A method for treating fecal incontinence in a body of a mammal having a rectum formed by a rectal wall extending to an anus wherein the rectal wall includes a sphincter muscle surrounding the anus. At least one nonaqueous solution is introduced into the rectal wall in the vicinity of the anus. A nonbiodegradable solid is formed in the rectal wall from the at least one nonaqueous solution.

Method for treating fecal incontinence

OBJECTIVE: The open Nissen fundoplication is effective therapy for gastroesophageal reflux disease. In this study, the outcomes in 198 patients treated with the laparoscopic Nissen fundoplication was evaluated for up to 32 months after surgery to ascertain whether similar positive results could be obtained. SUMMARY BACKGROUND DATA: To ensure surgical success, patients were required to have mechanically defective sphincters on manometry and increased esophageal acid exposure on 24-hour pH monitoring. The patients either had severe complications of gastroesophageal reflux disease or had failed medical therapy. These requirements have been found to be necessary to ensure a successful surgical outcome. METHODS: The disease was complicated by ulceration (46), stricture (25) and Barrett's esophagus (33). Patients underwent standard Nissen fundoplications identical in every detail to open procedures except that the procedures were carried out by the laparoscopic route. RESULTS: Perioperative complications included gastric or esophageal perforation (3), pneumothorax (2), bleeding (2), breakdown of crural repair (2) and periesophageal abscess (1). The only mortality occurred from a duodenal perforation. Six patients required conversion to the open procedure. The median hospital stay was 3 days. One hundred patients were observed for follow-up for 6 to 32 months (median 12 months), with outcomes similar to the open Nissen fundoplication. Further surgery was required for two patients who had recurrent gastroesophageal reflux and one who developed an esophageal stricture. Ninety-seven percent are satisfied with their decision to have the operation. CONCLUSIONS: The laparoscopic Nissen fundoplication can be carried out safely and effectively with similar positive results to the open procedure and with all of the advantages of the minimally invasive approach.

Laparoscopic Nissen fundoplication is an effective treatment for gastroesophageal reflux disease.

Objective The authors examined indications, evaluations, and outcomes after laparoscopic fundoplication in patients with gastroesophageal reflux through this single-institution study. of Background Data Laparoscopic fundoplication has been performed for less than 5 years, yet the early and intermediate results suggest that this operation is safe and equivalent in efficacy to open techniques of antireflux surgery. Methods Over a 4-year period, 300 patients underwent laparoscopic Nissen fundoplication (252) or laparoscopic Toupet fundoplication (48) for gastroesophageal reflux refractory to medical therapy or requiring daily therapy with omeprazole or high-dose H 2 antagonists. Preoperative evaluation included symptom assessment, esophagogastroduodenoscopy, 24-hour pH evaluation, and esophageal motility study. Physiologic follow-up included 24-hour pH study and esophageal motility study performed 6 weeks and 1 to 3 years after operation. Results The most frequent indication for surgery was the presence of residual typical and atypical gastroesophageal reflux symptoms (64%) despite standard doses of proton pump inhibitors. At preoperative evaluation, 51% of patients had erosive esophagitis, stricture, or Barrett's metaplasia. Ninety-eight percent of patients had an abnormal 24-hour pH study. Seventeen percent had impaired esophageal motility and 2% had aperistalsis. There were four conversions to open fundoplication (adhesions, three ; large liver, one). Intraoperative technical difficulties occurred in 19 (6%) patients and were dealt with intraoperatively in all but 1 patient (bleeding from enlarged left liver lobe). Minor complications occurred in 6% and major complications in 2%. There was no mortality. Median follow-up was 17 months. One year after operation, heartburn was absent in 93%. Four percent took occasional H 2 antagonists, and 3% were back on daily therapy. Atypical reflux symptoms (e.g., asthma, hoarseness, chest pain, or cough) were eliminated or improved in 87% and no better in 13%. Overall patient satisfaction was 97%. Four patients have subsequently undergone laparotomy for repair of gastric perforation (1 year after operation), severe dumping, slipped Nissen, and repair of acute paraesophageal herniation. Two patients had laparoscopic revision of herniated fundoplications. Results of follow-up 24-hour pH studies were normal in 91% of patients more than 1 year after operation. In patients with poor esophageal motility, esophageal body pressure improved 1 year after operation in 75% and worsened in 10%. Conclusions Although long-term efficacy data are lacking, intermediate follow-up shows laparoscopic fundoplication to be safe and effective. A physiologic approach to evaluation and follow-up of patients with gastroesophageal disease allows the surgeon to tailor antireflux surgery to esophageal body function and follow the function of the fundoplication and esophagus after operation.

A physiologic approach to laparoscopic fundoplication for gastroesophageal reflux disease.

An apparatus comprising an elongate probe member having proximal and distal extremities for use with a suction source to treat a portion of a wall forming a cavity in a body having a natural body opening for accessing the cavity. The elongate probe member has a length so that when the distal extremity is in the vicinity of the portion of the wall the proximal extremity is outside of the body. The distal extremity of the elongate probe member has an outer surface and is provided with at least one recess opening onto the outer surface and an internal passageway communicating with the recess. When the suction source is coupled to the apparatus a suction is created in the recess by means of the passageway to draw the portion of the wall into the recess. A hollow needle is slidably disposed in the elongate probe member and has a distal end portion. The needle is actuatable from outside the body for movement from a retracted position in which the distal end portion of the needle is out of the recess and an extended position in which the distal end portion of the needle extends into the recess. The needle can be extended into the portion of the wall drawn into the recess so as to introduce a material into the portion of the wall and form an implant in the portion of the wall.

Kit for forming implants in wall of gastrointestinal tract

The serendipitous discovery of the antireflux effect of wrapping the gastric fundus around the distal esophagus1 led Rudolph Nissen to perform the first fundoplication for gastroesophageal reflux disease (GERD) nearly half a century ago.2 Since then, various technical details of total fundoplication3–5 or partial fundoplications6–8 have been suggested. In 1991, the so-called “Nissen fundoplication” was performed for the first time through a laparoscopic approach.9,10 To date, various large series showed its safety, efficacy, good quality of life, short hospital stay, early return to work, and cost savings.11–14 However, little is known about the reproducibility of such results in nonspecialized centers,15 and about current indications and results faced by long-term acid suppression therapy.16,17 Gastroenterologists and surgeons definitely do not share the same enthusiasm in surgical referral of patients with GERD.18 The gastroenterological medical community appears at least skeptical about the efficacy of laparoscopic antireflux surgery,19–21 claiming also that too many technical modifications of fundoplication are performed and complications are often blamed on 1 type of modification or another.19,20 Furthermore, a recently introduced third party – endoscopic augmentation of lower esophageal sphincter pressure22,23 – might potentially compete in this arena.

When one of the authors, already experienced in laparoscopic antireflux surgery, moved to his current hospital, he needed to establish a new surgical referral of patients with GERD. He was asked to provide the available evidence on current status of antireflux surgery, and this need prompted this review.

/pdf/evidence-based-appraisal-of-antireflux-fundoplication-2c8468d7my.pdf

Evidence-based appraisal of antireflux fundoplication

• In 1976 we defined a technique of "floppy" Nissen fundoplication (FNF) that prevented experimental pathologic reflux without preventing gaseous eructations or vomiting (normal reflux) when appropriate. This report describes the one- to eight-year follow-up of the 77 patients operated on since that time. The FNF has been completely effective in preventing pathologic reflux in 75 of 77 patients and has been partially effective in two others who are now subjectively asymptomatic. Adverse side effects were reported by two patients, one with gas-bloat and one with inability to belch or vomit. The lower esophageal sphincter pressure of patients postoperatively was increased to low normal values from a mean of 8.94±1.66 to 14.31±0.7 mm Hg (normal, 21.2±4.2 mm Hg). Since FNF does not cause greatly increased lower esophageal sphincter pressure, the inference that the FNF prevents reflux by altering the physiology of a reflux event is supported. In conclusion, the floppy fundoplication has been an effective operation with a low incidence of adverse side effects and without a tendency for late failure. (Arch Surg1985;120:663-668)

The floppy Nissen fundoplication. Effective long-term control of pathologic reflux.

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The floppy Nissen fundoplication. Effective long-term control of pathologic reflux.