Association of Gastroesophageal Reflux and O2 Desaturation: A Novel Study of Simultaneous 24-h MII–pH and Continuous Pulse Oximetry

Background

Proof of the relationship between gastroesophageal reflux disease (GERD) and respiratory symptoms remains a challenge. Our aim was to determine the association between reflux events and O₂ desaturation in GERD patients with primary respiratory symptoms (RS) compared to those with primary esophageal symptoms (ES) using ambulatory monitoring systems.

Methods

One thousand eight hundred fifty-one reflux episodes were detected by multichannel intraluminal impedance (MII)–pH testing in 30 patients with symptoms of GERD (20 RS, ten ES.) All patients underwent simultaneous 24-h MII–pH and continuous O₂ saturation monitoring via pulse oximetry. Reflux-associated desaturation events were determined by correlating synchronized 24-h esophageal pH and/or impedance and O₂ desaturation.

Results

One thousand one hundred seventeen reflux events occurred in patients with RS and 734 in those with ES. Nearly 60% of these 1,851 reflux events were associated with O₂ desaturation. Markedly more events were associated with O₂ desaturation in patients with RS (74.5%, 832/1,117) than in patients with ES (30.4%, 223/734, p?<?0.0001). The difference in reflux desaturation association was more profound with proximal reflux—80.3% with RS vs. 29.4% with ES (p?<?0.0001).

Conclusions

A remarkably high prevalence of O₂ desaturation associated with gastroesophageal reflux was noted in patients with RS. Given further study, simultaneous combined esophageal reflux and O₂ saturation monitoring may prove a useful diagnostic tool in this difficult group of patients.     

Hiatal hernia, Barrett’s esophagus, and long-term symptom control after laparoscopic fundoplication for gastroesophageal reflux

Background

The aim of this study was to determine the long-term symptom control after laparoscopic fundoplication for gastroesophageal reflux disease (GERD), and possible prognostic factors.

Methods

A cohort of 271 patients, operated on at a university hospital from 1996 through 2002, was eligible for evaluation after a median interval of 102?months (range?=?12–158). The time between surgery and recurrence of reflux symptoms (i.e., time to treatment failure) served as the end point for statistical analysis. Putative risk factors for symptom recurrence were analyzed by univariate analysis and by using Cox’s multiple-hazards regression.

Results

According to Kaplan–Meier estimates, the rate of reflux symptom recurrence was 15?% after 108?months, 11?% in cases without intestinal metaplasia, but 43?% in patients with long-segment (≥3?cm) Barrett’s esophagus (BE; p?<?0.0001). Reflux symptoms recurred in 22?% of cases with a hiatal hernia (HH)?≥3?cm before operation, but only in 7?% with smaller or absent HH (p?=?0.005). Multivariate analysis revealed a relative risk of 6.6 (CI?=?3.0–13.0) for long-segment BE and 3.0 (CI?=?1.7–10.1) for HH?≥?3?cm. A strong statistical interaction was found between HH?≥?3?cm and long-segment BE: the small group (n?=?18) of cases exhibiting both risk factors had an exaggerated recurrence rate of 72?% at 108?months.

Conclusions

Laparoscopic fundoplication for symptomatic GERD provided a long-lasting abolition of reflux symptoms in 231 of 271 (85?%) patients. HH?≥?3?cm and long-segment BE were shown as independent prognostic factors favoring recurrence.     

Gastroesophageal Reflux after Vertical Banded Gastroplasty is Alleviated by Conversion to Gastric Bypass

Background

Conversion operations after vertical banded gastroplasty (VBG) are sometimes performed because of vomiting and/or acid regurgitation. Primary operation with gastric bypass (GBP) is known to reduce gastroesophageal reflux (GERD). Previous studies have not been designed to differentiate between the effects of the altered anatomy and of the ensuing weight loss. No series has reported data on acid reflux before and after conversion from VBG to GBP.

Methods

We invited eight VBG patients with current symptoms of GERD. All had intact staple lines as assessed by barium meal and gastroscopy. Acid reflux was quantified using 48-h Bravo capsule measurements. Conversion operations were performed creating an isolated 15?C20-ml pouch; the previously banded part of gastric wall was excised. Gastrojejunostomy was made end to end with a 28-mm circular stapler. The study is based on five patients consenting to early postoperative endoscopy and pH measurement.

Results

All patients were women with a mean age of 49.5?years and BMI of 36.3. Time since VBG was 132.1?months. Time from conversion to second measurement was 46.6?days and BMI at that time 32.7. There was no mortality and no serious morbidity. All patients improved clinically and no patient had to go back on proton pump inhibition or antacids. Total time with pH?p?p?Conclusions The effect of converting VBG-operated patients to GBP results in a near-normalisation of acid reflux parameters and a discontinuation of proton pump inhibitor medication.     

Can Different Subsets of Ineffective Esophageal Motility Influence the Outcome of Nissen Fundoplication?

Background

Ineffective esophageal motility (IEM) in patients with gastroesophageal reflux disease includes three different subsets that may affect symptom profiles. Our aim was to assess symptoms and functional outcome in patients with erosive esophagitis according to different subsets of IEM, before and after Nissen fundoplication (NF).

Methodology

A retrospective study with prospective follow-up of 72 patients with reflux esophagitis and IEM in whom open NF was performed. Based on principal manometric esophageal body motility disorder, patients were divided in three groups: predominantly low-amplitude (LAC, N?=?38), non-propulsive (NPC, N?=?18), and simultaneous low-amplitude esophageal contractions (SC, N?=?16). Patients underwent symptomatic questionnaire and stationary esophageal manometry before and 6 months, 1 year, and 3 years after surgery.

Results

Preoperatively, patients in NPC and SC groups had higher mean scores of dysphagia, without statistical significance as opposed to the LAC group (p?=?0.239). Postoperative dysphagia occurred in 36 patients, without statistical significance between groups regarding dysphagia grades (p?=?0.390). A longer duration of postoperative dysphagia was noted in the SC group (p?p?Conclusion Three years after NF, successful symptomatic and functional outcome was achieved in analyzed groups of patients with erosive esophagitis regardless of IEM subtype.     

Evaluation of symptoms related to reflux esophagitis in patients with esophagogastrostomy after proximal gastrectomy

Purpose

We investigated postoperative symptoms related to reflux esophagitis in patients who underwent esophagogastrostomy reconstruction after proximal gastrectomy (PG) by conducting a questionnaire survey.

Method

Quality of life was assessed using two different questionnaires, the gastrointestinal symptom rating scale (GSRS) for postoperative abdominal symptoms and F-scale for reflux esophagitis. The survey was conducted among 39 patients who underwent esophagogastrostomy after proximal gastrectomy for gastric cancer in the upper third of the stomach, and findings were compared with those in patients who underwent total gastrectomy (TG).

Results

The questionnaire was returned by 32 of 39 patients (82%) in the PG group and 40 of 45 patients (89%) in the TG group. On GSRS, the score for indigestion syndrome tended to be higher in the TG group than in the PG group (p?<?0.10), and the score for constipation was significantly higher in the PG group than in the TG group (p?<?0.05). The score for reflux syndrome, however, was almost the same in both groups. Similarly, there was no significant difference in the frequency of GERD symptoms between the PG and TG groups on F-scale questionnaire (47% vs. 63%, p?=?0.18).

Conclusions

Esophagogastrostomy after PG in an end-to-side manner with creation of acute angle at the anastomosis is not associated with an increased risk of reflux esophagitis compared with TG.     

Endoscopic grading of the gastroesophageal flap valve is correlated with reflux activity and can predict the size of the esophageal hiatus in patients with gastroesophageal reflux disease

Background

Endoscopic grading of the gastroesophageal flap valve (GEFV) is simple, reproducible, and suggested to be a good predictor of reflux activity. This study aimed to investigate the potential correlation between grading of the GEFV and quality of life (QoL), gastroesophageal reflux disease (GERD) symptoms, esophageal manometry, multichannel intraluminal impedance monitoring (MII) data, and size of the hiatal defect.

Methods

The study included 43 patients with documented chronic GERD who underwent upper gastrointestinal endoscopy, esophageal manometry, and ambulatory MII monitoring before laparoscopic fundoplication. The GEFV was graded 1–4 using Hill’s classification. QoL was evaluated using the Gastrointestinal Quality-of-Life Index (GIQLI), and gastrointestinal symptoms were documented using a standardized questionnaire. The size of the esophageal hiatus was measured during surgery by calculating the hiatal surface area (HSA). Analysis of the correlation between QoL, GERD symptoms, esophageal manometry, MII data, HSA size, and GEFV grading was performed. Statistical significance was set at a p value of 0.05.

Results

A significant positive correlation was found between increased GEFV grade and DeMeester score, total number of acid reflux events, number of reflux events in the supine position, and number of reflux events in the upright position. Additionally, a significant positive correlation was found between HSA size and GEFV grading. No significant influence from intensity of GERD symptoms, QoL, and the GEFV grading was found. The mean LES pressures were reduced with increased GEFV grade, but not significantly.

Conclusions

The GEFV plays a major role in the pathophysiology of GERD. The results underscore the importance of reconstructing a valve in patients with GERD and an altered geometry of the gastroesophageal junction when they receive a laparoscopic or endoscopic intervention.     

Length and Pressure of the Reconstructed Lower Esophageal Sphincter is Determined by Both Crural Closure and Nissen Fundoplication

Background

Laparoscopic Nissen fundoplication is comprised of: a wrap thought responsible for the lower esophageal sphincter function and crural closure performed to prevent herniation. We hypothesized gastroesophageal junction competence effected by Nissen fundoplication results from closure of the crural diaphragm and creation of the fundoplication.

Methods

Patients with uncomplicated reflux undergoing Nissen fundoplication were prospectively enrolled. After hiatal dissection, patients were randomized to crural closure followed by fundoplication (group 1) or fundoplication followed by crural closure (group 2). Intra-operative high-resolution manometry collected sphincter pressure and length data after complete dissection and after each component repair.

Results

Eighteen patients were randomized. When compared to the completely dissected hiatus, the mean sphincter length increased 1.3 cm (p?<?0.001), and mean sphincter pressure was increased by 13.7 mmHg (p?<?0.001). Groups 1 and 2 had similar sphincter length and pressure changes. Crural closure and fundal wrap contribute equally to sphincter length, although crural closure appears to contribute more to sphincter pressure.

Conclusion

The Nissen fundoplication restores the function of the gastroesophageal junction and thus the reflux barrier by means of two main components: the crural closure and the construction of a 360° fundal wrap. Each of these components is equally important in establishing both increased sphincter length and pressure.     

Ratio Between Proximal/Distal Gastroesophageal Reflux Does Not Discriminate Abnormal Proximal Reflux

Introduction

The threshold for pathologic proximal acid reflux is a controversial topic. Most values previously published are based on absolute numbers. We hypothesized that a relative value representing the quantitative relation between the amount of acid reflux that reaches proximal levels and the amount of distal reflux would be a more adequate parameter for defining pathologic proximal reflux.

Methods

We studied 20 healthy volunteers (median age 30 years, 70 % women) without gastroesophageal reflux disease (GERD); 50 patients (median age 51 years, 60 % women) with esophageal symptoms of GERD (heartburn, regurgitation); and 50 patients (median age 49 years, 60 % women) with extra-esophageal symptoms of GERD. All individuals underwent manometry and dual-probe pH monitoring. GERD was defined as a DeMeester score >14.7. The proximal/distal reflux ratio was calculated for all six parameters that constitute the DeMeester score.

Results

Absolute numbers for proximal reflux were not different for the three groups except for the number of episodes of reflux, which was higher for patients with GERD and esophageal symptoms than for patients with GERD and extra-esophageal symptoms (p = 0.007). The number of episodes of distal reflux reaching proximal levels was significantly higher in volunteers than in all patients with GERD and significantly higher in patients with GERD and esophageal symptoms than in those with extra-esophageal symptoms.

Conclusions

Our results suggest that the proximal/distal reflux ratio is not a good normative value for defining proximal reflux.     

Transoral incisionless fundoplication for treatment of gastroesophageal reflux disease in clinical practice

Background

Transoral incisionless fundoplication is a recently introduced endoluminal technique for the treatment of gastroesophageal reflux disease (GERD). The objective of this study was to determine outcomes in chronic GERD patients who were referred for surgical management.

Methods

A cohort of 38 patients underwent transoral incisionless fundoplication (TIF) in a tertiary care setting. Pre- and post-procedure assessment included GERD-related quality of life questionnaires, proton pump inhibitor (PPI) usage, 24-h pH measurements, upper gastrointestinal endoscopy, esophageal manometry, and registration of adverse events. Duration of follow-up was 36?months.

Results

Gastroesophageal valves were constructed of 4?cm (range, 4–6) in length and 220° (range, 180–240) in circumference. One serious adverse event occurred, consisting of intraluminal bleeding at a fastener site. Hiatal hernia was completely reduced in 56?% and esophagitis was cured in 47?% of patients. Postprocedure esophageal acid exposure did not significantly improve (p?>?0.05). At 36 (range, 29–41) months follow-up 14 patients (36?%) had undergone revisional laparoscopic fundoplication. Quality of life scores of the remaining cohort showed significant improvement (p?<?0.0001) and daily use of antisecretory medication was discontinued by 74?%.

Conclusions

Endoluminal fundoplication improved quality of life and reduced the need for PPIs in only a subgroup of patients at 3?years follow-up. The amount of patients requiring additional medication and revisional surgery was high.     

Significance of Limited Hiatal Dissection in Surgery for Achalasia

Introduction

It is speculated that postoperative pathologic gastroesophageal reflux after Heller’s myotomy can be diminished if the lateral and posterior phrenoesophageal attachments are left intact. The aim of this study was to evaluate the effectiveness of limited hiatal dissection in patients operated due to achalasia.

Methods

Prospective, randomized, 3 years follow-up of 84 patients operated due to achalasia. In 26 patients, Heller–Dor with complete hiatal dissection was done (G1), limited hiatal dissection combined with myotomy and Dor’s procedure was performed in 36 patients (G2), and with Heller’s myotomy alone in 22 (G3). Stationary manometry and 24 h pH study were performed in regular postoperative intervals.

Results

Postoperatively, higher median values of lower esophageal sphincter resting pressures were marked in G2 and G3, while patients in G1 were presented with higher median values of pH acid score (p?<?0.001). Abnormal DeMeester score 3 years after surgery was present in 23.1% of patients in G1 and 8.5% and 9.1% in G2 and G3 accordingly. There was no statistical difference between the groups concerning postoperative dysphagia recurrence.

Conclusion

Indicating further long-term studies, 3 years after the operation limited hiatal dissection compared to complete obtains better reflux control in achalasia patients, regardless of Dor’s fundoplication.     

Short- and Long-Term Results of Laparoscopic Versus Open Anti-Reflux Surgery: a Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background

There is an ongoing debate about whether laparoscopic anti-reflux surgery (LARS) or open anti-reflux surgery (OARS) is the better option for the surgical treatment of gastroesophageal reflux disease (GERD). This study was aimed to evaluate and compare the short- and long-term results of both surgical strategies by means of a systematic review and meta-analysis.

Methods

A systematic search of electronic databases (PubMed, Embase, The Cochrane Library) for studies published from 1970 to 2013 was performed. All randomized controlled trials (RCTs) that compared LARS with OARS were included. We analyzed the outcomes of each type of surgery over short- and long-term periods.

Results

Twelve studies met final inclusion criteria (total n?=?1,067). A total of 510 patients underwent OARS and 557 had LARS. The pooled analyses showed, despite of longer operation time, the hospital stay and sick leave were significantly reduced in the LARS group. Significant reductions were also observed in complication rates for the LARS group in both short (odds ratio (OR) 0.31, 95 % CI 0.17 to 0.56) and long-term periods (OR 0.24, 95 % CI 0.07 to 0.80). Although complaints of reflux symptoms were more frequent among LARS patients in the short-term follow-up, LARS achieved better control of reflux symptoms in the long-term period (P?<?0.05). Reoperation rate, patient’s satisfaction, and 24-h pH monitoring were all comparable between the two groups (all P?>?0.05).

Conclusions

LARS is an effective and safe alternative of OARS for the surgical treatment of GERD, which enables a faster convalescence, better control of long-term reflux symptoms, and with reduced risk of complications.     

Medical or Surgical Management of GERD Patients with Barrett’s Esophagus: The LOTUS Trial 3-Year Experience

Introduction

The long-term management of gastroesophageal reflux in patients with Barrett’s esophagus (BE) is not well supported by an evidence-based consensus. We compare treatment outcome in patients with and without BE submitted to standardized laparoscopic antireflux surgery (LARS) or esomeprazole treatment.

Methods

In the Long-Term Usage of Acid Suppression Versus Antireflux Surgery trial (a European multicenter randomized study), LARS was compared with dose-adjusted esomeprazole (20–40 mg daily). Operative difficulty, complications, symptom outcomes [Gastrointestinal Symptom Rating Scale (GSRS) and Quality of Life in Reflux and Dyspepsia (QOLRAD)], and treatment failure at 3 years and pH testing (after 6 months) are reported.

Results

Of 554 patients with gastroesophageal reflux disease, 60 had BE—28 randomized to esomeprazole and 32 to LARS. Very few BE patients on either treatment strategy (four of 60) experienced treatment failure during the 3-year follow-up. Esophageal pH in BE patients was significantly better controlled after surgical treatment than after esomeprazole (p?=?0.002), although mean GSRS and QOLRAD scores were similar for the two therapies at baseline and at 3 years. Although operative difficulty was slightly greater in patients with BE than those without, there was no difference in postoperative complications or level of symptomatic reflux control.

Conclusion

In a well-controlled surgical environment, the success of LARS is similar in patients with or without BE and matches optimized medical therapy.     

Impaired postoperative EGJ relaxation as a determinant of post laparoscopic fundoplication dysphagia: a study with high-resolution manometry before and after surgery

Background

Laparoscopic fundoplication (FP) reduces gastroesophageal reflux (GER) efficiently. Dysphagia is its main complication, but no clear data have been published in literature to evaluate risk factors associated with it. The goal of this retrospective study was to identify factors associated with dysphagia occurring after FP for GER disease, with high-resolution manometry (HRM) performed before and after surgery.

Methods

Twenty patients (11 women; mean age, 49 (range, 19?C68?years) underwent HRM before and 2?C3?months after laparoscopic Nissen?CRossetti FP. Analysis was performed with esophageal pressure topography according to the Chicago Classification.

Results

Before FP, ten patients had a manometric hiatal hernia (none after FP). Esophagogastric junction (EGJ) pressures increased after surgery (p?<?0.01). Bolus pressurization was present in 2?% of all swallows before FP and in 22?% after (p?=?0.01). Postoperative bolus pressurization percentage was significantly correlated with EGJ relaxation as measured with integrated relaxation pressure (IRP) (r?=?0.79, p?<?0.01). Eight patients reported dysphagia after FP. The only pre- or post-operative parameter significantly associated with dysphagia was postoperative IRP (5.1?mmHg without vs. 10.3 with dysphagia, p?<?0.02).

Conclusions

FP establishes an efficient antireflux mechanism by correcting hiatal hernia and increasing EGJ pressures. EGJ relaxation as measured by IRP is significantly altered after surgery, leading to more frequent motility disorders, and bolus pressurization. Postoperative dysphagia was associated with higher values of IRP.     

Short-Term Respiratory Physical Therapy Treatment in the PACU and Influence on Postoperative Lung Function in Obese Adults

Background

Even several days after surgery, obese patients exhibit a measureable amount of atelectasis and thus are predisposed to postoperative pulmonary complications. Particularly in ambulatory surgery, rapid recovery of pulmonary function is desired to ensure early discharge of the obese patient. In this study, we wanted to evaluate intensive short-term respiratory physical therapy treatment (incentive spirometry) in the postanesthesia care unit (PACU) and its impact on pulmonary function in the obese.

Methods

After ethics committee approval and informed consent, we prospectively studied 60 obese patients (BMI 30–40) undergoing minor peripheral surgery, half of which were randomly assigned to receive respiratory physiotherapy during their PACU stay, while the others received routine treatment. Premedication, general anesthesia, and respiratory settings were standardized. We measured arterial oxygen saturation by pulse oximetry on air breathing. Inspiratory and expiratory lung functions were measured preoperatively (baseline) and at 10 min, 1, 2, 6, and 24 h after extubation, with the patient supine, in a 30° head-up position. The two groups were compared using repeated-measure analysis of variance and t test analysis. Statistical significance was considered to be P?<?0.05.

Results

There were no differences at the first assessment, but, during the PACU stay, pulmonary function in the physiotherapy group was significantly better than the controls’ (p?<?0.0001), an effect which persisted for at least 24 h after surgery (p?<?0.009).

Conclusion

Short-term respiratory physiotherapy during the PACU stay promotes more rapid recovery of postoperative lung function in the obese during the first 24 h.     

Correlation of the gastroesophageal flap valve grade with the surgery rate in patients with gastroesophageal reflux disease

Background

The importance of endoscopic evaluation and grading of the gastroesophageal flap valve (GEFV) in patients with gastroesophageal reflux disease (GERD) was previously demonstrated with increased acid exposure and high grades of esophagitis in those with high-grade valves. On the other hand, no data exist on the relationship between GEFV appearance and surgical rate.

Methods

For 453 patients with symptoms suggestive of GERD, GEFV grading and 24-h ambulatory pH monitoring were performed. Surgery was performed for 82 of these patients who failed medical management or had disease complications.

Results

The GEFV grade 4 patients were younger than the patients with normal GEFV (grades 1 [p = 0.017] and 2 [p < 0.001]) and showed significant male predominance. The prevalence of hiatal hernia, the degree of esophageal acid exposure, and the prevalence and degree of erosive esophagitis significantly increased with GEFV grade (p < 0.001 for all). No GEFV grade 1 patients underwent surgery compared with 4.9 % of the grade 2 patients, 20.5 % of the grade 3 patients, and 63.6 % of the grade 4 patients who had surgery for various indications (p < 0.001).

Conclusions

Esophagogastric opening estimated by endoscopic grading of the GEFV was strongly correlated with surgery rate in GERD patients. In particular, patients with grade 4 valves showed the highest rates of erosive esophagitis and axial hiatal hernia and frequently underwent surgery for either failed medical management or disease complications.     

Intragastric Balloon Fundal or Antral Position Affects Weight Loss and Tolerability

Background

Intragastric balloons (BIB) are routinely used for weight reduction. They should be placed to the gastric fundus, as this place is believed more effective for achievement of satiety and thus weight reduction. The aim of the present study was to evaluate whether the balloon position may affect 6-month weight loss as well as first-month side-effects, i.e. nausea, vomiting, and gastroesophageal reflux.

Methods

From a total of 158 BIB-treated obese individuals, 105 females were found eligible, since the balloon in the stomach was found upon removal in the same position (fundus or antrum) placed at the time of insertion. These subjects were divided into fundus and antral groups. Data related to obesity were recorded on day 0 and upon BIB removal, 6?months thereafter. Data related to transient side-effects (nausea, vomiting, gastroesophageal reflux) were recorded on days 0?C3, 7, and weekly thereafter, for 1?month.

Results

BIB placed in the antrum was found to have significantly better results on weight loss parameters, while nausea, vomiting (p?=?0.02) as well as gastroesophageal reflux still remained up to the fourth week in a relation to the fundus group. Similarly, the rate of gastric distension was found significantly increased (p?=?0.001) during the days 1?C3 in fundus group in relation to antrum, followed by a progressive decrease in both groups.

Conclusions

Intragastric balloon placed in the antrum lead to better results in weight reduction but to longer duration of tolerability-related side-effects, i.e., nausea, vomiting, and gastroesophageal reflux.     

Efficacy and durability of robotic heller myotomy for achalasia: patient symptoms and satisfaction at long-term follow-up

Background

Laparoscopic Heller myotomy (LHM) has become the standard treatment for achalasia in the USA. Robot-assisted Heller myotomy (RHM) has emerged as an alternative approach due to improved visualization and fine motor control, but long-term follow-up studies have not been reported. We sought to report the long-term outcomes of RHM and compare them to those of LHM.

Methods

A retrospective cohort study was performed for patients who underwent laparoscopic or RHM between 1995 and 2006. Long-term follow-up was performed via mail or telephone questionnaire. The primary outcome measure was durable relief of dysphagia without need for further intervention. Secondary outcomes included gastroesophageal reflux symptoms, disease-specific quality of life, and patient satisfaction with their operation.

Results

Seventy-five patients underwent laparoscopic (n = 19) or robotic (n = 56) myotomy during the study period. Long-term follow-up was obtained in 53 (71 %) patients with a median interval of 9 years. RHM was associated with a decreased mucosal injury rate (0 vs. 16 %, p = 0.01) and median hospital stay (1 vs. 2 days, p < 0.01) compared to conventional laparoscopy. All patients reported initial dysphagia relief, and 80 % required no further intervention. This did not differ between groups. Sixty-two percent required medications to control reflux symptoms at long-term follow-up, including 56 % following robotic myotomy and 80 % after laparoscopic myotomy (p = 0.27). Overall, 95 % of patients were satisfied with their operation, and 91 % would choose surgery again given the benefit of hindsight.

Conclusion

There is a dearth of long-term follow-up data to support the effectiveness of RHM. This study demonstrates durable dysphagia relief in the vast majority of patients with a high degree of patient satisfaction and a low rate of esophageal mucosal injury. While a significant proportion of patients report reflux symptoms, these symptoms are well controlled with medical acid suppression.     

Effect of low volume ventilation during cardiopulmonary bypass on oxygenation and postoperative pulmonary outcome

Objective

This study was carried out to evaluate effect of low volume normal frequency ventilation during Cardiopulmonary Bypass (CPB) on immediate postoperative respiratory outcome in patients undergoing elective open heart surgeries.

Background

Lung deflation during CPB is considered as major cause of postoperative pulmonary dysfunction. Various methods of ventilation had been tried during CPB to prevent postoperative lung dysfunction. As yet, little information is available comparing low volume normal frequency ventilation with no ventilation during CPB.

Patients and Methods

Thirty six patients aged 18 years to 65 years were included and randomized into two groups; Group V (n?=?18) or Group NV (n?=?18). Group V patients were ventilated with a tidal volume of 2 mL?kg^?1with 100 % oxygen during CPB after aortic clamp placement, and respiratory rate was continued as per pre CPB period. Ventilation was discontinued in NV group after aorta was cross clamped. Normal ventilation was restored in both groups after release of aortic clamp.

Results

Intraoperative PaO₂ and PaCO₂ were similar in both groups. The group V patients had improved inspiratory capacity (p?=?0.0) in both day 1 (after extubation) and day 2 (24 h after extubation). Extubation was significantly earlier in group V patients (p?<?0.05).

Conclusion

Low volume normal frequency ventilation during cardiopulmonary bypass improves lung mechanics during early postoperative period in patients undergoing open heart surgery.     

Risk factors leading to midurethral sling revision: a multicenter case-control study

Introduction and hypothesis

To determine risk factors for sling revision after midurethral sling (MUS) placement.

Methods

This multicenter case-control study included patients who underwent MUS placement and subsequent revision secondary to voiding dysfunction from January 1999–2007 from nine Urogynecology centers across the USA. Direct logistic regression analysis was used to determine which diagnostic variables predicted sling revision.

Results

Of the patients, 197 met the study criteria. Patient demographics, urodynamic findings, and operative differences did not increase the risk for sling revision. Risk factors for sling revision did include: pre-existing voiding symptoms (OR 2.76, 95% CI 1.32–5.79; p?=?0.004) retropubic sling type (OR?=?2.28, 95% CI 1.08–4.78; p?=?0.04) and concurrent surgery (OR?=?4.88, 95% CI 2.16–11.05; p?<?0.001)

Conclusions

This study determined that pre-existing obstructive voiding symptoms, retropubic sling type, and concurrent surgery at the time of sling placement are risk factors for sling revision.