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Biomedical subjects

D I Watson

Publications and source records attributed to D I Watson.

At least 37 records · Page 2Linked to original sources
PubMed2002

Laparoscopic fundoplication for patients with symptoms but no objective evidence of gastroesophageal reflux.

In general terms, all patients who undergo a laparoscopic fundoplication procedure should have objective evidence of gastroesophageal reflux. However, occasionally patients without objective evidence of reflux disease are referred for surgery. This study assessed the outcome of a highly selected group of patients who underwent laparoscopic fundoplication without objective evidence of reflux at either preoperative endoscopy or pH monitoring. Data from all patients undergoing laparoscopic fundoplication in our department over a 9-year period from December 1991 to January 2001 were collected prospectively. From a total of 1,003 patients, a subgroup of 15 patients was identified who had no evidence of ulcerative oesophagitis at endoscopy or abnormal reflux on 24-h pH monitoring. Eight of these patients had typical symptoms of reflux (four had predominantly heartburn, four had predominantly volume regurgitation) and seven patients had atypical symptoms such as cough, bloating, chest pain, or sore throat. All patients had tried medication for acid suppression before surgery, with five gaining little or no benefit. The mean acid exposure time was 2% (range 0.1-3.6%). A correlation between typical symptoms and reflux events of over 50% was noted in three patients. All patients underwent laparoscopic fundoplication, with one conversion to an open procedure. Mean patient satisfaction score (0-10 linear score) was 8.7 at 3 months and 1 year postoperatively. Three patients failed to improve following surgery. These three all had atypical symptoms, a symptom correlation of less than 50% with acid reflux on pH monitoring, and two of the three had a poor response to medication. All other patients benefited symptomatically from surgery. We concluded that the absence of objective evidence of reflux should not always preclude patients from a laparoscopic fundoplication. Carefully selected patients with typical reflux symptoms can have a good outcome. However, patients who do not have typical symptoms and who respond poorly to acid suppression are not likely to benefit from surgery.

Adolescent↗
PubMed2001

Hematogenous spread as a mechanism for the generation of abdominal wound metastases following laparoscopy.

BACKGROUND: We designed this study to determine whether hematogenous spread has a role in the etiology of port site metastases following laparoscopic surgery. METHODS: The study design had two parts. In experiment 1, two groups (n = 30) of male Dark Agouti rats were studied. Under general anesthesia, the first group (20 rats) underwent 15 mins of laparoscopic insufflation, followed by an injection of a suspension of 105 Dark Agouti mammary adenocarcinoma (DAMA) cells into the internal jugular vein and a further 15-mins period of insufflation. The laparoscopic ports were then removed, and the wounds were closed and marked. In the second group (n = 10), the procedure was identical except that a 2.5-cm midline laparotomy was performed 15 mins after the commencement of anesthesia and insufflation was not used. The laparotomy was closed in two layers. In experiment 2, one group (n = 4) was studied. The study protocol was identical to the first laparoscopic group except that a larger number of 106 DAMA cells were injected. All rats in both experiments were killed 15 days later, and the injection site, laparoscopy wounds, and laparotomy wound were examined histologically by a blinded histopathologist. RESULTS: In experiment 1, one port site tumor was detected in the laparoscopic group and no wound metastases were found in the laparotomy group. Postoperative weight loss was significantly less in the laparoscopic group (p < 0.001). In experiment 2, no port site metastases were detected. CONCLUSION: Although hematogenous spread is a possible mechanism in the development of port site metastases, judging from the low number of port site metastases in this study as compared to previous reports using this tumor model, this mechanism is unlikely to be a major contributor to the problem of wound metastasis following laparoscopy.

Abdomen↗
PubMed2001

Laparoscopic cardiomyotomy and anterior partial fundoplication for achalasia.

BACKGROUND: Although surgical myotomy is considered the gold standard, many different treatments have been advocated for achalasia. There are now a number of reports of cardiomyotomy being performed laparoscopically. METHODS: This is a prospective study of 82 patients (47 male and 35 female; median age, 47 years) who underwent laparoscopic cardiomyotomy and anterior partial fundoplication for achalasia. RESULTS: Four of the 82 procedures required conversion to open surgery, all during the early stages of the series, and two required early reoperation for a postoperative problem. The median operating time was 80 min (range, 32-210). the median hospital stay was 3 days (range, 2-18), and normal physical activity was resumed after a median of 2 weeks (range, 3 days to 12 weeks). Follow-up ranged up to 8 years (median, 2). Postoperatively, symptoms of dysphagia (to both solids and liquids), heartburn, odynophagia, chest pain, regurgitation, and cough were significantly reduced in all patients. The median overall satisfaction score (graded from 0 to 10, with 10 representing total satisfaction) was 9 (range, 0-10), and 90% of patients were highly satisfied with the surgical outcome. CONCLUSION: Laparoscopic cardiomyotomy with anterior partial fundoplication achieves excellent symptomatic relief for patients with achalasia, and it can be performed with minimal morbidity.

Adolescent↗
PubMed2001

Helium and other alternative insufflation gases for laparoscopy.

BACKGROUND: Carbon dioxide (CO(2)) is currently the insufflation gas of choice for laparoscopy. It fulfills most of the requirements for an ideal insufflation gas, being colorless, noninflammable, and rapidly excreted from the circulation. However, its use is associated with adverse cardiorespiratory effects, especially in patients with preexisting cardiorespiratory compromise. METHODS: The descriptive review of relevant literature, moreover, has been proposed that it increases the incidence of port site (wound) metastases from abdominal cancers when used during oncological surgery. In addition, it may cause postoperative pain due to peritoneal irritation, and its use is associated with physiological and immunological impairment. Hence, there is scope for the investigation of alternative insufflation gases. Other possibilities include gasless laparoscopy, helium, nitrous oxide, (N(2)O), and argon. Helium insufflation has been used extensively in animal models but only to a limited extent in humans. In experimental studies, it has been shown to produce fewer changes in cardiorespiratory and intraperitoneal immunological status than CO(2) insufflation, and its use is associated with less spread of tumors to port sites in a variety of small animal tumor models. However, helium also has the potential for some adverse effects. Helium pneumothorax probably resolves more slowly than CO(2) pneumothorax, and helium gas embolism is tolerated poorly in animal models. The clinical significance of these potential problems has yet to be determined. CONCLUSIONS: Although the use of alternative gases appears to be promising, further evaluation is needed within both clinical and laboratory settings before their routine clinical use can be supported.

Abdominal Neoplasms↗
PubMed2001

Complications of laparoscopic antireflux surgery.

Over the last decade, the laparoscopic approach to antireflux surgery has been widely applied, resulting in improved early outcomes and greater patient acceptance of surgery for gastroesophageal reflux disease. However, although short-term outcomes are probably better overall than those following open surgery, it has become apparent that the laparoscopic approach is associated with an increased risk of some complications, and as well as the occurrence of new complications specific to the laparoscopic approach. Significant complications include acute paraesophageal hiatus herniation, severe dysphagia, pneumothorax, vascular injury, and perforation of the gastrointestinal tract. The incidence of some of these complications decreases as surgeons gain experience; others can be minimized by using an appropriate operative technique. In addition, laparoscopic reintervention is usually straightforward in the 1st postoperative week. For this reason, the surgeon should have a low threshold for early laparoscopic reexploration, facilitated by early radiological contrast studies, in order to reduce the likelihood that problems will arise later.

Deglutition Disorders↗
PubMed2001

Laparoscopic Nissen fundoplication: five-year results and beyond.

HYPOTHESIS: Laparoscopic Nissen fundoplication provides long-term relief of symptoms of gastroesophageal reflux disease. DESIGN: Prospectively evaluated case series. SETTING: University teaching hospital. PATIENTS: From September 1991 to December 1999, we performed more than 900 laparoscopic antireflux procedures. The outcome for patients who underwent surgery between September 1991 and June 1994 (178 cases) was determined. This included all patients having laparoscopic Nissen fundoplication, from the first procedure onward. INTERVENTIONS: Long-term follow-up for 5 or more years after laparoscopic Nissen fundoplication was obtained by an independent investigator who interviewed patients using a structured questionnaire. MAIN OUTCOME MEASURES: Prospective evaluation of clinical symptoms using a structured questionnaire. RESULTS: Outcome data covering a period of 5 or more years after surgery was available for 176 patients (99%), with 2 patients lost to follow-up. Nine patients died (8 of unrelated causes) at some stage following surgery, and the outcome was difficult to determine in 1 patient with cerebral palsy. Hence, questionnaire data were available for 166 patients at a median follow-up of 6 years (range, 5-8 years). Three patients (1.7%) underwent revision surgery for recurrent reflux; 87% of the 176 patients remained free of significant reflux. Reoperation was required for dysphagia in 7 patients (3.9%), 2 for a tight wrap and 5 for a tight diaphragmatic hiatus. In addition, reoperation was necessary for a paraesophageal hiatus hernia in 13 patients (7.3%). Of the reoperations, 56% were performed within 12 months of the original procedure, and 22% during the second year of follow-up. Further surgery was uncommon after 2 years. The long-term outcome was considered "good or excellent" by 90% of patients. CONCLUSIONS: The long-term outcome of laparoscopic Nissen fundoplication is similar to that following open fundoplication. Good results are obtained in most patients.

Follow-Up Studies↗
PubMed2001

A prospective randomized trial of laparoscopic Nissen fundoplication with anterior vs posterior hiatal repair.

HYPOTHESIS: The technique used for repair of the esophageal hiatus during laparoscopic Nissen fundoplication can influence the likelihood of postoperative dysphagia. DESIGN: A prospective double-blind randomized control trial. SETTING: A university teaching hospital. PARTICIPANTS: A total of 102 patients with proven gastroesophageal reflux disease, undergoing a laparoscopic Nissen fundoplication were randomized to undergo fundoplication with either anterior (47 patients) or posterior (55 patients) repair of the diaphragmatic hiatus. Patients were excluded for the following reasons: they had esophageal motility disorders, required a concurrent abdominal procedure, had undergone previous antireflux surgery, or had very large hiatus hernias. INTERVENTIONS: Laparoscopic Nissen fundoplication with anterior vs posterior hiatal repair. MAIN OUTCOME MEASURES: Independent assessment of dysphagia, heartburn, patient satisfaction, and other symptoms 1, 3, and 6 months following surgery, using multiple standardized clinical grading systems. Objective measurement of lower esophageal sphincter pressure, esophageal emptying time, distal esophageal acid exposure, and endoscopic assessment of postoperative anatomy and esophageal mucosa. RESULTS: Symptoms of postoperative dysphagia, relief of heartburn, and overall satisfaction 6 months after surgery were not influenced by the hiatal repair technique. However, to achieve a similar incidence of dysphagia, more patients who initially underwent posterior hiatal repair required a second surgical procedure (6 vs 0 patients). The hiatal repair technique did not affect the likelihood of early postoperative paraesophageal herniation. CONCLUSION: Anterior suturing of the hiatus appears to be at least as good in the short-term as posterior suturing as a method of narrowing the hiatus during laparoscopic Nissen fundoplication.

Adult↗
PubMed2001

Role of fundoplication in patient symptomatology after laparoscopic antireflux surgery.

BACKGROUND: Symptoms following antireflux surgery are often seen as unavoidable sequelae of the operation. The aims were to determine the frequency of new adverse sequelae following antireflux surgery and the preoperative incidence of similar symptoms. METHODS: Patients undergoing fundoplication underwent prospective assessment of symptoms using a structured interview before and 6 months after surgery. In addition to the presence or absence of symptoms, Visick scores, visual analogue scales and a composite dysphagia score were used. RESULTS: Some 312 patients were evaluated. Antireflux surgery significantly diminished the symptoms of heartburn, epigastric pain, regurgitation, bloating, odynophagia, nausea, vomiting, diet restriction, nocturnal coughing and wheezing. In contrast, there was a significant increase in inability to belch, diarrhoea and increased passage of flatus. The symptoms of dysphagia, postprandial fullness or early satiety and anorexia were not significantly altered by antireflux surgery. There was, however, a group of patients who experienced new or worsened dysphagia after surgery and were more likely to do so if they had no dysphagia before surgery (31 per cent) than if dysphagia was present before surgery (19 per cent). Some 93 per cent of patients were satisfied with the overall outcome of the operation. CONCLUSION: The majority of patients undergoing laparoscopic fundoplication for gastro-oesophageal reflux derive symptomatic benefit and are satisfied with the outcome. Many of the so-called postfundoplication sequelae are present before surgery in many patients. Overall, antireflux surgery does not lead to increased dysphagia or bloating.

Adolescent↗
PubMed2001

Effect of laparoscopy on immune function.

BACKGROUND: Laparoscopic surgery is believed to lessen surgical trauma and so cause less disturbance of immune function. This may contribute to the rapid recovery noted after many laparoscopic operations. Preservation of both systemic and intraperitoneal immunity is particularly important in surgery for sepsis or cancer and so an understanding of the impact of laparoscopy on immune function is relevant. METHODS: Literature on immunological changes following laparoscopy and open surgery was identified from Medline, along with cross-referencing from the reference lists of major articles on the subject. RESULTS AND DISCUSSION: Despite a few contradictory reports, systemic immunity appears to be better preserved after laparoscopic surgery than after open surgery. However, the local intraperitoneal immune system behaves in a particular way when exposed to carbon dioxide pneumoperitoneum; suppression of intraperitoneal cell-mediated immunity has been demonstrated in a number of studies. This feature may be clinically important and should be acknowledged when considering laparoscopic surgery in patients with malignancy or sepsis.

Acute-Phase Reaction↗
PubMed2001

Arthroscopic subacromial decompression with a holmium:YAG laser: review of the literature.

BACKGROUND: The Australian Safety and Efficacy Register of New Interventional Procedures-Surgical (ASERNIP-S) undertook to systematically review the literature regarding arthroscopic subacromial decompression (ASD) using a holmium:YAG laser for patients with impingement syndrome, with respect to the safety and efficacy of the procedure. METHODS: Studies on ASD with a holmium:YAG laser were identified using MEDLINE (1984 to July 2000), EMBASE (1974 to August 2000) and Current Contents (1993 to week 33 2000). A number of search terms were used: (laser and shoulder) and (surgery or arthroscop* or acromioplasty or orthopaed* or orthoped* or subacromial decompression or impingement syndrome). The Cochrane Library was searched from 1966 to issue 3 2000, using the search terms 'shoulder and surgery'. Human studies were included for patients with impingement syndrome but without full-thickness rotator cuff tears or rheumatological disorders, and where shoulder pain had been experienced for more than 3 months. A surgeon and reviewer independently assessed the retrieved articles for their inclusion in the review. RESULTS: Seven papers were identified that related to ASD with a holmium:YAG laser. None of the papers for review offered high-quality evidence. There were no properly designed randomized controlled studies. The highest level of evidence came from time series studies. No quantitative analysis could be undertaken for this review. CONCLUSIONS: Given the extremely low level of evidence available for this procedure it was recommended that further research be conducted to establish the safety and efficacy of the technique. This reinforces the conclusion reached in the Cochrane review of interventions for shoulder pain where insufficient evidence was found to either support or refute the efficacy of other interventions for shoulder pain.

Arthroscopy↗
PubMed2001

Metabolic and immunologic consequences of laparoscopy with helium or carbon dioxide insufflation: a randomized clinical study.

BACKGROUND: Previous studies using animal models have demonstrated that carbon dioxide (CO2) pneumoperitoneum during laparoscopy is associated with adverse physiological, metabolic, immunological and oncological effects, and many of these problems can be avoided by the use of helium insufflation. The present study was performed in patients to compare the effect of helium and CO2 insufflation on intraperitoneal markers of immunological and metabolic function. METHODS: Eighteen patients undergoing elective upper gastrointestinal laparoscopic surgery were randomized to have insufflation achieved by using either helium (n = 8) or CO2 (n = 10) gas. Intraperitoneal pH was monitored continuously during surgery, and peritoneal macrophage function was determined by harvesting peritoneal macrophages at 5 min and 30 min after commencing laparoscopy, and then assessing their ability to produce tumour necrosis factor-alpha (TNF-alpha), and their phagocytic function. RESULTS: Carbon dioxide laparoscopy was associated with a lower intraperitoneal pH at the commencement of laparoscopy, although this difference disappeared as surgery progressed. The production of TNF-alpha was better preserved by CO2 laparoscopy, but the insufflation gas used did not affect macrophage phagocytosis. Patients undergoing helium laparoscopy required less postoperative analgesia. CONCLUSION: The choice of insufflation gas can affect intraperitoneal macrophage function in the clinical setting, and possibly acid-base balance. The present study suggested no immunological advantages for the clinical use of helium as an insufflation gas. The outcomes of the present study, however, are different to those obtained from previous laboratory studies and further research is needed to confirm this outcome.

Carbon Dioxide↗
PubMed2001

Expandable metallic stents should not be used in the treatment of benign esophageal strictures.

Expandable metallic stents have become popular in recent years for the treatment of esophageal strictures. While they are undoubtedly of great value in the palliation of malignant strictures and tracheo-esophageal fistulas, there is concern over their use for the treatment of benign diseases. We report three cases, in which such problems were seen following stent insertion for benign esophageal strictures. All three patients developed further strictures above the stents, one was complicated by a tracheo-esophageal fistula and two stents (in one patient) migrated distally into the stomach. Two of the patients underwent subsequent esophageal surgery. In both cases, this proved extremely difficult and hazardous because of the intense fibrotic reaction induced by the stents. Expandable mesh stents should not be used for the treatment of benign esophageal strictures without careful consideration of the potential problems, which can include rendering the problem inoperable.

Aged↗
PubMed2001

Obesity and its effect on outcome of laparoscopic Nissen fundoplication.

Obesity has long been suspected as predisposing to gastroesophageal reflux disease, and it has also been claimed that it is an important cause of poor outcome following laparoscopic anti-reflux surgery. This study was performed to determine the validity of this proposition. The outcome of 194 patients from an overall experience of 971 laparoscopic anti-reflux procedures was determined in this study. Patients were included if they had undergone a laparoscopic Nissen fundoplication, had completed a minimum 12 months follow-up using a structured questionnaire, and had data available for the calculation of their preoperative body mass index (BMI). Patients were divided into three groups based on BMI: normal weight (BMI < 25), overweight (BMI 25-29.9), and obese (BMI >30). The association between BMI and outcome data from their most recent follow-up was analyzed. There was no correlation between increasing BMI and a poorer overall outcome. There was a slight trend toward less satisfaction with the surgical outcome in patients of normal weight. Preoperative obesity is not associated with a poorer outcome following laparoscopic Nissen fundoplication.

Body Mass Index↗
PubMed2001

Reflux disease without mucosal damage: is there a place for surgery?

Patients in whom regurgitation is a major problem usually require antireflux surgery even though they may have no evidence of esophageal mucosal damage. The most common symptom of reflux is heartburn, and there is good evidence that the severity of this symptom does not correlate with the degree of mucosal damage in the esophagus. With the advent of laparoscopic surgery and the great reduction in the morbidity of antireflux surgery, many patients now are looking for cure of their reflux rather than just symptom relief. Patients in this category do well with laparoscopic antireflux surgery regardless of whether thee have endoscopic evidence of mucosal damage or not; indeed, if the data in the literature are a guide, it seems that esophageal mucosal damage is not a necessary indication for antireflux surgery. An "acid-sensitive esophagus" is not yet an established indication for laparoscopic antireflux surgery, however.

Esophagitis, Peptic↗