Publications by authors named "Eelco Wassenaar"

19 Publications

  • Page 1 of 1

18F-Fludeoxyglucose-Positron Emission Tomography/Computed Tomography and Laparoscopy for Staging of Locally Advanced Gastric Cancer: A Multicenter Prospective Dutch Cohort Study (PLASTIC).

JAMA Surg 2021 Oct 27:e215340. Epub 2021 Oct 27.

Department of Surgery, Gelre Ziekenhuizen, Apeldoorn, the Netherlands.

Importance: The optimal staging for gastric cancer remains a matter of debate.

Objective: To evaluate the value of 18F-fludeoxyglucose-positron emission tomography with computed tomography (FDG-PET/CT) and staging laparoscopy (SL) in addition to initial staging by means of gastroscopy and CT in patients with locally advanced gastric cancer.

Design, Setting, And Participants: This multicenter prospective, observational cohort study included 394 patients with locally advanced, clinically curable gastric adenocarcinoma (≥cT3 and/or N+, M0 category based on CT) between August 1, 2017, and February 1, 2020.

Exposures: All patients underwent an FDG-PET/CT and/or SL in addition to initial staging.

Main Outcomes And Measures: The primary outcome was the number of patients in whom the intent of treatment changed based on the results of these 2 investigations. Secondary outcomes included diagnostic performance, number of incidental findings on FDG-PET/CT, morbidity and mortality after SL, and diagnostic delay.

Results: Of the 394 patients included, 256 (65%) were men and mean (SD) age was 67.6 (10.7) years. A total of 382 patients underwent FDG-PET/CT and 357 underwent SL. Treatment intent changed from curative to palliative in 65 patients (16%) based on the additional FDG-PET/CT and SL findings. FDG-PET/CT detected distant metastases in 12 patients (3%), and SL detected peritoneal or locally nonresectable disease in 73 patients (19%), with an overlap of 7 patients (2%). FDG-PET/CT had a sensitivity of 33% (95% CI, 17%-53%) and specificity of 97% (95% CI, 94%-99%) in detecting distant metastases. Secondary findings on FDG/PET were found in 83 of 382 patients (22%), which led to additional examinations in 65 of 394 patients (16%). Staging laparoscopy resulted in a complication requiring reintervention in 3 patients (0.8%) without postoperative mortality. The mean (SD) diagnostic delay was 19 (14) days.

Conclusions And Relevance: This study's findings suggest an apparently limited additional value of FDG-PET/CT; however, SL added considerably to the staging process of locally advanced gastric cancer by detection of peritoneal and nonresectable disease. Therefore, it may be useful to include SL in guidelines for staging advanced gastric cancer, but not FDG-PET/CT.
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http://dx.doi.org/10.1001/jamasurg.2021.5340DOI Listing
October 2021

Laparoscopic Versus Open Gastrectomy for Gastric Cancer (LOGICA): A Multicenter Randomized Clinical Trial.

J Clin Oncol 2021 03 6;39(9):978-989. Epub 2021 Jan 6.

Department of Surgery, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.

Background: The oncological efficacy and safety of laparoscopic gastrectomy are under debate for the Western population with predominantly advanced gastric cancer undergoing multimodality treatment.

Methods: In 10 experienced upper GI centers in the Netherlands, patients with resectable (cT1-4aN0-3bM0) gastric adenocarcinoma were randomly assigned to either laparoscopic or open gastrectomy. No masking was performed. The primary outcome was hospital stay. Analyses were performed by intention to treat. It was hypothesized that laparoscopic gastrectomy leads to shorter hospital stay, less postoperative complications, and equal oncological outcomes.

Results: Between 2015 and 2018, a total of 227 patients were randomly assigned to laparoscopic (n = 115) or open gastrectomy (n = 112). Preoperative chemotherapy was administered to 77 patients (67%) in the laparoscopic group and 87 patients (78%) in the open group. Median hospital stay was 7 days (interquartile range, 5-9) in both groups ( = .34). Median blood loss was less in the laparoscopic group (150 300 mL, < .001), whereas mean operating time was longer (216 182 minutes, < .001). Both groups did not differ regarding postoperative complications (44% 42%, = .91), in-hospital mortality (4% 7%, = .40), 30-day readmission rate (9.6% 9.1%, = 1.00), R0 resection rate (95% 95%, = 1.00), median lymph node yield (29 29 nodes, = .49), 1-year overall survival (76% 78%, = .74), and global health-related quality of life up to 1 year postoperatively (mean differences between + 1.5 and + 3.6 on a 1-100 scale; 95% CIs include zero).

Conclusion: Laparoscopic gastrectomy did not lead to a shorter hospital stay in this Western multicenter randomized trial of patients with predominantly advanced gastric cancer. Postoperative complications and oncological efficacy did not differ between laparoscopic gastrectomy and open gastrectomy.
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http://dx.doi.org/10.1200/JCO.20.01540DOI Listing
March 2021

SAGES guidelines for the surgical treatment of gastroesophageal reflux (GERD).

Surg Endosc 2021 09 19;35(9):4903-4917. Epub 2021 Jul 19.

Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA.

Background: Gastroesophageal Reflux Disease (GERD) is an extremely common condition with several medical and surgical treatment options. A multidisciplinary expert panel was convened to develop evidence-based recommendations to support clinicians, patients, and others in decisions regarding the treatment of GERD with an emphasis on evaluating different surgical techniques.

Methods: Literature reviews were conducted for 4 key questions regarding the surgical treatment of GERD in both adults and children: surgical vs. medical treatment, robotic vs. laparoscopic fundoplication, partial vs. complete fundoplication, and division vs. preservation of short gastric vessels in adults or maximal versus minimal dissection in pediatric patients. Evidence-based recommendations were formulated using the GRADE methodology by subject experts. Recommendations for future research were also proposed.

Results: The panel provided seven recommendations for adults and children with GERD. All recommendations were conditional due to very low, low, or moderate certainty of evidence. The panel conditionally recommended surgical treatment over medical management for adults with chronic or chronic refractory GERD. There was insufficient evidence for the panel to make a recommendation regarding surgical versus medical treatment in children. The panel suggested that once the decision to pursue surgical therapy is made, adults and children with GERD may be treated with either a robotic or a laparoscopic approach, and either partial or complete fundoplication based on surgeon-patient shared decision-making and patient values. In adults, the panel suggested either division or non-division of the short gastric vessels is appropriate, and that children should undergo minimal dissection during fundoplication.

Conclusions: These recommendations should provide guidance with regard to surgical decision-making in the treatment of GERD and highlight the importance of shared decision-making and patient values to optimize patient outcomes. Pursuing the identified research needs may improve future versions of guidelines for the treatment of GERD.
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http://dx.doi.org/10.1007/s00464-021-08625-5DOI Listing
September 2021

Learning Curves of Ivor Lewis Totally Minimally Invasive Esophagectomy by Hospital and Surgeon Characteristics: A Retrospective Multi-National Cohort Study.

Ann Surg 2021 Feb 10. Epub 2021 Feb 10.

Department of Surgery, Radboudumc, Nijmegen, The Netherlands Department of Operating Rooms, Radboudumc, Nijmegen, the Netherlands Department of Clinical Science, Intervention and Technology, Karolinska Institutet and Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands Amsterdam UMC, location AMC, University of Amsterdam, Department of Surgery, Cancer Center Amsterdam, Meibergdreef 9, 1105AZ Amsterdam, The Netherlands Department of Surgery, Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands Department of Surgery, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands Department of Surgery, Gelre Ziekenhuizen, Apeldoorn, The Netherlands Division of Thoracic and Esophageal Surgery, Heart and Lung Center, Helsinki University Hospital and Helsinki University Department of Surgery, medical Centre Leeuwarden, Leeuwarden, The Netherlands Department of UGI Surgery, Norfolk and Norwich University Hospital Foundation Trust, Norwich, UK Department of Surgery, Odense University Hospital, Denmark Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland Department of Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan, 1117, Amsterdam, The Netherlands Department of Surgery, Hospital Group Twente, Almelo, The Netherlands Department of Surgery, Zuyderland Medical Center, Heerlen, The Netherlands Department of Surgery and Cancer, Imperial College London, London, United Kingdom.

Objective: To describe the pooled learning curves of Ivor Lewis TMIE in hospitals stratified by predefined hospital and surgeon related factors.

Summary Background Data: Ivor Lewis totally minimally invasive esophagectomy (TMIE) is known to have a long learning curve which is associated with considerable learning associated morbidity. It is unknown whether hospital and surgeon characteristics are associated with more efficient learning.

Methods: A retrospective analysis of prospectively collected data of consecutive Ivor Lewis TMIE patients in 14 European hospitals was performed. Outcome parameters used as proxy for efficient learning were learning curve length, learning associated morbidity and the plateau level regarding anastomotic leakage and textbook outcome. Pooled incidences were plotted for the factor-based subgroups using generalized additive models and two-phase models. Casemix predicted outcomes were plotted and compared with observed outcomes. The investigated factors included annual volume, (TMIE) experience, clinic visits, courses and fellowships followed, and proctor supervision.

Results: This study included 2121 patients. The length of the learning curve was shorter for centers with an annual volume ≥50 compared to centers with an annual volume < 50. Analysis with an annual volume cut-off of 30 cases showed similar but less pronounced results. No outcomes suggesting more efficient learning were found for longer experience as consultant, visiting an expert clinic, completing a MIE fellowship or implementation under proctor supervision.

Conclusions: More efficient learning was observed in centers with higher annual volume. Visiting an expert clinic, completing a fellowship, or implementation under a proctor's supervision were not associated with more efficient learning.
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http://dx.doi.org/10.1097/SLA.0000000000004801DOI Listing
February 2021

Fit4SurgeryTV At-home Prehabilitation for Frail Older Patients Planned for Colorectal Cancer Surgery: A Pilot Study.

Am J Phys Med Rehabil 2019 05;98(5):399-406

From the Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands (ERJB, CJB, WAB); Department of Surgery, Gelre Hospitals, Apeldoorn, The Netherlands (ERJB, TEA, HJS, PvD, ESvdZ, EBW); Department of Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands (TEA, BCvM); Department of Surgery, OLVG Hospitals, Amsterdam, The Netherlands (MFG); Department of Surgery, Meander Medical Center, Amersfoort, The Netherlands (ECC); and Department of Geriatric Medicine, Gelre Hospitals, Apeldoorn, The Netherlands (BCvM).

Objective: The preoperative phase is a potential window of opportunity. Although frail elderly patients are known to be more prone to postoperative complications, they are often not considered capable of accomplishing a full prehabilitation program. The aim of this study was to assess the feasibility of Fit4SurgeryTV, an at-home prehabilitation program specifically designed for frail older patients with colorectal cancer.

Design: The Fit4SurgeryTV program consisted of a daily elderly adapted computer-supported strength training workout and two protein-rich meals. Frail patients 70 yrs or older with colorectal cancer were included. The program was considered feasible if 80% of the patients would be able to complete 70% of the program.

Results: Fourteen patients (median age, 79 yrs; 5 males) participated. At baseline, 86% patients were physically impaired and 64% were at risk for malnourishment. The median duration of the program was 26 days. The program was feasible as patients followed the exercises for 6 (86%) of 7 days and prepared the recipes 5 (71%) of 7 d/wk. Patients specifically appreciated at-home exercises.

Conclusions: This study showed that at-home prehabilitation in frail older patients with colorectal cancer is feasible. As a result, patients might be fitter for surgery and might recover faster. The perioperative period could serve as a pivotal time point in reverting complications of immobility.
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http://dx.doi.org/10.1097/PHM.0000000000001108DOI Listing
May 2019

Oral Nutrition as a Form of Pre-Operative Enhancement in Patients Undergoing Surgery for Colorectal Cancer: A Systematic Review.

Surg Infect (Larchmt) 2018 Jan 19;19(1):1-10. Epub 2017 Oct 19.

5 Department of Geriatrics, Gelre Hospitals , The Netherlands .

Background: Nutritional status has major impacts on the outcome of surgery, in particular in patients with cancer. The aim of this review was to assess the merit of oral pre-operative nutritional support as a part of prehabilitation in patients undergoing surgery for colorectal cancer.

Methods: A systematic literature search and meta-analysis was performed according to the Preferred Reporting of Systematic Reviews and Meta-Analyses (PRISMA) recommendations in order to review all trials investigating the effect of oral pre-operative nutritional support in patients undergoing colorectal surgery. The primary outcome was overall complication rate. Secondary outcomes were incision infection rate, anastomotic leakage rate, and length of hospital stay.

Results: Five randomized controlled trials and one controlled trial were included. The studies contained a total of 583 patients with an average age of 63 y (range 23-88 y), of whom 87% had colorectal cancer. Malnourishment rates ranged from 8%-68%. All investigators provided an oral protein supplement. Overall patient compliance rates ranged from 72%-100%. There was no significant reduction in the overall complication rate in the interventional groups (odds ratio 0.82; 95% confidence interval 0.52 - 1.25).

Conclusion: Current studies are too heterogeneous to conclude that pre-operative oral nutritional support could enhance the condition of patients undergoing colorectal surgery. Patients at risk have a relatively lean body mass deficit (sarcopenia) rather than an absolute malnourished status. Compliance is an important element of prehabilitation. Targeting patients at risk, combining protein supplements with strength training, and defining standardized patient-related outcomes will be essential to obtain satisfactory results.
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http://dx.doi.org/10.1089/sur.2017.143DOI Listing
January 2018

The impact of laparoscopic anti-reflux surgery in patients with Barrett's esophagus.

Surg Endosc 2014 Dec 17;28(12):3279-84. Epub 2014 Jun 17.

Division of General Surgery, Department of Surgery, University of Washington, 1959 N.E. Pacific Street, Box 356410, Seattle, WA, 98195-6410, USA,

Background: Barrett's esophagus (BE) is a major risk factor for esophageal adenocarcinoma. It is believed that BE is caused by chronic gastro-esophageal reflux disease (GERD). Laparoscopic anti-reflux surgery (LARS) restores the competency of the cardia and may thereby change the natural course of BE. We studied the impact of LARS on the histological profile of BE and on the control of GERD.

Methods: We identified all patients with BE who underwent LARS from 1994 to 2007 and contacted them to assess post-operative GERD symptoms via questionnaire. Endoscopy findings, histology, 24 hour pH monitoring, and manometry were also collected using our prospectively maintained database. Histological regression was defined as either loss of dysplasia or disappearance of BE.

Results: Two hundred and fifteen patients met the initial inclusion criteria; in 82 of them histology from post-operative endoscopy was available for review. Endoscopy was performed a median of 8 years (range, 1-16 years) after surgery. Regression of BE occurred in 18 (22%) patients while in 6 (7%) BE progressed to dysplasia or cancer. Thirty-six (43%) patients underwent pre- and post-operative manometry. The median lower esophageal sphincter pressure increased from 9 to 17 mmHg in these patients. Thirty-four (41%) patients underwent pre- and post-operative pH studies. The median DeMeester score decreased from 54 to 9. Sixty-seven (82%) of 82 patients completed the post-operative questionnaire; 86% of these patients reported improvement in heartburn and regurgitation.

Conclusions: LARS was associated with both physiologic and symptomatic control of GERD in patients with BE. LARS resulted in regression of BE in 22% of patients and progression in 7%. Thus, continued surveillance of Barrett's is needed after LARS.
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http://dx.doi.org/10.1007/s00464-014-3601-zDOI Listing
December 2014

Causes and treatments of achalasia, and primary disorders of the esophageal body.

Ann N Y Acad Sci 2013 Oct;1300:236-249

Department of Gastroenterology, Walter Reed National Military Medical Center, Bethesda, Maryland.

The following on achalasia and disorders of the esophageal body includes commentaries on controversies regarding whether patients with complete lower esophageal sphincter (LES) relaxation can be considered to exhibit early achalasia; the roles of different mucle components of the LES in achalasia; sensory neural pathways impaired in achalasia; indications for peroral endoscopic myotomy and advantages of the technique over laparoscopic and thorascopic myotomy; factors contributing to the success of surgical therapy for achalasia; modifications to the classification of esophageal body primary motility disorders in the advent of high-resolution manometry (HRM); analysis of the LES in differentiating between achalasia and diffuse esophageal spasm (DES); and appropriate treatment for DES, nutcracker esophagus (NE), and hypertensive LES (HTLES).
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http://dx.doi.org/10.1111/nyas.12254DOI Listing
October 2013

Outcomes of esophageal surgery, especially of the lower esophageal sphincter.

Ann N Y Acad Sci 2013 Oct;1300:29-42

Department of Surgery, University of Washington, Seattle, Washington.

This paper includes commentaries on outcomes of esophageal surgery, including the mechanisms by which fundoduplication improves lower esophageal sphincter (LES) pressure; the efficacy of the Linx™ management system in improving LES function; the utility of radiologic characterization of antireflux valves following surgery; the correlation between endoscopic findings and reported symptoms following antireflux surgery; the links between laparoscopic sleeve gastrectomy and decreased LES pressure, endoscopic esophagitis, and gastroesophageal reflux disease (GERD); the less favorable outcomes following fundoduplication among obese patients; the application of bioprosthetic meshes to reinforce hiatal repair and decrease the incidence of paraesophageal hernia; the efficacy of endoluminal antireflux procedures, and the limited efficacy of revisional antireflux operations, underscoring the importance of good primary surgery and diligent work-up to prevent the necessity of revisional procedures.
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http://dx.doi.org/10.1111/nyas.12232DOI Listing
October 2013

The safety of biologic mesh for laparoscopic repair of large, complicated hiatal hernia.

Surg Endosc 2012 May 16;26(5):1390-6. Epub 2011 Nov 16.

Department of Surgery, University of Washington, Box 356410, 1959 NE Pacific Street, Seattle, WA 98115, USA.

Background: Biologic mesh is widely used for repair of large, complicated hiatal hernias. Recently, there have been reports of complications after its implantation. We studied the course of a large group of patients who had undergone hiatal hernia repair with use of biologic mesh to determine the rate of immediate and late complications related to its use.

Methods: All patients who had biologic mesh placed at the hiatus and who had been followed for at least 1 year were included. Perioperative data were reviewed, and a questionnaire was administered, designed to identify symptoms of gastroesophageal reflux, other symptoms such as dysphagia, and all other operative or endoscopic interventions that occurred after mesh implantation. In addition, postoperative radiologic and endoscopic studies were reviewed to assess signs of complications related to use of mesh.

Results: There were 126 patients eligible for the study. We were able to contact 73 of these patients, at median follow-up of 45 months. No mesh-related complications were found. The frequency and severity of heartburn, regurgitation, and dysphagia improved significantly compared with preoperative values, and 89% of the patients reported good to excellent results in terms of overall satisfaction. Six patients recorded worsening of dysphagia postoperatively, but after careful work-up and review of each individual case, no case seemed to be directly related to the mesh. No erosions, strictures, or other complications directly related to use of mesh were found. One patient required reoperation due to hiatal hernia recurrence with gastroesophageal reflux disease (GERD) symptoms.

Conclusions: Use of biologic mesh for laparoscopic repair of large, complicated hiatal hernias appears safe. There were no major complications related to the mesh, and overall satisfaction with the operation was very good.
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http://dx.doi.org/10.1007/s00464-011-2045-yDOI Listing
May 2012

Comprehensive evaluation of endoscopic fundoplication using the EsophyX™ device.

Surg Endosc 2012 Apr 1;26(4):1021-7. Epub 2011 Nov 1.

Department of Surgery, University of Washington, 1959 N.E. Pacific St, 356410, Seattle, WA 98195, USA.

Background: There are limited studies that evaluate the efficacy of endoscopic fundoplication (EF) for gastroesophageal reflux disease (GERD) with the EsophyX™ device, especially with the most recent procedural iteration (TIF-2). This study was a prospective evaluation of our early experience with this device and procedure.

Methods: Data were collected prospectively on 23 consecutive patients undergoing EF (March 2009 to August 2010). All patients completed a symptom questionnaire assessing frequency and severity of gastrointestinal and respiratory symptoms, 24-h pH, and manometry studies preoperatively and were encouraged to repeat these at 6 months.

Results: All patients had abnormal pH studies and were on proton-pump inhibitor (PPI) therapy prior to EF. Median age was 47 years (19-62 years), and six (23%) were male. Nine (41%) patients had Body Mass Index (BMI) ≥ 30 kg/m(2), and three (14%) had a small hiatal hernia (≤ 2 cm). The procedure was aborted in two patients for retained food. Three patients underwent subsequent laparoscopic Nissen fundoplication for persistent or recurrent symptoms. Median hospitalization was 1 day, and there were no major perioperative complications. At 6 month follow-up, 19 (86%) patients completed a symptom questionnaire, and 14 (64%) and 11 (50%) patients underwent pH and manometry studies, respectively. There was a significant reduction in heartburn (P = 0.02), total percentage acid contact time (P = 0.002), DeMeester score (P = 0.002), and PPI use (P = 0.003). Overall, 8 out of 14 (57%) patients had abnormal pH studies and 11 out of 19 (58%) remained on PPI therapy at 6 months.

Conclusion: EF with EsophyX™ is associated with significant reduction in heartburn and abnormal acid exposure at 6 months, although the majority of patients did not experience normalization of their pH studies and remained on PPI therapy. The procedure has an acceptable safety profile, but the question remains as to whether it is effective enough to warrant a place in the armamentarium for the treatment of GERD.
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http://dx.doi.org/10.1007/s00464-011-1989-2DOI Listing
April 2012

Barrett's esophagus: surgical treatments.

Ann N Y Acad Sci 2011 Sep;1232:175-95

Department of General Surgery IV, Regional Referal Center for Esophageal Pathology, Pisa, Italy.

The following on surgical treatments for Barrett's esophagus includes commentaries on the indications for antireflux surgery after medical treatment; the effects of the various procedures on the lower esophageal sphincter; the role of impaired esophageal motility and delayed gastric emptying in the choice of the surgical procedure; indications for associated highly selective vagotomy, duodenal switch, and gastric electrical stimulation; therapeutic strategies for detection and treatment of shortened esophagus; the role of antireflux surgery on the regression of metaplastic mucosa and the risk of malignant progression; the detection of asymptomatic reflux brfore bariatric surgery; the role of non-GERD symptoms on the results of surgery; and the indications of Collis gastroplasty and choice of the type of fundoplication.
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http://dx.doi.org/10.1111/j.1749-6632.2011.06051.xDOI Listing
September 2011

Pepsin detection in patients with laryngopharyngeal reflux before and after fundoplication.

Surg Endosc 2011 Dec 22;25(12):3870-6. Epub 2011 Jun 22.

Department of Surgery, University of Washington, 1959 NE Pacific Street, Box 356410, 98195, Seattle, WA, USA.

Background: Some patients with gastroesophageal reflux disease (GERD) suffer from laryngopharyngeal reflux (LPR). There is no reliable diagnostic test for LPR as there is for GERD. We hypothesized that detection of pepsin (a molecule only made in the stomach) in laryngeal epithelium or sputum should provide evidence for reflux of gastric contents to the larynx, and be diagnostic of LPR. We tested this hypothesis in a prospective study in patients with LPR symptoms undergoing antireflux surgery (ARS).

Methods: Nine patients undergoing ARS for LPR symptoms were studied pre- and postoperatively using a clinical symptom questionnaire, laryngoscopy, 24-h pH monitoring, biopsy of posterior laryngeal mucosa, and sputum collection for pepsin Western blot assay.

Results: The primary presenting LPR symptom was hoarseness in six, cough in two, and globus sensation in one patient. Pepsin was detected in the laryngeal mucosa in eight of nine patients preoperatively. There was correlation between biopsy and sputum (+/+ or -/-) in four of five patients, both analyzed preoperatively. Postoperatively, pH monitoring improved in all but one patient and normalized in five of eight patients. Eight of nine patients reported improvement in their primary LPR symptom (six good, two mild). Only one patient (who had negative preoperative pepsin) reported no response to treatment of the primary LPR symptom. Postoperatively, pepsin was detected in only one patient.

Conclusions: Pepsin is often found on laryngeal epithelial biopsy and in sputum of patients with pH-test-proven GERD and symptoms of LPR. ARS improves symptoms and clears pepsin from the upper airway. Detection of pepsin improves diagnostic accuracy in patients with LPR.
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http://dx.doi.org/10.1007/s00464-011-1813-zDOI Listing
December 2011

Bulging of the mesh after laparoscopic repair of ventral and incisional hernias.

JSLS 2010 Oct-Dec;14(4):541-6

Department of Surgery, Twenteborg Hospital, Almelo, The Netherlands.

Background And Objectives: To investigate the prevalence, diagnosis, clinical significance, and treatment strategies for bulging in the area of laparoscopic repair of ventral hernia that is caused by mesh protrusion through the hernia opening, but with intact peripheral fixation of the mesh and actually a still sufficient repair.

Methods: Medical records of all 765 patients who underwent laparoscopic ventral hernia repair were reviewed, and all patients with a swelling in the repaired area were identified and analyzed.

Results: Twenty-nine patients were identified. They all underwent a computed tomography assessment. Seventeen patients (2.2% of the total group) had a hernia recurrence; in an additional 12 patients (1.6%), radiologic examinations indicated only bulging of the mesh but no recurrence. Bulging was associated with pain in 4 patients who underwent relaparoscopy and got a new, larger mesh tightly stretched over the entire previous repair. Eight asymptomatic patients decided on "watchful waiting." All patients remained symptom free during a median follow-up of 22 months.

Conclusion: Symptomatic bulging, though not a recurrence, requires a new repair and must be considered as an important negative outcome of laparoscopic ventral hernia repair. In asymptomatic patients, "watchful waiting" seems justified.
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http://dx.doi.org/10.4293/108680810X12924466008240DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3083046PMC
July 2011

Effect of medical and surgical treatment of Barrett's metaplasia.

World J Gastroenterol 2010 Aug;16(30):3773-9

Center for Videoendoscopic Surgery, Department of Surgery, University of Washington, Seattle, WA 98195, United States.

Barrett's esophagus (BE) is a change in the esophageal mucosa as a result of long-standing gastroesophageal reflux disease. The importance of BE is that it is the main risk factor for the development of esophageal adenocarcinoma, whose incidence is currently growing faster than any other cancer in the Western world. The aim of this review was to compare the common treatment modalities of BE, with the focus on proton pump inhibitors and operative fundoplication. We performed a literature search on medical and surgical treatment of BE to determine eligible studies for this review. Studies on medical and surgical treatment of BE are discussed with regard to treatment effect on progression and regression of disease. Although there is some evidence for control of reflux with either medical or surgical therapy, there is no definitive evidence that either treatment modality decreases the risk of progression to dysplasia or cancer. Even though there is a trend toward antireflux surgery being superior, there are no definitive studies to prove this.
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http://dx.doi.org/10.3748/wjg.v16.i30.3773DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2921088PMC
August 2010

Mesh-fixation method and pain and quality of life after laparoscopic ventral or incisional hernia repair: a randomized trial of three fixation techniques.

Surg Endosc 2010 Jun 24;24(6):1296-302. Epub 2009 Dec 24.

Department of Surgery, Center for Video-endoscopic Surgery, University of Washington, 1959 NE Pacific Street, Box 356410, Seattle, WA 98195, USA.

Background: Persistent, activity-limiting pain after laparoscopic ventral or incisional hernia repair (LVIHR) appears to be related to fixation of the implanted mesh. A randomized study comparing commonly used fixation techniques with respect to postoperative pain and quality of life has not previously been reported.

Methods: A total of 199 patients undergoing non-urgent LVIHR in our unit between August 2005 and July 2008 were randomly assigned to one of three mesh-fixation groups: absorbable sutures (AS) with tacks; double crown (DC), which involved two circles of tacks and no sutures; and nonabsorbable sutures (NS) with tacks. All operations were performed by one of two experienced surgeons, who used a standardized technique and the same type of mesh and mesh-fixation materials. The severity of the patients' pain was assessed preoperatively and at 2 weeks, 6 weeks and 3 months postoperatively by using a visual analogue scale (VAS). Quality of life (QoL) was evaluated by administering a standard health survey before and 3 months after surgery. Results in the three groups were compared.

Results: The AS, DC, and NS mesh-fixation groups had similar patient demographic, hernia and operative characteristics. There were no significant differences among the groups in VAS scores at any assessment time or in the change in VAS score from preoperative to postoperative evaluations. The QoL survey data showed a significant difference among groups for only two of the eight health areas analyzed.

Conclusion: In this trial, the three mesh-fixation methods were associated with similar postoperative pain and QoL findings. These results suggest that none of the techniques can be considered to have a pain-reduction advantage over the others. Development of new methods for securing the mesh may be required to decrease the rate or severity of pain after LVIHR.
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http://dx.doi.org/10.1007/s00464-009-0763-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2869434PMC
June 2010

Recurrences after laparoscopic repair of ventral and incisional hernia: lessons learned from 505 repairs.

Surg Endosc 2009 Apr 24;23(4):825-32. Epub 2008 Sep 24.

Department of Surgery, Twenteborg Hospital, Postbox 7600, 7600 SZ Almelo, The Netherlands.

Background: All hernia recurrences in a series of 505 patients who underwent laparoscopic repair of a ventral hernia (n=291) or incisional hernia (n=214) were analyzed to identify factors responsible for the recurrence.

Methods: In all laparoscopic repairs, an expanded polytetrafluoroethylene prosthesis overlapping the hernia margins by >or=3 cm was fixed with a double ring of tacks alone (n=206) or with tacks as well as sutures (n=299). During the mean follow-up time of 31.3 +/- 18.4 months, nine patients (1.8%) had a recurrence, eight of which were repaired laparoscopically. Operative reports and videotapes of all initial repairs and repairs of recurrences were analyzed.

Results: All recurrences followed an incisional hernia repair (p<0.001). Five recurrences developed after mesh fixation with both tacks and sutures and four after mesh fixation with tacks alone (p=1.0). All recurrences were at the site of the apparently sufficient original incision scar: in eight patients, the recurrent hernia was attached to the mesh; in one, it developed in another part of the scar. All initial repairs had been performed without technical errors. Upon repair of the recurrences, a new, larger mesh was placed over the entire incision, not just the hernia. There were no re-recurrences during follow-up (mean 19.8+/-10.3 months).

Conclusions: Recurrence after incisional hernia repair appears to be due primarily to disregard for the principle that the whole incision--not just the hernia--must be repaired. Our experience supports the idea that the entire incision has a potential for hernia development. Insufficient coverage of the incision scar is a risk factor for recurrence after laparoscopic repair of ventral and incisional hernia.
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http://dx.doi.org/10.1007/s00464-008-0146-zDOI Listing
April 2009

Removal of transabdominal sutures for chronic pain after laparoscopic ventral and incisional hernia repair.

Surg Laparosc Endosc Percutan Tech 2007 Dec;17(6):514-6

Department of Surgery, Twenteborg Hospital, Almelo, The Netherlands.

Some patients who have undergone laparoscopic repair of ventral and incisional hernia have persistent postoperative pain, assumed to be caused by the presence of transabdominal sutures (TAS). We investigated whether removal of these sutures relieves discomfort. Of 375 patients who underwent laparoscopic repair of ventral and incisional hernia, 6 patients (1.6%) had persistent pain resistant to conservative therapy. These patients underwent relaparoscopy and removal of TAS at all apparent pain sites. Postoperatively, 3 patients had complete pain relief. Two patients had some improvement but moderate, less localized, pain remained. The sixth patient experienced no change at all. Removal of TAS deemed responsible for pain may occasionally provide relief, but the results of removal seem unpredictable and less effective than previously assumed.
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http://dx.doi.org/10.1097/SLE.0b013e3181462b9eDOI Listing
December 2007

Compartment syndrome of the lower leg after surgery in the modified lithotomy position: report of seven cases.

Dis Colon Rectum 2006 Sep;49(9):1449-53

Department of General Surgery, University Medical Center, Utrecht, The Netherlands.

Purpose: Acute compartment syndrome is known to develop after trauma or after postischemic revascularization. It also can occur when a patient has been lying in the lithotomy position during prolonged surgery. Methods were searched for the prevention of this iatrogenic complication after a series of seven patients who developed compartment syndrome after surgery at our hospital.

Methods: A series of seven consecutive patients who developed compartment syndrome of the lower leg(s) after abdominoperineal surgical procedures from 1997 to 2002 is presented and so are the lessons learned to prevent this problem.

Results: When comparing our experiences with data from literature, the seven patients had the usual risk factors for development of a compartment syndrome: lengthy procedure (>5 hours); decreased perfusion of the lower leg because of Trendelenburg positioning combined with the lithotomy position; and external compression of the lower legs (because of positioning, stirrups, or antiembolism stockings). Measures have been taken to prevent compartment syndrome from developing after prolonged surgery in the lithotomy position. This complication has not occurred again after the introduction of these measures two years ago.

Conclusions: Acute compartment syndrome can be prevented if adequate measures are taken, but after lengthy surgery, maximum alertness for emerging acute compartment syndrome remains indicated. Early diagnosis and treatment by four-compartment fasciotomy is still the only way to prevent irreversible damage.
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http://dx.doi.org/10.1007/s10350-006-0688-xDOI Listing
September 2006
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