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J G Hunter

Publications and source records attributed to J G Hunter.

At least 19 recordsLinked to original sources
PubMed2005

Ten-year trend in the national volume of bile duct injuries requiring operative repair.

BACKGROUND: The objectives of this study were to determine the national proportions and mortality rate for bile duct injuries resulting from laparoscopic cholecystectomy (LC) that required operative reconstruction for repair over a 10-year period and to investigate the major factors associated with the mortality rate in this group of patients. METHODS: Using the Nationwide Inpatient Sample (NIS) of >7 million patient records per year, we extracted and analyzed data for LC during the years 1990-2000. Procedures that involved biliary reconstructions performed as part of another primary procedure were excluded. Using the Statistical Package for the Social Sciences (SPSS), we used procedure-specific codes that enabled us to calculate national estimates for LC for the time period under review. We then calculated biliary reconstruction procedures that occurred after LC for this cohort of patients. Finally, we analyzed in-hospital mortality, as well as the patient, institutional, and outcome characteristics associated with biliary reconstructions. RESULTS: The percentage of cholecystectomies performed laparoscopically has increased over the years for which data are available (from 52% in 1991 to 75% in 2000). Despite this increase, the mortality rate for this group of patients has remained consistently low over the study period (mean, 0.45%; range 0.33-0.58%). Within this group of patients, the average rate of bile duct injuries requiring operative repair was 0.15% for the years under study. The reconstruction rates ranged from 0.25% in 1992 to 0.09% in 1999. For 2000, the most recent year for which data are available, biliary reconstruction was performed in 0.10% of all patients who underwent LC. The average mortality rate for patients undergoing biliary reconstruction for the years 1991 to 2000 was 4.5%. After multivariate analysis, age, African American ethnicity, type of admission, source of admission, and hospital location, and teaching status were all found to correlate significantly with death after-biliary reconstruction. CONCLUSIONS: These data show an increase in the percentage of cholecystectomies performed laparoscopically over the years under study and an associated low mortality rate. In contrast, although the number of bile duct injuries appears to be decreasing, these procedures continue to be associated with a significant mortality rate.

Adult↗
PubMed2002

KTP laser ablation of Barrett's esophagus after anti-reflux surgery results in long-term loss of intestinal metaplasia. Potassium-titanyl-phosphate.

BACKGROUND: Efforts to ablate Barrett's epithelium have met with mixed results. We report the long-term follow-up evaluation of the preliminary cohort of patients who underwent thermal ablation of Barrett's epithelium with the potassium-titanyl-phosphate (KTP) laser after anti-reflux surgery. METHODS: Nine patients with intestinal metaplasia (IM) of the esophagus underwent fundoplication (7 laparoscopic Nissen, 1 laparoscopic Toupet, 1 open Nissen) between May 1993 and October 1994. Three patients had an IM less than 3 cm long (33%). One year after the operation, all the patients were symptom free, had discontinued medications, and had a normal 24-h pH study. From June 1995 to February 1996, these patients underwent a median of two (range, 1-5) endoscopic procedures with directed mucosal ablation using the KTP laser. A comparative cohort of 21 patients (IM length, <3cm; 38%) treated during the same period with fundoplication alone served as a control. The patients were followed prospectively with annual or biennial endoscopy and biopsy. All the patients were contacted by mail, telephone, or clinic visit annually to determine symptomatic and quality-of-life outcome of antireflux surgery. RESULTS: The mean follow-up period was 6.8 years (range, 6-7.5 years). At this writing, the study patients are alive and well. Eight of the patients have experienced histologic loss of IM (89%) according to their last biopsy result. One patient has had regression of low-grade dysplasia to IM. The patients treated with fundoplication alone had a mean follow-up period of 5.6 years (range, 4.7-7.2 years). On the basis of the last biopsy result, 7 of 21 patients (33%) had no evidence of IM. CONCLUSIONS: A program of tailored antireflux surgery followed by thermal mucosal ablation causes a loss of IM in a majority of patients with Barrett's esophagus. This may represent a significant improvement in histologic outcome over that of treatment with fundoplication alone (p = 0.007 Fisher's exact test).

Adult↗
PubMed2002

Long-term outcome of laparoscopic repair of paraesophageal hernia.

BACKGROUND: It has been reported that the laparoscopic repair of paraesophageal hernias is associated with higher complication and recurrence rates than the open methods of repair. METHODS: We identified 136 consecutive patients who underwent laparoscopic repair of a paraesophageal hernia between 1993 and 1999. Patient demographics and symptom scores for regurgitation, heartburn, chest pain, and dysphagia at presentation and at last follow-up were recorded (0 = none, 1 = mild, 2 = moderate, 3 = severe). The operative records were reviewed, and early and late complications were noted. Only patients with a follow-up of >1 were included in the analysis. RESULTS: The median age was 64 years, and there was a female preponderance (1.8:1). Most patients had some medical comorbidity; the American Society of Anesthesiologists (ASA) scores were <2 in eight patients and ?2 in 117 patients. Three laparoscopic operations were converted to open procedures. There were nine intraoperative complications, five early complications, and three related deaths (morbidity and mortality rates of 10.2% and 2.2%, respectively). Follow-up data were available for 83 patients (66%), and the mean follow-up time was 40 months (range, 12-82). The percentage of patients experiencing chest pain, dysphagia, heartburn, and regurgitation in the moderate to severe range dropped from a range of 34-47% to 5-7% (p <0.05). Three patients underwent repeat laparoscopic repair for symptomatic recurrence. CONCLUSION: The laparoscopic repair of paraesophageal hernias provides excellent long-term symptomatic relief in the majority of patients and has a low rate of symptomatic recurrence. The complication and death rates may be related in part to the higher incidence of comorbidities in this somewhat elderly patient population.

Female↗
PubMed2001

Peroxisome proliferator-activated receptor gamma ligands differentially modulate muscle cell differentiation and MyoD gene expression via peroxisome proliferator-activated receptor gamma -dependent and -independent pathways.

The effects of distinct classes of peroxisome proliferator-activated receptor gamma (PPARgamma) ligands on myogenesis and MyoD gene expression were examined in mouse skeletal muscle C2C12 myoblasts. Treatment of C2C12 cells with the PPARgamma ligand, 15-deoxy-Delta12,14-prostaglandin J2 (15d-PGJ2), repressed morphologically defined myogenesis and reduced endogenous mRNA levels of the myogenic differentiation markers MyoD, myogenin, and alpha-actin. In contrast, two synthetic PPARgamma ligands, L-805645 and ciglitazone, exhibited no effects. In transient transfection assays, 15d-PGJ2 specifically inhibited the expression of a MyoD promoter-luciferase reporter gene (MyoDLuc) in a cell type- and promoter-specific manner, indicating that 15d-PGJ2 functions in part by repressing MyoD gene transcription. The inhibition of MyoD gene expression by 15d-PGJ2 is mediated by the distal region of the MyoD gene promoter. PPARgamma on its own also inhibited MyoDLuc expression and further augmented the 15d-PGJ2 response. In contrast, L-805645 and ciglitazone did not inhibit MyoDLuc expression on their own but did so in the presence of ectopically expressed PPARgamma. Interestingly, a transdominant inhibitor of PPARgamma (hPPARgamma2Delta500) had no effect on the 15d-PGJ2-dependent repression of MyoDLuc expression but overcame L-805645/PPARgamma-dependent repression. Finally, saturating concentrations of L-805645, which did not affect myogenesis, failed to ablate 15d-PGJ2-mediated repression of the myogenic program. Thus, distinct PPARgamma ligands may repress MyoD gene expression through PPARgamma-dependent and -independent pathways, and 15d-PGJ2 can inhibit the myogenic program independent of its cognate receptor, PPARgamma.

Animals↗
PubMed2001

Resection and advancement of esophageal mucosa. A potential therapy for Barrett's esophagus.

BACKGROUND: Barrett's esophagus affects 5-10% of patients with gastroesophageal reflux disease (GERD) and is associated with a 40-fold increased risk of malignant transformation. Ablative therapies may lead to esophageal perforation or stricture formation if applied too liberally and residual glandular tissue and persistent cancer risk if utilized too sparingly. METHODS: Ten pigs underwent gastrotomy. Mucosa below the gastroesophageal (GE) junction was elevated by saline injections, circumferentially incised, and secured to an orogastric tube. By traction, the distal esophageal mucosa was inverted 10 cm proximally, then returned to the gastric lumen. In group A (n = 4), the mucosa (5 cm) was resected and the remnant was allowed to retract. In group B (n = 4), the mucosa was simply sutured back into its native position. In group C (n = 2), the mucosa (5 cm) was resected and the proximal segment was advanced and sutured to the gastric mucosa. At 6 weeks, or sooner if stricture developed, the animals were killed. Stricture formation was determined by ex vivo barium esophagram and gross assessment. The extent of fibrosis and epithelial healing were established histologically. RESULTS: Group A (mucosa resected) developed weight loss and anorexia within 4 weeks. Pathology revealed dense fibrotic stricture without reepithelialization. Group B (mucosa elevated/replaced) gained weight after the operation. Histology demonstrated mucosal healing without significant stricture or fibrosis. Group C (mucosa resected/advanced) also thrived postoperatively. Histology confirmed mucosal healing without evidence of retraction or dense stricture. CONCLUSIONS: Exposure of submucosal tissues causes esophageal stricture. Mucosal coverage minimizes submucosal fibrosis after injury. Mucosal resection and advancement allows healing without stricture and may have therapeutic potential for patients with Barrett's esophagus.

Anastomosis, Surgical↗
PubMed2001

Outcomes of laparoscopic fundoplication for gastroesophageal reflux disease and paraesophageal hernia.

BACKGROUND: Laparoscopic fundoplication has become the standard for operative treatment of gastroesophageal reflux disease (GERD). METHODS: We reviewed our experience with 1,000 consecutive patients receiving laparoscopic fundoplication for GERD (n = 882) or paraesophageal hernia (n = 118) between October 1991 and July 1999. Patients with achalasia and failed fundoplication were excluded from analysis. All the patients were evaluated preoperatively by upper endoscopy, esophageal manometry, and barium swallow. After 1994, 24-h pH monitoring was performed selectively in patients with extraesophageal symptoms and/or those without erosive esophagitis. There were 490 men 510 women in this review. Their mean age was 49 years. Procedures performed were 360 degrees floppy fundoplication (n = 879), 360 degrees fundoplication without fundus mobilization (Rossetti) (n = 22), 270 degrees posterior fundoplication (n = 96), and anterior fundoplication (n = 2). Esophageal lengthening procedure (Collis gastroplasty) was performed in combination with fundoplication in 15 patients. In seven patients the treatment was converted to open fundoplication. OUTCOMES: The average length of hospitalization was 2.2 days, and 136 patients stayed longer than 2 days. Major complications occurred in 21 patients: esophageal perforation (n= 10), acute paraesophageal herniation (n = 4), splenic bleeding (n = 2), cardiac arrest (n = 1), pneumonia (n = 3), and testicular abscess (n = 1). Additional operations were required to manage the complications in 14 patients (70%): Four of these procedures were performed emergently, and 10 patients underwent reoperation between 6 h and 10 days. There were three deaths, all of which involved elderly patients with paraesophageal hernia. There were 35 late failures requiring reoperation for recurrence of GERD or development of new symptoms: The treatment of 32 patients was revised laparoscopically, and 4 patients required laparotomy. Beyond 1 year (median follow-up period, 27 months), 94% of the reviewed patients were satisfied with their surgical outcome.

Aged↗
PubMed2001

Nissen fundoplication improves gastric motility in patients with delayed gastric emptying.

BACKGROUND: Fundoplication hastens gastric emptying in pediatric patients with gastroesophageal reflux disease (GERD). However, among adult GERD patients with impaired gastric emptying, the degree of improvement offered by fundoplication and the value of pyloroplasty are less well defined. Therefore, we compared outcomes in GERD patients with delayed gastric emptying after fundoplication alone or fundoplication with pyloroplasty. METHODS: Of 616 consecutive GERD patients who submitted to primary fundoplication (601 laparoscopic) between October 1991 and October 1997, 82 underwent preoperative solid-phase nuclear gastric emptying analysis. Of these, 25 had delayed gastric emptying (half-time >100 min). Of 12 patients with emptying half-times between 100 and 150 min, one underwent pyloroplasty at the time of Nissen fundoplication. Of 13 patients with emptying half-times >150 min, 11 had pyloroplasty at the time of Nissen fundoplication. Patients were asked to use a 0 ("none") to 4 ("incapacitating") scale to describe the severity of their symptoms of heartburn, regurgitation, dysphagia, bloating and diarrhea preoperatively and at 6 weeks and 1 year postoperatively. Eight patients consented to a postoperative analysis of gastric emptying. RESULTS: One year after fundoplication, patients with delayed gastric emptying and controls reported a similar improvement in heartburn, regurgitation, and dysphagia, with no increase in undesirable side effects such as bloating and diarrhea. Among the patients with delayed gastric emptying who consented to undergo a repeat gastric emptying study after their operation, fundoplication alone provided a 38% improvement (p < 0.05) in gastric emptying, whereas fundoplication with pyloroplasty resulted in a 70% improvement in gastric emptying (p < 0.05). CONCLUSION: Fundoplication improves gastric emptying. The addition of pyloroplasty results in even greater improvement and may have particular value for patients with severe gastric hypomotility.

Adolescent↗
PubMed2001

Are the favorable outcomes of splenectomy predictable inpatients with idiopathic thrombocytopenic purpura (ITP)?

BACKGROUND: Historically, splenectomy has been an accepted procedure in the management of immune thrombocytopenic purpura (ITP). However, it is also true that the response to splenectomy in patients with ITP seems to be unpredictable. Therefore, the purpose of this study was to identify clinical variables that might predict a favorable response to splenectomy in patients with ITP. METHODS: Data were collected retrospectively for 40 adult patients with ITP who underwent laparoscopic (LS) and open (OS) splenectomy at Emory University Hospital between 1992 and 1999. Demographics and outcomes were recorded. Age, sex, disease duration, comorbidities (ASA > 2), previous response to steroids and/or other medications, and preoperative platelet count were analyzed by univariate (t-test, Fisher's exact test) and multivariate statistical methods. RESULTS: Of the 20 patients in each group, improved platelet counts were noted in 18 patients (90%) in the LS group and 20 patients (100%) in the OS group. Follow-up (16 +/- 3 months) was obtained in 19 LS patients (95%) and 16 OS patients (80%), with 84% and 87.5% sustained response rates, respectively. After univariate analysis, two variables (age and disease duration) were found to be significantly related to the outcome of splenectomy (p <lt; 0.01). However, after multiple logistic regression analysis, only disease duration (relative risk = 1.083; CI, 1.004-1.167) was an independent prognostic factor for a sustained response to splenectomy. CONCLUSION: These results suggest that the response to splenectomy (laparoscopic and open) in patients with ITP cannot be adequately predicted on the basis of presplenectomy clinical variables. However, disease duration and patient age should be taken into consideration when selecting patients for splenectomy.

Adult↗
PubMed2001

Response of atypical symptoms of gastro-oesophageal reflux to antireflux surgery.

BACKGROUND: Atypical manifestations of gastro-oesophageal reflux (GOR) include asthma, chest pain, cough and hoarseness. The effectiveness of antireflux surgery for these symptoms is uncertain. The present study compared symptomatic response rates for typical and atypical GOR symptoms after fundoplication. METHODS: Between October 1991 and January 1998, 324 patients underwent laparoscopic fundoplication at Emory University Hospital and returned postoperative questionnaires. Severity of typical (heartburn) and atypical (asthma, chest pain, cough and hoarseness) GOR symptoms was reported by patients on a 0-4 scale before surgery, and at 6 and 52 weeks after operation. Patients were stratified based on preoperative symptoms into three groups: group 1 (severe heartburn/minimal atypical symptoms), group 2 (severe heartburn/severe atypical symptoms) and group 3 (minimal heartburn/severe atypical symptoms). RESULTS: In group 1 (n = 173) heartburn improved in 99 per cent and resolved in 87 per cent. In group 2 (n = 95) heartburn improved in 95 per cent and resolved in 76 per cent, and atypical symptoms improved in 94 per cent and resolved in 42 per cent. In group 3 (n = 56) atypical symptoms improved in 93 per cent and resolved in 48 per cent. Although all symptoms were improved by fundoplication, resolution was more likely for heartburn than for atypical symptoms. CONCLUSION: Atypical symptoms of GOR are improved by fundoplication, but symptom resolution occurs in fewer than 50 per cent of patients.

Asthma↗
PubMed2001

Transoral, flexible endoscopic suturing for treatment of GERD: a multicenter trial.

BACKGROUND: A totally transoral outpatient procedure for the treatment of GERD would be appealing. METHODS: A multicenter trial was initiated that included 64 patients with GERD treated with an endoscopic suturing device. Inclusion criteria were 3 or more heartburn episodes per week while not taking medication, dependency on antisecretory medicine, and documented acid reflux by pH monitoring. Exclusion criteria were dysphagia, grade 3 or 4 esophagitis, obesity, and hiatus hernia greater than 2 cm in length. Patients underwent manometry, endoscopy, 24-hour pH monitoring, and symptom severity scoring before and after the procedure. Patients were randomized to a linear or circumferential plication configuration. Adverse procedural events were recorded. RESULTS: Mean 6-month symptom score changes demonstrated procedural efficacy. Heartburn severity and frequency as well as regurgitation all improved (p > 0.0001 for each). Twenty-four-hour pH monitoring showed improvement in number of episodes below pH of 4 at 3 and 6 months (p < 0.0007 and 0.0002) and percentage of total time the pH was less than 4 at 6 months (p < 0.011). Plication configuration did not affect symptoms or pH monitoring results. One patient had a self-contained suture perforation that was successfully treated with antibiotics. CONCLUSION: Endoscopic gastroplasty is safe. It is associated with reduced symptoms and medication use at 6 month follow-up in patients with uncomplicated GERD.

Gastroesophageal Reflux↗
PubMed2001

Bile duct injury during laparoscopic cholecystectomy: results of a national survey.

OBJECTIVE: To determine whether surgical residency training has influenced the occurrence of common bile duct injuries during laparoscopic cholecystectomy, and to asses the anatomic and technical details of bile duct injuries from the practices of surgeons trained in laparoscopic cholecystectomy after residency versus surgeons trained in laparoscopic cholecystectomy during residency. SUMMARY BACKGROUND DATA: Shortly after the introduction of laparoscopic cholecystectomy, the rate of injury to the common bile duct increased to 0.5%, and injuries were more commonly reported early in each surgeon's experience. It is not known whether learning laparoscopic cholecystectomy during surgery residency influences this pattern. METHODS: An anonymous questionnaire was mailed to 3,657 surgeons across the United States who completed an Accreditation Council for Graduate Medical Education (ACGME)-approved residency between 1980 and 1990 (group A) or 1992 and 1998 (group B). All surgeons in group A learned laparoscopic cholecystectomy after residency, and all those in group B learned laparoscopic cholecystectomy during residency. Information obtained included practice description, number of laparoscopic cholecystectomies completed since residency, postgraduate training in laparoscopy, and annual volume of laparoscopic cholecystectomy in the surgeon's hospital. In addition, technical details queried included the completion of a cholangiogram, the interval between injury and identification, the method of repair, and the site of definitive treatment. The primary endpoint was the occurrence of a major bile duct injury during laparoscopic cholecystectomy (bile leaks without a major bile duct injury were not tabulated). RESULTS: Forty-five percent (n = 1,661) of the questionnaires were completed and returned. Mean practice experience was 13.6 years for group A and 5.4 years for group B. At least one injury occurrence was reported by 422 surgeons (37.6%) in group A and 143 surgeons (26.5%) in group B. Forty percent of the injuries in group A occurred during the first 50 cases compared with 22% in group B. Thirty percent of bile duct injuries in group A and 32.9% of all injuries in group B occurred after a surgeon had performed more than 200 laparoscopic cholecystectomies. Independent of the number of laparoscopic cholecystectomies completed since residency, group A surgeons were 39% more likely to report one or more biliary injuries and 58% more likely to report two or more injuries than their counterparts in group B. Bile duct injuries were more likely to be discovered during surgery if a cholangiogram was completed than if cholangiography was omitted (80.9% vs. 45.1%). Sixty-four percent of all major bile duct injuries required biliary reconstruction, and most injuries were definitively treated at the hospital where the injury occurred. Only 14.7% of injuries were referred to another center for repair. CONCLUSIONS: Accepting that the survey bias underestimates the true frequency of bile duct injuries, residency training decreases the likelihood of injuring a bile duct, but only by decreasing the frequency of early "learning curve" injuries. If one accepts a liberal definition of the learning curve (200 cases), it appears that at least one third of injuries are not related to inexperience but may reflect fundamental errors in the technique of laparoscopic cholecystectomy as practiced by a broad population of surgeons in the United States. Intraoperative cholangiography is helpful for intraoperative discovery of injuries when they occur. Most injuries are repaired in the hospital where they occur and are not universally referred to tertiary care centers.

Adult↗
PubMed2000

Choice of insufflating gas influences on wound metastasis.

BACKGROUND: Laparoscopic cancer surgery is limited by concerns about port-site metastasis. No study has definitively addressed the behavior and growth of tumor cells after the use of specific laparoscopic gases. METHODS: In athymic rats, 10,000 colon cancer cells were injected intraperitoneally. The rats received either no pneumoperitoneum (pneumo) or pneumo (8 mmHg, 10 min) with carbon dioxide (CO(2)), nitrous oxide (N(2)O), or air. Two full-thickness incisions were made and closed in the upper abdomen of each animal. After 4 weeks, implants were identified grossly at necropsy, and invasiveness was scored according to penetration through the layers of the abdominal wall. RESULTS: Rats receiving pneumo had more frequent implants (p < 0.01) with deeper penetration (p < 0.001) than rats not receiving pneumo. Implants were more common after air pneumo than after CO(2) (p < 0.05) or N(2)O (p = 0.07) pneumo, and were less penetrating after CO(2) pneumo than after air (p < 0.001) or N(2)O (p < 0.05) pneumo. CONCLUSIONS: Carbon dioxide gas may limit the viability and invasiveness of free intraperitoneal tumor cells, as compared with air or N(2)O.

Abdominal Muscles↗
PubMed2000

Outcomes assessment and minimally invasive surgery: historical perspective and future directions.

BACKGROUND: Outcomes assessment is being used increasingly to shape practice patterns in all areas of medicine. Although outcomes assessment is not a new concept, the widespread application of outcomes measurement for modifying practice is novel. Instead of focusing on results of interventions in highly controlled environments, outcomes studies usually report results as they occur in uncontrolled, real-world environments. Recently, the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) has initiated a society-wide initiative to monitor outcomes in patients undergoing various laparoscopic operations. METHODS: Pertinent literature is reviewed as it relates to outcomes assessment. The historical background underpinning the modern interest in outcomes is outlined. Definitions of terms useful for understanding outcomes research are given. The impact of outcomes assessment on minimally invasive surgery, both positive and negative, are examined. The SAGES outcome initiative is introduced. CONCLUSIONS: Although outcomes studies usually do not provide information on the causes of observations made, they have gained in popularity because they provide information about patient perceptions of disease, disability, and treatment. Minimally invasive surgical procedures often are reported in terms of outcomes assessment because a controlled clinical trial was rendered impossible by early and widespread application of laparoscopic surgery. The SAGES outcomes initiative will provide the necessary tools for the participation of surgeons in the process of practice profiling.

Forecasting↗
PubMed2000

Endogastric surgery.

Endogastric surgery is a branch of minimally invasive surgery that combines flexible endoscopy and laparoscopy. By placing trocars directly into the stomach, quite a number of procedures may be performed. Leiomyomas and other benign gastric tumors are readily removed, and in Asia early gastric cancers are removed with these techniques. Large pancreatic pseudocysts abutting the posterior wall of the stomach may be drained through the stomach using an endogastric approach. Lastly, intragastric bleeding in areas not reachable with a conventional endoscope may be approached with an endogastric approach. Although the indications for these procedures are-in general-rare, they are not difficult to perform, and outcomes have been superb.

Endoscopy↗
PubMed2000

Heartburn is more likely to recur after Toupet fundoplication than Nissen fundoplication.

Toupet (270 degrees) fundoplication is commonly recommended for patients with gastroesophageal reflux (GER) and esophageal dysmotility. However, Toupet fundoplication may be less effective at protecting against reflux than Nissen (360 degrees) fundoplication. We therefore compared the effectiveness and durability of both types of fundoplication as a function of preoperative esophageal motility. From January 1992 through January 1998, 669 patients with GER underwent laparoscopic fundoplication (78 Toupet, 591 Nissen). Patients scored heartburn, regurgitation, and dysphagia preoperatively, and at 6 weeks and 1 year postoperatively, using a 0 ("none") to 3 ("severe") scale. We compared symptom scores (Wilcoxon rank sum test) and redo fundoplication rates (Fisher exact test) in Toupet and Nissen patients. We also performed subgroup analyses on 81 patients with impaired esophageal motility (mean peristaltic amplitude, <30 mm Hg or peristalsis <70% of wet swallows) and 588 patients with normal esophageal motility. Toupet and Nissen patients reported similar preoperative heartburn, regurgitation, and dysphagia. At 6 weeks after operation, heartburn and regurgitation were similarly improved in both groups, but dysphagia was more prevalent among Nissen patients. After 1 year, heartburn and regurgitation were re-emerging in Toupet patients, and dysphagia was again similar between groups. Patients with impaired motility who have Nissen fundoplication are no more likely to suffer persistent dysphagia than their counterparts who have Toupet fundoplication. In addition, patients with normal motility are more likely to develop symptom recurrence after Toupet fundoplication than Nissen fundoplication, with no distinction in dysphagia rates. We conclude that since Toupet patients suffer more heartburn recurrence than Nissen patients, with similar dysphagia, selective use of Toupet fundoplication requires further study.

Deglutition Disorders↗