Zenker's diverticulum: Cricopharyngeal myotomy with diverticulopexy versus diverticulectomy

Fundoplication Prsop Postop Dysphagia Dysphagia score Reflux score

2426

No Fundoplication Preop Postop

100% 4.6 + 0,3

29%1. 1.2+ 0.3:L

100% 4.9±0.1

14%1. 0.8 ± 0.1:1:

3.6 ± 0.4

1.0± 0.3~

3.2±0.2

1.4+_0.2:[[

Quality of Life, Surgical Outcome and Patient's Satisfaction Three Years After Laparoscopic Antireflux Surgery Frank A. Granderath,Thomas Eamoiz, Ursula M. Schweiger, Tanja Bammer, Rudolph Pointner, Dept of Gen Surg, Zell am See Austria

1"p
2424 Laryngoscopy and Pharyngeal pH are Complimentary in the Diagnosis of Gaetroesphageal-laryngeal Reflux Brant K. Oeischlager,Thomas R. Eubanks, Nicole Maronian, Allan Hillel, Dmitry Oleynikov, Charles Pope II, Carlos A. Pellegrini, Univ of Washington, Seattle, WA Background PharyngealpH monitoring and laryngoscopyare used to diagnosegastroesophageal-pharyngealreflux as a cause of respiratory symptoms. Though their use seems intuitive, their ultimate role remains to be defined. Methods: We studied 10 asymptomatic subjects and 76 patientswith respiratory symptoms. Patients and subjects were queried regarding their symptoms and their frequency scored.Each underwent direct laryngoscopy using the Reflux Finding Score (RFS) to grade laryngeal injury, esophagealmanometry and 24-hour csophago-pharyngeal pH monitoring. The patients were RFS+ if the score was >7, and PR+ if they had >1 episode of pharyngealreflux detected during pH monitoring. Results: The most common symptoms reported by patients were hoarseness(87%), cough (53%), and heartburn (50%). Subjects had a significantly lower RFS (2.1 vs. 9.6, p<.01) and fewer episodes of PR (0.2 vs. 3.4, p<.01), than patients. No subject had more than one episode of PR. Fifty patients (66%) were RFS+ and 26 (34%)were RFS-. Thirty-two patients (42%) were PR+ and 44 (58%) were PR-. Fifteen patients had a normal RFS and no pharyngeal reflux (Group I = RFS-,PR-). Forty patients had discordancebetweenthe laryngoscopyfindings and the pH monitoring (Group II=RFS PR+ or RFS+PR-). Twenty-one patients had both an abnormal RFS and pharyngeal reflux (Group III=RFS+PR+), The heartburn score in Group I was 1.3; Group II, 0.9; and Group III, 1.8 (p<.05 for Group II vs. Group III). The mean distal esophagealacid exposure (% time pH<4) was 3% in Group I, 3.3% in Group II, and 5.9% in Group III (p<.05 for Group II vs. Group III). Conclusions: An abnormal PR or RFS differentiates normal subjects from patients with laryngeal symptoms. Agreement between PR and RFS helps establish or refute the diagnosis of gastroesophagealreflux as a cause of laryngeal symptoms. Patients who are RFS+ and PR - may have laryngeal injury from another source; whereas patients who are RFS- and PR+ may not have acid enter the larynx, despite pharyngeal reflux. Patients who are RFS+ and PR+ have more severe gastroesophageal reflux disease. Laryngoscopy and pharyngeal pH monitoring should be considered complimentary studies in establishing the diagnosis of laryngeal injury induced by pastroesophagealreflux.

2425 Robotic-Assisted Laparoscopic Esophageal Surgery Soji Ozawa,Toshiharu Furukawa, Go Wakabayashi,Nobutoshi Ando, Yuko Kitagawa, Masakai Kitajima, Sch of Medicine, Keio Univ, Tokyo Japan In 1997, the "master-slave" robot system was introduced in the clinical field for endoscopic surgery. Since March of 2000, we have used the da Vinci Surgical System (Intuitive Surgical, Inc., CA, USA),which consists of a surgeon's console,a patient-sidecart, a high - performance vision system, and proprietary instruments. The purpose of this study was to clarify the usefulness of this system for endoscopic surgery, in particular esophageal surgery. We performed surgery using the da Vinci Surgical System in 22 cases with benign abdominal diseases; laparoscopic esophageal surgery in 12, laparoscopic cholecystectomy in 9, and inguinal hernia repair in 1 case. Among those cases who underwentesophagealsurgery, we performed laparoscopic Nissen fundoplication in 8 cases, and laparoscopic Heller and Dor procedure in 4 cases, using the da Vinci system. The patient-side cart of the da Vinci system was placed on the left side of the patient, and a 3D camera and EndoWrists, which are proprietary instruments, were set up on it. We focused on the suturing steps using the da Vinci system.The entire suturing step (Nissen/ Dor fundoplication)was successfullyperformed using the da Vinci system in all the patients. While the suturing time (178 + / - 15 seconds), including that required to insert the needle and tie the four knots for crural repair, using the da Vinci system was significantly shorter than that recordedduring the surgery without using the da Vinci system (406 + / - 35 seconds, p = 0.0001), the suturing time (165 + / - 13 seconds) for wrapping was only slightly shorter (198 + / - 31 seconds, p = 0.3). The suturing time (185 + / - 11 seconds) for Dor suturing on the left side using the da Vinci system was significantly shorter than that recorded during the same surgery performed without using the da Vinci system (227 + / - 12 seconds, p = 0.0158). The suturing time (150 + / - 7 seconds) for Dor suturing on the right side using the da Vinci system was also significantly shorter than that recorded during the surgery performed without using the da Vinci system (210 + / - 10 seconds, p = 0.0001). It took about 15 minutes to set up the da Vinci Surgical System. There was no morbidity or mortality related to the use of this system for surgery. In conclusion, surgery using the da Vinci Surgical System is considered feasible, safe, and useful. The advantagesof using the da Vinci system include its usefulness for suturing in narrow surgical fields, such as in the case of crural repair, and its usefulness for multiple suturings, such as in Dor fundoplication, and securing Steadyproceduresthrough 30 view.

Quality of life data and patient's satisfaction to estimate outcome of laparoscopic antireflux surgery ( tARS ) is nowadays an important issue. Long-term outcome has not gone wide attention yet. Aim of the present study was to evaluate prospectively quality of life data of 150 patients who underwent laparoscopic "floppy" Nissenfundoplication in our surgical unit three years after surgery. Quality of life was evaluated using the Gastrointestinal Quality of Life Index (GIQU). Additionally, subjectivity and objectivity of the quality of the procedure and possible side-effects were evaluatedwith a questionnaire.Three years after laparoscopic Nissen fundoplication patients quoted their quality of life (GIQLI) in an overall score of 123.7 points. This is comparableto 122.6 points of a healthy population. There was no difference detectable in the subdimensions of GIQLI. 97% of the patients estimated their satisfaction with the procedure with "excellent" or "good" and would undergo tARS again if necessary. Eight patients suffered from minimal side-effects of the procedure but had no decrease of their quality of life. None of the patients neededantireflux medicationsafter surgery. Laparoscopic redo-surgery was performed in two patients 3 months after initial surgery because of persisting dysphagia. Both patients were free of symptoms three years after surgery. We conclude that the efficiacy and long-term outcome of treatment of gastroesophagealreflux diseasewith laparoscopic"floppy" Nissenfundoplication can be evaluatedby objectivetesting, but also with subjective judgement of the patient and with evaluation of quality of life. Gastrointesf~nalQualityof life Index3 yearsafter LARS GIQLI

Healthy

Preoperstiv 6 weeks 3 months I year after 3 years after e after LARS after LARS LARS LARS

General score

122.6

91.9

115.8

125.0

123.9

123.7

2427 Zenker's Diverticulum: Cricopharyngeal Myctomy with Diverticulopexy versus Oiverticuiectomy Hubert J. Stein, Bjocrn Bldm Bruecher, Joerg Theisen, Katja Prentl, Hubertus Feussner, Joerg-RuedigerSiewert, Tech Univ of Munich, Munich Germany Background: Controversystill exists in the treatment of Zenker's diverticula if the diverticulum should be resected(diverticulectomy) or fixed to the prevertebralfascia (diverticulopexy),The aim of this study was to compare the outcome of these two surgical options. Patients and methods:The study group consistedof 140 patientsoperatedon Zenker'sdiverticulum between 1984 and 1997. Morbidity data and symptomatic outcome (standardized questionnaire) between the two groups were assessed. Results: Out of a total of 140 operated patients with Zenker's diverticulum, complete follow-up was available in 116 cases with a median followup of 70.8 months (range: 19-171). Thirty-five patients underwent myotomy with diverticulopexy and 81 patients myotomy with diverticulectomy. The majority of patients in whom a divcrticulectomy was performed did have a big diverticulum (Brombart ill or IV) in contrast to patients with diverticulopexywith smaller size diverticula on average.The table shows the clinical and symptomatic outcome betweenthe two groups. Morbidity included only surgically related complications such as fistula, wound infection, and bleeding. More than 90% of the patients in both groups were satisfied with the operative result. Conclusion: Based on these findings diverticulectomy should be reserved for big Zenker's diverticula since it carries a high risk of postoperativecomplications. Treatment of choice for diverticula Brombart stage I-II should be myotomy with diverticulopexy Morbidityand symptomaticoutcomeof patientswith Zenker'sdiverlJculum

morbidity no postop. symptoms

diverticulopexy (n=35)

diverticulectomy (n=81)

p value

0/35 (o%) 29/35 (82.8%)

12/81 (14.8%) 74/81 (91.3%)

<0.05 n.s.

2428 Clinical Outcome Of Laparoscopic Actireflux Surgery (LARS) in Patients Eligible For Endoluminal Therapies Mary E. Klingensmith, Deannia L. Dunnegan, Peggy Frisella, Valerie J. Halpin, NathanielJ. Soper, Washington Univ Sch of Medicine, Saint Louis, MO Endoluminaltherapiesfor the treatment of gastroesophagealreflux disease(GERD)are gaining increased attention. Due to technical limitations, patients must be highly selected for this approach. Current practice excludes patients with hiatal hernia >2cm, Barrett s esophagus, dysphagia,esophagealstrictures, or esophagitis>grade 2. Long-termfollow up after endoluminal therapy is not available.However, in a recent study, at 3 months, only 2/3rds of patient~ reported successful outcomes. In the present study, we assessed outcome of tARS in patients eligible for an endoluminal approach. 410 consecutive patients undergoing tARS were prospectively entered into an ongoing database over a 7 year period. Of these, 116 (28%) met the inclusion criteria listed above. Mean (_+SD) age was 44+9 yrs (range 1871). Operativetime was 116_+39 min. Post operative LOS was 1.0_+1.0 days, and return to work occurred by 12-+5 days. Short-term complications were noted in 3 patients (3%). Three patients (3%) required reoperetion for failure. Symptoms and acid-reduction medication use were assessedpreoperatively,and at 1 month, and 1,2, and 4 years postoperatively.Significant and durable symptom improvement was noted compared to preop (see table), tARS was 1oundto be efficacious in providing relief of GERDsymptoms in >90% of patients. In addition,

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