 1995 we performed 20 laparo-scopic fundoplications for GERD. All patients had at leastgrade 3 esophagitis (Savary-Miller scale), increased esoph-ageal exposure to acid (median DeMeester score of 195),and decreased lower esophageal sphincter (LES) pressure.The median operative time was 175 min. There were noconversions to open surgery, and there was no mortality.Three patients developed transient postoperative dysphagiaand one patient had pneumonia. The median hospital staywas 3 days; all patients were free of reflux symptoms atfollow-up ranging from 7 to 42 months.Conclusion:We conclude that the techniques described byus aid in intraoperative decision making and allow laparo-scopic fundoplication to be both simple and effective.

Key words: Laparoscopy Fundoplication Gastro-esophageal reflux disease

Laparoscopic fundoplication was first introduced by Dalle-magne et al. and Geagea in 1991 [3, 6]. A year later, aprospective randomized study documented the superiority

of open surgery over medical treatment in the managementof complicated gastroesophageal reflux disease (GERD)[13]. Many different laparoscopic techniques have been re-ported since that time, with some authors recommendingsystematic, extensive fundal mobilization and other favor-ing preservation of the short gastric vessels (SGV). Wepresent here are methods for determining whether or not todivide the short gastrics intraoperatively, as well as severaltechnical innovations in this procedure.

Patients and methods

All patients referred to our institution for surgical treatment of GERD sinceSeptember 1992 have been considered for the laparoscopic approach. Anumber of preoperative data were collected prospectively: age, gender,prior abdominal surgery, esophagogastroduodenoscopy findings with pa-thology report when biopsies were taken, barium swallow findings, loweresophageal sphincter (LES) pressure and esophageal body mamometry,and Johnson and DeMeester composite score on 24-h pH studies [7].Operative data were: procedure performed, operative time, length of hos-pital stay, complications, and reoperations. Postoperative data were: symp-toms of reflux or dysphagia.

The procedure is performed with the patient under general anesthesia ina supine or modified lithotomy position (lower extremities minimallyflexed at hips and knee joints). A 30 angled scope is used. After theestablishment of pneumoperitoneum, five trocars are inserted in the supra-umbilical, subxiphoid, right midclavicular (subcostal), left anterior axillary(subcostal), and left midclavicular (supraumbilical) positions. Followinginitial exploration, the gastrohepatic ligament is opened. The hepaticbranch of the anterior vagus nerve is preserved. First the right and then theleft crura are exposed by incising the covering parietal peritoneum. Thegastroesophageal junction (GEJ) is retracted anteriorly, and the crura arefurther delineated by stripping the loose fatty areolar tissue caudad. Hiatalhernia is reduced if found. The posterior vagus is identified and preserved.

Anteriorly, the phrenogastric ligament is incised from the left border ofthe GEJ to the first short gastric vessel. An attempt is then made to encirclethe esophagus by dissecting posteriorly from the right side. If this provesdifficult, which is often the case in obese patients, methylene blue isinjected into the left crural fibers anterior to the esophagus (Fig. 1). As thedye tracks posteriorly it aids greatly in identifying the left side from below.After the esophagus has been freed posteriorly, a Penrose drain is passedaround it. This facilitates later passage of instruments and the fundal wrapbehind the GEJ.

At this point the need to divide the SGV is assessed by trying toapproximate the anterior gastric fundus to the abdominal wall (Fig. 2). Thedistance needed to reach the anterior abdominal wall is equal to the dis-tance required to perform the wrap without tension. If this can be accom-Correspondence to:G. S. Ferzli

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plished easily and without tension, the SGV are preserved; otherwise theyare taken. If the vessels must be divided, a window is opened in thegastrocolic ligament to retract the stomach anteriorly. This maneuverplaces the short gastric vessels in a vertical plane, which in our opinionallows a more controlled approach with less chance of splenic injury (Fig.3). Vessels are transected until the fundal lift to the abdominal wall can beperformed.

Finally, the fundus is passed behind and around the GEJ, retracting itlaterally to expose both crura. The hiatus is closed with interrupted non-absorbable sutures after passing a 5260 French bougie in the esophagus.A 360 circumferential loose wrap 1 to 2 cm long is then fashioned withnonabsorbable interrupted sutures tied intracorporeally.

Results

Between September 1992 and August 1995, 20 nonselectedconsecutive laparoscopic fundoplications were performed atour institution. There were 12 males and eight females, witha median age of 46 years (2175). None had undergone anyprior abdominal surgery. All patients were symptomatic,with common complaints of heartburn (19) and regurgita-tion (16); four had dysphagia and two persistent upperrespiratory tract symptoms. All had grade 3 or higher esoph-agitis, using the Savary-Miller scale [12]. Three patients hadBarretts esophagus, but none had dysplasia on multiplebiopsies. The medial DeMeester composite score on 24-hpH studies was 165, and the median LES pressure was 6mmHg on manometry. None had grossly abnormal esoph-ageal body motility.

Division of short gastric vessels along with complete

division of the gastrophrenic membrane was necessary in16; no vessels were divided in four, but a complete dissec-tion of the gastrophrenic membrane and the posterior at-tachments of the gastric fundus was always performed. Themedian operative time 175 min (90405). The median hos-pital stay was 3 days (16). There was no mortality. Onepatient developed postoperative pneumonia, which was suc-cessfully treated with intravenous antibiotics. Dysphagiadeveloped in three patients (15%) but resolved spontane-ously within 6 weeks after surgery in every case. All pa-tients are currently free of reflux symptoms, with follow-upsranging from 7 to 42 months.

Discussion

Comparative studies have demonstrated that laparoscopicfundoplication produces faster recovery [9, 10], shorter hos-pital stay [1, 9, 10], lower cost [9], and, most important,similar outcome [1], when compared with open surgery.Controversies regarding complete vs incomplete wraps andpreservation vs division of the short gastric vessels are stillbeing resolved.

A randomized trial from Sweden comparing Nissen(360 wrap) with Toupet (270 wrap) in open surgery re-ported superior functional results for the Toupet [15]. Thishas not, however, been supported by other studies [2]. Noprospective randomized trials have yet compared laparo-

Fig. 1. Injection of methylene blue into the crural fibers.

Fig. 2. Assessment of fundal mobility by lifting to theanterior abdominal wall.

Fig. 3. Posterior approach to division of the short gastricvessels.

489

scopic Nissen with laparoscopic Toupet, although a retro-spective review showed an increased delay in resumption ofnormal swallowing in the Nissen group [8]. The reportedincidence of successful reflux symptom relief and of post-operative dysphagia were similar in different series of Tou-pet and Nissen fundoplications. In light of the above data,we felt that the only strong contraindication to a Nissenwould be significant aperistaltic simultaneous contractionson preoperative esophageal manometry. Since these werenot present in any of our patients, we elected to perform acomplete wrap on all.

There are of course proponents both for and againstdivision of the short gastric vessels [4, 11], although there isprobably a consensus that the ideal fundoplication should beloose and without tension. Worldwide, a slightly greaternumber of laparoscopic fundoplications are done with divi-sion of the vessels than without, but there seems to be nodemonstrable advantage for either procedure. We thereforedeveloped the method described earlier for making this de-cision intraoperatively. The lift of the fundus to the anteriorabdominal wall proved to be a quick and reliable test fordetermining whether an appropriately loose wrap could bestbe fashioned with or without transection of the short gastricvessels.

The posterior gastric approach originally described forlaparoscopic splenectomies [5] was found to aid greatly inthe safety and speed of dividing these vessels if necessary,particularly when used in combination with ultrasonic co-agulating shears [14]. The posterior approach also allowsfor a better mobilization of the gastric fundus by totallyfreeing the gastrophrenic membrane and allowing direct ac-cess to the short gastric vessels that are most cephalad. Thispermits vessel division to proceed in a craniocaudad direc-tion so that the need for extensive division of vessels in theregion of the splenic hilum (which occurs in the traditionalanterior anesthesia) is obviated. Short gastric vessel divisionin mostly limited to one or two vessels.

We believe that the hiatus should be routinely closedaround a 5260 French bougie placed inside the esophagus.As noted by Watson et al., this closure may reduce theincidence of acute and chronic paraesophageal herniation[16]. Secure identification of crural fibers is necessary toaccomplish this, and the injection of methylene blue intothese fibers in difficult cases may reduce the risk of poste-rior gastric injury, pneumothorax, or esophageal perfora-tion. The surgeon simply stays inferior and anterior to theleft crus along the blue-tinged fibers.

By adopting strict indications for surgery, and by fol-lowing the methods outlined above, we feel that we haveachieved results comparing favorably with those from largerseries, while considerably simplifying intraoperative deci-sion-making.

Conclusion

Laparoscopic fundoplication is becoming increasingly em-ployed on the basis of two facts: the recognition that sur-gical as opposed to medical management offers superiorresults in the treatment of GERD, and the recognition thatlaparoscopy can attain outcomes equivalent to those of opensurgery, with the benefits of a minimally invasive proce-dure. We believe that the simple and efficient operativeapproach we have outlined above, combined with adherenceto strict operative indications, will enable the growth of thisprocedure to continue.

References

1. Collard JM, DeGheldere CA, DeKock M, Otte J, Kestens PJ (1994)Laparoscopic antireflux surgery: what is real progress? Ann Surg 220:146154

2. Crookes PF, DeMeester TR (1994) Does Toupet fundoplication out-perform the Nissen procedure as the operation of choice for gastro-esophageal reflux disease? Dis Esophagus 7: 265267

3. Dallemagne B, Weerts JM, Jehaes C, Markiewicz S, Lombard R(1991) Laparoscopic Nissen fundoplication: preliminary report. SurgLaparosc Endosc 1: 138143

4. DeMeester TR, Bonavina L, Albertucci M (1986) Nissen fundoplica-tion for gastro-esophageal reflux disease. Ann Surg 204: 920

5. Ferzli G, Fiorillo M (1995) A posterior gastric approach to laparo-scopic splenectomy. Surg Endosc 9: 10171019

6. Geagea T (1991) Laparoscopic Nissens fundoplication: preliminaryreport on ten cases. Surg Endosc 5: 170173

7. Johnson LF, DeMeester TR (1974) 24-Hour pH monitoring of thedistal esophagus: a quantitative measure of gastroesophageal reflux.Am J Gastroenterol 62: 325332

8. McKernan JB (1994) Laparoscopic repair of gastroesophageal refluxdisease: Toupet partial fundoplication versus Nissen fundoplication.Surg Endosc 8: 851856

9. Peters JH, Heimbucher J, Kauer WKH, Incarbone R, Bremner CG,DeMeester TR (1995) Clinical and physiologic comparison of laparo-scopic and open Nissen fundoplication. J Am Coll Surg 180: 385393

10. Rattner DW, Brooks DC (1995) Patient satisfaction following laparo-scopic and open antireflux surgery. Arch Surg 130: 289294

11. Rossetti M, Hell K (1977) Fundoplication for the treatment of gastro-esophageal reflux in hiatal hernia. World J Surg 1: 439444

12. Savary M, Miller G (1977) Gassman AG (ed) Der oesophagus, lehr-buch and endoskopischer Atlas. Solothurn, Switzerland

13. Spechler SJ (1992) Comparison of medical and surgical therapy forcomplicated gastroesophageal reflux disease in veterans. N Engl J Med326: 786792

14. Swanstrom LL, Pennings JL (1995) Laparoscopic control of shortgastric vessels. J Am Coll Surg 181: 347351

15. Thor KBA, Silander T (1989) Long-term randomized prospective trialof the Nissen procedure versus a modified Toupet technique. Ann Surg210: 719724

16. Watson DI, Jamieson GG, Devitt PG, Matthew G, Britten-Jones RE,Game PA, Williams RS (1995) Changing strategies in the performanceof laparoscopic Nissen fundoplication as a result of experience with230 operations. Surg Endosc 9: 961966

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Laparoscopic closure of esophageal perforation following pneumaticdilatation for achalasia

Report of two cases

R. C. W. Bell

Center for Advanced Endoscopic Surgery, 799 East Hampden, Suite 420, Englewood, CO 80110, USA

Received: 28 December 1995/Accepted: 24 April 1996

Abstract. Esophageal perforation following pneumatic di-lation of the esophagus is normally recognized shortly afterthe event. Two patients with esophageal perforation wererepaired utilizing a transabdominal laparoscopic techniquewith suture closure of the perforation, contralateral Hellermyotomy, and Toupet posterior partial fundoplication. Pa-tients recovered excellently, were started on liquids within 3days of surgery, and were discharged shortly thereafter. De-tails of the procedure are presented. This minimally invasiveapproach is well tolerated and appropriate in selected pa-tients.

Key words: Laparoscopic surgery Achalasia Pneu-matic dilatation Esophageal perforation

Perforation following pneumatic dilation of the esophagusfor achalasia occurs with a frequency of 015% [3]. Treat-ment of contained perforations may be conservative; butfree perforations typically require immediate surgical inter-vention [1, 2, 4, 10]. Surgical intervention most commonlyconsists of closure of the perforation with a contralateralmyotomy and, when indicated by the extent of the myoto-my, an antireflux procedure.

Video-endoscopic surgical techniques have been proveneffective in performing esophageal myotomy and antirefluxprocedures. A single case report of a videothoracic approachto esophageal perforation after pneumatic dilation demon-strated a favorable outcome [7]. To our knowledge, a trans-abdominal video-endoscopic approach to this type of esoph-ageal perforation has not previously been reported. We de-scribe here the treatment of two patients with esophagealperforation using an abdominal laparoscopic approach.

Case reports and surgical technique

Case 1

The first patient was a 49-year-old, 215-lb male with a 10-year history ofdysphagia. Achalasia was diagnosed 5 years previously, and confirmed byesophageal motility studies. Two prior pneumatic dilations had partiallysucceeded, but the patient persisted with grade 2 of 3 dysphagia (able to eatonly minced foods), grade 3 of 3 heartburn (severe, disruptive), and grade2 of 3 regurgitation (frequent). Pneumatic dilation for the third time to 35mm was performed. The patient immediately complained of chest pain, andblood was observed on the dilator. Gastrograffin esophagram showed freeextravasation into the mediastinum from the distal esophagus on anteriorposterior projection. Following intravenous antibiotic administration, thepatient was taken to surgery. The patient underwent a laparoscopic trans-abdominal repair of the distal esophageal perforation, which was 4 cm longand on the posterolateral aspect of the distal esophagus. A contralateralmyotomy was performed extending 5 cm on the esophagus and 1 cm ontothe stomach, sparing the anterior vagus nerve. A Toupet posterior fundo-plication was then performed. Operative time was 210 min and blood losswas minimal.

A gastrograffin swallow the following day demonstrated no leakagefrom the esophagus and prompt gastric emptying; the nasogastric tube wastherefore removed. Liquids were begun on postoperative day 2, and thepatient was discharged postoperative day 7 eating solid foods. Chest X-rayrevealed a left basilar pulmonary process which did not require thoracen-tesis. Intravenous antibiotics were administered until discharge.

At 6-month follow-up the patient has no dysphagia and no heartburn.Postoperative motility demonstrated an aperistaltic esophagus, with a mid-respiratory lower esophageal sphincter pressure (LESP) of 11 mmHg (nor-mal midrespiratory LESP is >12 mmHg); 24-h pH testing demonstrated nopathologic reflux.

Case 2

The patient was a 42-year-old, 180-lb male admitted to the hospital with a3-month history of progressive dysphagia and a 10-lb weight loss. He hadgrade 3 of 3 dysphagia (liquids only), grade 3 heartburn, and grade 2regurgitation. Barium esophagram on admission showed a classic birdsbeak distal esophagus. The patient underwent a pneumatic dilation to 35mm with a Rigiflex balloon. Postdilation esophagram showed a 2-cm con-tained perforation of the distal esophagus on the anteriorposterior projec-tion. Intravenous antibiotics were promptly administered and oral intake

Correspondence to:R. C. W. Bell, South Surgical Group, P.C., 499 EastHampden, Suite 210, Englewood, CO 80110, USA

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was restricted. However, within 6 h the patient complained of severe chestpain and dyspnea, and a decision was made to operate.

A transabdominal laparoscopic approach was used. A small mediastinalabscess was found and cultured. The perforation was 3 cm long, on thelateral aspect of the distal esophagus. Following closure and contralateralHeller myotomy (5 cm of distal esophagus, extended 1.5 cm onto thestomach), a posterior Toupet fundoplication was performed. Operativetime was 135 min.

The postoperative course was similar to case 1, but the patient wasdischarged on postoperative day 4 on oral antibiotics (ciprofloxacin, met-ronidazole, and fluconazole). At 1-month follow-up the patient is free ofdysphagia and reports no heartburn. Postoperative esophageal motilityshowed an aperistaltic esophageal body with a resting midrespiratory loweresophageal sphincter pressure of 7 mmHg; 24-h pH test was normal and atonly 2% of the time demonstrated acid reflux (Johnson-DeMeester score of9.9, normal < 22).

Surgical technique

The patient is placed in lithotomy position as for antireflux surgery, withthe surgeon between the legs. Trocar placement is outlined in Fig. 1. It isimportant to place the trocars as high as possible to facilitate suture place-ment in the thoracic esophagus. The diaphragmatic hiatus is dissected andthe esophagus is isolated circumferentially. The posterior phreno-esophageal membrane is divided to facilitate full mobilization of the distalesophagus, enabling visualization of the linear tear in the esophagus on theleft posterior aspect. A thorough dissection of the distal 6 cm of esophagusis performed. A nasal Levene tube may be gently inserted at this time, andits passagejust past the perforation is observed. The proximal extent of theperforation is identified.

The perforation is closed with a running suture of 3-0 PDS (Ethicon,USA), placing the first suture above the proximal extent of the perforation.Monofilament is preferable in a running suture, as a running suture isdifficult to follow laparoscopically and braided sutures bind up. Asingle layer is sufficient. After closure, air is insufflated into the Levenetube while the distal esophagus is immersed in irrigation to check for anyfurther leakage, which would be evidenced by air bubbling.

A Heller myotomy is then performed on the right anterior aspect of theesophagus. Gentle dissection of the mucosa from muscularis is performed,

taking care to stay away from the area of perforation. The myotomy maybe extended onto the proximal stomach. Again, an air insufflation test isperformed to check for any leakage from the esophagus. The short gastricvessels are divided. Ultrasonic shears (Ultracision, USA) facilitate thisdissection greatly. The posterior crura are reapproximated if needed. Aposterior fundoplication in the manner of Toupet is performed, suturing theedges of the myotomy to the limits of the plicated stomach over a lengthof 4 cm [9] (Fig. 2). This has the advantage of covering the closed esoph-ageal perforation with a gastric serosal patch. A closed suction drain isplaced into the mediastinum, and the procedure is completed by fascial andskin closure.

The patient is kept on antibiotics postoperatively as appropriate for thedegree of contamination. A gastrograffin swallow on postoperative day 1to evaluate the esophagus and gastric emptying will permit early removalof the Levene tube and resumption of a liquid diet. A pleural effusion is notuncommon, and may be observed without thoracentesis if the patient isclinically without evidence of infection. Discharge can be anticipatedwithin 35 days when the patient remains afebrile, has a normal whiteblood cell count, and is tolerating a full liquid diet.

Discussion

The approach to esophageal perforation following pneu-matic balloon perforation for achalasia depends on the se-verity of the perforation. All free perforations and containedperforations which progress clinically should be treated sur-gically. The location of the perforation is typically the leftposterior distal esophagus. Therefore both anterior and lat-eral projections of gastrograffin swallow are necessary tocompletely define the area of perforation. Full-thicknessperforations tend to begin within a centimeter of the squa-mocolumnar junction and extend proximally from a fewmillimeters to as much as 10 cm.

Early recognition of the perforation and prompt surgicalintervention within 1624 h allows successful primary clo-

Fig. 1. Trocar placement. Theports should be placed high inthe abdomen to allow adequateaccess to the mediastinalesophagus.

Fig. 2. The completed Toupetfundoplication with anteriormyotomy.

477

sure in the majority of instances without the need for mus-cular flaps or esophageal exclusion. Patients with evidenceof shock, respiratory failure, or advanced mediastinitis mayrequire more than simple primary closure [5, 6, 8]. The mostcommon open surgical approach has been transthoracic.However, the excellent visualization of the distal thoracicesophagus provided by transabdominal laparoscopy makesthe distal 67 cm of the esophagus amenable to a transab-dominal laparoscopic approach. Our experience with elec-tive transabdominal laparoscopic esophageal myotomy forachalasia, and the finding in these two patients of gastro-graffin swallow confirmation that the leak was limited to thedistal 45 cm of esophagus, led us to use this approach, andthere were excellent results.

The laparoscopic approach to this type of esophagealperforation has the advantagecompared to a thoraco-scopic approachof allowing a partial fundoplication to becreated with ease. The partial fundoplication creates a gas-tric serosal patch over the closed esophageal tear. Definitivetreatment of the inciting condition (achalasia) is permittedby laparoscopic performance of the myotomy with con-comitant fundoplication, diminishing the risk of postmy-otomy reflux. Additionally, the anatomic orientation is fa-miliar to the laparoscopist experienced in esophageal refluxsurgery, whereas the transthoracic anatomy may not be sofamiliar.

Proximal exposure of the lower esophagus is adequatefor a good 67 cm, which will enable the great majority ofballoon dilation associated esophageal perforations to bemanaged laparoscopically. However, the esophagram mustbe carefully evaluated with regard to the proximal extent ofthe disruption to select this approach. A transthoracic ap-proach should probably be used if the tear extends morethan about 5 cm proximally or if there is gross extravasationof contrast into the left pleural space. Adequate visualiza-tion of the posterior esophagus is available laparoscopicallyby gentle rotation of the esophagus, so the location of thetear on the circumference of the esophagus is not an issue indeciding upon this approach.

Conclusion

Esophageal perforation following pneumatic dilation of theesophagus for achalasia can be managed successfully with atransabdominal laparoscopic approach. Barium swallow toevaluate the proximal extent of the perforation is importantto determining the feasibility of this approach, which isappropriate for the majority of perforations limited to thedistal 5 cm of the esophagus. Circumferential dissection ofthe esophagus enables proper exposure of the perforation,which can then be closed with a running suture laparoscopi-cally. If desired, a contralateral myotomy or posterior fun-doplication can then be performed. This minimally invasiveapproach is well tolerated and appears to be safe in properlyselected patients.

Reference

1. Arrigoni E, Dederding JP, Baumann R, de Peyer R, Loizeau E (1991)Conservative treatment of esophageal perforations following pneu-matic dilatation. Schweiz Med Wochenschr 121: 793796

2. Cameron J, Kieffer RF, Hendrix TR, Mehigan DG, Baker RR (1978)Selective nonoperative management of contained intrathoracic disrup-tions. Ann Thoracic Surg 27: 404

3. Castell DO (1995) The Esophagus. 2nd ed. Little, Brown, Boston4. Michel L, Grillo HC, Malt RA (1981) Operative and nonoperative

management of esophageal perforations. Ann Surg 194: 575. Miller RE, Tiszenkel HI (1988) Esophageal perforation due to pneu-

matic dilation for achalasia. Surg Gynecol Obstet 166: 4584606. Nair LA, Reynolds JC, Parkman HP, Ouyang A, Strom BL, Rosato EF,

Cohen S (1993) Complications during pneumatic dilation for achalasiaor diffuse esophageal spasm. Analysis of risk factors, early clinicalcharacteristics, and outcome. Dig Dis Sci 38: 18931904

7. Nathanson LK, Gotley D, Smithers M, Branicki F (1993) Videotho-racoscopic primary repair of early distal oesophageal perforation. AustN Z J Surg 63: 399403

8. Schwartz HM, Cahow CE, Traube M (1993) Outcome after perforationsustained during pneumatic dilatation for achalasia. Dig Dis Sci 38:14091413

9. Swanstrom LL, Pennings J (1995) Laparoscopic esophagomyotomyfor achalasia. Surg Endosc 9: 286290

10. Swedlund A, Traube M, Siskind BN, McCallum RW (1989) Nonsur-gical management of esophageal perforation from pneumatic dilatationin achalasia. Dig Dis Sci 34: 379384

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Consensus statement

Laparoscopic antireflux surgery for gastroesophageal refluxdisease (GERD)

Results of a Consensus Development Conference

Held at the Fourth International Congress of the European Association for Endoscopic Surgery(E.A.E.S.), Trondheim, Norway, June 2124, 1996

Conference Organizers: E. Eypasch,1 E. Neugebauer2 with the support of F. Fischer1 and H. Troidl 1

for the Scientific and Educational Committee of the European Association for Endoscopic Surgery (E.A.E.S.)

Expert Panel: A. L. Blum, Division de Gastro-Enterologie, Centre Hospitalier, Universitaire Vaudois (CHUV)Lausanne (Switzerland);D. Collet, Department of Surgery, University of Bordeaux, (France);A. Cuschieri, Departmentof Surgery, Ninewells Hospital and Medical School, University of Dundee, Dundee, Scotland (U.K.);B. Dallemagne,Department of Surgery, Saint Joseph Hospital, Lie`ge (Belgium);H. Feussner,Chirurgische Klinik u. Poliklinik rechtsder Isar, Universitat Munchen, Munchen (Germany);K.-H. Fuchs, Chirurgische Universitatsklinik und PoliklinikWurzburg, Universitat Wurzburg, Wurzburg (Germany);H. Glise, Department of Surgery, Norra A lvsborgsLanssjukhus, Trollhattan (Sweden);C. K. Kum, Department of Surgery, National University Hospital, Singapore;T.Lerut, Department of Thoracic Surgery, University Hospital Leuven, Leuven (Belgium);L. Lundell, Department ofSurgery, Sahlgrens Hospital, University of Go teborg, Go teborg (Sweden);H. E. Myrvold, Department of Surgery,Regionsykehuset, University of Trondheim, Trondheim (Norway);A. Peracchia,Department of Surgery, University ofMilan, School of Medicine, Milan (Italy);H. Petersen,Department of Medicine, Regionsykehuset, University ofTrondheim, Trondheim (Norway);J. J. B. van Lanschot,Academisch Ziekenhuis, Department of Surgery, University ofAmsterdam, Amsterdam (Netherlands) Representative of Prof. Dr. Tytgat (Netherlands)

1 Surgical Clinic Merheim, II Department of Surgery, University of Cologne, Ostermerheimer Str. 200, 51109 Cologne, Germany2 Biochemical and Experimental Division, II Department of Surgery, University of Cologne, Ostermerheimer Str. 200, 51109 Cologne, Germany

Received: 29 November 1996/Accepted: 14 December 1996

AbstractBackground:Laparoscopic antireflux surgery is currently agrowing field in endoscopic surgery. The purpose of theConsensus Development Conference was to summarize thestate of the art of laparoscopic antireflux operations in June1996.Methods:Thirteen internationally known experts in gastro-esophageal reflux disease were contacted by the conferenceorganization team and asked to participate in a ConsensusDevelopment Conference. Selection of the experts wasbased on clinical expertise, academic activity, communityinfluence, and geographical location. According to the cri-teria for technology assessment, the experts had to weighthe current evidence on the basis of published results in theliterature. A preconsensus document was prepared and dis-tributed by the conference organization team. During theE.A.E.S. conference, a consensus document was prepared in

three phases: closed discussion in the expert group, publicdiscussion during the conference, and final closed discus-sion by the experts.Results:Consensus statements were achieved on variousaspects of gastroesophageal reflux disease and current lap-aroscopic treatment with respect to indication for operation,technical details of laparoscopic procedures, failure of op-erative treatment, and complete postoperative follow-upevaluation. The strength of evidence in favor of laparoscop-ic antireflux procedures was based mainly on type II studies.A majority of the experts (6/10) concluded in an overallassessment that laparoscopic antireflux procedures werebetter than open procedures.Conclusions:Further detailed studies in the future withcareful outcome assessment are necessary to underline theconsensus that laparoscopic antireflux operations can berecommended.

Key words: Consensus development conferences Lapa-roscopic antireflux operations Outcome assessmentCorrespondence to:E. Neugebauer

SurgicalEndoscopy

Springer-Verlag New York Inc. 1997Surg Endosc (1997) 11: 413426

In the last 2 years, growing experience and enormous tech-nical developments have made it possible for almost anyabdominal operation to be performed via endoscopic sur-gery. Laparoscopic cholecystectomy, appendectomy, andhernia repair have been going through the characteristic lifecycle of technological innovations, and cholecystectomy, atleast, seems to have proven a definitive success. To evaluatethis life cycle, consensus conferences on these topics havebeen organized and performed by the E.A.E.S. [76b].

Currently, the interest of endoscopic abdominal surgeryis focusing on antireflux operation. This is documented byan increasing number of operations and publications in theliterature. The international societies such as the EuropeanAssociation for Endoscopic Surgery (E.A.E.S.) have the re-sponsibility to provide a forum for discussion of new de-velopments and to provide guidelines on best practice basedon the current state of knowledge. Therefore, a consensusdevelopment conference on laparoscopic antireflux surgeryfor gastroesophageal reflux disease (GERD) was held,which included discussion of some pathophysiological as-pects of the disease. Based on the experience of previousconsensus conferences (Madrid 1994), the process of theconsensus development conference was slightly modified.The development process was concentrated on one sub-jectreflux diseaseand during the 4th InternationalMeeting of the E.A.E.S., a long public discussion, includingall aspects of the consensus document, was incorporatedinto the process.

The methods and the results of this consensus confer-ence are presented in this comprehensive article.

Methods

At the Annual Meeting in Luxemburg in 1995, the jointsession of the Scientific and Educational Committee of theE.A.E.S. decided to hold a Consensus Development Con-ference (CDC) on laparoscopic antireflux surgery for gas-troesophageal reflux disease. The 4th International Con-gress of the E.A.E.S. in June 1996 in Trondheim should bethe forum for the public discussion and finalization of theConsensus Development Conference.

The Cologne group (E. Neugebauer, E. Eypasch, F.Fischer, H. Troidl) was authorized to organize the CDCaccording to general guidelines. The procedure chosen wasthe following: A small group of 13 internationally knownexperts was nominated by the Scientific Committee of theE.A.E.S. The criteria for selection were

1. Clinical expertise in the field of endoscopic surgery2. Academic activity3. Community influence4. Geographical location

Internationally well-known gastroenterologists were askedto participate in the conference in the interest of a balanceddiscussion between internists and surgeons.

Prior to the conference, each panelist received a docu-ment containing guidelines on how to estimate the strengthof evidence in the literature for specific endoscopical pro-cedures and a document containing descriptions of the lev-els of technology assessment (TA) according to Mosteller

and Troidl [190a]. Each panelist was asked to indicate whatlevel of development, in his opinion, laparoscopic antirefluxsurgery has attained generally, and he was given a formcontaining specific TA parameters relevant to the endo-scopic procedure under assessment. In this form, the pan-elist was asked to indicate the status of the endoscopic pro-cedure in comparison with conventional open proceduresand also to make a comparison between surgical and medi-cal treatment of gastroesophageal reflux disease. The pan-elists view must have been supported by evidence in theliterature, and a reference list was mandatory for each item.Each panelist was given a list of relevant specific questionspertaining to each procedure (indication, technical aspects,training, postoperative evaluation, etc.). The panelists wereasked to provide brief answers with references. Guidelinesfor response were given and the panelists were asked tosend their initial evaluation back to the conference organiz-ers 3 months prior to the conference.

In Cologne, the congress organization team analyzed theindividual answers and compiled a preconsensus provi-sional document.

In particular, the input and comments of gastroenterolo-gists were incorporated to modify the preconsensus docu-ment.

The preconsensus documents were posted to each pan-elist prior to the Trondheim meeting. During the Trondheimconference, in a 3-h session, the preconsensus documentwas scrutinized word by word and a version to be presentedin the public session was prepared. The following day, a 2-hpublic session took place, during which the text and thetables of the consensus document were read and discussedin great detail. A further 2-h postconference session of thepanelists incorporated all suggestions made during the pub-lic session. The final postconsensus document was mailedto all expert participants, checked for mistakes and neces-sary corrections and finalized in September 1996. The fulltext of the statements is given below.

Consensus Statements on Gastroesophageal RefluxDisease (GERD)

1. What are the epidemiologic facts in GERD?

In western countries, gastroesophageal reflux has a highprevalence. In the United States and Europe, up to 44% ofthe adult population describe symptoms characteristic ofGERD [124, 127, 242]. Troublesome symptoms character-istic of GERD occur in 1015% with equal frequency inmen and women. Men, however, seem to develop refluxesophagitis and complications of esophagitis more fre-quently than women [23].

Data from the literature indicate that 1050% of thesesubjects will need long-term treatment of some kind fortheir symptoms and/or esophagitis [34, 195, 225, 242].

The panelists agreed that the natural history of the dis-ease varies widely from very benign and harmless reflux toa disabling stage of the disease with severe symptoms andmorphological alterations. There are no good long-term dataindicating how the natural history of the disease changes

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from one stage to the other and when and how complica-tions (esophagitis, stricture, etc.) develop.

Topics which were the subject of considerable debatebut which could not be resolved during this conference arelisted here [8, 11, 23, 28, 68]:

c The cause of the increasing prevalence of esophagitisc The cause of the increasing prevalence of Barretts

esophagus and adenocarcinomac The discrepancy between clinically and anatomically de-

termined prevalence of Barretts esophagusc The problem of ultrashort Barretts esophagus and its

meaningc The relationship betweenHelicobacter pylori infection

and reflux esophagitisc Gastroesophageal reflux without esophagitis and abnor-

mal sensitivity of the esophagus to acidc The role of so-called alkaline reflux, which is currently

difficult to measure objectively

2. What is the current pathophysiological conceptof GERD?

GERD is a multifactorial process in which esophageal andgastric changes are involved [27, 65, 98, 251, 283].

Major causes involved in the pathophysiology are in-competence of the lower esophageal sphincter expressed aslow sphincter length and pressure, frequent transient loweresophageal sphincter relaxations, insufficient esophagealperistalsis, altered esophageal mucosal resistance, delayedgastric emptying, and antroduodenal motility disorders withpathologic duodenogastroesophageal reflux [27, 65, 92, 95,134, 251, 283].

Several factors can play an aggravating role: stress, pos-ture, obesity, pregnancy, dietary factors (e.g., fat, chocolate,caffeine, fruit juice, peppermint, alcohol, spicy food), anddrugs (e.g., calcium antagonists, anticholinergics, theophyl-line, b-blockers, dihydropyridine). All these factors mightinfluence the pressure gradient from the abdomen to thechest either by decreasing the lower esophageal sphincter orby increasing abdominal pressure.

Other parts of the physiological mosaic that might con-tribute to gastroesophageal reflux include the circadianrhythm of sphincter pressure, gastric and salivary secretion,esophageal clearance mechanisms, as well as hiatal herniaandHelicobacter pyloriinfection.

3. What is a useful definition of the disease?

A universally agreed upon scientific classification of GERDis not yet available. The current model of gastroesophagealreflux disease sees it as an excessive exposure of the mu-cosa to gastric contents (amount and composition) causingsymptoms accompanied and/or caused by different patho-physiological phenomena (sphincter pressure, peristalsis)leading to morphological changes (esophagitis, cell infiltra-tion) [65, 98].

This implies an abnormal exposure to acid and/or othergastric contents like bile and duodenal and pancreatic juicein cases of a combined duodenogastroesophageal reflux.

GERD is frequently classified as a synonym for esoph-agitis, even though there is considerable evidence that only60% of patients with reflux disease sustain damage of theirmucosa [8, 91, 150, 200, 231, 243]. The MUSE and Savaryesophagitis classifications are currently used to stage dam-age, but they are poor for staging the disease [8].

The modified AFP Score (Anatomy-Function-Pathology) is an attempt to incorporate the presence of hia-tus hernia, reflux, and macroscopic and morphologic dam-age into a classification [83]. However, this classificationlacks symptomatology and should be linked to a scoringsystem for symptoms or quality of life; both scoring systemsare extremely important for staging of the disease and forthe indication for treatment [195a,b].

4. What establishes the diagnosis of the disease?

A large variety of different symptoms are described in thecontext of gastroesophageal reflux disease, such as dyspha-gia, pharyngeal pain, hoarseness, nausea, belching, epigas-tric pain, retrosternal pain, acid and food regurgitation,retrosternal burning, heartburn, retrosternal pressure, andcoughing. The characteristic symptoms are heartburn(retrosternal burning), regurgitation, pain, and respiratorysymptoms [150, 204]. Symptoms are usually related to pos-ture and eating habits.

In addition, typical reflux patients may have symptomswhich are not located in the region of the esophagus. Pa-tients with heartburn may or may not have pathologicalreflux. They may have reflux-type nonulcer dyspepsia orother functional disorders.

The diagnostic tests that are needed must follow a cer-tain algorithm. After the history and physical examinationof the patients, an upper gastrointestinal endoscopy is per-formed. A biopsy is taken if any abnormalities (stenosis,strictures, Barretts, etc.) are found [8].

If no morphologic evidence can be detected, only func-tional studies, e.g., measuring the acid exposure in theesophageal lumen by 24-h esophageal pH monitoring, arehelpful and indicated to detect excessive reflux [65]. It is ofvital importance that the pH electrode be accurately posi-tioned in relation to the lower esophageal sphincter (LES).Manometry is the only objective way to assess the locationof the LES.

Ordinary esophageal radiologic studies (barium swal-low) are considered another mandatory basic imaging study[105a].

At the next level of investigation there are a number oftests that look for the cause of pathologic reflux usingesophageal manometry as a basic investigative tool for thispurpose to assess lower esophageal sphincter and esopha-geal body function [27, 65, 91, 134, 283]. Video esopha-gography or esophageal emptying scintigraphy may also behelpful.

Optional gastric function studies are 24-h gastric pHmonitoring, photo-optic bilirubin assessment to assess duo-denogastroesophageal reflux, gastric emptying scintigraphy,and antroduodenal manometry [81, 93, 95, 118, 146, 234].

Currently these gastric function studies are of scientific

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interest but they do not yet play a role in overall clinicalpatient management, apart from selected patients. The di-agnostic test ranking order is displayed in Table 1.

5. What is the indication for treatment?

Pivotal criteria for the indication to medical treatment ingastroesophageal reflux disease are the patients symptoms,reduced quality of life, and the general condition of thepatient. When symptoms persist or recur after medication,endoscopy is strongly indicated.

Mucosal damage (esophagitis) indicates a strong needfor medical treatment. If the symptoms persist, partiallypersist, or recur after stopping medication, there is a goodindication for doing functional studies. Gastrointestinal en-doscopy, already mentioned as the basic imaging examina-tion in GERD, should be performed in context with thefunctional studies.

Indication for surgery is again centrally based on thepatients symptoms, the duration of the symptoms, and thedamage that is present.

Even after successful medical acid suppression the pa-tient can have persistent or recurrent symptoms of epigastricpain and retrosternal pressure as well as food regurgitationdue to the incompetent cardia, insufficient peristalsis, and/ora large hiatal hernia.

With respect to indication, one important factor in thepatients general condition is age. On the one hand, ageplays a role in the risks stratification when the individualrisk of an operation is estimated together with the comor-bidity of the patient. On the other hand, age is an economicfactor with respect to the break-even point between medicaland surgical treatment [21b].

Concerning the indication for surgery, a differentiationin the symptoms between heartburn and regurgitation isconsidered important. (Medical treatment appears to bemore effective for heartburn than for regurgitation.)

Therefore the indication for surgery is based on the fol-lowing facts:

c Noncompliance of the patient with ongoing effectivemedical treatment. Reasons for noncompliance are pref-erence, refusal, reduced quality of life, or drug depen-dency and drug side effects.

c Persistent or recurrent esophagitis in spite of currentlyoptimal medical treatment and in association with symp-toms.

c Complications of the disease (stenoses, ulcers, and Bar-retts esophagus [11, 68]) have a minor influence on theindication. Neither medical nor surgical treatment hasbeen shown to alter the extent of Barretts epithelium.Therefore mainly symptoms and their relation to ongoingmedical treatment play the major role in the indication forsurgery. However, antireflux surgery may reduce theneed for subsequent endoscopic dilatations [21a]. Theparticipants pointed out that patients with symptoms com-pletely resistant to antisecretory treatment with H2-blockers or proton-pump inhibitors are bad candidates forsurgery. In these individuals other diseases have to beinvestigated carefully. On the contrary, good candidatesfor surgery should have a good response to antisecretorydrugs. Thus, compliance and preference determine whichtreatment is chosen (conservative or operative).

6. What are the essentials of laparoscopic surgicaltreatment?

The goal of surgical treatment for GERD is to relieve thesymptoms and prevent progression and complications of thedisease creating a new anatomical high-pressure zone. Thismust be achieved without dysphagia, which can occur whenthe outflow resistance of the reconstructed GE junction ex-ceeds the peristaltic power of the body of the esophagus.Achievement of this goal requires an understanding of the

Table 1. Diagnostic test ranking order for GERD

Basic diagnostic tests Physiologic/pathologic criteria References

Endoscopy + histology Savary-Miller classification I, II, II, IV, V Savary [231]MUSE classification Armstrong [8](M) metaplasia(U) ulcer(S) stricture(E) erosions

Radiology Barium swallow Gelfand [105a]24-h esophageal pH monitoring Percentage time below pH 4 DeMeester score DeMeester [65]Stationary esophageal manometrya LES: DeMeester [65]

Overall lengthIntraabdominal lengthPressure

Dent [69a](Transient LES relaxations) esophageal body Eypasch [78]

disorders weak peristalsisOptional tests24-h gastric pH monitoring Persistent gastric acidity Barlow [14b]

Excessive duodenogastric reflux Fuchs [93, 95]Schwizer [234]

Gastric emptying scintigraphy Delayed gastric emptying Clark [40]Photo-optic bilirubin assessment Esophageal bile exposure Kauer [146]

Gastric bile exposure Fein [81]

a The concise numerical values for sphincter length, pressure, and relaxation depend on the respective manometric recording system used in the esophageal-function lab

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natural history of GERD, the stat